DrC. Mayra Ramos-Suzarte

1. Phase I on Hepatic Carcinomas(Transarterial Immuno-chemoembolizationfor hepatocellular carcinomas) "Immunotrans-arterial Chemoembolization (ITACE) in hepatocellular carcinoma patients treated with anti-EGFR MAb nimotuzumab plus Adriamycin. Phase I Clinical Trial, Final Results " reference #34 CIM-CIMEQ DrC. Mayra Ramos-Suzarte

2. Registered medical publications in MEDLINE 2

3. Phase I on Hepatocellular Carcinomas Why the interest for HCC? • It is the most frequent of the primary malignant liver tumors (+ 90%). • Their incidence rate is rising in new parts of the world. • 5th place among all the neoplasm that affect the man. • It is responsible of 500,000 to 1000,000 of annual deaths in the world. • Parkin DM, et al. Estimating the world cancer burden: GLOBOCAN 2000. Int J Cancer 2001;94, 153-156. • Befeler AS, et al. Hepatocellular carcinoma: diagnosis and treatment. Gastroenterology2002, 122:1609–1619.

4. Phase I on Hepatocellular Carcinomas (American Cancer Society. Cancer Facts and Figures 2005. Atlanta: American Cancer Society; 2005.)

5. Phase I on Hepatocellular Carcinomas Incidence rate of HCC according geographical areas and risk factors

6. Phase I on Hepatocellular Carcinomas Treatment of HCC • Definitive or curative treatment: • Surgical evaluation • surgical resection • or orthotopic liver transplantation • Palliative treatment: • TACE • Alcoholization • Radiofrequency

7. Phase I on Hepatocellular Carcinomas TACE • Survival elevation of the patients to 75% to the 8 months • Reduction of tumour size: 53% (vs 13%) 7

8. Phase I on Hepatocellular Carcinomas Phase I Clinical Trial • Unique dose • Open • Monocentric • Dose scale up • Main objective: to evaluate the toxicity of Nimotuzumab with the TACE for treatment of HCC • Work hypothesis: “In patients with HCCthe administration of Nimotuzumab in combination with the TACE (Doxorrubicin and lipiodol) is safe” 8

9. Phase I on Hepatocellular Carcinomas Secondary objectives • To determine the maximum tolerable dose or the best biological dose according to the clinical evaluations and toxicity of Nimotuzumab. • To evaluate the toxicity profile in the included patients • To determine the survival of the included patients. • To evaluate the time of duration of objective antitumoral answer. • To evaluate the relationship dose answer in the included patients with the proposed therapeutic outline. 9

10. Phase I on Hepatocellular Carcinomas Justification • EGF-R expression in HCC: 105 to 4x106 molecules/cells (Carlin CL, et al, 1988) 10

11. Phase I on Hepatocellular Carcinomas EGF-R expression levels Case Normal cells Tumoral cells Not available* Not available* Not available* * (Sample constituted by malignant tissue) 06-254 06-333 11

12. Phase I on Hepatocellular Carcinomas 20% 80% Vascular irrigation of HCC and metastatic liver tumors is by hepatic artery 12

13. Phase I on Hepatocellular Carcinomas Expanded Access ProgramCases Summary • Case 1 (male, 62 y, Cirrhosis, HCV) • Survival: 12 m. He died with upper gastrointestinal bleeding and encephalopaty. • Case 2 (female, 45 y, non cirrhotic liver) • Survival: 18 m. She died with a cholangitis. The final histological diagnosis: Hepatocholangiocarcinoma. • Case 3 (male, 43 y, Cirrhosis) • Survival: 23 m. It is alive with good quality of live. Stable disease • Case 4 (male, 63 y, non cirrhotic) • Survival: 13 m. He died with suprarenal gland metastases. • Case 5 (female, 36 y, non cirrhotic) • Survival: 21 m. She is alive with good quality of live but with located bone metastases. • Case 6 (female, 61 y, non cirrhotic) • Survival: 20 m. She is alive with good quality. Stable disease. • Case 7 (female, 43 y, non cirrhotic) • Survival: 5 m. She is alive with good quality. Stable disease. 13

