Multi-targeted TKI Research Articles

Anlotinib treatment in locally advanced or metastatic medullary thyroid carcinoma: A multicenter, randomized, double-blind, placebo-controlled phase IIB trial.

6019 Background: Anlotinib (AL3818) is a novel multi-target TKI, inhibiting tumor angiogenesis and proliferative signaling. Our previous single-arm phase 2 ALTN/MTC trial (NCT01874873) has demonstrated that anlotinib has a durable antitumor activity with a manageable adverse event profile in locally advanced or metastatic medullary thyroid carcinoma (MTC). Here we report results of the phase IIB trial (ALTER01031, NCT02586350) of anlotinib for locally advanced or metastatic MTC with a larger samples. Methods: Between September 2015 and September 2018, 91 patients were enrolled in China. Eligible patients have diagnosed as phase IV MTC with relapsed and measurable disease and without antiangiogenetic target therapy. The patients were randomly assigned in a 2:1 ratio to receive anlotinib or a matched placebo (12 mg QD from day 1 to 14 of a 21-day cycle). Patients who have been diagnosed with disease progression by the Independent Imaging Committee could be unblinded and crossed to the treatment group if the patient previous treated by placebo. The primary endpoint was progression-free survival (PFS). Results: 91 patients were randomized 62 to anlotinib arm and 29 to placebo arm. Until the data cutoff date (1 Feb 2019), median PFS was 20.67 months (95%CI, 14.03-34.63) in anlotinib arm vs 11.07 (95%CI, 5.82-14.32) months in placebo arm (HR 0.53, p = 0.0289). The OS data were not sufficiently mature for analysis. Considerable improvement in ORR was observed over the two arms (48.39% vs 3.45%, p < 0.0001). The adverse events (AEs) were 100% in anlotinib arm and 89.66% in placebo arm. The most common AEs in anlotinib arm were hand-foot syndrome, hypertension, hypertriglyceridemia and diarrhea. Conclusion: ALTER01031 met its primary endpoint of PFS shows that anlotinib treatment is effective and well tolerated. The safety profile was consistent and no new adverse events were identified. These data potentially extend the role of anlotinib monotherapy as a new therapy strategy for MTC patients. Clinical trial information: NCT02586350.

A Case of CCDC6-RET Fusion Mutation in Adult Acute Lymphoblastic Leukemia (ALL), a Known Activating Mutation Unreported in ALL

INTRODUCTIONUnderstanding the oncogenesis and the role of the different mutations observed are of crucial importance. They not only have prognostic importance, but also are evolving therapeutic targets. The first targeted mutation in ALL was the BCR-ABL gene(Thomas et al. 2004; Kim et al. 2015), which not only improved overall response and survival in “fit” patients, but also allowed for a promising alternative treatment strategy for elderly or frail patients(Delannoy et al. 2006). More recently, a subgroup of patient were noticed to share the same gene expression profile as Ph-positive, but lack the BCR-ABL translocation. These patients have several different genomic alteration, and are possibly targeted using different TKI's(Den Boer et al. 2009).CASE REPORTA 55 year-old female patient with past medical history of type 2 diabetes and hypothyroidism presented to the ED with 2 weeks of right flank pain radiating to her right groin. Her initial vital signs were stable, and she was afebrile. Her physical exam was remarkable for petechiae with no adenopathy or organomegaly.The patient's initial blood work was remarkable for pancytopenia with normal, coagulation studies, uric acid, renal and liver function except for elevated Alkaline phosphatase (481 U/L) Lactate dehydrogenase (17216 U/L). A bone marrow flow cytometry revealed a population of blasts that represented 77% of the sample. The blast were positive for CD9, CD19, CD10 (variable), CD20, cCD22, CD34, CD45, cCD79a, HLA-DR, and cTdT. These findings were compatible with B-lymphoblastic leukemia. Cytogenetics display abnormal 71-74, del(22) with high hypertriploidy. FoundatioOneHeme® was sent as part of her diagnostic work up, and revealed CCDC6-RET Fusion, FLT3 D835H and D835V, CDKN2A/B loss, DNMT3A Truncation in intron 14, MLL3 S793* and TP53 K132R as genomic alterations.The patient achieved complete response after 1 cycle of R-HyperCVAD and finished induction with this regimen. Afterwards, patient underwent myeloablative allogenic bone marrow transplant from. The patient developed Graft versus host disease 4 months after transplant that required steroids and Ruxolitinib. To date, 413 days since transplant, she continues to be in remission.DISCUSSIONActivating mutations involving tyrosine kinase receptors and other molecules involved in intracellular signal amplifications/transduction are known to be important drivers of oncogenesis. Moreover, the presence of the same mutation across different neoplasm, often represents an important pharmacological target. CCDC6-RET and other common fusion partners leads to homodimerization causing ligand independent activation(Truebestein and Leonard 2018). RET autophosphorylation lead to activation of several intracellular transduction cascades involved in cellular proliferation, including MAPK, AKT, PKC, JAK-STAT, PKA and PI3K(Santoro and Carlomagno 2013).RET fusion genes were first seen in patients with PTC, and then identified in subset of patient with NSCLC(Wang et al. 2012). These mutations are considered to have a considerable role in oncogenesis as they are usually mutually exclusive with other alterations such as BRAF and RAS in PTC(Xu et al. 2017; Mitsutake et al. 2006; Kimura et al. 2003), a hypothesis that is supported by clinical response to inhibition of such tyrosine kinase receptors.Several multikinase inhibitors with RET inhibition are available and have been approved for several different indications. Several TKI commercially available have been used in trials of NSCLC and other clinical settings and represent a potential option. RET TKI has showed worse clinical response when compared to EGFR, BRAF and ALK inhibition, possibly due to off target effect leading to poor compliance or less active RET inhhibition. Newer RET specific molecules currently being developed and evaluated in different clinical scenarios(Drilon et al. 2017). To our knowledge, there is no data regarding CCDC6-RET targeting in hematological malignancies.CONCLUSIONThis is the first report of CCDC6-RET rearrangement in ALL to date. The isolation of CCDC6-RET mutation raise the possibility of directed RET inhibition with selective or multitarget TKI in this disease. Comprehensive assessment of RET rearrangement and point mutations should be conducted in ALL in order to identify the prevalence and clinical implications of this new finding. DisclosuresNo relevant conflicts of interest to declare.

