First-In-Human Phase I Study of the Selective MET Inhibitor, Savolitinib, in Patients with Advanced

Author Manuscript Published OnlineFirst on April 5, 2019; DOI: 10.1158/1078-0432.CCR-18-1189 Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited.

1 First-in-Human Phase I Study of the Selective MET Inhibitor, Savolitinib, in Patients with Advanced

2 Solid Tumors: Safety, Pharmacokinetics and Anti-Tumor Activity

3 Running title: Phase I Study of Savolitinib, a Selective MET Inhibitor

4 Hui Gan1–3, Michael Millward4, Ye Hua5, Chuan Qi5, Yang Sai5, Weiguo Su5, Jian Wang5, Lilin Zhang5,

5 Melanie M. Frigault6, Shethah Morgan7, Liu Yang8, Jason D. Lickliter9,10

6 1Department of Medical Oncology, Austin Health and Olivia Newton-John Cancer Research Institute,

7 Melbourne, Victoria, Australia. 2School of Cancer Medicine, La Trobe University School of Cancer

8 Medicine, Melbourne, Australia. 3Department of Medicine, University of Melbourne, Melbourne,

9 Victoria, Australia. 4University of Western Australia, Perth, Australia and Linear Clinical Research,

10 Perth, Australia. 5Hutchison MediPharma Ltd, Shanghai, P.R. China. 6Oncology Translational Science,

11 IMED Biotech Unit, AstraZeneca, Boston, MA, USA. 7AstraZeneca, Cambridge, UK. 8AstraZeneca,

12 Shanghai, P.R. China. 9Monash Medical Center, Bentleigh East, Victoria, Australia. 10Nucleus

13 Network, Melbourne, Victoria, Australia.

14 Financial support

15 The research presented in this manuscript was funded by Hutchison MediPharma Ltd and

16 AstraZeneca.

17 Corresponding author: Dr Hui Gan, Austin Health and Olivia Newton-John Cancer Research Institute,

18 Melbourne, Victoria, Australia. Tel: + 61 3 9496 9925; Email: [email protected]

19 Disclosures

20 Hui Gan, Michael Millward and Jason Lickliter declare no potential conflicts of interest. At the time of

21 the study, Ye Hua, Chuan Qi, Yang Sai, Weiguo Su, Jian Wang and Lilin Zhang were employees of

22 Hutchison MediPharma Ltd. At the time of the study, Melanie M. Frigault, Shethah Morgan and Liu

23 Yang were employees of AstraZeneca.

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Downloaded from clincancerres.aacrjournals.org on September 30, 2021. © 2019 American Association for Cancer Research. Author Manuscript Published OnlineFirst on April 5, 2019; DOI: 10.1158/1078-0432.CCR-18-1189 Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited.

25 Word count: 3545 (limit 5000 words)

26 Number of tables: 3

27 Number of figures: 3

28 Suggested Journal keyword options: clinical trials, small molecule agents (kinase and phosphatase

29 inhibitors)

30 Suggested author-defined keywords: savolitinib, volitinib, MET inhibitor

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32 Abstract

33 Purpose: Aberrant activation of MET (hepatocyte growth factor receptor) signaling is

34 implicated in the tumorigenesis of human cancers. This phase I study assessed the safety, tolerability

35 and maximum tolerated dose (MTD) of the potent and selective MET inhibitor, savolitinib (AZD6094,

36 HMPL-504, volitinib).

37 Experimental design: This open-label, multi-center dose-escalation and -expansion study

38 evaluated oral savolitinib for patients with locally advanced or metastatic solid tumors. A 3+3 design

39 assessed repeated daily (QD) and twice daily (BID) dosing schedules. The dose expansion phase

40 included 12 patients. Primary objectives were to evaluate the safety, tolerability, MTD and dose-

41 limiting toxicities (DLT) of savolitinib. Secondary and exploratory objectives included

42 pharmacokinetics, biomarker research and anti-tumor activity.

43 Results: Overall, 48 patients were enrolled. Four patients had DLTs following QD savolitinib

44 (600 mg N=1, 800 mg N=1 and 1000 mg N=2); the MTD was 800 mg QD and not reached for BID

45 dosing. The recommended phase II dose (RP2D) was 600 mg QD. The most frequent adverse events

46 were nausea (30 patients, 63%), vomiting (20 patients, 42%), fatigue (20 patients, 42%), and

47 peripheral edema (15 patients, 31%). At 600 mg QD, Cmax was 2414.8 ng/mL, AUC was

48 17053.9 h·ng/mL and there was no apparent drug accumulation. Three patients with papillary renal

49 cell carcinoma (PRCC) and MET aberrations had partial responses with durations from 39 to 147

50 weeks.

51 Conclusion: The tolerability profile of savolitinib was acceptable and the RP2D was

52 established as 600 mg QD. Preliminary anti-tumor activity was demonstrated supporting further

53 study in patients with PRCC.

54 Word count: 250 (limit 250 words)

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56 Statement of Significance

57 This first-in-human study of savolitinib, a potent and highly selective inhibitor of MET

58 tyrosine kinase, established the recommended dose and confirmed the observed safety profile was

59 as expected for the drug based on its pharmacology. Early evidence of antitumor activity was

60 demonstrated; three partial responses were observed amongst patients with PRCC which tested

61 positive for MET gene copy number gain.

