unmet medical needs in nsclc treatment · mapk activity and emt-tf reprogramming in the time course...
TRANSCRIPT
Unmet medical needs in
NSCLC treatment
R Rosell Catalan Institute of Oncology, Badalona, Barcelona
Molecular Oncology Research Foundation (MORe) Barcelona Cancer Therapeutics Innovation Group (CTIG), New York
XIV Congreso Nacional de Oncología Médica Salamanca
23 October 2013
• Coactivation of PI3K/Akt/mTOR and Ras signaling pathways occurs frequently in advanced cancer and is associated with adverse patient outcome (well established)
• Crosstalk between oncogenic pathways induces continual MEK-ERK signaling which maintains a reconfigured pattern inducing EMT-TF reprogramming (well established)
• Therefore, almost all patients with advanced cancer eventually develop resistance to current available cytotoxic and targeted therapies (well established)
• Genotyping is not enough for the patient’s expectations and deciphering crosstalk could be crucial for synthetic lethal therapies
Rosell et al. NEJM 2013 (MED12) Rosell, Bivona & Karachaliou. The Lancet 2013 (BIM) Rosell & Karachaliou. Nat Rev Clin Oncol. 2013 (mTOR)
Contributions: Bivona et al. Nature 2011 (NFKBIA - I) Zhang et al. Nature Genetics 2012 (AXL) Rosell. Lancet Oncology 2012 (EURTAC)
BIOMARKERS POTENTIAL THERAPEUTIC COMBINATIONS
Intrinsic apoptopic pathway
MCL1, FBW7, Noxa, BIM Vorinostat plus ABT-737; gefitinib plus ABT-737
KRAS-mutant tumours: Bcl-XL, BIM ABT-263 (navitoclax) plus selumetinib
Extrinsic apoptopic pathway
Trail, BIM, FOXO3, miR-494 TIC10 plus EGFR TKIs
GALNT14, FUT3/6, SIX1 Dulanermin, drozitumab
DR4/DR5, PEA15 Dulanermin, Drozitumab
MAPK/AKT/AMPK
FOXO3a, BIM, MED23 EGFR TKIs +Taxanes
VEGF-A, T790M Erlotinib+Bevacizumab (BELIEF)
KRAS-mutant tumours: FOXO3, LKB1, IGF1R
Selumetinib/trametinib; selumetinib/trametinib plus triciribine; selumetinib/trametinib plus paclitaxel; phenformin/metformin; IGF1R inhibitors plus selumetinib/trametinib
NOTCH3: HES1, DUSP1, NUMB EGFR TKIs plus γ-secretase inhibitor
TP53: MDM2, iASPP BRAF inhibitors plus MDM2 inhibitors plus iASPP inhibitors
AXL:AXL, GAS6, RELA, NFκB EGFR TKIs plus AXL inhibitors
IL-6:IL-6, JAK, STAT3 EGFR TKIs plus AXL inhibitors; EGFR TKIs plus pan-JAK inhibitors
TGF-β:TGF-βR2, MED12 EMT phenotype
EGFR TKIs plus TGF-β inhibitors
HEDGEHOG: GLI1, SOX2, SOX9, CXCR4, FGF19, aPKCl/λ,
EGFR TKIs plus aPKCl/λ inhibitors
mTOR/S6K1 EGFR TKIs plus mTOR inhibitors
cAMP–PKA: PKA, PDE4A/D EGFR TKIs plus PDE4 inhibitors
Rosell, Bivona, Karachaliou. Lancet. 2013
Stromal HGF confers EGFR TKI resistance and induces interreceptor crosstalk with integrin-4, Eph2, CDCP1, AXL and JAK1 (Gusenbauer, Vlaicu & Ullrich. Oncogene 2013) Also, HGF is present in melanoma stromal cells and correlates with poor response. A similar resistance mechanism was shown in a subset of BRAF mutant colorectal and glioblastoma cell lines (Straussman et al. Nature 2012)
