현재임상시험중인기대되는 간세포암종치료법

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1 현재임상시험중인기대되는 간세포암종치료법 New Options, Emerging Combinations in Advanced Hepatocellular Carcinoma Department of Internal Medicine, School of Medicine, Kyungpook National University Soo Young Park

2 179 Studies found for: Recruiting, Not yet recruiting Studies Studies Without Results Interventional Studies Hepatocellular Carcinoma Phase 2, 3

3 Many Agents Have Failed Phase 3 Trials for HCC Brivanib 1,2,* Agent Target Trial Design Results 1L: Brivanib vs sorafenib (N = 1,150) 2L: Brivanib + BSC vs placebo + BSC (N = 395) 1L: mos = 9.5 vs 9.9 months 2L: mos = 9.4 vs 8.2 months Linifanib 3 Multikinase Linifanib vs sorafenib (N = 1,035) mos = 9.1 vs 9.8 months Sunitinib 4,5 inhibitors Sunitinib vs sorafenib (N = 1,074) mos = 7.9 vs 10.2 months Orantinib 6,8 TACE + orantinib vs placebo (N = 889) mos not available (did not reach primary end point) Tivantinib 7 Tivantinib vs placebo (N = 340) mos = 8.4 vs 9.1 months Everolimus 8 mtor inhibitor S-1 (TS-1 in Japan) 9 Fluoropyrimidine derivative trio Peretinoin 10 Synthetic retinoid Everolimus + BSC vs placebo + BSC (N = 546) TS-1 vs placebo (N = 334) Peretinoin lower dose and higher dose vs pl acebo (N = 377) mos: 7.6 vs 7.3 months mos: days vs 340 days 1-year RFS: 63.6% vs 71.9% vs 66. 0% 3-year RFS: 24.9% vs 43.7% vs 29. 3% *Dual inhibitor of vascular-endothelial growth factor and fibroblast growth factor receptors tyrosine kinases. 1. Johnson PJ et al. J Clin Oncol. 2013;31(28): ; 2. Llovet JM et al. J Clin Oncol. 2013;31(28): ; 3. Cainap C et al. J Clin Oncol. 2015;33(2): ; 4. Cheng AL et al. J Clin Oncol. 2013;31(32): Clinicaltrials.gov. NCT ; 6. Healio. Orantinib Ph3 termination. Available at: 1e432e3%7D/taiho-pharmaceutical-to-terminate-phase-3-trial-of-orantinib-tace-for-hepatocellular-carcinoma. Accessed July 29, 2016; 7. Rimassa L et al. Oral Presentation at ASCO Abstract 4000; 8. NCI Dru g Dictionary. Orantinib. Available at: Accessed September 26, Zhu AX et al. JAMA. 2014;312(1):57-67; 10. Kudo M, et al. ASCO Poster #127; 10. Okita K et al. J Gastroenterol. 2014;50(2):

4 New Investigational Therapies for HCC Agent Trial Phase Cabozantinib Phase 3 Tivantinib Phase 3 Apatinib Phase 3 Ramucirumab Phase 3 Lenvatinib Phase 3 Donafenib Phase 2/3 ADI-PEG20 Phase 3 Doxorubicin Transdrug Phase 3 ThermoDox Phase 3 Pembrolizumab Phase 2/3 Agent Trial Phase Vaccinia virus Phase 3 Hepatitis C immune globulin Phase 3 Peretinoin Phase 3 Tyroserleutide Phase 3 MEDI Tremelimumab, MEDI4736 or Tremelimumab Phase 2 Immuncell-LC Phase 2 Atezolizumab Phase 1 PF ± PF Phase 1 LY ± Ramucirumab Phase 1

5 Current and Ongoing Clinical Trials in HCC Locally Advanced or Potentially Resectable Disease Phase 3 Phase 2 Phase 1 TACE vs SBRT in patients with residual or recurrent disease after TACE (NCT ) CA : Nivolumab +/- ipilimumab as neoadjuvant therapy (NCT ) Pembrolizumab + Y90 in locally advanced HCC (NCT ) CA : Y90 + nivolumab in Asian patients (NCT ) RFA with neoadjuvant cabozantinib/nivolumab in locally advanced HCC (NCT ) AURORA: Neoadjuvant pembrolizumab (NCT ) Currently recruiting Not yet recruiting

