1. Highlights in the Managment of Urogenital Cancer Future directions for targeted therapies in advanced renal cell cancer Alessandro Morabito Unità Sperimentazioni Cliniche Istituto Nazionale Tumori di Napoli Roma, 10 maggio 2008

2. The past… IL-2, interferon

3. Advances in last years In understanding the biology and genetics of renal cell carcinoma Availability of novel targeted approaches for the treatment of metastatic RCC

4. New target-based agents Brugarolas, NEJM 2007 Temsirolimu s Everolimus Sunitinib Sorafenib Bevacizumab Erlotinib Cetuximab

5. Target-based agents: results of phase III trials AuthorAgentSettingPts PFS (months) OR (%) OS (months) Motzer (NEJM, 2007) Sunitinib vs IFN 1 st line750 11 vs 5 (p<0.0001) 31 vs 6 (p<0.001) HR: 0.65 (p=0.02)* Escudier (NEJM, 2007) Sorafenib vs Placebo 2 nd line903 5.5 vs 2.8 (p<0.001) 10 vs 2 (p<0.001) HR: 0.72 (p=0.02)* Hudes (NEJM, 2007) Temsirolimus vs IFN vs TEMSR+IFN 1 st line626 3.7 vs 1.9 vs 3.7 9 vs 7 vs 11 HR: 0.73 (p=0.0069) Escudier (ASCO, 2007) Bevacizumab + IFN vs placebo+IFN 1 st line649 10.2 vs 5.4 (p<0.0001) 31 vs 13 (p<0.0001) HR: 0.75 (p<0.0026)* * No statistically significant according to O’Brien-Fleming

6. The present…: an embarrassment of riches ?

7. Therapeutic algoritm PatientsSetting Therapy (level 1) Options (level  2) Naive MSK Risk: good or intermediate Sunitinib (Bevacizumab + IFN) HD IL-2 MSK Risk: poor Temsirolimus Sunitinib Refractory Cytokine refractory Sorafenib Sunitinib Bevacizumab Refractory to angiogenesis inhibitors Investigational

8. Future directions ?

9. Targeted therapies: challenges and future directions Combination therapy New schedules Sequential strategies Role of cytokines New agents Predictive biomarkers Adjuvant and neo-adjuvant therapy

10. Targeted therapies: challenges and future directions Combination therapy New schedules Sequential strategies Role of cytokines New agents Predictive biomarkers Adjuvant and neo-adjuvant therapy

11. Combination therapy What is the actual goal of therapy with combination of target based agents? What are the targets we want to direct therapy toward? How does one develop a rationale to proceed into the clinic with combination therapy?

12. Goal of combination therapy To increase the degree of the antitumor effects of single agents To induce more complete responses impeding the onset of refractory disease To overcome the resistance that develops with single-agent therapy

13. Morabito A, Ann Oncol 2006 Alternative end points for agents that are not expected to cause a major tumor regression…

14. Phase II design for targeted agents is similar to that of cytotoxics Objective response seems to be a useful end-point and it is predictive for success of the drug Agents with high response rates tended to have high non-progression rates Renal cell carcinoma is the exception to this…

15. Non PD rates...

16. Targets for RCC therapy VHL or HIF mediated pathways –VEGF –VEGF receptors –EGFR –mTOR –PDGF Non-VHL-mediated pathways –Raf kinase –Phosphatidylinositol 3-kinase –Akt –Nuclear factor  B

17. Rationale combinations of targeted therapies Horizontal blockade –Numerous target molecules downstream from HIF-  are inhibited Vertical blockade –The same pathway is targeted at two or more different levels

18. Horizontal blockade Targets generally in different cell types (tumor, endothelial, pericyte) Inhibition by multiple specific agents or by multitargeted agents To prevent cancer cell proliferation, promote apoptosis, ablate angiogenesis Sosman JA, Clin Cancer Res 2007

19. Horizontal blockade of VEGF and EGFR pathways Elevated levels of TGF-  in RCC TGF-  is a growth factor for RCC independent of stroma Elevated expression of VEGF has been considered to be a mechanism for acquired resistance to EGFR blockade Inhibition of EGFR results in suppression of VEGF expression in laboratory models Bevacizumab Sunitinib Sorafenib Erlotinib Gefitinib

20. Combination of bevacizumab and erlotinib: results of a phase 2 study (positive…) Single agent bevacizumab: 10% objective responses Poor results with single-agent treatment against EGFR Hainsworth JD, J Clin Oncol 2005 Bevacizumab Sunitinib Sorafenib Erlotinib Gefitinib

