The NEW ENGLAND JOURNALof MEDICINE
`
`
`
`ORIGINAL ARTICLE
`
`Efficacy ofLenalidomide in Myelodysplastic
`Syndromes
`
`Alan List, M.D., Sandy Kurtin, C.N.P., M.S., Denise J. Roe, Dr.P.H.,
`Andrew Buresh, M.D., Daruka Mahadevan, M.D., Ph.D., Deborah Fuchs, M.D.,
`Lisa Rimsza, M.D., Ruth Heaton, B.S., Robert Knight, M.D.,
`and Jerome B. Zeldis, M.D.
`
`ABSTRACT
`
`BACKGROUND
`
`Ineffective erythropoiesis is the hallmark ofmyelodysplastic syndromes. Management
`ofthe anemia caused by ineffective erythropoiesis is difficult. In patients with myelo-
`dysplastic syndromes and symptomatic anemia, we evaluated the safety and hemato-
`logic activity oflenalidomide,a novel analogueofthalidomide.
`
`METHODS
`
`Forty-three patients with transfusion-dependent or symptomatic anemia received le-
`nalidomide at doses of25 or 10 mg perday or of10 mgperday for 21 days ofevery 28-
`daycycle. All patients either had had no response to recombinanterythropoietin or had
`a high endogenouserythropoietin level with a low probability of benefit from such
`therapy. The response to treatmentwasassessed after 16 weeks.
`
`RESULTS
`
`Neutropenia and thrombocytopenia, the mostcommonadverseevents, with respective
`frequencies of65 percent and 74 percent, necessitatedthe interruption oftreatmentor
`a dose reduction in 25 patients (58 percent). Other adverse events were mild andinfre-
`quent. Twenty-four patients had a response (56 percent): 20 had sustained indepen-
`dencefrom transfusion, 1 had an increase in the hemoglobinlevel ofmore than 2 g per
`deciliter, and 3 had more than a 50 percentreduction in the needfor transfusions. The
`responserate was highest amongpatients with a clonal interstitial deletion involving
`chromosome 5q31.1 (83 percent, as compared with 57 percent amongthose with a
`normal karyotype and 12 percent amongthose with other karyotypic abnormalities;
`P=0,007) and patients with lower prognostic risk. Of20 patients with karyotypic ab-
`normalities, 11 had at least a 50 percent reduction in abnormal cells in metaphase, in-
`cluding 10 (50 percent) with a complete cytogenetic remission. After a median follow-
`up of 81 weeks, the median duration of transfusion independence had not been
`reached and the median hemoglobin level was 13.2 g perdeciliter (range, 11.5 to 15.8).
`
`CONCLUSIONS
`
`Lenalidomide has hematologic activity in patients with low-risk myelodysplastic syn-
`dromes whohave no response to erythropoietin or whoare unlikely to benefit from
`conventional therapy.
`
`From the Department ofInterdisciplinary
`Oncology, University of South Florida and
`the H. Lee Moffitt Cancer Center and Re-
`search Institute, Tampa (A.L., R.H.); the
`Departments of Medicine and Pathology,
`University ofArizona College of Medicine,
`Tucson (S.K., A.B., D.M., D.F., L.R.); the
`Mel and Enid Zuckerman Arizona College
`of Public Health, Tucson (D.J.R.); and Cel-
`gene, Warren, N.J. (R.K., J.B.Z.). Address
`reprint requeststo Dr. List at the Hemato-
`logic Malignancies Program, SRB Rm.
`24038, H. Lee Moffitt Cancer Center and
`Research Institute, 12902 Magnolia Dr.
`Tampa, FL 33612-9497, or at
`listaf@
`moffitt.usf.edu.
`
`N Engl J Med 2005;352:549-57.
`Copyright © 2005 Massachusetts MedicalSociety.
`
`N ENGL J MED 352;6 WWW.NEJM.ORG FEBRUARY 10, 2005
`
`549
`
`Redd
`r
`The New England Journal of Medicine
`Downloaded from nejm.org on September 26, 2018. For personal use only. RS Reo ses WII
`"S Laboratories Inc. v. Celgene Corp.
`out permission. 15299 18.01509
`Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`Exhibit 2029, Page 1
`
`

