1

Emerging Role for Targeting

Hsp90

Mark A. Socinski, MD,

Director, Lung Cancer Section, Division of Hematology/Oncology

University of Pittsburgh Cancer Institute

University of Pittsburgh

2

Hsp90: Background

• Hsp90 is an ATP-dependent

chaperone regulating late

stage maturation, activation

and stability of client proteins

• Maintains protein homeostasis

in normal cells

• Induced under stress, hypoxia

and oxidative damage

• Exploited by cancer cells for at

least 2 purposes:- support oncoproteins including many

kinases and transcription factors that are

mutated, translocated or overexpressed

- buffer cellular stresses induced by the

malignant lifestyleSoti et al, J Biol Chem, 2002.Neckers et al, CCR 2012.

3

Hsp90 serves as a buffer against the many environmental

stresses that cancer cells must endure and overcome

Neckers L , Workman P Clin Cancer Res 2012;18:64-76

©2012 by American Association for Cancer Research

4

Activated client; cell

survival, proliferationHsp90 binds to client

Hsp90 inhibitorsprevent Hsp90 binding to

client

Inactive client, degraded

through proteasome

HSP90 client

proteins: ALK, AKT,

BCR-ABL, BRAF,

CDK4, CHK1,

EGFR, FLT3, HER2,

HIF1a, KIT, MET,

PDGFRa, CRAF,

SRC, VEGFR, AR,

ER …

Hsp90 chaperone inhibition leads to

client protein degradation

5

Inhibition of distinct drivers distinct applications

HSP90

X

Ganetespib

X

X

Monotherapy

ALK, RAF,

HER2, …

Oncogene drivers,

targeted cancer

indications

Combination therapy

Tumor recovery/repair

mechanisms

DNA repair,

cell cycle

clients

HIF-1Tumor aggressiveness

Angiogenesis

EMT, metastasis

Immune evasion

Chemo-resistance

6

Hsp90 inhibition: single target, simultaneous

inhibition of multiple oncogenic pathways

HSP90

X

ALK

AKT

BCR-ABL

FLT3

RAF

c-KIT

c-MET

EGFR

HER2

VEGFR

PDGFR

HIF-1

Others

X

X

XXXX

X

X

XX

X

X

Hsp90 Inhibitor

X

H3122 ALK+ NSCLC cells

Hsp90 clients: many

key cancer drivers

7

Where are Hsp90 inhibitors likely to have most

pronounced activity as monotherapy?

X X

X √

Oncogene addicted tumor?

No Yes

Weak Hsp90

client

Strong Hsp90

client

ALK, HER2,

RAF, others

8

ALK rearranged cancer cell lines are

sensitive to heat-shock protein 90 (Hsp90)

inhibitors.

Sequist L V et al. JCO 2010;28:4953-4960

©2010 by American Society of Clinical Oncology

9

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

ganetespib (30

nM)

AZD6244 (24 nM) CombinationAZD6244

(24 nM)

… and synergy with other targeted agents

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

ganetespib (13

nM)

PLX4032 (59 nM) Combination

A375 melanoma

Fra

cti

on

Aff

ec

ted

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

ganetespib (7.5

nM)

everolimus (3.4

nM)

Combination

GIST882A375 melanoma

Ganetespib

(30 nM)

Combo PLX4032

(59 nM)

Ganetespib

(13 nM)

Combo Everolimus

(3.4 nM)

Ganetespib

(7.5 nM)

Combo

MEK Inhibitor mTOR InhibitorBRAF InhibitorALK Inhibitor

H3122 NSCLC

Ganetespib

10

How do Hsp90 inhibitors lead to changes

in gene expression and tumor biology ?

