molecular and genetic markers in crc - bgdo€¦ · siena. esmo 2016 raghav et al. asco 2016...
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Molecular and Genetic markers in CRC
Sabine Tejpar, MD PhDUniversity Hospital Leuven
Belgium
Outline
• Routine testing
• The elusive biology of CRC
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Where we are not
Actionable targets in NSCLC:
Awad MM et al. JCO 2016
?
Colorectal cancer
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Colorectal cancer
Metastatic CRC: to be RAS wild type or mutant
Negative predictor for anti EGFR therapy
RAS mutation
HER1 HER2inhibitors?
Impact
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WTMUT
Wirapati P, et al. J Clin Oncol. 2017;35 (suppl; abstr 3538); Ince WL et al. J Natl Cancer Inst. 2005;97:981‐9; Kubicka S et al. Ann Oncol. 2013;24:2342‒2349; Obermannova et al. Ann Oncol. 2016;27:2082‒2090; Wirapati P, et al. J Clin Oncol. 2017;35 (suppl; abstr 3538).
KRAS exon 2KRAS exon 2
Extended RASExtended RAS
Aflibercept
Insufficient predictor for anti VEGF therapy
In both human and mouse tumour cell lines, MEK inhibition caused upregulation of MHC class I when compared to control populations1
Blocking the MAPK pathway by inhibiting MEK causes upregulation of MHC class I
MEKi, MEK inhibitor1. Ebert et al. Immunity 2016Image adapted from Kim and Bar‐Sagi. Nat Rev Mol Cell Biol 2004
MHC class I expression1
15,000
10,000
0
5,000
MEKiNo drug
p=0.0024
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• T‐cell exhaustion is defined by:3
– Poor effector function
– Sustained expression of inhibitory receptors
– A transcription profile distinct from effector or memory T cells
• MEK inhibition can suppress this upregulation of PD‐1, to avoid inhibition of immune responses1,2
• MEK inhibition correlates with reduced expression of pro‐apoptotic factors, to protect against exhaustive death1
MEK inhibition can partially protect cytotoxic T cells from exhaustive death as a result of chronic activity1
1. Ebert et al. Immunity 2016; 2. Chen and Mellman. Nature 2017; 3. Wherry. Nat Immunol 2011
Differentiation of T cells2
MEK inhibition can reverse T‐cell exhaustion
• MEK inhibition resulted in an increase in CD8+ T cells in the tumour core
• MEK inhibition increased the proportion of CD8+ T cells with a cytotoxic effector phenotype
In preclinical models, MEK inhibition induced accumulation of antigen‐specific CD8+ effector T cells in the tumour core
1. Ebert et al. Immunity 2016
CD8+ T cells per tumour cell Proportion of IFNγ‐producing CD8+ T cells
60
0
20
40
80
MEKiNo drug
IFN
γ+(%
)
PD-1 expression was reduced in infiltrating CD8+ T cells in tumours treated with MEKi
Proportion of CD8+ cells with low PD‐1 expression
40
30
0
10
20
50
MEKiNo drug
PD‐1
lo/CD8+ cells (%)
0.04
0.03
0
0.01
0.02
MEKiNo drug
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IMblaze370: randomised, Phase III, multicentre, open‐label study in mCRC
• Unresectable locally advanced or metastatic CRC
• Received ≥ 2 prior regimens of cytotoxic chemotherapy for metastatic disease
• ECOG PS 0-1• MSI-H capped at 5%
Regorafenib 160 mg oral 21/7 days
Atezolizumab 840 mg IV q2w + cobimetinib 60 mg oral 21/7 days
Atezolizumab 1200 mg IV q3wR
2:1:1N=363 L
oss
of
cli
nic
al b
en
efi
t
Primary endpoint• OSa
– Atezo + cobi vs rego– Atezo vs rego
INV-assessed key secondary endpoints• PFS• ORR • DOR
