1. New Agents in the Treatment of Esophageal and Gastric Cancers Heinz-Josef Lenz, MD Professor of Medicine USC/Norris Comprehensive Cancer Center University of Southern California Keck School of Medicine Los Angeles, CA

2. Can Gastric Cancer be the next GIST? Intestinal versus Diffuse?

3. Critical Pathways Her2VEGF/VEGFREGFRIGFR1C-metPI3K/AKTE-Cadherin

4. Frequent Genetic and Molecular Abnormalities In Sporadic Gastric Cancer E-cadherin In 92%, down regulation or mutation Fibroblast growth factor70% expression, esp. undifferentiated tumors Telomerase expression85% of advanced tumors, poor prognosis VEGF/VEGFRabout 50% overexpression poor prognosis MET, c-metOver-expression in approximately 50%, a marker for poor prognosis a marker for poor prognosis Epidermal Growth Factor (EGF)Over-expression in over 50% of advanced cancers PI3K Mutations 35% have PI3K mutations HER2 over expression:10-25% overexpression (FISH) intestinal type Hundahl, Macdonald, & Smalley Chapter 45: Stomach in Chang F et al (eds) Oncology: An Evidence Based Approach, New York: Springer Verlag, 2008, Galizia W J Surg 31: 1458; 2007 Mammano Anticancer Res 26: 3547; 2006 Lee Oncogene 22: 6942; 2003 Yano Oncol Rep 15: 65; 2006

5. Overall Survival among Different Ethnicities (Differences in Genetic Make up?)

6. Targeted Therapies Conventional, cytotoxic chemotherapy has limited benefit Targeted agents: attempt to block specific tumor growth pathways –Monoclonal antibodies –Tyrosine kinase inhibitors –Soluble receptors/Ligands to growth factors –Inhibition of pathways involved in protein synthesis and degradation

7. Targeted Agents in Phase II Phase II Study RegimenN Response (%) TTP / OS Bang et al 2007 Sunitinib383%NS Muro 2008 RAD001240%NS Gold 2008 Cetuximab552% 1.8 mos / 4 mos Hecht 2008 Iqbal 2007 Lapatinib21470%7%-- 2 mos/ 5 mos

8. Advanced Gastric Cancer: Targeted Agents Phase II Study RegimenN RR (%) TTP / OS Lordick et al. 2006 4 Cetuximab + FUFOX 2856% 8.1 / 28.2 mos Di Fabio et al. 2006 2 Cetuximab + FOLFIRI 2752% Pinto et al. 2006 3 Cetuximab + FOLFIRI 2556% 8 / 16 mos Jhawer 2009 Bev + Modified DCF 3664% 12 mos / 16mos Shah et al. 2006 1 Bev + Cisplatin + Irinotecan 3465% 8.3 / 12.3 mos Enzinger et al. 2008 Bev + Irino/Docet/Cisplatin 2268%NS 1. Shah et al. J Clin Oncol. 2006;24:5201; 2. Di Fabio et al. ESMO, 2006. Abstract 1077PD; 3. Pinto et al. Ann Oncol 2007; 4. Lordick et al. Ann Oncol 2008.

9. Targeted Agents in Phase III (EGFR/VEGF/Her2) REAL 3:ECX + / - Panitumumab (U.K.) EXPAND:Cape-Cis + / Cetuximab AVAGAST:Cape-Cisplatin + / - Bevacizumab LOGIC:Cape-Ox + / - Lapatinib (HER2+) TOGA:HER+ Cape-Cisplatin + / - Trastuzumab

11. Angiogenesis in GC & EC VEGF-A expressed in 51% GC specimens w/o stage correlation (Feng, 2002) but w/ OS correlation (Maeda,1996) Serum VEGF-A correlated with OS in resected GC (Yoshikawa, 2000; Karayiannakis, 2002) Serum VEGF-A increased in SCC EC and correlated with stage and response to CT/RT (Shimada, 2001) VEGF-D & VEGFR-3 expression in GC correlated with poor OS (all pts & pN+) (Jüttner, 2006) Tight correlation between VEGF and EGFR pathways in GC (Akagi, 2003)

12. VEGFD & VEGFR-3 in GC VEGF-D & VEGFR-3 expression was correlated with decreased survival in the total population Combined analysis of VEGF-D & VEGFR-3 can be useful to identify patients with favourable vs unfavourable outcome (even pN+) Jüttner S, et al. JCO 2006 Total (n=91)pN+ (n=63)

13. CXCR IL-1R Tumor associated angiogenesis HIF1NFkb ARNT HIf1  NRP1 VEGFR Tumor cell DNA EGFR VEGF Endothelial cell Hypoxia EGF IL-8IL-1 β PAR-4 PAR-1 Endostatin Platelet  1-granules  2-granules Thrombin

