WHO ARE WREN LABORATORIES WHAT IS THE NETEST

WHO ARE WREN LABORATORIES WHAT IS THE NETEST? HOW DOES IT WORK AND HOW CAN IT HELP ME OR A MEMBER OF MY FAMILY

Introducing Wren Laboratories § Founded in 2013, by international authorities in the field of Neuroendocrine Tumors § Developed a multi-gene blood based assay that can accurately measure the biological activity of a NET § Similar Wren assays available for other cancers: colon, lung, ? breast, prostate and melanoma and myeloma § Wren is a CLIA-certified laboratory in Branford, Connecticut § NETest globally available and used in >50 different institutions worldwide § Currently, >10, 000 patients evaluated and peer-reviewed publications in >40 US and European medical and scientific journals

Wren Laboratories: Mission Statement § To develop an easily accessible, real-time molecular genomic tool to facilitate the diagnosis and management of neuroendocrine tumor disease. ? § To ensure that molecular genomic information for a specific person and tumor can be utilized to enhance the NET care pathway. § To enable patients and physicians to establish objective strategies that will positively inform clinical decision-making and add value to currently available imaging techniques. § To enable Liquid biopsy real time information to amplify management of NETdisease

What is a Neuroendocrine Tumor?

Neuroendocrine Cell Neoplasia § Neuroendocrine cells are sensory cells with ubiquitous distribution throughout the body § Neuroendocrine tumors (NETs) (also called carcinoids), represent abnormal neuroendocrine proliferation § Located in the GI tract, lung and pancreas § Tumor growth ranges from slow to highly aggressive with local invasion, hepatic, lung and bony metastases

Tumor Distribution § The majority (60%) occur in gut and pancreas (GEP) § Substantial number (>30%) in lung and rectum ~30%) § 60 -70% are metastatic at diagnosis. Average life expectancy after diagnosis: 4 -10 years

In 2003, Prof Irvin Modlin and Dr Mark Kidd were the first to identify the increasing incidence of NET disease . Subsequently more than 50 further publications by others confirmed the observation

This increase in disease represents Increased awareness and more effective Diagnostic Strategies. I. M Modlin MD

The Prevalence and Incidence of NETs Incidence steadily increasing (~5%/yr): Prevalence >50, 000 annually

What is a Biomarker?

Standard biomarkers Cg. A nin Gast Seroto rin Insulin l ina t s te n I ive tide t c oa lypep s a V Po NET 5 HIAA l. IMITE Ne uro n. S Pancreatic Polypeptide pe ci fic En ola se Limited if any value NO EFFECTIVE UNIVERSAL BIOMARKER FOR NETS

Monoanalytes versus Multianalytes Monoanalyte: A single type of product Provide 1 -dimensional data Limited information (simple biological processes) Multianalyte: Many products Provides multidimensional data Significant information capture (multiple biological processes)

The Novel Alternative - Liquid Biopsy Plasma: proteins, hormones, circulating DNA/RNA (m. RNA/mi. RNA) Cellular compartment: WBCs, platelets Circulating Tumor Cells “Oncosomes” Tumor Exosomes Circulating Nucleic Acids 0+ /10 ml 1010 -1012/10 ml pg-ng/10 ml Whole blood Analysis captures the tumor fingerprint

Liquid Biopsies Effective in Other Cancers § BREAST: Multigene classification assays (microarrays – tumor pathology e. g. , Mamma. Print, Oncotype Dx, etc) § PROSTATE: Multigene classification assays e. g. , Prolaris, Oncotype Dx § LEUKEMIA/MYELODYSLASTIC SYNDROME: Mutation testing § LUNG: EGFR mutation testing § COLON: Mutation/gene screens § GLIOBLASTOMA: Mutation/gene screens WHY NOT IN NETs? 14

NETest If positive : I have a NET !!! Now what? ? ? The Netest provides an Assessment of the NET “activity” Of a specific individual and their unique tumor during the entire course of the disease. THE SCORE IS THE MEASUREMENT OF THE MACHINERY THAT DRIVES TUMOR

Tumor genes in the blood TUMOR Modlin I et al. Plos. One 2013; e 63364 Kidd M et al. ERC 2015; 22: 561 -75 BLOOD NETest is a circulating molecular fingerprint that captures GEP-NET pathobiology and provides a disease activity risk scale (0 -100%)

Is the NETest more accurate than other biomarkers?

