British Journal of Haematology, 2001, 115, 881–894
`
`The clinical and biological effects of thalidomide in patients
`with myelodysplastic syndromes
`
`Francesca Zorat, Vilasini Shetty, Diya Dutt, Laurie Lisak, Fabiana Nascimben, Krishnan Allampallam,
`Saleem Dar, Aaron York, Sefer Gezer, Parameswaran Venugopal and Azra Raza MDS Center and the Section
`of Myeloid Diseases, Rush Presbyterian St Luke’s Medical Center, Chicago, IL, USA
`
`Received 20 April 2001; accepted for publication 31 July 2001
`
`Summary. Thirty patients with myelodysplastic syndromes
`(MDS) were treated with thalidomide at 100 mg/d p.o.,
`increased as tolerated to 400 mg/d for 12 weeks. Levels of
`apoptosis, macrophage number, microvessel density (MVD),
`tumour necrosis factor alpha (TNF-a), transforming growth
`factor beta (TGF-b), interleukin 6 (IL-6), vascular endothe-
`lial growth factor (VEGF) and basic fibroblast growth factor
`(bFGF) were determined in the serum, bone marrow (BM)
`plasma and BM biopsies before and after therapy. Pre-
`therapy biological characteristics of MDS patients were
`compared with similar studies performed in 11 normal
`volunteers. Ten patients demonstrated haematological
`improvement in the erythroid series, six becoming transfu-
`sion independent. Responders had a higher pretherapy
`platelet
`count
`(P , 0·048)
`and
`lower BM blasts
`(P , 0·013). Median time to response was 10 weeks, and
`four remain in remission beyond a year. Pretherapy MDS
`
`showed higher MVD (P , 0·001) and TGF-b
`BMs
`(P , 0·03) and higher serum TNF-a (P , 0·008) com-
`pared with normal control subjects. After therapy, only BM
`TGF-b decreased significantly (P , 0·002). Pretherapy
`haemoglobin was
`directly
`related
`to
`serum VEGF
`(P , 0·001) in responders and inversely related in non-
`responders
`(P , 0·05),
`suggesting the possibility that
`angiogenesis may be a primary pathology in the former
`and a consequence of anaemia-induced hypoxia in the
`latter. We conclude that thalidomide has important clinical
`and biological effects in at least a subset of MDS patients, but
`the precise mechanism of its action remains unknown and
`requires further study including a larger number of patients.
`
`Keywords: thalidomide, myelodysplastic syndromes, vascu-
`lar endothelial growth factor, transforming growth factor
`beta.
`
`A group of four prognostically and biologically variegated
`haematopoietic disorders linked by the common presenta-
`tion of cytopenia and monoclonal, dysplastic, hypercellular
`bone marrow (BM) has been assembled under the heading
`of myelodysplastic syndromes (MDS). The clinical and
`morphological manifestations, response to therapy as well
`as the clinical course of refractory anaemia (RA), RA with
`ringed sideroblasts (RARS) or with excess of blasts (RAEB)
`and chronic myelomonocytic leukaemia (CMMoL) tend to be
`quite distinct from each other. The French–American–
`British (FAB) morphological classification (Bennett et al,
`1982) alone failed to provide accurate information regard-
`ing survival and risk of transformation for individual MDS
`patients. Recognition of
`rather marked differences
`in
`survival within morphologic subtypes of MDS led to the
`
`Correspondence: Dr Azra Raza, MDS Center and the Section of
`Myeloid Diseases, Rush Presbyterian St Luke’s Medical Center, 2242
`West Harrison Street, Suite 108, Chicago, IL 60612, USA.
`E-mail: araza@rush.edu
`
`development of the International Prognostic Scoring System
`(IPSS) based on the severity of disease, as judged by the
`number of cytopenias, cytogenetic abnormalities and
`percentage of BM blasts (Greenberg et al, 1997). Further
`precision in prognostication is likely to be achieved by
`including some of the signature biological characteristics of
`individual patients into the system of classification. It is
`therefore critical to develop an understanding of the subtle
`biological differences between MDS patients and to deter-
`mine how these differences translate with reference to
`treatment outcome and natural history of the disease.
`The only curative treatment for MDS is bone marrow
`transplant (Deeg et al, 2000), generally restricted to patients
`younger than 55 years of age, whereas most MDS patients
`are elderly. In the past, many therapeutic approaches have
`been attempted in MDS, including the administration of
`recombinant haematopoietic growth factors such as gran-
`ulocyte colony-stimulating factor (G-CSF), granulocyte–
`macrophage CSF (GM-CSF) and erythropoietin alone or in
`combination (Ganser & Hoelzer, 1992; Negrin et al, 1993;
`
`q 2001 Blackwell Science Ltd
`
`881
`
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`

`882
`
`F. Zorat et al
`
`Zeigler et al, 1993), chemotherapeutic agents (DeWitt et al,
`1995; Economopoulos et al, 1996; Beran & Kantarjian, 1998)
`and differentiating agents such as retinoids and cholecal-
`ciferols (Koeffler et al, 1988; Morosetti & Koeffler, 1996). None
`have proved to be completely satisfactory, so that supportive
`care continues to be recommended for most patients who are
`not participating in experimental trials. The search for better
`therapies in MDS has acquired a greater urgency as the
`incidence of the disease appears to be on the rise.