`

`The NEW ENGLAND JOURNAL of MEDICINE
`
`EFRACTORYANEMIA RESULTING FROM
`J > }
`ineffective hematopoiesis is the principal
`:~ /
`.». “\.therapeutic challenge for patients with
`myelodysplastic syndromes. Recombinanteryth-
`ropoietin alone or in combination with myeloid
`growth factors ameliorates anemia in somepatients
`but is generally ineffective in patients who require
`two or more red-cell transfusions per month; its
`use rarely induces cytogenetic remissions.»
`Hematopoietic precursors in patients with mye-
`lodysplastic syndromes have an accelerated cell-
`cycle transition and impaired responsiveness to cy-
`tokine stimulation.** Survival signals from the
`microenvironmentare compromised, owing in part
`to the presence ofangiogenic molecules, disruption
`of the medullary architecture, and excess produc-
`tion ofinflammatory cytokines.> ?° Thalidomide, a
`multifunctional inhibitor of angiogenesis and an
`immune modulator, restores erythropoiesis andre-
`duces transfusion dependence in approximately 18
`percent of patients who have no responseto re-
`combinanterythropoietin.** ** However, long-term
`treatment and dose escalation are limited by the
`drug’s sedative and neurologic effects. Lenalido-
`mide is a novel 4-amino-glutarimide analogue of
`thalidomide that is more potent but does not have
`the neurotoxic and teratogenic effects of thalido-
`mide.+> 1” We report theresults ofa safety and effi-
`cacy study oflenalidomide in patients with myelo-
`dysplastic syndromes.
`
`
`METHODS
`
`PATIENTS
`
`Eligible patients had received a histologically con-
`firmed diagnosis of a primary myelodysplastic
`syndrome according to French—American-British
`(FAB) criteria (Fig. 1)*® more than three months
`before enrollmentand a diagnosis ofeither symp-
`tomatic anemia (defined by a hemoglobin level of
`less than 10.0 g perdeciliter) or tansfusion-depen-
`dent anemia (defined by the need forat least 4 units
`ofred cells within eight weeks before enrollment).
`Hematologic values obtained during the eightweeks
`preceding study treatmentserved as a reference
`for the assessmentofresponse.Patients either had
`had no response to treatment with recombinant
`erythropoietin or had an endogenousserum level
`of more than 500 mU permilliliter. Patients with
`severe neutropenia (defined by an absolute neutro-
`phil count ofless than 500 per cubic millimeter),
`
`severe thrombocytopenia (defined by a platelet
`countof less than 10,000 per cubic millimeter),
`treatment-related myelodysplastic syndromes, or
`clinically significant coexisting medical illnesses
`were excluded.
`
`STUDY DESIGN
`
`This open-label, single-center trial evaluated the
`safety and efficacy oflenalidomide in patients with
`myelodysplastic syndromes who had symptomatic
`anemia. All patients gave written informed consent,
`and the study was approvedbythe institutional re-
`view board ofthe University ofArizona. Theprinci-
`pal investigator designed and conducted the study,
`analyzed the data, and wrote the article in consulta-
`tion with Celgene. Lenalidomide (Revlimid) was
`supplied by Celgene as 5-mg or 25-mg capsules.
`Three oral dosing schedules were sequentially evalu-
`ated: 25 mgdaily, 10 mgdaily, and 10 mg daily for21
`days ofevery 28-day cycle. Treatmentwasinterrupt-
`ed in the event ofadverse events ofgrade3 or higher
`according to the CommonToxicity Criteria of the
`National Cancer Institute and resumedat the next
`lower doseafter the resolution of these effects.19
`Sequential dose reductions were asfollows: 10 mg
`per day, 10 mgperdayfor 21 days, 5 mgperday,
`5 mg perday for 21 days, and 5 mg every otherday.
`Complete blood counts were obtained every two
`weeks, with the response to treatment and adverse
`events assessed every four weeks. Bone marrow as-
`piration, biopsy, and cytogenetic analysis were re-
`peated every eight weeks. Thefinal response was
`assessedafter 16 weeksoftherapy. Patients with a
`responsecontinued taking lenalidomideuntil dis-
`ease progression,treatmentfailure, or dose-limiting
`adverse events occurred. Patients with hemato-
`logic improvementthatdid not qualify as a proto-
`col-defined responseafter 16 weeks could receive
`8 additional weeks of treatment before the final
`assessmentof response, whereas patients with-
`outa response who had beenfollowing the 21-day
`treatment schedule were offered continual dosing.
`Red-cell transfusions were administered accord-
`ing to prestudyclinical indicators with the following
`guidelines: 2 units were given to patients with a he-
`matocrit of less than 25 percent, 3 units to those
`with a hematocrit ofless than 21 percent, and 4 units
`to those with a hematocrit ofless than 18 percent.
`Myeloid growth factors for the managementofan
`exacerbation of neutropenia were the only cyto-
`kines permitted.
`
`550
`
`N ENGL J MED 352;6 WWW.NEJM.ORG FEBRUARY 10, 2005
`
`Inc. v. Celgene Cor
`Reddy's Lahoratories,
`5,
`The New England Journal of Medicine
`Downloaded from nejm.org on September 26, 2018. For personal use only. RSReo ses Laboral permission. PRO! 8-01 B00
`Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`Exhibit 2029, Page 2
`
`

