MOLEKULÁRIS DIAGNOSZTIKA KLINIKAI FELHASZNÁLÁSA GASZTROINTESZTINÁLIS DAGANATOKBAN Bodoky György Dél-Pesti Centrum Kórház, Budapest
CRYSTAL study Van Cutsem E, Bodoky G, KyungRohJ et al. ECCO 2007
OPUS study KRAS WT KRASM+ BokemeyerC et al, ASCO 2008
Analysis of KRAS/NRAS andbraf Mutations in the Phase 3 PRIME Study of Panitumumab(pmab) + FOLFOX vsfolfox as 1 st -line Treatment (tx) for Metastatic Colorectal Cancer (mcrc) Kelly S. Oliner, 1 Jean-Yves Douillard, 2 Salvatore Siena, 3 Josep Tabernero, 4 Ronald Burkes, 5 Mario Barugel, 6 Yves Humblet, 7 GyorgyBodoky, 8 David Cunningham, 9 Jacek Jassem, 10 Fernando Rivera, 11 IlonaKocákova, 12 Paul Ruff, 13 Maria Błasińska-Morawiec, 14 Martin Šmakal, 15 Richard Williams, 1 Alan Rong, 1 Jeffrey Wiezorek, 1 Roger Sidhu, 1 and Scott Patterson 1 1 Amgen Inc., Thousand Oaks, California, USA; 2 ICO René Gauducheau, Nantes, France; 3 Ospedale NiguardaCa Granda, Milan, Italy; 4 Vall d HebronUniversity Hospital, Barcelona, Spain; 5 Mount Sinai Hospital, Toronto, Canada; 6 Hospital de Gastroenterología, Buenos Aires, Argentina; 7 Université Catholiquede Louvain, Brussels, Belgium; 8 Szent Laszlo Hospital, Budapest, Hungary; 9 The Royal Marsden NHS Foundation Trust, London, United Kingdom; 10 Medical University of Gdansk, Poland; 11 Hospital UniversitarioMarquésde Valdecilla, Santander, Spain; 12 Masarykuv OnkologickyUstav, Brno, Czech Republic; 13 University of Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa; 14 Wojewodzki SzpitalSpecjalistyczny, im. M. Kopernika, Lodz, Poland; 15 Institut Onkologie a Rehabilitace na Plesi s.r.o., Nová Ves pod Pleší, Czech Republic
CONCLUSIONS In the wild-type RASsubgroup, a clinically significant 5.8 month improvement in OS(HR = 0.78, 95% CI: 0.62-0.99, p = 0.043) was observed in the panitumumabplus FOLFOX4 arm versus the FOLFOX4 alone arm Seventeen percent of patients had tumors that were wild-type KRAS exon 2/mutant in other RAS exons Additional RASmutations were negative predictive biomarkers in patients with mcrctreated with panitumumab plus FOLFOX4 BRAFmutations may not have been predictive of treatment effects and BRAFV600E mutations appeared to confer a poor prognosis regardless of treatment arm Panitumumabplus oxaliplatin-containing regimens should not be used in patients with mutant RAS mcrc tumors By excluding patients with mutant RASmCRCtumors, the benefit-risk profile of panitumumabplus FOLFOX4 was improved and resulted in improvements in survival Oliner et al ASCO 2013
Could expanded RAS analysis change the results? Presented By Josep Tabernero at 2014 ASCO Annual Meeting
