Caratterizzazione genomica dei tumori e impatto terapeutico per i pazienti

Andrea NecchiFondazione IRCCS Istitio Nazionale dei Ttmori, MilanoEtropean Associaton of Urology – Research Fotndaton

Disclosures

Consultng or Advisory Role:

• Company: Roche, Bayer, Merck & Co. Inc., Astra Zeneca, Janssen,

Astellas/Seatle enetcs, Clovis Oncology, BioClin Therapeutcs, Foundaton

Medicine

Travel, Accommodatons, Expenses:

• Company: Roche, Merck & Co. Inc., Janssen, PeerVoice

Research Funding (Insttuton):

• Company: Merck & Co. Inc., Astra Zeneca

Presentaton agenda

- To highlight the role of immunotherapy as a “precision therapy” in U cancers

- The TMB/microsaielliie insiabiliiy feaitre and ihe freqtency of germline mtiatons

- F FR inhibitors: a success story and insights into therapeutc sequences

- Emerging molecular targets from routne clinical testng and clinical research

- Q&A

©2015 Foundaton Medicine, Inc. | Confdental 4

CLIA-certfed, FDA-approved, CAP-accredited laboratory, NYS-approved

• Sample requirements:

• Surface area >25 mm2

• Sample volume >1mm3

• Tumor content >20%

• Laboratory process:

• >50 ng dsDNA• Library constructon

• Hybridizaton capture• Sequencing on Illumina HiSeq

platorm

• Customized computatonal biology algorithms

• Manual secondary review

• Report curaton:

• Clinically relevant A• FDA-approved therapies in

patent tumor type• FDA approved therapies in other

tumor types• Available clinical trials

Sample requirements:Sample requirements: Laboratory process:Laboratory process: Analytc methods:Analytc methods: Report curaton:Report curaton:

Turnaround tme ~14 days

FoundatonONETM Assay: comprehensive genomic profling

©2013 Foundaton Medicine, Inc. | Confdental 5

Analytcal Validaton• Demonstraton of high accuracy and reproducibility

required for clinical use

Base Substtutons (MAF 5-100%)Sensitvity: >99.9%; PPV: >99.9%

Insertons/Deletons (1-40bp, MAF 10-100%) Sensitvity: 98%; PPV: >99%

Copy Number Alteratons (>20% tumor content, zero or ≥8 copies)Sensitvity: >95%; PPV: >99%

Gene Fusions(>20% tumor content, select introns)Sensitvity: >99%; PPV: >99%

Controlled validaton studies:

Cell-line pools with known alteratons:

- 2056 subs 227 indels

- 210 CNAs 32 fusions

Concordance studies with existng platorms on clinical samples:

- 118 subs/indels: Sequenom, PCR

- 185 CNAs: FISH, IHC

- 43 fusions: break-apart FISH

Frampton et al, Naitre Bioiechnology 2013

To highlight the role of immunotherapy as “precision therapy” in GU cancers

Atezolizumab (US/EU) (2L)

26-year gap

Vinfunine (EU only)

BCG

Durvalumab (US) (2L)

Atezolizumab (US/EU)(1L) cisplatn-ineligible

Nivolumab (US/EU) (2L)

Avelumab (US) (2L)

Pembrolizumab (US/EU) (1L cisplatn-ineligible) (2L)

Five checkpoint inhibitors now approved for UC!

1990 2009 MAY 2016 FEB 2017 APR 2017 MAY 1, 2017 MAY 9, 2017 MAY 18, 2017

The therapeutc area of UBC has evolved rapidly following the 2016 approval of atezolizumab

1. htps://www.fda.gov/newsevents/newsroom/pressannouncements/ucm501762.htm; 2. htps://www.fda.gov/Drugs/InformatonOnDrugs/ApprovedDrugs/ucm539646.htm;3. htps://www.roche.com/media/store/releases/med-cor-2017-04-18.htm; 4. htps://www.fda.gov/drugs/informatonondrugs/approveddrugs/ucm555930.htm;5. htps://www.fda.gov/drugs/informatonondrugs/approveddrugs/ucm557162.htm; 6. htps://www.fda.gov/Drugs/InformatonOnDrugs/ApprovedDrugs/ucm559300.htm.