`One possible explanation for the ineffective haemato-
`poiesis may be attributed,
`in part, to cytokine-mediated
`excessive intramedullary apoptosis of haematopoietic cells
`(Raza et al, 1995; Yoshida & Mufti, 1999). Tumour necrosis
`factor alpha (TNF-a), interleukin 1-beta (IL-1b) and trans-
`forming growth factor beta (TGF-b) appear to be important
`proapoptotic cytokines (Zoumbos et al, 1991; Verhoef et al,
`1992; Mundle et al, 1996; Raza et al, 1996; Shetty et al,
`1996; Kitagawa et al, 1997; Gersuk et al, 1998; Allampal-
`lam et al, 1999). A novel anticytokine therapeutic approach
`has been tested based on the premise that neutralization of
`the proapoptotic cytokines in MDS patients should lead to
`the suppression of excessive intramedullary apoptosis and
`an improvement in the peripheral cytopenias. Some of the
`earliest trials in this area were conducted with pentoxifyl-
`line, ciprofloxacin and dexamethasone (PCD) and met with
`encouraging results
`(Raza et al, 1998, 2000). The
`cytoprotective agent amifostine was used alone (List et al,
`1997) and in combination with PCD (Raza et al, 2000), and
`also provided good palliation to at least a subset of MDS
`patients. Direct attenuation of TNF-a was attempted with
`the soluble TNF receptor Enbrel (Immunex), and improve-
`ments were noted in both platelet counts and absolute
`neutrophil counts (Raza, 2000). None of these approaches
`has been entirely satisfactory, and the search for more
`effective therapies continues.
`Another potentially useful therapeutic strategy would be
`to target neo-angiogenesis, a phenomenon that appears to
`be universally present in a variety of human cancers.
`Angiogenesis is the formation of new vessels from the
`existing vascular bed and is modulated by several cytokines
`and growth factors, including vascular endothelial growth
`factor (VEGF), basic fibroblastic growth factor (bFGF), TNF-a
`and TGF-b, the mechanism being only partly known (Fox
`et al, 1996). Increased angiogenesis is common in many
`pathological conditions,
`in both neoplastic and non-
`neoplastic diseases (Battegay, 1995; Folkman, 1995). In
`solid tumours, there is an inverse relationship between
`tumour vascularity and prognosis (Chaudhry et al, 1999;
`Giatromanolaki et al, 1999; Strohmeyer et al, 2000). Recent
`data indicate the importance of angiogenesis in haemato-
`logical diseases such as leukaemia (Perez-Atayde et al,
`1997),
`lymphoproliferative diseases (Vacca et al, 1995;
`Ribatti et al, 1996) and multiple myeloma (Vacca et al,
`1994, 1999; Rajkumar et al, 1999; Ribatti et al, 1999).
`Increased angiogenesis in myelodysplastic bone marrow
`biopsies has also been demonstrated compared with normal
`marrows, and a correlation between angiogenesis and
`progression to leukaemia has been suggested (Pruneri et al,
`1999). More recently, high levels of VEGF have been found
`
`in abnormally localized precursor cells in BM biopsies of
`CMMoL patients associated with an adverse prognosis
`(Bellamy et al, 2001). On this basis, it can be postulated
`that anti-angiogenic therapy could play a role in delaying or
`even preventing disease progression.
`One potentially useful drug in this context is thalidomide
`because of
`its anti-TNF, anti-angiogenic and immune-
`modulating activities (Keenan et al, 1991; Moreira et al,
`1993; D’Amato et al, 1994; Turk et al, 1996; Kenyon et al,
`1997; Singhal et al, 1999). All three effects are clearly
`desirable in MDS patients. Thalidomide was introduced into
`the clinic in Europe in the 1950s as a sedative. Because of its
`antiemetic properties, however, some pregnant women
`began to take thalidomide for the treatment of morning
`sickness. The drug was eventually withdrawn from the
`market in the 1960s when its teratogenic effects were
`discovered. The recent return of thalidomide results from its
`broad spectrum of pharmacological and immunological
`effects (Hales, 1999). We have been using thalidomide to
`treat patients with MDS since 1998. The preliminary
`clinical results have shown improvement in haematological
`parameters in at least a subset of these patients, mainly
`resulting from an erythroid response with a decrease in red
`cell transfusions and an increase in haemoglobin levels
`(Raza et al, 1999). The mechanism of action of thalidomide
`is not completely understood.
`The purpose of the present study was to investigate the
`mechanism of action of thalidomide by examining its effects
`on a number of biological parameters in MDS patients. The
`analysis follows 12 weeks of treatment and involves an
`investigation of the degree of apoptosis, number of macro-
`phages, angiogenesis (microvessel density, MVD) and levels
`of a variety of both angiogenic and proapoptotic cytokines
`including VEGF, bFGF,
`interleukin 6 (IL-6), TNF-a and
`TGF-b in the serum, BM plasma and BM biopsies of MDS
`patients. The results indicate that thalidomide may be a
`useful palliative agent for a subset of low-risk MDS patients,
`and that it has significant effects on a variety of biological
`parameters in both serum and bone marrows of these
`individuals.
