IART Cremona,

IART Cremona, 06-06-2018 Quale spazio per la terapia biologica? Nicola Fazio, M.D., Ph. D. Unit of Gastrointestinal Medical Oncology and Neuroendocrine Tumors European Institute of Oncology Milan, Italy

SUNITINIB SSA Endothelial cell Pericytes PDGFR SSTRs NET tumor cells VEGFR IGF1-R RAS PLC PI3K Jak/STAT RAF PKC Akt EVEROLIMUS MEK mtorc-1 ERK

Therapies for patients with advanced NET SSA Everolimus / Sunitinib Chemotherapy PRRT Liver-directed treatments Primary tumor removal

Therapies for patients with advanced NETs FDA/EMA Approved Sunitinib Everolimus in pnet Lanreotide in GEP Telotristat in refractory carcinoid syndrome diarrhea STZ in pnet Octreotide IFN in carcinoid syndrome Lanreotide in carcinoid syndrome Octreotide in midgut Everolimus in non functioning Lung and GI PRRT in GEP NET 70 80 90 2011 2015 2016 2017 TMZ Oxaliplatin Not FDA/EMA approved Liver-directed: TACE/TAE TARF/TARE Bevacizumab Pasireotide STZ: streptozotocin; TMZ: Temozolomide; IFN: Interferon; GEP: Gastroenteropancreatic; TACE: Trans-Arterial-Chemoembolization; TAE: Trans-arterial-embolization; TARE: Trans-arterial radioembolization

NET guidelines from several different scientific societes Oncological scientific societes NEN scientific societes Italian NEN guidelines

Advanced pancreatic NET

Phase III trial-related evidence in pnet trial Presented/pub lished therapy PFS exp. arm PFS PLB arm setting CLARINET Caplin, NEJM 2014 LAN A vs. PLB Not reached 12 mo Well-diff RADIANT-3 NCT00510068 Yao, NEJM 2011 Raymond, NEJM 2011 EVE vs. PLB 11.4 mo 5.4 mo Well-diff SUN vs. PLB 11.4 mo 5.5 mo Well-diff

Everolimus Placebo 11.4 m 5.4 m Yao, NEJM 2011 Sunitinib Placebo 11.4 m 5.5 m Early stop due to significant difference in deaths, SAEs, and PFS 340 pts planned 171 enrolled Raymond, NEJM 2011

2006 Phase I 2008 Phase II 2011 Phase III

Sunitinib in NET: preclinical and phase I experience Preclinical In the RIP1-Tag2 transgenic mouse model of pancreatic islet cell carcinoma, sunitinib: reduced tumor burden and increased survival reduced endothelial cell population (VEGFR inhibition) reduced pericyte coverage (PDGFR inhibition) Phase I A study of sunitinib in solid tumors included 4 patients with non-pancreatic NET, inducing: 1 confirmed PR (rectal NET with bulky peritoneal metastases; he received sunitinib 75 mg/day 4/2 weekly) 1 minor response/sd Pietras K & Hanahan D. J Clin Oncol 2005;23:939 52; Yao V, et al. EORTC-NCI-AACR, Prague, 2007, Abstract 78 Faivre S, et al. J Clin Oncol 2006;24:25 35;

Phase II trial 50 mg/day 4/6 weeks prior SSA 50% 2003 2005 105 pts with NET (small cell excluded) 65 pts With pnet 40 pts with NET from other origin 46 Non functioning 19 functioning prior SSA 30% Kulke et al., JCO 2008

Phase II trial PR m TTP Pancreatic 16.7 % 7.7 mo Non pancreatic 2.4 % 10.2 mo Kulke et al., JCO 2008

Phase III, Randomized, Double-Blind Study of Sunitinib vs. Placebo in Patients with Advanced, Progressive, Well-Differentiated Pancreatic Endocrine Tumors Accrual goal = 340 pts Primary endpoint: PFS R A N D. Secondary endpoints: OS, ORR, TTR, duration of response, safety, patient-reported outcomes 1:1 Arm A Sunitinib 37.5 mg/day orally, continuous daily dosing (CDD)* Arm B Placebo Crossover Progression of disease Open-label sunitinib protocol (NCT00443534 or NCT00428220)

Non functioning, well differentiated, advanced pancreatic NET Lanreotide or CLARINET trial Octreotide Everolimus or Sunitinib RADIANT-3 trial A6181111 trial 1 2

Metastatic pannet: Everolimus Sunitinib or Sunitinib Everolimus? Criterion Regulatory features Evidence Biological background Clinical wisdom