1L, frst-line; 2L, second-line; BC , Bacillus Calmete– uérin vaccine; UC, urothelial carcinoma.

Selecton of Appropriate Genitourinary Cancers for Immunotherapy

• Immunotherapy uses in genitourinary cancers– FDA Approved Indicatons

• Urothelial carcinoma• Clear cell renal cell carcinoma

– Other potental approvals• High-grade castrate resistant prostate cancer with high tumor mutaton burden• Platnum-resistant testcular germ cell tumors with high mutaton burden

• Biomarkers predictng immunotherapy response in genitourinary cancers– PD-L1 immunostaining– PD-L1 (CD-274) ene Amplifcaton– MSI status– Tumor Mutaton Burden– g-interferon signature– Emerging Single ene Biomarkers

• PBRM1 mutaton status• STK11 mutaton status• MDM2 amplifcaton status

SCORING DEFINITION1

SP1421SP1421 IC ≥5%IC ≥5%

CUT-OFF1-3ASSAY USED IN CLINICAL TRIALS BY!

Roche2Roche2

The proportion of tumour area occupied by PD-L1 expressing ICs of any intensity

UC: Roche algorithm uses IC score

• IC, tumour-infltratng immune cells; PD-L1, programmed cell death ligand-1; UC, urothelial carcinoma • 1. VENTANA PD-L1 (SP142) Assay package insert. htps://www.accessdata.fda.gov/cdrh_docs/pdf16/P160002c.pdf (accessed Dec 2017); 2. Powles T, et al. Oral presented at EACR 2017; 3. Rosenberg• JE, et al. Lancet 2016;387:1909–20.

Tumour area

IC area with PD-L1 expression

SCORING DEFINITION1

28-8128-81

TC ≥5%3TC ≥5%3

TC ≥1%1,2TC ≥1%1,2

CUT-OFFASSAY USED IN CLINICAL TRIALS BY!

Bristol-Myers Squibb2Bristol-Myers Squibb2The proportion of TCs with membrane staining for PD-L1 at any intensity above background staining

UC: BMS and Pfzer / Merck KGaA algorithms use TC score

• BMS, Bristol-Myers Squibb; IC, tumour-infltratng immune cells; PD-L1, programmed cell death ligand-1; TC, tumour cells; UC, urothelial carcinoma • 1. Dako 28-8 pharmDx UC interpretaton manual. htp://www.agilent.com/cs/library/usermanuals/public/29188_pdl1-ihc-28-8-uc-interpretaton-manual.pdf (accessed Dec 2017); 2. Sharma P, et al. Lancet Oncol • 2017;18:312-322; 3. Patel MR et al. Lancet Oncol 2018 19(1):51-64

TC area with PD-L1 expression

TC area

73-10 373-10 3 Pfizer / Merck KGaA3Pfizer / Merck KGaA3

SCORING DEFINITION1

22C31,222C31,2 CPS ≥10%*CPS ≥10%*

CUT-OFF1,2ASSAY USED IN CLINICAL TRIALS BY!

MSD/Merck USA1,2MSD/Merck USA1,2The percentage of PD-L1 expressing TCs and ICs relative to the total number of TCs (CPS)

UC: MSD/Merck USA algorithm uses CPS score of TCs and ICs

• CPS, combined positve score; IC, tumour-infltratng immune cells; MSD, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co; PD-L1, programmed cell death ligand-1; TC, tumour cells; UC, urothelial carcinoma • 1. Bellmunt J, et al. N Engl J Med 2017;376:1015-1026; 2. Balar AV, et al. Lancet Oncol 2017;18(11):1483-1492

TCs with PD-L1 expression

Total TCs

ICs with PD-L1 expression

+

*Combined positive score includes TCs and ICs (see scoring definition)

SCORING DEFINITION1

SP2631SP2631

IC ≥25%IC ≥25%ORORTC ≥25%TC ≥25%

CUT-OFF1,2ASSAY USED IN CLINICAL TRIALS BY!