Minimum 8,8 mm2 tumor and stroma tissue for the RNA analysis
Cuts of tissue mandatory 4 µm or more (5 cuts if block cannot be sent)
Further tissue can be cut as required from the FFPE block following pathology assessment if the whole block is sent
BELIEF trial. N Karachaliou, C Teixido
Rosell. NEJM 2013
Shin et al. JNCI 2013
Kanda et al. Cancer Res 2013
MAPK activity and EMT-TF reprogramming in the time course of tumor progression. A late EMT-TF reprogramming is dependent on continual MAPK signaling
Caramel Cancer Cell 2013
EGFRvIII induces secretion of IL-6 which activates gp130, generating a paracrin loop which promotes activation of EGFR in neighboring cells (Inda et al. Genes Dev 2010)
Wang et al. PNAS 2013
Gao et al. J Clin Investigation 2007
Zadeh et al. Cancer Cell 2013
Activated WT EGFR phosphorylates EGFRvIII triggering nuclear transport of EGFRvIII, and enhanced phosphorylation of STAT3 (Fan et al. Cancer Cell 2013)
Steder et al. Cancer Cell 2013
Bredel et al. NEJM 2010 Bivona et al. Nature 2011
Erlotinib treated EGFR mutant NSCLC
NFKBIA encoding IB the major negative regulator of NFB
BIM
IKK
α
IKK
β
Rosell, Bivona, Karachaliou. Lancet. 2013
• Nuclear factor of -light polypeptide gene enhancer in B-cells (NFB) a transcription factor activated by EGFR mutations (including EGFRvIII) and other oncogenes
• AXL/GAS6, mTORC2 and the non-cannonical NOTCH pathway activate NFB
• AXL also activates IL-6 and STAT3
• MYC-driven tumors can activate NFB (PDK1-PLK1-MYC)
- PLK1 inhibitor blocks mTOR inhibition-induced MYC activation (Tan et al. Cancer Cell 2010)
• EGFR T790M mutation-mediated acquired resistance – an unmet medical need
• Crosstalk of mTORC1 with Beclin, Bcl2 and BIM
• Cross-regulation DGK-PDE4A/D-PKA-cAMP-mTORC1
• Genomic fluidity (Wip1/PPM1D-LINE-1/APOBEC)
EURTAC
BREC/SCAT
BELIEF
GOAL
- Serial rebiopsy study
- AXL inhibitor trial
EUCROSS
NVALT
Platelets/plasma (EML4-ALK)
EGFR mutants (cDNA)
CTCs
EURTAC – cutoff January 2013 Rosell et al. Lancet Oncology 2012
• T790M mutation is present in up to 62-82% of cases at time of clinical
progression to erlotinib (Arcila CCR 2011; Su et al. JCO 2012)
• Allelic dilution makes it difficult to identify T790M by direct sequencing. A
low frequency of expression of the mutant allele HER2 T798M (3%) was
sufficient to confer drug resistance (Rexer et al. CCR 2013)
• Pre-existing T790M mutation found in 27% of EGFR-mutant patients by
massively parallel sequencing (Querings et al. PLoS ONE 2011), in 31.5% by MALDI-TOF
MS (Su et al. JCO 2012), in 35% by PCR-PNA assay (Rosell, Molina et al. CCR 2011), in 38% by
SARMS (Maheswaran et al. NEJM 2008), and related to shorter PFS to gefitinib or
erlotinib (Maheswaran et al. NEJM 2008; Rosell et al. CCR 2011; Su et al. JCO 2012)
