Safety and Pharmacokinetics of Ganitumab (AMG 479) Combined with Sorafenib, Panitumumab, Erlotinib, Or Gemcitabine in Patients with Advanced Solid Tumors

Published OnlineFirst April 17, 2012; DOI: 10.1158/1078-0432.CCR-11-3369

Clinical Cancer Cancer Therapy: Clinical Research

Safety and Pharmacokinetics of Ganitumab (AMG 479) Combined with Sorafenib, Panitumumab, Erlotinib, or Gemcitabine in Patients with Advanced Solid Tumors

Lee S. Rosen1, Igor Puzanov2, Gregory Friberg3, Emily Chan2, Yuying C. Hwang3, Hongjie Deng3, Jill Gilbert2, Devalingam Mahalingam4, Ian McCaffery3, Shaunita A. Michael2, Alain C. Mita4, Monica M. Mita4, Marilyn Mulay1, Poornima Shubhakar3, Min Zhu3, and John Sarantopoulos4

Abstract Purpose: This phase 1b dose-escalation study assessed safety, tolerability, and pharmacokinetics of ganitumab, a fully human monoclonal antibody against the insulin-like growth factor 1 (IGF1) receptor, combined with targeted agents or cytotoxic chemotherapy in patients with advanced solid tumors. Experimental Design: Patients with treatment-refractory advanced solid tumors were sequentially enrolled at 2 ganitumab dose levels (6 or 12 mg/kg i.v. every 2 weeks) combined with either sorafenib 400 mg twice daily, panitumumab 6 mg/kg every 2 weeks, erlotinib 150 mg once daily, or gemcitabine 1,000 mg/m2 on days 1, 8, and 15 of each 4-week cycle. The primary end points were safety and pharmacokinetics of ganitumab. Results: Ganitumab up to 12 mg/kg appeared well tolerated combined with sorafenib, panitumumab, erlotinib, or gemcitabine. Treatment-emergent adverse events were generally mild and included fatigue, nausea, vomiting, and chills. Three patients had dose-limiting toxicities: grade 3 hyperglycemia (ganitumab 6 mg/kg and panitumumab), grade 4 neutropenia (ganitumab 6 mg/kg and gemcitabine), and grade 4 thrombocytopenia (ganitumab 12 mg/kg and erlotinib). Ganitumab-binding and panitumumab-binding antibodies were detected in 5 and 2 patients, respectively; neutralizing antibodies were not detected. The pharmacokinetics of ganitumab and each cotherapy did not appear affected by coadministration. Circu- lating total IGF1 and IGF binding protein 3 increased from baseline following treatment. Four patients (9%) had partial responses. Conclusions: Ganitumab up to 12 mg/kg was well tolerated, without adverse effects on pharmacokinetics in combination with either sorafenib, panitumumab, erlotinib, or gemcitabine. Ganitumab is currently under investigation in combination with some of these and other agents. Clin Cancer Res; 18(12); 3414–27. 2012 AACR.

Introduction are several lines of evidence that implicate the IGF1R The insulin-like growth factor 1 receptor (IGF1R) is a type signaling axis in the development of human malignancies 1 transmembrane tyrosine kinase receptor that, with its (6). Not only have constitutive IGF1R expression, IGF1R ligands insulin-like growth factor 1 (IGF1) and 2 (IGF2), overexpression, and autocrine or paracrine signaling via regulates cell proliferation and apoptosis (1–4). The activity IGF1R been proposed as mechanisms of transformation in of IGFs is modulated by 6 IGF binding proteins (IGFBP), several tumor types (7–11), but studies using gene knock- which may affect tumor growth and IGF function (5). There out mice have shown that IGF1R is required for transformation (12, 13). In early-phase clinical trials, IGF1R inhibitors have Authors' Affiliations: 1Premiere Oncology, Santa Monica, California; 2Van- shown acceptable toxicity profiles and evidence of antitu- derbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nash- mor activity (14). Several lines of evidence suggest that these ville, Tennessee; 3Amgen Inc., Thousand Oaks, California; and 4Institute for Drug Development, Cancer Therapy and Research Center, The University agents might be combined with other anticancer agents in of Texas Health Science Center at San Antonio, San Antonio, Texas the treatment of solid tumors. Interactions between IGF1R Note: Supplementary data for this article are available at Clinical Cancer and epidermal growth factor receptor (EGFR) have been Research Online (http://clincancerres.aacrjournals.org/). reported in different cell types, and IGF1R may induce EGFR Corresponding Author: Lee S. Rosen, UCLA Hematology/Oncology, phosphorylation via autocrine or paracrine mechanisms 2020 Santa Monica Blvd, Suite 600, Santa Monica, CA 90404. Phone: involving EGF-like ligands (15–17). It was therefore pos- 310-633-8400; Fax: 310-633-8419; E-mail: [email protected] tulated that combined inhibition of IGF1R and vascular doi: 10.1158/1078-0432.CCR-11-3369 endothelial growth factor (VEGF) or EGFR would be of 2012 American Association for Cancer Research. therapeutic benefit. This rationale was further supported by