AstraZeneca2AstraZeneca2

UC: AstraZeneca algorithm uses TC and IC scores

• IC, tumour-infltratng immune cells; PD-L1, programmed cell death ligand-1; TC, tumour cells; UC, urothelial carcinoma • 1. VENTANA PD-L1 (SP263) Assay interpretaton guide. htps://www.accessdata.fda.gov/cdrh_docs/pdf16/P160046C.pdf (accessed Dec 2017); 2. Massard C, et at. J Clin Oncol 2016;34:3119-3125.

TC area with PD-L1 expression

TC area

OR IC area with PD-L1 expression

IC area

TC: proportion of TCs with membrane staining for PD-L1 at any intensity above background staining IC: proportion of ICs with staining for PD-L1 at any intensity above background staining

TC area with PD-L1 expression

TC area

TCsTCs ICsICs

UC

Not scoredTCs with PD-L1 expression + ICs with PD-L1 expression

Total number of TCs

TCsTCs ICsICs

TCsTCs

Not scored

ICsICs

IC area with PD-L1 expression

Tumour area

TCsTCs ICs*ICs*

TC area with PD-L1 expression

TC area

IC area with PD-L1 expression

IC area

Bristol-Myers Squibb, Pfizer / Merck KGaA1-3

Roche6-8 AstraZeneca9,10

MSD/Merck USA4,5

Summary of PD-L1 IHC assay scoring in UC

• *When ICs are >1% of the tumour area. When ICs =1% of the tumour area, normal scoring is believed to be beyond the limit of detecton for the pathologist; in these circumstances a simplifed method is used1

• IC, tumour-infltratng immune cells; IHC, immunohistochemistry; MSD, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co; PD-L1, programmed cell death ligand-1; TC, tumour cells; UC, urothelial carcinoma • 1. Dako 28-8 pharmDx UC interpretaton manual. htp://www.agilent.com/cs/library/usermanuals/public/29188_pd-l1-ihc-28-8-uc-interpretaton-manual.pdf (accessed Dec 2017); 2. Sharma P, et al. Lancet Oncol

2017;18:312-322; 3. Patel MR et al. Lancet Oncol 2018;19(1):51-64; 4. Bellmunt J, et al. N Engl J Med 2017;376:1015-1026; 5. Balar AV, et al. Lancet Oncol 2017;18(11):1483-1492; 6. VENTANA PD-L1 (SP142) Assay package insert. htps://www.accessdata.fda.gov/cdrh_docs/pdf16/P160002c.pdf (accessed Dec 2017); 7. Powles T, et al. Oral presented at EACR 2017; 8. Rosenberg JE, et al. Lancet 2016;387:1909–20; 9. VENTANA PD-L1 (SP263) Assay interpretaton guide. htps://www.accessdata.fda.gov/cdrh_docs/pdf16/P160046C.pdf (accessed Dec 2017); 10. Massard C, et at. J Clin Oncol 2016;34:3119-3125

SP263 TC/IC 25%

OPA 69.9%PPA 15.3%NPA 99.5%

OPA 81.5%PPA 62.7%NPA 91.7%

Caveat: In this sample cohort, only 6% of samples were classed as PD-L1 high by SP142 assay using IC 5% algorithmTC, tumour cell; IC, tumour-infiltrating immune cells; NPA, negative percentage agreement; OPA, overall percentage agreement; PPA, positive percentage agreementPowles T, et al. Oral presentation at EMUC 2017

Discordance explained by:• Inclusion of TC in SP263 algorithm vs SP142 algorithm• Lower TC cut off for 22C3 CPS algorithm vs SP263 algorithm • Different denominators for IC scoring approach in all 3 cases

There are diferences in the populatons selected by 22C3 (CPS 10%), SP142 (IC 5%) and SP263 (TC/IC 25%) algorithms

SP263TC/IC 25%

SP142 IC 5%

22C3CPS 10%

Lymphoepithelioma-like bladder UC: PD-L1 IHC sustained by PD-L1/2 gene amplifcaton

