CBTTC Investigator Meeting Washington DC, May 2017 PNOC003 A pilot trial testing the clinical benefit of using molecular profiling to determine an individualized treatment plan in children and young adults with newly diagnosed DIPG CBTTC Investigator Meeting Washington DC, May 2017

Precision medicine trial for children with DIPG PK and PD analysis in recurrent sample Child with newly diagnosed DIPG NO Candidate for biopsy / resection YES Patient is eligible Patient is not eligible Biopsy / clinical pathology Evidence of progression / recurrence: Re-consent patient for repeat biopsy NO Adequate sample: > 50% tumor YES Correlative Studies: Xenograft models Circulating tumor cells Whole-genome sequencing Clinical genomics (TGEN): Gene expression profiling Whole-exome sequencing Predictive modeling Off study Report Specialized tumor board issues treatment recommendation Monitor patient for safety and clinical response

PNOC003 Milestones 8/4/2014: Initial Protocol sent to sites 9/16/2014: First patient enrolled 5/11/2016: Protocol v3 sent to sites (feasibility portion completed) – manuscript in preparation

Enrollment Summary Total 31 patients enrolled to date Feasibility portion: enrolled total of 17 subjects: 2 were not eligible due to non eligible tissue diagnosis (astrocytoma grade 1, ETANTR) For one patient RNA seq analysis was unsuccessful 8/14 from feasibility portion followed treatment recommendation: One patient recommendation was single agent panobinostat but this was started already during radiation therapy One patient followed the therapy recommendation however was started late on therapy plan and therefore counted as not following therapy recommendation Several families decided not to pursue any further therapy or enroll into other trials such as CED etc. PNOC003 – astro grade 1 PNOC004 did not follow PNOC005- followed but started late and no communication with PNOC and therefore decision was made to not count as following therapy

DNA and RNA Alterations

Treatment Recommended DNA Level Alterations & Treatment Recommendations Treatment Recommended Etoposide, dasatinib Cabozantinib, etoposide, mebendazole AZD1775 (clinical trial), temozolomide, sertraline Panobinostat, mebendazole (or cabozantinib) Panobinostat, mebendazole Erlotinib, propranolol, everolimus, etoposide Panobinostat, everolimus, sertraline (mebendazole if well-tolerated) Panobinostat, everolimus, mebendazole (or dasatinib) Panobinostat Vemurafenib/dabrafenib, trametinib, minocycline, panobinostat Etoposide, metformin, mebendazole, sertraline Panobinostat, everolimus, mebendazole/cabozantinib, valproic acid Panobinostat, mebendazole, cabozantinib, valproic acid Panobinostat, cabozantinib, valproic acid, mebendazole Panobinostat, mebendazole, propranolol, valproic acid Panobinostat, olaparib, irinotecan Trametinib, everolimus, palbociclib, mebendazole Panobinostat, everolimus, metformin, etoposide Everolimus, trametinib, panobinostat, metformin Panobinostat, mebendazole, etoposide, consider ALK inhibitor Panobinostat, dasatinib, mebendazole Panobinostat, everolimus, propranolol, mebendazole/metformin Panobinostat, mebendazole, sorafenib Panobinostat, everolimus, mebendazole, etoposide (or dasatinib)

Recurrent sample driven by EGFR activation

Correlative Biology 7 cell lines established: PNOC003-04, PNOC003-5,PNOC003-26, SF10423, 10438, 10693, 10864 PNOC003-5, 11 and 26 have been passaged two times. PNOC3-04, SF10693, 10423 and 10844 in vivo have been passaged at least 3x with up to 7 passages; PNOC003-23, PNOC003-29,SF10424,10438, 10475, 10493,10516 and 10864 passaged once. => possible 7-15 new DIPG model systems Analysis of circulating tumor DNA at baseline and with MRI scans (Javad Nazarian) Whole genome analysis and methylation studies of both human samples and associated cell lines/xenografts (Adam Resnick)

Acknowledgements Patient & Families PNOC PIs PNOC OP’s Funding Adam Resnick Javad Nazarian Nalin Gupta Michael Prados Lindsay Kilburn John Kuhn Mike Berens Winnie Liang Sara Byron Mitch Berger Claudia Petritsch Nathalene Truffeaux Xiaodong Yang John Crawford Kellie Nazemi Eugene Huang Brian Hood Suresh Magge Roger Packer Allison Ross David Craig Alison Roos Patient & Families PNOC PIs PNOC OP’s Jenna Weight Lajhem Cambridge Jordana Sandy Annette Molinaro Funding NIH through Cancer Center Award V Foundation Pediatric Brain Tumor Foundation Vs. Cancer Foundation Department of Neurosurgery, UCSF