1. Daniele Santini Università Campus Bio-Medico Roma

2. 24 months Patients With SRE, % Pathologic fracture Radiation therapy Surgical intervention Spinal cord compression Any Saad F, et al. JNCI. 2002;94(19):1458-1468; Saad F, et al. Eur Urol Suppl. 2007;6(11):683-688. Patients With Bone Metastases From Pca Are at High Risk for Developing SREs

3. Skeletal Complications Reduce Quality of Life in Prostate Cancer Patients a P <.05. Data from Weinfurt KP, et al. Ann Oncol. 2005;16(4):579-584. Change in FACT-G score for patients with an event vs patients without an event a a a a a a Change/Standard Deviation Total Physical Functional Emotional

4. SREs Are Associated With Lower Survival in Prostate Cancer Abbreviations: CI, confidence interval; SRE, skeletal-related event. DePuy V, et al. Support Care Cancer. 2007;15:869-876. Probability 090180270 360 Survival, days 0 0.1 0.2 0.3 0.4 0.5 0.7 0.8 0.9 1 0.6 No SRE (n = 355) ≥ 1 SRE (n = 116) 360 Days Survival No SRE: 49.7% ≥ 1 SRE: 28.2% P =.02 Median Survival Times No SRE: 338 days (95% CI = 189, 460) ≥ 1 SRE: 248 days (95% CI = 181, 296)

5. PTHrP IL-6 F ISIOPATOLOGIA DELLA M ETASTASI A DDENSANTE IGF1 TGF  IGF1 TGF  ET1 uPA Osteocalcina ALP TGF-  1 Bertoldo F, Santini D Textbook of Osteoncology 2010 Wnt DDK-1 OPG >RANKL/<OPG

6. Molecular states and bone targeted therapies Nelson PS, J Clin Oncol, feb 2012 Armamentarium Androgen deprivation therapy Bisphosphonates (CITBL, only for BMD) Denosumab (CITBL, also for fracture rate)

7. Nelson PS, J Clin Oncol, feb 2012 Docetaxel (only in metastating setting) Cabazitaxel (in docetaxel-progressing patients) AR inhibitors (MDV3100) (in docetaxel- progressing patients, ASCO 2012) Bisphosphonates (zoledronic acid only in bone metastatic setting) Denosumab (both in bone metastasis prevention and in metastatig setting) Abiraterone (only in metastating setting, after docetaxel) Molecular states and bone targeted therapies Armamentarium Castration-resistant patients

8. Target therapies and potential applications in prostate cancer CTIBL Bone met prevention in castration resistant prostate cancer patients SREs in castration resistant metastatic disease

9. RANK is expressed by cancer cells both at primary tumor and at bone metastases a.confronto primitivi-metastasi considerando tutti i campioni b. confronto primitivi-metastasi considerando solo le coppie metastasi-tumore d’origine Santini D. J Cell Phys, 2010 PRIMITIVI METASTASI (p=.194) (p=.528)

10. Prevention of Bone Metastases in PC: Phase III Denosumab Trial (AMG 147) N = 1.435 Prostate cancer (non metastatic) Hormone-refractory disease High risk of bone metastases (PSA at least 8 and/or PSA doubling time less than 10 months Adequate organ function RANDOMIZATIONRANDOMIZATION Denosumab 120 mg SC every 4 weeks Denosumab 120 mg SC every 4 weeks Placebo Event-driven study: time to bone metastasis or death Primary endpoint: Time to development of bone metastasis or death Secondary endpoint: Time to development of bone metastasis (excluding death) Smith MR, et al. Lancet. 2012.

11. Bone metastasis-free survival Study month Placebo Denosumab 0.0 0.2 0.4 0.6 0.8 1.0 0 3 69 12 1518 2124 273033 36 3942 Median months 25.2 29.5 Events 370 335 HR = 0.85 (95% CI 0.73, 0.98) P = 0.028 Proportion of patients Placebo716691569500421375345300259215168137996036 Denosumab7166956055214564003683242792281851531115935 Smith MR, et al. Lancet. 2012.

