Acknowledgement of Support

Progress in the War Against Brain Tumors

Henry S. Friedman, MD receives clinical trial and speaking engagement (honorarium and travel) support from Genentech and other pharmaceutical companies.

Henry S. Friedman, MD The Preston Robert Tisch Brain Tumor Center at Duke

Brain Tumor Therapeutic Options

Brain Tumor Therapeutic Options

• Surgery • Radiation • Chemotherapy • Anti-Angiogenic Agents • Gene Therapy

• Vaccines • Monoclonal Antibody Targeted Therapy • Oncolytic Viruses • Molecular Pathway Inhibitors • Immune Augmentation

Incidence

Malignant Glioma

Distribution of All Primary Brain and CNS Tumors by Histology All Other 13.9%

LGG (grade 2) - 25% 5,000 cases/yr

Glioblastoma 20.3%

Lymphoma 3.1% Nerve Sheath 8.0%

Pituitary 6.3%

CBTRUS Report: 2004-2005.

GBM (grade 4) – 60% 13,000 cases/yr

Astrocytomas 9.8%

Craniopharyngioma 0.7%

Meningioma 30.1%

Ependymomas 2.3% Oligodendrogliomas 3.7% Embryonal, including Medulloblastoma 1.7%

AA (grade 3) 10% 2,000 cases/yr

AO (grade 3) 5% 800 cases/yr Hess et al. Cancer 101:2293, 2004 CBTRUS; Statistical Report, 2005-2006

1

GBM Clinical Prognostic Factors: Age, Performance Status (PS), Resection

Glioblastoma: Overall Characteristics

(RTOG recursive partitioning analysis (RPA) class)

RPA Class 3 4

• Grade IV malignant glioma • Most malignant, invasive,

5

Clinical Median OS Feature (months) age < 50; PS = 0 17 age < 50; PS = 1-2 15 age > 50; GTR/STR age > 50; biopsy 10

difficult-to-treat primary brain tumor

• Frequency:

most common in older adults (peak age, 55–65 years)

• Recurrence:

rapid growth; size may double every 10 days

• Median survival:

~ 1 year Mirimanoff, R.-O. et al. J Clin Oncol; 24:2563-2569 2006

Anaplastic Astrocytoma: Overall Characteristics

Glioblastoma (GBM)

• Grade III malignant glioma • Less aggressive than GBM, malignant with somewhat better prognosis

• Frequency:

highest in young adults (30–40 years)

• Recurrence: often as a higher-grade glioma • Challenge: difficult to remove completely with •

• Invasive • Hypoxic

surgery Median survival: 3–4 years

• Phenotypically heterogeneous • Resistant to therapy Courtesy of M. Prados, MD

Current Treatment: Surgery

Therapy of Glioblastoma: Surgery

Extent of Tumor Resection is Associated with Improved Outcomes

• Major resection increases duration and quality of survival compared to biopsy or minimal resection

• Not a curative intervention

2

Study

Conclusion

Stummer W, et al. Lancet Oncol. 2006;7:392-401

Complete resection (using fluorescence-guided surgery) results in longer progression-free survival rates

Laws ER, et al. J Neurosurg. 2003;99:467-473

Resection (vs. biopsy) is a strong prognostic factor for survival in the Glioma Outcomes Project

Lacroix M, et al. J Neurosurg. 2001;95:190-198

Significant survival advantage associated with resection of ≥ 98% mean tumor volume

Keles GE, et al. Surg Neurol. 1999;52:371-379

Extent of tumor removal and residual tumor volume are significant factors in predicting time to tumor progression and mean survival

Surgical Management

Therapy of Glioblastoma: Radiotherapy

Therapeutic Impact of Radical Surgery in Glioblastoma Lacroix M, et al. J Neurosurg. 2001;95:190-198.

• Addition of radiotherapy to surgery increases

Median survival, mos

14 P 7.0 Spontaneous hydrolysis CH3

Temozolomide

O C

NH2 N

N

N H

MTIC

MTIC, 5-(3-methyltriazen-1-yl) imidazole-4-carboxamide.

O N N

C

NH2 NH2

CH3

N

+N

N–CH3

N

AIC

Methyldiazonium ion

Failed radiotherapy ± chemotherapy with nitrosourea KPS ≥ 70 No stereotactic or interstitial radiotherapy

Children (CCG)

Phase 2

1st relapse GBM (national)

Phase 2

1st relapse AA (national)

Phase 2

Newly diagnosed malignant glioma (Duke)

Temozolomide (n = 112) 200 mg/m2 qd x 5 d or 150 mg/m2 qd x 5 d Procarbazine (n = 113) 150 mg/m2 qd x 5 d or 125 mg/m2 qd x 5 d

Temozolomide (TMZ) in Glioblastoma at First Relapse: Progression-free Survival (PFS) Rates TMZ PFS at 6 mo, %

1.0

PCB

21

0.8

8*

Median PFS, wks (mo)† 12.4 (2.89)

6-mo PFS

8.32 (1.88)‡

0.6 0.4

* p = 0.008. † Hazard ratio = 1.47. ‡ p = 0.00063.

TMZ 0.2 PCB 0.0 0

3

6

9

12

15

18

Time from start of treatment (months) KPS, Karnofsky performance status; PFS, progression-free survival.

