Medical Oncology Department University Hospital Perugia, Italy Targeting angiogenesis in Lung cancer Lucio Crinò, MD Medical Oncology Department University Hospital Perugia, Italy

VEGF: Targeted Approaches Vandetanib Sorafenib Nindetanib Ramucirumab Bevacizumab Aflibercept Antireceptor blocking antibodies Tyrosine kinase inhibitors Antiligand blocking Antibodies and VEGF-TRAP Adapted from Noonberg SB, et al. Drugs. 2000;59:753-767.

Outline Antiangiogenic agents in the first-line setting Bevacizumab Recently completed randomised trials Multi-targeted antiangiogenic orally administered TKIs Vascular disrupting agents Antiangiogenic agents in a relapsed/refractory setting Recently completed randomised trials Multi-targeted antiangiogenic orally administered TKIs Nindetanib Monoclonal antibodies and decoy receptors Vascular disrupting agents Other investigational agents Ramucirumab

Phase III Trials of Bevacizumab combined with P-based CT in NSCLC E4599 (US) CP (n=444) PD* Previously untreated stage IIIB/IV non-squamous NSCLC (n=878) Bevacizumab 15mg/kg† + CP (n=434) Bevacizumab PD Bevacizumab 7.5mg/kg† + CG (n=345) Bevacizumab AVAiL (Ex-US) PD Previously untreated, stage IIIB, IV or recurrent non-squamous NSCLC (n=1.043) Placebo + CG (n=347) PD* Bevacizumab 15mg/kg† + CG (n=351) Bevacizumab PD *No cross over permitted; †Dose of Avastin every 3 weeks NSCLC = non-small cell lung cancer CP = carboplatin/paclitaxel; PD = progressive disease CG = cisplatin/gemcitabine

E4599: Improvement in OS HR=0.79 (0.67–0.92); P = 0.003 10.3 12.3 1.0 Months Survival (%) 12 months 24 months CP + bevacizumab 51 23 CP 44 15 1.0 0.8 0.6 0.4 0.2 0 6 12 18 24 30 36 42 48 Probability 10.3 12.3 Sandler A et al. New Engl J Med 2006;355:2542–2550 5 5

AVAiL: Bevacizumab significantly prolongs PFS (primary endpoint) 1.0 0.8 0.6 0.4 0.2 Placebo + CG Bev 7.5mg/kg + CG Bev 15mg/kg + CG HR (95% CI) 0.75 (0.64–0.87) 0.85 (0.73–1.00) p value 0.0003 0.0456 Median PFS (months) 6.2 6.8 6.6 Probability of PFS 0 6 12 18 24 30 No. at risk Time (months) Placebo + CG 347 178 34 12 3 0 345 214 63 18 5 0 351 200 57 12 0 0 Bev 7.5mg/kg + CG Bev 15mg/kg + CG Reck M JCO 2009;27.1227-1234 6 6

AVAiL: no significant benefit in OS* (secondary endpoint) Placebo + CG Bev 7.5mg/kg + CG Bev 15mg/kg + CG 1.0 0.8 0.6 0.4 0.2 HR (95% CI) 0.93 (0.78–1.11) 1.03 (0.86–1.23) p value 0.42 0.76 Median OS (months) 13.1 13.6 13.4 Probability of OS 0 6 12 18 24 30 36 Time (months) 347 272 182 100 36 3 0 345 286 182 107 34 3 0 351 264 177 92 33 2 0 Placebo + CG Bev 7.5mg/kg + CG No. at risk Bev 15mg/kg + CG Reck M, Ann Oncol 2010;21:1804-1809 7

Meta-analysis of OS Meta-analysis of PFS Soriat JC et al. Ann Oncol. 2013 Jan;24(1):20-30.

