La biologia molecolare nei tumori del colon-retto avanzato

La biologia molecolare nel carcinoma del colon-retto avanzato

Chiara Cremolini Polo Oncologico

Azienda Ospedaliero-Universitaria Pisana Università di Pisa

Carcinoma del colon-retto: un approccio integrato

Pisa, 16 Gennaio 2016

mCRC before 2008

100%

mCRC after 2008

60% 40%

KRAS cod 12-13

mut Do not administer

anti-EGFR moAbs!

mCRC after 2013

50% 40%

KRAS cod 12-13

mutations Do not administer anti-EGFR moAbs!

“Ne w ” RAS mu ta tions

10%

mCRC after 2013

50% 50%

RAS

mutations Do not administer

anti-EGFR moAbs!

One negative predictive marker: are we satisfied?

mCRC today

50%

RAS

mutations Do not administer anti-EGFR moAbs!

BRAF mu ta tion

The magnitude of the problem

Clinical trials N=447

Real-life N= 442

21%

40%

39%

BRAF mut KRAS mut KRAS/BRAF wt

Modified by Loupakis et al, N Engl J Med ‘14

6%

49% 45%

BRAF mut KRAS mut KRAS/BRAF wt

Modified by Sorbye et al, Plos One ‘15

BRAF mutation : predictive?

Subgroup Trial (n) HR (95% CI)

BRAF mt

PRIME (n=53) 0.58 (0.29–1.15) OPUS/CRYSTAL (n=70) 0.67 (0.34–1.29) CO.17 (n=10) 0.76 (0.19–3.08) 20020408 (n=15) 0.34 (0.09–1.24) PICCOLO (n=68) 1.40 (0.82–2.39) 20050181 (n=45) 0.69 (0.32–1.49) COIN (n=102) 1.25 (0.81–1.94) Summary (n=351) 0.86 (0.61–1.21)

Subgroup Trial (n) HR (95% CI)

BRAF wt

PRIME (n=446) 0.68 (0.54–0.87) OPUS/CRYSTAL (n=730) 0.64 (0.52–0.79) CO.17 (n=198) 0.41 (0.30–0.55) 20020408 (n=115) 0.37 (0.24–0.55) PICCOLO (n=371) 0.71 (0.57–0.88) 20050181 (n=376) 0.68 (0.51–0.90) COIN (n=627) 0.93 (0.78–1.10) Summary (n=2748) 0.62 (0.50–0.77)

Rowland et al, Br J Canc ‘15

p for interaction: 0.07

PFS

But…

OS

PFS

Pietrantonio et al, Eur J Canc ‘15

FOIB study: BRAF subgroups

57 mCRC pts 1st line mCRC AGE 18 - 75 years PS ≤ 2 (0 if 71-75 years)

FOLFOXIRI+bev

(up to 12 cycles)

5-FU/LV

+Bev PD

Phase II, primary endpoint: 10 months-PFR

ITT population N = 57

10 months-PFR 42 (74%)

Response Rate 44 (77%)

Disease Control Rate 57 (100%)

Median PFS, mos 13.1

Median OS, mos 30.9

Masi et al. Lancet Oncol ‘ 10

NCT01163396

FOIB study: BRAF subgroups

57 mCRC pts 1st line mCRC AGE 18 - 75 years PS ≤ 2 (0 if 71-75 years)

FOLFOXIRI+bev

(up to 12 cycles)

5-FU/LV

+Bev PD

Phase II, primary endpoint: 10 months-PFR

ITT population N = 57

BRAF wt N = 45

BRAF mut N=10

10 months-PFR 42 (74%) - -

Response Rate 44 (77%) 34 (75%) 9 (90%)

Disease Control Rate 57 (100%) 45 (100%) 10 (100%)

Median PFS, mos 13.1 13.1 12.8

Median OS, mos 30.9 30.9 23.8

Masi et al. Lancet Oncol ‘ 10

NCT01163396

FOLFOXIRI plus bev in BRAF mut: step 2

Loupakis et al. Eur J Can ‘13

15 BRAF mut mCRC pts 1st line mCRC

AGE 18 - 75 years PS ≤ 2 (0 if 71-75 years)

ITT population N = 15

6 months-PFR 11 (73%)

FOLFOXIRI+bev

(up to 12 cycles)

