A Phase 1b/II Study of Vismodegib, a hedgehog inhibitor in combination with RO4929097, a notch (GSI) inhibitor in metastatic sarcomas. Mrinal Gounder*, Mark Dickson*, Sandra D'Angelo*, Mary Louise Keohan*, Li-Xuan Qin, Richard Carvajal, Ping Chi, Alexander Shoushtari, Mercedes Condy, Yelena Ustoyev, Armando Sanchez, Lanier Tanner, Rita Morales, Joseph Erinjeri, Nian Wu, Cristina Antonescu, Narasimhan Agaram, Samuel Singer, Sam Yoon, Aimee Crago, Robert Maki, S. Percy Ivy1, Naoko Takebe1, William D. Tap* and Gary K. Schwartz *. Sarcoma Medical Oncology Service Memorial Sloan-Kettering Cancer Center, New York, NY

Conflict of Interest: None

Rationale for study

Hedgehog: Embryonic pathway reactivated in cancer Hedgehog Pathway VISMODEGIB Survival and Growth GLI1 GLI2 Smooth GLI3 Patched Hedgehog

Notch: Embryonic pathway reactivated in cancer NICD MPNST γ-Secretase NICD CSL MAML RO4929097 Akt P HES1 HEY1 Survivin Survival and Growth

Combination of Cyclopamine (Hedgehog inhibitor) and GSI (Notch Inhibitor) Cell Viability Gary Schwartz lab, unpublished

Hypothesis #1: Combined inhibition of Hedgehog and Notch pathways is a rational therapeutic strategy in patients with advanced sarcoma.

Question #1: Are the two drugs safe to combine?

FDA approved in metastatic and advanced Basal Cell Carcinoma. GDC-0449 (Vismodegib) Hedgehog inhibitor FDA approved in metastatic and advanced Basal Cell Carcinoma. 150 mg oral, once daily. RO4929097 Notch inhibitor Phase 2 dose: < 20 mg oral, daily. A phase I study of RO4929097, a novel gamma secretase inhibitor, in patients with advanced solid tumors Journal of Clinical Oncology, April 23rd. 2012

Key Eligibility Criteria -- Age > 18 -- Advanced, metastatic sarcoma -- measurable disease (RECIST 1.1) -- 1 – 4 prior therapies.

Phase Ib: Maximum Administered Dose 3 + 3 design GDC -0449 (HH) RO4929097 (NCH) DLT Dose Level 1 150 mg daily 10 mg daily None Dose Level 2 15 mg daily -- 9 patients enrolled to Phase I: combination well tolerated. -- Detailed pharmacokinetic data presented at ASCO 2012

Question #2: Are the drugs getting into tumor and inhibiting the pathways?

Pre- and post- treatment tumor biopsies confirm inhibition of Notch Myxoid Chondrosarcoma Myxoid Liposarcoma Liposarcoma Epithelioid Clear Cell Desmoid

Pre- and Post-treatment biopsy of patients confirms inhibition of Hedgehog pathway GLI-1 by RT-PCR GLI-1 by RT-PCR

Phase II Study Design Stratified : Liposarcoma vs. other Number of prior 1 vs. >1

Primary Endpoint Progression Free Survival Sample Size: 90 pts (45 in each arm) With a 1-sided alpha of 0.1, this sample size allowed to detect a 75% improvement in the combination arm with a power of 0.9

Sarcoma study was closed in April 2014 In 2013, Roche discontinued further development of the Notch inhibitor (RO4929097) and ~ 15 studies nationwide in many solid tumors was prematurely closed. Sarcoma study was closed in April 2014 67 of the planned 90 pts were enrolled to the study.