21. Combination of bevacizumab and erlotinib: results of a randomized phase 2 study (negative…!) Bukowski, J Clin Oncol 2007

22. Horizontal blockade of VEGF and EGFR pathways: other combinations AgentsPhasePtsResults Sunitinib + Gefitinib* 1/2 42 Sunitinib 37.5 mg + Gefitinib 250 mg OR = 36% Sunitinib + Erlotinib** 213 Sunitinib 50 mg + Erlotinib 150 mg Activity: 10/11 pts Bevacizumab Sunitinib Sorafenib Erlotinib Gefitinib *Patel, ASCO 2007 **Ryan, Genitourinary Cancer Symposium 2008

23. Vertical blockade The same pathway is targeted at two or more different levels Vertical blockade could overcome an aspect of resistance that may develop through feedback mechanisms (ie.  VEGF levels in response to blocking VEGFR) Sosman JA, Clin Cancer Res 2007 Temsirolimus Everolimus Bevacizumab Sunitinib Sorafenib

24. Vertical blockade of VEGF pathway Temsirolimus Everolimus Bevacizumab Sunitinib Sorafenib AgentsPhasePtsResults Bevacizumab + sunitinib* 116 Sunitinib feasible at 37.5 mg + bevacizumab 10 mg/kg OR: 4/13 pts Bevacizumab + sorafenib** 1-218 Sorafenib feasible at 200 mg + bevacizumab 3 mg/kg 10 PR and 4 SD / 24 pts *Feldman DR, ASCO 2007 **Sosman JA, ASCO 2006

25. Vertical blockade of VEGF pathway Temsirolimus Everolimus Bevacizumab Sunitinib Sorafenib AgentsPhasePtsResults Temsirolimus + sorafenib* 124 Evaluation of sorafenib 200 mg BID + temsirolimus 25 mg ongoing Everolimus + sorafenib** 110 Sorafenib feasible at 400 mg BID + everolimus 5 mg ongoing PR: 33% *Patnaik A, ASCO 2007 **Rosenberg JE, Genitourinary Cancer Symposium 2008

26. Vertical blockade of VEGF pathway Temsirolimus Everolimus Bevacizumab Sunitinib Sorafenib AgentsPhasePtsResults Bevacizumab + temsirolimus* 1-212 DLT: hypertriglyceridemia and stomatitis Recommended dose of bevacizumab 10 mg/kg q 14 and temsirolimus 25 mg/w Primary endpoint (phase 2): 6-month PFS PR (phase 1): 67% Bevacizumab + everolimus** 114 Recommended dose of bevacizumab 10 mg/kg q 14 and everolimus 10mg Bevacizumab + everolimus + erlotinib*** 134 Recommended dose of bevacizumab 5 mg/kg q 14, everolimus 5 mg and erlotinib 75 mg/die Activity in RCC and CRC *Merchan JR, ASCO 2007; ** Zafar Y, ASCO 2006; *** Bendell JC, ASCO 2007

27. Phase II Study of Bevacizumab, Sorafenib, and Temsirolimus in mRCC (ECOG 2804 “BeST” Trial) Eligibility criteria ● Confirmed clear cell RCC ● Measurable metastatic disease ● <25% of any other histology (papillary, chromophobe, or oncocytic) ● Primary or metastatic lesion ● Not curable by standard radiotherapy or surgery ● Prior nephrectomy ● No more than 1 prior regimen containing vaccine- or cytokine-based immunotherapy ● No prior antiangiogenic therapy, bevacizumab or mTOR inhibitors Bevacizumab i.v. over 30−90 min d1−15 + Temsirolimus 25 i.v over 30 min d1, d8, d15, d22 Bevacizumab 10 i.v. over 30−90 min d1-15 Primary endpoint: PFS Start Date: September 2007; recruiting (N=360) + Sorafenib 200 b.i.d. p.o., d1−28 Bevacizumab 5 i.v. over 30−90 min d1−15 + Sorafenib p.o. b.i.d., d1−28 Temsirolimus i.v. over 30 min d1, d8, d15, d22 RANDOMIsATIONRANDOMIsATION NCT00378703. www.clinicaltrials.gov.

