Università Campus Bio-Medico Daniele Santini Università Campus Bio-Medico Roma

Patients With Bone Metastases From Pca Are at High Risk for Developing SREs Any Pathologic fracture Radiation therapy Surgical intervention Spinal cord compression Patients With SRE, % 24 months Saad F, et al. JNCI. 2002;94(19):1458-1468; Saad F, et al. Eur Urol Suppl. 2007;6(11):683-688. 2 2

Change/Standard Deviation Skeletal Complications Reduce Quality of Life in Prostate Cancer Patients Total Physical Functional Emotional a Change/Standard Deviation a a a a a Change in FACT-G score for patients with an event vs patients without an event a P < .05. Data from Weinfurt KP, et al. Ann Oncol. 2005;16(4):579-584. 3

SREs Are Associated With Lower Survival in Prostate Cancer 360 Days Survival No SRE: 49.7% ≥ 1 SRE: 28.2% P = .02 Median Survival Times No SRE: 338 days (95% CI = 189, 460) ≥ 1 SRE: 248 days (95% CI = 181, 296) No SRE (n = 355) ≥ 1 SRE (n = 116) 1 0.9 0.8 0.7 0.6 Probability 0.5 0.4 0.3 0.2 0.1 90 180 270 360 Survival, days Abbreviations: CI, confidence interval; SRE, skeletal-related event. DePuy V, et al. Support Care Cancer. 2007;15:869-876. 4

FISIOPATOLOGIA DELLA METASTASI ADDENSANTE Osteocalcina ALP TGF-b1 IGF1 TGFb-1 IGF1 TGFb-1 ET1 uPA Wnt DDK-1 >RANKL/<OPG PTHrP IL-6 OPG Bertoldo F, Santini D Textbook of Osteoncology 2010

Molecular states and bone targeted therapies Armamentarium Androgen deprivation therapy Bisphosphonates (CITBL, only for BMD) Denosumab (CITBL, also for fracture rate) Nelson PS, J Clin Oncol, feb 2012

Molecular states and bone targeted therapies Armamentarium Castration-resistant patients Docetaxel (only in metastating setting) Cabazitaxel (in docetaxel-progressing patients) AR inhibitors (MDV3100) (in docetaxel-progressing patients, ASCO 2012) Bisphosphonates (zoledronic acid only in bone metastatic setting) Denosumab (both in bone metastasis prevention and in metastatig setting) Abiraterone (only in metastating setting, after docetaxel) Nelson PS, J Clin Oncol, feb 2012

Target therapies and potential applications in prostate cancer CTIBL Bone met prevention in castration resistant prostate cancer patients SREs in castration resistant metastatic disease

confronto primitivi-metastasi considerando tutti i campioni RANK is expressed by cancer cells both at primary tumor and at bone metastases PRIMITIVI METASTASI PRIMITIVI METASTASI (p= .194) (p= .528) In animal models with intracardiac injection of human MDA-231 breast cancer cells, the ability of OPG to inhibit tumor-induced osteoclastogenesis, and osteolysis was evaluated.1 The injection of MDA-231 breast cancer cells into the left ventricle of nude mice resulted in experimental bone metastases that were associated with osteolytic lesions. Mice were treated with OPG (at the indicated doses, 3 times per week for 4 weeks) starting immediately after tumor cell inoculation. RANK Ligand inhibition with OPG dose-dependently decreased the number and area of radiographically evident lytic bone lesions.1 OPG treatment at the highest doses completely prevented the radiographic appearance of osteolytic lesions (right radiograph). In the animals treated with OPG, note the increased radio-opacity of the tibial and femoral metaphyseal growth plate region associated with OPG treatment. This increase is a normal pharmacological response to OPG treatment by growing mice, whereby resorption of the secondary spongiosa is inhibited, and trabecular bone accumulates. RANK Ligand inhibition was also observed to significantly decrease the number of osteoclasts within the tumor, with a maximal reduction of 90% at 3 mg/kg (P < 0.01). In this model of experimental bone metastases, RANK Ligand inhibition was associated with significant reductions in both the frequency and the size of skeletal tumor nests and in preventing tumor-associated osteolysis.1 Morony S, et al. Osteoprotegerin Inhibits Osteolysis and Decreases Skeletal Tumor Burden in Syngeneic and Nude Mouse Models of Experimental Bone Metastasis. Cancer Res. 2001;61:4432-6. confronto primitivi-metastasi considerando tutti i campioni b. confronto primitivi-metastasi considerando solo le coppie metastasi-tumore d’origine Santini D. J Cell Phys, 2010 9

