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New Strategies and Therapeutic Targets in PDATargets in PDA
Manuel Hidalgo, M.D., Ph.D.g
Multifaceted Biology of PDAgy
M Hidalgo, NEJM 2010
Genomic Diversity of Pancreas Cancer
Jones et al, Science 2008.
Core Gene Pathways in Pancreas Cancer
Jones et al, Science 2008.
PALB2 Mutations
Tischkowitz, CR 2010
Targeting PALB2 Mutations
Villaroel, MCT 2011
Mutational Analysis of Primary Tumor
Human genome reference sequenceHuman genome reference sequence18,655 genes
Capture tumor and normal DNA to enrich for coding exons37,806,033 bases of target sequence s g q
from 165,637 target regions
Sequence tumor and normal DNA usingnext-generation sequencing
15 904 958 898 bases of tumor DNAry A
naly
sis
15,904,958,898 bases of tumor DNA12,445,240,820 bases of normal DNA
Assemble sequence data and compare to target region 34,366,555 bases of target regions with at least 10 readsD
isco
ver
Analyze sequences for potential alterationsAverage of 37 distinct reads at each base in tumor DNAAverage of 28 distinct reads at each base in normal DNA
Compare tumor and normal sequence data to identify tumor-specific mutations
Somatic mutations in 62 genes
alys
is
Bioinformatic analyses of mutated genes
Id tifi ti f Id tifi ti f t t drmat
ic A
na
Identification of cancer genes
Identification of mutatedpathways
Analysis of individual mutationsBio
info
r
Selected Somatic Mutation
Mutation Position
Gene Symbol
Gene Description Pathway / Functional GroupTranscript Accession
Mutation TypeNucleotide
(genomic)
Nucleotide
(transcript)
Amino Acid
(protein)
MEFV Mediterranean fever Inflammatory response CCDS10498.1 chr16:3234255C>A 1759G>T 587V>F Missense
MRM1 mitochondrial rRNA methyltransferase 1 homolog RNA processing CCDS32631.1 chr17:32038218G>C IVS2‐1G>C NA Splice site
MYH10 myosin; heavy chain 10; non‐muscle Cytoskeletal organization CCDS11144.1 chr17:8352644A>C 3074T>G 1025L>W Missense
NES nestin CNS development CCDS1151.1 chr1:154906069T>C 4535A>G 1512K>R Missense
OR13F1 olfactory receptor; family 13; subfamily F; member 1 Sensory perception of smell CCDS35087 1 chr9:106306951A>G 587A>G 196Q>R MissenseOR13F1 olfactory receptor; family 13; subfamily F; member 1 Sensory perception of smell CCDS35087.1 chr9:106306951A>G 587A>G 196Q>R Missense
OR52N1 olfactory receptor; family 52; subfamily N; member 1 Sensory perception of smell CCDS31398.1 chr11:5766168A>C 455T>G 152L>R Missense
PABPC1L poly(A) binding protein; cytoplasmic 1‐like RNA and nucleotide binding CCDS42878.1 chr20:42992784G>T IVS8+3G>T NA Splice site
PAPPA2 pappalysin 2 Cell growth and differentiation CCDS41438.1 chr1:175035873C>A 5184C>A 1728H>Q Missense
PAPSS1 3'‐phosphoadenosine 5'‐phosphosulfate synthase 1 Xenobiotic metabolic process CCDS3676.1 chr4:108795472A>G 929T>C 310L>P Missense
PDE4B phosphodiesterase 4B; cAMP‐specific Cyclic nucletoide concentration CCDS632.1 chr1:66151609G>T 24G>T 8M>I Missense
PIK3C2A phosphoinositide‐3‐kinase; class 2; alpha polypeptide Phosphatidylinositol signaling CCDS7824.1 chr11:17147055C>G 810G>C 270W>C Missense
PIK3CA phosphoinositide‐3‐kinase; catalytic; alpha polypeptide Phosphatidylinositol signaling CCDS43171.1 chr3:180430545T>G 2726T>G 909F>C Missense
PLD5 phospholipase D family; member 5 Phospholipase activity CCDS1621.1 chr1:240330625T>G 1046A>C 349K>T Missense
PLS3 plastin 3 actin binding CCDS14568.1 chrX:114788511G>A 1678G>A 560D>N Missense
PUS3 pseudouridylate synthase 3 tRNA processing CCDS8466.1 chr11:125268896G>C 1440C>G 480I>M Missense
Bona Fide Candidate: PIK3CA
Validation in PDX Model
1800
2000
2200
CONTROL (n=8)
BEZ235 (n=9-8)
1400
1600
1800
SEM
( )
BKM120 (n=8)
GEMCITABINE (n=8)
1000
1200
e (m
m3 )
±
600
800
or V
olum
e
0
200
400
Tum
o
00 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
Time (days)
Genetic Evolution of PDA
Yachida, Nat 2010
Molecular Subtypes of PDA
Collison et al, Nat Med 2011.