28. SABRE-R: Phase II Study of Sunitinib With or Without Bevacizumab as First-line Therapy in mRCC (USA) Eligibility criteria ● Histologically confirmed mRCC ● Measurable disease by RECIST ● ECOG PS of 0 or 1 ● Prior nephrectomy ● No prior systemic or adjuvant therapy ● Adequately controlled hypertension (n=50) Primary endpoint: PFS and safety Secondary end points: ORR, duration of response, TTP, OS (N=100) + RANDOMISATIONRANDOMISATION Sunitinib 50 mg p.o. o.d. 4/2 schedule Bevacizumab 10 mg/kg i.v. q2w NCT00491738. www.clinicaltrials.gov. + Sunitinib 50 mg p.o. o.d. 4/2 schedule Placebo Start Date: August 2007; recruiting

29. Phase II Open-label Study of Bevacizumab plus Temsirolimus for First-line Treatment of mRCC (n=40) (n=80) Eligibility criteria ● Metastatic RCC ● No prior systemic treatment ● ECOG PS ≤2 Bevacizumab 10 mg/kg every 2 weeks + temsirolimus 25 mg/week Sunitinib 50 mg/day 4/2 schedule (N=160) Bevacizumab 10 mg/kg every 2 weeks + IFN-  9 MU q.i.w. RANDOMISATIONRANDOMISATION PIs: Escudier and Negrier Primary endpoint: PFS at 48 weeks Secondary endpoints: ORR, response duration, OS, QoL, safety

30. Targeted therapies: challenges and future directions Combination therapy New schedules Sequential strategies Role of cytokines New agents Predictive biomarkers Adjuvant and neo-adjuvant therapy

31. New schedules Dose escalation of Sorafenib * –Phase 2 study of intra-patient dose escalation of sorafenib, up to 800 mg BID –91% of pts escalated to 1200 mg or 1600 mg per day –OR: 52% Continuous daily administration of Sunitinib** –107 pts, refractory to cytokines, randomized in a phase 2 study (morning vs evening) –Manageable safety profile –OR: 19% and SD: 40% * Amato RJ, ASCO 2007 ** Srinivas S, ASCO 2007

32. Renal EFFECT: Phase II Trial of Sunitinib CD vs the 4/2 Schedule in First-line mRCC Primary end point: TTP Secondary end points: safety and tolerability, ORR, OS, QOL Eligibility criteria ● Advanced RCC ● Clear-cell histology ● Measurable disease ● No prior systemic therapy ● No brain metastasis (N=282) RANDOMISATIONRANDOMISATION Sunitinib 50 mg p.o. daily on 4/2 schedule Sunitinib 37.5 mg p.o. continuous daily NCT00267748. www.clinicaltrials.gov. Start Date: December 2005; recruiting

33. Targeted therapies: challenges and future directions Combination therapy New schedules Sequential strategies Role of cytokines New agents Predictive biomarkers Adjuvant and neo-adjuvant therapy

34. Sequencial strategies Is there a role? –TKIs have antitumor activity in RCC pts previously treated with antiangiogenic therapy Which agent? –Type of anti-angiogenic therapy received does not predict response to subsequent therapy Is there an optimal sequence? –Current data support use of sequential TKIs; prospective studies in progress will define efficacy and toxicity

35. Sequential TKIs in advanced RCC: retrospective analyses SequencePtsCR+PRSD Sorafenib  Sunitinib Tamaskar et al. 1 31 (33%)- Escudier et al. 2 348 (24%)22 (64%) Sunitinib  Sorafenib Tamaskar et al. 1 504 (80%) Escudier et al. 2 143 (21%)8 (57%) Tamaskar et al. ASCO 2006; Escudier et al. ASCO 2007

36. START: Randomised Phase II Sequential Two-agent Assessment in RCC Therapy (Proposed) Eligibility criteria ● mRCC of any type ● PS 0/1 ● No brain mets ● No prior systemic therapy Sunitinib (N=240) (n=120) Bevacizumab Sunitinib Bevacizumab Temsirolimus (n=60) Stratification: Clear cell vs non–clear cell Prior nephrectomy (yes/no) PS (0/1) Progression RANDOMISATIONRANDOMISATION R R Objectives: Estimate TTP1 and ORR with each drug (first-line setting) Estimate TTP2 and ORR with each drug (second-line setting) Estimate and rank TTP1 + TTP2 for each sequence

37. Randomised Phase III Study of Temsirolimus vs Sorafenib as second-line Therapy in mRCC Primary end point: PFS Secondary end points: OS, ORR, QoL, Safety Temsirolimus 25 mg i.v. + Best supportive care Sorafenib + Best supportive care N=440 Eligibility criteria Metastatic clear cell RCC Measurable disease Failed sunitinib Karnofsky PS ≥70% ≥1 measurable lesion by RECIST No prior mTOR inhibitors No brain metastases RANDOMISATIONRANDOMISATION NCT00474786. www.clinicaltrials.gov Start Date: July 2007; recruiting Expected Completion Date: October 2010