NETest vs other biomarkers Numerous validation studies have demonstrated greater accuracy and reliability of the NETest over currently used one-dimensional biomarkers NETest vs. Cg. A Metrics mete Optimal Biomarker Metric level NETest outperforms single tumor markers in all analytical metrics Modlin I et al. Plos. One 2013; e 63364 Modlin, Kidd et al. ERC 2014; 21: 615 -28

NETest versus Two Different Cg. A assays mete NETest outperforms 2 different Cg. A assays 99% accurate for image-detectable disease Detects residual disease even if image negative ! Malczewska et al. Neuroendocrinology 2020

How does NETest information provide actionable clinical information? Clinical Examples demonstrating the clinical utility of the NETest

Case Review # 1 Surgical Cure Male, 47 year, Caucasian Diagnosis: 5/2010 Asymptomatic screening colonoscopy Endoscopy: 5/2011; resection - 1. 5 cm NET, Cg. A negative on histology, Ki 67=4 -10% 80% Endoscopic Resection 60% Prophylactic SSAs discontinued 20% 2010 Colonoscopy 2010 2011 Post-Surgery CT/MRI: No findings 2012 15% 2014 -5 Serial imaging (e. g. , 68 Ga-PET) and biomarkers no longer required

Case Review #2 Evidence of effective surgical Resection…. ? Residual Disease Male, 72 year, Caucasian Diagnosis: 9/2009 (bleeding; initially 4/2007) Surgery: 2015; laparoscopic ileal resection (1. 2 cm NET, well-differentiated) Cg. A NORMAL Follow-up: No treatment, wait-and-watch Ileal resection 87% 48% 55% 20% Cg. A 2010 2011 2012 -2015 4/2016 CT-ve 68 Ga-PET-CT 6 mm LN ? +ve LN: 9 mm 1. 5 cm LN + 2 x NETs 6/2016

Case Review #3 – Am I “cured” (GEP-NET)? Female, 69 year, African American Diagnosis: 6/2009 (mixed symptomatology – INCORRECTLY considered “fauxnoid”) NETest elevated: correct diagnosis established Surgery: 2015; laparoscopic ileal resection (0. 6 cm NET, well-differentiated) Follow-up: No treatment, wait-and-watch Before surgery POS After surgery Negative NETest score Molecular signature confirms complete resection Surgery was effective for disease control (tumor removal)

Case Review #4 – Am I “cured” (BPNET)? Female, 58 year, Caucasian Diagnosis: 5/2013 (no symptoms, incidental finding on MRI) NETest elevated: correct diagnosis established Surgery: 2015; thoracotomy (LLL) (1. 1 cm NET, TC no lymph nodes positive) Follow-up: No treatment, wait-and-watch Before surgery After surgery POS Negative NETest score Molecular signature confirms complete resection Surgery was effective for disease control (tumor removal)

Case Review #5 – Detecting residual disease? Female, 64 year, Caucasian Diagnosis: 11/2011 atypical lung NET Three years of negative imaging and normal Cg. A levels. NETest always elevated Surgery: 2013; lower left lobectomy (1. 2 cm NET, AC lung carcinoids) Follow-up: No treatment, wait-and-watch 2018 2016 2017 POS 2015 NETest positive since 2015 Detected residual disease 3 years before identified by imaging! IMAGING POS Liver Metastases

Case #5 – What treatment needed - PRRT? PREDICTING THERAPY “COMPANION” DIAGNOSTIC 2018 MY PRRT SCORE 2018 2016 2017 2015 DIAGNOSED METASTATIC DISEASE WHAT TREATMENT PRRT? ? ? Prediction of Response to PRRT Molecular tool predicts patient will respond to PRRT (99%)

Case #5 – Response to PRRT! 2019 MOLECULAR TARGETED THERAPY MULTIGENE MOLECULAR SIGNATURE 2017 2016 2018 Before PRRT After PRRT 2019 2015 BEFORE AFTER Effective control of metastases using molecular-based diagnosis, treatment prediction and monitoring

What information can the NETest provide?

Clinical Utility of the NETest 1. Accurate diagnosis for: a. gastro-enteropancreatic NETS b. Bronchopulmonary NETs c. Familial Syndromes e. g. , MEN-1 d. Pheochromocytomas/Paragangliomas 2. Sensitive tool to define effectiveness of surgery 3. Sensitive tool to detect residual disease 4. Sensitive tool to identify drug efficacy 5. Sensitive tool to identify PRRT efficacy 6. Sensitive tool to monitor disease progression 7. More accurate, safer and sensitive than imaging 8. Potential to reduce costs and improve outcomes

Would you undertake a long car journey Through unknown territory without a GPS ? WHY WOULD YOU EMBARK ON AN ARDUOUS DISEASE JOURNEY WITHOUT A BIOMARKER TO GUIDE YOU ?