Eva Gallardo, MD Medical Manager, Biocompatibles UK

1. Drug Eluting Bead: Advanced Applications Colorectal Metastases Neuroendocrine Metastases Combination with RFA Eva Gallardo, MD Medical Manager, Biocompatibles UK

2. DEB: Clinical Programme Primary Liver Cancer Colorectal Metastases Very Early/Early Stage Prior to resection Bridge to transplant RFA + PRECISION TACE Intermediate Stage Precision I Precision II Precision V Advanced Stage Sorafenib + PRECISION TACE EarlyCT Lines Late Stage Doxorubicin Bead Irinotecan Bead Other Primary Cancers Secondary Liver Cancer Renal Breast Cholangiocarcinoma Melanoma Gastric Neuroendocrine Sarcoma

3. PRECISION TACE in treatment of Colorectal Metastases Investigators: Camillo Aliberti, MD Giammaria Fiorentini, MD Department of Diagnostic and Interventional Radiology, Delta Hospital AUSL Ferrara, Ferrara Italy Department of Oncology, General Hospital San Giuseppe, Empoli, Florence, Italy

4. Advanced Colorectal Cancer • The liver is the most common site of metastatic disease. • 15-30% of patients will have synchronous liver metastases at the time of diagnosis. Up to 60% will develop hepatic metastases during the course of their disease • Metastatic disease in the liver is the primary determinant of survival in patients with colorectal cancer • Low (around 20%) response rates to 5-FU containing chemotherapy regimens

5. Median Survival in First Line Phase III Studies Months Best supportive care 5 BMJ 1993 Biomodulation of 5-FU 10 Piedbois JCO1992 14 Saltz NEJM2001 (IFL) Irinotecan/5-FU/LV 15 2004 GoldbergJCO (IFL) 17 DouillardLancet 2000 (Folfiri) 16 De GramontJCO 2000 (Folfox) Oxaliplatin/5-FU/FA 20 Goldberg JCO 2004 (Folfox) FOLFOX/FOLFIRI 22 sequential 2 drugs TournigandJCO 2004 23 FOLFOXIRI Falcone ASCO 2006 concurrent 3 drugs - no biologics Hoschster ASCO 2006 - TREE2 Oxali/Bev + salvage CP11 24.4 2 drugs+biologic+salvage 25.1 Hurwitz NEJM 2004 IFL/Bev + salvage Oxali **subgroup

6. Rationale for Chemoembolization treatment in metastatic CRC • Blood supply from hepatic artery • Maximize tumour cell kill while minimizing toxicity to normal tissues (heavily systemically treated patients) • Increase tumour response throughout increased drug delivery into tumour • Increase resectability rates

7. Disease control after Chemoembolization • n= 207 • Local tumour control: • Partial response: 12%, stable: 51%, progression: 37% • Survival rates: • 1y: 62%, 2y: 38% • Median survival times: • From diagnosis: 3.4y, from TACE: 1.34y Prof T Vogl, ASCO 2007

8. Irinotecan Bead in Advanced Colorectal Cancer: Patient Selection • 62 patients (M/F = 42/20), median aged 64.6 (range 42-85) • Not operable and pretreated at least two lines of chemo (range 2-6) • Measurable lesions with size > 1cm • Tumour burden <70% of liver volume • Presence of minimal extrahepatic sites • Performance Status: 0-2 (WHO criteria), life expectancy >3 months, age < 86 years • Normal or 2xN bilirubine

9. Irinotecan Bead in Advanced Colorectal Cancer: Methods • Diagnostic angiography (DSA) was performed • Under fluoroscopic guidance, a solution of DC beads loaded with Irinotecan and mixed with non-ionic contrast was injected into: RHA 39%, LHA 36%, RHA & LHA 25% • Maximum dose 4 ml (2ml of 100-300mm and 2ml of 300-500mm) with 200mg of Irinotecan • 2-3 TACE 4 weeks

10. Irinotecan Bead in Advanced Colorectal Cancer: Feasibility • 138 TACE procedures • 48 with 100mgr Irinotecan into 2ml DC Bead • 98 with 200mgr Irinotecan into 4ml DC Bead (no significant toxicity observed) • 100% technical success • One case of acute pancreatitis, resolved spontaneously

11. Irinotecan Bead in Advanced Colorectal Cancer: Toxicity Postembolization-syndrome

12. Irinotecan Bead in Advanced Colorectal Cancer: Toxicity Postembolization-syndrome: Selected Therapy • Prophylactic treatment against nausea • Tropisetron 5mg, 1 vial before TACE and at +6 hours,Prednisone 25mg tb 08.00 am and 08.00 pm day 0,+1,+2,+3,+4,+5 • Prophylactic treatment against pain • Morphine 10mg, 1 vial, 30 minutes before TACE and at +6 hours. • Intra-arterial Lidocaine 5ml just before TACE. • Prophylactic treatment against infection • Cefazolin 2000mg 08.00 am and 08.00 pm day 0,+1,+2 • On day +1, +2 at 08.00 am and 08.00 pm following observed symptoms.