Prevention of Bone Metastases in PC: Phase III Denosumab Trial (AMG 147) Primary endpoint: Time to development of bone metastasis or death Secondary endpoint: Time to development of bone metastasis (excluding death) R A N D O M I Z T N = 1.435 Prostate cancer (non metastatic) Hormone-refractory disease High risk of bone metastases (PSA at least 8 and/or PSA doubling time less than 10 months Adequate organ function Denosumab 120 mg SC every 4 weeks Placebo Event-driven study: time to bone metastasis or death Smith MR, et al. Lancet. 2012. 10 10 10

Bone metastasis-free survival 1.0 HR = 0.85 (95% CI 0.73, 0.98) P = 0.028 0.8 0.6 Proportion of patients 0.4 0.2 Median months Events Placebo 25.2 370 Denosumab 29.5 335 0.0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 Study month Placebo 716 691 569 500 421 375 345 300 259 215 168 137 99 60 36 Denosumab 695 605 521 456 400 368 324 279 228 185 153 111 59 35 Smith MR, et al. Lancet. 2012.

Bone Metastasis-Free Survival in Patients with PSADT ≤ 6 Months Denosumab 147 Trial HR = 0.77 (95% CI 0.64, 0.93) P = 0.006 23% Risk Reduction Median Months Delay (Months) Events Placebo 18.7 242 7.2 Denosumab 25.9 197 Smith MR, et al. ASCO GU, 2012. 12

Sopravvivenza libera da metastasi ossee in pazienti con PSADT ≤4 mesi F. Saad, ASCO 2012

ZEUS: Zoledronic Acid for Prevention of Bone Metastases in Prostate Cancer Primary endpoint: Time to bone metastases Secondary endpoints: Overall survival, PSA doubling time, substudies on bone markers, adverse events N = 1,433 Prostate cancer, M0 ± previous local curative treatment, ± ADT High-risk PC with ≥ 1 of the following criteria: Gleason Score 8-10 pN+ PSA  20 at diagnosis R Zoledronic acid 4 mg q 3 months No zoledronic acid Treatment duration: 4 years Accrual complete Abbreviations: ADT, androgen-deprivation therapy; PC, prostate cancer; PSA, prostate-specific antigen. 14

Target therapies and potential applications in prostate cancer CTIBL Bone met prevention in castration resistant prostate cancer patients SREs in castration resistant metastatic disease

+ daily oral vitamin D 400 IU and calcium 500 mg Randomized Trial of Zoledronic Acid Versus Placebo in Patients With Prostate Cancer R A N DO M I Z E D n = 214 Zoledronic acid 4 mg q 3 wk + daily oral vitamin D 400 IU and calcium 500 mg n = 208 Placebo q 3 wk + daily oral vitamin D 400 IU and calcium 500 mg 15 months Core analysis1 24 months Final analysis2 1. Saad F, et al. J Natl Cancer Inst. 2002;94:1458-1468. 2. Saad F, et al. J Natl Cancer Inst. 2004;96:879-882.

Risk Ratio (ZOL 4 mg vs Placebo) Zoledronic Acid Reduced the Risk of SREs Regardless of Prior SRE History Risk Reduction P Value Before Study Entry 0.670 No Prior SRE 33% .027 0.603 Prior SRE 40% .028 0.640 Overall Trial Population 36% .002 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Risk Ratio (ZOL 4 mg vs Placebo) In favor of ZOL In favor of placebo Abbreviations: SRE, skeletal-related event; ZOL, zoledronic acid. Adapted from Saad F, et al. Clin Genitourin Cancer. 2007;5(6):390-396. 17 17