6 Current and Ongoing Clinical Trials in HCC First-Line Therapy Phase 3 Phase 2 Phase 1 HIMALAYA: Durvalumab +/- tremelimumab vs sorafenib (NCT ) CheckMate-459: Nivolumab vs sorafenib (NCT ) PHOCUS: Pexa-Vec + sorafenib vs sorafenib (NCT ) CheckMate-040: Nivolumab vs sorafenib, nivolumab + ipilimumab, nivolumab +/- ipilimumab + cabozantinib, nivolumab in Child Pugh B (NCT ) TACE + sorafenib (NCT ) Lenvatinib + pembrolizumab (NCT ) Sorafenib + pembrolizumab (NCT ) Pexa-Vec + nivolumab (NCT ) OPTIMA: Liposomal doxorubicin + RFA vs placebo + RFA (NCT ) Nivolumab + drug-eluting bead TACE (NCT ) STOP-HCC: Y90 glass microspheres + sorafenib vs sorafenib (NCT ) Sorafenib + napabucasin or amcasertib vs sorafenib (NCT ) Sorafenib + SBRT vs sorafenib (NCT ) Currently recruiting Not yet recruiting Regorafenib + pembrolizumab (NCT )

7 Current and Ongoing Clinical Trials in HCC Second-Line Therapy Beyond Phase 3 Phase 2 Phase 1 Pembrolizumab vs placebo in Asian patients (NCT ) REACH-2: Ramucirumab vs placebo in patients with elevated AFP (NCT ) Pembrolizumab vs BSC (NCT ) TATE-PD1: Transarterial tirapazamine embolization + PD-1 inhibitor (NCT ) Tumor infiltrating lymphocytes + pembrolizumab (NCT ) Pembrolizumab monotherapy (NCT ) Durvalumab, tremelimumab, or in combination (NCT ) SBRT followed by nivolumab +/- ipilimumab in unresectable HCC (NCT ) Durvalumab + tremelimumab with TACE, RFA, or cryotherapy (NCT ) Y90 glass microspheres + nivolumab in patients with no prior therapies (NCT ) Pembrolizumab + epacadostat [IDO inhibitor] (NCT ) Pembrolizumab + XL888 [HSP90 inhibitor] (NCT ) Currently recruiting Active but, not recruiting

8 HCC Treatment Modalities Current therapies Resection Emerging therapies Targeted therapies Transplant Locoregional thera pies Sorafenib Regorafenib Immunotherapy 33%-41% of patients experience disease progression after sorafenib treatment 1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) for Hepatobiliary Cancers V National Compre hensive Cancer Network All rights reserved. Accessed October 11, To view the most recent and complete version of the guideline, go online to NCCN.o rg; 2. He AR, Goldenberg AS. Ther Adv Gastroenterol. 2013;6(6):

9 HCC Treatment Modalities Current therapies 1 Resection Emerging therapies Targeted therapies Transplant Locoregional thera pies Sorafenib Regorafenib Immunotherapy 1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) for Hepatobiliary Cancers V National Compre hensive Cancer Network All rights reserved. Accessed October 11, To view the most recent and complete version of the guideline, go online to NCCN.o rg; 2. He AR, Goldenberg AS. Ther Adv Gastroenterol. 2013;6(6):

10 Key Clinical Data of Nonimmunotherapeutic Agents in HCC 7 Agents Have Target Overlap With Sorafenib FGF VEGF PDGFR FGFR VEGFR Regorafenib Cabozantinib Lenvatinib Ramucirumab Apatinib Agent Regorafenib 2 Target Sorafenib Cabozantinib 3 Lenvatinib 4 Dual/multi-TKIs Regorafenib Sorafenib Lenvatinib Regorafenib Lenvatinib RAS RAF MET-K Nucleus Regorafenib Sorafenib Donafenib Cabozantinib Tivantinib Donafenib 5 Tivantinib 6 Ramucirumab 7 TKI targeting MET mab targeting VEGFR2 Survival Apoptosis HCC cell Transcription factors Angiogenesis Metastases Cell proliferation Adapted from Bertino et al. 1 Apatinib 8 TKI targeting VEGFR2 1. Bertino G et al. Future Oncol. 2013;9(10): ; 2. Ravi S, Singal AK. Core Evid. 2014;9:81-87; 3. Abou-Alfa GK et al. Poster presentation at ESMO TiP; 4. Kudo M. Oral presentation at ILCA O-031; 5. Clinicaltrials.gov. NCT Santoro A et al. Lancet Oncol. 2013;14(1):55-63; 7. Zhu AX et al. Clin Cancer Res. 2013;19(23): ; 8. Qin S. J Clin Oncol. 2014;32(5s):suppl; abstr 4019.

