Strategies to Address Unmet Needs in

Small-Cell Lung Cancer

Ravi Salgia MD PhD

Professor and Chair,

Department of Medical Oncology & Therapeutics Research

Associate Director of Clinical Sciences,

City of Hope Comprehensive Cancer Center

Strategies to Address Unmet Needs in

SCLC

• Novel Therapy:

- Immunotherapy

- Targeted therapy (DLL3/DLL4, EZH2, EphB4,

MET/RON)

- Stem Cells

• Biomarkers:

- Liquid Biopsy (CTC, Exosomes)

• Animal Models

Small cell lung cancer (SCLC): no treatment advances in recent years

Koinis et al. Small cell lung cancer (SCLC): no

treatment advances in recent years. Transl

Lung Cancer Res 2016; Vol. 5.

Recent developments in genomic sequencing and immunotherapy may

translate to new treatment paradigms for SCLC

Immune checkpoint inhibition is another area of great promise in the

treatment of tumors with high mutational burden, and thus it is also of

interest in SCLC. Preliminary results from the KEYNOTE- 028 trial were

recently presented. In this Phase Ib trial, 135 patients with ES-SCLC who

had progressed on platinum-based chemotherapy were screened for PD-

L1 expression, with 27% testing positive. Ultimately, 17 patients were

enrolled and received the PD-1 antibody pembrolizumab leading to 25% of

patients with a partial response and a disease control rate of 31%.

Responses were durable at more than 16 weeks, but the trial is still

ongoing. The drug-related adverse event rate was high, however, at 53%,

though only one patient reportedly had a drug-related adverse event of at

least Grade 3.Curr Opin Oncol 2016; Vol 28

Novel Therapy: Immunotherapy

Monoclonal

antibodies

SCLC

Adaptive T-cell transfer

Checkpoint

inhibitors

Therapeutic vaccines

T-cell

from patient

Virus encodes

CAR

ex vivo

Dendritic cell

from patient

INGN225 encodes

TP53

ex vivo

MHC-I

p53 peptide

B7 CD8+

CD28

TCR

MHC-I

TCR

antigen

PD1

PDL1

Anti-PD1

Anti-PDL1

antigen

toxin

Immunotherapy in SCLC

Sattler and Salgia, 2016

Immunotherapy for small-cell lung cancer

Reck et al. Future Oncol. 2016; Vol 5

Positive Control Human Placenta PD-L1-positive tumor cellsPD-L1-positive tumor-infiltrating

immune cells

IHC of PD-L1 in Resected SCLC Using Different Antibodies and Criteria

Takada et al. An Immunohistochemical Analysis of

PD-L1 Protein Expression in Surgically Resected

Small Cell Lung Cancer Using Different Antibodies

and Criteria. Anticancer Res. 2016; Vol. 36

CTLA-4 blockade may remove the inhibitory signal and stimulate antitumor

immunity

Horn et al. The Future of Immunotherapy in the

Treatment of Small Cell Lung Cancer . The

Oncologist 2016; Vol. 21

Horn et al. The Future of Immunotherapy in the

Treatment of Small Cell Lung Cancer . The

Oncologist 2016; Vol. 21

Changes in tumour burden in individual patients Kaplan-Meier curves of overall survival (A)

and progression-free survival (B)

Time (weeks)

25

-25

-75

100

75

50

0

-50

-100

60 12 24 30 36 42 48 54 60 66

Time (weeks)

-100

-75

100

75

50

25

0

-25

-50

660 6 12 18 24 30 36 42 48 54 60

Changes in Tumor Burden

Nivolumab 3

Nivolumab 1 + Ipilimumab 1

First occurrence of new lesion

% change truncated to 100%

Confirmed PR or CR

Patients still on treatment

18

Nivolumab + IpilimumabaNivolumab

Nivolumab 1 + Ipilimumab 3P

erc

en

tag

e C

han

ge

Fro

m B

ase

lin

e (

%)

aCombined data for nivolumab 1 + ipilimumab 1 and nivolumab 1 + ipilimumab 3 cohorts. Only pts with target lesion at baseline and ≥1

on-treatment tumor assessment are included (nivolumab, n = 34, nivolumab + ipilimumab, n = 40).