14. Overall Survival among different IL-8 Polymorphisms Lurje et al Annals of Oncology 2009

15. Overall Survival among different PAR-1 Polymorphisms Lurje et al Annals of Oncology 2009

16. Overall Survival among different Endostatin Polymorphisms Lurje et al Annals of Oncology 2009

17. EGF and PAR1 associated with Time to Tumor Recurrence in Esophageal Cancers (n=237)

18. Anti VEGF (Bevacizumab) Shah, et al. JCO 2007 –Phase II met gastric or GEJ adenoca –First line therapy – cisplatin/irinotecan/bev –N = 47, 34 with measurable disease –RR 65%, OS 12.3 mo Enzinger, et al. ASCO 2008, Abstr 4552 –Phase II met esophagogastric cancer –First line therapy – docetaxel/cisplatin/irinotecan –N = 32 –RR 63% Jhawer, et al. GI ASCO 2009, Abstr 10 –mDCF plus bevacizumab –N = 45 –RR 67%, PFS 12 mo, OS 16.2 mo AVAGAST study accrual completed –XP +/- bevacizumab –Following toxicities carefully – thrombosis, perforation

19. Anti-VEGFR (Sorafenib) ASCO 2008, Abstr 4535, Sun, et al. ECOG 5203 Phase II study of sorafenib, docetaxel, cisplatin 44 pts with advanced gastric or GE junctional cancers RR 38.6%, PFS 5.8 mo, OS 14.9 mo

20. Meyerhardt JA, Mayer RJ. N Engl J Med. 2005;352:476-487; Venook A. Oncologist. 2005;10:250-261. Survival (anti- apoptosis) Gene transcription Cell-cycle progression MYC Cyclin D1 FOSJUN P P Cyclin D1 Angiogenesis Invasion and metastasis Chemotherapy/ radiotherapy resistance Proliferation/ maturation MAPK MEK RAS RAF SOS GRB2 PTEN AKT STAT P13K pY Ligand: AREG, EREG EGFR-TK Target for EGFT-TK inhibitor pY EGF Receptor: A Rational Target for CRC Therapy

21. EGFR/HER-2 Expression in GE cancer EGFR expression RangeRef. Esophageal43-89%Herbst (2002) Gastric50-63% Rojo (2003) Matsubara (2007) HER-2/neu expression RangeRef. Esophageal 36% IHC 2/3+ 22% FISH + Safran (2006) Brien (2000) Gastric 0-43% (20% GC, 34% GEJC) Rojo (2003) Safran (2006) Matsubara (2007) Kang (2008) Hecht (2008) EGFR expression correlates with OS in EC (Kitagawa, 1996) EGFR and TGF-  expression correlate with OS in EC (Lihara, 1993) and GC (Yonemura, 1992) HER2 gene amplification correlates with OS in EC (adeno) (Brien, 2000)

22. EGFr Tyrosine Kinase Inhibitors: Phase II, Adenocarcinoma Gastric Number Patients % Response Dragovich (Erlotinib) 250% Doi (Gefitinib) 751% GE Junction Ferry (Gefitinib) 2711% Janmaat (Gefitinib) 260% Tew (Erlotinib) 170% Dragovich(Erlotinib)43 Total: 7/113 9%6% Doi 1036 Proc ASCO 22, 2003; Ferry Clin Can Res 132:5869; 2007 Janmaat JCO 24: 1612; 2006;Tew GI ASCO 2005; Dragovich JCO 24: 4922; 2006

23. EGFr Tyrosine Kinase Inhibitors: Phase II, Squamous Carcinoma Number Patients % Response Gefitinib Janmaat(Squamous)911% Erlotonib Tew(Squamous)1315% Janmaat JCO 24: 1612; 2006;Tew GI ASCO 2005;

24. EGFR/HER-2 inhibitors in GE cancer Should KRAS gene status be revisited? KRAS mutations NRef. Esophageal9%Janmaat (2006) GE3%Gold (2008) Gastric7%Gylling (2007) No major impact of KRAS gene status in patients with esophageal and gastric cancer

25. Phase II CALGB 80403/ECOG 1206 Completed, ASCO 2010 Metastatic Esophagogastric Cancer Irinotecan + Cisplatin + Cetuximab ECF + Cetuximab FOLFOX + Cetuximab Primary end point: Response rate

26. Rationale for targeting other receptors & downstream signaling proteins Insulin-like growth factor receptor –ILGF1R expression in GC: 77%. Correlation with EGFR/HER2 expression, intestinal type and poor survival (Matsubara, 2007) –9 EC cell lines sensitive to picropodophyllin (PPI), an IGF1R TKI (Bergqvist, 2007)

