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1 Clinical Trials for Patients with Malignant Pleural Mesothelioma Lee M. Krug, M.D. Memorial Sloan-Kettering Cancer Center New York, New York

2 Challenges in MPM Clinical Trials Mesothelioma is a rare disease, and as a result.. Large trials take a long time to complete Less research funding available so fewer investigators interested Less interest by pharma companies due to low profitability

3 But there is a need MPM has an extremely high rate of relapse after surgical resection Pemetrexed + cisplatin is the only FDAapproved chemotherapy regimen for advanced disease Improves median survival by 3 months Disease ultimately progresses after treatment Very limited it data on the efficacy of second-line therapy

4 Approaches for Development of Novel MPM Therapies Adjuvant: After surgery or combined modality therapy First-line: Add new agent in combination with pemetrexed / cisplatin Develop new regimen Maintenance: After treatment with pemetrexed / cisplatin to maintain i response Second-line: At progression after 1 st line therapy

5 Ongoing (or Recently Completed) Large Clinical Trials in Advanced MPM Drug Line Phase Sponsor Bevacizumab 1 st with pem/cis II/III French Intergroup CBP st with pem/cis RP II CanBas Cediranib 1 st with pem/cis I/II SWOG Everolimus 2 nd or 3 rd II SWOG MORAb st with pem/cis /i II Morphotek NGR htnf Maintenance RP II MolMed Thalidomide Maintenance III Netherlands Cancer Institute Vorinostat 2 nd or 3 rd III Merck WT 1 vaccine Adjuvant RP II MSKCC

6 WT1 Peptide Vaccine Background: Why target WT-1? 1. The WT-1 gene encodes a protein that is a zinc transcription factor in tissue development, cell proliferation, differentiation and apoptosis. 2. WT-1 has limited it expression in normal tissues, but has high expression in many hematologic malignancies and solid tumors, particularly mesothelioma. 3. WT-1 is processed and presented to the immune system. 4. Peptide vaccines can induce CTL recognition and killing of WT-1 expressing malignant cells.

7 n Development of WT1 Peptide Vaccine Native WT-1 has low immunogenic due to poor processing or presentation of the peptide and poor complex stability in the surface HLA We designed new heteroclitic peptides by substituting specific amino acids in the anchor residues using a bioinformatic model system (BIMAS). Peptides were chosen based on their predicted binding affinities to HLA class I molecules The stability of the HLA-peptide complex was tested using the T2 stabilization assay Test for in vitro activity of stimulated T cells (IFN-γ ELISPOT and Cr 51 release)

8 WT1 Peptide Vaccine Background: WT-1 Vaccine - We created synthetic peptides derived from WT1 proteins - The 4 peptides below cross react with native proteins WT1 HLA-class I peptide (HLA-A0201) A0201) WT1-A1: YMFPNAPYL 9 aa ( ) 134) WT1 HLA-class II peptides (HLA-DRB1) 427 long:: RSDELVRHHNMHQRNMTKL 331 long:: PGCNKRYFKLSHLQMHSR NKRYFKLSHLQMHSRKHTG KHTG 19 aa ( ) 22 aa ( ) 352) 122A1 long: : SGQAYMFPNAPYLPSCLES 19 aa ( ) 140) Pinilla JI Leukemia 20: 2025, 2006 May R Clin. Cancer Res 13: 4547, 2007

9 WT1 Peptide Vaccine Pilot Trial Design Primary Objective: To test the safety and immunogenicity (CD4 and CD8 response) of the WT1 vaccine Eligibility: Mesothelioma (< 1 prior chemotherapy regimen) NSCLC (stage III or IV after completion of initial therapy WT1-positive by immunohistochemistry Treatment: Vaccine given weeks 0, 4, 6, 8, 10, 12 Montanide (1:1 volume) adjuvant GM-CSF 70 mcg on day -2 and 0 If positive response and no disease progression, patients can continue up to 12 vaccinations Monitoring: Immune response (after 3, 6, 9 and 12 vaccinations) DTH skin test T cell response (proliferation, IFN- ELISPOT) CT scans every 3 months

10 WT1 Peptide Vaccine Patient Characteristics Mesothelioma (N=9) Ages 47 86, 8 men and 3 women All epithelioid histology 5 relapsed after multi-modality modality therapy 4 unresectable with relapse after chemotherapy NSCLC (N=2) Ages 57 and 53, 1 woman and 1 man Both adenocarcinoma Both with stage III disease and treated with combined modality

11 WT1 Peptide Vaccine Immune Response Summary DTH Response 3 out of 8 pts had a DTH response CD4 Response 6 patients out of 9 had CD4 response. CD8 Response 5 out of 6 patients tested had CD8 response NOTE: Only patients with HLA-0201 were tested t for CD8 proliferation. Krug et al, Cancer Immunol Immunother, 2010

12 Vaccination induces CD4 T-Cell Proliferation Krug et al, Cancer Immunol Immunother, 2010

13 Analog peptide WT1-A1 induces IFN- secretion by CD3 T-cells that cross react with native peptide Krug et al, Cancer Immunol Immunother, 2010

14 WT1 Peptide Vaccine Patient t Outcomes Mesothelioma (N=9) 5 patients completed at least 6 vaccines 8 patients developed progression of disease 1 patient completed all 12 vaccines and remains without progression 36 months later Median survival 13 months

