1 Mesothelioma: Current Best Practices and Promising TherapiesThis program is supported by an educational grant from Lilly.

2 About These Slides Users are encouraged to use these slides in their own noncommercial presentations, but we ask that content and attribution not be changed. Users are asked to honor this intent These slides may not be published or posted online without permission from Clinical Care Options ( Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors of the CCO material, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.

3 Program Faculty Anne S. Tsao, MD Associate Professor Director, Mesothelioma Program Director, Thoracic Chemo-Radiation Program Department of Thoracic/Head and Neck Medical Oncology Division of Cancer Medicine University of Texas M. D. Anderson Cancer Center Houston, Texas Anne S. Tsao, MD, has no real or apparent conflicts of interest to report.

4 Agenda Malignant Pleural Mesothelioma: Diagnosis and StagingSystemic Therapy for Mesothelioma Novel Agents and Regimens in Clinical Trials Immunotherapy

5 Malignant Pleural Mesothelioma: Diagnosis and Staging

6 Mesothelioma: EpidemiologyMesothelioma: relatively uncommon insidious and potentially lethal disease linked to asbestos, erionite exposure and, potentially, radiation Male:female 3:1 Latency period: yrs from time of environmental exposure Age: 6th-8th decade Main causative agent: asbestos Mesothelioma is a relatively rare malignancy, but it is highly lethal. The main causative agent in MPM is asbestos exposure. Cases occur in men and women at a ratio of 3:1, and the latency period from time of asbestos exposure to disease is between 20 and 50 years, although the median is typically 32 years. Historically, patients presented in the sixth to eighth decades of life, but now we often see patients aged years due to childhood exposure to asbestos. Reference: Tsao AS, Wistuba I, Roth JA, Kindler HL. Malignant pleural mesothelioma. J Clin Oncol. 2009;27: Slide credit: clinicaloptions.com Tsao AS, et al. J Clin Oncol. 2009;27:

7 Mesothelioma: HistopathologyCan be confused with adenocarcinoma Gold standard: electron microscopy Immunohistochemical markers Cytokeratin 5/6 (+) Calretinin (+) WT-1 (+) CEA (-) Leu-M1 (-) TTF-1 (-) Mesothelioma is diagnosed by histopathology.[1] It may be confused with adenocarcinoma, so the gold standard for diagnosis is electron microscopy or IHC biomarkers. A typical expression pattern for mesothelioma is cytokeratin 5/6 positive, calretinin and WT‑1 positive and TTF‑1 negative.[2] References: 1. Inai K. Pathology of mesothelioma. Environ Health Prev Med. 2008;13:60-64. 2. Ordóñez NG. The immunohistochemical diagnosis of mesothelioma: a comparative study of epithelioid mesothelioma and lung adenocarcinoma. Am J Surg Pathol. 2003;27: Inai K. Environ Health Prev Med. 2008;13:60-64. Ordonez NG. Am J Surg Pathol. 2003;27: Slide credit: clinicaloptions.com

8 Mesothelioma: Germline Mutations and Asbestos ExposureCappadocia, Turkey: genetics influence risk of mesothelioma in persons exposed to erionite[1,2] BAP1 germline mutations can predispose pts to familial and sporadic mesothelioma and uveal melanoma[3-6] Tumor suppressor gene located on chromosome 3p21 Somatic mutations or 3p21.1 loss lead to BAP1 inactivation In these individuals, asbestos exposure may predispose mesothelioma MPM occurs in a minority of people exposed to asbestos, and clustering of cases is observed within families, suggesting genetic predisposition.[1] Genes that influence risk of mesothelioma in people exposed to erionite, an asbestos-like mineral, have been identified.[2] Germline mutations in BAP1, a tumor‑suppressor gene located on chromosome 3p21, predispose patients to develop either MPM or uveal melanoma following asbestos exposure.[1,3] It is possible that asbestos exposure may predispose these individuals to development of mesothelioma first before the uveal melanoma. References: 1. Testa JR, Cheung M, Pei J, et al. Germline BAP1 mutations predispose to malignant mesothelioma. Nat Genet. 2011;43: 2. Dogan AU, Baris YI, Dogan M, et al. Genetic predisposition to fiber carcinogenesis causes a mesothelioma epidemic in Turkey. Cancer Res. 2006;66: 3. Bott M, Brevet M, Taylor BS, et al. The nuclear deubiquitinase BAP1 is commonly inactivated by somatic mutations and 3p21.1 losses in malignant pleural mesothelioma. Nat Genet. 2011;43: 1. Dogan AU, et al. Cancer Res. 2006;66: Roushdy-Hammady I, et al. Lancet. 2001;357: Testa JR, et al. Nat Genet. 2011;43: Goldstein AM. Nat Genet. 2011;43: Bott M, et al. Nat Genet. 2011;43: Harbour JW, et al. Science. 2010;330: Slide credit: clinicaloptions.com

9 Mesothelioma: Diagnostic StagingRadiographic imaging Chest x-ray, chest CT: pleural effusions, pleural plaques, rindlike mass PET/CT: evaluate for distant metastases Head imaging: if neurologic symptoms Radiographic imaging is usually the first modality employed in diagnostic staging. Patients with an abnormal chest x‑ray are typically offered a chest CT scan that will identify pleural effusions, pleural plaques, or even a pleural rind‑like mass. A PET/CT scan is often obtained to look for distant metastatic disease. Head imaging is also necessary in patients with neurologic symptoms. Slide credit: clinicaloptions.com Images courtesy of Anne S. Tsao, MD.

10 Mesothelioma: Advanced Diagnostic StagingESS Laparoscopy with peritoneal lavage: evaluate for transdiaphragmatic spread of tumor cells into abdomen Bronchoscopy Mediastinoscopy: evaluate for N2 lymph nodes ESS, extended surgical staging. Extended surgical staging is often used to determine whether a patient’s disease is resectable. This approach includes a laparoscopy with peritoneal lavage to assess for transdiaphragmatic spread of tumor cells into the abdomen. If there is any microscopic spread of disease into the abdomen, the patient is not a surgical candidate. The patient will then undergo a mediastinoscopy to evaluate for N2 lymph nodes. Depending on the histologic subtype, patients with N2-positive disease will also not be surgical candidates. Reference: Rice DC, Erasmus JJ, Stevens CW, et al. Extended surgical staging for potentially resectable malignant pleural mesothelioma. Ann Thorac Surg. 2005;80: Slide credit: clinicaloptions.com Rice DC, et al. Ann Thorac Surg. 2005;80:

11 Mesothelioma: Diagnostic and Palliative Surgical InterventionDiagnostic procedures Thoracentesis: 33% rate of success VATS Palliative procedures Pleurodesis: 2-5 gm talc P/D Intrapleural chemotherapy (cisplatin, liposome- entrapped cisplatin analog) P/D, pleurectomy/decortication; VATS, video-assisted thoracoscopy. Commonly, patients with mesothelioma will receive external diagnostic procedures, such as repeated thoracenteses.[1] Unfortunately, the rate of success with use of thoracentesis to identify MPM is only 33%. VATS is frequently required for diagnosis. In this procedure, a small camera is inserted into the chest wall, and a biopsy of any abnormal pleural masses or plaquing is obtained. This will commonly confirm the diagnosis of mesothelioma. Patients may also receive palliative procedures, including a pleurodesis, where talc is injected into the pleural space, and potentially also a pleurectomy or decortication, where the pleural plaques or masses are peeled off the lung. Unfortunately, these procedures often leave microscopic disease behind, although there are new treatment modalities that administer radiation therapy to high‑risk patients following the initial procedure. There are also trimodality treatments involving pleurectomy or decortication that can render a patient disease free. The use of intrapleural chemotherapy with cisplatin or a liposome-entrapped cisplatin analogue is under investigation.[2-4] However, this approach is not a standard‑of‑care practice. References: 1. Thomas R, Francis R, Davies HE, Lee YC. Interventional therapies for malignant pleural effusions: the present and the future. Respirology. 2014;19: 2. Rusch V, Saltz L, Venkatraman E, et al. A phase II trial of pleurectomy/decortication followed by intrapleural and systemic chemotherapy for malignant pleural mesothelioma. J Clin Oncol. 1994;12: 3. Richards WG, Zellos L, Bueno R, et al. Phase I to II study of pleurectomy/decortication and intraoperative intracavitary hyperthermic cisplatin lavage for mesothelioma. J Clin Oncol. 2006;24: 4. Lu C, Perez-Soler R, Piperdi B, et al. Phase II study of a liposome-entrapped cisplatin analog (L-NDDP) administered intrapleurally and pathologic response rates in patients with malignant pleural mesothelioma. J Clin Oncol. 2005;23: Thomas R, et al. Respirology. 2014;19: Rusch V, et al. J Clin Oncol. 1994;12: Richards WC, et al. J Clin Oncol. 2006;24: Lu C, et al. J Clin Oncol. 2005;23: Pass HI, et al. Semin Surg Oncol. 1995;11: Slide credit: clinicaloptions.com

