evaristo maiello u.o.c. oncologia irccs casa sollievo della sofferenza san giovanni rotondo (fg)...

Evaristo MaielloU.O.C. Oncologia

IRCCS Casa Sollievo della SofferenzaSan Giovanni Rotondo (FG)

Napoli, 16 ottobre 2015

Molecular alterations in cancer cells offer potential for therapeutic intervention with

"target-based agents"

Hanahan & Weinberg Cell 2011

Meric-Bernstam JCO 2013

Target-based agents + predictive biomarkers: PERSONALIZED MEDICINE

Predictive biomarkers and personalized medicine

• Biomarkers that are associated with response to drugs (positive selection)– EGFR mutations in

NSCLC– BRAF mutations in

melanoma– ERBB2 gene

amplification in breast/gastric cancer

• Biomarkers that are associated with resistance to drugs (negative selection)– RAS mutations and

resistance to EGFR monoclonal antibosies in CRC

Oncogene-addicted vs NO

BIOMARKERS FRANCE: driver mutations in

10,000 patients with non-squamous NSCLC

Lung Cancer Mutation Consortium USA

Kris M et al JAMA. 2014;311(19):1998-2006

Survival ComparisonsALK indicates anaplastic lymphoma kinase gene; EGFR(s), epidermal growth factor receptor gene (sensitizing); EGFR(o), epidermal growth factor receptor gene (other); KRAS, Kirsten rat sarcoma; NA, not applicable.A, Median survival (95% CI): oncogenic driver + no targeted therapy, 2.38 (1.81-2.93); oncogenic driver + targeted therapy, 3.49 (3.02-4.33); no oncogenic driver, 2.08 (1.84-2.46). B, Survival by oncogenic driver detected for patients with the 5 most frequent oncogenic drivers and targeted treatment. Median survival (95% CI): EGFR(s), 3.78 (2.77-NA); EGFR(o), 2.70 (1.42-NA); ALK, NA (2.80-NA); KRAS, 4.85 (1.30-NA); doubletons (oncogenic drivers in 2 genes), 2.69 (1.94-NA). Vertical tick marks are censoring events.

Figure Legend:

Using Multiplexed Assays of Oncogenic Drivers in Lung Cancers to Select Targeted Drugs

It is worthwhile finding an actionable genetic alteration in Lung Cancer

Schiller et al, NEJM 2002

ECOG 1594

Kamalakaran S. et al , 2015

Heinemann V et al. ASCO 2013 (Abstract No. LBA3506); Stintzing S et al. ECC 2013 (Abstract No. LBA17)

KRAS wt (exon 2) population

RAS wt population(KRAS and NRAS wt)

~85% of KRAS wt (exon 2) population

0.75

1.0

0.50

0.25

0.0

Pro

babili

ty o

f su

rviv

al

12 24 36 48 60 72Months

Δ=3.7 months

0

Bevacizumab + FOLFIRI (n=295)

HR=0.77p=0.017

28.7

25.0

Cetuximab + FOLFIRI (n=297)

0.0

0.75

1.0

0.50

0.25Δ = 7.5 months

12 24 36 48 60 72Months

0

Pro

babili

ty o

f su

rviv

al

Bevacizumab + FOLFIRI (n=171)

HR=0.70p=0.011

33.1

25.6

Cetuximab + FOLFIRI (n=171)

15%

Fire3 – Expanded RAS analysis

Ciardiello F et al. Annals of Oncology 2014

Comparison of methodologiesStudy Method Sensitivity*

FIRE-31 Pyrosequencing ≤5%2

OPUS3 Inostics BEAMing technology (detection cut-off 0.1%)

0.01%4

CAPRI5 Next-generation sequencing: Ion AmpliSeq™ Colon and Lung Cancer Panel 2%5

PRIME6Bidirectional Sanger sequencing and WAVE-based SURVEYOR® Scan Kits (Transgenomic)

10−20% (Sanger sequencing)8

1% (WAVE-based SURVEYOR®)9PEAK7

200204088

Next-generation sequencing, Sanger sequencing, and independently conducted WAVE-based SURVEYOR® Scan Kits (Transgenomic)

10–20% (Sanger sequencing)8

De Roock et al10

Sequenom MALDI-TOF MassARRAY multiplex PCR and genotyping

5–15%10

1. Stintzing S, et al. ECC 2013 (Abstract No. LBA17); 2. Anderson SM. Expert Rev Mol Diagn 2011;11:635–642; 3. Data on file; 4. Aung KL, et al. Hugo J 2010;4:11–21; 5. Ciardiello F, et al. ECC 2013 (Abstract No. LBA31);