28 % Gén TP53 47 % 39 % KRAS 30 % 35 % APC 40 % 30 % PIK3CA 17 % 9 % Ritka driver mutációk jelentősége 203 203 79 79 % 107 TP53 37 HER2 FISH pozitív 4 % 7% 4%[ÉR TÉ 22 % 24 % TP53 KRAS APC BRAF 13 % 6 % SMAD4 9 % 5 % FBXW7 11 % 3 % ATM 11 % 1 % IDH1 2 % 1 % NRAS 5 % 1 % CDKN2A 2 % 1 % CTNNB1 5 % 1 % PIK3R1 4 % 1 % GNAS 4 % 0,5 % CHEK2 3 % 0,5 % CDH1 3 % 0,5 % KDR biomarker 23 % PIK3R1 biomarker 8 % Gén 5% 15 17 % % 7 9 0 KRAS 30 % 32 KRAS 34 % 46 % TP53 59 % 37 % APC 61 % 23 % PIK3CA 8 % 8 % FBXW7 12 % 5 % BRAF 3 % 4 % PTEN 4 % 1 % SMAD4 10 % 1 % AKT1 0,8 % 1 % ATM 4 % 1 % MET 1 % 1 % PIK3R1 3 % 1 % NRAS 8 % 1 % HER2 FISH pozitív 3 % KDR biomarker 25 % PIK3R1 biomarker 9 % TP53 Gén 4%8% KRAS 5% 34 % 1 0 7 50 % CDKN2 A KRAS 71 % 75 % TP53 44 % 50 % CDKN2A 13 % 7 % SMAD4 15 % 6 % PIK3CA 2 % 4 % APC 1 % 3 % GNAS 5 % 1 % CHEK2 0,1 % 1 % EGFR 0,4 % 1 % HER2 FISH pozitív 1 % FGFR1 FISH pozitív 1 % KDR biomarker 35 % PIK3R1 biomarker 19 % Gén 3 7 42 % 16 % 42 % TP53 25 % 22 % PIK3CA 9 % 8 % CTNNB1 4 % 5 % KRAS 4 % 3 % APC 4 % 3 % PTEN 4 % 3 % SMAD4 4 % 3 % HER2 FISH pozitív 3 % PIK3CA FISH pozitív 3 % KDR biomarker 35 % PIK3R1 biomarker 11 % TP53 PIK3CA egyéb >5% 2-5% <2%
A colorectalis daganat heterogén betegség
CRC az 50 leggyakrabban mutációt hordozó gén 2015, Foundation Medicine Inc.
Metasztatikus CRC: klinikailag potenciálisan releváns DNS alterációk Rutinban vizsgált genetikai alterációk BRAF 4.9% NRAS exon 4 NRAS exon 3 0.2% 2.2% NRAS exon2 2.3% KRAS exon4 3.2% KRAS exon3 2.5% KRAS amplificat ion 0.7% MET amplificat ion 2% HER2 amplification 3% KRAS WT 37.7% KRAS exon2 41.4% Misale S. et al.: Cancer Discov; 4(11) 1269 80. 2014 AACR.
Actionable targets in colorectal cancer BRAF 8% PIK3CA:8% OTHER:10% PTEN:8% RAS:45% HER-2:2% BRCA 1/2:2% MET:1% KIT2:0,3% % FLT3:0,3% JAK2:0,3 STK11:2 % GNAS:0,3 % PDGFRB:0,5% AKT1:0,3 % FEGFR:2% CDK8 FISH+:4% IGF2 FISH:4% HER-4:1% ALK-trsl:2% HER-3:1% EGFR:2% Alberto Bardelli, Ph.D. University of Torino, School of Medicine
A genetikai alterációk mindkét colonfélben jelen vannak Proportio on of positive cases, % 50 40 30 20 10 0 CIMP-high MSI-high BRAF mutation Yamauchi. 2012
Driver gének vastagbél adenocarcinomában Betege ek száma 60 50 40 30 20 10 0 8 50 45 23 14 145 58 3 1 1 0 1 2 3 4 5 7 9 Egyes betegekben együttesen azonosított driver alterációk száma 203 Azon betegek száma, akik mintájában nem detektáltunk kódoló mutációt Azon betegek száma, akik mintájában legalább 1 kódoló mutációt detektáltunk
