1

Progress in the War Against Progress in the War Against Brain TumorsBrain Tumors

Henry S. Friedman, MDHenry S. Friedman, MDThe Preston Robert The Preston Robert TischTisch Brain Tumor Center Brain Tumor Center

at Dukeat Duke

Acknowledgement of Support

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

Brain Tumor Therapeutic Options

• Surgery

• Radiation

• Chemotherapy

• Anti-Angiogenic Agents

• Gene Therapy

• Vaccines

• Monoclonal Antibody Targeted Therapy

• Oncolytic Viruses

• Molecular Pathway Inhibitors

• Immune Augmentation

Brain Tumor Therapeutic Options

IncidenceDistribution of All Primary Brain and CNS Tumors by Histology

Glioblastoma20.3%

Astrocytomas9.8%

Ependymomas2.3%

Oligodendrogliomas3.7%

Embryonal, including Medulloblastoma

1.7%Meningioma

30.1%

Pituitary6.3%

Craniopharyngioma0.7%

Nerve Sheath8.0%

Lymphoma3.1%

All Other13.9%

CBTRUS Report: 2004-2005.

Malignant Glioma

Hess et al. Cancer 101:2293, 2004CBTRUS; Statistical Report, 2005-2006

GBM (grade 4) – 60% 13,000 cases/yr

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

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

AO (grade 3) 5%800 cases/yr

2

Glioblastoma:Overall Characteristics

• Grade IV malignant glioma

• Most malignant, invasive, 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

GBM Clinical Prognostic Factors: Age, Performance S tatus (PS), Resection(RTOG recursive partitioning analysis (RPA) class)

RPA Clinical Median OSClass Feature (months)3 age < 50; PS = 0 174 age < 50; PS = 1-2 15

age > 50; GTR/STR5 age > 50; biopsy 10

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

Anaplastic Astrocytoma:Overall Characteristics

• 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 surgery

• Median survival: 3–4 years

Glioblastoma (GBM)

Courtesy of M. Prados, MD

• Invasive

• Hypoxic

• Phenotypically heterogeneous

• Resistant to therapy

Therapy of Glioblastoma: Surgery

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

• Not a curative intervention

Extent of Tumor Resection is Associated with Improved Outcomes

Study Conclusion

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

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

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

Resection (vs. biopsy) is a strong prognostic facto r 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

Current Treatment: Surgery

3

Surgical Management

Therapeutic Impact of Radical Surgery in Glioblastoma

>98% >98%

All patients (n=416)

No prior treatment(n=233)

P<0.0001 P=0.02

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

< 98%< 98%

0

2

4

6

8

10

12

14

<98% <98%

Med

ian

surv

ival

, m

os

Therapy of Glioblastoma: Radiotherapy

• Addition of radiotherapy to surgery increases duration and quality of survival

Treatment of Glioblastoma: Radiotherapy

Study

Shapiro 1976

*Anderson 1978

*Walker 1978

*Walker 1980

*Kristiansen 1981

*Sandberg-Wolheim 1991

Surgery Alone

15

14

23

Chemo

30

31

42

RT

23

36

37

47

RT + Chemo

44.5

62

*statistically significant

Median Survival (weeks)

Therapy of Glioblastoma: Chemotherapy

• Addition of nitrosoureas to surgery and radiotherapy produces a small increase in duration of survival

• Addition of Temozolomide to surgery and radiotherapy produces a small increase in 2 year progression free survival and overall survival

Current Treatment: Chemotherapy

Fine et al. 1 Stewart 2 Spiegel et al. 3

Date of meta-analysis 1993 2002 2007

Trials analyzed, n 16 12 16

Patients analyzed, n >3,000 3,004 >3,000

Agent(s) used Various Various Various

Absolute increase in survival, %

1 year 10.1 6.0 15.0*

2 year 8.6 4.0 17.0*

1. Fine HA, et al. Cancer. 1993;71:2585-2597.2. Stewart LA. Lancet. 2002;359:1011-1018.3. Spiegel BM, et al. CNS Drugs. 2007;21:775-787.

Three Major Meta-analyses

* TMZ treatment group only.

ChemotherapyMeta-analysis of Chemotherapy

in High-Grade Glioma

05

101520253035404550

1-year survival 2-year survival

% o

f pat

ient

s

No chemotherapyChemotherapy

Stewart LA. Lancet. 2002;359:1011–1018.