12. Bone Metastasis-Free Survival in Patients with PSADT ≤ 6 Months Denosumab 147 Trial Placebo Denosumab Median Months Delay (Months) Events 18.7 25.9 7.2 242 197 HR = 0.77 (95% CI 0.64, 0.93) P = 0.006 23% Risk Reduction Smith MR, et al. ASCO GU, 2012.

13. Sopravvivenza libera da metastasi ossee in pazienti con PSADT ≤4 mesi F. Saad, ASCO 2012

14. ZEUS: Zoledronic Acid for Prevention of Bone Metastases in Prostate Cancer Primary endpoint: Time to bone metastases Secondary endpoints: Overall survival, PSA doubling time, substudies on bone markers, adverse events Abbreviations: ADT, androgen-deprivation therapy; PC, prostate cancer; PSA, prostate-specific antigen. Zoledronic acid 4 mg q 3 months No zoledronic acid N = 1,433 Prostate cancer, M0 ± previous local curative treatment, ± ADT High-risk PC with ≥ 1 of the following criteria: Gleason Score 8-10 pN + PSA  20 at diagnosis Treatment duration: 4 years R Accrual complete

15. Target therapies and potential applications in prostate cancer CTIBL Bone met prevention in castration resistant prostate cancer patients SREs in castration resistant metastatic disease

16. RANDOMIZEDRANDOMIZED Placebo q 3 wk + daily oral vitamin D 400 IU and calcium 500 mg Zoledronic acid 4 mg q 3 wk + daily oral vitamin D 400 IU and calcium 500 mg Randomized Trial of Zoledronic Acid Versus Placebo in Patients With Prostate Cancer 0 15 months Core analysis 1 24 months Final analysis 2 n = 214 n = 208 1. Saad F, et al. J Natl Cancer Inst. 2002;94:1458-1468. 2. Saad F, et al. J Natl Cancer Inst. 2004;96:879-882.

17. 00.2 0.40.60.811.21.41.61.82.028 P Value 0.603 0.670.027 No Prior SRE 40% 33% Prior SRE Risk Ratio (ZOL 4 mg vs Placebo) In favor of ZOL In favor of placebo Risk Reduction.002 0.640 36% Overall Trial Population Abbreviations: SRE, skeletal-related event; ZOL, zoledronic acid. Adapted from Saad F, et al. Clin Genitourin Cancer. 2007;5(6):390-396. Before Study Entry Zoledronic Acid Reduced the Risk of SREs Regardless of Prior SRE History

18. N = 951 zoledronic acid 4 mg IV* and placebo SC Q4W N = 950 denosumab 120 mg SC and placebo IV Q4W Study Design: International, Randomised, Double- Blind, Active-Controlled Study Fizazi K, et al. Lancet. 2011;377:813–822. Primary Endpoint  Time to first on-study skeletal-related event (SRE) (noninferiority) Secondary Endpoints Time to first on-study SRE (superiority) Time to first on-study SRE (superiority) Time to first and subsequent on-study SRE(s) (superiority) Time to first and subsequent on-study SRE(s) (superiority) Supplemental calcium and vitamin D strongly recommended Key Inclusion Criteria Castration-resistant prostate cancer and  1 bone metastases Key Exclusion Criteria Current or prior IV bisphosphonate treatment

19. Baseline Characteristics Fizazi K, et al. Lancet. 2011;377:813–822. Characteristic Denosumab (N = 950) Zoledronic Acid (N = 951) Median age, years (IQR)71 (64–77)71 (66–77) ECOG performance status of 0 or 1, n (%)882 (93)886 (93) Stratification Factors PSA at randomisation  10  g/L, n (%) 805 (85)806 (85) Recent chemotherapy (  6 weeks before randomisation), n (%) 132 (14) Previous SRE, n (%)232 (24)231 (24) Median time from diagnosis of bone metastasis to randomisation, months (IQR) 3.94 (1.22–15.67)5.19 (1.31–16.10)

