Supplementary Figure 1

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Doris Armstrong
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1 Supplementary Figure 1 1

2 Supplementary Figure 1 Workflow for preclinical studies with GEMMs. A schematic representation of the criteria and experimental process used in this study is presented. Steps in the process are shown from top to bottom including criteria for model selection, characterization to determine preclinical trial suitability and intervals, and establishment of tumor imaging methods. Once a model is deemed ready for preclinical trials, it is important to ascertain human clinical context and endpoints that can be modeled in the selected GEMM. Finally, one must delineate the pharmacokinetic parameters and a dosing regimen for the agent(s) that best simulates the patient therapies being examined. 2

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4 Supplementary Figure 2 Overall survival, tumor progression, micro-ct imaging validation, and representative histology in the Kras LSL-G12D ; p53 frt/frt NSCLC GEMM. (a) Kaplan-Meier survival analysis of Kras LSL-G12D ; p53 frt/frt mice infected with different doses of Adenovirus-FLPe/IRES/Cre (Ad-FIC). The viral dose (in infectious units, iu), numbers of mice followed for each dose (in parentheses), and the median overall survival (in weeks post-infection, wpi) are denoted in the legend. Animals infected at 5.00E+05 iu were followed out to 20 wpi and terminated as they remained asymptomatic. All survival curves were significantly different from each other (P 0.05, log-rank test). (b) Representative volumetric renderings of ex vivo micro-ct images of lungs at four different time points and three doses (16 wpi) of Ad-FIC. The selected dose and time point for initiating preclinical regression studies was 5.00E+06 iu and 16 wpi, respectively. (c-d) The number of tumors (c) and total tumor volume (mm 3 ) (d) in the lungs of mice were analyzed by ex vivo micro-ct at three different time points and doses of Ad-FIC. Both parameters increased in a viral dose- and time-dependent manner. Both tumor number and volume at 5.00E+06 iu, 16 wpi were significantly increased over other time points and doses (P 0.05, student s t-test). (e) The correlation between in vivo tumor cross-product and ex vivo tumor volume as measured by micro-ct at 16 and 20 wpi is shown. To compare the linear relationship between tumor cross-product and tumor volume, the tumor cross-product values were raised to the 3/2 power. The correlation showed a significant relationship between the two data sets (P < ). (f) Kras LSL-G12D ; p53 frt/frt mice are born with normal lung morphology and disease is initiated via intranasal infection with Adeno-FLPe-IRES-Cre virus (Ad- FIC). Representative photomicrographs of H&E-stained lung sections depicting the various stages of disease progression are shown on top, left to right starting with (i) normal bronchial epithelium for comparison (40x). (ii) Atypical alveolar hyperplasia (AAH, 100x) is first evident at 2 weeks post-infection (wpi) and is characterized by thickening and increased layers in the bronchial epithelium. (iii) Solid, benign adenomas (Ad, 400x) first appear at ~4 wpi, showing increased cellular atypia. (iv) Progressive adenocarcinomas (AdC, 100x) first present at ~8 wpi. The bottom panel of photomicrographs show (v) a higher magnification (400x) within an AdC and 4

5 demonstrate the presence of characteristic giant cells (yellow arrows), (vi) invasion into the surrounding stroma (400x), and (vii) a metastasis to a regional lymph node (100x). A representative micro-ct image with visible lung lesions (yellow arrows) is shown in (viii). 5