Yung WKA et al. Br J Cancer. 2000;83:588-593.

PCB, procarbazine.

Yung WKA et al. Br J Cancer. 2000;83:588-593.

Temozolomide in Malignant Glioma* at First Relapse: Survival Rates

Temozolomide in Anaplastic Astrocytoma at First Relapse: Study Schematic

1.0

• • • •

Histologically confirmed anaplastic astrocytoma

No prior chemotherapy 200 mg/m2 qd x 5 d

Failed radiotherapy ± chemotherapy with nitrosourea KPS ≥ 70 No previous stereotactic or interstitial radiotherapy

KPS, Karnofsky performance status; PFS, progression-free survival.

0.8 Survival rates

• •

Histologically confirmed glioblastoma Randomization

•

Phase 1

Denny BJ et al. Biochemistry. 1994;33:9045-9051.

Temozolomide in Glioblastoma at First Relapse: Study Schematic •

Adult (Mayo clinic)

PFS rate

O

Phase 1

6-mo PFS

Median = 13.6 months 0.6 Overall survival

0.4 6-mo PFS = 46% 0.2

Prior chemotherapy 150 mg/m2 qd x 5 d

Progression-free survival

0.0 0

3

6

9

12

15

18

21

24

Time (months) from start of treatment * Intent-to-treat population, includes anaplastic astrocytoma and anaplastic oligoastrocytoma.

Yung WKA et al. J Clin Oncol. 1999;17:2762-2771.

4

Yung WKA et al. J Clin Oncol. 1999;17:2762-2771.

Temozolomide Duke Phase 2

Temozolomide Duke Phase 2 Eligibility

Treatment plan

• Newly diagnosed GBM, GS, AA • Surgery or biopsy • Measurable enhancing lesion > 1.5

• 200 mg/m2 po x 5 days every 4 weeks • 4 cycles given prior to RT • PE/MRI every 4 weeks • Radiographic response criteria

cm2 within 3 days or > 14 days from surgery

Temozolomide Duke Phase 2 GBM response • 33 patients with GBM – 3 complete responses – 14 partial responses – 5 stable disease – 11 progressive disease Treatment scheme. TMZ, temozolomide; RT, radiotherapy. Friedman, HS, et al. J Clin Oncol. 1998;16:3851-3857

R. Stupp NEJM 2005

Kaplan-Meier estimates of median survival of all patients (intent-to-treat).

5

2 year survival (%)

RT 10.4

RT + Temo 26.5

2 year PFS (%)

1.5

10.7

Median survival (M)

12.1

14.6

Adjuvant TMZ

RANDOMIZE

RT/TMZ

6

0

10

14

18

22

O6-alkylguanine-DNA Alkyltransferase (AGAT) Resistance to Chemotherapy

30

26

Weeks

RT Alone

Temozolomide 75 mg/m2 po qd for 6 weeks, then 150–200 mg/m2 po qd d1–5 every 28 days for 6 cycles

Stupp R et al. NEJM 352:987,2005

Nitrosourea

Focal RT daily — 30 x 200 cGy Total dose 60 Gy

Alkyl group

DNA X L

5 Year Follow-Up

PFS Survival

RT

RT + TMZ

2-year

10.9%

27.3%

3-year

4.4%

16.0%

4-year

3.0%

12.1%

5-year

1.9%

9.8%

O6-guanine

AGAT

OS

Procarbazine

Methyl group

Mismatch

Stupp Lancet Oncol 2009

06-alkylguanine DNA Alkyltransferase (AGT) • Ubiquitous DNA repair protein

NH 2

CH 3

• Removes the

SH

N

N

CH3 groups from the O6-methylguanine

% AGT + cells < 20% ≥ 20%

NH

O N

AGT and Response to Temozolomide

N

CH2

CH CO

NH 2

COOH

6

O -methylguanine

NH 2

• Irreversibly

O

inactivated

N

• De novo

N

synthesis required for recovery

NH CH3

NH N

S

CH2

CH CO

NH2

COOH

Guanine

Irreversible inactivation

AGT/MGMT Gene

Promoter

Responder

15

1

Non-Responder

10

10

Alkyltransferase

Coding Sequence

+ Methylation

No Expression

- Methylation

Yes Expression

X AGT AGT

6

5 Year Survival EORTC/NCIC Trial

Group Total MGMT unmethylated MGMT methylated

Radiation alone

Radiation + Temozolomide

1.9%

9.8%

0

8.3%

5.2%

13.8%

Anti-Angiogenesis

• Bevacizumab – what doesn’t it treat?

Rationale for Bevacizumab in GBM

Bevacizumab Development Timeline - 1

VEGF is highly expressed in Human GBM

James Vredenburgh + Patti Beaver February 2004

LOI to Genentech – denied IND to FDA – denied

6/19/1990

Survival (weeks)

VEGF expression correlates with tumor grade and outcome

September 2004 Virginia Stark-Vance shows Henry Friedman MRIs of 8 Bevacizumab + CPT-11 treated patients (7 responders)

Anti-VEGF inhibits growth of GBM xenograft r = -0.42 VEGF mRNA signal

Nature • Vol 362 • 29 April 1993

Bevacizumab Development Timeline - 2

Treatment plan

Henry Friedman calls Art Levinson Bevacizumab: 10 mg/kg Genentech says Go!