20. Primary Endpoint: Time to First On-Study SRE Fizazi K, et al. Lancet. 2011;377:813–822. 0.00 1.00 Proportion of Subjects Without SRE 03912 15182124 27 0.25 0.50 0.75 Kaplan-Meier Estimate of Median Months Denosumab Zoledronic acid 20.7 17.1 HR = 0.82 (95% CI, 0.71–0.95) P  0.001 (noninferiority) P = 0.008 (superiority) Study Month Patients at Risk: Zoledronic acid 951733544407299207140936447 Denosumab9507585824723612591681157039 6

21. Secondary Endpoint: Time to First and Subsequent On-Study SRE(s) (Multiple-Event Analysis) Fizazi K, et al. Lancet. 2011;377:813–822. Rate ratio = 0.82 (95% CI, 0.71–0.94) 0.0 2.0 Cumulative Mean Number of SREs per Patient 0.2 0.6 1.0 1.4 1.8 0.4 0.8 1.2 1.6 Denosumab Zoledronic acid 584 494 Events P = 0.009 (superiority) 03 6912 15 182124 2730 3336 Study Month

22. Exploratory Endpoint: Overall Survival. Fizazi K, et al. Lancet. 2011;377:813–822. HR = 1.03 (95% CI, 0.91–1.17) P = 0.65 0.00 Proportion of Patients Survived 369121518 2124 27 Study Month 1.00 0.25 0.50 0.75 Denosumab Zoledronic acid 95186474563551940129720714398 Denosumab95087274664555242731023315699 Patients at Risk: 55 54 30 0

23. Summary of Adverse Events ‡P = 0.09 Fizazi K, et al. Lancet. 2011;377:813–822. Patient Incidence Denosumab (N = 943) n (%) Zoledronic Acid (N = 945) n (%) Infectious AEs402 (43)375 (40) Acute phase reactions (first 3 days)79 (8)168 (18) Renal AEs139 (15)153 (16) Cumulative rate of osteonecrosis of the jaw (ONJ) ‡ 22 (2)12 (1) Year 110 (1) 5 (1) Year 222 (2) 8 (1) Hypocalcaemia121 (13)55 (6) New primary malignancy18 (2)10 (1)

24. Skeletal Complication Risk: Incremental Benefits in Prostate Cancer No bisphosphonate 49% risk at 2 yrs Zoledronic ~ 20% risk reduction Denosumab Additional ~ 12% risk reduction Denosumab Additional 18% time to first SRE increase Saad F, JNCI, 2004, Fizazi K, Lancet, 2011 +

25. Bone targeted therapies nella neoplasia prostatica metastatica - Aggiornamento 2012 - L’acido zoledronico si è dimostrato efficace nel ridurre le complicanze scheletriche di pazienti con metastasi ossee da carcinoma prostatico (Livello di evidenza 1++; positiva forte) (Livello di evidenza 1++; positiva forte) Il denosumab non è inferiore all’acido zoledronico in termini di tempo al primo SRE Il denosumab non è inferiore all’acido zoledronico in termini di tempo al primo SRE (Livello di evidenza 1++; positiva forte) (Livello di evidenza 1++; positiva forte) Il denosumab è superiore all’acido zoledronico in termini di tempo al primo SRE e di tempo al primo e ai successivi SRE Il denosumab è superiore all’acido zoledronico in termini di tempo al primo SRE e di tempo al primo e ai successivi SRE (Livello di evidenza 1-; positiva debole) (Livello di evidenza 1-; positiva debole) Safety: Safety: L’incidenza di ONJ durante il trattamento con denosumab è almeno pari a quella riscontratta durante il trattamento con acido zoledronico L’incidenza di ONJ durante il trattamento con denosumab è almeno pari a quella riscontratta durante il trattamento con acido zoledronico (Livello di evidenza 1++; positiva forte) (Livello di evidenza 1++; positiva forte)

