1. Updated results, multivariate and subgroups analysis confirm improved activity and efficacy for FOLFOXIRI vs FOLFIRI in the G.O.N.O. randomized phase III study in metastatic colorectal cancer. 2007 A.S.C.O. Annual Meeting Chicago (USA), June 1-5 A. Falcone 1,3, M. Andreuccetti 1, I. Brunetti 2, S. Ricci 2, C. Barbara 1, W. Evangelista 4, V. Passeri 5, S. Chiara 6, G. Allegrini 1, G. Masi 1 1 U.O. Oncologia Medica, Azienda USL-6, Livorno; 2 U.O. Oncologia Medica, Ospedale S. Chiara, Pisa; 3 Università degli Studi di Pisa, 4 Centro Oncologico ed Ematologico Subalpino, Ospedale S. Giovanni Battista Le Molinette, Torino, 5 Dipartimento di Medicina Sperimentale e Patologia, Oncologia Medica, Università la Sapienza, Roma, 6 Istituto Nazionale per la Ricerca sul Cancro, Genova ITALY

2. ABSTRACT Background: As previously reported (ASCO 2006) the G.O.N.O. conduced a phase III study comparing FOLFIRI to FOLFOXIRI in 244 patients (pts) with not resectable MCRC. At a median follow-up of 18.4 months (mos) we reported significant improvements in response-rate (RR), R0 resection of metastases (mts), PFS and OS for FOLFOXIRI. Methods: Results have been updated (median follow- up of 36.2 mos) and 14 variables were tested as possible prognostic factors for response, R0 resection, PFS and OS. Results: At this updated analysis 225 (111 vs 114) pts have progressed and 180 (84 vs 96) have died. Results confirm the significant improvements for FOLFOXIRI in terms of confirmed RR (60% vs 34% p 25%. Conclusions: FOLFOXIRI confirms to be the first combination demonstrated to be superior to an infusional 5FU containing doublet as FOLFIRI in terms of RR, R0 resections, PFS and OS. FOLFOXIRI represents a new treatment option in MCRC and its use and study is of particular interest in a neoadjuvant strategy, in pts with few chances to achieve a three-drug exposure in a sequential strategy and in combination with targeted agents. Partially supported by Fondazione ARCO.

3. RATIONALE Preclinical synergism between CPT-11, LOHP and 5FU and different dose-limiting toxicities (Fischel, BJC 2001) FOLFOXIRI can expose 100% of pts to all the 3 active agents (CPT- 11, LOHP and 5-FU) while in a sequential strategy 25-50% of pts does not receive II line CT and therefore is not exposed to all the 3 agents (Grothey, JCO 2004) FOLFOXIRI, if more active, may improve post-CT resection-rate of mts (Folprecht, Ann Oncol 2005) FOLFOXIRI RATIONALE FOLFIRI was a reference standard combination in MCRC (Douillard, Lancet 2000) FOLFOXIRI was a feasible regimen with manageable toxicities and promising activity in phase I-II studies (Falcone JCO 2002; Masi Ann Onc 2004) STUDY RATIONALE

4. STUDY DESIGN FOLFIRI* CPT-11180 mg/m 2 1-h d.1 L-LV100 mg/m 2 2-h d.1,2 5FU400 mg/m 2 bolus d.1,2 5FU 600 mg/m 2 22-h d.1,2 q. 2 wks x 12 cycles FOLFOXIRI** CPT-11165 mg/m 2 1-h d.1 LOHP 85 mg/m 2 2-h d.1 L-LV200 mg/m 2 2-h d.1 5FU 3200 mg/m 2 48-h CI d.1 q. 2 wks x 12 cycles Stratification Center PS 0/1-2 Adjuvant CT RANDOMRANDOM  In pts progressed after FOLFIRI a second-line CT with an LOHP containing regimen (FOLFOX) was recommended * Douillard Lancet 2000 ** Masi Ann Oncol 2004

5. FOLFOXIRI SCHEDULE 5FU flat continuous infusion 3200mg/m 2 L-LV 200 mg/m 2 Oxaliplatin 85 mg/m 2 2 hours Repeated every 14 days CPT-11 165 mg/m 2 48 hours Day 1 Day 2 Day 3 1 hour

6. MAIN PATIENTS SELECTION CRITERIA Metastatic and unresectable colorectal cancer Measurable disease Age 18-75 yrs ECOG PS 0-2 (ECOG PS=0 for pts 71-75 yrs) Adjuvant CT ended > 6 mos Adequate renal, hepatic and bone-marrow functions No previous CPT-11 or LOHP No previous CT for metastatic disease