5-FU/LV

+Bev PD

Phase II, primary endpoint: 6 months-PFR

H0: 6m-PFR: 45%

H1: 6m-PFR: 80%

a: 0.05; b:0.10

At least 10 out of 14 pts progression free at 6 mos

NCT01437618

FOLFOXIRI plus bev in BRAF mut: step 2

Loupakis et al. Eur J Can ‘13

15 BRAF mut mCRC pts 1st line mCRC

AGE 18 - 75 years PS ≤ 2 (0 if 71-75 years)

FOLFOXIRI+bev

(up to 12 cycles)

5-FU/LV

+Bev PD NCT01437618

ITT population N = 15

6 months-PFR 11 (73%)

Response Rate 9 (60%)

Disease Control Rate 12 (80%)

Median PFS, mos 9.2

Median OS, mos 24.1

N

FOLFIRI + bev Median PFS

FOLFOXIRI + bev

Median PFS

HR [95% CI] p

ITT population 508 9.7 12.3 0.77 [0.65-0.93] 0.006 RAS and BRAF

evaluable 357 9.8 12.1 0.80 [0.64-0.99] 0.042

RAS and BRAF wt 93 12.2 13.7 0.85 [0.55-1.30]

0.679*

RAS mutated 236 9.5 12.0 0.78 [0.60-1.02]

BRAF mutated 28 5.5 7.5 0.57 [0.27-1.23]

* p for interaction

Treatment effect in molecular subgroups - PFS

Cremolini et al, Lancet Oncol ’15

N

FOLFIRI + bev Median OS

FOLFOXIRI + bev

Median OS

HR [95% CI] p

ITT population 508 25.8 29.8 0.80 [0.65-0.98] 0.030 RAS and BRAF

evaluable 357 24.9 28.6 0.84 [0.66-1.07] 0.159

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

Treatment effect in molecular subgroups - OS

Cremolini et al, Lancet Oncol ‘15

Study

Reference N RR Median PFS Median OS

FOIB

Masi, Lancet Oncol ‘10 10 90% 12.8 23.8

Prospective phase II

Loupakis, EJC‘13 15 60% 9.2 24.1

TRIBE

Cremolini et al, Lancet Oncol’15 16 56% 7.5 19.0

FOLFOXIRI plus bev in BRAF mutant mCRC: summary

Schirripa et al, BJC 2015

BRAF mutation is highly prognostic also in pts with resected liver- limited disease

BRAF wt (n=178) mRFS=11.0 months BRAF mut (n=23) mRFS=7.0 months

p=0.084

Yaeger et al, Cancer 2014

BRAF nomogram

1.601

Loupakis et al, Br J Canc in press

Female gender + Right primary + Mucinous histology = 81% BRAF mut

Raf

MEK

Erk Tumor cell

proliferation and survival

EGF Tumor cell

P P Ras P P

Single-agent BRAF inhibitors: poor results

Kopetz et al, J Clin Oncol ‘15

Why?

Raf

MEK

Erk Tumor cell

proliferation and survival

EGF Tumor cell

P P Ras P P

Prahallad et al, Nature ‘12

Raf

MEK

Erk Tumor cell

proliferation and survival

EGF Tumor cell

P P Ras P P

Targeted approaches: BRAFi + EGFRi

Hyman et al, N Engl J Med ‘15

Raf

MEK

Erk Tumor cell

proliferation and survival

EGF Tumor cell

P P Ras P P

Targeted approaches: BRAFi + MEKi + EGFRi

Study

Reference N RR DCR PFS

Dabrafenib + Trametinib + Panitumumab

Atreya, ASCO Ann Meet ‘15 35 26% 60% 4.1

Encorafenib + Alpelisib + Cetuximab

Elez, WCGIC ‘15 28 32% 94% 4.3

mCRC today

50%

RAS

mutations Do not administer anti-EGFR moAbs!

BRAF mu ta tion

• Minimal impact of anti-EGFR moAbs

• If possible, treat with FOLFOXIRI plus bev

• Careful peri-op work up in the case of liver resection

• Consider targeted strategies

RAS/BRAF wild-type

40% 10%

Targeted approaches in mCRC

mCRC today

50%

RAS

mutations Do not administer anti-EGFR moAbs!

