884
`
`scientific correspondence
`
`transfusion-dependent MDS
`Table 1. Characteristics of
`patients who responded to thalidomide.
`
`Mamscript processing
`This manuscript was peer-reviewed by two external referees
`and by Dr. Caterina Borgna-Pignatti, who acted as an Asso-
`ciate Editor. The final decision to accept this paper for pub-
`lication was takenjointly by Dr. Borgna-Pignatti and the Edi-
`tors. Manuscript received April 23, 2002; accepted June 18,
`2002.
`
`References
`
`1. Winchester PH, Cerwin R, Dische R, Canale V. Hemosiderin
`laden lymph nodes. An unusual roentgenographic mani-
`festation of homozygous thalassemia. Am J Roentgenol
`Radium Ther Nucl Med 1973; 118:222-6.
`2. Parsons C. Abdominal lymphography in thalassaemia major.
`Clin Radiol 1977; 28:545-8.
`3. Long JA Jr, Doppman JL Bienhus AW, Mills SR. Computed
`tomographic analysis of b-thalassemic syndromes with
`hemochromatosis: pathologic findings with clinical and
`laboratory correlations. J Comput Assist Tomogr 1980; 4:
`159-65.
`4. Mitnick JS, Bosniak MA. Megibow AJ, Karpatkin M, Feiner
`HD, Kutin N, et al. CT in [3 thalassemia: iron deposition in
`the liver, spleen and lymph nodes. Am J Roentgenol 1981;
`136:1191-4.
`5. Yang WT, Ward SC, Metreweli C. Decrease in size of daisy
`chain nodes with age in normal subjects. Hong Kong Coll
`RadiolJ1998212113-7.
`6. Olivieri NF, Nathan DG, MacMillan JH, Wayne AS, Liu PP,
`McGee A, et al. Survival of medically treated patients with
`homozygous [5 thalassemia. N Engl J Med 1994; 331 :574—
`8
`7. Forsberg L, Floren CH, Hederstrom E, Prytz H. Ultrasound
`examination in diffuse liver disease. Clinical significance of
`enlarged lymph nodes in the hepato—duodena ligament.
`Acta Radiol 1987; 28:281-4.
`8. Lyttkens K, Prytz H, Forsberg L, Hederstrom E, Hagerstrand
`|. Ultrasound, hepatic lymph nodes and chronic active
`hepatitis. J Hepatol 1994; 21:578—81.
`9. Baynes R, Bezwoda W, Bothwell T, Khan 0, Mansoor N. The
`non-immune inflammatory response: serial changes in
`plasma iron, iron—binding capacity lactoferrin, ferritin and
`C-reactive protein. Scand J Clin Lab Invest 1986; 46:695-
`704.
`
`Thalidomide abolishes transfusion—dependenoe in
`selected patients with myelodysplastlc syndromes
`
`Among 25 transfusion-dependent patients with myelodys-
`plastic syndromes (M DS) receiving up to 300 mg/d thalido-
`mide p.0., 5 became transfusion-free within 4-9 weeks and
`for 6 to +24 months. Responders had a recent diagnosis, nor-
`mal karyotype, no excess of marrow blasts and were younger
`than non-responders. Thalidomide may be effective for treat-
`ing anemia in selected MDS patients.
`
`hematologic: 2002: 87:884—886
`(htth/www haematologica.ws/2002_08/884.htm)
`
`The potential efficacy of thalidomide in myelodysplastic syn-
`dromes (MDS), although recently reported,‘-5 has not been exten-
`sively investigated so far. We conducted a pilot study by admin-
`istering thalidomide to 25 patients with MDS (14 males, 11
`females, mean age 65 years, range 48—85), previously unre—
`sponsive to treatments including recombinant erythropoietin,
`
`baematologica vol. 87(8):august 2002
`
`
`
`
`
` 1 2 3 4 5
`
`
`
`
`
`Age
`Sex
`PSS
`lM-iO
`
`62
`M
`"lit-ion
`RA
`
`Time tam diagmis (morths)
`Karyaype
`Marmllblastsflfi)
`Tramfusions/Mondl
`
`9
`46XY
`<5
`3
`
`69
`M
`low
`RARS
`
`11
`46XY
`<5
`4
`
`48
`F
`irI-lou
`RA
`
`64
`M
`low
`RA with flxosis
`
`51
`F
`low
`RA
`
`3
`46XX
`<5
`6
`
`8
`46XY
`<5
`4
`
`11
`46XX
`<5
`4
`
`673MB 286/424 257/3900 155/667 303/612
`EP0 (miu/L) pre/post
`1.9/2.3
`9.3/4.2
`29/2]
`6.7/8.3
`3.5/3.2
`VBC (x109/L) rte/post
`39/26
`236/108
`42/32
`319/632 107/122
`PLT (x10‘lL) ire/post
`7.8/113 7.3/9.3
`7.5/10
`6.6/9.3
`7.1/11.4
`Hb (g/cl) pre/post
`1.1/n.d.