Irinotecan EIAED: 340 mg/m² Non-EIAED: 125 mg/m²

FDA approves IND from James Vredenburgh

James Vredenburgh / Annick Desjardins Trials

Combination bevacizumab/irinotecan

BRAIN Trial (Henry Friedman, PI)

1 1

FDA Approval in Recurrent GBM

7

2 2

3 4 3 4 Weeks Weeks

5 5

6 6

MRI

Repeat for Repeat for up to 1 year up to 1 year

Pre-treatment A

After 4 cycles

Is this a “glorified steroid” effect?

B

(If so, would not expect durable anti-tumor control)

Grade 3

Recurrent AA (Grade 3) C

Near CR after 4 cycles of BV/Irinotecan

D

Grade 4

OUTCOME

Duke (n = 35)

TMZ 1st PD1 (n=162)

Duke (n = 33)

CR/PR (%)

61

35

53

5

SD (%)

33

27

41

40

PD (%)

6

38

6

55

PFS (wks)

30

22

23

12

6 mth PFS (%)

65

46

43

21

OS (weeks)

65

54

42

30

1

Yung Journal of Clinical Oncology 17:2762, 1999. Endure

2 Yung

British Journal of Caner 83:588, 2000.

TMZ 1st PD2 (n = 112)

Vredenburgh J et al. Clin Ca Res 13:1253, 2007 Vredenburgh J et al. J Clin Oncol 25:4722 , 2007 Desjardins A et al. Clin Cancer Res 14:7068, 2008

BRAIN (phase II, multicenter, noncomparative trial) 167 patients with glioblastoma in first or second relapse

Bevacizumab Alone and in Combination With Irinotecan in Recurrent Glioblastoma

Prior radiotherapy and temozolomide

Henry S. Friedman, Michael D. Prados, Patrick Y. Wen, Tom Mikkelsen, David Schiff, Lauren E. Abrey, W.K. Alfred Yung, Nina Paleologos, Martin K. Nicholas, Randy Jensen, James Vredenburgh, Jane Huang, Maoxia Zheng, and Timothy Cloughesy

Stratification by Karnofsky score (70-80, 90-100) First, second relapse

BEV (n=85) 10 mg/kg q2 weeks

First progressive disease

Optional Post-Progression Phase BEV + CPT-11 (n=44)

BEV + CPT-11 (n-82) EIAED: 40 mg/m2 IV/90 min Non-EIAED: 125 mg/m2 IV/90 min

• Primary endpoints (by independent radiology review)

Journal of Clinical Oncology, 27(28):4733-4740, 2009.

• OR rate • 6-month PFS • Additional measurements • Updated safety and survival BEV=bevacizumab, CPT-11=irinotecan, EIAED=enzyme-inducing antiepileptic drug, OR=objective response, PFS=progression-free survival.

6-month PFS by External Review

Summary of Efficacy Bev (n = 85)

Bev/CPT (n = 82)

6 month PFS: %

35.6

51.0

ORR: %

21.2

34.1

6 month PFS: %

44.7

60.9

ORR: %

38.8

46.3

Independent Radiology Review

Investigator

+: censored subjects

8

Overall Survival Bevacizumab (n=85)

Bevacizumab/CPT-11 Bevacizumab/CPT(n=82)

31 (37) 8.2 (8.1, -)

34 (42) 8.7 (7.8, -)

No. of deaths (%) Median (mo (mo), ), 95% CI

Summary • Bevacizumab is active against recurrent glioblastoma

Proportion Surviving

• There were rare CNS hemorrhages and no unique toxicities in GBM patients • FDA approved bevacizumab for recurrent glioblastoma May 5th, 2009

Duration of Overall Survival (months)

G2

Response Rate and PFS6 in Pooled Analyses of Trials for Relapsed Glioblastoma Sample Size

Response Rate

6-month PFS

Overall Survival

12-month Survival

225

6%

15%

5.7 mo

21%

Response rate: Bevacizumab arm vs historical controls

(Wong 1999) 16 NCCTG trials 1980-2004

345

n/a

9%

5.1 mo

14%

(Ballman 2007) 12 NABTC trials 1998-2002

437

7%

16%

6.9 mo

25%

(Lamborn 2008) Lomustine control arm from Phase III study of enzastaurin

92

4.3%

19%

7.1 mo

24%

60

50

50

40

30

20

10

0

85

28.2%

42.6%

9.3 mo

40

30

20

10

0 AVF3708g Bevacizumab by IRF (n=85)

(Fine et al 2008)

AVF3708g

Six-month progression-free survival: Bevacizumab arm vs historical controls

60

Patients with PFS6, %

Publication 8 MD Anderson trials 19861995

Response Rate and PFS6 Significantly Higher Than Historical Controls

Patients with ORR (CR + PR), %

G1

AVF3708g Bevacizumab by INV (n=85)

Wong et al. 1999 (n=225)

Lamborn et al. 2008 (n=437)

Fine et al. 2008 Lomustine (n=92)

AVF3708g Bevacizumab by IRF (n=85)