Stress signals TGFα EGF HGF FGF PGE20 WNT Driver gének vastagbél adenocarcinomában 0,5% (CDH1) PM EGFR 4% (FISH) HER2 MET FGFR GPCR Frizzled ECAD DNA damage β-catenin 9% (PIK3CA) 35% (KRAS) 1% (PIK3R1) 1% ATM TGFβ TGFβR I/II Smad2/3 Smad4 1% 5% isocitrate IDH1 α-kg ATR PTEN 0,5% CHK2 CHK1 PI3K AKT mtor RAS RAF MEK ERK 1% (NRAS) αs AC camp PKA 30% Dvl GSK-3β APC Axin 0,5% (GNAS) 6% (BRAF) Cyclin E 203 3% FBXW7 1% (CDKN2A) NICD1 39% P16 Cdk4/6 p53 MDM2 P21 Cyclin D1 Rb EF2 Histone and DNA methylation β-catenin 1% (CTNNB1) apoptózis proliferáció aktiválás gátlás onkogén tumorszupresszor driver gén Adott gént érintő driver % mutációk aránya a vizsgált betegekben kapcsolódás plazmamembrán
Driver gének végbél adenocarcinomában 79 Betegek száma 25 20 15 10 5 0 3 23 17 11 0 1 2 3 4 5 3 59 Egyes betegekben együttesen azonosított driver alterációk száma 20 Azon betegek száma, akik mintájában nem detektáltunk kódoló mutációt Azon betegek száma, akik mintájában legalább 1 kódoló mutációt detektáltunk 2
Stress signals TGFα EGF HGF FGF PGE20 WNT Driver gének végbél adenocarcinomában PM EGFR 3% (FISH) HER2 1% MET FGFR GPCR Frizzled ECAD DNA damage β-catenin 8% 1% (PIK3CA) (PIK3R1) 1% ATM TGFβ TGFβR I/II Smad2/3 1% Smad4 isocitrate IDH1 α-kg CHK2 ATR CHK1 PTEN 1% PI3K AKT mtor 1% 46% (KRAS) RAS RAF MEK ERK 1% (NRAS) 4% (BRAF) αs AC camp PKA 23% Dvl GSK-3β APC Axin Cyclin E 79 5% FBXW7 NICD1 P16 37% p53 MDM2 P21 Cdk4/6 Cyclin D1 Rb EF2 Histone and DNA methylation β-catenin
Primary resistance to anti-egfr therapy in colorectal cancer Responder WT: 15% PIK3CA/PTEN: 15% MET FISH+: 2% K-NRAS: 35-45% HER-2 FISH+: 3% NR 4xWT = 20% BRAF: 5-10% KRAS FISH+: 1% Alberto Bardelli, Ph.D. University of Torino, School of Medicine
TARGETS in colorectal cancer EGFR-DRIVEN COLON CC 20-25% (EGFR CNG, +LIGANDS) HER-2 M+ 5% ALK/EML! 2,5% PIK3CA M+ MET+ 10% NRAS 2,3,4 M+ 10% 5-10% KRAS 2,3,4 exons M+ 10% BRAF M+ 5% KRAS 1 exons M+ 35-40% Cetuximab, Panitumumab Necitumumab, Neratinib Panitumumab Cetuximab Trastuzumab Lapatinib Neratinib Afatinib Crizotinib AMG 337 Tivantinib Foretinib everolimus vemurafenib MEK: Pimasertib, Trametinib, Selumetinib NOTCH: demcizumab, MK-0752 CDK9: AZD5438, dinaciclib, BAY1000394 PLK1: volaserib, GSK-461364
Primary resistance to anti-egfr therapy in colorectal cancer EGFR-DRIVEN COLON CC 10-20% (EGFR CNG, +LIGANDS) HER-2 M+ 5% ALK/EML! 2,5% PIK3CA M+ MET+ 10% NRAS 2,3,4 M+ 10% 5-10% KRAS 2,3,4 exons M+ 10% BRAF M+ 5% KRAS 1 exons M+ 35-40% EGFR Inhibitors EGFR Inhibitor is NO EGFR Inhibitors possible but increased risk of resistance!
HUNTING DRIVERS (EGFR DEPENDENCE BY ACTIVATION)
KRAS/NRAS/BRAF/PIK3CA WT COLON CC LIVER MET CETUXIMAB
EGFR MABS IN BRAF MUTANT COLON CC Wild-type BRAF is required for response to panitumumabor cetuximabin metastatic colorectal cancer.di NicolantonioF, Martini M, Molinari F, Sartore-Bianchi A, Arena S, SalettiP, De DossoS, MazzucchelliL, FrattiniM, Siena S, BardelliA. J Clin Oncol. 2008 Dec 10;26(35):5705-12.