Stratification• Extended RAS mutation status (≥ 50% patients in each arm)• Time since diagnosis of first metastasis (< 18 months vs ≥ 18 months)
• Data cutoff date: March 9, 2018
Overall survivalAtezo +
cobi(n = 183)
Atezo(n = 90)
Rego(n = 90)
Median OS, mo (95% CI)
8.9 (7.00, 10.61)
7.1 (6.05, 10.05)
8.5 (6.41, 10.71)
HR vs rego(95% CI)
1.00 (0.73, 1.38)
1.19 (0.83, 1.71)
N/A
P value 0.9871 0.3360a N/A
12-mo OS, % 38.5% 27.2% 36.6%
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Subgroup≥ 65 y < 65 y White Non-whiteECOG PS 0ECOG PS 1< 18 mo since 1st met diagnosis≥ 18 mo since 1st met diagnosis> 3 prior tx in met setting≤ 3 prior tx in met settingLeft side tumourRight side tumourRAS mutant RAS wildtypeMSI highMSI stable/lowPD-L1 highPD-L1 lowITT
n86187223391331408319070203148721481043
250110124273
Overall survival: key subgroupsAtezolizumab + cobimetinib vs regorafenib
Favours regoHazard Ratioa
Favours atezo + cobi
1.0
HR1.500.841.240.401.130.851.150.951.580.860.970.770.811.39NE
1.010.801.261.01
0,2 2
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But how does exposing the tumour help in a non‐inflamed tumour like MSS CRC?Combine with T cell priming and homing
Tumour cells (TC)
MHCMHC
MHC
MHC
Colorectal cancer
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Anti EGFR strategy in Ras wt
Patients with mCRC of indeterminate origin (n=3) were excluded from the analysis
Cetuximab + FOLFIRI (n=178)
FOLFIRI(n=189)
Left-sided tumors (n=142)
80%
Right-sided tumors (n=33)19%
mCRC of indeterminate origin (n=3)
1%
Left-sided tumors (n=138)
73%
Right-sided tumors (n=51)27%
CRYSTAL RAS-wtpopulation (n=367)
Relevant predictive value of primary tumor location: ORR (RAS‐wt)
42,433,3
0
25
50
75
100
Cetuximab +FOLFIRI(n=33)
FOLFIRI(n=51)
OR
R, %
Left-sided tumors
OR=3.99(95% CI: 2.40–6.62)
p<0.001
Right-sided tumors
OR=1.45(95% CI: 0.58–3.64)
p=0.43
72,5
40,6
0
25
50
75
100
Cetuximab +FOLFIRI(n=142)
FOLFIRI(n=138)
OR
R, %
Interaction p‐value: 0.07
EVC3
Diapositive 18
EVC3 should be consistent 72.5 and 40.6..... and not 72,5Eric Van Cutsem; 2/10/2016
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Relevant predictive value of primary tumor location: PFS (RAS‐wt)
24
Prob
abili
ty o
f PFS
Time (months)
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.00
Time (months)
Prob
abili
ty o
f PFS
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.00 24
1.0
7.1 8.118126
8.9 12.018126
HR=0.87(95% CI: 0.47–1.62)
p=0.66
HR=0.50(95% CI: 0.34–0.72)
p=0.0001
142138
3351
00
32
288
9973
11
33
1319
00
Cet + FOLFIRIFOLFIRI
No. at risk:Cet + FOLFIRI
FOLFIRI
No. at risk:
Interaction p‐value: 0.11
Left-sided tumors Right-sided tumorsEvents,n/N (%)
Cetuximab + FOLFIRI 19/33 (58)FOLFIRI 28/51 (55)
Events,n/N (%)
Cetuximab + FOLFIRI 54/142 (38)FOLFIRI 71/138 (51)
Negative predictor
Downstream signalling
Ligand activationamplification
Other measure of EGFR activation: Ligand, Left sided, lack of Her2…
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Right: Low ligand
Left: High ligand + low ligand
EREG2
L RMissiaglia, et al. ASCO 2013
CO17: Significant Cetuximab Benefit Only in high EREG mRNA Expression KRAS WT mCRC
WT, wild-type; mCRC, metastatic colorectal cancer; BSC, best standard care; HR, hazard ratio; CI, confidence interval; EREG, epiregulin, EGFR ligand; L, left; R, right.1. Jonker, et al. Br J Cancer. 2014; 2. Missiaglia, et al. ASCO 2013
Pro
po
rtio
n A
live
Time from Randomisation (months)
Low EREG1