AVF3708g Bevacizumab by INV (n=85)

Wong et al. 1999 (n=225)

Lamborn et al. 2008 (n=437)

37.6%

Treatment Plan Part A

The Addition of Bevacizumab to Standard Radiation Therapy and Temozolomide Followed by Bevacizumab, Temozolomide and Irinotecan for Newly Diagnosed Glioblastoma

Radiation therapy

James J. Vredenburgh, Annick Desjardins, David A. Reardon, Katherine B. Peters, James E. Herndon, II, Jennifer Marcello, John P. Kirkpatrick, John H. Sampson, Leighann Bailey, Stevie Threatt, Allan H. Friedman, Darell D. Bigner, and Henry S. Friedman

Temozolomide 75 mg/m2/day

Bevacizumab 10 mg/kg

Clinical Cancer Research 17(12): 4119-4124, 2011.

1

2

3

4

Weeks

9

5

6

Fine et al. 2008 Lomustine (n=92)

Slide 51 G1

GBM-006 Response Rate and PFS6 in Pooled Analyses of Trials for Relapsed Glioblastoma 1 GenenUser, 3/16/2009

Slide 52 G2

CC-006 Response Rate and PFS6 Significantly Higher than Historical Controls 1 Historical Control GenenUser, 3/25/2009

Treatment Plan Part B

Study Dates

Bevacizumab: 10 mg/kg

• Study Opened: 8/15/07

Irinotecan EIAED: 340 mg/m² Non-EIAED: 125 mg/m²

• Accrual: 125 patients through 3/26/09

Temozolomide 200 mg/m2/day

• Median Follow-Up: 48.6 mos

Bevacizumab / Irinotecan

1

2

3

4

5

6

7

8

Weeks

MRI

Progression free survival

Total

# PD

125

119

Median PFS (95% CI) 14.0 months (12.5 mo, 15.9 mo)

Overall Survival

6-month PFS (95% CI)

1-year PFS (95% CI)

2-year PFS (95% CI)

3-year PFS (95% CI)

87.2% (80.0%, 92.0%)

63.2% (54.1%, 71.0%)

17.6% (11.5%, 24.7%)

7.2% (3.5%, 12.6%)

Total

# Died

125

111

Median survival (95% CI) 20.9 months (18.0 mo, 24.1 mo)

6-month OS (95% CI)

1-year OS (95% CI)

2-year OS (95% CI)

3-year OS (95% CI)

92.8% (86.6%, 96.2%)

81.6% (73.6%, 87.4%)

42.4% (33.7%, 50.9%)

20.0% (13.5%, 27.4%)

AVAglio* Phase III BEV + TMZ and Radiotherapy in Newly Diagnosed GBM: Study Design

Conclusions • The addition of bevacizumab to daily temozolomide and radiation therapy is safe

TMZ 150-200 mg/m²/qd days 1-5 q28d Placebo 10 mg/kg q2w

Placebo 15 mg/kg q3w monotherapy until disease progression

RT 2 Gy 5 days/week for 6 weeks TMZ 75 mg/m²/qd BEV 10 mg/kg q2w

TMZ 150-200 mg/m²/qd days 1-5 q28d BEV 10 mg/kg q2w

Bevacizumab 15 mg/kg q3w monotherapy until disease progression

Concurrent phase

Maintenance phase for 6 cycles

RT 2 Gy 5 days/week for 6 weeks TMZ 75 mg/m²/qd Placebo 10 mg/kg q2w

• The addition of irinotecan and bevacizumab to standard 5-day temozolomide is tolerable

Debulking surgery or biopsy

Randomization with stratification 4-7 weeks post surgery Based on RPA class and country

• Bevacizumab/temozolomide and radiation followed by bevacizumab/temozolomide and irinotecan appear to improve the progression-free survival compared to historical controls

Treatment starts 28-49 days post surgery

• Phase III trials are necessary

(n=460) 4-week treatment break

(n=460)

Monotherapy phase until PD

BEV=bevacizumab; GBM=glioblastoma; PD=progressive disease; RPA=recursive partitioning analysis; RT=radiotherapy; TMZ=temozolomide Chinot, et al. Adv Ther 2011;28:334-340. *Genentech/Roche Sponsored Study

10

RTOG 0825* Phase III Concurrent Chemoradiation and Adjuvant TMZ + BEV vs Conventional Concurrent Chemoradiation and Adjuvant TMZ in Newly Diagnosed GBM: Study Design

3 weeks of chemoradiation therapy

3 weeks RT 30 Gy in 2 fraction Daily TMZ qd × 21d Placebo q2w (continues without stop)

Randomization (≤10 days after start of RT) Stratification by MGMT methylation status and molecular profile

AVAglio Results Standard of Care Arm

TMZ days 1-5 q28d Placebo q2w 12-cycle maximum 4-week treatment break

3 weeks RT 30 Gy in 2 fraction Daily TMZ qd × 21d BEV q2w (continues without stop)

PFS (mo)

7.3

10.7

OS (mo)

16.1

15.7

10.6

16.1

16.8

6

9

4

8

2.7

4.5

ICH (%)

2.2

2.6

Pseudoprogression (%)

9.3

2

Grade 5 tox (%)

