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Josep Tabernero MD PhDVall d’Hebron University Hospital
Vall d’Hebron Institute of Oncology (VHIO)Barcelona, Spain
Immunotherapy in Gastro -intestinal tumours
ESMO Preceptorship in Immuno-Oncology
February 2 - 3, 2017
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• Consultant/Advisory role:
Amgen, Bayer, Boehringer Ingelheim, Celgene,
Chugai, Imclone, Lilly, MSD, Merck Serono, Novartis,
Roche, Sanofi, Symphogen and Taiho
Disclosure / COIs
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Outline
• Molecular characterization in gastric/GEJ cancer• Immunotherapy in gastric/GEJ cancer• Molecular characterization in CRC• Immunotherapy in CRC
– MSI tumors– Other opportunities in CRC (including MSS tumors)
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Outline
• Molecular characterization in gastric/GEJ cancer• Immunotherapy in gastric/GEJ cancer• Molecular characterization in CRC• Immunotherapy in CRC
– MSI tumors– Other opportunities in CRC (including MSS tumors)
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Frequency of genetic m
utations in cancer
Altered proteins contain new
epitopes for imm
une recognition,
providing a comm
on denominator for cancer im
munothe
rapy
Rhabdoid tumour
Ewing sarcoma
Thyroid
Acute myeloid leukaemia
Medulloblastoma
Carcinoid
Neuroblastoma
Prostatre
Chronic lymphocytic leukaemia
Low-grade glioma
Breast
Pancreas
Multiple myeloma
Kidney clear cell
Kidney papillary cell
Ovarian
Glioblastoma multiforme
Cervical
Diffuse large B-cell lymphoma
Head and neck
Colorectal
Esophageal adenocarcinoma
Stomach
Bladder
Lung adeno-carcinoma
Lung squamous cell carcinoma
Melanoma
0.01
0.1 1 10
100
1000
Somatic mutation frequency (/Mb)
2220
52134
2623
81227
9157
12113
63214
11394
21920
49181
23176
8835
335179
121
C→
TC
→A
C→
GT
→C
T→
AT
→G
Lawrence M
S, et al. N
ature 2013
No at
Risk
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TCGA, Nature 2014
9%
20%
50%
22%
Molecular subtypes of gastric cancer
EBV, Epstein–Barr virus (red); MSI, microsatellite instability (blue), GS, genomically stable (green); CIN, chromosomal instability (light purple)
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TCGA, Nature 2014
Molecular characterization of GC
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1. Wu C, et al. Acta Histochem 2006; 2. Geng Y, et al. Int J Clin Oncol 2015; 3. Hou J, et al. Exp Mol Pathol 2014
PD-L1 expression (TC or IC)
42-65%1,2
Presence of tumour-infiltratinglymphocytes (TILs)
Yes2
PD-L1 as negative prognostic factor
Yes2,3
Rationale for PD1/PDL1 inhibition in gastric cancer
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Outline
• Molecular characterization in gastric/GEJ cancer• Immunotherapy in gastric/GEJ cancer• Molecular characterization in CRC• Immunotherapy in CRC
– MSI tumors– Other opportunities in CRC (including MSS tumors)
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Screening: 65 of 162 (40%) patients assessed for PD-L1 expression had PD-L1-positive tumors
Patients: 19 patients from Asia and 20 patients from the rest of the world
Treatment: 10 mg/kg IV Q2W
Response assessment: Performed every 8 weeks per RECIST v1.1 by central radiology review
aAssessed in archival tumor samples using a prototype IHC assay (22C3 antibody). Positivity defined as PD-L1 staining in stroma or ≥1% of tumor cells.