4

TMZ spontaneously converts to MTIC at physiologic pH

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

Temozolomide (TMZ): Second-generation Alkylating Agent

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

C

N

NN

O

NN

NH2

OCH3

pH > 7.0Spontaneous

hydrolysis NN

O

NN

CNH2

NH

CH3

O

NN

CNH2

NH2

Temozolomide MTIC AIC Methyldiazoniumion

+ N N–CH3

TemozolomideUSA Clinical Trials

Phase 1 Adult (Mayo clinic)

Phase 1 Children (CCG)

Phase 2 1st relapse GBM (national)

Phase 2 1st relapse AA (national)

Phase 2 Newly diagnosed malignant glioma (Duke)

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

Temozolomide in Glioblastoma at First Relapse: Study Schematic

• Histologically confirmed glioblastoma

• Failed radiotherapy ± chemotherapy with nitrosourea

• KPS ≥ ≥ ≥ ≥ 70

• No stereotactic or interstitial radiotherapy

TemozolomideTemozolomide(n = 112)(n = 112)

200 mg/m200 mg/m 2 2 qd x 5 dqd x 5 doror

150 mg/m150 mg/m 22 qd x 5 dqd x 5 d

ProcarbazineProcarbazine(n = 113) (n = 113)

150 mg/m150 mg/m 2 2 qd x 5 dqd x 5 doror

125 mg/m125 mg/m 2 2 qd x 5 dqd x 5 d

6-moPFS

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

Ran

dom

izat

ion

Temozolomide (TMZ) in Glioblastoma at First Relapse:

Progression-free Survival (PFS) Rates

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

TMZ PCB

PFS at6 mo, % 21 8*

Median PFS, wks (mo) † 12.4 (2.89) 8.32 (1.88)‡

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

PF

S ra

te

0.0

0.2

0.4

0.6

0.8

1.0

TMZ

PCB

Time from start of treatment (months)

0 3 6 9 12 15 18

PCB, procarbazine.

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

Temozolomide in Anaplastic Astrocytoma at First Relapse: Study Schematic

• Histologically confirmed anaplastic astrocytoma

• Failed radiotherapy ±chemotherapy with nitrosourea

• KPS ≥ ≥ ≥ ≥ 70

• No previous stereotactic or interstitial radiotherapy

No prior No prior chemotherapy chemotherapy

200 mg/m200 mg/m 2 2 qd x 5 dqd x 5 d

Prior Prior chemotherapy chemotherapy

150 mg/m150 mg/m 2 2 qd x 5 dqd x 5 d

6-moPFS

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

Temozolomide in Malignant Glioma* at First Relapse: Survival Rates

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

* Intent-to-treat population, includes anaplastic astrocytoma and anaplastic oligoastrocytoma.

0.0

0.2

0.4

0.6

0.8

1.0

0 3 6 9 12 15 18 21 24

Sur

viva

l rat

es

Time (months) from start of treatment

Overall survival

Progression-free survival

6-mo PFS = 46%

Median = 13.6 months

5

TemozolomideDuke Phase 2

Eligibility

• Newly diagnosed GBM, GS, AA

• Surgery or biopsy

• Measurable enhancing lesion > 1.5 cm2 within 3 days or > 14 days from surgery

TemozolomideDuke Phase 2

Treatment plan

• 200 mg/m 2 po x 5 days every 4 weeks

• 4 cycles given prior to RT

• PE/MRI every 4 weeks

• Radiographic response criteria

TemozolomideDuke Phase 2

GBM response

• 33 patients with GBM

– 3 complete responses

– 14 partial responses

– 5 stable disease

– 11 progressive disease

Friedman, HS, et al. J Clin Oncol. 1998;16:3851-3857

Treatment scheme. TMZ, temozolomide; RT, radiothera py.

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

R. Stupp NEJM 2005

RT RT + Temo2 year survival (%) 10.4 26.5

2 year PFS (%) 1.5 10.7

Median survival (M) 12.1 14.6

6

Stupp R et al. NEJM 352:987,2005Temozolomide 75 mg/m2 po qd for 6 weeks,

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

Focal RT daily — 30 x 200 cGy

Total dose 60 Gy

Adjuvant TMZ

6 10 14 18 22 26 30

RT AloneWeeksR

AN

DO

MIZ

E

RT/TMZ

0

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%

5 Year Follow-Up

Stupp Lancet Oncol 2009

PFS

OS

O6-alkylguanine-DNAAlkyltransferase (AGAT) Resistance

to Chemotherapy

Nitrosourea Alkyl group DNA X L

O6-guanine AGAT

Procarbazine Methyl group Mismatch

06-alkylguanine DNA Alkyltransferase (AGT)