BRAF mu ta tion

• Minimal impact of anti-EGFR moAbs

• If possible, treat with FOLFOXIRI plus bev

• Careful peri-op work up in the case of liver resection

• Consider targeted strategies

RAS/BRAF wild-type

40% 10%

HER-2 + (3%)

HERACLES trial

27 HER-2 +, KRAS wt mCRC pts progressed after fluoropyr,

oxaliplatin, irinotecan and an anti-EGFR moAb

Trastuzumab +

Lapatinib ^PD

ITT population N = 23

ORR 8 (34.7%)

Phase II, primary endpoint: ORR (Recist 1.1)

H0: ORR: 10%

H1: ORR> 30%

a: 0.05; b:0.15

At least 6 responders out of 27 pts

Siena et al, ASCO Ann Meet ‘15

27 HER-2 +, KRAS wt mCRC pts progressed after fluoropyr,

oxaliplatin, irinotecan and an anti-EGFR moAb

Trastuzumab +

Lapatinib ^PD

Phase II, primary endpoint: ORR (Recist 1.1)

H0: ORR: 10%

H1: ORR> 30%

a: 0.05; b:0.15

At least 6 responders out of 27 pts

ITT population N = 23

ORR 8 (34.7%)

Disease Control Rate 18 (78%) SD >= 4 mos 7 (30.4%)

Siena et al, ASCO Ann Meet ‘15

HERACLES trial

HERACLES trial

27 HER-2 +, KRAS wt mCRC pts progressed after fluoropyr,

oxaliplatin, irinotecan and an anti-EGFR moAb

Trastuzumab +

Pertuzumab ^PD

mCRC today

50%

RAS mutations

Do not administer anti-EGFR moAbs!

BRAF mu ta tion

RAS/BRAF wild-type

40% 10%

HER-2 + (3%)

MGMT methylation

(30%)

MGMT

Consider targeted approaches in

clinical trials

• Minimal impact of anti-EGFR moAbs

• If possible, treat with FOLFOXIRI plus bev

• Careful peri-op work up in the case of liver resection

• Consider targeted strategies

MGMT and TMZ

Amatu et al. Clin Can Res ‘13

MGMT and TMZ

Pietrantonio et al., Ann Oncol ‘13

ORIGINAL RESEARCH ARTICLE

Dose-Dense Temozolomide in Patients with MGMT-Silenced Chemorefr actor y Colorectal Cancer

Filippo Pietr antonio¹&Filippo de Braud¹&M assimo M ilione²&Claudia M aggi¹&

Rober to I acovelli¹&K atia Fiorella Dotti¹&Feder ica Per rone²&Elena Tambor ini²&

M ar ta Capor ale¹&Rosa Berenato¹&Giorgia L eone²&Alessio Pellegr inelli²&

I lar ia Bossi¹&Fabr izio Festinese³&Stefano Federici³&M ar ia Di Bar tolomeo¹

# Springer International Publishing Switzerland 2015

Abstr act

Background In a phase II study, we showed that temozolo- mide (TMZ) was tolerable and active in heavily pre-treated patients with advanced colorectal cancer (CRC) and MGMT methylation. A schedule of dose-dense TMZ may have en- hanced activity due to the higher cumulative dose and induc- tion of MGMT depletion, even in resistant tumors.

Methods Thirty-two patients with chemorefractory MGMT- methylated CRC were treated with TMZ at a daily dose of 75 mg/m²for 21 consecutive days every 4 weeks, for up to six cycles or until the occurrence of progressive disease/

unacceptable toxicity. The primary endpoint was treatment activity in terms of objective response rate (ORR). MGMT protein expression was tested by immunohistochemistry (IHC) on two pooled cohorts: patients from the previous study of standard-dose TMZ and those from the current investigation.

Results From November 2013 to December 2014, 32 patients were treated at Fondazione IRCCS Istituto Nazionale dei Tumori. We observed only three episodes of grade 3 asthenia and no significant myelotoxicity. The ORR was 16 % (all partial responses occurring in RAS-BRAF-mutated tumors).

Median progression-free survival (PFS) and overall survival (OS) were 2.3 and 6.7 months, respectively. Patients with

MGMT-low expression by IHC had a significantly higher ORR (p<0.0001) and PFS (p=0.001) compared to those with MGMT-high expression, while no difference was observed in OS.

Conclusions Our data confirm the encouraging activity of TMZ in chemorefractory CRC patients selected for MGMT silencing, even in the RAS-BRAF-mutated population. The role of MGMT IHC as a biomarker for improving patient selection warrants further prospective confirmation.

Key Points

Temozolomide had promising activity in 32 patients with advanced chemorefractory colorectal cancer selected for MGMT methylation with methylation-specific PCR (MSP).