`
`MATERIALS AND METHODS
`
`The study was carried out on 30 patients with a confirmed
`diagnosis of MDS. Morphological classification was per-
`formed according to the FAB proposal on all the patients.
`Bone marrows and peripheral blood samples from 11
`normal, healthy donors were studied simultaneously and
`served as a control group for the pretherapy biological
`characteristics of MDS patients. The normal donors signed
`an informed consent approved by the Institutional Review
`Board (IRB) of the Rush Presbyterian St Luke’s Medical
`Center before donating their blood and marrows for studies.
`Clinical studies. After signing an informed consent form
`approved by the IRB of Rush Presbyterian St Luke’s Medical
`Center, all patients participated in the study MDS 98–21
`entitled ‘A pilot study of
`thalidomide in patients with
`myelodysplastic syndromes’. The clinical results of
`the
`study in its entirety (83 patients) are reported in a separate
`
`q 2001 Blackwell Science Ltd, British Journal of Haematology 115: 881–894
`
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`

`

`paper (Raza et al, 2001). This paper presents the clinical and
`biological studies on a subset of the study patients. Every
`patient had a pretherapy bone marrow aspirate and biopsy
`examination performed at the Rush Cancer Institute (RCI).
`All samples were reviewed at the central
`facility by a
`haematopathologist at RCI/Rush Presbyterian St. Luke’s
`Medical Center to confirm the diagnosis of MDS. Each
`patient started by taking 100 mg of thalidomide p.o. hs and
`increased the dose as tolerated to 400 mg p.o. at bed
`time (hs) over the next several weeks. Celgene Corporation
`(NJ, USA) provided the drug free of charge for the patients.
`In the present study, no premenopausal woman of child-
`bearing age was included. Newly diagnosed as well as
`previously diagnosed patients were eligible, as were both
`primary de novo and secondary MDS cases. Patients
`belonging to all
`subtypes of MDS, as per
`the FAB
`classification, and to all risk categories according to the
`IPSS were eligible. Patients were required not to have
`received any therapy for MDS for at least 4 weeks before
`starting thalidomide except
`for
`supportive care with
`transfusions. No other treatment for the primary disease,
`such as growth factors, could be administered to study
`patients while they were on thalidomide. Pyridoxine at
`100 mg p.o. qds was prescribed for every patient as
`prophylaxis against peripheral neuropathy. Weekly complete
`blood counts (CBCs) with differentials were obtained and,
`upon completion of 12 weeks of
`therapy,
`the patients
`returned to RCI for a response evaluation, at which time all
`the pretherapy studies were repeated. In case of any evidence
`of a partial or complete response, or stable disease judged by
`the principal investigator, thalidomide was continued at the
`maximum tolerated dose for up to 1 year. Therapy was
`stopped in non-responding patients at this time, and they
`were taken off study.
`The clinical end-point of the study was to determine the
`efficacy of thalidomide in those patients who were able to
`complete at least 12 weeks of therapy at the maximally
`tolerated dose.
`criteria outlined in the
`Response criteria. Response
`report of an International Working Group (IWG)
`to
`standardize response criteria for MDS (Cheson et al, 2000)
`were applied by an independent team (Global Therapeutic
`Development) to assess responses. Minor modifications had
`to be made to these criteria, as it was a retrospective
`analysis. The modified criteria used are outlined below in
`italics.
`Complete remission (CR). Bone marrow evaluation: repeat
`BM showing , 5% myeloblasts with normal maturation of
`all cell lines, with no evidence for dysplasia. When erythroid
`precursors constituted , 50% of BM nucleated cells, the
`percentage blasts were based on all nucleated cells; when
`there were 50% or more erythroid cells, the percentage
`blasts were based on the non-erythroid cells.
`Peripheral blood evaluation (absolute values must last at
`least 2 months):
`X Haemoglobin: . 11 g/dl (untransfused patient not on
`erythropoietin);
`X Neutrophils: 0·1 (cid:2) 109/l or more (not on a myeloid
`growth factor);
`
`Thalidomide and MDS
`883
`X Platelets: 100 (cid:2) 109/l or more (not on a thrombo-
`poietic agent);
`X Blasts: 0%;
`X No dysplasia.
`Partial remission or PR (absolute values must last at least
`2 months): all the CR criteria (if abnormal before treat-
`ment), except bone marrow evaluation; blasts decreased
`by 50% or more over pretreatment, or a less advanced
`MDS FAB classification than pretreatment. Cellularity or
`morphology was not relevant.
`Stable disease: failure to achieve at least a PR, but with no
`evidence of progression for at least 2 months.
`Failure: death during treatment or disease progression
`characterized by worsening of cytopenias, increase in the
`percentage of BM blasts or progression to an MDS FAB
`subtype more advanced than pretreatment.
