research presentation jason m. leibowitz, md june 25, 2009 preceptor: marcia s. brose, md phd jason...
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Research PresentationResearch Presentation
Jason M. Leibowitz, MD
June 25, 2009
Preceptor: Marcia S. Brose, MD PhD
Jason M. Leibowitz, MD
June 25, 2009
Preceptor: Marcia S. Brose, MD PhD
Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870
OverviewOverview
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
Thyroid Cancer in the United StatesThyroid Cancer in the United States
Thyroid cancer is the most
common endocrine neoplasm.
Thyroid cancer will be diagnosed
in 33,550 individuals (8070 men
and 25,480 women) this year.
From 1997-2004 incidence of
thyroid cancer increased by 6.2%
mostly due to increased detection.
From 1985 to 2004 mortality rate
increased by 0.3% a year.
Thyroid cancer is the most
common endocrine neoplasm.
Thyroid cancer will be diagnosed
in 33,550 individuals (8070 men
and 25,480 women) this year.
From 1997-2004 incidence of
thyroid cancer increased by 6.2%
mostly due to increased detection.
From 1985 to 2004 mortality rate
increased by 0.3% a year.
RAI-Refractory DiseaseRAI-Refractory Disease
25-50% of metastatic thyroid cancers lose ability to take up Iodine.
Iodine Uptake inversely correlates with survival. This is attributed to down regulation of the Na+/I-
Symporter (NIS). Limited treatment options for unresectable
thyroid cancer refractory to RAI.
25-50% of metastatic thyroid cancers lose ability to take up Iodine.
Iodine Uptake inversely correlates with survival. This is attributed to down regulation of the Na+/I-
Symporter (NIS). Limited treatment options for unresectable
thyroid cancer refractory to RAI.
Molecular Changes in Thyroid Cancer
Molecular Pathway involved in Thyroid Cancer
Molecular Pathway involved in Thyroid Cancer
Activation of MAPK pathway Oncogenic activation
of this pathway in 70% of all thyroid cancers.
BRAF is a serine threonine kinase
Activation of MAPK pathway Oncogenic activation
of this pathway in 70% of all thyroid cancers.
BRAF is a serine threonine kinase
Xing, 2007.
BRAF V600E in Thyroid CancerBRAF V600E in Thyroid Cancer
2003: The BRAF V600E mutation is the most
common genetic alteration in thyroid cancer,
occurring in about 45% of sporadic papillary
thyroid cancers (PTCs).
2003: The BRAF V600E mutation is the most
common genetic alteration in thyroid cancer,
occurring in about 45% of sporadic papillary
thyroid cancers (PTCs).
V600E
BRAF V600EBRAF V600E Point mutation in 40-45% of
PTC Upregulation of MMP, VEGF -->
invasion, angiogenesis Silencing of tumor suppressive
genes, genes involved in iodine transport
BRAF mutation associated with multiple negative prognostic indicators.
Point mutation in 40-45% of PTC Upregulation of MMP, VEGF -->
invasion, angiogenesis Silencing of tumor suppressive
genes, genes involved in iodine transport
BRAF mutation associated with multiple negative prognostic indicators.
RASRAS
Family of small G-proteins involved in transduction of cellular signals from the cell membrane.
Mutations in RAS gene lead to inappropriate activation with constitutively activated downstream pathways and also promote chromosomal instability.
20% FTC contain a RAS mutation RAS mutations may correlate with aggressive behavior (tumor dedifferentiation and poorer prognosis).
Family of small G-proteins involved in transduction of cellular signals from the cell membrane.
Mutations in RAS gene lead to inappropriate activation with constitutively activated downstream pathways and also promote chromosomal instability.
20% FTC contain a RAS mutation RAS mutations may correlate with aggressive behavior (tumor dedifferentiation and poorer prognosis).
Targeted Therapy in Thyroid cancer
Targeted Therapy in Thyroid cancer
Loss of differentiation (inability to trap RAI), unresectable lesion, leads to poor prognosis
BRAF inhibitors BAY 43-9006 (Sorafenib) Multikinase inhibitor
Loss of differentiation (inability to trap RAI), unresectable lesion, leads to poor prognosis
BRAF inhibitors BAY 43-9006 (Sorafenib) Multikinase inhibitor
SorafenibSorafenib
Orally active multikinase inhibitor (study dose 400mg BID).
Monoclonal antibody with multiple targets including BRAF, VEGFR1, VEGFR2.
Blocks tumor cell proliferation and angiogenesis.
FDA approved for treatment of RCC and hepatocellular carcinoma.
Orally active multikinase inhibitor (study dose 400mg BID).
Monoclonal antibody with multiple targets including BRAF, VEGFR1, VEGFR2.
Blocks tumor cell proliferation and angiogenesis.
FDA approved for treatment of RCC and hepatocellular carcinoma.
