Abstract: Introduction: B cell receptor signal transduction kinase inhibitors (KI) represent a paradigm shift in CLL management; however, there are limited data regarding real world practice patterns of KI discontinuation and response to subsequent therapies. Two centers reported outcomes of ibrutinib (Ibr) failure patients (pts) treated on clinical trials (n=33, n=71) documenting an extremely poor prognosis (Jain 2014, Maddocks 2015). No analogous data in idelalisib (Ide) failure pts are available. Given the impressive activity of KI and the rarity of discontinuation events, 10 large US cancer centers collaborated to capture the experience of 123 CLL pts who discontinued Ibr- or Ide-based regimens focusing on reasons for discontinuation and response to subsequent KI therapies. Methods: We conducted a multicenter, retrospective analysis of CLL pts who discontinued Ibr- or Ide-based therapy for any reason. We examined demographics, reason for discontinuation, responses, survival data, toxicity, and post KI therapies. Primary endpoint was post KI PFS (time from post KI treatment to progression or last f/u) as determined by the Kaplan Meier method. Comparisons were made using log rank test. Each institution received IRB approval. Results: A total of 123 KI discontinuation pts (Ibr=93/Ide=30) were identified. Table 1 describes baseline characteristics at start of KI. Interestingly, 10% and 32% of Ibr (5% 140 mg, 5% 280 mg daily) and Ide pts (32% 100 mg BID), respectively, were initiated at doses less than FDA labeled dose. Further, 23% and 42% of Ibr pts and 30% and 65% Ide pts had doses modified or held, respectively, prior to discontinuation. Overall median time on KI therapy was 5 months (mos) (4.8 Ibr, 5.5 Ide). ORR to KI was 63% (CR 15%, PR 39%, PR-L 9%). Most common reasons for KI discontinuation were toxicity (58% Ibr, 60% Ide), CLL progression (24% Ibr, 30% Ide), and RT DLBCL (8% Ibr, 7% Ide). Table 2 describes the most common toxicities leading to KI discontinuation. Median PFS from KI initiation for the cohort was 9 mos (77 events, median f/u 6 mos, Figure A). When stratified by discontinuation reason (Figure B), PFS was significantly inferior in RT pts (5 mos RT vs 8 mos progression vs 9 mos toxicity, P=0.04). Median OS for the entire cohort has not been reached (34 deaths, med f/u 12 mos). Median OS was inferior in RT pts (10 mos in RT vs. not reached in CLL progression/toxicity pts; P=0.01). At the time of analysis, 66 (54%) pts following KI discontinuation (21 progression, 36 toxicity, 7 RT, 2 SCT) received a first salvage regimen: 20% R-chemotherapy, 18% Ibr-based, 17% Ide-based, 15% anti-CD20 mab, 14% BCL2-inhibitor, 5% cellular therapy, 5% experimental KI, 3% IMID, 3% other. In evaluable pts, ORR to non-KI therapies following Ibr/Ide discontinuation was 40%. ORR to Ide-based therapy (n=12) following Ibr discontinuation was 50% (42% PR, 8% PRL). ORR to Ibr-based therapy following Ide discontinuation (n=13) was 77% (54% PR, 23% PRL). Responses to alternate KI were similar in pts who discontinued KI for toxicity (ORR 60% PR+PRL) and progression (ORR 67% PR + PRL). PFS (median f/u 5 mos, Figure C) for pts treated with an alternate KI therapy (Ibr → Ide, Ide → Ibr) has not been reached vs 7 mos in non-KI therapies (Figure D). Conclusions: We describe the largest combined experience of practice patterns and outcomes post KI discontinuation in CLL. The majority of pts discontinued KI therapy due to toxicity or progression, not RT. For the first time, we demonstrate that the majority of pts who discontinue a KI due to toxicity or