6. Douillard J-Y, et al. N Engl J Med 2013;369:1023–1034; 7. Karthaus M, et al. ECC 2013 (Abstract No. 2262); 8. Peeters M, et al. WCGC 2013 (Abstract No. PD-0008); 9. Jänne PA et al. Clin Cancer Res 2006;12:751–758;

10. De Roock W, et al. Lancet Oncol 2010;11:753–762

*Values refer to the lowest percentage of mt sequence that is detectable

Multiple gene mutations in KRAS mutated tumors

Multiple gene mutations in PIK3CA mutated tumors

Type of mutations n Type of mutations nKRAS only (no other mutation detected) 15 PIK3CA only (no other mutation detected) 5KRAS + TP53 8 PIK3CA + KRAS 5KRAS + PIK3CA ex9 3 PIK3CA + BRAF 1KRAS + FBXW7 2 PIK3CA + TP53 2KRAS + PIK3CA ex20 2 PIK3CA + NRAS 1KRAS + FGFR3 1 PIK3CA + MET 1KRAS + PTEN 1 PIK3CA + KRAS + TP53 3KRAS + MET 1 PIK3CA + FBXW7 + TP53 1KRAS + SMAD4 1 PIK3CA + KRAS + ERBB2 + TP53 1KRAS + PIK3CA ex9 + BRAF + TP53 1 PIK3CA + KRAS + BRAF + TP53 2KRAS + PIK3CA ex9 + TP53 2 PIK3CA + KRAS + EGFR + TP53 1KRAS + FBXW7 + TP53 2 PIK3CA + KRAS + BRAF + FBXW7 1KRAS + EGFR + PIK3CA ex9 + TP53 1 Total PIK3CA mutations 24KRAS + PIK3CA ex20 + BRAF + TP53 1 Two tumors had two concomitant PIK3CA mutations in

both exon 9 and exon 20KRAS + PIK3CA ex20 + TP53 1KRAS + PIK3CA ex20 + BRAF + FBXW7 1KRAS + BRAF + TP53 1KRAS + PIK3CA ex9 + PIK3CA ex20 + ERBB2 + TP53 1Total KRAS mutations 45

Gene mutations are not mutually exclusive in mCRC treated with FOLFIRI + cetuximab

One tumor had two concomitant KRAS mutations

Multiple gene mutations in BRAF mutated tumors

Multiple gene mutations in NRAS mutated tumors

Type of mutations n Type of mutations nBRAF only (no other mutation detected) 3 NRAS only (no other mutation detected) 8BRAF + TP53 5 NRAS + TP53 3BRAF + PIK3CA (ex20) 1 NRAS + MET 1BRAF + FBXW7 1 NRAS + PIK3CA ex9 1BRAF + KRAS + TP53 1 Total NRAS mutations 13BRAF + KRAS + PIK3CA (ex9) + TP53 1BRAF + KRAS + PIK3CA (ex20) + TP53 1BRAF + SMAD4 + FGFR2 + TP53 1BRAF + KRAS + PIK3CA (ex20) + FBXW7 1Total BRAF mutations 15

Gene mutations are not mutually exclusive in mCRC treated with FOLFIRI + cetuximab

Mutated cases (N=182 analyzed)

KRAS NRAS BRAFPIK3CA ex9

PIK3CA ex20

MET EGFR SMAD

4CTNN

B1 FGFR3 PTEN ERBB2FGFR2 FBXW7 TP53

KRAS (30/45)* 4 9 5 1 1 1 1 1 1 5 18

NRAS (5/13)* 1 1 3

BRAF (12/15)* 4 1 3 1 1 1 2 9

PIK3CA ex9 (14/16)* 9 1 1 2 1 1 1 8

PIK3CA ex20 (7/10)* 5 3 2 1 2 3

MET (4/7)* 1 1 1 1

EGFR (1/2)* 1 1 1

SMAD4 (2/2)* 1 1 1 1

CTNNB1 (2/2)* 1

FGFR3 (2/2)* 1 1 1

PTEN (1/1)* 1

ERBB2 (1/1)* 1 1 1 1

FGFR2 (1/1)* 1 1

FBXW7 (9/9)* 5 2 2 5

TP53 (36/72)* 18 3 9 8 3 1 1 1 1 1 1 5

*cases with multiple mutations/total mutated cases

22 multiple gene mutation analysis in mCRCtreated with FOLFIRI + cetuximab

Clinical activity of FOLFIRI + cetuximab

Total patients(KRAS exon 2 wt, n=340)