FOLFOXIRI+BEVACIZUMAB IN BRAF MUTANT COLON CC N FOLFIRI + bev median OS FOLFOXIRI + bev median OS HR [95% CI] p RASand BRAF wt 93 33.5 41.7 0.77 [0.46-1.27] RAS mutated 236 23.9 27.3 0.88 [0.65-1.18] 0.522 * BRAF mutated 28 10.7 19.0 0.54 [0.24-1.20] * p for interaction Cremolini et al., Lancet Oncol 2015
BRAF-V600E Melanoma: vemurafenib, dabrafenib-trametinib NSCLC: vemurafenib, dabrafenib Papillárispajmirigydaganat: vemurafenib Hajassejtesleukémia: vemurafenib Cholangiocarcinoma: dabrafenib+trametinib Vastagbéladenokarcinoma:?
BRAF GÁTLÓK HATÉKONYSÁGA VASTAGBÉLDAGANATOKBAN BRAF BRAF+EGFR BRAF+EGFR+MEK BRAF+EGFR+PIK3CA BRAF+EGFR+irinotecan Yan Y, Grothey A. Molecular profiling in the treatment of colorectal cancer: focus on regorafenib. Onco Targets Ther. 2015 Oct 15;8:2949-57.
Randomized trial of irinotecan and cetuximab with or without vemurafenib inbraf-mutant metastatic colorectal cancer (SWOG S1406) Scott Kopetz, 1 Shannon McDonough, 2 Heinz-Josef Lenz, 3 Anthony Magliocco, 4 Chloe Atreya, 5 Luis A. Diaz Jr., 6 Carmen Allegra, 7 KanwalRaghav, 1 Van Morris, 1 Stephen Wang, 8 Christopher Lieu, 9 Katherine A. Guthrie, 2 Howard S. Hochster 10 1 The University of Texas MD Anderson Cancer Center, Houston, TX; 2 Fred Hutchinson Cancer Research Center, Seattle, WA; 3 USC Norris Comprehensive Cancer Center, Los Angeles, CA; 4 H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL; 5 University of California, San Francisco, San Francisco, CA; 6 Memorial Sloan Kettering Cancer Center, NewYork, NY; 7 University of Florida, Gainesville, FL; 8 Kaiser Permanente, Sacramento, CA; 9 University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO; 10 Yale Cancer Center, New Haven, CT
Secondary Endpoint: Overall Survival 100% 80% 60% N Events Median 95% Conf Int Cetuximab + Irinotecan 50 38 5.9 (3.0 9.9) Vemurafenib + Cetuximab 49 32 9.6 (7.5 13.1) + Irinotecan HR = 0.73 (95% CI 0.45 1.17) P=0.19 40% 20% 0% 0 3 6 9 12 15 18 Months after randomization Presented by: Scott Kopetz, MD, PhD April 18. 2017 data cutoff
MULTICENTRIKUS VIZSGÁLAT BRAFMUTÁNS VASTAGBÉLDAGANATOKBAN ÚJ GENERÁCIÓS BRAF ÉS MEK GÁTLÓKKAL BRAFi+MEKi+cetuxumab BRAFi+cetuxumab FOLFIRI+cetuximab
FIGHTING SECONDARY RESISTANCE: HER-2 1L cetuximab-folfiri, PR liver resection in 16APR2012, the 1L therapy was continued (until OCT2013), 2L FOLFOX, then panitumumab-folfox (RFTS: CR in OCT2014), right upper lung lobe VATS resection in 07APR2015, 3L bevacizumab-folfiri (from 28JUL2015 until 09FEB2016, PD), HER-2 amplification 4L afatinib(from JUL2016 until 12SEP2016, PD), 5L regorafenib(2x, PD), 6L tegafur, 7L metronomic capecitabine, Antwerp University lapatinib/trastuzumab (compassionate)
FIGHTING SECONDARY DRUG RESISTANCE: Secondary mutant KRAS can be detectedafterprogressiononegfributmkraslevelsdropduring EGFRi holiday Nat Med. 2015 July; 21(7): 795 801. doi:10.1038/nm.3870.
