molekulÁris diagnosztika klinikai felhasznÁlÁsa ...€¦ · analysis of kras/nras and braf...

MOLEKULÁRIS DIAGNOSZTIKA KLINIKAI FELHASZNÁLÁSA GASZTROINTESZTINÁLIS DAGANATOKBAN

Bodoky GyörgyDél-Pesti Centrum Kórház, Budapest

CRYSTAL study

Van Cutsem E, Bodoky G, Kyung Roh J et al. ECCO 2007

OPUS study

KRAS WT KRASM+

Bokemeyer C et al, ASCO 2008

Analysis of KRAS/NRAS and BRAF Mutations in the

Phase 3 PRIME Study of Panitumumab (pmab) +

FOLFOX vs FOLFOX as 1st-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 Gyorgy Bodoky,8 David Cunningham,9 Jacek Burkes, Mario Barugel, Yves Humblet, Gyorgy Bodoky, David Cunningham, Jacek

Jassem,10 Fernando Rivera,11 Ilona Kocákova,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 Patterson1

1Amgen Inc., Thousand Oaks, California, USA; 2ICO René Gauducheau, Nantes, France; 3Ospedale Niguarda Ca’ Granda, Milan, Italy; 4Vall d’Hebron University Hospital, Barcelona, Spain; 5Mount Sinai Hospital, Toronto, Canada;

6Hospital de Gastroenterología, Buenos Aires, Argentina; 7Université Catholique de Louvain, Brussels, Belgium; 8Szent Laszlo Hospital, Budapest, Hungary; 9The Royal Marsden NHS Foundation Trust, London, United Kingdom; 10Medical

University of Gdansk, Poland; 11Hospital Universitario Marqués de Valdecilla, Santander, Spain; 12Masarykuv Onkologicky Ustav, Brno, Czech Republic; 13University of Witwatersrand Faculty of Health Sciences, Johannesburg,

South Africa; 14Wojewodzki Szpital Specjalistyczny, im. M. Kopernika, Lodz, Poland; 15Institut Onkologie a Rehabilitace na Plesi s.r.o., Nová Ves pod Pleší, Czech Republic

CONCLUSIONS

• In the wild-type RAS subgroup, 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 panitumumab plus FOLFOX4 arm versus the FOLFOX4 alone arm

• Seventeen percent of patients had tumors that were wild-type KRAS exon 2/mutant in other RASexons

• Additional RAS mutations were negative predictive biomarkers in patients with mCRC treated with panitumumab plus FOLFOX4with panitumumab plus FOLFOX4

• BRAF mutations may not have been predictive of treatment effects and BRAF V600E mutations appeared to confer a poor prognosis regardless of treatment arm

• Panitumumab plus oxaliplatin-containing regimens should not be used in patients with mutant RAS mCRC tumors

• By excluding patients with mutant RAS mCRC tumors, the benefit-risk profile of panitumumab plus 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