Novel Therapy:

Targeted therapy: Targeted

therapy (DLL3/DLL4, EZH2,

EphB4, MET/RON)

Mamdani et al. Novel therapies in small cell lung cancer.

Transl Lung Cancer Res. Vol 5, No 1 :2016

Signaling pathways recurrently affected in SCLC

George J et al., Nature, 2015.

Karachaliou et al. Cellular and molecular biology of small cell lung

cancer: an overview. Transl Lung Cancer Res. Vol 5, No 1 :2016

Pharmacologic inhibition of EZH2 in SCLC inhibits growth in vitro and in

vivo

EZH2 expression is high in SCLC and correlates with progression of SCLC.

These results suggested new therapeutic strategies for targeting EZH2 and

ASCL1 in SCLC therapy.

Murai et al. Cell Discovery 2015

Human Receptor Tyrosine Kinases (MET/RON)

Cell proliferation,

Motility, Scattering,

Angiogenesis, EMT,

Invasion and Metastasis

MET and RON Synergism

The protein tyrosine kinase activity profile on PamChip microarrays

and their network analyses using MetaCore (GeneGo).

Ichiro Kawada et al. Cancer Res 2014

EphB4 in SCLC

Figure 2. EPHB4 mutations are mutually exclusive of other frequently aberrant cancer genes. A multiplex analysis of genes related to cancer using the SNaPshot platform was conducted on 23 SCLC patient samples.

Figure 3. EPHB4 protein expression in SCLC patient tissues. (A) Representative images of EPHB4 staining by IHC. (B) Summary of automated IHC scoring for EPHB4 expression between normal and tumor tissues (n=13). (C) Patient demographics and staging.

Figure 1. EphB4 protein structure and mutations identified in patient samples. Domains: LB, ligand binding;

CRD, cysteine-rich; FNIII, fibronectin III repeats; TM, transmembrane; TK, tyrosine kinase; SAM, sterile alpha motif.

Four novel nonsynonymous mutations were detected in SCLC patients samples: W534*, E536K, G723S, and P881S.

Novel Therapy:

Stem Cells

Codony-Servat et al. Cancer stem cells in small cell lung

cancer. Transl Lung Cancer Res. Vol 5, No 1 :2016

CSC characteristics:

Capacity of self-renewal;

asymmetric cell division;

slow division kinetic;

multipotency;

persistence;

infrequent;

tumorigenicity;

drug resistance;

metastasis and relapse

CSCs are associated with aggressive cancer behavior

Delta-like Protein 3 (DLL3): a novel target in neuroendocrine tumors

• An atypical inhibitory Notch ligand

• Induced by the key neuroendocrine transcription

factor, ASCL1

• Aberrant cell surface expression in >80% of small

cell lung and large cell neuroendocrine cancers

• On both cancer stem and tumor cells but not normal adult

tissues

• Not prognostic, and does not predict response to

chemotherapy

p53-/-

Precancerous

Lung

Stem Cell

Mature

Neuroendocrine

Tumor Cell

p53-/- RB1-/-

ASCL1

NotchDLL3

Cancer

Stem Cell

Tumor

Progenitor

Cell

Tu

mo

r-In

itia

tin

g C

ell

s

Saunders et al., Sci Transl Med 2015Rudin ASCO 2016

RECIST Confirmed Responses per Investigator

18%

39%

68%

89%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

60 26 60 26

≥50%

Number Evaluable

AllDLL3

Objective Response Rate

(ORR = PR+CR)

Clinical Benefit Rate

(CBR = SD+PR+CR)

Rate

≥50%All

Response-Evaluable Subjects

Active Doses (0.2-0.4 mg/kg)

Rudin ASCO 2016

Best Responses per Investigator by DLL3

-100

-80

-60

-40

-20

0

20

40

60

80

100

% C

hange f

rom

Baselin

e

+20%

-30%

Active Doses (0.2-0.4 mg/kg)

+20%

Rudin ASCO 2016

Comparison of the chemosensitivities of SCLC CTCs and tumor cell lines to cisplatin and etoposide

GLC14 and GLC16 stem cells from the same patient

before and after first cycles of chemotherapy.

