Belang van K-RAS/EGFR mutatie analyse bij longtumoren, nieuwe richtlijn 5de bijeenkomst Moleculaire diagnostiek in de pathologie 2010
Patient / Pulmonologist
pathologist - histology
Harry J.M. Groen Universitair Medisch Centrum Groningen
Molecular biology - mutation
TTF-1 TTF-1: 80-85% in adenocarcinoma !!! 20-30% in large cell carcinoma !!! 50% large cell neuro-endocrine carcinoma !!! Metastatic thyroid carcinoma
Histological subtyping
1
Histologische variatie in overleving Tevreden met de uitslag en resultaat
Conclusie:
1. Adenocarcinoom: beter met pemetrexed, EGFR TKIs 2. Plaveiselcelcarcinoom: tendens dat ze beter doen met gemcitabine of IGFR antagonisten
Key mutations in lung cancer
Somatic mutations in adenocarcinoma of the lung
Points of attack. Several mutations found in lung adenocarcinomas, a common type of lung cancer, make them vulnerable to molecularly targeted drugs
Science, October 2009
N=188 tumors
2
Significantly mutated pathways in lung adenocarcinomas
L Ding et al. Nature 455, 1069-1075 (2008) doi:10.1038/nature07423
EGFR mutaties • EGFR mutaties worden gevonden in 4 exonen van het EGFR gen; exon 18 tot 21 Tyrosine Kinase Domein Exon 18-24 EGFR Gen
Exon 18 G719C G719S G719A
5%
Irmer D. et al Oncogene, 2008
Exon 19 Del E746-A750 Del E746_S752>V Del E746_T751>A Del E746_T751 Del L747_A750>P Del L747_E749 Del L747_P753>Q Del L747_P753>S Del L747_S752 Del L747_T751>P Del L747_T751 Del S752_I759 & additional deletions
~45%
Exon 20
Exon 21
T790M D770_N771 (ins NPG) D770_N771 (ins SVQ) D770_N771 (insG) S768I
L858R L861Q
~45%
~5% Lynch et al., 2004 Paez et al., 2004 Sharma et al., 2007 Hirsch and Bunn, 2009
3
EGFR mutations
Presence of T790M Mutations in TumorTumor-Biopsy Specimens and Decreased ProgressionProgression-free Survival
Maheswaran S et al. N Engl J Med 2008;10.1056/NEJMoa0800668
Randomized studies confirming the role of EGFR TKI as first line therapy
Example of the Response to Gefitinib in a Patient with Refractory Non-Small-Cell Lung Cancer
Author
Study
N (EGFR mut +)
RR (TKI vs PFS (HR, 95%CI) Chemo)
Mok et al
IPASS
261
71.2% vs 47.3%
0.48 (0.36, 0.64)
Lee et al
FirstSIGNAL
42
84.6% vs 37.5%
0.61 (0.31, 1.22)
Mitsudomi et WJTOG al 3405
198
62.1% vs 32.2%
0.49 (0.34, 0.71)
Kobayashi et al
NEJGSG00 2
177
74.5% vs 29%
0.36 (0.25, 0.51)
Zhou et al
OPTIMAL
150
NA
NA
Rosell
EURTAC
130
NA
NA
Lynch T et al. N Engl J Med 2004;350:2129-2139
Mok et al NEJM 2009, Lee et al WCLC 2009, Mitsudomi et al ESMO 2009, Kobayahsi et al ASCO 2009
4
Randomized studies confirming the role
PFS by EGFR mutation status IPASS study
of EGFR TKI as first line therapy Author
Study
N (EGFR mut +)
RR (TKI vs PFS (HR, 95%CI) Chemo)
Mok et al
IPASS
261
71.2% vs 47.3%
0.48 (0.36, 0.64)
Lee et al
FirstSIGNAL
42
84.6% vs 37.5%
0.61 (0.31, 1.22)
Mitsudomi et WJTOG al 3405
198
62.1% vs 32.2%
0.49 (0.34, 0.71)
Kobayashi et al
NEJGSG00 2
177
74.5% vs 29%
0.36 (0.25, 0.51)
Zhou et al
OPTIMAL
150
NA
NA
Rosell
EURTAC
130
NA
NA Mok T et al, NEJM 2009
Mok et al NEJM 2009, Lee et al WCLC 2009, Mitsudomi et al ESMO 2009, Kobayahsi et al ASCO 2009
Zelfde overleving met erlotinib in eerste als in tweede lijnsbehandeling
First Line- Median 14 (9.7-18.3) p= 0.62 Second Line- Median 13 (9.7-16.3)
Effecten van EGFR mutatie of FISH op overleving
EGFR mutation
First Line- Median 28 (22.7-33.3) p= 0.67 Second Line- Median 27 (19.9-34.1)
EGFR FISH
Mutant (n=25):MST 24.9m Wild (n=47):MST 8.5m
1.0
1.0
P=0.0031
0.6
Rosell et al NEJM 361:958, 2009