Patients
• Recurrent or metastatic adenocarcinoma of the stomach or GEJ
• ECOG PS 0-1• PD-L1–positive
tumor a
• No active brain metastases
Pembrolizumab
10 mg/kg Q2W
Complete Response
Partial Response or Stable Disease
Confirmed Progressive
Disease
Discontinuation Permitted
Treat for 24 months
or until progression
or intolerable
toxicity
Discontinue
KEYNOTE-012: Gastric Cancer Cohort
Muro K et al. Lancet Oncol 2016
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Best Overall Response (RECIST v1.1)
Muro K et al. Lancet Oncol 2016
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53.1% of patients experienced a decrease from
baseline
–100
–80
–60
–40
–20
0
20
40
60
80
100C
hang
e F
rom
Bas
slin
e, %
Maximum Change
Asia
Rest of world
Total population• 6-month OS rate: 66%• Median OS: 11.4 months (95% CI, 5.7-NR)
OS
0
10
20
30
40
50
60
70
80
90
100
0 2 4 6 8 10 12 14 16
Time, months
Ove
rall
Sur
viva
l, %
n at risk
17 15 12 11 10 8 1 0 0Asia
19 16 13 11 8 7 6 5 0ROW
Asia
Rest of world
KEYNOTE-012: Gastric Cancer Cohort
Muro K et al. Lancet Oncol 2016
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Association of Immune-Related Gene Expression Signatures and ORR and PFS
Signature
Nominal 1-Sided
P Valuea
ORRb PFSb
IFN-γ (6 gene) 0.077 0.032
TCR signaling (13 gene)
0.034 0.024
Expanded immune(18 gene)
0.062 0.049
De novo (33 gene)
0.068 0.037
Similar results observed for other signatures
Potential diagnostic performance of IFN-γsignature• Negative predictive value = 92%• Positive predictive value = 45%• Prevalence = 61%
Association of IFN- γ Signature and PFS
Patients with lowvalues of the signaturedo not show delays inprogression
PF
S, d
ays
Increasing Gene Expression Levels
IFN-γ Signature Score
Other Partial Response Stable Disease
1.5 2.0 2.5
100
200
300
Bang YJ et al. Proc ESMO GI 2015
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KEYNOTE-061 – 2nd line
Patient population
• Recurrent or metastatic adenocarcinoma of the stomach or GEJ
• Failure of chemotherapy combinations containing platinum and fluoropyrimidine doublet Pembrolizumab
200 mg q3w
Progressive disease orunacceptable toxicity
Randomized1:1
Paclitaxel 80 mg/m2 qw
Randomized Study of Pembrolizumab vs Paclitaxel in P atients With Metastatic Gastric Adenocarcinoma Who
Progressed After 1L Therapy With Platinum and Fluor opyrimidine
Survival follow-up
• If KEYNOTE-059 monotherapy arm is negative, will not include 1L monotherapy arm in this trial
• The treatment arm will be modified due to the result from KEYNOTE-059 safety run cohort
• Patients: 30% Asian cap (98 [13%] Japanese patients)• Response Assessment: Scans will be at 6 weeks (Scan 1) and 12 weeks
(Scan 2); Scan 2 used for futility analysis
Target enrollment: 720
• OS by RECIST 1.1 by central review
• PFS
• TTP
• BOR
• ORR by RECIST 1.1
• PD-L1 status
• Safety/tolerability
• QoL
• Immunogenicity
• PK profile
Primary Endpoints
Secondary Endpoints
Exploratory Endpoints
• PD profile
• Biomarkers and genomics
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KEYNOTE-062 – 1st line
• If KEYNOTE-059 monotherapy arm is negative, will not include 1L monotherapy arm in this trial
• The treatment arm will be modified due to the result from KEYNOTE-059 safety run cohort
• 30% Asian cap (98 [13%] Japanese patients)
• PFS by RECIST 1.1 by central review
• OS
• PFS by RECIST 1.1
• PFS by irRECIST
• ORR by RECIST 1.1
• DOR by RECIST 1.1
• Safety/tolerability
Primary Endpoints
Secondary Endpoints
Exploratory Endpoints
• HRQoL
• EuroQoL
Patient population
• Metastatic gastric/ gastroesophagealadenocarcinoma
• HER2/neu negative
• PD-L1 positive
Target enrollment: 750
Pembrolizumabn=250
Progressive disease orunacceptable toxicity
PD-L1 positive
5-FU +cisplatinn=250
Randomized Study of Pembrolizumab With Fluoropyrimid ine and Cisplatin Combination Chemo in 1L Patients With Metastatic Ga stric/Gastroesphageal
Adenocarcinoma
Survival follow-up
Pembrolizumab +5-FU + cisplatinn=250
Dosing: Pembro 200 mg q3w; 5FU 800 mg/m2/day continuous IV infusion,days 1–5 q3w; cisplatin 80 mg/m2 q3w
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BOR, best overall response; DCR, disease control rate; DOR, duration of response; ECOG PS, Eastern Cooperative Oncology Group performance status; IV; intravenous; ORR,
objective response rate; OS, overall survival; PFS, progression-free survival; Q2W, every 2 weeks; R, randomization; RECIST, Response Evaluation Criteria In Solid Tumors; TTR,
time to tumor response.