* PD

L1/2

am

p

PD-L1 CPS: 95%

Necchi A, et al. AACR2018, AUA2018, ASCO2018

Case ID#31: T3N0 > pT0pN0

Beyond PD-L1: The Search for New Biomarkers—A Multparameter Approach

BATF3, basic leucine aipper ATF-like transcripton factor 3; CCL5, chemokine (C-C motf) ligand 5; CCR5, C-C chemokine receptor type 5; CRP, C-reactve protein; DC, dendritc cell; ESR, erythrocyte sedimentaton rate; IDO, indoleamine 2,3-dioxygenase; IL, interleukin; LA 3, lymphocyte-actvaton gene 3; LDH, lactate dehydrogenase; MHC, major histocompatbility complex; TIL, tumor infltratng lymphocyte; TI IT, T-cell immunoreceptor with immunoglobulin and immunoreceptor tyrosine-based inhibiton motf domains.

Adapted from Blank CU, et al. Science. 2016;352(6286):658-660.

Tumor sensitvity to immune efectors

MHC expression/ftnctonMHC polymorphisms/mtiatons

IFN-γ sensitvityGene expression

Absence of soluble inhibitorsIL-6 CRP/ESR

CD73 adenosine

General immune statusLymphocyie cotni, TIM3, LAG3, TIGIT, CD27,

Ki67, PD-1 + CD8

MicrobiomeLow baciericides

High Faecalibacterium prausnitzil

Tumor foreignnessNeoantgen load

TMB, DDR and ctDNA

Absence of inhibitory tumor metabolism

LDH, gltcose ttlizatonIDO1, itmor acidiiy

Immune cellinfltraton

Iniraitmoral T cellsShared T-cell clones

B7-H3/CD276 macrophagesCCL5-atractng T cells

NK cellsCCR5-expressing BATF3 DCs

Spatal correlatonsAbsence of checkpoints PD-L1

Predictve Biomarkers: MSI Status

• FDA-approved as a companion biomarker for pembrolizumab for all solid tumors including U cancers

• MSI-high status extremely uncommon in U cancers (1-2% of cases)

• Virtually all MSI-High cancers are TMB high

MSI-High is a subset of high TMB specimens (100,000 htman cancer genomes)~84% of MSI-H specimens are TMB-H… ….However only 14.5% of TMB-H specimens are MSI-H

Microsatellite stable

Microsatellite ambiguous

Microsatellite instable

All specimensn = 46,465

MSI and TMB High n = 550

TMB-Highn = 3,531

Chalmers et al. enome Medicine (2017);9:34

High MSI sensor score (MSK-IMPACT) is associated with increased mutaton burden

Presented By Gopa Iyer at 2017 ASCO Annual Meeting

High MSI sensor score is associated with Lynch Syndrome

Tumor-Specifc Mutatons Have the Potental to Generate Neoantgens

Zehir A, et al. Nat Med. 2017 Jun;23(6):703-713

Mutaton Load Comparisons

Johnson, DB et al. Hybrid Capture-Based Next- eneraton Sequencing in Melanoma Identfes Markers of Response to ant-PD-1/PD-L1. ASCO, 2016

FoundatonONE and MSK-IMPACT next generaton sequencing panels (both FDA-approved) can accurately impute mutaton load

Zehir A, et al. Nat Med. 2017 Jun;23(6):703-713

TMB Categories

TMB - High greater than or equal to 20 mutatons per megabase (~7% of specimens tested at Foundaton Medicine are TMB-High)

TMB – Intermediate between 6 and 19 mutatons per megabase (~38% of specimens tested at Foundaton Medicine are TMB-Intermediate)

TMB - Low less than or equal to 5 mutatons per megabase (~55% of specimens tested at Foundaton Medicine are TMB-Low)

TMB – Unknown (cannot be determined)

A determinaton of TMB could not be made for this specimen due at least in part to low tumor content, high contaminaton rate, or poor exon coverage.

