I FARMACI MULTITARGETED NEL CANCRO DELLA MAMMELLA

2. Farmaci che bloccano pi� recettori della stessa famiglia, per aumentare l�efficienza del �targeting� selettivo. Farmaci che bloccano recettori e proteine di segnale di classi e funzioni diverse, per bloccare a pi� livelli la trasmisione di segnali.

5. Co-expression of EGFR and ErbB-2 has been observed in 10-30% primary human breast carcinomas. Overexpression of both ErbB-2 and EGFR is associated with a poorer prognosis than overexpression of either receptor alone in breast cancer patients. A recent study has demonstrated an adverse prognostic independent role of ErbB-2 and EGFR coexpression in a subset of radically resected early breast cancers. (Di Giovanna et al., JCO, 23: 1152-1160, 2005).

10. EGF20009: A Phase II, Randomized trial using Lapatinib as a first-line treatment in patients with FISH Positive Advanced or Metastatic Breast Cancer

11. Randomized Phase III Study EGF100151

12. Prior Therapy

13. Time to Progession � ITT Population

14. Progression-Free Survival - ITT Population

15. Overall Survival - ITT Population

16. Brain Metastases as Site of Progression

17. Mean LVEF at Scheduled Assessments

18. EGF103009 A Phase II Trial of Lapatinib (Tykerb) Monotherapy in Patients With Relapsed/Refractory Inflammatory Breast Cancer (IBC): Clinical Activity and Biologic Predictors of Response

19. Preliminary Results: Treatment Response 100% of responders in Cohort A are ErbB2 3+ and FISH + Change to 100% of responders are p-ErbB2 positive 100% of responders in Cohort A are ErbB2 3+ and FISH + Change to 100% of responders are p-ErbB2 positive

20. The proposed phase II and III dose for this combination is 1000 mg/day lapatinib and standard weekly trastuzumab The most frequent AEs with this combination were diarrhea, fatigue, nausea, and anorexia The combination of lapatinib and trastuzumab was very active (6/27 CR+PR and 2/27 PR in the PK groups = 8% total) in this heavily pretreated population, all of whom had progressed on prior trastuzumab Additional randomized studies are planned with lapatinib and trastuzumab EGF10023: Phase I, open-label study of the Safety, Tolerability and Pharmacokinetics of Lapatinib in combination with Trastuzumab

22. The prevalence of certain ErbB heterodimers may cause an alternative driving force for the growth of cancer cells bypassing the blackade by specific inhibitors. For instance the heterodimer HER2-HER3 is an �odd couple� with a powerful kinase activity.

23. There are data showing that the insulin-like growth factor-1 (IGF-1) receptor pathway can also negate the effect of trastuzumab. I say this because there are a number of small molecules of antibodies in the industry that are being developed, and the plan is to eventually combine them with trastuzumab to abrogate this putative resistance. This is an experiment published recently in which Pollak had transfected HER2 into MCF-7 cells that have low levels of HER2. These cells are not that sensitive to trastuzumab, as shown here, but because they have high levels of the IGF-1 receptor, they make a lot of IGF-1 and IGF-2. So they are not very sensitive to trastuzumab, but they are sensitive to IGF-1 receptor inhibitors. This shows an IGF-1 receptor antibody and an insulin-like growth factor binding protein (IGFBP)-3 that binds IGF-1. If one uses them in combination there is very nice synergistic activity, implying that these 2 receptors are operative in this cell, and its combined inhibition leads to synergist contact tumor activity. We're testing this in mice right now. There are data showing that the insulin-like growth factor-1 (IGF-1) receptor pathway can also negate the effect of trastuzumab. I say this because there are a number of small molecules of antibodies in the industry that are being developed, and the plan is to eventually combine them with trastuzumab to abrogate this putative resistance. This is an experiment published recently in which Pollak had transfected HER2 into MCF-7 cells that have low levels of HER2. These cells are not that sensitive to trastuzumab, as shown here, but because they have high levels of the IGF-1 receptor, they make a lot of IGF-1 and IGF-2. So they are not very sensitive to trastuzumab, but they are sensitive to IGF-1 receptor inhibitors. This shows an IGF-1 receptor antibody and an insulin-like growth factor binding protein (IGFBP)-3 that binds IGF-1. If one uses them in combination there is very nice synergistic activity, implying that these 2 receptors are operative in this cell, and its combined inhibition leads to synergist contact tumor activity. We're testing this in mice right now.