11 Cabozantinib: Overview and Key Efficacy Data Cabozantinib: Dual TKI (MET and VEGFR2) 1 Together VEGFR2 and MET promote tumor invasion, metastasis, and new bloo d vessel formation 1 Study endpoints 1 Efficacy: objective response for lead-in stage and PFS for randomized stage Safety Trial design and efficacy 1 Trial Ph Arms Patients N Key Efficacy Data (ITT) RDT after open-label lead-in phase 1 2 After 12 weeks daily cabo: Open-label cabo extension if PR or CR Cabo vs placebo if SD Discontinue if PD Measurable advanced HCC a 1 line previous systemic therapy CP A Asian and Non-Asian HCC etiology: HBV, 24%; HCV, 22%; alcohol relat ed, 15%; other/unknown, 39% 41 a Documented PD per RECIST N = 41 DCR: 66% (week 12) AFP: > 50% in 35% patient s mpfs: 4.4 months mos: 15.1 months Key safety data (ITT) 1 Most common AEs during cabozantinib lead-in (N = 41) All grades (> 50%) Fatigue, diarrhea, hand-foot syndrome Grade 3 4 Diarrhea (20%) Hand-foot syndrome, thrombocytopenia (15% each) Fatigue, increased AST (10% each) Asthenia, hypertension (7% each) Nausea, vomiting, weight decreased (2% each) Cabozantinib is approved for medullary thyroid cancer and has a black box warning for GI perforations and hemorrhage 2

12 Cabozantinib: CELESTIAL Trial: Cabozantinib vs Placebo Randomized, double-blind phase 3 trial of cabozantinib vs placebo after sorafenib in patients with advanced HCC 1 Key eligibility criteria 1,2 CP A No fibrolamellar carcinoma or mixed hepatocellular cholangiocarcinoma No known brain metastases or cranial epidural dise ase Stratification factors: Geographic region: Asia, other regions Disease etiology: HBV (+/- HCV), HCV (without HB V), other Extrahepatic disease or macrovascular invasion N = 760 R 2: 1 Cabozantinib 60 mg QD Placebo QD Start Date: August 2013 Estimated Study Completion Date: October 2018 Estimated Primary Completion Date: October Status: Recruiting Study Director: Exelixis Primary outcome measure: OS Secondary outcome measures: PFS, ORR a a By RECIST v Clinicaltrials.gov. NCT ; 2. Abou-Alfa GK et al. Poster presentation at ESMO TiP.

13 Cabozantinib: CELESTIAL Trial: Cabozantinib vs Placebo

14 Cabozantinib: CELESTIAL Trial: Cabozantinib vs Placebo

15 Cabozantinib: CELESTIAL Trial: Cabozantinib vs Placebo

16 Cabozantinib: CELESTIAL Trial: Cabozantinib vs Placebo

17 Ramucirumab: Anti-VEGFR2 monoclonal antibody Overview of Phase 3 REACH-2 Trial REACH-2 study 3 : Key eligibility criteria Prior sorafenib treatment only Progression on or during sorafeni b treatment OR intolerance to So rafenib Baseline AFP 400 nanograms/m illiliter CP score < 7 (A) BCLC C or B N = 399 (est) R Ramucirumab Placebo Primary outcome measure: OS Secondary outcome measures: PFS, ORR, TTP, QOL, P K, and immunogenicity FGF VEGF Start Date: July 2015 Estimated Study Completion Date: April 2018 Estimated Primary Completion date: October Status: Recruiting 1. Clinicaltrials.gov. NCT PDGFR FGFR VEGFR Regorafenib Sorafenib Lenvatinib Regorafenib Lenvatinib RAS RAF MET-K Nucleus Regorafenib Cabozantinib Lenvatinib Ramucirumab Apatinib Sorafenib Regorafenib Sorafenib Donafenib Cabozantinib Tivantinib Survival Apoptosis HCC cell Transcription factors Angiogenesis Metastases Cell proliferation Adapted from Bertino et al. 1

18 Donafenib: oral multikinase inhibitor that targets Raf and other receptor tyrosine kinases Phase 2/3 Trial Multicenter, randomized trial of donafenib vs sorafenib in patients with advanced HCC 1 Key eligibility criteria 1 Inoperable HCC No prior systemic treatments ECOG PS 2 or less CP score 7 or less Adequate hepatic, renal, and hematologic function Geographic region: China N = 600 Start Date: March 2016 Estimated Study Completion Date: August 2019 Estimated Primary Completion Date: February Status: Recruiting participants Study Director: Suzhou Zelgen Biopharmaceuticals Co, Ltd R 1:1 Donafenib 200 mg BID Sorafenib 400 mg BID Primary outcome measure: OS Secondary outcome measures: PFS, % of adverse e vents FGF PDGFR FGFR VEGFR VEGF Regorafenib Cabozantinib Lenvatinib Ramucirumab Apatinib 1. Clinicaltrials.gov. NCT Regorafenib Sorafenib Lenvatinib Regorafenib Lenvatinib Sorafenib RAS Regorafenib Sorafenib RAF Donafenib MET-K Nucleus Cabozantinib Tivantinib Survival Apoptosis HCC cell Transcription factors Angiogenesis Metastases Cell proliferation

