Targeted therapies in NSCLC beyond EGFR and ALK

Transcription

1 Targeted therapies in NSCLC beyond EGFR and ALK David Planchard (MD, PhD) Department of Cancer Medicine Thoracic Unit Gustave Roussy Villejuif (France)

2 Great advances have been made in lung cancer therapy: targeting of oncogenic drivers Stratification for EGFR, ALK and histology EFGR-activating mutation ALK translocation EGFR WT/ALKnon-squamous EGFR WT/ALKsquamous Erlotinib Gefitinib Afatinib Exon 20 T790M Osimertinib Crizotinib Ceritinib Alectinib 4 6 cycles Platinum-based doublet +/ bevacizumab +/- maintenance 4 6 cycles Platinum-based doublet ALK, anaplastic lymphoma kinase; EGFR, epidermal growth factor receptor; WT, wild-type

3 Frequency of genetic alterations 1-year nationwide programme in France analysed samples F.Barlesi et al, lancet 2016

4 Out of EGFR and ALK there are many other potential driver mutations in lung adenocarcinoma Biomarker France (IFCT) Unknown/ wild type 50% EGFR (sensitizing) 10.1% KRAS 29% EGFR (resistance) 0.9% HER2 1% Cancer Genome Atlas Research Network MET amp ERBB2 amp HRAS 0.4% 2.2% 0.9% 2.2% RIT1 NRAS 0.4% RET fusion 0.9% NF1 MAP2K1 0.9% 8.3% ALK fusion 1.3% None ROS1 fusion 1.7% 24.4% ERBB2 1.7% MET ex14 4.3% BRAF 7.0% KRAS BRAF 2% (V600E 1.4%) EGFR 11.3% 32.2% ALK 5% PI3K 2% By including amplification of MET and ERBB2, MET exon 14 splicing mutations, RIT1 mutations, and NF1 loss-of-function mutations, the driver-positive group increases to ~75% of cases IFCT, French Cooperative Thoracic Intergroup. Barlesi F, et al. Lancet. 2016;387: Cancer Genome Atlas Research Network. Nature. 2014;511:

5 ROS1 rearrangements in NSCLC SLC34A2-ROS1 TPM3-ROS1 SDC4-ROS1 Present in ca. 1% of NSCLC cases (also found in some GBMs and cholangiocarcinomas) Enriched in younger, never or light smokers with adenocarcinoma histology No overlap with other oncogenic drivers CD74-ROS1 LRIG3-ROS1 EZR-ROS1 ROS1 GBM, glioblastoma. Bergethon K, et al. J Clin Oncol. 2012;30: Takeuchi K, et al. Nat Med. 2012;18:

6 Diagnostic Break-Apart FISH Assay for ROS1 Rearrangement Bergethon et al., JCO 30(8): , 2012

7 Signaling Pathways Activated by ROS1? Ligand(s) ECM Proteins ROS1 ROS1 PDK1 Akt PIP3 PI3K PIP2 IRS- 1/GAB1 SHP-1/2 TORC2 RAS VAV3 TORC1 MEK STAT 3 Cdc42 Rho S6K1 rs6 4E-BP1 elf4e ERK Adapted from Acquaiva et al., Biochim Biophys Acta 1795(1): 37-52, 2009

8 ROS1 Encodes a Receptor Tyrosine Kinase ROS1 ROS1 ALK LTK PTK7 Brock TG, Receptors and Tyrosine Kinases

9 Crizotinib: Inhibitor of c-met, ALK and ROS1 Co-crystal structure of crizotinib (PF ) bound to c-met Kinase IC 50 (nm) mean* Selectivity ratio c-met 8 ALK X ROS1 60 7X RON 80 10X Axl X X Tie X Trk A X Trk B X Abl 1, X IRK 2, X Lck 2, X Sky >10,000 >1,000X VEGFR2 >10,000 >1,000X PDGFRβ >10,000 >1,000X Camidge et al, ASCO 2014 Cui et al. J Med Chem 54: , 2011 and Pfizer data on file

10 Significant Responses to Crizotinib in Patients with ROS1-Positive NSCLC Baseline After 3 months of crizotinib Bergethon et al., JCO 30(8): , 2012

11 Rapid Responses to Crizotinib in Patients with ROS1-Positive NSCLC Baseline After 4 weeks of crizotinib Image courtesy of Ignatius Ou

12 Crizotinib and ROS1+ patients Change from baseline (%) patients (6%) CR 33 patients (66%) PR 9 patients (18%) SD PD SD PR CR * Overall response rate: 72% M A Best response N = 50 ORR, n (%) 36 (72) CR, n (%) 3 (6) PR, n (%) 33 (66) SD, n (%) 9 (18) DOR, median (95% CI), mo PFS, median (95% CI), mo 17.6 (14.5 NR) 19.2 (14.4 NR) OS, median (95% CI), mo 12.7 ( ) NR, not reached. Shaw AT, et al. N Engl J Med. 2014;371:

13 AcSé Crizotinib : objectives Single biomarker tests in the 15 malignancies To identify patients with an advanced malignancy presenting a crizotinib-target alteration and to generate epidemiological data Gilles Vassal et al, ESMO-ECCO 2015

