Heinz-Josef Lenz
Associate Director, Clinical Research
Kathryn Balakrishnan Chair for Cancer Research
Co-Director, USC Center for Molecular Pathways and Drug
Discovery
Co-Leader GI Oncology Program
USC/Norris Comprehensive Cancer Center

• EGFR Ligands
• Angiogenesis/Ethnicity
• Stem Cell/Tumor Dormancy
• Acquired vs Inherited resistance
• Integrated System Biology

Khambata-Ford S, et al. J Clin Oncol 2007;25:3230
–3237;
Tabernero J & Macarulla T. J Clin Oncol 2009;27:5487 –5491

30
20
10
0
40
Breast Colon Melanoma
Tumor
NSCLC Ovarian


Predictive analysis
Modelled survival plots by chemo regimen within the KRAS-wt subgroup
KRAS-wt, mFOLFOX
Interaction
P=0.0042
KRAS-wt, Xelox
Interaction
P=0.14
0 6 12 18 24 30 36 42
Time from randomisation (months)
Arm A Arm B
Upper quartile of EREG expression
Median of EREG expression
Lower quartile of EREG expression
0 6 12 18 24 30 36 42
Time from randomisation (months)
In the mFOLFOX subgroup, high
EREG expression is predictive of increased cetuximab efficacy.
Adams et al ASCO 2012

Prognostic: Ligand expression and KRAS
Control arm
EREG, OS
Global log-rank test: P=0.004
EREG, PFS
Global log-rank test: P=0.014
KRAS-mut low expression
KRAS-mut high expression
KRAS-wt low expression
KRAS-wt high expression
0 6 12 18 24 30 36 42
Time from randomisation (months)
0 6 12 18 24 30 36 42
Time from randomisation (months)
•
The combination of KRAS=wt and high EREG expression selects a good prognostic group.
•
This is in the absence of cetuximab use, suggesting previously reported similar findings in a non randomised series of patients treated with cetuximab (Jacob) may be a prognostic effect not a predictive effect.
Adams et al ASCO 2012

Amphiregulin (AREG) Epiregulin (EREG) EGFR-FISH
ORR mPFS
(m)
PFS low
(n=35)
46%
4.9
high
(n=24) p
83% 0.00
6
8.4
low
(n=28) high
(n=31) p low
(n=27) high
(n=3
5) p
46% 74% 0.036
33% 71% 0.004
4.9
7.9
4.6 8.4
HR:
0.35
<0.001
HR:0.
58
0.026
HR:
0.49
0.004
mOS (m) 17.1
39.9
20.2
33.0
15.2
30.5
OS HR:
0.36
<0.001
HR:
0.57
0.041
HR
0.44
0.001

Proposed Biomarkers for Optimal Treatment of Advanced
Untreated Colorectal Cancer
ERCC1 low optimal for oxaliplatin.
•
Both KRAS WT AND High EGFR Ligands optimal for cetuximab.
Standard Optimal Rx
1: Lo ERRC1,
EGFR Res
2: Lo ERRC1,
EGFR Sen
3: Hi ERRC1,
EGFR Res
4: Hi ERRC1,
EGFR Sen
Folflox/Bev
Folfox/Bev
Folfox/Bev
Folfox/Bev
Folfox/Cetux
Folfiri/Bev
Folfox/Bev Folfiri/Cetux
Estimate PFS for median of groups 2, 3, 4 with selected therapy is 14 months (harzard ratio 1.55)

Emergence of circulating (new) mutant KRAS
and Kras amplification as mechanisms of resistance to EGFR inhibitors
S Misale et al. Nature 000 , 1-5 (2012) doi:10.1038/nature11156
LAD Jr et al. Nature 000 , 1-4 (2012) doi:10.1038/nature11219

Most Resistance Manuscripts and Reviews Focus on
Redundant Angiogenic Pathways
Ellis ASCO 2012 c-Met
Ellis, Hicklin, CCR 2008

Cremolini et al. ASCO 2012

VEGFR2 associated with PFS
100
80
60
40
20
0
0
C- (N= 118) mPFS: 9.5 m
TT (N= 306) m PFS: 10.9 m
HR: 1.40 (1.07-1.84)
Log-rank test p=0.015
CC/CT
TT
20
Time
40 60