High TMB associated with ICPI OS in bladder cancer

Quartle-split TMB is associated with ant-PD-L1 OS in urothelial carcinomaPatents with the highest TMB (Q4) had signifcantly longer OS vs those in Q1-Q3a

Rosenberg J, et al. IMvigor210: Biomarkers of atezolizumab in mUC. The Lancet, 2016; ASCO 2016

OS

prob

abili

ty

100%

75%

50%

25%

0%

Days0 100 200 300 400 500 600

Cohort 11L cisplatn-ineligible mUC

Pa= 0.0079

Median load quartile (range)

– Q4: ( > 13.5 to ≤ 46.8) – Q3: ( > 9.0 to ≤ 13.5)– Q2: ( > 5.4 to ≤ 9.0)– Q1: (≥ 0 to ≤ 5.4)

(n = 150)

Mut

aton

load

/MB

0

10

20

30

40

OS

prob

abili

ty

Days0 100 200 300 400 500 600

100%

75%

50%

25%

0%

Cohort 2Platntm-ireaied mUC

Pa= 0.0012

Median load quartile (range)

– Q4: ( > 16.0 to ≤ 62.2) – Q3: ( > 8.1 to ≤ 16.0)– Q2: ( > 5.4 to ≤ 8.1)– Q1: (≥ 0.9 to ≤ 5.4)

TMB Distribution

SD/PD CR/PR

0 10 20 300

20

40

60

80

100

PD-L

1 CP

S (%

)TMB (mut/Mb)

Lack of correlaton between PD-L1 IHC and TMB in UC treated with IO in diferent clinical stages• PD-L1 IHC and TMB meastre distnci biological feaitres

Powles T, et al. U-ASCO 2018 Necchi A, et al. ASCO 2018

Pearson’s r =-0.118, p=0.416

Necchi A, et al. Eur Urol Focus 2018

Predictve Biomarkers of response to immunotherapy in UC cancers: DDR-gene amplifcatons and response to IO – MSKCC cohort

Teo MY, et al. J Clin Oncol 2018

Emerging Single Gene Predictve Biomarkers of ICPI Response

Markers of EfcacyBRAF mutatonMET Exon 14 splice site mutatonPBRM1 mutaton

Markers of ResistanceSTK11 (LKB1)JAK1/2

Markers of Hyper-ProgressionMDM2 amplifcaton

Sharma et al., Cell 2017

PBRM1 Mutaton and Clinical Beneft from ICPI in ccRCC

D. Miao ei al., Science 10.1126/science.aan5951 (2018)

Predictve Biomarkers: PBRM1 Mutaton in ccRCCMetastatc clear cell renal cell carcinoma to bone in a 70 year old Caucasian man. Comprehensive genomic profling revealed an inactvatng splice site 528+1 >C mutaton in PBRM1 and an inactvatng N141fs*3 mutaton in the VHL gene. The tumor was MSI stable and the TMB was 4 mutaton/Mb. In additon, IHC staining for PD-L1 was negatve (inset). PBRM1 protein loss or mutaton is correlated with late tumor stage, low diferentaton grade, and/or poor patent prognosis in ccRCC. In ccRCC, PBRM1 alteratons are generally observed to be uniformly detected in ccRCC with VHL inactvatng mutatons as seen in this case. PBRM1 mutatons in ccRCC, in contrast with mesotheliomas, appear to be mutually exclusive with BAP1 alteratons.

PBRM1Mtiaton

VHL Mutaton

Bratslavsky , et al. ASCO 2018

PBRM1 Mutaton Frequencies and Co-Altered Genes

Tumor Type Frequency of PRMB1 Genomic

Alteratons

Clear Cell RCC 41%

Papillary RCC 23%

Peritoneal Mesothelioma 19%

Intra-hepatc Cholangiocarcinoma

9%

Extra-hepatc Cholangiocarcinoma

7%

Pleural Mesothelioma 7%

Melanoma 3%

Non-small Cell Lung Cancer

2%

Breast Carcinoma 2%

Colorectal Carcinoma 1%

Bratslavsky et al. ASCO 2018

STK11/LKB1 Mutatons and PD-1 Inhibitor Resistance in KRAS-Mutant Lung AdenocarcinomaInactiaton of STK11 (or iis proiein prodtci, LKB1) by mtiatonal or nonmtiatonal mechanisms is associaied wiih an ineri or “cold” itmor immtne microeniironmeni, wiih redtced densiiy of infliratng cyioioxic CD8+ T lymphocyies