368O - Tumor mutation index as a biomarker for responsive stratification on multi-targeted TKI anlotinib: An ALTER-0303 companion diagnostic study

368O - Tumor mutation index as a biomarker for responsive stratification on multi-targeted TKI anlotinib: An ALTER-0303 companion diagnostic study

Phase Ib study of neoadjuvant chemoradiation (CRT) with midostaurin, 5-fluorouracil (5-FU) and radiation (XRT) for locally advanced rectal cancer: Sensitization of RAS mutant tumors.

e15674Background: RAS mutations confer radiation resistance in rectal cancer, with very low pCR rates, below 5%. Midostaurin is an oral, multi-target TKI, FDA-approved for FLT3 mutated leukemia, th...

OS outcomes to anlotinib in patients (pts) with refractory NSCLC of both wild-type (WT) and mutant EGFR.

e21013Background: Anlotinib, a novel multi-targeted TKI targeting VEGFR, FGFR, PDGFR and c-Kit, significantly prolonged OS and PFS in ALTER0303 trial (NCT02388919) Here we report the efficacy of an...

Midostaurin: A New Oral Agent Targeting FMS-Like Tyrosine Kinase 3-Mutant Acute Myeloid Leukemia.

Acute myeloid leukemia (AML), a clonal hematologic malignancy that results in bone marrow failure, is the most common acute leukemia in adults (median age of diagnosis 67 yrs), and treatment options, especially in the elderly population, are limited. Induction chemotherapy with 7 + 3, the combination of continuous-infusion cytarabine and intermittent dosing of an anthracycline administered over 7 and 3 days, respectively, has remained the standard of care since its introduction in 1973 in the United States. Midostaurin is a first-generation FMS-like tyrosine kinase 3 (FLT3) inhibitor (TKI) that was approved by the U.S. Food and Drug Administration in April 2017 for the treatment of FLT3-mutant AML. We performed a search of the PubMed database (January 1990-January 2017) to review pertinent clinical trials of midostaurin. Phase I, II, and III trials reported in English evaluating the safety and efficacy of midostaurin in patients with AML or myelodysplastic syndrome were included. The ClinicalTrials.gov database was also searched for ongoing trials. In the only phase III trial that has been conducted to date, midostaurin demonstrated significant improvement compared with placebo in overall and event-free survival in patients aged 18-59 years with newly diagnosed FLT3-mutant AML treated with standard induction chemotherapy. The median overall survival for patients randomized to the midostaurin group was 74.7 months versus 25.6 months in the placebo group (hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.63-0.96, p=0.009). Median event-free survival was 8.2 months with midostaurin compared with 3.0 months with placebo (HR 0.78, 95% CI 0.66-0.93, p=0.002). In addition to being evaluated in combination with conventional chemotherapy, midostaurin has been studied as monotherapy, in combination with the hypomethylating agents azacitidine and decitabine, and as single-agent maintenance. Studies evaluating midostaurin in the maintenance setting after allogeneic stem cell transplantation are underway. Midostaurin is the first oral multitargeted TKI to improve overall survival in patients with FLT3-mutant AML and represents an important addition to the limited armamentarium against AML.

P-gp is involved in the intestinal absorption and biliary excretion of afatinib in vitro and in rats.

Afatinib is an irreversible multi-targeted TKI, used in the treatment with EGFR mutated non-small cell lung cancer (NSCLC). The purpose of this study is to explore the molecular pharmacokinetic mechanism underlying the effect of P-gp inhibitors on the intestinal absorption and biliary excretion and to understand how P-gp inhibitors affect afatinib pharmacokinetics. Pharmacokinetics in vivo, in situ intestinal perfusion, perfused rat liver in situ, Caco-2 cells, P-gp ATPase activity, sandwich-cultured rat hepatocytes (SCRH) and transfected-cell transport were used in the evaluation. P-gp inhibitor verapamil (Ver) markedly increased the plasma concentrations and significantly decreased the biliary excretion of afatinib in vivo. Ver increased the intestinal absorption and decreased biliary excretion of afatinib in situ single-pass intestinal perfusion studies and in situ perfused rat liver, respectively. The accumulation of afatinib in Caco-2 cells was enhanced by Ver and Cyclosporin A (CsA). The biliary excretion index (BEI) of afatinib in SCRH was decreased by Ver and CsA, respectively. The net efflux ratio of afatinib was 2.3 across vector-/MDR1-MDCKII cell monolayers and was decreased by P-gp inhibitor. The activity of P-gp ATPase was induced by afatinib and the Km and Vmax were 1.05μM and 59.88nmol ATP/mg hP-gp/min, respectively. At least partly P-gp is involved in increasing the intestinal absorption and decreasing the biliary excretion of afatinib in rats.

Phase II clinical trial evaluating the activity and tolerability of pazopanib in patients (pts) with advanced and/or metastatic liposarcoma (LPS): A joint Spanish Sarcoma Group (GEIS) and German Interdisciplinary Sarcoma Group (GISG) Study—NCT01692496.