63 Translational Relevance

64 This first-in-human study of savolitinib (previously referred to as AZD6094, HMPL-504 and

65 volitinib) in patients with advanced solid malignancies established the recommended dose as

66 600 mg QD and confirmed the observed safety profile was as expected for the drug based on its

67 pharmacology. Evidence of antitumor activity with savolitinib was seen in some patients, in

68 particular, three partial responses were observed amongst patients with PRCC which tested positive

69 for MET gene copy number gain. A phase II trial of savolitinib in patients with advanced or metastatic

70 PRCC including analysis of treatment response by MET status biomarker was conducted based on

71 the data presented here (Clinicaltrials.gov identifier: NCT02127710) and has been published

72 (Choueiri TK, et al. J Clin Oncol 2017;35(26):2993-3001) and a phase III trial to assess the efficacy and

73 safety of savolitinib versus sunitinib in patients with MET-driven, unresectable and locally advanced,

74 or metastatic PRCC is underway (Clinicaltrials.gov identifier: NCT03091192).

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76 Introduction

77 MET (hepatocyte growth factor [HGF] receptor) is a key regulator of angiogenesis, cell

78 survival, invasion and proliferation and is expressed on the epithelial cells in numerous organs

79 including the kidney, bone marrow and liver (1). Dysregulation of the HGF/MET signaling pathway

80 has been implicated in the tumorigenesis of a variety of human cancers (2). Binding of the ligand

81 HGF to its receptor activates the MET tyrosine kinase, leading to the initiation of a cascade of

82 downstream signals including activation of the Ras/Raf/MEK/ERK and phosphatidylinositol-3-

83 kinase/Akt pathways (1). Activating MET mutations and MET gene amplification have been reported

84 in various malignancies including gastric carcinomas, gliomas, and prostate cancer (3-5). MET

85 amplification is also a potential mechanism for the development of treatment resistance of

86 epidermal growth factor receptor (EGFR) mutant non-small cell lung cancer (NSCLC) with the EGFR

87 inhibitors, erlotinib, gefitinib and osimertinib (3,6,7). Recent studies have also linked MET

88 dysregulation with papillary renal cell carcinoma (PRCC) (8-10).

89 Various strategies to inhibit the HGF/MET signaling pathway have been explored.

90 Monoclonal antibodies directed against HGF and MET, such as rilotumumab, onartuzumab and

91 emibetuzumab, have demonstrated anti-tumor activity in early phase clinical trials (11,12). Further

92 developments include the small-molecule tyrosine kinase inhibitors crizotinib, cabozantinib and

93 foretinib, multi-kinase inhibitors that inhibit a number of intracellular pathways, including MET (13-

94 15).

95 Savolitinib (previously referred to as AZD6094, HMPL-504 and volitinib) is a potent and

96 highly selective small-molecule inhibitor of MET tyrosine kinase (16). Savolitinib effectively inhibited

97 the in vitro activity of recombinant MET (half maximal inhibitory concentration value of 4 nmol/L)

98 and the in vitro growth of gastric cell lines with dysregulated MET signaling (17). Also, MET signaling

99 was reduced and tumor regression observed following savolitinib treatment of in vivo human

100 xenograft tumor models of MET-amplified gastric cancer and PRCC (17,18).

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101 We present the results of the first-in-human phase I trial of savolitinib in patients with

102 advanced solid tumors. The study was designed to evaluate the safety, tolerability and maximum

103 tolerated dose (MTD) of savolitinib, with the additional exploratory objectives of evaluating

104 pharmacokinetics, biomarker research and anti-tumor activity.

105

106 Patients and Methods

107 Study design and objectives

108 This was a phase I, open-label, multi-center dose-escalation and -expansion study of oral

109 savolitinib in patients with locally advanced or metastatic solid tumors (Clinicaltrials.gov identifier:

110 NCT01773018). The dose escalation phase (Figure 1) determined the MTD. The starting dose of

111 100 mg was chosen based on pre-clinical studies of savolitinib. The study utilized a 3+3 design with a

112 total of nine cohorts. The initial cohorts received a single dose of savolitinib (100, 200, 400, 600, 800

113 or 1000 mg) followed by a 7-day wash-out period, prior to starting repeated once daily (QD) dosing.

114 Twice daily (BID) dosing of savolitinib was also assessed (300, 400 and 500 mg), exploring total daily

115 doses between 600–1000 mg. The duration of each continuous treatment cycle was 21 days.

116 Following determination of the MTD, the dose expansion phase commenced with the enrollment of

117 12 additional patients (Figure 1).

118 Patients who completed the first treatment cycle and dose-limiting toxicity (DLT)

119 observation period were considered to have completed the trial. After completion of the first cycle,

120 patients with acceptable toxicity and ongoing clinical benefit could continue to receive savolitinib for

121 up to 1 year or longer, at the discretion of the investigator and with the sponsor’s agreement.

122 The primary objectives were to evaluate the safety, tolerability, MTD and DLTs of savolitinib.

123 The secondary objective was to describe the pharmacokinetics of savolitinib. Exploratory objectives

124 included assessment of anti-tumor activity and collection of tumor biopsies and blood samples for

125 biomarker and mutation analysis.

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126 Patients

127 Eligible patients had a histologically or cytologically documented, incurable, locally advanced

128 or metastatic solid tumor that had either progressed, failed to respond to standard systemic

129 therapy, or had no standard or effective existing therapy. Other important eligibility criteria

130 included: adults ≥18 years of age and an Eastern Cooperative Oncology Group (ECOG) performance

131 status of 0 or 1. Patients with poor hematologic status, who were pregnant, had received cancer

132 treatment within 4 weeks of the first dose of savolitinib, had a history of significant liver disease, had

133 previous or current exposure to a MET inhibitor, were excluded. Patients with poor liver or renal

134 function were also excluded. Poor liver function was defined as total bilirubin >1.5 x the upper limit

135 of normal (ULN) and AST and ALT >2.5 X ULN (patients with Gilbert disease and serum bilirubin levels

136 ≤3 x ULN and normal aspartate and alanine aminotransferase [AST, ALT] could be enrolled and

137 patients with documented liver metastases could have AST and/or ALT levels ≤5 x ULN at screening).

