what is new: beyond kras and any markers for anti vegf?

What is New:Beyond Kras and any Markers

for Anti VEGF? Heinz-Josef Lenz

Associate Director, Clinical Research Kathryn Balakrishnan Chair for Cancer Research

Co-Director, USC Center for Molecular Pathways and Drug Discovery

Co-Leader GI Oncology Program USC/Norris Comprehensive Cancer Center

Little New Biomarker Data New Understandings

Developing New Paradigms

• EGFR Ligands• Angiogenesis/Ethnicity • Stem Cell/Tumor Dormancy• Acquired vs Inherited resistance• Integrated System Biology

Amphiregulin and Amphiregulin and epiregulin: epiregulin:

Patient response to Patient response to cetuximabcetuximab

Khambata-Ford S, et al. J Clin Oncol 2007;25:3230–3237;Tabernero J & Macarulla T. J Clin Oncol 2009;27:5487–5491

EREG mRNA in diferrent EREG mRNA in diferrent Cancers Cancers

Rel

Gen

e Ex

p

0

10

20

30

40

Breast Colon Melanoma NSCLC Ovarian

Tumor

0 6 12 18 24 30 36 42Time from randomisation (months)

KRAS-wt, Xelox

00.

20.

40.

60.

81.

0Su

rviv

or fu

nctio

n


Arm AUpper quartile of EREG expressionMedian of EREG expressionLower quartile of EREG expression

Arm B

KRAS-wt, mFOLFOX

In the mFOLFOX subgroup, high EREG expression is predictive of increased cetuximab efficacy.

InteractionP=0.0042

InteractionP=0.14

Modelled survival plots by chemo regimen within the KRAS-wt subgroupModelled survival plots by chemo regimen within the KRAS-wt subgroup

Predictive analysis

Adams et al ASCO 2012

Prognostic: Ligand expression Prognostic: Ligand expression and KRASand KRAS

Control armControl arm

• The combination of KRAS=wt and high EREG expression selects a good prognostic group.

• This is in the absence of cetuximab use, suggesting previously reported similar findings in a non randomised series of patients treated with cetuximab (Jacob) may be a prognostic effect not a predictive effect.

0.00

0.25

0.50

0.75

1.00

Surv

ival


EREG, OS


KRAS-mutlow expressionKRAS-muthigh expressionKRAS-wtlow expressionKRAS-wthigh expression

EREG, PFS

Global log-rank test: P=0.004

Global log-rank test: P=0.014

Adams et al ASCO 2012

Stintzing: FIRE 3 ResultsAmphiregulin (AREG) Epiregulin (EREG) EGFR-FISH

low(n=35)

high(n=24) p

low(n=28)

high(n=31) p

low(n=27)

high(n=3

5)p

ORR 46% 83% 0.006

46% 74% 0.036 33% 71% 0.004

mPFS (m)

4.9 8.4 4.9 7.9 4.6 8.4PFS HR:

0.35<0.001

HR:0.58

0.026

HR: 0.490.004

mOS (m) 17.1 39.9 20.2 33.0 15.2 30.5

OS HR: 0.36<0.001

HR: 0.57

0.041

HR 0.440.001

Proposed Biomarkers for Optimal Treatment of Advanced Proposed Biomarkers for Optimal Treatment of Advanced Untreated Colorectal CancerUntreated Colorectal Cancer

ERCC1 low optimal for oxaliplatin.•Both KRAS WT AND High EGFR Ligands optimal for cetuximab.