…roughly 4000 “real life” pts !! Two phase IV studies investigated the safety of the combination of bevacizumab and chemotherapy as first-line …roughly 4000 “real life” pts !! Crino L, et al. Lancet Oncol.11(8),733–740 (2010). Wozniak AJ, et al .J. Clin. Oncol.28(7s), (2010)

Main grade ≥3 AE of Phase III and IV trials of bevacizumab + platinum-based first-line CHT for stage IV non-squamous NSCLC

Comparison of the results of Phase III and IV trials of bevacizumab + platinum-based first-line CHT for stage IV non-squamous NSCLC : OS

Comparison of the results of Phase III and IV trials of bevacizumab + platinum-based first-line CHT for stage IV non-squamous NSCLC : PFS

Outline Other investigational agents Antiangiogenic agents in the first-line setting Bevacizumab Recently completed randomised trials Multi-targeted antiangiogenic orally administered TKIs Vascular disrupting agents Antiangiogenic agents in a relapsed/refractory setting Recently completed randomised trials Multi-targeted antiangiogenic orally administered TKIs Nindetanib Monoclonal antibodies and decoy receptors Vascular disrupting agents Other investigational agents Ramucirumab

VEGFR-TKIs in Development in NSCLC Vandetanib EGFR/VEGFR/RET-TKI Phase III First line/refractory Sorafenib VEGFR-TKI Sunitinib Refractory Cediranib First line Motesanib Nindetanib Pazopanib Maintenance/refractory Linifanib Phase II Axitinib Tivozanib ClinicalTrials.gov.

Reported Potencies of Selected Molecules Targeting VEGFRs 1,000 VEGFR-1 Less potent VEGFR-2 VEGFR-3 100 10 More potent 1 Motesanib (AMG-706) Sunitinib ABT-869 Pazopanib Sorafenib Vatalanib (PTK787) Vandetanib (ZD6474) Cediranib (AZD-2171) Axitinib (AG13736) 0.1 Tivozanib (AV-951) Chow, JCO 2007 Eskens, Proceedings of the 99th Annual Meeting of the AACR 2008

ESCAPE: Phase III Trial of Carboplatin and Paclitaxel ± Sorafenib Stratified by region, ECOG PS (0 vs 1), squamous vs nonsquamous, stage (IIIB wet vs IV) CPS Carboplatin AUC 6 Day 1 + Paclitaxel 200 mg/m2 Day 1 + Sorafenib 400 mg BID Days 2-19 q3w Sorafenib 400 mg BID Patients with stage IIIb/IV NSCLC and no previous CHT (N = 926) CPP Carboplatin AUC 6 Day 1 + Paclitaxel 200 mg/m2 Day 1 + Placebo Days 2-19 q3w Placebo There was no significant improvement in PFS (4.6 vs 5.4 mos; p=0.43) or OS (10.7 vs 10.6 mos; p=0.13) Scagliotti G, et al. J Clin Oncol. 2010;28:1835-1842.

Outline Other investigational agents Antiangiogenic agents in the first-line setting Bevacizumab Recently completed randomised trials Multi-targeted antiangiogenic orally administered TKIs Vascular disrupting agents Antiangiogenic agents in a relapsed/refractory setting Recently completed randomised trials Multi-targeted antiangiogenic orally administered TKIs Nindetanib Vandetanib Monoclonal antibodies and decoy receptors Vascular disrupting agents Other investigational agents Ramucirumab

Nintedanib: mechanism of action Nintedanib is a triple angiokinase inhibitor which targets three classes of receptors critical for the formation and maintenance of tumour blood vessels: VEGFR, PDGFR and FGFR* VEGFR 1 / 2 / 3 PDGFR a / b FGFR IC50 [nM] 34 / 21 / 13 59 / 65 69 / 37 / 108 IGF1R, InsR EGFR, HER2, CDK1, CDK2, CDK4 IC50 [nM] >1000, <10000 >50000 Nintedanib è sottoposto a sperimentazione clinica *Hilberg F, et al. Cancer Res, June 15, 2008; 68: (12) :4774–4782

Oral nintedanib* 200 mg twice daily Oral Placebo twice daily LUME-Lung 1 Patients with stage IIIB/IV or recurrent NSCLC (all histologies) after failure of first-line chemotherapy N=1,300 1:1 Randomization Oral nintedanib* 200 mg twice daily + Docetaxel x n cycles Oral Placebo twice daily + Docetaxel x n cycles NINDETANIB MAINTENANCE** Primary endpoint: PFS Secondary endpoints: OS; RR according to modified RECIST criteria; clinical improvement; AEs (according to CTCAE version 3.0); changes in safety laboratory parameters; QoL M. Reck et al, the Lancet Oncology 2014;15:143-55