3414 Clin Cancer Res; 18(12) June 15, 2012

Safety of Ganitumab Plus Targeted or Cytotoxic Agents

Patients and Methods Translational Relevance Patients Ganitumab (AMG 479) is a fully human immuno- Patients aged 18 years or more with pathologically or globulin G1 monoclonal antibody against the insulin- cytologically documented advanced solid tumors or renal like growth factor 1 receptor (IGF1R). In early-stage cell carcinoma (sorafenib cohorts) refractory to at least 1 trials, ganitumab had acceptable toxicity and evidence line of therapy or for which no standard or curative therapy of activity in patients with advanced solid tumors and was available; measurable or evaluable disease per World increased overall survival when combined with gemci- Health Organization (WHO) guidelines; an Eastern Coop- tabine in patients with previously untreated metastatic erative Oncology Group performance status of 2 or less; life pancreatic cancer. Combinations of IGF1R inhibitors expectancy of 3 months or more; and adequate hemato- and targeted or cytotoxic agents may improve treatment logic, renal, and hepatic function were eligible to enroll. efficacy. We assessed the safety, pharmacokinetics, and Exclusion criteria included unresolved toxicities from antitumor activity of ganitumab combined with the prior anticancer therapy; primary or metastatic central ner- multikinase inhibitor sorafenib, the fully human anti– vous system tumors (sorafenib cohorts only; controlled epidermal growth factor receptor (EGFR) monoclonal central nervous system tumors were allowed in other antibody panitumumab, the EGFR small-molecule cohorts); uncontrolled hypertension; ascites or pleural effu- inhibitor erlotinib, or the nucleoside analogue gemci- sion requiring treatment; abnormal pulmonary function, tabine. Ganitumab in combination with these agents including impaired carbon monoxide diffusion capacity was generally well tolerated, had favorable pharmaco- (gemcitabine cohorts); magnesium below the lower limit kinetics, and resulted in partial responses and tumor of normal (panitumumab cohorts); myocardial infarction, reductions in some patients. Ganitumab is currently arterial thrombosis, or venous thrombosis within the pre- under investigation in combination with targeted and vious 6 months; clinically significant hypoglycemia or cytotoxic agents for the treatment of several tumor types. hyperglycemia per investigator assessment; symptomatic congestive heart failure; unstable angina; unstable cardiac arrhythmia requiring treatment; peptic ulcer disease (sorafenib cohorts); major surgery within the previous 4 weeks (8 weeks for the sorafenib cohorts); anticoagulation therapy preclinical studies reporting additive or synergistic inhibi- (except low-dose warfarin) within the previous week; active tion of tumor cell growth, induction of apoptosis, and infection within the previous 2 weeks; and history of chron- regression of tumor xenografts in several models when ic hepatitis. Diabetes (type 1 or 2) and existence or risk for small-molecule tyrosine kinase inhibitors of IGF1R were primary hepatic tumors were added as exclusion criteria combined with either of the EGFR inhibitors erlotinib or after enrollment had begun. gefitinib (18–20). Similarly, combined treatment with an Previous treatment with ganitumab or gemcitabine was IGF1R inhibitor and the multikinase inhibitor sorafenib not permitted. Prior treatment with cetuximab, panitumu- was also associated with additive inhibition of cholangio- mab, sorafenib, bevacizumab, or erlotinib was allowed. carcinoma cell growth (21). Furthermore, combination Patients were excluded for anticancer therapy, radiation treatment with an IGF1R inhibitor and the cytotoxic che- therapy, antibody therapy, retinoid therapy, hormonal motherapy gemcitabine was associated with additive inhi- therapy, or participation in clinical trials within the previ- bition of human pancreatic tumor xenograft growth (22). ous 4 weeks before enrollment (within the previous 6 weeks Ganitumab (AMG 479) is a fully human immunoglob- for nitrosoureas and mitomycin C). Concurrent hormone ulin G1 monoclonal antibody against IGF1R that inhibits replacement therapy or gonadotropin-releasing hormone tumor cell proliferation, promotes tumor cell death, and modulators were allowed for prostate cancer. Concomitant causes regression of established tumor xenografts (23, 24). medications that interfered with cytochrome P450 3A In a phase 1, first-in-human study, ganitumab as mono- metabolism were prohibited in the sorafenib and erlotinib therapy had acceptable toxicity up to the maximum tested cohorts. Institutional Review Board approval was obtained dose (20 mg/kg i.v. every 2 weeks) and showed antitumor for all study procedures. All patients provided written activity in patients with solid tumors (25). The objectives of informed consent before enrollment. this study were to assess the safety, tolerability, and pharmacokinetics of ganitumab combined with the multikinase Study design inhibitor sorafenib, the fully human anti-EGFR monoclo- This phase 1b open-label, dose-escalation study used a nal antibody panitumumab, the EGFR tyrosine kinase 3 þ 3 þ 3 design to investigate the safety, tolerability, and inhibitor erlotinib, or the cytotoxic chemotherapy gemci- pharmacokinetic profiles of ganitumab combined with tabine in patients with advanced solid tumors. In a phase 2 sorafenib, panitumumab, erlotinib, or gemcitabine. The study, which used the data from this study to justify the dose primary end points were safety [incidence of adverse events of ganitumab combined with gemcitabine, the combina- (AE), clinically significant changes in vital signs and labo- tion had acceptable toxicity and improved overall survival ratory tests] and pharmacokinetics of ganitumab. Second- in patients with previously untreated metastatic pancreatic ary end points included the pharmacokinetics of each cancer (26). cotherapy, anti-ganitumab antibody formation, tumor

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Rosen et al.

response per WHO criteria, and volumetric tumor response administered until disease progression or intolerable AE. by independent central assessment. Exploratory biomarker Doses of study drugs could be withheld, reduced, or delayed analyses were conducted, which included a pharmacody- per protocol-specified rules for the occurrence of toxicities; namic analysis of serum IGF1 and IGFBP-3, immunohis- interruptions lasting more than 6 weeks resulted in study tochemical analysis of phosphatase and tensin homologue discontinuation. If ganitumab dosing was delayed, missed, (PTEN) expression in archival tumors, and an analysis of or discontinued, cotherapies were also delayed, missed, or somatic mutations in archival tumors. discontinued; however, ganitumab dosing was not altered as a result of altered dosing of cotherapies. Treatment and dose escalation Fourteen dose cohorts of 3 to 9 patients each were initially DLT and maximum tolerated dose planned, which included 10 cohorts to assess 2 dose levels A DLT in all cohorts (except for the gemcitabine and of ganitumab (6 or 12 mg/kg every 2 weeks) combined with sorafenib cohorts) was defined as any related grade of 3 or bevacizumab 10 mg/kg every 2 weeks, sorafenib 400 mg higher hematologic toxicity or nonhematologic toxicity twice daily, panitumumab 6 mg/kg every 2 weeks, erlotinib occurring during the initial 21 days of treatment with 150 mg once daily, or gemcitabine 1,000 mg/m2 on days 1, ganitumab (except for alopecia or other well-described 8, and 15 of each 28-day cycle. Four optional ganitumab de- toxicity of the agents being investigated) according to escalation cohorts were to be enrolled if intolerable toxi- National Cancer Institute Common Terminology Criteria cities occurred. Two planned bevacizumab cohorts were not for Adverse Events (NCI-CTCAE) version 3.0. A DLT in the enrolled after new evidence indicated that bevacizumab gemcitabine cohorts was defined as any related grade of 3 or might have limited activity as a monotherapy in previously higher nonhematologic toxicity occurring during the initial treated patients (27). The starting dose of 6 mg/kg and the 21 days of treatment with ganitumab (except for alopecia or target dose of 12 mg/kg for ganitumab were based on other well-described toxicities). Grade 3 anemia, neutrope- pharmacokinetic results from a preclinical tumor xenograft nia, and thrombocytopenia were not considered DLTs study and from the first-in-human study (25). Doses and unless the neutropenia was accompanied by fever higher schedules for sorafenib, panitumumab, erlotinib, and gem- than 38.5C, the neutropenia lasted more than 7 days, or citabine were based on product label information (28–31). the thrombocytopenia was accompanied by bleeding. Reduced doses of sorafenib and gemcitabine were allowed Grade 4 anemia, neutropenia, and thrombocytopenia were depending on the toxicities observed. considered DLTs. The maximum tolerated dose of ganitu- Initially, 3 patients were enrolled in each cohort at the mab was defined as the highest dose level at which fewer first ganitumab dose level. Up to 9 patients could be than 33% of treated patients in each arm had a DLT. enrolled in each cohort for additional safety and pharmacokinetic data. The decision to escalate to the second gani- Study assessments tumab dose level for each combination was made by the Safety and laboratory. All AEs occurring from enroll- investigators and sponsor following review of available ment until the last follow-up (30 days after the last dose) safety, laboratory, and pharmacokinetic data from a 21-day were recorded by investigators and graded per NCI-CTCAE assessment period following the first dose. If 1 of 3 patients version 3.0. Clinical chemistry, hematology, and urinalysis at the first dose level had a dose-limiting toxicity (DLT), were assessed at screening, predose on days 1 and 8, before then 3 additional patients were to be enrolled at the first all subsequent ganitumab doses, and at the end-of-study dose level. If no further DLTs or serious ganitumab-related visit. AEs were observed, enrollment in the second dose level Anti-ganitumab and anti-panitumumab antibodies. could begin. If 2 of 6 patients at the first dose level had a DLT Blood samples for the assessment of anti-ganitumab anti- or serious ganitumab-related AE, then 3 additional patients bodies were collected predose on days 1 (for panitumu- were to be enrolled at the first dose level (for a total of 9 mab) or 2 (for ganitumab), days 29 and 57, every 12 weeks patients). A dose was considered toxic if 33% of patients or thereafter, and at the end-of-study visits (4 and 8 weeks after more experienced a DLT or serious ganitumab-related AE the last dose). Anti-ganitumab antibodies were assayed during the 21-day assessment period; the dose was to be using an electrochemiluminescence bridging immunoassay stopped if 3 of 9 patients had a DLT. as described previously (25). Anti-panitumumab antibo- Ganitumab was administered as a 1-hour intravenous dies were assayed using a bridging ELISA and a Biacore assay infusion on day 2 of cycle 1 and on day 1 of each subsequent as described previously (32). 2-week cycle. If 1-hour infusions were tolerated, subsequent Pharmacokinetics. Blood samples for the measurement infusions could be reduced to 30 minutes. If 1-hour infu- of pharmacokinetic profiles of ganitumab, sorafenib, pani- sions were poorly tolerated, subsequent infusions could be tumumab, erlotinib, and gemcitabine and its metabolite extended to 2 hours. Sorafenib was administered orally [2020-difluorodeoxyuridine (dFdU)] were collected between twice daily beginning on day 1. Panitumumab was admin- weeks 5 (cycle 3, predose and postdose) and 7 (cycle 4, istered as a 1-hour intravenous infusion on day 1 of each predose). Sparse samples were collected in weeks 1 (cycle 1, 2-week cycle. Erlotinib was administered orally once daily predose and postdose), 3 (cycle 2, predose and postdose), beginning on day 1. Gemcitabine was administered i.v. on 11 (cycle 6, predose), and 15 (cycle 8, predose); predose days 1, 8, and 15 of each 4-week cycle. Study drugs were every 12 weeks thereafter; and at the end-of-study visits (4