`1/ 4.1
`‘13/483
`0/0.5
`1/5.1
`Hb F (95) Pie/post
`2(1)
`200
`250
`200
`300
`Dose of thalidomide (mg)
`Duration of response (months) +24
`6
`12
`+5
`+19
`‘Cmcomitam l‘h las emic syndome caused by a fi “39 point mmatim.
`
`alone or in association with other growth factors or amifos-
`tine.‘5-8 All patients were heavily transfusion-dependent (Hb < 8
`g/dL), requiring 4-8 units of packed red-cell transfusions every
`month. According to the WHO classification, there were 12 cas-
`es of refractory anemia (9 with trilineage myelodysplasia), 8 of
`refractory anemia with blast excess (4 < 10%, 4 > 10%), and 5
`cases of refractory anemia with ring sideroblasts (1 with trilin-
`eage myelodysplasia). The Intemational Prognostic System Score
`was low in 9 patients, intermediate 1—2 in 13 and high in 3
`patients. Thalidomide was given at the dose of 100 mg/d peros,
`at bedtime, for 1 week (to test tolerance) and then the dose was
`progressively increased every 4 weeks. No patient tolerated more
`than 300 mg/d.
`Ten patients (eight more than 75 years old), stopped thalido-
`mide early because of relevant side effects (fatigue, somnolence,
`constipation, numbess and tingling in fingers and/or toes, fluid
`retention, renal failure, skin rash). Ten additional patients
`stopped the treatment after 2 months because of inefficacy. The
`remaining 5 patients became completely transfusion-free with-
`in 4-9 weeks (Table 1). Due to a slight worsening of peripheral
`white blood cell and platelet counts, thalidomide was stopped
`in two of the responders. Since the hemoglobin value rapidly
`dropped to less than 8 g/dL, the drug was re-started and both
`patients retumed to being transfusion-free (Figure 1). No further
`significant cytopenias were recorded in non-responders. Ery-
`throid responses are currently maintained in 3 patients (Table 1).
`Two of them are still receiving thalidomide therapy, with adjust-
`ed doses of 50 to 100 mg/d. The patient who maintains his ery-
`throid response after 2 years received the drug for only 12
`months because of the subsequent occurrence of gastric carci-
`noma.
`
`Few studies have investigated the therapeutic role of thalido-
`mide in M08 so far, and all of them agree that thalidomide may
`significantly increase Hb levels in about one third of treated
`patients."5 In one study thalidomide also improved neutrope-
`nia and thrombocytopenia in some patients.5 Our findings con-
`firm that thalidomide, at a relatively low dose, may be a very
`effective therapy for treating anemia in a selected group of
`
`Dr. Reddy's Laboratories, Inc. v. Celgene Corp.
`IPR2018-O1509
`Exhibit 2008, Page 1
`
`

`

`scientific correspondence
`
`885
`
`Figure 1. Modifications of hemoglo-
`bin in a representative 62-year old
`male patient with refractory anemia
`treated with thalidomide. Note the
`decrease of hemoglobin after inter-
`ruption of thalidomide therapy and
`the new response when the drug was
`given again
`
`transfusion-dependent, younger MDS patients with a recent
`diagnosis, normal karyotype and no excess of marrow blasts. In
`fact, despite the overall response rate being 20% on an inten-
`tion-to-treat analysis, 5 out of 7 (71.4%) patients with these
`characteristics responded to the treatment in our series. It is
`also interesting to note that we obtained erythroid responses in
`4 transfusion-dependent subjects with initial serum levels of
`endogenous erythropoietin > 200 miu/L, a subset of MDS
`patients with a very low chance of responding to treatment with
`recombinant erythropoietin, alone or in combination with G
`CSF.9,10 Elderly patients, however, tolerated the drug poorly,
`despite the dose used in our study being lower than those
`employed in other trials.
