CTOS 2013 Discussion of four presentations on Sarcomas with complex karyotypes Medical Oncology, Lyon UCBL1- CLB JY Blay

CTOS 2013 GIST Sarcomas and locally aggressive connective tissue tumors KinaseMutations Translocations SySDFSPEwing MutationsAPC/bCat Desmoids WD/DDLPS Amplification12q13-15MDM2/CDK4 MPNSTPEComas TSG NF1, TSC1/2 Complexgenomics LMS, UPS

CTOS 2013 Sarcoma subtypes Other very rare subtypes (8%) Endometrial stromal sarcoma (2%) Synovial sarcoma (2%) Myxofibrosarcoma (2%) Angiosarcoma (3%) Rhabdomyosarcoma (3%) Leiomyosarcoma (11%) Unclassified sarcoma (16%) Dermatofibrosarcoma (5%) Kaposi sarcoma (3%) Soft-tissue Ewing sarcoma/pNET (4%) Liposarcoma (15%) GIST (18%) Bone primary (osteosarcoma/ chondrosarcoma) (8%) 8% 18% 15% 4% 3%5% 16% 11% 3% 3% 2% 2% 2% 8%

CTOS 2013 Sarcomas with complex karyotypes GIST Lipo_s Sarcoma NOS Leiomyo_s Kaposi_s Dermatofibro_s Uterine leiomyo_s Other MFH Myxofibro_s Rhabdomyo_s Synovial_s Ewing_s Angio_s Fibromyxoid_s MPNST Fibro_s Solitary_ Osteo_s Rate per 100,000

CTOS 2013 Systemic treatments Doxorubicin Doxorubicin ifosfamide Trabectedine Pazopanib Gemcitabine Docetaxel Gemcitable DTIC Localized phase - Adjuvant CT controversial Advanced phase - Median PFS = 4-6 mos in 1st line = 2-4 mos in 2+ lines

CTOS 2013 Barretina et al Nat Gen 2010

CTOS 2013 We need To better predict relapse To identify better the « driver » mutations Biomarkers to predict for primary and secondary resistance

CTOS presentations Preclinical model –p53-/+ PTEN-/+ mice developping LMS Theranostics –Guiding treatment of patients with NGS results Biomarker for response –For new generation of cytotoxic treatments CTC in sarcoma –Monitoring micrometastatic disease

A DETECTION SYSTEM FOR CIRCULATING TUMOR CELLS USING GFP EXPRESSING TELOMERASE-SPECIFIC REPLICATION-COMPETENT ADENOVIRUS IN BONE AND SOFT TISSUE SARCOMA T. Kunisada 1 J. Hasei 1 K. Takeda 1 Y. Urata 3 T. Fujiwara 2 T. Ozaki 1 1 Dept. of Orthopaedic Surgery 2 Dept. of Gastroenterological Surgery Okayama University, Okayama, Japan 3 Oncolys BioPharma, Inc., Tokyo, Japan

CTOS 2013 CTC in sarcoma Predictive value in other cancers Commercial tools imperfect for sarcoma cells Novel technology - detects telomerase + cells

CTOS 2013 CTC in sarcoma 11/22 patients with detectable sarcoma cells All histotypes (even DFSP) Fewer CTC vs other cancer? Predictive value? –4/11 relapse CTC+ –1/11 relapses CTC-

CTOS 2013 CTC in sarcoma : questions? To be expanded and confirmed Biological significance of CTC? To guide adjuvant treatment? Help to monitor response or relapse?

Identification of potential molecular biomarkers for response of soft tissue sarcoma to eribulin. Translational results of EORTC trial A. Wozniak*, E.A.C. Wiemer*, H. Burger, J. Allemeersch, R. van Eijsden, R.H.J. Mathijssen, S. Sleijfer, M. Smid, G.Floris, S. Marreaud, A. Nzokirantevye, R.Sciot, P. Schöffski (*equal contribution) 18th CTOS Meeting, 30/10-2/11/2013, New York, USA

ALS2CR11 amyotrophic lateral sclerosis 2 (juvenile) chromosome region, candidate 11 protein (locus 2q33.1) Overexpressed in Leydig cells, germ cells, adipocytes Role not known Single reports on genomic status in cancer (mainly LOH) In our experiment higher expression in non- responders (p= ) 18th CTOS Meeting, 30/10-2/11/2013, New York, USA Differentially expressed mRNAs (responders vs. non-responders) Non-responders Responders

CTOS 2013 Differentially expressed mRNAs and miRNAs, assessed in STS subtypes mRNAsmiRNAs STS subtype Down- regulated* Up- regulated* Potential biomarker s Down- regulated* Up- regulated* Potential biomarker s ADI 58500MYLK380miR-106b LMS 1113SLC8A162miR- 146a; 1271; 590-3p; 29b-2# OTH 6693IGF2, COL1A2 10miR-186 ADI – adipocytic sarcomas, LMS - leiomyosarcomas, OTH – other sarcoma subtypes; *in responders

CTOS 2013 mRNAs and miRNAs are differentially expressed in STS from eribulin responders and non-responders Significance of biological pathways? Possible predictive biomarker? Why differences across histotypes? Further validation studies are required A research tool Eribulin : questions?

CTOS 2013 We need To better predict relapse To identify better the « driver » mutations Biomarkers to predict for primary and secondary resistance

CTOS 2013 What is a good target? Expression Possible target Expression + activation Promising target Expression + activation + mechanism A major target Expression + activation + mechanism + drug Clinical trial

Dual PTEN/P53 suppression promotes high grade sarcomas by activating Notch Eva Hernando, Ph.D.

CTOS 2013 Dual PTEN/TP53 suppression and sarcomagenesis Mutational profling of sarcoma patients Dual suppression in SMC P53-/+ & PTEN -/+ HGUPS, LMS Activation of the Notch pathway, and sensitivity to GSI

Gamma-secretase inhibition suppresses the clonogenic and invasive potential of tumor cells

CTOS 2013 Sarcomagenesis: questions A relevant model for LMS/UPS subsets? Screen human tumors To reevaluate the role of GSI/Notch pathway modulators in vivo in the clinics?

CTOS 2013

N=57 patients, Druggable alterations Documented responses Documented SD NGS analysis

CTOS 2013 N=57 patients, Documented responses Documented SD Value of GMI? –PFS2/PFS1 Denominator? From N of 1 to prospective series with homogenous molecular diagnosis NGS analysis

CTOS 2013 Valuable strategy N of 1 trials methodology Guide research programs in larger patients sets Negative results also should be informative Difficult analysis when combinations are used Theranostics : questions

CTOS 2013 Conclusions Four important reports Biomarkers and predictive factors for relapse and resistance are needed. Preclinical models to guide us for drug development. Translational research : biopsy and rebiopsy

CTOS 2013 A World Sarcoma Network is needed 10/11/ Join us!

CTOS 2013 Connective tissue tumours 5 types of sarcomas Specific translocations generating fusion genes15% Kinase mutations (KIT…)15% Gene inactivation (NF1…)10% (?) Amplifications chromosome 12 (MDM2+CDK4)15% Complex genetic alterations (MFH, LMS,...)50%