1. Cáncer de Colon: Resultados de los estudios CRYSTAL, FIRE3 y CALGB-80405
Andrés Cervantes

2. EGFR-expressing, previously untreated, mCRC
CRYSTAL study design
FOLFIRI +
cetuximab
n=599
(KRAS codon 12/13 WT, n=316)
EGFR-expressing, previously untreated, mCRC R R
FOLFIRI
n=599
(KRAS codon 12/13 WT, n=350)
Stratification factors:
ECOG performance status
Region
n=1198
(KRAS codon 12/13 WT, n=666:
PCR clamping and melting curve analysis)
FOLFIRI (q2w)
Cetuximab
Irinotecan
180 mg/m2, day 1
400 mg/m2
initial dose then LV
200 mg/m2*, day 1
250 mg/m2
weekly
5-FU
400 mg/m2 bolus, then
2400 mg/m2 infusion over 46 h
Treatment until disease progression, unacceptable toxicity, withdrawal of consent
*L-form; 400 mg/m2, racemic. 5-FU, 5-fluorouracil; ECOG, Eastern Cooperative Oncology Group; LV, leucovorin; PCR, polymerase chain reaction; R, randomization; WT, wild-type
Van Cutsem E, et al. N Engl J Med 2009;360:
Van Cutsem E, et al. J Clin Oncol 2011;29:2011-9
Presented by: Eric Van Cutsem

3. RAS mutation analysis: BEAMing
KRAS and NRAS codons screened for particular missense* mutations:
KRAS exon 3; codons 59, 61
exon 4; codons 117, 146
NRAS exon 2; codons 12, 13
exon 3; codons 59, 61
In line with other techniques which may be used clinically to determine RAS mutation status, a cutoff of ≥5% mutant to wild-type alleles was selected
Tumors were scored as RAS mutant if mutant alleles were detected at a prevalence of ≥5% of total amplified sequences, regardless of whether all loci were evaluable
Tumors were scored as RAS wild-type only if all 26 mutation assays were evaluable and prevalence of mutations was <5%
*Resulting in a change in the specified amino acid
Presented by: Eric Van Cutsem

4. Study profile Presented by: Eric Van Cutsem Randomized and treated;
full analysis population
n=1198
FOLFIRI + cetuximab
n=599
FOLFIRI alone
n=599
Tumors evaluable for KRAS codon 12/13 status
n=530
Tumors evaluable for KRAS codon 12/13 status
n=533
KRAS codon 12/13 wild-type
n=316
KRAS codon 12/13 mutant
n=214
KRAS codon 12/13 wild-type
n=350
KRAS codon 12/13 mutant
n=183
Evaluable for
RAS status
n=210
Evaluable for
RAS status
n=220
RAS
wild-type
n=178
Other RAS mutant
n=32
RAS
wild-type
n=189
Other RAS mutant
n=31
Any RAS mutant
n=246
Any RAS mutant
n=214
Presented by: Eric Van Cutsem

5. Other RAS mutations: CRYSTAL
430/666 patients with KRAS codon 12/13 wild-type tumors evaluable for tumor RAS status
Other RAS mutations: 63/430 (14.7%) patients
KRAS
EXON 2
EXON 3
EXON 4
12 13
59 61
117
146 WT
3.3%
5.6%
NRAS
EXON 2
EXON 3
EXON 4
12 13
59 61
117
146
3.5%
2.8%
0.9%
In 5 tumors with KRAS mutations, an NRAS mutation also detected (low prevalence, 0.1%–<5%, in 4/5 samples)
In 1 tumor, 2 NRAS mutations detected (1 with low prevalence)
Percentages relate to fraction of RAS evaluable
patients with mutations in particular exons
Presented by: Eric Van Cutsem

6. RAS mutation rates: first-line studies
Patients with KRAS codon 12/13 wild-type tumors
Study
Evaluable patients*
Method
Other RAS mutations, %
CALGB/SWOG 80405
670
BEAMing††
15.3
OPUS
118
BEAMing†
26.3
CRYSTAL
430
14.7
FIRE-3‡
407
Pyrosequencing
16.0
PRIME§
620
Dideoxy sequencing/WAVE
17.4
PEAK
221
23.1
*For other tumor RAS mutations
†5% mutant/wild-type alleles diagnostic cutoff
† †1% mutant/wild-type alleles diagnostic cutoff
‡KRAS codons 59 and 117 not considered
§KRAS and NRAS codon 59 not considered