26. Effect of Abiraterone Acetate on Pain Control and Skeletal-Related Events in Patients With Metastatic Castration- Resistant Prostate Cancer Post Docetaxel: Results From The COU-AA-301 Phase 3 Study C. Logothetis, J. S. de Bono, A. Molina, E. M. Basch, K. Fizazi, S. North, K. N. Chi, R. J. Jones, O. B. Goodman, P. N. Mainwaring, C. N. Sternberg, D. D. Gagnon, R. Dhawan, M. Rothman, Y. Hao, C. S. Liu, T. S. Kheoh, H. I. Scher, and C. M. Haqq Logothetis et al. JCO 2011; 29 (Suppl): Abst4520 (oral)

27. Meccanismo azione abiraterone Cholesterol Pregnenolone Progesterone Corticosterone 17α-OH- pregnenolone DHEA Androstenedione 17α –OH- progesterone Cortisol CYP17 C17,20-lyase CYP17 17α- hydroxylase Aldosterone Deoxy- corticosterone DHT 5α-reductase 11-Deoxy- cortisol Desmolase X X ACTH Abiraterone Testosterone Yang, Drugs. 2011; Attard, JCO 2008 Gli androgeni che stimolano la proliferazione tumorale sono prodotti in tre siti critici: –Testicoli –Ghiandola surrenale –Cellule tumorali prostatiche Abiraterone inibisce la sintesi degli androgeni in tutti e tre i siti Testosteronemia < 1ng/dl

28. Overall Study Design AA 1000 mg daily Prednisone 5 mg BID n = 797 Primary end point: OS Secondary end points: PSA response rPFS Tertiary end points: Pain SREs Efficacy end points Placebo daily Prednisone 5 mg BID n = 398 RANDOMIZEDRANDOMIZED (N = 1195) Patients Baseline, Cycle 1 (Day 15), subsequent treatment cycles (Day 1) BPI questionnaire de Bono et al. NEJM 2011

29. Symptomatic Improvement - Pain Intensity Palliation 155/349 (44.4%) 44/163 (27.0%) P = 0.0002

30. ResultsAA (n = 797) Placebo (n = 398) P Value Overall survival Median, months 14.810.9 < 0.0001 PSA response rate Total38.0%10.1% < 0.0001 Confirmed29.1%5.5% Radiographic PFS Median, months 5.63.6 < 0.0001 Time to first SRE (pathologic fracture/spinal cord compression/ palliative radiation/bone surgery) 25 th percentile, days 301.0150.0 < 0.0001 Logothetis et al. JCO 2011; 29 (Suppl): Abst4520 (oral)

31. JS De Bono, ASCO, 2012

35. No standard drugs Src inhibitors (dasatinib, saracatinib)? Endothelin RA inhibitors (atresartan, zibotentan)? Anti-HER2/neu? Inhibitor of MET and VEGFR2 (cabozantinib)? AR inhibitors (MDV3100)? Bisphosphonates (problably) Denosumab (strong biological rational – src in a down stream gene of rank- rank is expressed also in prostate cancer cells) Denosumab works also in patients without NTX suppression during zoledronic acid Molecular states and bone targeted therapies Armamentarium Nelson PS, J Clin Oncol, feb 2012

36. Overview: bone health and target molecules Src inhibitors (Saracatinib, Dasatinib)

37. Evidence for a Role of Src in Bone Metabolism and Metastatic Bone Disease Src kinase is a nonreceptor tyrosine kinase, highly expressed in normal osteoclasts 1,2 Src plays an essential role in RANKL-mediated osteoclast activation 3 and perhaps survival 4 Src knockout mice are osteopetrotic 5 Src may be critical for tumor cell survival in bone microenvironment 6 1. Horne WC, et al. J Cell Biol. 1992;119(4):1003-1013; 2. Tanaka S, et al. FEBS Lett. 1992;313(1):85-89; 3. Boyce BF, et al. J Clin Invest. 1992;90(4):1622-1627; 4. Wong BR, et al. Mol Cell. 1999;4(6):1041-1049; 5. Lowe C, et al. Proc Natl Acad Sci U S A. 1993;90(10):4485-4489; 6. Zhang XH, et al. Cancer Cell. 2009;16(1):67-78.