Primary Endpoint: PFS Independent Central Review in All Patients 100 Nintedanib + docetaxel Placebo + docetaxel Median, mo 3.4 2.7 HR (95% CI) 0.79 (0.68 to 0.92) p-value 0.0019 80 60 Probability of progression free survival (%) 40 20 0 2 4 6 8 10 12 14 16 18 Time (months) No. at risk Nintedanib 565 295 155 57 19 4 3 1 0 Placebo 569 250 116 43 21 2 1 0 0

PFS Independent Central Review in Major Histologies Adenocarcinoma Squamous Cell Carcinoma 100 100 Nintedanib + docetaxel Placebo + docetaxel Median, mo 4.0 2.8 HR (95% CI) 0.77 (0.62 to 0.96) p-value 0.0193 Nintedanib + docetaxel Placebo + docetaxel Median, mo 2.9 2.6 HR (95% CI) 0.77 (0.62 to 0.96) p-value 0.0200 80 80 60 60 Probability of progression free survival (%) Probability of progression free survival (%) 40 40 20 20 0 2 4 6 8 10 12 14 16 0 2 4 6 8 10 12 14 16 Time (months) Time (months) No. at risk Nintedanib 240 122 59 22 5 3 2 1 0 Placebo 247 101 36 13 8 1 0 0 0 No. at risk Nintedanib 277 150 86 32 13 1 1 0 Placebo 285 129 70 288 12 1 1 0

Overall Survival Patients with Adenocarcinoma Histology 100 Nintedanib + docetaxel Placebo + docetaxel Median, mo 12.6 10.3 HR (95% CI) 0.83 (0.70 to 0.99) p-value 0.0359 80 60 52.7% Feb 2013, 535 events Probability of survival (%) 40 25.7% 44.7% 20 19.1% 0 4 8 12 16 20 24 28 32 36 Time (months) No. at risk Nintedanib 322 263 203 163 131 96 72 46 25 10 Placebo 336 269 184 139 101 73 55 33 15 7 OS Adeno T<9mo OS Adeno OS All pts

Nintedanib + docetaxel Probability of survival (%) OS: Patients with Adenocarcinoma and Time Since Start of 1st Line Therapy <9mo 100 Nintedanib + docetaxel Placebo + docetaxel Median, mo 10.9 7.9 HR (95% CI) 0.75 (0.60 to 0.92) p-value 0.0073 80 60 Feb 2013, 345 events Probability of survival (%) 44.7% 40 17.0% 20 31.2% 8.5% 0 2 4 6 8 10 12 14 16 18 Time (months) No. at risk Nintedanib 206 167 119 92 73 51 35 16 9 3 Placebo 199 154 91 62 42 25 17 12 5 1 OS Adeno T<9mo OS Adeno OS All pts

Safety in All Treated Patients Summary of Adverse Events (AEs) Patients with AE, n (%) Nintedanib + docetaxel (n=652) Placebo + docetaxel (n=655) Any AE, all grades 610 (93.6) 609 (93.0) Drug-related AE, all grades 498 (76.4) 446 (68.1) Any AE, grades ≥3 465 (71.3) 421 (64.3) Drug-related AE, grades ≥3 331 (50.8) 275 (42.0) Any AE leading to discontinuation 148 (22.7) 142 (21.7) Any serious AE 224 (34.4) 206 (31.5) Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 was used The most common adverse events were diarrhoea (42.3% versus 21.8%) and reversible ALT and AST elevations (28.5% versus 8.4%).