R
2:1
Nivolumab
3 mg/kg IV Q2W
Placebo
Key eligibility criteria:
• Age ≥ 20 years
• Unresectable advanced or
recurrent gastric or
gastroesophageal junction cancer
• Histologically confirmed
adenocarcinoma
• Prior treatment with ≥ 2 regimens
and refractory to/intolerant of
standard therapy
• ECOG PS of 0 or 1
Primary endpoint:
• OS
Secondary endpoints:
• Efficacy (PFS, BOR,
ORR, TTR, DOR, DCR)
• Safety
Exploratory endpoint:
• Biomarkers
Stratification based on:
• Country (Japan vs Korea vs Taiwan)
• ECOG PS (0 vs 1)
• Number of organs with metastases (< 2 vs ≥ 2)
• Patients were permitted to continue treatment beyond initial RECIST v1.1–defined disease progression, as assessed by the investigator, if receiving clinical benefit and tolerating study drug
Kang YK et al. Proc ASCO GI 2017
Nivolumab in refractory GC/GEJCStudy design
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Characteristic Nivolumab 3 mg/kg (n = 330) Placebo (n = 163)Median age (range), years
< 65 years, n (%)
62 (20–83)
189 (57.3)
61 (26–83)
95 (58.3)
Male, n (%) 229 (69.4) 119 (73.0)
Country, n (%)
Japan
Korea
Taiwan
152 (46.1)
146 (44.2)
32 ( 9.7)
74 (45.4)
74 (45.4)
15 ( 9.2)
ECOG PS, n (%)
0
1
95 ( 28.8)
235 ( 71.2)
48 ( 29.4)
115 ( 70.6)
Primary site of disease, n (%)
Gastric
Gastroesophageal junction
Unknown
272 (82.4)
30 ( 9.1)
28 ( 8.5)
135 (82.8)
12 ( 7.4)
16 ( 9.8)
Prior gastrectomy, n (%)
No
Yes
133 (40.3)
197 (59.7)
58 (35.6)
105 (64.4)
Organs with metastases (≥ 2), n (%) 246 (74.5) 119 (73.0)
Prior treatment regimens, n (%)
2
3
≥ 4
69 (20.9)
137 (41.5)
124 (37.6)
29 (17.8)
62 (38.0)
72 (44.2)
Any prior therapy, n (%)
Fluoropyrimidine
Platinum
Taxane
Irinotecan
Ramucirumab
330 (100)
329 (99.7)
311 (94.2)
284 (86.1)
247 (74.8)
35 (10.6)
163 (100)
163 (100)
157 (96.3)
140 (85.9)
123 (75.5)
22 (13.5)
Kang YK et al. Proc ASCO GI 2017
Nivolumab in refractory GC/GEJC
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Time (months)
Pro
ba
bil
ity
of
Su
rviv
al
(%)
22181614121086420
0
10
20
30
40
50
60
70
80
90
100
Hazard ratio, 0.63 (95% CI, 0.50–0.78)
P < 0.0001
0351019395795142275330
0133410163253121163
Nivolumab
Placebo
At risk:
20
193
82
Patients,
n Events, n
Median OS
[95% CI], months
12-Month OS Rate
[95% CI], %
Nivolumab 330 225 5.32 [4.63–6.41] 26.6 [21.1–32.4]
Placebo 163 141 4.14 [3.42–4.86] 10.9 [6.2–17.0]
Kang YK et al. Proc ASCO GI 2017
Nivolumab in refractory GC/GEJCOverall Survival
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Subgroup Hazard Ratio [95%
CI]
Histological type (Lauren classification)
Intestinal type
Diffuse type
Mixed
Unknown
0.59 [0.41–0.85]
0.82 [0.57–1.17]
0.37 [0.13–1.04]
0.56 [0.37–0.84]
Number of organs with metastasis
< 2
≥ 2
0.70 [0.46–1.08]
0.61 [0.48–0.78]
Peritoneal metastasis
No
Yes
0.63 [0.50–0.81]
0.74 [0.48–1.15]
Liver metastasis
No
Yes
0.63 [0.50–0.80]
0.67 [0.42–1.07]
Measurable lesion
No
Yes
0.70 [0.43–1.14]
0.63 [0.50–0.80]
Number of previous regimens
2
3
≥ 4
0.82 [0.50–1.35]
0.87 [0.61–1.22]
0.44 [0.31–0.61]
Subgroup Hazard Ratio [95%
CI]
All 0.64 [0.52–0.80]
Country
Japan
Korea
Taiwan
0.63 [0.46–0.85]
0.70 [0.51–0.96]
0.46 [0.23–0.92]
Age, years
< 65
≥ 65
0.75 [0.57–0.98]
0.53 [0.38–0.74]
Sex
Male
Female
0.58 [0.45–0.75]
0.83 [0.56–1.23]
ECOG PS
0
1
0.59 [0.40–0.87]
0.67 [0.52–0.86]
Prior gastrectomy
No
Yes
0.69 [0.49–0.98]
0.60 [0.46–0.79]
Primary sites
Gastric (fundus, corpus, antrum, and pylorus)
Gastroesophageal junction
Unknown
0.69 [0.55–0.87]
0.44 [0.20–0.97]
0.52 [0.26–1.06]
0 1 2 3
Favors nivolumab Favors placebo
Hazard ratio [95% CI]
0 1 2 3
Favors nivolumab Favors placebo
Hazard ratio [95% CI]
Kang YK et al. Proc ASCO GI 2017
Nivolumab in refractory GC/GEJCOverall Survival by Subgroups