7. EFFICACCY ACCORDING TO RAS SUBGROUPSOS
PFS
Van Cutsem E, et al. J Clin Oncol 2015; 33: ahead of print.

8. Progression-free survival
KRAS codon 12/13 wild-type*
RAS wild-type
HR (95% CI) (0.56–0.87)
No. of events
Median, months
95% CI
146
9.9
9.0–11.3
189
8.4
7.4–9.2
HR (95% CI) (0.41–0.76)
No. of events
Median, months
95% CI 73
11.4
10.0–14.6 99
8.4
7.4–9.4
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Probability of PFS
Probability of PFS
FOLFIRI + cetuximab
FOLFIRI
FOLFIRI + cetuximab
FOLFIRI 4 8 12 16 20 3 6 9 12 15 18 21 24
Months
Months
Number of patients at risk
Number of patients at risk
316
227
128 40 8 1
178
153
114 75 31 8 4
350
237
111 22 4
189
154 92 44 11 5 3
*Van Cutsem E, et al. J Clin Oncol 2011;29:2011-9
Presented by: Eric Van Cutsem

9. Overall survival KRAS codon 12/13 wild-type* RAS wild-type
HR (95% CI) (0.67–0.95)
No. of events
Median, months
95% CI
242
23.5
21.2–26.3
288
20.0
17.4–21.7
HR (95% CI) (0.54–0.88)
No. of events
Median, months
95% CI
130
28.4
24.7–31.6
154
20.2
17.0–24.5
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Probability of OS
Probability of OS
FOLFIRI + cetuximab
FOLFIRI
FOLFIRI + cetuximab
FOLFIRI 6 12 18 24 30 36 42 48 54 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57
Months
Months
Number of patients at risk
Number of patients at risk
316
281
237
198
144
108 82 65 21 4
178
174
163
155
142
140
128
108 97 89 73 66 56 52 45 29 16 5 3
350
311
246
179
132 92 64 48 18 2
189
182
171
160
135
115 98 85 79 70 58 47 38 32 28 20 10 6 2
*Van Cutsem E, et al. J Clin Oncol 2011;29:2011-9
Presented by: Eric Van Cutsem

10. Conclusions
This retrospective subgroup analysis supports the use of FOLFIRI + cetuximab as first-line treatment in patients with RAS wild-type mCRC
Significant improvements in PFS (HR 0.56), OS (HR 0.69) and ORR (odds ratio 3.11) associated with addition of cetuximab to FOLFIRI
No benefit nor deleterious effect seen in patients with RAS mutations
The safety profile in the RAS wild-type and RAS mutant subgroups is similar and in line with expectations
Exclusion of patients with other RAS mutations from the KRAS codon 12/13 wild-type treatment population improves the benefit-risk ratio associated with the addition of cetuximab to FOLFIRI
Molecular testing of tumors for all activating mutations of KRAS and NRAS is therefore essential in selecting the most appropriate first-line treatment for patients with mCRC
Presented by: Eric Van Cutsem

11. FIRE-3 study design FOLFIRI + Cetuximab FOLFIRI + Bevacizumab
Cetuximab: 400 mg/m2 i.v. 120min initial dose
250 mg/m2 i.v. 60min q 1w
mCRC
1st-line therapy
KRAS wild-type
Randomize 1:1
FOLFIRI + Bevacizumab
Bevacizumab: 5 mg/kg i.v min q 2w
FOLFIRI q2w: 5-FU: 400 mg/m2 (i.v. bolus); folinic acid: 400mg/m2
irinotecan: 180 mg/m2
5-FU: 2,400 mg/m2 (i.v. 46h)
Primary endpoint: Overall response rate (RECIST 1.0)
Amendment in October 2008 to include only KRAS wild-type patients
150 active centers in Germany and Austria 11 11