`Disease transformation: transformation to acute myeloid
`leukaemia (AML), 30% or more blasts.
`Cytogenetic response. requires 20 analysable metaphases
`using conventional cytogenetic techniques. Major: no
`detectable cytogenetic abnormality if pre-existing abnorm-
`ality was present. Minor: 50% or more reduction in
`abnormal metaphases.
`Pretherapy assessments: baseline CBC with which improve-
`ments were compared was standardized using a mean value of the
`4 weeks before the start of therapy for all patients.
`During therapy: responses were assessed at 12, 16 and
`20 weeks of therapy. Absolute values closest to the 12 weeks
`and 16 weeks were used, and responses had to be sustained for
`at least the subsequent 8 weeks. With regard to packed red
`blood cell transfusions (PRBC) and transfusion independence,
`the same 4-week time period was used before treatment to
`determine transfusion dependence and to obtain a baseline
`monthly requirement. Subsequent transfusions were reviewed at
`the 12-, 16-, 20-, 24- and 28-week time points. If a patient
`received transfusion from d 0 to week 12, they were not
`considered transfusion independent; however, if the patient did
`not receive any transfusion at week 16 and sustained that
`independence for another 8 weeks, they were then considered to
`be transfusion independent. Patients were called late responders
`if
`they showed haematological
`improvement
`(HI)
`after
`20 weeks of therapy.
`Haematological improvement: all improvements must last
`at least 8 weeks. For a designated response (CR, PR HI), all
`relevant response criteria must be noted on at least two
`successive determinations at least 1 week apart after an
`appropriate period following therapy.
`for patients
`Erythroid response (HI-E). Major response:
`with pretreatment Hb , 11 g/dl, . 2 g/dl increase in Hb;
`for transfusion-dependent patients,
`transfusion indepen-
`dence. Minor response: for patients with pretreatment Hb
`, 11 g/dl, 1–2 g/dl
`increase in Hb;
`for
`transfusion-
`dependent patients, 50% decrease in PRBC requirements.
`Platelet response (HI-P). Major response: for patients with
`a pretreatment platelet count , 100 (cid:2) 109/l, an absolute
`increase of 30 (cid:2) 109/l or more; for platelet transfusion-
`dependent patients, stabilization of platelet counts and
`platelet
`transfusion independence. Minor
`response:
`for
`patients with a pretreatment platelet count , 100 (cid:2) 109/l,
`
`q 2001 Blackwell Science Ltd, British Journal of Haematology 115: 881–894
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
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`
`

`

`884
`
`F.
`
`Zorat et al
`
`Table I. Detailed characteristics of 10 responding patients.
`
`FAB
`
`BM
`cellularity
`
`PRBC
`dependent
`
`Reduction
`in
`
`Responses
`
`Patient
`no.
`
`Before After
`
`Before After Before After PRBC (%)
`
`Increase
`in Hb
`
`Response
`Platelets ANC type
`
`Response
`duration
`in days
`
`937
`
`RA
`
`RA
`
`20
`
`30
`
`1011
`
`RA
`
`RARS 99
`
`70
`
`Y
`
`Y
`
`277
`
`RA
`
`RA
`
`90
`
`N/A Y
`
`963
`400
`
`RARS 80
`RA
`RARS RARS 70
`
`90
`70
`
`Y
`Y
`
`N
`
`N
`
`N
`
`N
`Y
`
`100
`
`Yes
`
`No
`
`No
`
`100
`
`100
`
`100
`50
`
`Yes
`
`No
`
`No
`No
`
`No
`
`No
`
`No
`No
`
`No
`
`No
`
`No
`No
`
`HI-E major, 100% PRBC tx
`reduction at week 16,minor
`Hb response at week 16
`HI-E major (PRBC), Tx independent at week 16,major (Hb) 422*
`
`200
`
`454*
`
`227
`306
`
`620*
`
`Comment
`
`Died of
`lymphoma
`
`460
`
`RARS RARS 50
`
`1016
`
`RA
`
`RA
`
`340
`
`RARS RA
`
`30
`
`80
`
`50
`
`30
`
`90
`
`N
`
`Y
`
`Y
`
`333
`
`RARS N/A
`
`50
`
`N/A Y
`
`123
`
`RA
`
`RA
`
`80
`
`90
`
`Y
`
`N
`
`N
`
`Y
`
`Y
`
`N
`
`100
`
`50
`
`50
`
`100
`
`Yes
`
`Yes
`
`No
`
`No
`
`Yes
`
`HI-E major, 100% PRBC tx
`reduction
`HI-E major
`HI-E minor, 50% PRBC tx
`reduction
`HI-E major (Hb)
`
`No
`
`No
`
`HI-E major
`
`No
`
`No
`
`HI-E minor, at 16 week and post
`50% reduction in PRBC tx
`50% PRBC reductionfrom week 20 to weeks 24 and 28
`
`No
`
`No
`
`No
`
`No
`
`Yes
`
`Yes
`
`Late responder, trilineage
`
`Continues
`in remission
`Continues
`in remission
`Stopped responding
`Stopped after 1
`year due toside-effects
`Continues in
`remission
`Continues in
`remission
`Stopped responding
`
`Stopped due
`to side-effects
`Late response after
`thalidomide stopped
`
`527*
`
`168
`
`239
`
`210
`
`RA, refractory anaemia; RARS, RA with ringed sideroblasts; RAEB, RA with excess blasts; HI-E, haematological improvement, erythroid series; HI-P, haematological improvement, platelets;
`Tx, transfusion; PRBC, packed red blood cells.
