CPNM Diagnóstico Molecular: en busca de la Diana Perdida

Problemas y alternativas

Carlos Camps. Panticosa 2014

“New Era of Personalized Medicine” portada en 1999 en The Wall Street Journal

15 años despues y > 3 Billones $ invertidos en estudios genomicos 2013

1

/2/

02/ z

n

xzP

2

KRAS as Prognostic Biomarkers for LUNG CANCER

Table 2 . KRAS mutations: correlation with Histology Table 3. KRAS mutations: correlation with Smoking Status

81.2 meses

23 meses

KRAS SCC ADC* Others Total p

WT 67 51 16 134

0.002 98.5% 79.7% 88.9% 89.3%

Mutated 1 13 2 16

1.5% 20.3% 11.1% 10.7%

Poster145

Madariaga, et al SEPAR 2014, Camps C ASCO 2013

KRAS Non Smoker

Former Smoker

Current Smoker

Total p

WT 13 54 67 134

0.007 Mutated

6 4 6 16

37.5% 25% 37.5% 100%

Terapia basada en dianas en Oncologia

The hope for the future

Individualized Medicine

Breast cancer

Prostate cancer

Lung cancer

Molecular diagnostics

Treatment A

Treatment B

Treatment C

Standard TX

Modified from American Association for Cancer Research

Nuevas mutaciones en el proceso de metastasis

Scott Valastyan and Robert A. Weinberg, Cell 2011, 147: 275-292

" Unless you can express your knowledge with numbers, your knowledge is meager and unsatisfactory." William Thompson. Lord Kelvin 1824-1907

Smithsonian Institution of Washington, 1857

Cuando y Como empezó esta historia en Ca de Pulmón ?

EGFR /2004

Dominio extracelular

Dominio Trans-

membrana

Dominio Tirosin Kinasa

Dominio Regulador

EGFR

Chr

omos

ome

7 C

rom

osom

a 7

Cell-cycle checkpoints (Hemmungseinrichtung: inhibitory mechanism) that would allow cell division only when a specific external stimulus is experienced by the cell.

The clonal origin of tumours

Tumour-suppressor genes (Teilungshemmende Chromosomen), the effects of which can be overcome by external signals, and which are physically lost in progressively growing tumours.

Oncogenes (Teilungsfoerdernde Chromosomen) that become amplified (im permanenten Übergewicht) during tumour development.

Tumour progression from benign to malignant, involving sequential changes of increased growth-stimulatory chromosomes & loss of growth-inhibitory chromosomes.

Cancer predisposition through inheritance of chromosomes (genes) that are less able to suppress malignancy.

Cancer predisposition through inheritance of genes that cause aberrant mitoses.

The role of wounding and inflammation in tumour promotion.

Loss of cell adhesion in metastasis.

Sensitivity of malignant cells to radiation therapy.

Prediciones de Boveri(1902)

Combined OS analysis: mutation categories

Presented by: James Chih-Hsin Yang ASCO 2014

1.0

0.8

0.6

0.4

0.2

0

Estim

ated

OS

prob

abilit

y

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51

Time (months)

1.0

0.8

0.6

0.4

0.2

0

Estim

ated

OS

prob

abilit

y Time (months)