Ritka driver mutációk jelentősége

79

107

37

GénTP53 47 % 39 %

KRAS 30 % 35 %

APC 40 % 30 %

PIK3CA 17 % 9 %

KRAS 34 % 46 %

TP53 59 % 37 %

APC 61 % 23 %

GénKRAS 71 % 75 %

TP53 44 % 50 %

CDKN2A 13 % 7 %

Gén

TP53 25 % 22 %

PIK3CA 9 % 8 %

CTNNB1 4 % 5 %

Gén

203 79203 79 107 37

28%

24%

22%

7%4%

[ÉRTÉ…

TP53

KRAS

APC

32%

30%

17%

5%15%

0 KRAS

TP53

50%34

%

5%4%8%KRAS

TP53

CDKN2A

42%16

%

42%

TP53

PIK3CA

egyéb

HER2 FISH pozitív 4 %

PIK3CA 17 % 9 %

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 %

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 %


KDR biomarker 25 %


CDKN2A 13 % 7 %

SMAD4 15 % 6 %

PIK3CA 2 % 4 %

APC 1 % 3 %

GNAS 5 % 1 %

CHEK2 0,1 % 1 %

EGFR 0,4 % 1 %


FGFR1 FISH pozitív 1 %

KDR biomarker 35 %


CTNNB1 4 % 5 %

KRAS 4 % 3 %

APC 4 % 3 %

PTEN 4 % 3 %

SMAD4 4 % 3 %


PIK3CA FISH pozitív 3 %

KDR biomarker 35 %


>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

KRAS WT

KRAS amplificat

ion0.7%

METamplificat

ion2%

HER2amplification

3%BRAF 4.9%

KRAS exon 43.2%

NRAS exon 22.3%

NRAS exon 32.2%

NRAS exon 40.2%

Rutinban vizsgált

KRAS WT37.7%KRAS exon 3

2.5%

KRAS exon 241.4%

Misale S. et al.: Cancer Discov; 4(11) 1269–80. 2014 AACR.

vizsgált genetikai alterációk

Actionable targets in colorectal cancer

RAS:45%

OTHER:10%

PIK3CA:8%

PTEN:8%

HER-2:2%

BRAF 8%

PDGFRB:0,5%

GNAS:0,3

%

AKT1:0,3%

Alberto Bardelli, Ph.D.University of Torino, School of Medicine

MET:1%BRCA 1/2:2%

ALK-trsl:2%

EGFR:2%HER-4:1%

HER-3:1%

FEGFR:2%

CDK8 FISH+:4%

IGF2 FISH:4%

STK11:2%

JAK2:0,3

%FLT3:0,3%

KIT2:0,3%

A genetikai alterációk mindkét colonfélben jelen vannak

50

Pro

po

rtio

n o

f p

osi

tive

cas

es, %

40

30

20

CIMP-high

MSI-high

BRAF mutation

Pro

po

rtio

n o

f p

osi

tive

cas

es, %

10

0

Yamauchi. 2012

5045

2330

40

50

60

Bet

egek

szá

ma

Driver gének vastagbél adenocarcinomában203

58

145

8

23

14

3 1 10

10

20

30

0 1 2 3 4 5 7 9

Bet

egek

szá

ma

Egyes betegekben együttesen azonosított driver alterációk száma

Azon betegek száma, akik mintájában nem detektáltunk kódoló mutációtAzon betegek száma, akik mintájában legalább 1 kódoló mutációt detektáltunk

Stress signals DNA damage

PTEN

ATM

ATR

CHK2

CHK1p53

MDM2

P21

P16

Cdk4/6

Cyclin D1Rb EF2

TGFα

EGF

EGFR

HER2PI3K AKT mTOR

Driver gének vastagbél adenocarcinomában

FBXW7

NICD1

Cyclin E 203

PM

39%0,5%

1%(PIK3R1)

1% (CDKN2A)

1%

3%

9%(PIK3CA)

4% (FISH)

EGF

HGF

FGF

PGE20

WNT

HER2

MET

FGFR

GPCR

Frizzled

ECAD

RAS RAF MEK ERK

αs AC cAMP PKA

APC

β-catenin

Dvl GSK-3β

β-catenin

Axin

TGFβ TGFβR I/II Smad2/3Smad4

isocitrate IDH1 α-KGHistone and DNA methylation

0,5%(CDH1)

0,5% (GNAS)

1% (CTNNB1)

1%(NRAS)

1%5%

6%(BRAF)

30%

35%(KRAS)

onkogéntumorszupresszor

aktiválásgátlás

kapcsolódásplazmamembrán

apoptózisproliferáció

driver gén

% Adott gént érintő driver mutációk aránya a vizsgált betegekben

79

Driver gének végbél adenocarcinomában

23

17

1115

20

25

Bet

egek

szá

ma

20

59

3

11

3 2

0

5

10

0 1 2 3 4 5

Bet

egek

szá

ma




PTEN

ATM

ATR

CHK2

CHK1p53

MDM2

P21

P16

Cdk4/6

Cyclin D1Rb EF2

TGFα

EGF

EGFR

HER2PI3K AKT mTOR

FBXW7

NICD1

Cyclin E 79

Driver gének végbél adenocarcinomábanPM

1%(PIK3R1)

1%

1%

1%

5%

8%(PIK3CA)

37%

3% (FISH)

