Josep Tabernero MD PhD Medical Oncology Department Vall dHebron University Hospital amp Vall dHebron Institute of Oncology Barcelona Spain Molecular subtyping in colorectal cancer implications for therapeutic decisions ID: 763806
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Josep Tabernero, MD PhD Medical Oncology DepartmentVall d’Hebron University Hospital & Vall d’Hebron Institute of OncologyBarcelona, Spain Molecular subtyping in colorectal cancer: implications for therapeutic decisions Great Debates & Updates in GI Malignancies New York, March 27 th 2015
RR 20% mTTP 5−6 months mOS 10−12 monthsFirst-line efficacy5-FULow efficacy1995 One option Issues 5-FU Capecitabine , S-1 Irinotecan Oxaliplatin 2000 More options RR ≈ 45-50% mTTP 8−9 months mOS 17-21 months Optimal regimensSequencingTreatment duration RR 50-60% mTTP 9+ months mOS 22-30 monthsCure 5-FUCapecitabine, S-1IrinotecanOxaliplatin Cetuximab, PanitumumabBevacizumab, AfliberceptRegorafenib, TAS-102 2014Many options Optimal regimens Correct sequencing & dosingCostBiomarkersPatients’ selection Advances in the treatment of mCRC EGFR inh . Angiogenesis inh .
Molecular determinants of primary and secondary resistance to EGFR inhibitors in mCRC Unsupervised genotyping of CRCGenotype -driven targeted treatment combinations in mCRC: BRAF and RAS mutant populationsOutline
Molecular determinants of primary and secondary resistance to EGFR inhibitors in mCRC Unsupervised genotyping of CRC Genotype-driven targeted treatment combinations in mCRC:BRAF and RAS mutant populationsOutline
Targeting the EGFR pathway in CRC BRAF mutation 5-10% KRAS mutation 45– 50% NRAS mutation 5-8% EGFR expression 27– 99% EGFR mutation 1-2% MAPK MEK BRAF KRAS EGF TGF- α Amphiregulin Epiregulin Grb2Sos EGFR Anti-EGFR MoAbs : Cetuximab Panitumumab (RAS inh .) RAF inh . MEK inh . ERK inh . Inhibitors
Responder (15%) PIK3CA and/or PTEN (15%) BRAF (5-10%) KRAS/PIK3CA/PTEN BRAF/PIK3CA/PTEN KRAS-NRAS (35-45%) Non responder (16%) Primary resistance to anti-EGFR therapy in colorectal cancer HER2 amplification (3%) MET amplification (2%) KRAS amplification (1%) Modified from Bardelli, J Clin Oncol 201 0
Hobor S et al, Clin Cancer Res 2014; Salazar R & Tabernero J, Clin Cancer Res 2014Multiple mechanisms of acquired resistance to EGFR inhibition in CRC
Liquid biopsies to monitor gene amplification associated with acquired resistance Bardelli et al., Science Discovery, 2014
RAS mut BRAF mut PIK3CA mutc MET & HER2 amplificationsTP53 mutPTEN mutEGFR mutEGF & EGFR polymorphismsGenomic/ProteomicPotential biomarkers in mCRC for EGFR inhibitorsCOX-2 PTENEGFEpiregulin Amphiregulin EGFR expression DUSPs Mitogen -activated protein kinase phosphatase-1 (MKP-1) On/Off marker Threshold marker Signatures (-) predictive biomarkers
Molecular determinants of primary and secondary resistance to EGFR inhibitors in mCRCUnsupervised genotyping of CRC Genotype-driven targeted treatment combinations in mCRC:BRAF and RAS mutant populationsOutline