38. MD Anderson: Study Proposal

39. Targeted therapies: challenges and future directions Combination therapy New schedules Sequential strategies Role of cytokines New agents Predictive biomarkers Adjuvant and neo-adjuvant therapy

40. Role of cytokines VEGF has been shown to suppress immune function by: –blocking maturation of myeloid cells into mature dendritic cells –inducing the immature myeloid cells to suppress normal T-cell responses Anti-VEGF therapy may reverse these immunosuppressive effects

41. Bukowski RM, Berlin 2008 Interferon and…. bevacizumab

42. *Bracarda S, Genitourinary Cancer Symposium 2008; **Gollob J, ASCO 2006; ***Ryan W, ASCO 2006 § Kondagunta GV, ASCO 2007 Interferon and…. VEGFR inhibitors SchedulesPhasePtsResults Sorafenib + interferon* 2, randomized 100OR: 34%; clinical benefit: 80% Sorafenib + interferon **231OR: 42%; clinical benefit: 88% Sorafenib + interferon ***267OR: 19%; clinical benefit: 66% Sunitinib + interferon §125 Recommended dose: sunitinib 37.5 mg and IFN 3 MUI OR: 12%; clinical benefit: 92%

43. IL-2 and…bevacizumab SchedulesPhasePtsResults Low dose IL-2 + bevacizumab* 224OR: 9%; clinical benefit: 36% Low dose IL-2 + bevacizumab + Gem + 5-FU* 1-232OR: 30%; clinical benefit: 60% *Tamaskar IR, Genitourinary Cancer Symposium 2008; Buti S, ASCO 2007

44. Targeted therapies: challenges and future directions Combination therapy New schedules Sequential strategies Role of cytokines New agents Predictive biomarkers Adjuvant and neo-adjuvant therapy

45. New agents VEGFR inhibitors –Axitinib –AZD2171 –Pazopanib –Everolimus (RAD001) Integrin inhibition –M200 (volociximab) Akt/MAP kinase inhibition –Perifosine –Tie 2 inhibition –AMG 386 C-Met inhibition –ARQ 197 –XL880

46. New VEGFR inhibitors in RCC AgentPhasePtsResults AG-013736 (Axitinib)* as second line in patients refractory to sorafenib 262OR: 14%; clinical benefit: 50% AZD2171 (Cediranib)** as first line 224OR: 38%; clinical benefit: 75% Pazopanib*** as first/second line 2 RDT60OR: 40%; clinical benefit: 82% *Rini BI, ASCO 2007; **Sridhar SS; ASCO 2007; ***Hutson TE, ASCO 2007

47. Everolimus 10 mg/d + BSC Everolimus: Phase III in RCC (RECORD-1 study) ● Oral inhibitor of mTOR ● Patients with metastatic RCC and PD after receiving sunitinib and/or sorafenib ● Stratified by number of prior treatments and MSKCC risk criteria (favourable vs intermediate vs poor) ● The trial was stopped after a planned interim results showed significantly better progression-free survival with everolimus….Complete results will be presented at ASCO 2008 Placebo + BSC N=362 2 : 1 RAD001 : Placebo NCT00410124. www.clinicaltrials.gov

48. PatientsSetting Therapy (level 1) Options (level  2) Naive MSK Risk: good or intermediate Sunitinib (Bevacizumab + IFN) HD IL-2 MSK Risk: poor Temsirolimus Sunitinib Refractory Cytokine refractory Sorafenib Sunitinib Bevacizumab Refractory to angiogenesis inhibitors Investigational The next algorithm…? Everolimus?

49. Targeted therapies: challenges and future directions Combination therapy New schedules Sequential strategies Role of cytokines New agents Predictive biomarkers Adjuvant and neo-adjuvant therapy

50. Predictive biomarkers Serum/plasma markers: –VEGF –sVEGFR Tissue/cells: –HIF expression –VHL gene mutation

51. Bukowski RM, ASCO 2007

53. VHL status and clinical outcome Hypothesis: tumors with VHL gene inactivation should exhibit a greater objective response rate to VEGF-targeted therapy 123/189 pts treated with: –sunitinib (n=63) –axitinib (n=15) –bevacizumab (n=17) –sorafenib (n=28) Choueiri et al. ASCO 2007

54. 53%0%

55. Targeted therapies: challenges and future directions Combination therapy New schedules Sequential strategies Role of cytokines New agents Predictive biomarkers Adjuvant and neo-adjuvant therapy

