circulating tumor cells (dr. minetta liu)
TRANSCRIPT
Circulating Tumor CellsCirculating Tumor Cells
Minetta C. Liu, MDMinetta C. Liu, MDAssociate Professor of Medicine and OncologyAssociate Professor of Medicine and Oncology
Director, Translational Breast Cancer Research Director, Translational Breast Cancer Research Lombardi Comprehensive Cancer CenterLombardi Comprehensive Cancer CenterGeorgetown University Medical CenterGeorgetown University Medical Center
Era of Personalized MedicineEra of Personalized Medicine
• need an individualized approach to need an individualized approach to treatment to maximize benefit and treatment to maximize benefit and minimize costminimize cost
assessment of prognosisassessment of prognosis measurement of treatment benefitmeasurement of treatment benefit understanding of tumor biologyunderstanding of tumor biology
Biomarker StrategiesBiomarker Strategies
serial biomarker assessmentsserial biomarker assessments
single biomarker assessmentsingle biomarker assessment
prognosisprognosisdirect therapydirect therapy
prediction prediction
diagnosisdiagnosisprognosisprognosis
direct therapydirect therapy
Improving OutcomesImproving Outcomes
• the enumeration and characterization of the enumeration and characterization of circulating tumor cells (CTCs) are useful circulating tumor cells (CTCs) are useful in the clinical settingin the clinical setting
alterations in CTC levelsalterations in CTC levels
CTC phenotype and CTC phenotype and genotypegenotype
identification of CTCidentification of CTC
prognosisprognosisprediction prediction
diagnosisdiagnosisprognosisprognosisdirect therapydirect therapy
diagnosisdiagnosisprognosisprognosis
(Paterlini-Brechot et al. Cancer Letters 2007. 253:180.)(Paterlini-Brechot et al. Cancer Letters 2007. 253:180.)
Origin of CTCsOrigin of CTCs
• etiologyetiology disseminated cancer cellsdisseminated cancer cells cancer stem cellscancer stem cells bystander cellsbystander cells
• rare cells in a dormant, nonproliferative rare cells in a dormant, nonproliferative statestate unaffected by chemotherapyunaffected by chemotherapy unrecognized by the host immune systemunrecognized by the host immune system difficult to isolatedifficult to isolate
Origin of CTCsOrigin of CTCs
Isolation of CTCsIsolation of CTCs
enrichment
detection
characterization
density gradient centrifugation
filtration by sizeimmunomagnetic labeling
quantitation of growth factor expression
gene expression profilingdetection of epigenetic alterations
Alix-Panabieres et al. Clin Cancer Res 2008. 14:5013.
Detection of CTCsDetection of CTCs
• antibody based markersantibody based markers cytokeratins (CK8, CK18, CK19)cytokeratins (CK8, CK18, CK19) epithelial membrane antigen (EMA)epithelial membrane antigen (EMA) epithelial cell adhesion molecule (EpCAM)epithelial cell adhesion molecule (EpCAM)
• nucleic acid based markersnucleic acid based markers CK19 by RT-PCRCK19 by RT-PCR mammoglobin by RT-PCRmammoglobin by RT-PCR erbB2 by RT-PCR or FISHerbB2 by RT-PCR or FISH EGFR by RT-PCREGFR by RT-PCR
Available Technologies Available Technologies for Isolation of CTCsfor Isolation of CTCs
Circulating Tumor CellCirculating Tumor Cell
CK
YEpCAM
NucleusDAPI
Anti-Anti-CK-PECK-PE
YAnti-Anti-EpCAMEpCAMFerrofluidFerrofluid
Immunomagnetic CaptureImmunomagnetic Capture
LeukocyteLeukocyte
CD45Nucleus
DAPI
YAnti -CD45-APC
Immunomagnetic LabelingImmunomagnetic Labeling and Immunofluorescent Identification of and Immunofluorescent Identification of CellsCells
Immunomagnetic CaptureImmunomagnetic Capture
DAPIDAPIcytokeratincytokeratincontrolcontrolCD45CD45compositcompositee
intact tumor cellsintact tumor cells
(Zheng et al. J Chromatogr A 2007. 1162:154.)(Zheng et al. J Chromatogr A 2007. 1162:154.)
Parylene Filter MicrodeviceParylene Filter Microdevice
(Nagrath et al. Nature 2007. 450:1235.)(Nagrath et al. Nature 2007. 450:1235.)