12 Systemic Therapy for Mesothelioma

13 Chemotherapy in Resectable DiseaseDespite a lack of randomized trial data, induction chemotherapy is now accepted as standard practice[1,2] Previously no good systemic therapies, chemo not standard Trials of induction therapy with cisplatin/gemcitabine and cisplatin/pemetrexed demonstrated feasibility Trial Regimen Pts, n EPP, n RR, % Median OS, Mos Weder 2004[3] Cisplatin/gemcitabine 19 16 32 23 Flores 2006[4] 21 8 26 Weder 2007[5] 61 37 NR 19.8 Rea 2007[6] Carboplatin/gemcitabine 17 33 25.5 Krug 2009[7] Cisplatin/pemetrexed 77 54 32.5 16.8 EPP, extrapleural pneumonectomy; NR, not reported; RR, response rate. Chemotherapy has been evaluated in patients with mesothelioma who have resectable disease.[1] Unfortunately, there are no data from randomized prospective trials comparing neoadjuvant chemotherapy with adjuvant therapy, nor even randomized trials of neoadjuvant vs no systemic therapy. This lack of data is a reflection of the rarity of patients with resectable mesothelioma, and the fact that these patients must undergo significant evaluation and need to have very early‑stage disease and very good performance status is also a reflection. However, despite the lack of randomized controlled trial data, neoadjuvant chemotherapy or adjuvant chemotherapy is accepted as a standard practice in this setting and is included in the NCCN guidelines on management of MPM.[2] In the past, systemic therapies for MPM were lacking. However, cisplatin/pemetrexed is now approved in the frontline setting for metastatic disease and is commonly given in resectable mesothelioma. Neoadjuvant cisplatin/gemcitabine has been evaluated in a series of trials conducted in patients with MPM, most of whom also received an extrapleural pneumonectomy.[3-6] These studies typically enrolled very small numbers of patients, ranging from Neoadjuvant cisplatin/pemetrexed was evaluated in 77 patients with MPM in a phase II trial.[7] In this study, 54 patients completed extrapleural pneumonectomy. The radiologic response rate was 32.5%, and the median OS was 16.8 months. In the subgroup of patients who had a response to neoadjuvant chemotherapy, median survival was improved (26.0 vs 13.9 months in patients with stable or progressive disease; P = .05). References: 1. Tsao AS, Wistuba I, Roth JA, Kindler HL. Malignant pleural mesothelioma. J Clin Oncol. 2009;27: 2. National Comprehensive Cancer Network. Clinical practice guidelines in oncology: malignant pleural mesothelioma. v Available at: https://www.nccn.org. Accessed June 21, 2016. 3. Weder W, Kestenholz P, Taverna C, et al. Neoadjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma. J Clin Oncol. 2004;22: 4. Flores RM, Krug LM, Rosenzweig KE, et al. Induction chemotherapy, extrapleural pneumonectomy, and postoperative high-dose radiotherapy for locally advanced malignant pleural mesothelioma: a phase II trial. J Thorac Oncol. 2006;1: 5. Weder W, Stahel RA, Bernhard J, et al. Multicenter trial of neo-adjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma. Ann Oncol. 2007;18: 6. Rea F, Marulli G, Bortolotti L, et al. Induction chemotherapy, extrapleural pneumonectomy (EPP) and adjuvant hemi-thoracic radiation in malignant pleural mesothelioma (MPM): feasibility and results. Lung Cancer. 2007;57:89-95. 7. Krug LM, Pass HI, Rusch VW, et al. Multicenter phase II trial of neoadjuvant pemetrexed plus cisplatin followed by extrapleural pneumonectomy and radiation for malignant pleural mesothelioma. J Clin Oncol. 2009;27: 1. Tsao AS, et al. J Clin Oncol. 2009;27: NCCN. Malignant pleural mesothelioma. V Weder W, et al. J Clin Oncol. 2004;22: Flores R, et al. J Thorac Oncol. 2006;1: Weder W, et al. Ann Oncol. 2007;18: Rea F, et al. Lung Cancer. 2007;57: Krug LM, et al. J Clin Oncol. 2009;27: Slide credit: clinicaloptions.com

14 Unresectable Mesothelioma: Frontline Systemic TherapyAlmost every chemotherapy known to man has been tried in mesothelioma[1] Mesothelioma largely chemoresistant with response rate ≤ 15% Combination regimens improved response rate Historically, the most efficacious agents in combination included doxorubicin, epirubicin, mitomycin, cyclophosphamide, ifosfamide, and platinum agents Current standard of care in the United States[1,2] Cisplatin 75 mg/m2 + pemetrexed 500 mg/m2 every 3 wks Many chemotherapies have been evaluated in patients with advanced mesothelioma and found to be largely ineffective, with response rates < 15%.[1] The use of combination regimens, including doxorubicin, epirubicin, mitomycin, cyclophosphamide, ifosfamide, and platinum agents, improved response rates, but since 2003, the standard of care in the United States has been cisplatin 75 mg/m2 with pemetrexed 500 mg/m2 given IV every 3 weeks.[2] References: 1. Ellis P, Davies AM, Evans WK, et al. The use of chemotherapy in patients with advanced malignant pleural mesothelioma: a systematic review and practice guideline. J Thorac Oncol. 2006;1: 2. National Comprehensive Cancer Network. Clinical practice guidelines in oncology: malignant pleural mesothelioma. v Available at: https://www.nccn.org. Accessed June 21, 2016. 1. Ellis P, et al. J Thorac Oncol. 2006;1: NCCN. Malignant pleural mesothelioma. V Slide credit: clinicaloptions.com

15 Phase III Front-line Cisplatin/Pemetrexed vs Cisplatin in Unresectable MesotheliomaStratified by center, PS, pain/dyspnea on entry, histology, sex, WBC, homocysteine level; Randomized 1:1 Cisplatin 75 mg/m2 + Pemetrexed 500 mg/m2 IV every 3 wks (n = 226) Pts with unresectable mesothelioma, chemo naive, Karnofsky PS ≥ 70 (N = 456*) Cisplatin 75 mg/m2 IV every 3 wks (n = 222) *8 pts did not receive treatment. PS, performance status; QoL, quality of life; RR, response rate; TTP, time to progression; WBC, white blood cell count. The approval of cisplatin/pemetrexed for MPM in the United States and Europe was based on the results of a randomized phase III trial that compared cisplatin/pemetrexed with cisplatin alone in 456 chemotherapy-naive patients with unresectable mesothelioma. The primary endpoint of the study was OS. Reference: Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21: Primary endpoint: OS Secondary endpoints: TTP, RR, QoL, toxicity Slide credit: clinicaloptions.com Vogelzang NJ, et al. J Clin Oncol. 2003;21:

16 Frontline Cisplatin/Pemetrexed vs Cisplatin in Mesothelioma: EfficacyEvent Cisplatin/ Pemetrexed Cisplatin HR P Value Response rate, % 41.3 16.7 < .001 Median TTP, mos 5.7 3.9 0.68 .001 Median OS, mos 12.1 9.3 0.77 .028 Global QoL score 45 38 .012 Improved symptom distress 51 44 .009 ITT, intent to treat; QoL, quality of life; TTP, time to progression. Patients received cisplatin/pemetrexed for a maximum of 6 cycles. Median OS was superior with use of combined cisplatin/pemetrexed compared with cisplatin alone (12.1  vs 9.3 months; P = .020). Median time to progression also favored cisplatin/pemetrexed, at 5.7 months vs 3.9 months for cisplatin alone. Although the response rate for cisplatin/pemetrexed was 41% in this trial, we do tend to see rates closer to 30% to 35% in the general population of patients. Reference: Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21: Slide credit: clinicaloptions.com Vogelzang NJ, et al. J Clin Oncol. 2003;21:

17 Frontline Cisplatin/Pemetrexed vs Cisplatin in Mesothelioma: ToxicitySelect Adverse Events ≥ Grade 3, % Cisplatin/Pemetrexed (n = 226) Cisplatin (n = 222) Neutropenia 27.9 2.3 Anemia 4.8 Nausea 14.6 6.3 Vomiting 13.3 3.6 Fatigue 10.2 8.6 Diarrhea 4.4 Dehydration 4.0 0.5 Stomatitis Febrile neutropenia 1.8 Rash 1.3 The most common adverse event of at least grade 3 severity seen in patients receiving cisplatin/pemetrexed in the phase III trial was neutropenia, which occurred in 27.9%. Anemia, nausea, vomiting, and fatigue were also observed.[1] Patients who develop neutropenia should be managed in line with ASCO guidelines, particularly if the patient is high risk or in cases of febrile neutropenia.[2] Such patients need growth‑factor support. References: 1. Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21: 2. Flowers CR, Seidenfeld J, Bow EJ, et al. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013;31: Slide credit: clinicaloptions.com Vogelzang NJ, et al. J Clin Oncol. 2003;21:

18 Other Platinum/Antifolate Regimens in MesotheliomaCarboplatin/pemetrexed (N = 102; phase II)[1] ORR: 18.6%; SD: 47%; TTP: 6.5 mos OS: 12.7 mos Cisplatin/raltitrexed vs cisplatin (N = 250; phase III, Europe)[2] ORR: 24% vs 14% (P = .06) Median PFS: 5.3 vs 4.0 mos (P = .058) Median OS: 11.4 vs 8.8 mos (P = .048) 1-yr OS rate: 46.2% vs 39.6% SD, stable disease; TTP, time to progression. Several other platinum/antifolate regimens have been evaluated in patients with mesothelioma in clinical trials. In the setting of unresectable disease, carboplatin/pemetrexed is an acceptable option. A single-arm phase II study of carboplatin/pemetrexed in 102 patients with MPM reported an ORR of 18.6% (95% CI: 11.6% to 27.5%).[1] Median time to progression was 6.5 months, and median OS was 12.7 months. Cisplatin/raltitrexed is approved for the treatment of mesothelioma in Europe but not in the United States. Like pemetrexed, raltitrexed is an inhibitor of thymidylate synthase. A phase II study of cisplatin/raltitrexed vs cisplatin alone, conducted in 250 patients with MPM, observed a response rate of 23.6% with the combined therapy vs 13.6% with cisplatin alone (P = .056).[2] Median OS with the combined therapy was 11.4 months, similar to that seen in the previous study of carboplatin/pemetrexed. References: 1. Ceresoli GL, Zucali PA, Favaretto AG, et al. Phase II study of pemetrexed plus carboplatin in malignant pleural mesothelioma. J Clin Oncol. 2006;24: 2. van Meerbeeck JP, Gaafar R, Manegold C, et al. Randomized phase III study of cisplatin with or without raltitrexed in patients with malignant pleural mesothelioma: an intergroup study of the European Organisation for Research and Treatment of Cancer Lung Cancer Group and the National Cancer Institute of Canada. J Clin Oncol. 2005;23: 1. Ceresoli GL, et al. J Clin Oncol. 2006;24: 2. Van Meerbeeck JP, et al. J Clin Oncol. 2005;23: Slide credit: clinicaloptions.com

19 MAPS: Frontline Cisplatin/Pemetrexed ± Bevacizumab in Unresectable MPMOpen-label, multicenter, randomized phase III trial Primary endpoint: OS (ITT population) IDMC requested early release of data due to efficacy of experimental arm Stratified by center; epithelioid vs sarcomatoid or mixed histology; PS (0-1 vs 2); smoking status 6 cycles Q21D Pts with MPM; no CV comorbidity; PS 0-2; no previous chemotherapy; eligible for bevacizumab therapy (N = 448) Pemetrexed 500 mg/m² Day 1 + Cisplatin 75 mg/m² Day 1 + Bevacizumab 15 mg/kg Day 1 (n = 223) Bevacizumab 15 mg/kg Day 1 Q21D until progression Pemetrexed 500 mg/m² Day 1 + Cisplatin 75 mg/m² Day 1 (n = 225) Surveillance* CV, cardiovascular; IDMC, Independent Data Monitoring Committee; ITT, intent to treat; MPM, malignant pleural mesothelioma; PS, performance status. The most recent development in frontline treatment for unresectable MPM is the use of cisplatin/pemetrexed together with the VEGF inhibitor bevacizumab, a strategy that was evaluated in the randomized, phase III MAPS trial.[23] The MAPS study assessed open-label cisplatin/pemetrexed, given with or without bevacizumab 15 mg/kg, in 21-day cycles for a maximum of 6 cycles in 448 chemotherapy-naive patients with MPM. Patients assigned to the cisplatin/pemetrexed/bevacizumab arm subsequently received continued maintenance therapy with bevacizumab until disease progression. The study included approximately 223 patients in each treatment arm, and the primary endpoint was OS. All patients who were enrolled were required to be eligible for bevacizumab, with an Eastern Cooperative Oncology Group performance status of 0-2 and no substantial cardiovascular comorbidity. Reference: Zalcman G, Mazieres J, Margery J, et al. Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial. Lancet. 2016;387: *No crossover allowed. Slide credit: clinicaloptions.com Zalcman G, et al. Lancet. 2016;387:

