1. MET inhibitors against NSCLC
Istituto Toscano Tumori-Livorno-Italy
Federico Cappuzzo
Istituto Toscano Tumori
Ospedale Civile
Livorno-Italy

2. MET Structure and Function
MET is a receptor tyrosine kinase
MET gene located on chromosome 7 (7q21–q31)
Produces HGF receptor
Single precursor protein
Extracellular α-chain and transmembrane β-chain, linked by disulfide bonds
MET normally activated via ligation with its natural ligand HGF
Normal MET activation facilitates cell processes for embryonic development, wound healing, and tissue regeneration
Istituto Toscano Tumori-Livorno-Italy
HGF, hepatocyte growth factor; NSCLC, non-small-cell lung cancer.
MET is a receptor tyrosine kinase with the gene located on chromosome 7 (7q21-7q31); it encodes the receptor for hepatocyte growth factor (HGF), and it’s also called HGFR or HGF receptor. MET is produced first as a precursor protein composed of the extracellular alpha chain and transmembrane beta chain, linked by disulfide bonds. MET is normally activated via ligation or binding with its natural ligand HGF, which is also called scatter factor. Normal or physiologic MET activation facilitates cell processes for embryonic development, wound healing, and tissue regeneration.
Figure source: Faria C, Smith C, Rutka J. The Role of HGF/c-Met Pathway Signaling in Human Medulloblastoma, Molecular Targets of CNS Tumors. In: Garami (Ed.). InTech Publications. Available from:

3. MET dysregulation in NSCLC
MET abnormalities leading to dysregulated activation of MET/HGF pathway:
Protein overexpression
Increased gene copy number (amplification)
Mutations
Aberrant splicing
Negative biologic effects result in malignancy and metastasis
Istituto Toscano Tumori-Livorno-Italy

4. MET expression in solid tumors
p-MET
100% 3 2 1
90%
80%
70%
Istituto Toscano Tumori-Livorno-Italy
60%
50%
40%
30%
20%
10% 0%
Lung
Ovary
Breast
Renal
Colon
Lung Cancer expresses highest pMET among common solid cancers
Human Cancers

5. MET amplification in NSCLC Istituto Toscano Tumori-Livorno-Italy
Total evaluated: 435
Istituto Toscano Tumori-Livorno-Italy
Low copy number:
383 (88.9%)
High polysomy:
30 (7.0%)
Gene amplification:
18 (4.1%)
Cappuzzo et al. J Clin Oncol 2009;27:1667–74.

6. Istituto Toscano Tumori-Livorno-Italy Cumulative Survival (proportion)
High MET Copy Number: Poor Prognosis in Surgically Resected/Early Stage NSCLC
1.0
1.0
0.9
0.9
0.8
0.8
0.7
0.7
Istituto Toscano Tumori-Livorno-Italy
≥ 4 to < 5 copies/cell
0.6
0.6
MET < 5 copies/cell (n = 383)
Cumulative Survival (proportion)
< 2 copies/cell
0.5
0.5
≥ 3 to < 4 copies/cell
0.4
0.4
≥ 2 to < 3 copies/cell
0.3
≥ 6 copies/cell
0.3
NSCLC, non-small-cell lung cancer.
Cappuzzo et al has recently reported that high MET copy number, as shown in this survival analysis here, leads to poor prognosis in surgically resected early stage non-small-cell lung cancer.
0.2
≥ 5 to < 6 copies/cell
0.2
MET ≥ 5 copies/cell (n = 48)
0.1
0.1
P = .0045 20 40 60 80
100 20 40 60 80
100
120
Time (months)
Time (months)
Cappuzzo et al. J Clin Oncol 2009;27:1667–74.