Patients with 22 multiple gene mutation analysis(n=182)

Complete response, % 26/340 (7.6%) 12/182 (6.6%)

Partial response, % 166/340 (48.8%) 92/182 (50.5%)

Stable disease, % 115/340 (33.8%) 61/182 (33.5%)

Progressive disease, % 33/340 (9.7%) 17/182 (9.3%)

ORR, % 192/340 (56.4%) 104/182 (57.1%)

Median PFS, months (95% CI)

9.9(8.8–11.3)

9.8(8.7–11.5)


KRAS/NRAS wt (n=124) KRAS/NRAS mt (n=58)



Stable disease, % 35/124 (28.2%) 26/58 (44.8%)


ORR, % 77/124 (62%) 27/58 (46.6%)


11.1(9.2–12.8)

8.9(7.4–9.6)


KRAS/RAS/BRAF/PIK3CA wt (n=104)

KRAS/NRAS/BRAF/PIK3CA mt (n=78)



Stable disease, % 28/104 (26.9%) 33/78 (42.3%)


ORR, % 67/104 (64.4%) 37/78 (47.4%)


11.3(9.4–13.2)

7.7(5.4–9.4)

A

B

C

Conclusions• Results confirm the activity of cetuximab + FOLFIRI in 1st line treatment of

mCRC: ORR, 56.4%; mPFS, 9.9 months.

• A 22 multiple gene mutation analysis using the next generation sequencing Ion AmpliSeq™ Colon and Lung Cancer Panel was feasible on FFPE tumor tissues

• Increased clinical activity of FOLFIRI + cetuximab was observed in mCRC patients whose tumors were wild type for both KRAS and NRAS genes:

– KRAS, NRAS wild type: ORR, 62.0%; mPFS, 11.1 months.– KRAS or NRAS mutant: ORR, 46.6%; mPFS, 8.9 months.

• Similar differences in clinical activity were observed in mCRC patients whose tumors were wild type for KRAS, NRAS, BRAF and PIK3CA genes:

– KRAS, NRAS, BRAF, and PIK3CA wild type: ORR 64.4%; mPFS 11.3

months. – KRAS, NRAS, BRAF or PIK3CA mutant: ORR, 47.4%; mPFS, 7.7 months

CAPRI GOIM trial

Cetuximab beyond progression in RAS wild type (WT) metastatic colorectal cancer

(mCRC): The CAPRI-GOIM randomized Phase II study of FOLFOX versus FOLFOX

plus cetuximab

Fortunato Ciardiello*, Nicola Normanno, Erika Martinelli, Teresa Troiani, Claudia Cardone, Anna Nappi, Anna Maria Rachiglio, Matilde Lambiase,

Salvatore Pisconti, Francesco Giuliani, Carlo Barone, Maria Biglietto, Vincenzo Montesarchio, Giuseppe Tonini, Daniele Rizzi, Saverio

Cinieri, Roberto Bordonaro, Antonio Febbraro, Ferdinando De Vita, Michele Orditura, Giuseppe Colucci, and Evaristo Maiello on the behalf

of the CAPRI-GOIM Investigators

*Second University of Naples, Italy

153 patientsrandomized to

154 patientsa) no second line for R0 operated LLD (20)b) lost to follow-up (32)c) refusal (19)d) other 2nd line therapies (68)e) KRAS or NRAS mutant after November 2013 (15)

340 patients(KRAS exon 2 wt according to

local pathology lab assessment)

FOLFIRI + cetuximab

307 patients

CR/PR/SD at progression

FOLFOX(Arm B)

79 patients

FOLFOX + cetuximab(Arm A)

74 patients

33 patientsPD

Progression free survival* (n=153 [ITT])(KRAS exon 2 wild type patients by local laboratory assessment)

32

N at Risk:Arm AArm B

32

00

22

7479

75

4236

2014

01

Months

Pro

gres

sion

-Fre

e Su

rviv

al (P

FS)

Arm B (FOLFOX)

Arm A (FOLFOX + cetuximab)

FOLFOX + cetuximab (Arm A) (n=74)