N

N

N

N NH2

OCH3

O -methylguanine6

NH

N

N

N NH2

O

Guanine

Alkyltransferase

Irreversible inactivation

NH2

NH

CH2 CH

CO

COOH

CH3 S

NH2

NH

CH2 CH

CO

COOH

SH

• Ubiquitous DNA repair protein

• Removes theCH3 groupsfrom the O6-methylguanine

• Irreversiblyinactivated

• De novosynthesis required for recovery

AGT and Response to Temozolomide

% AGT + cells< 20% ≥≥≥≥ 20%

Responder 15 1

Non-Responder 10 10

AGT/MGMT Gene

Coding SequencePromoter

No Expression X AGT

Yes Expression AGT

+ Methylation

- Methylation

7

5 Year Survival EORTC/NCIC Trial

Group Radiation aloneRadiation +

TemozolomideTotal 1.9% 9.8%

MGMT unmethylated 0 8.3%

MGMT methylated 5.2% 13.8%

• Bevacizumab – what doesn’t it treat?

Anti-Angiogenesis

6/19/1990

Rationale for Bevacizumab in GBMVEGF is highly expressed

in Human GBM

Anti-VEGF inhibits growth of

GBM xenograft

VEGF expression correlateswith tumor grade and outcome

Sur

viva

l (w

eeks

)

r = -0.42

VEGF mRNA signal Nature • Vol 362 • 29 April 1993

Bevacizumab Development Timeline - 1James Vredenburgh

+ Patti Beaver

February 2004

LOI to Genentech – deniedIND to FDA – denied

September 2004Virginia Stark-Vance

shows Henry Friedman MRIs of 8 Bevacizumab + CPT-11 treated patients

(7 responders)

Bevacizumab Development Timeline - 2

Henry Friedman calls Art Levinson

Genentech says Go!

FDA approves IND from James Vredenburgh

James Vredenburgh / Annick Desjardins Trials

BRAIN Trial(Henry Friedman, PI)

FDA Approval in Recurrent GBM

Treatment plan

WeeksRepeat for up to 1 year

IrinotecanEIAED: 340 mg/m²Non-EIAED: 125 mg/m²

1 2 3 4 5 6

Bevacizumab: 10 mg/kg

MRI

Combination bevacizumab/irinotecan

Weeks Repeat for up to 1 year

1 2 3 4 5 6

8

Recurrent AA

(Grade 3)

Near CR after 4 cycles of BV/Irinotecan

A B

C D

Pre-treatment After 4 cycles Is this a “glorified steroid” effect?(If so, would not expect durable anti-tumor control )

Grade 3 Grade 4

OUTCOME Duke(n = 35)

TMZ 1st PD1

(n=162)Duke

(n = 33)TMZ 1st PD2

(n = 112)

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 (%)

OS (weeks)

65

65

46

54

43

42

21

30

1 Yung Journal of Clinical Oncology 17:2762, 1999. En dure2 Yung British Journal of Caner 83:588, 2000.

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

Bevacizumab Alone and in Combination With Irinotecan in Recurrent Glioblastoma

Henry S. Friedman, Michael D. Prados, Patrick Y. We n, Tom Mikkelsen, David Schiff, Lauren E. Abrey, W.K. Alfr ed Yung, Nina Paleologos, Martin K. Nicholas, Randy Jensen, James

Vredenburgh, Jane Huang, Maoxia Zheng, and Timothy Cloughesy

Journal of Clinical Oncology, 27(28):4733-4740, 200 9.

BRAIN(phase II, multicenter, noncomparative trial)

167 patients with glioblastoma in first or second relapse

Prior radiotherapy and temozolomide

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

BEV (n=85)

10 mg/kg q2 weeks

Optional Post-Progression

PhaseBEV + CPT-11

(n=44)

BEV + CPT-11(n-82)

EIAED: 40 mg/m 2 IV/90 minNon-EIAED: 125 mg/m 2 IV/90 min

First progressive disease

• Primary endpoints (by independent radiology review)• OR rate• 6-month PFS

• Additional measurements• Updated safety and survival

BEV=bevacizumab, CPT-11=irinotecan, EIAED=enzyme-indu cing antiepileptic drug, OR=objective response, PFS=progression-free survival.