Everolimus Investigation in NETs RADIANT (RAD001 in Advanced Neuroendocrine Tumors) Phase III Phase II RADIANT-3 RADIANT-4 RADIANT-2 RADIANT-1 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 EVE+OCT RAMSETE LUNA EVE+OCT 1 ST Line ITMO

Targ Oncol DOI 10.1007/s11523-017-0506-5 REVIEW ARTICLE Predictive Markers of Response to Everolimus and Sunitinib in Neuroendocrine Tumors Diana Martins 1 &Francesca Spada 1 &Ioana Lambrescu 1 &Manila Rubino 1 & ChiaraCella 1 &Bianca Gibelli 2 &ChiaraGrana 3 &Dario Ribero 4 &Emilio Ber tani 4 & Davide Ravizza 5 &Guido Bonomo 6 &Luigi Funicelli 7 &EleonoraPisa 8 &Dario Zer ini 9 & Nicola Fazio 1 &IEO ENETS Center of Excellence for GEP NETs # Springer International Publishing Switzerland 2017 Abstract Neuroendocrine tumors (NETs) represent a large and heterogeneous group of malignancies with various bio- accurate biomarkers for predicting tumor response and effica- No validate predictive biomarker for sunitinib and everolimus so far * Nicola Fazio nicola.fazio@ieo.it logical and clinical characteristics, depending on the site of origin and the grade of tumor proliferation. In NETs, as in other cancer types, molecularly targeted therapies have radically changed the therapeutic landscape. Recently two targeted agents, the mammalian target of rapamycin inhibitor everolimus and the tyrosine kinase inhibitor sunitinib, have both demonstrated significantly prolonged progression free survival in patients with advanced pancreatic NETs. Despite these important therapeutic developments, there are still significant limitationsto theuseof theseagentsdueto thelack of cy of therapy. In this review, we provide an overview of the current clinical data for the evaluation of predictive factors of response to/efficacy of everolimus and sunitinib in advanced pancreatic NETs. Surrogate indicators discussed include circulating and tissue markers, as well as non-invasive imaging techniques. Key Points Everolimus and sunitinib are widely investigated targeted cancer therapies, and they are both globally approved by regulatory authorities for the treatment of pancreatic NETs. 1 2 3 4 Unit of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Instituteof Oncology, IEO, 20141 viaripamonti, 435 Milan, Italy Division of Otolaryngology-Head and Neck Surgery, European Institute of Oncology, IEO, Milan, Italy Division of Nuclear Medicine, European Institute of Oncology, IEO, Milan, Italy Division of Hepatobiliopancreatic Surgery, European Institute of Oncology, IEO, Milan, Italy The establishment of predictive markers of response to everolimus and sunitinib in NETs is of extreme importance for their efficient use. Most efforts to define predictive biomarkers have failed, with the exception of chromogranin-a and neuron-specific enolase for advanced pancreatic NETs treated with everolimus. Martins et al., Targeted Oncol 2017

Dual modulation of Mcl-1 and mtor by sunitinib determines the response of cancer cells Comparison of patient samples prior and post sunitinib treatment suggests that increasing Mcl-1 levels and mtorc1 activity correlates with resistance to sunitinib in patients Suni4nib ERK GSK3b Combinatorial treatment Mcl- 1 inhibitors Mcl- 1 mtor Rapalogs/ Starva4on Sensi4za4on Elgendy et al., JCI 2016

Everolimus > Sunitinib vs. Sunitinib > Everolimus in renal cancer RECORD-3 trial

Everolimus > Sunitinib was not non-inferior to the opposite sequence

An Italian real world analysis of sunitinib in pannet 73 pts with advanced pnet (71% >/= 3 lines) 82% with prior Everolimus PR 19 % SD 53 % PFS 11 mo mos 36 mo Confirmed activity and toxicity profile even beyond Everolimus and/or PRRT Panzuto et al., Pancreatology Nov 2017