27. CpG Island Methylator Phenotype (CIMP) Tumor A: Tumor B: Tumor C: Tumor D: Tumor E: Tumor F:

30. HER2 Inhibitors: Trastuzumab and Lapatinib ASCO 2008, Abstr 4526, Bang, et al. –Analysis of 2484 gastric cancer samples from the Ph III ToGA trial –21.9% HER2 positivity ASCO 2009, Abstr LBA 4509, ToGA Trial –Rand Ph III, HER2+ gastric cancer –5-FU/capecitabine + cisplatin +/- trastuzumab –RR 47.3 vs. 34.5%, OS 13.5 vs. 11.1 mo (p = 0.0048) –HR 0.74 (0.60-0.91) –Practice changing!!! LOGIC Trial –Rand Ph III, HER 2+ gastric cancer –Capecitabine + oxaliplatin +/- lapatinib

31. Her2 gene expression associated with OS in patients with metastatic gastric cancer treated with lapatinib

32. Il-8 associated with PFS in patients with metastatic gastric cancer treated with lapatinib

33. ToGA trial design HER2-positive advanced GC (n=584) 5-FU or capecitabine a + cisplatin (n=290) R a Chosen at investigator’s discretion GEJ, gastroesophageal junction 5-FU or capecitabine a + cisplatin + trastuzumab (n=294) Stratification factors −advanced vs metastatic −GC vs GEJ −measurable vs non-measurable −ECOG PS 0-1 vs 2 −capecitabine vs 5-FU Phase III, randomized, open-label, international, multicenter study 1 Bang et al; Abstract 4556, ASCO 2009 3807 patients screened 1 810 HER2-positive (22.1%)

34. Primary end point: OS Time (months) 294 290 277 266 246 223 209 185 173 143 147 117 113 90 64 71 47 56 32 43 24 30 16 21 14 13 7 12 6 6565 4040 1010 0000 No. at risk 11.113.8 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 024681012141618202224262830323436 Event FC + T FC Events 167 182 HR 0.74 95% CI 0.60, 0.91 p value 0.0046 Median OS 13.8 11.1 T, trastuzumab

35. Secondary end point: tumor response rate 2.4% 5.4% 32.1% 41.8% 34.5% 47.3% Intent to treat ORR= CR + PR CR, complete response; PR, partial response p=0.0599 p=0.0145 F+C + trastuzumab F+C p=0.0017 Patients (%) CRPRORR

36. Nucleotide excision repair

37. Pre-clinical studies showing ERCC1 to be a determinant of platinum efficacy Youn et al Oncogenic H-Ras Up-Regulates Expression of ERCC1 to Protect Cells from Platinum-Based Anticancer Agents Cancer Res 2004:64, 4849-4857.

38. ERCC1 mRNA Levels vs Response in Gastric Cancer Patients Receiving FP Metzger R, et al. J Clin Oncol. 1998;16(1):309-316. ERCC1: p=.004 by Kruskal-Wallis test. ERCC1 Expression 20 16 12 8 4 0 ResponseNo Response

39. Clinical Study ERCC1 Threshold for Platin Sensitivity: Response Genetics Scale Percent Patients with Low ERCC1BenefitRef NSCLC: GILT (Platin Doublets)ERCC1<1.753RR=53%Cobo et al JCO 2007 NSCLC: MADeIT (Platin Doublets)ERCC1<1.4450 RR=44%, Increased SurvivalSim et al JCO 2007 CRC: FOLFOXERCC1<1.780 Increased Survival and ResponseShirota et al JCO 2001 CRC: FOLFOX ValidationERCC1<1.780 Increased SurvivalLenz et al ASCO 2008 Gastric: 5-FU/CisERCC1<1.4650 Increased SurvivalMetzger et al JCO 1998 Gastric: FOLFOXERCC1<1.7964 Increased SurvivalJ Wei et al ASCO 2007 Gastric: FOLFOXERCC1<2.280 Increased Survival J Wei et al British J of Cancer 2008 Gastric: Platin (S-1/Oxaliplatin)ERCC1<1.8567 Increased RR and Survival Matsubara et al British J of Cancer 2008 ERCC1 Thresholds and Increased Benefit from Platin Therapy (Low ERCC1)

40. ERCC-1 gene expression associated with overall survival in 76 patients with gastric cancer treated with 5-FU/oxaliplatin Wei Jia et al Br j Cancer 2008

41. n=99 Endpoints feasibility and increase of PFS SWOG Prospective Trial Proposed ERCC1 of FOLFOX versus CPT11/Taxotere PI: Iqbal Genotypic Arm ERCC1 Selection High ERCC1 CPT11/Taxotere ASSIGNMENTASSIGNMENT RANDOMRANDOM Her2+ receive trastuzumab in both arms

42. Future Directions: Tailoring of Therapy Molecular Signatures for Targeted and Cytotoxic Therapies –Her2 –ERCC-1 Identification of critical pathways in Gastric Cancer (IGFR, cmet, HSP90) to introduce novel therapies Identification of Predictive and Prognostic Markers –Tumor, Host, Environment

43. Sharon Carpenter Laboratory