circulating tumor cells (dr. minetta liu)

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Circulating Tumor Cells Circulating Tumor Cells Minetta C. Liu, MD Minetta C. Liu, MD Associate Professor of Medicine and Oncology Associate Professor of Medicine and Oncology Director, Translational Breast Cancer Research Director, Translational Breast Cancer Research Lombardi Comprehensive Cancer Center Lombardi Comprehensive Cancer Center Georgetown University Medical Center Georgetown University Medical Center

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Page 1: Circulating Tumor Cells (Dr. Minetta Liu)

Circulating Tumor CellsCirculating Tumor Cells

Minetta C. Liu, MDMinetta C. Liu, MDAssociate Professor of Medicine and OncologyAssociate Professor of Medicine and Oncology

Director, Translational Breast Cancer Research Director, Translational Breast Cancer Research Lombardi Comprehensive Cancer CenterLombardi Comprehensive Cancer CenterGeorgetown University Medical CenterGeorgetown University Medical Center

Page 2: Circulating Tumor Cells (Dr. Minetta Liu)

Era of Personalized MedicineEra of Personalized Medicine

• need an individualized approach to need an individualized approach to treatment to maximize benefit and treatment to maximize benefit and minimize costminimize cost

assessment of prognosisassessment of prognosis measurement of treatment benefitmeasurement of treatment benefit understanding of tumor biologyunderstanding of tumor biology

Page 3: Circulating Tumor Cells (Dr. Minetta Liu)

Biomarker StrategiesBiomarker Strategies

serial biomarker assessmentsserial biomarker assessments

single biomarker assessmentsingle biomarker assessment

prognosisprognosisdirect therapydirect therapy

prediction prediction

diagnosisdiagnosisprognosisprognosis

direct therapydirect therapy

Page 4: Circulating Tumor Cells (Dr. Minetta Liu)

Improving OutcomesImproving Outcomes

• the enumeration and characterization of the enumeration and characterization of circulating tumor cells (CTCs) are useful circulating tumor cells (CTCs) are useful in the clinical settingin the clinical setting

alterations in CTC levelsalterations in CTC levels

CTC phenotype and CTC phenotype and genotypegenotype

identification of CTCidentification of CTC

prognosisprognosisprediction prediction

diagnosisdiagnosisprognosisprognosisdirect therapydirect therapy

diagnosisdiagnosisprognosisprognosis

Page 5: Circulating Tumor Cells (Dr. Minetta Liu)

(Paterlini-Brechot et al. Cancer Letters 2007. 253:180.)(Paterlini-Brechot et al. Cancer Letters 2007. 253:180.)

Origin of CTCsOrigin of CTCs

Page 6: Circulating Tumor Cells (Dr. Minetta Liu)

• etiologyetiology disseminated cancer cellsdisseminated cancer cells cancer stem cellscancer stem cells bystander cellsbystander cells

• rare cells in a dormant, nonproliferative rare cells in a dormant, nonproliferative statestate unaffected by chemotherapyunaffected by chemotherapy unrecognized by the host immune systemunrecognized by the host immune system difficult to isolatedifficult to isolate

Origin of CTCsOrigin of CTCs

Page 7: Circulating Tumor Cells (Dr. Minetta Liu)

Isolation of CTCsIsolation of CTCs

enrichment

detection

characterization

density gradient centrifugation

filtration by sizeimmunomagnetic labeling

quantitation of growth factor expression

gene expression profilingdetection of epigenetic alterations

Alix-Panabieres et al. Clin Cancer Res 2008. 14:5013.