15 Malig Pleural Meso WT-1 positive 4-12 weeks since completion of multi-modality treatment including surgery PS > 70% WT-1 Peptide Vaccine Adjuvant Study Design R A N D O M I Z E Specific Immunotherapy: WT-1 vaccine / Montanide + GM-CSF Non-specific Immunotherapy: Montanide + GM-CSF Primary endpoint: 1-year PFS Aim to increase from 50% to 70% N=78 patients (39 per arm)

16 CBP501 - Background Malignant cells preferentially repair damaged DNA at the G2 checkpoint, because of loss of the G1 checkpoint. CBP501, a synthetic duodecapeptide, inhibits several kinases involved in G2 arrest and thereby affects DNA repair selectively l in malignant cells. CBP501 enhances DNA damage by cisplatin by reinforcing the doublestrand breaks and increasing the number of platinum-dna adducts Hypothetical structural model for the CBP501-hCHK1 complex

17 %G2/M %G2/M %G2/ /M CBP501 enhances the effect of cisplatin on the cell cycle distribution of mesothelioma cell lines 4 fold MSTO 2 fold 4 fold H28 FACS analysis on mesothelioma lines (simultaneous) Day 1: CBP501/CDDP 3hr treat, Day 3: FACS %G2/M %G G2/M 4 fold H226 H2452 Yamamoto et al., AACR annual meeting,

18 CBP501 suppresses mesothelioma tumor xenograft growth in combination with cisplatin me relat tive tumor volu Relative tumor volume change of Scid mice 4.90 bearing NCI-H226 mesothelioma CBP mg/kg Cisplatin 9mg/kg 18 CBP days after first treatment Vehicle Cisplatin CBP501+Cisplatin Yamamoto et al., AACR annual meeting, 2009

19 CBP501 Randomized Phase II Trial In MPM First patient enrolled: Oct 2008 Expected last patient: Nov 2011 MPM - Unresectable - No prior chemotherapy Trial Design Stratify: P.S: 0-1 vs 2 Histology: Epithelioid vs Other Randomization Ratio 2:1 (Arm A:B) If 50% of the patients in Arm A remain progression-free for more than 4 months, the combination will be considered suitable for further study in MPM. Arm A (42 patients) - CBP501: 25mg/m 2 IV - Cisplatin: 75 mg/m 2 IV - Pemetrexed: 500 mg/m 2 IV every 3 weeks Arm B (21 patients) - Cisplatin: 75 mg/m 2 IV - Pemetrexed: 500 mg/m 2 IV every 3 weeks

20 Histone Deacetylase Inhibitors: Mechanism of Action HDAC=histone deacetylase; HDACi=histone deacetylase inhibitor; HAT=histone acetyltransferase; STAT 1=signal transducer and activator of transcription 1; NF B=nuclear factor kappa B; VEGF=vascular endothelial growth factor Paik et al. J Thorac Oncol. 2010;5(2);

21 Suberoylanilide Hydroxamic Acid (SAHA, Vorinostat) t) H N O Oral inhibitor of HDAC1, 2, 3, and 6 and other proteins that regulate gene transcription Approved for treatment of CTCL. In a phase I trial of oral SAHA, 13 patients with malignant pleural mesothelioma enrolled with two unconfirmed partial responses and four patients with stable disease. O N H OH Krug et al, Clin Lung Cancer, 2005

22 Possible Mechanisms of Antineoplastic Activity of Vorinostat in MPM Induction of expression of p21/waf1 Downregulation of thymidylate synthase Inhibition of proteasome function Reduced expression of HIF-1alpha and VEGF leading to reduced angiogenesis g Degradation of Akt via acetylation of Hsp90 Downregulation of antiapoptotic proteins

23 Vorinostat Phase III Trial in MPM Study Design R Vorinostat 300 mg PO BID A Stratification N 3 of 7 d in a 3-week cycle Performance status D Histology O (epithelial vs other) M No. prior therapies (1 vs 2) I Placebo PO BID Z E 3 of 7 d in a 3-week cycle N=330 N=330 Global, multicenter, phase III, randomized, double-blind, placebo- controlled study Patients receive oral vorinostat 300 mg (or matching placebo) BID for 3 days each week of a 21-day cycle BID=twice daily; PO=by mouth

24 July, 2005 Vorinostat Phase III Trial in MPM July, 2006 Study Timeline May, 2008 December, 2009 February, 2011 July, 2011 First 1st Interim 2nd interim 3rd interim Complete Final patient in analysis analysis analysis enrollment analysis N= wk F/U Enrollment suspended until February 12, 2007 N 220 N events 270 events Continue enrolling Continue enrolling N= events

25 Conclusions Despite many hurdles, several novel agents are being studied d in clinical i l trials for MPM Efforts to develop therapies with targets specifically relevant to MPM should continue Collaborations across institutions is necessary to complete large studies Support from patients and foundations will increase the chance of success

Mesothelioma Applied Research Foundation www.curemeso.org

Mesothelioma Applied Research Foundation www.curemeso.org Mesothelioma Applied Research Foundation www.curemeso.org Board of Directors Michael Becich PhD Gen. Steven Blum Lee Krug MD David Ettinger MD Axel Ranier Richard Mosca Erica Iacono Terry Lynch Hanne Minz

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