3511 Parseghian. Anti-EGFR resistant clones decay exponentially after progression:implications for anti-egfr rechallenge <br /> Presented By Alberto Sobrero at 2018 ASCO Annual Meeting
Slide 12 Presented By Alberto Sobrero at 2018 ASCO Annual Meeting
My take Presented By Alberto Sobrero at 2018 ASCO Annual Meeting
Drugable driver genes in pancreatic cancer ²¹²Pb-TCMC-Trastuzumab 20% IHC+ 0% M+ Dovitinib Crizotinib Trastuzumab, lapatinib, IHC+ 40% 7% CNG Cabozantinib TDM-1 FGFRvIIIc HGF FGFR AMP 5% M+ FGFRvIIIb XL184 HER-2 EPI 0% CNG ALK/EML4 C-MET IHC+ 70% Erlotinib EGFR AMG 479 IGFR IGFI 70-90% (M+) RON IGFII KRAS PIK3CA BKM120 INSRA/B INS HRAS NRAS 8% (M+) 1% (M+) vemurafenib 2% (M+) BRAF AKT/PKB PTEN Naflivir 3% (M+) SMO Vismodegib Trametinib, AS703026 1% (M+) MEK MTOR GDC-0980 Vismodeglib BAY 86-9766, AZD6244 Palbociclib Metformin, everolimus BAY1000394 NOTCH MRK003 AZD5438 91% (M+) CDKN2A CDK4 G-SECRETASE Volasertib PLK1 MDM2 TAK-960 SMAD4 50%(M+) P53 84% (M+)
Clinical Significance of the Genetic Landscape of Pancreatic Cancer 1% 18% 44% 37% OS= 24 months OS= 9 months (p=0,04) Yachida S, et al.. Clinical significance of the genetic landscape of pancreatic cancer and implications for identification of potential long-term survivors. Clin Cancer Res. 2012 Nov 15;18(22):6339-47.
Platform trial design in pancreatic cancer EGFR HER-2 5-10% 7-20% AKT 3% PIK3CA M+ 5% PIK3CA CNG?% PTEN M+?% C-MET-HGF AUTOCRINE LOOP 40% KRAS M+ (70-90%) ERLOTINIB HER-2 AKT INH INH PI3K/MTO R inhibitor PLK1, CDK4, NOTCH, MEK, MET INHIBITOR
Driver gének hasnyálmirigy adenocarcinomában Betegek száma 50 40 30 20 10 0 7 32 42 10 94 13 2 1 0 1 2 3 4 5 Egyes betegekben együttesen azonosított driver alterációk száma 107 Azon betegek száma, akik mintájában nem detektáltunk kódoló mutációt Azon betegek száma, akik mintájában legalább 1 kódoló mutációt detektáltunk
Driver gének hasnyálmirigy adenocarcinomában Stress signals TGFα EGF HGF FGF PGE20 WNT PM 1% EGFR 1% (FISH) HER2 MET 1% (FGFR1 FISH) FGFR GPCR Frizzled ECAD DNA damage β-catenin 4% (PIK3CA) 75% (KRAS) ATM TGFβ TGFβR I/II Smad2/3 6% Smad4 isocitrate IDH1 α-kg ATR PTEN CHK2 CHK1 PI3K AKT mtor RAS RAF MEK ERK αs AC camp PKA 1% (GNAS) 3% Dvl GSK-3β APC Axin Cyclin E FBXW7 7% (CDKN2A) 107 NICD1 P16 50% p53 MDM2 P21 Cdk4/6 Cyclin D1 Rb EF2 Histone and DNA methylation β-catenin
Drugable driver genes in gastric cancer 4% M+ 5% FISH+ 1,1% M+ 1,8% M+ 25% FISH+ EGFR 6,5% M+ HER-2 0,8% M+ 4,1% FISH+ FGFR KRAS NRAS HRAS BRAF ALK/EML4 PIK3CA AKT/PKB 1% M+, 15% FISH+ C-MET 8% M+ 67% FISH+ PTEN KIT 2% M+ PDGFR 3,8% M+ 1% M+ MEK MTOR