CTC MicrochipCTC Microchip
Immunomagnetic Labeling: Immunomagnetic Labeling: Enumeration in MBCEnumeration in MBC
Clinical ParametersClinical Parameters
• CTCs in individuals with MBC detected in ~70% >5 per 7.5 mL blood in ~50%
• CTCs in individuals without a malignancy detected in <10% >5 per 7.5 mL blood in 0%
Prevalence of CTCsPrevalence of CTCs
CTC threshold (per 7.5 mL CTC threshold (per 7.5 mL blood)blood)
% p
ati
ents
at
or
above t
he C
TC
thre
shold
%
pati
ents
at
or
above t
he C
TC
thre
shold
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
1 2 3 4 5 6 7 8 9 10
11
12
13
14
15
20
30
40
50
100
1000
cancer, baseline (n = 177)
3%
16%
21%21%23%
27%
34%34%34%36%
38%38%42%
45%46%47%49%
53%
58%61%
71%
cancer, first follow-Up (n = 163)
1%
8%
13%13%15%
20%21%21%22%23%23%23%24%26%
28%29%30%32%
35%
40%
55%
6%
healthy volunteers (n = 145)benign diseases (n = 200)
1%
8%
IMC-001IMC-001
time pointstime points
imagingimaging
bloodblood
00 22 33 44 5511 66
• 177 patients (223 total)177 patients (223 total)• metastatic breast cancer metastatic breast cancer • measurable diseasemeasurable disease
(Hayes et al. Clin Cancer Res 2006. 12:4218.)(Hayes et al. Clin Cancer Res 2006. 12:4218.)
IMC-001: CTCs at BaselineIMC-001: CTCs at Baseline
Logrank p = 0.0001
Cox Hazards Ratio = 1.8523chi-square = 14.44(p-value = 0.0001)
7.0 Months2.7
Months
CTCs / 7.5mL Median PFS in at Baseline N (%) Months (95% C.I.) <5 CTC 89 (50%) 7.0 (5.6 to 8.9) >5 CTC 88 (50%) 2.7 (2.1 to 4.4)
%Pr
obab
ility
of P
rogr
essi
on F
ree
Surv
ival
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Time from Baseline (Months)0 5 10 15 20 30 35 40 45 5025P
rob
ab
ilit
y o
f P
rog
res
sio
n F
ree
Su
rviv
al
%Pr
obab
ility
of S
urvi
val
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Time from Baseline (Months)0 5 10 15 20 30 35 40 45 5025
Logrankp < 0.0001
Cox Hazards Ratio = 2.3581chi-square = 19.54(p-value < 0.0001)
21.9 Months
10.9Months
CTCs / 7.5mL Median OS in at Baseline N (%) Months (95% C.I.) <5 CTC 89 (50%) 21.9 (20.1 to 28.6) >5 CTC 88 (50%) 10.9 ( 7.0 to 15.2)
n = 177
(Cristofanilli et al. N Engl J Med 2004. 351:781.)(Cristofanilli et al. N Engl J Med 2004. 351:781.)
p value < 0.001Cox Hazards Ratio = 5.4537
p value < 0.001Cox Hazards Ratio = 2.4842
IMC-001: CTCs at 1IMC-001: CTCs at 1stst Follow- Follow-UpUp
n = 177
(Cristofanilli et al. N Engl J Med 2004. 351:781.)(Cristofanilli et al. N Engl J Med 2004. 351:781.)
% p
robabili
ty o
f PFS
% p
robabili
ty o
f PFS
time from baseline (weeks)time from baseline (weeks)00 55 1010 1515 2020 2525 3030 3535 4040 4545 5555 6060 6565 7070 7575 8080
0%0%
10%10%
20%20%
30%30%
40%40%
50%50%
60%60%
70%70%
80%80%
90%90%
100%100%
5050
~7.0 months~7.0 months
~2.1 months~2.1 months
~7.6 months~7.6 months
p value < 0.0001p value < 0.0001Cox Hazards Ratio = 1.6600Cox Hazards Ratio = 1.6600
# patients (median # patients (median PFS)PFS)
< 5 CTC at baseline & at 1< 5 CTC at baseline & at 1stst follow- follow-upup
81 (30.3 weeks)81 (30.3 weeks)
decrease in CTC to < 5 at 1decrease in CTC to < 5 at 1stst follow-upfollow-up
33 (32.9 weeks)33 (32.9 weeks)
>> 5 CTC at 1 5 CTC at 1stst follow-up follow-up 49 (8.9 weeks)49 (8.9 weeks)
IMC-001: Changes in CTCIMC-001: Changes in CTC
n = 177
(Cristofanilli et al. J Clin Oncol 2005. 23:1420.)(Cristofanilli et al. J Clin Oncol 2005. 23:1420.)n = 83
IMC-001: CTCs and ImagingIMC-001: CTCs and Imaging
(Budd et al. Clin Cancer Res 2006. 12:6403.)(Budd et al. Clin Cancer Res 2006. 12:6403.)n = 138
IMC-001: CTCs and ImagingIMC-001: CTCs and Imaging
(Budd et al. Clin Cancer Res 2006. 12:6403.)(Budd et al. Clin Cancer Res 2006. 12:6403.)n = 138
IMC-001: CTCs and ImagingIMC-001: CTCs and Imaging
LCCC Validation StudyLCCC Validation Study
imagingimaging
bloodblood
00 66 99 1212 1515 2121 2424
cyclescycles33 1818
• 74 evaluable patients74 evaluable patients• metastatic breast cancer metastatic breast cancer • measurable diseasemeasurable disease
(Liu et al. J Clin Oncol 2009. 27:5153.)(Liu et al. J Clin Oncol 2009. 27:5153.)