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7 Supplementary Figure 3 Overall survival, tumor progression, ultrasound imaging validation, and representative histology in the Kras LSL-G12D ; p16/p19 fl/fl ; Pdx1-Cre PDAC GEMM. (a) Kaplan-Meier survival analysis of Kras LSL-G12D ; p16/p19 fl/fl ; Pdx1-Cre (KPP), Kras LSL-G12D ; p16/p19 fl/+ ; Pdx1-Cre (KPH), and p16/p19 fl/fl ; Pdx1-Cre (PP) mice. The numbers of mice followed for each genotype (in parentheses) and the median overall survival (in weeks, wks) are denoted in the legend. KPH mice showed a significant reduction in lifespan as compared to asymptomatic PP mice (P < , log-rank test), while KPP mice showed a further significant reduction in survival (P < compared to KPH mice, log-rank test). (b) The increase in KPP pancreas weight over time due to tumor development (n = 3-7 mice/group). The weights in the 8 week old mice were significantly increased relative to the 6 week old mice (P = 0.02, student s t- test); the 6.5 and 7 week old weights were not significantly increased, but reflected a similar trend. (c) Tumor volumes of the same mice shown in (b) were measured by ultrasound and reflected similar trends with increasing age. (d) The correlation between pancreas weight and tumor volume by ultrasound over time showed a significant relationship. (e) Representative photomicrographs of H&E-stained pancreas sections from Kras LSL-G12D ; p16/p19 fl/fl ; Pdx1-Cre mice with (i) normal histology (40x) shown top left for comparison. Continuing from left to right, (ii) and (iii) progressively advanced pancreatic intraepithelial neoplasia (PanIn) is first evident at ~5 weeks of age and is characterized by thickening ductal epithelium and deformation. (iv) Focal ductal adenocarcinoma (top right) is observed beginning at ~6 weeks of age. All grades of pancreatic adenocarcinoma (PDAC), including (v) ductal adenocarcinoma and (vi) sarcomatoid tumors, are detectable by weeks of age, as well as (vii) frequent local invasion and metastases into the mesenteric lymph nodes as shown in the bottom panels. A representative ultrasound image of a tumor (outlined) is shown in (viii). 7

8 Supplementary Figure 4 Supplementary Figure 4 Dosing regimens for preclinical studies in NSCLC and PDAC GEMMs. (a-b) NSCLC (a) or PDAC (b) mice were dosed according to the regimens depicted. Abbreviations: mpk = mg per kg, i.p. = intraperitoneal, p.o. = per os (oral) dosing, qd = daily dosing, qdx5 = daily dosing for five consecutive days, q3dx4 = dosing every three days for 4 cycles, D = day, US = ultrasound. 8

9 Supplementary Figure 5 Supplementary Figure 5 Kaplan-Meier plots from TRIBUTE for patients treated with chemotherapy alone or chemotherapy plus erlotinib. (a, c) OS data from the total patient populations 1 (a), or the patient subsets with KRAS wild-type (wt) tumors 2 (c). (b) TTP data from the total patient populations 1. (d) PFS data from the patient subsets with KRAS wt tumors 2. The number of patients in each treatment cohort is indicated in parentheses. Relevant P values (log-rank test) and hazard ratios are depicted for each graph, and the comparator group (denominator) is denoted with a hyphen (-). The 95% confidence intervals for hazard ratios shown are: (a) , (c) , and (d) Abbreviations: OS = overall survival, TTP = time to tumor progression, PFS = progression-free survival, C = carboplatin, P = paclitaxel, E = erlotinib, HR = Hazard 9

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12 Supplementary Figure 6 Tolerability of drug regimens used for preclinical studies in NSCLC and PDAC GEMMs. (a, c) Body weight averages for the NSCLC (a) and PDAC (c) study mice described in this report. Mice were weighed at least twice weekly throughout the course of study and the averages of two measurement intervals (a and b on the x-axis) are plotted along with their standard deviation. Weights are represented as the percentage of weight from the start of treatment for each mouse. (b, d) The number of mice weighed at each interval is tabulated for NSCLC (b) and PDAC (d). Abbreviations: C = carboplatin, E = erlotinib, A = anti-vegf, G = gemcitabine. 12

13 Supplementary Figure 7 13

14 Supplementary Figure 7 Human KRAS mutant xenografts treated with single agent chemotherapy, erlotinib, and anti-vegf or combinations thereof. (a, c, e, and g) Tumor growth curves over time. (b, d, f, and h) Kaplan-Meier overall survival (OS) analyses of the fraction of mice with tumors < 1000 mm 3 are plotted. Regimens that provided significant (P 0.05, log-rank test) tumor growth delays relative to vehicle controls are marked with an asterisk. N = 10 mice/group in all experiments. (a, b) A549 NSCLC xenografts were treated with vehicle control, paclitaxel (30 mg/kg, qodx5 at study start), erlotinib (100 mg/kg, qd, starting on day 15 until the end of study EOS)), or the combination. (c, d) A549 NSCLC xenografts were treated with vehicle control, paclitaxel (30 mg/kg, qodx5 at study start), anti-vegf/b (5 mg/kg, twice-weekly, starting on day 15 the until EOS), or the combination. (e, f) A549 NSCLC xenografts were treated with various combinations of paclitaxel, erlotinib and anti-vegf/b using the same doses and regimens indicated in (a-d). (g, h) BxPC3 PDAC xenografts were treated vehicle control, gemcitabine (160 mg/kg, q3dx4 at study start), anti- VEGF/B (5 mg/kg, once-weekly, starting on day 1 until the EOS), or the combination. 14