13. Irinotecan Bead in Advanced Colorectal Cancer: Response to Treatment • The median follow-up was 15.4 months • 1 month CT scan showed reduction of metastatic CE 85%, range 75-100% in all patients • RECIST at 3 months: 78% • 55/62 pts (90%) declared a general improvement of QoL lasting 6.5 months, range 3-12 

14. Irinotecan Bead in Advanced Colorectal Cancer: Survival • Median survival not reached at 22 months • Median Free Time from symptoms 5.3 (5-20 months) • Median Time to further chemoteraphy 6.3 (5-22 months )

15. Irinotecan Bead in Advanced Colorectal Cancer: Cases 18 months after TACE

16. Irinotecan Bead in Advanced Colorectal Cancer: Cases 09.2005 02.2005 6 months after TACE

17. Irinotecan Bead in Advanced Colorectal Cancer: Conclusion • TACE with Irinotecan DC Bead could be proposed as palliative therapy for unresectable pretreated Liver Metastases from CRC • Promising preliminary results should be confirmed in further studies in larger population

18. Neuroendocrine Metastasis Principal Investigator: Thierry De Baere, MD Chief of Interventional Radiology Department Institut de Cancérologie Gustave Roussy - Villejuif - France

19. NeuroendocrineTumours • Variety of primaries with shared characteristics including hormone secretion, high vascularization and somatostatin receptor expression • Tumours arise most often from the gastro-intestinal tract and mainly the small bowel • The malignancy grade and the stage at diagnosis are the two major prognostic factors

20. Management Protocol

21. Reported HAE and HACE Series

22. Doxorubicin Bead in NET:Materials and Methods • 20 patients with liver metastases from low-grade GEP tumour • Progressive liver disease on two subsequent imaging studies according to RECIST criteria • Disease predominant to the liver • Up to 4ml DC Bead 500-700mm loaded with up to 100mg doxorubicin • Concomitant treatment with long-acting ST analog

23. Doxorubicin Bead in NET:Results • 34 sessions (6 unilobar, 14 bilobar) • RECIST 3M: • 16/20 (80%) partial response • 3/20 (10%) stable disease • 1/20 (15%) progressive disease • After a median follow-up of 15 months (6-24), disease remained controlled without tumour progression in 45% • 1 patient become resectable Median Time to Progression: 15 months

24. Doxorubicin Bead in NET:Toxicity • Post-embolisation syndrome: • < 7 days in 67% sessions • > 7 days in 22% sessions • No symptoms in 11% sessions • Hypodense subsegmental peripheral areas (TACE-induced necrotic liver tissue?) in 5 patients at 1 month CTscan • 1 death: resected patient due to postoperative septic complications

25. Doxorubicin Bead in NET:Cases

26. Doxorubicin Bead in NET:Cases

27. Doxorubicin Bead in NET:Cases Tumour resected 2 months after PRECISION TACE

28. Doxorubicin Bead in NET: Conclusion • TACE with doxorubicin bead yielded a 90% response rate in patients with progressive liver metastases from a GEP tumor without severe complications • These promising preliminary results warrant a comparative study in a larger population

29. Combined PRECISION TACE/RFA: Results and Outcome Principal Investigator: Riccardo Lencioni, MD Associate Professor of Diagnostic and Interventional Radiology Department of Oncology, Transplants, and Advanced Technologies in Medicine – Pisa University, Italy

30. TACE New agents BSC HCC PST > 2 Child Pugh C PST 0 Child Pugh A PST 0-2, Child-Pugh A-B Very early stage Single < 2 cm Early stage Single or 3 < 3 cm PS 0 Intermediate stage Multinodular PS 0 Advanced stage Portal invasion N1 – M1 PS 1-2 Terminal stage Associated diseases Single No portal HT Normal bilirubin No Yes Resection Transplant Ablation

31. RFA: Inherent Limitations Bio-Heat Equation Coagulation Necrosis Energy Deposited Tissue Interactions Heat Loss = x - modified from Goldberg SN et al, AJR 2000

32. Sub-lethal heating(45-50 °C) Vessel RFA: Inherent Limitations 50 °C

33. RFA plus Doxorubicin vs RFA Alone in Animal Tumour Models modified from Ahmed et al, Radiology 2005

34. RF-induced coagulation Increased peripheral necrosis Normal tissue RFA plus Doxorubicin vs RFA Alone in Animal Tumour Models modified from Ahmed et al, Radiology 2005