11

Ganetespib selective in-vivo accumulation

in tumor vs normal tissue

12

Changing the biology of tumors

Foley et al., AACR April 2010 #2638; Ying et al., Mol Canc

Therap Jan 2012; Mahaseth et al, AACR 2012 Abst #2326

HT-29 CRC cells

__ +

Ganetespib

Ganetespib inhibits hypoxia-induced-factor, HIF-1

Preclinical Patients treated with G

HIF-1α

VEGF

ACTIN

RT-PCR, patient tumor samples

First 3 pts, Emory university G rectal ca trial

Control – before treatment

*** p<0.005

Ganji, Diaz, El-Rayes et al, “Antiangiogenic Effects of

Ganetespib in Colorectal Cancer Mediated Through

Inhibition of HIF-1α and STAT-3,” submitted

13

Hypoxia, HIF drive tumor aggressiveness

HIF-1Genomic instability,

tumor progression

Adapted from R. Jain, ASCO 2012 plenary session; G. Semenza “HIFs: mediators of cancer

progression and targets for cancer therapy” (2012). Not an exhaustive list of genes

Switch to anaerobic

metabolismEMT Invasion,

metastasis

Angiogenesis

Resistance to radio-,

chemo-, immuno-therapy

Inflammation,

immunosuppressionVEGF, ANGPT, SDF, PGF

GLUT, LDH-A

ID2, SNAI,

VIM

TGFA, IGF2, EDN1, ADM

AMF, MET, CXCR4,

MMP, LOX, L1CAM,

Stem cell

immortalizationTERT, NANOG, GPI, PGM

MDR1, BCL2, …

CCL28, T-Reg

HYPOXIA

14

Changing the biology of tumors: angiogenesis

Methods of angiogenesis inhibition

1. Block ligand bevacizumab

2. Block receptor TKI

3. Inhibit transcription ganetespib

HT-29

HCT-116

Control Ganetespib

Egg cam assay

HT-29

HCT-116

Matrigel plug assay

Ganji, Diaz, El-Rayes et al, “Antiangiogenic Effects of Ganetespib in Colorectal Cancer Mediated

Through Inhibition of HIF-1α and STAT-3,” submitted; Mahaseth et al., AACR 2012 Abstr 2326

Ganetespib inhibits

production of VEGFControl Ganetespib

15

Implications to combination therapy?

….Ganetespib synergy w/ anti-angiogenic therapy

1

10

100

1000

10000

10 13 16 19 22 25 28 31 34 37 40

Days After Tumor Implantation

i.v. / i.p. Dosing (1X/Week):

Vehicle

Bevacizumab (10 mg/kg)

Ganetespib (150 mg/kg)

Bevacizumab (10 mg/kg) + Ganetespib (150 mg/kg)

17

3

-90

Avera

ge T

um

or

Volu

me (

mm

3)

H1975 NSCLC

16

…. tumor sensitization to chemo- / radiotherapy

0

100

200

300

400

500

600

700

800

18 21 24 27 30 33 36 39 42 45 48 51

Days After Tumor Implantation i.v. Compound #1:

Radiation:

Ave

rag

e T

um

or

Vo

lum

e (

mm

3)

Vehicle

Ganetespib (150 mg/kg)

Radiation (2 Gy)

Ganetespib (150 mg/kg) + Radiation (2 Gy)