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18 Supplementary Figure 8 Supplementary Figure 8 Tumor growth measurements of individual Kras LSL-G12D ; p53 frt/frt NSCLC mice. (a, d) In vivo x-ray micro-ct was used to monitor tumor growth in individual NSCLC mice for each treatment regimen examined in this study. Thin blue lines represent the interval between images at baseline and either ~15 days (a) or ~28 days (d) post-study start. Thick black lines represent the mean trend for each cohort. The number of animals in each cohort is denoted above each individual panel. (b, e) P values from pair-wise comparisons between each treatment cohort at either ~15 days (b) or ~28 days (e) post-study start are tabulated. (c, f) The anti-logged values of the slopes in each longitudinal plot are graphed for ~15 days (c) or ~28 days (f) poststudy start and depict the differences in daily fold change in each treatment group. The number of animals for which a second image was available for determining the slope 18

19 calculation is represented on the x-axes. Please note that distinct cohorts of mice were used for the ~15 day (a-c) and ~28 day (d-f) image assessments and analyses. Abbreviations: C = carboplatin, E = erlotinib, A = anti-vegf. 19

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21 Supplementary Figure 9 Supplementary Figure 9 Tumor growth measurements of individual Kras LSL-G12D ; p16/p19 fl/fl ; Pdx1-Cre PDAC mice. (a) In vivo high-resolution micro-ultrasound imaging was used to monitor tumor growth in individual PDAC mice for each treatment regimen examined in this study. Thin blue lines represent the interval between serial images at baseline, ~12 days, and ~28 days (if alive) post-study start. Thick black lines represent the mean trend for each cohort. The number of animals in each cohort is denoted above each individual panel. (b) P values from pair-wise comparisons between each treatment cohort at ~12 days post-study start are tabulated. (c) The antilogged values of the slopes in each longitudinal plot are graphed and depict the differences in daily fold change in each treatment group. The number of animals for which a second image was available for determining the slope calculation is 21

22 represented on the x-axis. Abbreviations: G = gemcitabine, E = erlotinib, A = anti- VEGF. 22