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Time (months)
Pro
ba
bil
ity
of
Pro
gre
ssio
n-F
ree
Su
rviv
al
(%)
20181614121086420
0
10
20
30
40
50
60
70
80
90
100
0024819314683131330
011224791741163
Nivolumab
Placebo
At risk:
Nivolumab
Placebo
Hazard ratio, 0.60 (95% CI, 0.49–0.75)
P < 0.0001
Median Progression-Free Survival
1.61 months
1.45 months
Patients,
n Events, n
Median PFS
[95% CI], months
12-Month PFS Rate
[95% CI], %
Nivolumab 330 253 1.61 [1.54–2.30] 7.6 [4.2–12.2]
Placebo 163 145 1.45 [1.45–1.54] 1.5 [0.3–4.8]
Kang YK et al. Proc ASCO GI 2017
Nivolumab in refractory GC/GEJCProgression-free Survival
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Nivolumab 3 mg/kg
(n = 268)
Placebo
(n = 131)
ORR, n (%)
[95% CI]
P value
30 (11.2)
[7.7–15.6]
< 0.0001
0
[0–2.8]
—
BOR, n (%)
Complete response
Partial response
Stable disease
Progressive disease
0
30 (11.2)
78 (29.1)
124 (46.3)
0
0
33 (25.2)
79 (60.3)
DCR, n (%)
[95% CI]
P value
108 (40.3)
[34.4–46.4]
0.0036
33 (25.2)
[18.0–33.5]
—
Median TTR (range), months 1.61 (1.4–7.0) —
Median DOR, months
[95% CI]
9.53
[6.14–9.82]—
Kang YK et al. Proc ASCO GI 2017
Nivolumab in refractory GC/GEJCRECIST Response and Disease Control
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Nivolumab Placebo
Ma
xim
um
Re
du
ctio
n F
rom
Ba
seli
ne
in T
arg
et
Lesi
on
s (%
)
-100
-80
-60
-40
-20
0
20
40
60
80
100
-100
-80
-60
-40
-20
0
20
40
60
80
100
a
a Patients with a change in tumor burden that exceeds 100%.
a
Patients with Tumor reduction: 37.3% Patients with Tumor reduction: 12.4%
Kang YK et al. Proc ASCO GI 2017
Nivolumab in refractory GC/GEJCMaximum Reduction in Tumor Burden From Baseline
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Nivolumab +/- Ipilimumab (Checkmate 032)
• Phase I/II with a GC/GEJ/EC cohort (160 pts)
�Irrespectively of PD-L1 status
• 3 different schemes of treatment
• ORR (1st End Point)
Nivo 3 mg/kg Q2W
Nivo 1 mg/kg + Ipi 3 mg/kg Q3W
Nivo 3 mg/kg + Ipi 1 mg/kg Q3W
x 4 cyclesNivo 3 mg/kg Q2W
Janjigian YY et al. Proc ASCO 2016
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N3 N1+I3 N3+I1
ORR 14% 26% 10%
mOS (m) (95% CI) 5.0 (3.4–12.4) 6.9 (3.6–NA) 4.8 (3.0–9.1)
• 12% of pts stopped therapy due to treatment toxicity
• Treatment-related serious AEs of any grade and Grade 3-4
occurred in 10% and 5% (N3), 43% and 35% (N1+I3), and 23%
and 15% (N3+I1) of pts
� 1 Grade 5 → tumor lysis syndrome (N3+I1)
Nivolumab +/- Ipilimumab (Checkmate 032)
Janjigian YY et al. Proc ASCO 2016
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• Primary endpoint: irPFS
• The study was stopped post-interim analysis
• 143 pts screened
• irPFS similar between arms: mirPFS (95% CI) Ipi 2.92 (1.6 – 5.2)
vs BSC 4.9 (3.5-6.5) (HR=1.44, p=0.097)
• median OS for both arms ≈ 1 yr
• Treatment-related adverse events occurred in 41/57 (72%) on
Ipi pts and 25/45 (56%) pts on active BSC
�Pruritus (32%), diarrhea (25%), fatigue (23%), and rash (18%)
1st Line Tx• Ipi 10 mg/kg Q3W x4 → Ipi 10 mg/kg Q12W x3yr
• BSC (≈ 80% chemotherapy)
Ipilimumab Maintenance treatment – RP2 study
Moehler MH et al. Proc ASCO 2016
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Line Study N Treatment Arms Primary EP
1st Line
KEYNOTE-062
NCT02494583
(TPS 4138)
750
Pembrolizumab 200mg Q3W
vs
Pembro + Cisplatin + 5-FU/CPC
vs
Placebo + Cisplatin + 5-FU/CPC
OS
PFS
(RECIST 1.1)
CG & CUGE
PS 0-1, PD-L1+/HER2-
Stratification: Europe/North
America/Australia vs Asia vs ROW
RECIST 1.1 & irRECIST
Maintenance
JAVELIN Gastric
100
NCT02625610
(TPS 4134)
666
FOLFOX/XELOX x12 weeks,
thereafter:
Avelumab 10mg/kg Q2W
vs
Continuation FOLFOX/XELOX
OS
PFS (from
random)
CG & CUGE, PS 0-1, PD-L1+