Study Design: International, Randomised, Double-Blind, Active-Controlled Study XGEVA™ PI 2010: 9,14 Fizazi K, et al. Lancet 2011;377: 815,Table 1 Key Inclusion Criteria Castration-resistant prostate cancer and 1 bone metastases Key Exclusion Criteria Current or prior IV bisphosphonate treatment N = 950 denosumab 120 mg SC and placebo IV Q4W XGEVA™ PI 2010: 2,2.1 Fizazi K, et al. Lancet 2011;377: 815,A,1 Fizazi K, et al. Lancet 2011;377: 814,B,1-2 Supplemental calcium and vitamin D strongly recommended Fizazi K, et al. Lancet 2011;377: 815,A,2 N = 951 zoledronic acid 4 mg IV* and placebo SC Q4W XGEVA™ PI 2010: 9,14 Fizazi K, et al. Lancet 2011;377: 813,Methods Key Points This was an international, randomized, double-blind, active-controlled trial comparing denosumab with zoledronic acid for the treatment of bone metastases in patients with castration-resistant prostate cancer The primary endpoint was time to first on-study SRE comparing denosumab with zoledronic acid for noninferiority Secondary efficacy endpoints, evaluated only if noninferiority was demonstrated, were superiority tests comparing denosumab and zoledronic acid for time to first on-study SRE and time to first and subsequent SRE(s) (multiple-event analysis) Background Eligible patients were men  18 years old with histologically confirmed prostate cancer and current or prior radiographic evidence of at least one bone metastasis and documented failure of at least 1 hormonal therapy Patients were randomized 1:1 to receive either SC injections of denosumab 120 mg and an IV placebo Q4W, or an IV infusion (lasting no less than 15 minutes) of zoledronic acid 4 mg and an SC injection of placebo Q4W Daily supplementation with calcium and vitamin D was strongly recommended Key exclusion criteria included current or prior IV bisphosphonate or oral bisphosphonate administration to treat bone metastasis References XGEVA™ (denosumab) prescribing information, Amgen. Fizazi K, Carducci M, Smith M, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377:813-822. Primary Endpoint Time to first on-study skeletal-related event (SRE) (noninferiority) Secondary Endpoints Time to first on-study SRE (superiority) Time to first and subsequent on-study SRE(s) (superiority) Fizazi K, et al. Lancet 2011;377: 815,A,2 XGEVA™ PI 2010: 9,14 Fizazi K, et al. Lancet 2011;377: 814,A,2;B,1 Fizazi K, et al. Lancet 2011;377: 814,B,5; 815,A,1 Fizazi K, et al. Lancet. 2011;377:813–822. XGEVA™ PI 2010: 2,2.1 Fizazi K, et al. Lancet 2011;377: 815,A,1 XGEVA™ PI 2010: 3,6.1 Fizazi K, et al. Lancet 2011;377: 814,B,1-2 18

Baseline Characteristics Denosumab (N = 950) Zoledronic Acid (N = 951) Median age, years (IQR) 71 (64–77) 71 (66–77) ECOG performance status of 0 or 1, n (%) 882 (93) 886 (93) Stratification Factors PSA at randomisation  10 g/L, n (%) 805 (85) 806 (85) Recent chemotherapy ( 6 weeks before randomisation), n (%) 132 (14) Previous SRE, n (%) 232 (24) 231 (24) Median time from diagnosis of bone metastasis to randomisation, months (IQR) 3.94 (1.22–15.67) 5.19 (1.31–16.10) Fizazi K, et al. Lancet 2011;377: 815,Table 1 Key Points A total of 1901 patients were randomized to receive denosumab (n = 950) or zoledronic acid (n = 951) Baseline age, race, and ECOG performance status variables were balanced between groups Background Randomization was stratified by previous SRE, PSA level ( 10 g/L vs  10 g/L), and chemotherapy for prostate cancer within 6 weeks before randomization Patients in the zoledronic acid arm had a slightly longer median time from bone metastases diagnosis to study randomization (denosumab, 3.94 months; zoledronic acid, 5.19 months) although the quartiles were similar Reference Fizazi K, Carducci M, Smith M, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377:813-822. Fizazi K, et al. Lancet 2011;377: 815,Table 1 Fizazi K, et al. Lancet. 2011;377:813–822. 19