Summary of Efficacy

Bev Bev (n = 85)(n = 85)

Bev/CPT Bev/CPT (n = 82)(n = 82)

Independent Radiology Review

6 month PFS: %6 month PFS: % 35.6 35.6 51.051.0

ORR: %ORR: % 21.2 21.2 34.1 34.1

Investigator

6 month PFS: %6 month PFS: % 44.7 44.7 60.9 60.9

ORR: %ORR: % 38.8 38.8 46.3 46.3

6-month PFS by External Review

+: censored subjects

9

Overall SurvivalBevacizumab Bevacizumab

(n=85)(n=85)Bevacizumab/CPTBevacizumab/CPT--11 11

(n=82)(n=82)

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

31 (37)31 (37)8.2 (8.1, 8.2 (8.1, --))

34 (42)34 (42)8.7 (7.8, 8.7 (7.8, --))

Duration of Overall Survival (months)Duration of Overall Survival (months)

Proportion S

urvivingP

roportion Surviving

Summary

• Bevacizumab is active against recurrent glioblastoma

• There were rare CNS hemorrhages and no unique toxicities in GBM patients

• FDA approved bevacizumab for recurrent glioblastoma May 5 th, 2009

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

Publication Sample Size

Response Rate

6-month PFS

Overall Survival

12-month Survival

8 MD Anderson trials 1986-1995

(Wong 1999)

225 6% 15% 5.7 mo 21%

16 NCCTG trials 1980-2004

(Ballman 2007)

345 n/a 9% 5.1 mo 14%

12 NABTC trials 1998-2002

(Lamborn 2008)

437 7% 16% 6.9 mo 25%

Lomustine control arm from Phase III study of enzastaurin

(Fine et al 2008)

92 4.3% 19% 7.1 mo 24%

AVF3708g 85 28.2% 42.6% 9.3 mo 37.6%

G1

Response Rate and PFS6 Significantly Higher Than Historical Controls

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

0

10

20

30

40

50

60

Wong et al.

1999(n=225)

Lamborn et al.

2008(n=437)

Fine et al.

2008Lomustine

(n=92)

Patients

with P

FS6, %

0

10

20

30

40

50

60

Patients

with O

RR (

CR +

PR),

%

Wong et al.

1999(n=225)

Lamborn et al.

2008(n=437)

Fine et al.

2008Lomustine

(n=92)

AVF3708gBevacizumab

by IRF(n=85)

AVF3708gBevacizumab

by INV(n=85)

AVF3708gBevacizumab

by IRF(n=85)

AVF3708gBevacizumab

by INV(n=85)

Response rate:Bevacizumab arm vs historical controls

G2

The Addition of Bevacizumab to Standard Radiation Therapy and Temozolomide Followed by Bevacizumab, Temozolomide and Irinotecan for Newly Diagnosed GlioblastomaJames J. Vredenburgh, Annick Desjardins, David A. Reardon, Katherine B. Peters, James E. Herndon, II, Jennifer Marcello, John P. Kirkpatrick, John H. Sampson, Lei ghann Bailey, Stevie Threatt, Allan H. Friedman, Darell D . Bigner, and Henry S. Friedman

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

Treatment PlanPart A

Weeks1 2 3 4 5 6

Bevacizumab10 mg/kg

Temozolomide75 mg/m2/day

Radiation therapy

Slide 51

G1 <slide>GBM-006<slide><title>Response Rate and PFS6 in Pooled Analyses of Trials for Relapsed Glioblastoma<title><rank>1<rank><keywords><keywords><QCname><QCname><QCdate><QCdate><QCcomment><QCcomment>GenenUser, 3/16/2009

Slide 52

G2 <slide>CC-006<slide><title>Response Rate and PFS6 Significantly Higher than Historical Controls<title><rank>1<rank><keywords> Historical Control<keywords><QCname><QCname><QCdate><QCdate><QCcomment><QCcomment>GenenUser, 3/25/2009

10

Treatment PlanPart B

IrinotecanEIAED: 340 mg/m²Non-EIAED: 125 mg/m²

Bevacizumab: 10 mg/kg

Bevacizumab / Irinotecan

Temozolomide200 mg/m 2/day

Weeks

1

MRI

8763 542

Study Dates

• Study Opened: 8/15/07

• Accrual: 125 patients through 3/26/09

• Median Follow-Up: 48.6 mos

Progression free survival

Total # PDMedian PFS

(95% CI)

6-month PFS

(95% CI)

1-year PFS

(95% CI)

2-year PFS

(95% CI)

3-year PFS

(95% CI)