38. Role of Src in Prostate Tumor Cell and Osteoclast Activities Tumor cells Systemic factorsLocal factors Osteoclast activity Growth factors Osteolysis Bone complications Direct bone destruction Activated osteoclast Bone Src

39. Tumor cells Systemic factorsLocal factors Osteoclast activity Growth factors Osteolysis Direct bone destruction Bone Src Dasatinib in PC: Inhibition of Tumor Cells and Osteoclast Activity Through Src Dasatinib

41. Doc + P vs Doc + P + DASATINIB Preliminary results: 4.8 months OS improvement with the combination Longer PFS with the combination Median time to SRE longer (7.5 vs. 6.0 months) Phase III study: READY (ongoing) (metastatic hormonorefractory prostate cancer patients)

42. Autori, Matthew Raymond Smith, Christopher Sweeney, Dana E. Rathkopf, Howard I. Scher, Christopher Logothetis, Daniel J. George, Celestia S. Higano, Evan Y. Yu, Andrea Lynne Harzstark, Eric Jay Small, A. Oliver Sartor, Michael S. Gordon, Nicholas J. Vogelzang, David C. Smith, Maha Hussain, Johann Sebastian De Bono, Naomi B. Haas, Christian Scheffold, Yihua Lee, Paul G. Corn; ASCO 2012 Abstract 4513 Cabozantinib (XL184) in chemotherapy- pretreated metastatic castration resistant prostate cancer (mCRPC): Results from a phase II nonrandomized expansion cohort (NRE).

43. Risposta sulle lesioni ossee (revisione indipendente)

44. No standard drugs Src inhibitors (dasatinib, saracatinib)? Endothelin RA inhibitors (atresartan, zibotentan)? Anti-HER2/neu? Octreotide? Pasireotide? TKIs? Inhibitor of MET and VEGFR2 (cabozantinib)? Bisphosphonates (problably) Denosumab (strong biological rational – src in a down stream gene of rank- rank is expressed also in prostate cancer cells) Denosumab works also in patients without NTX suppression during zoledronic acid Molecular states and bone targeted therapies Armamentarium Nelson PS, J Clin Oncol, feb 2012

45. Autori, Chris Parker, Sten Nilsson, Daniel Heinrich, Joe M. O'Sullivan, Sophie D. Fossa, Ales Chodacki, Pawel J. Wiechno, John P. Logue, Mihalj Seke, Anders Widmark, Dag Clement Johannessen, Peter Hoskin, David Bottomley, Robert Edward Coleman, Nicholas J. Vogelzang, C. Gillies O'Bryan-Tear, Jose E. Garcia- Vargas, Minghua Shan, A. Oliver Sartor; TLA Abstract LBA4512 Updated analysis of the phase III, double-blind, randomized, multinational study of radium-223 chloride in castration-resistant prostate cancer (CRPC) patients with bone metastases (ALSYMPCA). C Parker et al, ASCO, 2012 …. and how to place radium-223 ?

46. A.O. Sartor et al, ASCO GU, 2012 Disegno dello studio

47. Analisi aggiornata della sopravvivenza globale C Parker et al, ASCO, 2012

48. Analisi aggiornata del tempo allo sviluppo del primo evento scheletrico C Parker et al, ASCO, 2012

49. Nuovi farmaci per nuovi e vecchi Target Santini D et al. Cancer Treat Reviews, 2010

50. Thank you very much for your attention d.santini@unicampus.it