Bevacizumab Beyond Progression Treatment Plan Part A

RTOG 0825 Results Experimental Arm

6.2

OS (mo)

QoL stable or better (mo)

BEV=bevacizumab; GBM=glioblastoma; RT=radiotherapy; RTOG=Radiation Therapy Oncology Group; TMZ=temozolomide http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0825 *Independently Sponsored Study that is supported by as of 12/11. Genentech/Roche with study drug and, in some instances, funds

Standard of Care Arm

PFS (mo)

KPS > 70 (mo)

TMZ days 1-5 q28d BEV q2w 12-cycle maximum

Experimental Arm

Radiation therapy Temozolomide 75 mg/m2/day

Bevacizumab 10 mg/kg

Bevacizumab treated patients had poor information processing, global cognitive function and executive function

0

1

3

2

4

5

6

Weeks

Treatment Plan Part B

Treatment Plan Part C

Temozolomide 200 mg/m2/day

For 12 months

Until progression

Bevacizumab

Bevacizumab

0

1

2

3

4

5

6

7

8

0

Weeks

1

2

3

4

5

6

7

8

Weeks

MRI

MRI

11

Treatment Plan Part D

Gene Therapy

Treating physician best management

• TK gene/herpes virus • Does anyone have a vector that will work and be

For 12 months

safe?

Bevacizumab

0

1

2

3

4

5

6

7

8

Weeks

MRI

Epidermal Growth Factor Receptor Mutation (EGFRvIII) 1 5

Vaccines

6

Transmembrane Segment

273

NH2

COOH Deleted Segment

• Direct presentation • Dendritic cell presentation • Do you use generic or tumor specific antigen?

Intracellular Domain

EGF Binding Domain

Extracellular Domain 1 5 6 273 LEU-GLU-GLU-LYS-LYS-VAL-CYS-...-PRO-ARG-ASN-TYR-VAL-VAL-THR-ASP-HIS Wild Type Amino Acid Sequence CTG-GAG-GAA-AAG-AAA-GTT-TGC-...-CCC-CGT-AAT-TAT-GTG-GTG-ACA-GAT-CAC Wild Type cDNA Sequence LEU-GLU-GLU-LYS-LYS-GLY-ASN-TYR-VAL-VAL-THR-ASP-HIS-CYS-KLH

PEPvIII-KLH

(CDX-110) CTG-GAG-GAA-AAG-AAA-GGT-AAT-TAT-GTG-GTG-ACA-GAT-CAC Variant III cDNA Sequence LEU-GLU-GLU-LYS-LYS-GLY-ASN-TYR-VAL-VAL-THR-ASP-HIS Variant III Amino Acid Sequence

ACTIVATE / ACT II Trial Immunologic Monitoring

Leukapheresis

PEPvIII-KLH + GM-CSF (Every 2 weeks i.d.)

PEPvIII-KLH + GM-CSF with temozolomide (Every 1 month i.d.)

< R710-A >: CD 107a A X6 80

IFN-γγ

4.19

Temozolomide:

6000 cGy with Temozolomide

ACT II A

- 200 mg/m2 5/28 days

ACT II B

- 100 mg/m2 21/28 days

IL-2 TNF-α α

EGFRvIII vaccine

Median OS

ACT III (n = 65)

24.6 months

ACT II (n = 22)

24.4 months

0.31

1.14

12

ACTIVATE (n = 18)

24.6 months

Matched control

15.2 months

Table IV. Data for RPA IV, Corrected for time to Randomization Median OS, wks

Actuarial 2-year OS

Vaccine Patients

113

60%

Patients treated with XRT/Temozolomide

63

0%

Patients treated with Older Regimens

54

11%

Detection of Cytomegalovirus Antigens in Malignant Astrocytomas by Immunohistochemistry

EGFRvIII-expressing Cells Eliminated by Vaccine

Malignant Glioma Samples

Pre-Vaccine Primary Tumor

Post Vaccine Recurrent Tumor

A

B

Negative control

wtEGFR

G

Smooth Muscle Actin D

C

Lung from CMV-infected AIDS Patient

Smooth Muscle Actin H

wtEGFR

HCMV IE1 E

EGFRvIII

HCMV IE1

HCMV IE1 F

I

EGFRvIII

HCMV pp65

Summary

HCMV pp65

HCMV pp65

Celldex Phase 3 Rindopepimut

• EGFRvIII is a unique tumor- specific antigen • Vaccines with PEPvIII-KLH (CDX-110) are immunogenic

Temo + Vaccine

• EGFRvIII+ tumor cells are less frequent by IHC after vaccine in most patients.

Surgery

• Temozolomide enhances immunogenicity

RT + Temo Temo + placebo

• Repetitive, multi-center studies in selected patient populations show prolong TTP and overall survival • Vaccination against CMV antigens may also prove to be a successful vaccine approach

Importance of Peritumoral Targeting

Monoclonal Antibody Targeted Therapy

• Route of administration? • Armed or unarmed?