20 MAPS: PFS in the ITT Population100 PFS (Median) C/P + Bev: 9.6 mos (95% CI: ) C/P: 7.5 mos (95% CI: ) 80 60 HR: 0.61 (95% CI: ; P < .0001) PFS (%) 40 20 Bev, bevacizumab; C/P, cisplatin/pemetrexed; ITT, intent to treat. PFS was superior in the cisplatin/pemetrexed/bevacizumab arm compared with the cisplatin/pemetrexed alone arm (9.6 vs 7.5 months; HR: 0.61; 95% CI: ; P < .0001). Reference: Zalcman G, Mazieres J, Margery J, et al. Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial. Lancet. 2016;387: 20 40 60 80 Mos Slide credit: clinicaloptions.com Zalcman G, et al. Lancet. 2016;387:

21 MAPS: OS in the ITT Population100 OS (Median) C/P + Bev: 18.8 mos (95% CI: ) C/P: 16.1 mos (95% CI: ) 80 60 HR: (95% CI: ; P = .0167) OS (%) 40 20 Bev, bevacizumab; C/P, cisplatin/pemetrexed; ITT, intent to treat. Median OS was also significantly longer with the addition of bevacizumab (18.8 vs 16.1 months without bevacizumab; HR: 0.77; 95% CI: ; P = .0167). Reference: Zalcman G, Mazieres J, Margery J, et al. Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial. Lancet. 2016;387: 20 40 60 80 Mos Slide credit: clinicaloptions.com Zalcman G, et al. Lancet. 2016;387:

22 MAPS: OS Subgroup AnalysesHR (95% CI) P Value All Male Female Age < 65.7 yrs Age ≥ 65.7 yrs ECOG PS 0/1 ECOG PS 2 Epithelioid histology Sarcomatoid or mixed histology Smoker Never smoker Platelet count < 400 x 109/L Platelet count ≥ 400 x 109/L Hemoglobin concentration ≤ 140 g/L Hemoglobin concentration > 140 g/L Leucocyte count ≥ 8.3 x 109/L Leucocyte count < 8.3 x 109/L 0.77 ( ) 0.84 ( ) 0.70 ( ) 0.80 ( ) 0.74 ( ) 0.80 ( ) 0.44 ( ) 0.82 ( ) 0.64 ( ) 0.81 ( ) 0.73 ( ) 0.83 ( ) 0.67 ( ) 0.90 ( ) 0.62 ( ) 0.86 ( ) 0.78 ( ) .19 .79 .07 .29 .78 .14 .08 .72 Bev, bevacizumab; C/P, cisplatin/pemetrexed; ECOG, Eastern Cooperative Oncology Group; PS, performance status. A subgroup analysis appeared to favor use of bevacizumab across the range of subgroups evaluated. Reference: Zalcman G, Mazieres J, Margery J, et al. Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial. Lancet. 2016;387: 0.5 1.0 1.5 2.0 2.5 3.0 Favors C/P + Bev Favors C/P Slide credit: clinicaloptions.com Zalcman G, et al. Lancet. 2016;387:

23 MAPS: QoL Analysis QoL Questionnaire C30 Scores Global health statusFunctional scales Physical functioning Role functioning Emotional functioning Cognitive functioning Social functioning Symptom scales Fatigue Nausea and vomiting Pain Dyspnea Insomnia Appetite loss Constipation Diarrhea Financial difficulties C/P + Bev C/P Bev, bevacizumab; C/P, cisplatin/pemetrexed; QoL, quality of life. The MAPS study assessed the impact of treatment on quality of life using a patient questionnaire. The proportion of patients who reported an improvement in quality-of-life markers between baseline and follow-up assessment was generally similar between the 2 treatment arms. Patients receiving the triplet regimen reported significantly greater improvement in fatigue and insomnia but less impact in constipation compared with the cisplatin/pemetrexed only arm. Reference: Zalcman G, Mazieres J, Margery J, et al. Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial. Lancet. 2016;387: 5 10 15 20 25 30 35 40 45 Patients improved between baseline and second assessment (%) Slide credit: clinicaloptions.com Zalcman G, et al. Lancet. 2016;387:

24 MAPS: Summary Based on MAPS, regimen now recommended in NCCN guidelines as first-line combination therapy Cisplatin: 75 mg/m2, Day 1 Pemetrexed: 500 mg/m2, Day 1 Bevacizumab: 15 mg/kg Regimen every 3 wks for 6 cycles Follow with bevacizumab maintenance 15 mg/kg every 3 wks until disease progression Based on the results of the MAPS trial, cisplatin/pemetrexed/bevacizumab is now recommended as an option for first-line combination therapy in the NCCN guidelines on MPM. Bevacizumab is given at a dose of 15 mg/kg IV, with cisplatin 75 mg/kg and pemetrexed 500 mg/kg every 3 weeks. It is recommended that the triplet regimen is given for a maximum of 6 cycles of therapy, with continuation of bevacizumab maintenance therapy at 15 mg/kg every 3 weeks until disease progression. Reference: National Comprehensive Cancer Network. Clinical practice guidelines in oncology: malignant pleural mesothelioma. v Available at: https://www.nccn.org. Accessed June 21, 2016. Slide credit: clinicaloptions.com NCCN. Malignant pleural mesothelioma. V

25 Current Salvage Systemic Chemotherapy Options in MesotheliomaNo current standard (FDA approved) therapy for salvage therapy RR: 2% to 15% PFS: mos OS: mos Current choices include: Pemetrexed (RR: 5.5%; RR + SD: 46.6%)[1] (if not administered in first- line; NCCN Category 1) Gemcitabine monotherapy (RR: 0% to 31%)[2] Vinorelbine monotherapy (RR: 16%; OS: 9.6 mos)[3] Clinical trials[4] RR, response rate; SD, stable disease; TTP, time to progression. There are currently no FDA approved second-line therapies for mesothelioma. Typically, response rates for salvage therapies have ranged between 2% and 15%, and PFS between 2.2 and 3.6 months, with OS being highly variable, from months. For patients who are not being treated in a clinical trial, which is our preference, current options include gemcitabine or vinorelbine monotherapy, a combination of gemcitabine and vinorelbine, or rechallenge with pemetrexed may be considered in patients who have not received pemetrexed for at least 6 months. Single-agent gemcitabine has produced response rates between 0% and 31%.[1] Vinorelbine monotherapy produced a response in 16% of 63 patients with relapsed mesothelioma and a median OS of 9.6 months.[2] Combined gemcitabine/vinorelbine was studied in 30 pemetrexed/pretreated patients with mesothelioma.[3] The response rate was 10%, and median survival was 10.9 months. Finally, pemetrexed was evaluated alone and in combination with cisplatin in previously treated patients with MPM.[4] The ORR was 32.5% with the dual regimen and 5.5% for pemetrexed alone, and disease control occurred in 68.7% vs 46.6%, respectively. Median survival was 7.6 months in the combined treatment arm and 4.1 months in the single-agent arm. Before we discuss investigational agents for mesothelioma, let us take a moment to revisit the second polling question. References: Kelly RJ, Sharon E, Hassan R. Chemotherapy and targeted therapies for unresectable malignant mesothelioma. Lung Cancer. 2011;73: Stebbing J, Powles T, McPherson K, et al. The efficacy and safety of weekly vinorelbine in relapsed malignant pleural mesothelioma. Lung Cancer. 2009;63:94-97. Zucali PA, Ceresoli GL, Garassino I, et al. Gemcitabine and vinorelbine in pemetrexed-pretreated patients with malignant pleural mesothelioma. Cancer. 2008;112: Jänne PA, Wozniak AJ, Belani CP, et al. Pemetrexed alone or in combination with cisplatin in previously treated malignant pleural mesothelioma: outcomes from a phase IIIB expanded access program. J Thorac Oncol. 2006;1: 1. Jänne PA, et al. J Thorac Oncol. 2006;1: Kelly RJ, et al. Lung Cancer. 2011;73: Stebbing J, et al. Lung Cancer ;63: NCCN. Malignant pleural mesothelioma. v Slide credit: clinicaloptions.com

26 Novel Agents and Regimens in Clinical Trials

27 Novel Targeted Therapies in MPMEGFR inhibitors and PDGFR inhibitors as single agents have failed to provide response rates Gefitinib (RR: 2%) or erlotinib (RR: 0%) Imatinib mesylate (RR: < 5%) VEGF/VEGFR pathway looked promising Mesothelioma secretes high levels of VEGF suggesting that the angiogenic pathway would be important to focus on in mesothelioma MPM, malignant pleural mesothelioma; RR, response rate. A number of novel agents are currently under investigation for treatment of mesothelioma in clinical trials. Several targeted therapies have been evaluated in mesothelioma, particularly drug classes that target the angiogenic pathway by inhibition of PDGFR, VEGFR and their ligands. Many targeted therapies that have been used in other tumor types have been assessed in trials for mesothelioma. Unfortunately, when used as monotherapies, EGFR and PDGFR inhibitors have not shown significant response rates in this setting. A phase II study of gefitinib in 43 patients with previously untreated malignant mesothelioma observed a complete response in 1 patient (2%) and a partial response in 1 other (2%).[1] Erlotinib and imatinib mesylate produced no objective responses when evaluated as single agents for malignant mesothelioma in phase II studies.[2,3] As noted in our earlier discussion of the MAPS trial, inhibition of the VEGF/VEGFR pathway appears to be a more promising approach. Mesothelioma secretes high levels of VEGF, which suggests that this angiogenic pathway is involved in the proliferative mechanism for mesothelioma tumor cells. Reference: 1. Govindan R, Kratzke RA, Herndon JE 2nd, et al. Gefitinib in patients with malignant mesothelioma: a phase II study by the Cancer and Leukemia Group B. Clin Cancer Res. 2005;11: 2. Garland LL, Rankin C, Gandara DR, et al. Phase II study of erlotinib in patients with malignant pleural mesothelioma: a Southwest Oncology Group Study. J Clin Oncol. 2007;25: 3. Mathy A, Baas P, Dalesio O, van Zandwijk N. Limited efficacy of imatinib mesylate in malignant mesothelioma: a phase II trial. Lung Cancer. 2005;50:83-86. Slide credit: clinicaloptions.com Hiddinga B, et al. J Adv Res. 2015;6:

28 SWOG 0905: Cisplatin/Pemetrexed With VEGFR/PDGFR Inhibitor CediranibPts with unresectable mesothelioma, chemo naive, Karnofsky PS ≥ 70 Cisplatin 75 mg/m2 + Pemetrexed 500 mg/m2 + IV Q3W + Cediranib PO daily Randomized Phase II Chemotherapy maximum 6 cycles Phase I Cisplatin + Pemetrexed + Cediranib Cediranib Doses: Cohort 1: 30 mg Cohort 2: 20 mg Cisplatin 75 mg/m2 + Pemetrexed 500 mg/m2 + IV Q3W + Placebo PS, performance status; QoL, quality of life; RR, response rate. SWOG 0905 is an ongoing phase I/II trial of the VEGFR and PDGFR inhibitor, cediranib, combined with cisplatin/pemetrexed in unresectable MPM.[31] Enrollment to this study was recently completed, and the initial phase I study results were reported at the 2013 ASCO meeting. In phase I, the study enrolled 20 chemotherapy-naive patients into 2 cediranib-dosing cohorts, with all patients receiving cisplatin/pemetrexed. Patients then progressed to a randomized phase II in which they received standard dosing of cisplatin/pemetrexed plus either daily oral cediranib or placebo, with chemotherapy given for a maximum of 6 cycles. The primary endpoint of phase II of the study is the PFS. Reference: Tsao AS, Moon J, Wistubaet II, et al. A phase I study of cediranib (NSC #732208) in combination with cisplatin and pemetrexed in chemonaive patients with malignant pleural mesothelioma (SWOG S0905). Program and abstracts of the 2013 Annual Meeting of the American Society of Clinical Oncology; May 31 - June 4, 2013; Chicago, Illinois. Abstract 7527. Chemotherapy maximum 6 cycles Primary endpoint: PFS Secondary endpoints: safety, OS, RR, QoL Slide credit: clinicaloptions.com Tsao AS, et al. ASCO Abstract 7527.