138 Poor renal function was defined as serum creatinine >1.5 x ULN (patients with a creatinine clearance

139 of ≥50 mL/min based on a documented 24-hour urine collection were eligible). The protocol did not

140 mandate specific tumor types or evidence of MET dysregulation at baseline. However, patients with

141 PRCC, NSCLC, colorectal cancer (for whom EGFR inhibitors had failed), breast cancer, and

142 hepatocellular carcinoma were preferred for enrollment during the dose expansion phase. A later

143 protocol amendment (14 August 2014) restricted the patient population of this phase to patients

144 with cancers associated with MET dysregulation using local MET FISH testing for MET gene copy

145 number gains.

146 All patients provided written, informed consent prior to participating in the study. The study

147 was performed in accordance with ethical principles that originate from the Declaration of Helsinki

148 and were consistent with International Committee on Harmonisation Good Clinical Practice

149 guidelines, applicable regulatory requirements and the AstraZeneca policy on Bioethics and Human

150 Biological Samples. The protocol was reviewed and approved by the Human Research Ethics

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151 Committee at each study site. The first patient was enrolled on 15th February 2012 and the last

152 patient completed the study on 23rd December 2015.

153 Safety assessments

154 All adverse events (AEs) during this study, including those leading to determination of DLTs,

155 were graded according to the National Cancer Institute Common Terminology Criteria for Adverse

156 Events (Version 3.0). All AEs and serious AEs (SAEs) were collected from the first study dose of

157 savolitinib until 30 days after the last dose of savolitinib or study discontinuation/termination,

158 whichever was later. A DLT was defined as one of the following toxicities: any non-hematological

159 toxicity ≥Grade 3, Grade 4 neutropenia lasting >7 days, febrile neutropenia (defined as absolute

160 neutrophil count [ANC] <1000 cells/mm3 and fever ≥38.5°C or documented infection ≥Grade 3 with

161 ANC ≤1000 cells/mm3), Grade 4 thrombocytopenia (lasting >48 hours or requiring intervention or

162 associated with increased bleeding) and dose interruption for >14 days due to toxicity. The MTD was

163 defined as the maximum dose at which no more than one of six patients in a single cohort

164 experienced a DLT in the first cycle.

165 Medical, surgical and demographic history were collected at screening. Vital signs, physical

166 examinations, 12-lead electrocardiogram and all clinical laboratory tests were recorded at screening

167 and various time points throughout cycles 1–3 and every second cycle thereafter until study

168 completion or early termination.

169 Pharmacokinetic assessments

170 Blood samples were taken to determine the plasma concentrations of savolitinib and its

171 metabolites analyzed using a pre-validated liquid chromatography with tandem mass spectrometry

172 assay. Samples were collected pre-dose and at 0.25, 0.5, 1, 2, 4, 6, 8, 12, 24, 30 and 48 hours post-

173 dose following single doses. For multiple doses, samples were collected on Days 1, 8, 15 and 21 (pre-

174 dose and at 0.5, 2, 4, 6, 8 and 12 (BID) or 24 (QD) hours post-dose, with the 12 (BID) or 24 (QD) hour

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175 sample being taken prior to the next dose). Pharmacokinetic values were processed according to

176 standard non-compartmental analytical procedures, using Phoenix™ WinNonlin® v6.4 (Pharsight

177 Corporation, USA) and Microsoft® Excel® 2010 (Microsoft Corporation) software. The plasma

178 concentration–time profile was used to determine pharmacokinetic parameters for savolitinib and

179 the two major metabolites, M2 (active, with a potency 3–6-fold less than savolitinib for p-MET

180 inhibition and tumor cell growth inhibition in a variety of tumor cells with MET amplification) and

181 M3 (inactive), including area under the plasma concentration-time curve (AUC), maximum plasma

182 concentration (Cmax), oral clearance (CL/F), apparent volume of distribution (Vd/F), time to reach

183 Cmax, accumulation ratio and elimination half-life (t1/2).

184 Anti-tumor activity

185 Tumor assessments were performed according to Response Evaluation Criteria in Solid

186 Tumors (RECIST) (Version 1.0) at screening, the start of cycle 3 and every second cycle thereafter

187 until savolitinib discontinuation. The objective tumor response for target and non-target lesions was

188 assessed using the RECIST criteria of complete response (CR), partial response (PR), incomplete

189 response/stable disease (SD) and progressive disease (PD). Progression-free survival (PFS) was

190 defined as the length of time from the date of the first dose of savolitinib until the earliest date of

191 disease progression or death (from any cause). Anti-tumor activity was assessed in all patients with

192 at least one post-baseline tumor assessment (tumor evaluable population).