Page 8: Circulating Tumor Cells (Dr. Minetta Liu)

Detection of CTCsDetection of CTCs

• antibody based markersantibody based markers cytokeratins (CK8, CK18, CK19)cytokeratins (CK8, CK18, CK19) epithelial membrane antigen (EMA)epithelial membrane antigen (EMA) epithelial cell adhesion molecule (EpCAM)epithelial cell adhesion molecule (EpCAM)

• nucleic acid based markersnucleic acid based markers CK19 by RT-PCRCK19 by RT-PCR mammoglobin by RT-PCRmammoglobin by RT-PCR erbB2 by RT-PCR or FISHerbB2 by RT-PCR or FISH EGFR by RT-PCREGFR by RT-PCR

Page 9: Circulating Tumor Cells (Dr. Minetta Liu)

Available Technologies Available Technologies for Isolation of CTCsfor Isolation of CTCs

Page 10: Circulating Tumor Cells (Dr. Minetta Liu)

Circulating Tumor CellCirculating Tumor Cell

CK

YEpCAM

NucleusDAPI

Anti-Anti-CK-PECK-PE

YAnti-Anti-EpCAMEpCAMFerrofluidFerrofluid

Immunomagnetic CaptureImmunomagnetic Capture

LeukocyteLeukocyte

CD45Nucleus

DAPI

YAnti -CD45-APC

Immunomagnetic LabelingImmunomagnetic Labeling and Immunofluorescent Identification of and Immunofluorescent Identification of CellsCells

Page 11: Circulating Tumor Cells (Dr. Minetta Liu)

Immunomagnetic CaptureImmunomagnetic Capture

DAPIDAPIcytokeratincytokeratincontrolcontrolCD45CD45compositcompositee

intact tumor cellsintact tumor cells

Page 12: Circulating Tumor Cells (Dr. Minetta Liu)

(Zheng et al. J Chromatogr A 2007. 1162:154.)(Zheng et al. J Chromatogr A 2007. 1162:154.)

Parylene Filter MicrodeviceParylene Filter Microdevice

Page 13: Circulating Tumor Cells (Dr. Minetta Liu)

(Nagrath et al. Nature 2007. 450:1235.)(Nagrath et al. Nature 2007. 450:1235.)

CTC MicrochipCTC Microchip

Page 14: Circulating Tumor Cells (Dr. Minetta Liu)

Immunomagnetic Labeling: Immunomagnetic Labeling: Enumeration in MBCEnumeration in MBC

Page 15: Circulating Tumor Cells (Dr. Minetta Liu)

Clinical ParametersClinical Parameters

• CTCs in individuals with MBC detected in ~70% >5 per 7.5 mL blood in ~50%

• CTCs in individuals without a malignancy detected in <10% >5 per 7.5 mL blood in 0%

Page 16: Circulating Tumor Cells (Dr. Minetta Liu)

Prevalence of CTCsPrevalence of CTCs

CTC threshold (per 7.5 mL CTC threshold (per 7.5 mL blood)blood)

% p

ati

ents

at

or

above t

he C

TC

thre

shold

%

pati

ents

at

or

above t

he C

TC

thre

shold

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

20

30

40

50

100

1000

cancer, baseline (n = 177)

3%

16%

21%21%23%

27%

34%34%34%36%

38%38%42%

45%46%47%49%

53%

58%61%

71%

cancer, first follow-Up (n = 163)

1%

8%

13%13%15%

20%21%21%22%23%23%23%24%26%

28%29%30%32%

35%

40%

55%

6%

healthy volunteers (n = 145)benign diseases (n = 200)

1%

8%

Page 17: Circulating Tumor Cells (Dr. Minetta Liu)

IMC-001IMC-001

time pointstime points

imagingimaging

bloodblood

00 22 33 44 5511 66

• 177 patients (223 total)177 patients (223 total)• metastatic breast cancer metastatic breast cancer • measurable diseasemeasurable disease

Page 18: Circulating Tumor Cells (Dr. Minetta Liu)

(Hayes et al. Clin Cancer Res 2006. 12:4218.)(Hayes et al. Clin Cancer Res 2006. 12:4218.)