12. Months since start of treatment
FIRE-3 study results
ITT KRAS exon 2 wild-type population
Overall survival
28.7 months
1.0
Cetuximab + CT (FOLFIRI) (n=297)
Bevacizumab + CT (FOLFIRI) (n=295)
25.0 months
0.75
0.50
OS estimate
0.25
HR=0.77 p=0.017
0.0 12 24 36 48 60 72
Months since start of treatment
Cetuximab + CT
Bevacizumab + CT
p value
Overall response rate (primary endpoint not met)
62%
58%
0.183
Progression-free survival
10.0 months
10.3 months
0.547
Heinemann V, et al. Lancet Oncol Lancet Oncol Sep;15(10):

13. Tumor samples N= 637 tumor samples not KRAS wild-type ITT: 115
redundant tumor samples: 14
no tumor on block: 20
KRAS exon 2 WT n=592 (100%)
N= 488 (82.4%)
tumor material available of KRAS wild-type ITT
DNA of insufficient quality:
N= 475 (80.2%)
RAS mutational analyses successful in all RAS locations
Final RAS wild-type population
N=400
New RAS mutant
N= 75 (15.8%) 13 13

14. Probability of survival months since start of treatment
ORR and PFS
Final RAS* wild-type population
Events n/N (%)
Median
(months)
95% CI
― FOLFIRI + Cetuximab
164/199
(82.4%)
10.3
9.5 – 11.8
― FOLFIRI + Bevacizumab
169/201
(84.1%)
10.2
9.3 – 11.7
HR 0.97 (95% CI: 0.78 – 1.20)
p (log-rank)= 0.77
1.0
0.75
Probability of survival
0.50
0.25
0.0 12 24 36 48 60 72
months since start of treatment
No. at risk
199
201 70 16 11 10 4 5 1 3
N=400
Cetuximab + FOLFIRI
(N=199)
Bevacizumab + FOLFIRI
(N=201)
OR/
(95% CI)
p-value
ORR, % (95% CI)
65.3
(58.3–51.6)
58.7
(51.6–65.6)
1.33
(0.88–1.99)
0.18
* KRAS and NRAS exon 2, 3 and 4 wild-type 14 14

15. Probability of survival months since start of treatment
Overall survival
Final RAS* wild-type population
Events n/N (%)
Median
(months)
95% CI
― FOLFIRI + Cetuximab
107/199
(53.8%)
33.1
24.5 – 39.4
― FOLFIRI + Bevacizumab
133/201
(66.2%)
25.0
23.0 – 28.1
HR (95% CI: 0.54 – 0.90)
p (log-rank)=
1.0
0.75
Probability of survival
0.50
0.25
Δ = 8.1 months
0.0 12 24 36 48 60 72
months since start of treatment
No. at risk
199
201
147 79 82 46 34 23 11 7 1
* KRAS and NRAS exon 2, 3 and 4 wild-type 15 15

16. Independent radiological review
An independent, centralized radiological review (blinded to treatment arms) was performed to evaluate:
Tumor response according to RECIST 1.1
Early tumor shrinkage (ETS) (-20% diameter change) measured at 1st CT after baseline (6 weeks)
Depth of response defined as the percentage of maximal tumor shrinkage observed at the nadir compared with baseline

17. CT evaluable population
Independent evaluation
of response
CT evaluable population
FOLFIRI + Cetuximab
FOLFIRI + Bevacizumab
ORR %
95%-CI
Odds ratio p
KRAS exon 2 wt
n= 493
66.5
60.1 – 72.5
55.6
49.3 – 61.8
1.58
( )
0.016
Final RAS wt
n= 330
72.0
64.3 – 78.8
56.1
48.3 – 63.6
2.01
( )
0.003
p = Fisher´s exact test (two-sided)

18. Evaluation of ETS Rate (Early Tumor Shrinkage)
Rate of Early Tumor Shrinkage*
CT evaluable
population
FOLFIRI + Cetuximab
FOLFIRI + Bevacizumab
Odds
ratio p %
95%-CI
KRAS exon 2 wt
n= 493
62.3
55.8 – 68.5
47.9
41.6 – 54.2
1.80
( )
0.0015
Final RAS wt
n= 330
68.2
60.3 – 75.4
49.1
41.5 – 56.8
2.22
( )
0.0005
*ETS: early tumor shrinkage ≥20% at 6 weeks
p = Fisher´s exact test (two-sided)