11039Background: Pazopanib, a multitarget TKI, has been approved as second or later line treatment for advanced non-adipocytic soft-tissue sarcoma. This open-label, phase II clinical trial was desi...

Abstract LB-B02: Acquisition of stem cell-like properties accompanying with Src family kinase/Focal adhesion kinase activation contributes to acquired resistance to afatinib in lung cancer cells

Abstract [Background] Most NSCLC patients harboring activating EGFR mutations benefit from treatment with EGFR-TKIs, but the final clinical efficacy of EGFR-TKIs varies because of development of tumor resistant to EGFR-TKIs. Multiple kinase-targeted 2nd generation TKIs such as afatinib have been developed to overcome drug resistance to the 1st generation TKIs. Afatinib is an irreversible multitargeted TKI targeting EGFR including T790M, HER2 and HER4. To develop further personalized therapeutics and drug resistance modifiers, we should understand the molecular based mechanism of drug resistance to 2nd as well as 3rd generation TKIs. In our present study, we present a novel finding that acquisition of cancer stem-like cells properties accompanying with activation of residual Src family kinase (SFK)/focal adhesion kinase (FAK) is responsible for the survival of afatinib-resistant lung cancer cells when expression of targeted EGFR, HER2 and HER4 is abraded. [Materials and methods] We have established afatinib-resistant subclones from human lung cancer cell lines, HCC827, harboring activating EGFR mutation after stepwise exposure to afatinib. The afatinib-resistant clones do not harbor T790M, K-ras mutation or PTEN loss. We have characterized biochemical properties of drug-resistant subclones as compared with their drug-sensitive counterparts by Western blot and RT-PCR. ALDEFLUOR kit was used to isolate cell populations with the stem cell specific ALDH enzymatic activity. [Results] We characterized two independent afatinib-resistant subclones, BR1-8 and BR2-3. [1] Afatinib-resistant subclones showed markedly decreased expression of EGFR, HER2, HER3, c-Met and PDGFRβ as compared with their parental cell lines, HCC827; [2] Akt phosphorylation in afatinib-resistant subclones was not suppressed by afatinib; [3] SFK and FAK were activated in resistant subclones, and combination of afatinib with c-Src siRNA or with dasatinib moderately suppressed cell growth and AKT phosphorylation; [4] Combination of afatinib with siFAK moderately blocked cell growth of resistant subclones. [5] Cancer stem like cell marker, ALDH1, positive cell population increased in afatinib-resistant sublines compared with HCC827 cell lines. [Conclusions] Together, our present study presents that increase of cancer stem like cells and SFK/FAK activation could be a mechanism responsible for acquired resistance to afatinib. We would further discuss the association of ALDH1 expression and SFK/FAK activation with afatinib resistance in lung cancer. Citation Format: Yuichi Murakami, Kahori Sonoda, Koichi Azuma, Kosuke Watari, Michihiko Kuwano, Mayumi Ono. Acquisition of stem cell-like properties accompanying with Src family kinase/Focal adhesion kinase activation contributes to acquired resistance to afatinib in lung cancer cells. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr LB-B02.

EL2 - Standards of care for Soft Tissue Sarcoma

The mainstay of care for unresectable, metastatic, and relapsed sarcoma is chemotherapy, and the principle treatment aims are disease palliation and control. Historically, all soft tissue sarcoma (STS) subtypes have been treated similarly, because of the lack of information about the outcome differences for conventional chemotherapy. The treatment strategies for sarcomas need to be adapted considering the histological subtype and tumor characteristics. However the rarity of STS makes it difficult to develop personalized treatment for advanced STS based on the phenotype or genotype.Doxorubicin is the most frequently used agent in first-line treatment of metastatic STS, and results in response rates of 10–20%. Multiple phase III clinical trials of doxorubicin-containing chemotherapy have been conducted in study groups in the US and Europe, but no treatment has shown superior activity considering the survival benefit compared to doxorubicin monotherapy. The combination of doxorubicin and ifosfamide is used as one of the options for situations in which tumor shrinkage is required, such as symptom palliation or when a critical structure is threatened.Currently, the clinical development of targeted therapy for STS has been initiated. For STSs, the multi-targeted TKI pazopanib, which has activity against VEGFR 1–3, PDGFRA and PDGFRB, and KIT, was approved in Japan 3 years ago. Potential drug targets in STS have been reported, such as the ALK fusion gene in inflammatory myofibroblastic tumors, activation of PDGFRB in dermatofibrosarcoma protuberans, and amplification of MDM2 and CDK4 in well-differentiated and de-differentiated liposarcoma. Other targets have also been reported, and the clinical utility of targeted therapy for specific histological subtypes harboring such target genes has been indicated in some cases. Thus, histology- or target-based therapies for advanced STS are expected to be introduced in clinical practice in the future. The mainstay of care for unresectable, metastatic, and relapsed sarcoma is chemotherapy, and the principle treatment aims are disease palliation and control. Historically, all soft tissue sarcoma (STS) subtypes have been treated similarly, because of the lack of information about the outcome differences for conventional chemotherapy. The treatment strategies for sarcomas need to be adapted considering the histological subtype and tumor characteristics. However the rarity of STS makes it difficult to develop personalized treatment for advanced STS based on the phenotype or genotype. Doxorubicin is the most frequently used agent in first-line treatment of metastatic STS, and results in response rates of 10–20%. Multiple phase III clinical trials of doxorubicin-containing chemotherapy have been conducted in study groups in the US and Europe, but no treatment has shown superior activity considering the survival benefit compared to doxorubicin monotherapy. The combination of doxorubicin and ifosfamide is used as one of the options for situations in which tumor shrinkage is required, such as symptom palliation or when a critical structure is threatened. Currently, the clinical development of targeted therapy for STS has been initiated. For STSs, the multi-targeted TKI pazopanib, which has activity against VEGFR 1–3, PDGFRA and PDGFRB, and KIT, was approved in Japan 3 years ago. Potential drug targets in STS have been reported, such as the ALK fusion gene in inflammatory myofibroblastic tumors, activation of PDGFRB in dermatofibrosarcoma protuberans, and amplification of MDM2 and CDK4 in well-differentiated and de-differentiated liposarcoma. Other targets have also been reported, and the clinical utility of targeted therapy for specific histological subtypes harboring such target genes has been indicated in some cases. Thus, histology- or target-based therapies for advanced STS are expected to be introduced in clinical practice in the future.