IMC-001: CTCs at BaselineIMC-001: CTCs at Baseline

Logrank p = 0.0001

Cox Hazards Ratio = 1.8523chi-square = 14.44(p-value = 0.0001)

7.0 Months2.7

Months

CTCs / 7.5mL Median PFS in at Baseline N (%) Months (95% C.I.) <5 CTC 89 (50%) 7.0 (5.6 to 8.9) >5 CTC 88 (50%) 2.7 (2.1 to 4.4)

%Pr

obab

ility

of P

rogr

essi

on F

ree

Surv

ival

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Time from Baseline (Months)0 5 10 15 20 30 35 40 45 5025P

rob

ab

ilit

y o

f P

rog

res

sio

n F

ree

Su

rviv

al

%Pr

obab

ility

of S

urvi

val

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Time from Baseline (Months)0 5 10 15 20 30 35 40 45 5025

Logrankp < 0.0001

Cox Hazards Ratio = 2.3581chi-square = 19.54(p-value < 0.0001)

21.9 Months

10.9Months

CTCs / 7.5mL Median OS in at Baseline N (%) Months (95% C.I.) <5 CTC 89 (50%) 21.9 (20.1 to 28.6) >5 CTC 88 (50%) 10.9 ( 7.0 to 15.2)

n = 177

Page 19: Circulating Tumor Cells (Dr. Minetta Liu)

(Cristofanilli et al. N Engl J Med 2004. 351:781.)(Cristofanilli et al. N Engl J Med 2004. 351:781.)

p value < 0.001Cox Hazards Ratio = 5.4537

p value < 0.001Cox Hazards Ratio = 2.4842

IMC-001: CTCs at 1IMC-001: CTCs at 1stst Follow- Follow-UpUp

n = 177

Page 20: Circulating Tumor Cells (Dr. Minetta Liu)

(Cristofanilli et al. N Engl J Med 2004. 351:781.)(Cristofanilli et al. N Engl J Med 2004. 351:781.)

% p

robabili

ty o

f PFS

% p

robabili

ty o

f PFS

time from baseline (weeks)time from baseline (weeks)00 55 1010 1515 2020 2525 3030 3535 4040 4545 5555 6060 6565 7070 7575 8080

0%0%

10%10%

20%20%

30%30%

40%40%

50%50%

60%60%

70%70%

80%80%

90%90%

100%100%

5050

~7.0 months~7.0 months

~2.1 months~2.1 months

~7.6 months~7.6 months

p value < 0.0001p value < 0.0001Cox Hazards Ratio = 1.6600Cox Hazards Ratio = 1.6600

# patients (median # patients (median PFS)PFS)

< 5 CTC at baseline & at 1< 5 CTC at baseline & at 1stst follow- follow-upup

81 (30.3 weeks)81 (30.3 weeks)

decrease in CTC to < 5 at 1decrease in CTC to < 5 at 1stst follow-upfollow-up

33 (32.9 weeks)33 (32.9 weeks)

>> 5 CTC at 1 5 CTC at 1stst follow-up follow-up 49 (8.9 weeks)49 (8.9 weeks)

IMC-001: Changes in CTCIMC-001: Changes in CTC

n = 177

Page 21: Circulating Tumor Cells (Dr. Minetta Liu)

(Cristofanilli et al. J Clin Oncol 2005. 23:1420.)(Cristofanilli et al. J Clin Oncol 2005. 23:1420.)n = 83

IMC-001: CTCs and ImagingIMC-001: CTCs and Imaging

Page 22: Circulating Tumor Cells (Dr. Minetta Liu)

(Budd et al. Clin Cancer Res 2006. 12:6403.)(Budd et al. Clin Cancer Res 2006. 12:6403.)n = 138

IMC-001: CTCs and ImagingIMC-001: CTCs and Imaging

Page 23: Circulating Tumor Cells (Dr. Minetta Liu)

(Budd et al. Clin Cancer Res 2006. 12:6403.)(Budd et al. Clin Cancer Res 2006. 12:6403.)n = 138

IMC-001: CTCs and ImagingIMC-001: CTCs and Imaging

Page 24: Circulating Tumor Cells (Dr. Minetta Liu)

LCCC Validation StudyLCCC Validation Study

imagingimaging

bloodblood

00 66 99 1212 1515 2121 2424

cyclescycles33 1818

• 74 evaluable patients74 evaluable patients• metastatic breast cancer metastatic breast cancer • measurable diseasemeasurable disease

Page 25: Circulating Tumor Cells (Dr. Minetta Liu)

(Liu et al. J Clin Oncol 2009. 27:5153.)(Liu et al. J Clin Oncol 2009. 27:5153.)