• Pre-existing EGFR T790M found in 65% of EURTAC samples . Also, 50%
found in the BELIEF and GOAL studies
G3: Chemotherapy and T790M present (n=28)
G1: Erlotinib and T790M present (n=34)
G4:Chemotherapy and T790M absent (n=17)
G2: Erlotinib and T790M absent (n=16)
5·1 9·7 15·8 6·0
Patients at risk
G2
G4
G3 G1
EURTAC – cutoff January 2013
BIM
TRAIL
TRAIL
BIM
AC
GPCR
DR4/DR5
Rosell, Bivona, Karachaliou. Lancet. 2013
EURTAC – cutoff January 2013
EGFR mutant NSCLC patients
DGKa/PDE4/PKA/ERK/mTORC1
H1650 (ABT-263/gefitinib) Cragg et al. PLoS MED 2007
ABT-263/Erlotinib TORCi/SOCE agonists (IGR1)Corcoran et al. Science Transl Med 2013
Rosell & Karachaliou. Nat.Rev.Clin.Oncol. 2013
Maes et al. Trends in Molecular Medicine 2013 Wirawan et al. Cell Death and Disease. 2010
ULK1/2
FIP200
Atg13
mTORC1
Beclin1 Ambra1
CIII-PI3K/Vps34
Atg101 1) Autophagosome initiation
Atg14L p150
2) Nucleation
Atg5
Atg7
Atg10
Atg12 Atg16L
LC3 LC3-II
3) Elongation
Bcl-XL Bcl2
p62 U NBR1
U
LC3-II
4) Delivery & Degradation
BIM
ABT-737/ABT-263
AMPK
LKB1
TSC1/TSC2 Rheb
Metformin
KRAS/LKB1 (A549)
PDE4A/D DGKa
ERK
H1650
PI3K/AKT
L858R/T790M (H1975)
EGFR
AKT
Rubicon
Courtesy of Niki Karachaliou
Wei et al. Cell 2013
In the TKI-sensitive HCC827 cells (but not in TKI-resistant H1975 cells), erlotinib led to EGFR dephosphorylation, disruption of EGFR/Beclin 1 binding, disruption of Beclin 1/Rubicon binding, increased Beclin 1/VPS34 binding, decreased Beclin 1/Bcl-2 binding, and increased Beclin 1-associated VPS34 kinase activity. Also HCC827 cells but not H1975 cells show LC3-II conversion and P62 degradation after erlotinib treatment.
Beclin1 Ambra1 CIII-PI3K/Vps34
LC3 I LC3 II
BIM-EL
ABT-737/ABT-263
LKB1
TSC1/TSC2
Rheb ERK
(H1650)
Akt
Vasculogenic
mimicry
TAK-1
↑Ca++
CaMKKα/β
Soluble form Lipidated form
Autophagosome
RAS
DGKa
(H1975, A549)
p62 U
NBR1
U
LC3-II
(↑LC3 & Beclin1 mRNA & IHC)
autophagy
apoptosis
Enobosarm
Bcl-XL Bcl2 Mcl-1 Rubicon
VEGFA/VEGFR1
Hypoxia
ULK1/2 FIP200
Atg13 Atg101
AR SARMs
Atg5 Atg7
Atg10
Atg12 Atg16L
Atg9
mTORC1
Akt
FKBP5 PI3K
RAF
Amino-acid
starvation
Sirolimus/SOCE
agonists
PTEN PHLPP
AMPK
PDE4A/D
autophagy
Modified from Rosell, Bivona, Karachaliou. Lancet 2013
L858R/T790M (H1975)
Afatinib
STIM1
SOCE
Rap1 GTPase DOCK4 PRKA2
• PLK1 inhibitor blocks mTOR inhibitor-induced MYC activation (Tan et al. Cancer Cell 2010)
• A number of genes implicated in ESC are upregulated in HEK-PDK1 cells and HEK-MYC cells: SOX2, LIN28B, SALL4, EZH2. Others such as EPCAM, ALDHIA, S100A4 are also upregulated and considered markers of CSCs (Tan et al. Cancer Discovery 2013)
Cunningham & Ruggero. Cancer Discovery 2013
Well-characterized panel of cell lines for determination of clinically relevant markers
• H1975(EGFR del /T790M) rolipram sensitive PDE4D Our findings
(DGKa/PDE4/PKA/↑ERK/mTORC1)
• A549 (KRAS/LKB1) rolipram sensitive PDE4D Our findings