14 Tumor ALK ALK MET ROS1 ALK MET transloc. amp. amp. transloc. mut. mut. ALCL 50% Colorectal 2,40% 3,60% 3,30% NSCLC 4% 3,50% 3% Breast 2,40% Gastric and 6% oesogastric junction Cholangiocarcinoma 9% Ovary 12% Renal cell carcinoma 2% 10,10% 13% Hepatocarcinoma 2,30% Neuroblastoma 3% Inflammatory myofibroblastic tumor 50% 10% Rhabdomyosarcoma 28% Glioblastoma 45% Thyroid 2% 11% 8% Spitzoid melanoma 10% 17% Gilles Vassal et al, ESMO-ECCO % 30% Crizotinib Inhibitor of ALK, MET and ROS1 Indication ALK+ NSCLC Targets altered in more than 15 malignancies in adults and children

15 1 uterine leiomyosarcoma - ALK translocation, 1 pancreatic cancer - ROS1 mutation, 1 neuroblastoma - ROS1mutation, 1 kidney cancer - ROS1 amplification, 3 NSCLC - MET mutation, 1 NSCLC - ALK mutation, 1 NSCLC - ALK amplification, 1 SCLC - MET mutation + ROS1 mutation, 1 adenoca. ouraque - MET amplification, 1 cholangiocarcinoma - MET amplification, 1 gallbladder - MET amplification, 1 B lymphoma, large cell - ALK translocation, 1 carcinoma of the esophagus - MET amplification, 1 sarcomatoid carcinoma hail - ALK translocation, 1 unknown primary carcinoma. - ALK translocation. Results : 24 cohorts STOP STOP STOP Gilles Vassal et al, ESMO-ECCO 2015

16 Tumor shrinkage at best response Best response ORR = 26/36 72 % [55% ; 86%] DCR = 32/36 89 % [74% ; 97%] 44% PFS at 12 months Results: ROS1+ NSCLC Gilles Vassal et al, ESMO-ECCO 2015

17 Comparison of crizotinib efficacy across studies on ROS1+ NSCLC Profile (N = 50) EUROS1 2 (N = 31) AcSé 3 (N = 36) Trial Phase 1 expansion Retrospective Phase 2 Ethnicity Global (42% Asian) Europe France Diagnostic Local FISH Local FISH FISH Response rate 72% 80% 72% Median PFS, months % at 12 months Median follow-up, months 16.4?? NA EMA, European Medicines Agency; FDA, Food and Drug Administration; FISH, fluorescent in situ hybridization; NA, not applicable. 1. Shaw AT, et al. N Engl J Med. 2014;371: Mazières J, et al. J Clin Oncol. 2015;33: Vassal G, et al. ECCO 2015; abstract 12LBA.

18 The FDA and EMA approved crizotinib for the treatment of ROS1+ NSCLC (March and August 2016, respectively)

19 Ceritinib in ROS1-rearranged NSCLC: a Korean nationwide phase II study Baseline 5 months Baseline 3 months -66% PR CR 1.0 Progression-free survival Best response, n (%) All patients (N=32) Crizotinib-naïve (N=30) Proportion of progression-free All patients (n = 32) Crizontinib-naïve patients (n = 30) ORR 20 (62) 20 (67) CR 1 (3) 1 (3) PR 19 (59) 19 (59) SD 6 (19) 6 (19) PD 2 (6) 2 (6) Duration (months) NE 4 (6) 2 (7) DCR (CR+PR+SD) 26 (81) 26 (87) Lim S, et al. Presented at ESMO Abstract 1205PD.

20 Acquired Resistance to Crizotinib from a Mutation in CD74 ROS1 Acquired resistance to crizotinib from a mutation in CD74-ROS1. N Engl J Med Jun 20;368(25):

21 Overcoming Crizotinib Resistance in Advanced ROS1+ NSCLC WT ROS1 G2032R Trials Alectinib 1 3,700 nm --- None not active Ceritinib nm 277 nm Phase 2 (SIGNATURE) Brigatinib nm 322 nm Investigator initiated trials Lorlatinib nm 167 nm Phase 2 Cabozantinib 2 2 nm 13.5 nm Phase 2 (MSKCC) Foretinib 4 ~3 nm 50 nm None Crizotinib nm 254 nm Phase 1 (PROFILE 1001) 1 Kodama et al., Mol Cancer Ther 13: , 2014; 2 Katayama et al., Clin Cancer Res 21(1): , 2015; 3 Zou et al., AACR-EORTC-NCI, 2013; 4 Davare et al., PNAS 110(48): , 2013

22 ROS1 - Acquired Resistance to Crizotinib Ba/F3 EZR ROS1 100 crizotinib ceritinib lorlatinib % Cell Viability Drug Concentration (nm) Biopsy S1986 MTB Francesco Facchinetti et al, CCR 2015

23 Sensitivity of the CD74 ROS1 mutant reintroduced Ba/F3 cells to crizotinib or ceritinib Ryohei Katayama et al, CCR 2015

24 Cabozantinib (XL184) overcomes crizotinib resistance caused by the mutations in CD74 ROS1 cmet/ret/vascular endothelial growth factor (VEGFR) inhibitor cabozantinib Ryohei Katayama et al, CCR 2015

25 Modeling theoretical sensitivity of ROS1 patients according to their mutational status Francesco Facchinetti et al, CCR 2015