100

-36

32

28

Cervical Cancer Xenograft Model

Cervical cancer xenograft

17

Isobologram

analysis, H522

NSCLC cells

Synergy in

H1975 NSCLC

xenografts

Synergistic mechanisms

– Complementary cell cycle effects

– G suppresses anti-apoptotic factors

– G Inhibits tumor invasiveness and

angiogenesis

Synergy in preclinical models

Phase 2 NSCLC monotherapy

– G single-agent clinical activity

– G toxicity profile non-overlapping with

taxanes

Phase I combination trial

– Established RP2D, schedule

– Combination well tolerated

– No PK interaction

G inhibits VEGF production, angiogenesis

Rationale for ganetespib+docetaxel in NSCLC

18

Ganetespib effects on cell cycle and DNA repair

HEL92.1.7 cells treated for 24 hrs

Cell-cycle genes inhibited

by ganetespib

Gene Fold Change

CDC2 -21.0

E2F-7 -15.2

Cyclin E2 -12.0

Cyclin F -10.2

CDC25A -6.1

CDC25C -5.3

Cyclin E1 -5.1

DHFR -4.6

E2F-1 -3.7

Cyclin A2 -3.6

Ganetespib

Ganetespib

W. Ying et al. Molec Canc Therap Dec 2011;

D. Proia et al PLoS One 2011;6:e18552

19

19

Hsp90 Inhibitors- The History

1962 2000 20051970

Heat shock

proteins

discovered

Geldanamycin

purified for use as

antibiotic

1st-generation

2010

• 17-AAG derivatives

• Formulation issues, limited clinical activity, toxicity (hepatic, ocular)

2nd-generation

• Structurally unrelated to 17-AAG

• Higher potency, improved safety

19

21

Development of Hsp90i: 1st-gen vs. 2nd-gen

W. Ying et al Molec Canc Therap 2012; 11 p. 475

17-AAGHydroquinone salt form 17-AAG

17-DMAG IPI-504

Ganetespib

1st-gengeldanamycinderivatives

Synthetic

Low molecular weight

Absence benzoquinone moiety, liver DLTs

10-100x more potent than 1st-gen

Benzoquinone moiety implicated in liver toxicity and 17-DMAG

22

Accumulation of Hsp90 inhibitors in eye:

ocular toxicity

17-DMAG, AUY-922, SNX-5422, AT-13387, …

Hsp90 inhibitor

Clinical

observationCommon ocular tox

Retina – in vivo

Properties

17-AAG, ganetespib

Little/no ocular tox

Hydrophilic, greater accumulation in retina

ONL

INL

ONL

INL

ONL

INL

INL

ONL

AUY-922

17-DMAG

17-AAG

Ganetespib

Rodent model

ONL: outer nuclear layer, elevated Hsp90

Hydrophobic; reduced accumulation in retina

Zhou et al, “Associating retinal drug exposure and retention with the ocular toxicity profiles of Hsp90 inhibitors”

ASCO June 2012 Abst. #3086

24

HSP 90 Inhibitors in Clinical Development

Agent Sponsor Administration

17AAG NCI/Kosan iv

KOS-953 (tanespimycin) Kosan iv

17DMAG Kosan Iv & oral

IPI-504 (Retaspimycin) Infinity iv

STA-9090 (Ganetespib) Synta iv

AUY-922 Novartis iv

DS-2248 Daiichi Oral

XL-888 Exelixis Oral

IPI-493 Infinity Oral

MPC-3100 Myrexis Oral

SNX-5422 Serenex Oral

CNF-2024 Biogen Idec Oral

Source: Clinicaltrials.gov, accessed 3/29/2011.

25

HSP 90 Inhibitors in Clinical Development

Agent Sponsor Administration

17AAG NCI/Kosan iv

KOS-953 (tanespimycin) Kosan iv

17DMAG Kosan Iv & oral

IPI-504 (Retaspimycin) Infinity iv

STA-9090 (Ganetespib) Synta iv

AUY-922 Novartis iv

DS-2248 Daiichi Oral

XL-888 Exelixis Oral

IPI-493 Infinity Oral

MPC-3100 Myrexis Oral

SNX-5422 Serenex Oral

CNF-2024 Biogen Idec Oral

Source: Clinicaltrials.gov, accessed 3/29/2011.