7. Anti-MET agents in development in patients with NSCLC
Target
Type
Development phase
Ligand antagonists
Ficlatuzumab (AV-299)
HGF
Monoclonal antibody
I and II
Rilotumumab (AMG-102) II
TAK-701 I
Receptor inhibitors
Onartuzumab (OA5D5)
MET
III completed
Receptor TKIs
Tivantinib (ARQ-197)
Non-ATP competitive TKI
Cabozantinib (XL-184)
MET, RET, VEGFR1-3, KIT, FLT3, TIE2
ATP competitive TKI
Foretinib (XL-880)
MET, RON, VEGFR1-3, PDGFR, KIT, FLT3, TIE2
Crizotinib (PF )
MET, ALK
II and III
MGCD-265
MET, RON, VEGFR1-2, PDGFR, KIT, FLT3, TIE2
Istituto Toscano Tumori-Livorno-Italy

8. Istituto Toscano Tumori-Livorno-Italy
Co-inhibition of Met and EGF Receptors is More Potent than Inhibiting Either Alone in an EGFR WT NSCLC Model
In Vitro
In Vivo
Control
NSCLC Lines
Erlotinib IC50 (μM)
TGFα
TGFα+HGF
H596
0.508
>10
H596+MetMAb
0.997
Istituto Toscano Tumori-Livorno-Italy
H596: WT EGFR cell line
-Co-inhibition of Met and EGFR results in more robust activity, relative to either alone – including in an EGFR WT preclinical model.
-In vitro, growth of a WT EGFR NSCLC line H596 is inhibited by erlotinib. In the presence of HGF, the cells are no longer sensitive to single-agent erlotinib; rather a combination of MetMAb and erlotinib is required to inhibit growth.
-Similarly, in mouse models that express human HGF, growth of H596 is not inhibited by erlotinib; There is modest single-agent MetMAb activity, and sustained inhibition with the combination of MetMAb and erlotinib
Met activation by HGF decreases sensitivity to erlotinib.
MetMAb restores sensitivity.
Combination of erlotinib+MetMAb exhibits robust activity.

9. Onartuzumab (MetMAb): Randomized Phase II Trial
Onartuzumab (MetMAb): monovalent (single-arm) antibody to MET, prevents MET activation by HGF
Primary endpoint: PFS in Met-positive and ITT population
Secondary endpoints: OS, ORR, safety
Previously treated advanced-stage NSCLC patients N = 137*
Stratified by: History of tabacco use, ECOG PS, histology
MetMAb (15 mg/kg IV every 3 weeks) + Erlotinib (150 mg daily)
(n = 69)
Istituto Toscano Tumori-Livorno-Italy
PD*
Placebo (IV every 3 weeks) + Erlotinib (150 mg daily)
(n = 68)
ECOG PS, Eastern Cooperative Oncology Group Performance Score; HGF, hepatocyte growth factor; ITT, intent-to-treat; IV, intravenous; NSCLC, non-small cell lung cancer; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; q3w, every 3 weeks.
This slide represents MetMAb, or onartuzumab, in the initial Phase 2 clinical trial that was performed. The Phase I clinical trial was performed at the University of Chicago; it showed very good toxicity profile[1] and therefore a Phase II clinical trial was instituted by Dr. Spiegel and colleagues. That was presented in 2011 and this was a randomized study looking at onartuzumab, which is also known as MetMAb, plus erlotinib or placebo plus erlotinib, as one can appreciate here. This was for previously-treated advanced stage non-small cell lung cancer patients, with 137 patients, and it was stratified by a history of tobacco use, ECOG performance status, as well as histology.
Reference:
1. Surati M, Patel P, Peterson A, Salgia R. Role of MetMAb (OA-5D5) in c-MET active lung malignancies. Expert Opin Biol Ther Dec;11(12):
*Includes 9 patients with squamous cell histology †Patients in placebo arm allowed to cross-over to receive MetMAb (n = 27)
Spigel, et al. ASCO Abstract 7505.