Genomic Landscape of CRC… 2012 Cancer Genome Atlas Network, Nature 2012 Facts: 224 T/N pairsNext-Generation Sequencing – Whole Exome Seq >20X coverage32 somatic recurrent mutations per tumor Hypermutated tumors16% Non-hypermutated tumors 84%
Lawrence et al. Nature 2013 Somatic mutations in different tumor types
Genomic Landscape of CRC… 2012 Cancer Genome Atlas Network, Nature 2012 Facts: 224 T/N pairs Next-Generation Sequencing – Whole Exome Seq >20X coverage 32 somatic recurrent mutations per tumor Hypermutated tumors 16% Non- hypermutated tumors 84%
Molecular Classification of CRC… 2012 Right-sided, MSI-H, Hypermethylated , BRAF mut, Chromosomal stability Left-sided, Rectal, MSS, KRAS mut , CIN + ve Cancer Genome Atlas Network, Nature 2012
A BC Roepman et al. Int J Cancer 2013 Training cohort: 188Validation cohort: 543 Deficient EpithelialProliferative Epithelial Mesenchymal
A-type B-type C-type 22%62%17%BRAFmt 39%BRAFmt 2%BRAFmt 13% MSI 49%MSS 87% MSI 13%dMMR 68% dMMR 1% dMMR 36% Adj Rx + Adj Rx +Adj Rx - Roepman et al. Int J Cancer 2013 Loboda et al. BMC Medical Genomics 2011
Unsupervised molecular subtyping of CRC - Microarray Multiple signatures 3-6 subtypes Mainly stages II-IIIDiscordant (nightmare?)
Colorectal cancer subtyping consortium (CRCSC) identifies consensus molecular subtypes Dienstmann R. J Clin Oncol 2014
Data set Source Platform TissueSamplesGEO (14 data sets)publicAffymetrix HG133plus2Fresh-frozen1,542 PETACC-3 proprietary Almac's Affymetrix ADXCRC FFPE 688 TCGA public RNA sequencing Fresh-frozen 603 French (GSE39582) public*Affymetrix HG133plus2Fresh-frozen 566KFSYSCCproprietary Affymetrix HG133plus2 Fresh-frozen320MDACCproprietaryAgilent 37K discoverprint_32627Fresh-frozen219Agendia ICO208proprietaryAgilent 37K discoverprint_19742Fresh-frozen208Agendia (GSE42284) public*Agilent 37K discoverprint_19742 Fresh-frozen188AMC-AJCCII (GSE 33113)publicAffymetrix HG133plus2 Fresh-frozen 90 Agendia VH70proprietary Agilent 37K discoverprint_32627 Fresh-frozen 76 NKI-AZ (GSE35896) public Affymetrix HG133plus2 Fresh-frozen 62 Population 4,562 Total *with private clinical annotation Dienstmann R. J Clin Oncol 2014
Features Samples Statistics Age 3,063Median (range) 66 years (21-98)Gender 3,394 Male 54% Female 46% Site 3,164 Right colon 39% Left colon 46% Rectum 15% Stage at diagnosis 3,499 I 11%II 39%III 43% IV 7% Microsatellite status 2,597 MSS 84% MSI 16% Relapse-free survival 2,252 Median follow-up 72 months Overall survival 2,796 Median follow-up 68 months Population Dienstmann R. J Clin Oncol 2014
Results - network of subtypes Dienstmann R. J Clin Oncol 2014 MSI - Immune Canonical Metabolic Mesenchymal
IV III II I Age diagnosis Gender (median) (female) CMS1 13% 69 y 57% CMS2 35% 66 y 43% CMS3 11% 67 y 47% CMS4 20% 64 y 44% Uncl. 21% 21% 65 y 44% CMS1 CMS2 CMS3CMS4Unclassified Stage Results – distribution & clinical correlates Dienstmann R. J Clin Oncol 2014
MSI status MSS MSI Right Rectum Left Site CMS1 CMS2 CMS3 CMS4 Unclassified CMS1 CMS2 CMS3 CMS4 Unclassified Results – clinical and molecular correlates Dienstmann R. J Clin Oncol 2014