`

`LENALIDOMIDE FOR MYELODYSPLASTIC SYNDROMES
`
`
`
`Figure 1. Characteristics of Myelodysplastic Syndromes.
`The bone marrow aspirate in patients with myelodysplasia is hypercellular, reflecting trilineal dysplasia (Panel A; Wright-
`Giemsastain). In this specimen, hypolobated megakaryocytes and hyposegmented neutrophils are prominent. Myeloid
`maturationis shifted to theleft, and myeloblasts may be increased, as shownin Panel B in a patient with refractory
`anemiawith excess blasts (Wright-Giemsastain). Dyserythropoiesis accompanies the hypolobated megakaryocytes and
`hyposegmented neutrophils. There may bea left-sided shift in erythroid maturation, nuclear budding, megaloblastic
`changes, and as shown in PanelC, a decrease in the numberoferythroid precursors (Wright-Giemsastain). The cellu-
`larity ofa core-biopsy specimen can approach 100 percent, with readily apparent dysplasia (Panel D; hematoxylin and
`eosin). (Provided by Lynn Moscinski, M.D., H. Lee Moffitt Cancer Center and ResearchInstitute, Tampa,Fla.)
`
`ASSESSMENT OF RESPONSE AND ADVERSE EVENTS
`
`The hematologic response was assessed according
`to the modified criteria ofthe International Working
`Group,with the requirementthat an improvement
`had to be sustained for at least eight consecutive
`weeks,”° A majorerythroid response was defined
`as freedom from the need for transfusionor an in-
`crease in the hemoglobin level ofmore than 2 g per
`deciliter in patients with transfusion-independent
`anemia. A minor response wasdefined as at least a
`50 percent reductionin transfusions ora sustained
`elevation in the hemoglobin level of 1 to 2 g per
`deciliter. A major cytogenetic response wasdefined
`by the absence ofthe pretreatment cytogenetic ab-
`normality on standard metaphase analysis (e.g., at
`least 20 cells in metaphase), and a minor response
`
`by a reduction in the number of abnormal cells in
`metaphase ofatleast 50 percent. Cytogenetic pro-
`gression wasdefined as the sustained acquisition
`ofa new chromosomal abnormality.
`Responses were compared by means ofthe Inter-
`national Prognostic Scoring System (IPSS), which
`assessesthe percentageofblasts in bone marrow,
`the karyotype, and the number ofcytopenias.?*
`Blinded review ofbone marrow specimens wasper-
`formed by two investigators. Immunohistochemi-
`cal staining ofbiopsy specimensandclot sections
`used monoclonal antibodies against IgG2a (Ven-
`tana Medical Systems) recognizing CD3(PSI clone)
`and CD20 (L26 clone) antigens. Cytologic dyspla-
`sia was graded with the use ofa 10 percentthresh-
`old. Adverse events were graded with the use ofthe
`
`N ENGL J MED 352;6 WWW.NEJM.ORG FEBRUARY 10, 2005
`
`551
`
`The New England Journal of Medicine
`.
`Downloaded from nejm.org on September 26, 2018. For personal use only. RSReddy'sLaboratories Inc. v. Celgene Corp.
`ut permission.
`Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`exhibsoneage3
`
`

