The new england journal of medicine
`
`original article
`
`Efficacy of Lenalidomide 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 of myelodysplastic syndromes. Management
`of the anemia caused by ineffective erythropoiesis is difficult. In patients with myelo-
`dysplastic syndromes and symptomatic anemia, we evaluated the safety and hemato-
`logic activity of lenalidomide, a novel analogue of thalidomide.
`
`methods
`Forty-three patients with transfusion-dependent or symptomatic anemia received le-
`nalidomide at doses of 25 or 10 mg per day or of 10 mg per day for 21 days of every 28-
`day cycle. All patients either had had no response to recombinant erythropoietin or had
`a high endogenous erythropoietin level with a low probability of benefit from such
`therapy. The response to treatment was assessed after 16 weeks.
`
`results
`Neutropenia and thrombocytopenia, the most common adverse events, with respective
`frequencies of 65 percent and 74 percent, necessitated the interruption of treatment or
`a dose reduction in 25 patients (58 percent). Other adverse events were mild and infre-
`quent. Twenty-four patients had a response (56 percent): 20 had sustained indepen-
`dence from transfusion, 1 had an increase in the hemoglobin level of more than 2 g per
`deciliter, and 3 had more than a 50 percent reduction in the need for transfusions. The
`response rate was highest among patients with a clonal interstitial deletion involving
`chromosome 5q31.1 (83 percent, as compared with 57 percent among those with a
`normal karyotype and 12 percent among those with other karyotypic abnormalities;
`P=0.007) and patients with lower prognostic risk. Of 20 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 per deciliter (range, 11.5 to 15.8).
`
`conclusions
`Lenalidomide has hematologic activity in patients with low-risk myelodysplastic syn-
`dromes who have no response to erythropoietin or who are unlikely to benefit from
`conventional therapy.
`
`From the Department of Interdisciplinary
`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 of Arizona 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 requests to 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 Medical Society.
`
`n engl j med 352;6 www.nejm.org february 10, 2005
`
`549
`
`The New England Journal of Medicine
`
`Downloaded from nejm.org on September 26, 2018. For personal use only. No other uses without permission.
`
` Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2029, Page 1
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`

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`r
`
` new england journal
`The
`
`of
`
` medicine
`
`efractory anemia resulting from
`ineffective hematopoiesis is the principal
`therapeutic challenge for patients with
`1
`myelodysplastic syndromes.
` Recombinant eryth-
`ropoietin alone or in combination with myeloid
`growth factors ameliorates anemia in some patients
`but is generally ineffective in patients who require
`two or more red-cell transfusions per month; its
`2,3
`use rarely induces cytogenetic remissions.
`Hematopoietic precursors in patients with mye-
`lodysplastic syndromes have an accelerated cell-
`cycle transition and impaired responsiveness to cy-
`1,4
`tokine stimulation.
` Survival signals from the
`microenvironment are compromised, owing in part
`to the presence of angiogenic molecules, disruption
`of the medullary architecture, and excess produc-
`5-10
` Thalidomide, a
`tion of inflammatory cytokines.
`multifunctional inhibitor of angiogenesis and an
`immune modulator, restores erythropoiesis and re-
`duces transfusion dependence in approximately 18
`percent of patients who have no response to re-
`11-14
`combinant erythropoietin.
` 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-
`15-17
`mide.
` We report the results of a safety and effi-
`cacy study of lenalidomide 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
`18
`(FAB) criteria (Fig. 1)
` more than three months
`before enrollment and a diagnosis of either symp-
`tomatic anemia (defined by a hemoglobin level of
`less than 10.0 g per deciliter) or transfusion-depen-
`dent anemia (defined by the need for at least 4 units
`of red cells within eight weeks before enrollment).