Primary Endpoint: Time to First On-Study SRE XGEVA™ PI, 2010: 11,Table 2 Fizazi K, et al. Lancet 2011;377: 816,Figure 2 HR = 0.82 (95% CI, 0.71–0.95) P  0.001 (noninferiority) P = 0.008 (superiority) 1.00 0.75 Proportion of Subjects Without SRE 0.50 Kaplan-Meier Estimate of Median Months 0.25 Key Points Denosumab significantly delayed the time to first on-study SRE by 18% compared with zoledronic acid (HR = 0.82; 95% CI, 0.71–0.95; P  .001 for noninferiority and P = .008 for superiority)1 The median (95% CI) time to first on-study SRE was 20.7 months in the denosumab group and 17.1 months in the zoledronic acid group, a difference of 3.6 months1 Between-group divergence is evident beginning at 3 months after initiation of treatment2 References XGEVA™ (denosumab) prescribing information, Amgen. Fizazi K, Carducci M, Smith M, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377:813-822. Denosumab Zoledronic acid 20.7 XGEVA™ PI, 2010: 11,Table 2 17.1 0.00 Fizazi K, et al. Lancet 2011;377: 816,Figure 2 3 6 9 12 15 18 21 24 27 Study Month Patients at Risk: Zoledronic acid 951 733 544 407 299 207 140 93 64 47 Denosumab 950 758 582 472 361 259 168 115 70 39 Fizazi K, et al. Lancet. 2011;377:813–822. 20

Cumulative Mean Number of SREs per Patient Secondary Endpoint: Time to First and Subsequent On-Study SRE(s) (Multiple-Event Analysis) XGEVA™ PI, 2010: 11,Table 2 Fizazi K, et al. Lancet 2011;377: 816,Figure 3 2.0 Rate ratio = 0.82 (95% CI, 0.71–0.94) P = 0.009 (superiority) 1.8 1.6 1.4 1.2 Cumulative Mean Number of SREs per Patient 1.0 0.8 0.6 Key Points Denosumab significantly delayed the time to first and subsequent on-study SREs (rate ratio = 0.82; 95% CI, 0.71–0.94; adjusted P = .009)1 A total of 1078 events occurred, 494 in the denosumab treatment group, and 584 in the zoledronic acid treatment group2 References XGEVA™ (denosumab) prescribing information, Amgen. Fizazi K, Carducci M, Smith M, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377:813-822. XGEVA™ PI, 2010: 11,Table 2 Events 0.4 Denosumab 494 Fizazi K, et al. Lancet 2011;377: 816,Figure 3 0.2 Zoledronic acid 584 0.0 3 6 9 12 15 18 21 24 27 30 33 36 Study Month Fizazi K, et al. Lancet. 2011;377:813–822. 21

Exploratory Endpoint: Overall Survival Fizazi K, et al. Lancet 2011;377: 817,Figure 4,A HR = 1.03 (95% CI, 0.91–1.17) P = 0.65 1.00 0.75 Proportion of Patients Survived 0.50 0.25 Fizazi K, et al. Lancet 2011;377: 817,Figure 4,A Key Points Overall survival (HR = 1.03; 95% CI, 0.91–1.17; P = .65) was similar between study groups1 Overall survival and progression-free survival were similar between arms in all three trials1 Mortality was higher with denosumab in a subgroup analysis of patients with multiple myeloma (HR = 2.26; 95% CI, 1.13–4.50; n = 180)2 References Fizazi K, Carducci M, Smith M, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377:813-822. XGEVA™ (denosumab) prescribing information, Amgen. Denosumab Zoledronic acid XGEVA™ PI, 2010: 10-14 0.00 3 6 9 12 15 18 21 24 27 30 Study Month Patients at Risk: Zoledronic acid 951 864 745 635 519 401 297 207 143 98 Denosumab 950 872 746 645 552 427 310 233 156 99 55 54 Fizazi K, et al. Lancet. 2011;377:813–822. 22