3416 Clin Cancer Res; 18(12) June 15, 2012 Clinical Cancer Research

Safety of Ganitumab Plus Targeted or Cytotoxic Agents

and 8 weeks after the last dose). Serum concentrations of lesions to qualify for a partial response nor sufficient ganitumab and panitumumab were measured using a dou- increase to qualify for progressive disease, taking as refer- ble anti-idiotypic antibody sandwich immunoassay (25) ence the nadir SPD since the treatment started. For duration and an electrochemiluminescence assay (33), respectively. of responses, responders who had not progressed or Plasma concentrations of sorafenib, erlotinib, gemcitabine, died during the study were censored at the last disease and dFdU were measured by liquid chromatography with assessment. tandem mass spectrometry (see Supplementary Material). Pharmacokinetic parameters were estimated using non- Statistical analysis compartmental methods with WinNonlin software (ver- Descriptive statistics were used to summarize demo- sion 5.1.1; Pharsight Corp.). graphic, safety, pharmacokinetic, biomarker, tumor assess- Pharmacodynamic assessments. To assess the pharma- ment, and response data. The safety analysis set included all codynamic response of circulating IGF1 and IGFBP-3 to patients who received 1 or more doses of investigational treatment with ganitumab, blood samples for the measure- product. All patients were included in efficacy analyses. ment of serum total IGF1 and IGFBP-3 were collected Patients were categorized by the initial dose received. predose in cycles 1 (days 1, 2, and 8), 2 (day 15), 4 (day 43), and 6 (day 71), and at the end-of-study visit (4 weeks Results after the last dose of ganitumab). Serum IGF1 and IGFBP-3 were measured using competitive binding radioimmunoas- Patient demographics and disposition says following alcohol/acid extraction. Briefly, extracts were Forty-six patients were enrolled at 3 centers in the United incubated with rabbit polyclonal antisera specific for IGF1 States between December 5, 2006, and September 2, 2009. or IGFBP-3 followed by radioiodinated purified recombi- All patients received at least 1 dose of ganitumab; 9 received nant human IGF1 or purified IGFBP-3. Concentrations of at least 24 weeks of treatment. All patients received at least 1 IGF1 and IGFBP-3 from control and test samples were dose of their respective cotherapies. Administration of the determined from a dose–response curve generated in each study drugs is summarized in Supplementary Table S1. assay using purified IGF1 or IGFBP-3. The sensitivities of the Patients were enrolled sequentially, first completing treat- assays for IGF1 and IGFBP-3 were 15 and 0.3 ng/mL, ment in the gemcitabine and panitumumab cohorts, fol- respectively. lowed by the sorafenib and erlotinib cohorts. Demo- Analysis of tumor PTEN expression. Archival tumor sam- graphics and baseline characteristics are summarized ples were stained for nuclear and cytoplasmic expression of in Table 1. The most common tumor types were colon n ¼ n ¼ n ¼ PTEN by immunohistochemistry and scored on a relative ( 11), ovarian ( 6), breast ( 4), and non–small cell n ¼ n ¼ scale of 0 to 3 (0, no stain; 3, maximal stain). Tumor cells lung ( 3). The majority of patients ( 31; 67%) had with a staining intensity of 1 or more in the nuclear or received 3 or more lines of prior cancer therapy and approx- n ¼ cytoplasmic compartments were considered PTEN positive. imately one half had received radiotherapy ( 24; 52%). Detailed staining methods are described in the Supplemen- Eleven patients (24%) discontinued the study early; n ¼ tary Material. reasons included consent withdrawn ( 4), loss to fol- n ¼ Exploratory genetic analysis. DNA was extracted from low-up ( 2; after 4 and 6 doses, respectively), alternative n ¼ n ¼ n ¼ archival formalin-fixed paraffin-embedded sections. To therapy ( 2), noncompliance ( 1), AE ( 1; see n ¼ determine the somatic mutation status of HRAS, KRAS, below, DLTs), and administrative decision ( 1). Thirty- NRAS, BRAF, PIK3CA, PTEN, and TP53, sequence libraries five patients (76%) completed the end-of-study visit. were generated and analyzed using the Roche 454 GS FLX Amplicon Sequencing platform. Detailed methods are Dose escalation, DLTs, and maximum tolerated dose available in the Supplementary Material. Overall 8 cohorts were enrolled in the study, comprising 20 patients in the ganitumab 6 mg/kg cohorts and 26 Tumor assessment patients in the ganitumab 12 mg/kg cohorts. Initially, 3 Tumor assessment was carried out by computed tomog- patients were enrolled in cohorts to receive ganitumab raphy (CT) or magnetic resonance imaging and was eval- 6 mg/kg combined with sorafenib 400 mg twice daily uated by investigators within 4 weeks before enrollment (cohort 1), panitumumab 6 mg/kg every 2 weeks (cohort and every 8 weeks (1 week) thereafter. Volumetric CT 2), erlotinib 150 mg once daily (cohort 3), or gemcitabine analysis was performed by a central imaging laboratory 1,000 mg/m2 (cohort 4). Two of these patients had DLTs: 1 (VirtualScopics). Response was assessed by investigators in cohort 2 and 1 in cohort 4. In cohort 2, a patient with a per WHO criteria (34). A partial response was defined as thyroid tumor and history of diabetes had grade 3 hyper- a 50% or more decrease from baseline in the sum of the glycemia considered by investigators to be related to cross-products of the longest diameters (SPD) of index ganitumab. The patient’s baseline fasting glucose was 103 lesions for 4 or more weeks. Progressive disease was defined mg/dL; subsequent levels ranged from 189 to 350 mg/dL. as at least a 25% increase in the SPD of index lesions taking The patient received treatment with insulin and the pani- as reference the nadir SPD recorded since the last treatment tumumab dose was altered; the patient was eventually started or the presence of one or more new lesions. Stable removed from the study owing to hyperglycemia. In disease was defined as neither sufficient shrinkage of index cohort 4, a patient with a small cell lung tumor had grade

www.aacrjournals.org Clin Cancer Res; 18(12) June 15, 2012 3417

Downloaded from clincancerres.aacrjournals.org on September 29, 2021. © 2012 American Association for Cancer Research. 3418 lnCne e;1(2 ue1,2012 15, June 18(12) Res; Cancer Clin oe tal. et Rosen Downloaded from Table 1. Patient demographics and baseline characteristics