`

`The NEW ENGLAND JOURNAL of MEDICINE
`
`ofthe 43 Patients.*
`
`Characteristic
`
`Age— yr
`Median
`
`Range
`
`Sex — no. (%)
`Male
`
`Female
`FABclass — no. (%)
`Refractory anemia
`
`Refractory anemia with ringed sideroblasts
`Refractory anemia with excess blasts
`
`Refractory anemia with excess blasts
`in transformation
`
`Chronic myelomonocytic leukemia
`IPSSrisk category — no.(%)
`Low
`
`Intermediate 1
`
`Intermediate 2
`High
`Transfusion dependence
`
`72
`
`28-85
`
`25 (58)
`
`18 (42)
`
`20 (47)
`
`13 (30)
`8 (19)
`
`1 (2)
`
`1 (2)
`
`22 (51)
`
`16 (37)
`
`4 (9)
`1 (2)
`
` Table 1. Clinical and Hematologic Characteristics
`
`CommonToxicity Criteria of the National Cancer
`Institute.?9
`
`STATISTICAL ANALYSIS
`
`The duration oftransfusion independencewascal-
`culated from the date ofthe last red-cell transfusion
`to the resumption oftransfusion through April 1,
`2004, according to the method ofKaplan and Mei-
`er.?? The duration of major responsesin transfu-
`sion-independentpatients was recorded from the
`initial date of the sustained elevation in hemoglo-
`bin levels of more than 2 g per deciliter. The analy-
`ses ofadverse events and response were carried out
`according to the intention-to-treat principle. Uni-
`variate comparisons were performedwith the use
`of Fisher’s exact test, a two-sample independent
`t-test, or a Wilcoxon rank-sum test. The duration
`oftransfusion independence was compared among
`the groups by meansofthe log-ranktest.All report-
`ed P valuesare two-sided. Data are reported as me-
`dians +SD.
`
`
`RESULTS
`
`From March 2002 to August 2003, 55 candidates
`were screened and 43 were enrolled. Thirty-three
`patients (77 percent) had refractory anemia or re-
`fractory anemia with ringed sideroblasts, and 38
`(88 percent) hadIPSSrisk scores oflow or interme-
`diate 1 (Table 1). Overall, 74 percent were transfu-
`sion-dependent, 33 (77 percent) had had no re-
`sponseto treatmentwitherythropoietin, and 13 (30
`percent) had had noresponse to treatment with
`thalidomide. None hadreceived cytotoxic therapy.
`The median numberofprior nontransfusiontreat-
`ments was 1.7 (range, 0 to 5). Moderate-to-severe
`neutropenia waspresent in 28 percentofpatients,
`and moderate-to-severe thrombocytopenia in 23
`percent ofpatients; 37 percent had at least two
`cytopenias. Twenty patients (46 percent) had clonal
`karyotypic abnormalities (defined by the presence
`of at least two abnormal cells in metaphase),
`including interstitial deletions of chromosome
`5q31.1 alone (11 patients) or in association with
`trisomy 21(1), an interstitial deletion of chromo-
`some 20q11.2 (2), a complex karyotype (1), and
`other abnormalities (5).
`
`ADVERSE EVENTS
`
`Neutropenia and thrombocytopenia were the most
`common adverse events (Table 2). Severe myelo-
`suppression (grade 3 or higher) was dose-depen-
`
`No. (%)
`Median no.ofred-cell units transfused/mo
`
`32 (74)
`3
`
`Range
`
`2-6
`
`Pretransfusion hemoglobin level — g/dl
`Transfusion-dependentpatients
`Median
`
`Range
`Other
`
`Median
`
`Range
`Duration of disease — mo
`Median
`
`Range
`
`Neutropenia — no. (%){
`Thrombocytopenia — no. (%)+
`Karyotype — no. (%)
`Normal
`
`Abnormal
`
`29
`
`3-169
`
`12 (28)
`10 (23)
`
`23 (53)
`
`20 (47)
`
`* FAB denotes French-American—British, and IPSS Inter-
`national Prognostic Scoring System.
`+ Neutropenia was defined by an absolute neutrophil
`countof less than 1500 percubic millimeter.
`+ Thrombocytopenia wasdefined by a platelet count of
`less than 100,000 per cubic millimeter.
`
`552
`
`N ENGL J MED 352;6 WWW.NEJM.ORG FEBRUARY 10, 2005
`
`The New England Journal of Medicine
`RS Reo ses Laboral permission. IPR2018-01509
`r. Reddy’s Laboratories,
`Inc. v. Celgene Corp.
`Downloaded from nejm.org on September 26, 2018. For personal use only.
`Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`Exhibit 2029, Page 4
`
`