13

Radioimmunotherapy (RIT): 131I-81C6

via Surgically Created Resection Cavity (SCRC)

131I-81C6 Activity Distribution

81C6

Neuradiab Completed Trials

murine monoclonal antibody (Mab) to tenascin-C

Consistent clinical benefit, progressive improvements Tenascin C - Abundant target in malignant glioma - Not expressed on normal brain

Trial

Dosing

Indication

n=

Survival (weeks)

Control (weeks)

Phase I

Fixed

Recurrent GBM

28

52

23

Phase I

Fixed

Recurrent GBM

14

52

23

Phase II

Fixed

Recurrent GBM

39

68

23

Phase I

Fixed

Newly Diag GBM

32

80

53

Phase II

Fixed

Newly Diag GBM

27

79

53

Phase II

Fixed

Newly Diag GBM

33

84

53

Phase II

Pt Spec

Newly Diag GBM

20

91-102*

64

7

(S+XRT)

(+Tem)

193 patients

of 10 trials published

*Subsequent analysis after 231 weeks using time of surgery as t=0

MR1-1 Patient 7

MR1-1 Glioblastoma

Imaging of Immunotoxin Delivery to Tumor

Pseudomonas exotoxin (PE)

Ia Amino Acid Function

MR1-1

II

1-252

253-364

Receptor binding

Cytosol translocation

EGFRvIII Ia

II

Ib 365-399 Unknown

Ib

III 400-635 Inhibits protein synthesis

a) Baseline T1-weighted MRI

III

14

b) 72-hour T1-weighted MRI

c) Gd-DTPA Concentration (0.05 – 0.5 μMol/mL)

d) I-124 HSA Concentration (0.1 – 1.0 μCi/mL)

Oncolytic Viruses

Red Guidance Molecule Green Pseudomonas Bacterial Toxin (Bomb)

VH NH2

• Poliovirus

Peptide Linker

S

EGFRwt/ EGFRvIII

S 280

II

III

KDEL

COOH VL

D2C7 (scdsFv)-PE38KDEL

Results

Patient Characteristics Nbre of patients Age, years Median Range Sex Male (%) Female (%) Karnofsky performance status 90 (%) 80 (%) 70 (%) Type of surgery at diagnosis Gross total resection (%) Partial resection (%) Biopsy (%) Prior treatment Radiation therapy (%) Temozolomide (%) median nbre of cycles (range) Bevacizumab (%) median nbre of cycles (range) Gliadel wafers (%)

Results n = 14 59 21-70

Table 2. Dose escalation and current survival status

9 (64) 5 (36)

Dose level 1.0 x 10E8 TCID50

N=14 1

Survival post PVSRIPO infusion (months) 27+

DLT

3.3 x 10E8 TCID50

6

26+, 7, 3.5+, 3.3+, 2.5+, 1.9+

0

1.0 x 10E9 TCID50

1

6

0

3.3 x 10E9 TCID50

2

6, 11+

0

1.0 x 10E10 TCID50

4

20, 12, 15, 14+

1

9 (64) 4 (29) 1 (7) 12 (86) 2 (14) 0 14 (100) 14 (100) 9 (1-14) 7 (50) 13 (2-25) 1 (8)

15

0

Total

# Failed

Median survival in months (95% CI)

6-month survival (95% CI)

12-month survival (95% CI)

18-month survival (95% CI)

14

5

15.2 (5.6, ∞)

80% (40.9%, 94.6%)

70% (32.9%, 89.2%)

43.8% (11.9%, 72.6%)

Survival as of 8/27/14 Patient

Bevacizumab status

1

1

Failure

27+

Alive with no deficit, no progression

2

2

Naïve

26+

Alive with no deficit, no progression

3

3

Failure

6

Died 6 months post infusion

4

4

Failure

6

Died 6 months post infusion

5

5

Naïve

20

Died 20 months post infusion

5

6

5

7

Naive

15

Died 15 months post infusion

5

8

Prior exposure, no failure

14+

Intracranial hemorrhage at catheter removal, walking and back to work, improving

4

9

Failure

11+

Alive, gait difficulties

2

10

Naive

7

Died 7 months post infusion

2

11

Failure

3+

Alive, speech difficulties

2

12

Naive

3+

Alive, stable deficits

2

Naïve

Survival since PVSRIPO infusion (months)

Patient 2 – 26+ months

Dose level

12

Status

Died 12 months post infusion

13

Failure

2+

2

14

Naive

2+

Alive, stable deficits

2

Single pt protocol

Naive

6+

Alive, speech difficulties

Baseline 6/13/12

Chin, L., Meyerson, M. and the TCGA (The Cancer Genome Atlas) Investigators: Comprehensive genomic characterization defines novel cancer genes and core pathways in human gliomas. Nature 455:10611068, 2008. Parsons, D.W., Jones, S., Zhang, X., Lin, J.C.-H., Leary, R.J., Angenendt, P., Mankoo, P., Carter, H., Siu, I.-M., Gallia, G., Olivi, A., McLendon, R., Rasheed, B.A., Keir, S., Nikolskaya, T., Nikolsky, Y., Busam, D.A., Tekleab, H., Diaz, Jr., L.A., Hartigan, J., Smith, D.R., Strausberg, R.L., Marie, S.K.N., Shinjo, S.M.O., Yan, H., Riggins, G.J., Bigner, D.D., Karchin, R., Papadopoulos, N., Parmigiani, G., Vogelstein, B., Velculescu, V.E., and Kinzler, K.W.: An integrated genomic analysis of human glioblastoma multiforme. Science 32:1807-1812, 2008. \\\\