26 Frequency of genetic alterations 1-year nationwide programme in France analysed samples F.Barlesi et al, lancet 2016

27 Inhibition of BRAF V600 Kinase RTKs P P SOS Grb2 P P SHC P P RAS Dabrafenib Vemurafenib BRAF V600 BRAF CRAF MEK PI3K/AKT/mTOR pathway ERK1/2 p90rsk MSK1 Proliferation, Growth, Survival

28 V600E mutation results in an amino acid substitution at position 600 in BRAF, from a valine (V) to a glutamic acid (E) V600D from a valine (V) to an aspartic acid (D) V600K from a valine (V) to a lysine (K) V600R from a valine (V) to an arginine (R)

29 BRAF inhibitors: quick tumour responses in PET scans and clinically Before After 2 weeks Before After 2 weeks Images courtesy of Grant McArthur and Rod Hicks, Peter MacCallum Cancer Centre, Melbourne, Australia.

30 Vemurafenib in NSCLC with BRAF V600 mutations Basket trial (multiple non-melanoma cancers) Variable Patients with 1 postbaseline assessment, n NSCLC a (N = 20) Colorectal cancer a Vemurafenib (N = 10) Vemurafenib + cetuximab (N = 27) CR, n (%) PR, n (%) 8 (42) 0 1 (4) SD, n (%) 8 (42) 5 (50) 18 (69) PD, n (%) 2 (11) 5 (50) 7 (27) Missing data, n (%) 1 (5) 0 0 OR, n (%) [95% CI] 8 (42) [20 67] 0 1 (4) [< 1 20] Target tumour diameter sum (% change from baseline) NSCLC cohort mpfs: 7.3 months (95% CI ) a Patients with several pre-specified cancers were enrolled into the study, including NSCLC and colorectal cancer. CI, confidence interval; CR, complete response; mpfs, median PFS; OR, overall response; PD, progressive disease; PFS, progression-free survival; PR, partial response; SD, stable disease. Hyman DM, et al. N Engl J Med. 2015;373:

31 BRAF V600E and Vemurafenib B.Besse, Gustave Roussy

32 BRF study design Multicohort, non-randomized, open-label phase 2 study Cohort A (dabrafenib monotherapy) planned n = 60 Interim futility analysis Stage IV NSCLC BRAF V600E ECOG PS platinum-based chemotherapy Dabrafenib 150 mg b.i.d. Stage 1 n = 20 Stage 2 n = 20 Expansion n = 20 n = 78 ( 2nd line) Cohort B (combination dabrafenib + trametinib) planned n = 40 Stage IV NSCLC BRAF V600E ECOG PS prior treatments 1 platinum-based chemotherapy Dabrafenib 150 mg b.i.d. Trametinib 2 mg q.d. Stage 1 n = 20 Cohort C (combination dabrafenib + trametinib in 1st line) planned n = 25 Stage 2 n = 20 n = 57 (2nd 4th line) Stage IV NSCLC BRAF V600E ECOG PS 0 2 No prior treatment Dabrafenib 150 mg b.i.d. Trametinib 2 mg q.d. n = 34 ENROLLMENT COMPLETED b.i.d., twice daily; ECOG, Eastern Cooperative Oncology Group; PS, performance status; q.d., once daily. Planchard D, et al. Lancet Oncol. 2016;17: Planchard D, et al. Lancet Oncol. 2016;17:

33 380 Dabrafenib monotherapy: maximum reduction Maximum percent reduction from baseline measurement Best Confirmed confirmed Response response PR SD PD NE Best response 2nd line (N = 78) Response rate (confirmed CR + PR) 32% 95% CI ( ) DCR (CR + PR + SD) 56% 95% CI ( ) DCR, disease control rate; NE, not evaluable. Planchard D, et al. Lancet Oncol. 2016;17:

34 Dabrafenib monotherapy: Progression-free survival (independent review) No. at risk PFS Time from first dose (months) Independent PFS: 5.5 months (95% CI ) Planchard D, et al. Lancet Oncol. 2016;17:

35 Dabrafenib Activity in BRAF V600E NSCLC 72 year old white female, 2 nd line, former smoker, 10 pack years (stop in1985) ECOG PS2 Adenocarcinoma, BRAFV600E, T3N3M1b (pleural, pulmonary, lymph nodes) Progression after one line of platinum-pemetrexed October weeks of Dabrafenib Baseline CT-Scan. Mazieres et al, Hôpital Larrey CHU Toulouse ECOG PS0 D.Planchard et al, ESMO 2014

36 Unique residual disease in the lower left lung Discussion for a local treatment 2 years after the start of dabrafenib J. Mazieres et al, Hôpital Larrey CHU Toulouse D.Planchard et al, ESMO 2014 ECOG PS:0 Asymptomatic Very good safety profile (rare episodes of fever) September 2014

37 Acquired resistance to BRAF inhibition: many hypotheses Johannessen CM, et al. Nature. 2010;468: Nazarian R, et al. Nature. 2010;468: Poulikakos PI, et al. Nature. 2011;480: Shi H, et al. Nature Commun. 2012;3:724. Straussman R,et al. AACR. 2012;abstract Villanueva J, et al. Cancer Cell. 2010;18: Wagle N, et al. J Clin Oncol. 2011;29:

38 Wagle N, et al. J Clin Oncol. 2011;29:

39 Dabrafenib P RTKs P SOS P P Grb2 SHC P P RAS BRAF V600 BRAF CRAF PI3K/AKT/mTOR pathway MEK ERK1/2 Trametinib p90rsk MSK1 Proliferation, growth, survival Luke JJ, Ott PA. Drug Healthc Patient Saf. 2014;24:77-88.