29 SWOG 0905: Cisplatin/Pemetrexed ± Cediranib Efficacy ResultsSWOG 0905 Cohort[1] RECIST 1.1 RR, % DCR, % mPFS, Mos Modified RECIST RR, % Modified RECIST DCR, % Modified RECIST mPFS, Mos Median OS, Mos All pts (n = 20) 22 89 14 53 79 10 16 30 mg Cediranib (n = 7) 29 86 13 71 20 mg Cediranib (n = 13) 18 75 42 Historical Phase III Trial[2] Cisplatin/Pemetrexed (n = 226) Cisplatin (n = 222) HR P Value RR, % 41.3 16.7 < .001 Median TTP, mos 5.7 3.9 0.68 .001 Median OS, mos 12.1 9.3 0.77 .020 DCR, disease control rate; m, median; RECIST, Response Evaluation Criteria In Solid Tumors; RR, response rate; TTP time to progression. Among 13 patients who received cisplatin/pemetrexed plus cediranib 20 mg/day in phase I of the study, the median OS was 14 months, whereas in 7 patients who received a 30-mg daily dose of cediranib, median OS was 16 months. Response rates were also quite high: 22% overall using Response Evaluation Criteria In Solid Tumors (RECIST) 1.1 criteria and 53% by modified RECIST criteria.[1] When these findings are compared with historical data from the phase III study of cisplatin/pemetrexed vs cisplatin, discussed earlier, there is a significant improvement over the historical control, for which the combined regimen observed a response rate of 41.3% and median OS of 12.1 months.[2] Clearly, the use of cediranib in this setting requires additional investigation. The phase II portion of SWOG 0905 has completed enrollment, and hopefully results will be available in the next year. References: 1. Tsao AS, Moon J, Wistubaet II, et al. A phase I study of cediranib (NSC #732208) in combination with cisplatin and pemetrexed in chemonaive patients with malignant pleural mesothelioma (SWOG S0905). Program and abstracts of the 2013 Annual Meeting of the American Society of Clinical Oncology; May 31 - June 4, 2013; Chicago, Illinois. Abstract 7527. 2. Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21: 1. Tsao AS, et al. ASCO Abstract 7527. 2. Vogelzang NJ et al. J Clin Oncol. 2003;21: Slide credit: clinicaloptions.com Tsao et al. ASCO 2013

30 Arginine Metabolism: Novel Approach For Cancer TreatmentArginine is an amino acid that the human body needs to maintain normal metabolic functions and survive In normal cells, arginine can be obtained via two different routes: External nutritional intake Internal synthesis via urea cycle Some cancer cells lack urea cycle enzyme argininosuccinate synthetase (ASS) and cannot make arginine internally These cells rely exclusively on external supplies of arginine for survival and growth It was reported in the 1990s that many hepatocellular carcinoma and melanoma cell lines are deficient in ASS More recent publications have reported many additional cancer types to also have deficiency in ASS  ASS, argininosuccinate synthetase. The arginine metabolism pathway is also under investigation as a potential target for cancer therapies. In normal cells, arginine is synthesized via the urea cycle or by external nutritional intake and is necessary to maintain normal metabolic functions. Cancer cells commonly lack the urea cycle enzyme argininosuccinate synthetase (ASS) and cannot make arginine internally. Consequently, these cells rely exclusively on external supplies of arginine for their survival and growth, which may mean that ASS is a good target for cancer therapy since this approach would target cancer cells and spare normal cells. Reference: Delage B, Fennell DA, Nicholson L, et al. Arginine deprivation and argininosuccinate synthetase expression in the treatment of cancer. Int J Cancer. 2010;126: Slide credit: clinicaloptions.com Delage B, et al. Int J Cancer. 2010;126:

31 ADI-PEG 20: Novel Treatment For ASS 1- Deficient MPMArginine deiminase (ADI) is a microbial enzyme that catalyzes arginine into citrulline ADI is a homodimer with two identical 46.2 kDa subunits Native ADI is highly antigenic and has a short half-life in vivo ADI-PEG 20 is ADI conjugated with polyethylene glycol of 20,000 M.W.; pegylation increases the circulating half-life and decreases immunogenicity ADI-PEG 20 is administered intra-muscularly once a week and it can efficiently deplete external supplies of arginine from circulation within minutes ASS-deficient cancer cells are fatally affected by ADI treatment because they cannot obtain arginine internally or externally Normal cells are not affected by ADI because they can produce arginine internally via the urea cycle ASS, argininosuccinate synthetase; MPM, malignant pleural mesothelioma. Pegylated arginine deiminase (ADI-PEG 20) is a novel treatment that targets ASS 1–deficient mesothelioma cells by depleting external supplies of arginine, thereby starving cancer cells from circulation. A phase I study of ADI-PEG 20 in combination with cisplatin/pemetrexed observed a PR in 9 of 17 patients (53%) with ASS 1–deficient MPM. Reference: Szlosarek P, Spicer J, Phillips M, et al. Phase 1 dose expansion experience of ADI-PEG20, pemetrexed and cisplatin in patients with malignant mesothelioma (TRAP study). Program and abstracts of the 13th International Conference of the International Mesothelioma Interest Group; May 1-4, 2016; Birmingham, United Kingdom. Abstract MS10.02. Slide credit: clinicaloptions.com Szlosarek PW, et al. J Clin Oncol. 2013;31:e111-e113.

32 Phase II/III POLARIS2015-003/ATOMIC: ADI-PEG 20 in ASS 1–Deficient MPMPhase II (n = 140): ORR; interim PFS to re-estimate phase III sample size Phase III: (n = ~ 232): PFS Coprimary objectives: PFS, ORR Secondary objectives: DCR, OS, DoR, safety Treatment-naive pts with advanced ASS1–deficient MPM of biphasic or sarcomatoid histology, ASS 1 deficiency (IHC) determined by central lab (est. N = 372)* Platinum-Pemetrexed + ADI-PEG 20 Estimated start July 2016 Platinum-Pemetrexed-Placebo ADI-PEG, pegylated arginine deiminase; ASS, argininosuccinate synthetase; DCR, disease control rate; DoR, duration of response; MPM, malignant plural mesothelioma. ATOMIC is an ongoing phase II/III trial of ADI-PEG 20 combined with cisplatin/pemetrexed in ASS 1–deficient chemotherapy-naive mesothelioma patients.[1] Initially, the study will enroll 140 patients (phase II) with an assessment of ORR and PFS. These findings will inform the phase III study, which will include approximately 230 patients and assess for the coprimary endpoint of PFS and ORR. Eligible patients will have ASS 1–deficient disease and biphasic or sarcomatoid histology. ASS 1 deficiency will be detected by immunohistochemistry. The study is estimated to start in July 2016. Reference: ClinicalTrials.gov. Subjects with MPM w/low ASS 1 expression to assess ADI-PEG 20 with pemetrexed and cisplatin (ATOMIC). Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. *~ 70% estimated to be eligible (80% of sarcomatoid, 60% of biphasic). Slide credit: clinicaloptions.com ClinicalTrials.gov. NCT

33 Neurofibromatosis Type 2 Gene (NF2)Located on chromosome 22q12; encoding for the Merlin tumor suppressor protein[1] Loss of function occurs in 40% to 50% of pts with mesothelioma[1-3] Possible gatekeeper gene for asbestos-induced mesothelioma Higher incidence of mesothelioma development occurs in mice with 1 NF2 allele loss that are exposed to asbestos[4] Preclinical data indicate NF2-loss results in increased invasion and increased FAK expression[5] FAK is a nonreceptor tyrosine kinase that mediates growth factor and adhesion-dependent signaling Kinase activity regulates anchorage independent growth and survival The NF2 gene, found on chromosome 22q12, encodes for the tumor suppressor protein, merlin. Mutations in NF2 are found in approximately 40% of patients with mesothelioma.[1] Loss of NF2/merlin is associated with upregulation of FAK,[2] which is a nonreceptor tyrosine kinase that mediates growth-factor and adhesion-dependent signaling and regulates anchorage‑independent growth and survival. References: Thurneysen C, Opitz I, Kurtz S, Weder W, Stahel RA, Felley-Bosco E. Functional inactivation of NF2/merlin in human mesothelioma. Lung Cancer. 2009;64: Poulikakos PI, Xiao GH, Gallagher R, Jablonski S, Jhanwar SC, Testa JR. Re-expression of the tumor suppressor NF2/merlin inhibits invasiveness in mesothelioma cells and negatively regulates FAK. Oncogene. 2006;25: 1. Thurneysen C, et al. Lung Cancer. 2009;64: Bianchi AB, et al. Proc Natl Acad Sci U S A. 1995;92: Sekido Y, et al. Cancer Res ;55: Fleury-Feith J, et al. Oncogene. 2003;22: Poulikakos PI, et al. Oncogene. 2006;25: Slide credit: clinicaloptions.com