CI=confidence interval; mpfs=median progression-free survival; PFS=progression-free survival; pnets=pancreatic neuroendocrine tumors 1: Trial ORRwas Profile Sunitinib in pannet: data about first-line and cytoreductive effect 24.5% (95% CI, 16.7 33.8) according to the investigator assessment (Table 2). 123 patients screened Table 2: Best Observed Response by RECIST, Assessed by Investigators 106 patients enrolled Previously Treatment-naïve Treated 1 txt-naïve patients treated 45 previously treated n=61 patients treated n=45 Best overall response, n (%) 3 txt-naïve Complete patients discontinued response txt 39 previously 2 treated (3.3) patients discontinued 1 txt(2.2) 3 (2.8) 26 Objective progression/relapse 23 Objective progression/relapse Partial response 11 (18.0) 12 (26.7) 23 (21.7) 6 Adverse events 8 Adverse events 4 Refusal Stable of txt disease for reason other than AE 1 Refusal 40 of txt (65.6) for reason other than AE 29 (64.4) 69 (65.1) 2 Global Progressive health deterioration disease 2 Global health 7 (11.5) deterioration 2 (4.4) 9 (8.5) 1 Death Indeterminate 1 Death 1 (1.6) 1 (2.2) 2 (1.9) 4 Other 4 Other ORR,* n (%) 13 (21.3) 13 (28.9) 26 (24.5) 95% CI 11.9 33.7 16.4 44.3 16.7 33.8 fficacy * Complete analysis: response 61 txt-naïve + partial patients response. 45 previously treated patients * Complete response + partial response. Raymond et al., ENETS 2017, Poster session afety CI=confidence analysis: 61 interval; txt-naïve ORR=objective patients response 45 rate; previously RECIST=Response treated patients Evaluation Criteria in Solid Tumors CI=confidence interval; ORR=objective response rate; pnet=pancreatic neuroendocrine tumor; RECIST=Response Evaluation Criteria in Manuscript under review vent; txt=treatment RECIST-based Table 2: Best Observed Response Based on Independent Third-Party Radiology According to Choi Criteria in Treatment-Naïve and Previously Treated Patients With pnets Choi-based Total N=106 Best overall response, n (%) Vomiting 8 (13.1) 1 (1.6) 1 Asthenia 10 (16.4) 0 (0.0) 7 Abdominal pain upper 5 (8.2) 1 (1.6) 7 ALT increased 2 (3.3) 1 (1.6) 9 AST increased 4 (6.6) 1 (1.6) 7 Constipation 3 (4.9) 0 (0.0) 7 Dizziness 3 (4.9) 0 (0.0) 7 Hypophosphatemia 2 (3.3) 2 (3.3) 7 Myalgia 2 (3.3) 0 (0.0) 7 Treatment-Naïve n=61 Previously Treated n=45 Adverse events are listed by highest to lowest % for Total/All Grades patie * Adverse events reported by 15% in any treatment group per MedDRA ALT=alanine aminotransferase; AST=aspartate aminotransferase; MedDR Complete response 0 1 (2.2) CONCLUSIONS Partial response 32 (52.5) 24 (53.3) n The study confirmed sunitinib is an efficac Stable disease n Median 12 (19.7) PFS of 13.2 months 17 (37.8) (95% CI, 10. Progressive disease 16.7 33.8) 9 (14.8) observed in this 2 (4.4) phase IV trial Indeterminate phase III trial of sunitinib in pnets and co 8 (13.1) 1 (2.2) ORR,* n (%) n OS data 32 (52.5) were not mature 25 at (55.6) the time of t 95% CI n AEs 39.3 65.4 were consistent with 40.0 70.4 the known safet Solid Tumors in progressive, locally advanced and/or m unresectable pnets. TTP (mo) 14.8 14.5 TTP (mo) 18.7 16.7

Metastatic indolent SSTR-2 + pancreatic NET TAE / TACE / TARE Liver surgery RT Primary tumor removal SSA Everolimus or Sunitinib Sunitinib or Everolimus PRRT Chemotherapy 1 2 3 4 5 Clinical trials

Advanced pannets 2016 ENETS guidelines Minimal consensus statement: Everolimus or sunitinib are generally recommended after failure of SSA or chemotherapy in pancreatic NET. Everolimus and sunitinib.. can be considered a first line therapy, especially if SSA is not an option, and if systemic chemotherapy is not clinically required, not feasible or not tolerated. Pavel et al., Neuroendocrinology Jan 2016

Advanced well differentiated pannet According to ENETS guidelines SSA Chemotherapy Everolimus or Sunitinib Sunitinib or Everolimus PRRT 1 2 3 4 5

Everolimus in pannets: Prior chemotherapy Prior therapy EVE PBO Surgery n.r. n.r. Radiotherapy 23 % 20 % Chemotherapy 50 % 50 % SSA 49 % 50 % Yao et al., NEJM 2011

Sunitinib in pannets: Prior chemotherapy Concomitant SSA treatment, n (%) of patients Started prior to study and continued Started during study 17 (20.5) 15 (18.1) 2 (2.4) 18 (22.0) 12 (14.6) 6 (7.3) Raymond et al., NEJM 2011

Advanced pancreatic NET G3

Overall survival of 136 patients with GEP NEC according to subtype Type A = well diff. + Ki-67 21-55 % Type B = poorly diff. + Ki-67 21-55% Type C = poorly diff. + Ki-67 > 55% Milione et al., Neuroendocrinology Mar 2016