40 Rationale for combination of dabrafenib + trametinib Dabrafenib + trametinib was more efficacious than BRAF-inhibitor monotherapy in BRAF V600-mutant melanoma dabrafenib + trametinib demonstrated clinically meaningful and significantly superior efficacy while reducing the risk of cutaneous squamous cell carcinoma COMBI-d 1 COMBI-v 2 Dabrafenib + trametinib (n = 211) Dabrafenib + placebo (n = 212) Dabrafenib + trametinib (n = 351) Vemurafenib (n = 350) Median OS, months Median PFS, months ORR, n (%) 144 (69) 112 (53) 226 (64) 180 (51) Median DOR, months DOR, duration of response; ORR, overall response rate. 1. Long GV, et al. Lancet. 2015;386: Robert C, et al. N Engl J Med. 2015;372:30-9.

41 Dabrafenib + trametinib: best confirmed response Investigator assessment (n = 57) Independent assessment (n = 57) ORR (CR + PR), n (%) [95% CI] 36 (63) [49 76] 36 (63) [49 76] Best response, n (%) CR PR SD a PD Non-CR/non-PD b NE 2 (4) 34 (60) 9 (16) 7 (12) 0 5 (9) 0 36 (63) 4 (7) 8 (14) 3 (5) 6 (11) DCR (CR + PR + SD), n (%) [95% CI] 45 (79) [66 89] 43 (75) [62 86] a SD is defined as meeting SD criteria for 12 weeks. b Patients were non-measurable by independent review committee. Planchard D, et al. Lancet Oncol. 2016;17:

42 Maximum reduction from baseline measurement (%) Dabrafenib + trametinib: maximum change in target lesion Best confirmed response Maximum change in target lesion by best investigatorassessed confirmed response CR PR SD PD NE ORR: 63% (95% CI 49 76) Patients NE patients either had no post-baseline CT scan or discontinued before 12 weeks without documented progression. Planchard D, et al. Lancet Oncol. 2016;17:

43 Dabrafenib + trametinib: progression-free survival Progression-free survival by investigator assessment PFS, median (95% CI), mo Progressions or deaths, n (%) Investigator assessment 9.7 ( ) 32 (56) Independent assessment 8.6 ( ) 34 (60) Time from first dose (months) No. at risk No. censored Dashed lines represent 95% CIs. Median follow-up of 11.6 months. Planchard D, et al. Lancet Oncol. 2016;17:

44 61-year-old woman, never smoked Dabrafenib + trametinib: case study 1 Adenocarcinoma with pleural effusion, liver metastases, 4th line (CDDP-pemetrexed, docetaxel, gemcitabine) Baseline (July 2014) Dabrafenib + trametinib +25 months (August 2016) PR at Week 6 with 54% reduction (confirmed and still response, 73% +25 months) CDDP, cisplatin. Planchard D, et al. Gustave Roussy Villejuif.

45 Dabrafenib + trametinib: case study 2 59-year-old man, former smoker, 70 packs/year Adenocarcinoma with irradiated brain metastases, 2nd line (1st line carboplatin + pemetrexed) Dabrafenib + trametinib Baseline (July 2014) +27 months (July 2016) PR at Week 6 with 70% reduction (confirmed and still response, 80% +27 months) Planchard D, et al. Gustave Roussy Villejuif.

46 Dabrafenib + trametinib vs dabrafenib monotherapy: adverse events Category Dabrafenib + trametinib Dabrafenib monotherapy AEs, n (%) All grades Grade 3 All grades Grade 3 General Pyrexia 26 (46) 1 (2) 30 (36) 2 (2) Asthenia 18 (32) 2 (4) 25 (30) 3 (4) Decreased appetite 17 (30) 0 24 (29) 1 (1) Chills 13 (23) 1 (2) 13 (15) 1 (1) Peripheral oedema 13 (23) 0 Arthralgia 11 (19) 0 14 (17) 1 (1) Skin Dry skin 15 (26) 1 (2) 19 (23) 0 Rash 12 (21) 1 (2) 17 (20) 1 (1) Hyperkeratosis 6 (10) 1 (2) 25 (30) 1 (1) Basal-cell carcinoma 2 (2) 1 (2) 4 (5) 4 (5) Squamous-cell carcinoma 2 (4) 2 (4) 10 (12) 10 (12) Skin papilloma 22 (26) 0 Digestive Nausea 23 (40) 0 23 (27) 1 (1) Vomiting 20 (35) 0 17 (20) 1 (1) Diarrhoea 19 (33) 1 (2) 14 (17) 1 (1) Planchard D, et al. Lancet Oncol. 2016;17: Planchard D, et al. Lancet Oncol. 2016;17:

47 Dabrafenib + trametinib provided an important treatment option for patients with BRAF V600E-mutant NSCLC With greater clinical activity compared with dabrafenib monotherapy Based on investigator assessment Dabrafenib + trametinib 1 (n = 57) Dabrafenib monotherapy 2 (n = 78) ORR, % (95% CI) 63 (49 76) 33 (23 45) DCR, % (95% CI) 79 (66 89) 58 (46 67) Median PFS, mo (95% CI) 9.7 ( ) 5.5 ( ) Median DOR, mo (95% CI) 9.0 ( ) a 9.6 ( ) The safety profile was manageable and similar to previous experience in melanoma a One-half of responses were ongoing at data cut-off. 1. Planchard D, et al. Lancet Oncol. 2016;17: Planchard D, et al. Lancet Oncol. 2016;17:

48 MET activation: amplification and/or exon 14 mutation/skipping Implicated in tumour cell migration, invasion, proliferation, and angiogenesis MET testing Mechanisms of MET activation amplification, point mutations, deletions MET amplification poor prognosis in NSCLC resistance to EGFR TKI 1 4% of lung NSCLC MET exon 14 mutation 3 4% of nonsquamous NSCLCs 20 30% of sarcomatoid lung carcinomas TKI, tyrosine kinase inhibitors. Ou SH, et al. J Thorac Oncol. 2011;6: Cancer Genome Atlas Research Network. Nature. 2014;511:

49 Tumour shrinkage seen with crizotinib treatment in intermediate and high MET cohorts Change from baseline (%) Best percent change from baseline in target tumour lesions by patient Low MET n = Intermediate MET n = MET/CEP7 ratio 5 High MET n = 6 ORR, % (95% CI) 0 (0 84) 17 (0 64) 67 (22 96) PD SD PR CR Threshold for partial response Camidge DR, et al. ASCO J Clin Oncol. 2014;32:5s (suppl; abstract 8001).

50 8/16/ /9/2011 3/27/2014 a MET/CEP7 ratio: >5 Duration of response: 31+ months Images: G. Shapiro DFCI

51 The French national AcSé Program Results: METAMP NSCLC Tumor shrinkage at best response Best response ORR = 7/25 28 % [12% ; 49%] DCR = 15/25 60 % [41%;79%] No correlation observed between the number of MET copies and best response (p=0,10). G.Vassal et al 2015

52 Tumour shrinkage observed with capmatinib treatment in intermediate and high MET cohorts Best response n (%) GCN < 4 (n = 17) GCN 4 and < 6 (n = 12) GCN 6 (n = 15) CR PR 0 2 (17) 7 (47) SD 8 (47) 3 (25) 5 (33) PD 5 (29) 3 (25) 2 (13) Unknown 4 (24) 4 (33) 1 (7) ORR 0 2 (17) 7 (47) 95% CI DCR 95% CI 8 (47) (42) (80) Best % change from baseline cmet GCN < 4 n/n (%) = 11/17 (64.7%) Best % change from baseline cmet GCN 4 and < 6 n/n (%) = 7/12 (58.3%) Best % change from baseline cmet GCN 6 n/n (%) = 12/15 (80.0%) GCN, gene copy number. Schuler M, et al. ASCO J Clin Oncol. 2016;34 Suppl:abstract 9067.

53 Prevalence of MET Exon 14 Mutations in NSCLC Awad MM, et al, J Clin Oncol Jan 4.

54 Normal MET Signaling HGF/SF Exon 14 Mutated/Skipped Cbl P Ub Ub Ub TKD Ex14 TKD Ex14 P Tyr1003 P P P P P TKD TKD Ex14 skipping P P P Grb2 P P Receptor Activation (Ras/MAPK, PI3K/Akt, Src, STAT3) Receptor internalization Receptor degradation Exon 14 mutation/skipping Loss of c-cbl binding site Decreased ubiquitination Impaired receptor degradation Increased MET signaling Awad MM, J Clin Oncol Jan 19.

55 Prognosis of MET Exon 14 Mutant NSCLC MET exon 14 wild type MET exon 14 mutant METΔ14 occurred mutually exclusively with known driver mutations but tended to coexist with MET amplification or copy number gain (p<0.001) Tong, JH, et al Clin Cancer Res Feb 4.

56 MET 14 skipping in pulmonary sarcoma Eight (22%) of 36 patient with pulmonary sarcoma. One with a concurrent PIK3CA mutation Liu et al. JCO

57 MET exon 14-mutant NSCLC may respond to treatment with c-met inhibitors such as crizotinib and cabozantinib Cabozantinib Antitumour activity of crizotinib (PROFILE 1001 study) Response-evaluable population (n = 18) Best OR, n (%) CR 0 Crizotinib PR 8 (44%) SD 9 (50%) Unconfirmed CR/PR a 5 (28%) Crizotinib PD 0 Indeterminate b 1 (6%) ORR 8 (44%) 95% CI a Of the 5 patients, 2 await confirmation, 3 cannot be confirmed. b This patient discontinued therapy in cycle 1; response imaging could not be performed but response-evaluable per protocol. Drilon AE, et al. ASCO J Clin Oncol. 2016;34 Suppl:abstract 108. Frampton GM, et al. Cancer Discov. 2015;5: Paik PK, et al. Cancer Discov. 2015;5: Waqar SN, et al. J Thorac Oncol. 2015;10:e Paik et al. Cancer Discovery