4.8 6.5
HR 0.93, p = 0 .81
1.0
0.8
0.6
0.4
0.2
0.00.0 2.0 4.0 6.0 8.0 10.0
Cetuximab + BSCBSC
HR 0.46, p<0.001
Time from Randomisation (months)
Pro
po
rtio
n A
live
100
80
60
40
20
00.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0
High EREG1
5.0 9.9
Cetuximab + BSCBSC
L R
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MSI Immune (CMS1): 14%- µsatellite instability- CMP high- Hypermutation- B-Raf mutation- Immune activation
Metabolic (CMS3): 13%- Heterogenous chromosomal
and µsatellite status- k-Ras mutation- Metabolic reprogramming
Canonical (CMS2): 37%- High chromosomal instability - µsatellite stable- CMP negative- WNT and MYC activation
Mesenchymal (CMS4): 23%- High chromosomal instability - TGF activation- Invasion and matrix
remodelling- Angiogenesis
Right colon
31%
26%19%
24%
Rectum51%
3%
31%
15%
Left colon
56%
7%
27%
10%
Left/right: a poor man’s molecular tool
| 24
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HER1 and HER2 amplification
Her2 amplified, other therapies
Siena. ESMO 2016Raghav et al. ASCO 2016Bertotti et al. Nature 2015
Right‐sided tumours
• HER2 gain: present in 5% KRAS WT
• Of these, 84% are left‐sided tumours
Left‐sided tumours
IHC 3+
10X 40X
HER2+ patients most likely do not respond to aEGFR
100X
FISHCohort 1: PFS on aEGFR
1.0
0.5
00 5 1
015
20
25
Median: 2.9 vs 8.1 months(p<0.001)
HER2 amplificationHER2 non‐amplified
Time (months)
PFS estim
ate
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CALGB 80405: effect of tumour location on OS in all RAS WT patients
100
80
60
40
20
0
Eve
nt
free
(%
)
Months from study entry
Left: 32.7 monthsRight: 29.2 months
100
80
60
40
20
0E
ven
t fr
ee (
%)
Months from study entry
Left: 39.3 monthsRight: 13.7 months
Bevacizumab Cetuximab
0 24 48 72 84603612 0 24 48 72 84603612
Lenz et al. ESMO 2016
HR=0.55 (95% CI: 0.39–0.79)Adjusted p=0.001
HR=0.88 (95% CI: 0.62–1.25)Adjusted p=0.50
Colorectal cancer
Metastatic
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Strong Prognostic Value in mCRC
Richamn S et al, J Clin Oncol ‘09
V600E braf versus non V600E
Meta-Analysis: BRAF MT Patients Do Not Benefit Significantly from anti-EGFR Treatment
SE, standard error; CI, confidence interval; mCRC, metastatic colorectal cancer; WT, wild-type.Pietrantonio, et al. Eur J Cancer. 2015.
EGFR inhibitors are authorised only for RAS WT mCRC
Meta-Analysis of Randomised Clinical Trials of Cetuximab or Panitumumab
Bokemeyer 2012
Douillard 2013
Karapetis 2013
Seymour 2013
Peeters 2014
Stintzing 2014
Total (95% CI)
–0.478
–0.105
–0.174
0.61
–0.446
–0.139
Log(hazard ratio)Study
0.275
0.342
0.736
0.263
0.354
0.314
0.62 (0.36–1.06)
0.90 (0.46–1.76)
0.84 (0.20–3.56)
1.84 (1.10–3.08)
0.64 (0.32–1.28)
0.87 (0.47–1.61)
0.91 (0.62–1.34)
Hazard ratio(95% CI)SE
0.2 1 5
Favourscontrol
Favours EGFR inhibitors
20.7
17.0
6.0
21.5
16.4
18.5
100.0
Weight(%)
Heterogeneity: Tau2 = 0.11; Chi2 = 10.09df = 5 (p =0.07); I2 = 50%Test for overall effect: Z = 0.48 (p =0.63)
20.5
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NFOLFIRI + bev
Median OS
FOLFOXIRI + bev
Median OSHR [95% CI] p
RAS and BRAF wt 93 33.5 41.7 0.77 [0.46-1.27]
0.522*RAS mutated 236 23.9 27.3 0.88 [0.65-1.18]
BRAF mutated 28 10.7 19.0 0.54 [0.24-1.20]
* p for interaction
Cremolini et al, Lancet Oncol ’15
TriBe: OS outcome according to molecular subgroups
Targetted therapies for BRAF V600 mut
anti‐EGFRs: not enough...
anti‐BRAF single‐agent : not enough...