125 119 14.0 months

(12.5 mo, 15.9

mo)

87.2%

(80.0%, 92.0%)

63.2%

(54.1%, 71.0%)

17.6%

(11.5%, 24.7%)

7.2%

(3.5%, 12.6%)

Overall Survival

Total # DiedMedian survival

(95% CI)

6-month OS

(95% CI)

1-year OS

(95% CI)

2-year OS

(95% CI)

3-year OS

(95% CI)

125 111 20.9 months

(18.0 mo, 24.1 mo)

92.8%

(86.6%, 96.2%)

81.6%

(73.6%, 87.4%)

42.4%

(33.7%, 50.9%)

20.0%

(13.5%, 27.4%)

Conclusions

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

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

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

• Phase III trials are necessary

(n=460)

(n=460)

Treatment starts28-49 days

post surgeryConcurrent phase Maintenance phase

for 6 cyclesMonotherapy phase

until PD

Debulking surgery or

biopsy

Placebo15 mg/kg q3wmonotherapy until disease progression

TMZ 150-200 mg/m²/qd

days 1-5 q28dBEV 10 mg/kg q2w

Bevacizumab15 mg/kg q3wmonotherapy until disease progression

4-weektreatment

break

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

RT 2 Gy 5 days/week for6 weeks

TMZ 75 mg/m²/qdBEV 10 mg/kg q2w

RT 2 Gy 5 days/week for6 weeks

TMZ 75 mg/m²/qdPlacebo 10 mg/kg q2w

TMZ 150-200 mg/m²/qd

days 1-5 q28dPlacebo

10 mg/kg q2w

*Genentech/Roche Sponsored StudyChinot, et al. Adv Ther 2011;28:334-340.

BEV=bevacizumab; GBM=glioblastoma; PD=progressive d isease; RPA=recursive partitioning analysis; RT=rad iotherapy; TMZ=temozolomide

Randomization with stratification

4-7 weeks post surgery

Based on RPA class and country

11

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

TMZ days 1-5 q28d

Placebo q2w

12-cycle maximum

TMZ days 1-5 q28d

BEV q2w

12-cycle maximum

4-weektreatment

break

3 weeksRT 30 Gy in 2 fractionDaily TMZ qd ×××× 21d

Placebo q2w(continues without stop)

3 weeksRT 30 Gy in 2 fractionDaily TMZ qd ×××× 21dBEV q2w (continues

without stop)

Randomization ( ≤10 days after start of

RT)Stratification by

MGMT methylation status and

molecular profile

*Independently Sponsored Study that is supported by Genentech/Roche with study drug and, in some instan ces, funds

http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0825

as of 12/11.

BEV=bevacizumab; GBM=glioblastoma; RT=radiotherapy; RTOG=Radiation Therapy Oncology Group; TMZ=temozol omide

AVAglio Results

Standard of Care Arm

ExperimentalArm

PFS (mo) 6.2 10.6

OS (mo) 16.1 16.8

KPS > 70 (mo) 6 9

QoL stable or better (mo) 4 8

Grade 5 tox (%) 2.7 4.5

ICH (%) 2.2 2.6

Pseudoprogression (%) 9.3 2

RTOG 0825 Results

Standard of Care Arm

ExperimentalArm

PFS (mo) 7.3 10.7

OS (mo) 16.1 15.7

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

Bevacizumab Beyond Progression Treatment Plan

Part A

Bevacizumab10 mg/kg

Temozolomide75 mg/m2/day

Radiation therapy

Weeks2 3 4 5 610

Treatment PlanPart B

Bevacizumab

Temozolomide

200 mg/m2/day

Weeks

0

MRI

7652 431

For 12 months

8

Treatment PlanPart C

Until progression

Bevacizumab

Weeks

0

MRI

7652 431 8

12

Treatment PlanPart D

Bevacizumab

Treating physician

best management

Weeks

0

MRI

7652 431

For 12 months

8

• TK gene/herpes virus

• Does anyone have a vector that will work and be safe?

Gene Therapy

• Direct presentation

• Dendritic cell presentation

• Do you use generic or tumor specific antigen?