`The mechanism (s) by which thalidomide acts in MDS remains
`unclear. Zorat et al.5 extensively investigated this aspect, exam-
`ining marrow apoptosis and angiogenesis in 30 MDS patients
`treated with thalidomide, reaching heterogeneous results and no
`firm conclusion. Bertolini et al.3 have reported that plasma lev-
`els of angiogenic growth factors and the number of activated
`endothelial cells in bone marrow significantly decrease in MDS
`patients responding to thalidomide. In contrast, preliminary data
`from our4 and other laboratories (Dr. A. List, personal communi-
`cation) indicate that circulating molecules with angiogenic
`activity, such as vascular endothelial growth factor, hepatocyte
`growth factor and basic fibroblast growth factor, often appear
`to be increased, rather than decreased, in MDS patients treated
`with thalidomide. Furthermore, microvessel density on trephine
`biopsy also increased in two of our responders under thalidomide
`therapy (unpublished data). These observations do not support
`a possible anti- angiogenic effect of thalidomide in MDS. Anoth-
`er interesting finding that emerged from our study was the pro-
`gressive increase of HbF and serum erythropoietin values during
`thalidomide treatment in some of the responders (Table 1).
`Whether these aspects may really contribute to the improvement
`of anemia in MDS patients receiving thalidomide warrants fur-
`ther and larger investigations.
`Pellegrino Musto, Antonietta Falcone, Grazia Sanpaolo,
`Michele Bisceglia,° Rosella Matera,# Angelo Michele Carella
`*Unit of Hematology and Stem Cell Transplantation; °Unit of
`Pathologic Anatomy, IRCCS “Casa Sollievo della Sofferenza
`”S. Giovanni Rotondo; #Unit of Hematology and Oncology,
`CROB, Rionero in Vulture Italy
`
`Key words: thalidomide, myelodysplastic syndromes, anemia,
`erythropoietin, fetal hemoglobin, angiogenesis.
`Correspondence: Dr. Pellegrino Musto, MD, Unit of Hematology
`and Stem Cell Transplantation, IRCCS “Casa Sollievo della
`Sofferenza” Hospital 71013, S. Giovanni Rotondo, Italy.
`Fax: international +39.0882.411389. E-mail: p.musto@tin.it
`
`Manuscript processing
`This manuscript was peer-reviewed by two external referees
`and by Professor Mario Cazzola, Editor-in-Chief. The final
`decision to accept this paper for publication was taken joint-
`ly by Professor Cazzola and the Editors. Manuscript received
`March 18, 2002; accepted June 11, 2002.
`
`References
`
`1. Raza A, Meyer P, Dutt D, Zorat F, Lisak L, Nascimben F, et
`al. Thalidomide produces transfusion independence in long-
`standing refractory anemias of patients with myelodys-
`plastic syndromes. Blood 2001; 98:958-65.
`2. Zorat F, Shetty V, Dutt D, Lisak L, Nascimben F, Allampal-
`lam K, et al. The clinical and biological effects of thalido-
`mide in patients with myelodysplastic syndromes. Br J
`Haematol 2001; 115:881-94.
`3. Bertolini F, Mingrone W, Alietti A, Ferrucci PF, Cocorocchio
`E, Peccatori F, et al. Thalidomide in multiple myeloma,
`myelodysplastic syndromes and histiocytosis. Analysis of
`clinical results and of surrogate angiogenesis markers. Ann
`Oncol 2001; 12:987-90.
`4. Musto P, Falcone A, Bodenizza C, Sanpaolo G, Matera R,
`Bisceglia M, et al. Thalidomide significantly improves ane-
`mia in selected transfusion-dependent patients with
`myelodysplastic syndromes: relationship to serum and mar-
`row levels of angiogenetic growth factors. Blood 2001;
`98:622a[abstract].
`5. Strupp C, Germing U, Aivado M, Misgeld E, Haas R, Gatter-
`man N. Thalidomide in the treatment of patients with
`myelodysplastic syndromes. Leukemia 2002; 16:1-6.
`6. Musto P, Sanpaolo G, D'Arena G, Scalzulli PR, Matera R, Fal-
`cone A, et al. Adding growth factors or interleukin-3 to
`
`haematologica vol. 87(8):august 2002
`
`© Ferrata Storti Foundation
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01509
`Exhibit 2008, Page 2
`
`

`

`886
`
`scientific correspondence
`
`erythropoietin has limited effects on anemia of transfu-
`sion-dependent patients with myelodysplastic syndromes
`unresponsive to erythropoietin alone. Haematologica 2001;
`86:44-51.