Targeted Therapy and GenotypeTargeted Therapy and Genotype
K-RAS gene mutation and metastatic colorectal carcinoma. Recent results from Phase II & III clinical trials demonstrate that
patients with metastatic colorectal cancer benefit from anti-EGFR therapy.
Patients with K-RAS mutation in codon 12 & 13 should not receive anti-EGFR therapy since they do not receive any benefit.
EGFR and non-small cell lung cancer: Epithelial growth factor receptor 10% mutated in NSCLC EGFR mutations are predictors of TKIs responsiveness and may
show a long lasting response to TKIs EXON 19 Deletion respond better to TKIs.
K-RAS gene mutation and metastatic colorectal carcinoma. Recent results from Phase II & III clinical trials demonstrate that
patients with metastatic colorectal cancer benefit from anti-EGFR therapy.
Patients with K-RAS mutation in codon 12 & 13 should not receive anti-EGFR therapy since they do not receive any benefit.
EGFR and non-small cell lung cancer: Epithelial growth factor receptor 10% mutated in NSCLC EGFR mutations are predictors of TKIs responsiveness and may
show a long lasting response to TKIs EXON 19 Deletion respond better to TKIs.
Prior DataPrior Data
84 weeks
N= 52
N=43
WDTC
Papillary vs. FollicularPapillary vs. Follicular
P<0.095FTC = 19
PTC= 24
Prior DataPrior Data
Conclusions from prior data: Improved PFS with Sorafenib. Improved PFS of FTC treated with Sorafenib
when compared to PTC.
Conclusions from prior data: Improved PFS with Sorafenib. Improved PFS of FTC treated with Sorafenib
when compared to PTC.
OverviewOverview
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
HypothesisHypothesis
There are specific genotypes (i.e. BRAF V600E, RAS mutations) that predict favorable response to targeted therapy (Sorafenib).
There are specific genotypes (i.e. BRAF V600E, RAS mutations) that predict favorable response to targeted therapy (Sorafenib).
Null HypothesisNull Hypothesis
Specific genetic mutations do not predict response to targeted therapy in thyroid cancer.
Specific genetic mutations do not predict response to targeted therapy in thyroid cancer.
OverviewOverview
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
Research PlanResearch Plan Tissue samples collected from patients with
treatment-resistant thyroid cancer with long term follow-up (approximately 30 patients).
All patients received targeted therapy (Sorafenib). Samples with WDTC analyzed for mutations in
BRAF and RAS genes when available: BRAF - V600E RAS - Exon 12, 13, 61
Tissue samples collected from patients with treatment-resistant thyroid cancer with long term follow-up (approximately 30 patients).
All patients received targeted therapy (Sorafenib). Samples with WDTC analyzed for mutations in
BRAF and RAS genes when available: BRAF - V600E RAS - Exon 12, 13, 61
RESULTS
Sequence OutputSequence Output Computer program interprets
data and produces an electropherogram, (aka trace)
Each peak represents a base: A = Adenosine T = Thymine C = Cytosine G = Guanine N = Reading cannot be
determined
Computer program interprets data and produces an electropherogram, (aka trace)
Each peak represents a base: A = Adenosine T = Thymine C = Cytosine G = Guanine N = Reading cannot be
determined
OverviewOverview
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
Results of Stage 1 AnalysisResults of Stage 1 Analysis•N= 30 •M = F = 15•PTC=17, FTC= 9, Other (ATC/PD, MTC): 4•Samples analyzed for BRAF mutation:
• 23/30 (76.6%): samples analyzed for BRAF mutation• 4/30 (13%): definite genotype but questioned due to phenotype
(ATC/PD, MTC)• 2/30 (6%): unable to amplify DNA despite multiple PCR attempts• 1/30 (3%): pending analysis
•18/30 samples analyzed for RAS mutation, all WT copies of the gene
•N= 30 •M = F = 15•PTC=17, FTC= 9, Other (ATC/PD, MTC): 4•Samples analyzed for BRAF mutation:
• 23/30 (76.6%): samples analyzed for BRAF mutation• 4/30 (13%): definite genotype but questioned due to phenotype
(ATC/PD, MTC)• 2/30 (6%): unable to amplify DNA despite multiple PCR attempts• 1/30 (3%): pending analysis
•18/30 samples analyzed for RAS mutation, all WT copies of the gene
Results of Stage 1 AnalysisResults of Stage 1 Analysis
N=22 (interim analysis) 13 WT BRAF 9 BRAF V600E 16 PTC
9 WT BRAF, 7 V600E
6 FTC 4 WT BRAF, 2 V600E
N=22 (interim analysis) 13 WT BRAF 9 BRAF V600E 16 PTC
9 WT BRAF, 7 V600E
6 FTC 4 WT BRAF, 2 V600E
BRAF V600EBRAF V600E
P<0.02
N=13 (WT=8,
V600E=5)
Updated geneticsUpdated genetics In our expanded
analysis to 22 pts with WDTC, the effect is no longer significant but the trend exists.
We are further investigating BRAF copy number in these patients
In our expanded analysis to 22 pts with WDTC, the effect is no longer significant but the trend exists.