Cohort 1 Cohort 5 Cohort 2 Cohort 6 Cohort 3 Cohort 7 Cohort 4 Cohort 8 6 mg/kg 12 mg/kg 6 mg/kg 6 mg/kg 12 mg/kg 6 mg/kg 12 mg/kg ganitumab þ ganitumab þ ganitumab þ 12 mg/kg ganitumab þ ganitumab þ ganitumab þ ganitumab þ 6 mg/kg Q2W 6 mg/kg Q2W 150 mg qd ganitumab þ 1,000 mg/m2 1,000 mg/m2 clincancerres.aacrjournals.org 400 mg b.i.d 400 mg b.i.d panitumumab panitumumab erlotinib 150 mg qd gemcitabine gemcitabine Total Published OnlineFirstApril17,2012;DOI:10.1158/1078-0432.CCR-11-3369 sorafenib (n ¼ 3) sorafenib (n ¼ 10) (n ¼ 6) (n ¼ 4) (n ¼ 3) erlotinib (n ¼ 9) (n ¼ 8) (n ¼ 3) (n ¼ 46)

Sex, n (%) Men 2 (67) 5 (50) 5 (83) 2 (50) 2 (67) 2 (22) 2 (25) 1 (33) 21 (46) Women 1 (33) 5 (50) 1 (17) 2 (50) 1 (33) 7 (78) 6 (75) 2 (67) 25 (54) Race, n (%) White/Caucasian 1 (33) 10 (100) 5 (83) 4 (100) 3 (100) 8 (89) 5 (63) 1 (33) 37 (80) Black/African 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13) 2 (67) 3 (7) American Hispanic/Latino 2 (67) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11) 2 (25) 0 (0) 5 (11) Asian 0 (0) 0 (0) 1 (17) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) on September 29, 2021. © 2012American Association for Cancer Median age, y (range) 65 (61—74) 51 (41–63) 56 (51–63) 55 (33–68) 63 (55–69) 59 (44–73) 58 (32–64) 70 (44–73) 57 (32–74)

Research. ECOG performance status, n (%) 0 0 (0) 3 (30) 2 (33) 2 (50) 1 (33) 2 (22) 4 (50) 0 (0) 14 (30) 1 3 (100) 7 (70) 4 (67) 2 (50) 2 (67) 7 (78) 4 (50) 3 (100) 32 (70) Primary tumor type, n (%) Colon 0 (0) 0 (0) 3 (50) 3 (75) 0 (0) 2 (22) 2 (25) 1 (33) 11 (24) Ovarian 0 (0) 2 (20) 0 (0) 0 (0) 0 (0) 2 (22) 2 (25) 0 (0) 6 (13) Breast 0 (0) 1 (10) 0 (0) 0 (0) 1 (33) 1 (11) 1 (13) 0 (0) 4 (9) Non–small cell lung 0 (0) 1 (10) 0 (0) 0 (0) 1 (33) 0 (0) 1 (13) 0 (0) 3 (7) Carcinoid 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 1 (11) 0 (0) 0 (0) 2 (4) Endometrial 1 (33) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) Small cell lung 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11) 1 (13) 0 (0) 2 (4) Thyroid 1 (33) 0 (0) 1 (17) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) Angiosarcoma 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11) 0 (0) 0 (0) 1 (2) Carcinoma of 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (33) 1 (2)

lnclCne Research Cancer Clinical unknown origin Esophageal 0 (0) 0 (0) 0 (0) 0 (0) 1 (33) 0 (0) 0 (0) 0 (0) 1 (2) Gastroesophageal 0 (0) 0 (0) 1 (17) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) junction Head and neck 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11) 0 (0) 0 (0) 1 (2) adenocarcinoma (Continued on the following page) www.aacrjournals.org Downloaded from

Table 1. Patient demographics and baseline characteristics (Cont'd ) Cohort 1 Cohort 5 Cohort 2 Cohort 6 Cohort 3 Cohort 7 Cohort 4 Cohort 8 clincancerres.aacrjournals.org 6 mg/kg 12 mg/kg 6 mg/kg 6 mg/kg 12 mg/kg Published OnlineFirstApril17,2012;DOI:10.1158/1078-0432.CCR-11-3369 6 mg/kg 12 mg/kg ganitumab þ ganitumab þ ganitumab þ 12 mg/kg ganitumab þ ganitumab þ ganitumab þ ganitumab þ 6 mg/kg Q2W 6 mg/kg Q2W 150 mg qd ganitumab þ 1,000 mg/m2 1,000 mg/m2 400 mg b.i.d 400 mg b.i.d panitumumab panitumumab erlotinib 150 mg qd gemcitabine gemcitabine Total sorafenib (n ¼ 3) sorafenib (n ¼ 10) (n ¼ 6) (n ¼ 4) (n ¼ 3) erlotinib (n ¼ 9) (n ¼ 8) (n ¼ 3) (n ¼ 46)

Hepatocellular 1 (33) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) carcinoma Leiomyosarcoma 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) Squamous cell 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) carcinoma of the anus Neuroendocrine 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2)

Research. Prostate 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (33) 1 (2) Rectal 0 (0) 0 (0) 0 (0) 1 (25) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) Sacrum chordoma 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) Squamous cell 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13) 0 (0) 1 (2) head/neck Lines of prior therapy, n (%) aeyo aiua lsTree rCttxcAgents Cytotoxic or Targeted Plus Ganitumab of Safety 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13)a 1 (33)a 2 (4) 1 0 (0) 1 (10) 1 (17) 0 (0) 0 (0) 1 (11) 0 (0) 0 (0) 3 (7) 2 0 (0) 2 (20) 3 (50) 0 (0) 0 (0) 3 (33) 2 (25) 0 (0) 10 (22) 3 3 (100) 7 (70) 2 (33) 4 (100) 3 (100) 5 (56) 5 (63) 2 (67) 31 (67) Lines of prior radiotherapy, n (%)

lnCne e;1(2 ue1,2012 15, June 18(12) Res; Cancer Clin 0 1 (33) 4 (40) 1 (17) 4 (100) 0 (0) 5 (56) 5 (63) 2 (67) 22 (48) 1 0 (0) 2 (20) 4 (67) 0 (0) 2 (67) 4 (44) 0 (0) 0 (0) 12 (26) 2 1 (33) 2 (20) 1 (17) 0 (0) 0 (0) 0 (0) 2 (25) 1 (33) 7 (15) 3 1 (33) 2 (20) 0 (0) 0 (0) 1 (33) 0 (0) 1 (13) 0 (0) 5 (11)

NOTE: Safety analysis set includes patients who received more than 1 dose of ganitumab. Abbreviations: b.i.d, twice daily; ECOG, Eastern Cooperative Oncology Group; Q2W, every 2 weeks; qd, once daily. aPatients were eligible if they had advanced solid tumors refractory to more than 1 line of therapy, if no standard or curative therapy was available, or if standard noncurative therapy was refused. 3419 3420 lnCne e;1(2 ue1,2012 15, June 18(12) Res; Cancer Clin oe tal. et Rosen Downloaded from Table 2. Summary of AEs