All CTCAE grades (%) ≥15% incidence CTCAE grades ≥3 (%) ≥1% incidence Safety in All Treated Patients Most Frequent AEs, All Grades and Grades ≥3 All CTCAE grades (%) ≥15% incidence CTCAE grades ≥3 (%) ≥1% incidence 50 50 45 45 Nintedanib + docetaxel Placebo + docetaxel 40 40 35 35 30 30 Patients (%) 25 25 20 20 15 15 10 10 5 5 Diarrhea Fatigue Nausea Dyspnea Cough Vomiting Alopecia Pyrexia Diarrhea Fatigue Dyspnea Asthenia Constipation Pneumonia Chest pain ALT increased AST increased ALT increased AST increased Appetite decreased Appetite decreased Decreased neutrophils Decreased neutrophils

Safety in All Treated Patients AEs Frequently Observed with VEGF/VEGFR Inhibitors All CTCAE grades (%) CTCAE grades ≥3 (%) 25 25 Nintedanib + docetaxel Placebo + docetaxel 20 20 15 14.1 15 11.6 Patients (%) 10 10 5.1 5 4.6 3.5 5 2.8 3.1 2.3 2.1 1.5 1.4 1.8 0.5 0.5 0.6 0.9 0.5 1.2 1.1 0.2 0.5 0.6 0.6 0.2 VTE ATE VTE ATE Bleeding Bleeding GI perforation Hypertension GI perforation Hypertension Thromboembolism Thromboembolism VTE, venous thromboembolism; ATE, arterial thromboembolism

LUME-Lung 2 (planned n 1111 non-squamous NSCLC) nintedanib (200 mg twice daily; day 2–21) plus pemetrexed (500 mg/m2 every 21 days) vs pemetrexed alone Recruitment was halted early (n 713 pts) based on a pre- planned futility analysis of investigator-assessed PFS by an independent data monitoring committee although no safety concerns were raised. Subsequent analysis showed that the primary end-point of centrally reviewed PFS was met . Nintedanib plus pemetrexed significantly improved PFS (HR 0.83, 95% CI 0.70–99; 4.4 vs 3.6 mos; p=0.04), but not OS, vs pemetrexed alone. T he incidence of G3 hypertension, bleeding and thromboembolism was similar between treatment arms. Hanna et al. J Clin Oncol 2013; 31: 8034.

Outline Other investigational agents Ramucirumab Antiangiogenic agents in the first-line setting Bevacizumab Recently completed randomised trials Multi-targeted antiangiogenic orally administered TKIs Vascular disrupting agents Antiangiogenic agents in a relapsed/refractory setting Recently completed randomised trials Multi-targeted antiangiogenic orally administered TKIs Nindetanib Monoclonal antibodies and decoy receptors Vascular disrupting agents Other investigational agents Ramucirumab

Ramucirumab (IMC-1121B) Ramucirumab is a fully human IgG1 monoclonal antibody that binds with high affinity to human VEGFR-2 (Kd ~ 50 pM)1 Ramucirumab is specific for the human VEGFR-2 receptor2 Ramucirumab potently blocks binding of VEGF-A to VEGFR-2 (IC50 = 0.8 nM)1 Ramucirumab blocks binding of VEGF-C and VEGF-D to VEGFR-23 Lu et al. J Biol Chem 2003;278(44):43496-507. Data on file, ImClone Systems, a wholly-owned subsidiary of Eli Lilly and Company.

Treatment until disease progression or unacceptable toxicity REVEL: Study Design 1:1 R A N D O M I Z E Ramucirumab 10 mg/kg + Docetaxel 75 mg/m2 q3wks N=628 Stage IV NSCLC after one platinum- based chemo +/- maintenance Prior Bev allowed All histologies PS 0 or 1 Treatment until disease progression or unacceptable toxicity Placebo + Docetaxel 75 mg/m2 q3wks N=625 Stratification factors: ECOG PS 0 vs 1 Gender Prior maintenance East-Asia vs. ROW Primary endpoint: Overall Survival Secondary endpoints: PFS, ORR, safety, patient-reported outcomes Abbreviations: Bev=bevacizumab; ECOG PS=Eastern Cooperative Oncology Group performance status; ORR=objective response rate; PFS=progression-free survival; ROW=rest of the world; q3wks=every 3 weeks.