35. Combined TACE / TAE and RFA in HCC • Rossi S, Radiology 2000 • Yamasaki T, Cancer 2001 • Yamakado K et al,JVIR 2002 • Gasparini D, Radiol Med 2002 • Akamatsu M, Liver Int 2004 • Luo BM, World J Gastroenterol 2005 • Maluccio M, JVIR 2005 • Shen SQ, Hepatogastroenterology 2005 • Yamasaki T, J Gastroenterol 2005 • Liu YM, World J Gastroenterol 2006 • Veltri A, Eur Radiol 2006 • Kurokohchi K, Oncol Rep 2006 • Lim HS, AJR 2006 • Takaki H, JVIR 2007 • Kobayahi M, Liver Int 2007 • Helmberger T, Digestion 2007 • Wang JB, Qual Life Res 2007 • Liao GS, Eur J Surg Oncol 2008 • Fuke H, Aliment Pharmacol Ther 2008 • Yamakado K, Radiology 2008 20 clinical studies all “support” the combined approach

36. DC Bead (Biocompatibles, UK): embolic microsphere that has the ability to actively sequester doxorubicin hydrochloride from solution and release it in a controlled and sustained fashion Hypothesis: intra-arterial administration of doxorubicin eluting bead to HCC tumours incompletely killed by RFA induces necrotic phenomena in peripheral areas exposed to sub-lethal heating, improving tumour response DEB-Enhanced RFA of HCC: A Pilot Study Background / Hypothesis Lencioni R et al, J Hepatol 2008 (in press)

37. Prospective, intention-to-treat, single-arm pilot study Primary endpoints: safety and tumour response • Inclusion criteria • Adult patient with single HCC 3.0 – 7.0 cm • Residual viable tumour at CT / MRI 1-2 hrs after RFA • - Child-Pugh class A, ECOG 0, ASA ≤ 3 • - PT ratio > 50%, platelets > 50,000/mm3 • Exclusion criteria • - Eligibility for liver resection or transplantation • - Vascular invasion / extrahepatic disease • - Any previous treatment for HCC DEB-Enhanced RFA of HCC: A Pilot Study Design / Enrollment Criteria

38. 20 pts (mean age, 70 ± 6 ) enrolled 09/05 – 11/06 • - Tumour diameter 3.3-7.0 cm (mean, 5.0 cm ± 1.4) Follow-up period 6-20 months (mean, 12 months ± 5) • DC Bead (Biocompatibles) injection < 24 hrs of RFA • - 50 mg doxorubicin in 2 ml of 100-300 μm beads • - Additional loads (100-300 / 300-500 µm) if needed • Tumour response: RECIST criteria - EASL amendment • - CR: absence of enhancement at 1-month CT / MRI • - Confirmed CR: CR lasting no less than 6 months • - OR: confirmed CR target lesion, no new lesions DEB-Enhanced RFA of HCC: A Pilot Study Materials and Methods

39. DEB-Enhanced RFA of HCC: A Pilot Study Results – Change in Ablation Volume 180,000 160,000 140,000 61% + 120,000 100,000 Ablation Volume (mm3) 80,000 60,000 40,000 20,000 0,000 Standard RFA DEB-Enhanced RFA

40. DEB-Enhanced RFA of HCC: A Pilot Study Results – Clinical Case # 2 6 cm Pre-treatment CT

41. DEB-Enhanced RFA of HCC: A Pilot Study Results – Clinical Case # 2 MRI after standard RFA

42. DEB-Enhanced RFA of HCC: A Pilot Study Results – Clinical Case # 2 DEB administration

43. DEB-Enhanced RFA of HCC: A Pilot Study Results – Clinical Case # 2 MRI after DEB administration

44. Final Response (mean follow-up, 1 year) 15 12 10 6 5 2 CR IR PD DEB-Enhanced RFA of HCC: A Pilot Study Results – Target Tumour Response Initial Response (1-month CT / MRI)) 14 15 10 6 5 CR IR PD

45. DEB-Enhanced RFA of HCC: A Pilot Study Results – Overall Response Table. Overall Response at the End of Follow-Up New lesions No. (%) Overall response Target lesions NoNoYesYes / No CRPRCR / PRPD 10 (50%)5 (25%) 3 (15%) 2 (10%) CRPRPD Note: Numbers are numbers of patients. Overall number of patients: 20.

46. 30 24 DEB-Enhanced RFA of HCC: A Pilot Study Results – Overall Survival 100% 92% 100 80 60 40 20 DEB-enhanced RFA (n = 20) 0 0 6 12 18 months

47. DEB-Enhanced RFA of HCC: A Pilot StudyResults – Conclusion • This pilot clinical study provides the first evidence of the synergy between RF ablation and local delivery of a chemotherapeutic agent in human cancer treatment • Intraarterial DEB administration substantially increased the effect of RF ablation and did not cause any major complication. DEB-enhanced RF ablation induced a high rate of CR and has potential to become the standard of care for uninodular nonsurgical HCC resistant to standard RF treatment