58 Antitumor Activity and Safety of Crizotinib in Patients with Advanced MET Exon 14-Altered Non-Small Cell Lung Cancer 20 ORR: 44% (95% CI: 22 69), n=8/18 % change from baseline * * Partial response (PR), confirmed Stable disease (SD): includes 4 unconfirmed PRs concurrent MET Amplification -100 Central testing for both MET exon 14 alterations and high-level MET amplification via ThermoFisher Scientific Inc., Ion Torrent (Cancer Genetics, CA) Presented by: Alexander Drilon MD

59 Early signs of glesatinib clinical activity in NSCLC patients with MET copy gain or METex14del mutations 76-year-old male METex14del (+) 70-year-old female METex14del (+) 51-year-old female EGFR L858R / MET AMP First scan post-treatment Baseline Kollmannsberger ASCO 2015 Abstract 2589.

60 RET rearrangements 1 2% of unselected NSCLCs Clinical features: young, never or former light cigarette smokers 5 KIF5B RET exon 12 3 kinase KIF5B-RET fusions kinase Intact tyrosine kinase domain fused to an upstream gene partner most common: KIF5B others: CCDC6, NCOA4, TRIM33, KIAA1468 exon 8 exon 11 kinase kinase kinase kinase Result in ligand-independent dimerization and downstream growth pathway activation CCDC6 exon 12 kinase CCDC6-RET Oncogenic in vitro and in vivo NCOA4 kinase NCOA4-RET TRIM33 kinase TRIM33-RET Drilon A, et al. Cancer Discov. 2013;3: Kohno T, et al. Nat Med. 2012;18: Lipson D, et al. Nat Med. 2012;18: Saito M, et al. Carcinogenesis. 2014;35: Suehara Y, et al. Clin Cancer Res. 2012;18: Takeuchi K, et al. Nat Med. 2012;18:

61 Multi-kinase inhibitors targeting RET activity Compound Target KDR IC50 (nm) RET IC50 (nm) Cabozantinib KDR/MET 1 7 Vandetanib KDR/EGFR 2 5 Ponatinib ABL/Pan-RTK 2 1 Lenvatinib KDR 4 2 Sorafenib RAF/VEGF 21 6

62 Best response (%) Response to cabozantinib in patients with RET-rearranged lung adenocarcinomas Confirmed PR SD Stage 1 (N = 16) 90 Best response Stage 1 (N = 16) PR, % (n/n) 44 (7/16) Confirmed 38 (6/16) Unconfirmed 6 (1/16) SD, % (n/n) 56 (9/16) ORR, % (95% CI) 38 (95% CI 15 65) ORR 12wks 36 (95% CI 13 65) DOR, median (range), mo 8 ( months) Baseline 4 weeks PFS (95% CI), mo 7 (95% CI 5 NA) Drilon AE, et al. ASCO J Clin Oncol. 2015;33 Suppl:abstract 8007.

63 A Drilon et al, ASCO 2015 Response to Cabozantinib 46-year-old female never smoker with CLIP1-RET-rearranged lung adenocarcinoma baseline 4 weeks received cabozantinib as first-line therapy confirmed partial response lasting 19 months

64 Phase 2 study to evaluate efficacy and safety of vandetanib in RET-rearranged NSCLC Maximum tumour shrinkage from baseline (%) KIF5B-RET CCDC6-RET Unknown-RET n = 19, ITT population Efficacy according to RET fusion All (n = 19) KIF5B-RET (n = 10) CCDC6-RET (n = 6) Unknown (n = 3) ORR, % (95% CI) 47 (24 71) 20 (3 56) 83 ( ) 67 (9 99) DCR, % (95% CI) 90 (67 99) 90 ( ) 100 (54 100) 67 (9 99) Median PFS, mo (95% CI) 4.7 ( ) 2.9 ( ) 8.3 ( ) 4.7 ( ) 1-year OS, % (95% CI) 47 (21 69) 42(11 71) 67 (5 95) 33 (1 77) ITT, intention-to-treat. Seto T, et al. ASCO J Clin Oncol. 2016;34 Suppl:abstract 9012.

65 Treatment n Response rate (%) Vandetanib (Seto 2016) Vandetanib (Lee 2016) Vandetanib (Gautschi 2016) Vandetanib (Horiike 2016) Cabozantinib (Drilon 2015) Cabozantinib (Gautschi 2016) Sunitinib (Gautschi 2016) Lenvatinib (Velcheti 2016) Overview of RET studies PFS (months) OS (months) % 1yr OS NR Drilon AE, et al. ASCO J Clin Oncol. 2015;33 Suppl:abstract Gautshi O, et al. ASCO J Clin Oncol. 2016;34 Suppl:abstract Lee SH, et al. ASCO J Clin Oncol. 2016;34 Suppl:abstract Seto T, et al. ASCO J Clin Oncol. 2016;34 Suppl:abstract Horiike A, et al. ESMO Abstract 1203PD. Velcheti V, et al. ESMO Abstract 1204PD.

