1. Long-term outcome of unresectable metastatic colorectal cancer (MCRC) patients (pts) treated with first-line FOLFOXIRI followed by R0 surgical resection of metastases. ECCO Barcelona, 23-27 September 2007 G. Masi 1, S. Bursi 1, F. Loupakis 1, C. Barbara 1, I. Brunetti 2, R. Ferraldeschi 3, W. Evangelista 4, S. Chiara 5, C. Granetto 6, A. Falcone 1,7 1 U.O. Oncologia Medica, Az. USL 6, Livorno, 2 U.O. Oncologia Medica, Ospedale S.Chiara, Pisa, 3 Dipartimento di Medicina Sperimentale e Patologia, Oncologia Medica, Università la Sapienza, Roma, 4 Centro Oncologico ed Ematologico Subalpino, Ospedale S. Giovanni Battista Le Molinette, Torino, 5 Dipartimento di Oncologia Medica, IST, Genova, 6 Azienda Ospedaliera S.Croce e Carle, Cuneo, 7 Università degli Studi di Pisa, ITALY.

2. ABSTRACT (updated) Background: Prognosis of pts with initially unresectable MCRC can be improved if chemotherapy induces a significant down-sizing of metastatic disease thus allowing an R0 surgical resection of metastases (mts). In particular it has been demonstrated a clear correlation between the activity of the regimen used and the rate of secondary R0 resections (Folprecht et al, Ann Oncol 2005). Methods: We studied the triple drug combination FOLFOXIRI (irinotecan 165 mg/sqm d1, oxaliplatin 85 mg/sqm d1, l-LV 200 mg/sqm d1, 5-FU 3200 mg/sqm 48-h flat continuous infusion starting on d1, repeated every 2 weeks) in phase II and III trials. Overall 196 pts with initially unresectable MCRC and not selected for a neo-adjuvant strategy were treated. This regimen was associated with an elevated activity (response rate ranging from 66% to 72%) and 37 patients (19%) could undergo to a secondary R0 surgery on mts Results: Characteristics of the 37 radically resected pts were: median age 64 years (45-73), ECOG PS ≥1 in 11 pts (30%), median CEA 10 ng/ml (1-288), liver involvement ≥ 25% in 18 pts (49%). Sites of disease were: liver only 25 pts (68%), lung only 4 pts (11%), liver + lymphnodes 5 pts (13%), liver + peritoneum 1 pt (3%), liver + lung 2 pts (5%). Mts were synchronous in 24 pts (65%) and metachronous in 13 pts (35%). There was no perioperative mortality. After a median follow up of 60.5 mos median OS is 41+ mos. The actuarial 5-year survival is 45% from the onset of chemotherapy. In 11 pts progressed after surgery a surgical re-resection and/or radiofrequency ablation was performed. Conclusions: These data indicate that FOLFOXIRI allows an R0 surgical resection in about one out of five pts with initially unresectable MCRC not selected for a neoadjvant approach. Long term survival of resected pts is significant and comparable with the survival of pts resectable up-front. This FOLFOXIRI regimen should be considered as neo-adjuvant treatment in initially unresectable metastatic colorectal cancer pts. Partially supported by Fondazione ARCO.

3. Synergism between 5-FU/LV, CPT-11 and LOHP in experimental models. Zeghari-Squalli 1997 Different dose limiting toxicities. Exposure of MCRC patients to all the 3 active cytotoxics (5-FU/LV, L-OHP and CPT-11) is associated with the best outcome, but in a sequential strategy only 50-80% of patients receive second-line CT. Tournigand 2004, Goldberg 2003, Grothey 2004 A more active first-line CT allows an higher rate of post- CT R-0 surgical resections, and these pts may have a long-term survival. Giachetti 1999, Adam 2001, Pozzo 2004, Folprecht 2005 FOLFOXIRI: BACKGROUND

4. STUDIES DESIGN We studied the outcome of 196 pts with initially unresectable MCRC treated in 3 separate studies: STUDY 1: a phase I-II study with bi-weekly irinotecan, oxaliplatin and infusional 5-FU/LV (FOLFOXIRI, 42 pts). Falcone et al, JCO 2002 STUDY 2: a phase II study with the same combination with a simplified schedule (simplified FOLFOXIRI, 32 pts). Masi et al, Ann Oncol 2004 STUDY 3: a phase III study comparing FOLFOXIRI vs FOLFIRI. Falcone et al, JCO 2007 Surgical resection of mts was not a prospective part of these 3 studies, but was routinely reconsidered in pts responsive to CT. This retrospective analysis evaluates the outcome of pts treated with CT followed by a potentially curative resection of mts.