`Hematologic values obtained during the eight weeks
`preceding study treatment served as a reference
`for the assessment of response. Patients either had
`had no response to treatment with recombinant
`erythropoietin or had an endogenous serum level
`of more than 500 mU per milliliter. Patients with
`severe neutropenia (defined by an absolute neutro-
`phil count of less than 500 per cubic millimeter),
`
`severe thrombocytopenia (defined by a platelet
`count of 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 of lenalidomide in patients with
`myelodysplastic syndromes who had symptomatic
`anemia. All patients gave written informed consent,
`and the study was approved by the institutional re-
`view board of the University of Arizona. The princi-
`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 mg daily, 10 mg daily, and 10 mg daily for 21
`days of every 28-day cycle. Treatment was interrupt-
`ed in the event of adverse events of grade 3 or higher
`according to the Common Toxicity Criteria of the
`National Cancer Institute and resumed at the next
`19
`lower dose after the resolution of these effects.
`Sequential dose reductions were as follows: 10 mg
`per day, 10 mg per day for 21 days, 5 mg per day,
`5 mg per day for 21 days, and 5 mg every other day.
`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. The final response was
`assessed after 16 weeks of therapy. Patients with a
`response continued taking lenalidomide until dis-
`ease progression, treatment failure, or dose-limiting
`adverse events occurred. Patients with hemato-
`logic improvement that did not qualify as a proto-
`col-defined response after 16 weeks could receive
`8 additional weeks of treatment before the final
`assessment of response, whereas patients with-
`out a response who had been following the 21-day
`treatment schedule were offered continual dosing.
`Red-cell transfusions were administered accord-
`ing to prestudy clinical 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 of less than 21 percent, and 4 units
`to those with a hematocrit of less than 18 percent.
`Myeloid growth factors for the management of an
`exacerbation of neutropenia were the only cyto-
`kines permitted.
`
`550
`
`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. No other uses without permission.
`
` Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2029, Page 2
`
`

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`lenalidomide for myelodysplastic syndromes
`
`A
`
`C
`
`B
`
`D
`
`Figure 1. Characteristics of Myelodysplastic Syndromes.
`The bone marrow aspirate in patients with myelodysplasia is hypercellular, reflecting trilineal dysplasia (Panel A; Wright–
`Giemsa stain). In this specimen, hypolobated megakaryocytes and hyposegmented neutrophils are prominent. Myeloid
`maturation is shifted to the left, and myeloblasts may be increased, as shown in Panel B in a patient with refractory
`anemia with excess blasts (Wright–Giemsa stain). Dyserythropoiesis accompanies the hypolobated megakaryocytes and
`hyposegmented neutrophils. There may be a left-sided shift in erythroid maturation, nuclear budding, megaloblastic
`changes, and as shown in Panel C, a decrease in the number of erythroid precursors (Wright–Giemsa stain). The cellu-
`larity of a 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 Research Institute, Tampa, Fla.)
`
`assessment of response and adverse events
`The hematologic response was assessed according
`to the modified criteria of the International Working
`Group, with the requirement that an improvement
`had to be sustained for at least eight consecutive
`20
` A major erythroid response was defined
`weeks.
`as freedom from the need for transfusion or an in-
`crease in the hemoglobin level of more than 2 g per
`deciliter in patients with transfusion-independent
`anemia. A minor response was defined as at least a
`50 percent reduction in transfusions or a sustained
`elevation in the hemoglobin level of 1 to 2 g per
`deciliter. A major cytogenetic response was defined
`by the absence of the 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 of at least 50 percent. Cytogenetic pro-
`gression was defined as the sustained acquisition
`of a new chromosomal abnormality.
`Responses were compared by means of the Inter-
`national Prognostic Scoring System (IPSS), which
`assesses the percentage of blasts in bone marrow,
`21
`the karyotype, and the number of cytopenias.
`Blinded review of bone marrow specimens was per-
`formed by two investigators. Immunohistochemi-
`cal staining of biopsy specimens and clot 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 of a 10 percent thresh-
`old. Adverse events were graded with the use of the
`
`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. No other uses without permission.