193 Biomarker analyses

194 MET status was assessed as a retrospective exploratory analysis using formalin-fixed

195 paraffin-embedded (FFPE) archival tissue. MET gene copy number and MET mutations were

196 determined by using DNA next generation sequencing (NGS) (Foundation Medicine Inc, Cambridge

197 MA, USA) and amplifications were confirmed with MET fluorescent in situ hybridization (FISH;

198 Abbott Probe, AstraZeneca Laboratory, UK). Archival tumor FFPE sections were also analyzed by

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199 immunohistochemistry (IHC) for total MET protein expression (Ventana SP144 Ab, AstraZeneca

200 Laboratory, UK).

201 Statistical considerations

202 The study had a planned enrollment of approximately 44–56 patients, with 34–46 patients in

203 the dose-escalation stage and approximately 10 patients in the dose-expansion stage. Descriptive

204 statistics were used to measure the safety, pharmacokinetics and preliminary signs of activity of

205 savolitinib. The safety population consisted of all the enrolled patients who received at least one

206 dose of savolitinib. All patients had samples taken and measured for pharmacokinetics. Analysis of

207 anti-tumor response was performed on the tumor evaluable population (all patients with at least

208 one post-baseline tumor assessment). PFS was analyzed using the Kaplan-Meier method.

209

210 Results

211 Patient population and drug exposure

212 A total of 48 patients were enrolled and 45 patients (94%) completed the study (first

213 treatment cycle; 21 days). Three patients (6%) did not complete the study due to withdrawal of

214 consent (N = 1), grade two fatigue (N = 1), and lost to follow-up (N = 1; Figure 1). The majority of

215 patients (85%) had metastatic disease and the most common primary tumor locations were the

216 kidney (N = 18; 38%) and large bowel (N = 9; 19%) (Table 1).

217 After study completion, the primary subsequent reason for savolitinib discontinuation was

218 radiologically-confirmed disease progression (27 patients, 56%). Other reasons were withdrawal of

219 consent (six patients, 12.5%), investigator decision (five patients, 10.4%: three patients with

220 suspected disease progression, one patient with worsening liver function tests due to biliary

221 obstruction by the tumor, and one patient with a growing tumor and problematic nausea), AEs (four

222 patients, 8.3%), DLT (two patients 4.2%), lost to follow-up (one patient, 2.1%) and other (three

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223 patients, 6.3%: two patients with suspected disease progression and one patient due to sponsor

224 ending study). Patients with suspected disease progression were withdrawn on clinical grounds

225 before radiological progression. There appeared to be no relationship between the savolitinib dose

226 and frequency of study withdrawal or treatment discontinuation following study completion (Figure

227 1).

228 Safety

229 No immediate DLTs were observed following a single dose of savolitinib of between 100 and

230 1000 mg (followed by a 7-day wash-out period). In the subsequent QD dosing cohorts that began

231 treatment 1 week after the single dose of savolitinib, five Grade 3 DLTs, all considered related to

232 treatment, were experienced by four patients (8%); fatigue (N = 1 at 800 mg QD, N = 2 at 1000 mg

233 QD), headache (N = 1 at 1000 mg QD), and abnormal liver function test (increased AST and ALT;

234 N = 1 at 600 mg QD) (Figure 1). When considering any treatment-emergent AE (TEAE), whether or

235 not related to study treatment, QD dosing resulted in withdrawal of savolitinib in 10 patients (21%)

236 and dose interruption or reduction in 17 patients (35%). Treatment modification due to a Grade 3

237 TEAE occurred in nine patients who experienced 14 events, of which eight were considered possibly

238 or probably related to savolitinib. The MTD of savolitinib was determined to be 800 mg QD. For BID

239 dosing, there were no DLTs observed up to 500 mg BID (total daily dose 1000 mg), and it was

240 considered therapeutically unnecessary to proceed with further dose escalation. Therefore, the MTD

241 for BID dosing was not reached.

242 TEAEs occurring in ≥5% of patients, whether or not considered related to savolitinib

243 treatment, are shown in Table 2. Of those AEs considered related to savolitinib, the most common

244 were nausea (28 patients, 58%), fatigue (18 patients, 38%), vomiting (16 patients, 33%), peripheral

245 edema (11 patients, 23%), and diarrhea (six patients, 13%). Overall, 29 patients (60%) experienced

246 an AE ≥Grade 3, including increased ALT (N = 4), increased AST (N = 3) and fatigue (N = 3) (Table 2).

247 In determining the RP2D, the incidence of TEAEs ≥Grade 3 was considered. These were 7 events in

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248 four patients (57%) at 600 mg QD, 7 events in five patients (71%) at 800 mg QD and 18 events in 11

249 patients (92%) at 500 mg BID. In addition, there were 5 events of abnormal liver function test that

250 occurred in the 500 mg BID cohort outside of the DLT period. Consequently, the RP2D was

251 determined to be 600 mg QD.

252 AEs ≥Grade 3 considered related to savolitinib are shown by dose in Table 3 and SAEs are

253 shown in Supplementary Table 1. A total of 19 patients (40%) reported 29 SAEs. Five SAEs were

254 considered probably related to savolitinib: abnormal liver function test (two events) and individual

255 events of increased ALT, pyrexia and fatigue. Two further SAEs, small intestinal obstruction and

256 pyrexia, were considered possibly drug related. The frequency of SAEs did not appear to be clearly

257 related to the dose of study drug (Table 3). Seven patients each experienced one Grade 4 AE; five

258 events were considered probably not drug-related and two events, increased ALT and abnormal liver

259 function test, were considered probably drug-related. Three patients (6%) died during the study as a

260 result of disease progression.

261 Pharmacokinetics

262 Following a single oral dose of savolitinib, t1/2 (geometric mean) ranged from 3.77 hours

263 (200 mg, N = 3) to 6.80 hours (800 mg, N = 6; Figure 2a), the geometric mean CL/F ranged from

264 approximately 32.95 L/h to 48.33 L/h and the apparent Vd/F was approximately 227.64 to 325.41 L.