We are further investigating BRAF copy number in these patients
p=NS
N =22WT = 13BRAF V600E = 9
OverviewOverview
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
Background Hypothesis Methods Results Discussion Conclusions & Future Directions
BRAFV600E Correlates with worse SurvivalBRAFV600E Correlates with worse Survival
Elisei et. al, J Clin Endocrinol Metab, October 2008, 93(10):3943–3949
BRAFV600E Correlates with worse SurvivalState of the mutation in PTC, 10/2008
BRAFV600E Correlates with worse SurvivalState of the mutation in PTC, 10/2008
THE BRAF connectionTHE BRAF connection
Ciampi et al. 2005
Updated geneticsUpdated genetics In our expanded
analysis to 22 pts with WDTC, the effect is no longer significant but the trend exists.
We are further investigating BRAF copy number in these patients
In our expanded analysis to 22 pts with WDTC, the effect is no longer significant but the trend exists.
We are further investigating BRAF copy number in these patients
p=NS
N =22WT = 13BRAF V600E = 9
BRAF (red) x 3
7 centromere (green) x 3
BRAF x4
7 centromere x4
4 copies each
3 copies each
THE BRAF connection! Positive Predictor!
THE BRAF connection! Positive Predictor!
Ciampi et al, 2005.
Future DirectionsFuture Directions
Completion of genotyping analysis of all patients
Evaluation of copy number gains in WDTC Hypothesis: Copy number gain accounts for
improved survival in FTC treated with Sorafenib
Null: Copy number gain does not influence survival in FTC
Completion of genotyping analysis of all patients
Evaluation of copy number gains in WDTC Hypothesis: Copy number gain accounts for
improved survival in FTC treated with Sorafenib
Null: Copy number gain does not influence survival in FTC
Selected SourcesSelected Sources
Ciampi R, Zhu Z, Nikiforov YE. BRAF copy number gain in thyroid tumors detected by fluorescence in situ hybridization. Endocrine Pathology 2005; 16(2): 99-105.
Ciampi R, Nikiforov YE. Alterations of the BRAF gene in thyroid tumors. Endocrine Pathology 2005; 16:3): 163-171.
Gupta-Abramson V, Troxel AB, Nellore A, et al. Phase II Trial of Sorafenib in Advanced Thyroid Cancer. Journal Clin Onc 2008; 26 (29): 4714-4719.
Kundra P, Burman KD. Thyroid Cancer Molecular Signaling Pathways and Use of Targeted Therapy. Endoc Metab Clin N Am 2007;36: 839-853
Murer B. Targeted Therapy in Non-Small Cell Lung Cancer. Arch Path Lab Med. 2008; 132: 1573-1575.
Nikiforov YE. Thyroid Carcinoma: Molecular Pathways and Therapeutic targets. Modern Pathology 2008; 21: S37-S43.
Vasko V, Ferrand M, Cristofaro JD et al. Specific Pattern of RAS Oncogene Mutations in Follicular Thyroid Tumors. J. Clin Endocrin. & Metab. 2003; 88(6):2745-2752.
Xing M. BRAF Mutation in Papillary Thyroid Cancer: Pathogenic Role, Molecular Basis, and Clinical Implication. End Rev 2007; 28(7): 742-762.
Ciampi R, Zhu Z, Nikiforov YE. BRAF copy number gain in thyroid tumors detected by fluorescence in situ hybridization. Endocrine Pathology 2005; 16(2): 99-105.
Ciampi R, Nikiforov YE. Alterations of the BRAF gene in thyroid tumors. Endocrine Pathology 2005; 16:3): 163-171.
Gupta-Abramson V, Troxel AB, Nellore A, et al. Phase II Trial of Sorafenib in Advanced Thyroid Cancer. Journal Clin Onc 2008; 26 (29): 4714-4719.
Kundra P, Burman KD. Thyroid Cancer Molecular Signaling Pathways and Use of Targeted Therapy. Endoc Metab Clin N Am 2007;36: 839-853
Murer B. Targeted Therapy in Non-Small Cell Lung Cancer. Arch Path Lab Med. 2008; 132: 1573-1575.
Nikiforov YE. Thyroid Carcinoma: Molecular Pathways and Therapeutic targets. Modern Pathology 2008; 21: S37-S43.
Vasko V, Ferrand M, Cristofaro JD et al. Specific Pattern of RAS Oncogene Mutations in Follicular Thyroid Tumors. J. Clin Endocrin. & Metab. 2003; 88(6):2745-2752.
Xing M. BRAF Mutation in Papillary Thyroid Cancer: Pathogenic Role, Molecular Basis, and Clinical Implication. End Rev 2007; 28(7): 742-762.
ThanksThanks
Marcia Brose, MD PhD
Cathy Ma MD, PhD Kanchan Puttaswamy, MS
Marcia Brose, MD PhD
Cathy Ma MD, PhD Kanchan Puttaswamy, MS