10. Onartuzumab (MetMAb): MET Diagnostic IHC
Negative
Weak
Strong
Moderate -
Istituto Toscano Tumori-Livorno-Italy
IHC, immunohistochemistry.
The slide here shows the immunohistochemical pattern for MET, and the MET receptor tyrosine kinase can be stained by the SP44 monoclonal antibody clone. And, as one can appreciate, it can be negative in certain tumors or weak in other tumors, or moderate as well as strong; this will be important as we select out the patient population that could potentially respond to this kind of therapeutic. +
Spigel D, et al. ASCO Abstract 7505.

11. Onartuzumab (MetMAb): PFS and OS in MET Dx+ (High-Positive) Population
PFS: HR = 0.53
OS: HR = 0.37
Placebo + erlotinib
MetMAb + erlotinib
Median (mo)
1.5
2.9 HR
0.53
(95% CI)
( )
Log-rank p-value
0.04
No. of events 27 20
Placebo + erlotinib
MetMAb + erlotinib
Median (mo)
3.8
12.6 HR
0.37
(95% CI)
( )
Log-rank p-value
0.002
No. of events 26 16
1.0
1.0
Istituto Toscano Tumori-Livorno-Italy
0.8
0.8
0.6
0.6
Probability of progression free
Probability of survival
0.4
CI, confidence interval; HR, hazard ratio; PFS, progression free survival; OS, overall survival.
As the data that was presented for onartuzumab phase II trial for survival, and this was for MET high-positive population, on the left one can see the 2 curves, and the curves are separating out very nicely in the sense that the MetMAb and erlotinib have better progression-free survival (PFS) as compared to placebo and erlotinib. Also, as you can see on the curve on the right, the overall survival (OS) for placebo/erlotinib is actually worse as compared to MetMAb plus erlotinib itself. Now, the molecular mechanism of this needs to be understood even further, but these are quite exciting findings.
0.4
0.2
0.2
0.0
0.0 3 6 9 12 15 18 3 6 9 12 15 18 21
Time to progression (months)
Overall survival (months)
Spigel D, et al. ASCO Abstract 7505.

12. Istituto Toscano Tumori-Livorno-Italy
The prevalence of MET expression by immunohistochemistry (IHC) in the METLung (OAM4971g) trial: a randomized, placebo-controlled Phase III study with erlotinib + placebo vs. erlotinib + onartuzumab (MetMAb) in patients with previously treated NSCLC.
Istituto Toscano Tumori-Livorno-Italy
Martin J. Edelman1, David Spigel2, Kenneth O’Byrne3, Tony Mok4, Wei Yu5, Simonetta Mocci5, Virginia Paton5, Luis Paz-Ares Rodriguez6
1Univeristy of New Mexico Health Sciences Center, Albuquerque, NM USA; 2Sarah Cannon Research Institute and Tennessee Oncology PLLC, Nashville, TN USA; 3Princess Alexandra Hospital, Brisbane, Australia; 4The Chinese University of Hong Kong, Hong Kong; 5Genentech, Inc. South San Francisco, CA USA; 6Instituto de Biomedicina de Sevilla (HUVR, US and CSIC) and Hospital Universitario Virgen del Rocio, Seville, Spain

13. Onartuzumab (MetMAb) Phase III 2L/3L MET-positive NSCLC
erlotinib + onartuzumab
Treat until PD
Randomise
1:1
2L and 3L NSCLC pts (1 prior Pt-based line)
Central testing for*:
MET status
EGFR mutation status
Treatments:
Tarceva 150 mg PO qd
onartuzumab/placebo 15 mg/kg IV q3wk
N = 490
erlotinib + placebo
Istituto Toscano Tumori-Livorno-Italy
No crossover tx
Key eligibility criteria:
Stage IIIB or IV Met diagnostic positive NSCLC
1-2 prior lines of tx
No prior EGFR inhibitor
ECOG PS 0 or 1
Stratification criteria:
EGFR mut status
MET 2+ or 3+ score
# of prior lines of tx
Histology
Primary endpoint:
Overall survival (OS)
Secondary endpoints:
Progression-free survival (PFS)
Overall response rate (ORR)
Quality of life (QoL)
Safety
*PRE-SCREENING: Patients could submit tumor samples for testing prior to requiring treatment with 2L or 3L therapy 13