Cohort 1 Cohort 5 Cohort 2 Cohort 6 Cohort 3 Cohort 7 Cohort 4 Cohort 8 6 mg/kg 12 mg/kg 6 mg/kg 12 mg/kg 6 mg/kg 12 mg/kg 6 mg/kg 12 mg/kg Total (n ¼ 46) ganitumab þ ganitumab þ ganitumab þ ganitumab þ ganitumab þ ganitumab þ ganitumab þ ganitumab þ 400 mg b.i.d 400 mg b.i.d 6 mg/kg Q2W 6 mg/kg Q2W 150 mg qd 150 mg qd 1,000 mg/m2 1,000 mg/m2 sorafenib sorafenib panitumumab panitumumab erlotinib erlotinib gemcitabine gemcitabine clincancerres.aacrjournals.org Published OnlineFirstApril17,2012;DOI:10.1158/1078-0432.CCR-11-3369 Patients, n (%) (n ¼ 3) (n ¼ 10) (n ¼ 6) (n ¼ 4) (n ¼ 3) (n ¼ 9) (n ¼ 8) (n ¼ 3) (n ¼ 46)

Patients with 1 3 (100) 10 (100) 6 (100) 4 (100) 3 (100) 9 (100) 8 (100) 3 (100) 46 (100) treatment-emergent AE Patients with 1 serious AE 1 (33) 6 (60) 1 (17) 0 (0) 2 (67) 4 (44) 1 (13) 0 (0) 15 (33) Patients with fatal AEs 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) Patients with 3 (100) 8 (80) 4 (67) 3 (75) 2 (67) 7 (78) 5 (63) 3 (100) 35 (76) ganitumab-related AEsa Fatigue 1 (33) 3 (30) 2 (33) 1 (25) 1 (33) 1 (11) 2 (25) 0 (0) 11 (24) Nausea 1 (33) 1 (10) 1 (17) 0 (0) 0 (0) 2 (22) 2 (25) 0 (0) 7 (15) Chills 1 (33) 3 (30) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13) 1 (33) 6 (13)

Research. Stomatitis or mucosal 0 (0) 2 (20) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13) 1 (33) 4 (8) inﬂammation Rash or 0 (0) 1 (10) 0 (0) 0 (0) 1 (33) 0 (0) 1 (13) 1 (33) 4 (8) maculopapular rash Anorexia 1 (33) 0 (0) 1 (17) 0 (0) 0 (0) 0 (0) 1 (13) 0 (0) 3 (7) Thrombocytopenia 0 (0) 0 (0) 0 (0) 0 (0) 1 (33) 1 (11) 0 (0) 1 (33) 3 (7) Alopecia 1 (33) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) Diarrhea 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 1 (11) 0 (0) 0 (0) 2 (4) Hypertension 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13) 0 (0) 2 (4) Hypomagnesemia 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13) 0 (0) 2 (4) Myalgia 0 (0) 2 (20) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) Pruritus 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13) 1 (33) 2 (4) Pyrexia 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 1 (13) 0 (0) 2 (4) Patients with grade 3 2 (67) 10 (100) 5 (83) 3 (75) 2 (67) 4 (44) 5 (63) 2 (67) 33 (72) treatment-emergent AEsa

lnclCne Research Cancer Clinical Neutropenia 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 4 (50) 2 (67) 7 (15) Palmar-plantar 2 (67) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 3 (7) erythrodysesthesia syndrome Fatigue 0 (0) 2 (20) 0 (0) 0 (0) 1 (33) 1 (11) 0 (0) 0 (0) 4 (9) Anemia 1 (33) 2 (20) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (33) 4 (9) Rash 0 (0) 1 (10) 0 (0) 1 (25) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) Intestinal obstruction 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (11) 1 (13) 0 (0) 2 (4) (Continued on the following page) Published OnlineFirst April 17, 2012; DOI: 10.1158/1078-0432.CCR-11-3369

Safety of Ganitumab Plus Targeted or Cytotoxic Agents

4 neutropenia. As a result of the DLTs, cohorts 2 and 4 were 46) each expanded to 6 patients to collect additional safety ¼

n and pharmacokinetic data. In addition, 2 patients were 46)

¼ enrolled in cohort 4 as replacements for 2 patients who 2 (4) 2 (4) n

Total ( received ganitumab dosing errors (12 mg/kg instead of 6 mg/kg ganitumab) during the DLT assessment window. 2 þ Subsequently, 3 patients were enrolled in cohorts to receive ganitumab 12 mg/kg combined with sorafenib 3) ( (cohort 5), panitumumab (cohort 6), erlotinib (cohort ¼

n 7), or gemcitabine (cohort 8). One patient in cohort 7 with 0 (0) 0 (0) 12 mg/kg ganitumab 1,000 mg/m gemcitabine ovarian cancer had a DLT (grade 4 thrombocytopenia) after 2 þ the ﬁrst dose of ganitumab (day 5). The patient was removed from the study and did not receive subsequent

8) ( treatment. Subsequently, cohorts 5 and 7 were expanded to ¼ 9 patients to collect additional safety and pharmacokinetic n 6 mg/kg ganitumab 1,000 mg/m 0 (0) gemcitabine data. In addition, 1 patient each in cohorts 5 and 6 was

þ replaced due to consent withdrawal and failure to complete DLT window, resulting in a total enrollment of 10 and 4

9) ( patients, respectively. Ganitumab at the highest tested dose

¼ of 12 mg/kg appeared to be well tolerated when combined n 1 (11) 0 (0) 12 mg/kg ganitumab 150 mg qd erlotinib 0 (0) with full doses of each cotherapy (as deﬁned by a DLT < þ rate 33%).

Safety and tolerability 3) (

¼ Toxicity is summarized in Table 2. The most frequent n 0 (0) 0 (0) 6 mg/kg ganitumab 150 mg qd erlotinib ganitumab-related AEs were fatigue, nausea, vomiting, chills not associated with infusion, anorexia, and throm- þ bocytopenia. The AEs considered related to treatment with the cotherapies were consistent with those previously

4) ( reported for these agents (35–37). Grade 3 or higher treat- ¼ ment-emergent AEs occurred in 33 patients (72%). The n 0 (0) 0 (0) 12 mg/kg ganitumab 6 mg/kg Q2W panitumumab most common (occurring in 4% of patients) grade 3 or

þ higher treatment-emergent AEs were neutropenia, fatigue, anemia, palmar-plantar erythrodysesthesia syndrome, hypomagnesemia, rash, intestinal obstructions, and dehy- 6) (

¼ dration (see Table 2). Grade 3 or higher ganitumab-related n 6 mg/kg ganitumab 6 mg/kg Q2W panitumumab AEs (each n ¼ 1) were fatigue (cohort 5), thrombocytopenia (cohort 4), cataract (cohort 1), hyperglycemia (cohort 2), þ hyponatremia (cohort 5), and neutropenia (cohort 5). Serious AEs occurred in 15 patients (33%), none of which 10) ( were considered by investigators to be related to ganitumab. ¼ 1 (10) 0 (0) 0 (0) 2 (34)