FOLFOX (Arm B) (n=79)

Median PFS, months 6.4 4.5

HR (95% CI) 0.81 (0.58–1.12)

p=0.19

*From randomization at start of 2nd line treatment

Tumor responses:FOLFOX + cetuximab

(Arm A) (n=74)FOLFOX (Arm B)

(n=79)

Complete response, n (%) 2 (2.7) 1 (1.3)

Partial response, n (%) 14 (18.9) 9 (11.4)

Stable disease, n (%) 32 (43.2) 37 (46.8)

Progressive disease, n (%) 22 (29.7) 27 (34.2)

Not evaluable, n (%) 4 (5.4) 5 (6.3)

Response rate (n=153 [ITT])(KRAS exon 2 wild type patients by local laboratory assessment)

Overall survival* (n=153 [ITT])(KRAS exon 2 wild type patients by local laboratory assessment)

32


76

00

35

22

4747

7479

1914

6764

3427

10

Ove

rall

Surv

ival

(OS)

FOLFOX + cetuximab (Arm A) (n=74)


Median OS, months 17.6 14.0

HR (95% CI) 0.86 (0.61–1.2)

p=0.41

Arm B (FOLFOX)


Months


Mutations in KRAS, NRAS, BRAF and PIK3CA genes as detected by next generation

sequencing1,2 (n=117)

1. Ciardiello F et al., Annals of Oncology 25:1756-61, 2014;

2. Normanno N et al., Annals of Oncology, 2015 in press

*Analysis of single tumor multiple gene mutations, as detected by NGS, has been previously reported1, 2.

**19/117 (16.2%) cases had a KRAS exon 2 mutation, but were originally classified as KRAS exon 2 wild type upon local laboratory assessment and, therefore, were treated with FOLFIRI plus cetuximab in 1st line

Gene:Number of cases with at least one mutation*, n (%)

(n=51/117, 43.6%)

KRAS 32 (27.4) 19 at exon 2 (16.2)**;13 at exons 3 or 4 (11.1)

PIK3CA 2 (1.8) 1 at exon 9 (0.9); 1 at exon 20 (0.9)

BRAF 7 (6.0) 6 at codon 600 (5.1); 1 at other (0.9)

NRAS 10 (8.5) 10 at exons 2 or 3 (8.5)

Progression free survival* according to KRAS/NRAS (n=117)

21


21

00

21

3936

53

2420

118

01

Months

Prog

ress

ion-

Free

Sur

viva

l (PF

S)

01


01

00

01

1428

02

411

15

00

Months

Prog

ress

ion-

Free

Sur

viva

l (PF

S)

KRAS/NRAS mutated (n=42)

Arm A (n=14) Arm B (n=28)


HR (95% CI) 1.53 (0.78–2.96)

p=0.2

KRAS/NRAS wild type (n=75)



HR (95% CI) 0.80 (0.50–1.29)

p=0.4

Arm B (FOLFOX)


Arm B (FOLFOX)



Tumor responses in KRAS/NRAS wt patients:

FOLFOX+cetuximab (Arm A) (n=39)


Complete response, n (%) 1 (2.6) 1 (2.8)


Stable disease, n (%) 18 (46.2) 19 (52.8)


Not evaluable, n (%) 2 (5.1) 1 (2.8)

Response rates according to KRAS/NRAS (n=117)

Tumor responses in KRAS/NRAS mt patients:

FOLFOX+cetuximab (Arm A) (n=14)


Complete response, n (%) 0 0


Stable disease, n (%) 4 (28.6) 11 (39.3)


Not evaluable, n (%) 2 (14.2) 2 (7.1)

Overall survival* according to KRAS/NRAS (n=117)

54


168

10

22

3936

2318

3728

2824

10

Months

Ove

rall

Surv

ival

(OS)

02


14

00

02

1428

46

1123

516

00

Months

Ove

rall

Surv

ival

(OS)

21

21

KRAS/NRAS mt (n=42)



HR (95% CI) 1.45 (0.74–2.83)

p=0.27

KRAS/NRAS wt (n=75)



HR (95% CI) 0.78 (0.46–1.32)

p=0.35

Arm B (FOLFOX)


Arm B (FOLFOX)



Progression free survival* according to KRAS/NRAS/BRAF/PIK3CA (n=117)

20


20

00

20

3432

41

2317

105

00

Months

Prog

ress

ion-

Free

Sur

viva

l (PF

S)

