BIOMARKERS.Roberto Bordonaro

Struttura Complessa di Oncologia MedicaARNAS Garibaldi

Catania

- The management of breast cancer, both in early and in advanced stages, had become a “receptor-driven therapy”.

- Main breast cancer determinants have both prognostic and predictive role, such as ER, PgR and Her2.

- They also reflect the moment when the cell develops the tumor phenotype.

BIOMARKERS.

image by Katie Vicari, from Prat and Perou, Nature Medicine, Aug;15(8):842-4 (2009)

image by Katie Vicari, from Prat and Perou, Nature Medicine, Aug;15(8):842-4 (2009)

Her2+ve tumours

Her2+ve / ER and/or PgR+ve

ER and/or PgR+ve

image by Katie Vicari, from Prat and Perou, Nature Medicine, Aug;15(8):842-4 (2009)

Her2+ve tumours

Her2+ve / ER and/or PgR+ve

ER and/or PgR+ve

BIOMARKERS.

• Triple-negative breast cancer are a heterogenous subgroup of tumours.

• The 75 per cent of them shown a “Basal-like signature” (more than a half express TP53-mutations, some are BRCA1-mut carriers).

• They have high proliferative rate and a poor prognosis (in terms of poor relapse-free and/or overall survival).

Claudin-low Subtype1. 5-10% of all tumors2. typically TNBC3. low expression of cell-cell junction proteins4. lymphocyte infiltrates5. stem cell + EMT features

Claudin 7

Claudin 3Claudin 4

E-Cadherin

Basal

Luminal

Proliferation

HER2

Claudin-low Subtype1. 5-10% of all tumors2. typically TNBC3. low expression of cell-cell junction proteins4. lymphocyte infiltrates5. stem cell + EMT features

Claudin 7

Claudin 3Claudin 4

E-Cadherin

Basal

Luminal

Proliferation

HER2

Phenotypic and Molecular Characterization of the Claudin-low Intrinsic Subtype of Breast Cancer, Prat et al., Breast Cancer Res. 2010 Sep 2;12(5):R68. (PMID: 20813035)

CRYABID4

c-KITKeratin 5

Keratin 17P-Cadherin

EGFR/HER1

HER2

Basal-like phenotype (75% of TNBC cancers; 10-20% of BC);● >50% TP53-mutated;● high proliferative rate (RB loss)

DNA-recombination defects related to BRCA1-mutations.

Luminal

Proliferation

CRYABID4

c-KITKeratin 5

Keratin 17P-Cadherin

EGFR/HER1

HER2

Basal-like phenotype (75% of TNBC cancers; 10-20% of BC);● >50% TP53-mutated;● high proliferative rate (RB loss)

DNA-recombination defects related to BRCA1-mutations.

Luminal

Proliferation

Deconstructing the Molecular Portraits of Breast Cancer,Prat and Perou, Molecular Oncology, Nov 24, 2010

(PMID: 21147047)

BRCA1- Associated Breast Cancer

• “BRCAness”• High grade• ER- and HER2-negative• C-myc amplified• Medullary• Pushing margins• DCIS less common• Lymphocytic infiltrate• TP53 mutations• Basal phenotype• EGFR expression• X-chromosome inactivation

pattern• Sensitivity to DNA damage

• One defective gene copy carried in a germ cell

• 5-10% of breast cancers

• 50-90% lifetime risk of disease

• Shared characteristics with sporadic basal-like breast cancer: “BRCA-ness”

BRCA1 Is Key to Repairing DNA Damage

Several DNA damage response pathways exist:• Homologous recombination (HR)

– DEPENDS ON BRCA1

• Base excision repair (BER)– DEPENDS ON PARP

• Nucleotide excision repair (NER)• Mismatch repair (MMR)

Platinum-sensitivity of BRCA1mut – TNBCs

• Neo-adjuvant setting:

– Retrospective trials suggest platinum-based regimens activity;

– Data from prospective trials on TNBCs are controversial;

• Metastatics TNBCs:

– control arm in BALI-1 study with DDP alone – 10% RR

Trial Characteristics Regimen n° pRC

Byrski BRCA1+mut carriers

Not-platinum-based 90 14 (16%)

BRCA1+mut carriers

CDDP 75mg/m2 x4 12 10 (83%)

Silver sporadics TNBCs(not BRCA1+mut

carriers)

CDDP 75mg/m2 x4 26 4 (15%)

BRCA1mut carriers “ “ 2 2 (100%)

Ryan sporadics TNBCs (not BRCA1+mut

carriers)

CDDP 75mg/m2 x4 + bevacizumab 15 mg/kg

q3wk x3

51 8 (16%)

Byrski, JCO 2009; Silver JCO 2009: Baselga ESMO 2010; Isakoff SABCS 2010

Good platinum response (p =)

Young age .001

low BRCA1 mRNA expression .03

BRCA1 promoter methylation .04

p53 mutation .01

gene expression profile of E2F3 activation .03

Interesting biological analysis; small series (28), only two BRCA1 mutation carriers enrolled.

Biomarkers.

• Are there any biological characteristic expressed by triple-negative tumours that may influence the therapeutic choice?

FOS/JUN

Fibroblast

CXCL12

ImmuneCell

13-geneVEGF-signature

A compact VEGF signature associated with distant metastases andpoor outcomes, Hu et al. BMC Medicine 2009, doi:10.1186/1741-7015-7-9

FOS/JUN

Fibroblast

CXCL12

ImmuneCell

13-geneVEGF-signature

A compact VEGF signature associated with distant metastases andpoor outcomes, Hu et al. BMC Medicine 2009, doi:10.1186/1741-7015-7-9

Hypoxia-related Features andBasal-like Tumors

VEGF 13-gene VEGF-signature

Expr

essi

on

Hu, BMC Medicine 2009

• Antiangiogenic approaches work in TNBC at least as well as other subtype, possibly more.