Abstract 4301: Endothelial angiopoietin-2 expression correlates with tumor angiogenesis and response to sunitinib in metastatic renal cell carcinoma

Abstract Background: Angiopoietin-2 (Ang2) is an endothelial cell derived growth factor, which promotes tumor angiogenesis, tumor growth and metastasis. Ang2 is a promising target for anti-angiogenic therapies, but its potential as a biomarker for anti-angiogenic therapies remains unknown. The purpose of this study was to evaluate expression of the Ang2-Tie2 signalling pathway components in metastatic RCC (mRCC) patients treated with sunitinib, a modern multitarget TKI. Materials and methods: We evaluated Ang2, CD31 and Ki67 expression in tumors of 136 patients with metastatic RCC (mRCC) treated with first-line sunitinib from formalin-fixed paraffin-embedded tumor samples using immunohistochemistry. Results: Ang2 was exclusively expressed in the endothelial cells of tumor blood vessels. Using a cutoff of ≥50 Ang2+ vessels/microscopic field, 38% of the samples had high Ang2 expression. High Ang2 expression correlated with high CD31+ vessel density (p = 0.002). 91% of patients with high Ang2 expression had partial response (PR) or stable disease (SD) as best response to sunitinib as compared with 76% of those with low Ang2 expression (P = 0.033). High CD31+ vessel density correlated with a high clinical benefit rate (P = 0.015), and with low levels of Ki-67+ tumor cells (P = 0.018). Combined high expression of both Ang2 and CD31 predicted even better clinical benefit rate with 100% of the patients with high Ang2 and CD31 expression (n = 25) achieving PR/SD as compared with 77% among the rest of the patients (n = 101; P = 0.007). Only one patient (8%, n = 12) with papillary RCC, but 49 (41%) patients with clear cell RCC had high Ang2 expression (P = 0.03). Conclusions: In this first study to investigate Ang2 expression and outcome in mRCC patients treated with sunitinib, high Ang2 expression in the tumor vasculature was predictive for sunitinib efficacy. Citation Format: Anita Lampinen, Juhana Rautiola, Tuomas Mirtti, Ari Ristimäki, Heikki Joensuu, Petri Bono, Pipsa Saharinen. Endothelial angiopoietin-2 expression correlates with tumor angiogenesis and response to sunitinib in metastatic renal cell carcinoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4301. doi:10.1158/1538-7445.AM2015-4301

A multi-parameter in vitro screen in human stem cell-derived cardiomyocytes identifies ponatinib-induced structural and functional cardiac toxicity.

Ponatinib, a multi-targeted TKI and potent pan-ABL inhibitor, approved for the treatment of Ph + ALL and CML, was temporarily withdrawn from the U.S. market due to severe vascular adverse events. Cardiac-specific toxicities including myocardial infarction, severe congestive heart failure, and cardiac arrhythmias have also been shown with ponatinib. Targeted oncology agents such as ponatinib have transformed cancer treatment but often induce toxicity due to inhibition of survival pathways shared by both cancer and cardiac cells. These toxicities are often missed by the standard preclinical toxicity assessment methods, which include human Ether-à-go-go-related gene (hERG) and animal toxicity testing. In this study, we show that a multiparameter in vitro toxicity screening approach using human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM) accurately predicted the cardiac toxicity potential of ponatinib. This in vitro model evaluated ponatinib's effect on the overall cell health, mitochondrial stress, and function of hiPSC-CM and also provided mechanistic insight into the signaling pathways and cellular structures altered with treatment. We show here that ponatinib rapidly inhibits prosurvival signaling pathways, induces structural cardiac toxicity (as shown by actin cytoskeleton damage, mitochondrial stress, cell death, and troponin secretion), and disrupts cardiac cell beating. Most of these effects occurred at doses between 10× and 50× ponatinib's Cmax, a dose range shown to be relevant for accurate prediction of in vivo toxicity. Together these studies show that a comprehensive in vitro screening tool in a more relevant human cardiac cell model can improve the detection of cardiac toxicity with targeted oncology agents such as ponatinib.