19. Depth of Response (DpR*)
Evaluation of
Depth of Response (DpR*)
FOLFIRI + Cetuximab
FOLFIRI + Bevacizumab p
median
DpR % SE
KRAS exon 2 wt
n= 493
- 44.1
(±54.6%)
- 32.9
(± 44.3%)
0.0003
Final RAS wt
n= 330
- 48.9
(±54.8%)
- 32.3%
(± 42.3%)
<0.0001
Depth of response correlated significantly with OS and PFS (two-sided Bravais Pearson test)
*DpR: percentage of maximal tumor shrinkage observed at the nadir compared with baseline
SE = standard error; p = two-sided Wilcoxon test p

20. Depth of response correlates with overall survival
Time under treatment
OS
ETS
DpR (smallest tumor size)
Model
ETS predicts sensitivity to treatment
ETS predicts the potential DpR
DpR predicts OS
CRYSTAL study
Cetuximab + FOLFIRI
(n=315)
FOLFIRI
(n=348) p
Median DpR (95% CI)
50.9
33.3
p<0.0001
Median OS (95% CI)
23.5 ( )
20.0 ( )
P<0.0093
adopted from Mansmann et al, ASCO GI 2013 abstract #427

21. Depth of response correlates with overall survival
Time since start of treatment
OS
ETS
Tumor nadir
Fire-3 data
Lethal tumor load
ETS predicts sensitivity to treatment
DpR predicts OS
Tumor load at Baseline
PFS
FIRE-3 Study
(AIO KRK-0306)
Cetuximab + FOLFIRI
(n=157)
Bevacizumab + FOLFIRI
(n=173) p
Median DpR (95% CI)
48.9
32.2
p<0.0001
Median OS (95% CI)
33.1 (24.5 – 39.4)
25.0 (23.0 – 28.1)
P=0.0056

22. Summary of RAS analyses
Extended RAS testing was possible in >80% of FIRE-3 ITT.
The RAS evaluable population was in all respects comparable to the ITT population.
In patients with all-RAS wild-type tumors ORR and PFS were not significantly different between treatment arms
Median OS was markedly superior (Δ = 8.1 months, HR ) in all-RAS wild-type patients receiving 1st-line therapy with cetuximab

23. for the ALLIANCE and SWOG
CALGB/SWOG 80405: PHASE III trial of irinotecan/5-FU/leucovorin (FOLFIRI) or oxaliplatin/5-FU/leucovorin (mFOLFOX6) with bevacizumab (BV) or cetuximab (CET) for patients (pts) with untreated metastatic adenocarcinoma of the colon or rectum (MCRC): Expanded ras analyses
Heinz-Josef Lenz, Donna Niedzwiecki, Federico Innocenti, Charles David Blanke, Michelle R. Mahoney, Bert H. O'Neil, James Edward Shaw, Blase N. Polite, Wilbur Franklin, Wendy Frankel, Howard Hochster, James Norman Atkins, Richard M. Goldberg, Robert J. Mayer, Richard L. Schilsky, Monica M. Bertagnolli, Alan Venook
for the ALLIANCE and SWOG

24. RAS mutation analysis: BEAMing
KRAS and NRAS genes were screened for particular missense* mutations:
KRAS exon 2; codons 12, 13
exon 3: codon 59, 61
exon 4; codons 117, 146
NRAS exon 2; codons 12, 13
exon 3; codons 59, 61
In line with other techniques which may be used clinically to determine RAS mutation status, a cutoff of ≥1% mutant to wild-type alleles was used to discriminate patients
Tumors were scored as RAS mutant if mutant alleles were detected at a prevalence of ≥1% of total amplified sequences, regardless of whether all loci were evaluable
Tumors were scored as RAS wild-type only if all 26 mutation assays were evaluable and prevalence of mutant alleles was <1%
*Resulting in a change in the specified amino acid

25. Evaluable for RAS analysis
Study profile
KRAS WT codons 12/13
N=1137
Chemo + Bev
N=559
Evaluable for RAS analysis
N=324 (26 NA)
RAS WT
N=256
RAS mut
N=42
Chemo + Cetux
N=578
N=346 (23 NA)
N=270
N=53