66 Trk prone to fusion proteins, similar to ALK, that induce constitutive activation of cell signalling Oncogenic drivers across a variety of cancers upstream partner can provide dimerization domains and ligand-independent signalling activation of downstream pathways Prevalence (%) NTRK1 NTRK2 NTRK3 ROS1 ALK Detectable in the clinic FISH RNAseq DNA-based NGS 0 Select fusions are clinically actionable responses to targeted therapy can be dramatic and durable PTC, papillary thyroid cancer; CRC, colorectal cancer. Drilon A, et al. AACR 2016:abstract CT007. Farago AF, et al. J Thorac Oncol. 2015;10:

67 Entrectinib: a First-in-Class Trk Inhibitor Target TrkA TrkB TrkC ROS1 ALK IC50* (nm) Initially discovered by Nerviano Medical Sciences (NMS) as nextgeneration ALK inhibitor Later discovered to have potent TrkA/B/C and ROS1 activity Trk and ROS1 prone to fusion proteins, similar to ALK, that induce constitutive activation of cell signaling Entrectinib demonstrates inhibition of its RTK targets and downstream effectors in the PLCγ, MAPK and PI3K/AKT pathways * Biochemical kinase assay

68 Antitumor Activity (phase I studies) Alexander Drilon et al, AACR 2016

69 Duration of Clinical Benefit PTC: Papillar y thyroid cancer, CRC: colorectal cancer Alexander Drilon et al, AACR 2016

70 Baseline Day 26: - 47% response Day 155: - 77% response Anna F. Farago et al, JTO 2015

71 Baseline Day 26 Day 155

72 Current Directions

73 Principales mutations/insertions de HER2 Insertion de l exon 20 de 3 à 12 pdb. Entre les codons 775 and 881 : 12 pdb : 83% entrainant une insertion de 4 AA(YVMA). Insertion de 3 pdb 8% Mutations ponctuelles exon 20 : L755S et G776C 8%. Mutations de l exon 17 : G660D, V659E. Arcila ME, CCR 2012 Yamamoto H, JNCI 2014

74 Afatinib, efficace sur modèle préclinique 3 réponses objectives De Greve, Lung Cancer 2012

75 HER2 gene Polysomy Baseline After 2 months June 22, 2005 After 4 months Aug 31, 2005 Nov 8, 2005 Cappuzzo NEJM, 2006

76 Prédominance de femmes, non fumeurs, adénocarcinomes Mazières J, JCO 2013

77 Patients de stade IV traités avec des anti-her2 Patient 1 st line T Best disease response 1 VIN-HER PR 2 CAR-PAC-TRAS SD 3 TXT-MASA PD 4 VIN-TRAS PR 5 CAR-PAC-TRAS PR 6 VIN-TRAS PR 7 VIN-TRAS SD 8 LAP PD 9 NVB-HER PR 2 nd line T Best disease response 3rd line T Best disease response 4th line T Best disease response 10 LAP PD TRAS-VIN PR AFA SD CAR-TRAS SD 11 VIN-TRAS PD 12 DOC-TRAS PR 13 VIN-TRAS PR AFA PR 14 VIN-TRAS PR AFA SD 15 VIN-TRAS SD PAC-TRAS SD 16 TRAS PR SD: Stable Disease, PR: Partial Response, PD: Progressive disease, NE: non evaluated Conventional treatment: CAR: Carboplatin, PAC: Paclitaxel, VIN: Vinorelbin, DOC: Docetaxel. HER2 specific treatments: TRAS: Trastuzumab, LAP: Lapatinib, AFA: Afatinib, MASA: masatinib Taux de controle de la maladie : 96% pour le trastuzumab (n = 15), 100 % pour afatinib (n = 4).

78 Aberrant ERBB activation by: Gene amplification Receptor overexpression Somatic mutations EGFR:EGFR HER2:EGFR HER2:HER3 HER2:HER2 HER2:HER4 ERBB receptor dimerization Kinase activation Neratinib PI3K RAS PI3K Pathway AKT RAF MEK MAPK Pathway Downstream signal transduction Temsirolimus mtor ERK Nucleus Tumor growth, survival and spread Cell cycle control and proliferation Cell survival and decreased apoptosis Cellular migration and metastasis Angiogenesis B.Besse et al, ESMO 2014

79 Targeting HER2 aberrations HER2 mutations in 1 4% and HER2 amplifications in 2 5% of lung ADC Change from baseline (%) Dacomitinib (pan-her inhibitor) (HER2-mutated or amplified NSCLC) Partial response n = 30 HER2 mutation HER2 amplification Only 3/26 of HER2-mutant patients had a response (ORR 12%) Change in sum LD (%) PD PD PD Neratinib (pan-her inhibitor) ± temsirolimus (mtor inhibitor) (HER2-mutated NSCLC) PD SD SD PD SD * * SD SD SD SD PD * 30% threshold for reduction in tumour burden (response) Neratinib Neratinib + temsirolimus Partial response 0 (0) 3 (21)* SD SD SD SD SD SD SD SD SD SD SD PR PR PR 21% ORR and mpfs of 4 months * Patients had < 20% increase in tumour burden, but were considered PD due to the appearance of new lesions Kris MG, et al. Ann Oncol. 2015; 26: Besse B, et al. Presented at ESMO Abstract LBA 39.