Exclusion HER2+
RECIST 1.1
2nd Line
KEYNOTE-061
NCT02370498
(TPS 4137)
720
Pembrolizumab 200mg Q3W
vs
Paclitaxel
PFS
(RECIST 1.1)
OS in PD-L1+
CG & CUGE, PS 0-1
No molecular selection
RECIST 1.1 & irRECIST
3rd Line
JAVELIN Gastric
300
NCT02625623
(TPS4135)
330
Avelumab 10mg/kg Q2W + BSC
vs
Paclitaxel/Irinotecan/BSC
OS
CG & CUGE, PS 0-1
No molecular selection
Stratification: Asia vs non Asia
Exclusion of previous
immunotherapy
RECIST 1.1
Ongoing Phase III Clinical Studies
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Outline
• Molecular characterization in gastric/GEJ cancer• Immunotherapy in gastric/GEJ cancer• Molecular characterization in CRC• Immunotherapy in CRC
– MSI tumors– Other opportunities in CRC (including MSS tumors)
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Genomic Landscape of CRC… 2012
Cancer Genome Atlas Network, Nature 2012
Facts:224 T/N pairsNext-Generation Sequencing – Whole Exome Seq >20X coverage32 somatic recurrent mutations per tumor
Hypermutated tumors16%
Non-hypermutated tumors84%
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Molecular Classification of CRC… 2012
Right-sided, MSI-H, Hypermethylated, BRAF mut, Chromosomal stability
Left-sided, Rectal, MSS, KRAS mut, CIN +ve
Cancer Genome Atlas Network, Nature 2012
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CRC subtyping consortium – 2015
Guinney J, Dienstmann R et al. Nat Med 2015
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Summary – clinical and molecular correlates
CMS1 - MSI – Immune 14%
CMS2 – Canonical 37% CMS3 – Metabolic 13%
CMS4–Mesenchymal 23%
Immune checkpoint inhibitorsImmune regulatorsBRAF-driven strategies
Guinney J, Dienstmann R et al. Nat Med 2015
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Becht E et al, Clin Cancer Res 2016
Immune vs Transcriptomic subtypes of CRC
Supervised immune infiltration analysis
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Immune vs Transcriptomic subtypes of CRC
dMMR – MSIHypermutation
Immune-activated
Th1 cells
PDL1
MacrophagesNK cells
Cytotoxic T cells
Th1 cells IFNγIFNγ
CXCL9/10/13
Cancer cell
Cancer cell
Immune-ignorant
Inflammation
Cancer cell
TGFβ
Complement
Stromal cellsTh17 cells
MDSC
Stromal cells
MacrophagesNK cells
Cytotoxic T cells
CCL2
CCL2TGFβ IL-23
IL-17
Immune-tolerant
Inflamed
Monocytes
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Outline
• Molecular characterization in gastric/GEJ cancer• Immunotherapy in gastric/GEJ cancer• Molecular characterization in CRC• Immunotherapy in CRC
– MSI tumors– Other opportunities in CRC (including MSS tumors)
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Pembrolizumab (anti-PD 1) in mismatch repair-deficient/-proficient CRC: phase II
Le DT et al. ASCO 2015, Le DT NEJM 2015
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KEYNOTE-164 – 3rd line (refractory)
Patient population
• Locally advanced or metastatic MSI CRC
• Patients must have received at least 2 prior treatments
• Stage IV disease
Pembrolizumab200 q3w IV
Complete response Discontinuation permitted
Confirmed
progressive
disease
Discontinue
Partial response
or stable disease
Treat for up to 2 years or
until progression or
unacceptable toxicity
• ORR by RECIST 1.1
Primary Endpoint
Target enrollment: 60
Assessments: Radiological assessments using RECIST 1.1 and irRC
every 9 weeks
A Phase 2, Single-arm Study of Pembrolizumab in Pre treated Patients to Address Significant Patient Unmet Needs
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mFOLFOX6 + bevacizumab:• Bevacizumab 5 mg/kg
+ • Oxaliplatin 85 mg/m2 IV
+• Leucovorin 400 mg/m2 IV
+ • 5-FU 400 mg/m2 IV bolus on
