Advances in Treatment of Renal Cell Carcinoma: Evolving Role of mTOR Inhibitors Robert J. Motzer MD Memorial Sloan-Kettering Cancer Center New York, NY

Renal Cell Carcinoma (RCC) RCC is the most common cancer of the kidney 1,2 –Current analyses estimate more than 50,000 new cases and 13,000 deaths in the United States in ,4 Recurrence develops in approximately 40% of patients with localized tumors 5 Approximately 30% of patients with RCC present with metastatic disease 1 –5-year survival rate for patients with metastatic RCC is <10% 6 1. Motzer RJ, et al. N Engl J Med. 2007;356: Parkin DM, et al. CA Cancer J Clin. 2005;55: Pickle LW, et al. CA Cancer J Clin. 2007;57: Jemal A, et al. Ca Cancer J Clin. 2007;57: Lam JS, et al. World J Urol. 2005;23: Motzer RJ, et al. N Engl J Med.1996;335:

Treatment of Advanced/Metastatic RCC RCC is highly resistant to chemotherapy Cytokines have response rates of 5% to 20% and median OS of 12 months but their use is limited by toxicity 1,2 Therapies targeted to VEGF and mTOR are the new standard of care 1,3 1. Motzer RJ, et al. N Engl J Med. 2007;356: Hutson TE, et al. Clin Genitourin Cancer Suppl.2006;5(Suppl 1):S31-S39 3. Escudier B, et al. N Engl J Med. 2007;356: OS = overall survival; VEGF = Vascular endothelial growth factor.

Clear Cell RCC: VHL Gene Mutation DeVita. Cancer: Principles and Practice of Oncology. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2005;1826. Elongin B Elongin C Rbx1 E2 CUL2 Β-domain VHL complex disrupted VHL protein HIFα accumulation VEGF PDGF Glut1 Mutant α-domain VHL = von Hippel-Lindau HIF = hypoxia-inducible factor VEGF = vascular endothelial growth factor PDGF = Platelet-derived epithelial growth factor

RCC Treatment Algorithm RegimenSettingTherapyOptions Treatment-naive patient MSK risk: good or intermediate Sunitinib Bevacizumab + IFN-α High-dose IL-2 MSK risk: poorTemsirolimusSunitinib Treatment-refractory patient (≥ second-line) Cytokine refractorySorafenibSunitinib Bevacizumab Refractory to VEGF/VEGFR or mTOR inhibitors EverolimusSequential TKIs or VEGF Inhibitor Bukowski RM. Presented at: 43rd ASCO Annual Meeting. June 1-5, 2007; Chicago, IL. Adapted from M Atkins MSK = Memorial Sloan-Kettering; mTOR = mammalian target of rapamycin. TKI = tyrosine kinase inhibitor; VEGF = vascular endothelial growth factor. VEGFR = vascular endothelial growth factor receptor.

PI3K/Akt/mTOR pathway

von Hippel–Lindau (VHL) mutations are commonly observed (57%) in clear-cell RCC 1 Loss of VHL function leads to accumulation of hypoxia-inducible factor (HIF)-1 and HIF-2, and overexpression of VEGF, PDGF, and TGF 2,3 Activation of mTOR augments production of proangiogenic growth factors by increasing HIF-1 activity 4,5 Therefore, inhibiting mTOR could block HIF-1/-2 signaling 4 1. Maxwell et al. Nature 1999;399:271–5 2. Ohh et al. Nat Cell Biol 2000;2:423–7 3. Iliopoulos et al. Proc Natl Acad Sci USA 1996;93:10595–9 4. Hudson et al. Mol Cell Biol 2002;22:7004–14 5. Hopfl et al. Cancer Res 2002;62:2962–70 Rationale for mTOR Inhibitors in RCC

Rationale for mTOR Inhibition in mRCC Brugarolas et al. N Engl J Med. 2007;356: Copyright 2007 Massachusetts Medical Society. All rights reserved. Gnarra et al. Nat Genet. 1994;7: Schips et al. Am J Clin Pathol. 2004;122: Shin Lee et al. J Surg Oncol. 2003;84: Horiguchi et al. J Urol. 2003;169: Thomas et al. Nat Med. 2006;12: Brugarolas. N Engl J Med. 2007;356: VHL = Von Hippel-Lindau; HIF = hypoxia-inducible factor.