24. mTOR Pathway islinked to EGFR and VEGF In cancer cells one or more of the proteins which positively (?) or negatively (�|) regulate mTOR may be deregulated, and this loss of regulation contributes to, and in some cases drives, the malignancy. These include overproduction of hormones, cytokines, and growth factors and aberrant expression of growth factor receptors and signaling molecules, such as PI3-K, PTEN, Akt, and TSC1/2 (and LKB1, which is not shown). Aberrant signaling in parallel signaling pathways also affects signaling through mTOR because these pathways are connected to the mTOR pathway. These connections are referred to as �cross-talk� and involve the Ras/Raf/MAPK pathway and Abl signaling1-5. Thus aberrant signaling in cancer cells upstream of mTOR converges on mTOR and is translated into the signals that regulate cell growth, cell division, production of angiogenic growth factors and contribute to other cellular processes. RAD001 inhibits only mTOR activity but, because mTOR is downstream of the signaling defects that characterize many cancer cells, RAD001 counters the effects of these defects on cell growth, proliferation, and angioigenesis. Unlike other agents that directly affect signaling through the upstream kinases such as the several growth factor receptor kinase inhibitors (e.g., PTK/ZK, gefitinib, erlotinib, sorafenib, sunitinib), RAD001 acts downstream of these kinases and may be used in combination to enhance inhibition of signaling through the PI3-k/Akt pathways. References Bjornsti and Houghton. Nat Rev Cancer. 2004;4335-4348. Crespo and Hall. Microbiol Mol Biol Rev. 2002;66:579-591. Huang et al. Cancer Biol Ther. 2003;2:222-232. Mita et al. Clin Breast Cancer 2003;4:126-137 Wullschleger et al. Cell 2006;124:471-484In cancer cells one or more of the proteins which positively (?) or negatively (�|) regulate mTOR may be deregulated, and this loss of regulation contributes to, and in some cases drives, the malignancy. These include overproduction of hormones, cytokines, and growth factors and aberrant expression of growth factor receptors and signaling molecules, such as PI3-K, PTEN, Akt, and TSC1/2 (and LKB1, which is not shown). Aberrant signaling in parallel signaling pathways also affects signaling through mTOR because these pathways are connected to the mTOR pathway. These connections are referred to as �cross-talk� and involve the Ras/Raf/MAPK pathway and Abl signaling1-5. Thus aberrant signaling in cancer cells upstream of mTOR converges on mTOR and is translated into the signals that regulate cell growth, cell division, production of angiogenic growth factors and contribute to other cellular processes. RAD001 inhibits only mTOR activity but, because mTOR is downstream of the signaling defects that characterize many cancer cells, RAD001 counters the effects of these defects on cell growth, proliferation, and angioigenesis. Unlike other agents that directly affect signaling through the upstream kinases such as the several growth factor receptor kinase inhibitors (e.g., PTK/ZK, gefitinib, erlotinib, sorafenib, sunitinib), RAD001 acts downstream of these kinases and may be used in combination to enhance inhibition of signaling through the PI3-k/Akt pathways. References Bjornsti and Houghton. Nat Rev Cancer. 2004;4335-4348. Crespo and Hall. Microbiol Mol Biol Rev. 2002;66:579-591. Huang et al. Cancer Biol Ther. 2003;2:222-232. Mita et al. Clin Breast Cancer 2003;4:126-137 Wullschleger et al. Cell 2006;124:471-484

25. 109 patients randomized to receive 75 mg or 250 mg i.v weekly. Toxicity profile favored 75mg dose: Anaemia, hyperglycemia, hypophostatemia & hypertrigliceridemia as grade 3/4 events Overall response: 9% (10 PRs), 26% MR mTTP: 3 m, mOS: 15m Phase III development ongoing in combination with letrozole

28. Novel Paradigm :�Multi-targeted therapy� Multiple targeted cells Cancer cells Endothelial cells Pericytes Fibroblasts Multiple molecular targets HER VEGF/VEGFR PDGF/PDGFR KIT/MET/RET Others kinases