CMS1 CMS2 CMS3 CMS4Unclassified Mutations exome -level (n=282) CMS1 CMS2 CMS3 CMS4 Unclassified Copy number alterations g enome-level (n =550) Results – molecular correlates Dienstmann R. J Clin Oncol 2014
CMS1 CMS2 CMS3 CMS4Unclassified CMS1 CMS2 CMS3 CMS4 Unclassified KRAS mut BRAF mut Results – mutation profile (n=2,386) Dienstmann R. J Clin Oncol 2014
CMS1 DNA repair, cell cycle, apoptosis, inflammation CMS2Beta-catenin, receptors, kinasesCMS3 Beta-catenin, receptors, kinases, IGFBP2CMS4 NOTCH3, VEGFR2, fibronectin , caveolin Unclassified - CMS1 CMS2 CMS3 CMS4 Unclassified IGFBP2 expressionResults – reverse phase protein arrays (n=439)Dienstmann R. J Clin Oncol 2014
Epithelial signature WNT activation MYC activation Mesenchymal signature Epithelial-mesenchymal transition TGFβ activation Stromal infiltration Immune activation Immune infiltration VEGFR ligands Fisher’s combined probability test of p values (across all datasets) for enrichment in Gene Set Analysis (GSA) p > 0.05* p = 0.05 – 0.00005* p < 0.00005* CMS1 CMS2 CMS3 CMS4 Unclassified Results – pathway analysis (n=3,891) Epithelial signature WNT activation MYC activation Mesenchymal signature Epithelial- mesenchymal transition TGFβ activation Stromal infiltration Immune activation Immune infiltration VEGFR ligands Dienstmann R. J Clin Oncol 2014
Summary – clinical and molecular correlates CMS1 Females, older age, right colonMSI, hypermutation, BRAF mut, immune activation CMS2 Left colon Epithelial, MSS, high CIN, TP53 mut, WNT/MYC pathway activation CMS3 Epithelial, heterogeneous CIN/MSI, KRAS mut , IGFBP2 overexpression CMS4 Younger age, stage III/IVMesenchymal, CIN/MSI, TGFβ/VEGF activation, NOTCH3 overexpression Unclassified Immune and stromal infiltration, variable epithelial-mesenchymal activation Dienstmann R. J Clin Oncol 2014
Summary – clinical and molecular correlates Dienstmann R. J Clin Oncol 2014 MSI - Immune Canonical MetabolicMesenchymalImmune checkpoint inhibitorsImmune regulatorsBRAF strategies WNT and MYC inhibitors? Metabolic inhibitors? TGFb inhibitors New antiangiogenics Matrix inhibitors
Survival curves Dienstmann R. J Clin Oncol 2014
Molecular determinants of primary and secondary resistance to EGFR inhibitors in mCRCUnsupervised genotyping of CRC Genotype-driven targeted treatment combinations in mCRC:BRAF and RAS mutant populationsOutline
BRAF (V600E) mutated CRC Small population: 8-10% early stage 4-5% late stageBRAF V600E mutations as a biomarker?very poor prognosis in late stage (mCRC )no clear prognostic effect in early stagepredictive: negative predictive effect for anti-EGFR MoAbs in some studies:Cetuximab: refractory (European cons.)1,2 & first-line setting (CRYSTAL study)3Panitumumab: 2nd line setting (PICCOLO study)4No change in the label by any regulatory authority predicted 1 Di Nicolantonio F, J Clin Oncol 2018; 2 De Roock et al, Lancet Oncol 2010; 3Van Cutsem et al, J Clin Oncol 2011; 4 Seymour MT et al, Lancet Oncol 2013