19 HCC Treatment Modalities Current therapies 1 Resection Emerging therapies Targeted therapies Transplant Locoregional thera pies Sorafenib Regorafenib Immunotherapy Rationale for Immunotherapy in Hepatocellular Carcinoma 1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) for Hepatobiliary Cancers V National Compre hensive Cancer Network All rights reserved. Accessed October 11, To view the most recent and complete version of the guideline, go online to NCCN.o rg; 2. He AR, Goldenberg AS. Ther Adv Gastroenterol. 2013;6(6):

20 World J Gastroenterol. Jan 7, 2016; 22(1):

21 The Immune System Is Capable of Eliminating Tumor Cells 3 Priming and ac tivation Trafficking of 4 T cells to tumors 2 1 Cancer-antigen presentation Release of canc er cell antigens Lymph node Blood vessel Tum or Infiltration of T cells into tum ors Recognition of cancer cells by T cells Killing of cancer cells Chen DS, Mellman I. Immunity. 2013;39(1):1-10. The cancer-immunity cycle

22 Regulation of the T-Cell Response T cell responses require 2 signals 1,2 : TCR recognition of MHC-presented antigen Co-signaling interaction, which can be either co-stimulatory or co-inhibitory T cell function is thus regulated by a balance between co-stimulatory and co-inhibitory signals, which are also referred to as checkpoint pathways 1,2 : APC MHC TCR Co-stimulatory signal MHC TCR Co-inhibitory signal T cell T cell activation T cell inhibition 1. Pardoll DM. Nat Rev Cancer. 2012;12(4): ; 2. Weber J. Semin Oncol. 2010;37(5): Adapted from Pardoll

23 Immune Checkpoint Pathways Regulate T-Cell Activation Various tumors have been found to exploit immune checkpoint pathways to evade immune detection 1,2 APC/Tumor Activation CD40 CD137L OX40L B7-2 (CD86) CD40L CD137 OX40 T cell Activation Activation B7-1 (CD80) CTLA-4 Inhibition PD-L1 PD-1 Inhibition PD-L2 B7-1 (CD80) Inhibition MHC Immune Checkpoint Pathways CD28 LAG-3 TCR Activation Inhibition Adapted from Pardoll [1] 1. Pardoll DM. Nat Rev Cancer. 2012;12(4): ; 2. Weber J. Semin Oncol. 2010;37(5): Adapted from Pardoll

24 Regulation of the T-Cell Response PD-1: Key immune checkpoint receptor expressed by activated T cells as well as other immune cells 1 Negatively regulates T-cell activation upon interaction with its ligands PD-L1 (B7-H1) and PD-L2 (B7-DC) 2 PD-L1 upregulation is associated with poor prognosis in multiple tumor types 3 Tumor PD-L1 PD-L2 T cell PD-1 Adapted from Keir Keir ME et al. Annu Rev Immunol. 2008;26: ; 2. Nurieva RI et al. Immunol Rev. 2011;241(1): ; 3. Zou W, Chen L. Nat Rev Immunol. 2008;8(6): T cell TCR MHC HCC T cell TCR MHC PD-1 HCC

25 PD-L1 vs PD-L2 PD-L1 and PD-L2 Expressed by a variety of immune and non-immune cells 1 Expression patterns are distinct 1 Compete for binding to PD-1 to elicit distinct inhibitory immune signals 1,2 PD-L1 Higher constitutive expression than PD-L2 1 Primary signal for induction is IFN-γ, which is predominantly expressed by CD4 T H 1 cells 3 Binding to PD-1 involves complex conformational change 1 Regulation of activated T cells at effector site 1 PD-L2 Primary signal for induction is presence of T H 2 cytokines 1 Binds PD-1 in a more direct manner 1 Binds PD-1 with 2 6 times higher affinity than PD-L1 1,4 Regulates T cell response at induction and effector phases 1 1. Rozali EN et al. Clin Dev Immunol doi: /2012/656340; 2. Ghiotto M et al. Int Immunol. 2010;22(8): ; 3. Pardoll DM. Nat Rev Cancer. 2012;12(4): ; 4. Youngnak P et al. Biochem Biophys Res Commun. 2003;307(3):