Day 1, then 1,200 mg/m2/day for 2 day continuous infusion; repeat every 2 weeks until progressive disease
KEYNOTE-177 – 1st line
Patient population
• Locally advanced or unresectable or metastatic CRC
• MSI
Target enrollment: 270
Pembrolizumab
200 mg q3w
Up to 2 years
A Phase 3 Study of Pembrolizumab Monotherapy vs Stan dard Chemotherapy in 1L MSI CRC
Randomization1:1
PD
PD
OffStudy
Crossover
Primary Endpoint
• PFS
• OS
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Nivolumab +/- Ipilimumab (Checkmate 142)
• Primary end-point: Investigator-assessed ORR (RECIST 1.1) in MSI-H pts
MSS
Cohort
MSI
Cohort
N = 70 (47 evaluable)1
N = 30 (27 evaluable)1
Overman MJ et al. Proc ASCO 20161; Overman MJ et al. Proc ASCO GI 20172
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MSI-H
Nivo
3mg/kg
MSI-H
Nivo 3 +
Ipi 1
MSS
Nivo 1 +
Ipi 3
MSS
Nivo 3 +
Ipi 1
≥12w follow-
up
N=47 N=27 N=10 N=10
ORR, N (%) 12 (25.5) 9 (33.3) 1 (10) 0
CR 0 0
PR 12 (25.5) 9 (33.3)
SD 14 (29.8) 14 (51.9)
PD 17 (36.2) 3 (11.1)
UNK 4 (8.5) 0
All pts N=70 N=30 N=10 N=10
mPFS (m) 5.3
(1.5-NE)
NE
(3.4-NE)
2.28
(0.6-4.4)
1.31
(0.9-1.7)
mOS (m) 17.1
(8.6-NE)
NE
(NE-NE)
11.5
(0.6-NE)
3.7
(1.2-5.6)
Nivolumab +/- Ipilimumab (Checkmate 142)
Overman MJ et al. Proc ASCO 2016
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Nivolumab +/- Ipilimumab (Checkmate 142)
Overman MJ et al. Proc ASCO 2016
Response in patients with MSI-H tumors
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Nivolumab +/- Ipilimumab (Checkmate 142)
Overman MJ et al. Proc ASCO 2016
Survival in patients with MSI-H tumors
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Patients, n (%)
dMMR/MSI-H per
Local Laboratory
(N = 74)
dMMR/MSI-H per
Central Laboratory
(n = 53)
Investigator BICR Investigator BICR
ORR, n (%)
95% CI
23 (31.1)
20.8, 42.9
20 (27.0)
17.4, 38.6
19 (35.8)
23.1, 50.2
17 (32.1)
19.9, 46.3
Best overall response, n (%)
CR
PR
SD
PD
Unable to determine
0
23 (31.1)
29 (39.2)
18 (24.3)
4 (5.4)
2 (2.7)
18 (24.3)
28 (37.8)
20 (27.0)
6 (11.1)
0
19 (35.8)
21 (39.6)
10 (18.9)
3 (5.7)
1 (1.9)
16 (30.2)
21 (39.6)
12 (22.6)
3 (5.7)
Disease control for ≥ 12 weeks, n
(%)a51 (68.9) 46 (62.2) 39 (73.6) 37 (69.8)
BICR, blinded independent central review.a Patients with CR, PR, or SD for ≥ 12 weeks.
Nivolumab (Checkmate 142 update)Response and disease control
Overman MJ et al. Proc ASCO GI 2017
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PFS per Investigator
Median [95% CI], months
12-month rate [95% CI], %
9.6 [4.3, NE]
48.4 [33.6, 61.7]
PFS per BICR
12-month rate [95% CI], % 45.6 [32.2, 58.1]
BICR, blinded independent central review; NE, not estimable. a Investigator assessed dMMR/MSI-H by local laboratory.
0 3 6 9 12 15 18 21 24
Months
74 48 22 14 12 10 7 3 0No. at risk
0
10
20
30
40
50
60
70
80
90
100
Pro
babi
lity
of P
FS
(%
)a
Nivolumab (Checkmate 142 update)Progression-free survival
Overman MJ et al. Proc ASCO GI 2017
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NR, not reached. a dMMR/MSI-H assessed by local laboratory.
3 6 9 12 15 18 21 2724
74 64 54 24 21 21 14 10 3 0
0
10
20
30
40
50
60
70
80
90
100
Pro
babi
lity
of S
urvi
val (
%)
a
Median OS [95% CI], months
12-month OS rate [95% CI], %
NR [17.1, NE]
73.8 [59.8, 83.5]
Months
No. at risk
0
Nivolumab (Checkmate 142 update)Overall survival
Overman MJ et al. Proc ASCO GI 2017
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ORR, n/N (%) Investigator BICR
Tumor PD-L1 expression
≥ 1%
< 1%
6/21 (28.6)
13/45 (28.9)
7/20 (35.0)
11/45 (24.4)
ORR, n/N (%) Investigator BICR
Abundance of PD-L1 expressing
immune cells
Rare
Intermediate
Numerous
5/23 (21.7)
5/20 (25.0)
9/23 (39.1)
4/22 (18.2)
4/20 (20.0)
10/23 (43.5)n/N, responders/evaluable patients.