`7. Anonymous. A randomized double-blind placebo-controlled
`study with subcutaneous recombinant human erythropoi-
`etin in patients with low-risk myelodysplastic syndromes.
`Italian Cooperative Study Group for rHuEpo in Myelodys-
`plastic Syndromes. Br J Haematol 1998; 103:1070-4.
`8. Grossi A, Musto P, Santini V, Balestri F, Fabbri A, Falcone A,
`et al. Combined therapy with amifostine plus erythropoi-
`etin for the treatment of myelodysplastic syndromes.
`Haematologica 2002; 87:322-3.
`9. Hellstrom-Lindberg E. Efficacy of erythropoietin in the
`myelodysplastic syndromes: a meta-analysis of 205
`patients from 17 studies. Br J Haematol 1995; 89:67-71.
`10. Hellstrom-Lindberg E, Negrin R, Stein R, Krantz S, Lindberg
`G, Vardiman J, et al. Erythroid response to treatment with
`G-CSF plus erythropoietin for the anaemia of patients with
`myelodysplastic syndromes: proposal for a predictive mod-
`el. Br J Haematol 1997; 99:344-51.
`
`Morphologic characterization of acute myeloid leukemia
`with cytogenetic or molecular evidence of t(8;21),
`t(15;17), inv(16) and 11q23 abnormalities
`
`We reviewed the morphology of 110 acute myeloid
`leukemias (AML) with recurrent cytogenetic/molecular
`translocations. The t(8;21) cases had some pseudolymphoid
`blasts and severe dysgranulopoiesis. Acute promyelocytic
`leukemia showed atypical promyelocytes in peripheral blood
`and maturation of abnormal granulocytes. The atypical
`eosinophils were exclusive to inv(16). The cases with 11q23-
`abnormalities had blasts of monocytic appearance.
`
`haematologica 2002; 87:886-887
`(http://www.haematologica.ws/2002_08/886.htm)
`
`The WHO classification1 has divided AML into four categories,
`one of which includes the well established types of AML with
`recurrent cytogenetic/molecular translocations: AML with
`t(8;21), AML with t(15;17) and variants AML with inv(16) and
`variants, and AML with 11q23 abnormalities. These AML have
`some degree of correlation with morphology, together with
`prognostic influence.2-8 We reviewed the morphologic and lab-
`oratory characteristics of 110 cases of these AML subtypes diag-
`nosed in seven hospitals in Catalonia from January 1994 to
`December 1999. The aim was to know whether the morpholog-
`ic findings associated with these cytogenetic/ molecular abnor-
`malities were as constant as stated in the literature. Table 1
`shows the main clinical and laboratory data. Leukocytosis was
`significantly higher in 11q23 than in the other types. Cases with
`t(15;17) and M3 variant morphology had a mean (SD) leukocyte
`count of 28.5 (27.2) (cid:215)109/L, higher than those with classical M3
`[9.7 (24.8) (cid:215)109/L], but the difference was of borderline signifi-
`cance (p=0.05). The percentage of blasts in peripheral blood (PB)
`was significantly higher in 11q23 than in the other types, and
`in bone marrow (BM), higher in 11q23 and t(15;17). Eosinophils
`in BM were present in an appreciable amount in inv(16) and in
`t(8;21). Table 2 shows the main morphologic data.
`Twenty-two cases were AML-t(8;21), 4 M1 and 18 M2, coin-
`ciding with the FAB subtypes usually described.1-3,9 Dysgranu-
`lopoiesis was severe in all cases, with constant abnormal nuclear
`segmentation (hyposegmentation or bizarrely segmented nuclei)
`and hypo or hypergranulation. Two types of blasts were observed
`in 9 (41%) cases in PB and 13 (59%) cases in BM, one type being
`of myeloid appearance, and the other one of pseudolymphoid
`
`haematologica vol. 87(8):august 2002
`
`Table 1. Comparison of the main clinical and laboratory results
`of the four types of AML. Results expressed as mean (SD).