Phase 2 Study of Ponatinib in Patients (Pts) with Advanced Gastrointestinal Stromal Tumors (Gist) After Failure of Tyrosine Kinase Inhibitor (Tki) Therapy: Early Results

ABSTRACT Aim: Ponatinib is an oral multi-targeted TKI with potent preclinical activity against mutant oncoproteins KIT and PDGFRa, including a broad range of clinically-relevant primary (especially KIT exon 11) and secondary (including KIT exon 17) resistance mutants. This in vitro activity suggests it may be effective in GIST pts with failure of prior TKI therapies. Methods: This phase 2 single arm trial evaluated efficacy and safety of ponatinib at 45 mg qd in advanced GIST pts after failure of prior TKI therapies. Pts were enrolled in Cohorts based on the presence (A) or absence (B) of KIT exon 11 mutations. Primary end point: clinical benefit rate (CBR=CR+PR+SD at 16 wks) by modified RECIST 1.1 in Cohort A. Secondary end points: CBR in Cohort B and total; ORR, PFS, OS, safety/tolerability in each cohort and total. New pt enrollment was held due to safety observations in other ponatinib trials; enrollment criteria are being revised to include only pts with failure of all 3 GIST-approved TKI. NCT01874665. Results: From Jun to Oct 2013, 35 pts were enrolled (Cohorts A: 24, B: 11). Median age: 58 yrs; 46% had 2 prior approved TKIs, 46% had 3 prior approved TKIs. 74% pts had ≥4 prior cancer regimens. Median time since diagnosis: 6 yrs. Median follow-up as of Apr 7 2014: Cohorts A: 7 mos, B: 4 mos. 14 pts on study, 21 discontinued: 10 PD, 7 AE, 4 other. Cohort A CBR: 50% (11/22 pts); ORR: 9% (2/22); Best Response: 2 PR and 14 SD. All 5 Cohort A pts with matched PET scans (BL v. C1) had decreased FDG uptake in active lesions, 3 remain on study with SD or better. Cohort B CBR: 27% (3/11); ORR: 0%. Most common (≥30%) treatment-emergent AE (TEAE): rash (57%), fatigue (49%), myalgia (46%), dry skin (43%), headache (43%), constipation (40%), abdominal pain (37%), hypertension (34%) and increased serum alkaline phosphatase (31%). Serious TEAE (≥2 pts): abdominal pain (11%), nausea (6%), vomiting (6%), and fatigue (6%). One pt had myocardial ischemia and 1 pt had right ventricular dysfunction. There was 1 death (pneumonia) that was possibly ponatinib-related. Conclusions: Initial analysis of this ongoing trial suggests that ponatinib has clinical activity in advanced GIST pts after failure of prior TKI therapies. Disclosure: M.C. Heinrich: Compensated consultant and/or advisor for Novartis, ARIAD, Pfizer, MolecularMD. Stock or other ownership interests in MolecularMD. I received honoraria directly from Novartis, Pfizer and Onyx. Conducted research funded by ARIAD; M. von Mehren: I am a compensated consultant and/or advisor for Novartis, ARIAD and GSK I have received honoraria directly from Novartis; G.D. Demetri: Compensated consultant/advisor for ARIAD, Novartis, Pfizer, Bayer & Blueprint Medicines, stock /other ownership in Blueprint Medcine. Received research funding from Novartis, Bayer and Pfizer; provided compensated expert testimony for ARIAD and Bayer; J. Fletcher: I am a compensated consultant and/or advisor for ARIAD, and received honoraria directly from Novartis; J. Sun: I have an employment /leadership role with ARIAD Pharmaceuticals – Senior Biostatistician. I have stock or other ownership interest in ARIAD Pharmaceuticals; J.G. Hodgson: I have an employment/leadership role with ARIAD Pharmaceuticals: Associate Director. I have stock or other ownership interest in ARIAD Pharmaceuticals; V.M. Rivera: I have an employment/leadership role with ARIAD Pharmaceuticals - Vice President, Preclinical and Translational Research. I have stock or other ownership interest in ARIAD Pharmaceuticals; C.D. Turner: I have an employment /leadership role with ARIAD Pharmaceuticals – Senior Medical Director. I have stock or other ownership interest in ARIAD Pharmaceuticals; S. George: I am a compensated consultant and/or advisor for Novartis, Bayer, Pfizer, ARIAD. I have received honoraria directly from Novartis. I have conducted research funded by Bayer, Novartis, and ARIAD

Abstract C280: Oncology therapeutics show unique cardiotoxic profiles in human cardiac cells.

Abstract Tyrosine Kinase Inhibitors (TKI) have greatly improved the treatment and prognosis of multiple cancer types. However unexpected clinical cardiotoxicity has been shown with some of these agents that was not wholly predicted by current preclinical toxicity assessment methods. Since cardiotoxicity with TKI are often caused by the inhibition of signaling pathways critical to cardiac cell function, multi-targeted TKI that block multiple pathways increases the likelihood for cardiac cell damage. We recently demonstrated that an in vitro multi-parameter test panel assessing the effect of drug treatment on overall cardiac health and function could accurately predict the cardiotoxicity of 4 FDA-approved TKI. The 3 multi-targeted TKI clinically associated with severe cardiac adverse events (crizotinib, sunitinib, nilotinib) all proved to be cardiotoxic in our in vitro tests while the more targeted and relatively cardiac-safe drug erlotinib showed only minor changes in cardiac cell health. The present studies expand upon this initial observation to include other TKI, chemotherapeutic agents, and non-oncology compounds which were grouped based on their known clinical toxicity profiles ranging from cardiac safe to withdrawn. We then assessed the cardiotoxic potential of these compounds by examining their effect on cell viability, reactive oxygen species (ROS) generation, lipid formation, troponin secretion and beating activity in a human induced pluripotent-derived cardiac stem (iPS) cell model. The results showed a unique cardiotoxic signature of oncology therapeutics that was significantly different from other classes of drugs such as anti-arrhythmics. Oncology compounds induced potent cell death and lipid formation (metabolic stress) in iPS cells while anti-arrhythmics more potently disrupted cardiac cell beating with minimal impact on cell viability. In addition, troponin secretion was directly correlated with cardiac cell death for all of the oncology agents. In comparison, the cardiac-safe drugs, including non-oncology compounds and more targeted TKI, did not negatively affect any of the endpoints that assessed cardiac cell health and function. Thus different classes of drugs appear to show unique toxicity profiles that may reflect multiple mechanisms which lead to cardiotoxicity. Specifically our data suggest that more promiscuous TKI which inhibit the function of multiple oncogenic targets may be affecting pathways which are critical for cardiac cell health while more targeted agents are less cardiac toxic. These studies show that a multi-parameter approach can provide a robust characterization of drug-induced cardiac cell toxicity that can be leveraged to improve drug safety during early phase development. Furthermore, these studies emphasize the importance of developing more targeted oncology agents which are effective at killing cancer cells but lack toxic effects on cardiac cells. Citation Information: Mol Cancer Ther 2013;12(11 Suppl):C280. Citation Format: Dominique Talbert, Kimberly Doherty, Diarmuid Moran, Robert Wappell, Patricia Trusk, Scott Shell, Sarah Bacus. Oncology therapeutics show unique cardiotoxic profiles in human cardiac cells. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr C280.