STK11 alteratons enriched in TMB HIGH, PD-L1 LOW tumors STK11-mutant NSCLCs may do worse on immunotherapies

HR = 2.59; P = 0.0314Bonferroni P = 3.23*10-12

This obseriaton is now confrmed by oiher grotps and while proiocatie, reqtires ialidaton in additonal cohoris

Skoulidis F, et al. Cancer Discov 2018 (ePub ahead of print)

Bladder cancerF FR inhibitors – a success story;insights into therapeutc sequences

Foundaton Medicine Cohort (n=295)

Ross JS, et. al. Cancer, 2015

• There were 75% male and 25% female patents with a mean age of 66 years

• 295/295 (100%) of UC were high grade 295/295 (100%) of UC were advanced stage (III and IV)

• 294/295 (99.7%) UC featured at least 1 genomic alteraton ( A) on comprehensive profling with a mean of 6.4 A/UC

• 61% SUB + INDEL

• 37% CNA

• 2% fusions.

• 275 (93%) UC had at least 1 clinically relevant A (CR A) involving 75 individual genes with a mean of 2.6 CR A/UC

• The most common clinically CR As were:

• CDKN2A (34%)

• F FR3 (21%)

• PIK3CA (20%)

• F FR3 A were of diverse type and included 10% fusions

Foundaton Medicine Cohort (n=295)

Ross JS, et. al. Cancer, 2015

ene Substtuton Truncaton Amplifcaton Deleton Fusion/Rearrangement

Total count % of samples

F FR3 53 2 1 0 7 63 21.4%

Foundaton Medicine Cohort (n=295)

Ross JS, et. al. Cancer, 2015

Phase 2 Erdafnitb in FGFR – Altered mUC

• Pan-F FR (1-4) actvity

• Study evaluated multple dose/schedules– 8 mg QD (N=99)

• Centrally selected for F FR fusions or mutatons

36 Siefer-Radtke et al J Clin Oncol 36, 2018 (suppl; abstr 4503)

FGFR3% TACC3%

FGFR3)TACC3%fusion'gene'

PKinase'

!!!!!!!aa1!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!aa794!!!!!!aa1!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!aa838!

Protein'domains'

Ex'2416'

TACC'

Ex'1418'

TM''Ig'''''''''I4set''''I4set'

FGFR (3%) TACC3 (3%) Fusion Gene

• 66F with stage IV disease

• FGFR3-TACC3 fusion as well as CDKN2A/B loss, MDM2 amplifcaton and the MLL2 5467fs*20 mutaton seen

• 21.4% of the UC in this study harbored alteratons of FGFR3 including base substtutons (83%), amplifcatons (2%) and fusions (11%)

Foundaton Medicine Cohort (n=295)

Ross JS, et. al. Cancer, 2015

Enrichment of F FR3-TACC3 Fusions in Patents With Bladder Cancer Who Are Young, Asian, or Have Never Smoked – combined DFCI and TC A cohorts

Nassar AH, et al. JCO Precis Oncol 2018

Strategies for taking genomic profling

into the clinic

1 2 3 4 5 6 7 8 9 10 11 12 13 140

20

40

60

80

100

%

genomic alterations unique in pre-therapy samples genomic alterations unique in post-therapy samplesShared genomic alterations

Pembrolizumab > Radical Cystectomy in MIBC (PURE-01 study)• The proporton of pre-therapy versus shared versus post-therapy genomic alteratons

(FoundatonONE assay) in 14 patents with paired tumor tssue samples

Necchi A, et al. ASCO 2018, ESMO 2018

Need for tumor biopsy afer IO

Patent journey and therapeutc optons across the clinical stages

MIBC/1L metastatc• Neoadjuvant/

Adjuvant/1L Cisplatn-base chemo frst

Cis-ineligible/treated pts, FGFR-mutaton/fusion+

tumorpan-F FR inhibitor-

frst?