26 PD-L1 Is Expressed in HCC and Related Cancers PD-L1 expression by IHC in HCC tumor samples (N = 80): 1 74% (59/80) PD-L1 positive 22 samples weakly positive, 24 moderately positive, 13 strongly positive HCC tumor samples from 240 patients: PD-L1 expressing cells distributed throughout tumors* 2 PD-L1 expression levels classified as low in 180 samples and high in 60 samples (below or above 75 th percentile of density ) Levels of PD-L1 on circulating PBMCs correlated with intratumoral PD-L1 (P < 0.001; N = 23 patients), and higher PD-L1 levels on circulating cells correlated with more advanced BCLC stage 3 Higher PD-1 levels were detected in HCC tumor samples (N = 20) than in samples from cirrhotic patients and healthy controls (N = 20) 4 Cholangiocarcinoma tumor samples: PD-L1 expression detected in 94% (35/37) 5 *219/240 patients were HBV+; 1 was HCV+; 4 were HBV+ and HCV+; 16 were negative for both viruses. 2 Density was defined as the ratio of integrated absorbance of all positive PD-L1 IHC staining to the total area of each image Umemoto Y et al. J Gastroenterol. 2015;50(1):65-75; 2. Gao Q et al. Clin Cancer Res. 2009;15(3): ; 3. Zeng Z et al. PLoS One. 2011;6(9):e doi: /journal.pone ; 4. Shi F et al. Int J Cancer. 2011;128(4): ; 5. Suleiman Y et al. Poster presentation at ASCO Gastrointestinal Cancers Symposium Poster 197.

27 Immunosuppression in HCC PD-L1 expression (observed in 74% of HCC cases) predicts recurrence/survival in HCC patients after resection 1,2 PD-L1 expression 2 Disease-free survival P = PD-L1 Low PD-L1 High Overall survival P = PD-L1 Low PD-L1 High Time after surgery (months) Time after surgery (months) PD-L2 expression 2 Disease-free survival P = PD-L2 Low PD-L2 High Overall survival P = PD-L2 Low PD-L2 High Time after surgery (months) Time after surgery (months) 1. Umemoto Y et al. J Gastroenterol. 2015;50(1):65-75; 2. Gao Q et al. Clin Cancer Res. 2009;15(3):

28 Immunosuppression in HCC Although HCC is an immunogenic tumor, several mechanisms may limit T cell responses to tumor-associated antigens 1 A. Impaired TAA processing and presentation 1 B. Insufficient CD4 T cell help 1 C. T cell suppression by Tregs 1 D. Negative regulation by PD-1/PD-L1 pathway 1 a. HCC TIL are characterized by PD-1 expression 1 b. Intratumoral Kupffer cells and MDSC PD-L1 1 Kupffer cell D MDSC C PD-L1 PD-1 DC Effector CD8 + (TIL) Failure to kill X A TAA TAA Tumor cell B Treg Helper CD4 + Adapted from Breous E [1] Adapted from Breous E Breous E, Thimme R. J Hepatol. 2011;54(4): DC, dendritic cell; HCC, hepatocellular carcinoma; IL-10, interleukin-10; MDSC, myeloid-derived suppressor cell; PD-1, programmed death-1; PD-L1, PD ligand-1; TAA, tumor-associated antigens; TIL, tumorinfiltrating lymphocytes; Treg, regulatory T cell.

29 Immune Escape Mechanisms as Therapeutic Targets Tumors can escape immune detection by creating an immunosuppressive microenvironment that prevents an effective antitumor response 1,2 Immune Escape Mechanism A. Ineffective presentation of tumor antigens 2 B. Recruitment of immunosuppressive cells 1,2 Example of Therapeutic Targeting Vaccines: Antigen processing/ immune priming TAAs APCs C. Release of immunosuppressive factors 1-3 D. T-cell checkpoint dysregulation 2 Checkpoint Pathways: T-cell activation/ inhibition CD28 OX40 GITR CD137 CD27 HVEM T cell CTLA-4 PD-1 B7-1 TIM-3 BTLA VISTA LAG-3 1. Bremnes RM et al. J Thorac Oncol. 2011;6(4): ; 2. Mellman I et al. Nature. 2011;480(7378): ; 3. Jackson CM et al. Clin Cancer Res. 2014;20(14):

30 Therapeutic Targets: CTLA-4 and PD-1 Pathways Lymph nodes Tumor microenvironment Dendritic cell MHC B7 TCR CD B7 CTLA Anti-CTLA-4 Activation (cytokines, lysis, proliferation, migration to tumor) +++ CTLA-4 pathway T cell T cell TCR PD-1 MHC PD-L1 Anti-PD-1/PD-L1 PD-1 PD-L2 Anti-PD-1 PD-1 pathway Tumor cell Adapted from Pardoll DM [1] Adapted from Pardoll DM [1] 1. Pardoll DM. Nat Rev Cancer. 2012;12(4): Adapted from Pardoll