Heatmaps in 7 Favorable Polymorphisms in Bevacizumab race
VEGFR2 rs12505758 VEGFR1 rs9582036 VEGFA rs699946 VEGFR2 rs11133360 VEGF rs833061 VEGF rs699947 VEGF rs1570366 race VEGFR2 rs12505758 VEGFR1 rs9582036 VEGFA rs699946 VEGFR2 rs11133360 VEGF rs833061 VEGF rs699947 VEGF rs1570366
Caucasian
Caucasian
2
2
2
2
2
2
2
2
2
0
2
0
2
0
Caucasian 2 2 2 2 2 2 2
2 2 2 2 0 0 0
Caucasian
Caucasian 2 2 2 2 2 2 2 2 2 2 1 2 2 2
Caucasian
Caucasian 2 2 2 2 2 2 1
2 2 2 1 2 2 2
Caucasian
Caucasian 2 2 2 1 2 2 2
2 2 2 1 2 2 1
Caucasian
Caucasian 2 2 2 1 2 2 1
2 2 2 1 2 2 1
Caucasian
Caucasian 2 2 2 1 1 1 1
2 2 2 1 2 2 1
Caucasian
Caucasian 2 2 2 1 1 1 1
2 2 2
2
2
2
1
1
1
1
2
1
1
1
2 1
Caucasian
Caucasian
Caucasian
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
Caucasian
Caucasian
Caucasian
Caucasian
2
2
2
2
2
2
2
1
1
2
1
0
Caucasian 2 2 0 0 0
2 2 2 1 0 0 0
Caucasian
Caucasian 2 2 2 0 2 2 2
2 2 2 0 1 1 1
Caucasian
Caucasian 2 2 2 0 1 1 1
2 2 2 0 1 1 1
Caucasian
Caucasian 2 2 2 0 1 1 0
2 2 2 0 1 1 0
Caucasian
Caucasian 2 2 1 2 1 1 0
2 2 1 2 1 1 1
Caucasian
Caucasian 2 2 1 2 0 0 0
2 2 1 2 1 1 1
Caucasian
Caucasian 2 2 1 1 1 1 1
2 2 1 2 1 1 1
Caucasian
Caucasian 2 2 1 1 1 1 1
2 2 1 2 1 1 1
Caucasian
Caucasian 2 2 1 1 1 1 1
2 2 1 1 1 1 1
Caucasian
Caucasian 2 2 1 1 1 1 1
2 2 1 1 0 0 0
Caucasian
Caucasian 2 2 1 1 0 0 0
2 2 1 1 0 0 0
Caucasian
Caucasian 2 1 2 2 2 2 0
2 2 1 0 1 1 0
Caucasian
Caucasian 2 1 2 2 2 1 1
2 2 0 1 0 0 0
Caucasian
Caucasian 2 1 2 1 2 2 2
2 1 2 2 2 2 2
Caucasian
Caucasian 2 1 2 1 2 2 2
2 1 2 2 1 1 0
Caucasian
Caucasian 2 1 2 1 1 1 1
2 1 2 1 2 2 2
Caucasian 2 1 1 2 1 1 0 Caucasian
2 1 2 1 1 1 0
Caucasian
Caucasian 2 1 1 1 0 0 0
2 1 2 1 0 0 0
Caucasian
Caucasian 2 1 1 1 0 0 0
2 1 2 0 1 1 0
Caucasian 2 1 1 0 1 1 0 Caucasian
2 1 2 0 0 0 0
Caucasian 2 1 1 0 1 1 0 Caucasian
2 1 1 2 0 0 0
Caucasian
Caucasian 2 1 1 0 0 0 0
2 1 1 0 1 1 1
Caucasian
Caucasian 2 1 0 2 0 0 0
2 1 0 1 0 0 0
Caucasian 2 1 0 1 0 0 0 Caucasian
2 1 0 1 0 0 0
Caucasian 1 2 2 2 2 2 1 Caucasian
2 0 2 2 1 1 1
Caucasian
Caucasian 1 2 2 2 1 1 1
2 0 1 1 1 1 0
Caucasian 1 2 2 1 2 2 2 Caucasian
1 2 2 2 2 2 2
Caucasian 1 2 2 1 1 1 1 Caucasian
1 2 2 1 1 1 1
Caucasian 1 2 2 1 1 1 1 Caucasian
1 2 1 2 0 0 0
Caucasian 1 2 2 0 2 2 1 Caucasian
1 2 1 2 0 0 0
Caucasian 1 2 1 1 1 1 0 Caucasian
1 1 2 1 2 2 2
Caucasian 1 2 1 1 1 1 0 Caucasian
1 1 2 1 2 2 2
Caucasian 1 2 1 1 0 0 0 Caucasian
1 1 2 0 1 1 1
Caucasian 1 1 2 2 1 1 1
Caucasian