12 mg/kg ganitumab 400 mg b.i.d sorafenib The most frequent (occurring in 4% of patients) serious AEs were dehydration [cohort 5, n ¼ 1 (10%); þ cohort 7, n ¼ 1 (11%)], diarrhea [cohort 5, n ¼ 1 (10%); cohort 7, n ¼ 1 (11%)], and intestinal obstruction [cohort 3,

3) ( n ¼ 1 (13%); cohort 7, n ¼ 1; (11%)]. Dehydration and ¼ diarrhea were the only serious AEs considered by investi- 0 (0) ( n Cohort 16 mg/kg ganitumab Cohort400 5 mg b.i.d sorafenib Cohort 2 Cohort 6 Cohort 3 Cohort 7 Cohort 4gators Cohort 8 to be potentially related to treatment with a study drug (sorafenib; cohort 5). Hyperglycemia was not reported in any patient aside from the occurrence considered a DLT. Two patients had hepatotoxicity events (grade 2 hepatic pain and grade 3 increased alanine aminotransferase), neither of which was (%) Summary of AEs (Cont'd )

n considered by investigators to be related to ganitumab; however, the increased alanine aminotransferase was considered by investigators to be potentially related to treat- HypomagnesemiaDehydration 1 (33)

AEs listed include those occurring in at least 4% of all patients. ment with sorafenib. Three patients (7%) had AEs identiﬁed NOTE: Safety analysis set includesAbbreviations: patients b.i.d, who twice received daily; more Q2W, than every 1 2 dose weeks; of qd, ganitumab. once daily. Table 2. a Patients, as potential sensorineural hearing loss. However, only 1

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Rosen et al.

patient (cohort 7) had sensorineural hearing loss (grade 2 cancer for 10 years, had multiple surgeries and had been hypoacusis) considered by investigators to be potentially heavily pretreated with various chemotherapy agents before related to ganitumab. The patient had prior exposure to enrollment. loud noises and a 3- to 6-month history of diminished hearing before enrollment. No infusion reactions were Antibodies reported during the study. Ganitumab-binding antibodies were detected in 5 AEs considered potentially related to treatment with the patients (11%) during the study, 2 of whom had detectable cotherapies were consistent with those previously reported binding antibodies at or before baseline. Ganitumab-neu- for these agents (35–37). Neutropenia events were reported tralizing antibodies were not detected in any patient before in 7 patients (15%) overall and occurred predominantly in or during the study. Panitumumab-binding antibodies the gemcitabine cohorts (cohort 4, n ¼ 4; cohort 5, n ¼ 1; were detected in 2 patients (1 each in cohorts 2 and 6) cohort 8, n ¼ 2). In addition to the 1 case of grade 4 with the Biacore assay but were not detected with the ELISA. neutropenia in cohort 4 considered a DLT, grade 3 neutro- In the patients with detectable binding antibodies with the penia occurred in 5 patients (cohort 4, n ¼ 3; cohort 8, Biacore assay, none were detected at or before baseline or n ¼ 2), grade 4 neutropenia occurred in 1 patient in within 90 days of the last dose. Panitumumab-neutralizing cohort 5, and grade 1 leukopenia occurred in 1 patient in antibodies were not detected in any patient during the cohort 8. Of these events, only the grade 1 leukopenia and study. the grade 4 neutropenia were considered by the investigators to be potentially related to ganitumab. The grade 4 Pharmacokinetics neutropenia was not considered a DLT because it occurred The pharmacokinetic parameters of ganitumab and each after the 21-day assessment period. Thrombocytopenia cotherapy are shown in Tables 3 and 4, respectively. Esti- events occurred in the gemcitabine cohort (n ¼ 7) and in mates of mean ganitumab exposure (maximum observed the erlotinib cohort (n ¼ 3). serum concentration, minimum observed serum concen- Skin rash occurred in 33 patients (72%) overall and in tration, and area under the concentration versus time curve 76%, 100%, 75%, and 36% of patients in the sorafenib, for a dosing interval) were approximately 2-fold greater panitumumab, erlotinib, and gemcitabine cohorts, respec- among patients who received ganitumab 12 mg/kg versus tively. One patient who received sorafenib (cohort 5) had a 6 mg/kg in all cohorts, indicating that dose linearity was not grade 3 superior vena cava occlusion that was not consid- affected by coadministration with sorafenib, panitumu- ered related to ganitumab. mab, erlotinib, or gemcitabine. Ganitumab clearance at The only treatment discontinuations as a result of AEs are both the 6 and 12 mg/kg doses in combination with described above (cohort 2, hyperglycemia; cohort 7, throm- sorafenib, panitumumab, erlotinib, and gemcitabine ran- bocytopenia). Delays in and reduced dosing of ganitumab ged from 8.94 to 17.0 mL/d/kg, which was within the occurred in 6 and 3 patients, respectively, as a result of AEs. expected range with monotherapy (25). Estimated phar- One patient (cohort 5) died on study day 61 of respiratory macokinetic parameters for sorafenib, panitumumab, erlo- failure not considered by investigators to be related to tinib, and gemcitabine did not seem to be affected by treatment with ganitumab. This patient, who had ovarian coadministration with ganitumab (Table 4).

Table 3. Pharmacokinetic parameter estimates of ganitumab after coadministration with sorafenib, panitumumab, erlotinib, or gemcitabinea

Cohort 1 Cohort 5 Cohort 2 Cohort 6 Cohort 3 Cohort 7 Cohort 4 Cohort 8 6 mg/kg 12 mg/kg 6 mg/kg 12 mg/kg 6 mg/kg 12 mg/kg 6 mg/kg 12 mg/kg ganitumab þ ganitumab þ ganitumab þ ganitumab þ ganitumab þ ganitumab þ ganitumab þ ganitumab þ 400 mg b.i.d 400 mg b.i.d 6 mg/kg Q2W 6 mg/kg Q2W 150 mg qd 150 mg qd 1,000 mg/m2 1,000 mg/m2 Parameter, sorafenib sorafenib panitumumab panitumumab erlotinib erlotinib gemcitabine gemcitabine mean (SD) (n ¼ 2) (n ¼ 9) (n ¼ 5) (n ¼ 3) (n ¼ 3) (n ¼ 4) (n ¼ 8) (n ¼ 3)

Cmax, mg/mL 106 (0) 231 (54.1) 129 (42.5) 359 (84.6) 133 (32.0) 251 (64.1) 114 (23.6) 264 (28.0) a b Cmin, mg/mL 5.28 (NA) 17.7 (13.5) 18.0 (6.46) 34.6 (15.4) 13.6 (3.29) 33.9 (6.94) 17.6 (9.80) 31.7 (4.64) a b AUCT,h mg/mL 388 (NA) 879 (337) 643 (205) 1,430 (234) 529 (102) 1,250 (186) 592 (168) 1,170 (266) CL, mL/d/kg 17.0 (NA)a 16.6 (7.49)b 10.7 (5.02) 8.94 (1.51) 12.1 (1.85) 10.1 (1.24) 11.2 (3.46) 10.8 (2.30)

Abbreviations: AUCt, area under the concentration versus time curve for a dosing interval; b.i.d, twice daily; CL, systemic clearance;

Cmax, maximum observed serum concentration after dosing; Cmin, minimum observed serum concentration after dosing; NA, not assessable; Q2W, every 2 weeks; qd, once daily. aData were available from only 1 patient. bData available from only 8 patients.