What about doublets, triplets?Enough?...adapted from Clarke C, JGO ‘15
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Figure 1: CRC algorithm• Prognostic
• stageII• (Stage III)
• Predictive• Stage IV
Genetic predisposition to colorectal cancer: syndromes, genes, classification of genetic variants and implications for precision medicine
The Journal of Pathology, Volume: 247, Issue: 5, Pages: 574-588, First published: 25 December 2018, DOI: (10.1002/path.5229)
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TEST: mismatch repair (MMR) proteins (MLH1, MSH2, MSH6, PMS2) (IHC)
IF Loss of MLH1
TEST: methylation of MLH1 promoter
Sporadic tumor
Suspicious Lynch syndrome / or other familial cancer syndromes?
IF Loss of MSH2 OR MSH6OR loss of PMS2
CRC
Genetic counseling
All CRC
IF No loss of nuclear expression for MMR proteins (MSS)
If TEST + If TEST ‐
Family history suspect for Lynch syndrome / or other familial cancer syndromes?
IF Yes IF No
TEST: PCR MSI
IF MSI + IF MSI ‐
OR TEST: mut BRAF2‐3 %
25 %Sporadic tumor
Immunotherapy!
MSI high= Microsatellite unstable CRC
38
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Genetic predisposition to colorectal cancer: syndromes, genes, classification of genetic variants and implications for precision medicine
The Journal of Pathology, Volume: 247, Issue: 5, Pages: 574-588, First published: 25 December 2018, DOI: (10.1002/path.5229)
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In mCRC, only 3‐5% of tumoursare MSI‐H and inflamed
Kim and Chen. Ann Oncol 2016; Hegde et al. Clin Cancer Res 2016; Roth et al. J Clin Oncol 2010 Koopman et al. Br J Cancer 2009 Fujiyoshi et al. Anticancer Res 2017
Increase number of antigen‐specific T cells or
increase antigen presentation
Bring T cells in contact with cancer cells
Accelerate or remove brakes on T cell response
CD8+ T cells absent from tumour and
periphery
CD8+ T cells accumulated but not efficiently
infiltrated
CD8+ T cells infiltrated, but non‐functional
MSI‐H (3–5%) MSS (>95% of mCRC)
NON INFLAMEDINFLAMED
Iterative revolutions of the cancer immunity cycle are critical for generating strong anti-tumour response
Chen and Mellman Immunity 2013
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47
StateoftheartImmunoscore forColonCancerPatientsoutcome(Jerôme Galon)
haliodx.com/clinical‐research‐services/immunogram/
Pages F. Galon J et al., Lancet May 10 2018
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ALL ABOUT TUMOR –MICROENVERINMENT INTERACTION
TCGA Nat Genet 2013
Smart synthesis of Morphological & Molecular information
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TEST: NGS Standard of Care min (BRAF, KRAS, NRAS)
CRCIF metastatic CRC
IF KRAS OR NRAS mut
No EGFR therapy
IF BRAF mut
bad prognosisDepending on MSI result immunotherapy
TEST: ampl (Her2) (ISH OR/AND IHC)
IF KRAS AND NRAS wt
TEST: NGS CT/CUT CT OR compassionate use
IF ISH HER2 +IF ISH HER2 ‐
3‐4%
30‐50%5‐10%
CT with/wo biological
Anti‐EGFR therapy
10‐15%
If progression
40‐65%
Level 2B
Left‐right?
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Colorectal cancer
Deep Interrogation of the Anti‐tumor Immune State
Deep TME characterization at baseline and post Interventions
Cell Phenotypes
Integrated Omics
Tumor Landscapes