≥ 1%
< 1%
+ Confirmed CR/PR
Inv
est
iga
tor-
Ass
ess
ed
Be
st C
ha
ng
e in
Ta
rge
t Le
sio
n
Siz
e (
%)
Tumor PD-L1 Expression
100
-50
-100
50
0
Rare
Intermediate
Numerous
+ Confirmed CR/PR
Inv
est
iga
tor-
Ass
ess
ed
Be
st C
ha
ng
e in
Ta
rge
t Le
sio
n
Siz
e (
%)
Abundance of PD-L1 Expressing Tumor-
Associated Immune Cells
100
-50
-100
50
0
Nivolumab (Checkmate 142 update)Reduction in Target Lesions regardless of PD-L1 exp ression
Overman MJ et al. Proc ASCO GI 2017
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ORR, n/N (%) Investigator BICR
BRAF mutation status
Mutant
Wild type
3/12 (25.0)
12/28 (42.9)
2/12 (16.7)
9/27 (33.3)
KRAS mutation status
Mutant
Wild type
7/26 (26.9)
12/28 (42.9)
6/26 (23.1)
9/27 (33.3)
ORR, n/N (%) Investigator BICR
Clinical history of Lynch
syndrome
Yes
No
8/23 (34.8)
8/26 (30.8)
8/23 (34.8)
6/26 (23.1)
n/N, responders/evaluable patients.
BRAF Mutation Status
100
-50
-100
50
0
Inv
est
iga
tor-
Ass
ess
ed
Be
st C
ha
ng
e in
Ta
rge
t Le
sio
n
Siz
e (
%)
Mutant
Wild type
+ Confirmed CR/PR
Clinical History of Lynch Syndrome
100
-50
-100
50
0
Inv
est
iga
tor-
Ass
ess
ed
Be
st C
ha
ng
e in
Ta
rge
t Le
sio
n
Siz
e (
%)
Yes
No
+ Confirmed CR/PR
Nivolumab (Checkmate 142 update)Reduction in Target Lesions Regardless of BRAF Mut S tatus and Lynch Syndrome
Overman MJ et al. Proc ASCO GI 2017
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Examples of anti-PDL1/PD1 therapies currently under investigation in CRC*
*Recruiting studies Clinicaltrials.gov
Target Therapy Phase Trial Design Trial ID
Anti-PDL1
Atezolizumab (engineered
IgG1, no ADCC)
I Solid tumours NCT01375842
Ib Solid tumours (+ bevacizumab ± FOLFOX) NCT01633970
II mCRC (+ bevacizumab + fluoropyrimidine) NCT02291289
MEDI4736(modified IgG1,
no ADCC)II mCRC NCT02227667
Anti-PD1
Nivolumab(IgG4)
I/II mCRC (± ipilimumab) (CheckMate 142) NCT02060188
I/II Solid tumours (+INCB24360) NCT02327078
I/II Solid tumours (+ chemotherapy) NCT02423954
I/II Solid tumours (+ varlilumab) NCT02335918
Pembrolizumab(IgG4,
humanised)
I Solid tumours (+ aflibercept) NCT02298959
I/II GI cancers (+mFOLFOX6) NCT02268825
I/II WT mCRC (+ cetuximab) NCT02318901
II mCRC (+ radiotherapy or ablation) NCT02437071
II mCRC (+ chemotherapy) NCT02375672
II mCRC (+ azacitidine) NCT02260440
II MSI-positive/-negative CRC NCT01876511
II MSI-positive CRC (to address response) NTC02460198
III MSI-H and dMMR (Pembro vs 1st Line) NTC02563002
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Cobimetinib + Atezolizumab
• PD-L1 and MEK inhibition: a rational combination
Bendell J et al. Proc ASCO 2016
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Cobimetinib + Atezolizumab
Bendell J et al. Proc ASCO 2016
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KRAS
MT
CRC
All CRC
pts
N=20 N=23
ORR 20% 17%
CR 0 0
PR 20% 17%
SD 20% 22%
PD 50% 52%
NE 10% 9%
mPFS (m) 2.3
(1.8-9.5)
2.3
(1.8-9.5)
mOS (m) NE
(6.5-NE)
NE
(6.5-NE)
Cobimetinib + Atezolizumab
Bendell J et al. Proc ASCO 2016
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ARMA
Cobimetinib +atezolizumab
n=180
ARMB
Atezolizumabn=90
ARMC
Regorafenibn=90
Treatment to continue until loss of clinical benefit
� Stratified by tumor extended RAS status and time since diagnosis of first metastasis � MSI-H capped at approximately 5%� At least 180 patients with extended RAS-mutant tumors to be enrolled
n=360
2:1:1
� UnresectablemCRC patients
� Received at least 2 regimens in metastatic setting (not including maintenance)
COTEZO TRIAL
Cobimetinib + Atezolizumab
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Other agents with specific development in CRC
Therapy Target 1 Construct Phase Trial Design Trial ID
Cytokine-