`

`LENALIDOMIDE FOR MYELODYSPLASTIC SYNDROMES
`
`Table 2. Treatment-Associated Adverse Events.
`
`Adverse Event
`
`Neutropenia
`
`Thrombocytopenia
`Pruritus
`
`Diarrhea
`
`Urticaria
`
`Fatigue
`
`Bonepain
`Pneumonia
`
`Edema
`
`Hypothyroidism
`Hypogonadism
`Myalgias
`
`Autoimmunehemolytic anemia
`me&wOOOFOOOYNCO
`ooolcUcrUWmUChUMUCUCOUCUNCOCUNHTNOYHYOO
`oocococluUcOCUMrmPpDmCOFCOOoOCUcUDUOmUmN
`oorNRCOOFKYF&FNYLSSF
`ooooeoc¢eoeooooeooew
`
`ooocoooenorocrsd
`
`Lenalidomide,
`25 mg/day
`(N=13)
`Grade Grade
`lor2 3o0r4
`
`Lenalidomide,
`10 mg/day
`(N=13)
`Grade Grade
`lor2 30r4
`
`Lenalidomide,
`10 mg/day for 21 days
`(N=17)
`Grade Grade
`lor2 3o0r4
`
`All Patients,
`Any Grade
`(N=43)
`
`io
`
`numberofpatients
`8
`0
`
`io
`
`no. ofpatients (%)
`28 (65)
`
`32 (74)
`
`12 (28)
`
`9 (21)
`
`6 (14)
`
`3 (7)
`
`4 (9)
`
`3 (7)
`
`2 (5)
`
`2 (5)
`
`2 (5)
`
`1 (2)
`
`1 (2)
`
`dent and necessitated treatment interruption or
`dose reduction in 25 patients (58 percent). Treat-
`ment was interrupted because of myelosuppres-
`sion in 77 percent ofpatients in the 25-mg group
`after a median of4.6 weeks(range, 3 to 9), as com-
`pared with 62 percentofthose whowere receiving
`10 mgdaily (median, 8.5 weeks; range, 2 to 20) and
`47 percent ofthose whowerereceiving 10 mg daily
`for 21 days (median, 6 weeks; range, 1 to 11) (P=
`0.62). The median interval betweenthefirstinter-
`ruption of treatment and the resumption oftreat-
`mentwas 22 daysin each cohort(range, 9 to 55).
`Atweek 8, marrow cellularity was reduced by 75
`percent amongpatients whowerereceiving 25 mg
`oflenalidomide per day, as compared with a reduc-
`tion of12 percentin both 10-mg cohorts. Pneumo-
`nia developed in three patients, one ofwhom had
`worsening ofpreexisting neutropenia. One patient
`was removedfrom the study on day 5 becauseofau-
`toimmune hemolytic anemia with escalating trans-
`fusion requirements that preceded enrollmentin
`the study. There were three deaths, none ofwhich
`were thoughtto be treatment-related: one was due
`to cholecystitis with rupture (day 8), one to splenic
`infarct in a patient with massive splenomegaly (day
`5) and a history ofsuch events, and one to pneumo-
`nia without neutropenia (week 20). All other ad-
`
`verse events were either minor or of moderate se-
`verity.
`Pruritus, generally self-limited andrestricted to
`the scalp, was reported by 28 percent ofpatients
`during the first week of treatment. Isolated and
`transient urticaria was reported by 14 percent of
`patients, whereasa systemic rash with anurticarial
`componentdeveloped in one patient and resolved
`after treatment wasinterrupted. Diarrhea occurred
`in 21 percentofpatients after prolonged treatment
`(more than three months) but was manageable with
`the use ofeither medication for diarrhea or the in-
`terruption of treatment with lenalidomide. Four
`patients required hormone replacement — twofor
`hypothyroidism, and twofor gonadal dysfunction.
`Seven patients discontinued lenalidomide prema-
`turely (before 28 days) because of withdrawal of
`consentby three patients, autoimmune hemolytic
`anemia in one, early myelosuppression in one, and
`early death in two.
`
`HEMATOLOGIC RESPONSE
`
`Twenty-four patients (56 percent) had a response
`(Table 3); 20 of32 transfusion-dependentpatients
`(63 percent) achieved independence from transfu-
`sion. Of11 patients whorequired no transfusions,
`1 had anincrease in the hemoglobinlevel of more
`
`N ENGL J MED 352;6 WWW.NEJM.ORG FEBRUARY 10, 2005
`
`553
`
`The New England Journal of Medicine
`Downloaded from nejm.org on September 26, 2018. For personal use only. RSRead LSLahoratones,Inc.Visanore
`Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`Exhibit 2029, Page 5
`
`