DGKa/PDE4/PKA/ERK
• H460 (KRAS/LKB1) rolipram resistant PDE4D intermediate / PDE4A (N Karachaliou)
NOTCH3/HES1/ERK1. Sensitive to erlotinib/secretase inhibitors
• H1650 (EGFR del/↓BIM) sensitive to ABT-263/gefitinib
DGKa/PDE4/PKA/↑ERK/mTORC1, rolipram partly sensitive
• IGR1 (BRAF melanoma) ↑BIM resistant to VEM (↓ERK/ ↑mTORC1 ) Sensitive to VEM/ABT-263, or a TORC inhibitor (Corcoran et al. Science Trans Med 2013)
Pullamsetti et al. Oncogene 2013 Dominguez et al. Cancer Discovery 2013
Rolipram reduces proliferation in H1975 cell line Serum-starved (0%, 0.1% and 0.5% FBS, normoxia)
0
0,2
0,4
0,6
0,8
1
1,2
0 1 50 250
Viability
Rolipram μM
H1975 0% FBS
0
0,2
0,4
0,6
0,8
1
1,2
0 1 50 250
Viability
Rolipram μM
H1975 0.1% FBS
0
0,2
0,4
0,6
0,8
1
1,2
0 1 50 250
Viability
Rolipram μM
H1975 0.5%
Pullamseti et al. Oncogene 2013
Molina & Bertran-Alamillo
BIM high/mTOR low-intermediate: mOS=35.8m BIM high/mTOR high: mOS=20.3m
BIM low/mTOR low-intermediate: mOS=17.7m BIM low/mTOR high: mOS=25.1m
N. Karachaliou and A. Droz
erlotinb gefitinib afatinib
erlotinb gefitinib afatinib
High
Low
High
T790M present
mTOR high
T790M absent
mTOR low
T790M model
mTOR model
+ mTORi+SOCE agonists or PLK i metformin or 2DG
BIM BIM
BIM mRNA expression
erlotinb gefitinib afatinib
+ Bcl2i PDE4i Taxanes
erlotinib gefitinib afatinib
A potential algorithm for directing EGFR TKI therapy in EGFR mutant NSCLC
Courtesty N Karachaliou
afatinib/pemetrexed Afatinib/bevacizumab
Conclusions
• Only BIM mRNA expression is an independent marker of both PFS and OS in
the EURTAC study
• mTORC1 modulates survival in NSCLC expressing high BIM (Karachaliou et al.)
• BIM and mTOR essential markers for adequate treatment of NSCLC patients
with EGFR mutations, and probably other subclasses of lung cancer
Acknowledgements
Ana Drozdowskyj, Miguel Angel Molina, Andres Felipe Cardona, Ana Giménez-Capitán,
Jordi Bertran-Alamillo, Clara Mayo, Jordi Codony, Radj Gervais,Teresa Moran,
Margarita Majem, Enriqueta Felip, Enric Carcereny, Felipe Cardenal, Ramon Palmero, Ruth Porta, Joaquim Bosch,
Santiago Ponce-Aix, Ana Estival, Rosario Garcia-Campelo, Santiago Viteri,
Amaya Gasco, Daniela Morales-Espinosa, Cristina Teixido,
Jose Luis Ramirez, Miquel Taron, Carlos Camps, Manuel Cobo, Manuel Domine, Isabel Bover, Mariano Provencio,
Guillermo Lopéz-Vivanco, Dolores Isla, Bartomeu Massuti, Alain Vergnenegre, Solange Peters,
Rolf Stahel, Jia Wei, Baroui Liu, Silvia Garcia-Roman, Roger Estrada, Trever Bivona, Niki Karachaliou
Spanish Lung Cancer Group (SLCG)
French Lung Cancer Group
European Thoracic Oncology Group (ETOP)
Comprehensive Cancer Center of Drum Tower Hospital Nanjing
Cancer Therapeutics Innovation Group (CTIG)
Pangaea Biotech S.L, Quirón Dexeus University Hospital
Pivotal, Madrid
Institut Químic de Sarrià (IQS) / Grup d’Enginyeria Molecular (GEM)