56. S-TRAC: Sunitinib Phase III Trial in Adjuvant Renal Cancer Treatment High-risk patients according to UISS Staging System* N=236 *T3 N0 or NX, M0, Fuhrman’s grade ≥2, ECOG ≥1 or T4 N0 or NX, M0, any Fuhrman’s grade, and any ECOG status or Any T, N1-2, M0, any Fuhrman’s grade, and any ECOG status Endpoint: Disease-free survival NCT00375674. www.clinicaltrials.gov NEPHRECTOMYNEPHRECTOMY RANDOMISERANDOMISE Sunitinib 50 mg/day 4 weeks on/2 weeks off for 1 year Placebo for 1 year Stratify Primary end point: Disease-free survival Secondary end points: OS, safety, patient- related outcomes, association of molecular markers with regression - free survival Start Date: September 2007; recruiting

57. Non-metastatic RCC Disease stage II–IV N=1,332 ASSURE: Adjuvant Sorafenib or Sunitinib for Unfavourable RCC NEPHRECTOMYNEPHRECTOMY Stratify* RANDOMISERANDOMISE Sunitinib 50 mg/day 4 weeks on/2 weeks off Total = 9 cycles † Placebo twice daily for 6 weeks Total = 9 cycles † Sorafenib 400 mg twice daily for 6 weeks Total = 9 cycles † Duration: 1 year Primary endpoint: DFS *UISS (II–V); Histologic subtype clear cell/non-clear cell † Biopsy at recurrence NCT00326898. www.clinicaltrials.gov ECOG-sponsored, randomised, double-blind, multicentre phase III trial; currently recruiting Start Date: May 2006; recruiting

58. SORCE: Sorafenib in Patients with Resected Primary RCC at High or Intermediate Risk of Relapse Stratify Sorafenib 400 mg b.i.d. for 3 years Placebo for 3 years Sorafenib 400 mg b.i.d. for 1 year then placebo for 2 years Endpoint: time to metastases Duration: 1 vs 3 years Patients with high- and intermediate- risk resected RCC N=1420 NEPHRECTOMYNEPHRECTOMY RANDOMISATIONRANDOMISATION NCT00492258. www.clinicaltrials.gov. Start Date: June 2007; recruiting

59. Phase II study of neoadjuvant Sunitinib for Patients with RCC ● Non-randomised, open label, uncontrolled, single group assignment, safety/efficacy study ● Primary outcome measures –radiological response rate associated with 2 cycles of sunitinib ● Secondary outcome measures: –change in tumour vascularity –assessment of tissue markers –safety and tolerability ● Enrollment: 30 ● Inclusion/exclusion criteria –locally confined tumour ≤7 cm –has not undergone nephrectomy and is a candidate for surgical treatment of RCC –ECOG performance status 0 or 1 –no prior therapy of any kind for RCC (including nephrectomy, immunotherapy, chemotherapy, radiation, hormonal, or investigational therapy) ● University Health Network, Toronto Start Date: October 2007 (University of Toronto) NCT00480935. www.clinicaltrials.gov.

60. Group 3 –Oral sorafenib twice daily on days 1−28 –Cytoreductive nephrectomy on day 29 –Oral sorafenib twice daily on days 43−84 Group 2 –Oral sorafenib twice daily on days 1−7 –Cytoreductive nephrectomy on day 8 –Oral sorafenib twice daily on days 22−84 Group 1 –Cytoreductive nephrectomy on day 1 –oral sorafenib twice daily on days 15−84 Sorafenib for Patients Who Are Undergoing Surgery for Metastatic Kidney Cancer ● Objectives: –determine the efficacy and toxicity of neoadjuvant sorafenib in patients (N=45) with mRCC who are undergoing cytoreductive nephrectomy ● Non-randomised study – patients are sequentially assigned to 1 of 3 treatment groups NCT00126659. www.clinicaltrials.gov. Start Date: January 2006; ongoing, not recruiting

61. ● Non-randomised, open-label, uncontrolled, single group assignment, safety/efficacy study ● Primary objectives –time to progression and safety ● Secondary objectives (Clinical) –response rate, duration of response, OS ● Enrollment: 50 ● Inclusion/exclusion criteria –patients with histologically or cytologically confirmed clear cell metastatic RCC who are eligible for cytoreductive nephrectomy –ECOG performance status less than or equal to 1 –patients must not have received any systemic anticancer therapy Radiation therapy is allowed if >/= 2 weeks from study drug administration NCT00113217. www.clinicaltrials.gov. Start Date: February 2005; recruiting Neoadjuvant phase II clinical trial of bevacizumab for RCC

62. In the next years.... Ongoing studies will clarify: –The role of combination therapy (also including cytokines) –The optimal sequence of therapy –Therapy for resistant disease –Molecular biomarkers defining groups benefiting from anti-VEGF therapy

63. The future …: an embarrassment of results?