`Patient no., unique Rush Cancer Institute (RCI) number.
`*Continuing response.
`
`q 2001 Blackwell Science Ltd, British Journal of Haematology 115: 881–894
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`

`

`a 50% or more increase in platelet count with a net increase
`. 10 (cid:2) 109/l but , 30 (cid:2) 109/l.
`Absolute neutrophil response (HI-ANC). Major response: for
`ANC , 1·5 (cid:2) 109/l before therapy, at least a 100% increase
`or an absolute increase of 0·5 (cid:2) 109/l, whichever is greater.
`for ANC , 1·5 (cid:2) 109/l before therapy,
`Minor response:
`ANC increase of at
`least 100% but absolute increase
`, 0·5 (cid:2) 109/l.
`Biological studies. Peripheral blood (PB) and bone marrow
`(BM) biopsy samples were obtained from 11 normal healthy
`volunteers and 30 MDS patients before and after 12 weeks
`following therapy with thalidomide.
`Measurement of bone marrow angiogenesis. The angiogen-
`esis studies were carried out on paraffin-embedded BM
`biopsies in 30 patients with MDS and 11 control subjects.
`Two BM biopsy samples were obtained from MDS patients,
`one immediately before starting therapy and the other after
`12 weeks of thalidomide treatment. All blood vessels were
`highlighted by staining endothelial cells with an anti-factor
`VIII murine monoclonal antibody using the standard
`peroxidase–anti-peroxidase technique. Briefly, after depar-
`affinization and hydration, the sections were incubated for
`30 min in 3% H2O2 to inactivate endogenous peroxidase
`activity. For antigen retrieval, the slides were placed in a
`0·1 mol/l citrate buffer at pH 6·0 and boiled twice for
`5 min each. The primary antibody (M616; Dako, Glostrup,
`Denmark; diluted 1:30) was applied to tissue sections for
`1 h,
`followed by biotinylated secondary antibody for
`30 min. The biotinylated antibody was detected using an
`avidin–biotin–peroxidase conjugate and diaminobenzidine
`tetrachloride. Slides were counterstained with haematox-
`ylin. MVD enumeration was performed according to the
`method of Perez-Atayde et al (1997). The number of vessels
`in 20 high-power fields (HPF) was counted using the entire
`BM core, each field representing an area of 0·72 mm2, and
`the median was calculated. The area with the highest
`microvessel count was designated as a hot-spot.
`Detection of the cytokines in the microenvironment. Levels of
`two cytokines, TNF-a and TGF-b, were determined immuno
`histochemically using a semi-quantitative technique in the
`BM biopsies as follows. The BM biopsy tissues were fixed in
`Bouin’s solution and embedded in plastic using glycol
`methacrylate. The sections were then labelled individually
`for each cytokine using the respective antibodies: rabbit
`anti-human TNF-a polyclonal antibody (Genzyme item no.
`ip300; 1:40) and mouse anti-human TGF-b (1:70) by
`methods described previously (Goyal et al, 1999). All the
`slides were observed blindly on a televised screen by several
`investigators. A subjective quantitative scale was formulated
`to determine the degree of positivity of the various cytokines
`as follows: negative (0), low (1–3), intermediate (4–6) and
`high (7–8).
`Detection of macrophages. Macrophages were detected
`immunohistochemically using a specific monoclonal anti-
`body (CD68; Dakopatts, Denmark) by the method described
`previously (Goyal et al, 1999).
`Measurement of apoptosis using in situ end labelling (ISEL).
`ISEL of
`fragmented DNA was carried out on plastic-
`embedded BM biopsies as described in earlier studies
`
`Thalidomide and MDS
`
`885
`
`(Mundle & Raza, 1995; Raza et al, 1995). Briefly, the
`sections were first pretreated with sodium chloride–sodium
`citrate (SSC) solution at 808C and with 1% Pronase
`[1 mg/ml
`in 0·15 mol/l phosphate-buffered saline (PBS);
`Calbiochem, La Jolla, CA, USA] followed by incubation
`with a mixture of dATP, dCTP, dGTP (0·01 mol/l;
`Promega, Madison, WI, USA), bio-dUTP (0·001 mol/l,
`Sigma) and DNA polymerase I
`(20 U/ml, Promega) at
`198C.
`Incorporation of bio-dUTP was finally visualized
`using an avidin–biotin–peroxidase conjugate (Vectastain
`Elite ABC kit; Vector, Burlingame, CA, USA) and
`diaminobenzidine
`tetrachloride. Dark
`brown nuclear
`staining indicated cells undergoing apoptotic death. The
`stained slides were examined by a group of observers on a
`television screen attached to the microscope. A subjective
`rating scale from 0 to 81 was formulated to determine
`the extent of apoptosis as described before (Mundle &
`Raza, 1995).
`Determination of cytokine levels in serum and bone marrow
`plasma. Peripheral blood was collected in sterile tubes before
`and after therapy, centrifuged at 2000 g for 10 min and
`stored at 2408C. Levels of serum VEGF, bFGF, IL-6, TNF-a
`and TGF-b were determined using a quantitative enzyme-
`linked immunosorbent assay (ELISA) technique (Quantikine; R
`and D Systems, Minneapolis, MN, USA). BM aspirate plasma
`was collected before and after treatment using heparin as an
`anticoagulant. The plasma was collected in the same way
`as described above and stored in aliquots at 2408C. Levels
`of plasma IL-6, bFGF, TNF-a and VEGF were determined
`using a quantitative ELISA technique as above.
`
`RESULTS
`
`Eleven normal age-matched volunteers and 30 patients with
`a confirmed diagnosis of MDS were treated with thalidomide
`
`Fig 1. Angiogenesis as seen in a normal bone marrow biopsy after
`factor VIII staining at a magnification of 20(cid:2) (A) and increase in
`microvessel density in MDS patients with factor VIII staining
`primarily seen in large vessels, sinusoid-like vessels and small
`endothelial sprouts at a magnification of 20(cid:2) (B), 20(cid:2) (C) and
`100(cid:2) (D).
`
`q 2001 Blackwell Science Ltd, British Journal of Haematology 115: 881–894
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2021, Page 5
`
`

`

`886
`
`F. Zorat et al
`
`Table II. Pretreatment parameters in MDS patients compared with control subjects.
`
`Immunohistochemistry – BM Bx
`
`ELISA – serum
`
`RCI no.
`
`FAB
`
`MVD/hot-spot
`
`TGF-b
`
`TNF-a
`
`ISEL
`
`CD68
`
`TGF-b
`
`TNF-a
`
`bFGF
`
`VEGF
`
`IL-6
`
`38
`891
`541
`920
`893
`562
`269
`529
`992
`277*
`123*
`963*
`937*
`1011*
`1016*
`552
`15
`
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`RA
`
`22/25
`26/29
`29/50
`36/37
`10/13
`37/44
`18/22
`
`20/31
`12/21
`
`16/19
`
`15/22
`
`Median
`
`19·5/25
`
`400*
`531
`333*
`460*
`340*
`585
`
`RARS
`RARS
`RARS
`RARS
`RARS
`RARS
`
`43/59
`20
`26/34
`25/30
`38/50
`
`6
`8
`0
`6
`1
`8
`1
`1
`0
`4
`6
`2
`0
`0
`
`2
`
`5
`4
`1
`0
`2
`
`3
`5
`2
`1
`
`4
`2
`0
`0
`
`6
`2
`0
`0
`7
`
`2
`
`8
`0
`1
`0
`1
`
`7
`3
`0
`6
`
`2
`0
`
`5
`4
`3
`1
`1
`0
`
`3
`
`8
`1
`1
`0
`2
`1
`
`6
`0
`2
`7
`0
`2
`0
`
`0
`0
`7
`4
`2
`0
`
`2
`
`5
`6
`
`1
`0
`6
`
`8679
`
`3165
`15 849
`
`24 495
`8436
`51 030
`22 899
`9087
`11 506
`12 039
`
`7·65
`5·55
`
`4·68
`9·02
`
`5·89
`5·41
`6·43
`6·58
`2·09
`7·05
`25·43
`
`10·21
`4·35
`
`0·00
`10·97
`
`10·45
`3·02
`4·38
`0·39
`4·27
`3·34
`2·55
`
`308·53
`295·23
`
`10·44
`595·68
`
`237·31
`71·43
`349·94
`168·90
`93·15
`439·26
`418·17
`
`11 772·50
`
`6·43
`
`4·27
`
`295·23
`
`19 896
`14 280
`9081
`22 899
`8628
`4272
`
`4·51
`8·57
`39·04
`39·04
`5·59
`3·28
`
`0·27
`44·93
`25·08
`0·35
`0·92
`0·08
`
`115·55
`266·81
`115·78
`191·52
`81·66
`8·63
`
`0·00
`0·00
`
`0·05
`0·00
`
`1·64
`1·98
`8·84
`0·00
`0·68
`0·00
`34·70
`
`0·05
`
`0·00
`2·51
`1·29
`0·00
`2·82
`2·44
`
`Median
`
`25·5/34
`
`582
`255
`536
`919
`555
`969
`1008
`
`RAEB
`RAEB
`RAEB
`RAEB
`RAEB
`RAEB
`RAEB
`
`10/21
`10/23
`23/30
`12/16
`15/30
`
`34/42
`
`Median
`
`13·5/26·5
`
`Total MDS
`patients – median
`23
`Normal
`24
`Normal
`25
`Normal
`26
`Normal
`27
`Normal
`28
`Normal
`29
`Normal
`30
`Normal
`31
`Normal
`10
`Normal
`11
`Normal
`
`Median
`
`21/30
`
`10/19
`2/7
`3·5/10
`3/9
`5/11
`2/10
`8/18
`9/17
`8·5/12
`4/12
`6/9
`
`5/11
`
`2
`
`1
`1
`1
`3
`8
`8
`0
`
`1
`
`2
`
`0
`0
`0
`0
`2
`2
`0
`0
`0
`2
`1
`
`0
`
`1
`
`0
`0
`0
`7
`7
`6
`0
`
`0
`
`1
`
`2
`0
`0
`0
`0
`1
`0
`3
`0
`0
`6
`
`0
`
`1
`
`2
`7
`1
`3
`5
`0
`
`3
`
`2
`
`3
`0
`0
`4
`1
`6
`1
`0
`0
`4
`2
`
`1
`
`5
`
`0
`2
`4
`7
`7
`1
`0
`
`2
`
`2
`
`1
`0
`2
`1
`6
`7
`4
`1
`2
`
`6
`
`2
`
`11 681
`
`12 480
`6795
`5112
`3477
`28 896
`8406
`
`7601
`
`10 297
`
`29 841
`34 563
`45 324
`28 878
`38 322
`40 344
`33 841
`
`35 496
`30 015
`63 891
`
`35 496
`
`7·08
`
`4·38
`30·04
`12·26
`3·07
`4·32
`
`4·38
`
`6·16
`
`2·85
`2·53
`4·19
`3·66
`3·7
`3·79
`5·8
`4·57
`3·04
`
`4·08
`
`3·79
`
`0·64
`
`0·00
`0·00
`2·45
`0·00
`0·00
`
`0·00
`
`2·50
`
`0
`0
`0
`7·2
`0
`0·9
`0·2
`2·4
`3·4
`13·5
`0·6
`
`115·66
`
`134·87
`0·00
`686·00
`65·10
`22·56
`
`1·87
`
`0·00
`117·29
`86·00
`10·54
`0·00
`
`65·10
`
`10·54
`
`151·88
`
`0·99
`
`118·3
`318
`822
`79
`2·9
`173·4
`510
`649·6
`80
`256·6
`278
`
`0·75
`
`267·30
`
`Refer to Table I; Normal, normal subjects; MVD, microvessel density; hot-spot, area with highest MVD; TGF-b, transforming growth factor
`beta; TNF-a, tumour necrosis factor alpha; ISEL, in situ end labelling; bFGF, basic fibroblast growth factor; VEGF, vascular endothelial growth
`factor; IL-6, interleukin-6.
`*Responding patients.
`Blank spaces signify missing values.
`
`q 2001 Blackwell Science Ltd, British Journal of Haematology 115: 881–894
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2021, Page 6
`
`

`

`Table III. Pre- vs. post-treatment parameters in BM biopsies of MDS patients compared with normal subjects.
`
`Angiogenesis
`
`TGF-b
`
`TNF-a
`
`ISEL
`
`CD68
`
`Normal
`
`Pre-Tx
`MVD
`
`Post-Tx Normal
`
`Pre-Tx
`hot-spot Post-Tx Normal Pre-Tx Post-Tx Normal Pre-Tx Post-Tx Normal Pre-Tx Post-Tx Normal Pre-Tx Post-Tx
`
`11
`Number
`5·5
`Mean
`5
`Median
`2·9
`Standard deviation
`2–10
`Range
`Normal vs. pre-Tx (P-value) 0·001
`Pre-Tx vs. post-Tx (P-value)
`
`17
`17
`19·5
`21·1
`20·5
`19·5
`11
`10
`9–42·5 7–52
`
`0·6
`
`11
`12·2
`11
`4
`7–19
`0·001
`
`17
`29·7
`29·5
`12·5
`13–59
`
`0·4
`
`17
`26
`25·5
`11
`9–53
`
`11
`0·6
`0
`0·9
`0–2
`0·03
`
`0·9
`0
`2
`0–8
`
`22
`2·7
`1·5
`2·8
`0–8
`
`0·002
`
`11
`1·1
`0
`1·9
`0–6
`0·25
`
`21
`2·3
`1·5
`2·7
`0–8
`
`0·6
`
`21
`1·7
`1
`2·3
`0–8
`
`11
`1·9
`1
`2·07
`0–6
`0·35
`
`21
`2
`1
`2·1
`0–8
`
`21
`2·7
`2
`2·4
`0–8
`
`0·27
`
`10
`3·1
`2
`2·7
`0–7
`0·8
`
`22
`2·7
`3
`1·9
`0–6
`
`22
`3·1
`3
`2·8
`0–7
`
`0·76
`
`Refer to Table II. Pre-Tx, pretreatment for MDS patients; post-Tx, post-treatment for MDS patients.
`
`Thalidomide and MDS
`
`887
`
`Table IV. Pre- vs. post-treatment serum cytokines in MDS patients compared with normal subjects.
`
`TGF-b (ng/ml)
`
`TNF-a (pg/ml)
`
`bFGF(pg/ml)
`
`VEGF(pg/ml)
`
`Normal
`
`Pre-Tx
`
`Post-Tx
`
`Normal
`
`Pre-Tx
`
`Post-Tx
`
`Normal
`
`Pre-Tx
`
`Post-Tx
`
`Normal
`
`Pre-Tx
`
`Post-Tx
`
`Number
`Mean
`Median
`Standard deviation
`Range
`Normal vs. pre-Tx (P-value)
`Pre-Tx vs. post-Tx (P-value)
`
`10
`37
`35
`11·3
`23·8–63·9
`0·0001
`
`24
`14
`10·3
`11·2
`3·1–5·1
`
`0·498
`
`24
`17·2
`11·5
`16·5
`2·4–64·7
`
`10
`3·8
`3·79
`0·9
`2·5–5·8
`0·008
`
`22
`10·9
`6·158
`11·3
`2·1–39·0
`
`0·5
`
`22
`9·16
`7·93
`4·35
`3·8–22·4
`
`11
`2·5
`0·75
`4·2
`0–13·5
`0·3
`
`22
`4·1
`1·65
`7
`0–29
`
`22
`5·8
`2·735
`10·5
`0–45
`
`0·5
`
`11
`298·8
`267·3
`260
`2·9–822
`0·2
`
`22
`212·7
`142·336
`191
`0–686
`
`0·864
`
`22
`225·6
`102·5
`300·6
`1·6–1190
`
`Refer to Table II. Pre-Tx, pretreatment for MDS patients; Post-Tx, post-treatment for MDS patients.
`
`q 2001 Blackwell Science Ltd, British Journal of Haematology 115: 881–894
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2021, Page 7
`
`

`

`203·10423·377
`
`73·452
`
`10·319237·31
`
`12·2559·074
`
`19·70511·16
`
`2·45
`
`9·916
`
`2·4
`
`0
`
`1·516
`
`0
`
`888
`
`F. Zorat et al
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`7
`
`N
`
`Plasma
`
`Serum
`
`Plasma
`
`SerumPlasmaSerumPlasmaSerumPlasmaSerum
`
`PlasmaSerumPlasma
`
`SerumPlasmaSerum
`
`Post-treatment
`
`Pretreatment
`
`Post-treatment
`
`Pretreatment
`
`Post-treatment
`
`Pretreatment
`
`Post-treatment
`
`Pretreatment
`
`VEGF
`
`TNF-a
`
`bFGF
`
`IL-6
`
`TableV.Comparisonofcytokinelevelsinserumvs.plasmainpre-andpost-treatmentsamplesfromMDSpatients.
`
`0·06
`48·5726·967615·27936·37193·623130·93496·29432·13915·58913·3744·42466·0314225·459197·024422·079134·738
`1·643
`
`RefertoTableII.
`
`Pre-vs.post-Txserum(P-value)
`Pre-vs.post-Txplasma(P-value)
`Serumvs.plasma(P-value)
`Standarddeviation
`Median
`
`as a single agent for at least 12 weeks. Among the 30 MDS
`patients, there were 19 males and 11 females. The median
`age was 69 years. FAB (Bennett et al, 1982) classification
`was used for a morphological classification, and the
`International Prognostic Scoring System (IPSS) (Greenberg
`et al, 1997) was used for a prognostic risk assessment. There
`were 17 patients with RA, six with RARS and seven with
`RAEB.
`
`Clinical studies
`Drug tolerance and toxicity. Thalidomide was well tolerated
`in lower doses, but less well at higher doses. Only 22
`patients were able to increase the dose to 400 mg within
`4 weeks of starting therapy. Unfortunately, only six of these
`22 patients could continue at this high dose; the rest had to
`decrease the dose to 150–200 mg. Achievement of response
`was not significantly different between responders and non-
`responders. Only one patient had grade 4 toxicity with fluid
`retention and shortness of breath. The most common side-
`effects were constipation (87%),
`fatigue (87%),
`fluid
`retention (65%), dizziness
`(58%),
`shortness of breath
`(55%), numbness and tingling in the fingers and toes
`(35%), mouth sores (22%), nausea (20%) and diarrhoea
`(13%).
`Haematological responses. Of the 30 patients registered on
`this study, there were no complete responders. Ten patients
`showed a haematological
`improvement, as described in
`Table I, all responding in the erythroid series and one
`showing a delayed response after stopping thalidomide.
`There were no ANC responders. Responders showed a
`higher initial platelet count (P , 0·048), whereas non-
`responders had a higher pretherapy blast count in the BM
`aspirate (P , 0·013). Among the 10 showing HI or HI-E,
`eight had a major erythroid response, and two had a minor
`erythroid response. Of
`the eight major responders, six
`responded by reducing their PRBC transfusion requirements
`by 100%, four showed both a decrease in transfusions by
`100% and an increase in Hb, and one non-PRBC-dependent
`patient showed an increase in Hb of . 2 g/dl. Responders
`showed a significant increase in haemoglobin (P , 0·039)
`and platelets (P , 0·043), as well as a trend towards a
`decrease in BM aspirate blast percentage (P