Standard Optimal Rx1: Lo ERRC1, EGFR Res Folflox/Bev Folfox/Bev2: Lo ERRC1, EGFR Sen Folfox/Bev Folfox/Cetux3: Hi ERRC1, EGFR Res Folfox/Bev Folfiri/Bev4: Hi ERRC1, EGFR Sen Folfox/Bev Folfiri/Cetux

Estimate PFS for median of groups 2, 3, 4 with selected therapy is 14 months (harzard ratio 1.55)

LAD Jr et al. Nature 000, 1-4 (2012) doi:10.1038/nature11219

Emergence of circulating (new) mutant KRAS and Kras amplification as mechanisms of

resistance to EGFR inhibitors

S Misale et al. Nature 000, 1-5 (2012) doi:10.1038/nature11156

Most Resistance Manuscripts and Reviews Focus on Redundant Angiogenic Pathways

Ellis, Hicklin, CCR 2008

c-Met

Ellis ASCO 2012

Cremolini et al. ASCO 2012

VEGFR2 associated with PFS

C- (N= 118) mPFS: 9.5 m TT (N= 306) m PFS: 10.9 m

HR: 1.40 (1.07-1.84)Log-rank test p=0.015

race VEGFR2 rs12505758 VEGFR1 rs9582036 VEGFA rs699946 VEGFR2 rs11133360 VEGF rs833061 VEGF rs699947 VEGF rs1570366Caucasian 2 2 2 2 2 2 2