Temsirolimus Mechanism of Action Adapted from Adjei et al.

Temsirolimus mTOR Pathway Inhibitor Rapamycin derivative Intravenous Daily or weekly dose –Daily IV  5: 15 (19.2) mg/day –Weekly IV: mg Temsirolimus Bjornsti. Nat Rev Cancer. 2004;4:335.

mTOR Inhibitors 3 Analogs of rapamycin developed as antitumor agents –Temsirolimus –Everolimus (RAD001) –AP23573 Bjornsti. Nat Rev Cancer. 2004;4:335. Temsirolimus Everolimus (RAD001) O O OH O O O N O O O O O OH O OH

Randomized Phase 2 Trial of Temsirolimus: Median Survival by Risk Group Risk Groupn (%) Median Survival Months (95% CI) Temsirolimus (second line, n = 105*) Favorable 8 (8%) 24 (18, 27) Intermediate 48 (46%) 23 (17, 26) Poor49 (47%) Overall (10, 18) MSKCC data (first line, n = 437 † ) Favorable79 (18%)30 (21, 38) Intermediate271 (62%)14 (12, 16) Poor87 (20%) Overall46313 (12, 15) * Patients for whom prognostic factor data available. † IFN-based treatments. 4.9 (4.3, 6.3) 8.2 (7, 10) Atkins MB, et al. J Clin Oncol. 2004;22(5): Reprinted with permission from the American Society of Clinical Oncology.

Phase 1 Trial of Temsirolimus and IFN-α: Results MTD/Recommended doses: Temsirolimus: 15 mg weekly IFN-  : 6 MU SC 3 times a week EndpointTotal PopulationMTD Population Response rate11%8% Clinical benefit46%44% Median PFS9.1 months7.6 months Motzer et al. J Clin Oncol 25: , 2007 MTD = maximum tolerated dose; PFS = progression-free survival

N = 626 Eligibility Criteria Phase 3 Trial: Temsirolimus vs IFN-α in First-Line Treatment of Poor-Risk mRCC Hudes G, Motzer RJ et al. N Engl J Med. 2007;356:  Previously untreated mRCC  Poor prognosis (≥3 predictors of poor risk): –LDH >1.5 × ULN –Hemoglobin <LLN –Corrected calcium >10 mg/dL –Diagnosis to first treatment <1 year –KPS –Multiple organ sites of metastasis Temsirolimus 25 mg IV weekly (n = 209) IFN-α escalating to 18 MU SC tiw (n = 207) Temsirolimus 15 mg IV weekly + IFN-  6 MU SC tiw (n = 210) LLN = lower limit of normal; ULN = upper limit of normal; OS = overall survival.  Randomized, international multicenter trial  All histologies included  Primary end point: OS  Treatment continued until PD, toxicity, or symptom deterioration

Phase 3 Study of Temsirolimus and IFN-  Patient Baseline Characteristics Characteristic IFN -  (n = 207) Temsirolimus (n = 209) Temsirolimus + IFN -  (n = 210) Median age (years) Male (%) Karnofsky PS (% ≤ 70) Previous nephrectomy (%) Clear-cell tumor histology (%) < 1 year from initial diagnosis to randomization (%) ≥ 3 poor prognostic features (%) < 3 poor prognostic features (%)576 Poor risk by MSKCC criteria (%) ≥ 2 sites of organ metastasis (%) Hudes et al. N Engl J Med. 2007;356: PS = performance status; MSKCC = Memorial Sloan-Kettering Cacner Center.