29. I recettori del VEGF

35. SU11248 increased activity in combination with Docetaxel in a breast cancer model SU11248 enhanced the antitumor activity of docetaxel (15 mg/kg) in a breast cancer model. Athymic mice were implanted subcutaneously with MX-1 estrogen-independent human breast cancer tumor xenografts. The tumors were allowed to grow until they reached a volume of 100 mm3. At this point, the mice were dosed orally with SU11248 at 40 mg/kg per day Docetaxel 15 mg/kg IV once weekly for 3 weeks Both SU11248 and docetaxel at the same concentrations and on the same daily or weekly schedule There were 10 mice per treatment group. The above data represent the average tumor volume � SEM. By day 58: SU11248 + docetaxel inhibited tumor growth by 82% compared with docetaxel alone (P = 0.008) Three months after stopping SU11248 on day 72, one third of the mice treated with SU11248 + docetaxel were tumor-free. SU11248 enhanced the antitumor activity of docetaxel (15 mg/kg) in a breast cancer model. Athymic mice were implanted subcutaneously with MX-1 estrogen-independent human breast cancer tumor xenografts. The tumors were allowed to grow until they reached a volume of 100 mm3. At this point, the mice were dosed orally with SU11248 at 40 mg/kg per day Docetaxel 15 mg/kg IV once weekly for 3 weeks Both SU11248 and docetaxel at the same concentrations and on the same daily or weekly schedule There were 10 mice per treatment group. The above data represent the average tumor volume � SEM. By day 58: SU11248 + docetaxel inhibited tumor growth by 82% compared with docetaxel alone (P = 0.008) Three months after stopping SU11248 on day 72, one third of the mice treated with SU11248 + docetaxel were tumor-free.

39. BAY 43-9006 (Sorafenib) Bisaryl urea, multiple targeted inhibitor. Inhibits B-Raf-1 kinase (including the mutated form) with IC50 of 6 nM, MAPK, ERK. Inhibits also endothelial cells and VEGFR2, VEGFR-3, FLT-3, PDGFR, c-Kit. Raf is probably important in endothelial cells and double targeting (Raf and VEGFR-2) may be critical. BAY 43-9006 has clear activity in several tumor types and is going on to phase II studies.BAY 43-9006 has clear activity in several tumor types and is going on to phase II studies.

40. Sorafenib Phase II trial in metastatic breast cancer patients failing anthracycline and/or taxane Limited single-agent activity. Only 1/23 patients responding to therapy. Moreno-Aspitia A et al., JCO 24:18S, 2006 (abstract #577) A phase I trial combining sorafenib with bevacizumab Dose escalation trial in 34 patients with multiple tumor types. Both toxicity and efficacy are increased compared with single-agent therapy. Azad N et al., ASCO 2006, abstract # 3004 BAY 43-9006 has clear activity in several tumor types and is going on to phase II studies.BAY 43-9006 has clear activity in several tumor types and is going on to phase II studies.

41. The purpose of this slide is to introduce PTK/ZK as a multi-VEGF receptor inhibitor PTK/ZK is multi-VEGF receptor inhibitor that completely inhibits the activation of VEGF receptors: VEGFR-1, VEGFR-2, and VEGFR-31,2 PTK/ZK also inhibits the PDGF? receptor which plays a role in blood vessel stabilization PTK/ZK is being codeveloped by Novartis Pharmaceuticals Corporation AG and Schering AG Berlin, Germany 1. Wood JM, Bold G, Buchdunger E, et al. PTK787/ZK 222584, a novel and potent inhibitor of vascular endothelial growth factor receptor tyrosine kinases, impairs vascular endothelial growth factor-induced responses and tumor growth after oral administration. Cancer Res. 2000;60:2178-2189. 2. Bold G, Altmann KH, Frei J, et al. New anilinophthalazines as potent and orally well absorbed inhibitors of the VEGF receptor tyrosine kinases useful as antagonists of tumor-driven angiogenesis. J Med Chem. 2000;43(12):2310-23. The purpose of this slide is to introduce PTK/ZK as a multi-VEGF receptor inhibitor PTK/ZK is multi-VEGF receptor inhibitor that completely inhibits the activation of VEGF receptors: VEGFR-1, VEGFR-2, and VEGFR-31,2 PTK/ZK also inhibits the PDGF? receptor which plays a role in blood vessel stabilization PTK/ZK is being codeveloped by Novartis Pharmaceuticals Corporation AG and Schering AG Berlin, Germany 1. Wood JM, Bold G, Buchdunger E, et al. PTK787/ZK 222584, a novel and potent inhibitor of vascular endothelial growth factor receptor tyrosine kinases, impairs vascular endothelial growth factor-induced responses and tumor growth after oral administration. Cancer Res. 2000;60:2178-2189. 2. Bold G, Altmann KH, Frei J, et al. New anilinophthalazines as potent and orally well absorbed inhibitors of the VEGF receptor tyrosine kinases useful as antagonists of tumor-driven angiogenesis. J Med Chem. 2000;43(12):2310-23.