Cis-ineligible/treated pts, FGFR wild-type tumors

ICI frst opton

(IO combo?)

ICI progression, FGFR wild-type

Ramucirumab-docetaxel frst1

Contnue ICI

Salvage chemo

1. Petrylak DP, et al. Lancet. 2017 Sep 12. pii: S0140-6736(17)32365-6F FR: fbroblas growth-factor receptor; ICI: immune checkpoint inhibitors; IO: immune-oncology; MIBC: muscle-invasive bladder cancer

Strategies for taking genomic profling into the clinic

Detailed analyses of: MET mutation, MET amplification

S1500 (N=180)

P.I.: SK Pal; NCT02761057

A Phase II Trial of Risk Enabled Therapy Afer Initatng Neoadjuvant Chemotherapy for Bladder Cancer (RETAIN BLADDER) NCT02710734

Major Inclusion Criteria:

• cT2-T3 N0M0• ECO 0-1• Urothelial Predominant Histology • MFS is defned as the absence of a recurrence of urothelial carcinoma that is

>cN1 (more than one clinically suspicious pelvic lymph node) or surgically unresectable local recurrence (eg, cT4a) or M1 disease.

Sequencing(Caris)

Mutaton positvedefned as any alteratons in:

• ATM• RB1• FANCC• ERCC2

No residualtumor/ cT-0

ANDMutaton Pos (+1)

cTa or cTis or cT1 or Pos (+)

cytology or cT0 mutaton Neg (-)

cT2

≥cT3

Patent & Physician Choose

Primary Endpoint: Metastasis-free survival (MFS) at 2 years.Non-inferiority design with a 14% margin between risk-adapted design (MFS=78%) and standard-of-care (MFS=64%).Sample size=70 with an 82% power. Type I error=0.045

TURBT #1 AMVAC x 3 TURBT #2

ActveSurveillance

Intravesicle Tx

OR

Chemo-RT

OR

Cystectomy

Chemo-RT

OR

Cystectomy

Cystectomy

Patent & Physician Choose

Study NCT02710734. ClinicalTrials.gov website. Accessed May 25, 2018

BISCAY: open-label, randomised, mult-drug, biomarker-directed, multcentre, mult-arm Phase 1b study in patents with muscle-invasive bladder cancer who have progressed on prior treatment

*STUDY OPEN in UK, US, France, Spain, Canada centres

A Phase 1b umbrella* study and the first multi-drug study combining immunotherapy and small molecule agents in metastatic bladder cancer

1. Objective is to explore predictive value of common molecular aberrations in MIBC

2. Assign patients to a cohort with the best chance of benefit

3. Primary endpoint is ORR

4. Ensure that all patients have the option to receive immunotherapy

5. Signal search within each cohort and make early decisions based on the benefit-risk

6. Carry out further collaborative translational science work

7. Option for additional cohorts to be added to the overall study based on translational science evidence

8. Steer the study in direction of where the science is leading

9. Can enable rapid deployment to earlier stages

FGFR3 mutation or FGFR1,2,3 fusion AZD4547Yes

ATM and / or BRCA1/2 and / or Other HRR genes

alterations*

OlaparibYes

AZD1775

MYC / MYCL1 / MYCN or CCNE1 amplification or

CDKN2A and / or RB1 alteration

Yes

NoDurvalumab

Yes

Central Foundation

Medicine Report

No alteration detected in any genes determining eligibility for the study

RICTOR amplification or TSC1 / TSC2

alterationVistusertibYes

Vistusertib

Randomise to AZD4547 + Durva or AZD4547 alone

(2:1)

Durvalumab plus

No

No

No

AZD9150

A

B

E

E

C

D

F

Of-label therapy:Oct 2017 > Sept 2018Olaparib 400 mg bid

Previous treatments: Atezolizumab > MVAC > Vinfunine

Exceptonal response to olaparib in BRCA2-altered urothelial carcinoma afer PD-L1 inhibitor and chemotherapy failure