Driver gének gyomor adenocarcinomában 37 Betegek száma 16 14 12 10 8 6 4 2 0 14 11 2 28 0 1 2 4 Egyes betegekben együttesen azonosított driver alterációk száma 9 Azon betegek száma, akik mintájában nem detektáltunk kódoló mutációt Azon betegek száma, akik mintájában legalább 1 kódoló mutációt detektáltunk 1
Stress signals TGFα EGF HGF FGF PGE20 WNT Driver gének gyomor adenocarcinomában PM EGFR 3% (FISH) HER2 MET FGFR GPCR Frizzled ECAD DNA damage β-catenin 8% (PIK3CA) ATM ATR 3% PTEN CHK2 CHK1 22% p53 PI3K AKT mtor Cyclin E 37 FBXW7 P16 NICD1 MDM2 P21 RAS RAF MEK ERK 3% (KRAS) TGFβ TGFβR I/II Smad2/3 3% Smad4 isocitrate IDH1 α-kg αs AC camp PKA Dvl GSK-3β 3% APC Histone and DNA methylation Axin β-catenin 5% (CTNNB1) Cdk4/6 Cyclin D1 Rb EF2
Most frequently mutated driver genesin gastriccancers (N=16, 58 genes tested) 4+ mutacions; 1 3 mutacions; 2 16,67% Wiltype; 1 only polymophism ; 1 2 mutacions; 3 83,34 % 1 mutacion; 4
Distribution of all mutations in gastric cancers 5 6 1 1 1 1 1 1 1 1 1
Platform trial design in gastric cancer EGFR + szuper wt and FISH+/M+ PIK3CA-/MET- /HER-2- HER-2 + PIK3CA- /MET - C-MET + (FISH+/M+) FGFR FISH+ PIK3CA - PIK3CA + (FISH+/M+/PTEN M+) Erlotinib Gefitinib Cetuximab Panitumumab Necitumumab Neratinib Lapatinib Neratinib Afatinib Crizotinib AMG 337 Tivantinib Foretinib AZD4547 Dovitinib Ponatinib nintedanib Everolimus Metforimn Temsirolimus XL147 BKM120 BEZ235
TARGETING PARP IN HOMOLOGEUS RECOMBINATION DEFICIENT (HRD) TUMORS
John L. Marshall, MD Chief, Division of Hematology/Oncology Georgetown University Hospital Director, Otto J. RueschCenter for the Cure of Gastrointestinal Cancer Washington, DC
Patient case A 72-yr-old male presents with abdominal pain, jaundice CT scan shows a pancreas head mass and several small liver lesions Biopsy of the liver positive for adenocarcinoma c/w pancreas cancer Family history: mother and maternal aunt with ovarian cancer Patient is of Ashkenazi Jewish heritage Biliary stent placed; patient eager to start treatment a) Start standard chemotherapy? b) Order molecular profiling?
Patient Case Tumor biopsy sent for molecular profile and was positive for a BRCA mutation Patient enrolled on a trial of FOLFOX + veliparib Achieved CR, in response for 26 mos
PDL-1 és MSI hazai GI betegekben Epeúti daganat PD-L1 expresszió vizsgálat Hasnyálmirigy daganat n=8 n=13 Epeúti daganat MSI vizsgálat Hasnyálmirigy n=8 daganat n=21 13% 15% 0% 5% 87% 85% 100% 95% PD-L1 negatív PD-L1 pozitív PD-L1 negatív PD-L1 pozitív MSS MSI-H MSS MSI-H Vastag- és végbéldaganat Gyomor daganat n=7 n=15 7% 14% Vastag-és végbéldaganat 3% Gyomor daganat n=99 n=10 10% 86% 93% 97% 90% PD-L1 negatív PD-L1 pozitív PD-L1 negatív PD-L1 pozitív MSS MSI-H MSS MSI-H FDA: PEMBROLIZUMAB
EVER TRIED. EVER FAILED. NO MATTER. TRY AGAIN. FAIL AGAIN. FAIL BETTER. Samuel Beckett