ALK in lung cancer: Past, present, and future

1. ALK in lung cancer: Past, present, and future

3. Gene Mutations in Lung Adenocarcinomas

4. 17 years ago…… • 2;5 chromosomal translocation in most anaplastic large-cell non-Hodgkin's lymphomas , which fused the NPM gene on chromosome 5q35 to ALK, on chromosome 2p23. • Expressed in the small intestine, testis, and brain but not in normal lymphoid cells, ALK shows greatest sequence similarity to the insulin receptor subfamily of kinases. • Unscheduled expression of the truncated ALK may contribute to malignant transformation in these lymphomas.

5. The Mechanism of Carcinogenesis

7. Discovery of the EML4-ALK fusion in NSCLC • Initially reported in 2007 as a result of an inversion in chromosome 2p, which results in the fusion of the N-terminal portion of the echinoderm microtubule-associated protein-like 4 (EML4) with the kinase domain of ALK. Soda et al., Nature 2007; 448:561-567

8. EML4–ALK Is an Oncogenic Driver Vector EML4 ALK EML4–ALK K589M NPM–ALK v-Ras 3T3 Nude mice tumour/ injection 0/8 0/8 0/8 8/8 0/8 8/8 2/2 • Expression plasmids for WT, EML4, ALK, EML4-ALK, EML4-ALK K589M, • and NPM-ALK were introduced into 3T3 fibroblasts. • Subcutaneous injection of the transfected 3T3 cells into nude mice revealed • those that formed tumors 1Soda M, et al. Nature. 2007;448:561–67.

9. Evidence for EML4-ALK as a Lung Cancer Oncogene • Insertion of EML4-ALK into NIH 3T3 fibroblasts was tumorigenic when implanted subcutaneously into nude mice • Engineered the specific expression of EML4-ALK fusion gene in lung progenitor cells using a surfactant protein C gene promoter • 100% of EML4-ALK transgenic mice developed lung adenocarcinoma that were + for ALK by IHC. No other primary cancers were observed. • Following IV injection of EML4-ALK/3T3 • cells into nude mice, all developed lung • cancer. Ten animals were treated with an • ALK-specific TKI and 10 were observed: PNAS December 16, 2008 vol. 105 no. 50 19893–19897

10. Frequency of ALKRearrangements

11. ALK fusions occur in numerous tumors Grande et al., Mol Cancer Ther2011; 10:569-579 Barreca et al., J MolecEndocrinol 2011; 47:R11-R23 Garber, J Natl Cancer Inst 2010; 102:672-675 Röttgers et al., Leukemia 2010; 24:1197-1200

12. Other ALK alterations (mutations, gene amplification) Murugan et al., Cancer Res 2011; 71:4403–4411 Grande et al., Mol Cancer Ther2011; 10:569-579 Powers et al., J BiolChem 2002; 277:14153-14158 Lu et al., J BiolChem 2005; 280:26953-26964

13. Histology/IHC FISH/Cytogenetics PCR Sequencing How do we test for ALK rearrangments?

14. What can we do in ALK+ NSCLC patient?

15. Crizotinib: A Dual MET/ALK Tyrosine Kinase Inhibitor Co-crystal structure of crizotinib (PF-02341066) bound to c-MET Cui et al. J. Med. Chem. 2011;54:6342-63 and Pfizer data on file

16. Early-phase clinical trial of crizotinib (PF-02341066) • Key entry criteria • Positive for ALK by central laboratory • Expanded from phase I dose escalation trial • Most were previously treated • N=82 • Crizotinib 250mg bid for 28-day cycle 6-month PFS among crizotinib users was estimated at 72% (95% CI, 61–83%) N Engl J Med 2010;363:1693-703.

17. Updated of the phase I study Common treatment-related grade 1/2 AE Lancet Oncol 2012; 13: 1011–19

18. Overview of ongoing trials • ALK inhibition, NSCLC • PROFILE 1007 – Ph III 2nd line (NCT00932893) • PROFILE 1014 – Ph III frontline (NCT01154140) • PROFILE 1005 – Ph II pretreated (NCT00932451) • PROFILE 1001 – Ph II expansion cohort (NCT00585195) • ALK inhibition, other tumor types • PROFILE 1013 – Ph I in non-NSCLC (NCT01121588) • Met inhibition • Study 1002 – Ph I/II with erlotinib (NCT00965731) • Study 1006 – Ph I with PF-0299804 (dacomitinib), NSCLC (NCT01121575)

19. PROFILE 1005 – phase II • Key entry criteria • Positive for ALK by central laboratory • Progressive disease in Arm B of study A8081007 • >1 prior chemotherapy • Crizotinib 250 mg BID (N=250) • administered on a continuous • dosing schedule Primary endpoint = ORR PROFILE 1007 – phase III • Crizotinib 250 mg BID (n=159) • administered on a continuous • dosing schedule • Key entry criteria • Positive for ALK by central laboratory • 1 prior chemotherapy (platinum-based) • Pemetrexed500 mg/m2or • docetaxel 75 mg/m2 (n=159) • infused on day 1 of a 21-day cycle PROFILE 1007: NCT00932893; PROFILE 1005: NCT00932451 • Primary endpoint = PFS met

20. Marked Activity of Crizotinib in ALK+ NSCLCUpdate of the Phase 2 Study 100 PD SD PR CR 80 60 40 20 0 Decrease or increase from baseline (%) –20 –40 –60 + + –80 –100 + + –120 *n=240 response-evaluable patients from the mature population, and excludes patients with early death, indeterminate response and non-measurable disease +Per RECIST 1.1, percent change from baseline for subjects with best overall response of CR can be less than 100% when lymph nodes are included as target lesions Kim et al., ASCO 2012