As examples of clinical trials evaluating the combination of BRAFV600E inhibitors plus anti-EGFR inhibitors in the BRAF mutant population in CRC:NCT01524978 : Vemurafenib + Cetuximab (BASKET) – Roche: Phase IbNCT01750918: BRAF/MEK Inhibitors (dabrafenib + trametinib) + Panitumumab – GSK: Phase Ib RP2NCT01719380: LGX818 and Cetuximab or LGX818, BYL719, and Cetuximab – Novartis: Phase Ib RP2 NCT01787500 (MDACC): Vemurafenib + Cetuximab + Irinotecan New studies in the BRAFV600E mutant CRC population Dienstmann R & Tabernero J. ASCO Educ Book 2014
Early efficacy comparison of BRAFi/ EGFRi combos *No confirmation response assessment Regimen N PR/CR (%) SD (%) DCR (%) Dabrafenib + Trabetinib 43 12 51 63 Dabrafenib + Panitumumab 15 13 73 87 Vemurafenib + Cetuximab * 11 - 36 36 Encorafenib + Cetuximab 24 29 50 79 Dabrafenib + Trabetinib + Panitumumab 15 40 40 80 Vemurafenib + Cetuximab + Irinotecan 8 50 50 100 Encorafenib + Cetuximab + BYL719 20 30 60 90 Dienstmann R & Tabernero J. ASCO Educ Book 2014
RAS mutant CRC Big population: 49-52% KRAS mutations5-11% NRAS mutations RAS mutations as a biomarker?no clear prognostic effect in early/late stagepredictive: negative predictive effect for anti-EGFR MoAbs :KRAS for Cetuximab & Panitumumab: 1st, 2nd and late stageNRAS for Cetuximab & Panitumumab: 1st, 2nd and late stage1 Di Nicolantonio F, J Clin Oncol 2018; 2 De Roock et al. Lancet Oncol 2010; 3 Van Cutsem et al, J Clin Oncol 2011; 4Seymour MT et al, Lancet Oncol 2013
MEK inhibition leads to PI3K/AKT activation by relieving a negative feedback on ERBB receptors Turke A et al. Cancer Res 2012
Studies in RAS mutant mCRC Genomic profileStrategyTrial KRAS mut anti-EGFR mAbs + MEK inhibitors Phase 1/2 Panitumumab + MEK162 NCT01927341 novel anti-EGFR/HER3 mAbs + MEK inhibitors Phase 1/2 MEHD7945A + Cobimetinib NCT01986166 anti-IGF1R mAbs + MEK inhibitors Phase 1/2 AMG -479 + MEK162 NCT01562899 KRAS G13D anti-EGFR mAbs Phase 2 Cetuximab ICECREAM KRAS mut FcγRIIa genotype (CD32) anti-EGFR mAbs Phase 2 Cetuximab NCT01450319 NRAS mut MEK inhibitors +/- PI3K path inh . Phase 1/2 MEK162 + BKM120 NCT01363232 Dienstmann R & Tabernero J. ASCO Educ Book 2014
Summary Target discovery has resulted in numerous novel drugs in clinical development but with very limited survival gain in mCRC Within the largest collection of CRC samples CRCSC has identified recurrent signals of 4 biologically distinct subtypes that are enriched for key clinical, molecular, pathway traits and have prognostic implications Need for strong science-sound rationale for the combinations, these addressing mechanistic interactions: BRAF mutantNeed to sequentially evaluate tumor cells (tumor tissue, CTCs, circulating DNA, …) to have evolutive/dynamic information
Acknowledgements All the patients and their families Vall d’Hebron University Hospital Oncology Dep.Pathology Dep. S. LandolfiP. Nuciforo J. Jiménez R. Dienstmann E . Elez T. Macarulla G. ArgilesJ. Rodon Genomic Lab. A. VivancosA. PratTranslational Lab. V. Serra H. García-Palmer R. Dienstmann J. Guinney S. Friend R. SalazarG. CapellaV. Moreno I. Simon L. Dekker R. Bernards S. Kopetz E. Vilar E. Van Cutsem S. Tejpar A. Bardelli F. Di Nicolantonio F. Ciardiello E. Martinelli . S. Siena A. Sartore -Bianchi . A. Cervantes . J. Schellens