34 Phase II COMMAND: Defactinib in MesotheliomaControl Of Mesothelioma with MAintenaNce Defactinib Unresectable mesothelioma; ≥ 4 cycles platinum-pemetrexed with SD or PR; KPS > 70 (N = 344) Randomized Maintenance defactinib 200 mg PO BID Maintenance placebo Stratified by tumor merlin IHC status DSMB, data safety monitoring board; ITT, intention to treat; KPS, Karnofsky performance status; PD, progressive disease; PO, orally; PR, partial response; SD, stable disease. The phase II COMMAND trial was a randomized, placebo-controlled phase II study of the FAK inhibitor defactinib in patients with unresectable mesothelioma.[36] All patients had stable disease or a PR following at least 4 cycles of platinum-based pemetrexed. They were then randomized to receive maintenance defactinib or placebo. Patients were stratified by tumor merlin immunohistochemistry status (high vs low) prior to randomization, and the study aimed to measure the effect of treatment allocation on OS and PFS. Unfortunately, in September 2015, the trial was stopped for futility. There was no difference in efficacy between the 2 treatment arms in the intent-to-treat population or in patients who had merlin-low tumors. It is anticipated that defactinib will probably not be developed further in mesothelioma. Reference: ClinicalTrials.gov. Placebo controlled study of VS-6063 in subjects with malignant pleural mesothelioma (COMMAND). Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. September 2015 COMMAND trial was stopped for futility by DSMB. There was no difference in efficacy between the 2 arms in the ITT population and in patients with merlin-low tumors. Slide credit: clinicaloptions.com ClinicalTrials.gov. NCT

35 Vorinostat in Malignant Pleural Mesothelioma: Phase III StudyVorinostat: SAHA; histone deacetylase inhibitor Stratified by histology, KPS, number of previous regimens Vorinostat 300 mg BID for 3 consecutive days/wk (n = 329) Pts with advanced MPM, KPS ≥ 70, 1-2 previous chemo regimens* (N = 661) Placebo (n = 332) *Most recent must include pemetrexed. KPS, Karnofsky performance status; MPM, malignant pleural mesothelioma; PFT, pulmonary function test; QoL, quality of life; SAHA, suberoylanilide hydroxamic acid. Vorinostat is a histone deacetylase inhibitor, which was investigated in VANTAGE-014, a large phase III trial of 661 patients with advanced MPM who had previously failed 1 or 2 chemotherapy regimens. Participants were randomized to vorinostat vs placebo. The primary endpoint was OS. Reference: Krug LM, Kindler HL, Calvert H, et al. Vorinostat in patients with advanced malignant pleural mesothelioma who have progressed on previous chemotherapy (VANTAGE-014): a phase 3, double-blind, randomised, placebo-controlled trial. Lancet Oncol. 2015;16: Primary endpoints: OS, safety/tolerability First interim analysis after 50 pts had 18 wks follow-up Second interim analysis after 25% of deaths occurred Third interim analysis after 50% of total deaths occurred Correlative studies: tissue collection for genotyping, volumetrics, serial PFTs, symptom and QoL assessment Slide credit: clinicaloptions.com Krug LM, et al. Lancet Oncol. 2015;16:

36 Vorinostat in MPM: PFS and OS (ITT Population)PFS by IRR favored vorinostat but OS was negative 100 Vorinostat (median OS: 31 wks) Placebo (median OS: 27 wks) HR (vorinostat vs placebo): 0.98 (P = .858) 75 OS (%) 50 25 IRR, independent radiologic review; ITT, intent to treat; MPM, malignant pleural mesothelioma. Unfortunately, although PFS was improved with vorinostat by 0.2 weeks and statistically significant, there was no significant benefit regarding OS. Median OS in the vorinostat arm was 30.7 weeks vs 27.1 weeks in the placebo arm (HR: 0.98; 95% CI: ; P = .86). Reference: Krug LM, Kindler HL, Calvert H, et al. Vorinostat in patients with advanced malignant pleural mesothelioma who have progressed on previous chemotherapy (VANTAGE-014): a phase 3, double-blind, randomised, placebo-controlled trial. Lancet Oncol. 2015;16: 168 336 504 672 840 1008 1176 1344 1512 1680 Days Slide credit: clinicaloptions.com Krug LM, et al. Lancet Oncol. 2015;16:

37 Selected Investigational Targeted Agents for Salvage Treatment of MPMMultitargeted Tyrosine Kinase Semaxanib (SU5416) Sunitinib Sorafenib Vatalanib Pazopanib Others Alisertib (aurora kinase inhibitor) Antimesothelin (SS1P, amatuximab, CRS-207, anetumab ravtansine) Bortezomib Brentuximab (CD30+ inhibitor) C-Met inhibitors Focal adhesion kinase (FAK) inhibitors Gene therapy: IFN-β HSV-thymidine kinase adenoviral vectors Immunotherapies Atezolizumab Nivolumab Pembrolizumab Tremelimumab WT-1 vaccine HSV, herpes simplex virus; IFN, interferon; MPM, malignant pleural mesothelioma; WT, wild type. Several other agents have been under investigation for the salvage treatment of mesothelioma, including additional tyrosine kinase inhibitors, immunotherapies, and other targeted agents, such as antimesothelin agents and aurora kinase inhibitors. Slide credit: clinicaloptions.com

38 MetaCore Suite Analysis: Top 10 Pathways Altered in MesotheliomaMSAC pathway is the most significantly altered pathway in surgically resected MPM tumors Log (P Value) 2 4 6 8 10 1 Cell cycle: the metaphase checkpoint Cell adhesion: tight junctions Cell adhesion: endothelial cell contacts by junctional mechanisms Transcription: CREB pathway Cell cycle: spindle assembly and chromosome separation Neurophysiological process: receptor-mediated axon growth repulsion Cell adhesion: histamine H1 receptor signaling in the interruption of cell barrier integrity Regulations of CFTR activity (norm and CF) Cell adhesion: endothelial cell contacts by nonjunctional mechanisms Cell cycle: role of Nek in cell cycle regulation 2 3 4 5 6 CF, cystic fibrosis; CFTR, cystic fibrosis transmembrane conductance regulator; MPM, malignant pleural mesothelioma; MSAC, mitotic spindle assembly checkpoint. Genetic expression profiling has identified key pathways that are altered in mesothelioma. The mitotic spindle assembly checkpoint (MSAC) pathway was noted to be the most significantly altered pathway in a panel of surgically resected mesothelioma tumors. MSAC has also been evaluated in unresectable disease and shown to be a highly dysregulated pathway. Reference: Suraokar MB, Nunez MI, Diao L, et al. Expression profiling stratifies mesothelioma tumors and signifies deregulation of spindle checkpoint pathway and microtubule network with therapeutic implications. Ann Oncol. 2014;25: 7 8 9 10 Slide credit: clinicaloptions.com Suraokar MB, et al. Ann Oncol. 2014;25:

39 Aurora Kinase in MesotheliomaAurora kinase A and B are potential therapeutic targets Aurora kinase A: inhibition leads to mitotic delay, monopolar spindles, and chromosomal segregation errors Aurora kinase B: inhibition causes dysfunctional cytokinesis, polyploidy, and apoptosis Preclinical studies: Aurora kinase gene expression is upregulated in mesothelioma tumor tissue and is a negative prognostic factor[1-3] Aurora kinase inhibitor ZM led to cell growth arrest of mesothelioma cell lines and was target specific[4] Inhibition of survivin and aurora kinase B resulted in mitotic cell arrest of irradiated mesothelioma cells[5] Aurora kinases are among the main proteins involved in MSAC pathway. Both aurora kinase A and B are therefore potential therapeutic targets. Aurora kinase A inhibits mitotic delay, monopolar spindles, and chromosomal segregation errors, whereas aurora kinase B causes dysfunctional cytokinesis, polyploidy and apoptosis. Preclinical studies have shown that aurora kinase A and B gene expression is upregulated in more aggressive mesotheliomas.[1] An aurora kinase inhibitor, ZM447439, has been shown to inhibit cell growth in mesothelioma tissues in a preclinical model, with a target-specific reduction in histone H3 phosphorylation.[2] In addition, aurora kinase B has been shown to induce mitotic cell arrest in irradiated mesothelioma cells.[3] References: 1. López-Ríos F, Chuai S, Flores R, et al. Global gene expression profiling of pleural mesotheliomas: overexpression of aurora kinases and P16/CDKN2A deletion as prognostic factors and critical evaluation of microarray-based prognostic prediction. Cancer Res. 2006;66: 2. Crispi S, Fagliarone C, Biroccio A, et al. Antiproliferative effect of Aurora kinase targeting in mesothelioma. Lung Cancer. 2010;70: 3. Kim KW, Mutter RW, Willey CD, et al. Inhibition of survivin and aurora B kinase sensitizes mesothelioma cells by enhancing mitotic arrests. Int J Radiat Oncol Biol Phys. 2007;67: 1. López-Ríos F, et al. Cancer Research. 2006;66: Romagnoli S, et al. Am J Pathol. 2009;174: Suraokar M, et al. Ann Oncol. 2014;25: Crispi S, et al. Lung Cancer. 2006;70: Kim KW, et al. Int J Radiat Oncol Biol Physics ;67: Slide credit: clinicaloptions.com

40 Phase II Alisertib in MesotheliomaSingle center study (MDACC) Alisertib: selective Aurora kinase A inhibitor Primary objective: 4-mo PFS Secondary objectives: DCR, OS, ORR, DOR, safety Exploratory objectives: tissue/blood biomarkers Pts with unresectable pleural or peritoneal mesothelioma; > 1 prior pemetrexed regimen; ≤ 4 lines of therapy; archived tissue and baseline blood collection (N = 60) Alisertib 50 mg PO BID for 7 d then 2-wk treatment-free period (Cycle = 21 d) DCR, disease control rate; DoR, duration of response. A selective aurora kinase A inhibitor, alisertib is under investigation in an ongoing, single-center phase II trial in 60 patients with unresectable pleural or peritoneal mesothelioma, who have failed at least 1 previous platinum‑based pemetrexed therapy. Alisertib is given orally at a dose of 50 mg twice daily for 7 days, followed by a 2-week treatment-free period, for a 21-day cycle. The primary outcome measure is 4-month PFS. Reference: ClinicalTrials.gov. Phase II trial of alisertib (MLN8237) in salvage malignant mesothelioma. Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. ClnicalTrials.gov. NCT Tsao AS. IASLC Santa Monica. February 2016. Slide credit: clinicaloptions.com

41 Alisertib in Mesothelioma: SafetyAEs ≥ 5% Grade 1 Grade 2 Grade 3 Grade 4 Fatigue 21 Alopecia 18 Mouth sores/blisters 2 3 Anemia 16 Anorexia 15 Thrombocytopenia 8 Somnolence 7 Anxiety/depression 5 AE, adverse event. The preliminary results from this phase II study show that alisertib was well tolerated. There were very few grade 3 events and no grade 4 events. The main findings noted from patients so far have been fatigue, alopecia, mouth sores, anemia, and anorexia, although in most cases these were of grade 1 severity. Reference: Tsao AS. Alisertib in mesothelioma. Program and abstracts of the IASLC 16th Annual Targeted Therapies of Lung Cancer Meeting; February 17-20, 2016; Santa Monica, California. Slide credit: clinicaloptions.com Tsao AS. IASLC Santa Monica. February 2016. Tsao et al. IASLC Santa Monica February 2016

42 Preliminary Disease ControlCycles of Therapy 19 1 cycle = 3 wks 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 17 Pts who are ongoing on trial 16 15 14 13 12 11 10 9 8 7 6 Preliminary findings on disease control were presented at the Santa Monica International Association for the Study of Lung Cancer meeting in February Several patients remain on study. A number of patients gained significant benefit regarding disease response and control beyond the 4-month endpoint. Reference: Tsao AS. Alisertib in mesothelioma. Program and abstracts of the IASLC 16th Annual Targeted Therapies of Lung Cancer Meeting; February 17-20, 2016; Santa Monica, California. 5 4 3 2 1 2 4 6 8 10 12 Slide credit: clinicaloptions.com Tsao AS. IASLC Santa Monica. February 2016.