26. Efficacy: RAS Subgroups
Chemo + BV N
Chemo + CET
Response
Rate (%)*
BV vs CET
p-value
PFS time
Hazard ratio
95% CI
OS time
RAS evaluable**
324
346
56.0 vs 68.8
p<0.01
11.4 vs 10.9‡
1.1
p=0.34
30.3 vs 30.8‡
0.9
p=0.49
RAS
wild-type
256
270
53.8 vs 68.6
11.3 vs 11.4‡
0.9–1.3
p=0.31
31.2 vs 32.0‡
0.7–1.1
p=0.40
*406 RAS evaluable and 319 RAS WT patients evaluable for response
**Patients with KRAS codon 12/13 wild-type tumors for which tumor DNA samples were evaluable for other RAS mutations
‡Median, months

27. Progression Free Survival By Arm (All RAS Wild Type Patients)
(Events)
Median
(95% CI) HR p
Chemo + Bev
256
(221)
11.3
( )
1.1
( ) 
0.31
Chemo + Cetux
270
(241)
11.4
( )

28. Overall Survival By Arm (All RAS Wild Type Patients)
(Events)
Median
(95% CI) HR p
Chemo + Bev
256
(178)
31.2
( )
0.9
( )
0.40
Chemo + Cetux
270
(177)
32.0
( )

29. Overall Survival by Arm (All RAS Wild Type FOLFOX Patients)
(Events)
Median
(95% CI) HR p
Chemo + Bev
192
(137)
29.0
( )
0.86
( )
0.2 
Chemo + Cetux
198
(129)
32.5
( )

30. Overall Survival by Arm (All RAS Wild Type FOLFIRI Patients)
(Events)
Median
(95% CI) HR p
Chemo + Bev 64
(41)
35.2
( )
1.1
( )
0.7 
Chemo + Cetux 72
(48)
32.0
( )

31. Conclusions
All patients with newly diagnosed mCRC should be tested for RAS
Overall Survival > 30 months in both arms sets a new benchmark for patients with mCRC which was achieved across a broad clinical trials network and suggests that the results apply in a variety of practice settings.
First line therapy should reflect treatment goal and concern for potential side effects.
With additional data such as dose intensity, treatment duration, location, tumor shrinkage, second line therapies and additional biomarker for anti-EGFR and anti VEGF AB we might understand better the differences between FIRE3 and 80405

32. Venook AP and Tabernero J. J Clin Oncol 2015; 33:4-6

33. Venook AP and Tabernero J. J Clin Oncol 2015; 33:4-6

34. Venook AP and Tabernero J. J Clin Oncol 2015; 33:4-6

35. Shi Q, et al. J Clin Oncol 2015; 33:22-28.

36. CALGB/SWOG 80405: Baseline Characteristics Resected Patients
Kras WT codons 12/13
n=1137
Resected Pts
n=180
Chemo + Bev n=559
Chemo + Cetux n=578
Chemo + Bev n=75
Chemo + Cetux n=105
Age, years
Median (range)
59 (21–85)
59 (20–89)
55 (24–82)
55 (21–79)
Male, %
62.3
60.4
64.0
60.0
Non-Caucasian, %
14.6
16.5
9.3
20.0
FOLFOX, %* 73 74 77 81
Prior Radiation, %*
14.5
13.7
8.0
6.7
Prior Adjuvant Chemotherapy, %*
8.9
9.0
9.5
Palliative intent, %
86.4
82.5
62.7
Primary in place, % 28 27 30 20
Liver metastases only, %
29.3
39.8
53.3
50.0
Achieve NED: 132 /180
*Stratification Factor

37. CALGB/SWOG 80405: Overall Survival (KRAS wild type, NED Post-Surgery, N=132)
Arm N
(Events)
Median
(95% CI) HR p
Chemo + Bev
50(15)
67.4
(50.6-NA)
1.2
( )
0.56
Chemo + Cetux
82(30)
64.1
( )

38. CALGB/SWOG 80405: Patients undergoing surgery and rendered NED
Subset of patients survive > 5 years
Patients likelier to have “curative” surgery on cetuximab-containing regimen
Outcomes similar between arms
Expanded RAS may distinguish prognosis in this already select group of patients
Opportunity to interrogate clinical and tumor factors related to curability