26

Dose and Schedule of Hsp90 inhibitors

Agent Dose (mg/m2) Schedule

IPI-5041 400 ↓ to 225* d1, 4, 8, 11 q21d

AUY9222 70 Weekly

Ganetespib3 200 d1, 8, 15 q28d

*Dose decreased from 400 to 225 mg/m2 due to hepatotoxicities seen in a separate trial of

IPI-504 in GI stromal tumors. 75 of 76 patients started at 400 mg/m2 and 19 were still on therapy

when the dose reduction was implemented

1. Sequist LV et al J Clin Oncol 28:4953-4960, 2010

2. Garon EB et al J Clin Oncol 30: ASCO 2012, abstr # 7543

3. Wong K et al. J Clin Oncol 29:ASCO 2011, abstr # 7500 (Socinski MA et al, manuscript submitted)

27

Most Common Grade 3/4 Toxicities in Phase II

Trials of Hsp90 Inhibitors in NSCLC

IPI-5041 AUY9222 Ganetespib3

Diarrhea 11 7 8

Nausea 8 0 0

Vomiting 8 2 0

Anorexia 5 3 0

Fatigue 8 4 14

Myal/Arthral 3 1 0

Visual 0 7* 0

Dyspnea 8 8 12

ALT 7 - 4

AST 9 - 0

*70% had grade 1-2 eye disorders – most commonly photopsia, visual impairment, blurred vision, night blindness

and reduced visual acuity

1. Sequist LV et al J Clin Oncol 28:4953-4960, 2010

2. Garon EB et al. J Clin Oncol 30: ASCO 2012, abstr# 7543

3. Wong K et al. J Clin Oncol 29: ASCO 2011, abstr# 7500 (Socinski MA et al. manuscript submitted)

28

Clinical Activity of Hsp90 Agents in

Advanced NSCLC

# pts ORR (%) ORR/DCR (%) by genotype

EGFR mt KRAS mt ALK +

IPI-5041 76 7 4/21 0/42 67/100

AUY9222 120 14 20/57 0/39 29/57

Ganetespib3 99 4 0/13 0/6 50/87

1. Sequist LV et al. J Clin Oncol 28:4953-4960, 2010

2. Garon EB et al. J Clin Oncol 30: ASCO 2012, abstr # 7543

3. Wong K et al. J Clin Oncol 29: ASCO 2011, abstr # 7500 (Socinski MA et al. Manuscript submitted)

29

Enrolled N=96

Evaluable N=76

• Previously treated

stage IIIB/IV

NSCLC

• ECOG - PS 0, 1

• Disease

progression at

study entry

• Genotyping*

Study Design

F/U

Until

PD

Stra

tifica

tion

*1 patient with unknown genotype

First Patient First Visit, Dec, 2009;

Last Patient first visit, May, 2011

A: mEGFR (n=16)

B: mK-Ras (n=17)

C: wild-type EGFR/wild-type K-Ras (n=25)

D: Adenocarcinoma only (n=37)

Simon two stage design

Ganetespib 200 mg/m2 q wk for 3 out of 4 weeks

Primary endpoint: PFS rate at 16 weeks

E: addition of qw docetaxel on PD if clinical benefit

Wong K….Shapiro G, Socinski MA. J Clin Oncol 29:2011, abstr# 7500

30

Adverse Events Occurring in ≥ 10% Patients

0

10

20

30

40

50

60

70

80

90

100

Dia

rrhea

Fatig

ue

Nause

a

Decr

eased

Appet

ite

Dysp

nea

Constip

ation

Back

Pain

Vom

iting

Cough

Dehyd

ratio

n

Diz

zines

s

Inso

mnia

Anxie

ty

Head

ache

Hypona

trae

mia

Incr

eased

ALT

Incr

eased

ALK

PHOS

Hyper

glyca

emia

Musc

ular W

eakn

ess

UTI

G5

G4

G3

G2

G1

Drug-related SAEs, one patient each: asthenia, atrial fibrillation,

cardiac arrest, diarrhea, lipase elevation, renal failure, vomiting

31

Best Response in Target Lesions

31

*

■ Cohort A (mEGFR)

■ Cohort B (mKRas)

■ Cohort C+D (WT)

*

* * ** * * *

** **** **

* SD ≥ 16 wks

* Partial Responses

32

Genetic Profiling

For crizotinib-naïve patients:

7 out of 8 (88%) patients with ALK-positive tumors had disease control lasting at least 16 weeks.