MOST FREQUENTLY ALTERED GBM CAN-GENES

CDKN2A TP53

MOST FREQUENTLY ALTERED GBM CAN-GENES

Amplifications

Number of tumors 0/22

Fraction of tumors 0%

Number of tumors 0/22

Fraction of tumors 0%

37/105

35%

0/22

0%

EGFR

15/105

14%

5/22

23%

PTEN

27/105

26%

0/22

0%

NF1

16/105

15%

0/22

0%

0/22

0%

3/22

14%

CDK4

07/21/14

COMPREHENSIVE GENOMIC ANALYSIS OF GLIOBLASTOMA

• Iressa • Tarceva • Gleevec • Rapamycin • Others

Point mutations

3/29/13

Alive, right hemiparesis

Molecular Pathway Inhibitors

Gene

10/25/12

RB1

8/105

8%

0/22

0%

IDH1

12/105

11%

0/22

0%

PIK3CA

10/105

10%

0/22

0%

PIK3R1

8/105

8%

0/22

0%

Homozygous deletions Gene

16

Number of tumors

Fraction of tumors

Fraction of tumors with any alteration

CDKN2A

11/22

50%

50%

TP53

1/22

5%

40%

EGFR

0/22

0%

37%

PTEN

1/22

5%

30%

NF1

0/22

0%

15%

CDK4

0/22

0%

14% 12%

RB1

1/22

5%

IDH1

0/22

0%

11%

PIK3CA

0/22

0%

10%

PIK3R1

0/22

0%

8%

Coding Mutations/Tumor

Cancers Sequenced at Genome-Wide Level

12 Core Cancer Pathways TGFß/SMAD Signaling

200 180 160 140 120 100 80 60 40 20 0

20 - 80

RAS/RAF Signaling

WNT Signaling

PIK3/PTEN Signaling

Hedgehog/GLI Signaling

All Cancers

Chromatin Remodeling

HIF1ɑ Signaling

JAK/STAT Signaling

Apoptosis

NOTCH Signaling

DNA Damage Signaling Conrol of G1/S Signaling

Tumor Type

Courtesy of Bert Vogelstein.

CCC = clear cell carcinoma; AML = acute myelogenous leukemia. Courtesy of Bert Vogelstein.

RTK/RAS/PI-3K Signaling Altered in 88% of GBM Tumors RTK/RAS/PI-3K signaling altered in 88%

EGFR ERBB2

Mutation, amplification in 45%

Homozygous deletion mutation in 18%

NF1

Mutation in 8%

P53 Signaling Altered in 87% of GBM Tumors

PDGFRA MET

P53 signaling altered in 87%

Amplification Amplification in 13% in 4%

Activated Oncogenes CDKN2A (ARF)

RAS

PI3K

Mutation in 2%

PTEN

Mutation in 15%

Amplification in 14%

Homozygous deletion mutation in 36%

Homozygous deletion mutation in 49%

MDM2 MDM4 Amplification in 7%

AKT Proliferation survival translation

Amplification in 2%

TP53 Senescence

Mutation in 1%

FOXO

Single Agent Targeted Therapy: Unselected Recurrent Malignant Glioma

RB Signaling Altered in 78% of GBM Tumors Target (P16/IIJK4A)

Homozygous deletion mutation in 52% Amplification in 8%

CDKN2B

CDKN2C

Homozygous deletion in 47%

Homozygous deletion in 2%

Amplification in 2%

CDK4

Agents

Anti-Glioma Benefit

Gefitinib; Erlotinib; Cetuximab

Minimal

PDGFR

Imatinib

Minimal

mTOR

CCI-779; Sirolimus

Minimal

Tipifarnib

Minimal

Enzastaurin

Minimal

EGFR

Amplification in 1%

CCND2

CDK6

Farnesyl Transferase Protein Kinase C β

Homozygous deletion mutation in 11%

RB1

G1/S progression

Apoptosis

The Cancer Genome Atlas Research Network. Nature. 2008;455:1061-1068.

The Cancer Genome Atlas Research Network. Nature. 2008;455:1061-1068. Permission requested.

CDKN2A

Homozygous deletion mutation in 35%

RB signaling altered in 78%

Modest rate of radiographic response and/or stable disease does not translate into durable anti-tumor activity

The Cancer Genome Atlas Research Network. Nature. 2008;455:1061-1068.

17

Normal Functions of IDH1 and IDH2 in the cell

Mitochondria

Peroxisome

Cytosol

Citrate

Cholesterol synthesis

Citrate

Isocitrate NADP+

Aconitase

Aconitase

IDH1 NADPH

Volume 360:765-773 February 19, 2009 Number 8

Isocitrate

Isocitrate

NADP+

NAP+

IDH1 and IDH2 Mutations in Gliomas

IDH2

NADPH NADH

H+-TH

Hai Yan, M.D., Ph.D., D. Williams Parsons, M.D., Ph.D., Genglin Jin, Ph.D., Roger McLendon, M.D., B. Ahmed Rasheed, Ph.D., Weishi Yuan, Ph.D., Ivan Kos, Ph.D., Ines Batinic-Haberle, Ph.D., Siân Jones, Ph.D., Gregory J. Riggins, M.D., Ph.D., Henry Friedman, M.D., Allan Friedman, M.D., David Reardon, M.D., James Herndon, Ph.D., Kenneth W. Kinzler, Ph.D., Victor E. Velculescu, M.D., Ph.D., Bert Vogelstein, M.D., and Darell D. Bigner, M.D., Ph.D.