02


02

00

02

1932

14

614

28

01

Months

Prog

ress

ion-

Free

Sur

viva

l (PF

S)




HR (95% CI) 1.70 (0.94–3.05)

p=0.07

KRAS/NRAS/BRAF/PIK3CA wt (n=66)



HR (95% CI) 0.56 (0.33–0.94)

p=0.025


Tumor responses in KRAS/NRAS/BRAF/PIK3CA wt patients:

FOLFOX+cetuximab (Arm A) (n=34) FOLFOX (Arm B) (n=32)

Complete response, n (%) 1 (2.9) 0


Stable disease, n (%) 16 (47.1) 19 (59.4)


Not evaluable, n (%) 2 (5.9) 1 (3.1)

Response rates according to KRAS/NRAS/BRAF/PIK3CA (n=117)

Tumor responses in KRAS/NRAS/BRAF/PIK3CA mutant patients:

FOLFOX+cetuximab (Arm A) (n=19) FOLFOX (Arm B) (n=32)

Complete response, n (%) 0 1 (3.1)

Partial response, n (%) 0 6 (18.8)

Stable disease, n (%) 7 (36.8) 12 (37.5)


Not evaluable, n (%) 2 (10.5) 2 (6.2)

Overall survival* according to KRAS/NRAS/BRAF/PIK3CA (n=117)

51


156

00

21

3432

2215

3225

2621

10

Months

Ove

rall

Surv

ival

(OS)

03


04

00

01

1932

59

1627

719

00

Months

Ove

rall

Surv

ival

(OS)

20

20

16

00




HR (95% CI) 1.60 (0.89–2.96)

p=0.10

KRAS/NRAS/BRAF/PIK3CA wt (n=66)



HR (95% CI) 0.57 (0.32–1.02)

p=0.056

Arm B (FOLFOX)


Arm B (FOLFOX)



● CAPRI-GOIM is an academic non-profit, multicenter, randomized Phase II

study in which 153 patients with KRAS exon 2 wt mCRC (by local

pathology lab assessment), who initially responded to 1st line therapy

with FOLFIRI plus cetuximab, were treated in 2nd line with FOLFOX plus

cetuximab (Arm A; n=74) or FOLFOX (Arm B; n=79)

● In the ITT patient population a non-significant difference was observed for

both PFS and OS:

Median PFS

Arm A: 6.4 monthsArm B: 4.5 months

Median OS


Conclusions (1)

HR=0.81 (95% CI 0.58–1.12); p=0.19

HR=0.86 (95% CI 0.61–1.22); p=0.41

Conclusions (2)

● In 117/153 (76.5%) cases, KRAS, NRAS, BRAF and PIK3CA mutations were

centrally assessed by NGS

● In 66/117 cases, tumors had no mutations in KRAS, NRAS, BRAF and

PIK3CA genes, whereas in 51/117 cases a mutation in at least one of these

genes was found

● 19/117 (16.2%) tumors, that were originally classified as wt, had a

KRAS exon 2 mutation

Median PFS


Median OS


Median PFS


Median OS


● A significant improvement in PFS with a similar trend in OS was observed in the FOLFOX plus cetuximab arm in patients with KRAS, NRAS, BRAF and PIK3CA wild type tumors, whereas a detrimental effect was observed in patients whose tumors were mutated for at least one of these genes

● KRAS, NRAS, BRAF, PIK3CA wild type

● KRAS, NRAS, BRAF, PIK3CA mutated

Conclusions (3)

HR=0.56 (95% CI 0.33–0.94), p=0.025

HR=0.57 (95% CI 0.32–1.02), p=0.056

HR=1.70 (95% CI 0.94–3.05), p=0.07

HR=1.60 (95% CI 0.89–2.96), p=0.10

Continuing EGFR inhibition with cetuximab and switching chemotherapy backbone is a potential therapeutic strategy that deserves further evaluation in a randomized Phase III study in mCRC

patients with an EGFR-dependent cancer

Dubbink HJ et al, Neuro-Oncology 2015


Molecular Pathological

NGS

“FINESTRA SULLA COMPLESSITA’ “

evaristo maiello u.o.c. oncologia irccs casa sollievo della sofferenza san giovanni rotondo (fg)...

Documents

driver mutations

na kras

na egfro

lung cancer schiller

lung cancer panel2

frequent oncogenic drivers

na alk

targeted drugs