265 The geometric mean t1/2, Cmax and AUC to the last detectable concentration are shown for single

266 doses as well as repeated QD and BID dosing in Supplementary Table 2. QD dosing (100–1000 mg)

267 and BID dosing (300 mg and 400 mg) did not lead to accumulation of savolitinib. At 500 mg BID,

268 some accumulation of savolitinib was observed (accumulation ratios were 1.312 and 1.420 for days

269 15 and 21, respectively). Formation of the two major metabolites, M2 (active) and M3 (inactive),

270 occurred rapidly and the elimination half-lives of these two metabolites were similar to that of the

271 parent compound. Figure 2b shows the mean concentration of savolitinib over time following

272 repeated QD dosing.

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273 Anti-tumor activity

274 In the tumor evaluable population (N = 39), three patients achieved a PR (8%; Figure 3a).

275 Nineteen patients (49%) had a best response of SD. Fifteen patients (39%) had PD and two patients

276 (5%) had no evaluable lesions. The three patients who achieved a PR all had PRCC, with two patients

277 receiving 600 mg QD and one patient 1000 mg QD (Supplementary Figure 1 shows tumor response

278 in one patient treated with 600 mg QD). The PRs were durable with one patient (MET focal

279 amplification) remaining on study for 75 weeks and two patients (chromosome 7 gain) for 39 and

280 147 weeks. Overall, these patients achieved PFS of 17.1, 8.4, and ≥33.5 months, respectively.

281 Biomarkers

282 After finding that all responders to savolitinib (N = 3) had PRCC histology, retrospective

283 exploratory biomarker analysis was performed on available archival samples from 12 patients to

284 determine their tumor MET status (representative data are shown in Figure 3b-d). NGS analysis was

285 performed on tumor samples from patients with PRCC (N = 8), clear cell renal cell carcinoma (ccRCC)

286 (N = 2), colorectal cancer (N = 1) and thymoma (longest duration of SD; N = 1). Amongst these tumor

287 samples, no MET gene mutations were identified. Notably, only those patients with PRCC with MET

288 copy number changes (focal amplification or chromosome 7 gains) had a response to treatment with

289 savolitinib (Figure 3a). Samples from two patients with PRCC (one with no MET copy number change

290 and one with MET focal amplification) did not have any on-treatment tumor measurements

291 available for correlation to response. One patient with colorectal cancer had MET amplification and

292 achieved a best response of SD with a decrease in tumor measurement of 29.7% from baseline

293 (Figure 3a).

294 Discussion

295 This first-in-human phase I study demonstrated that the selective MET tyrosine kinase

296 inhibitor, savolitinib, was generally well tolerated in patients with locally advanced or metastatic

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297 solid tumors. The MTD of savolitinib was determined to be 800 mg for QD dosing and the MTD for

298 BID dosing was not reached (maximum dose investigated was 500 mg BID). The RP2D was

299 determined as 600 mg QD based on toxicity, incidence of TEAEs ≥Grade 3 in severity,

300 pharmacokinetic data, and the indication of anti-tumor activity at this dose. Preclinical modelling

301 demonstrated phosphorylated-MET (pMET) inhibition at an effective concentration (EC)50 of 0.35

302 ng/mL and EC90 of 3.2 ng/mL; this is equivalent to an EC90 of 6.5 ng/mL in humans (19). At 600 mg

303 QD in humans, the minimal plasma concentration at steady-state exceeded this value (following 21-

nd 304 day continuous dosing, the median Cmin [pre-dose on day 1 of the 2 treatment cycle] was 25.4

305 ng/mL; range 18.0–54.6), providing the extensive and durable inhibition of pMET required to achieve

306 optimal efficacy. In practice this is considered to provide >90% pMET inhibition throughout the

307 treatment cycle.

308 The most frequent drug-related AEs reported (nausea, vomiting, fatigue, peripheral edema,

309 constipation and diarrhea) were similar to those reported by other MET inhibitors (crizotinib,

310 foretinib, cabozantinib) (13-15). The majority of fatigue and headache AEs were Grade 1–2, and the

311 few Grade ≥3 events reported were limited to high doses of savolitinib (800 mg QD and 1000 mg

312 QD). Most events of fatigue were considered possibly or probably related to savolitinib, however,

313 only events of Grade 3 led to study withdrawal (three patients with DLTs). As with other tyrosine

314 kinase inhibitors, there is the potential for hepatotoxicity such as raised AST and/or ALT (13-15). This

315 was seen in some patients following treatment with savolitinib, although such events generally

316 resolved after stopping treatment with savolitinib. However, AEs frequently reported (≥20% in phase

317 I, II and III trials) with other less selective MET inhibitors (foretinib, cabozantinib), such as

318 hypertension, hypophosphatemia and proteinuria, were rarely reported (≤2%) with savolitinib. This

319 is possibly due to the multi-kinase activity (including, VEGF, AXL, TIE–2 receptors) of foretinib and

320 cabozantinib (14,15,20).

321 Interestingly, three patients with PRCC obtained a PR in this study (two in the 600 mg QD

322 cohort and one in the 1000 mg QD cohort), therefore supporting the selection of the monotherapy

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323 RP2D of 600 mg QD. During this trial, patients had not been selected based on MET status; a

324 subsequent analysis of MET status was undertaken, comparing responders to non-responders.