Caucasian 2 2 2 2 2 2 2

Caucasian 2 2 2 2 2 2 1

Caucasian 2 2 2 1 2 2 2

Caucasian 2 2 2 1 2 2 1

Caucasian 2 2 2 1 1 1 1

Caucasian 2 2 2 1 1 1 1

Caucasian 2 2 2 1 1 1 1

Caucasian 2 2 2 1 1 1 1

Caucasian 2 2 2 1 1 1 1

Caucasian 2 2 2 1 0 0 0

Caucasian 2 2 2 0 2 2 2

Caucasian 2 2 2 0 1 1 1

Caucasian 2 2 2 0 1 1 0

Caucasian 2 2 1 2 1 1 0

Caucasian 2 2 1 2 0 0 0

Caucasian 2 2 1 1 1 1 1

Caucasian 2 2 1 1 1 1 1

Caucasian 2 2 1 1 1 1 1

Caucasian 2 2 1 1 1 1 1

Caucasian 2 2 1 1 0 0 0

Caucasian 2 1 2 2 2 2 0

Caucasian 2 1 2 2 2 1 1

Caucasian 2 1 2 1 2 2 2

Caucasian 2 1 2 1 2 2 2

Caucasian 2 1 2 1 1 1 1

Caucasian 2 1 1 2 1 1 0

Caucasian 2 1 1 1 0 0 0

Caucasian 2 1 1 1 0 0 0

Caucasian 2 1 1 0 1 1 0

Caucasian 2 1 1 0 1 1 0

Caucasian 2 1 1 0 0 0 0

Caucasian 2 1 0 2 0 0 0

Caucasian 2 1 0 1 0 0 0

Caucasian 1 2 2 2 2 2 1

Caucasian 1 2 2 2 1 1 1

Caucasian 1 2 2 1 2 2 2

Caucasian 1 2 2 1 1 1 1

Caucasian 1 2 2 1 1 1 1

Caucasian 1 2 2 0 2 2 1

Caucasian 1 2 1 1 1 1 0

Caucasian 1 2 1 1 1 1 0

Caucasian 1 2 1 1 0 0 0

Caucasian 1 1 2 2 1 1 1

Caucasian 1 1 2 1 1 1 2

Caucasian 1 1 2 1 1 1 2

Caucasian 1 1 2 1 1 1 1

Caucasian 1 1 2 1 1 1 0

Caucasian 1 1 1 0 0 0

Caucasian 1 0 1 1 0 0 0

Hispanic 2 2 2 2 2 2 2

Hispanic 2 2 2 2 1 1 1

Hispanic 2 2 2 1 2 2 1

Hispanic 2 2 2 1 2 2 0

Hispanic 2 2 2 1 1 1 0

Hispanic 2 2 2 1 1 1 0

Hispanic 2 2 2 0 1 1 1

Hispanic 2 2 2 0 1 1 0

Hispanic 2 2 1 2 1 1 1

Hispanic 2 2 1 2 1 1 1

Hispanic 2 2 1 1 1 1 1

Hispanic 2 2 1 1 1 1 0

Hispanic 2 2 1 1 0 0 0

Hispanic 2 2 1 0 1 1 0

Hispanic 2 2 1 0 1 1 0

Hispanic 2 2 1 0 1 1 0

Hispanic 2 2 1 0 0 0 0

Hispanic 2 2 1 0 0 0 0

Hispanic 2 2 1 0 0 0 0

Hispanic 2 2 1 0 0 0

Hispanic 2 2 0 2 0 0 0

Hispanic 2 2 0 1 0 0 0

Hispanic 2 2 0 1 0 0 0

Hispanic 2 2 0 1 0 0 0

Hispanic 2 2 0 0 0 0 0

Hispanic 2 1 2 1 1 1 1

Hispanic 2 1 2 1 1 1 0