Treatment at Time of CTC

ResultOR 95% CI

p-value

Overall 6.3 (3.2, 13)<0.00

1

Chemotherapy 6.3 (2.9, 14)<0.00

1

Endocrine 8.9 (2.2, 35) 0.002

CTCs Drawn at the Time of Radiographic Imaging

Treatment at Time of CTC

ResultOR 95% CI

p-value

Overall 4.9(2.2, 118)

<0.001

Chemotherapy 6.9 (3.0, 16)<0.00

1

Endocrine 2.9 (0.6, 14) 0.2

CTCs Drawn 7-9 Weeks Prior to Radiographic Imaging

Treatment at Time of CTC

ResultOR 95% CI

p-value

Overall 3.1 (1.6, 5.8) 0.001

Chemotherapy 2.7 (1.2, 6.3) 0.02

Endocrine 5.2 (1.2, 23) 0.03

CTCs Drawn 3-5 Weeks Prior to Radiographic Imaging

LCCC: CTCs and ImagingLCCC: CTCs and Imaging

Page 26: Circulating Tumor Cells (Dr. Minetta Liu)

Recommendations for UseRecommendations for Use

• to assess for progression in patients with measurable metastatic disease

• to provide a guide by which to determine the timing of radiographic restaging studies

• to assess the feasibility and timing of drug holidays in patients with stable disease and intolerable drug related toxicities

Page 27: Circulating Tumor Cells (Dr. Minetta Liu)

ConclusionsConclusions

Page 28: Circulating Tumor Cells (Dr. Minetta Liu)

• meaningful rate of detectionmeaningful rate of detection

• reliable thresholdreliable threshold

• correlation with clinical outcomes (validity)correlation with clinical outcomes (validity)

• ability to improve clinical outcomes ability to improve clinical outcomes (utility)(utility)

Response/Futility MarkerResponse/Futility Marker

Page 29: Circulating Tumor Cells (Dr. Minetta Liu)

CTCs – PresentCTCs – Present

• clinical validity IMC-001 LCCC study

• clinical utility assess disease status (with imaging) guide the timing of radiographic studies guide the timing of drug holidays guide systemic therapy (?????)

Page 30: Circulating Tumor Cells (Dr. Minetta Liu)

blood drawn at baseline prior to first-line chemotherapy

Arm B

maintain first-line chemotherapy until progression

Arm C1

maintain first-line chemotherapy until progression

Arm C2

switch to alternate chemotherapy

Arm A

monitor for PFS & OS

eligible for other first-line chemotherapy trials R

CTC <5 CTC ≥5

blood drawn three weeks after the first chemotherapy dose

CTC ≥5CTC <5

target n = 120

Prospective Validation: Prospective Validation: Means to Improve SurvivalMeans to Improve Survival

SWOG S0500

Page 31: Circulating Tumor Cells (Dr. Minetta Liu)

Prospective Validation:Prospective Validation:The Liquid BiopsyThe Liquid Biopsy

nucleusnucleuscytokeratincytokeratincontrolcontrolleukocyteleukocytecompositcompositee

HER2 and SE17 FISH Probes

HER2 and SE17 FISH Probes

Page 32: Circulating Tumor Cells (Dr. Minetta Liu)

Prospective Validation:Prospective Validation:The Liquid BiopsyThe Liquid Biopsy

CALGB 40601

bloodblood

00 44 66 88 1010 1414 1616weeksweeks

22 1212

paclitaxel and trastuzumab and lapatinib

N = 400N = 400 paclitaxel and trastuzumab

paclitaxel and lapatinib

tissuetissue

Page 33: Circulating Tumor Cells (Dr. Minetta Liu)

(Harris et al.J Clin Oncol 2007.33:5287.)(Harris et al.J Clin Oncol 2007.33:5287.)

ASCO Tumor Marker GuidelinesASCO Tumor Marker Guidelines

• Circulating tumor cell assays as Circulating tumor cell assays as markers for breast cancermarkers for breast cancer

Page 34: Circulating Tumor Cells (Dr. Minetta Liu)

THANK YOU