21. Marked Activity of Crizotinib in ALK+ NSCLCUpdate of the Phase 2 Study 1.0 Median PFS 8.1 months (95% CI: 6.8–9.7) 28% patients in follow-up for progression 0.8 + Censored 95% Hall-Wellner Band 0.6 Probability of survival without progression 0.4 0.2 0 0 5 10 15 20 Time (months) n at risk 261 175 95 26 2 Kim et al., ASCO 2012

22. PROFILE 1005: Any-Grade Treatment-Related AEs in ≥10% of Patients *Includes visual impairment, photopsia, vision blurred, vitreous floaters, photophobia and diplopiaRare instances of fatal pneumonitis and fatal hepatotoxicitywere reported in crizotinib clinical trial program

23. Result of PROFILE 1007 N Engl J Med 2013. DOI: 10.1056/NEJMoa1214886

24. 1st line setting (PROFILE 1014): • Crizotinib 250 mg BID • administered on a continuous • dosing schedule RANDOMIZE • Key entry criteria • Positive for ALK by central laboratory • No prior systemic therapy • Pemetrexed500 mg/m2+ Cisplatin • 75mg/m2 OR Pemetrexed 500mg/m2 • + Carboplatin AUC 5 or 6 • infused on day 1 of a 21-day cycle Study Start Date: January 2011 Estimated Study Completion Date: December 2013 • Primary endpoint = PFS

25. The Future: Overcoming Crizotinib Resistance Resistance develops on average within the first year or two of TKI therapy…

26. AcquiredCrizotinibResistance • The target gene can be altered by mutation or by amplification, limiting the ability of the drug to inhibit the kinase. (like T790M in EGFR and T315I in BCR-ABL) • Alternative signaling pathways (bypass tracks) can be activated in resistant cells, bypassing the need for signaling from the target. Nat Rev ClinOncol. 2012 Apr 3 Current Opinion in Pharmacology 2013

27. AcquiredCrizotinibResistanceMutation • Up to 1/3 of relapsing patients, crizotinib resistance is mediated by secondary resistance mutations located in the ALK TK domain.

28. AcquiredCrizotinib ResistanceAmplification • Amplification of the ALK fusion gene has also been reported in a small number of crizotinib-resistant tumors

29. AcquiredCrizotinib ResistanceAlternative Pathway • In crizotinib-resistant tumors, several distinct bypass tracks mediating resistance have been reported. • EGFR • ½ cases with crizotinib resistance showed increased EGFR activity • c-KIT • Confirmed by IHC, FISH, and c-Kit ligand Stem cell factor (SCF) • Can be overcome by Imatinib combine with crizotinib • There may be more than 1 bypass pathway in 1 individual Sci Transl Med 2012 Cancer 2011 Sci Transl Med 2012

30. Mechanisms of resistance to crizotinib in ALK-positive NSCLC Camidge, D. R. Nat Rev ClinOncol. 2012 Apr 3

31. What Can We Do?

32. Summary of Crizotinib Resistance

33. Novel Agents to Overcome Crizotinib-resistance ALK+ NSCLC • LDK378 (Novartis, Basel, Switzerland) • AP26113(ARIAD Pharmaceuticals, Cambridge, MA), • AF802(Chugai Pharmaceutical, Tokyo, Japan) • ASP3026 (AstellasPharma, Tokyo, Japan) • STA-9090(Ganetespib) • AUY922 • IPI-504 • AT 13387 • DS-2248 2nd generation ALK inhibitors HSP90 inhibitors

37. The Possible Difficulties • There may be more than 1 bypass mechanisms in one patient, therefore combination therapy may be needed. • The mutation may be different in different tumor sites in the same patient. Biopsy in different site may be indicated • There may be other unknown bypass pathway • Frontline 2nd ALK inhibitor, sequential use, or combine with other agent/CT (cocktail use)

38. ALK-Positive Timeline FDA approves crizotinib for treatment of ALK+ NSCLC[6] EML4-ALK defines a molecular subset of NSCLC with distinct clinical characteristics[4] EML4-ALK chromosomal rearrangements reported in NSCLC[1] 2011 2009 2007 ? 2012 ? 2nd generation ALK inhibitor TKIs and hsp inhibitors 2008 2010 Preclinical studies document antitumor activity of ALK inhibitors in lung cancer cell lines and xenografts[2,3] Crizotinib produces a response in 47/82 ALK+ patients and a 6-month PFS of 72%[5] 1. Soda M, et al. Nature 2007; 448: 561-566. 2. McDermott U, et al. Cancer Res 2008; 68: 3389-3395. 3. Koivunen JP, et al. Clin Cancer Res 2008; 14: 4275-4283. 4. Shaw AT, et al. JCO 2009; 27: 4247-4253. 5. Kwak EL, et al. N Engl J Med. 2010; 363: 1693-1703. 6. US Food and Drug Administration.

39. Take Home Message • EML4-ALK defines a new molecular subset of NSCLC • Patients are more likely to be young, never/light smokers with adenocarcinoma • Crizotinib results in a 6-month PFS of 72% and overall response rate of 57% at 6.4 months • 2nd generation ALK TKIs and HSP90 inhibitors offer promise in patients with crizotinibresistance

40. Thanks for Your Attention!!