6 out of 8 (75%) patients with ALK-positive tumors had tumor shrinkage in target lesions.

4 out of 8 (50%) patients with ALK-positive tumors had objective response.

*

*

* = presumed ALK+; prior crizotinib

ALK Rearrangement Cohorts C/D

• no mutations detected beyond EGFR and KRAS (Sequenom)

• 4 patients had EGFR polysomy

*

33

Proof of principle: ganetespib monotherapy

clinical activity, ALK+ NSCLC

24 year old male

• Chemotherapy, progressed; crizotinib 1 year (PR), progressed

• Enrolled ganetespib monotherapy (single-agent)

Baseline

After three weeks

(3 doses) ganetespib

34

Responses in EGFR-mutant and ALK+ NSCLC in

AUY922 trial

Baseline Cycle 3, Day 1

Baseline Cycle 7, Day 1

3rd line EGFRm+ patient

5th line ALK+ patient

35

Rationale for Combining Hsp90

inhibitors and Taxanes

• Both drugs have single agent activity in NSCLC

• STA-9090 and docetaxel have synergistic effects on

– Cell cycle

– Both drugs affect microtubuli

– Hsp90 inhibitors interfere with taxane resistance mechanisms (eg, AKT expression, anti-apoptotic signaling through VEGF)

– Effects of Hsp 90 inhibition on microenvironment sensitize tumors to docetaxel (vasculature, blood flow, metabolic state)

36

Emory Univ. Phase 1 Docetaxel + Ganetespib Combination

• Phase I study in patients with advanced solid organ malignancies (ongoing)

• Docetaxel – day 1

• Ganetespib- days 1 & 15

• N=20 patients to date

• Recommended phase II dose: Docetaxel 75 mg/m2; Ganetespib 150 mg/m2

• DLTs- myelosuppression and diarrhea (with 200 mg/m2)

• 8 patients are still on study therapyPI: Drs. Harvey and Ramalingam

37

Phase Ib Study of Docetaxel + IPI-504 in Advanced

NSCLC

• Partial Response

seen in 6 patients

(ORR = 26%)

• Stable Disease

seen in 7 patients

Riely et al, Abstract # 7516, ASCO 2011.

38

Preliminary results from a randomized 2b/3

study of ganetespib and docetaxel combination

versus docetaxel in advanced NSCLC (the

GALAXY Trial, NCT01348126)

Suresh S. Ramalingam1, Bojan Zaric2, Glenwood D. Goss3, Christian

Manegold Sr.4, Rafael Rosell5, Vojo Vukovic6, Iman El-Hariry6, Florentina

Teofilovici6, Sarah Mulcahey6, Wei Guo6, Dean Anthony Fennell7

1Emory University, Atlanta, GA; 2Institute for Pulmonary Diseases of Vojvodina, Serbia; 3The

Ottawa Hospital Cancer Centre, Ottawa, ON; 4University Medical Center, Mannheim, Germany; 5Catalan Institute of Oncology, Hospital Germans Trias i Pujol, Barcelona, Spain; 6Synta

Pharmaceuticals, Lexington, MA; 7University of Leicester, Leicester, United Kingdom

ESMO 2012, Vienna, Austria

Abstract #1248P_PR

39

Study design

Stratification

• ECOG PS

• Time since diagnosis of

advanced disease

• Baseline serum LDH

• Smoking history

Eligibility criteria

• Stage IIIB/IV NSCLC

• ECOG 0,1

• 1 prior Rx advanced setting

• Measurable disease

• Documented PD

• Clinically stable CNS metastases

• Available tumor tissues

• Adequate organ function

Statistical assumptions

Co-primary: 90% power PFS 6 12

wks (elevated LDH pts); 5 10 wks

(mKRAS pts)