1 1 1 2 1 1 1
Caucasian 1 1 2 1 1 1 2 Caucasian
1
1
Caucasian 1 1 2 1 1 1 2 Caucasian
1
0
1
2
2
1
1
2
1
2
1
1
Caucasian
Caucasian
1
1
1
1
2
2
1
1
1
1
1
1
1
0
Caucasian
Caucasian
Caucasian
1 0 1 2 1 1 0
Caucasian 1 1 1 0 0 0
0 1 2 2 1 1 0
2
2
2
2
2
2
2
2
1
0
1
0
0
0
Caucasian
Hispanic
1
2
0
2
1
2
1
2
0
2
0
2
0
2
Hispanic
Hispanic
2 2 2 1 1 1 1
Hispanic 2 2 2 2 1 1 1
Hispanic
2 2 2 0 1 1 0
Hispanic 2 2 2 1 2 2 1
Hispanic
Hispanic Hispanic
Hispanic
2
2
2
2
2
2
1
1
2
1
2
1
0
0
2
2
2
2
2
2
0
0
1
0
1
0
0
0
Hispanic
2 2 2 2 2 2
Hispanic 2 2 2 1 1 1 0
Hispanic
2 2 1 1 1 1 1
Hispanic
Hispanic
2
2
2
2
2
2
0
0
1
1
1
1
1
0
Hispanic
Hispanic
2
2
2
2
1
1
1
1
0
0
0
0
0
0
Hispanic 2 2 1 2 1 1 1
Hispanic
2 2 1 0 1 1 1
Hispanic 2 2 1 2 1 1 1
Hispanic
2 2 1 0 1 1 0
Hispanic
Hispanic
2
2
2
2
1
1
1
1
1
1
1
1
1
0
Hispanic
Hispanic
2 2 1 0 1 1 0
Hispanic 2 2 1 1 0 0 0 2
2
2
2
1
1
0
0
0
0
0
0
0
0
Hispanic
Hispanic
2
2
2
2
1
1
0
0
1
1
1
1
0
0
Hispanic
Hispanic
2 2 1 0 0 0 0
Hispanic
Hispanic 2 2 1 0 1 1 0 2 2 1 0 0 0
Hispanic
Hispanic
Hispanic 2 2 1 0 0 0 0 2
2
2
2
0
0
1
0
0
0
0
0
0
0
Hispanic
Hispanic
2
2
2
2
1
1
0
0
0
0
0
0
0
0
Hispanic
2 1 2 2 1 0 0
Hispanic
Hispanic 2 2 1 0 0 0 2 1 2 1 2 1 1
Hispanic
Hispanic
Hispanic
Hispanic
2
2
2
2
0
0
2
1
0
0
0
0
0
0
2
2
1
1
2
2
1
1
1
0
1
0
0
0
Hispanic
Hispanic 2 2 0 1 0 0 0 2 1 2 0 2 2 2
Hispanic
Hispanic
Hispanic
2
2
2
2
0
0
1
0
0
0
0
0
0
0
2 1 2 0 2 2 1
Hispanic
Hispanic
2 1 2 0 2 2 0
Hispanic 2 1 2 1 1 1 1
2
2
1
1
2
2
0 1
1
1
1
1
0 Hispanic 2 1 2 1 1 1 0
Hispanic
Hispanic
Hispanic
Hispanic
2
2
1
1
2
2
0
0
1
0
1
0
1
0
2 1 1 2 1 1 1
Hispanic
2 1 1 0 1 1 1
Hispanic
Hispanic
Hispanic 2 1 1 2 1 1 1
2
2
1
0
1
2
0
1
0
1
0
1
0
1 Hispanic
Hispanic
2
2
1
1
1
1
2
1
0
1
0
1
0
1
Hispanic
2 0 2 1 0 0 0
Hispanic
Hispanic 2 1 1 0 1 1 0
1 2 2 2 2 2 2
Hispanic
Hispanic
Hispanic 2 1 0 1 0 0 0
1
1
2
2
2
2
2
1
2
1
2
1
1
1 Hispanic
Hispanic
2
2
1
1
0 0
0
0
2
0
2
0
0
Hispanic
1 2 2 0 2 2 1
Hispanic
Hispanic 1 2 2 1 2 2 1
1 2 2 0 1 1 1
Hispanic
Hispanic
Hispanic
Hispanic
1
1
2
2
2
2
1
1
1
1
1
1
1
1
1 2 2 0 1 0 0
1
1
2
2
1
1
2
1
0
1
0
1
0
1
Hispanic 1 2 2 1 1 1 0
Hispanic
Hispanic
Hispanic 1 2 2 0 0 0
1 2 1 0 0 0 0
Hispanic
Hispanic
Hispanic
Hispanic
1
1
2
2
1
1
2
2
1
0
1
0
0
0
1 2 0 1 0 0 0
1
1
1
1
2
2
2
1
1
2
1
1
0
0
Hispanic 1 2 1 1 1 1 1
Hispanic
Hispanic
Hispanic
Hispanic
1
1
2
2
1
0
0
1
1
0
1
0
1
0
Hispanic
1 1 2 1 0 0 0
1 1 2 1 1 1
Hispanic
Hispanic
Hispanic 1 2 0 1 0 0 0
0 2