43 Immunotherapy

44 Different Mechanism of Action Between PD-L1 and PD-1 InhibitorsAnti–PD-L1 Targeting PD-L1 blocks signaling between the tumor cell and both PD-1 and B7.1, preventing downregulation of T-cell activity[1-3] PD-L2/PD-1 interaction is preserved, potentially minimizing effects on immune homeostasis[1] Anti–PD-1 Targeting PD-1 blocks signaling between the tumor cell and PD-1, sparing the interaction between the tumor cell and B7.1[1-3] PD-L2/PD-1 interaction is blocked, potentially increasing autoimmunity[1,4] Numerous novel immunotherapies are in development for mesothelioma. Inhibitors of PD-L1 and PD-1 have demonstrated preliminary efficacy in a range of tumor types.[1] These agents differ in their mechanisms of action. Targeting PD-L1 and PD-1 blocks signaling between the tumor cell and both PD-1 and B7.1 and prevents downregulation of T-cell activity.[2,3] Theoretically, targeting PD-L1 preserves the PD-L2/PD-1 interaction, potentially minimizing the effect on homeostasis, whereas this interaction is blocked when PD-1 is targeted, potentially increasing autoimmunity.[4] References: 1. Chen DS, Irving BA, Hodi FS. Molecular pathways: next-generation immunotherapy–inhibiting programmed death-ligand 1 and programmed death-1. Clin Cancer Res. 2012;18: 2. Paterson AM, Brown KE, Keir ME, et al. The programmed death-1 ligand 1:B7-1 pathway restrains diabetogenic effector T cells in vivo. J Immunol. 2011;187: 3. Yang J, Riella LV, Chock S, et al. The novel costimulatory programmed death ligand 1/B7.1 pathway is functional in inhibiting alloimmune responses in vivo. J Immunol. 2011;187: 4. Brahmer JR, Tykodi SS, Chow LQ, et al. Safety and activity of anti-PD-L1 antibody in patients with advanced cancer. N Engl J Med. 2012;366: 1. Chen DS, et al. Clin Cancer Res. 2012;18: Paterson AM, et al. J Immunol. 2011;187: Yang J, et al. J Immunol. 2011;187: Brahmer JR, et al. N Engl J Med. 2012;366: Slide credit: clinicaloptions.com

45 PD-L1 in Mesothelioma 1.0 PD-L1 negative PD-L1 positive 0.8 0.6 OS (%)PD-L1 identified in mesothelioma tumor cells and associated with poor prognosis 40% (42/106) of pleural mesothelioma pts exhibited PD-L1 expression by IHC with antihuman B7-H1 (clone 5H1-A3) antibody PD-L1 IHC expression correlated with fewer offers of surgery and worse survival (5.0 vs mos without; P < .0001) PD-L1 is a negative prognostic biomarker in mesothelioma 1.0 PD-L1 negative PD-L1 positive 0.8 0.6 IHC, immunohistochemistry; MPM, malignant plural mesothelioma. PD-L1 IHC expression has been identified in mesothelioma cells and associated with poor prognosis. Mansfield and colleagues found that 42 of 106 (40%) patients with MPM exhibited PD‑L1 IHC expression and that patients with PD‑L1 IHC expression had a worse survival (median: 5.0 vs 14.5 months in patients without PD-L1 expression; P < .0001). PD-L1 IHC expression is therefore a negative prognostic biomarker for their patient population. Reference: Mansfield AS, Roden AC, Peikert T, et al. B7-H1 expression in malignant pleural mesothelioma is associated with sarcomatoid histology and poor prognosis. J Thorac Oncol. 2014;9: OS (%) 0.4 0.2 12 24 36 48 60 Mos Slide credit: clinicaloptions.com Mansfield AS, et al. J Thorac Oncol. 2014;9:

46 KEYNOTE-028: PD-1 Inhibitors in MPMStudy design: Nonrandomized, multicohort, phase Ib trial of pembrolizumab for PD-L1–positive advanced solid tumors MPM cohort (N = 84): PD-L1 expression in ≥ 1% of cells in tumor nests or PD-L1–positive bands in stroma as determined by a prototype central lab IHC assay Pembrolizumab 10 mg/kg Q2W for up to 2 yrs or until PD/unacceptable toxicity Primary endpoints: safety/tolerability, preliminary efficacy Response (RECIST v1.1 by investigators) Q8W for 6 mos followed by Q12W thereafter MPM, malignant pleural mesothelioma; PD, progressive disease; RECIST, Response Evaluation Criteria in Solid Tumors. Several ongoing studies are evaluating the use of PD-1 and PD-L1 inhibitors in mesothelioma. The KEYNOTE-028 trial is a nonrandomized phase Ib study of pembrolizumab, an anti–PD-1 monoclonal antibody, in PD-L1–positive advanced solid tumors. The study included a mesothelioma cohort of 84 patients. All patients with mesothelioma had at least 1% of tumor cells identified as positive for PD‑L1, or PD-L1–positive bands in stroma. Pembrolizumab was given at a dose of 10 mg/kg every 2 weeks for up to 2 years or until disease progression or unacceptable toxicity. Response rates were evaluated every 8 weeks for 6 months, followed by every 3 months thereafter. The primary endpoints were safety, tolerability, and efficacy. Reference: Alley EW, Molife LR, Santoro A, et al. Clinical safety and efficacy of pembrolizumab (MK-3475) in patients with malignant pleural mesothelioma: preliminary results from KEYNOTE-028. Program and abstracts of the American Association for Cancer Research Annual Meeting; April 18-22, 2015; Philadelphia, Pennsylvania. Abstract CT103. Slide credit: clinicaloptions.com Alley EW, et al. AACR Abstract CT103.

47 KEYNOTE-028: Efficacy and Safety of Pembrolizumab in MPM45% (38/84) of pts had PD-L1–positive tumors 25 pts were treated (88% with ≥ 1 prior therapy; 28% ≥ 2) ORR: 24% (n = 6); SD: 52% (n = 13); DCR: 76%; PD: 16% (n = 4) No new safety signals with this regimen 60% (n = 15) DRAE: nausea (40%), fatigue (32%), decreased appetite (28%) 12% (n = 3) grade ≥ 3 drug related AE 16% (n = 4) immune-related AE, but only 2 pts required dose interruption No treatment-related discontinuations or mortality AE, adverse event; DCR, disease control rate; DRAE, drug-related adverse event; MPM, malignant pleural mesothelioma; PD, progressive disease; SD, stable disease. Of 84 patients with mesothelioma who were screened, 45% had PD‑L1–positive tumors. Twenty-five patients were treated, and preliminary data from these individuals were presented at the 2015 American Association for Cancer Research annual meeting. The ORR was 24%, with disease stabilization in 52%, for a disease control rate of 76%. There were no new safety signals identified with this regimen. Sixty percent of patients experienced a drug-related adverse event, and those with the greatest incidence were nausea (40%), fatigue (32%), and decreased appetite (28%). Grade 3 or higher drug-related adverse events occurred in 12% of patients. Sixteen percent experienced immune-related adverse events, but only 2 patients required dose interruption. There were no treatment-related deaths or discontinuations. Overall, pembrolizumab appears to be a promising agent for mesothelioma. Reference: Alley EW, Molife LR, Santoro A, et al. Clinical safety and efficacy of pembrolizumab (MK-3475) in patients with malignant pleural mesothelioma: preliminary results from KEYNOTE-028. Program and abstracts of the American Association for Cancer Research Annual Meeting; April 18-22, 2015; Philadelphia, Pennsylvania. Abstract CT103. Slide credit: clinicaloptions.com Alley EW, et al. AACR Abstract CT103.

48 Atezolizumab (MPDL3280A) Humanized anti–PD-L1 antibody that inhibits binding of PD-L1 to PD-1 and B7.1 Inhibiting PD-L1/PD-1 and PD-L1/B7.1 interactions can restore antitumor T-cell activity and enhance T-cell priming Targeting PD-L1 leaves the PD-L2/PD-1 interaction intact, thereby potentially preserving peripheral immune homeostasis Has demonstrated promising response rates in NSCLC that correlated with PD-L1 expression on TC and/or IC IC, tumor-infiltrating immune cells; NSCLC, non-small-cell lung cancer; TC, tumor cells. Atezolizumab is an anti–PD‑L1 antibody that is designed to block interactions between PD-1 and B7.1 receptors. This mechanism of action may preserve some peripheral immune homeostasis and thereby have less risk of autoimmunity. Aspneumonitis is a specific concern in this setting. Atezolizumab has demonstrated promising response rates in non-small-cell lung cancer that correlated with PD‑L1 IHC expression on tumor cells and tumor-infiltrating immune cells. Atezolizumab was also recently approved by the FDA as second-line therapy for patients with advanced urothelial carcinoma. Reference: Fehrenbacher L, Spira A, Ballinger M, et al. Atezolizumab versus docetaxel for patients with previously treated non-small-cell lung cancer (POPLAR): a multicentre, open-label, phase 2 randomised controlled trial. Lancet. 2016;387: Slide credit: clinicaloptions.com Fehrenbacher L, et al. Lancet. 2016;387:

49 SWOG Neoadjuvant Mesothelioma Trial Part 1Resectable mesothelioma; chemo-naive; ESS tissue and serum collection (N = 6) If no progression then surgery; P/D or EPP depending on surgeon’s decision; and then hemithoracic XRT after EPP Maintenance Atezolizumab (1200 mg IV Q3W) x 1 yr Monitor Q9 yrs x 1 yr Cisplatin/ Pemetrexed* *Cisplatin 75 mg/m2, pemetrexed 500 mg/m2 IV Q3W x 4 cycles. EPP, extrapleural pneumonectomy; ESS, extended surgical staging; P/D, pleurectomy/decortication; PD, progressive disease; XRT, radiation therapy. An ongoing trial sponsored by SWOG is evaluating use of atezolizumab in resectable, chemotherapy-naive mesothelioma in the neoadjuvant setting. This 2‑part trial will look at safety and feasibility. In Part 1, the first 6 patients will undergo trimodality or bimodality therapy with cisplatin/pemetrexed and surgery if there is no disease progression. Patients will then receive maintenance atezolizumab at a dose of 1200 mg given IV every 3 weeks for 1 year and will be monitored every 9 weeks thereafter. Serum blood for translational correlates obtained baseline, cycle 1-4, postop, then prior to maintenance therapy, at time of PD Slide credit: clinicaloptions.com Tsao AS, et al. SWOG 1619.