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51

236 230 223 217 202 192 173 160 145 131 117 90 50 38 22 6 1 0

119 113 103 95 87 72 63 55 51 43 38 27 14 9 1 1 0 0

Afatinib

Chemo

No of patients

183 181 167 154 141 128 111 91 80 70 64 51 27 20 11 3 0 0

93 86 82 78 75 69 61 55 50 40 32 25 20 14 9 4 1 0

Afatinib

Chemo

No of patients

Del19 Afatinib n=236

Chemo n=119

Median, months 31.7 20.7

HR (95%CI), p-value

0.59 (0.45–0.77), p=0.0001

L858R Afatinib n=183

Chemo n=93

Median, months 22.1 26.9

HR (95%CI), p-value

1.25 (0.92–1.71), p=0.1600

Look to Mechanisms of EGFR TKI Acquired Resistance to Choose Systemic Therapies

T790M 63%

small cell + EGFR T790M

2%

small cell alone 1%

small cell+MET 1%

MET amplification alone

3%

MET + EGFR T790M 3%

Unknown 27%

Yu, Clin Cancer Res 2013

AZD9291 94%

Control

July 2009 January 2012

Mujer de 72 años ALK-Positivo tratada con Crizotinib

Desde publicacion EC pivotal NEJM 2010 hasta fijacion de precios España 2013

Acquired Resistance in ALK+ NSCLC

• ALK+ NSCLC is sensitive to crizotinib[1-3 ] – ORR: 60% – Median PFS: 8-10 mos

• Most patients with develop resistance to crizotinib[4,5] – Usually within 1-2 yrs – CNS relapses are common[6]

• Mechanisms of resistance are diverse[4,5]

– ALK resistance mutations – Alternative signaling pathways

Unknown

Bypass tracks EGFR MT KRAS MT

No ALK amp or mut

ALK amp

ALK mut ALK+

1. Camidge DR, et al. Lancet Oncol. 2012;13:1011-1019. 2. Kim DW, et al. ESMO 2012. Abstract 1230PD. 3. Show AT, et al. ESMO 2012. Abstract LBA1_PR. 3. Katayama R, et al. Sci Trans Med. 2012;4:120ra17. 4. Doebele RC, et al. Clin Cancer Res. 2012;18:1472-1482. 5. Takeda M, et al. J Thorac Oncol. 2013; 8:654-657.

Ou et al., Abstract # O16.07

Crizotinib Phase II trial in ROS1+ NSCLC Patients (1%)

Nuevas dianas en desarrollo Potential Treatment Model According to Genomic Drivers

AdvancedAdenocarcinoma

of lung

Genomic Profile

HER 2 mutation p

Afatinib + Herceptin

BRAF mutation GSK2118436

pC-MET

amplification Ficlatuzumab

ROS-1 LDK378

PI3K mutation BEZ235

KIF5B-RET Lenvatinib

La 1º Pregunta: Problemas:

La Complejidad y la Heterogeneidad

La teoría Darwiniana

Liquid

Nonsynonymous Somatic Mutations by Tumor Type

Vogelstein B, et al. Science. 2013;339:1546-1558.

Non

syno

nym

ous

Mut

atio

ns

per T

umor

(med

ian

± on

e qu

artil

e) 1500

1000

250 225

500

200 175 150 125 100

75 50 25

0

Col

orec

tal (

MSI

)

Lung

(SC

LC)

Lung

(NSC

LC)

Mel

anom

a

Esop

hage

al (E

SCC

)

Non

-Hod

gkin

’s ly

mph

oma

Col

orec

tal (

MSS

)

Hea

d an

d ne

ck

Esop

hage

al (E

AC)

Gas

tric

Endo

met

rial (

endo

met

riod)

Panc

reat

ic a

deno

carc

inom

a

Ova

rian

(hig

h-gr

ade

sero

us)

Pros

tate

Hep

atoc

ellu

lar

Glio

blas

tom

a

Brea

st

Endo

met

rial (

sero

us)

Lung

(nev

er s

mok

ed N

SCLC

)

Chr

onic

lym

phoc

ytic

leuk

emia

Acut

e m

yelo

id le

ukem

ia

Glio

blas

tom

a

Neu

robl

asto

ma

Acut

e ly

mph

obla

stic

leuk

emia

Med

ullo

blas

tom

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Rha

bdoi

d

Mutagens Adult Solid Tumors Pediatric

ADJ CT in early stage NSCLC Where do we are? Where are we going?

Personalized treatment needed predictive biomarkers Pathologic factors Tumor heterogeneity and Host characteristics Microenvironment biomarkers immunotherapies ¿?