7. PATIENTS CHARACTERISTICS * Accrual from November 2001 to April 2005 FOLFIRI (122 pts) FOLFOXIRI (122 pts) Age, median (range)64 (21-75)62 (27-75) Sex (M/F)69/5375/47 ECOG PS 0 / 1-261% / 39% Previous adjuvant CT24% Synchronous mts65% Multiple sites of disease45%47% Liver mts only34%32% Liver involvement ≥ 25%57%53% LDH >UNL25%23%

8. NON-HEMATOLOGICAL TOXICITY (NCI) GRADE 3-4 PER PATIENT (N=122) p < 0.0001 ** Grade 2-3 **

9. HEMATOLOGICAL TOXICITY (NCI) GRADE 3-4 PER PATIENT (N=122) p =0.0006

10. FOLFIRI 122 pts FOLFOXIRI 122 pts Complete6%8% Partial35%58% Complete + Partial41%*66%* 95% Confidence Interval0.32-0.500.56-0.74 Stable33%21% Progression24%11% Not evaluable2% *p = 0.0002 RESPONSES (ITT analysis) INVESTIGATORS’ ASSESSMENT INVESTIGATORS’ ASSESSMENT

11. FOLFIRI 122 pts FOLFOXIRI 122 pts Complete6%7% Partial28%53% Complete + Partial34%*60%* 95% Confidence Interval0.25-0.430.51-0.68 Stable34%21% Progression24%11% Not evaluable8% *p < 0.0001 EXTERNALLY REVIEWED EXTERNALLY REVIEWED RESPONSES (ITT analysis)

12. Logistic regression multivariate analysis of predictive factors for Response CovariateP valueHR(95% CI) Treatment FOLFIRI1.0 FOLFOXIRI<0.0012.91.7-4.9 Variables tested: Treatment, sex, age, PS, primary, N. organs involv., sites of mts,% liver involv., time from diagnosis to mets, previous adjuvant CT, LDH, CEA, WBC, HB

13. FOLFIRI (122 pts) FOLFOXIRI (122 pts) R0 6%* (7 pts) 15%* (18 pts) R11%2% Explorative8%1% * p=0.033 POST-CT SURGICAL RESECTIONS (all patients) POST-CT SURGICAL RESECTIONS (all patients)

14. FOLFIRI (42 pts) FOLFOXIRI (39 pts) R0 12%* (5 pts) 36%* (14 pts) * p=0.017 POST-CT SURGICAL RESECTIONS (patients with liver mts only) POST-CT SURGICAL RESECTIONS (patients with liver mts only)

15. Logistic regression multivariate analysis of predictive factors for secondary R0-Surgery CovariateP valueHR(95% CI) Treatment FOLFIRI1.0 FOLFOXIRI0.0183.11.2-7.9 Liver only metastases Yes1.0 No0.0540.270.1-1.0 Variables tested: Treatment, Sex, age, PS, primary, N. organs involv., Sites of mts,% liver involv., Time from diagnosis to mets, previous adjuvant CT, LDH, CEA, WBC, HB

16. FOLFIRI 122 pts FOLFOXIRI 122 pts Progressed114111 Median PFS6.9 m9.9 m HR: 0.65 (95%CI: 0.47-0.83) log-rank P value = 0.0009 PROGRESSION FREE SURVIVAL

17. Cox’s multivariate analysis of prognostic factors for Progression Free Survival Covariatep valueHR(95% CI) Treatment FOLFIRI1.0 FOLFOXIRI<0.0010.640.49-0.83 ECOG PS > 11.0 00.020.730.55-0.95 Gender Female1.0 Male0.0540.770.59-1.0 Variables tested: Treatment, sex, age, PS, primary, N. organs involv., sites of mts,% liver involv., time from diagnosis to mets, previous adjuvant CT, LDH, CEA, WBC, HB

18. Hazard ratios for risk of progression in subgroups (1) CaracteristcsTotal n Median n HR95% CI All Patients 2441226.91229.90.650.43-0.83 PS (ECOG) 0 1-2 148 96 74 48 8.2 5.6 74 48 9.9 9.6 0.68 0.59 0.47-0.94 0.36-0.87 Age <65 yr ≥65 yr 147 97 66 56 5.2 7.9 81 41 9.6 10.4 0.58 0.70 0.38-0.79 0.46-1.06 Gender Male Female 145 99 69 53 6.9 76 46 10.2 9.4 0.62 0.67 0.42-0.88 0.43-1.01 Primary Colon Rectum 176 68 95 27 7.0 6.6 81 41 9.4 10.4 0.70 0.55 0.50-0.94 0.29-0.90 Previous adjuvant CT Yes No 58 186 29 93 7.5 6.7 29 93 11.2 9.8 0.81 0.60 0.46-1.40 0.43-0.80 Time from diagnosis to randomization < 3 months ≥ 3 months 158 86 79 43 6.8 7.4 79 43 9.8 10.5 0.62 0.72 0.43-0.84 0.45-1.11 LDH ≤UNL >UNL n.a. 120 59 65 56 31 35 6.9 6.8 6.7 64 28 30 10.2 9.7 9.4 0.53 0.69 0.89 0.32-0.73 0.39-1.16 0.53-1.48 FOLFIRIFOLFOXIRI