`

`The NEW ENGLAND JOURNAL of MEDICINE
`
`Table 3. Erythroid Responses.
`
`than 2 g perdeciliter. The median time to a response
`increased from 9 weeks in the 25-mg cohort to
`Lenalidomide
`No. of
`11.5 weeks in the cohort given 10 mg perday for 21
`Dose
`Patients
`Erythroid Response
`Weeks to Response
`days. Patients with a major response reached a me-
`
`Major Minor Total Median+SD Range|dian hemoglobinlevel of 13.2+1.4 g perdeciliter
`number(percent)
`(range, 11.5 to 15.8), with acorresponding median
`25 mg/day 9.05.8=2.5-18.5|increase in hemoglobin from baseline of 5.3 g per6 0 6 (46)
`
`
`
`
`
`
`
`10 mg/day 105264==2-17.5|deciliter (range, 4.4 to 8.7). After a medianfollow-6 1 7(54)
`
`
`10 mg/dayfor 6-24|up of81 weeks (range, 42 to 110), the median dura-9 2 =11(65) 1154103
`
`
`
`
`21 days
`i
`j
`had not been reached
`Total
`21 (49)
`3(7)
`24 (56)
`tion ofthe major response
`(more than 48 weeks; range, more than 13 to more
`than 101). Amongthe 21 patients with a majorre-
`sponse, anemia recurred in 4, with the resumption
`oftransfusionsafter intervals of 12, 19, 56, and 74
`weeks. In one of these patients, treatment failure
`
`Table 4. Relation between Clinical and Biologic Features and Erythroid
`=
`
`was associated with karyotypic evolution and sub- No.of—Erythroid
`
`Variable
`
`Sex
`
`Male
`Female
`Race
`White
`Other
`Prior recombinant erythropoietin
`Yes
`No
`Priorthalidomide
`Yes
`No
`FABclass
`Refractory anemia
`Refractory anemia with ringed sideroblasts
`Refractory anemia with excess blasts,
`with or without transformation
`.
`.
`.
`Chronic myelomonocytic leukemia
`.
`IPSS risk category
`v7
`intermediate 1
`Intermediate 2 or high
`Karyotype
`Del
`(5)(431.1)
`Normal
`Other
`> Grade 3 myelosuppression
`Yes
`No
`
`P
`Patients Response Value;
`no. (%)
`
`0.35
`
`12 (48)
`12 (67)
`
`20 (54)
`4 (67)
`
`16 (48)
`8 (80)
`
`6 (46)
`18 (60)
`
`15 (75)
`6 (46)
`3 (33)
`
`0
`
`15 (68)
`8 (50)
`1 (20)
`
`10 (83)
`13 (57)
`1 (12)
`
`14 (56)
`10(56)
`
`.
`
`.
`
`.
`
`i
`
`sequentprogression to leukemia.
`Of10 patients with moderate-to-severe throm-
`bocytopenia, 1 hada sustained improvementin the
`platelet count(i.e., an increase ofmore than 30,000
`per cubic millimeter). Of the 12 patients with neu-
`tropenia, 2 had a sustained increase in the neutro-
`phil count ofmore than 500 per cubic millimeter.
`
`CYTOGENETIC FINDINGS
`The cytogenetic pattern correlated significantly with
`the hematologic response: 83 percent of patients
`with a deletion of5q31.1 had a response, as com-
`pared with 57 percentofthose with a normal kary-
`otype and 12 percentofthose with other cytogenetic
`abnormalities (P=0.007) (Table 4). The FAB cate-
`gory hadnosignificant correlation with response
`(P=0.07), nor did theIPSSrisk category, age, dura-
`tion of disease, or number ofprior treatments
`(Table 4). The median time to a response was
`tae
`.
`.
`.
`morerapid in patients with a deletion of 5q31.1
`.
`:
`(8.0+4.4 weeks; range, 2.5 to 16.0) than in patients
`:
`.
`with a normal karyotype or other karyotypic ab-
`normalities (11.2+6.7 weeks; range, 2.0 to 26.0;
`P=0.029).
`.
`.
`.
`Among20patients with clonal cytogenetic ab-
`normalities, 11 had cytogenetic responses, includ-
`.
`. .
`.
`ing 10 witha complete cytogenetic remission (Table
`5). Ofthese 10 patients, 9 had del(5)(q31.1) and
`1had t(1;22)(q21p11.2). All cytogenetic respons-
`es occurred in patients whoalso had a hematologic
`response. Overall, 10 of 12 patients (83 percent)
`with a 5q31.1 deletion had a cytogenetic response.
`Fluorescence in situ hybridization with the use
`of the 5q31 (EGR1X2)-specific probe (Vysis) con-
`:
`firmed the absence ofthe 5q31.1 deletion among
`200 cells in interphase in eachoffive patients who
`
`* FAB denotes French-American-British, and IPSS International Prognostic
`Scoring System.
`{ Fisher's exact test was used.
`+ Race was determined from patient registration forms.
`
`554
`
`N ENGL J MED 352;6 WWW.NEJM.ORG FEBRUARY 10, 2005
`
`The New England Journal of Medicine
`;
`.
`Downloaded from nejm.org on September 26, 2018. For personal use only. RSRead LSLahoratones,Inc.Visanore
`Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`Exhibit 2029, Page 6
`
`