14. Expanded Access ProgramSurvival Phase I on Hepatocellular Carcinomas Survival Time (months) Mean: 17,23 14

15. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 1 15

16. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 1 16

17. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 2 17

18. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 2 18

19. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 3 Case 3 19

20. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 3 20

21. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 3 21

22. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 3 22

23. Phase I on Hepatocellular Carcinomas Case 4 Expanded Access Program Case 4 23

24. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 4 24

25. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 5 25

26. Phase I on Hepatocellular Carcinomas Expanded Access Program Case 5 26

27. Phase I on Hepatocellular Carcinomas Phase I Clinical Trial • Chemotherapy: • Doxorrubicin 25 a 50mg/m2 • Lipiodol 10 ml • Biotherapy: • Nimotuzumab: dose scale up (50mg-100mg-200mg-400mg) • Embolic agent: • Gelfoam 27

28. Phase I on Hepatocellular Carcinomas Selection of the patients • Universe • Patients with HCC. • Diagnostic criteria • Histological diagnosis • Or if comply with the “Non-invasive criteria of HCC in cirrhotic patients” • Two coincident imagenological studies: • Focal lesion more than 2 cm with arterial hypervascularization Bruix J, et al. J Hepatol 2001;35:421-430 28

29. Phase I on Hepatocellular Carcinomas Inclusion Criteria • 1) Patients with CHC diagnosed, eligible for chemo-embolization.2) Capacity to understand the study and readiness to sign the informed consent document.3) Patients with measurable lesions (in, at least, one dimension: greater diameter) using conventional techniques (CAT and US).4) Age >= 18 years and under 75 years.5) ECOG general health condition <= 2 (Karnofsky >= 60%,).6) Mean life expectancy over 2 months.7) Child- Pugh-Turcotte A or B functional stage.8) OKUDA I or II staging system.9) Patients with organs and bone marrow working well 10) Female reproductive-age patients should be pregnancy-tested negative and use appropriate contraceptives such as IU devices, hormonal contraceptives, barrier methods or tubal ligation. Men should use contraceptives while on treatment. 29

30. Phase I on Hepatocellular Carcinomas Exclusion Criteria • 1) Terminally ill patients with life expectancy shorter than 1 month.2) Cirrhotic patients in functional stage C according to Child-Pugh-Turcotte Classification.3) Patients on other research product.4) Patients with allergy history attributed to chemical or biological compounds similar to nimotuzumab MAb or the chemotherapy used in the trial.5) Patients with uncontrolled intercurrent diseases, including active infections, symptomatic congestive heart failure, unstable angina pectoris, and mental or social diseases limiting adherence to clinical trial requirements.6 As a result of potential and unknown adverse events in infants, breastfeeding women will not be included in the clinical trial.7) Patients with previous malignant neoplasias, except those patients who have been on appropriate treatment for skin carcinomas or in situ uterus carcinomas.8) Patients with extra hepatic metastasis.9) Patients with hepatic encephalopathy.10) Patients with biliary obstruction.11) Patients with hepatofugal portal flow.12) Tumor size exceeding liver size by 50 percent.13) Patients with serum bilirubin over 40umol/l or with TGP over 100 UI/l. 30

31. Distribution by group

32. Demographic characteristic (n=10).

33. Efficacy Evaluation Safety Profile

36. Adverse Events (reportedbysystem).

39. Overall Survival

40. Overall Survival

41. Phase I on Hepatocellular Carcinomas • CIM: Mayra Ramos Suzarte, Mercedes Cedeño Ramos, Enrique Rengifo, Milagros Prometa, Carmen Elena Viada, Maylen Acosta Martínez, Liana Martínez. • CIMEQ: Alejandro Roque Valdés, José Carlos Ugarte Suárez, José Jordán, Marcia Samada Suárez, Mauricio Catalá Ferrer, Denis Josell, Caridad Rojas Mosquera, Carlos Ramos Pachón, Marlen Castellanos Fernández, Katia Aroche Estalella, Emilia González Pérez, Keytel García, Eduardo Fermín Hernández, Alexei Nerey Rodríguez. 41