2
1
2
1
0
0
0
0
0
0
0
Hispanic 1 1 2 1 1 0 0
Hispanic
Hispanic
Hispanic
1
0
1
1
2
1
1
1
0
0
0
0
0
0
Hispanic
2 1 1 1 1 1
2 2 2 2 2 2 1
Japanese
Japanese
Japanese 2 2 2 2 2 2 0
2 2 2 2 1 1 1
Japanese
Japanese
2
2
2
2
2
2
2
1
1
1
0
1
1
0
Japanese
2
2
2
2
2
1
2
2
1
1
1
1
1
1
Japanese
Japanese 2 2 1 2 1 1 1
2 2 1 2 0 0 0
Japanese
Japanese
Japanese 2 2 1 2 1 1 0
2 2 1 1 1 1 0
Japanese
Japanese
2
2
2
2
1
1
2
2
0
0
0
0
0
0
Japanese
2
2
2
2
1
1
1
1
1
0
0
0
0
0
Japanese
Japanese 2 2 1 1 1 1 1
2 2 1 1 0 0 0
Japanese
Japanese
Japanese
2
2
2
2
1
1
1
1
1
1
1
0
0
0 Japanese
Japanese
2 2 1 0 2 1 0
Japanese 2 2 1 0 1 1 2
2
2
2
2
1
0
0
2
0
0
0
0
0
0
Japanese
Japanese 2 2 1 0 1 1 0
2 2 0 2 0 0 0
Japanese
Japanese
Japanese
2
2
2
2
1
0
0
2
0
0
0
0
0
0 Japanese
Japanese
2 2 0 1 0 0 0
Japanese 2 2 0 2 0 0
2 1 2 1 1 1 0
2
2
1
1
1
1
2
2
1
1
1
0
1
2
Japanese
Japanese
2
2
2
2
0
0
1
1
0
0
0
0
0
0
Japanese
Japanese
2 1 1 1 1 1 1
Japanese 2 1 2 2 2 2 1 Japanese
Japanese
Japanese 2 1 2 1 2 2 1
2 1 1 1 0 0 0
2
2
1
1
1
0
0
2
0
0
0
0
0
0
Japanese
Japanese
2
2
1
1
2
1
1
1
1
0
1
0
0
0
Japanese
Japanese
2 1 0 1 1 1 1
Japanese 2 1 1 0 1 1 0 Japanese
2 0 2 1 1 1 1
Japanese
Japanese
2
2
1
1
1
0
0
2
0
0
0
0
0
0
Japanese
Japanese
1
1
2
2
2
2
2
2
1
1
1
1
1
0
Japanese 2 1 0 1 0 0 0 Japanese
1 2 2 1 1 1 1
Japanese
Japanese
2
1
0
2
1
2
2
2
1
2
1
2
1
2
Japanese
Japanese
Japanese
1 2 2 0 2 2 2
Japanese 1 2 2 2 1 1 1
1 2 1 2 1 1 0
1
1
2
2
1
1
2
2
1
0
1
0
0
0
Japanese 1 2 2 2 1 1 0 Japanese
Japanese
Japanese
1
1
2
2
2
1
1
2
1
0
1
0
0
0
Japanese
Japanese
1 2 1 2 0 0 0
1 2 1 1 1 1 0
Japanese 1 2 1 2 0 0 0
Japanese
Japanese Japanese 1 2 1 1 1 1 1
1
1
2
2
1
1
1
0
0
0
0
0
0
0
Japanese
Japanese
1
1
2
2
1
0
1
2
1
0
1
0
0
0
Japanese
Japanese
1 2 0 1 0 0 0
1 1 2 2 1 1 2
Japanese 1 2 0 1 0 0 0
Japanese
Japanese Japanese
Japanese
1
1
2
1
0
1
1
2
0
1
0
1
0
0
1
1
1
1
2
2
2
1
1
2
1
1
0
0
Japanese
1 1 2 0 0 0 0
Japanese 1 1 0 2 0 0 0
Japanese
1 0 0 0 0 0
Japanese
Japanese
1
0
1
2
0
2
1
2
0
0
0
0
0
0
Japanese
Japanese
0 2 2 2 2 2 1
Japanese 0 2 1 2 1 1 1 0
0
2
2
2
1
2
2
0
1
0
1
0
0
Japanese 0 2 1 2 1 1 0
Japanese
Japanese
0 2 1 2 0 0 0
Japanese
Japanese
0
0
2
1
1
1
2
2
0
1
0
1
0
0
Japanese
0 2 1 1 1 1 1
Japanese
Japanese
Japanese 0 1 1 1 0 0 0 0
0
2
2
1
1
1
1
1
1
1
1
1
1
Japanese
Japanese
0
0
1
1
0 1 0 0
0
0
Japanese
0 2 0 2 0 0 0
Japanese
Japanese 2 1 2 0 0 0 0 1 1 2 0 0 0
Japanese
Japanese
Japanese 1 0 1 2 2 2 0 0 0 favorable intermediate poor