progression respond to other therapies, particularly alternate KI therapy. Collectively, these data provide supporting evidence that: (1) reason for KI discontinuation is toxicity in the majority of cases; (2) alternate KI therapy following KI discontinuation is efficacious; (3) non-overlapping toxicity profiles permit utilization of alternate KI following discontinuation due to toxicity; and (4) mechanisms of KI resistance may not overlap. Table 1. Baseline Characteristics Median time diagnosis to KI 84 mos (1-333) Median age (range) 61 yr (33 - 89) Median prior Therapies (range) 2 (0 - 11) del17p (n) 34% (36/107) del11q (n) 31% positive (32/103) p53 mut (n) 27% positive (22/81) Complex karyotype (n) 31% (33/106) Table 2. Reasons for KI Discontinuation Ibrutinib Idelalisib Afib 27% Pneumonitis 33% Infection 14% Colitis 28% Pneumonitis 10% Rash 17% Cytopenias 10% Transaminitis 11% Bleeding 10% Infection 5% Figure 1. Figure 1. Disclosures Mato: Gilead: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Genentech: Consultancy; Pronai Pharmaceuticals: Research Funding; Pharmacyclics: Consultancy, Research Funding; Janssen: Consultancy; Celgene Corporation: Consultancy, Research Funding; TG Therapeutics: Research Funding. Nabhan:Celgene Corporation: Honoraria, Research Funding. Barr:Abbvie: Consultancy; Gilead: Consultancy; Pharmacyclics LLC, an AbbVie Company: Consultancy, Research Funding. Ujjani:Genentech: Membership on an entity's Board of Directors or advisory committees. Hill:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Lamanna:Gilead: Membership on an entity's Board of Directors or advisory committees, Research Funding. Skarbnik:Genentech: Honoraria, Speakers Bureau; Gilead Sciences: Honoraria, Speakers Bureau; Pharmacyclics: Honoraria, Membership on an entity's Board of Directors or advisory committees. Howlett:Teva: Speakers Bureau. Pu:Merck: Research Funding; BMS: Consultancy; Cyclacel: Research Funding; Medimmune: Research Funding; Ambit: Research Funding; Astellas: Research Funding. Rago:AbbVie: Membership on an entity's Board of Directors or advisory committees; Gilead Sciences: Speakers Bureau. Zent:Genzyme-Sanofi: Research Funding; Biothera: Research Funding; GlaxoSmithKline: Research Funding; Novartis: Research Funding. Feldman:Celgene: Honoraria, Speakers Bureau; Pharmacyclics/JNJ: Honoraria, Speakers Bureau; Seattle Genetics: Honoraria, Speakers Bureau. Goy:Allos, Biogen Idec, Celgene, Genentech, and Millennium. Gilead: Speakers Bureau; Celgene: Consultancy, Research Funding, Speakers Bureau. Claxton:Cyclacel: Research Funding; BMS: Consultancy; Merck: Research Funding; Astellas: Research Funding; Ambit: Research Funding; Medimmune: Research Funding. Svoboda:Celgene: Research Funding; Celldex: Research Funding; Immunomedics: Research Funding; Seattle Genetics: Research Funding. Dwivedy Nasta:BMS: Research Funding; Millenium: Research Funding. Porter:Genentech: Other: Spouse employment; Novartis: Other: IP interest, Research Funding. Schuster:Nordic Nanovector: Membership on an entity's Board of Directors or advisory committees; Janssen: Research Funding; Novartis: Research Funding; Genentech: Consultancy; Gilead: Research Funding; Hoffman-LaRoche: Research Funding; Celgene: Consultancy, Research Funding; Phamacyclics: Consultancy, Research Funding. Cheson:Celgene: Consultancy, Research Funding; Pharmacyclics: Consultancy, Research Funding; Gilead: Consultancy, Research Funding; Rochr-Genentech: Consultancy, Research Funding; Seattle Genetics: Consultancy, Research Funding; Astellas: Consultancy; Acerta: Research Funding.