23 Supplementary Table 1. Relevant phase II and III trials examining bevacizumab and erlotinib in NSCLC and PDAC. Trial Trial name phase Setting Treatment Arms BR.21 3 III Second and third line, Stage IIIB-IV NSCLC Arm 1: Placebo Arm 2: Erlotinib Primary Endpoint OS Secondary Endpoint PFS, ORR, Response Duration, Safety, & QoL OSI II Second line, Stage IIIB-IV NSCLC Arm 1: Docetaxel or Pemetrexed + Placebo Arm 2: Docetaxel or Pemetrexed + Bevacizumab Arm 3: Erlotinib + Bevacizumab Safety & preliminary efficacy (PFS) OS BeTA 5 III Second line, Stage IIIB-IV NSCLC Arm 1: Erlotinib + Placebo Arm 2: Erlotinib + Bevacizumab OS PFS, ORR, Response Duration, & molecular/efficacy outcome relationship TRIBUTE 1 III First line, Stage IIIb-IV NSCLC Arm 1: Carboplatin + Paclitaxel + Placebo Arm 2: Carboplatin + Paclitaxel + Erlotinib OS TTP, ORR, Response Duration, & Safety TALENT 6 III First line, Stage IIIb-IV NSCLC Arm 1: Cisplatin + Gemcitabine + Placebo Arm 2: Cisplatin + Gemcitabine + Erlotinib OS TTP, RR, Response Duration, & QoL SATURN 7 III First line, Stage IIIb-IV NSCLC Arm 1: Platinum-based chemotherapy ---> Placebo maintenance Arm 2: Platinum-based chemotherapy ---> Erlotinib maintenance PFS in all patients & EGFR IHC+ patients PFS in EGFR IHC- patieints, EGFR FISH EGFR mutations, & KRAS mutaitons ATLAS 8 IIIb First line or recurrent, Stage IIIb-IV NSCLC Arm 1: Carboplatin-based doublet + Bevacizumab ---> Bevacizumab + Placebo maintenance Arm 2: Carboplatin-based doublet + Bevacizumab ---> Bevacizumab + Erlotinib maintenance PFS OS, RR, & Safety ECOG III First line or recurrent, Stage IIIb-IV NSCLC Arm 1: Carboplatin + Paclitaxel Arm 2: Carboplatin + Paclitaxel + Bevacizumab OS PFS, RR, & Safety AVAiL 10 III First line or recurrent, Stage IIIb-IV, non-squamous NSCLC Arm 1: Cisplatin + Gemcitabine + Placebo, 7.5 /kg Arm 2: Cisplatin + Gemcitabine + Placebo, 15.0 mg/kg Arm 3: Cisplatin + Gemcitabine + Bevacizumab, 7.5 mg/kg Arm 4: Cisplatin + Gemcitabine + Bevacizumab, 15.0 mg/kg PFS OS, RR & Safety TOPICAL 11 III First line, patients unsuitable for chemo, Stage IIIb-IV, NSCLC Arm 1: Placebo Arm 2: Erlotinib 1 year OS PFS, RR, Safety, & QoL TITAN 11 III Second line, Stage IIIB-IV NSCLC Arm 1: Erlotinib Arm 2: Docetaxel or Pemetrexed OS PFS, TTP, ORR, Response Duration, & Safety NCIC CTG PA.3 12 III First line, Locally advanced or metastatic, PDAC Arm 1: Gemcitabine + Placebo Arm 2: Gemcitabine + Erlotinib OS PFS, RR, QoL, Safety, & molecular/effica outcome relationships CALGB III First line, Locally advanced or metastatic, PDAC Arm 1: Gemcitabine + Placebo Arm 2: Gemcitabine + Bevacizumab OS PFS, ORR, Response Duration, Safety, & molecular/efficacy outcome relationship AViTA 14 III First line, Locally advanced or metastatic, PDAC Arm 1: Gemcitabine + Erlotinib + Placebo Arm 2: Gemcitabine + Erlotinib + Bevacizumab OS PFS, RR, Safety, & Tolerability Definitions: PDAC = Pancreatic Ductal Adenocarcinoma; OS = Overall Survival; PFS = Progression Free Survival; TTP = Time to Tumor/Disease Progression; ORR = Objective or Overall Response Rate; RR = Response Rate; QoL = Quality of Life. 23

24 Supplementary Table 2. Pharmacokinetic profiles of therapeutic agents in mice & humans. Human C57Bl/6J Mice Drug Regimen Dose Exposure (AUC) Regimen Dose Exposure (AUC) Carboplatin q3w x 6 ~400 mg/m ug/ml*min 15 qdx5 25 mg/kg 1300 ug/ml*min^ Gemcitabine qw x 3, Q4w x mg/m ug/ml*min 16 q3d x mg/kg 1120 ug/ml*min Erlotinib qd 150 mg 1744 ug/ml*min 17 qd 100 mg/kg ug/ml*min anti-vegfa* q3w 15 mg/kg 1560 ug/ml*day 2x/wk 5 mg/kg 147 ug/ml*day Definition: *Bevacizumab in human and B in mice; ^Exposure delivered as 25 mg/kg PO due to tolerability issues; cumulative exposure = 6500 ug/ml*min 24