Final Phase II results: 67 pts (planned 90) Notch alone Notch + Hedgehog p-value Number enrolled 34 33 Age 56 46 NS Gender - Male 58% 54% ECOG PS 0 88% 87% # Prior therapy 2 3 Liposarcoma 8 9 Other histology 26 24

TOXICITIES Notch Alone Hedgehog + Notch Grade 1 - 2 Grade 3 -4 Grade 1 -2 Grade 3-4 Anemia 21 (6%) 3 (7%) 22 (5%) 5 (13%) Thrombocytopenia 8 (2%) 11 (3%) Diarrhea 22 (6%) 56 (13%) 1 Metabolic 193 (56%) 24 (57%) 177 (43%) 10 (27%) Fatigue 34 (10%) 51 (12%) 2 Other 10 (3%) 4 (9.5%) 19 (4.6%) 3 Total 343 42 410 37

Response No RECIST responses (CR or PR) were seen. Minor response and stable disease was seen in epithelioid sarcoma, liposarcoma and MFH/UPS.

Notch Single Agent: Best response – Duration on study drug TIME ON STUDY RESPONSE 20 months 11 months 5 months

Notch and Hedgehog: Best response – Duration on study drug TIME ON STUDY 6 months

Progression Free Survival Notch + Hedgehog: mPFS: 12 weeks 6 week PFS: 60% Notch alone mPFS: 8.8 wks 6 week PFS: 60%

What can we learn from this study?

De-differentiated Liposarcoma Nov 2012 March 2012 Notch Inhibitor – Single agent

PFS: prior drug vs. study drug 12 months 8 months 3 months

20% tumor shrinkage – 5 months SD Epithelioid Sarcoma 1 20% tumor shrinkage – 5 months SD 2 POD – 1 cycle 3 4 NTRK1 and TET2 mutations

Desmoid : Wnt pathway -- Cross talk between Wnt, Notch and Hedgehog. -- Partial responses with PF-03084014 and OMP54-F28.

Desmoid Tumor: No Responses NOTCH HEDGEHOG + NOTCH

Chondrosarcoma Up-regulation of the Hedgehog pathway 5 pts enrolled: No responses or stable disease.

Chordoma -- gain of 7q – SHH upregulation 4 patients with chordoma enrolled. No responses or stable disease with the Hedgehog inhibitor or Notch inhibitor.

Conclusions The combination of Vismodegib and RO4929097 is well tolerated. Notch and Hedgehog was successfully inhibited in tumor tissues. The study did not meet its PFS endpoint Notch inhibition may have a role in a subset of liposarcoma, epithelioid sarcoma and MFH. Hedgehog/Smoothened inhibitors (GDC-0449 and IPI-926) have not shown meaningful clinical activity in chondrosarcoma (or chordoma). Despite pathway inhibition, lack of responses in desmoid tumor cannot be fully explained.

Acknowledgements MSKCC William Tap Gary Schwartz Mark Dickson Mary Louise Keohan Sandra D’Angelo Richard Carvajal Robert Maki Li-Xuan Qin Joseph Erinjeri Mercedes Condy Yelena Usteyov Lanier Tanner Rita Morales NCI Percy Ivy Naoko Takebe FUNDING Gateway Foundation Siskind Family Fund

Crosstalk between Hedgehog and Notch pathway Smooth GLI2 GLI3 GLI1 Patched Hedgehog Hedgehog Pathway NICD Notch γ-Secretase MAML CSL Notch Pathway Akt Pathway Akt mTOR Hes3 Survival and Growth P

Fibrosarcoma – MFH/UPS

Histology Histology Notch Hedgehog + Notch Liposarcoma 9 10 MFH 5 2 LMS 3 1 Desmoid 4 Epithelioid GIST Chondrosarcoma Chordoma Ewing RMS, Clear cell, DSRCT, Fibrosarcoma, GIST, MPNST, SFT, Synovial Sarcoma, PEComa, Osteosarcoma 7

STS and Notch-4 Sam S. Yoon et. al Angiogenic Profile of Soft Tissue Sarcomas Based on Analysis of Circulating Factors and Microarray Gene Expression Journal of Surgical Research, Volume 135, Issue 2, 2006, 282 - 290

MPNST

Notch inhibition in Liposarcoma Unpublished. Raymond Meng (Schwartz and Singer lab), MSKCC

Notch Inhibition (Ro) and Apoptosis