14. Patient Characteristics Overall MET Status
Screened*
Age (n=1580)
Median (yrs)
63.0
Race (n=1580)
White
1290 (82%)
Asian
179 (11%)
Other
111 ( 7%)
Sex (n=1580)
Male
991 (63%)
Histology (n=1552)
Non-Squamous
1183 (76%)
Squamous
369 (24%)
EGFR Activating Mutation (n=1531)
Yes
122 ( 8%) No
1409 (92%)
Screened*
MET IHC Status (n=1587)
MET-positive
782 (49%)
MET-negative
805 (51%)
MET IHC Score (n=1587) 3+
175 (11%) 2+
607 (38%) 1+
666 (42%)
139 ( 9%)
* Patients with valid MET results were summarized.

15. MET+ prevalence by Histology MET+ prevalence by EGFR status
Non-Squamous
Squamous
MET IHC Status
n=1183
n=369
MET-positive
655 (55%)
114 (31%)
*P<0.0001
 n=1531
EGFR mut
Non EGFR mut
MET IHC Status
n=122
n=1409
MET-positive
74 (61%)
696 (49%)
*P=0.02
MET+ prevalence by Smoking History
 n=1575
Never
Previous
Current
MET IHC Status
n=260
n=997
n=318
MET-positive
142 (55%)
496 (50%)
133 (42%)
*P=0.002 (vs Never)
*P=0.01 (vs Previous)
MET+ prevalence by Asian vs. ROW
 n=1580
Asian
White
Other
Met IHC Status
n=179
n=1290
n=111
MET-positive
94 (53%)
611 (47%)
71 (64%)
*P=0.2 (vs Asian)
*Chi square test

16. Tivantinib (ARQ 197): a Novel and Selective Tyrosine Kinase Inhibitor
Non-ATP competitive inhibitor of c-MET
Novel mechanism of binding stabilizes inactive conformation of c-MET
Istituto Toscano Tumori-Livorno-Italy
Compound demonstrates broad-spectrum, anti-tumor activity in a number of tumor xenograft models (including NSCLC)
In vivo anti-tumor activity of ARQ EGFR inhibitor greater than either drug alone
Demonstration of safety and linear PK in phase I combination with EGFR inhibitor erlotinib

17. Istituto Toscano Tumori-Livorno-Italy
Tivantinib: Study Design Randomized, placebo-controlled, double-blind clinical trial R A N D O M I Z E
Erlotinib 150 mg PO QD
+ ARQ mg PO BID
28-day cycle
NSCLC
Inoperable locally adv/ metastatic dz.
≥1 prior chemo (no prior EGFR TKI) PD
Erlotinib 150 mg PO QD
+ Placebo
28-day cycle
Istituto Toscano Tumori-Livorno-Italy
Endpoints
1° PFS
2° ORR, OS
Subset analyses
Crossover: ORR
33 sites in 6 countries
Study accrual over 11 months (10/08-9/09)
Randomization stratified by prognostic factors incl. sex, age, smoking, histology, performance status, prior therapy and best response, and geography (U.S. vs. ex-U.S.)