`

`LENALIDOMIDE FOR MYELODYSPLASTIC SYNDROMES
`
`had a complete response and whowereevaluated
`by meansofstandard metaphaseanalysis.
`The median timeto a cytogenetic response was
`8 weeks(range, 8 to 24). Of10 patientswith a5q31.1
`deletion, 9 had a cytogenetic responseafter 8 weeks,
`whereas1 patienthad a response at 16 weeks. Four
`patients had transient emergence ofkaryotypically
`unrelated clones, including trisomy 8 (in two), a
`reciprocal translocation [t(12;16)(p13;p13.3)], and
`monosomy7. Sustained acquisition ofkaryotypical-
`ly discordant clones occurred in four patients: three
`patients with remitting disease and a 5q31.1 dele-
`tion hadtranslocations involving the long arm of
`chromosome7 [t(7;11)(q22;q12), t(7;8)(q22;p21),
`and t(7;21)(q31q11.1)] and one patient with a nor-
`mal karyotype before treatment had deletion 20
`(q21q13.1). Only one ofthese four patients had an
`exacerbation of anemia coincident with the ap-
`pearance of the new abnormality and subsequent
`evolution to acute leukemia. All others remained
`free ofthe needfor transfusion.
`
`PATHOLOGICAL RESPONSES
`AND MORPHOLOGIC FINDINGS
`
`Amongsix patients with excess myeloblasts (at least
`5 percent; range, 6 to 21 percent) who could be
`evaluated, three had more than a 50 percent reduc-
`tion in blasts, with a return to the normal range.
`Thepercentageofringed sideroblasts was reduced
`from 36 percent to 11 percent in 1 of 10 patients
`with refractory anemia with ringed sideroblasts
`whocould be evaluated. All reductions in myelo-
`blasts and sideroblasts occurred in patients with a
`hematologic response. Only one patient with re-
`fractory anemia with ringed sideroblasts had an in-
`crease in blasts during lenalidomide treatment,
`and this patient was removed from the study after
`16 weeks.
`Serial marrow preparations from 28 patients
`weresuitable for a detailed assessmentofdyspla-
`sia and architecture. The morphologic character-
`istics ofmegakaryocytes became normal aftertreat-
`mentwith lenalidomide in 14 of 22 patients (64
`percent) with pretreatment dysplasia, including
`12 patients with a response; 10 ofthese 12 patients
`had a 5q31.1 deletion (Fig. 2). Lymphoid aggre-
`gates, often multiple and not paratrabecular, were
`detected in 10 of28 patients (36 percent) after le-
`nalidomide treatment(including 5 patients with a
`5q31.1 deletion) and corresponded with a hemato-
`logic response in 7. Lymphoid aggregates were
`composed ofpolytypic B cells and T cells. Dysplas-
`
`Table 5. Cytogenetic Responses According to Chromosomal Abnormality.
`
`Chromosomal Abnormality
`
`Del(5)(q31.1)
`Isolated
`
`Withtrisomy 21
`Del(20)(q11.2)
`t(1;22)(q21p11.2)
`Other*
`
`Total
`
`No. of
`Patients
`
`2=50% Decrease
`in AbnormalCells
`in Metaphase
`
`Complete
`Cytogenetic
`Response
`
`number ofpatients (percent)
`10 (83)
`9 (75)
`
`11 (55)
`
`10 (50)
`
`
`
`
`
`* Other chromosomal abnormalities were as follows: +19, t(3;3)(q21;q26.3),
`+8, -X, and complex.
`
`<
`
`
`
`ase eee
`
`A ia “9u's
`
`
`La >Tews,a
`¢ *Bibee
`emEy?ay
`
`
`Figure 2. Morphologic Changes in a Bone Marrow Specimenfrom a Patient
`with a 5q31.1 Deletion.
`Numerous small, mononuclear megakaryocytesare readily identified in the
`bone marrow specimenobtained by trephinebiopsy before treatment (Panel
`A, hematoxylin and eosin). After 16 weeks of lenalidomide therapy, megakary-
`ocytes appear normalin size and have multiple nuclei (Panel B, hematoxylin
`and eosin), and multiple aggregates of benign-appearing lymphocytes are
`apparent (Panel C, hematoxylin and eosin).
`
`tic erythroid elements and myeloid elements were
`common(present in 22 and 11 patients, respec-
`tively), whereas resolution of cytologic atypia was
`infrequent(occurring in 2) and unrelated to hema-
`tologic response. Reticulin fibrosis resolved after
`lenalidomide treatmentin one oftwo patients with
`extensive fiber deposition in the pretreatmenttre-
`phine-biopsy specimen, concordantwith a hemato-
`logic response. Marrow orperipheral-blood eosin-
`ophilia or both (7.5 percentto 14 percent) developed
`in three patients,including two with a hematologic
`response.
`
`N ENGL J MED 352;6 WWW.NEJM.ORG
`
`FEBRUARY 10, 2005
`
`555
`
`The New England Journal of Medicine
`Downloaded from nejm.org on September 26, 2018. For personal use only. RS oO
`Inc. v. Celgene Corp.
`eddy’s Lahoratories,
`ses without permission. IPR2018-01509
`Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`Exhibit 2029, Page 7
`
`