Hispanic 2 1 2 0 1 1 1

Hispanic 2 1 2 0 0 0 0

Hispanic 2 1 1 2 1 1 1

Hispanic 2 1 1 2 0 0 0

Hispanic 2 1 1 1 1 1 1

Hispanic 2 1 1 0 1 1 0

Hispanic 2 1 0 1 0 0 0

Hispanic 2 1 0 0 0 0 0


Hispanic 1 2 2 1 2 2 1

Hispanic 1 2 2 1 1 1 1

Hispanic 1 2 2 1 1 1 1

Hispanic 1 2 2 1 1 1 0


Hispanic 1 2 1 2 1 1 0

Hispanic 1 2 1 2 0 0 0

Hispanic 1 2 1 1 1 1 1

Hispanic 1 2 1 0 1 1 1

Hispanic 1 2 0 1 0 0 0

Hispanic 1 2 0 1 0 0 0

Hispanic 1 1 2 1 1 0 0

Hispanic 1 1 2 1 0 0 0

Hispanic 0 1 1 1 0 0 0

Japanese 2 2 2 2 2 2 0

Japanese 2 2 2 2 1 0 1

Japanese 2 2 2 1 1 1 0

Japanese 2 2 1 2 1 1 1

Japanese 2 2 1 2 1 1 0

Japanese 2 2 1 2 0 0 0

Japanese 2 2 1 2 0 0 0

Japanese 2 2 1 1 1 1 1

Japanese 2 2 1 1 1 1 0

Japanese 2 2 1 1 1 0 0

Japanese 2 2 1 0 1 1 2

Japanese 2 2 1 0 1 1 0

Japanese 2 2 1 0 0 0 0

Japanese 2 2 0 2 0 0 0

Japanese 2 2 0 2 0 0

Japanese 2 2 0 1 0 0 0

Japanese 2 2 0 1 0 0 0

Japanese 2 1 2 2 2 2 1

Japanese 2 1 2 1 2 2 1

Japanese 2 1 2 1 1 1 0

Japanese 2 1 1 1 0 0 0

Japanese 2 1 1 0 1 1 0

Japanese 2 1 1 0 0 0 0

Japanese 2 1 0 2 0 0 0

Japanese 2 1 0 1 0 0 0

Japanese 2 0 1 2 1 1 1

Japanese 1 2 2 2 2 2 2

Japanese 1 2 2 2 1 1 1

Japanese 1 2 2 2 1 1 0

Japanese 1 2 2 1 1 1 0

Japanese 1 2 1 2 0 0 0

Japanese 1 2 1 2 0 0 0

Japanese 1 2 1 1 1 1 1

Japanese 1 2 1 1 1 1 0

Japanese 1 2 0 2 0 0 0

Japanese 1 2 0 1 0 0 0

Japanese 1 2 0 1 0 0 0

Japanese 1 1 1 2 1 1 0

Japanese 1 1 0 2 0 0 0

Japanese 1 1 0 1 0 0 0

Japanese 0 2 2 2 0 0 0

Japanese 0 2 1 2 1 1 1

Japanese 0 2 1 2 1 1 0

Japanese 0 2 1 2 0 0 0

Japanese 0 1 1 2 1 1 0

Japanese 0 1 1 1 0 0 0

Japanese 0 1 0 1 0 0 0

Japanese 0 1 0

Japanese 2 1 2 0 0 0

Japanese 1 0 1

Cauc

asia

nHi

span

icJa

pane

se

Heatmaps in 7 Favorable Polymorphisms in BevacizumabraceVEGFR2 rs12505758 VEGFR1 rs9582036 VEGFA rs699946 VEGFR2 rs11133360 VEGF rs833061 VEGF rs699947 VEGF rs1570366