Abstract 2095: A phase 2 study of Amuvatinib (MP-470), the first RAD51 inhibitor in combination with platinum-etoposide (PE) in refractory or relapsed small cell lung cancer (ESCAPE).

Abstract Background: Amuvatinib is an oral multi-targeted TKI of c-Kit and PDGFRα and modulates DNA repair by down regulation of Rad51. Rad51 is a key protein in the homologous recombination repair pathway for DNA double strand breaks which can mediate resistance to DNA-damaging agents. Amuvatinib has demonstrated synergistic activity preclinically with DNA damaging chemotherapy agents including etoposide and doxorubicin. Amuvatinib in combination with DNA damaging agents resulted in clinical responses in SCLC patients, induced Rad51 suppression, and increased DNA damage (53BP1 foci) in skin punch biopsies. These results provided the justification for a Phase 2, OL study of amuvatinib in combination with platinum and etoposide (PE) chemotherapy in SCLC patients who have not responded to or relapsed after standard treatment (ESCAPE; TrEatment of Small Cell lung cancer with Amuvatinib in combination with Platinum Etoposide). Methods: Patients ≥ 18 years, ECOG PS 0-2, with confirmed SCLC who met one of the following major eligibility criteria were enrolled based on prior PE response: 1) disease progression during PE, 2) relapse ≤ 90 days, 3) SD as best response after at least 2 cycles. Patients who received second-line therapy were eligible if they met any one of these 3 conditions and all other study eligibility criteria. An optimal Simon 2-stage design was employed (α=10%, β=10%, p0=10%, p1=25%). In Stage 1, 21 patients were to be enrolled and ≥ 3 confirmed responses (CR or PR) were required in order to proceed to Stage 2, where an additional 29 patients were to be enrolled. Amuvatinib was administered PO 300 mg TID. Results: Twenty-three patients, median age of 62 years (range, 44-80); 11 M/12 F; ECOG PS 0 (n=3), 1 (n=12), 2 (n=6), were enrolled in Stage 1 and received a median of two 21-day cycles (range, 1-10). At study entry, 9 (39%), 11 (48%), and 3 (13%) patients presented with disease progression, relapse ≤ 90 days, and SD after at least 2 cycles of PE, respectively. Per PI's assessment, 4 PRs and 7 SDs were observed as best response. Per RECIST 1.1, 2 PRs and 3 SDs were confirmed by follow-up scan ≥ 4 weeks apart for an overall clinical benefit rate (CBR) of 5/23 (22%). No CRs were observed. Grade 3/4 suspected amuvatinib related AEs were neutropenia, thrombocytopenia, atrial fibrillation, diarrhea, esophagitis, and hypercalcemia (1 patient each; 4%); hypokalemia and leukopenia, (2 patients each; 9%). By IHC, baseline expression of RAD51, ERCC1, Chk2, ATM, cKit, and RB will be evaluated and correlated with response. Conclusions: Amuvatinib demonstrated an overall CBR of 22% in refractory SCLC. While clinical activity was observed, the response rate in Stage 1 did not meet pre-specified study primary endpoint. The safety profile of amuvatinib is consistent with previous published reports of manageable toxicity with non-overlapping toxicities with PE chemotherapy. Citation Format: Lauren Byers, Leora Horn, Jitendra Gandhi, Goetz Kloecker, Taofeek K. Owonikoko, Saiama Waqar, Maciej J. Krzakowski, Gavin Choy, Nancy Cecchettini, Pietro Taverna, Amarpal Sahai, Mojtaba Noursalehi, Mohammad Azab, D. Ross Camidge. A phase 2 study of Amuvatinib (MP-470), the first RAD51 inhibitor in combination with platinum-etoposide (PE) in refractory or relapsed small cell lung cancer (ESCAPE). [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2095. doi:10.1158/1538-7445.AM2013-2095

Abstract 4423: Implications for cardiotoxicity with targeted therapies.