Phase 3 Study of Temsirolimus and IFN-  Overall Survival Temsirolimus (n = 209) Temsirolimus + IFN-α (n = 210) IFN-α (n = 207) Probability of survival Months n Median OS, months (95% CI) IFN-α ( ) Temsirolimus ( ) Temsirolimus + IFN ( ) Hudes et al. N Engl J Med. 2007;356: Copyright © 2007 Massachusetts Medical Society. All rights reserved. No. at Risk Interferon-α Temsirolimus Combination

Phase 3 Study of Temsirolimus and IFN-  Progression-free Survival and Response n Median PFS (months)ORR (%) IFN-α Temsirolimus Temsirolimus + IFN-α PFS, progression-free survival; ORR, objective response rate Hudes et al. N Engl J Med. 2007;356: Copyright © 2007 Massachusetts Medical Society. All rights reserved. No. at Risk Interferon-α Temsirolimus Combination

Temsirolimus ± IFN-α Maximum Percent Reduction in Tumor Measurement* *Investigator assessed measurements Change from baseline (%) –100 IFN 44%67%77% TEMSRIFN + TEMSR Patients

Percent (%) of Patients with Selected Adverse Events All Grades and Grade 3–4 Temsirolimus Phase III Trial Adverse Event IFN-α n=203 TEMSR n=209 TEMSR + IFN-α n=209 AllGr 3–4AllGr 3–4AllGr 3–4 Asthenia Nausea Rash Dyspnea Diarrhea Edema Vomiting Stomatitis Hudes et al. N Engl J Med. 2007;356:

Temsirolimus Phase III Trial Abnormality IFN-α n=203 TEMSR n=209 TEMSR + IFN-α n=209 AllGr 3–4AllGr 3–4AllGr 3–4 Anemia Hyperlipidemia Hyperglycemia Hypercholesteremia Creatinine increase Thrombocytopenia Neutropenia Percent Patients with Laboratory Abnormalities All Grades and Grade 3–4 Hudes et al. N Engl J Med. 2007;356:

Phase III Trial Temsirolimus vs IFN-α Subset Analyses Median survival IFN-αTEMSRHR Intermediate Risk (n=51)13.0 (n=64)1.17 Poor Risk (n=156)10.2 (n=145)0.76 Clear Cell 8.2 (n=170)10.6 (n=169)0.85 Other 4.3 (n=36)11.6 (n=37)0.55 HR : hazard ratio 1. MSK prognostic groups Dutcher et al. ASCO, 2007.

Subset Analysis: Effect of Prior Nephrectomy Logan. ASCO (abstract 5050). No NephrectomyNephrectomy P Value* IFN-αTemsirolimusIFN-αTemsirolimus Number of patients OS6.2 mo11.5 mo7.8 mo10.4 mo 0.20 OS HR** PFS2.0 mo5.7 mo3.5 mo5.3 mo 0.47 PFS HR** *Test of interaction between nephrectomy and treatment status based on unstratified Cox proportional hazard model. **Temsirolimus:IFN-α. OS = overall survival; PFS = progression-free survival. OS and PFS are prolonged in patients receiving temsirolimus vs IFN-α regardless of nephrectomy status

RAD001 An Oral mTOR Pathway Inhibitor Rapamycin derivative Oral Daily or weekly dose –Daily: 10 mg –Weekly: mg Inhibits cell growth, angiogenesis, and bioenergetics Phase 2 trial shows activity Phase 3 trial under way RAD001 Bjornsti. Nat Rev Cancer. 2004;4:335.

Rationale for RECORD-1 Phase III trial: Renal Cell cancer treatment with Oral RAD001 given Daily New unmet medical need for patients after VEGFr-TKI therapy (sunitinib or sorafenib) Phase II trial of everolimus treatment shows activity in previously treated RCC patients 1 Everolimus, as an oral mTOR inhibitor, has a mechanism distinct from that of VEGFr TKIs 2 1. Jac et al. J Clin Oncol. 2008;26 [Abstract 5113]. 2. Lane et al. Clin Cancer Res 2009;15:1612– Time (months) Progression free survival (%) Progression-free survival n = 37 Median = ( ) months TKIs = tyrosine kinase inhibitors.

RECORD-1: Study Summary Multicenter, Phase III, randomized trial of everolimus vs placebo Primary endpoint: progression-free survival (PFS) –33% risk reduction (hazard ratio = 0.67) –290 events to achieve 90% power Key eligibility criteria –mRCC with clear-cell component –Progressive disease on or within 6 months of treatment with sunitinib, sorafenib, or both –Prior bevacizumab and cytokines permitted

RECORD-1: Study Design and Conduct Survival follow-up: 15-Nov-08 Upon disease progression N=416 Stratification by: Prior VEGFr-TKI: 1 or 2 MSKCC risk group 1: favorable, intermediate, or poor RANDOMIZATIONRANDOMIZATION Placebo + BSC (n=139) Everolimus 10 mg/day + BSC (n=277) Safety interim analysis 2nd interim analysis data cut-off: 15-Oct-07, n=410 End of double- blind analysis data cut-off: 28-Feb-08 Study unblinded ●416 patients randomized between Dec-06 and Nov-07 ●Analysis cut-off: 28-Feb-08, based on 266 PFS events ●Second interim analysis cut-off: 15-Oct-07, efficacy boundary crossed with 410 patients / 191 PFS events Motzer et al. Lancet 2008;372:449–456; complete study unblinded on 28-Feb-08. 2:1 BSC = best supportive care; MSKCC = Memorial Sloan-Kettering Cancer Center.

RECORD-1: Baseline Patient Characteristics (N=416) *Motzer et al. J Clin Oncol 2004;22:454–63. Escudier et al. Ann Oncol 2008;19:viii45 [Abstract 720]. CharacteristicEverolimusPlacebo No. of patients, n Median age, years (range)61 (27–85)60 (29–79) MSKCC risk *, % Favorable/intermediate/poor29/56/1428/57/15 Prior VEGFR-TKI therapy, % Sunitinib4644 Sorafenib2830 Both26 Other systemic therapy, % Interferon50 Interleukin Chemotherapy1316 Bevacizumab 910

RECORD-1: PFS by Treatment; End of Double-blind Log rank P value <0.001 Everolimus (n=277) Placebo (n=139) Hazard ratio = % CI [0.25, 0.43] Median PFS Everolimus: 4.90 months Placebo: 1.87 months Time (months) Probability (%) Central radiology review 1 Number of patients at risk, n Everolimus Placebo Number of patients at risk, n Everolimus Placebo Time (months) Probability (%) Log rank P value <0.001 Everolimus (n=277) Placebo (n=139) Hazard ratio = % CI [0.25, 0.41] Median PFS Everolimus: 5.49 months Placebo: 1.87 months Investigator assessment 2 PFS = progression-free survival 1. Escudier B et al. Ann Oncol 2008;19:viii45 [Abstract 720]; 2. Kay et al. Presented at ASCO-GU 2009 [Abstract 278] by Motzer. Analysis on Feb 2008 data cut-off.

RECORD-1: PFS by Investigator 106 Placebo Patients Crossed Over to Receive Everolimus Number of patients at risk, n Everolimus Everolimus (# events/106 treated = 45/106) Kaplan–Meier median Everolimus: 5.09 mo 95% CI [3.71,7.56] Probability (%) Time (months) Analysis on Feb 2008 data cut-off. Kay et al. Presented at ASCO-GU 2009 [Abstract 278] by Motzer.