Abstract: Introduction: CLL is a clinically and biologically heterogeneous disease; cytogenetic evaluation with fluorescence in situ hybridization (FISH) is routinely used to guide therapy. For example, del17p is associated with chemoimmunotherapy (CIT) refractoriness and decreased survival. The use of kinase inhibitors (KI) has improved clinical outcomes; however, some pts progress on KI and require subsequent therapies. Next generation sequencing (NGS) can further define genetic alterations that may act in concert to drive malignancy, and identify pathways that can be targeted with novel approaches. Here we describe the mutational landscape of a cohort of 57 CLL pts treated at the University of Pennsylvania and identify potentially targetable pathways for intervention. Methods: We identified 57 pts who underwent analysis of tumor DNA using NGS (2013-2015) and analyzed clinical characteristics, genetic mutations, and progression free survival (PFS). NGS was performed on an Illumina MiSeq using a 33 gene amplicon-based panel developed at our center with detection limit of 5% allele frequency with a minimum depth of coverage of 250x. We used custom bioinformatic pipelines combining open source tools and custom algorithms for analysis. Pathogenic mutations were defined as those that have been reported in studies with functional data. Results: Of the57 pts who underwent NGS the median age at NGS was 65.5 yr (range 17.7-90.7), 65% were male, 21% patients received CIT alone, 21% patients received KI alone and 39% pts received both CIT and KI, and 32% received KI in relapse. 74% (42/57) of pts had at least one genetic mutation identified by NGS. The median number of mutations per pt was 1 (range 0-8). 25% of pts had ≥ unique 3 mutations). Mutations in 24 unique genes (n=94) were identified and were categorized as likely pathogenic (69%), variants of uncertain significance (27%), or likely benign (4%). The most frequently mutated genes were ATM (20%), SF3B1 (12%), NOTCH1 (10%), DNMT3A (7%), and TP53 (7%). We identified 19 low frequency gene mutations, which in aggregate affect 24.5% of the pt cohort (Table). The median PFS for CIT pts was 31.4 mo (median f/u 15 mo) and 8 mo for KI pts (median f/u 4 mo). Using Cox regression, the presence of ≥ 1 mutation was associated with an inferior PFS (Figure) following CIT when controlled for del11q status (HR 3.1, p=.05) or complex karyotype (HR 3.4, p=.03) and a PFS trend when controlled for del17p (HR 2.7, p=.08). Pts with ≥ 4 mutations had a shorter PFS on ibrutinib (Ibr) compared to those with fewer mutations (p=0.0002). Conclusion: NGS identifies several mutations that may be targetable using agents which have not been tested in CLL. The presence of a mutation identified by NGS predicts for inferior PFS on CIT, and the presence of ≥ 4 mutations predict early treatment failure on Ibr. These genetic alterations demonstrate the diversity of pathways that are involved in CLL biology. These results support a rationale for clinical trial design using a precision medicine approach selecting therapies which are already available in practice based on individual pt genetic profiles. Table 1. Mutation Events Summary Putative Pathway Frequency (%) Potential Therapy DNA Damage and Cell Cycle Control 32 (34) ATMTP53XPO1STAG2 19 (20.2)7 (7.4)5 (5.3)1 (1.1) PARP inhibitorsSelective inhibitors of Nuclear Export RNA Processing 20 (21.3) SF3B1XPO1TBL1XR1PRPF40BZRSR2 11 (11.7)5 (5.3)2 (2.1)1 (1.1)1 (1.1) Epigenetic modification 11 (11.7) DNMT3ATET2 7 (7.4)4 (4.3) DNA methyltransferase inhibitors RAS-RAF-MEK-MAPK 10 (10.6) BRAFKRASNRASNF1 5 (5.3)2 (2.1)2 (2.1)1 (1.1) BRAF inhibitorsRAS/MEK inhibitors RAF/MEK inhibitors Transcriptional regulation activity 10 (10.6) BCORPHF6TBL1XR1ASXL1 4 (4.3)2 (2.1)2 (2.1)2 (2.1) Notch Signaling 9 (9.6) Notch1 9 (9.6) Notch inhibitors Inflammatory Pathways 3 (3.2) MYD88BIRC3 1 (1.1)2 (2.1) B cell receptor signal transduction inhibitors Cellular metabolism 2 (2.2) IDH1IDH2 1 (1.1)1 (1.1) IDH inhibitors Telomere maintenance 2 (2.1) POT1 2 (2.1) Chromatin modification 2 (2.1) ZMYM3 2 (2.1) Figure 1. Figure 1. Disclosures Schuster: Phamacyclics: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Janssen: Research Funding; Hoffman-LaRoche: Research Funding; Nordic Nanovector: Membership on an entity's Board of Directors or advisory committees; Novartis: Research Funding; Gilead: Research Funding; Genentech: Consultancy. Rago:Gilead Sciences: Speakers Bureau; AbbVie: Membership on an entity's Board of Directors or advisory committees. Porter:Genentech: Other: Spouse employment; Novartis: Other: IP interest, Research Funding. Dwivedy Nasta:Millenium: Research Funding; BMS: Research Funding. Svoboda:Seattle Genetics: Research Funding; Celgene: Research Funding; Celldex: Research Funding; Immunomedics: Research Funding. Loren:Merck: Research Funding. Mato:Pronai Pharmaceuticals: Research Funding; Celgene Corporation: Consultancy, Research Funding; Genentech: Consultancy; Pharmacyclics: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Janssen: Consultancy; TG Therapeutics: Research Funding; Gilead: Consultancy, Research Funding.