Summary of Adverse Events Patient Incidence Denosumab (N = 943) n (%) Zoledronic Acid (N = 945) n (%) Infectious AEs 402 (43) 375 (40) Acute phase reactions (first 3 days) 79 (8) 168 (18) Renal AEs 139 (15) 153 (16) Cumulative rate of osteonecrosis of the jaw (ONJ)‡ 22 (2) 12 (1) Year 1 10 (1) 5 (1) Year 2 8 (1) Hypocalcaemia 121 (13) 55 (6) New primary malignancy 18 (2) Fizazi K, et al. Lancet 2011;377: 818,Table 4 Fizazi K, et al. Lancet 2011;377: 819,A,3 Fizazi K, et al. Lancet 2011;377: 818,Table 4 Key Point The incidence of AEs of interest was similar between the two study treatment groups Background During the first 3 days of treatment, AEs potentially associated with acute phase reactions occurred in 8% of denosumab and 18% of zoledronic acid patients AEs potentially associated with renal impairment occurred in 15% of the denosumab group and 16% of the zoledronic acid group Positively adjudicated ONJ occurred in 22 (2%) patients in the denosumab group and 12 (1%) patients in the zoledronic acid group (P = .09) AEs of hypocalcemia were reported in 121 (13%) patients in the denosumab group and 55 (6%) patients in the zoledronic acid group New primary malignancies were identified in 18 (2%) patients in the denosumab group and 10 (1%) patients in the zoledronic acid group Reference Fizazi K, Carducci M, Smith M, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377:813-822. Fizazi K, et al. Lancet 2011;377: 819,A,3 Fizazi K, et al. Lancet 2011;377: 818,Table 4 ‡P = 0.09 Fizazi K, et al. Lancet. 2011;377:813–822. 23

Skeletal Complication Risk: Incremental Benefits in Prostate Cancer Zoledronic ~ 20% risk reduction No bisphosphonate 49% risk at 2 yrs Denosumab Additional 18% time to first SRE increase Denosumab Additional ~ 12% risk reduction + Saad F, JNCI, 2004, Fizazi K, Lancet, 2011 24

Bone targeted therapies nella neoplasia prostatica metastatica - Aggiornamento 2012 - L’acido zoledronico si è dimostrato efficace nel ridurre le complicanze scheletriche di pazienti con metastasi ossee da carcinoma prostatico (Livello di evidenza 1++; positiva forte) Il denosumab non è inferiore all’acido zoledronico in termini di tempo al primo SRE Il denosumab è superiore all’acido zoledronico in termini di tempo al primo SRE e di tempo al primo e ai successivi SRE (Livello di evidenza 1-; positiva debole) Safety: L’incidenza di ONJ durante il trattamento con denosumab è almeno pari a quella riscontratta durante il trattamento con acido zoledronico

Effect of Abiraterone Acetate on Pain Control and Skeletal-Related Events in Patients With Metastatic Castration-Resistant Prostate Cancer Post Docetaxel: Results From The COU-AA-301 Phase 3 Study C. Logothetis, J. S. de Bono, A. Molina, E. M. Basch, K. Fizazi, S. North, K. N. Chi, R. J. Jones, O. B. Goodman, P. N. Mainwaring, C. N. Sternberg, D. D. Gagnon, R. Dhawan, M. Rothman, Y. Hao, C. S. Liu, T. S. Kheoh, H. I. Scher, and C. M. Haqq Logothetis et al. JCO 2011; 29 (Suppl): Abst4520 (oral)

Meccanismo azione abiraterone Gli androgeni che stimolano la proliferazione tumorale sono prodotti in tre siti critici: Testicoli Ghiandola surrenale Cellule tumorali prostatiche Abiraterone inibisce la sintesi degli androgeni in tutti e tre i siti Testosteronemia < 1ng/dl Cholesterol Desmolase Deoxy- corticosterone Pregnenolone Progesterone Corticosterone Aldosterone X CYP17 17α-hydroxylase 17α-OH- pregnenolone 17α –OH- progesterone 11-Deoxy- cortisol Cortisol ACTH CYP17 C17,20-lyase 5α-reductase DHEA Androstenedione Testosterone DHT Abiraterone Yang, Drugs. 2011; Attard, JCO 2008