EGF

HGF

FGF

PGE20

WNT

HER2

MET

FGFR

GPCR

Frizzled

ECAD

RAS RAF MEK ERK

αs AC cAMP PKA

APC

β-catenin

Dvl GSK-3β

β-catenin

Axin


isocitrate IDH1α-KG

Histone and DNA methylation

1%(NRAS)

1%

1%

1%

4%(BRAF)

23%

46%(KRAS)

3%

Primary resistance to anti-EGFR therapy in colorectal cancer

Responder WT: 15%

K-NRAS: 35-45%

BRAF: 5-10%

PIK3CA/PTEN: 15%

NR 4xWT = 20%

KRAS FISH+: 1%

HER-2 FISH+: 3%

MET FISH+: 2%

Alberto Bardelli, Ph.D.University of Torino, School of Medicine

BRAF M+5%

PIK3CA M+10%

EGFR-DRIVEN COLON CC

20-25%(EGFR CNG, +LIGANDS)

NRAS 2,3,4 M+ 10%HER-2 M+

5%

ALK/EML!2,5%

MET+5-10%

KRAS 2,3,4 exons M+ 10%

KRAS 1 exons M+ 35-40%

TARGETS in colorectal cancer

Panitumumab

Cetuximab

Cetuximab, PanitumumabNecitumumab, Neratinib

MEK: Pimasertib, Trametinib, SelumetinibNOTCH: demcizumab, MK-0752CDK9: AZD5438, dinaciclib, BAY1000394PLK1: volaserib, GSK-461364

TrastuzumabLapatinibNeratinibAfatinib

CrizotinibAMG 337TivantinibForetinib

vemurafenib

everolimus

BRAF M+5%

PIK3CA M+10%

EGFR-DRIVEN COLON CC

10-20%(EGFR CNG, +LIGANDS)

NRAS 2,3,4 M+ 10%HER-2 M+

5%

ALK/EML!2,5%

MET+5-10%

KRAS 2,3,4 exons M+ 10%

KRAS 1 exons M+ 35-40%

Primary resistance to anti-EGFR therapy in colorectal cancer

EGFR Inhibitors NO EGFR InhibitorsEGFR Inhibitor is 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 panitumumab or cetuximab in metastatic colorectal cancer. Di Nicolantonio F, Martini M, Molinari F, Sartore-Bianchi A, Arena S, Saletti P, De Dosso S, Mazzucchelli L, Frattini M, Siena S, Bardelli A. 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

RAS and BRAF wt

93 33.5 41.7 0.77 [0.46-1.27]

0.522 *RAS

mutated236 23.9 27.3 0.88

[0.65-1.18]

BRAF

mutated28 10.7 19.0 0.54

[0.24-1.20]

* p for interaction

Cremolini et al., Lancet Oncol 2015

Melanoma: vemurafenib, dabrafenib-trametinib

NSCLC: vemurafenib, dabrafenib

Papilláris pajmirigy daganat: vemurafenib

BRAF-V600E

Hajas sejtes leukémia: vemurafenib

Cholangiocarcinoma: dabrafenib+trametinib

Vastagbél adenokarcinoma: ?

BRAF+EGFR

BRAF GÁTLÓK HATÉKONYSÁGA VASTAGBÉLDAGANATOKBAN

BRAF

Yan Y, Grothey A. Molecular profiling in the treatment of colorectal cancer:focus on regorafenib. Onco Targets Ther. 2015 Oct 15;8:2949-57.

BRAF+EGFR+MEK

BRAF+EGFR+irinotecan

BRAF+EGFR+PIK3CA

Randomized trial of irinotecan and cetuximab

with or without vemurafenib in BRAF-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 Kanwal Raghav,1 Van Morris,1 Stephen Wang, 8 Christopher Lieu, 9

Katherine A. Guthrie, 2 Howard S. Hochster10Katherine A. Guthrie, 2 Howard S. Hochster10

1The University of Texas MD Anderson Cancer Center, Houston, TX; 2Fred Hutchinson Cancer Research Center, Seattle, WA; 3USC Norris Comprehensive Cancer Center, Los Angeles, CA; 4H. Lee Moffitt Cancer

Center & Research Institute, Tampa, FL; 5University of California, San Francisco, San Francisco, CA; 6Memorial Sloan Kettering Cancer Center, NewYork, NY; 7University of Florida, Gainesville, FL; 8Kaiser