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Table 4. Pharmacokinetic parameter estimates of sorafenib, panitumumab, erlotinib, and gemcitabine after coadministration with ganitumab

Agent Week Dose Regimen n Mean (SD) Cmax, mg/mL Mean (SD) AUCT,h mg/mL Sorafenib 5 400 mg b.i.d 2–4 5.36 (4.03) 37.0 (14.0) Panitumumab 5 6 mg/kg Q2W 8 197 (52.3) 35,280 (8,952) Erlotinib 5 150 mg qd 6–9 1.59 (1.21) 33.5 (24.3) Gemcitabine 1 1,000 mg/m2 QW 11 11.5 (3.51) 6.53 (0.967) dFdUa 11 36.6 (5.66) 210 (29.1) Gemcitabine 5 1,000 mg/m2 QW 11 11.0 (12.5) 6.38 (5.69) dFdUa 11 31.3 (7.58) 220 (48.1)

NOTE: Week 1 without ganitumab or week 5 with ganitumab.

Abbreviations: AUCT, area under the concentration versus time curve for a dosing interval; b.i.d, twice daily; Cmax, maximum observed serum concentration after dosing; Q2W, every 2 weeks; qd, once daily; QW, once weekly. adFdU is a metabolite of gemcitabine.

Tumor response SPD of index lesions of 35 patients are shown in Fig. 1. Four Overall, 39 of 46 patients had evaluations of tumor re- patients (9%) had partial responses as a best result. For these sponse per WHO criteria (34) per investigator assessment. Of 4 patients, the duration of objective response was: 24 weeks these, 35 had both baseline and posttreatment imaging; for a patient with endometrial cancer in cohort 1 (sorafenib), 4 had assessments based on new lesions or nonindex lesions 25.4 weeks for a patient with breast cancer in cohort 3 (described in Fig. 1). The best result changes from baseline in (erlotinib; censored at last assessment), 24.1 weeks for a

Ganitumab + Sorafenib Ganitumab + Panitumumab Ganitumab + Erlotinib Ganitumab + Gemcitabine (n = 10) (n = 8) (n = 7) (n = 10) 70

60 Partial response Stable disease 50 Progressive disease 40

0 SCL SCL HC –10 CUO Colon Colon Colon Colon SCCA SCHN Breast Thyroid NSCLC Ovarian Ovarian Ovarian HGSL Colon

–20 Pancreatic Colon Colon GE junction –30 Rectal –40 Carcinoid NSCLC Thyroid SC Maximum change from baseline in SLD, % –50 Endometrial –60 NSCLC Ovarian Breast –70 Neuroendocrine Colon Prostate Endometrial

Figure 1. The best result changes from baseline in sum of the cross-products of the longest diameters of index lesions among evaluable patients with measurable disease (n ¼ 35) per World Health Organization criteria and independent central review for patients who received ganitumab combined with sorafenib, panitumumab, erlotinib, or gemcitabine. Four patients are not included: 1 colon cancer patient (ganitumab 6 mg/kg þ panitumumab) had progressive disease due to new lesions; 1 esophageal cancer patient (ganitumab 6 mg/kg þ erlotinib) had progressive disease due to new lesions; 1 breast cancer patient (ganitumab 6 mg/kg þ gemcitabine) with only nonindex lesions had stable disease; and 1 ovarian cancer patient (ganitumab 12 mg/kg þ sorafenib) had progressive disease due to new lesions. CUO, carcinoma of unknown origin; GE, gastroesophageal; HC, hepatocellular carcinoma; HGSL, high-grade sarcoma, leiomyosarcoma; NSCLC, non–small cell lung cancer; SC, sacrum chordoma; SCCA, squamous cell carcinoma of the anus; SCHN, squamous cell head/neck; SCLC, small cell lung cancer.

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A 2.0 Ganitumab 6 mg/kg Ganitumab 12 mg/kg

1.5

1.0 Serum IGF1 level relative to baseline 0.5 0 1020304050607080 Figure 2. Time, d Mean (SD) change from baseline in serum total IGF1 (A) and B IGFBP-3 (B). 2.0 Ganitumab 6 mg/kg Ganitumab 12 mg/kg

1.5

1.0 Serum IGFBP-3 level relative to baseline 0.5 0 1020304050607080 Time, d

patient with colon cancer in cohort 6 (panitumumab), and remained relatively constant through week 11 or the end of 16.9 weeks for a patient with prostate cancer in cohort 8 study (Fig. 2A). At day 15 (collected at trough levels before (gemcitabine). These 4 patients were heavily pretreated, the second dose), the IGF1 ratio to baseline was 1.31 at the having previously received multiple cytotoxic and targeted 12 mg/kg dose of ganitumab and 1.20 at the 6 mg/kg dose, therapies. Twenty-three patients had best result of stable indicating the presence of a dose-dependent pharmacody- disease [sorafenib cohorts: cohorts 1 (n ¼ 2), cohort 5 namic effect at both ganitumab dose levels. Mean total (n ¼ 5); panitumumab cohorts: cohort 2 (n ¼ 5), cohort serum levels of IGFBP-3 increased from baseline to the end 6(n ¼ 1); erlotinib cohorts: cohort 3 (n ¼ 1), cohort 7 (n ¼ 1); of study at both dose levels of ganitumab (Fig. 2B). No dose- gemcitabine cohorts: cohort 4 (n ¼ 7), cohort 8 (n ¼ 1)]. dependent differences were observed. No associations were Among these, 6 received treatment of 24 or more weeks, and observed between the pharmacodynamic markers and the most frequent primary tumor types were colon (n ¼ 5), change from baseline in SPD of target lesions. thyroid, non–small cell lung, squamous cell, and ovarian (all We assessed potential associations between PTEN expres- n ¼ 2). The remaining 12 evaluable patients had progressive sion and response to treatment with ganitumab combined disease as a best result [sorafenib cohorts: cohort 1 (n ¼ 0), with sorafenib, panitumumab, erlotinib, and gemcitabine. cohort 5 (n ¼ 3); panitumumab cohorts: cohort 2 (n ¼ 1), Although immunohistochemical analysis of archival tumor cohort 6 (n ¼ 1); erlotinib cohorts: cohort 3 (n ¼ 1), cohort samples conﬁrmed cytoplasmic and nuclear expression of 7(n ¼ 4); gemcitabine cohorts: cohort 4 (n ¼ 1), cohort 8 PTEN in the majority of available specimens, there was no (n ¼ 1)]. There were no signiﬁcant discordances in tumor observed association between the proportion of PTEN- response between the investigator and central assessments. positive cells and percentage change in SPD of target lesions (Supplementary Table S2). Assessment of potential biomarkers An exploratory analysis of somatic mutations in genes At the 6 and 12 mg/kg doses of ganitumab, mean total with potential involvement in the IGF1R and EGFR signal- serum levels of IGF1 increased from baseline to day 8 and ing pathways (KRAS, BRAF, HRAS, NRAS, PIK3CA, PTEN,