Baseline, Cycle 1 (Day 15), subsequent treatment cycles (Day 1) Overall Study Design R A N D O M I Z E D Efficacy end points AA 1000 mg daily Prednisone 5 mg BID n = 797 Primary end point: OS Secondary end points: PSA response rPFS Tertiary end points: Pain SREs Patients (N = 1195) Placebo daily Prednisone 5 mg BID n = 398 This was a Phase 3, multinational, multicenter, randomized, double-blind, placebo-controlled study conducted at 147 sites in the United States/Europe/Australia/Canada comparing the efficacy and safety of AA plus prednisone with placebo plus prednisone in men with metastatic CRPC who had failed 1 or 2 chemotherapy regimens, one of which contained docetaxel Patients were randomized in a 2:1 ratio and were stratified according to ECOG performance status (0-1 vs. 2), worst pain over the past 24 hours on the Brief Pain Inventory (BPI)-Short Form (0-3 [absent] vs. 4-10 [present]), prior chemotherapy regimens (1 vs. 2), and type of progression (PSA only vs. radiographic progression with or without PSA progression). Patients could receive treatment until documented disease progression (of all 3 types including 1) PSA progression, 2) radiographic progression and 3) symptomatic or clinical progression) or unacceptable toxicity Efficacy analysis set: ITT (intent-to-treat) Primary efficacy endpoint: Overall survival (OS) Important secondary efficacy endpoints: prostate‑specific antigen (PSA) response rate, radiographic progression-free survival (rPFS). Note: All analyses presented here are based on the interim data of this study! (Recently published in NEJM) BPI questionnaire Baseline, Cycle 1 (Day 15), subsequent treatment cycles (Day 1) de Bono et al. NEJM 2011 28 28

Symptomatic Improvement - Pain Intensity Palliation 155/349 (44.4%) 44/163 (27.0%) This figure compares improvement in patient reported pain intensity (based on the single item of the BPI questionnaire called "worst pain over the last 24 hours”) between AA and placebo Shown is the proportion of patients in both study arms who experienced clinically meaningful palliation (for at least 2 cycles, as per prospective definitions) at any time during the study Not shown: The cumulative proportion of patients with a change (vs baseline) in pain intensity was consistently in favor of AA. (See backup slide.)

Results AA (n = 797) Placebo (n = 398) P Value Overall survival Median, months 14.8 10.9 < 0.0001 PSA response rate Total 38.0% 10.1% Confirmed 29.1% 5.5% Radiographic PFS 5.6 3.6 Time to first SRE (pathologic fracture/spinal cord compression/ palliative radiation/bone surgery) 25th percentile, days 301.0 150.0 SRE defined as: pathological fracture, spinal cord compression, palliative radiation to bone, or bone surgery Convergence between additional outcomes and Pain/SRE data: AA not only delayed pain progression, but also provided pain palliation, associated with delayed time to SRE, increased overall survival, and greater progression free survival Logothetis et al. JCO 2011; 29 (Suppl): Abst4520 (oral)

JS De Bono, ASCO, 2012

JS De Bono, ASCO, 2012

JS De Bono, ASCO, 2012

JS De Bono, ASCO, 2012

Molecular states and bone targeted therapies Armamentarium No standard drugs Src inhibitors (dasatinib, saracatinib)? Endothelin RA inhibitors (atresartan, zibotentan)? Anti-HER2/neu? Inhibitor of MET and VEGFR2 (cabozantinib)? AR inhibitors (MDV3100)? Bisphosphonates (problably) Denosumab (strong biological rational – src in a down stream gene of rank- rank is expressed also in prostate cancer cells) Denosumab works also in patients without NTX suppression during zoledronic acid Nelson PS, J Clin Oncol, feb 2012

Overview: bone health and target molecules Src inhibitors (Saracatinib, Dasatinib) Overview delle nuove molecole target nel controllo dellabone health. E pertanto Parlerò