PARP inhibitor trials in UC:• RUCAPARIB (unselected pts); NCT03375307 and

NCT03397394• OLAPARIB (enriched populaton); NCT03375307 and

NCT03448718• OLAPARIB + DURVALUMAB (enriched populaton); BISCAY

trial, NCT02546661• OLAPARIB + DURVALUMAB (CDDP-ineligible pts); BAYOU

trial, NCT 02516241

Necchi A, et al. Eur J Cancer 2018See Chung JH, et al. Pan-cancer assessment of BRCA1/2 genomic alteratons ( As) by comprehensive genomic profling (C P) of tssue and circulatng tumor DNA (ctDNA). ESMO 2018

ermline/somatc status was determined computatonally2 for short variant mutatons in each of the DNA repair genes

ermline mutatons were observed in 57.8% of BRCA2-mutated cases, 25.0% of BRCA1-mutated cases, 35.8% of ATM-mutated cases, 80.0% of CHEK2-mutated cases, 52.2% of FANCA-mutated cases, 42.3% of MSH2-mutated cases, 20.0% of MSH6-mutated cases, 25.0% of MLH1-mutated cases, and 44.4% of PMS2-mutated cases

1. Chung J, et al. (paper in press); 2. Sun JX, et al. PLOS Comput. Biol. 2018

Prospectve comprehensive genomic profling of 3,476 primary and metastatc prostate tumors1

Somatc vs Germline DDR gene alteratons in UC, RCC and PCaFrequency and distributon of pathogenic germline mutatons in 176 patents with UC

Carlo MI, et al. J Clin Oncol 36, 2018 (suppl; abstr 1516)Carlo MI, et al. JAMA Oncol. 2018 Sep 1;4(9):1228-1235

16.1%

• N S has revolutonized precision oncology, with paired somatc and germline DNA variant analysis becoming more powerful and more widely accessible for clinical applicaton

• A signifcant porton of patents have been incidentally found to have pathogenic or likely pathogenic germline mutatons

• Many of these patents do not meet current clinical criteria for germline testng

• Thus, mutatons in genes that are potentally associated with a patent’s cancer treatment and care, as well as cancer risk and preventon for the patent’s family members, are going undiscovered

Broadening the View of Germline Mutatons in GU cancers

Confdental – Do Not Distribute

Everolimus: Applying FM Results to an Individual Case

• A 60 year old female post neo-adjuvant cisplatn and gemcitabine with cystectomy showing advanced UC

• Afer tumor progression, C P revealed alteratons in NF2 Y153*1 (minor allele frequency MAF]: 7%), ATM V2119fs*8 (MAF: 8%), ATR splice site 7349+2T>C (MAF: 44%), and TP53 R280K (MAF: 6%)

• iven preclinical work suggestng NF2 loss may be associated with sensitvity to MTOR inhibitors, the patent was started on everolimus and paclitaxel using a dosing regimen currently being examined in a phase II study in urothelial carcinoma (everolimus at 10 mg oral daily and paclitaxel at 80 mg/m2 intravenous weekly)

• Imaging over 11 months of therapy with this regimen has demonstrated contnued regression of the vaginal cuf lesion and disappearance of the previously noted iliac adenopathy

Ali SM, Miller VA, Ross JS, Pal SK: Exceptional Response on Addition of Everolimus to Taxane in Urothelial Carcinoma Bearing an NF2 Mutation. Eur Urol 67:1195-6, 2015

Germ cell tumors - the most frequently reported genomic alteratons in the two histologic subgroups

Necchi A, et al. Eur Urol Focus 2018

Nonseminoma Seminoma

Necchi A, et al. Eur Urol Focus 2018

Clinical case of refractory testcular seminoma with outstanding response to FMI-based everolimus therapy

Patent-centric vision Vs. Patent-engaged vision in personalized medicine

New fgures are joining multdisciplinary discussions and clinical trials planning

The patent enetc counselor

Biostatstcian The engaged patentMolecular pathologist

andrea.necchi@isttutotumori.mi.it@AndreaNecchi