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Rilevanza dell’innovazione tecnologica per la ricerca traslazionale e la terapia in oncologiaricerca traslazionale e la terapia in oncologia
Ruggero De Maria
Dipartimento di Ematologia Oncologia e Medicina Molecolare,
Istituto Superiore di Sanità
Translational research: the central role of biotechnologiesthe central role of biotechnologies
Bench scientists Clinical scientistsClinicians Bench scientists Clinical scientistsClinicians
PathophysiologyDiseases
GenomicsProteomics
Clinical trialsDiseasesNew infections Stem cells
Transgenic/knockoutsStructuralStructuralbiology/Imaging
Clinical problem ClinicalClinical applicationapplication
Association of molecular markers with toxicity outcomes in a randomized trial of chemotherapy for advanced colorectal cancer: the FOCUS trialpy
How Could Molecular Markers InfluenceHow Could Molecular Markers Influence Treatment Decisions?
Treatment Clinical Genomic Impact
“Sparing” Yes No ↓ Unnecessary Therapy
“Selection” No Yes ↑ CurabilityAvoid undertreatment
“Direction” Equipoise Yes or no More appropriate treatment choices
“Confirmation” Yes No
YesNo
Confirm clinical decision
Innovative screening tools: BRCA1/2 mutation screening for hereditary Breast and Ovarian Cancer syndromehereditary Breast and Ovarian Cancer syndrome
Lifetime risk estimates of developing breast and ovarian cancer among
h h dwomen with inherited BRCA1 or BRCA2 mutations
Reduction of cancer incidence with surgical and nonsurgical interventions
Roukos DH. Nat Clin Pract Oncol. 2007
Association of molecular markers with toxicity outcomes in a randomized trial of chemotherapy for advanced colorectal cancer: the FOCUS trial
Marker/Function Variant At Risk GT Drug EffectedHypothesized Impact
Activity Toxicity Other
py
ABCB1/cellular efflux 3435 C to T TT Irinotecan ↓ ↑ ↓ clearance
DPYD/detoxification IVS14 + 1G to A (*2A) Variants Fluorouracil ↓ ↑ ↑ active metabolite
ERCC2/DNA repair 35 931 A to C CC Oxaliplatin ↓ ↑ ↓ DNA repairERCC2/DNA repair 35,931 A to C CC Oxaliplatin ↓ ↑ ↓ DNA repair
GSTP1/detoxification 313 A to G AA Oxaliplatin ↓ ↑ ↓ detoxification
MLH1/DNA repair -93 G to A AAFluorouracilIrinotecan Oxaliplatin
↓ ↑ ↓ DNA repairOxaliplatin
MTHFR/folate pool, modifies FU response 667 C to T TT Fluorouracil ↓ ↑ --
TYMS/target for FU metabolite
1494: 6 bp insertion +/+ Fluorouracil -- ↑ ↓ expressionmetabolite ER: VNTR 28 bp 2R/2R Fluorouracil -- ↑ ↓ expression
UGT1A1/detoxification VNTR: 6 or 7 TA repeats (*28) 7/7 Irinotecan ↓ ↑ ↓ detoxification
XRCC1/DNA repair 23 885 G to A AA Irinotecan ↓ ↑ ↓ DNA repairXRCC1/DNA repair 23,885 G to A AA Oxaliplatin ↓ ↑ ↓ DNA repair
Individuals who are homozygous for the UGT1A1*28 allele are at increased risk for neutropenia following initiation of irinotecan treatment
Braun MS, et al. J Clin Oncol. 2009
p g
Molecular profiling for individual risk assessment :MammaPrint® (70 genes involved in cancer biology)( g gy)
Van ‘t Veer et al, Nature2002
MicroRNAs are endogenous non coding single-stranded RNAs of ~ 22nt that play important roles in
animals and plants by targeting 3’UTR of mRNAs for cleavage or translational repression
MiRNAs may thus represent one of the largest class of gene regulators
They are implicated in a variety of processes, such as development, organogenesis,
stemness and differentiation, growth control and programmed cell death
Relationship between the expression levels of 9 MicroRNAs and time from diagnosis to initial therapy in patients with chronic lymphocytic leukemia (CLL)
(P<0.01)
Calin GA et al. N Engl J Med 2005
( )
Present and future of targeted therapy
Siena S et al,JNCI 2009
Biomarkers discovery: predictive value of EGFR‐activating mutations for anti‐EGFR therapy (lung cancer)
EGFRMutation Positive EGFRMutation Negative
HR: 0.48 ty of P
FS
1.0
0.8
0.6 ty of P
FS
1.0
0.8
0.6
EventsGefitinib: 97 (73.5%)Pac/carbo: 111 (86.0%)