`
`Cytogenetic anomaly/
`N. cases
`
`t(8;21)
`N=22
`
`t(15;17)
`N=52
`
`inv16
`N=27
`
`11q23
`N=9
`
`p
`
`0.04
`58 (23)
`41 (17)
`42 (16)
`48 (17)
`Age (years)
`0.07
`108 (32)
`86 (22)
`92 (23)
`85 (25)
`Hemoglobin (g/L)
`0.4
`61 (37)
`50 (42)
`45 (41)
`39 (22)
`Platelets ((cid:215)109/L)
`12.1 (7.1) 12.6 (25.6) 45.5 (49.2) 85.3 (53.4) <0.001
`Leukocytes ((cid:215)109/L)
`42.8 (25)
`42.2 (34)
`42.7 (33)
`69.3 (32)
`0.03
`Blasts in peripheral blood (%)
`50.4 (19.9) 74.8 (17.3) 54.4 (19)
`82.4 (14.8) 0.001
`Blasts in bone marrow (%)
`Eosinophils in bone marrow (%) 2.1 (2.9)
`0.1 (0.5)
`13 (9.6)
`0.6 (1.7)
`<0.001
`
`appearance (high nuclear-cytoplasmic ratio, irregular nucleus,
`scant cytoplasm and moderate basophilia). Although the WHO
`review states that the small b asts are predominantly found in
`PB, we found them more frequently in BM. The myeloblasts had
`fine granulation, frequent Auer rods, and in some cases pseudo-
`Chediak granules, in agreement with the WHO report. Though
`uncommon in the other subtypes, cytoplasmic vacuolization was
`
`Table 2. Main morphologic data in the four types of AML wih recur-
`rent cytogenetic abnormalities.
`
`Cytogenetic anomaly
`
`t(8;21)
`n (%)
`
`t(15;17)
`n (%)
`
`inv16
`n (%)
`
`11q23
`n (%)
`
`p
`
`Peripheral blood
`Granulocytes
`Abnormal granulation
`Abnormal segmentation
`Single Auer rods
`Hybrid eosinophils
`
`Red cells
`Dysplasia
`
`Platelets
`Dysplasia
`
`Bone marrow
`Dyserythropoiesis
`Dysmegakaryopoiesis
`
`Granulocytes
`Abnormal granulation
`Abnormal segmentation
`Single Auer rods
`Vacuoles
`Hybrid eosinophils
`
`Blast characteristics
`Irregular or bilobed nuclei
`Fine granulation
`Large granulation
`Pseudo-Chediak granules
`Single Auer rods
`Faggots
`
`5/30 (16) 16/23 (70) 1/7 (14) <0.0001
`17/18 (94)
`18/18 (100) 3/30 (10) 17/23 (74) 3/7 (43) <0.0001
`0/18 (0)
`1/30 (3)
`3/23 (13)
`0/7 (0)
`ns
`0/22 (0)
`0/50 (0)
`8/27 (30)
`0/9 (0)
`0.008
`
`1/21 (5)
`
`13/49 (26) 3/22 (13) 2/9 (22)
`
`ns
`
`0/19 (0)
`
`2/42 (5)
`
`2/26 (7)
`
`2/9 (22)
`
`ns
`
`2/17 (12)
`2/15 (13)
`
`3/39 (7)
`0/17 (0)
`
`3/22 (13)
`2/18 (11)
`
`0/5 (0)
`0/5 (0)
`
`ns
`ns
`
`21/21 (100) 22/30 (73) 19/24 (79) 1/6 (16) <0.0001
`21/21 (100) 14/30 (46) 17/24 (71) 0/6 (0) <0.0001
`5/21 (24)
`2/30 (6)
`5/24 (21)
`0/6 (0)
`ns
`8/21 (38)
`1/30 (3)
`1/24 (4)
`0/6 (0)
`0.001
`0/22 (0)
`0/50 (0) 27/27 (100) 0/9 (0)
`<0.001
`
`0.001
`11/22 (50) 40/50 (80) 20/27 (74) 3/9 (33)
`15/22 (68) 8/50 (16) 18/27 (66) 5/9 (55) 0.0001
`4/22 (18)
`42/50 (84)
`1/27 (4)
`0/9 (0) 0.0001
`6/22 (27)
`7/50 (14)
`1/27 (4)
`0/9 (0)
`ns
`16/22 (73)
`8/50 (16)
`7/27 (26) 2/9 (22)
`0.002
`0/22 (0)
`46/50 (92) 1/27 (4)
`0/9 (0) <0.0001
`
`© Ferrata Storti Foundation
`
`Dr. Reddy’s Laboratories, Inc. v. Celgene Corp.
`IPR2018-01509
`Exhibit 2008, Page 3
`
`