31 CTLA-4 vs PD-1 Checkpoints Type CTLA-4 PD-1 Co-inhibitory receptor 1 Co-inhibitory receptor 1 Ligands B7.1 and B7.2 1 PD-L1 and PD-L2 3 Expressio n Activation Blockade Receptor expression: On activated T cells 1, 3 Ligand expression: On lymphoid cells and APCs 1 Through association of APC and T cell in priming phase 3 Blockade results in distribution of activated T cells to tumor sites 1 May reactivate antitumor responses Can be induced through T-cell activation 2 Receptor expression: On a range of immune cells, including T cells 3 Ligand expression: On tumors and immune cells and low levels in normal tissues 3 Through interaction of tumor and T cell at tumor site 3 Blockade results in target cell killing Interrupts PD-1-mediated inhibition of PI3K/AKT activity 3,4 1. Korman AJ et al. Adv Immunol. 2006;90: ; 2. Keir ME et al. Annu Rev Immunol. 2008;26: ; 3. Hamid O, Carvajal RD. Exp Opin Biol Ther. 2013;13(6): ; 4. Parry RV et al. Mol Cell Biol. 2005;25(21):

32 Select Investigational Checkpoint Inhibitors for HCC Agent 1. Clinicaltrials.gov. Accessed February 1, 2018 Ongoing HCC studies (phase; N) 1 Design; arms 1 Estimated primary completion date/outcom e measures 1 Checkpoint inhibitor (anti-pd1 mab) Nivolumab Pembrolizumab a Patients with malignant neoplasms including HCC. b Patients with metastatic cancer including HCC. NCT (1/2; 620) OL; parallel; ± ipilimumab vs sorafenib / AE/SAE; CRR; ORR; DCR; DOR; TTR; TTP; PFS; OS; PK NCT (3; 726) Randomized; OL; parallel; vs sorafenib / TTP; OS; ORR; PFS; PD-L1 NCT (1/2; 100) OL; +galunisertib / MTD; PK; phase 2: PFS; ORR; DOR; OS NCT (1; 35) OL; +Y 90 glass spheres / MTD; ORR; AE; PFS; DCR NCT (1; 19) a OL; single-arm; +p53 vaccine / AE; responses NCT (2; 100) OL; single-arm / ORR; DOR; DCR; TTP; PFS; OS NCT (1; 39) a OL; single-arm (HIV+) / AE; DOR; ORR; OS; PFS NCT (2; 290) b OL; +TIL / Safety; tumor regression NCT (3; 408) Randomized, double-blind vs BSC / PFS; OS; ORR; DCR; TTP; DOR NCT (2; 28) OL; single-arm / DCR; AE; PFS; OS; ORR; DOR Agent Current HCC studies (phase; N) 1 Design; arms 1 Primary completion date/outcome measures 1 Checkpoint inhibitor (anti-ctla4 mab) NCT (1; 100) OL; parallel; + TACE or RFA / Safety; ORR; TTP; OS 21 Tremelimumab NCT (2; 144) Randomized; OL; ± durvalumab vs durvalumab / AE/SAE; DLT; ORR; DOR; OS; PD-L1 NCT (1/2; 90) a OL; parallel; + durvalumab ± TACE, RFA, or cryoablation / Safety/preliminary efficacy (PFS) a Patients with HCC or biliary tract carcinomas. 1. Clinicaltrials.gov. Accessed February 1, 2018

33 Select Investigational Checkpoint Inhibitors for HCC Agent Ongoing HCC studies (phase; N) Checkpoint inhibitor (anti-pd-l1 mab) Durvalumab (MEDI4736) Atezolizumab (MPDL3280A) Design; arms Primary completion date/outcome measu res 1 NCT (1; 114) a OL; + ramucirumab / DLT; ORR; DCR; DOR; TTR; PFS; OS; PK; ATA NCT (2; 144) Randomized; OL; ± tremelimumab vs tremelimumab / AE/SAE; DLT; ORR; DOR; OS; PD-L1 NCT (1; 120) b OL; single-arm (Chinese pts on / PK; AE; ATA; BOR; ORR; TTP; PFS; OS ly) NCT (1; 291) c OL; + bev (HCC); + bev / AE; PK; BOR; ORR; DOR; PFS; OS +FOLFOX (gastric cancer); + bev + G + nab-p (metastatic pancreatic cancer) NCT (2; 725) d OL; single-arm; multi-cohort / NPR; PK; ORR; BOR; CBR; DOR; PFS; TTP; OS; AE; ATA a Patients with advanced gastrointestinal or thoracic malignancies; b Patients with locally advanced or metastatic solid tumors, including HCC; c Patients with HCC, gast ric cancer, or metastatic pancreatic cancer; d Patients with advanced solid tumors. 1. Clinicaltrials.gov. Accessed February 1, 2018

