molecular and genetic markers in crc - bgdo€¦ · siena. esmo 2016 raghav et al. asco 2016...

BGDO DIGESTIVE ONCOLOGY COURSE 27 APRIL 2019

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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)

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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

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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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22


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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

molecular and genetic markers in crc - bgdo€¦ · siena. esmo 2016 raghav et al. asco 2016...

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