Src knockout mice are osteopetrotic5 Evidence for a Role of Src in Bone Metabolism and Metastatic Bone Disease Src kinase is a nonreceptor tyrosine kinase, highly expressed in normal osteoclasts1,2 Src plays an essential role in RANKL-mediated osteoclast activation3 and perhaps survival4 Src knockout mice are osteopetrotic5 Src may be critical for tumor cell survival in bone microenvironment6 1. Horne WC, et al. J Cell Biol. 1992;119(4):1003-1013; 2. Tanaka S, et al. FEBS Lett. 1992;313(1):85-89; 3. Boyce BF, et al. J Clin Invest. 1992;90(4):1622-1627; 4. Wong BR, et al. Mol Cell. 1999;4(6):1041-1049; 5. Lowe C, et al. Proc Natl Acad Sci U S A. 1993;90(10):4485-4489; 6. Zhang XH, et al. Cancer Cell. 2009;16(1):67-78. 37

Role of Src in Prostate Tumor Cell and Osteoclast Activities Tumor cells Src Systemic factors Local factors Direct bone destruction Osteoclast activity Growth factors Src The Src kinase pathway is important both in the cancer cell growth as well as in bone activity. Activated osteoclast Osteolysis Src Bone Bone complications 38

Direct bone destruction Dasatinib in PC: Inhibition of Tumor Cells and Osteoclast Activity Through Src Tumor cells Src Dasatinib Systemic factors Local factors Direct bone destruction Osteoclast activity Src Growth factors Dasatinib, a small-molecule Src tyrosine kinase inhibitor, should have some efficacy in both tumor cells and osteoclasts. Osteolysis Dasatinib Bone 39

Phase III study: READY (ongoing) (metastatic hormonorefractory prostate cancer patients) Doc + P vs Doc + P + DASATINIB Preliminary results: 4.8 months OS improvement with the combination Longer PFS with the combination Median time to SRE longer (7.5 vs. 6.0 months)

Abstract 4513 Cabozantinib (XL184) in chemotherapy-pretreated metastatic castration resistant prostate cancer (mCRPC): Results from a phase II nonrandomized expansion cohort (NRE). Autori, Matthew Raymond Smith, Christopher Sweeney, Dana E. Rathkopf, Howard I. Scher, Christopher Logothetis, Daniel J. George, Celestia S. Higano, Evan Y. Yu, Andrea Lynne Harzstark, Eric Jay Small, A. Oliver Sartor, Michael S. Gordon, Nicholas J. Vogelzang, David C. Smith, Maha Hussain, Johann Sebastian De Bono, Naomi B. Haas, Christian Scheffold, Yihua Lee, Paul G. Corn; ASCO 2012

Risposta sulle lesioni ossee (revisione indipendente)

Molecular states and bone targeted therapies Armamentarium No standard drugs Src inhibitors (dasatinib, saracatinib)? Endothelin RA inhibitors (atresartan, zibotentan)? Anti-HER2/neu? Octreotide? Pasireotide? TKIs? Inhibitor of MET and VEGFR2 (cabozantinib)? Bisphosphonates (problably) Denosumab (strong biological rational – src in a down stream gene of rank- rank is expressed also in prostate cancer cells) Denosumab works also in patients without NTX suppression during zoledronic acid Nelson PS, J Clin Oncol, feb 2012

…. and how to place radium-223 ? Abstract LBA4512 Updated analysis of the phase III, double-blind, randomized, multinational study of radium-223 chloride in castration-resistant prostate cancer (CRPC) patients with bone metastases (ALSYMPCA). Autori, Chris Parker, Sten Nilsson, Daniel Heinrich, Joe M. O'Sullivan, Sophie D. Fossa, Ales Chodacki, Pawel J. Wiechno, John P. Logue, Mihalj Seke, Anders Widmark, Dag Clement Johannessen, Peter Hoskin, David Bottomley, Robert Edward Coleman, Nicholas J. Vogelzang, C. Gillies O'Bryan-Tear, Jose E. Garcia-Vargas, Minghua Shan, A. Oliver Sartor; TLA C Parker et al, ASCO, 2012

Disegno dello studio A.O. Sartor et al, ASCO GU, 2012

Analisi aggiornata della sopravvivenza globale C Parker et al, ASCO, 2012

Analisi aggiornata del tempo allo sviluppo del primo evento scheletrico C Parker et al, ASCO, 2012

Nuovi farmaci per nuovi e vecchi Target Santini D et al. Cancer Treat Reviews, 2010

Thank you very much for your attention d.santini@unicampus.it