Rapid evolution of NGS and ↓ costs complete molecular profiling of each patient`s tumor is a realistic goal

Govidan, Cell 2012

SEGMENTACION

Burrell, Mcgranahan, Bartek and Swanton Nature 2013

Intertumour Heterogeneity Intratumour Heterogeneity Intercellular Heterogeneity

Review principles of intratumour heterogeneity learned from Renal Cancer Apply methods to study cancer evolution in Non-Small Cell Lung Cancer

Charlie Swanton, Sidney 2013

Intratumoral EGFR Mutational Heterogeneity Hua Bay et al, PLoS One. 2013; 8(2): e54170

1. Cancer Stem Cell (or like) – only few founders with tumorgenic potential

2. Therapeutic importance – target the few

3. BUT, although most evidence supports CSC - we don’t really know

Charlie Swanton, Sidney 2013

RELACIÓN FILOGENÉTICA DE LAS DISTINTAS REGIONES TUMORALES

•La evolución del tumor no es lineal, sino ramificada. •La longitud de ramificaciones es proporcional al nº de genes con mutaciones •Las mutaciones “driver ” son adquiridas en las ramificaciones. •En los tumores “convergencia fenotípica”: diferentes regiones del tumor tienen distintas mutaciones en los mismos genes.

… en otras palabras

NO ES ASI ES ASI

Una biopsia simple puede mostrar un máximo 50% de todas las mutaciones . Una biopsia no es representativa de un tumor .

Heterogeneidad T vs M

Bulletin Cancer 2013, S Vignot and JC Soria

Las mutaciones son dinámicas y los tumores heterogéneos y plásticos

Clonal Evolution

Peter C. Nowell. The Clonal Evolution of Tumor Cell Populations. Science (1976). Douglas Hanahan & Robert A. Weinberg. Hallmarks of Cancer: The Next Generation. Cell (2011). Felipe De Sousa E Melo. Cancer heterogeneity - a multifaceted view. EMBO report (2013).

1. Genetic disease (of the aged)

2. Evolving « system » (time &

space).

3. Heterogeneity !

Clonal Evolution (stepwise acquisition of mutations)

Epigenetics (DNA methylation, histone deacetylation )

Interaction (cell-cell, micro-enviroment)

4. Metabolism (almost) everywhere

27

NEW BIOMARKERS FOR LUNG CANCER: A METABOLOMIC APPROACH

Ayudas • Mutua Madrileña • AICR 2014 Camps C ASCO 2014

Multivariate modeling resulting from the analysis of serum 1H-NMR spectra.: (A) control individuals (red dots) vs early and advanced stage NSCLC patients (green and blue dots); (B) control individuals (red dots) vs early stage NSCLC patients (green dots); (C) control individuals (red dots) vs advanced stage NSCLC patients (blue dots) and (D) early stage NSCLC patients (green dots) vs advanced stage NSCLC patients (blue dots).

A B

C D

Inmunidad Uso M et al, PASCO 2014

PFS

Markers Median

(months) p-value

CTLA4 (≤ median vs > median)

19.23 vs 81.23

0.008

PD1 (≤ median vs > median)

19.13 vs 49.30

0.048

PDL1 (≤ median vs > median)

19.23 vs 66.96

0.034

Combined Checkpoints (Other combinations vs PD1high PDL1high)

19.23 vs NR 0.008 (0.048*)

81.2 m 22.1

m 25.6 m

NR NR

37.9 m miR-

188-5p miR-196b

miR-21

Gallach et al PASCO 2014

Existen otra formas de analizar el tumor?

CTCs

Cell free DNA

MA

TRIX

Serum Plasma (EDTA)

Proteins

Metabolites

En busca de las dianas Las Alternativas

Existen Modelos Organizativos de Éxito?

Principios rectores para construir estrategias en Genómica del Cáncer: Medicina Genómica del Cancer

Principio #1: Las Vías moleculares implicadas en la supervivencia y la progresión tumoral son activadas por alteraciones genéticas.

Garraway, J. Clin. Oncol., 2013

Principio #1: Las Vías moleculares implicadas en la supervivencia y la progresión tumoral son activadas por alteraciones genéticas. . Principio #2: Los Agentes anticancerígenos dirigidos a muchas vías oncogénicas podemos usarlos en ensayos clínicos

Garraway, J. Clin. Oncol., 2013

Principios rectores para construir estrategias en Genómica del Cáncer: Medicina Genómica del Cancer

Principio #1: Las Vías moleculares implicadas en la supervivencia y la progresión tumoral son activadas por alteraciones genéticas Principio #2: Los Agentes anticancerígenos dirigidos a muchas vías oncogénicas podemos usarlos en ensayos clínicos Principio #3: Las tecnologías genómicas permiten utilizar el perfil genómico en el ámbito clínico.