Key secondary: all adenocarcinoma

pts – 88% power PFS 3 4.5 mo,

73% power OS 6 8.5 mo

1-sided alpha of 0.05

40

All adenocarcinoma patients (N=172)D (N=88)

n (%)

G+D (N=84)

n (%)

Median Age (Range) 58 (34, 86) 60 (41, 79)

Sex Male

Female

54 (61)

34 (39)

46 (55)

38 (45)

ECOG Status 0 1

39 (44)

49 (56)

41 (49)

43 (51)

Stage at Study Entry IIIB

IV

4 (5)

83 (94)

5 (6)

79 (94)

Smoking History Current

Past

Never

25 (28)

43 (49)

20 (23)

17 (20)

44 (52)

23 (27)

Interval since dx advanced ≤ 6 mo

disease > 6 mo

25 (28)

54 (61)

26 (31)

54 (64)

LDH Normal

Elevated

63 (72)

25 (28)

60 (71)

24 (29)

Prior Therapy Plat-Based chemo

Bevacizumab

Maintenance

81 (92)

8 (9)

7 (8)

78 (93)

5 (6)

8 (10)

Geographic Region North America

Eastern Europe

Western Europe

16 (18)

58 (66)

14 (16)

18 (21)

52 (62)

14 (17)

Baseline characteristics

41

* Neutropenia and Anemia from both reported AEs and laboratory results of ANC and RBC, respectively

All grades Grade 3 or 4

D (N=86)

n (%)

G + D (N=81)

n (%)

D (N=86)

n (%)

G + D (N=81)

n (%)

Neutropenia * 43 (50) 40 (49) 29 (34) 28 (35)

Diarrhea 10 (12) 34 (42) 0 3 (4)

Fatigue 17 (20) 25 (31) 2 (2) 4 (5)

Anemia* 9 (11) 17 (21) 1 (1) 4 (5)

Nausea 13 (15) 15 (19) 2 (2) 2 (3)

Decreased appetite 8 (9) 12 (15) 1 (1) 0

Dyspnea 9 (11) 11 (14) 2 (2) 1 (1)

Alopecia 8 (9) 11 (14) 0 0

Rash 5 (6) 11 (14) 0 2 (3)

Vomiting 8 (9) 9 (11) 1 (1) 0

Asthenia 8 (9) 8 (10) 2 (2) 1 (1)

Pyrexia 6 (7) 8 (10) 0 0

Febrile neutropenia 2 (2) 8 (10) 2 (2) 8 (10)

Cough 9 (11) 7 (9) 0 0

Adverse events in >10% patients

42

D

(N=88)

G + D (N=84)

p-Value*

PFS 2.8 mo 4.2 mo 0.076HR=0.782

(90% CI: 0.55, 1.11)

ORR 8% 16% 0.078

PFS, ORR

* All p-values are calculated using 1-sided stratified log-rank test for survival endpoints and using Fisher’s Exact

test for response rate.

43

OS, ITT (Sep cutoff, N=172)

ganetespib + docetaxel

docetaxel

D G+D

N 88 84

Deaths 26 (30%) 19 (23%)

Median OS 7.38 mo NR

p-Value 0.183 (stratified log-rank,1-sided)

HR 0.688 (90% CI: 0.417, 1.135)

Median follow-up: 3.26 mo

44

Hsp90 Inhibition in NSCLC - Conclusions

• Hsp90 inhibitors are active agents in NSCLC

• Design of 2nd generation agents have overcome toxicities

seen with the 1st generation inhibitors

• As single agents mostly likely to be active in oncogene

addicted tumors that are also strong hsp90 clients

- ALK+ disease best example to date

- Best as single agents vs combinations? Best schedule?

• Preclinical models suggest synergism with chemotherapy

and HIF-1α inhibition

• Future directions

- combinations with other targeted agents, chemo, RT

- biomarker development