Permanente, Sacramento, CA; 9University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO; 10Yale Cancer Center, New Haven, CT

Secondary Endpoint: Overall Survival

HR = 0.73 (95% CI 0.45 – 1.17)P=0.19

80%

100%

60%

N Events Median 95% Conf IntCetuximab + Irinotecan 50 38 5.9 (3.0 – 9.9)Vemurafenib + Cetuximab 49 32 9.6 (7.5 – 13.1)

+ Irinotecan

0 3 6 9 12 15 18Months after randomization

40%

20%

0%

April 18. 2017 data cutoff

Presented by: Scott Kopetz, MD, PhD

MULTICENTRIKUS VIZSGÁLAT BRAF MUTÁNS VASTAGBÉLDAGANATOKBAN ÚJ GENERÁCIÓS BRAF ÉS MEK GÁTLÓKKAL

BRAFi+cetuxumab

BRAFi+MEKi+cetuxumab

FOLFIRI+cetuximab

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),

FIGHTING SECONDARY RESISTANCE: HER-2

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 canbe detected after progression on EGFRi but mKRAS levels drop during 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

My take


EGFR

HER-2

20% IHC+0% M+7% CNG

IGFR

C-MET IHC+ 70%

FGFR

ALK/EML4

70-90% (M+) RON

5% M+0% CNG

AMPEPI

HGF

IHC+ 40%

IGFI

CrizotinibCabozantinib

XL184

Erlotinib

²¹²Pb-TCMC-TrastuzumabTrastuzumab, lapatinib , TDM-1

AMG 479

Dovitinib

FGFRvIIIb

FGFRvIIIc

Drugable driver genes in pancreatic cancer

KRAS

BRAF

MEK

AKT/PKB

PIK3CA

MTOR

70-90% (M+)

2% (M+)

1% (M+)

8% (M+)

3% (M+)

PTEN

RON

NRASHRAS1% (M+)

INSRA/B

IGFII

INS

NOTCH

G-SECRETASE

Trametinib, AS703026BAY 86-9766, AZD6244

MRK003

PLK1VolasertibTAK-960

Naflivir GDC-0980 Metformin, everolimus

vemurafenibVismodegibVismodeglib

SMO

CDK4

BKM120

PalbociclibBAY1000394AZD5438

CDKN2A91% (M+)

P53

MDM2

84% (M+)SMAD4 50%(M+)

Clinical Significance of the Genetic Landscape of Pancreatic Cancer

1% 18% 44% 37%

Yachida S, et al.. Clinical significance of the genetic landscapeof pancreatic cancer and implications for identification of potential long-term survivors.

Clin Cancer Res. 2012 Nov 15;18(22):6339-47.

OS= 9 months (p=0,04)OS= 24 months

PIK3CA M+5%

EGFR 5-10%

C-MET-HGF AUTOCRINE LOOP 40%HER-27-20%

AKT 3%

PIK3CA CNG?%

PTEN M+?%

Platform trial design in pancreatic cancer

KRAS M+ (70-90%)

ERLOTINIB

HER-2 INH

AKTINH

PI3K/MTOR inhibitor

PLK1, CDK4, NOTCH, MEK, MET INHIBITOR

107

Driver gének hasnyálmirigy adenocarcinomában

32

42

30

40

50

Bet

egek

szá

ma

13

94

710

2 10

10

20

0 1 2 3 4 5

Bet

egek

szá

ma




PTEN

ATM

ATR

CHK2

CHK1p53

MDM2

P21

P16

Cdk4/6

Cyclin D1Rb EF2

TGFα

EGF

EGFR

HER2PI3K AKT mTOR

FBXW7

NICD1

Cyclin E 107

Driver gének hasnyálmirigy adenocarcinomábanPM

1%

1% (FISH)

4%(PIK3CA)

7% (CDKN2A)

50%

EGF

HGF

FGF

PGE20

WNT

HER2

MET

FGFR

GPCR

Frizzled

ECAD

RAS RAF MEK ERK

αs AC cAMP PKA

APC

β-catenin

Dvl GSK-3β

β-catenin

Axin




1% (FGFR1 FISH)