EventsGefitinib: 88 (96.7%) Pac/carbo: 70 (82.4%)
(95% CI: 0.36‐0.64; P < .001)
Prob
abilit
GefitinibPaclitaxel/carboplatin
0.4
0.2
0
Prob
abili
Gefitinib
Paclitaxel/carboplatin
0.4
0.2
0
Mos Since Randomization
00 4 8 12 16 20 24
Mos Since Randomization
00 4 8 12 16 20 24
ORR, % Gefitinib Paclitaxel/ P ValueORR, % Gefitinib Paclitaxel/Carboplatin
P Value
Overall population 43.0 32.2 < .001EGFR mutation positive 71 2 47 3 < 001EGFR mutation positive 71.2 47.3 < .001EGFR wild type 1.1 23.5 .001
Mok TS, et al. NEJM 2009
Biomarkers discovery: predictive value ofK‐ras status for anti‐EGFR therapy (CRYSTAL trial)K ras status for anti EGFR therapy (CRYSTAL trial)
Influence of KRAS status on efficacy of cetuximab plus FOLFIRINormanno N et al. Nat. Rev. Clin. Oncol 2009
Translational Potential of Protein Microarraysfor Routine Use in Clinical Research Specimens
Tumor biopsy MicrodissectionTumor biopsy Microdissection
Protein Microarray
Data AnalysisData Analysis
Patient/Tumor‐SpecificSignaling Network Profile
Tailored targeted therapy
Patient A Patient B
Patient A
Patient B
Pathology Report of the Future:
Glioblastoma Mulitforme Patient 1 Glioblastoma Mulitforme Patient 2
Individualized Protein Pathway Activation Maps
Glioblastoma Mulitforme Patient 1 Glioblastoma Mulitforme Patient 2
Symmetricdivision
Asymmetricdivisiondivision division
Non tumorigenicdifferentiated cell
Non tumorigenic transient amplifying progenitors
Tumorigeniccancer stem cells
Non
Old view New view
x Non
New view
xPotentially
Metastatic
xx
Potentially
Metastatic
xx
metastatic
NonMetastatic
xxxxx x
xmetastatic
NonMetastatic
xxxxx xx
xMetastaticx x
xxxx
xxx
Metastaticx xxxxx
xxx xxxx xxxx
Symmetricdivision
Asymmetricdivisiondivision division
Non tumorigenicdifferentiated cell
Non tumorigenic transient amplifying progenitors
Tumorigeniccancer stem cells
Non
Old view New view
x Non
New view
Potentially
Metastatic
xx
Potentially
Metastatic
metastatic
NonMetastatic
xxxxx x
xmetastatic
NonMetastaticxx
xxx x Metastaticx xxxxx
xxx
Metastaticx xxxxx xxxx xxx
Symmetricdivision
Asymmetricdivisiondivision division
Non tumorigenicdifferentiated cell
Non tumorigenic transient amplifying progenitors
Tumorigeniccancer stem cells
Non
Old view New view
x Non
New view
xPotentially
Metastatic
xx
Potentially
Metastatic
xx
metastatic
NonMetastatic
xxxxx x
xmetastatic
NonMetastatic
xxx
xxx x Metastaticx xxxxx
xxx
Metastatic
xxxxx x
xxxx xxxx
xx xxx
Colon cancer spheres are tumorigenic and reproduce the original tumor even
CDX2 beta-catenin CK 20
after long term expansion
patient
50 spheres106 adherent cells
500 spheres
m3 )
2.0
2.5
Volu
me
(cm
0 5
1.0
1.5
mouse
Time (weeks)
V
0
0.5
0 2 4 6 8 10 12 14
patient mouse mouse after ½ year mouse after 1 year
( )
H&E
Ricci-Vitiani et al. Nature 445:111, 2007
Need for more reliable animal models: CSC‐derived vs cell line‐derived xenograftsCSC derived vs cell line derived xenografts
Cancer stem cellsNCI 60 cell lines
RPPM
MRI
ISS has the largest collection of cancer stem cellsMRI
Tumor database
Diagnosis and tissue banking
Tumor dissociation
H&E
Cancer stem cellbanking
dissociationStem cell cultureand expansion
g
Tumor Type Histotype Total availableGlioblastoma ‐ 32
Tumor Type Histotype Total availableColorectal Colon 18 Glioblastoma ‐ 32
Melanoma ‐ 9Ovary ‐ 3Breast Infiltrating ductal 9
Infiltrating lobular 1
Colorectal Colon 18Rectum 8Squamous 7Adenocarcinoma 8
Lung Large Cell 5
ThyroidAnaplastic 4Papillary 8Follicular 6
Small Cell 2Carcinoid 1TBD 3
Translating the CSC concept into clinical studies
Banking and characterization of CSCs
Identification of druggable pathways T t f th t t d i hibitIdentification of druggable pathways through high‐throughput technologies (i.e. RPPM): in vitro drug screening
Test of pathway‐targeted inhibitors on CSC‐derived xenografts
Clinical studies:
R t ti (bi k lid ti )‐Retrospective (biomarkers validation)
‐Prospective (adaptive trials)