34 Key Clinical Data Kupffer cell D MDSC C DC PD-L1 Effector CD8 + (TIL) Failure PD-1 to kill X A TAA Tumor cell B TAA Pembrolizumab Tremelimumab Durvalumab Tremelimumab/Durvalumab Atezolizumab Treg Helper CD4 + Adapted from Breous E

35 Pembrolizumab: Overview Pembrolizumab (MK-3475): Checkpoint inhibitor (anti-pd-1 mab) 1 Binds to PD-1 and blocks its interaction with immune-suppressing ligands PD-L1 and PD-L2 1,2 Indications in melanoma, NSCLC, HNSCC 3 Pembrolizumab in HCC No published clinical trial data Ongoing clinical investigation 4 - Phase 1: 2 studies - Phase 2: 3 studies - Phase 3: 1 study Single case report of response in patient with metastatic HCC 5 Adapted from Pardoll Pardoll DM. Nat Rev Cancer. 2012;12(4): ; 2. Merck: Pembrolizumab Mechanism of Action. Available at: 3. National Cancer Institute: Pembrolizumab. Available at 4. Clinicaltrials.gov; 5. Truong P et al. Cureus Jun 4;8(6):e631.

36 Pembrolizumab: Ongoing Phase 2 or 3 Trials in HCC Study Treatment arms/patients N (Identifier; Primary Completion Date) Phase 2 single-arm efficacy (NCT ; 04/2018) 1 Pembrolizumab monotherapy in advanced HCC 28 Phase 2 single-arm efficacy/safety (NCT ; 08/2017) 2 Phase 2 open-label, safety and efficacy (NCT ; 12/2023) 3 Pembrolizumab monotherapy post systemic therapy in HCC TIL therapy in combination with pembrolizumab in patients with a metastatic digestive tract, urothelial, breast, and ovarian cancer Phase 3 randomized Pembrolizumab + BSC vs placebo + BSC 408 (NCT ; 02/2019) 4 1. Clinicaltrials.gov. NCT , 2. Clinicaltrials.gov. NCT , 3. Clinicaltrials.gov. NCT , 4. Clinicaltrials.gov. NCT ;

37 Pembrolizumab: Phase 3 Study in HCC Randomized, double-blind, phase 3 study of pembrolizumab vs BSC in patients with previously systemicallytreated advanced HCC (KEYNOTE-240) 1 Eligibility Criteria N=408 HCC with 1 measurable lesion No fibrolamellar or mixed histology BCLC stage B or C CP Class A Score within 7 days of first dose ECOG PS 0 1 Progression after sorafenib or intolerant Geographic region: Asia, Australia, Europe, North America, South America R 2:1 Pembrolizumab (200 mg IV Q3W) + BSC Saline Placebo Q3W + BSC Response assessed Q6W Safety and survival follow-up Start Date: May 2016 Estimated Study Completion Date: February 2019 Estimated Primary Completion Date: February 2019 Status: Recruiting 1. Clinicaltrials.gov. NCT ; 2. Finn RS et al. Poster Presentation at ASCO GI TPS

38 Tremelimumab: Overview and Clinical Trials Tremelimumab: Checkpoint inhibitor (anti-ctla-4 mab) 1 Inhibits B7-CTLA-4-mediated downregulation of T cell activation 1 Tremelimumab Clinical Trials Completed phase 2 monotherapy trial: Tremelimumab in pts with HCC and chronic HCV infection 1 Adapted from Pardoll Ongoing phase 1 trial of tremelimumab with TACE or RFA in advanced HCC patients post sorafenib, or in patients who received at least one line of chemo and/or in patients not amenable to potentially curative resection, transplantation, or ablation 2,3 Ongoing phase 2 trial and future phase 1/2 trial in combination with durvalumab (MEDI4736) in patients with HCC and BTC (biliary tract carcinomas) 4,5 1. Sangro B et al. J Hepatol. 2013;59(1):81-88; 2. Clinicaltrials.gov. NCT , 3. Duffy AG et al. Poster presentation at ASCO ; 4. Clinicaltrials.gov. NCT , 5. Clinicaltrials.gov. NCT , 6. Pardoll DM. Nat Rev Cancer. 2012;12(4):