18. Tivantinib: PFS in Histologic and Molecular Subgroups
ARQ197/erlotinib
Placebo/erlotinib
Unadjusted HR (95% CI) N
Median PFS (95% CI, weeks)
Squamous Cell
26 / 24
13.7 (8.0‒18.1)
8.4 (7.9‒21.0)
Non-Squamous Cell
58 / 59
18.9 (15.0‒31.1)
9.7 (8.0‒16.0)
c-MET FISH >4
19 / 18
15.4 (8.1‒24.4)
15.3 (7.1‒16.3)
c-MET FISH >5
8 / 11
24.1 (16.3‒NE)
15.6 (7.9‒31.4)
EGFR mutant
6 / 11
24.1 (8.0‒32.1)
21.0 (8.1‒36.0)
EGFR wt
51 / 48
13.7 (8.1‒18.1)
8.1 (7.9‒9.9)
KRAS mutant
10 / 5
9.7 (7.9‒NE)
4.3 (1.1‒8.0)
KRAS wt
49 / 45
15.4 (8.1‒18.1)
9.9 (8.0‒16.0)
HR=1.05
HR=0.71
Istituto Toscano Tumori-Livorno-Italy
HR=0.71
HR=0.45
HR=1.23
HR=0.70
HR=0.18
HR=1.01
0.5
1.0
1.5
2.0
5.0
Favors ARQ 197/Erlotinib
Favors Erlotinib/placebo

19. MARQUEE phase III study design
Istituto Toscano Tumori-Livorno-Italy
Primary end-point: OS

20. MARQUEE study biomarkers
Istituto Toscano Tumori-Livorno-Italy

21. MARQUEE: PFS in the study population
Istituto Toscano Tumori-Livorno-Italy

22. MARQUEE: OS in the study population
Istituto Toscano Tumori-Livorno-Italy

23. MARQUEE: PFS and OS in MET-
Istituto Toscano Tumori-Livorno-Italy

24. MARQUEE: PFS and OS in MET+
Istituto Toscano Tumori-Livorno-Italy

25. MARQUEE: Forest plot for OS in key subgroups
Istituto Toscano Tumori-Livorno-Italy

26. Foretinib (EXEL-2880): A MET and VEGFR2 Tyrosine Kinase Inhibitor
Pre-clinical evidence of efficacy[1]
Phase I/II (phase II is randomized erlotinib +/- foretinib) trial currently ongoing[2]
Istituto Toscano Tumori-Livorno-Italy
HGF, hepatocyte growth factor; VEGFR2, vascular endothelial growth factor receptor 2.
Foretinib is a MET and VEGF receptor tyrosine kinase inhibitor, there is preclinical evidence of efficacy as can be appreciated from these diagrams here. A phase I/II clinical trial is currently enrolling patients, and this is actually erlotinib plus or minus foretinib.
1. Reprinted from Qian F, et al. Cancer Res. 2009;69: , with permission from the AACR ClinicalTrials.gov. NCT

27. Biomarker Analysis of NCIC Clinical Trials Group IND
Biomarker Analysis of NCIC Clinical Trials Group IND.196: a Phase I Study of Erlotinib plus Foretinib in patients with Advanced Pretreated NSCLC Patients
NB Leighl, MS Tsao, G Liu, D Tu, Z Chen, S Sakashita, C Ho, FA Shepherd, N Murray, J Goffin, G Nicholas, L Kim, S Kamel-Reid, J Ho, T Zhang, NA Pham, M Sukhai, L Seymour, G Goss, PA Bradbury
NCIC Clinical Trials Group, Kingston, Canada
Istituto Toscano Tumori-Livorno-Italy
NCIC CTG received trial support from GSK;
presenter and co-authors report no other conflicts

28. Istituto Toscano Tumori-Livorno-Italy
Erlotinib plus Foretinib: responses observed in EGFR mut+ and in MET IHC+
MET+
Istituto Toscano Tumori-Livorno-Italy

29. Istituto Toscano Tumori-Livorno-Italy
Conclusions
MET is a negative prognostic factor in NSCLC
Several agents are under investigation
MET overexpressing patients seem more sensitive to anti- MET agents
Efficacy in MET amplified/mutated patients is unknown
Anti-MET strategies should be investigated in individuals with EGFR mutations with acquired resistance to anti-EGFR agents
Istituto Toscano Tumori-Livorno-Italy