Abstract Tyrosine kinase inhibitors (TKi) have greatly improved the treatment and prognosis of multiple cancer types. However, unexpected cardiotoxicity has arisen that was not wholly predicted by current FDA mandated pre-clinical tests. Thus a more robust tool to predict the cardiotoxic potential of these compounds is warranted. For this purpose, we developed a panel of in vitro tests in a clinically relevant human cardiomyocyte model that assesses drug impact on overall cardiac health (cell viability, apoptosis, and morphology), mitochondria and metabolic intactness (reactive oxygen species (ROS) generation, AMPK activity, and lipid accumulation), and electrophysiological function (impedance (beat rate) and ion channel blockage). To demonstrate the utility of our panel, we examined the effect of 4 FDA-approved TKi with known clinical outcome on cardiac health. The 3 drugs with known cardiac adverse events (crizotinib, sunitinib, and nilotinib) all proved to be cardiotoxic by our panel although each showed distinct mechanisms of toxicity. However erlotinib, a cardiac-safe drug that targets EGFR and is used primarily in non-small cell lung cancer (NSCLC), did not show any indications of toxicity. Surprisingly, the most cardiotoxic drug by our panel was crizotinib, an ALK/ MET inhibitor that has revolutionized treatment for ALK+ NSCLC patients. Crizotinib potently impaired overall cardiac health by increasing ROS and apoptosis but also impeded electrophysiological function by inducing ion channel blockage and reducing cardiac beat rate. Interestingly crizotinib also induced lipid and cholesterol accumulation which was shown to be correlated with increased expression of the sterol-regulatory binding protein (SREBP) pathway by transcriptome analysis. The multi-targeted TKi sunitinib (used in renal cell carcinoma and gastrointestinal stromal tumors) and nilotinib (used in chronic myelogenous leukemia) also showed unique cardiotoxicity profiles. In conclusion, our studies showed a distinct cardiotoxicity profile for each TKi that correlates with clinical outcome. These results suggest that caution should be taken with these TKi especially when used long-term or in the adjuvant setting. Furthermore, these effects may be exacerbated in patients with adverse cardiac genetic predispositions and studies are ongoing in our lab on patient-derived cardiac cell lines to investigate this possibility. This multi-parameter screening approach allows for a more complete assessment of the potential for drug-induced cardiotoxicity and may allow for earlier detection in the drug development process. In addition, understanding the mechanisms of cardiac toxicities may lead to the discovery of novel mitigation strategies and combination therapies to improve cardiac cell health during treatment with oncology therapies. Citation Format: Kimberly R. Doherty, Robert L. Wappel, Dominique R. Talbert, Patricia B. Trusk, Scott A. Shell, Diarmuid M. Moran, James W. Kramer, Arthur Brown, Sarah Bacus. Implications for cardiotoxicity with targeted therapies. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4423. doi:10.1158/1538-7445.AM2013-4423

854P - Sunitinib in Advanced RCC: Cost-Effectiveness Evaluation Based on Clinical Practice

ABSTRACT The approval trials have established sunitinib, multi-targeted TKI, a standard treatment in patients with metastatic RCC. RCTs may fail to show relevant clinical benefit in wider population and routine use, as certain patient subtypes are under-represented, notably those with poorer prognostic factors and pretreated. The data were collected through national registry Onco-AIFA as part of the mandatory surveillance. RCC patients receiving sunitinib once daily, on schedule 4/2, between 2007 and 2011, had been checked prospectively for toxicity, clinical outcomes and length of treatment. Based on the difference in effectiveness in PFS between approval RCT and clinical practice, a new price adjusted for effectiveness has been calculated. A total of 106 patients (64 years, M 70/F 36) were reviewed, 77% had prior nephrectomy and 74% were treatment-naive. At first evaluation we found 28% partial responses, 25% stable diseases, 45% progressions and one discontinuation due to toxicity. The median PFS and OS were 7 and 11.3 months, respectively. Among 79 RCC patients (pts) with metastases (mets) at first diagnosis, 63% had lung mets, 21% pts had liver mets, 21% had bone mets and 9% had brain mets. Cox regression model showed in subgroups analysis significantly worse survival prognosis in males, brain and liver mets, ECOG PS > 1, non-clear cell histology and non prior nephrectomy. Sorafenib treatment after progression on sunitinib (33% pts) did not improved OS. Grade 3 thrombocytopenia, neutropenia, mucositis and HFS caused dosage reductions. Effectiveness adjusted price was 3,87 euro/mg as opposed to the ex-factory price of 2,46 euro/mg proportionally to the difference of PFS form RCTs (11 months) and that form clinical practice oncology (7 months). The results show that sunitinib clinical benefit in RCC patients was gained in selected responders, but in overall the effectiveness was nearly half of that reported in the approval RCTs. Evaluating cost-effectiveness ratio, price should be at least 36% lower than actual ex-factory price based on net clinical benefit achieved in real life practice. Post-marketing studies in real life practice are required in order to verify both effectiveness and safety in general population, testing for external validity of randomized trials. Disclosure All authors have declared no conflicts of interest.

Chemotherapy plus multitargeted antiangiogenic tyrosine kinase inhibitors or chemotherapy alone in advanced NSCLC: a meta-analysis of randomized controlled trials