325 Interestingly, none of the responding patients had activating MET mutations, but they did have MET

326 gene copy number increases (chromosome 7 gains or MET focal gene amplification) and high MET

327 protein expression. Intriguingly, one colorectal cancer patient who had received four prior lines of

328 treatment, achieved a best response of SD, over 5.5 months of treatment, with a 29.7% decrease in

329 tumor size from baseline and had MET gene amplification and protein overexpression. Indeed, MET

330 is a promising biomarker for PRCC with the concept of targeting MET previously proposed in a phase

331 II trial with foretinib, and with recent research reporting MET abnormalities in Type II PRCC; a

332 subtype previously thought to be unrelated to MET (8,10). Interest in MET-inhibitors for the

333 treatment of PRCC is increasing, and an ongoing phase II randomized trial is comparing several MET

334 kinase inhibitors, including savolitinib, cabozantinib, and crizotinib, for the treatment of locally

335 advanced or metastatic kidney cancer (www.ClinicalTrials.gov; NCT02761057). Entry criteria do not

336 include MET amplification or mutation although tumor response by MET abnormality and expression

337 level is being assessed. Furthermore, recent studies have looked at identifying biomarkers associated

338 with the pathological stage of PRCC (21). This is important as it has been shown that outcomes for

339 PRCC, as well as being inferior to ccRCC, can be stratified into risk groups according to the

340 International Metastatic Renal Cell Carcinoma Database Consortium prognostic model; the definition

341 of additional biomarkers will only serve to strengthen such prognostic models (22).

342 Based on the results of this first-in-man study, a phase II single-arm trial of savolitinib in

343 patients with advanced or metastatic PRCC was conducted (Clinicaltrials.gov identifier:

344 NCT02127710). The study included analysis of treatment response by MET status biomarker, with

345 MET-driven status being defined as any of: MET copy number gain (either chromosome 7 gain or a

346 MET focal amplification of ≥6 copies), HGF gene amplification (≥6 copies), or MET kinase domain

347 mutations (allele frequency >5%) (23). The phase II study found savolitinib monotherapy at 600 mg

348 QD to have an acceptable safety and tolerability profile in patients with PRCC with the most

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349 commonly reported AEs (nausea, fatigue, vomiting, and peripheral edema) similar to those reported

350 in this present study. Increases in ALT and AST were similar between studies; 10–11% of patients in

351 the phase II study and 8% in the present study. Savolitinib demonstrated favorable anti-tumor

352 activity with 61% (N = 27) of patients with MET-driven PRCC reported to have experienced some

353 tumor shrinkage compared to 20% (N = 9) of patients with MET-independent PRCC. Moreover,

354 patients with MET-driven PRCC demonstrated a significantly higher objective response rate of 18%

355 (8 PRs) compared to MET-independent PRCC (0%; P = 0.002). Savolitinib treatment of patients with

356 MET-driven PRCC led to a longer median PFS compared with patients with MET-independent PRCC

357 (6.2 months, 95% confidence interval (CI) 4.1–7.0 months versus 1.4 months, 95% CI 1.4–2.7

358 months) (24). The safety of savolitinib has also been explored in other phase I studies in combination

359 with osimertinib and gefitinib. The monotherapy toxicity profile of savolitinib at active doses makes

360 combinations with other targeted therapies, such as osimertinib, feasible and such combination

361 regimens are currently being investigated with preliminary data demonstrating a potentially

362 acceptable tolerability profile (25,26).

363 Although the present study met its predetermined primary and secondary endpoints, it does

364 have some limitations. Firstly, as this study was primarily designed to evaluate the safety and

365 tolerability profile of savolitinib, care must be taken when interpreting initial anti-tumor results due

366 to the exploratory nature of these findings. Additionally, only a very small number of patients with

367 MET-driven PRCC were enrolled, so conclusions cannot be drawn in this study regarding the anti-

368 tumor characteristics of savolitinib in such a patient population, although the results of the phase II

369 trial described above were in line with these findings (22).

370 In summary, oral administration of savolitinib in patients with locally advanced or metastatic

371 solid tumors was generally well tolerated, and may have an advantageous toxicity profile compared

372 to less selective agents. Results from this study suggest that savolitinib exhibits anti-tumor activity in

373 patients with dysregulated MET signaling, particularly for PRCC. As survival for PRCC patients with

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374 monotherapy remains poor (23,27,28), the outcomes of a phase III study evaluating the efficacy and

375 safety of savolitinib compared with sunitinib in MET-driven PRCC (Clinicaltrials.gov identifier:

376 NCT03091192), will be of interest.

377

378 Acknowledgments

379 Data underlying the findings described in this manuscript may be obtained in accordance with

380 AstraZeneca’s data sharing policy described at

381 https://astrazenecagrouptrials.pharmacm.com/ST/Submission/Disclosure. Medical writing support

382 was provided by Dr Matthew deSchoolmeester PhD (Bioscript Medical) and funded by AstraZeneca.