Neuroendocrinology (DOI:10.1159/000445165) Table 1. Clinico-pathological features of 136 patients with NEC ALL Type A Type B Type C Total 136 24 30 82 Gender Men 81 15 15 51 Women 55 9 15 31 Tumor site Esophagus 5 0 1 4 Stomach 28 5 6 17 Duodenum 5 0 3 2 Ileum cecum appendix 17 4 3 10 Colon rectum 46 4 8 34 Pancreas 33 11 9 13 Gallbladder 2 0 0 2 Mitotic count /10HPF <20 44 17 24 3 20-29 18 7 3 8 30 74 0 3 71 CD117 Negative 63 7 12 44 Positive 20 1 4 15 Missing 53 16 14 23 pannec = 24% of the total population 30% of pnec were NET G3 (or type A) Pancreas as the most frequent primary site among NET G3 MMRd Angio-invasion Absent 61 5 11 45 Present 6 2 2 2 Missing 69 17 17 35 Milione et al., Neuroendocrinology Mar 2016

GEP NEC heterogeneity: possible clinical implications WD = well differentiated; PD = poorly differentiated

Everolimus in pannet G3 15 pts with pannet (all well/moderately differentiated) and 20-55% Ki-67 All pre-treated, mostly with chemotherapy mpfs = 6 mo mos = 28 mo Panzuto et al., Pancreas 2017

Sunitinib in NET/NEC G3 Clinical and biomarker evaluations of sunitinib in patients (pts) with advanced well-differentiated grade 3 (G3) and poorly differentiated neuroendocrine neoplasms (PD-NEN). Dreyer et al., POSTER ASCO GI 2016 7/26 pts (23%) had SD or PR 3 pts were NET G3

Pancreatic NET G3 IEO patient with liver mets from moderately differentiated pancreatic NET, Ki67 40% Resistant to platinum-based chemotherapy 1 month of Sunitinib 37.5 mg/d

GETNE-1206 (SEQTOR): Phase III Study in Patients With Advanced GETNE pnet1206 (SEQTOR) phase III trial in patients with advanced pannets Compare efficacy and safety of everolimus followed by chemotherapy with STZ + 5-FU upon progression, or the enrolling reverse sequence (chemotherapy with STZ + 5-FU followed by everolimus upon progression) Arm A: Everolimus Everolimus Progression Arm B: STZ + 5-FU STZ + 5-FU Primary end point: rate of second PFS at 84 weeks of treatment Unpublished data. Clinicaltrials.gov ID, NCT02246127. 26

Therapies sequencing in non-functioning metastatic midgut NET: evidence 1 2

Metastatic SSTR-2 positive midgut NET Primary tumor removal TAE / TACE / TARE Liver surgery RT SSA PRRT Everolimus 1 2 3 Clinical trials

Sequence of therapies in refractory carcinoid syndrome SSA dose/schedule Locoregional PRRT IFN adjustment treatments EVE diarrhea

New TKIs

Novel TKIs in GEP NETs Phase III Phase III Phase III

CDK 4/6 inhibitors

CDK 4/6 inhibition in NET: preclinical studies with RIBOCICLIB and PALBOCICLIB Neuroendocrinology (DOI:10.1159/000463386) 2017 S. CDK4/6 controls cell cycle progression from G1 to S phase by regulating the activity of Rb Prada et al, Neuroendocrinology 2016 Tang L. et al., Clin Cancer Res 2012 Fig. 1. Proposed and simplified mode of action of the CDK4/6 inhibitor LEE01

Immune checkpoint inhibitors

PDR001 in GEP and Lung NET/NEC Phase II multi-cohort international study PDR001 binds to PD-1 so blocking both PD-L1 and PD-L2 Well differentiated: GI cohort (n=30) Pancreatic cohort (n=30) Thoracic cohort (n=30) Poorly differentiated: GEP cohort (n=20)

A multicohort phase II study of durvalumab plus tremelimumab for the treatment of patients (PTS) with advanced neuroendocrine neoplasms (NENs) of gastroenteropancreatic (GEP) or lung origin (the DUNE trial-getne1601-). Single-arm Phase II 126 pts Well differentiated: GI cohort (n=30) Pancreatic cohort (n=30) Thoracic cohort (n=30) Durvalumab (anti-pd-l1) Poorly differentiated: GEP cohort (n=20) Tremelimumab (anti-ctla-4)

European Institute of Oncology, IEO, Milan, Italy ENETS Center of Excellence for GEP NETs IEO NET MDT