`
` Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2029, Page 3
`
`

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`
` new england journal
`The
`
` medicine
`of
`
`Common Toxicity Criteria of the National Cancer
`19
`Institute.
`
`statistical analysis
`The duration of transfusion independence was cal-
`culated from the date of the last red-cell transfusion
`to the resumption of transfusion through April 1,
`2004, according to the method of Kaplan and Mei-
`22
`er.
` The duration of major responses in transfu-
`sion-independent patients was recorded from the
`initial date of the sustained elevation in hemoglo-
`bin levels of more than 2 g per deciliter. The analy-
`ses of adverse events and response were carried out
`according to the intention-to-treat principle. Uni-
`variate comparisons were performed with the use
`of Fisher’s exact test, a two-sample independent
`t-test, or a Wilcoxon rank-sum test. The duration
`of transfusion independence was compared among
`the groups by means of the log-rank test. All report-
`ed P values are 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) had IPSS risk scores of low or interme-
`diate 1 (Table 1). Overall, 74 percent were transfu-
`sion-dependent, 33 (77 percent) had had no re-
`sponse to treatment with erythropoietin, and 13 (30
`percent) had had no response to treatment with
`thalidomide. None had received cytotoxic therapy.
`The median number of prior nontransfusion treat-
`ments was 1.7 (range, 0 to 5). Moderate-to-severe
`neutropenia was present in 28 percent of patients,
`and moderate-to-severe thrombocytopenia in 23
`percent of patients; 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-
`
`Table 1. Clinical and Hematologic Characteristics
`of the 43 Patients.*
`
`Characteristic
`
`Age — yr
`
`Median
`
`Range
`
`Sex — no. (%)
`
`Male
`
`Female
`
`FAB class — no. (%)
`
`Refractory anemia
`
`Value
`
`72
`
`28–85
`
`25 (58)
`
`18 (42)
`
`20 (47)
`
`Refractory anemia with ringed sideroblasts
`
`13 (30)
`
`Refractory anemia with excess blasts
`
`Refractory anemia with excess blasts
`in transformation
`
`Chronic myelomonocytic leukemia
`
`IPSS risk category — no. (%)
`
`Low
`
`Intermediate 1
`
`Intermediate 2
`
`High
`
`Transfusion dependence
`
`No. (%)
`
`8 (19)
`
`1 (2)
`
`1 (2)
`
`22 (51)
`
`16 (37)
`
`4 (9)
`
`1 (2)
`
`32 (74)
`
`Median no. of red-cell units transfused/mo
`
` 3
`
`Range
`
`Pretransfusion hemoglobin level — g/dl
`
`Transfusion-dependent patients
`
`Median
`
`Range
`
`Other
`
`Median
`
`Range
`
`Duration of disease — mo
`
`Median
`
`Range
`
`Neutropenia — no. (%)†
`
`Thrombocytopenia — no. (%)‡
`
`Karyotype — no. (%)
`
`Normal
`
`Abnormal
`
`2–6
`
`
`
`8.0
`
`6.7–8.6
`
`8.3
`
`7.0–8.5
`
` 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
`count of less than 1500 per cubic millimeter.
`‡ Thrombocytopenia was defined 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
`
`Downloaded from nejm.org on September 26, 2018. For personal use only. No other uses without permission.
`
` Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2029, Page 4
`
`

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`lenalidomide for myelodysplastic syndromes
`
`Table 2. Treatment-Associated Adverse Events.
`
`Adverse Event
`
`Lenalidomide,
`25 mg/day
`(N=13)
`
`Lenalidomide,
`10 mg/day
`(N=13)
`
`Lenalidomide,
`10 mg/day for 21 days
`(N=17)
`
`All Patients,
`Any Grade
`(N=43)
`
`Neutropenia
`
`Thrombocytopenia
`
`Pruritus
`
`Diarrhea
`
`Urticaria
`
`Grade
`1 or 2
`
`Grade
`3 or 4
`
`Grade
`1 or 2
`
`Grade
`3 or 4
`
`Grade
`1 or 2
`
`Grade
`3 or 4
`
`number of patients
`
` no. of patients (%)
`
`0
`
`2
`
`5
`
`0
`
`0
`
`10
`
`7
`
`0
`
`0
`
`0
`
`0
`
`4
`
`4
`
`2
`
`4
`
`1
`
`8
`
`7
`
`0
`
`1
`
`0
`
`1
`
`0
`
`3
`
`3
`
`6
`
`2
`
`0
`
`10
`
`9
`
`0
`
`0
`
`0
`
`0
`
`28 (65)
`
`32 (74)
`
`12 (28)
`
`9 (21)
`
`6 (14)
`
`3 (7)
`
`Fatigue
`
`Bone pain
`
`Pneumonia
`
`Edema
`
`Hypothyroidism
`
`Hypogonadism
`
`Myalgias
`
`Autoimmune hemolytic anemia
`
`0
`
`1
`
`0
`
`0
`
`0
`
`1
`
`1
`
`1
`
`1
`
`0
`
`1
`
`0
`
`0
`
`0
`
`0
`
`0
`
`1
`
`0
`
`0
`
`2
`
`1
`
`0
`
`0
`
`0
`
`2
`
`0
`
`0
`
`0
`
`0
`
`0
`
`2
`
`0
`
`2
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`0
`
`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 of patients in the 25-mg group
`after a median of 4.6 weeks (range, 3 to 9), as com-
`pared with 62 percent of those who were receiving
`10 mg daily (median, 8.5 weeks; range, 2 to 20) and
`47 percent of those who were receiving 10 mg daily
`for 21 days (median, 6 weeks; range, 1 to 11) (P=
`0.62). The median interval between the first inter-
`ruption of treatment and the resumption of treat-
`ment was 22 days in each cohort (range, 9 to 55).
`At week 8, marrow cellularity was reduced by 75
`percent among patients who were receiving 25 mg
`of lenalidomide per day, as compared with a reduc-
`tion of 12 percent in both 10-mg cohorts. Pneumo-
`nia developed in three patients, one of whom had
`worsening of preexisting neutropenia. One patient
`was removed from the study on day 5 because of au-
`toimmune hemolytic anemia with escalating trans-
`fusion requirements that preceded enrollment in
`the study. There were three deaths, none of which
`were thought to 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 of such 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 and restricted to
`the scalp, was reported by 28 percent of patients
`during the first week of treatment. Isolated and
`transient urticaria was reported by 14 percent of
`patients, whereas a systemic rash with an urticarial
`component developed in one patient and resolved
`after treatment was interrupted. Diarrhea occurred
`in 21 percent of patients after prolonged treatment
`(more than three months) but was manageable with
`the use of either medication for diarrhea or the in-
`terruption of treatment with lenalidomide. Four
`patients required hormone replacement — two for
`hypothyroidism, and two for gonadal dysfunction.
`Seven patients discontinued lenalidomide prema-
`turely (before 28 days) because of withdrawal of
`consent by 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 of 32 transfusion-dependent patients
`(63 percent) achieved independence from transfu-
`sion. Of 11 patients who required no transfusions,
`1 had an increase in the hemoglobin level 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. No other uses without permission.
`
` Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2029, Page 5
`
`

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` new england journal
`The
`
` medicine
`of
`
`Table 3. Erythroid Responses.
`
`Lenalidomide
`Dose
`
`No. of
`Patients
`
`Erythroid Response
`
`Weeks to Response
`
`25 mg/day
`10 mg/day
`10 mg/day for
`21 days
`Total
`
`13
`13
`17
`
`43
`
`Total Median ±SD Range
`Major Minor
`number (percent)
`0
`6 (46)
`1
`7 (54)
`2
` 11 (65)
`
`9.0±5.8
`10.5±6.4
`11.5±10.3
`
`2.5–18.5
`2–17.5
`6–24
`
`6
`6
`9
`
`21 (49) 3 (7)
`
`24 (56)
`
`—
`
`—
`
`Table 4. Relation between Clinical and Biologic Features and Erythroid
`Response.*
`
`No. of
`Patients
`
`Erythroid
`Response
`
`P
`Value†
`
`Variable
`
`Sex
`
`Male
`Female
`Race‡
`White
`Other
`Prior recombinant erythropoietin
`Yes
`No
`Prior thalidomide
`Yes
`No
`FAB class
`Refractory anemia
`Refractory anemia with ringed sideroblasts
`Refractory anemia with excess blasts,
`with or without transformation
`Chronic myelomonocytic leukemia
`IPSS risk category
`Low
`Intermediate 1
`Intermediate 2 or high
`Karyotype
`Del(5)(q31.1)
`Normal
`Other
`≥ Grade 3 myelosuppression
`Yes
`No
`
`25
`18
`
`37
`6
`
`33
`10
`
`13
`30
`
`20
`13
`9
`
`1
`
`22
`16
`5
`
`12
`23
`8
`
`25
`18
`
`no. (%)
`
`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)
`
`0.35
`
`0.68
`
`
`0.15
`
`0.51
`
`0.07
`
`0.14
`
`0.007
`
`
`1.0
`
`* FAB denotes French–American–British, and IPSS International Prognostic
`Scoring System.
`† Fisher’s exact test was used.
`‡ Race was determined from patient registration forms.
`
`than 2 g per deciliter. The median time to a response
`increased from 9 weeks in the 25-mg cohort to
`11.5 weeks in the cohort given 10 mg per day for 21
`days. Patients with a major response reached a me-
`dian hemoglobin level of 13.2±1.4 g per deciliter
`(range, 11.5 to 15.8), with a corresponding median
`increase in hemoglobin from baseline of 5.3 g per
`deciliter (range, 4.4 to 8.7). After a median follow-
`up of 81 weeks (range, 42 to 110), the median dura-
`tion of the major response had not been reached
`(more than 48 weeks; range, more than 13 to more
`than 101). Among the 21 patients with a major re-
`sponse, anemia recurred in 4, with the resumption
`of transfusions after intervals of 12, 19, 56, and 74
`weeks. In one of these patients, treatment failure
`was associated with karyotypic evolution and sub-
`sequent progression to leukemia.
`Of 10 patients with moderate-to-severe throm-
`bocytopenia, 1 had a sustained improvement in the
`platelet count (i.e., an increase of more than 30,000
`per cubic millimeter). Of the 12 patients with neu-
`tropenia, 2 had a sustained increase in the neutro-
`phil count of more than 500 per cubic millimeter.
`
`cytogenetic findings
`The cytogenetic pattern correlated significantly with
`the hematologic response: 83 percent of patients
`with a deletion of 5q31.1 had a response, as com-
`pared with 57 percent of those with a normal kary-
`otype and 12 percent of those with other cytogenetic
`abnormalities (P=0.007) (Table 4). The FAB cate-
`gory had no significant correlation with response
`(P=0.07), nor did the IPSS risk category, age, dura-
`tion of disease, or number of prior treatments
`(Table 4). The median time to a response was
`more rapid 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).
`Among 20 patients with clonal cytogenetic ab-
`normalities, 11 had cytogenetic responses, includ-
`ing 10 with a complete cytogenetic remission (Table
`5). Of these 10 patients, 9 had del(5)(q31.1) and
`1 had t(1;22)(q21p11.2). All cytogenetic respons-
`es occurred in patients who also 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 of the 5q31.1 deletion among
`200 cells in interphase in each of five patients who
`
`554
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`n engl j med
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`352;6
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`www.nejm.org february
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`10
`
`2005
`
`The New England Journal of Medicine
`
`Downloaded from nejm.org on September 26, 2018. For personal use only. No other uses without permission.
`
` Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2029, Page 6
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`lenalidomide for myelodysplastic syndromes
`
`had a complete response and who were evaluated
`by means of standard metaphase analysis.
`The median time to a cytogenetic response was
`8 weeks (range, 8 to 24). Of 10 patients with a 5q31.1
`deletion, 9 had a cytogenetic response after 8 weeks,
`whereas 1 patient had a response at 16 weeks. Four
`patients had transient emergence of karyotypically
`unrelated clones, including trisomy 8 (in two), a
`reciprocal translocation [t(12;16)(p13;p13.3)], and
`monosomy 7. Sustained acquisition of karyotypical-
`ly discordant clones occurred in four patients: three
`patients with remitting disease and a 5q31.1 dele-
`tion had translocations involving the long arm of
`chromosome 7 [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 of these 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 of the need for transfusion.
`
`pathological responses
`and morphologic findings
`Among six 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.
`The percentage of ringed sideroblasts was reduced
`from 36 percent to 11 percent in 1 of 10 patients
`with refractory anemia with ringed sideroblasts
`who could 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
`were suitable for a detailed assessment of dyspla-
`sia and architecture. The morphologic character-
`istics of megakaryocytes became normal after treat-
`ment with lenalidomide in 14 of 22 patients (64
`percent) with pretreatment dysplasia, including
`12 patients with a response; 10 of these 12 patients
`had a 5q31.1 deletion (Fig. 2). Lymphoid aggre-
`gates, often multiple and not paratrabecular, were
`detected in 10 of 28 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 of polytypic B cells and T cells. Dysplas-
`
`Table 5. Cytogenetic Responses According to Chromosomal Abnormality.
`
`Chromosomal Abnormality
`
`No. of
`Patients
`
`≥50% Decrease
`in Abnormal Cells
`in Metaphase
`
`Complete
`Cytogenetic
`Response
`
`Del(5)(q31.1)
`Isolated
`With trisomy 21
`Del(20)(q11.2)
`t(1;22)(q21p11.2)
`Other*
`Total
`
`12
`11
`1
`2
`1
`5
`20
`
`number of patients (percent)
`10 (83)
`9 (75)
`9
`8
`1
`1
`0
`0
`1
`1
`0
`0
`11 (55)
`10 (50)
`
`* Other chromosomal abnormalities were as follows: +19, t(3;3)(q21;q26.3),
`+8, –X, and complex.
`
`A
`
`B
`
`C
`
`Figure 2. Morphologic Changes in a Bone Marrow Specimen from a Patient
`with a 5q31.1 Deletion.
`Numerous small, mononuclear megakaryocytes are readily identified in the
`bone marrow specimen obtained by trephine biopsy before treatment (Panel
`A, hematoxylin and eosin). After 16 weeks of lenalidomide therapy, megakary-
`ocytes appear normal in 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 treatment in one of two patients with
`extensive fiber deposition in the pretreatment tre-
`phine-biopsy specimen, concordant with a hemato-
`logic response. Marrow or peripheral-blood eosin-
`ophilia or both (7.5 percent to 14 percent) developed
`in three patients, including two with a hematologic
`response.
`
`n engl j med
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`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. No other uses without permission.
`
` Copyright © 2005 Massachusetts Medical Society. All rights reserved.
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01504
`Exhibit 2029, Page 7
`
`

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` new england journal
`The
`
` medicine
`of
`
`discussion
`
`In this study, lenalidomide had substantial activity
`in patients with myelodysplastic syndromes who
`had had no response to treatment with erythropoi-
`etin or who had high endogenous erythropoietin
`levels and therefore a low probability of benefit from
`erythropoietin treatment. Overall, 56 percent of pa-
`tients had a response, with most having sustained
`independence from the need for transfusion and
`restoration of hemoglobin to levels within or near
`the normal range. Cytogenetic remissions, which
`occur rarely with erythropoietin therapy, were ob-
`served in 55 percent of patients. The high rate of
`complete cytogenetic response in patients with a
`5q31.1 deletion (75 percent), which was confirmed
`by more sensitive fluorescence in situ hybridiza-
`tion probes, indicates that this subtype of myelo-
`dysplastic syndrome is especially sensitive to lena-
`lidomide treatment. Indeed, the time to response
`was more rapid in patients with the 5q31.1 dele-
`tion, and response was associated with the disap-
`pearance of dysplastic megakaryocytes, the mor-
`23
`phologic hallmark of the 5q¡ syndrome.
` These
`findings suggest that lenalidomide restores red-cell
`production in part by eliminating ineffective my-
`elodysplastic clones but does not extinguish the
`myelodysplastic syndrome–initiating stem cell.
`The persistence of ringed sideroblasts in patients
`with refractory anemia with ringed sideroblasts
`who had a response, however, indicates that clonal
`suppression is selective and complemented by the
`restoration of erythropoiesis in susceptible myelo-
`dysplastic syndrome progenitors. This notion is
`supported by the transient emergence of karyotyp-
`ically distinct and unrelated clones, which mirrors
`the experience reported with imatinib treatment in
`24,25
`patients with chronic myeloid leukemia.
` In ad-
`dition, three patients with a 5q31.1 deletion acquired
`new translocations involving chromosome 7 despite
`the complete suppression of the initial karyotypic
`abnormality. Despite its unfavorable prognostic im-
`plication in primary myelodysplastic syndromes,
`the clinical significance of the acquired transloca-
`tions is unclear. Only one of these patients had cyto-
`genetic and disease progression, whereas the oth-
`ers had a sustained hematologic response. Further
`observation is necessary before the clinical signifi-
`cance of these findings can be determined.
`Several effects of lenalidomide may contribute
`to its activity in myelodysplastic syndromes. It sup-
`presses the production of tumor necrosis factor
`a
`
` have
`), but selective antagonists of TNF-
`(TNF-
`a
`a
`minimal clinical activity in myelodysplastic syn-
`26-28
`dromes.
` Lenalidomide affects a broad range of
`ligand-induced responses that may be integral to
`its activity in myelodysplastic syndromes, includ-
`ing angiogenesis, inflammation, cell adhesion, and
`the immune response. Indeed, vascular endothe-
`lial growth factor (VEGF) is an autocrine growth
`factor elaborated by myeloid precursors in my-
`elodysplastic syndromes that contributes to their
`self-renewal while exacerbating ineffective erythro-
`poiesis in erythroid progenitors, which lack VEGF
`9,29
`receptors.
` Lenalidomide enhances cell-mediat-
`ed immunity by potentiating the production of in-
`terleukin-2 and interferon-
` and increasing the re-
`g
`sponses of cytolytic T cells and natural killer cells
`15,16
` Of particular inter-
`in experiments in animals.
`est in our study was the appearance of multiple lym-
`phoid aggregates composed of a mixture of B cells
`and T cells in the trephine-biopsy specimens from
`patients with a response. Whether this finding rep-
`resents an immune response against the ineffective
`clone is unknown. Furthermore, lenalidomide sen-
`sitizes erythroid progenitors to the trophic effects of
`recombinant erythropoietin (unpublished data).
`The promising activity of lenalidomide in my-
`elodysplastic syndromes must be balanced against
`its potential to cause clinically significant myelo-
`suppression, which necessitates close laboratory
`monitoring during the initial weeks of treatment.
`Neutropenia or thrombocytopenia developed in
`more than half the patients and was not limited to
`patients with preexisting lineage deficits. The ex-
`tent of myelosuppression varied according to the
`dose and cumulative exposure