Drug Response in Molecular Subtypes of PDASubtypes of PDA
Collison et al, Nat Med 2011.
PRODIGE 4/ACCORD 11 Trial
GemcitabineOS (months)
Advanced PDA(n= 342)
OS (months)
Gem FOLFIRINOX
6.8 11.1
FOLFIRINOX
• Primary endpoint: Survival
Conroy et al, NEJM 2011
First Line Treatment
FOLFIRINOX(-/+)
FOLFIRINOX
FOLFIRI(+/+)
5FU ERCC1/Topo1
FOLFOX( )
(-/-)
TS
(-)
(+/-)GEM + Capecitabina
(+)(No Ampl/No WT)
SPARC
(+)GEM + nab
GEM EGFR/K.Ras
GEM + Erlotinib
SPARCGEM
( -)
GEM + Erlotinib(Ampl ó WT)
PSCA Targetg• PSCA is GPI-linked cell surface protein of unclear function.
• Shares 30% homology with stem cell antigen type-2, but expressed mostly in differentiating epithelial cells of GI and p m y ff g p fGU tracts.
• Literature suggests PSCA expression in 87 100% of prostate • Literature suggests PSCA expression in 87-100% of prostate tumors1,2,3 and ~60% of pancreatic tumors.
• Germline SNPs in PSCA associated with risk of gastric and bladder cancer. Strongest association with missense variant in 1st exon, shown to alter PSCA expression levelsin 1st exon, shown to alter PSCA expression levels
AGS-1C4D4 in PDA
Gemcitabine6m Suv Rate
Advanced PDA(n= 196)
2:1 Randomization
6m Suv Rate
Gem Gem + AGS
44 % 61 %2:1 RandomizationGem + AGS1CD4 p = 0.016
• Primary endpoint: 6-m Survival Rate
Wolpin et al, ECCO 2011
Multifaceted Biology of PDAgy
M Hidalgo, NEJM 2010
SPARC (Secreted Protein and Rich in Cystein)
• Sparc is a member of a family of matricellular proteins whose function is to modulate cell-matrix interactions. (Bornstein and Sage, Curr. Opin. Cell Biol.,2002, Brekken and Sage, Matrx Biol., 2001)
• Sparc was shown to be expressed in tumors and the surrounding stroma of Sparc was shown to be expressed in tumors and the surrounding stroma of different types of cancer: breast, melanoma, glioblastoma, ovarian, colorectal and pancreatic.
M i i h i ll i S KO i h • Murine pancreatic tumors grown orthotopically in Sparc KO mice show increased metastatic potential. (Arnold S., et al.,Disease models and mechanism, 2010)
• The expression of SPARC by peritumoral fibroblasts accounts for a poorer prognosis for patients with pancreatic cancer. (Infante J. et al., Journal of Clinical Oncology, 2007)
• Sparc is a target for nanoparticle – albumin bound (Nab) drugs due to its high affinity for binding serum-albumin. (Desai N., et al., Clinical Cancer Research., 2006; Sage et al.,1984)
SPARC Expression in Tumor Stroma pis Associated with Worse Outcome
Infante et al, 2007
Nab Paclitaxel – (Abraxane®) 1 C m ph f ll id l p n i n f n n p ti l 1. Cremophor – free colloidal suspension of nanoparticle
paclitaxel (Abraxane®) stabilized with human serum albumin (130 nm particles )
2 R id di t ib ti t t 2. Rapid distribution to tumor (Sparreboom et al. Clin Cancer Res. 11: 4136, 2005)
3. Intra-tumoral accumulation of nab-paclitaxel - (Desai l Cli C R 12 1317 2006)et al. Clin. Cancer Res. 12: 1317, 2006)
Fluorescent nab-paclitaxel nanoparticles in syringe injected via tail
vein
Imaged Tumor
Phase I/II Trial of Gem + Nab-paclitaxel
• Multicenter trial run through PCRT.F d b l • Fix dose-gemcitabine + escalating dose of nab-paclitaxel.p
• 67 patients with stage IV disease.• Expansion cohort of 44 patients at Expansion cohort of 44 patients at the MTD.R d b PET d • Response assessed by PET and CA199.