Vaccines

Extracellular Domain

EGFBindingDomain

1 5 6 273

NH2 COOH

Intracellular DomainDeleted

Segment

TransmembraneSegment

1 5 6 273LEU-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-CACWild Type cDNA Sequence

CTG-GAG-GAA-AAG-AAA-GGT-AAT-TAT-GTG-GTG-ACA-GAT-CACVariant III cDNA Sequence

LEU-GLU-GLU-LYS-LYS-GLY-ASN-TYR-VAL-VAL-THR-ASP-HISVariant III Amino Acid Sequence

Epidermal Growth Factor Receptor Mutation (EGFRvIII )

LEU-GLU-GLU-LYS-LYS -GLY-ASN-TYR-VAL-VAL-THR-ASP-HIS- CYS-KLH PEPvIII-KLH(CDX-110)

ACTIVATE / ACT II Trial

Immunologic MonitoringLeukapheresis

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

6000 cGy

with Temozolomide

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

Temozolomide:

- 200 mg/m 2 5/28 days

- 100 mg/m 2 21/28 days

<R710-A>: CD107a AX6 80<R710-A>: CD107a AX6 80<R710-A>: CD107a AX6 80<R710-A>: CD107a AX6 80

1.141.141.141.14

IL-2

TNF-αααα

IFN-γγγγ

0.310.310.310.31

4.194.194.194.19

ACT II A

ACT II B

Table IV. Data for RPA IV, Corrected for time to Ra ndomization

Median OS, wks

Actuarial2-year OS

Vaccine Patients 113 60%

Patients treated with XRT/Temozolomide

63 0%

Patients treated with Older Regimens 54 11%

EGFRvIII vaccine Median OS

ACT III (n = 65) 24.6 months

ACT II (n = 22) 24.4 months

ACTIVATE (n = 18) 24.6 months

Matched control 15.2 months

13

Pre-Vaccine Primary Tumor Post Vaccine Recurrent Tumor

wtEGFR wtEGFR

EGFRvIII EGFRvIII

EGFRvIII-expressing Cells Eliminated by Vaccine

Detection of Cytomegalovirus Antigens in Malignant Astrocytomas by Immunohistochemistry

E

HCMV pp65

F

HCMV pp65

I

HCMV pp65

HCMV IE1

C D

HCMV IE1

H

HCMV IE1

B

Smooth Muscle Actin

A

Negative control

G

Smooth Muscle Actin

Malignant Glioma SamplesLung from CMV-infected AIDS

Patient

Summary

• EGFRvIII is a unique tumor- specific antigen

• Vaccines with PEPvIII-KLH (CDX-110) are immunogenic

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

• Temozolomide enhances immunogenicity

• Repetitive, multi-center studies in selected patien t populations show prolong TTP and overall survival

• Vaccination against CMV antigens may also prove to be a successful vaccine approach

Celldex Phase 3Rindopepimut

Surgery RT + Temo

Temo + Vaccine

Temo + placebo

• Route of administration?

• Armed or unarmed?

Monoclonal Antibody Targeted Therapy

Importance of Peritumoral Targeting

14

Radioimmunotherapy (RIT): 131I-81C6 via Surgically Created Resection Cavity (SCR C)

131I-81C6Activity Distribution

81C6murine monoclonal antibody (Mab) to tenascin-C

Tenascin C- Abundant target in malignant glioma

- Not expressed on normal brain

Neuradiab Completed Trials

Consistent clinical benefit, progressive improvements

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

193 patients

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

of 10 trials published7

(S+XRT)

(+Tem)

MR1-1

Ia II Ib III

Pseudomonas exotoxin (PE)

Amino Acid

Function

1-252

Receptor binding

253-364

Cytosoltranslocation

365-399

Unknown

400-635

Inhibits proteinsynthesis

MR1-1 Ia II Ib IIIEGFRvIII

MR1-1 Patient 7

a) Baseline T1-weighted MRI 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)

GlioblastomaImaging of Immunotoxin

Delivery to Tumor

15

D2C7 (scdsFv)-PE38KDEL

VH

VL

NH2

COOH

S

S

II III

280

KDEL

Peptide Linker

Green Pseudomonas Bacterial Toxin (Bomb)

EGFRwt/ EGFRvIII

Red Guidance Molecule Oncolytic Viruses

• Poliovirus

ResultsPatient Characteristics

Nbre of patients n = 14

Age, years

Median 59

Range 21-70

Sex

Male (%) 9 (64)

Female (%) 5 (36)

Karnofsky performance status

90 (%) 9 (64)

80 (%) 4 (29)

70 (%) 1 (7)

Type of surgery at diagnosis

Gross total resection (%) 12 (86)

Partial resection (%) 2 (14)

Biopsy (%) 0

Prior treatment

Radiation therapy (%) 14 (100)