Caucasian2 2 2 2 2 2 2


















































Hispanic2 2 2 2 1 1 0

Hispanic2 2 2 2 0 0 0

Hispanic2 2 2 1 1 1 1

Hispanic2 2 2 0 1 1 0

Hispanic2 2 2 0 1 1 0

Hispanic2 2 2 0 0 0 0

Hispanic2 2 2 2 2 2

Hispanic2 2 1 1 1 1 1

Hispanic2 2 1 1 0 0 0

Hispanic2 2 1 1 0 0 0

Hispanic2 2 1 0 1 1 1

Hispanic2 2 1 0 1 1 0

Hispanic2 2 1 0 1 1 0

Hispanic2 2 1 0 0 0 0

Hispanic2 2 1 0 0 0 0

Hispanic2 2 1 0 0 0 0

Hispanic2 2 1 0 0 0

Hispanic2 2 0 1 0 0 0

Hispanic2 2 0 0 0 0 0

Hispanic2 1 2 2 1 0 0

Hispanic2 1 2 1 2 1 1

Hispanic2 1 2 1 1 1 0

Hispanic2 1 2 1 0 0 0

Hispanic2 1 2 0 2 2 2

Hispanic2 1 2 0 2 2 1

Hispanic2 1 2 0 2 2 0

Hispanic2 1 2 0 1 1 1

Hispanic2 1 2 1 1 0

Hispanic2 1 1 2 1 1 1

Hispanic2 1 1 0 1 1 1

Hispanic2 1 1 0 0 0 0

Hispanic2 0 2 1 1 1 1

Hispanic2 0 2 1 0 0 0

Hispanic1 2 2 2 2 2 2

Hispanic1 2 2 2 2 2 1

Hispanic1 2 2 1 1 1 1

Hispanic1 2 2 0 2 2 1

Hispanic1 2 2 0 1 1 1

Hispanic1 2 2 0 1 0 0

Hispanic1 2 1 2 0 0 0

Hispanic1 2 1 1 1 1 1

Hispanic1 2 1 0 0 0 0

Hispanic1 2 0 1 0 0 0

Hispanic1 1 2 2 1 1 0

Hispanic1 1 2 1 2 1 0

Hispanic1 1 2 1 0 0 0

Hispanic1 1 2 1 1 1

Hispanic0 2 1 1 0 0 0

Hispanic2 2 0 0 0 0

Hispanic2 1 1 1 1 1

Japanese2 2 2 2 2 2 1

Japanese2 2 2 2 1 1 1

Japanese2 2 2 2 1 1 1

Japanese2 2 1 2 1 1 1

Japanese2 2 1 2 0 0 0

Japanese2 2 1 1 1 1 0

Japanese2 2 1 1 1 0 0

Japanese2 2 1 1 0 0 0

Japanese2 2 1 1 0 0 0

Japanese2 2 1 0 2 1 0

Japanese2 2 1 0 0 0 0

Japanese2 2 0 2 0 0 0

Japanese2 2 0 2 0 0 0

Japanese2 2 0 1 0 0 0

Japanese2 1 2 1 1 1 0

Japanese2 1 1 2 1 1 1

Japanese2 1 1 2 1 0 2

Japanese2 1 1 1 1 1 1

Japanese2 1 1 1 0 0 0

Japanese2 1 1 0 0 0 0

Japanese2 1 0 2 0 0 0

Japanese2 1 0 1 1 1 1

Japanese2 0 2 1 1 1 1

Japanese1 2 2 2 1 1 1

Japanese1 2 2 2 1 1 0

Japanese1 2 2 1 1 1 1

Japanese1 2 2 0 2 2 2

Japanese1 2 1 2 1 1 0

Japanese1 2 1 2 1 1 0

Japanese1 2 1 2 0 0 0

Japanese1 2 1 2 0 0 0

Japanese1 2 1 1 1 1 0

Japanese1 2 1 1 0 0 0

Japanese1 2 1 0 0 0 0

Japanese1 2 0 1 0 0 0

Japanese1 1 2 2 1 1 2

Japanese1 1 2 2 1 1 0

Japanese1 1 2 1 2 1 0

Japanese1 1 2 0 0 0 0

Japanese1 0 0 0 0 0

Japanese0 2 2 2 2 2 1

Japanese0 2 2 2 0 0 0

Japanese0 2 1 2 1 1 0

Japanese0 2 1 2 0 0 0

Japanese0 2 1 1 1 1 1

Japanese0 2 1 1 1 1 1

Japanese0 2 1 1 1 1 1

Japanese0 2 0 2 0 0 0

Japanese0 1 1 2 0 0 0

Japanese2 2 2 0 0 0

Training set

Validation set

favorable

intermediate poor

AVAGAST Trial, A Simulation Study

Characteristics Asian Europe Pan-AmericaAVAGAST Avastin Placebo Avastin Placebo Avastin Placebo

N 188 188 125 124 74 75

Median PFS, ms 6.7 5.6 6.9 4.4 5.9 4.4

HR 0.92 0.71 0.65

1,000 Simulations

Median PFS, ms 6.5 5.6 6.1 4.4 5.3 4.5

HR 0.85 0.71 0.84

% significant (Log-rank p <0.05 and HR <1)

27% 71% 19%

Cytokines Increased Prior to Cytokines Increased Prior to Progression On FOLFIRI + BevProgression On FOLFIRI + Bev

Kopetz JCO 2009

FOLFOX + Bevacizumab-

Refractory CRC

N=100 screened

Primary endpoint: non-comparative

PFS

HIGH plasma bFGF (n=30):

Irinotecan 180mg/m2Brivanib 800mg PO qd

Low/normal bFGF (n=30):

Irinotecan 180mg/m2Brivanib 800mg PO qd

Prospective Trials with FGF Levels

Other Resistance Pathways Not Discussed

Mostly refuted

Untested in the clinic

Untested in the clinic

Under investigation:

Are we targeting ECs or Cancer Stem Cells or

Both?(Notch inhibitors

slow in development)Ellis ASCO 2012

Vilar E et al. Clin Cancer Res 2011;17:7207-7209

We are still early in molecular classification of colorectal cancer

Sotiriou et al NEJM, 2009; Alizadeh et al, Nature 2000

Bas

al

Lum

inal

A

Lum

inal

B

Her

2-po

s

?Breast Cancer Lymphoma Colorectal Cancer

Ca++ SignalingCa++ Signaling

GPCRsGPCRs

Cell CycleCell Cycle

ILs & CXCLs

Metabolism Information/signaling Energy

Systems biology of cancer: Systems biology of cancer: Integration of networks Integration of networks

(Yarden et al) (Yarden et al)

http://gut.bmj.com/content/57/4/538/F8.large.jpg

Stem Cell Markers (LRG5, ALDH, CD44)

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

0 2 4 6 8 10 12 14 16 18

Est

imat

ed re

curr

ence-

free

prob

abili

ty

Years since diagnosis of stage II or III colon cancer

Node 1+2 (n=46): 10.7 (7.1, 11.4+)Node 3 (n=50): 11.3+ (4.8, 11.3+)Node 4 (n=88): 5.7 (2.4, 16.8+)Node 5 (n=25): 1.7 (1.0, 5.9)

Median, years (95%CI) Hazard Ratio (95%CI) 1 (Reference) 2.030 (0.821, 5.018) 4.052 (1.769, 9.279) 6.713 (2.710, 16.633)