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AKT, and TP53) did not show an association between tions with cytotoxic and targeted therapies. Although anti- mutation status and change from baseline in SPD of tumor activity was not a primary objective of this phase 1b target lesions. However, it is important to note that this study of heavily pretreated patients, 4 of 46 patients (9%) analysis, and the analysis of tumor PTEN expression, was with the following tumor types had partial responses: limited by the small number of samples and mixed patient endometrial (cohort 1), breast (cohort 3), colon (cohort population. 6), and prostate cancer (cohort 8). Twenty-three patients (59%) had stable disease, including 1 patient with neuroendocrine cancer and 1 patient with pancreatic cancer. One Discussion partial response occurred in each of the sorafenib, erlotinib, In this study, ganitumab was well tolerated up to the panitumumab, and gemcitabine cohorts with ganitumab at maximum tested dose of 12 mg/kg when combined with either dose level. Although these results suggest that there sorafenib, panitumumab, erlotinib, or gemcitabine in was some evidence of antitumor activity for each of the patients with advanced solid tumors. Three patients had combinations, larger studies will be required to assess DLTs (cohorts 2, 4, and 7), but when cohorts were expand- whether there were improvements in outcomes with these ed, there were no further DLTs. AEs related to treatment with combinations versus single-agent treatment. agents other than ganitumab were consistent with those In the pharmacodynamic biomarker analysis, serum total expected for each agent. IGF1 and IGFBP-3 increased from baseline following treat- Grade 3 hyperglycemia was observed in a patient in ment with ganitumab at both dose levels. Similar increases cohort 2 (ganitumab 6 mg/kg combined with panitumu- in circulating IGF1 were observed following treatment with mab) who had a history of controlled diabetes. Among ganitumab 20 mg/kg in the first-in-human study (25). patients in the first-in-human study who did not have In an exploratory analysis, we investigated whether there diabetes (n ¼ 50), hyperglycemia occurred in 3 patients was an association between tumor expression of PTEN and who received ganitumab 12 mg/kg every 2 weeks and 2 tumor response. Preclinical evidence has suggested that the patients who received ganitumab 20 mg/kg every 2 weeks; IGF1 signaling pathway promotes tumor cell proliferation an additional 2 of 3 patients with diabetes had decreased and invasiveness through dephosphorylation of the tumor glucose control (25). In a randomized phase 2 study, grade suppressor PTEN and activation of the PI3K/PTEN/Akt/NF- 3 or 4 hyperglycemia was observed in 18% of patients with kB signaling pathway (44). Furthermore, loss of PTEN metastatic pancreatic cancer who received ganitumab plus expression has been associated with poor outcomes among gemcitabine (26). In addition, grades 1 to 4 hyperglycemia cancer patients (45, 46) and with lack of response to anti- have been reported in phase 1 studies of the IGF1R inhibitor EGFR therapy for metastatic colorectal cancer (47). Although figitumumab (38–40). Thrombocytopenia has been previ- the majority of tumor samples in this study was assessed as ously reported among patients receiving ganitumab treat- PTEN positive, there was no association between PTEN ment (25, 26). In this study, thrombocytopenia events and expression and change in tumor dimensions in the limited severe neutropenia occurred predominantly among number of samples from a mixed patient population. patients who also received erlotinib or gemcitabine, which In conclusion, ganitumab at the target dose of 12 mg/kg is consistent with studies assessing these agents in metastatic combined with the approved doses of sorafenib, panitu- cancer of the pancreas (41, 42). Thus, although this study mumab, erlotinib, or gemcitabine had acceptable toxicity was small, there was no evidence of interactions that and showed evidence of antitumor activity, suggesting that resulted in toxicity greater than expected with any of the further studies of ganitumab combinations for the treat- combinations assessed. ment of solid tumors may be warranted at the doses estab- The ganitumab pharmacokinetic parameters estimated in lished in this trial. Ganitumab combined with gemcitabine this study were generally consistent with those in the in metastatic pancreatic cancer is currently being investi- monotherapy first-in-human study (25), suggesting that gated in a randomized phase 3 study (Gemcitabine and the pharmacokinetics of ganitumab was not affected in AMG 479 in Metastatic Adenocarcinoma of the Pancreas combination with sorafenib, panitumumab, erlotinib, or [GAMMA]; Clinicaltrials.gov, NCT01231347). gemcitabine. There is no mechanism-based pharmacokinetic interaction expected when ganitumab is administered Disclosure of Potential Conflicts of Interest with small-molecule drugs, owing to different elimination G. Friberg, Y.C. Hwang, H. Deng, I. McCaffery, and M. Zhu are employees pathways, or with monoclonal antibodies, owing to the of and shareholders in Amgen Inc. L.S. Rosen has received research funding from Amgen Inc. E. Chan has served as a consultant/advisor for Amgen Inc., large capacity in elimination of immunoglobulin G anti- Genentech, ImClone, Celgene, Bristol-Myers Squibb, and Sanofi-Aventis. bodies. It has been reported that baseline serum albumin No potential conflicts of interest were disclosed by the other authors. and creatinine levels could affect ganitumab exposure levels (43), which underscores the potential influence of baseline Authors' Contributions Conception and design: L.S. Rosen, I. Puzanov, G. Friberg, I. McCaffery, disease status and characteristics. P. Shubhakar, M. Zhu We hypothesized that combination therapy might Development of methodology: L.S. Rosen, I. Puzanov, G. Friberg, improve patient outcomes versus single-agent inhibition I. McCaffery, M. Zhu Acquisition of data: L.S. Rosen, I. Puzanov, E. Chan, J. Gilbert, D. Maha- of the IGF1R pathway, and therefore chose to explore the lingam, I. McCaffery, A.C. Mita, M.M. Mita, M. Mulay, P. Shubhakar, antitumor activity of ganitumab in a variety of combina- J. Sarantopoulos

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Analysis and interpretation of data: L.S. Rosen, I. Puzanov, G. Friberg, E. Benjamin Scott, PhD, whose work was funded by Amgen Inc., for assistance Chan, Y. Hwang, H. Deng, D. Mahalingam, I. McCaffery, A.C. Mita, M.M. in writing this manuscript. Mita, M. Zhu, J. Sarantopoulos Writing, review, and/or revision of the manuscript: L.S. Rosen, I. Puzanov,G.Friberg,E.Chan,Y.Hwang,H.Deng,J.Gilbert,D.Maha- Grant Support lingam,I.McCaffery,A.C.Mita,M.M.Mita,P.Shubhakar,M.Zhu,J. This work was supported by Amgen Inc. Additional investigator support Sarantopoulos for this study was provided by a Cancer Center Support grant Administrative, technical, or material support: L.S. Rosen, I. Puzanov, G. (P30CA054174) from The University of Texas Health Science Center at San Friberg, D. Mahalingam, M. Mulay, P. Shubhakar, M. Zhu Antonio, San Antonio, TX. Study supervision: L.S. Rosen, I. Puzanov, G. Friberg, D. Mahalingam, S. The costs of publication of this article were defrayed in part by the Michael, P. Shubhakar, J. Sarantopoulos payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate Acknowledgments this fact. The authors thank Li Chen (Amgen Inc.), PhD, ScD, for biostatistical analysis; Jessica Johnson (Amgen Inc.), BS, for pharmacokinetic data anal- Received December 29, 2011; revised March 28, 2012; accepted March 31, ysis; Jennifer L. Gansert (Amgen Inc.), MD, PhD, for helpful comments; and 2012; published OnlineFirst April 17, 2012.

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www.aacrjournals.org Clin Cancer Res; 18(12) June 15, 2012 3427

Safety and Pharmacokinetics of Ganitumab (AMG 479) Combined with Sorafenib, Panitumumab, Erlotinib, or Gemcitabine in Patients with Advanced Solid Tumors

Lee S. Rosen, Igor Puzanov, Gregory Friberg, et al.

Clin Cancer Res 2012;18:3414-3427. Published OnlineFirst April 17, 2012.

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