NADPH

α-KG Gamma and ionizing radiation, high glucose, TNF-α, heat shock

α-KG

NADP+

IDH1

IDH3

Gamma radiation, UVB phototoxicity, singlet oxygen

α-KG Reduced glutathione

α-KG DH

Glutamate DH Glucose-stimulated insulin secretion

Glutamate

Succinate

Some information based on work by JW Park and104 Page colleagues, as well as by C Newgard and colleagues

IDH1 and IDH2 are frequently mutated in gliomas

IDH1 Targeted therapy?

3/3

100%

7/7

43/51

α-ketoglutarate

IDH1 mutated

11/13 38/52

80%

isocitrate

IDH2 mutated

34/36

27/30

60% 40% 1/7

20% 0/21

Isocitrate – Blue

6/123

0/30

0/15

0/55

0/494

0%

NADP+ - Red Arg132 – Yellow Ser94 – Orange Asp279 - Cyan Page 105

Yan et al.

IDH1 R132 mutations in other cancers

• • • •

16/85 acute myeloid leukemias 2/30 prostate cancers 1/60 B-acute lymphoid leukemia 1/12 colorectal cancer

IDH1 and IDH2 mutations at residues R132 and R172

Mardis et al., 2009 Kang et al., 2009 Sjoblom et al., 2006 Yan et al., 2009 Bleeker et al., 2009 Park et al., 2009

• IDH1 and IDH2 mutations are not present in thousands of other cancer samples analyzed

Yan et al. NEJM 2009

18

Glioma patients with IDH mutations are clinically distinct from patients without IDH mutations

Survival of Adult Patients with Malignant Gliomas With or Without IDH Gene Mutations

The median survival Patients with mutated IDH: 39 months patients with wildtype IDH1:13.5 months

the median survival was 65 months for patients with mutated IDH1 or IDH2, as compared to 19 months for patients with wildtype IDH1 and IDH2.

IDH1 mutations produce 2-hydroxyglutarate LC-MS Metabolite Profiles R132H vs WT

Immune Augmentation

• Nivolumab + Ipilimumab

IDH1R132H

IDH1 Isocitrate

α-Ketoglutarate NADP+

NADPH

2-hydroxyglutarate NADP+

NADPH

IDH1 wild type

IDH1 mutant Dang et al. Nature 2009

Checkmate 143: Phase IIb Study of Nivolumab vs Nivolumab + Ipilimumab vs Bevacizumab in rGBM

Summary

Cohort 1: Safety Lead-In (N=20)

Nivolumab 3 mg/kg IV q2w

1:1

• Brain Tumors, and Cancer in General are Entering a New Era of Genetic and Molecular Analysis, Followed by Individualized Treatment

Nivolumab 1 mg/kg IV + Ipilimumab 3 mg/kg IV q3w

Completion of 4 doses or discontinuation prior to completing 4 doses (all randomized patients) Safety endpoint: determine safety and tolerability • Grade IV rGBM after RT + TMZ • Karnofsky PS > 70

Nivolumab 3 mg/kg IV q2w until PD or study drug discontinuation (posttreatment follow-up)

• Multiple Molecular “Targets” Will Be Identified and Treated

Cohort 2 (N=240) Randomization 1:1:1

Nivolumab 3 mg/kg IV q2w

Nivolumab 1 mg/kg IV + Ipilimumab 3 mg/kg IV q3w (4 doses): Then Nivolumab 3 mg/kg IV q2w

PD

PD

• Primary endpoint: OS (nivolumab vs bevacizumab and nivolumab plus ipilimumab vs bevacizumab) • Secondary endpoints: PFS, ORR, OS (nivolumab plus ipilimumab vs nivolumab)

• Growth Signaling Pathways Will Be Identified and Treated

Bevacizumab 10 mg/kg IV q2w

• Immunotherapy including immune augmentation may be highly effective therapy

PD

Sponsor: Bristol-Myers Squibb Status Open: study start date 01/01/2014. Sampson JH, et al. Presented at ASCP 2014 (abstr TPS2101

19

DUKE STANDARD OF CARE Malignant Glioma

DUKE STANDARD OF CARE Malignant Glioma

Recurrent Disease

Newly Diagnosed Best Available Therapy:

Clinical Trials:

Surgery

Upfront Chemo CED – MAB Chemo Vaccine Stem Cell

RT + Temo + Avastin

Regional Therapy Trials

Poliovirus

Non- Regional Therapy Trials

Chemo Biologics Vaccine

Commercially available agents off-label

Avastin + Temo

Major Impediments to Successful Therapy of Brain Tumors

• Nihilism - lack of hope • Reliance on community standard of care • Lack of active regimens • Insurance denials - to centers

Political Commentary

- for clinical trials

20

Small Molecule Inhibitors

21