Tumor Response by RECIST v1.1 ITT Population, Investigator Assessment RAM+DOC N=628 PL+DOC N=625 P-value Response, n (%) CR 3 (0.5) 2 (0.3) PR 141 (22.5) 83 (13.3) SD 258 (41.1) 244 (39.0) PD 128 (20.4) 206 (33.0) Unknown/not assessed 98 (15.6) 90 (14.4) ORR (CR+PR), % (95% CI) 22.9 (19.7-26.4) 13.6 (11.0-16.5) <.001 DCR (CR+PR+SD), % (95% CI) 64.0 (60.1-67.8) 52.6 (48.6-56.6 ) Abbreviations: CI=confidence interval; CR=complete response; DCR=disease control rate; ITT=intention-to-treat; ORR=objective response rate; PD=progressive disease; PR=partial response; RECIST=Response Evaluation Criteria in Solid Tumors; SD=stable disease.

Progression-Free Survival ITT Population, Investigator Assessment RAM+DOC PL+DOC Number at risk Censored 3 6 9 12 15 18 21 24 27 30 33 383 301 204 172 120 95 59 37 38 17 11 7 4 2 36 Survival Time (months) 628 625 20 40 60 80 100 Median (95% CI) Censoring Rate RAM+DOC vs PL+DOC: 4.5 (4.2-5.4) 11.1% 3.0 (2.8-3.9) 6.7% Stratified HR (95% CI) = 0.762 (0.677-0.859) Stratified log-rank P < .0001 RAM+DOC PL+DOC

Forest Plot of PFS by Subgroups Unstratified Analysis Category Subgroup RAM+DOC, n PL+DOC, n Unstratified HR Geographic region ROW 585 579 0.78 East Asia 43 46 0.68 Sex Male 419 415 0.79 Female 209 210 0.74 Age, years 127 125 0.94 ≥70 <70 501 500 0.73 ECOG PS 1 420 425 0.79 207 199 0.74 Smoking history Never 109 141 0.81 Ever 518 483 0.76 Best response to platinum PD 178 182 0.71 CR/PR/SD 420 417 0.80 No 475 476 0.74 Prior taxane Yes 153 149 0.90 No 540 533 0.77 Prior bevacizumab Yes 88 92 0.83 No 493 482 0.79 Prior maintenance Yes 135 143 0.74 Histology Squamous 157 171 0.76 Nonsquamous 465 447 0.77 0.3 0.6 1.0 1.6 2.7 4.5 Favors RAM+DOC Favors PL+DOC

Overall Survival ITT Population 20 40 60 80 100 Overall Survival (%) RAM+DOC PL+DOC Number at risk 3 6 9 12 15 18 21 24 27 30 33 527 501 415 386 329 306 231 197 156 129 103 86 70 56 45 36 23 11 2 Survival Time (months) 628 625 Censored Median (95% CI) Censoring Rate RAM+DOC RAM+DOC vs PL+DOC: 10.5 (9.5-11.2) 31.8% PL+DOC 9.1 (8.4-10.0) 27.0% Stratified HR (95% CI) = 0.857 (0.751-0.979) Stratified log-rank P = .0235

REVEL: Conclusions REVEL met its primary endpoint of OS improvement. RAM+DOC showed statistically significant improvement in PFS and ORR compared to PL+DOC. OS and PFS improvement were consistent in most major subgroups, including squamous and nonsquamous histology. The addition of RAM to DOC did not result in an increase of SAEs and AEs leading to death. Safety profile was as expected for an anti-VEGFR agent in combination with DOC. REVEL is the first study showing that addition of a novel agent to standard chemotherapy improves survival in stage IV NSCLC patients with progression after platinum-based chemotherapy.

Predictive markers antiangiogenic agents Imaging PET Dynamic Contrast enhanced (DCE) MRI Alternative RECIST criteria Physiologic: hypertension Circulating endothelial cells VEGF polymorphisms Circulating vascular Marker

Take home messages Why there has been such an high failure rate of trials of antiangiogenic agents in NSCLC? - agents may not effectively combat the redundancy of angiogenic pathways. - highly heterogeneous nature of NSCLC Confirmed efficacy of bevacizumab in eligible patients in first-line (non-squamous, no invasion of central blood vessels, no history of gross hemoptysis, no major cardiovascular disease) Nindetanib and Ramucirumab might be important news in the NSCLC scenario in the second line setting Currently no predictive biomarkers available