Gerger et al Clin Cancer Res 2011

TCF

CBP

CBP

TCF

p300

cyclin D1axin 2HnkdSurvivinS100A4

p300

TCF

ICG-001

c-junfra-1

-catenin

-catenin

-catenin

-catenin-catenin

-catenin

Cytoplasm

Nucleus

Non-differentiation

Differentiation

A Critical Cellular Switch

Teo et al., PNAS 2005

ICG-001

Colon Colon Cancer Cancer

Stem Cell Stem Cell Models Models

Miyabayashi T, et al PNAS 104, 5668, 2007

Relative Survivin expression fold change in CTC in patients treated with PRI724

Current “Targetable” Subsets of Colorectal Cancer

Subset Prognostic Significance

Distinctive Clinical Features

CRC Trials ongoing?*

APC/β-catenin mutation No No No

KRAS mutation Mixed/No No Yes

p53 mutation Mixed No No

BRAF mutations Yes Yes Yes

PI3K mutations No Mixed Yes

CIMP (hypermethylating) Yes Yes Yes

IGFR activation Unknown Unknown Yes

FGFR overexpression/amp Unknown Unknown Yes

cMET amplification Unknown Unknown Yes

NRAS mutation Unknown Unknown No

PTEN loss Mixed Unknown Yes

* Trials utilizing inhibitors specific for pathway derangement

BRAF Inhibitor: PLX4032

81% Response Rate

-100

-75

-50

-25

0

25

50

75

100

%C

hang

e Fr

om B

asel

ine

(Sum

of L

esio

n Si

ze)

-100

-75

-50

-25

0

25

50

75

100

%C

hang

e Fr

om B

asel

ine

(Sum

of L

esio

n Si

ze)

5% Response Rate

Refractory Melanoma Refractory Colorectal

Hurdle : Oncogene mutation does not imply oncogene dependence

Flaherty et al NEJM ‘10 Kopetz et al ASCO ‘10

Understand the biological context in which particular mutations occur.

A Prahallad et al. Nature 000, 1-5 (2012) doi:10.1038/nature10868

EGFR and BRAF(V600E) inhibitors synergize to induce apoptosis of CRC cells and to suppress CRC tumour

growth in a xenograft model.

Cel

l gro

wth

at 7

2 ho

urs

rela

tive

to c

ontr

ol

Col

o201

Col

o205

LIM

2551

Vaco

5H

T29

LIM

2537

Co1

15LI

M24

08R

KO

LS41

1N

SW14

63LI

M25

50

SKM

EL-3

SKM

EL-2

8

-75%-50%-25%

0%25%50%75%

100%125%

BRAFmut

PTENnull

PIK3CAmut

Colon Melanoma

Su et al CR 2012

A murine study in a resistant BRAFmut CRC cell line combining venurafenib and an AKT

inhibitor showed promising activity

Tumor effects with available results of tumor genomic alterations.

Shimizu T et al. Clin Cancer Res 2012;18:2316-2325

Comparison of Ongoing Approaches

ATTACC BATTLE iSPY2Statistical design Allocation, Modular Adaptive

RandomizationAdaptive

Randomization

Patients per arm 20-30 50-70 100+

Individual study timing

Flexible Fixed Flexible

Pharma integration Easier Difficult Moderate

Duration Indefinite Fixed Indefinite

Biomarker source Primary FFPE Prospective fresh Prospective fresh

Biomarker maturity Standard of care and qualified: KRAS/BRAF,

PTEN, bFGF, CIMP, PI3K

Standard of care and qualified: EGFR

mutation, KRAS/BRAF, VEGFR-2, RXR/Cyclin

D1

Standard of care only: ER/PR, HER2, MammoPrint

Cost $ $$ $$$

Validation Phase III +/- enrichment

Phase III Phase III

USC Approach: Integrative Sequencing Strategy to Capture Relevant Genes

What do we need to do

• Molecular Evaluation of Tumor Heterogeneity

• Molecular Evaluation of refractory Patients

• Development of Stem Cell targeted drugs• Integrated System Biology • Increase Biomarker Driven Clinical Trial

DHONT Foundation

Sharon Carpenter Laboratory

What the Germans couldn’t do: USA:Italy 1:0 (March 2012)

what is new: beyond kras and any markers for anti vegf?

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