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486 Table 1. Demographic and baseline characteristics

Safety population (N = 48)

Mean age, years (SD) 60.0 (11.9)

Gender (female), N (%) 19 (40)

Ethnicity, N (%)

Asian 5 (10)

Caucasian 43 (90)

ECOG performance status

0 24

1 24

Primary cancer diagnosis, N (%)

Renal cell carcinoma

Papillary 14 (29)

Clear cell 3 (6)

Translocation Xp11 1 (2)

Colorectal 9 (19)

Gastric 3 (6)

Mesothelioma 3 (6)

Non-small cell lung carcinoma 3 (6)

Thyroid 3 (6)

Pancreatic 2 (4)

Other tumorsa 7 (15)

Prior anti-cancer treatment (yes), N (%) 34 (71)

487 a Primary cancer diagnosis: adenoid cystic carcinoma, breast cancer, gallbladder cancer, melanoma,

488 ovarian cancer, thymic carcinoma, and adenocarcinoma of unknown primary (each N = 1). ECOG,

489 Eastern Cooperative Oncology Group; SD, standard deviation

Page 22 of 31

490

491

Page 23 of 31

492 Table 2. TEAEs reported by ≥5% patients as Grade 1–2, ≥Grade 3 or any Grade overall and

493 considered related to savolitinib treatment

AE, N (%) Safety population (N = 48)

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Any Grade considered

related to treatmenta

Any TEAE 47 (98) 33 (69) 27 (56) 7 (15) 1 (2) 38 (79)

Grade 1–2 Grade ≥3 Any Grade considered

related to treatmenta

Any SAE (including death) 2 (4)b 17 (35) 6 (13)

Treatment discontinuation 2 (4)b 8 (17) –

due to any AE

Dose modification due to 6 (13) 11 (23) –

any AE

TEAEs reported by ≥5% patients

Nausea 30 (63) 0 28 (58)

Vomiting 20 (42) 0 16 (33)

Fatigue 17 (35) 3 (6) 18 (38)

Peripheral edema 13 (27) 2 (4) 11 (23)

Constipation 14 (29) 0 1 (2)

Diarrhea 11 (23) 0 6 (13)

Chest pain 8 (17) 1 (2) 0

Decreased appetite 8 (17) 0 6 (13)

Upper respiratory tract 6 (13) 0 0

infection

Dizziness 6 (13) 0 1 (2)

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Headache 5 (10) 1 (2) 2 (4)

Cough 6 (13) 0 1 (2)

Deep vein thrombosis 1 (2) 5 (10) 0

Abdominal pain 5 (10) 0 0

Arthralgia 5 (10) 0 0

Pyrexia 1 (2) 3 (6) 2 (4)

Urinary tract infection 3 (6) 1 (2) 0

ALT increased 0 4 (8) 2 (4)

AST increased 1 (2) 3 (6) 2(4)

Insomnia 3 (6) 1 (2) 0

Dyspnea 4 (8) 0 2 (4)

Erythema 4 (8) 0 0

Gastro-esophageal reflux 3 (6) 0 0

disease

Edema 3 (6) 0 4 (8)

Blood creatinine increased 3 (6) 0 1 (2)

Back pain 3 (6) 0 0

Rash 3 (6) 0 2 (4)

494 a Events considered possibly or probably related to study treatment. b Grade 1-2 AEs considered

495 serious were one instance each of scrotal edema and pyrexia which led to interruption or

496 withdrawal of savolitinib dosing.

497 AE, adverse event; ALT, alanine aminotransferase; AST, aspartate aminotransferase; SAE, serious

498 adverse event; TEAE, treatment-emergent adverse event

499

Page 25 of 31

500 Table 3. Summary of AEs ≥Grade 3 by dose considered related to study treatment

AE, N (%) 100 mg 200 mg 400 mg 600 mg 800 mg 1000 mg Total 300 mg 400 mg 500 mg Total Safety

QD QD QD QD QD QD QD BID BID BID BID population

(N = 4) (N = 3) (N = 5) (N = 7) (N = 7) (N = 6) (N = 32) (N = 4) (N = 4) (N = 12) (N = 20) (N = 48)

Fatigue 0 0 0 0 1 2 3 (6) 0 0 0 0 3 (6)

Edema peripherala 0 0 1 1 0 0 2 (4) 2 0 0 2 (4) 4 (8)

Liver function test 0 0 0 1 0 0 1 (2) 0 0 5c 5 (10) 6 (12)

abnormalb

Pyrexia 0 0 0 1 0 0 1 (2) 1d 0 0 1 (2) 2 (4)

Headache 0 0 0 0 0 1 1 (2) 0 0 0 0 1 (2)

Lymphopenia 0 0 0 1 0 0 1 (2) 0 0 0 0 1 (2)

Small intestinal 0 0 0 0 1 0 1 (2) 0 0 0 0 1 (2)

obstruction

501 a Includes penile edema (N = 1), swelling (N = 1) and edema peripheral (N = 2). b Includes ALT increased (N = 2), AST increased (N = 2) and abnormal liver

502 function test (N = 2). c One patient had a Grade 4 event of ALT increased that after 7 days of onset reduced to a severity of Grade 3; this event has only been

503 counted once in this table. d Patient was receiving reduced dosing (200 mg BID) at time of event.

Page 26 of 31

504 AE, adverse event; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BID, twice daily dosing; QD, once daily dosing

Page 27 of 31

Figure legends

Figure 1.

Patient disposition (dose escalation and expansion). The study followed a 3+3 design with each cohort containing between 3–6 patients and a total of 48 patients being treated. The DLT observation period was 21 days. The decision to escalate dosing was decided based upon the review of any observed DLTs. BID, twice daily dosing; DLT, dose-limiting toxicity; QD, once daily dosing

Figure 2.

Plasma concentration-time of savolitinib after a single dose of savolitinib (followed by ≥7–day wash- out period) at 100–1000 mg (a) and following repeated QD dosing (b). Savolitinib reached peak concentration levels by 5 hours following administration. Concentration of savolitinib is shown on a log scale. BID, twice daily dosing; H, hour; QD, once daily dosing.

Figure 3.