1% (GNAS) 3%

6%

75%(KRAS)

EGFR

HER-2

1,8% M+

25% FISH+

KIT 2% M+

C-MET

1% M+, 15% FISH+

FGFR

0,8% M+

4,1% FISH+

ALK/EML4

PDGFR

4% M+

5% FISH+

Drugable driver genes in gastric cancer

KRAS

BRAF

MEK

AKT/PKB

PIK3CA

MTOR

6,5% M+

1,1% M+

1% M+

8% M+

67% FISH+

3,8% M+PTEN

PDGFR

HRASNRAS

Driver gének gyomor adenocarcinomában37

14

11

8

10

12

14

16

Bet

egek

szá

ma

9

28

21

0

2

4

6

8

0 1 2 4

Bet

egek

szá

ma




PTEN

ATM

ATR

CHK2

CHK1p53

MDM2

P21

P16

Cdk4/6

Cyclin D1Rb EF2

TGFα

EGF

EGFR

HER2PI3K AKT mTOR

Driver gének gyomor adenocarcinomábanFBXW7

NICD1

Cyclin E 37PM

3%8%(PIK3CA)

22%

3% (FISH)

EGF

HGF

FGF

PGE20

WNT

HER2

MET

FGFR

GPCR

Frizzled

ECAD

RAS RAF MEK ERK

αs AC cAMP PKA

APC

β-catenin

Dvl GSK-3β

β-catenin

Axin




3%

3%

3%(KRAS)

5% (CTNNB1)

Wil type; 1only

polymophism

; 13 mutacions;

2

4+ mutacions;

1

16,67%

Most frequently mutated driver genes in gastric cancers (N=16, 58 genes tested)

1 mutacion; 42 mutacions;

3

83,34

%

5

6

Distribution of all mutations in gastric cancers

1 1 1 1 1 1 1 1 1

EGFR +„szuper wt” and

FISH+/M+PIK3CA-/MET-

/HER-2-C-MET +

(FISH+/M+)

HER-2 +PIK3CA-/MET -

PIK3CA + (FISH+/M+/PTEN M+)

FGFR FISH+PIK3CA -

Platform trial design in gastric cancer

LapatinibNeratinibAfatinib

AZD4547DovitinibPonatinib

nintedanib

CrizotinibAMG 337TivantinibForetinib

ErlotinibGefitinib

CetuximabPanitumumabNecitumumab

Neratinib

EverolimusMetforimn

TemsirolimusXL147

BKM120BEZ235

TARGETING PARP IN HOMOLOGEUS RECOMBINATION DEFICIENT (HRD) TUMORS

John L. Marshall, MD Chief, Division of Hematology/OncologyGeorgetown University Hospital Director, Otto J. Ruesch Center 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 cancerpancreas 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• Patient enrolled on a trial of FOLFOX + veliparib

• Achieved CR, in response for 26 mos

PDL-1 és MSI hazai GI betegekben

MSI vizsgálatPD-L1 expresszió vizsgálat

100%

0%

Epeúti daganatn=8

95%

5%

Hasnyálmirigydaganat n=21

87%

13%

Epeúti daganat

85%

15%

Hasnyálmirigy daganatn=8 n=13

FDA: PEMBROLIZUMAB

MSS MSI-H MSS MSI-H

90%

10%

Gyomor daganat

MSS MSI-H

97%

3%

Vastag- és végbéldaganat

MSS MSI-H

n=99 n=10

PD-L1 negatív PD-L1 pozitív PD-L1 negatív PD-L1 pozitív

86%

14%

Vastag- és végbéldaganat

PD-L1 negatív PD-L1 pozitív

93%

7%

Gyomor daganat

PD-L1 negatív PD-L1 pozitív

n=7 n=15

EVER TRIED.EVER TRIED.EVER FAILED.EVER FAILED.NO MATTER.NO MATTER.TRY AGAIN.TRY AGAIN.TRY AGAIN.TRY AGAIN.FAIL AGAIN.FAIL AGAIN.FAIL BETTER.FAIL BETTER.

Samuel Beckett

molekulÁris diagnosztika klinikai felhasznÁlÁsa ...€¦ · analysis of kras/nras and braf...

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