In this study, dose-dense temozolomide reached 16%

response rate in heavily pre-treated patients.

Our data showed that loss of MGMT immunohistochemical expression can further improve patients selection and should be externally validated.

1 I ntroduction

O⁶-methylguanine DNA methyltransferase (MGMT) gene promoter methylation plays an important role in colorectal carcinogenesis, occurring in about 30–40 % of metastatic co- lorectal cancer (CRC) [1,2]. The loss of DNA repair activity of MGMT, which may besecondary to genesilencing through promoter methylation, has resulted in a promising response to alkylating agents such as dacarbazine and temozolomide (TMZ) [3]. Although MGMT can be considered a validated predictive biomarker only in patients with glioblastoma [4],

* Filippo Pietrantonio

filippo.pietrantonio@istitutotumori.mi.it

1 Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian, 1 - 20133 Milan, Italy

2 Pathology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

3 Pharmacy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

Targ Oncol

DOI 10.1007/s11523-015-0397-2

MGMT and TMZ

53% 0%

Response Rate: p<0.0001

MGMT low MGMT high

mCRC today

50%

RAS mutations

Do not administer anti-EGFR moAbs!

BRAF mu ta tion

RAS/BRAF wild-type

40% 10%

HER-2 + 3%

MGMT methylation

(30%)

MGMT

Consider targeted approaches in

clinical trials

• Minimal impact of anti-EGFR moAbs

• If possible, treat with FOLFOXIRI plus bev

• Careful peri-op work up in the case of liver resection

• Consider targeted strategies

Consider TMZ/Deticene in

advanced lines

mCRC today

50%

RAS mutations

Do not administer anti-EGFR moAbs!

BRAF mu ta tion

RAS/BRAF wild-type

40%

10%

HER-2 + 3%

MGMT methylation

(30%)

MGMT

Consider targeted approaches in

clinical trials

• Minimal impact of anti-EGFR moAbs

• If possible, treat with FOLFOXIRI plus bev

• Careful peri-op work up in the case of liver resection

• Consider targeted strategies

Consider TMZ/Deticene in

advanced lines

MSI

5%

Mutation rate and neoantigens’ load

Giannakis et al. ASCO Ann Meet ‘15

Highest mutation rate Highest neoantigens’ load

Neoantigens’ load and lympho infiltration

Giannakis et al. ASCO Ann Meet ‘15

Highest lymphocitic infiltration Highest neoantigens’ load

Pembrolizumab in refractory mCRC

Le et al. N Eng J Med ‘15

Pembrolizumab in refractory mCRC

Le et al. N Eng J Med ‘15

mCRC today

50%

RAS mutations

Do not administer anti-EGFR moAbs!

BRAF mu ta tion

RAS/BRAF wild-type

40%

10%

HER-2 + 3%

MGMT methylation

(30%)

MGMT

Consider targeted approaches in

clinical trials

• Minimal impact of anti-EGFR moAbs

• If possible, treat with FOLFOXIRI plus bev

• Careful peri-op work up in the case of liver resection

• Consider targeted strategies

Consider TMZ/Deticene in

advanced lines

MSI 5%

Consider immunotherapy

trials!

How the lab has changed our view of mCRC?

100%

Before 2008

50%

RAS mutations

BRAF mu ta tion

RAS/BRAF wild-type

40%

10%

HER-2 + 3%

MGMT methylation

(30%)

MGMT

MSI 5%

Today

In the next future

Sartore Bianchi et al. J Nat Can Inst ‘15

Dynamic Heterogeneity in mCRC

Drug(s)

INITIAL TUMOR TUMOR AT RESPONSE TUMOR AT PD

Bettegowda C, et al. Sci Transl Med. 2014;6(224):224ra24.

What Happens at the Time of PD on Anti-EGFR MoAbs?

Emergence of RAS mutations at the time of PD on anti-EGFR-targeted

agents in initially responding

patients

Clonal evolution: in blood veritas?

Siravegna et al. Nat Med ‘15

How the lab has changed our view of mCRC?

Precision medicine in mCRC:

DIFFICULT, but…yes we can!

BRAF, HER-2 Molecular selection in mCRC:

yes we can!

RAS, MGMT, MSI

Dynamic monitoring of response/resistance:

Toward the identification of new targets and

new strategies

chiaracremolini@gmail.com

Gianluca Federica Marta Prof! Chiara Lisa Carlotta Fotios