Treatment at Time of CTC
ResultOR 95% CI
p-value
Overall 6.3 (3.2, 13)<0.00
1
Chemotherapy 6.3 (2.9, 14)<0.00
1
Endocrine 8.9 (2.2, 35) 0.002
CTCs Drawn at the Time of Radiographic Imaging
Treatment at Time of CTC
ResultOR 95% CI
p-value
Overall 4.9(2.2, 118)
<0.001
Chemotherapy 6.9 (3.0, 16)<0.00
1
Endocrine 2.9 (0.6, 14) 0.2
CTCs Drawn 7-9 Weeks Prior to Radiographic Imaging
Treatment at Time of CTC
ResultOR 95% CI
p-value
Overall 3.1 (1.6, 5.8) 0.001
Chemotherapy 2.7 (1.2, 6.3) 0.02
Endocrine 5.2 (1.2, 23) 0.03
CTCs Drawn 3-5 Weeks Prior to Radiographic Imaging
LCCC: CTCs and ImagingLCCC: CTCs and Imaging
Recommendations for UseRecommendations for Use
• to assess for progression in patients with measurable metastatic disease
• to provide a guide by which to determine the timing of radiographic restaging studies
• to assess the feasibility and timing of drug holidays in patients with stable disease and intolerable drug related toxicities
ConclusionsConclusions
• meaningful rate of detectionmeaningful rate of detection
• reliable thresholdreliable threshold
• correlation with clinical outcomes (validity)correlation with clinical outcomes (validity)
• ability to improve clinical outcomes ability to improve clinical outcomes (utility)(utility)
Response/Futility MarkerResponse/Futility Marker
CTCs – PresentCTCs – Present
• clinical validity IMC-001 LCCC study
• clinical utility assess disease status (with imaging) guide the timing of radiographic studies guide the timing of drug holidays guide systemic therapy (?????)
blood drawn at baseline prior to first-line chemotherapy
Arm B
maintain first-line chemotherapy until progression
Arm C1
maintain first-line chemotherapy until progression
Arm C2
switch to alternate chemotherapy
Arm A
monitor for PFS & OS
eligible for other first-line chemotherapy trials R
CTC <5 CTC ≥5
blood drawn three weeks after the first chemotherapy dose
CTC ≥5CTC <5
target n = 120
Prospective Validation: Prospective Validation: Means to Improve SurvivalMeans to Improve Survival
SWOG S0500
Prospective Validation:Prospective Validation:The Liquid BiopsyThe Liquid Biopsy
nucleusnucleuscytokeratincytokeratincontrolcontrolleukocyteleukocytecompositcompositee
HER2 and SE17 FISH Probes
HER2 and SE17 FISH Probes
Prospective Validation:Prospective Validation:The Liquid BiopsyThe Liquid Biopsy
CALGB 40601
bloodblood
00 44 66 88 1010 1414 1616weeksweeks
22 1212
paclitaxel and trastuzumab and lapatinib
N = 400N = 400 paclitaxel and trastuzumab
paclitaxel and lapatinib
tissuetissue
(Harris et al.J Clin Oncol 2007.33:5287.)(Harris et al.J Clin Oncol 2007.33:5287.)
ASCO Tumor Marker GuidelinesASCO Tumor Marker Guidelines
• Circulating tumor cell assays as Circulating tumor cell assays as markers for breast cancermarkers for breast cancer
THANK YOU