39 Durvalumab: Overview and Clinical Trials Durvalumab (MEDI4736): Checkpoint inhibitor (anti-pd-l1 mab) 1 Inhibits PD-L1/PD-1 and PD-L1/CD80 interactions that lead to downregulation of T-cell activation 1 Durvalumab Clinical Trials in HCC Adapted from Pardoll Adapted from Pardoll Open-label phase 1/2 dose-escalation/expansion trial in patients with advanced solid tumors 2 Efficacy results for > 400 patients reported, including 21 patients with HCC 1 Ongoing phase 2 trial and future phase 1/2 trial in combination with tremelimumab 2 Phase 1 trial of combination durvalumab/ramucirumab in GI tumors including HCC 2 1. Segal NH et al. Poster presentation at ESMO PD; 2. Clinicaltrials.gov.; 3. Pardoll DM. Nat Rev Cancer. 2012;12(4):

40 Tremelimumab/Durvalumab Combination Trials Rationale for combined CTLA-4/PD-1 blockade in HCC CTLA-4 and PD-1 checkpoints: Non-redundant pathways for regulation of T-cell responses 1,2 Anti-CLTA-4 and PD-1 therapies have potential for additive or synergistic effects 1 Clinical efficacy of combined CTLA-4/PD-1 blockade Ipilimumab/nivolumab combination indicated in metastatic melanoma based on increased ORR and improved PFS vs monotherapy 3 CTLA-4/PD-1 blockade with tremelimumab/durvalumab in HCC Tremelimumab: Objective responses in HCC 4 Combination with PD-L1 inhibitor durvalumab investigated in phase 1/2 pilot trial with ablative therapies, and vs monotherapies in randomized phase 2 clinical trials in HCC 5 Adapted from Pardoll Buchbinder EI, Desai A. Am J Clin Oncol. 2016;39:98-106; 2. Abou-Alfa GK, et al. Abstract presented at ASCO TPS3103; 3. FDA, Approved Drugs; Nivolumab in combination with ipilimumab; 4. Sangro B et al. J Hepatol. 2013;59(1):81-88; 5. Clinicaltrials.gov.; 6. Pardoll DM. Nat Rev Cancer. 2012;12(4):

41 HIMALAYA Trial: Durvalumab and Tremelimumab as 1L Treatment in Patients With Unresectable HCC A randomized, open-label, multicenter, global, phase 3 study to assess the efficacy and safety of durvalu mab plus tremelimumab combination therapy and durvalumab monotherapy vs sorafenib 1 Eligibility Criteria N = 1200 HCC (unresectable) No prior systemic therapy for HCC Child-Pugh Score A BCLC stage B or C ECOG PS 0 or 1 Age 18 years Anticipated Start Date: October 2017 Estimated Study Completion Date: March 2021 Estimated Primary Completion Date: February 2020 Status: Recruiting R Durvalumab IV Regimen 1 Durvalumab + tremelimumab IV Regimen 2 Durvalumab + tremelimumab IV Sorafenib, per standard of care Primary Outcome Measure: OS Secondary Outcome Measures: Presence of ADA, DCR, DOR, EORTC QLQ-30 and EORTC QLQ-HCC18, ORR, PFS, PK, TTP

42 Summary of Checkpoint Inhibitors for HCC IMMUNO-ONCOLOGY IN HCC Key investigational agents in clinical development: Pembrolizumab: Currently, 3 phase 2 and 1 phase 3 trials are ongoing in patients with HCC 1 Tremelimumab: Completed phase 2 trial in patients with HCC and chronic HCV infection. Currently, there is an ongoing phase 1 study with ablation therapy in patients with HCC 1,2 Durvalumab: Open-label phase 1/2 dose-escalation/expansion trial in patients with advanced solid tumors and multiple ongoing trials in combination regimens 1,3 Tremelimumab/durvalumab Combination: Phase 2 trial in unresectable HCC, and phase 1 study in combination with ablative therapies in HCC cohort 1. Currently recruiting, HIMALAYA a phase 3 study Atezolizumab: Currently, 2 ongoing phase 1 studies include specific HCC cohorts (monotherapy and combination with bevacizumab) 1 1. Clinicaltrials.gov.; 2. Sangro B et al. J Hepatol. 2013;59(1):81-88; 3. Segal NH et al. Poster presentation at ESMO PD.

43 Immunotherapy against hepatocellular carcinoma cells By Yu Sawada, Kazuya Ofuji, Mayuko Sakai and Tetsuya Nakatsura DOI: /54594

44 NK cell therapy approaches

45 Unanswered Questions in HCC Management Transitioning from locoregional therapy to systemic therapy Treatment sequencing Patient selection Lack of biomarkers of response Treatment beyond progression with checkpoint inhibitors Advent of local plus systemic therapy is the frontier yet to be tackled