50 SWOG Neoadjuvant Mesothelioma Trial Part 2Resectable mesothelioma; chemo-naive; ESS tissue and serum collection (N = 24) If no progression then surgery; P/D or EPP depending on surgeon’s decision; and then hemithoracic XRT after EPP Maintenance atezolizumab (1200 mg IV Q3W) x 1 yr Monitor Q9 yrs x 1 yr Cisplatin/ Pemetrexed + Atezolizumab* *Cisplatin 75 mg/m2, pemetrexed 500 mg/m2 IV Q3W x 4 cycles + atezolizumab 1200 mg IV Q3W. EPP, extrapleural pneumonectomy; ESS, extended surgical staging; P/D, pleurectomy/decortication; PD, progressive disease; XRT, radiation therapy. If treatment in Part 1 of the study appears to be safe, then Part 2 will include an additional 24 patients who will receive neoadjuvant cisplatin/pemetrexed with atezolizumab and then undergo surgical resection and potentially hemithoracic radiation therapy, followed by maintenance atezolizumab, again for 1 year. The primary endpoints of the study are feasibility and safety, but other endpoints such as surgical toxicity and survival outcomes will also be evaluated. Numerous exploratory endpoints investigating tissue and blood markers are also included. Serum blood for translational correlates obtained baseline, cycle 1-4, postop, then prior to maintenance therapy, at time of PD Slide credit: clinicaloptions.com Tsao AS, et al. SWOG 1619.

51 Wilms’ Tumor-1 WT-1, a nuclear transcription factor, is processed and presented to the cell surface, thus may be an excellent target for immunotherapy WT-1 was first identified in childhood renal tumors mapping to chromosome 11 p13 WT-1 can differentially regulate various genes involved in cell proliferation, differentiation, apoptosis, organ development and sex determination In normal adult tissue, WT-1 is found in low levels in the nuclei of normal CD34+ hematopoietic stem cells, myoepithelial progenitor cells, renal podocytes, testis/ovarian cells WT-1 proteins are involved in tumorigenesis Peptide vaccines derived from WT-1 protein can induce T-cell recognition and attack WT-1-expressing mesothelioma cell lines WT-1 is a nuclear transcription factor that is processed and presented to the cell surface.[1] WT‑1 regulates various genes involved in cell differentiation, proliferation, organ development, and sex determination. In normal adult tissues, WT‑1 is found in very low levels in the nuclei of normal CD34+ hematopoietic stem cells, myoepithelial progenitor cells, renal podocytes, and testis/ovarian cells. It is also typically found in mesothelioma tumor cells. Peptide vaccines derived from WT-1 can induce T-cell recognition and attack WT-1–expressing mesothelioma cell lines.[2] References: 1. Rosenfeld C, Cheever MA, Gaiger A. WT1 in acute leukemia, chronic myelogenous leukemia and myelodysplastic syndrome: therapeutic potential of WT1 targeted therapies. Leukemia. 2003;17: 2. Krug LM, Dao T, Brown AB, et al. WT1 peptide vaccinations induce CD4 and CD8 T cell immune responses in patients with mesothelioma and non-small cell lung cancer. Cancer Immunol Immunother. 2010;59: Slide credit: clinicaloptions.com Rosenfeld C, et al. Leukemia. 2003;17:

52 WT-1 Vaccine for MesotheliomaStimulates peptide-specific CD4+ response that can recognize WT-1 tumor cells in multiple HLA-DRB1 settings Preclinical models showed that human T-cells stimulated with the analog WT-1-A1 can kill WT-1–positive mesothelioma cell lines Vaccine contains 4 separate WT-1 peptides, with SC injection dose of µg WT-1 HLA Class I Peptide (HLA-A0201) WT-A1: YMFPNAPYL 9 aa ( ) WT-1 HLA Class II Peptides (HLA-DRB1) 427 long: RSDELVRHHNMHQRNMTKL 19 aa ( ) 331 long: PGCNKRYFKLSHLQMHSRKHTG 22 aa ( ) 122A1 long: SGQAYMFPNAPYLPSCLES 19 aa ( ) WT-1, Wilms’ tumor-1. Krug and colleagues developed a WT-1 vaccine using analog peptides derived from WT-1 sequences. Nine patients with mesothelioma and 3 with non-small-cell lung cancer were vaccinated. Vaccination was associated with proliferation of CD4+ T-cells in most patients, and the stimulated T-cells demonstrated cytotoxicity against WT‑1–positive tumor cells. Reference: Krug LM, Dao T, Brown AB, et al. WT1 peptide vaccinations induce CD4 and CD8 T cell immune responses in patients with mesothelioma and non-small cell lung cancer. Cancer Immunol Immunother. 2010;59: Slide credit: clinicaloptions.com Krug LM, et al. Cancer Immunol Immunother. 2010;59:

53 Phase II Trial of Adjuvant WT-1 Vaccine in Pts With MPMPI: Dr. Lee Krug, MSKCC Specific immunotherapy: WT-1 Vaccine/Montanide + GM-CSF Pts with MPM after completion of multimodality Tx, including surgery; WT-1 IHC tumor positive (N = 90) Nonspecific immunotherapy: Montanide + GM-CSF Primary endpoint: 1-yr PFS; aim to increase PFS at 1 yr from 50% to 70% Secondary endpoints: confirm immunogenicity of WT-1 analogue peptide vaccine; assess utility of using serum markers (SMRP and osteopontin) for disease progression GM-CSF, granulocyte-macrophage colony-stimulating factor; MDACC, University of Texas M. D. Anderson Cancer Center; MPM, malignant pleural mesothelioma; MSKCC, Memorial Sloan-Kettering Cancer Center; PI, primary investigator; SMRP, soluble mesothelin-related peptide; Tx, treatment; WT-1, Wilms’ tumor-1. A phase II trial evaluated the WT‑1 vaccine in the adjuvant setting in patients who had MPM after multimodality therapy. All patients enrolled on this trial had to have WT‑1–positive mesothelioma by immunohistochemistry. Ninety patients were randomized to receive the WT‑1 vaccine, an incomplete Freund’s adjuvant (IFA) and granulocyte-macrophage colony-stimulating factor (GM-CSF) or an IFA and GM‑CSF alone. The primary endpoint is PFS at 1 year. Reference: ClinicalTrials.gov. Randomized study of adjuvant WT-1 analog peptide vaccine in patients with malignant pleural mesothelioma (MPM) after completion of combined modality therapy. Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. . Open for enrollment MSKCC, MDACC Slide credit: clinicaloptions.com ClinicalTrials.gov. NCT

54 Adjuvant WT-1 Vaccine in Patients With MPM—Survival1.0 1.0 WT-1 Control WT-1 Control 0.9 0.9 0.8 0.8 Median OS, mo (95%CI) WT-1: 24.8 ( ) Control: 16.6 ( ) Median PFS, mo (95%CI) WT-1: 11.5 ( ) Control: 9.9 ( ) 0.7 0.7 0.6 0.6 PFS 0.5 OS 0.5 0.4 0.4 0.3 0.3 0.2 0.2 0.1 0.1 6 12 18 24 30 36 42 48 6 12 18 24 30 36 42 48 WT-1, Wilms’ tumor-1. The trial has completed enrollment, and results were presented at the ASCO meeting in June The WT-1 vaccine showed an improved PFS (11.5 vs 9.9 months) and OS (24.8 vs 16.6 months) over the control arm. A phase III trial is under development. Reference: Zauderer MG, Dao T, Rusch VW, et al. Randomized phase II study of adjuvant WT1 vaccine (SLS-001) for malignant pleural mesothelioma (MPM) after multimodality therapy. Program and abstracts from the 2016 American Society of Clinical Oncology annual meeting; June 3-7, 2016; Chicago, Illinois. Abstract 8519. Mos Mos WT-1 vaccine (galinpepimut-S) is well tolerated and increases PFS and OS in study pts with MPM Galinpepimut-S induced CD4/8 T cell activation Recently granted Orphan Drug Designation, with future studies planned Slide credit: clinicaloptions.com Zauderer M et al. ASCO Abstract 8519.

55 Tremelimumab Tremelimumab is an IgG2 mAb that targets CTLA-4 and blocks its interaction with B7.1 (CD80) and B7.2 (CD86) Enhances T-cell activation by blocking inhibitory effect of CTLA-4 Tremelimumab blocks the inhibitory effect of CTLA-4 and, therefore, enhances T-cell activation Most common AEs reported to date have been dermatologic (rash, pruritus), gastrointestinal (colitis, diarrhea), and fever AE, adverse event; mAb, monoclonal antibody. Tremelimumab is an experimental monoclonal antibody that targets CTLA‑4, an immune checkpoint molecule that interacts with B7.1 and B7.2. This is thought to enhance T-cell activation by blocking the inhibitory effects of CTLA‑4. Reference: Calabrò L, Danielli R, Sigalotti L, Maio M. Clinical studies with anti–CTLA-4 antibodies in non-melanoma indications. Semin Oncol. 2010;37: Slide credit: clinicaloptions.com Calabrò L, et al. Semin Oncol. 2010;37:

56 Tremelimumab in MesotheliomaAn Italian phase II study: 29 previously treated pts with advanced mesothelioma received tremelimumab at a dose of 15 mg/kg every 90 days Preliminary results (as of May 2012) for the 29 subjects suggested that tremelimumab is well tolerated Clinical activity in refractory mesothelioma has been reported Response: 2 PR (including 1 that occurred after initial PD); 7 SD (4 of which have a duration > 180 days); DCR of 33.4% Median PFS: 6.2 mos Median OS: 10.7 mos; 1-yr survival rate: 48.3%; 2-yr survival rate: % DCR, disease control rate; PD, progressive disease; SD, stable disease. Tremelimumab was evaluated in an open-label, single-arm phase II study of 29 patients with unresectable MPM and progression of disease after an initial platinum-based regimen.[55] Participants received tremelimumab at a dose of 15 mg/kg every 90 days. The study did not meet its primary endpoint. Two patients had a PR (7%), one of which occurred after initial progression. Nine patients experienced control of disease, and the median PFS was 6.2 months. Median OS was 10.7 months (range: ). Grade 1/2 treatment-emergent adverse events occurred in 93% of patients, most of which were rash, pruritus, colitis, and diarrhea. Fourteen percent had at least 1 grade 3/4 treatment-emergent adverse event. Reference: Calabrò L, Morra A, Fonsatti E, et al. Tremelimumab for patients with chemotherapy-resistant advanced malignant mesothelioma: an open-label, single-arm, phase 2 trial. Lancet Oncol. 2013;14: Slide credit: clinicaloptions.com Calabrò L, et al. Lancet Oncol. 2013;14:

57 Phase II DETERMINE: Tremelimumab in Pts With Unresectable MesotheliomaRandomized 2:1; stratified by EORTC (low vs high risk), previous lines of therapy (2 vs 3), and primary site (pleural vs peritoneal) Tremelimumab 10 mg/kg IV at 250 mL/hr Q4W for 6 mos, then Q12W until PD or unacceptable toxicity Pleural or peritoneal mesothelioma with 1-2 previous therapy (which included first-line pemetrexed), no autoimmune disease (est. N = 180) Placebo DCR, disease control rate; DoR, duration of response; EORTC, European Organisation for Research and Treatment of Cancer; PD, progressive disease. Tremelimumab was then studied in a placebo-controlled phase II trial, the DETERMINE study. DETERMINE recruited 180 patients with unresectable pleural or peritoneal mesothelioma who had received 1 or 2 previous therapies, including a first‑line pemetrexed-based regimen. Patients were randomized to tremelimumab 10 mg/kg IV at 250 mL/hour every 4 weeks for 6 months and then every 12 weeks until disease progression or unacceptable toxicity The primary outcome measure was OS. In March 2016, it was announced that the DETERMINE trial had failed to meet its primary endpoint of OS. Further development of tremelimumab in mesothelioma will be limited to combination therapies. Reference: ClinicalTrials.gov. Randomized, double-blind study comparing tremelimumab to placebo in subjects with unresectable malignant mesothelioma (tremelimumab). Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. Primary objective: OS Secondary objectives: DCR, PFS, pt-reported outcomes, ORR, DoR, safety Announced March 2016 DETERMINE failed to meet primary objective OS Slide credit: clinicaloptions.com ClinicalTrials.gov. NCT

58 Ongoing Checkpoint Inhibitor TrialsPD-1 inhibitors Pembrolizumab: KEYNOTE-028 (mesothelioma cohort; frontline chemotherapy + pembrolizumab)[1] Nivolumab: Netherlands NivoMes trial[2]; IFCT MAPS2 (nivolumab vs nivolumab + ipilimumab)[3] PD-L1 inhibitors Atezolizumab: SWOG neoadjuvant trial[4] Combination trials Tremelimumab + durvalumab: NIBIT-MESO-1 Italy[5]; Baylor[6] Additional ongoing trials are investigating use of checkpoint inhibitors in mesothelioma. Of the PD-1 inhibitors, the KEYNOTE-028 study discussed above is evaluating pembrolizumab,[1] while nivolumab is under investigation as a single agent in the NivoMes trial and in combination with ipilimumab in MAPS2.[2,3] The combination of tremelimumab with durvalumab is being evaluated in 2 investigator‑initiated studies,[4,5] and, as noted above, SWOG is evaluating use of atezolizumab in resectable, chemotherapy-naive mesothelioma in the neoadjuvant setting. References: 1. Alley EW, Molife LR, Santoro A, et al. Clinical safety and efficacy of pembrolizumab (MK-3475) in patients with malignant pleural mesothelioma: preliminary results from KEYNOTE-028. Program and abstracts of the American Association for Cancer Research Annual Meeting; April 18-22, 2015; Philadelphia, Pennsylvania. Abstract CT103. 2. ClinicalTrials.gov. Nivolumab in patients with recurrent malignant mesothelioma (NivoMes). Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. 3. ClinicalTrials.gov. Nivolumab monotherapy or nivolumab plus ipilimumab, for unresectable malignant pleural mesothelioma (MPM) patients (MAPS2). Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. 4. ClinicalTrials.gov. A study of tremelimumab combined with the anti-PD-L1 MEDI4736 antibody in malignant mesothelioma (NIBIT-MESO-1). Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. 5. ClinicalTrials.gov. MEDI4736 or MEDI tremelimumab in surgically resectable malignant pleural mesothelioma. Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. 1. ClinicalTrials.gov. NCT Clinicaltrials.gov. NCT Clinicaltrials.gov. NCT Tsao AS, et al. SWOG ClinicalTrials.gov. NCT ClinicalTrials.gov. NCT Slide credit: clinicaloptions.com

59 Mesothelin Cell surface glycoproteinExpression in normal human tissues limited to the mesothelial cells lining pleura, peritoneum, and pericardium Cell membrane Precursor protein (71 kDa) GPI Furin Antimesothelin agents are another important class of drugs in mesothelioma. Mesothelin is a cell surface glycoprotein expressed in normal human tissues, specifically mesothelial cells lining the pleura, peritoneum, and pericardium.[1,2] References: 1. Chang K, Pastan I. Molecular cloning of mesothelin, a differentiation antigen present on mesothelium, mesotheliomas, and ovarian cancers. Proc Natl Acad Sci U S A. 1996;93: 2. Pastan I, Hassan R. Discovery of mesothelin and exploiting it as a target for immunotherapy. Cancer Res. 2014;74: GPI Mesothelin (40 kDa) MPF (31 kDa) Image courtesy of Dr. Raffit Hassan. Chang K, et al. PNAS USA. 1996;93: Pastan I, et al. Cancer Res. 2014;74: Slide credit: clinicaloptions.com

60 Anti-Mesothelin Antibody Localizes to Mesothelin Expressing Human CancersUptake of 111In-MORAb-009 in a pt with metastatic mesothelioma CT Scan SPECT Imaging Mesothelin IHC SPECT, single-photon emission computerized tomography. Antibodies targeting mesothelin, including amatuximab, have been shown to localize it to mesothelin-expressing cancers. The images to the right show targeted amatuximab uptake in a patient with metastatic mesothelioma. Reference: Lindenberg L, Thomas A, Adler S, et al. Safety and biodistribution of 111In-amatuximab in patients with mesothelin expressing cancers using single photon emission computed tomography-computed tomography (SPECT-CT) imaging. Oncotarget. 2015;6: SPECT/CT Fusion Image Lindenberg L, et al. Oncotarget. 2015;28: Images courtesy of Dr. Raffit Hassan. Slide credit: clinicaloptions.com

61 Pilot Study: SS1P with Pentostatin and Cyclophosphamide in MPMPreviously treated pts with treatment refractory and progressive disease Determine safety and feasibility of this regimen Primary endpoint: determine if pretreatment with pentostatin and cyclophosphamide can delay anti-SS1P antibody formation Cycle 1 (Days 1-30) Cycle 2 and 3 (Days 1-21) Day (Days 1-12) (Days 1-4) Cyclophosphamide (200 mg/day) MPM, malignant pleural mesothelioma. SS1P, an antimesothelin immunotoxin, has been evaluated in a pilot trial in 10 patients with chemotherapy-refractory mesothelioma. Patients also received pentostatin and cyclophosphamide. Three patients experienced major tumor regression, 3 had stable disease, and 4 had progressive disease. Reference: Hassan R, Miller AC, Sharon E, et al. Major cancer regressions in mesothelioma after treatment with an anti-mesothelin immunotoxin and immune suppression. Sci Transl Med. 2013;5:208ra147. 1 5 9 1 Pentostatin (4 mg/m2) 10 12 14 2 4 6 SS1P (35 or 45 µg/kg) Hassan R, et al. Sci Transl Med. 2013;5:208ra147. Slide courtesy of Dr. Raffit Hassan. Slide credit: clinicaloptions.com 61

62 Pilot Study: Antitumor Response to SS1P Chemotherapy in MPMPt 5 with widely metastatic peritoneal mesothelioma MPM, malignant pleural mesothelioma. The images on the right are from a patient with metastatic peritoneal mesothelioma who was treated with SS1P and experienced a 70% tumor shrinkage at 5 months, which was maintained at 8 months of therapy. Reference: Hassan R, Miller AC, Sharon E, et al. Major cancer regressions in mesothelioma after treatment with an anti-mesothelin immunotoxin and immune suppression. Sci Transl Med. 2013;5:208ra147. Before treatment 1.6 mos 8.0 mos Hassan R, et al. Sci Transl Med. 2013;5:208ra147. Images courtesy of Dr. Raffit Hassan. Slide credit: clinicaloptions.com

63 Phase II ARTEMIS: Amatuximab/Pemetrexed and Cisplatin for Unresectable MPMA randomized, double-blind, placebo controlled study Primary endpoint: OS 80% power to detect a statistically significant treatment effect at a 2-sided α = 0.05 Interim analysis for futility after approximately 86 OS events Stratified by ECOG PS Pemetrexed/Cisplatin Q3W x 4-6 cycles Amatuximab 5 mg/kg/wk Previously untreated epithelial MPM (est. N = 560) Until disease progression Pemetrexed/Cisplatin Q3W x 4-6 cycles Placebo weekly Cis, cisplatin; ECOG, Eastern Cooperative Oncology Group; MPM, malignant pleural mesothelioma. Amatuximab is currently under investigation in the randomized, double-blind, placebo-controlled phase II ARTEMIS trial. ARTEMIS is evaluating cisplatin/pemetrexed with and without amatuximab in previously untreated patients with epithelial MPM. Patients receive cisplatin/pemetrexed every 21 days, plus either amatuximab or placebo weekly, for 6 cycles until disease progression. The trial will enroll 560 patients, and the primary endpoint is OS. Reference: ClinicalTrials.gov. Study of the safety and efficacy of amatuximab in combination with pemetrexed and cisplatin in subjects with unresectable malignant pleural mesothelioma (MPM). (ARTEMIS). Available at: https://clinicaltrials.gov/ct2/show/NCT Accessed June 21, 2016. Slide courtesy of Dr. Raffit Hassan. Slide credit: clinicaloptions.com ClinicalTrials.gov. NCT

64 Conclusions: More Funding Is Needed to Invest in Mesothelioma ResearchGene mutations (BAP1, NF2 loss) identify distinct populations of mesothelioma pts and may ultimately guide therapeutic decisions Identification of prognostic and predictive biomarkers is crucial Design future targeted therapy trials around predictive biomarkers, ideally in the neoadjuvant setting Account for tumor heterogeneity and consider multiple biopsies from different sites of the tumor Mechanisms of drug resistance must be elucidated; design trials with biopsies at different time points during therapy This is a very exciting time with many developments for mesothelioma care. We now know that there are gene mutations, such as BAP1 and NF2, which can identify distinct populations of patients with mesothelioma. This observation may lead to different screening practices and possibly to different therapeutic decisions in the future. We still need to identify prognostic and predictive biomarkers and use these to design our future targeted therapy trials, ideally in the neoadjuvant setting. We also need to account for tumor heterogeneity and consider multiple biopsies from different sites of the tumor to understand the natural biology of this disease better. Finally, we need to identify mechanisms for drug resistance by designing our trials to include biopsies at different time points during therapy. Thank you for your participation. Slide credit: clinicaloptions.com

65 Go Online for More CCO Coverage of Thoracic Cancers!Expert reviews of key thoracic cancer data Additional slidesets on thoracic cancer management with expert faculty commentary on key studies Webcast presentations by expert faculty regarding treatment strategies for patients with thoracic cancer clinicaloptions.com/oncology