Waterfall plot of best tumor response and MET biomarker analysis

(a) Best tumor response from baseline according to assessment of MET copy number by NGS, tumor type and savolitinib dose (tumor evaluable population, N = 39; two patients did not have evaluable lesions post-baseline). (b-d) Representative data showing (b), NGS assessment of chromosome 7 gain (PRCC patient with a PR), (c), focal MET gain (CRC patient with SD) and (d), no change in chromosome 7 number or MET focal gain (PRCC patient with PD) with examples of FISH (MET copy number) and IHC (MET protein expression) staining results. In the waterfall plot (a), these patients are labelled b, c and d, respectively. BID, twice daily dosing; ccRCC, clear cell renal cell carcinoma;

CN, copy number; CRC, colorectal cancer; FISH, fluorescent in situ hybridization; IHC, immunohistochemistry; NSCLC, non-small cell lung cancer; NGS, next generation sequencing; PRCC, papillary renal cell carcinoma, QD, once daily dosing.

Page 28 of 31

Figure 1

Page 29 of 31

Figure 2 a.

Page 30 of 31

Figure 3 a

Page 31 of 31

Figure 1

Enrolled (N = 48) Early study withdrawal/ treatment discontinuation following study completion? Dose escalation Completed study? DLT observed? 100 mg QD Yes, = 3 N Disease progression N = 3 No = 3) (N (N = 4) No, N = 1; lost to follow-up Lost to follow-up N = 1

200 mg QD Investigators decision N = 2 N N (N = 3) Yes,= 3 No= 3) ( Disease progression N = 1

400 mg QD N N N (N = 3) Yes,= 3 No= 3) ( Disease progression = 3

Disease progression N = 4 600 mg QD Yes, = 1; abnormalN Liver function test (Grade 3) N N Yes, = 6 N DLT = 1 ( = 6) Drug withdrawn Other N = 1

Disease progression N = 2 Adverse event N = 1 N 800 mg QD N Yes,= 1; fatigue (Grade 3) DLT N = 1 N Yes,= 6 ( = 6) Drug withdrawn Investigators decision N = 1 Withdrew consent N = 1

Adverse event N = 1 1000 mg QD Yes, = 5 N Yes, = 2; headacheN (N = 1), fatigue (N = 2) (all Grade 3) Withdrew consent N = 1 (N = 6) No, N = 1; Grade 2 fatigue Dose reduced (N = 1) & interrupted (N = 1) Disease progression N = 4

300 mg BID N N N (N = 4) Yes,= 4 No= 4) ( Disease progression = 4

Investigators decision N = 2 400 mg BID N N Withdrew consent N = 1 (N = 4) Yes,= 4 No= 4) ( Disease progression N = 1

Dose expansion Disease progression N = 5 500 mg BID Yes, = 1 N Withdrew consent N = 3 No = 11) (N (N = 12) No, N = 1; withdrew consent Adverse event N = 2 Downloaded from clincancerres.aacrjournals.org on September 30, 2021. © 2019 American Association for Other N = 2 Cancer Research. Author Manuscript Published OnlineFirst on April 5, 2019; DOI: 10.1158/1078-0432.CCR-18-1189 Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited.

Figure 2a

10000 100 mg QD 200 mg QD 400 mg QD 1000 600 mg QD 800 mg QD 1000 mg QD 100

1 Savolitinibconcentration (ng/mL)

0.1 0 10 20 30 40 50 Downloaded from clincancerres.aacrjournals.org on September 30, 2021. © 2019 American Association for TimeCancer (nominal) Research. (H) Author Manuscript Published OnlineFirst on April 5, 2019; DOI: 10.1158/1078-0432.CCR-18-1189 Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited.

Figure 2b

Figure 3a

60 MET status (NGS) Chromosome 7 gain 40 MET focal amplification No MET copy number change Tissue not analyzed 20

0 d -20

-40 c from baseline (%) -60

Best tumor measurement change -80

-100 b

Savolitinib dose (mg) 800 QD 600 QD 800 QD 100 QD 100 QD 800 QD 100 QD 400 QD 800 QD 200 QD 600 QD 600 QD 600 QD 800 QD 400 QD 200 QD 600 QD 400 QD 800 QD 600 QD 400 BID 400 BID 500 BID 400 BID 500 BID 500 BID 300 BID 300 BID 500 BID 500 BID 500 BID 300 BID 300 BID 1000 QD 1000 QD 1000 QD 1000 QD

Primary tumor type CRC CRC CRC CRC CRC CRC CRC CRC PRCC PRCC PRCC PRCC PRCC PRCC PRCC PRCC PRCC PRCC Breast ccRCC Gastric ccRCC Gastric Thyroid Thyroid Thyroid NSCLC NSCLC NSCLC Ovarian Thymus Unknown Melanoma Pancreatic Mesothelioma Mesothelioma Mesothelioma

Figure 3b

MET CN (FISH) MET protein (IHC) 5 b 4 3 2 MET (tumor/normal) 2 1

Log 0 MET CN = 3.5/cell

5 c MET 4 3 2 (tumor/normal) 2 1

Log 0 MET CN = 37/cell

5 d 4 3 2 (tumor/normal) 2 1 MET

Log 0 MET CN = 1.8/cell 17 genes along Chromosome 7 60X 20X MET highlighted Red: MET Green: CEP7 Blue: dapi nucleus

First-in-Human Phase I Study of the Selective MET Inhibitor, Savolitinib, in Patients with Advanced Solid Tumors: Safety, Pharmacokinetics and Anti-Tumor Activity

Hui K Gan, Michael J. Millward, Ye Hua, et al.

Clin Cancer Res Published OnlineFirst April 5, 2019.

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