25 SUPPLEMENTARY REFERENCES 1. Herbst, R.S. et al. TRIBUTE: a phase III trial of erlotinib hydrochloride (OSI-774) combined with carboplatin and paclitaxel chemotherapy in advanced non-small-cell lung cancer. J. Clin. Oncol. 23, (2005). 2. Eberhard, D.A. et al. Mutations in the epidermal growth factor receptor and in KRAS are predictive and prognostic indicators in patients with non-small-cell lung cancer treated with chemotherapy alone and in combination with erlotinib. J. Clin. Oncol. 23, (2005). 3. Shepherd, F.A. et al. Erlotinib in previously treated non-small-cell lung cancer. The New England journal of medicine 353, (2005). 4. Herbst, R.S. et al. Phase II study of efficacy and safety of bevacizumab in combination with chemotherapy or erlotinib compared with chemotherapy alone for treatment of recurrent or refractory non small-cell lung cancer. J. Clin. Oncol. 25, (2007). 5. Hainsworth, J.D. & Herbst, R.S. A phase III, multicenter, placebo-controlled, doubleblind, randomized clinical trial to evaluate the efficacy of bevacizumab (Avastin) in combination with erlotinib (Tarceva) compared with erlotinib alone for treatment of advanced non-small cell lung cancer after the failure of standard first-line chemotherapy (BeTA). J. Thorac. Oncol. 3, S302 (2008). 6. Gatzemeier, U. et al. Phase III study of erlotinib in combination with cisplatin and gemcitabine in advanced non-small-cell lung cancer: the Tarceva Lung Cancer Investigation Trial. J. Clin. Oncol. 25, (2007). 7. Cappuzo, F. et al. SATURN: A double-blind, randomized, phase III study of maintenance erlotinib versus placebo following nonprogression with first-line platinumbased chemotherapy in patients with advanced NSCLC. J. Clin. Oncol. 27, 15s suppl, abstr 8001 (2009). 8. Miller, V.A., O'Conner, P., Soh, C. & Kabbinavar, F. A randomized, double-blind, placebo-controlled, phase IIIb trial (ATLAS) comparing bevacizumab (B) therapy with or without erlotinib (E) after completion of chemotherapy with B for first-line treatment of locally advanced, recurrent, or metastatic non-small cell lung cancer (NSCLC). J. Clin. Oncol. 27, 15s suppl, abstr LBA8002 (2009). 9. Sandler, A. et al. Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer. The New England journal of medicine 355, (2006). 10. Reck, M. et al. First-line bevacizumab combined with cisplatin/gemcitabine (CG) in patients (Pts) with advanced or recurrent non-squamous, non-small cell lung cancer (NSCLC): AVAiL (BO17704), a phase III randomised study. J. Thorac. Oncol. 3, S302 (2008). 11. ClinicalTrials.gov at Moore, M.J. et al. Erlotinib plus gemcitabine compared with gemcitabine alone in patients with advanced pancreatic cancer: a phase III trial of the National Cancer Institute of Canada Clinical Trials Group. J. Clin. Oncol. 25, (2007). 13. Kindler, H.L., Niedzwiecki, D., Hollis, D., Oraefo, E., Schrag, D., Hurwitz, H., McLeod, H., Mulcahey, M., Schilsky, R., Golberg, R. A double-blind, placebo-controlled, randomized phase III trial of gemcitabine (G) plus bevacizumab (B) versus gemcitabine 25

26 plus placebo (P) in patients (pts) with advanced pancreatic cancer (PC): A preliminary analysis of Cancer and Leukemia Group B (CALGB 80303). J. Clin. Oncol. ASCO Annu Meet Proc Part I. 25, 4508 (2007). 14. Van Cutsem, E. et al. Phase III trial of bevacizumab in combination with gemcitabine and erlotinib in patients with metastatic pancreatic cancer. J. Clin. Oncol. 27, (2009). 15. Amgen (ed.) Guide to Selected Chemotherapy Regimens and Associated Adverse Events, Edn. Sixth. (2005). 16. Grimison, P. et al. Randomized crossover study evaluating the effect of gemcitabine infusion dose rate: evidence of auto-induction of gemcitabine accumulation. J. Clin. Oncol. 25, (2007). 17. Frohna, P. et al. Evaluation of the absolute oral bioavailability and bioequivalence of erlotinib, an inhibitor of the epidermal growth factor receptor tyrosine kinase, in a randomized, crossover study in healthy subjects. J. Clin. Pharmacol. 46, (2006). 26

Targeted Agents as Maintenance Therapy. Karen Kelly, MD Professor of Medicine UC Davis Cancer Center

Targeted Agents as Maintenance Therapy Karen Kelly, MD Professor of Medicine UC Davis Cancer Center Disclosures Genentech Advisory Board Maintenance Therapy Defined Treatment Non-Progressing Patients Drug