Most patients with advanced non-small-cell lung cancer (NSCLC) require systemic chemotherapy. Chemotherapy plus multitargeted antiangiogenic tyrosine kinase inhibitors (TKI; e.g., sorafenib, sunitinib, cediranib, vandetanib, BIBF 1120, pazopanib, axitinib) has recently been evaluated in patients with NSCLC. However, the advantage of this therapy over chemotherapy alone in patients with advanced NSCLC remains largely unknown. A meta-analysis of randomized controlled trials (RCTs) was performed to compare the efficacy and toxicity of chemotherapy plus multitargeted antiangiogenic TKI with chemotherapy alone in patients with advanced NSCLC. PubMed, the ASCO and ESMO databases, and the Cochrane Library were searched for references to published articles. Two reviewers independently assessed the quality of the trials. Data were extracted, and overall response rate (ORR), pooled progression-free survival (PFS), overall survival (OS) with 95 % confidence intervals (CI), and major toxicities/adverse effects were analyzed. Six RCTs involving 3,337 patients with advanced NSCLC were ultimately analyzed. Compared to chemotherapy alone, chemotherapy plus multitargeted antiangiogenic TKI significantly increased the ORR [relative risk (RR) 1.71, 95 % CI 1.43-2.05] and PFS [hazard ratio (HR) 0.83, 95 % CI 0.76-0.90], but not OS (HR 0.93, 95 % CI 0.83-1.03). Patients who received chemotherapy plus multitargeted antiangiogenic TKI exhibited more rash, diarrhea and hypertension (OR 2.78, 95 % CI 2.37-3.26; OR 1.92, 95 % CI 1.65-2.24; OR 2.90, 95 % CI 2.19-3.84, respectively) and less nausea and vomiting (OR 0.71, 95 % CI 0.60-0.83; OR 0.75, 95 % CI 0.61-0.92, respectively). The incidence of hemorrhage, fatigue, cough, constipation, anorexia, and alopecia were comparable between the two groups. Therapy consisting of chemotherapy plus multitargeted antiangiogenic TKI was found to have specific advantages over chemotherapy alone in terms of PFS and ORR. The toxicity was comparable between the two therapies. Therefore, chemotherapy plus multitargeted antiangiogenic TKI may be a safe and valid therapeutic option for patients with advanced NSCLC.

Final results of a phase II study of sorafenib in combination with carboplatin and paclitaxel in patients with metastatic or recurrent squamous cell cancer of the head and neck (SCCHN).

5592 Background: Cytotoxic chemotherapy (CT) is the current standard treatment for metastatic/recurrent SCCHN. The prognosis for these patients (PTS) is poor with a median progression free survival (PFS) of 4 months with CT. Survival in PTS with SCCHN may correlate inversely with the number of angiogenic growth factors secreted. Sorafenib is a potent inhibitor of c-Raf, b-Raf, VEGFR-1/2/3 and PDGFR-β. To investigate the hypothesis that a multi-targeted TKI added to chemotherapy would improve outcomes in patients with metastatic/recurrent SCCHN, we performed a phase II trial of paclitaxel and carboplatin and sorafenib (PCS). Methods: PTS were required to have ECOG PS 0-1, measurable disease, controlled blood pressure, and may have received one regimen of induction, concomitant or adjuvant CT, but not CT for recurrent/metastatic disease. Sites of primary disease excluded nasopharynx and paranasal sinus. Treatment consisted P 200mg/m2 and C AUC 6 intravenously on day 1 followed by S 400 mg orally bid (days 2-19) in every 3-week cycles. Primary endpoint was PFS, targeting median PFS of 6 months (M). Secondary endpoints include overall survival (OS), response rate (RR), exploratory biomarkers, and toxicity. Results: Forty-eight PTS with SCCHN were enrolled with 44 PTS evaluable for PFS and response using RECIST. Median age: 56 years (22-79 years), 89% male, median ECOG PS 1. Median follow-up was 24.1 M. RR was 55% (n=24), disease control rate was 84% (n=37), median PFS was 8.51 M (95% CI: 5.98 ~ 13 months), and median OS was 22.6 M (95% CI: 13.1 - NA months). Grade ³3 treatment related toxicities included hand-foot syndrome (n=10), neutropenia (n=5), pain (n=6), elevated lipase (n=4), elevated amylase (n=3), anemia (n=3), fatigue (n=2), hypertension (n=2), neuropathy (n=2), febrile neutropenia (n=2), and thrombocytopenia (n=2). Conclusions: The combination of PCS was well tolerated and had encouraging activity in recurrent/metastatic SCCHN. Blood-based and tissue biomarkers are being analyzed. Final outcomes, toxicity, and correlative biomarker data will be reported.

Sunitinb in advanced renal cell carcinoma (RCC): Is effectiveness good enough in real life practice?

e15072 Background: The sunitnib approval trials have established this multi-targeted TKI as a standard treatment in patients with metastatic RCC. However, even RCTs may fail to show relevant clinical benefit in wider population, as certain patient subtypes are under-represented, notably those with poorer prognostic factors and pretreated. The purpose of the study was to evaluate effectiveness of sunitinb in unselected RCC patients in real life practice in Italy. Methods: The data were collected through national registry on oncology drugs as part of mandatory surveillance program, which allows prospective investigations of effectiveness. RCC patients receiving sunitinb once daily, on schedule 4/2, between 2007 and 2011, had been included. All patients were checked prospectively for toxicity, clinical outcomes and length of treatment using registry inputs. Retrospective analysis of previous and following treatments and mortality data was performed based on clinical records and hospital databases. Results: A total of 106 patients (median age 64 years, M 70/F 36) were reviewed, 77% had prior nephrectomy and 74% were treatment-naïve. At first evaluation we found 28% partial responses, 25% stable diseases, 46% progressions and one discontinuation due to toxicity. The median TTP and OS were 7 and 11.3 months, respectively. Among 102 RCC patients (pts) with metastases (mets) at first diagnosis, 65% had lung mets, 19% pts had liver mets, 25% had bone mets and 8% had brain mets. The Cox regression model showed in subgroups analysis significantly worse survival prognosis in males, brain and liver mets, ECOG PS>1, non-clear cell histology and non prior nephrectomy. Sorafenib treatment after progression on sunitinib (33% pts) did not improved OS. Grade 3 thrombocytopenia, neutropenia, mucositis and HFS caused dosage reductions. Conclusions: The results on examined RCC study population show that sunitinib clinical benefit was gained in selected responders, but in overall the effectiveness was nearly half of that reported in the approval RCTs. Post-marketing studies in real life practice are required in order to verify both effectiveness and safety in general population, testing for external validity of randomized trials.