5. FOLFOXIRI Phase I-II (N=42) S-FOLFOXIRI Phase II (N=32) S-FOLFOXIRI Phase III (N=122) CPT-11 mg/m 2 IV 1-h, d1 175165 L-OHP mg/m 2 IV 2-h, d1 10085 l-LV mg/m 2 IV 2-h, d1 200 5-FU mg/m 2 IV 48-h, d1  3 3.800 chrono 3.200 continuous 3.200 continuous repeated every 2 weeks FOLFOXIRI: SCHEDULES

6. MAIN PATIENTS CHARACTERISTICS FOLFOXIRI Phase I-II (N=42) S-FOLFOXIRI Phase II (N=32) S-FOLFOXIRI Phase III (N=122) Median age (range) 62.5 (43-73)63 (43/74)62 (27/75) ECOG PS O / 1-2 62% / 38%56% / 44%61%/39% Previous CT 48%28%24% Synchronous mts 55%66%65% Multiple sites of disease 40%53%68% Liver only disease 50%44%32% Liver involvement > 25% 76%71%40%

7. ACTIVITY & EFFICACY FOLFOXIRI Phase I-II (N=42) S-FOLFOXIRI Phase II (N=32) S-FOLFOXIRI Phase III (N=122) Complete Response12%13%7% Partial Response59%59%53% Response Rate71%72%66% R0-surgery19%26%15% Median PFS 10.4 mos 10.8 mos 9.9 mos Median OS 26.5 mos 28.4 mos 23.6 mos Median follow up 21.5 mos 18.1 mos 36.2 mos

8. 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

9. 19% 36% First line FOLFOXIRI 196 pts Surgery revaluated 71 pts POST-CT SURGICAL RESECTIONS R0 surgery performed 37 pts R1 surgery 5 pts Explorative S. 5 pts S. not performed 35 pts

10. CHARACTERISTICS of R0-PATIENTS (n=37) Age, median 64 years (45-73) ECOG PS, 0/1 26 (70%) / 11 (30%) Mts, synchronous/metachronous 24 (65%) / 13 (35%) Disease Free Interval, median 20.1 months (7-55) N. sites of disease, single/multiple 29 (78%) / 8 (22%) Sites of diseaseliver only25 (68%) liver + lymphonodes 5 (14%) liver + peritoneum 1 (3%) liver + lung 2 (5%) lung 4 (10%) Number of mts, median 5 (1-12) Liver involvement≥25% 18 (49%) Median CEA10 (1-288)

11. ONCOSURGE CRITERIA MAIN REASON OF INITIAL UNRESECTABILITY Extensive liver involvement19 (51%) > 6 segments involved 7 (19%) > 70% liver parenchyma involved10 (27%) all three hepatic veins involved 2 (5%) Unresectable extrahepatic disease 6 (16%) Patient unfit for surgery 1 (3%) Immediate resection not appropriate 11 (30%) inadequate radiological margins 4 (11%) portal lymph nodes involvement3 (8%) number of mts >4 or <4 but bilobar4 (11%)

12. PRE-OPERATIVE CT Median N. of cycles:11 (3-15) Median duration of CT:5.5 mos (1.6-8.3) Median time end of CT  S:1.9 mos (0.5-11.9) Objective responses:Complete 5 pts Partial28 pts Stable 4 pts POST-OPERATIVE CT Post-operative CT was not planned, but allowed. Ten patients received postoperative CT. CHEMOTHERAPY of R0 PATIENTS RR: 85%

13. Major hepatectomy (> 3 segments):19 pts Minor hepatectomy (< 3 segments):14 pts Multiple segmental lung resection: 4 pt Surgical removal of circumscribed extra-hepatic disease was also performed in 8 pts with liver mts (abdominal lymphonodes 4 pts, peritoneum 1 pt, lung 2 pt). Intra-operative RF ablation of hepatic mts was used in combination with liver resection, in 8 pts to treat small (< 1 cm) residual nodules that could not be resected, but that could be fully ablated with radiofrequency. There was no intraoperative or postoperative mortality within 2 months after surgery LOCAL TREATMENTS

14. PROGRESSION FREE SURVIVAL of R0 PTS Median PFS: 17.8+ months 5-years PFS: 16% N. of pts: 37 N. of events: 31 Median Follow up: 61 months

15. OVERALL SURVIVAL of R0 PTS N. of pts: 37 N. of events: 21 Median Follow up: 61 months Median Survival: 40.8+ months 5-years Survival: 45%

16. TREATMENTS AFTER PROGRESSION Second-line Chemotherapy25 (80%) FOLFOXIRI 8 (26%) FOLFOX 5 (24%) FOLFIRI11 (35%) Surgical Re-Resection/RF 11 (35%)

17. CONCLUSIONS The GONO-FOLFOXIRI regimen improves RR, PFS and OS in patients with unresectable MCRC and enables a potentially curative surgery in about one out of five of them. Survival of resected pts is considerable with an actuarial 5-year survival of 45% from the onset of CT. These data compare well to that achieved with other regimens in more selected pts with liver-only disease. These data suggest that in some pts with MCRC an aggressive approach of intensive CT followed by surgery might led to long term survival even if the disease is initially unresectable and a minimal extra-hepatic disease is present.

18. Thank you to all patients and investigators! Centro TrialM. Andreuccetti, C. Orlandini, C. Barbara 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, E. Pfanner, S. Di Donato, I. Petrini 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