Characteristics
AVAGAST
N
Median PFS, ms
HR
1,000 Simulations
Median PFS, ms
HR
% significant
(Log-rank p <0.05 and HR <1)
Asian Europe Pan-America
Avastin Placebo Avastin Placebo Avastin Placebo
188
6.7
188
5.6
125
6.9
124
4.4
74
5.9
75
4.4
0.92
0.71
0.65
6.5
0.85
27%
5.6
6.1
0.71
71%
4.4
5.3
0.84
19%
4.5

Cytokines Increased Prior to
Progression On FOLFIRI + Bev
Kopetz JCO 2009

Prospective Trials with FGF Levels
FOLFOX +
Bevacizumab-
Refractory CRC
N=100 screened
Primary endpoint: non-comparative
PFS
HIGH plasma bFGF
(n=30):
Irinotecan 180mg/m2
Brivanib 800mg PO qd
Low/normal bFGF
(n=30):
Irinotecan 180mg/m2
Brivanib 800mg PO qd

Other Resistance Pathways Not Discussed
Mostly refuted
Ellis ASCO 2012
Untested in the clinic
Untested in the clinic
Under investigation:
Are we targeting
ECs or Cancer
Stem Cells or
Both?
(Notch inhibitors slow in development)

Vilar E et al. Clin Cancer Res 2011;17:7207-7209

We are still early in molecular classification of colorectal cancer
Breast Cancer Lymphoma Colorectal Cancer
?
Sotiriou et al NEJM, 2009; Alizadeh et al, Nature 2000

