Safety and efficacy of etigilimab in combination with nivolumab in select recurrent/advanced solid tumors

2651

Background: Etigilimab (etig), a humanized IgG1 monoclonal antibody, blocks TIGIT interaction with PVR (poliovirus receptor) and inhibits downstream signalling with target cell killing. Etig +/- nivolumab (nivo) showed acceptable safety and preliminary activity in a FIH Phase 1a/b study in solid tumors. ACTIVATE, an open-label Phase 1b/2 basket study is evaluating further efficacy, safety, tolerability and PK/PD of etig+nivo. This is a preliminary efficacy and safety analysis from ACTIVATE. Methods: Subjects with advanced/metastatic solid tumors without curative/standard of care therapies are given IV etig+nivo Q2W until disease progression or intolerable toxicity. Six open cohorts are enrolling in parallel: endometrial cancer (post-front-line platinum), endometrial cancer (2-3 prior lines), PD-L1+ checkpoint-inhibitor-naïve (CPI-n) cervical cancer, rare cancers (germ cell tumor (GCT), sarcoma, uveal melanoma), ovarian cancer (post-front-line platinum) and TMB-h/MSS, (TMB >10mut/mb) tumors. Tumor assessments are done every 8 weeks following baseline scan. Primary endpoint is investigator-assessed ORR by RECIST 1.1. Secondary endpoints include duration of response and safety. Results: Of 27 efficacy-evaluable subjects enrolled in the 6 open cohorts with minimum 1 staging scan or radiological/clinical progression at data cut-off of 02/10/22, 12 had clinical benefit with 1 complete response (CR), 2 partial responses (PRs) and 9 stable diseases (SDs) and 15 had radiological/clinical progressive disease (PD), with an overall response rate (ORR) of 11% and disease control rate (DCR) of 44%. Conclusions: Etig+nivo is safe and well tolerated with no new safety signals. Early efficacy was noted in cervical cancer (1CR, 1PR and 1SD) and uveal melanoma (3 SDs >20 weeks). Encouraging activity was also noted in ovarian cancer and post-CPI treated TMB-H/MSS NSCLC. These early data support continued evaluation of the combination of etig+nivo. Clinical activity was notable as below. Clinical trial information: NCT04761198. [Table: see text]

A Phase 1a/b Open‑Label, Dose‑Escalation Study of Etigilimab Alone or in Combination with Nivolumab in Patients with Locally Advanced or Metastatic Solid Tumors

PURPOSE

TIGIT is a co-inhibitory receptor of T cell and natural killer cell activity. Targeting TIGIT with or without PD-1/PD-L1 checkpoint inhibition may enhance anti-tumor immunity.

PATIENTS AND METHODS

This Phase 1a/b trial was a first-in-human, open label, multicenter, dose escalation and expansion study in patients with locally advanced or metastatic solid tumors. Using 3+3 design, patients underwent 14-day treatment cycles with anti-TIGIT antibody etigilimab alone (phase 1a; 0.3, 1.0, 3.0, 10.0, 20.0 mg/kg intravenously) or in combination with anti-PD-1 antibody nivolumab (phase 1b; 3.0, 10.0, 20.0 mg/kg etigilimab and 240 mg nivolumab). Primary objective was safety and tolerability.

RESULTS

Thirty-three patients were enrolled (Phase 1a, n=23; Phase 1b, n=10). There were no DLTs. MTD for single and combination therapy was not determined; maximum administered dose was 20 mg/kg. The most commonly reported adverse events (AEs) were rash (43.5%), nausea (34.8%) and fatigue (30.4%) in Phase 1a and decreased appetite (50.0%), nausea (50.0%) and rash (40%) in Phase 1b. Six patients experienced Grade {greater than or equal to}3 treatment-related AEs. In phase 1a, 7 patients (30.0%) had stable disease. In Phase 1b, 1 patient had a partial response; 1 patient had prolonged stable disease of nearly 8 months. Median progression-free survival was 56.0 days (Phase 1a) and 57.5 days (Phase 1b). Biomarker correlative analyses demonstrated evidence of clear dose-dependent target engagement by etigilimab.

CONCLUSION

Etigilimab had an acceptable safety profile with preliminary evidence of clinical benefit alone and in combination with nivolumab and warrants further investigation in clinical trials.

Phase Ib clinical trial of the anti-frizzled antibody vantictumab (OMP-18R5) plus paclitaxel in patients with locally advanced or metastatic HER2-negative breast cancer

PURPOSE

Vantictumab is a monoclonal antibody that binds to frizzled (FZD) receptors and inhibits canonical WNT signaling. This phase Ib dose escalation study enrolled patients with locally recurrent or metastatic HER2-negative breast cancer who were treated with weekly paclitaxel in combination with escalating doses of vantictumab.

METHODS

Patients were enrolled in dose escalation cohorts treated with weekly paclitaxel 90 mg/m² on days 1, 8 and 15 in combination with vantictumab 3.5-14 mg/kg days 1 and 15 or 3-8 mg/kg day 1 of every 28-day cycle. Primary endpoints were safety, dose-limiting toxicities (DLTs). Secondary endpoints included pharmacokinetics, efficacy and an exploratory biomarker analysis.

RESULTS

Forty-eight female patients with a mean age of 54 were enrolled. The majority (66.6%) received prior chemotherapy for recurrent or metastatic disease; 45.8% were hormone receptor (HR)-positive, HER2-negative and 54.2% triple-negative. The most frequent adverse events related to any study treatment were nausea (54.2%), alopecia (52.1%), fatigue (47.9%), and peripheral neuropathy (43.8%). No DLTs occurred; however, 6 patients experienced fractures outside of the DLT window. The overall response rate was 31.3% and the clinical benefit rate was 68.8%. A 6-gene WNT pathway signature showed significant association with progression-free survival (PFS) and overall survival (OS) for the biomarker high versus biomarker low groups (PFS: p = 0.029 and OS: p = 0.00045, respectively).

CONCLUSIONS

The combination of vantictumab and weekly paclitaxel was generally well tolerated with promising efficacy; however, the incidence of fractures limits future clinical development of this particular WNT inhibitor in metastatic breast cancer.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov registration: NCT01973309.

Phase Ib Study of Wnt Inhibitor Ipafricept with Gemcitabine and nab-paclitaxel in Patients with Previously Untreated Stage IV Pancreatic Cancer

PURPOSE

The recombinant fusion protein ipafricept blocks Wnt signaling, and in combination with gemcitabine and nab-paclitaxel caused tumor regression in xenografts. This phase Ib study evaluated the combination of ipafricept with nab-paclitaxel + gemcitabine in patients with untreated metastatic pancreatic adenocarcinoma (mPDAC).

PATIENTS AND METHODS

Dose escalation started with standard dose nab-paclitaxel + gemcitabine and ipafricept (3.5 mg/kg days 1, 15). Because of fragility fractures seen with different anti-Wnt agents, following cohorts had ≥6 patients treated with ipafricept 3 to 5 mg/kg on day 1, and included bone marker monitoring and prophylactic bisphosphonates as indicated. On the basis of preclinical data, sequential dosing was evaluated in cohort 4 (ipafricept day 1 followed nab-paclitaxel + gemcitabine day 3). Objectives included safety, MTD, recommended phase II dose, pharmacokinetics, immunogenicity, pharmacodynamics, and efficacy.

RESULTS

A total of 26 patients were enrolled, five in cohort 1 and seven each in cohorts 2-4. ipafricept-related adverse events (AEs) of any grade included fatigue, nausea, vomiting, anorexia, and pyrexia. ipafricept-related AEs grade ≥3 included two events of aspartate aminotransferase elevation, and one each of nausea, rash, vomiting, and leucopenia. No dose-limiting toxicities or fragility fractures were observed. Nine patients (34.6%) had partial response, 12 (46.2%) stable disease as best response, with clinical benefit rate of 81%. Median progression-free survival was 5.9 m [95% confidence interval (CI), 3.4-18.4], median overall survival was 9.7 m (95% CI, 7.0-14). The study was terminated by the sponsor due to bone-related toxicity within this therapeutic program and concerns for commercial viability. One patient remains on therapy under compassionate use.

CONCLUSIONS

Ipafricept can be administered with nab-paclitaxel + gemcitabine with reasonable tolerance. Wnt pathway remains a therapeutic target of interest in mPDAC.

A phase 1b dose escalation study of Wnt pathway inhibitor vantictumab in combination with nab-paclitaxel and gemcitabine in patients with previously untreated metastatic pancreatic cancer

Vantictumab is a fully human monoclonal antibody that inhibits Wnt pathway signaling through binding FZD1, 2, 5, 7, and 8 receptors. This phase Ib study evaluated vantictumab in combination with nab-paclitaxel and gemcitabine in patients with untreated metastatic pancreatic adenocarcinoma. Patients received vantictumab at escalating doses in combination with standard dosing of nab-paclitaxel and gemcitabine according to a 3 + 3 design. A total of 31 patients were treated in 5 dosing cohorts. Fragility fractures attributed to vantictumab occurred in 2 patients in Cohort 2 (7 mg/kg every 2 weeks), and this maximum administered dose (MAD) on study was considered unsafe. The dosing schedule was revised to every 4 weeks for Cohorts 3 through 5, with additional bone safety parameters added. Sequential dosing of vantictumab followed by nab-paclitaxel and gemcitabine was also explored. No fragility fractures attributed to vantictumab occurred in these cohorts; pathologic fracture not attributed to vantictumab was documented in 2 patients. The study was ultimately terminated due to concerns around bone-related safety, and thus the maximum tolerated dose (MTD) of the combination was not determined. The MAD of vantictumab according to the revised dosing schedule was 5 mg/kg (n = 16).

Targeting the Wnt signaling pathway through R-spondin 3 identifies an anti-fibrosis treatment strategy for multiple organs

The Wnt/β-catenin signaling pathway has been implicated in human proliferative diseases such as cancer and fibrosis. The functions of β-catenin and several other components of this pathway have been investigated in fibrosis. However, the potential role of R-spondin proteins (RSPOs), enhancers of the Wnt/β-catenin signaling, has not been described. A specific interventional strategy targeting this pathway for fibrosis remains to be defined. We developed monoclonal antibodies against members of the RSPO family (RSPO1, 2, and 3) and probed their potential function in fibrosis in vivo. We demonstrated that RSPO3 plays a critical role in the development of fibrosis in multiple organs. Specifically, an anti-RSPO3 antibody, OMP-131R10, when dosed therapeutically, attenuated fibrosis in carbon tetrachloride (CCl₄)-induced liver fibrosis, bleomycin-induced pulmonary and skin fibrosis models. Mechanistically, we showed that RSPO3 induces multiple pro-fibrotic chemokines and cytokines in Kupffer cells and hepatocytes. We found that the anti-fibrotic activity of OMP-131R10 is associated with its inhibition of β-catenin activation in vivo. Finally, RSPO3 was found to be highly elevated in the active lesions of fibrotic tissues in mouse models of fibrosis and in patients with idiopathic pulmonary fibrosis (IPF) and nonalcoholic steatohepatitis (NASH). Together these data provide an anti-fibrotic strategy for targeting the Wnt/β-catenin pathway through RSPO3 blockade and support that OMP-131R10 could be an important therapeutic agent for fibrosis.

A phase I dose-escalation and dose-expansion study of brontictuzumab in subjects with selected solid tumors

Background

Brontictuzumab is a monoclonal antibody that targets Notch1 and inhibits pathway activation. The purpose of this first-in-human study was to determine the maximum tolerated dose (MTD), safety, pharmacokinetics, immunogenicity and preliminary efficacy of brontictuzumab in patients with solid tumors.

Patients and methods

Subjects with selected refractory solid tumors were eligible. Brontictuzumab was administered intravenously at various dose levels and schedule during dose escalation, and at 1.5 mg/kg every 3 weeks (Q3W) during expansion. Evidence of Notch1 pathway activation as determined by an immunohistochemistry assay was required for entry in the expansion cohort. Adverse events were graded according to the NCI-CTCAE v 4.03. Efficacy was assessed by RECIST 1.1.

Results

Forty-eight subjects enrolled (33 in dose escalation and 15 in the expansion phase). The MTD was 1.5 mg/kg Q3W. Dose-limiting toxicities were grade 3 diarrhea in two subjects and grade 3 fatigue in one subject. The most common drug-related adverse events of any grade were diarrhea (71%), fatigue (44%), nausea (40%), vomiting (21%), and AST increase (21%). Brontictuzumab exhibited nonlinear pharmacokinetics with dose-dependent terminal half-life ranging 1-4 days. Clinical benefit was seen in 6 of 36 (17%) assessable subjects: 2 had unconfirmed partial response (PR) and 4 subjects had prolonged (≥ 6 months) disease stabilization (SD). Both PRs and three prolonged SD occurred in adenoid cystic carcinoma (ACC) subjects with evidence of Notch1 pathway activation. Pharmacodynamic effects of brontictuzumab were seen in patients' blood and tumor.

Conclusion

Brontictuzumab was well tolerated at the MTD. The main toxicity was diarrhea, an on-target effect of Notch1 inhibition. An efficacy signal was noted in subjects with ACC and Notch1 pathway activation.

ClinicalTrials.gov identifier

NCT01778439.

A randomized phase II trial of nab-paclitaxel and gemcitabine with tarextumab or placebo in patients with untreated metastatic pancreatic cancer

Purpose

Notch signaling dysregulation is implicated in the development of pancreatic adenocarcinoma (PDAC). Tarextumab is a fully human IgG2 antibody that inhibits Notch2/3 receptors.

Patients and Methods

Aphase 2, randomized, placebo‐controlled, multicenter trial evaluated the activity of tarextumab in combination with nab‐paclitaxel and gemcitabine in patients with metastatic PDAC. Patients were stratified based on ECOG performance score and Ca 19‐9 level and randomized 1:1 to nab‐paclitaxel, gemcitabine with either tarextumab or placebo. Based on preclinical and phase Ib results suggesting a positive correlation between Notch3 gene expression and tarextumab anti‐tumor activity, patients were also divided into subgroups of low, intermediate, and high Notch3 gene expression. Primary endpoint was overall survival (OS) in all and in patients with the three Notch3 gene expression subgroups (≥25th, ≥50% and ≥75% percentiles); secondary end points included progression‐free survival (PFS), 12‐month OS, overall response rate (ORR), and safety and biomarker investigation.

Results

Median OS was 6.4 months in the tarextumab group vs 7.9 months in the placebo group (HR = 1.34 [95% CI = 0.95, 1.89], P = .0985). No difference observed in OS in the Notch3 gene expression subgroups. PFS in the tarextumab‐treated group (3.7 months) was significantly shorter compared with the placebo group (5.5 months) (hazard ratio was 1.43 [95% CI = 1.01, 2.01]; P = .04). Grade 3 diarrhea and thrombocytopenia were more common in the tarextumab group.

Conclusions

The addition of tarextumab to nab‐paclitaxel and gemcitabine did not improve OS, PFS, or ORR in first‐line metastatic PDAC, and PFS was specifically statistically worse in the tarextumab‐treated patients.

Clinical trial registry no

NCT01647828.

A phase 1b dose escalation study of ipafricept (OMP54F28) in combination with paclitaxel and carboplatin in patients with recurrent platinum-sensitive ovarian cancer

OBJECTIVES

The WNT pathway is an important oncologic driver of epithelial ovarian cancer (EOC). The first-in-class recombinant fusion protein ipafricept (IPA) blocks Wnt signaling through binding of Wnt ligands. This phase Ib trial was designed to determine the maximum tolerated dose (MTD) and recommended phase 2 dose (RPh2) for IPA in combination with taxane and platinum therapy (C/P).

METHODS

Dose escalation started with a standard 3 + 3 design for IPA/C/P with q3w intravenous IPA on Day 1, in cycles 1 to 6 with C (AUC = 5 mg/ml·min) and P (175 mg/m²). For enhanced bone safety the trial was revised to 6-patient cohorts with a q3w regimen of IPA on Day 1 and C/P on Day 3 (IPA → C/P).

RESULTS

37 patients have been treated; 30 of whom were treated following protocol revision to q3w IPA(D1) → C/P(D3) (2 & 4 mg/kg). IPA-related TEAEs that occurred in ≥15% included: fatigue (40%); nausea (35%); diarrhea and decreased appetite (22%) each; dysgeusia (19%); and vomiting (16.2%). 22% reported ≥1 IPA related TEAE Grade ≥3 the most common of which was neutropenia at 16%. There were no DLTs; the MTD was not reached. The maximum administered dose based on bone safety was 6 mg/kg. The overall response rate (ORR) was 75.7%. Median PFS was 10.3 months (95% CI 8.5-14.2) and OS 33 months (95% CI 23.4-NR).

CONCLUSIONS

IPA is well tolerated in combination with sequential C/P. ORR, PFS and OS are comparable to historical data but bone toxicity at efficacy doses of this particular Wnt inhibitor limit further development in EOC.

Phase Ib study of WNT inhibitor ipafricept (IPA) with nab-paclitaxel (Nab-P) and gemcitabine (G) in patients (pts) with previously untreated stage IV pancreatic cancer (mPC)

369

Background: The first-in-class recombinant fusion protein IPA blocks WNT signaling by binding WNT ligands, and in combination with Nab-P/G caused tumor regression in pt-derived PC xenografts. This open-label Phase 1b dose escalation study evaluated the combination of IPA with Nab-P/G in untreated mPC pts using a standard 3+3 design. Methods: Dose escalation in cohort 1 started with Nab-P 125 mg/m2 and G 1000 mg/m2 given on days 1, 8 ,15, with IV IPA (3.5 mg/kg) on days 1 and 15, in 28-day cycles. Due to fragility fractures seen in other studies with similar targeted agents, cohorts 2-4 were 6-pt cohorts treated with weekly Nab-P/G + IPA 3 mg/kg (cohort 2) or 5 mg/kg (cohorts 3 and 4) on day 1. These cohorts included strict bone marker monitoring and use of bisphosphonates as indicated. Based on pre-clinical data suggesting improved efficacy with sequential dosing, pts in Cohort 4 received IPA on day 1 followed by weekly chemotherapy starting on day 3 of 28-day cycles. Objectives included safety, maximum tolerated dose, recommended phase 2 dose, pharmacokinetics, immunogenicity, pharmacodynamics, and preliminary efficacy. Results: Twenty-six pts in four dose escalation cohorts were enrolled, five in the cohort one and seven each in cohorts 2-4. Median age was 61.7 years and a majority were male (73%). Reported IPA-related AEs of any grade occurring in ≥ 20% of pts included fatigue, nausea, vomiting, anorexia and pyrexia. IPA-related AEs grade ≥ 3 included 2 events of AST elevation, and 1 each of nausea, maculopapular rash, vomiting and WBC decrease. No dose limiting toxicities or fragility fractures were observed. Of 26 evaluable pts, 9 (34.6%) had a partial response and 12 (46.2%) stable disease, with clinical benefit rate of 80.8%. The study was closed due to termination of the program by the sponsor. At time of data cut off, median progression free survival was 5.9 months (95% CI 3.4-18.4), median overall survival was 9.7 months (95% CI: 7.0-14). One pt remains on therapy under compassionate use with ongoing response. Conclusions: IPA can be safely administered with Nab-P and G in pts with mPC. Additional studies targeting the WNT pathway in pancreatic cancer are warranted. Clinical trial information: NCT02050178.

A phase Ib dose escalation study of vantictumab (VAN) in combination with nab-paclitaxel (Nab-P) and gemcitabine (G) in patients with previously untreated stage IV pancreatic cancer

249

Background: Vantictumab is a fully human monoclonal antibody that inhibits Wnt pathway signaling through binding FZD1, 2, 5, 7, and 8 receptors. A phase Ib study of VAN in combination with Nab-P and G was performed in patients with untreated stage IV pancreatic adenocarcinoma. Methods: Patients received VAN at escalating doses (3-7 mg/kg) in combination with standard dosing of Nab-P and G according to a 3+3 design. Due to fragility fractures occurring in this and other related clinical trials, dosing on an every 2 week schedule in cohorts 1 and 2 was transitioned to every 4 week dosing for cohorts 3 through 5. In these later cohorts, a minimum of six patients were treated at each dose level and additional criteria for maximum tolerated dose (MTD) integrating bone safety parameters were added. The bone safety plan was also revised for these cohorts. Sequential dosing of VAN followed by Nab-P and G was explored in cohort 5. Results: Thirty-one patients (52% male, 48% female) were enrolled and treated in 5 dosing cohorts. Median age was 66. Most common study-treatment related adverse events were nausea (68%) and fatigue (52%). One dose limiting toxicity (DLT) event occurred in the study population—grade 3 dehydration in 1 of 9 patients in cohort 4 (5 mg/kg q4w). Fragility fractures attributed to VAN occurred in two patients in cohort 2 (7 mg/kg q2w). Once the dosing schedule was revised to every 4 weeks, the maximum administered VAN dose was 5 mg/kg. No fragility fractures attributed to VAN occurred in these cohorts; pathologic fracture not attributed to VAN was documented in 2 patients. The study was terminated due to lack of an acceptable therapeutic index. Partial response was documented in 13 patients (42%) and stable disease in 11 (36%). Conclusions: The MTD of VAN plus Nab-P and G was not determined, but the maximum administered dose (MAD) of VAN, 7 mg/kg every 2 weeks, was considered unsafe related to bone toxicity, a known effect of WNT inhibition. After the study was revised, the MAD was 5 mg/kg every 4 weeks, with no protocol-specified bone toxicity observed (n = 16). Clinical trial information: NCT02005315.

A first-in-human phase 1a study of the bispecific anti-DLL4/anti-VEGF antibody navicixizumab (OMP-305B83) in patients with previously treated solid tumors

Purpose Navicixizumab (OMP-305B83) is a bispecific antibody that inhibits delta-like ligand 4 and vascular endothelial growth factor. This Phase 1a trial assessed escalating doses of navicixizumab in refractory solid tumors patients. Design A 3 + 3 dose escalation design was used followed by the treatment of additional patients in an expansion cohort. Study objectives were determination of the maximum tolerated dose, safety, pharmacokinetics, pharmacodynamics, immunogenicity and efficacy. Results Sixty-six patients were treated once every 3 weeks in 8 dose-escalation cohorts (0.5, 1, 2.5, 3.5, 5, 7.5, 10, and 12.5 mg/kg) and an expansion cohort (7.5 mg/kg). The median age was 60 years and 68% of the patients were female. The most commonly enrolled tumor types were ovarian (12), colorectal (11) and breast, pancreatic, uterine and endometrial (4 each) cancers. As only 1 dose limiting toxicity occurred, the maximum tolerated dose was not reached, but 7.5 mg/kg was chosen as the dose for the expansion cohort. The treatment related adverse events (≥15% of patients) were hypertension (57.6%), headache (28.8%), fatigue (25.8%), and pulmonary hypertension (18.2%). Pulmonary hypertension was mostly asymptomatic at doses ≤5 mg/kg (6 Gr1, 1 Gr2), but was more severe at higher doses (4 Gr2, 1 Gr3). Navicixizumab's half-life was 11.4 days and there was a moderate (29%) incidence of anti-drug antibody formation. Four patients (3 ovarian cancer, 1 uterine carcinosarcoma) had a partial response and 17 patients had stable disease. Nineteen patients had a reduction in the size of their target lesions including 7/11 patients with ovarian cancer. Four patients remained on study for >300 days and 2 of these patients were on study for >500 days. Conclusions Navicixizumab can be safely administered with manageable toxicities and these data showed preliminary signs of antitumor activity in multiple tumor types, but was most promising in ovarian cancer. As a result these data justify its continued development in combination Phase 1b clinical trials.

Abstract 3826: GITRL-Fc biomarker and mechanism study: GITRL-Fc reduces Treg frequency in tumors and requires effector function for inhibition of tumor growth

Activation of the co-stimulatory receptor GITR (Glucocorticoid-Induced Tumor Necrosis Factor Receptor) by GITR-Ligand (GITRL) promotes proliferation and activation of effector T cells (T eff) and inhibits suppressive activity of regulatory T cells (Treg). Here, we have further characterized the mechanism of action of a single-gene GITRL trimer fused to an immunoglobulin Fc domain (GITRL-Fc, 336B3) by examining pharmacodynamic (PD) biomarkers in time course studies. Mice bearing CT26.WT colon tumors were treated with weekly GITRL-Fc and sacrificed 24 hours, 7 and 14 days after the first dose. Immuno-phenotyping of tumor-associated immune cells revealed a reduction in Treg frequency in tumor by 24 hours post-dose that was maintained at 7 and 14 days. Furthermore, GITRL-Fc treatment increased activation markers on tumor-associated CD4+ and CD8+ T cells, suggesting an increased cytotoxic environment within the tumor. This was supported by significant and sustained increase in CD8+ T cell:Treg ratio in the tumor after GITRL-Fc treatment. To determine whether intratumoral (IT) injection of GITRL-Fc is an effective route of administration, we compared efficacy, pharmacodynamic (PD) markers and pharmacokinetics in IT- and intraperitoneal (IP)-injected mice bearing bilateral CT26.WT tumors. Both routes of administration showed similar tumor growth inhibition (TGI) and PD markers in both the treated and the abscopal tumors, but IT injection resulted in a significantly lower serum GITRL-Fc concentration, suggesting that IT administration may be an alternative route of administration to IP with similar efficacy. The GITRL-Fc molecule 336B3 is effector function competent and able to induce cell-mediated cytotoxicity upon binding. To determine whether this effector function is required for GITRL-Fc-induced TGI, we treated CT26.WT tumor-bearing mice with 336B3 and 336B22, a GITRL-Fc molecule deficient in effector function. The effector function-competent 336B3 induced significant TGI and a more robust activation of Teff cells and reduction in Treg frequency, when compared to 336B22, suggesting that effector function is important for efficacy. To identify biomarkers for GITRL-Fc, we performed microarray analyses on multiple syngeneic mouse models treated with GITRL-Fc and developed GITRL gene signatures from blood and from tumors. We also developed multiplexed immunohistochemistry panels designed to quantify frequency of GITR and GITRL expression (GITR+CD8, GITR+FOXP3) in tumors. In conclusion, we have examined the effects of GITRL-Fc on preclinical mouse models. Biomarker analysis showed that loss of Tregs, activation of T cells and Fc-mediated effector function are key elements in the mechanism of action of the molecule. We have identified potential biomarkers to be used for PD and potential predictive analysis in clinical trial patient samples.

Citation Format: Gretchen M. Argast, Belinda Cancilla, Fiore Cattaruzza, Pete Yeung, Reyhaneh Lahmy, Erwan Le Scolan, Rose Harris, Alayne Brunner, Min Wang, Fumiko Axelrod, Jorge Monteon, Jennifer Elechko, Andrew Lam, MingHong Xie, Earth Light Lowe, Gilbert O'Young, Austin Gurney, Ann M. Kapoun. GITRL-Fc biomarker and mechanism study: GITRL-Fc reduces Treg frequency in tumors and requires effector function for inhibition of tumor growth [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3826.

Abstract A055: RSPO3 overexpression is a characteristic feature of signet ring gastrointestinal malignancies

Introduction: The Wnt/β-catenin pathway is critical in the pathogenesis of many gastrointestinal malignancies, and, when disrupted, promotes aberrant cell proliferation and loss of cell stemness. Mutations in APC are the most common etiology of Wnt/β-catenin signaling dysfunction in colorectal (CRC) cancers. However, in the approximately 20% of CRCs that are APC wild-type, abnormalities in cell-surface genes like RNF43 and RSPO drive pathologic Wnt/β-catenin activity. We sought to characterize further gastrointestinal tumors harboring RSPO alterations. Methods: Under an IRB-approved protocol at MD Anderson, tumors from 665 patients with metastatic CRC at MD Anderson were evaluated by next-generation sequencing for APC mutations and for the presence of signet ring cells. Mutation profiling and gene expression data from the TCGA (www.cbioportal.org) were analyzed in 223 patients with CRC for APC mutations and for RSPO overexpression for a correlation using a Fisher’s exact test. RNA extracted from 19 separate frozen tumors from patients with confirmed signet ring metastatic CRC was next analyzed by RNA-seq for the presence for RSPO fusions and for RSPO gene expression levels. In a validation set of FFPE samples derived from patients with signet ring metastatic CRC or signet ring gastric adenocarcinomas, RSPO3 gene expression was analyzed using RT-PCR in a CLIA-validated setting (Oncomed Pharmaceuticals). Results: APC mutations were detected less frequently in signet ring CRC tumors relative to non-signet ring counterparts (18% vs. 56%, P< .001). RSPO overexpression was also observed more commonly in APC wild-type CRC tumors (16% vs. 7%, P= .04). Given these associations, we investigated further a correlation between signet ring adenocarcinomas and RSPO overexpression. Gene expression analysis of signet ring CRC tumors revealed high RSPO3 expression in 13 of 19 cases (68%). Here, a trend towards higher RSPO3 expression was observed in tumors with > 50% signet ring cells present (P=.20). In a validation cohort of patients with signet ring adenocarcinomas, RSPO3 overexpression was noted in 20/38 (52%) CRCs and 21/22 (96%) gastric adenocarcinomas. RSPO fusions were detected in 0 of 19 patients with signet ring CRC analyzed by RNA-seq. Conclusions: In molecularly specified populations of patients with colorectal and gastric malignancies, RSPO3 overexpression is detected in high frequencies in signet ring adenocarcinomas. Given the cell surface localization of RSPO3 and the importance of Wnt/β-catenin signaling in the tumorigenesis of gastrointestinal malignancies, our findings warrant further evaluation for anti-RSPO3 therapies as novel treatment options for patients with signet ring adenocarcinomas.

Citation Format: Van Morris, Alexey Sorokin, Mariela Blum, Krittiya Korphaisarn, Jeannelyn Estrella, Leonardo Faoro, Min Wang, Stanley Hamilton, Ann M. Kapoun, Scott Kopetz. RSPO3 overexpression is a characteristic feature of signet ring gastrointestinal malignancies [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A055.

Abstract A030: Biomarker study of vantictumab plus paclitaxel in HER2- breast cancer patients

Introduction: We have developed a monoclonal antibody, vantictumab, that blocks canonical Wnt/β-catenin signaling through binding of five FZD receptors (1, 2, 5, 7, and 8). This antibody inhibits the growth of several tumor types, including breast. Vantictumab reduces tumor-initiating cell frequency and exhibits synergistic activity with standard-of-care (SOC) agents (Gurney et al., 2012). To confirm the mechanism of action and to potentially target breast cancer patients most likely to respond to vantictumab, we undertook a biomarker study. Methods: We previously identified a 6-gene Wnt pathway-related signature, FBXW2, CCND2, RHOU, CTBP2, WIF1, and DKK1, based on microarray gene expression data from 8 BC patient-derived xenograft (PDX) models with established in vivo response to vantictumab plus SOC. This signature successfully predicted the response of 8 additional and independent PDX breast tumors. We further developed a qPCR Research Use Only (RUO) assay for the 6 genes for use on FFPE human breast tumor samples. This assay was evaluated in the phase 1b study of vantictumab in combination with paclitaxel in locally recurrent or metastatic HER2- breast cancer (NCT01973309) and the signature was refined using a Lasso model with overall survival as the outcome. A repeated 10 fold cross-validation was used to evaluate the performance of the gene signature. The association of the signature with progression-free survival (PFS) and overall survival (OS) was examined (n=40 patients). Furthermore, pharmacodynamic (PD) biomarker analyses were performed on tumor biopsies and hair follicles by comparing gene expression data from post-treatment time points versus baseline data (Affymetrix U133 plus 2 Microarrays). Results: A potential predictive 6-gene Wnt pathway biomarker was identified based on preclinical data and the biomarker was evaluated and refined in a phase 1b study of vantictumab in combination with paclitaxel in HER2- breast cancer. In the phase 1b study, AUC = 75% with repeated 10 fold cross-validation measuring the performance of the gene signature. Based on this analysis, two genes, RHOU and DKK1, were dropped from the preclinical gene signature, which was consistent with the feature ranking in the preclinical qPCR data. The refined 4-gene signature was significantly associated with both PFS and OS at a 50% percentile cut-off. In addition, analysis of PD biomarkers demonstrated that Wnt pathway target genes including AXIN2, LEF1, and CTNNB1 were downregulated while differentiation markers, e.g., KRT19 and Wnt pathway inhibitors, e.g., SFRP1, DKK3 were upregulated by vantictumab plus paclitaxel. Conclusions: We developed a 4-gene signature as a potential predictive biomarker for the response to vantictumab plus paclitaxel in HER2- breast cancer. PD biomarker analysis in tumors and hair follicles confirmed the mechanism of action of vantictumab in patient samples. Preliminary efficacy of vantictumab plus paclitaxel in the phase 1b study was encouraging, particularly in breast cancer patients positive for the 4-gene signature. Updated biomarker and PK/PD data from the phase 1b trial (NCT01973309) will also be presented.

Citation Format: Chun Zhang, William R. Henner, Min Wang, Fiore Cattaruzza, Pete Yeung, Gilbert O'Young, Yuwang Liu, Gretchen Argast, Lu Xu, Shailaja Uttamsingh, John Lewicki, Ann M. Kapoun. Biomarker study of vantictumab plus paclitaxel in HER2- breast cancer patients [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A030.

A First-in-Human Phase I Study of the Anticancer Stem Cell Agent Ipafricept (OMP-54F28), a Decoy Receptor for Wnt Ligands, in Patients with Advanced Solid Tumors

Purpose: Wnt signaling is implicated in tumor cell dedifferentiation and cancer stem cell function. Ipafricept (OMP-54F28) is a first-in-class recombinant fusion protein with the extracellular part of human frizzled 8 receptor fused to a human IgG1 Fc fragment that binds Wnt ligands. This trial evaluated ipafricept in patients with solid tumors.Experimental design: A 3+3 design was used; ipafricept was given intravenously every 3 weeks. The objectives were determination of dose-limiting toxicities (DLTs), recommended phase 2 dose (RP2D), safety, pharmacokinetics (PK), immunogenicity, pharmacodynamics (PD), and preliminary efficacy.Results: 26 patients were treated in seven dose-escalation cohorts (0.5, 1, 2.5, 5, 10, 15, and 20 mg/kg). No further dose escalation was pursued as PK modeling indicated that the target efficacious dose was reached at 10 mg/kg, and fragility fractures occurred at 20 mg/kg. Most common related grade 1 and 2 adverse events (AEs; ≥20% of patients) were dysgeusia, decreased appetite, fatigue, and muscle spasms. Ipafricept-related grade 3 TEAEs included hypophosphatemia and weight decrease (1 subject each, 3.8%). Ipafricept half-life was ∼4 days and had low incidence of antidrug antibody formation (7.69%) with no impact on drug exposure. Six patients had β-C-terminal telopeptide (β-CTX) doubling from baseline, which was reversible. PD modulation of Wnt pathway genes in hair follicles occurred ≥2.5 mg/kg. Two desmoid tumor and a germ cell cancer patient experienced stable disease for >6 months.Conclusions: Ipafricept was well tolerated, with RP2D of 15 mg/kg Q3W. Prolonged SD was noted in desmoid tumor and germ cell cancer patients. Clin Cancer Res; 23(24); 7490-7. ©2017 AACR.

Abstract 5621: Prevalence of GITR expression and pharmacodynamic (PD) biomarkers in syngeneic tumor models treated by a GITR agonist (GITRL-Fc)

GITRL (Glucocorticoid-Induced Tumor Necrosis Factor Receptor Ligand, TNFSF18) is a member of the tumor necrosis factor (TNF) ligand superfamily. GITRL binds and activates the co-stimulatory surface receptor GITR, which promotes proliferation and activation of effector T cells (Teff) and inhibits suppressive activity of regulatory T cells (Treg). It is thus hypothesized that co-stimulation of GITR by agonist agents will promote anti-tumor immunity. We generated a novel single-gene GITRL trimer fused to an immunoglobulin Fc domain (GITRL-Fc) that shows robust single agent antitumor efficacy and immune effects in multiple syngeneic mouse models, suggesting its potential benefit in cancer immunotherapy To investigate the prevalence of GITR expression in human tumors, RNA-Seq data analyses of 33 tumor types in TCGA showed GITR is highly expressed in a subset of solid tumors, including head & neck, lung, breast, esophageal, and bladder cancers. In most solid tumors, GITR expression correlated poorly with T cell markers, implying that GITR may not be exclusive to immune cells and may be expressed in tumor cells as well. Similar findings emerged from RNA-Seq data analysis of patient-derived xenograft (PDX) samples from 24 tumor types. The gene expression data was corroborated by immunohistochemistry (IHC) analysis of GITR expression in 17 tumor types which showed that in addition to immune cells, GITR was expressed on tumor cell membranes. A multi-platform approach was taken to investigate GITRL-Fc pharmacodynamic (PD) biomarkers in tumors and in matched whole blood samples from mice bearing CT26 colon, 4T1 breast, and B16F10 melanoma carcinoma models. Global gene expression levels were profiled by microarray on treated and control tissues. We also monitored the changes of immune cell populations and cytokine secretions by flow cytometry, Luminex and IHC. Immune gene changes were more robust in tumors than in blood samples. In tumor samples, GITRL-Fc increased the gene expression associated with T cells, CD8 T cells, cytotoxicity, Th1 cells, interferon gamma (IFN-γ), natural killer cells, Teff cells, and T cell activation markers. These gene changes were validated by quantitative real-time PCR. Similarly, flow cytometry analysis showed that GITRL-Fc promoted activation of CD4+ effector cells, decreased Treg frequency, and increased the ratio of CD8+ T cell/Treg in the tumor. GITRL-Fc also modulated secretion of cytokines in splenocytes, including an increase in IFN-γ. Taken together, the PD biomarker changes in immune-related gene expression, immune cell populations, and cytokine secretions observed in these preclinical tumor models are consistent with GITRL-Fc mechanism of action and demonstrated target engagement of GITRL-Fc. Additional approaches, including in-silico sorting, to monitor rare immune cell populations in tumor samples will be discussed.

Citation Format: Min Wang, Fiore Cattaruzza, Pete Yeung, Alayne Brunner, Erwan LeScolan, Yuwang Liu, Jennifer Cain, Gilbert OYoung, Earth Light Lowe, Belinda Cancilla, Rose Harris, Tim Hoey, Austin Gurney, John Lewicki, Gretchen Argast, Ann M. Kapoun. Prevalence of GITR expression and pharmacodynamic (PD) biomarkers in syngeneic tumor models treated by a GITR agonist (GITRL-Fc) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5621. doi:10.1158/1538-7445.AM2017-5621

Abstract 1727: Circulating Tumor Cells (CTCs) in patients with extensive stage small cell lung cancer and their association with clinical outcome

Background: The NOTCH pathway has been identified as a key therapeutic pathway in SCLC. Tarextumab (TRXT, anti-Notch2/3, OMP-59R5) is a fully human monoclonal antibody that targets the Notch2 and Notch3 receptors. PINNACLE is a Phase 1b/2 trial of TRXT in combination with etoposide and platinum therapy (EP) in patients with untreated extensive stage small cell lung cancer (ES-SCLC). Baseline CTCs and post treatment changes in CTCs have previously been shown to predict the response to chemotherapy in SCLC. CTCs may also serve as pharmacodynamic biomarkers. Here we describe a study of baseline and longitudinal CTCs in ES-SCLC patients from the PINNACLE phase 1b trial (clinicaltrials.gov:NCT01859741).

Materials and methods: CTCs, CTC clusters, apoptotic CTCs and N-Cadherin+ CTCs were identified and enumerated from patient blood samples using Epic Sciences CTC technology. Baseline CTCs from 26 patients were correlated with clinical outcome: progression-free survival (PFS), overall survival (OS) and best overall response, as well as metastatic status. A mixed effects model was used to investigate the post treatment changes in CTCs among the dose groups. Association of CTCs with PFS/OS and best overall response, including CTCs at each time point, as well as temporal changes of CTC status, were studied. Multivariate analysis was performed to identify CTC numbers in a subset of time points to correlate with response to treatment.

Results: CTCs were present in 81% of the patients (21/26). CTC clusters and apoptotic CTCs were detected in 38% and 77% of the patients, respectively. At baseline, CTC counts ≥ 5/mL were significantly associated with poor OS (p=0.04). There was a trend that the presence of CTC clusters was associated with worse OS. With a cut-off of 3.4/mL, apoptotic CTCs showed a trend in association with overall survival. CTC numbers in patients with liver metastasis were significantly higher than in patients without liver metastasis. CTCs were also found to be correlated significantly with the number of metastatic sites. When measuring at Day 7 post dosing, CTC numbers were significantly decreased.

Conclusions: Our findings suggest that CTCs are frequently detectable in patients and are a prognostic factor in ES-SCLC. CTCs decrease with TRXT and platinum-based chemotherapy. Updated results will be presented. CTCs will be further evaluated in the phase 2 portion of the PINNACLE trial.

Citation Format: Chun Zhang, Ryon Graf, Adam Jendrisak, Amanda K. Anderson, Priscilla Ontiveros, Sarah Orr, Anne Chiang, David Spigel, Charles Rudin, Eric Holmgren, Jakob Dupont, Gretchen Argast, Leonardo Faoro, Lei Zhou, John Lewicki, Ann M. Kapoun. Circulating Tumor Cells (CTCs) in patients with extensive stage small cell lung cancer and their association with clinical outcome [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1727. doi:10.1158/1538-7445.AM2017-1727

WNT antagonists exhibit unique combinatorial antitumor activity with taxanes by potentiating mitotic cell death

The WNT pathway mediates intercellular signaling that regulates cell fate in both normal development and cancer. It is widely appreciated that the WNT pathway is frequently dysregulated in human cancers through a variety of genetic and epigenetic mechanisms. Targets in the WNT pathway are being extensively pursued for the development of new anticancer therapies, and we have advanced two WNT antagonists for clinical development: vantictumab (anti-FZD) and ipafricept (FZD8-Fc). We examined the antitumor efficacy of these WNT antagonists in combination with various chemotherapies in a large set of patient-derived xenograft models. In responsive models, WNT blockade led to profound synergy with taxanes such as paclitaxel, and the combination activity with taxanes was consistently more effective than with other classes of chemotherapy. Taxane monotherapy increased the frequency of cells with active WNT signaling. This selection of WNT-active chemotherapy-resistant tumorigenic cells was prevented by WNT-antagonizing biologics and required sequential dosing of the WNT antagonist followed by the taxane. The WNT antagonists potentiated paclitaxel-mediated mitotic blockade and promoted widespread mitotic cell death. By blocking WNT/β-catenin signaling before mitotic blockade by paclitaxel, we found that this treatment effectively sensitizes cancer stem cells to taxanes. This combination strategy and treatment regimen has been incorporated into ongoing clinical testing for vantictumab and ipafricept.

Intratumoural heterogeneity generated by Notch signalling promotes small-cell lung cancer

The Notch signaling pathway mediates cell fate decisions^1,2 and is tumor suppressive or oncogenic depending on the context^2,3. During lung development, Notch pathway activation inhibits the differentiation of precursor cells to a neuroendocrine (NE) fate^4–6. In small cell lung cancer (SCLC), an aggressive NE lung cancer⁷, loss-of-function NOTCH mutations and the inhibitory effects of ectopic Notch activation indicate that Notch signaling is tumor suppressive^8,9. Here, we show that Notch signaling can be both tumor suppressive and pro-tumorigenic in SCLC. Endogenous activation of the Notch pathway results in a NE to non-NE fate switch in 10-50% of tumor cells in a mouse model of SCLC and in human tumors. This switch is mediated in part by Rest/Nrsf, a transcriptional repressor that inhibits NE gene expression. Non-NE Notch-active SCLC cells are slow growing, consistent with a tumor suppressive role for Notch, but these cells are also relatively chemoresistant and provide trophic support to NE tumor cells, consistent with a pro-tumorigenic role. Importantly, Notch blockade in combination with chemotherapy suppresses tumor growth and delays relapse. Thus, SCLC tumors generate their own microenvironment via activation of Notch signaling in a subset of tumor cells, and the presence of these cells may serve as a biomarker for the use of Notch pathway inhibitors in combination with chemotherapy in select SCLC patients.

Results of a randomized phase II trial of an anti-notch 2/3, tarextumab (OMP-59R5, TRXT, anti-Notch2/3), in combination with nab-paclitaxel and gemcitabine (Nab-P+Gem) in patients (pts) with untreated metastatic pancreatic cancer (mPC)

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Background: Tarextumab (TRXT), fully human IgG2 antibody inhibits signaling of Notch2/ 3 receptors. Tumor regression seen in Notch3 (N3) expressing pt-derived pancreatic cancer xenografts when TRXT combined with Nab-P+Gem. Phase 2, randomized, placebo-controlled trial conducted to evaluate efficacy, safety of combination in mPC. Methods: Pts randomized 1:1 to TRXT or placebo (PL). TRXT given IV at 15 mg/kg q 2wks (D 1, 15), nab-P 125 mg/m2, GEM 1000mg/m2 on D1, 8, 15 q 28 days. Tissue for N3 gene expression determination was required. Primary endpoints: overall survival (OS) in all and in 3 subgroups determined by Notch 3 gene expression. Secondary: safety, progression-free survival (PFS) and overall response rate (ORR). Results: N = 177 pts randomized. Performance status (0 or 1), CA19-9 stratum (0 – ULN, > ULN – 59ULN, ≥ 59ULN) balanced. Clinical trial information: NCT01647828. .  Conclusions: Addition of TRXT to Nab-P+Gem did not improve OS in 1st line mPC. A potential detrimental effect on PFS and ORR was seen in subjects with N3 < 25%ile.[Table: see text]

Activating NOTCH1 Mutations Define a Distinct Subgroup of Patients With Adenoid Cystic Carcinoma Who Have Poor Prognosis, Propensity to Bone and Liver Metastasis, and Potential Responsiveness to Notch1 Inhibitors

Purpose

Adenoid cystic carcinomas (ACCs) represent a heterogeneous group of chemotherapy refractory tumors, with a subset demonstrating an aggressive phenotype. We investigated the molecular underpinnings of this phenotype and assessed the Notch1 pathway as a potential therapeutic target.

Methods

We genotyped 102 ACCs that had available pathologic and clinical data. Notch1 activation was assessed by immunohistochemistry for Notch1 intracellular domain. Luciferase reporter assays were used to confirm Notch1 target gene expression in vitro. The Notch1 inhibitor brontictuzumab was tested in patient-derived xenografts from patients with ACC and in a patient with ACC who was enrolled in a phase I study.

Results

NOTCH1 mutations occurred predominantly (14 of 15 patients) in the negative regulatory region and Pro-Glu-Ser-Thr–rich domains, the same two hotspots seen in T-cell acute lymphoblastic leukemias, and led to pathway activation in vitro. NOTCH1-mutant tumors demonstrated significantly higher levels of Notch1 pathway activation than wild-type tumors on the basis of Notch1 intracellular domain staining ( P = .004). NOTCH1 mutations define a distinct aggressive ACC subgroup with a significantly higher likelihood of solid subtype ( P < .001), advanced-stage disease at diagnosis ( P = .02), higher rate of liver and bone metastasis ( P ≤ .02), shorter relapse-free survival (median, 13 v 34 months; P = .01), and shorter overall survival (median 30 v 122 months; P = .001) when compared with NOTCH1 wild-type tumors. Significant tumor growth inhibition with brontictuzumab was observed exclusively in the ACC patient-derived xenograft model that harbored a NOTCH1 activating mutation. Furthermore, an index patient with NOTCH1-mutant ACC had a partial response to brontictuzumab.

Conclusion

NOTCH1 mutations define a distinct disease phenotype characterized by solid histology, liver and bone metastasis, poor prognosis, and potential responsiveness to Notch1 inhibitors. Clinical studies targeting Notch1 in a genotype-defined ACC subgroup are warranted.

Activating NOTCH1 Mutations Define a Distinct Subgroup of Patients With Adenoid Cystic Carcinoma Who Have Poor Prognosis, Propensity to Bone and Liver Metastasis, and Potential Responsiveness to Notch1 Inhibitors

Purpose Adenoid cystic carcinomas (ACCs) represent a heterogeneous group of chemotherapy refractory tumors, with a subset demonstrating an aggressive phenotype. We investigated the molecular underpinnings of this phenotype and assessed the Notch1 pathway as a potential therapeutic target. Methods We genotyped 102 ACCs that had available pathologic and clinical data. Notch1 activation was assessed by immunohistochemistry for Notch1 intracellular domain. Luciferase reporter assays were used to confirm Notch1 target gene expression in vitro. The Notch1 inhibitor brontictuzumab was tested in patient-derived xenografts from patients with ACC and in a patient with ACC who was enrolled in a phase I study. Results NOTCH1 mutations occurred predominantly (14 of 15 patients) in the negative regulatory region and Pro-Glu-Ser-Thr-rich domains, the same two hotspots seen in T-cell acute lymphoblastic leukemias, and led to pathway activation in vitro. NOTCH1-mutant tumors demonstrated significantly higher levels of Notch1 pathway activation than wild-type tumors on the basis of Notch1 intracellular domain staining ( P = .004). NOTCH1 mutations define a distinct aggressive ACC subgroup with a significantly higher likelihood of solid subtype ( P < .001), advanced-stage disease at diagnosis ( P = .02), higher rate of liver and bone metastasis ( P ≤ .02), shorter relapse-free survival (median, 13 v 34 months; P = .01), and shorter overall survival (median 30 v 122 months; P = .001) when compared with NOTCH1 wild-type tumors. Significant tumor growth inhibition with brontictuzumab was observed exclusively in the ACC patient-derived xenograft model that harbored a NOTCH1 activating mutation. Furthermore, an index patient with NOTCH1-mutant ACC had a partial response to brontictuzumab. Conclusion NOTCH1 mutations define a distinct disease phenotype characterized by solid histology, liver and bone metastasis, poor prognosis, and potential responsiveness to Notch1 inhibitors. Clinical studies targeting Notch1 in a genotype-defined ACC subgroup are warranted.

Abstract A42: Using a PDX tumor bank to screen for cancer stem cell therapies

OncoMed Pharmaceuticals is focused on discovering novel therapies that target cancer stem cells (CSCs), specifically those which depend on the Notch or Wnt pathways. Since Patient Derived Xenografts (PDXs) recapitulate both tumor cell heterogeneity and maintain the histopathological characteristics of the original tumor, they represent an important preclinical model for CSC drug discovery and can be used to effectively screen for new therapeutic candidates. To this end, OncoMed has established a fully characterized PDX Tumor Bank for its monoclonal antibody discovery and developmental efforts and has used PDX models to advance seven candidates into clinical trials. The goal of this study is to: 1) review the operational steps needed to propagate PDX's; 2) define the quality controls necessary to maintain these tumors; 3) assess how the Tumor Bank has helped in the selection and advancement of these targeted biologics into the clinic; and 4) review the role of the Tumor Bank in defining biomarkers for clinical use.

Tumor specimens were received from surgery and processed into fragments, cell clumps, or dissociated cells. Tumor tissue or cells were either implanted into NOG or Nod/scid mice or frozen for later implantation. Primary tumors that grew were serially transplanted to establish working stocks for drug screening experiments. Every tumor was characterized for a variety of molecular, cellular, and tumor endpoints. All pertinent data and samples were captured into a custom designed database which included lineage diagrams to easily track tumor propagation and characterization endpoints.

The quality control of the established PDXs must be carefully monitored throughout the process. We have used DNA fingerprinting to ensure the identification of each tumor and subsequent passages, but the larger problem of identifying and monitoring the development of spontaneous lymphomas (both human and murine) that can infiltrate and contaminate the PDX required a rigorous monitoring strategy. The infection of mice with Lactate Dehydrogenase Elevating Virus from contaminated reagents can severely affect animal health and, therefore the screening process. Surprisingly, the misdiagnosis of tumors received from surgery was higher than expected and resulted in tumors being correctly reclassified before being used.

The strategy employed to effectively screen selected targets in the Notch and Wnt pathways was to first review the molecular characterization data from our PDX models, and then select appropriate models for in vivo efficacy testing. In order to assess how the Tumor Bank has helped both in the screening process and the identification of biomarkers, we will review both pre-clinical and clinical data for selected OncoMed antibodies. As an example, one anti-CSC agent, OMP-59R5 (Tarextumab), which targets Notch2/3 was tested in ten pancreatic PDX models. Six pancreatic PDX tumors were responders to anti-NOTCH2/3 while four were non-responders. Bioinformatic analysis of the responder/non-responder data sets identified tumors that had high Notch3 gene expression as responders to OMP-59R5 treatment. Based on this preclinical data, Notch3 levels were evaluated in a Phase 1b pancreatic trial as a potential predictive biomarker. In this trial, higher response rate and longer survival was noted in patients with Notch3 high tumors receiving GEM/Nab-P/ Tarextumab (at 5-15mg/kg). These observations are being tested in a placebo-controlled, randomized Ph2 setting.

The creation of a working PDX Tumor Bank across multiply human solid tumor types has allowed us to implement an effective preclinical screening program to select candidate biologics and potential predictive biomarkers for targets in the Notch and Wnt pathways.

Citation Format: James Evans, Chun Zhang, Angie InKyung Park, Alayne Brunner, Min Wang, Cristina Dee-Hoskins, Roger Lopez, Xiaomei Song, Kellie Pickell, Wan-Cheng Yen, Marcus Fischer, Raymond Tam, Gilbert O'Young, Jakob Dupont, Lei Zhou, Austin Gurney, John Lewicki, Tim Hoey, Ann M. Kapoun, Belinda Cancilla. Using a PDX tumor bank to screen for cancer stem cell therapies. [abstract]. In: Proceedings of the AACR Special Conference: Patient-Derived Cancer Models: Present and Future Applications from Basic Science to the Clinic; Feb 11-14, 2016; New Orleans, LA. Philadelphia (PA): AACR; Clin Cancer Res 2016;22(16_Suppl):Abstract nr A42.

Abstract 4652: Effects of anti-DLL4 treatment on non-small cell lung cancer (NSCLC) human xenograft tumors

Background: Non-small cell lung cancer (NSCLC) accounts for the vast majority of lung cancers, the leading cause of cancer-related deaths. Notch signaling has been shown to play an important role in lung cancer initiation and progression. Delta-like ligand 4 (DLL4) activates the Notch pathway and is important for cancer stem cell (CSC) survival. Demcizumab (OMP-21M18) is a humanized IgG2 anti-DLL4 antibody currently being tested in a Phase 2 trial in combination with pemetrexed and carboplatin for first-line treatment of patients with NSCLC. Previously, OMP-21M18 in combination with its mouse anti-DLL4 surrogate has been shown to inhibit tumor growth, decrease cancer stem cell frequency, and cause dysfunctional sprouting of new vessels resulting in an anti-angiogenic effect in patient-derived tumor xenograft (PDX) models in breast, colon, ovarian, and pancreatic cancers. Here we show results from NSCLC PDX models.

Methods and Results: Anti-DLL4 treatment was tested in a series of NSCLC PDX models. Because DLL4 inhibition has been shown to have effects on the tumor as well as the vasculature, the combination of OMP-21M18 (targeting human DLL4) and 21R30 (antibody targeting mouse DLL4) treatment in the PDX models was used to model demcizumab treatment in humans. Treatment with anti-DLL4 in combination with chemotherapy inhibited tumor growth in a series of NSCLC PDX models. Additionally, a tumorigenicity assay showed a decrease in the frequency of tumor-initiating cells following treatment with anti-DLL4 and chemotherapy. Gene expression analysis of tumor samples provided insights into the mechanism of action.

Conclusions: Anti-DLL4 treatment in a panel of NSCLC PDX tumor models in vivo showed inhibition of tumor growth and a decrease in the frequency of tumor-initiating cells. Mechanism of action and gene expression analysis of these models treated with anti-DLL4 will be presented. These findings provide additional evidence supporting demcizumab as an effective treatment for NSCLC patients.

Citation Format: Alayne Brunner, Fiore Cattaruzza, Wan-Ching Yen, Pete Yeung, Marcus Fischer, Belinda Cancilla, Gilbert O’Young, Raymond Tam, Yu-Wang Liu, Austin Gurney, John Lewicki, Tim Hoey, Min Wang, Ann M. Kapoun. Effects of anti-DLL4 treatment on non-small cell lung cancer (NSCLC) human xenograft tumors. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4652.

Abstract 404: Development of a RSPO3 CLIA-validated assay as a predictive biomarker for response to anti-RSPO3 antibody treatment in patients with solid tumors

R-Spondin (RSPO) proteins bind to LGR receptors and potentiate Wnt/β-catenin signaling. We have identified a therapeutic anti-RSPO3 antibody targeting the RSPO-LGR pathway. In preclinical studies, RSPO3 gene expression has shown correlation with anti-RSPO3 antibody efficacy in multiple solid tumor types. A qPCR-based RSPO3 assay has been developed as a predictive biomarker for response to the anti-RSPO3 antibody. In addition, RSPO gene fusions may play a role in the activation of Wnt signaling. A gene fusion detection workflow consisting of a RSPO3 CLIA assay, a RSPO3 RUO assay and next generation sequencing (NGS) has also been developed.

We designed 6 qPCR-based assays for the RSPO3 CLIA assay development and 2 assays for the RUO assay. These assays were designed to span exon-exon junctions or target microarray probe set sequences. Amplification sensitivity and specificity were assessed for assay selection. The analytic performance of the candidate RSPO3 CLIA assay and quality control measures were established in a validation study. The validation study included: 1) performance specifications of the RSPO3 assay including analytical sensitivity, linearity, and precision, 2) determination of a reportable range, 3) establishment of a cut-off for the RSPO3 CLIA assay for patient selection, and 4) establishment of quality control procedures. 104 human cancer tissues and 24 independent patient-derived tumor xenografts (PDX) were used in these studies. To evaluate the fusion detection workflow, the RUO assay was performed on samples that tested above the CLIA assay cut-off. The delta Ct difference between the CLIA and RUO assays was calculated to identify potential fusions.

The limit of quantification was established for the RSPO3 CLIA assay. The 95% reference interval was estimated to be (-2.44, 16.02) with 90% confidence interval for the lower bound (-3.45, -2.12) and upper bound (15.26, 16.57). The delta Ct cut-off for the RSPO3 CLIA assay was set based on sensitivity, specificity and prevalence. No statistically significant difference in the total variance across the tested samples was observed. A549 and OV56 were identified to be cell line controls with established acceptable delta Ct limits. Using NGS, RSPO3 fusions were identified in 6 PDX tumors with delta Ct RUO - delta Ct CLIA&gt;7, including a novel fusion. This cut-off was further refined with NGS of 9 clinical samples. Prevalence of the RSPO3 expression and fusions will be presented.

A qPCR based RSPO3 assay was developed and CLIA-validated for use as a potential predictive biomarker for response to anti-RSPO3 therapy. This RSPO3 CLIA assay, together with the fusion detection workflow, will be evaluated in a Phase 1a/b dose escalation study of anti-RSPO3 (OMP-131R10) in advanced solid tumors and in combination with FOLFIRI in metastatic colorectal cancer (NCT02482441).

Citation Format: Chun Zhang, Yuwang Liu, Min Wang, Gilbert OYoung, Joy Kavanagh, Cheryl McFarlane, Fiore Cattaruzza, Pete Yeung, Jennifer Cain, Wan-Ching Yen, Marcus Fischer, Belinda Cancilla, Edwina Dobbin, Michelle McCarthy, Austin Gurney, Leonardo Faoro, John Lewicki, Tim Hoey, Ann M. Kapoun. Development of a RSPO3 CLIA-validated assay as a predictive biomarker for response to anti-RSPO3 antibody treatment in patients with solid tumors. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 404.

Targeting Notch signaling with a Notch2/Notch3 antagonist (tarextumab) inhibits tumor growth and decreases tumor-initiating cell frequency

PURPOSE

The Notch pathway plays an important role in both stem cell biology and cancer. Dysregulation of Notch signaling has been reported in several human tumor types. In this report, we describe the development of an antibody, OMP-59R5 (tarextumab), which blocks both Notch2 and Notch3 signaling.

EXPERIMENTAL DESIGN

We utilized patient-derived xenograft tumors to evaluate antitumor effect of OMP-59R5. Immunohistochemistry, RNA microarray, real-time PCR, and in vivo serial transplantation assays were employed to investigate the mechanisms of action and pharmacodynamic readouts.

RESULTS

We found that anti-Notch2/3, either as a single agent or in combination with chemotherapeutic agents was efficacious in a broad spectrum of epithelial tumors, including breast, lung, ovarian, and pancreatic cancers. Notably, the sensitivity of anti-Notch2/3 in combination with gemcitabine in pancreatic tumors was associated with higher levels of Notch3 gene expression. The antitumor effect of anti-Notch2/3 in combination with gemcitabine plus nab-paclitaxel was greater than the combination effect with gemcitabine alone. OMP-59R5 inhibits both human and mouse Notch2 and Notch3 function and its antitumor activity was characterized by a dual mechanism of action in both tumor and stromal/vascular cells in xenograft experiments. In tumor cells, anti-Notch2/3 inhibited expression of Notch target genes and reduced tumor-initiating cell frequency. In the tumor stroma, OMP-59R5 consistently inhibited the expression of Notch3, HeyL, and Rgs5, characteristic of affecting pericyte function in tumor vasculature.

CONCLUSIONS

These findings indicate that blockade of Notch2/3 signaling with this cross-reactive antagonist antibody may be an effective strategy for treatment of a variety of tumor types.

Abstract P3-07-57: Development of a 6-gene qPCR RUO-validated assay as a predictive biomarker for response of vantictumab (OMP-18R5; anti-frizzled) in HER2- breast cancer patients

Background: We have developed a monoclonal antibody, vantictumab that blocks canonical WNT/β-catenin signaling through binding of five FZD receptors (1, 2, 5, 7, 8). This antibody inhibits the growth of several tumor types, including breast. Vantictumab reduces tumor-initiating cell frequency and exhibits synergistic activity with standard-of-care (SOC) agents (Gurney et al, 2012). To target breast cancer patients most likely to respond to vantictumab, we undertook a predictive biomarker study.

Methods: We have identified a 6-gene Wnt pathway-related signature, FBXW2, CCND2, RHOU, CTBP2, WIF1, and DKK1, based on microarray gene expression data from 8 breast cancer patient derived xenograft (PDX) models with established in vivo response to vantictumab plus SOC. This signature successfully predicted the response of 8 additional and independent PDX breast tumors. We further developed a qPCR Research Use Only (RUO) assay for the 6 genes to be used on FFPE human breast tumor samples. Multiple assays targeting different regions spanning each mRNA transcript were tested and selected based on PCR efficiency, specificity and sensitivity. We compared assay sensitivity under different cDNA synthesis and pre-amplification conditions: random vs. gene-specific priming, number of pre-amplification cycles, pre-amplification reaction volumes, and cDNA synthesis kits. A repeatability study was performed to test assay performance. The pre-amplification and PCR were repeated over three separate days and across two independent labs.

Results: Our results showed that cDNA synthesis by gene-specific priming followed by 18 cycles of pre-amplification performed the best and the assay is robust with minimal starting FFPE RNA input. The results of the repeatability study were consistent among the different days and the different labs (&lt;5% CV). Using the 6-gene qPCR RUO assay, the signature score from the microarray data was further refined using 12 PDX HER2- breast tumors with known in vivo response to vantictumab with SOC. The prevalence of the 6-gene signature was established using ∼100 HER2- breast cancer samples.

Conclusions: A robust 6-gene RUO-validated assay was developed as a predictive biomarker for vantictumab in HER2- breast cancer. The assay is currently being evaluated in a Phase 1b study of vantictumab with paclitaxel in HER2- breast cancer.

Citation Format: Zhang C, O'Young G, Wikstrom K, Davison T, Yeung P, Cattaruzza F, Yen W-C, Hoey T, Lewicki J, Rachmann R, Kerr P, Hill L, Eason R, McErlean S, Liu Y, Kapoun AM. Development of a 6-gene qPCR RUO-validated assay as a predictive biomarker for response of vantictumab (OMP-18R5; anti-frizzled) in HER2- breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-57.

A phase 1b study of the anti-cancer stem cell agent demcizumab (DEM) and gemcitabine (GEM) +/- nab-paclitaxel in patients with pancreatic cancer

341

Background: Delta-like ligand 4 (DLL4) activates the Notch pathway. DEM is a humanized anti-DLL4 antibody that inhibits tumor growth & decreases cancer stem cell frequency in human tumor xenograft models. DEM also has an antiangiogenic effect & synergistic activity when combined with GEM & nab-paclitaxel in pt derived xenograft models of pancreatic cancer. Methods: Pts with 1st line pancreatic cancer were enrolled. Pts in cohorts 1-3 received DEM (2.5 every 2 or 4 wks or 5 mg/kg every 4 wks including 3 truncated pts) & GEM 1000 mg/m2 7 of 8 wks, then 3 of 4 wks. Pts in cohorts 4, 5, 6 & 7 received truncated DEM (2.5, 3.5 or 5 mg/kg every 2 wks through Day 70) & nab-paclitaxel 125 mg/m2 + gemcitabine 1000 mg/m2 3 of 4 wks. The primary objective was to determine the MTD. Other objectives were safety, efficacy, immunogenicity, PK & biomarkers. Results: Fifty-six pts were enrolled; 8, 8, 8, 6, 8, 9 & 9 pts received 2.5 mg/kg every 2 wks, 2.5 mg/kg every 4 wks, 5 mg/kg every 4 wks, 2.5 mg/kg every 2 wks (truncated), 5 mg/kg every 2 wks (truncated), 3.5 mg/kg every 2 wks (truncated) & 3.5 mg/kg every 2 wks (truncated), respectively. Related AEs in > 20% of pts were fatigue (36%), nausea (32%), vomiting (23%), hypertension (21%) & diarrhea (20%). Hypertension was managed with anti-hypertensives. Increased BNP is an early indicator of the cardiac effects of DEM & mildly elevated values were used to initiate a cardioprotective ACE inhibitor or carvedilol. Two pts who received DEM continuously developed reversible pulmonary hypertension & 1 of these pts developed heart failure. As a result, DEM was limited to 70 days in cohorts 4, 5, 6 & 7. In cohorts 1-3, 4 of 16 (25%) pts had a PR. In cohorts 4, 5, 6 & 7, 14 of 28 (50%) pts had a PR & 11 had SD. The truncated DEM pts had a median PFS of 9.0 mos (95% CI: 3.7 mos-NR) & a median survival of 10.1 mos (95% CI: 6.5-16.2 mos), respectively. Conclusions: This therapy was generally well tolerated with fatigue, nausea & vomiting being the most common related AEs. Truncated DEM dosing (i.e., limited to 70 days) avoided clinically significant cardiopulmonary toxicity. Encouraging clinical activity was observed. Biomarker analysis showed modulation of the Notch pathway. Final data will be presented. Clinical trial information: NCT01189929.

Abstract A30: Predictive and pharmacodynamic biomarkers of vantictumab (OMP-18R5; anti-Frizzled) in non-small cell lung cancer

Background: Vantictumab is a monoclonal antibody that blocks canonical WNT/β-catenin signaling through binding of five FZD receptors (1, 2, 5, 7, 8). This antibody inhibits the growth of several tumor types, reduces tumor-initiating cell frequency (TIC) and exhibits synergistic activity with standard-of-care (SOC) chemotherapeutic agents (Gurney et al., 2012). To target responsive patients and understand the mechanism of action of the drug, we set out to identify predictive and pharmacodynamic (PD) biomarkers of vantictumab in non-small cell lung cancer (NSCLC).

Materials and methods: The response to vanticutmab was established from in vivo efficacy experiments including different treatment groups: control, vantictumab, paclitaxel and vantictumab in combination with paclitaxel. For combination treatment, same day dosing and sequential dosing (paclitaxel dosed 2 days after the antibody) were compared. Samples were collected for PD biomarker analysis. To identify a predictive biomarker for the response to vantictumab in NSCLC patients, gene expression data from 7 NSCLC patient derived xenograft (PDX) models was analyzed. We utilized support vector machine-recursive feature elimination (SVM-RFE, Guyon et al., 2002) to select genes and support vector machine (SVM) for classification.

Results: Vantictumab showed significant tumor growth inhibition as a single agent as well as in combination with paclitaxel. The reduction of TIC and the antitumor efficacy of vantictumab were significantly enhanced with sequential dosing compared with same day dosing. These findings suggested that optimal synergy occurs using sequential dosing, likely due to enhanced blockade of cell cycle progression at mitosis. PD biomarker analysis confirmed inhibition of genes in Wnt, Notch, and stem cell pathways by vantictumab both as a single agent and also in combination with paclitaxel. Wnt pathway targets including AXIN2 and LEF1 were down-regulated significantly by vantictumab in both sequential dosing and same day dosing confirming the mechanism of action. From a series of 7 in vivo efficacy PDX experiments, LEF1 was identified as a predictive biomarker of vantictumab response and achieved the best performance with cross-validated positive predictive value (PPV) = negative predictive value (NPV) = sensitivity = specificity = 100%. Strong correlation was also observed between LEF1 gene expression and the ratio of tumor volume. Furthermore, LEF1 was able to successfully predict the response to vantictumab in 2 independent NSCLC PDX models. Prevalence estimation for LEF1 ranged from 35% to 50% based on public microarray datasets. LEF1 was also found to be significantly correlated with the response to vantictumab in combination with paclitaxel in 12 NSCLC PDX models (p = 0.0162), indicating LEF1 as a potential predictive biomarker of the response vantictumab as a single agent and in combination with SOC in NSCLC.

Conclusions: A biomarker study for the pharmacodynamics and response to vantictumab was performed using a series of PDX NSCLC models. PD biomarkers were identified which confirmed the mechanism of action of vantictumab. LEF1 was identified as a predictive biomarker and is being evaluated in the Phase 1b study of vantictumab in combination with SOC in previously treated NSCLC: NCT01957007. Comprehensive PD and predictive biomarker data will be presented.

Citation Format: CHUN ZHANG, Fiore Cattaruzza, Pete Yeung, Wan-Ching Yen, Marcus Fischer, Alayne Brunner, Min Wang, Belinda Cancilla, Rainer Brachmann, Tim Hoey, John Lewicki, Ann M. Kapoun. Predictive and pharmacodynamic biomarkers of vantictumab (OMP-18R5; anti-Frizzled) in non-small cell lung cancer. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr A30.

Abstract 1549: Development and validation of a biomarker for prospective selection of Notch1 activation in patients with certain advanced solid tumors in a first-in-human phase1 study of the cancer stem cell targeting antibody OMP-52M51 (anti-Notch1)

The Notch pathway plays a key role in embryonic development, the regulation of stem and progenitor cells, and is implicated centrally in many forms of human cancer. Notch1 is known to be frequently activated in certain solid tumor types. OMP-52M51 is a humanized IgG2 antibody that inhibits the signaling function of the Notch1 receptor. Mouse xenograft studies using minimally-passaged, patient-derived xenografts have shown that OMP-52M51 impedes tumor growth and selectively eliminates CSCs in a range of tumor types particularly in tumors with activated Notch1 signaling.

We previously reported the frequency of Notch pathway activation across a large panel of human tumors (n&gt;600) by an Immunohistochemistry (IHC) assay that detects the activated form of Notch1 using an antibody that specifically recognizes the Notch1 intracellular domain (ICD). Using this test and a rigorous H-score cut-off, we found elevated Notch1 ICD in 7-53% of the following cancers: chemo-resistant breast (29%), gastric (13%), cholangiocarcinoma (20%), esophageal (27%), hepatacellular carcinoma (HCC, 7%), small cell lung cancer (SCLC, 12%), pancreatic (12%) and colorectal cancer (53%).

Here we developed a specific CLIA-validated IHC assay capable of identifying patients with Notch1 activation. The assay has a rapid turn-around time and shows robust precision, reproducibility and accuracy. The sensitivity of the method was confirmed by comparing results obtained on xenograft tumor tissue samples with known levels of Notch1 expression and response to anti-Notch1 therapy. From these results, the cut-off of the assay was set. This predictive biomarker was specifically designed to screen patients for prospective selection in the first-in-human Phase1 study of OMP-52M51 (anti-Notch1) in certain advanced solid tumors (NCT01778439). Detailed assay validation data and its application to the analysis of clinical trial samples will be highlighted.

Citation Format: Belinda Cancilla, Raymond Tam, Chun Zhang, Steve Anderson, John Lewicki, Tim Hoey, Bryan McCune, Lori Johnson, Esohe Idusogie, Ann M. Kapoun. Development and validation of a biomarker for prospective selection of Notch1 activation in patients with certain advanced solid tumors in a first-in-human phase1 study of the cancer stem cell targeting antibody OMP-52M51 (anti-Notch1). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1549. doi:10.1158/1538-7445.AM2015-1549

A phase I dose escalation and expansion study of the anticancer stem cell agent demcizumab (anti-DLL4) in patients with previously treated solid tumors

PURPOSE

This phase I trial evaluated the safety, pharmacokinetics, and pharmacodynamics of demcizumab (OMP-21M18), a humanized IgG2 mAb targeting the Notch ligand DLL4 in adult patients with advanced malignancies.

EXPERIMENTAL DESIGN

Standard 3+3 design, with demcizumab 0.5, 1, 2.5, or 5 mg/kg weekly or 2.5, 5, or 10 mg/kg every other week, with an expansion cohort at 10 mg/kg every other week. Dose-limiting toxicities (DLT) were assessed during the first 28 days.

RESULTS

Fifty-five patients received demcizumab (15 weekly, 18 every other week, 21 expansion cohort, 1 loading dose). No more than one DLT was seen at any dose level. The MTD was not reached for either schedule. Treatment-related adverse events occurring in >10% of patients were hypertension or blood pressure increased (47%), fatigue (31%), anemia (22%), headache (20%), nausea (13%), hypoalbuminemia (11%), dizziness (11%), and dyspnea (11%). One patient dosed at 2.5 mg/kg developed reversible right-sided heart failure after 63 days on treatment and 4 dosed at 10 mg/kg developed congestive heart failure after ≥98 days on treatment. Five patients were hospitalized with bleeding episodes (2 episodes of tumor-associated bleeding). Sixteen of 25 (64%) evaluable patients at 10 mg/kg had evidence of stabilization of disease or response.

CONCLUSION

Demcizumab was generally well tolerated at doses ≤5 mg weekly with disease stabilization and decreases in tumor size demonstrating antitumor activity. Hypertension was the most common adverse event that was clearly related to treatment. Prolonged administration was associated with an increased risk of congestive heart failure.

Abstract 910: NOTCH3 expression is predictive of efficacy in pancreas tumor models treated with OMP-59R5, a monoclonal antibody targeting the NOTCH2 and NOTCH3 receptors

The Notch signaling pathway regulates key functions during embryonic development, stem cell maintenance and differentiation in adult tissues, and is implicated in many human cancers. OMP-59R5 is a ligand-blocking antibody targeting both the NOTCH2 and NOTCH3 receptors. We have developed a series of primary human xenograft models from patients with pancreatic cancer and used these models to examine efficacy response to OMP-59R5. We found that anti-NOTCH2/3, either as a single agent or in combination with chemotherapeutic agents, was efficacious in pancreatic tumor models. Expression of NOTCH3 mRNA by next-generation sequencing in ten baseline pancreatic tumors correlates with response to OMP-59R5, where growth of tumors with moderate to high expression of NOTCH3 was significantly reduced compared to tumors with low expression. We developed a Research-Use-Only (RUO) qPCR assay for measuring NOTCH3 mRNA expression using Formalin-Fixed, Paraffin-Embedded (FFPE) samples. This assay shows consistent NOTCH3 expression data with the next-generation sequencing data in the ten pancreatic xenograft tumors. Expression levels of NOTCH3 were also examined in ∼120 human metastatic pancreatic specimens to determine the reportable range of the assay and to identify association with clinical factors. This analysis showed that NOTCH3 gene expression maintained the same distribution across different specimen types, such as biopsy, surgical biopsy and surgical resection, etc. Samples with clinically relevant sites of recurrence also showed a similar range in NOTCH3 gene expression. Moreover, we developed an immunohistochemistry (IHC) assay for NOTCH3 protein expression. The correlation between the IHC assay and the qPCR assay was examined in both the metastatic pancreatic human specimens and the primary human pancreatic xenograft models. A significant correlation was found between the gene and protein levels, suggesting that both NOTCH3 gene expression and protein expression may predict the response to OMP-59R5 in pancreatic cancer. We are evaluating NOTCH3 levels and patient response in ALPINE, a Ph1b/2 Anti-NOTCH2/3 trial in first-line advanced pancreatic cancer patients.

Citation Format: Belinda Cancilla, Wan-Ching Yen, Chun Zhang, Marcus M. Fischer, May Ji, Tracy Tang, Yu-Wang Liu, Raymond S. Tam, Min Wang, Austin Gurney, Timothy Hoey, John Lewicki, Ann M. Kapoun. NOTCH3 expression is predictive of efficacy in pancreas tumor models treated with OMP-59R5, a monoclonal antibody targeting the NOTCH2 and NOTCH3 receptors. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 910. doi:10.1158/1538-7445.AM2014-910

Abstract 3048: OMP-59R5 (Anti-Notch2/3) inhibits tumor growth and reduces cancer stem cell frequency in patient derived SCLC xenografts

Small cell lung cancer (SCLC) is a devastating disease with very poor prognosis and few treatment options. We have established patient derived xenografts from SCLC tumors and determined that Notch pathway target genes are up-regulated in this disease relative to normal lung tissues and relative to other tumor types. We examined the in vivo efficacy of OMP-59R5, an antibody that was initially identified by binding to Notch2 and was subsequently shown to block signaling of both human and mouse Notch2 and Notch3. We performed in vivo growth inhibition and tumorigenicity studies with this Notch2/3 antibody alone or in combination with chemotherapeutic agents in a panel of six patient-derived SCLC xenograft models. We found that OMP-59R5 treatment significantly reduced tumor recurrence in combination with chemotherapy in five of the six models. Through a serial transplantation study from a sensitive tumor, we found that OMP-59R5 in combination with chemotherapy (cisplatin plus irinotecan) profoundly reduced the cancer stem cell (CSC) frequency. In contrast, treatment with chemotherapeutic agents alone had the opposite effect and increased CSC frequency. In minimal residual disease models, we analyzed the ability of OMP-59R5 to delay tumor recurrence following chemotherapy-induced tumor regression. While chemotherapeutic agent-treated tumors re-grew rapidly following treatment termination, the growth of recurrent tumors was delayed by OMP-59R5. We also evaluated changes in gene expression post treatment and found that OMP-59R5 modulated the expression of Notch pathway, epithelial-to-mesenchymal transition, stromal and vasculature genes. Furthermore, we observed an increase in expression of neuroendocrine differentiation markers after OMP-59R5 treatment in sensitive tumors. Following up on these preclinical findings, OMP-59R5 is currently being evaluated for safety and efficacy in combination with cisplatin and etoposide for treatment of SCLC in an ongoing Phase 1b/2 clinical trial (PINNACLE).

Citation Format: Marcus M. Fischer, Jalpa Shah, Jennifer Cain, Belinda Cancilla, James W. Evans, Christopher L. Murriel, Tracy Tang, Jie Wei, Wan-Ching Yen, Chun Zhang, Austin Gurney, John Lewicki, Ann M. Kapoun, Timothy Hoey. OMP-59R5 (Anti-Notch2/3) inhibits tumor growth and reduces cancer stem cell frequency in patient derived SCLC xenografts. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3048. doi:10.1158/1538-7445.AM2014-3048

Abstract B48: A first-in-human Phase I study of the novel cancer stem cell (CSC) targeting antibody OMP-52M51 (anti-Notch1) administered intravenously to patients with certain advanced solid tumors

Background: The Notch pathway plays a central role in embryonic development, the regulation of stem and progenitor cells, and is implicated centrally in many forms of human cancer. Notch1 is known to be frequently activated in certain solid tumor types. OMP-52M51 is a humanized IgG2 antibody that inhibits the signaling function of the Notch1 receptor. Mouse xenograft studies using minimally-passaged, patient-derived xenografts have shown that OMP-52M51 impedes tumor growth and selectively eliminates CSCs in a range of tumor types particularly in tumors with activated Notch1 signaling. In these models, anti-Notch1 antibody also has anti-angiogenic effects leading to tumor growth inhibition. As such, OMP-52M51 is a novel anti-cancer agent that inhibits tumor growth through direct actions on tumor cells, including CSCs, and effects on tumor angiogenesis.

Methods: A phase I dose escalation and expansion study was initiated in patients with certain advanced solid tumor indications (cholangiocarcinoma, breast, colorectal, esophageal, gastric, and small cell lung cancers) that have frequencies of Notch1 activation of 12-29% (AACR 2013; #3728). OMP-52M51 was administered intravenously to study safety, pharmacokinetics (PK), pharmacodynamics (PD), preliminary efficacy, and to determine the maximum tolerated dose (MTD). The trial has a Notch1 IHC biomarker selected expansion cohort to test for single-agent response rate.

Results: Ten patients have been enrolled in 4 dose-escalation cohorts at doses of 0.25, 0.5, 1, and 2.5mg/kg administered every 4 weeks (Q4W). The most frequently reported drug-related adverse events were: mild to moderate diarrhea (56%), rash (22%), and nausea (22%). One patient developed grade 3 diarrhea for 24 hours controlled with Imodium. No dose-limiting toxicities (DLTs) have occurred and dose escalation continues. The PK of OMP-52M51 in patients is characterized by dose-dependent clearance. One patient with colorectal cancer has prolonged stable disease for &gt;100 days with a decline in CEA tumor marker. Biomarker analyses for Notch pathway modulation and activation are ongoing.

Conclusions: OMP-52M51 is generally well tolerated. Dose escalation continues and updated results will be presented.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B48.

Citation Format: S. Lindsey Davis, Patricia LoRusso, Lu Xu, Ann M. Kapoun, Jakob Dupont, Pamela Munster, S. Gail Eckhardt, Amita Patnaik. A first-in-human Phase I study of the novel cancer stem cell (CSC) targeting antibody OMP-52M51 (anti-Notch1) administered intravenously to patients with certain advanced solid tumors. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B48.

Abstract B24: Biomarker analysis in the first-in-human phase 1a study for vantictumab (OMP-18R5; anti-Frizzled) demonstrates pharmacodynamic (PD) modulation of the Wnt pathway in patients with advanced solid tumors

Background: The Wnt/β-catenin pathway signals through the Frizzled (Fzd) receptor family and is implicated in many human cancers. Vantictumab is a monoclonal antibody that blocks canonical WNT/β-catenin signaling through binding of five Fzd receptors (1, 2, 5, 7, 8) at a conserved epitope within the extracellular domain. Mouse xenograft studies using minimally-passaged, patient-derived xenografts show that vantictumab impedes tumor growth, promotes differentiation, and reduces cancer stem cell (CSC) frequency in multiple tumor types and synergizes with many chemotherapeutic agents (PNAS 109, 11717). In nonclinical models, vantictumab modulates gene expression in tumor cells associated with stem cell and differentiation pathways and down-regulates Wnt pathway genes in the tumor and stroma. As such, vantictumab is a novel anti-cancer agent that inhibits tumor growth through direct actions on tumor cells, including CSCs, and effects on the stroma. We sought to determine the pharmacodynamic (PD) effects of various doses of vantictumab on Wnt signaling and stem cell pathways by examining surrogate tissues and serial tumor biopsies from Phase 1a patients.

Methods: PD biomarker analysis of surrogate tissues and tumors was performed in the vantictumab Phase 1a dose escalation study in patients with solid tumors. Samples from sixteen patients enrolled in 4 dose-escalation cohorts with vantictumab administered 0.5 mg/kg weekly (QW), 0.5 mg/kg every other week (QoW), 1 mg/kg QW, and 1 mg/kg every three weeks (Q3W) were analyzed. Hair follicle samples and 3 biopsied tumors were collected at Day 0 and Day 28 or Day 35 after vantictumab administration. Additionally, bone turnover markers including β-C-terminal telopeptide (β-CTX), bone-specific alkaline phosphatase (BSAP), Osteocalcin, and Procollagen Type 1 N-Terminal Propeptide (P1NP) were analyzed.

Results: Wnt pathway genes (e.g., AXIN2), and stem cell and differentiation genes (e.g., BMP8B, GFI1) were found to be regulated in hair follicles by vantictumab treatment. In tumors, vantictumab inhibited Wnt target (e.g., AXIN2, TCF4), stem cell and EMT genes (HOXA2, ZEB2) and increased the expression of differentiation genes, including MUC4, MUC5B, and MUC20. These PD effects were observed 1 to 2 weeks after dosing and were evident at the lowest vantictumab Phase 1a dose (0.5 mg/kg QoW). There was dose- and schedule-dependent modulation of bone turnover markers.

Conclusions: The PD effects of vantictumab on Wnt target, stem cell and differentiation pathway genes in surrogate tissues and tumor tissues from serial biopsies, as well as on bone turnover markers, were clearly established in this first-in-human study.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B24.

Citation Format: David C. Smith, Lee Rosen, Min Wang, Chun Zhang, Lu Xu, Rashmi Chugh, Anthony Tolcher, Jonathan Goldman, Jakob Dupont, Raiiner K. Brachmann, Kyriakos Papadopoulos, Ann M. Kapoun. Biomarker analysis in the first-in-human phase 1a study for vantictumab (OMP-18R5; anti-Frizzled) demonstrates pharmacodynamic (PD) modulation of the Wnt pathway in patients with advanced solid tumors. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B24.

Abstract 213: Novel NOTCH3 activating mutations identified in tumors sensitive to OMP-59R5, a monoclonal antibody targeting the Notch2 and Notch3 receptors

The Notch signaling pathway, driven by four Notch family receptors (NOTCH1-4) and five canonical Notch ligands (DLL1, DLL3, DLL4, JAG1, and JAG2) in humans, critically regulates key functions during embryonic development as well as stem cell maintenance and differentiation in adult tissues. Altered Notch signaling activity has been documented in many types of cancers; depending on the tumor type, Notch signaling can be oncogenic or tumor suppressing. Activating mutations in NOTCH1 have been identified in hematopoietic cancers including T-cell acute lymphoblastic leukemia and chronic lymphoblastic leukemia. With the advance in high-throughput genomic sequencing platforms, mutations in the NOTCH genes have also been identified in solid tumors, albeit at much lower frequencies. Here we report for the first time the identification of two activating mutations in NOTCH3. One is a frameshift mutation in the PEST domain, and the other a frameshift mutation in the ankyrin (ANK) domain. The PEST frameshift mutation leads to the production of C-terminally truncated NOTCH3 protein, and by Western Blotting of nuclear fractions of tumor tissues and Immunohistochemistry (IHC) we show that this mutant NOTCH3 accumulates stably in the nuclei of the breast tumor in which it was identified. Breast xenograft tumors carrying this mutation are highly sensitive to OMP-59R5, a ligand-blocking antibody targeting the Notch2 and Notch3 receptors, suggesting that the mutation, although activating, is still ligand dependent. Consistent with this finding, expression of this mutant NOTCH3 constructed by site-directed mutagenesis exhibits higher baseline activity compared to wild type NOTCH3 and is equally responsive to ligands in in vitro NOTCH reporter assays. We are not able to observe increased nuclear accumulation of the ANK frameshift mutant NOTCH3 in the colon tumor in which it was identified. However, in vitro the ANK mutant NOTCH3 has higher baseline activity than wild-type NOTCH3 in the absence of ligands and remains highly responsive to ligands. The colon xenograft tumors carrying this NOTCH3 ANK mutation are also sensitive to OMP-59R5 in in vivo efficacy studies. Taken together our data suggest that NOTCH3 is oncogenic in certain subtypes of tumors, and tumors with these activating mutations may predictive sensitivity to therapeutic antibodies targeting the receptor.

Citation Format: Breanna Wallace, Min Wang, Chris Muriel, Jennifer Cain, Belinda Cancilla, Jalpa Shah, Jie Wei, Austin Gurney, John Lewicki, Aaron Sato, Tim Hoey, Tracy Tang, Ann M. Kapoun. Novel NOTCH3 activating mutations identified in tumors sensitive to OMP-59R5, a monoclonal antibody targeting the Notch2 and Notch3 receptors. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 213. doi:10.1158/1538-7445.AM2013-213

Abstract 4330: In vivo evaluation of anti-tumor activity by an anti-VEGF and anti-DLL4 bispecific antibody in a humanized model of skin graft

Both Notch/Delta-like ligand 4 (DLL4) and vascular endothelial growth factor (VEGF) pathways play a critical role in angiogenesis and tumor growth. Due to differential regulatory effects of VEGF and DLL4 on the vasculature, blockage of DLL4 or VEGF inhibits tumor growth by distinct mechanisms: anti-DLL4 treatment induces an abnormal increase of poorly perfused blood vessels, which results in a nonproductive angiogenesis unable to support tumor growth, whereas the anti-VEGF therapy significantly decreases vasculature reducing the blood supply to tumors. In our study, we have developed a bispecific monoclonal antibody that targets both human DLL4 (hDLL4) and human VEGF (hVEGF). In vitro, this antibody demonstrated nanomolar affinity to hVEGF and hDLL4, and reduced HUVEC proliferation induced by VEGF (EC50 0.86 ug/ml). To test the activity of this bispecific antibody in vivo, we developed a human skin graft model in NOD/SCID mice, and implanted human tumor specimen-derived colon cancer cells intradermally into these skin transplants. The tumor model was selected based on its sensitivity to both the anti-human DLL4 antibody, OMP-21M18, and to the human VEGF inhibitor bevacizumab. The skin graft model provides a suitable human microenvironment for evaluating anti-tumor efficacy and anti-angiogenesis of the bispecific antibody directed against the human component of DLL4 and VEGF and allows a comparison to OMP-21M18 and also to bevacizumab. Each of these treatments was administered to mice intraperitoneally at a dose of 25 mg/Kg weekly. The bispecific antibody caused a significant inhibition of tumor growth (87% TGI) compared to control antibody (p=0.00001), and this effect was superior to either OMP-21M18 (45% TGI) or bevacizumab (70%TGI). The inhibition of tumor growth by the bispecific antibody was consistently associated with increased blood vessels, up-regulated VEGFA and VEGFR2, and enhanced hypoxia and these effects were more pronounced compared to OMP-21M18. As expected, in this model bevacizumab caused a significant decrease of blood vessels, down-regulated VEGFR2, and increased hypoxia. In separate experiments with mice bearing subcutaneous human colon tumors, the bispecific antibody delayed tumor recurrence following termination of chemotherapy and impacted tumorigenicity by decreasing the frequency of tumor initiating cells. These results suggest that our bispecific anti-DLL4 and anti-VEGF antibody is a potential candidate in the treatment of tumors driven by both VEGF and Notch/DLL4 signaling pathways.

Citation Format: Lucia Beviglia, Pete Yeung, Wang-Ching Yen, Belinda Cancilla, Sato Aaron, Chris Bond, Janak Raval, Fumiko Axelrod, Cecile Chartier, Shirley Ma, Austin Gurney, John Lewicki, Ann M. Kapoun, Timothy Hoey. In vivo evaluation of anti-tumor activity by an anti-VEGF and anti-DLL4 bispecific antibody in a humanized model of skin graft. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4330. doi:10.1158/1538-7445.AM2013-4330

Abstract 3728: Anti-Notch1 antibody (OMP-52M51) impedes tumor growth and cancer stem cell frequency (CSC) in a chemo-refractory breast cancer xenograft model with an activating Notch1 mutation and screening for activated Notch1 across multiple solid tumor types

The Notch pathway plays a central role in embryonic development, the regulation of stem and progenitor cells, and is implicated in many human cancers. Notch1 is also known to be activated by oncogenic mutations in tumors including T cell leukemia, chronic lymphocytic leukemia and non-small cell lung cancer. Here we report the discovery of similar mutations in breast cancer. We have developed a primary human xenograft model from a patient bearing an activating Notch1 mutation and have shown that blocking Notch signaling in this model with a novel anti-Notch1 antibody, OMP-52M51, impeded tumor growth and reduced cancer stem cell (CSC) frequency. OMP-52M51 is a humanized antibody that binds with high affinity and selectivity to human Notch1 and antagonizes Notch signaling.

Additionally, we sought to determine the frequency of Notch pathway activation across a large panel of human tumors (n&gt;600) by an immunohistochemistry assay that detects the activated form of Notch1 using a polyclonal antibody that specifically recognizes the Notch1 intracellular domain (ICD). Using this test and a rigorous H-score cut-off of 30, we found elevated Notch1 in 7-29% of the following cancers: chemo-resistant breast, gastric, cholangiocarcinoma, esophageal, hepatacellular carcinoma (HCC), and small cell lung cancer (SCLC).

The class of patients that showed the highest frequency of elevated Notch1.ICD was chemo-resistant breast cancer (∼30%). This frequency was significantly higher than in unselected breast cancer patients, suggesting that Notch1 signaling plays a significant role in breast cancer chemoresistance. Interestingly, the human xenograft model which showed sensitivity to OMP-52M51 was derived from a patient that failed to respond to pre-operative chemotherapy and developed metastatic disease following surgery. Thus, chemo-resistant breast cancer as well as the other tumors with high Notch1.ICD may represent important classes of patients who could benefit from anti-Notch1 therapy in the clinic.

Citation Format: Belinda Cancilla, Jennifer Cain, Min Wang, Lucia Beviglia, Jalpa Shah, Austin Gurney, John Lewicki, Laura Esserman, Tim Hoey, Ann M. Kapoun. Anti-Notch1 antibody (OMP-52M51) impedes tumor growth and cancer stem cell frequency (CSC) in a chemo-refractory breast cancer xenograft model with an activating Notch1 mutation and screening for activated Notch1 across multiple solid tumor types. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3728. doi:10.1158/1538-7445.AM2013-3728