`

`The NEW ENGLAND JOURNAL of MEDICINE
`
`DISCUSSION
`
`(TNF-a), but selective antagonists of TNF-a have
`minimal clinical activity in myelodysplastic syn-
`dromes.?° 78 Lenalidomideaffects a broad range of
`In this study, lenalidomide had substantial activity
`ligand-induced responsesthat maybe integral to
`in patients with myelodysplastic syndromes who
`its activity in myelodysplastic syndromes,includ-
`had had no responseto treatmentwith erythropoi-
`ing angiogenesis, inflammation,cell adhesion, and
`etin or who had high endogenouserythropoietin
`the immuneresponse. Indeed, vascular endothe-
`levels and therefore a low probability ofbenefit from
`lial growth factor (VEGF) is an autocrine growth
`erythropoietin treatment. Overall, 56 percentofpa-
`tients had a response, with most having sustained
`factor elaborated by myeloid precursors in my-
`elodysplastic syndromes that contributes to their
`independence from the need for transfusion and
`self-renewal while exacerbating ineffective erythro-
`restoration ofhemoglobin tolevels within or near
`poiesis in erythroid progenitors, which lack VEGF
`the normal range. Cytogenetic remissions, which
`receptors.%?9 Lenalidomide enhancescell-mediat-
`occurrarely with erythropoietin therapy, were ob-
`ed immunity by potentiating the production ofin-
`served in 55 percentofpatients. The high rate of
`terleukin-2 and interferon-y andincreasingthere-
`complete cytogenetic response in patients with a
`sponsesofcytolytic T cells and natural killer cells
`5q31.1 deletion (75 percent), which was confirmed
`in experimentsin animals,1>7° Of particularinter-
`by moresensitive fluorescence in situ hybridiza-
`est in our study was the appearanceofmultiple lym-
`tion probes, indicates that this subtype ofmyelo-
`phoid aggregates composed ofa mixture ofB cells
`dysplastic syndromeis especially sensitive to lena-
`
`lidomide treatment. Indeed, the time to response andTcells in the trephine-biopsy specimens from
`patients with a response. Whetherthis finding rep-
`was more rapid in patients with the 5q31.1 dele-
`resents an immuneresponse againstthe ineffective
`tion, and response wasassociated with the disap-
`pearance ofdysplastic megakaryocytes, the mor-
`clone is unknown. Furthermore, lenalidomide sen-
`phologic hallmark of the 5q— syndrome.?? These
`sitizes erythroid progenitors to the trophic effects of
`findings suggest thatlenalidomiderestores red-cell
`recombinanterythropoietin (unpublished data).
`production in part by eliminating ineffective my-
`The promising activity of lenalidomide in my-
`elodysplastic clones but does not extinguish the
`elodysplastic syndromes mustbe balanced against
`myelodysplastic syndrome-initiating stem cell.
`its potential to causeclinically significant myelo-
`Thepersistence ofringed sideroblasts in patients
`suppression, which necessitates close laboratory
`with refractory anemia with ringed sideroblasts
`monitoring during the initial weeks oftreatment.
`whohad a response, however, indicates that clonal
`Neutropenia or thrombocytopenia developed in
`suppressionis selective and complemented by the
`more than half the patients and was notlimited to
`patients with preexisting lineage deficits. The ex-
`restoration oferythropoiesis in susceptible myelo-
`dysplastic syndrome progenitors. This notion is
`tent of myelosuppression varied according to the
`supportedby the transient emergenceofkaryotyp-
`dose and cumulative exposure to lenalidomide and
`ically distinct and unrelated clones, which mirrors
`wasreversed by the interruption of treatmentor a
`reduction in the dose. Althoughearly exacerbation
`the experience reported with imatinib treatmentin
`patients with chronic myeloid leukemia.?*?> In ad-
`of cytopenias may be expected with an agent that
`dition, three patients with a5q31.1 deletion acquired
`selectively suppresses myelodysplastic clones that
`new translocations involvingchromosome7 despite
`dominate steady-state hematopoiesis, many pa-
`the complete suppression oftheinitial karyotypic
`tients did not have myelosuppression despite pro-
`abnormality. Despite its unfavorable prognostic im-
`longed lenalidomide treatment. A reduction in
`plication in primary myelodysplastic syndromes,
`marrowcellularity coincided with myelosuppres-
`the clinical significance ofthe acquired transloca-
`sion in patients treated with 25 mgdaily, indicat-
`ing that lenalidomide suppresses myelopoiesis at
`tionsis unclear. Only oneofthese patients had cyto-
`genetic and disease progression, whereas the oth-
`higher doses. At lower doses, however, this effect
`ers had a sustained hematologic response. Further
`was not apparent. Other adverse events were un-
`observation is necessary beforetheclinical signifi-
`common andgenerally mild in severity. Hypothy-
`canceofthesefindings can be determined.
`roidism or gonadal dysfunction developedin four
`patients,raising the possibility that the action ofle-
`Several effects of lenalidomide may contribute
`nalidomide on ligand-induced responses may ex-
`to its activity in myelodysplastic syndromes.It sup-
`presses the production of tumornecrosis factor @
`tend to hypophyseal hormones.
`
`556
`
`N ENGL J MED 352;6 WWW.NEJM.ORG FEBRUARY 10, 2005
`
`Inc. v. Celgene Cor
`Reddy's Lahoratories,
`5,
`The New England Journal of Medicine
`Downloaded from nejm.org on September 26, 2018. For personal use only. RSReo ses Laboral permission. PRO! 8-01 B00
`Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`Exhibit 2029, Page 8
`
`

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