Metabolism Information/signaling Energy
ILs & CXCLs

Median, years (95%CI) Hazard Ratio (95%CI)
Node 1+2 (n=46): 10.7 (7.1, 11.4+)
Node 3 (n=50): 11.3+ (4.8, 11.3+)
Node 4 (n=88): 5.7 (2.4, 16.8+)
Node 5 (n=25): 1.7 (1.0, 5.9)
1 (Reference)
2.030 (0.821, 5.018)
4.052 (1.769, 9.279)
6.713 (2.710, 16.633)
1,0
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0,0
0 2 4 6 8 10 12 14
Years since diagnosis of stage II or III colon cancer
Gerger et al Clin Cancer Res 2011
16 18

b
-catenin Cytoplasm
Nucleus A Critical Cellular
Switch b
-catenin
TCF
Teo et al., PNAS 2005
Differentiation
Non-differentiation
ICG-001
CBP b
-catenin p300 b
-catenin
ICG-001
CBP b
-catenin
TCF cyclin D1 axin 2
Hnkd
Survivin
S100A4 p300 b
-catenin
TCF c-jun fra-1

Miyabayashi T, et al PNAS 104, 5668, 2007

Relative Survivin expression fold change in CTC in patients treated with PRI724

Current “Targetable” Subsets of
Subset
Colorectal Cancer
Prognostic
Significance
Distinctive
Clinical Features
APC/β-catenin mutation No No
CRC Trials ongoing?*
No
KRAS mutation p53 mutation
BRAF mutations
PI3K mutations
CIMP (hypermethylating)
IGFR activation
FGFR overexpression/amp cMET amplification
NRAS mutation
PTEN loss
Mixed/No
Mixed
Yes
No
Yes
Unknown
Unknown
Unknown
Unknown
Mixed
No
No
Yes
Mixed
Yes
Unknown
Unknown
Unknown
Unknown
Unknown
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
* Trials utilizing inhibitors specific for pathway derangement

Refractory Melanoma
100
75 81% Response Rate
50
25
0
-25
-50
-75
-100
Flaherty et al NEJM ‘10
Refractory Colorectal
100
75
5% Response Rate
50
25
0
-25
-50
-75
-100
Kopetz et al ASCO ‘10
Hurdle : Oncogene mutation does not imply oncogene dependence
Understand the biological context in which particular mutations occur.

EGFR and BRAF(V600E) inhibitors synergize to induce apoptosis of CRC cells and to suppress CRC tumour growth in a xenograft model.
A Prahallad et al. Nature 000 , 1-5 (2012) doi:10.1038/nature10868

A murine study in a resistant BRAFmut CRC cell line combining venurafenib and an AKT inhibitor showed promising activity
125%
100%
75%
50%
25%
0%
-25%
-50%
-75%
BRAF m ut
PTEN null
PIK3CA m ut
Su et al CR 2012
Colon Melanoma

Tumor effects with available results of tumor genomic alterations.
Shimizu T et al. Clin Cancer Res 2012;18:2316-2325

ATTACC BATTLE iSPY2
Statistical design Allocation, Modular Adaptive
Randomization
50-70
Adaptive
Randomization
100+ Patients per arm 20-30
Individual study timing
Pharma integration
Flexible Fixed Flexible
Easier Difficult Moderate
Duration Indefinite Fixed Indefinite
Biomarker source Primary FFPE Prospective fresh
Biomarker maturity
Standard of care and qualified: KRAS/BRAF,
PTEN, bFGF, CIMP, PI3K
Standard of care and qualified: EGFR mutation, KRAS/BRAF,
VEGFR-2, RXR/Cyclin
D1
Prospective fresh
Standard of care only:
ER/PR, HER2,
MammoPrint
Cost $ $$ $$$
Validation Phase III
+/- enrichment
Phase III Phase III

USC Approach: Integrative Sequencing
Strategy to Capture Relevant Genes

• Molecular Evaluation of Tumor
Heterogeneity
• Molecular Evaluation of refractory
Patients
• Development of Stem Cell targeted drugs
• Integrated System Biology
• Increase Biomarker Driven Clinical Trial

What the Germans couldn’t do:
USA:Italy 1:0 (March 2012)