constructsCEA-IL2v
Anti-CEA
antibody
carrying
mod. IL-2
molecule
I Tumors expressing CEA NCT02004106
Ib
Tumors expressing CEA in
combination with
atezolizumab
NCT02004106
Bi-Specific
Antibodies
CEA-CD3
T-Cell bi-
specific
antibody
I Tumors expressing CEA NCT02324257
Ib
Tumors expressing CEA in
combination with
atezolizumab
NCT02650713
CEA-CD3 BITE I/II Tumors expressing CEA NCT01284231
Clinicaltrials.gov
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• Very high potency with EC50 values in the fM to pM range
• Serial killing of tumour cells, activity at low effector–to-target (E:T) ratio
• T cell engagement independent of specificity, activation and differentiation status
• Mode of action may overcome most escape mechanisms that cancer cells employ to evade T cell recognition
T cell bispecific antibodies (TCBs)Highly potent molecules leading to T cell-mediated killing of tumour cells
Bacac, et al. ITOC 2014
T cell
Tumour cell
Cytotoxic granules
Mode of action
CD3 T cell engagement
Silent Fc forhalf-life extension
High avidity binding to tumor antigen
Format
• Simultaneous binding to tumour and T cells results in– T cell engagement, activation and killing of
tumour cells by delivery of cytotoxic granules– T cell proliferation (expansion) at site of
activation
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Examples of vaccines for immune-stimulation in CRC
Therapy Antigen Enhancer PhaseStudy
populationTrial ID
Anti-tumor
vaccines
Autologous
tumor cells
BCG
II Adjuvant CRC PMID: 8445413
III Adjuvant CRC PMID: 15755632
IIIAdjuvant Stage
II CRC NCT02448173
Newcastle
Disease Virus II
CRC Liver M1
resectedPMID: 18488223
Dendritic cell
vaccines
CEADendritic
cellsI
Adjuvant Stage
III CRC NCT01890213
MUC 1Dendritic
cellsII
CRC Liver or
lung M1
resected
NCT00103142
Pubmed - Clinicaltrials.gov
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Examples of adoptive cell therapy for immune-stimulation in CRC
Therapy Target Enhancer Phase Trial Design Trial ID
TILsAutologous
tumor cells
IL-2
PembrolizumabII GI tumors NCT01174121
CAR T Cells
CEA ITumors
expressing CEANCT02349724
CEA Yttrium 90 ITumors
expressing CEANCT02416466
EGFR I/IITumors
expressing EGFRNCT01869166
Cytokine-
induced-killer
cells
Autologous
tumor cellsII
Adjuvant CRC in
combination
with XELOX
NCT01929499
Clinicaltrials.gov
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Strategy:
PD1 blockade
Molecular-driven therapeutic hypothesis
Immune
CMS1
Immune
CMS1
MSI
PD1 blockade responsive
Giannakis M et al. Cell Reports 2016
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?
Molecular-driven therapeutic hypothesis
MSS
Metabolic
CMS3
Epithelial
CMS2
Strategy: PD1 blockade +
epigenetic modulation
or MEK inhibitors or TCBs?
Strategy: combination of immune-
stimulatory drugs and inhibitors of
immune suppression
Mesenchymal
CMS4
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Acknowledgements
All the patients and their familiesVall d’Hebron University Hospital
Oncology Dep.
Pathology Dep.• S. Landolfi• P. Nuciforo• J. Jiménez
• R. Dienstmann• E. Elez• G. Argiles• M. Alsina• E. Sanz• C. Hierro
Genomics Lab.• A. Vivancos• A. Prat
Translational Lab.• V. Serra• H. García-Palmer
• R. Dienstmann• J. Guinney• S. Friend
• R. Salazar• G. Capella• V. Moreno
• I. Simon• L. Dekker• R. Bernards
• S. Kopetz• E. Vilar
• E. Van Cutsem• S. Tejpar
• A. Bardelli• F. Di Nicolantonio
• F. Ciardiello• E. Martinelli
• S. Siena• A. Sartore-Bianchi
• A. Cervantes
• J. Schellens
• I. Melero• J.L. Pérez-García
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Colorectal cancer subtyping consortium (CRCSC)
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THANK YOU