• SPARC assessment in tumor biopsies.
Von Hoff et al, JCO 2011
Rapid Response b PET d CT Sby PET and CT Scans
Scan Baseline Post Rx 1 Post Rx 2
Post Rx 3
Post Rx 4
Post Rx 5
Post Rx 6
Post Rx 7
RECIST Total
19.4 15.2 12.6 10.7 10.4 9.3 9.6 7.6
Baseline: 6.03.2007
ET S
cans
Total
% Change
- -21.6 -35.1 -44.8 -46.4 -52.1 -50.5 -60.8
nse
by P
E
Scan
s Baseline: 9.10.2008
d R
espo
n
se b
y C
T S
8.15.2007
Rap
id
Res
pons Cycle 7:
04.13.2009
Von Hoff et al, JCO 2011
Preclinical Platform
Rubio et al, CCR 2006
Average Response Rate in Xenografts (n = 11)
50
60al
siz
e (%
)
40
of it
s in
itia
20
30
ssed
50%
o
10
mor
s re
gres
0GEM ABI GEM+ABI
Tum
Effects of nab-Paclitaxel in Tumor Stroma
Effects of nab-Paclitaxel on GemcitabineDeliveryDelivery
6000
7000
8000
an ±
SEM
)
GEM alone
GEM+ABI22000
24000
an ±
SEM
)
GEM aloneGEM+ABI
3000
4000
5000
6000
g/g
tum
or (M
ea
20000
22000
g/g
tum
or (M
ea0
1000
2000
3000
once
ntra
tion
n
16000
18000
once
ntra
tion
n0
GEM
Co 16000
dFdU
Co
Pancreatic Cancer is Hypovascular
Olive…Tuveson, Science 2009
Anti-Stromal Agent Combination Activity(Panc163)(Panc163)
Roles of Hh Pathway in PDAy
Hidalgo and Maitra, NEJM 2009
Targeting CSC Pathways
Jimeno et al, MCT 2009
High DR-5 Expression in Cancer Stem Cells
Bulk Population
CD24+CD44+ Population
89.4%
30.1%
Cel
l #
l #
DR5
ALDH+ PopulationDR5
Cel
6.22%
94.3%
CD
44
SSC
Cel
l #
4.62%
CD24 ALDEFLUORDR5
Rajeshkumar et al, MCT 2010
Targeting Extrinsic PathwayTargeting Extrinsic Pathway
TGI of Established Human Pancreatic Tumor Xenografts Treated with CS1008, GEM and GEM+CS1008 on day 28
Rajeshkumar et al, MCT 2010
Conclusions• Genetically complex, unstable and heterogenous
diseasedisease.
I i i t t iti f li di i • Incipient opportunities for personalize medicine are emerging.
• Targeting pancreatic cancer stroma is appealing preclinically and clinicallypreclinically and clinically.
• Pancreas CSC directed therapies may be needed • Pancreas CSC directed therapies may be needed for full prevention of cancer failure.
GI Group at CNIOM. Mustenau A. CalleP. Lopez-Casas M. MuñozP M lli R S h
SU2C Team at JHUC. Iacobuzio-DonahueR HrubanP. Morelli R. Sanchez
R. Martinez E. GarciaR. HrubanA. MaitraR. KumarE. OliveiraGI Program at Johns HopkinsV. VelculescuC. Dang
GI rogram at Johns Hopk nsD. LaheruA. De Jesus
TGenTGenD. Von HoffR. Ramanathan
CBID. SidranskyE. Bruckheimer
PCRT
GI Group at CIOCCE. VicenteY. QuijanoA Cubillo
J. Martell
A. StollC. MoriartyPCRT Investigators
A. CubilloJ. RodriguezC. RubioO. Hernando
Pancreas Team at CNIOM. Barbacid/C GuerraP Real
LDT Lab at CIOCCF. Lopez-Rios
P. RealC. HeeschenN. Malats
Imaging Unit at CNIOP. Mulero