19. CaracteristcsTotal n Median n HR95% CI All patients 2441226.91229.80.630.47-0.81 CEA <100 ≥100 n.a. 142 74 28 70 38 14 7.4 5.4 72 36 14 10.2 8.7 10.9 0.63 0.76 0.52 0.43-0.87 0.46-1.21 0.20-1.12 HGB <11 ≥11 n.a. 37 198 9 20 96 6 7.3 6.7 7.6 17 102 3 10.4 9.8 10.5 0.70 0.63 0.94 0.35-1.33 0.45-0.83 0.22-3.96 GB <8000 ≥8000 n.a 123 111 10 61 54 7 7.5 6.4 4.4 62 57 3 10.2 9.2 10.5 0.67 0.58 0.81 0.45-0.96 0.37-0.84 0.21-3.19 Liver mts only yes no 81 163 42 80 6.9 6.8 39 83 9.2 10.0 0.75 0.57 0.46-1.20 0.39-0.77 n° organ involvement 1 >1 132 112 67 55 7.1 6.4 65 57 9.8 10.0 0.80 0.48 0.55-1.13 0.28-0.65 Liver involvement <25% >25% n.a. 83 102 59 40 54 31 7.4 6.9 6.8 43 48 28 11.8 9.1 10.5 0.54 0.79 0.67 0.32-0.82 0.52-1.16 0.36-1.17 FOLFIRIFOLFOXIRI Hazard ratios for risk of progression in subgroups (2)

20. FOLFIRIFOLFOXIRI Progressed pts114111 Second-line CT78% 73% FOLFOX87% 15% FOLFIRI5% 23% FOLFOXIRI1% 20% Mitomycin-C0% 17% Infusional 5FU3%11% Cetuximab1% 7% Bevacizumab0% Other3% 6% SECOND-LINE CHEMOTHERAPY

21. OVERALL SURVIVAL FOLFIRI 122 pts FOLFOXIRI 122 pts Died9684 Median OS16.7 m23.6 m HR: 0.74 (95%CI: 0.55-0.99) log-rank P value = 0.042 19% 13% Median follow up: 36.2 months

22. Cox’s multivariate analysis of prognostic factors for Survival CovariateP valueHR(95% CI) Treatment FOLFIRI1.0 FOLFOXIRI0.0410.740.55-0.99 Liver involvement > 25%1.0 < 25%0.0010.510.34-0.77 no0.610.43-0.85 Variables tested: Treatment, Sex, age, PS, primary, N. organs involv., Sites of mts,% liver involv., Time from diagnosis to mets, previous adjuvant CT, LDH, CEA, WBC, HB

23. Hazard ratios for risk of OS in subgroups (1) CaracteristcsTot aln Median n HR95% CI All Patients 24412216.712223.60.740.55-0.98 PS (ECOG) 0 1-2 148 96 74 48 17.6 14.1 74 48 24.2 20.8 0.70 0.80 0.47-1.01 0.50-1.26 Age <65 yr ≥65 yr 147 97 66 56 13.4 20.2 81 41 23.9 23.6 0.58 1.02 0.38-0.82 0.63-1.67 Gender Male Female 145 99 69 53 17.1 16.7 76 46 27.3 17.2 0.60 1.02 0.44-0.87 0.65-1.62 Primary Colon Rectum 176 68 95 27 16.7 14.9 81 41 23.4 24.1 0.74 0.77 0.52-1.05 0.42-1.37 Previous adjuvant CT Yes No 58 186 29 93 20.9 15.4 29 93 23.8 23.6 1.05 0.66 0.56-1.97 0.47-0.92 Time from diagnosis to randomization < 3 months ≥ 3 months 158 86 79 43 15.3 19.9 79 43 23.6 24.1 0.66 0.92 0.46-0.93 0.54-1.56 LDH ≤UNL >UNL n.a. 120 59 65 56 31 35 16.5 19.4 14.9 64 28 30 24.1 20.8 27.1 0.70 0.82 0.81 0.45-1.06 0.45-1.46 0.45-1.42 FOLFIRIFOLFOXIRI