Temozolomide (%) 14 (100)

median nbre of cycles (range) 9 (1-14)

Bevacizumab (%) 7 (50)

median nbre of cycles (range) 13 (2-25)

Gliadel wafers (%) 1 (8)

Results

Table 2. Dose escalation and current survival status

Dose level N=14 Survival post PVSRIPO infusion (months) DLT

1.0 x 10E8 TCID50 1 27+ 0

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

Total # FailedMedian 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%)

16

Dose level Patient Bevacizumabstatus

Survival since PVSRIPO infusion (months)

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 Naïve 12 Died 12 months post infusion

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 13 Failure 2+ Alive, right hemiparesis

2 14 Naive 2+ Alive, stable deficits

2 Single ptprotocol

Naive 6+ Alive, speech difficulties

Survival as of 8/27/14

Patient 2 – 26 + months

Baseline 6/13/12 10/25/12 3/29/13 07/21/14

• Iressa

• Tarceva

• Gleevec

• Rapamycin

• Others

Molecular Pathway Inhibitors

COMPREHENSIVE GENOMIC ANALYSIS OF GLIOBLASTOMA

Chin, L., Meyerson, M. and the TCGA (The Cancer Genome Atlas)Investigators: Comprehensive genomic characterization d efines novelcancer genes and core pathways in human gliomas. Nature 455: 1061-1068, 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., Busa m, D.A.,Tekleab, H., Diaz, Jr., L.A., Hartigan, J., Smith, D.R., Str ausberg, R.L.,Marie, S.K.N., Shinjo, S.M.O., Yan, H., Riggins, G.J., Bign er, D.D.,Karchin, R., Papadopoulos, N., Parmigiani, G., Vogelstein , B.,Velculescu, V.E., and Kinzler, K.W.: An integrated genomic analysis ofhuman glioblastoma multiforme. Science 32:1807-1812, 200 8.\\\\

MOST FREQUENTLY ALTERED GBM CAN-GENES

Point mutations Amplifications

Gene Number of tumors

Fraction of tumors

Number of tumors

Fraction of tumors

CDKN2A 0/22 0% 0/22 0%

TP53 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%

CDK4 0/22 0% 3/22 14%

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%

MOST FREQUENTLY ALTERED GBM CAN-GENES

Homozygous deletions

Gene 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%

RB1 1/22 5% 12%

IDH1 0/22 0% 11%

PIK3CA 0/22 0% 10%

PIK3R1 0/22 0% 8%

17

Cancers Sequenced at Genome-Wide Level

Tumor Type

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

Cod

ing

Mut

atio

ns/T

umor

200

20406080

100

0

180160140120

20 - 80

12 Core Cancer Pathways

Courtesy of Bert Vogelstein.

TGFß/SMADSignaling

WNTSignaling

Hedgehog/GLISignaling

DNA DamageSignaling

HIF1ɑSignaling

JAK/STATSignaling

NOTCHSignaling

Conrol of G1/SSignaling

Chromatin Remodeling

Apoptosis

PIK3/PTENSignaling

RAS/RAFSignaling

All Cancers

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

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

NF1 PTENHomozygous

deletion mutation in 36%

Homozygous deletion

mutation in 18%

Mutation,amplification

in 45%

RTK/RAS/PI-3Ksignalingaltered in

88%

EGFR ERBB2 PDGFRA MET

Amplification in 13%

Mutationin 8%

Amplification in 4%

Mutation in 2% Mutation in 15%

Amplification in 2%

Mutation in 1%

Proliferationsurvival

translation

RAS PI3K

AKT

FOXO

P53 Signaling Altered in 87% of GBM Tumors

MDM2

Activated Oncogenes

Homozygous deletion mutation in 49%

TP53

CDKN2A(ARF)

MDM4

Homozygous deletion

mutation in 35%

Apoptosis Senescence

Amplification in 14%

Amplification in 7%

P53signalingaltered in

87%

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

RB Signaling Altered in 78% of GBM Tumors

CDKN2A(P16/IIJK4A) CDKN2B CDKN2C

CDK4 CDK6CCND2

RB1

Homozygous deletion in 2%

Homozygous deletion in 47%

Homozygous deletion mutation in 52%

Amplificationin 8%

Amplificationin 2%

Amplificationin 1%

Homozygous deletion mutation in

11%

G1/S progression

RBsignalingaltered in

78%

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

Single Agent Targeted Therapy: Unselected Recurrent Malignant Glioma

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

Target Agents Anti-Glioma Benefit

EGFR

PDGFR

mTOR

Farnesyl Transferase

Protein Kinase C β

Gefitinib; Erlotinib; Cetuximab

Imatinib

CCI-779; Sirolimus

Tipifarnib

Enzastaurin

Minimal

Minimal

Minimal

Minimal

Minimal

18

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

IDH1 and IDH2 Mutations inGliomas

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., IvanKos, 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. , DavidReardon, 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.