A compact VEGF signature associated with distant metastases andpoor outcomes, Hu et al. BMC Medicine 2009, doi:10.1186/1741-7015-7-9

Identification of a clinically relevant gene signature in triple negative and basal like breast cancer. Rody et

al. SABCS 2010 Oral Presentation.

slide courtesy of Lajos Pusztai (MDACC)

679 consecutive Bc patients; among them, 87 (13%) where ER, PgR andHer2-ve.TN patients had significantly higher VEGF activiity: mValue = 8.2 pg/μg (versus 2.7 pg/μg in non-TN ones; p <.001) 62% of TN-patients had a VEGF acitivity above the median value, respect to the 47% of ER and/or PgR and/or Her2+ve ones. (p = 0.036).

TN status seems do not correlate with other clinical prognostic factors such as Tumour size (p = 0.07), nodal status (p =0.1), histological grade (p = 0.17) type of relapse (p = 0.82), age (p = 0.18).

Her2 overexpression was associated with high levels of VEGF (p <.001).

RFSdDFS

OS BCCS

Linderholm, Ann Oncol 2009

Outcome parameters

Univariate Multivariate

RFS H.r. significance (p) H.r. significance (p)

TNBC 1.8 0.0023 1.7 0.078

VEGF 1.6 0.0057 1.3 0.1663

dDFSTNBC 1.6 0.087 1.3 0.4099

VEGF 1.7 0.0166 1.4 0.2136

OSTNBC 1.8 0.0048 1.5 0.1672

VEGF 1.6 0.0021 1.3 0.1353

BCSSTNBC 2.2 0.0039 1.6 0.2621

VEGF 2.0 0.0044 1.5 0.0921

Linderholm, Ann Oncol 2009

Biomarkers.

• But, which chemoterapeutic agents shown activity and/or efficacy when administered to triple-negative breast cancer?

Pathologic Response to Anthracycline/Taxane by Subtype

369 patients from 3 neoadjuvant datasets

Modified PAM50

Overall pCR rate = 22% (82/369)

Classification Residual dz pCR

Basal-like 47 (58%) 34 (42%)

Claudin-low 29 (67%) 14 (33%)

HER2-enriched 31 (63%) 18 (37%)

LumA 110 (98%) 2 (2%)

LumB 56 (85%) 10 (15%)

Normal-like 13 (76%) 4 (24%)

Courtesy C. Perou

Majority of TNBC

Chemotherapy Advances BenefitTriple Negative

ER Negative ER Positive

HE

R2

NE

GH

ER

2 P

OS

paclitaxel

No paclitaxel

paclitaxel

No paclitaxel

paclitaxel

No paclitaxel

paclitaxel

No paclitaxel

Hayes, NEJM 2008; Perez, BCRT 2010; Di Leo, SABCS 2008

(CALGB 9344: AC + Paclitaxel)

• Docetaxel – Same findings (ECOG/Geicam)

• Anthracycline added to CMF

Anthracycline versus Non-AnthracyclineMA.5 Revisited

CEF CMF

Biologic # 5 Year # 5 Year p

Subtype OS OS

Luminal A 62 93% 71 90%

Luminal NOS 36 94% 26 85%

Luminal B 67 71% 65 71%

Luminal B 21 71% 27 44%<0.001

HeR2+/ER- 20 55% 23 30%

Basal by IHC 35 51% 35 71%<0.0001

TNBC Non-Basal 9 65% 20 63%

Cheang M et al, ASCO 2009

Intriguing, although retrospective and small

Responsiveness to Conventional Chemotherapy

Basal-like / triple negative:

Often responsive

If pCR achieved = good outcome!

Nonresponse = poor outcome

Predicting Markers of Clinical Benefit

• VEGF genotypes associated with improved OS in E2100.

• Higher levels of circulating endothelial cells at baseline have consistently correlated with prolonged clinical benefit and in one study improved TTP

Dahlberg SE, et al. J Clin Oncol. 2010;28:949-954

Biomarkers.

• AVF2119: 462 patients with MBC randomized to receive Capecitabine alone or capecitabine plus Bevacizumab.

• Among them, for 223 patients tissue samples were collected and tested with:

• a) in situ hybridization (VEGF-A, VEGF-B, Thrombospondin-2, Flt4)

• b) HIC (VEGF-C, PDGF-C, Neuropilin-1, Delta-like-ligand-4/DLL4, BV8, p53 and Timidine Phosphorilase).

Jubb, Clin Cancer Res, 2011

A = low endothelial Delta-like ligand-4 expression

B = high endothelial Delta-like ligand-4 expression.

R. Danesi Il ruolo dell'angiogenesi 35

Clinical trials assessing in-situ biomarkers in relation to the efficacy of bevacizumab

Biomarkers.

Conclusions:

1)The absence of a target seems define a target in itself.

2)For a high percentage of triple-negative tumours we may hypotize an angiogenesis addiction.

3)Anti-VEGf agents seem work well in all the subtypes of triple-negative tumours.

BIOMARKERS.Roberto Bordonaro

Struttura Complessa di Oncologia MedicaARNAS Garibaldi

Catania

Thanks for your kindly attention…