80 And other targetable mutations Gene Alteration Histology Frequency (%) Inhibitor (Phase 1 and 2) BRAF Mutation, fusion ADC 1 3 Vemurafenib, dabrafenib, dabrafenib + trametinib ROS1 Chromosomal rearrangement ADC 1 2 Crizotinib (approved), ceritinib, cabozantinib, entrectinib, lorlatinib, DS-6051b MET Amplification, exon14 splicing ADC 1 4 (amplifications) 2 4 (mutations) Crizotinib, cabozantinib, tivantinib, capmatinib, volitinib, onartuzumab, glesatinib RET Fusion ADC 1 2 Carbozantinib, sunitinib, sorafenib, lenvatinib, vandetanib, ponatinib, alectinib, apatinib NTRK Fusion ADC < 1 Entrectinib, LOXO-101, cabozantinib, DS-6051b, merestinib HER2 Mutation (exon 20), amplification ADC 1 4 Trastuzumab, neratinib + temsirolimus, afatinib, lapatinib, dacomitinib KRAS Mutation ADC Selumetinib, trametinib PIK3CA Mutation, amplification SCC 15 (amplifications) (mutations) LY , PQR309, AZD2014, GDC-0032, AZD8186, IPI-549, BYL719 FGFR1 Amplification SCC 20 FGFR2-3 Mutation SCC 3 Lucitanib, nintedanib, dovitinib, AZD4547 FGFR1-3 Fusion SCC 3.5 DDR2 Mutation SCC 4 Dasatinib

81 Hyman DM, et al. N Engl J Med. 2015;373: Gautschi O, et al. J Thorac Oncol. 2015;10: Planchard D, et al. Lancet Oncol. 2016;17: Planchard D, et al. Lancet Oncol. 2016;17:

82 In summary. Diagnostic workup Molecular profiling 1. Multidisciplinary discussion to determine optimal procedure for tissue procedure 2. Biopsy 3. Morphology 4. Review of patient and tumour data Integrated NGS-based assay to detect mutations, amplifications, and translocations Patient selection Treatment EGFR ALK BRAF ROS1 RET MET exon 14mut/Amp NTRK1/2/3 HER2 No actionable alterations 1. Firstgeneration EGFR TKI 2. Thirdgeneration EGFR TKI 1. Crizotinib 2. 2nd or 3nd ALK TKI (Ceritinib, alectinib, Brigatinib) Dabrafenib + trametinib Vemurafenib Crizotinib Ceritinib Lorlatinib Cabozantinib Cabozantinib Vandetanib Sunitinib Crizotinib Cabozantinib Glesatinib Entrectinib Trastuzumab Neratinib+/- Temsirolimus Afatinib Dacomatinib Chemotherapy or immunotherapy Treatment cessation Subsequent therapies Treatment until response, progressive disease, or unacceptable adverse effects Therapy switch/combination based on re-biopsies or liquid therapy Adapted from Thomas A, et al. Nat Rev Clin Oncol. 2015;12:

83 Thoracic Molecular Tumor Board ON- PURPOSE FRESH TUMOR BIOSPSY & PATHOLOGY CONTROL MOLECULAR PROFILING (CGH & NGS) MOLECULAR TUMOR BOARD Since 2010 TREATMENT Max 21 calendar days

84 Acknowledgments Jean-Charles SORIA Benjamin BESSE Thierry LE CHEVALIER THANK YOU

85 ALK+ TKI + Immunotherapy.? EGFR+

86 Entrectinib: study of a first-in-class Trk inhibitor in various previously treated solid tumours Tumour reduction (%) Best response in TKI treatment-naïve NTRK-, ROS1-, and ALK-rearranged solid tumours (n = 24) a Fusion Confirmed response (n) ORR (%) NTRK1/3 3/3 100% PD PR CR Clinical response to entrectinib NTRK1- rearranged NSCLC Baseline Day 26: 47% response Day 155: 77% response ROS1 12/14 86% a Patients with ALK different tumour 4/7 types were 57% included in this study, including NSCLC, mammary analogue secretory carcinoma, and renal cell carcinoma. Images courtesy of A. Shaw and A. Farago, Massachusetts General Hospital. Drilon A, et al. AACR 2016:abstract CT007. Farago AF, et al. J Thorac Oncol. 2015;10:

87 ROS inhibitors ALK/ROS1 inhibitors Crizotinib Ceritinib Brigatinib (AP26113) Entrectinib (RXDX-101) Lorlatinib Non-ALK inhibitor DS6051b (inhibitor of the tyrosine kinases ROS1 and NTRKs)

88 Overview of the side-effects of the combination therapy with vemurafenib and cobimetinib Squamous cell carcinoma Increased CK Alopecia Arthralgia QTc prolongation Hyperkeratosis BRAFinhibitor Nausea Diarrhoea Exanthema Sensitivity to light Fatigue Liver function test* MEKinhibitor Serous retinopathy Ejection fraction Ejection fraction *Liver function tests including AST and ALT. Includes chorioretinopathy and retinal detachment. CK, creatine kinase; QTc, corrected QT interval. Provided by Prof. Dummer. Gibney GT, et al. Nat Rev Clin Oncol. 2013;10: Grimaldi AM, et al. Curr Opin Oncol. 2014;26: Larkin J, et al. N Engl J Med. 2014;371: ; 2014;26: Larkin J, et al. Lancet Oncol.2014;15: