1. XXV^ Riunione Nazionale MITO Innovation in gynecologic cancer: optimal therapy, quality of life, precision medicine. Naples, June 25-26 2015 Targeting angiogenesis in ovarian cancer: why, when, how? Presenter: Claudia Marchetti Discussant: Delia Mezzanzanica XXV^ Riunione Nazionale MITO Innovation in gynecologic cancer: optimal therapy, quality of life, precision medicine. Naples, June 25-26 2015 Targeting angiogenesis in ovarian cancer: why, when, how? Presenter: Claudia Marchetti Discussant: Delia Mezzanzanica Unit of Molecular Therapies Department of Experimental Oncology and Molecular Medicine

2. Vaughan S. Nature Rev Cancer 2011 Despite the introduction of new drug combinations, cure rates of ovarian cancer have not improved over the last decades. Targeting angiogenesis in ovarian cancer: why Conventional chemotherapy has proven to have therapeutic limitations that need to be overcome possibly exploring molecular- driven therapy options.

3. D Hanahan, Cell 2011 Targeting angiogenesis in ovarian cancer: how Ovarian cancer lacks driving mutations that can be targeted, tumor microenvironment, particularly the tumor vasculature, is therefore an attractive target for therapeutic intervention. VEGF is one of the most important cytokines responsible for tumor-mediated angiogenesis and is over-expressed in most EOC correlating to prognosis

4. Targeting angiogenesis in ovarian cancer: how Approaches to manipulate VEGF pathway include Extracellular interference with VEGF itself: Bevacizumab, a humanized monoclonal antibody, preventing binding of VEGF to its receptor inhibiting angiogenesis. Four phase III randomized clinical trials testing bevacizumab in ovarian cancer: Front-line treatment: GOG-218 and ICON-7 Platinum-sensitive recurrent disease: OCEANS Platinum-resistant ovarian cancer: AURELIA Intracytoplasmic inhibition of VEGFR tyrosine kinase domain: Pazopanib, a multitargeted tyrosine kinase inhibitor, inhibits several tyrosine kinase receptors involved in angiogenic, proliferative, or cell survival signaling pathways. A phase III, placebo-controlled trial evaluating pazopanib in ovarian cancer: Maintenance after standard paclitaxel and carboplatin: AGO-OVAR 16

5. Targeting angiogenesis in ovarian cancer: how Incorporation of antiangiogenic therapy in EOC treatment: statistically significant PFS advantage but failure in OS improvement. Vaughan S. Nature Rev Cancer 2011 We are still in this situation

6. Targeting angiogenesis in ovarian cancer: when Retrospective analysis within a subset of high-grade serous cancers from the ICON-7 trial identified a molecular signature in which antiangiogenic therapy might actually confer a worse PFS. Molecular separation of tumors may allow for identification of patients who are most likely to benefit from these targeted therapies from those who are most likely to be harmed.

7. Targeting angiogenesis in ovarian cancer: when Molecular subgroup of high-grade serous ovarian cancer (HGSOC) as a predictor of outcome following bevacizumab. Charlie Gourley et al. ASCO 2014 Gene expression profile on 265 microdissected FFPE high grade serous samples from chemo-naive ovarian cancer patients (Edinburgh data set) identified 3 subgroups of patients.

8. Targeting angiogenesis in ovarian cancer: when PFS OS Immune subgroup showed better PFS and OS compared to the other two subgroups A 63-gene signature was developed to distinguish patients belonging to Immune subgroup

9. Targeting angiogenesis in ovarian cancer: when Application of the 63-gene Immune signature to 284 high grade serous translational specimens from ICON7 The immune molecular subtype is characterised by absence of angiogenic biology: genes related to angiogenesis are downmodulated Hypothesis: this group would not benefit from anti-angiogenic agents Immune subgroup; 41% of ICON7 TR patients Non-immune (pro-angiogenic) subgroup; 59% of ICON7 TR patients Immune subgroup patients have inferior PFS and inferior OS when treated with bevacizumab

10. Targeting angiogenesis in ovarian cancer: when Bevacizumab may Differentially Improve Survival for Patients with the Proliferative and Mesenchymal Molecular Subtype of Ovarian Cancer. Boris Winterhoff et al. ASCO 2014 Applying the TCGA molecular classification of HGS Ovarian Cancer in Differentiated, Immunoreactive, Mesenchymal and proliferative subtypes they separated a new case material in 4 groups with different survival proportion Both subtypes have proangiogenic signatures { Hypothesis: Subtypes with proangiogenic signatures might derive more benefit from treatment with bevacizumab.

11. Targeting angiogenesis in ovarian cancer: when The subgroup that most benefit from bevacizumab treatment are the proliferative and mesenchymal subtypes No detrimental effects were observed into the immunoreative subtype. Application of TCGA molecular classification to 359 translational specimens from ICON7

12. Targeting angiogenesis in ovarian cancer: when Retrospecive analysis of candidate predictive tumor biomarkers for efficacy in the GOG-218 trial. Michael J Birrer et al. ASCO 2015 No efficacy predictive plasma biomarkers were identified potential correlation between tumor biomarkers and PFS/OS: Samples from 1455 patients (out of 1873 entered into the study) were analyzed by IHC for

13. Targeting angiogenesis in ovarian cancer: when CD31 was the only biomarker showing impact on PFS

14. Targeting angiogenesis in ovarian cancer: when Patients with high expression of CD31 had a great benefit from bevacizumab treatment

15. Targeting angiogenesis in ovarian cancer: when High expression of CD31 maintained a significan impact also on OS and high expression of VEGF-A showed a trend of benefit for bevacizumab treated patients

16. Targeting angiogenesis in ovarian cancer: when When referring to quartiles rather than median cut-off for CD31 expression, there is a direct correlation between vassels density and impact of bevacizumab on OS

17. Targeting angiogenesis in ovarian cancer: when The same apply for VEGF-A expression on OS of patients treated with bevacizumab

18. Targeting angiogenesis in ovarian cancer: when A clear molecular indication for selecting ovarian cancer patients who may benefit from bevacizumab treatment is not yet available. Are we torturing data to obtaine an answer?

19. Targeting angiogenesis in ovarian cancer: answering unsolved questions The MITO16/MaNGO-OV2 clinical trial, designed with translational end- points and with a prospective collections of tissue and blood, will possibly help in define:  the best molecular portrait responding to bevacizumab treatment  patients possibly harmed by the treatment  treatmen schedule: front-line or at relapse On the bases of the available molecular information a critical ridefinition of the original MITO16 proposed biomarkers is probably needed.