24. CaracteristcsTotal n Median n HR95% CI All patients 24412216.712223.60.740.55-0.98 CEA <100 ≥100 n.a. 142 74 28 70 38 14 19.8 15.9 11.0 72 36 14 23.4 21.3 28 0.90 0.68 0.34 0.61-1.33 0.39-1.14 0.09-0.6 HGB <11 ≥11 n.a. 37 198 9 20 96 6 16.7 15.9 14.3 17 102 3 18.4 23.4 27.2 0.85 0.73 0.91 0.41-1.73 0.52-1.01 0.19-4.26 GB <8000 ≥8000 n.a. 123 111 10 61 54 7 19.1 14.8 11.9 62 57 3 29.3 21.3 27.3 0.75 0.71 0.78 0.49-1.15 0.46-1.09 0.18-3.30 Liver mts only yes no 81 163 42 80 17.3 15.7 39 83 24.2 21.1 0.82 0.71 0.49-1.36 0.49-1.01 N° organ involvement 1 >1 132 112 67 55 19.8 13.9 65 57 24.3 21.1 0.96 0.53 0.64-1.45 0.34-0.79 Liver involvement <25% >25% n.a 83 102 59 40 54 31 18.0 15.7 24.1 43 48 28 24.8 20.8 25.2 0.91 0.53 1.02 0.55-1.52 0.47-0.81 0.52-1.01 FOLFIRIFOLFOXIRI Hazard ratios for risk of OS in subgroups (2)

25. Survival of pts radically resected after FOLFOXIRI in phasae II and III GONO’s trials N. of pts: 37 N. of events: 18 Median Follow up: 55 months Median Survival: 39.0+ months 5-years Survival: 40% Falcone at al. J Clin Oncol 2002; Masi et al. Ann Oncol 2004; Falcone et al. J Clin Oncol 2007

26. Grothey A, Sargent D. J Clin Oncol. 2005;23:9441-9442. Survival improves with availability of three active drugs * “GONO” FOLFOXIRI P=0.0001

27. Studies incl. selected pts. (liver metastases only, no extrahepat. disease) r=.96, p=.002 Studies incl. all patients with metastatic CRC (solid line) r=.74, p<.001 Phase III studies in metastatic CRC (dashed line) r=.67, p=.024 G Folprecht, A Grothey, S Alberts, HR Raab, and CH Köhne, Ann Oncol 2005 * * “GONO” FOLFOXIRI CORRELATION BETWEEN TUMOR RESPONSE AND RESECTION RATES

28. Doublet + 1 biologic or Triplet in phase III studies Doublet + 1 biologic or Triplet in phase III studies Treatment IFL + BV NEJM ‘04 FOLFOX or XELOX + BV ASCO-GI ‘07 FOLFOXIRI ASCO‘07 N pts402700122 RR (%)44.8%38.0%60.0 % R0 surgery< 2%?15% PFS (months)10.69.49.9 OS (months)20.3?23.6

29. CONCLUSIONS “GONO” FOLFOXIRI is the first studied combination, in a phase III study, that compared to an infusional doublet as FOLFIRI, although at the cost of a modest increase in toxicity, significantly improves ORR, post-CT resection of mts, PFS and OS “GONO” FOLFOXIRI represents a new first-line option in metastatic colorectal cancer patients with similar characteristics to those included in this study The study of FOLFOXIRI should be of particular interest in a neoadjuvant strategy, in pts with few chances to achieve a 3 drugs exposure in a sequential strategy and in combination with targeted agents

30. Thank you to all patients and investigators! Centro TrialM. Andreuccetti, C. Barbara, C. Orlandini AlbaG. Porcile, M. Boe BolognaL. Crinò, G. Benedetti, S. Bartolini, C. Calandri CaltanissettaS. Vitello CorreggioS. Bagnulo CuneoM. Merlano, C. Granetto, E. Fea FirenzeL. Fioretto, A. Ribecco GenovaR. Rosso, S. Chiara LivornoA. Falcone, G. Masi, G. Allegrini, S. Bursi, F. Loupakis NovaraO. Alabisio, S. Miraglia, L. Forti ParmaA. Ardizzoni, R. Camisa, F. Pucci PisaS. Ricci, I. Brunetti, R. Murr, E. Pfanner PistoiaM. Di Lieto, A. Chiavacci PontederaM. Filidei, S. Cupini RomaE. Cortesi, V. Picone, S. Ferraldeschi, G. D’Auria TorinoO. Bertetto, L. Fanchini, W. Evangelista Gruppo Oncologico Nord Ovest