RECORD-1: Maximum % Change in Target Lesions and Objective Response Rate* NE = not evaluable; * Central radiology review. Escudier et al. Ann Oncol 2008;19:viii45 [Abstract 720]. EverolimusPlacebo Best responsen (%) PR5 (2) Stable185 (67) PD57 (21) NE30 (11) −100% −75% −50% −25% 0% 25% 50% 75% 100% −100% −75% −50% −25% 0% 25% 50% 75% 100% Best responsen (%) PR0 Stable45 (32) PD74 (53) NE20 (14)

RECORD-1: Selected Treatment-related Adverse Events; End of Double-blind Everolimus %, (n = 274) Placebo %, (n = 137) All gradesGrade 3/4All gradesGrade 3/4 Stomatitis42 3/0 8 0/0 Asthenia22 2/0 9<1/0 Fatigue23 3/017<1/0 Rash28 1/0 5 0/0 Diarrhea21 1/0 4 0/0 Nausea18 <1/0 8 0/0 Mucosal inflammation17 1/0 1 0/0 Edema peripheral13 <1/0 4 0/0 Infections (total)13 2/2 2 0/0 Dyspnea10 2/0 3 0/0 Pneumonitis14 4/0 0 0/0 Laboratory Abnormalities Hypercholesterolemia18 3/02 0/0 Hypertriglyceridemia15 1/02 0/0 Hyperglycemia 8 4/0<1 <1/0 ●Four treatment-related deaths: one each of candidal sepsis/ARDS, sepsis, acute respiratory failure, and recurrent bronchopulmonary aspergillosis Analysis on Feb 2008 data cut-off. Kay et al. Presented at ASCO-GU 2009 [Abstract 278] by Motzer.

Temsirolimus: Predictors of Response 20 specimens from patients with advanced RCC who had been treated with temsirolimus Expression levels of pS6 and pAkt correlated with patient response to temsirolimus Low pS6Intermediate pS6High pS6 Low pAkt0/30/1 Intermediate pAkt0/10/32/6 High pAkt0/01/11/3 Number of Objective Responses (Minor Response or PR)/Total Number of Patients With Composite Expression High tumor pS6 or pAkt expression may predict response to temsirolimus (4/10 vs 0/9 [low expression of pS6 or pAkt]; P=0.02) Cho. Clin Genitourinary Cancer. 2007;5:379. pAkt = phosphorylated Akt gene; PR = partial response.

Combination Therapies: Targeting VEGF at Multiple Levels HIF Temsirolimus Bevacizumab Sorafenib, sunitinib O2O2 VEGFR VEGF Adapted with permission from Kaelin. Clin Cancer Res. 2004;10:6290s; Atkins. ASCO 2006 Plenary session; Pantuck. Cancer. 2007;109:2257. Vertical blockade mTOR

Combination Drug Therapy Selected Adverse Events with Agents Rash or Hand-foot ReactionHypertensionCytopeniaProteinuria Gastro-intestinal Mucosal Sunitinib Yes Sorafenib Yes Bevacizumab Yes Temsirolimus Yes

Dose LevelTemsirolimus (mg)Sunitinib (mg) (starting dose) DLT as defined in protocol Grade 4 neutropenia > 7 days; febrile neutropenia Persistent grade 3 nonhematologic toxicity > 7days Grade 4 HTN, hemorrhage Any thromboembolic event Phase I Trial of Sunitinib + Temsirolimus Two of 3 patients in 1 st cohort developed DLT: rash (1 pt), cellulitis + thrombocytopenia (1 pt) DLT = dose-limiting toxicity Fischer P, Motzer et al; JCO 26, 672s, Abst 16020

Phase 2 Trial of Bevacizumab plus Everolimus: Adverse Events AEsGrade 3Grade 4 Nonhematologic Fatigue4(7%)1 (2%) Hypertension1(2%)0 Proteinuria10(17%)2 (3%) Mucositis/stomatitis4(7%)0 Diarrhea5(8%)0 Hyperlipidemia2(3%)0 Hematologic Neutropenia1(2%)0 Thrombocytopenia1(2%)0 Anemia1(2%) Whorf et al. ASCO, Abstract 5010.

RAD mg/d + Bevacizumab 10 mg/kg IV q 2 wks Patients with previously untreated metastatic RCC RAD001 + bevacizumab vs. interferon-α + bevacizumab Open label, randomized, group sequential design RECORD-2 Phase II First-line in RCC: RAD001 + Bevacizumab SCREENSCREEN Interferon-α dose escalation SQ + Bevacizumab 10 mg/kg IV q 2 wks Prim Endpoint: PFS Sec Endpoints: Response Survival Safety QoL 1 : 1 Randomize

*Accrual goal. † Arm to be added when phase II doses are available from ongoing phase I trials. ECOG = Eastern Cooperative Oncology Group; BeST = Bevacizumab-Sorafenib-Temsirolimus; PFS = progression-free survival; ORR = overall response rate; OS = overall survival Primary endpoint: PFS Secondary endpoints: ORR, OS, and correlates (dynamic contrast-enhanced MRI, biomarkers) Phase II Trial: ECOG BeST Bevacizumab 10 mg/kg IV every 2 weeks (days 1 and 15) Advanced RCC Stratified by: Prior therapy (cytokine/vaccine vs no cytokine) Motzer risk category (low, intermediate, or high) (N=360*) Bevacizumab 10 mg/kg IV every 2 weeks (days 1 and 15) + Sorafenib 400 mg bid Bevacizumab 10 mg/kg IV every 2 weeks (days 1 and 15) + Temsirolimus 25 mg IV weekly (days 1, 8, 15, and 22) Sorafenib bid + Temsirolimus IV weekly (days 1, 8, 15, and 22) †

Randomized Phase II Crossover Design (RECORD-3) First-line treatment of patients with previously untreated mRCC Primary end point: Progression-free survival (part I) Secondary end points: Progression-free survival at the end of part II, overall survival, safety, quality of life Everolimus 10 mg/day SCREENSCREEN Sunitinib 50 mg/day, 4 wk on/2 wk off Randomized 1 : 1 Sunitinib 50 mg/day, 4 wk on/2 wk off Everolimus 10 mg/day Disease progression Part I Part II ClinicalTrials.gov. NCT

Temsirolimus vs Sorafenib in Advanced Renal Cell Carcinoma as Second-Line Therapy in Patients Who Have Failed First-Line Sunitinib Therapy Patients with advanced RCC, PD by RECIST criteria while receiving 1 st -line sunitinib therapy, at least 1 measureable lesion, at least 2 wks since prior treatment with sunitinib, palliative radiation therapy, and/or surgery, and resolution of all toxic effects of prior therapy, age ≥18 Temsirolimus 25 mg IV q week n = 220 Primary endpoints: PFS, safety, and tolerability Secondary endpoints: RR (CR & PR), OS, SD at 12, 24, 36 wks, clinical benefit (CR+PR+SD at > 24 wks), duration of response and best tumor shrinkage Study Design: International, Prospective, Randomized, Open-label, Outpatient, Multicenter Study Sorafenib 400 mg PO BID n = 220 RANDOMIZATIONRANDOMIZATION ClinicalTrials.gov. NCT PD = pre-determined; RECIST = Response Evaluation Criteria In Solid Tumors; PFS = progression-free survival; PR = partial response; CR = complete response; OS = overall survival; SD = standard deviation.

mTOR Inhibitors in mRCC Conclusions Phase 3 trial in patients with poor prognosis shows survival benefit for temsirolimus over IFN-  Phase 3 trial of everolimus in TKI-refractory shows improvement in progression-free survival mTOR is an important therapeutic target Studies of tumor biology, combination programs, and novel mTOR inhibitors are of high priority

Advances in Treatment of Renal Cell Carcinoma: Evolving Role of mTOR Inhibitors Robert J. Motzer MD Memorial Sloan-Kettering Cancer Center New York, NY