42. The purpose of this slide is to introduce PTK/ZK as a multi-VEGF receptor inhibitor PTK/ZK is multi-VEGF receptor inhibitor that completely inhibits the activation of VEGF receptors: VEGFR-1, VEGFR-2, and VEGFR-31,2 PTK/ZK also inhibits the PDGF? receptor which plays a role in blood vessel stabilization PTK/ZK is being codeveloped by Novartis Pharmaceuticals Corporation AG and Schering AG Berlin, Germany 1. Wood JM, Bold G, Buchdunger E, et al. PTK787/ZK 222584, a novel and potent inhibitor of vascular endothelial growth factor receptor tyrosine kinases, impairs vascular endothelial growth factor-induced responses and tumor growth after oral administration. Cancer Res. 2000;60:2178-2189. 2. Bold G, Altmann KH, Frei J, et al. New anilinophthalazines as potent and orally well absorbed inhibitors of the VEGF receptor tyrosine kinases useful as antagonists of tumor-driven angiogenesis. J Med Chem. 2000;43(12):2310-23. The purpose of this slide is to introduce PTK/ZK as a multi-VEGF receptor inhibitor PTK/ZK is multi-VEGF receptor inhibitor that completely inhibits the activation of VEGF receptors: VEGFR-1, VEGFR-2, and VEGFR-31,2 PTK/ZK also inhibits the PDGF? receptor which plays a role in blood vessel stabilization PTK/ZK is being codeveloped by Novartis Pharmaceuticals Corporation AG and Schering AG Berlin, Germany 1. Wood JM, Bold G, Buchdunger E, et al. PTK787/ZK 222584, a novel and potent inhibitor of vascular endothelial growth factor receptor tyrosine kinases, impairs vascular endothelial growth factor-induced responses and tumor growth after oral administration. Cancer Res. 2000;60:2178-2189. 2. Bold G, Altmann KH, Frei J, et al. New anilinophthalazines as potent and orally well absorbed inhibitors of the VEGF receptor tyrosine kinases useful as antagonists of tumor-driven angiogenesis. J Med Chem. 2000;43(12):2310-23.

46. E4599 was a randomised, phase III trial of CP with or without Avastin in previously untreated patients with advanced (stage IIIb/IV) NSCLC.1 In this trial, 878 patients were randomised to one of two arms: CP alone or CP plus Avastin 15mg/kg every 3 weeks. Patients receive paclitaxel 200mg/m2 i.v. every 3 weeks with carboplatin i.v. to AUC 6mg/mL every 3 weeks for a total of six cycles. In contrast to the phase II study, patients were not allowed to cross over in this phase III study. Patients in the CP plus Avastin arm could continue to receive single-agent Avastin after disease progression. The primary endpoint was survival and the secondary endpoints included overall response rate. Based on bleeding events seen in phase II trials, patients with squamous cell histology, in addition to central nervous system (CNS) metastases and active cardiovascular disease, were excluded from this trial. Sandler AB, Gray R, Brahmer J, et al. Randomized phase II/III trial of paclitaxel (P) plus carboplatin (C) with or without bevacizumab (NSC # 704865) in patients with advanced non-squamous non-small cell lung cancer (NSCLC): an Eastern Cooperative Oncology Group (ECOG) trial � E4599. J Clin Oncol 2005;23(June 1 Suppl.):2s (Abstract LBA4). E4599 was a randomised, phase III trial of CP with or without Avastin in previously untreated patients with advanced (stage IIIb/IV) NSCLC.1 In this trial, 878 patients were randomised to one of two arms: CP alone or CP plus Avastin 15mg/kg every 3 weeks. Patients receive paclitaxel 200mg/m2 i.v. every 3 weeks with carboplatin i.v. to AUC 6mg/mL every 3 weeks for a total of six cycles. In contrast to the phase II study, patients were not allowed to cross over in this phase III study. Patients in the CP plus Avastin arm could continue to receive single-agent Avastin after disease progression. The primary endpoint was survival and the secondary endpoints included overall response rate. Based on bleeding events seen in phase II trials, patients with squamous cell histology, in addition to central nervous system (CNS) metastases and active cardiovascular disease, were excluded from this trial. Sandler AB, Gray R, Brahmer J, et al. Randomized phase II/III trial of paclitaxel (P) plus carboplatin (C) with or without bevacizumab (NSC # 704865) in patients with advanced non-squamous non-small cell lung cancer (NSCLC): an Eastern Cooperative Oncology Group (ECOG) trial � E4599. J Clin Oncol 2005;23(June 1 Suppl.):2s (Abstract LBA4).