Page 104

IDH2

Aconitase

IDH3

α-KG DH

Citrate Citrate

IDH1

Mitochondria

Cytosol

Peroxisome

NADP+

Isocitrate

α-KG

IDH1

NADP+

NAP+

NADH

NADP+

NADPH

Succinate

Cholesterol synthesis

NADPH

Reduced glutathione

NADPH

Glutamate

Aconitase

IsocitrateIsocitrate

α-KG α-KG

Gamma radiation, UVB phototoxicity, singlet oxygen

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

H+-TH

Glucose-stimulated insulin secretion

Normal Functions of IDH1 and IDH2 in the cell

Some information based on work by JW Park and

colleagues, as well as by C Newgard and colleagues

Page 105

IDH1

Targeted therapy?

Isocitrate – Blue

NADP+ - Red

Arg132 – Yellow

Ser94 – Orange

Asp279 - Cyan

isocitrate α-ketoglutarate

0%

20%

40%

60%

80%

100%IDH2 mutated

IDH1 mutated

0/21

1/7

27/3043/51

3/3

38/52

34/367/7

11/13

6/1230/15 0/55 0/4940/30

Yan et al.

IDH1 and IDH2 are frequently mutated in gliomas

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 are not present in thousands of other

cancer samples analyzed

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 at residues R132 and R172

Yan et al. NEJM 2009

19

Glioma patients with IDH mutations are clinically distinct

from patients without IDH mutations

The median survival

Patients with mutated IDH: 39 months

patients with wildtype IDH1:13.5 months

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

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

Dang et al. Nature 2009

LC-MS Metabolite Profiles R132H vs WT

Isocitrate α-KetoglutarateIDH1

NADP+ NADPH

IDH1 wild type IDH1 mutant

2-hydroxyglutarate

IDH1R132H

NADPH NADP+

Immune Augmentation

• Nivolumab + Ipilimumab

• Grade IV rGBM after RT + TMZ• Karnofsky PS > 70

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

Sponsor: Bristol-Myers Squibb

Status Open: study start date 01/01/2014.• Primary endpoint: OS (nivolumab vs bevacizumab and nivolumab plus ipilimumab vs bevacizumab)• Secondary endpoints: PFS, ORR, OS (nivolumab plus ipilimumab vs nivolumab)

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

Nivolumab 1 mg/kg IV + Ipilimumab 3 mg/kg IV q3wNivolumab 3 mg/kg IV q2w

Completion of 4 doses or discontinuation prior to c ompleting 4 doses (all randomized patients)

Safety endpoint: determine safety and tolerability

Nivolumab 3 mg/kg IV q2w until PD or study drug discontinuation (post-

treatment follow-up)

Cohort 2 (N=240)

Randomization 1:1:1

Bevacizumab 10 mg/kg IV q2wNivolumab 3 mg/kg IV q2wNivolumab 1 mg/kg IV + Ipilimumab 3

mg/kg IV q3w (4 doses): Then Nivolumab3 mg/kg IV q2w

1:1

Sampson JH, et al. Presented at ASCP 2014 (abstr TPS2101

PD PDPD

Summary

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

• Multiple Molecular “Targets” Will Be Identified and Treated

• Growth Signaling Pathways Will Be Identified and Treated

• Immunotherapy including immune augmentation may be highly effective therapy

20

DUKE STANDARD OF CAREMalignant Glioma

Newly Diagnosed

Best Available Therapy:

Surgery

RT + Temo + Avastin

Avastin + Temo

Clinical Trials:

Upfront ChemoCED – MABChemoVaccineStem Cell

DUKE STANDARD OF CAREMalignant Glioma

Recurrent Disease

Regional Therapy Trials Non- Regional Therapy Trials

Chemo SmallMoleculeInhibitors

Commercially availableagents off-label

VaccinePoliovirus Biologics

• Nihilism - lack of hope

• Reliance on community standard of care

• Lack of active regimens

• Insurance denials - to centers- for clinical trials

Major Impediments to SuccessfulTherapy of Brain Tumors

Political CommentaryPolitical Commentary

21