Principios rectores para construir estrategias en Genómica del Cáncer: Medicina Genómica del Cancer

Solomon, Sidney 2013

EL TIEMPO NECESARIO PARA TOMAR DECISIONES

COSMIC. Nucleic Acids Research, 2011, Vol. 39, Database issue

somatic mutation content of cell line NCI-H209. Concentric rings summarize the data on different types of mutation. From the inside out, the core displays the structural rearrangements; intrachromosomal are in green, interchromosomal in purple. The next ring out shows the chromosomal copy number in histogram form, with inner red patches indicating regions of LOH. Further out, several rings of single base coding substitutions are shown (black tiles show splice site mutations, red stop-gained, purple non synonymous and grey synonymous changes).

Describes over 136 000 coding mutations in almost 542 000 tumour samples; 26% have one or more mutations. Full scientific literature curations are available on 83 major cancer genes and 49 fusion gene pairs (19 new cancer genes and 30 new fusion pairs this year) and this number is continually increasing.

LCMC: frecuency of oncogenic drivers 83 specimens with all 10 drivers assesed

Ben Solomon, Sidney 2013

• Worldwide Innovative Networking • Initiated By MDACC and IGR

Only 50 % cured Late diagnosis Therapeutic failure

GAP

WIN

WORLDWIDE INNOVATIVE NETWORKING IN CANCER PERSONALIZED MEDICINE

The WIN organization www.winconsortium.org

Biomarcadores. Diferente implementación

Plataformas en España 2014 • PLATAFORMA 1DENTIFY (>22.000 muestras)

– H Doce de Octubre (Madrid) – H General de Valencia – H Virgen del Rocío (Sevilla) – Complejo Hospital Santiago – Pangaea Biotech (Barcelona) – Clinica Univ Navarra – H Valle de Hebron ( Barcelona) – H Germans i Pujol (Badalona) – H Joan XXIII ( Tarragona)

• PLATAFORMA DETERMINA RAS ( > 24.000) – Hospital del Mar (Barcelona) – Hospital Clínico San Carlos

(Madrid) – Hospital Universitario de Canarias

(Tenerife) – Fundación Jiménez Díaz, (Madrid) – Hospital Valle de Hebron – Hospital General de Valencia – Hospital Carlos Haya (Málaga)

Una red de equipos españoles trabajando coordinadamente en medicina personalizada?

Porque No?

Preguntas • ¿Qué perfiles mutacionales serán los más

adecuados para impulsar la medicina genómica? • ¿Qué arbol de decisiones puede hacer los datos

genómicos accesibles a los oncólogos? • ¿Qué diseños de ECs serán óptimos para analizar

la utilidad de la genómica en tumores? • ¿ Cómo van los oncólogos y los pacientes asumir

las cargas de la genómica a gran escala

Cancer Pulmón

Sexta Pregunta: la estrategia del “ME TOO” en Cancer es razonable?

Genetech Merck Novartis Eli Lilly Boeringher

Farmaceuticas + Academia + Investigadores

Tony Mok, Sidney 2013

Necesitamos un esfuerzo Global para evitar el “Me

Too”

51

Rafael Sirera

Jerónimo Forteza María Campos Segura Rut Lucas

LAB. ONCOLOGIA MOLECULAR Eloisa Jantus Lewintre

Silvia Calabuig Sandra Gallach

Marta Usó E. Sanmartin Eva Escorihuela

INVESTIGACION CLINICA

Belén Vazquez Vicente Castellano

Marta Aguiló

SERVICIO DE ONCOLOGIA Carlos Camps

Alfonso Berrocal Ana Blasco

Ma. José Safont Cristina Caballero Ma. José Godes

Vega Iranzo

SERVICIO DE CIRUGIA TORACICA Ricardo Guijarro Antonio Arnau

Santiago Figueroa Enrique Pastor

UNC F. Innocenti UCSF Trever Bivona

Antonio Pineda Rosa Farràs