DMS153 was cultured from a liver metastases and NCI-

H526 from bone metastases.

NCI-H417 was established from a primary lung SCLC

before treatment.

Comparison of the chemosensitivities of SCLC CTCs and tumor cell lines to epirubicin and topotecan

Hamilton et al. Second-line therapy for small cell lung

cancer: exploring the potential role of circulating tumor cells.

Transl Lung Cancer Res. Vol 5, No 1 :2016

Biomarkers:

Liquid Biopsy-(CTC, Exosomes)

Comparison of patient CTCs and CDXs

Hodgkinson et al. Nat Med. 2014

EXOSOMES IN LUNG CANCER PATIENTS

Exosome

s

Taverna et al. Oncotarget 2016

Animal Models SCLC:Genetically Engineered Models

(GEMMs)

Orthotopic Models

PDX Models

Gazdar et al. The comparative pathology of genetically engineered mouse models for neuroendocrine carcinomas of

the lung. J Thorac Oncol. 2015; Vol. 10

New orthotopic model for SCLC metastasis

Sakamoto et al. New metastatic model of

human small-cell lung cancer by

orthotopic transplantation in mice.

Cancer Sci 2015; Vol. 106

• Patient-Derived Xenograft (PDX) Mouse Models

Tentler et al., 2012

• PDX models are established by directly implanting patient tumor tissue into immune-deficient mice

• Passaging of the tumor is done by removal from one mouse and re-implanting a piece of the tumor in the new mouse

• There is no “in vitro” culturing of the tumor cells

Fig. 4. Demonstration of in vivo efficacy with

SC16LD6.5 (A to F) Mice bearing SCLC LU64

(A and D), SCLC LU86 (B and E), or LCNEC

LU37 (C and F) PDX tumors were treated with

IgG1LD6.5 or SC16LD6.5 (1 mg/kg) (A to C) on

a Q4D×3 regimen, or vehicle (saline) or SOC

chemotherapy (D to F). (G) DLL3 surface

expression quantified by IHC (H-score)

correlated with dTTP in 10 SCLC and 1 LCNEC

PDX model. (H and I) Mice bearing SCLC LU64

PDX tumors were treated with C/E and, upon

tumor recurrence (35 days after initial C/E

treatment), were randomized and treated again

either with (H) IgG1LD6.5 or SC16LD6.5 (1

mg/kg) on a Q4D×3 regimen or with (I) vehicle

or C/E.

Saunders et al. Sci Transl Med. 2016

The availability of a large high-grade pulmonary neuroendocrine PDX tumor repository facilitated the

discovery and validation of DLL3 as a therapeutic target.

Ideogram summarising variants predicted to result in mutations commonly seen in SCLC and Small Cell Lung Cancer Patient-

Derived Xenografts Generated from Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Specimens

PDX models have recently emerged as a way of more accurately modelling therapeutic responses outcome and as source of high quality material for next-generation sequencing.

Genes are ranked by % according to their prevalence in the COSMIC database. Mutations detected in both

the primary sample and the xenograft are shown. doi:10.1371/journal.pone.0106862.g004

Leong et al. 2014

Conclusions

• Novel Therapies need to be tested more rapidly

• The role of immunotherapy is beginning to be

defined

• Genomics and other ‘omics’ platforms will be crucial

for us to identify newer targets

• Animal modeling has become more sophisticated

and needs to be utilized pre-clinically and hopefully

also clinically