0.6
0.4
0.4
0.2
0.2
0
Spanish Lung Cancer Study Group 217 EGFR mutation positive patient receiving erlotinib as first- or second line therapy
FISH+ (n=29):MST 9.8 m FISH– (n=43):MST 12.4 m
0.8
OS
OS
0.8
P=0.82
0 0
1
2
3
year after gefitinib treatment
0
1
2
3
year after gefitinib treatment
Toyooka et al., Okayama University, Japan
5
Individualizing anti-EGFR treatment
EGFR biomarkers voor NSCLC in de Westerse population (ISEL) Fig 1. Overlap in biomarker status: epidermal growth factor receptor (EGFR) gene copy number, protein expression, and mutation
Hirsch, F. R. et al. J Clin Oncol; 24:5034-5042 2006
Copyright © American Society of Clinical Oncology
EGFR biomarkers voor NSCLC in de Aziatische population (IPASS)
Prognostische en predictieve biomarkers in NSCLC
25 51
High EGFR gene copy number
13
n = 198 28
EGFR mutationpositive n = 209
Positive for all three biomarkers N = 132
34 15
N = 329 with known biomarker status for all three biomarkers
EGFR expressionpositive n = 242
Negative for all three biomarkers N = 31
Fukuoka M, et al. J Clin Oncol 2009;27(Suppl 15):Abstract 8006
Coate L.E. et al. Lancet Oncology, 2009
6
Moleculaire biomarker analyses van gerandomiseerde studies
Coate L.E. et al. Lancet Oncology, 2009
DualDual-target EGFR drugs in the pipeline • Agent
Target
Sponsor
Status
•
Lapatinib
EFGR,HER2
GlaxoSmithKline
Phase III breast, kidney cancer
•
ZD6474
EGFR, HER2, VEGFR
AstraZeneca
Phase III, NSCLC; phase II, medullary thyroid carcinoma
•
HKI-272
EGFR, HER2
Wyeth
Phase II, breast, NSCLC
•
BIBW-2992
EGFR, HER2
Boehringer-Ingelheim Planning for phase II in breast, prostate, and ovarian cancer
• • • •
AEE788 BMS-599626 CI-1033 XL-647
EGFR, HER2, VEGFR Novartis Phase I solid tumor EGFR, HER2 Bristol-Myers Squibb Phase I for solid tumors EGFR, HER2, HER4 Pfizer Phase II breast, NSCLC EGFR, HER2, VEGFR2, EphB4 Exelixis Phase I completed; phase II planned fo rNSCLC
EGFR biomarker analyses van gerandomiseerde studies
Coate L.E. et al. Lancet Oncology, 2009
Richtlijn diagnostiek en behandeling niet-kleincellig longcarcinoom • Bij alle adenocarcinomen en misschien wel bij alle longcarcinomen KRAS en EGFR mutatie verrichten • Omdat goed te kunnen doen hebben we voldoende tumorweefsel nodig dus biopten en liefst geen cytologie • NVALT-14 studie om aard en frequentie van mutaties in Nederland te onderzoeken
7
EGFR mutaties • EGFR mutaties worden gevonden in 4 exonen van het EGFR gen; exon 18 tot 21 Tyrosine Kinase Domein Exon 18-24
Tumor tissue:
EGFR Gen
Enough amount Enough %, >50% Exon 18 G719C G719S G719A
5%
Exon 19 Del E746-A750 Del E746_S752>V Del E746_T751>A Del E746_T751 Del L747_A750>P Del L747_E749 Del L747_P753>Q Del L747_P753>S Del L747_S752 Del L747_T751>P Del L747_T751 Del S752_I759 & additional deletions
~45%
Exon 20
Exon 21
T790M D770_N771 (ins NPG) D770_N771 (ins SVQ) D770_N771 (insG) S768I
L858R L861Q
Histology/ paraffin embedded Diagnostic tumor tissue **
~45%
~5%
Circulating tumor cells ??
** Primary lung carcinoma versus
Lynch et al., 2004 Paez et al., 2004 Sharma et al., 2007 Hirsch and Bunn, 2009
Metastatic tumor tissue
De activatie in tumorcellen
De activatie in normale cellen
1. Verhoogde expressie van groeifactor
2. Verhoogde expressie van EGFR PTEN
PTEN
door DNA amplificatie
3. Mutaties in EGFR 4. Mutaties in KRAS
8
Detectie van EGFR amplificatie/polysomie Amplificatie van het EGFR-gen
Patiënten met deze tumoren hebben
Mutaties in het EGFR-gen
voordeel van EGFR-targeted therapie
mbv fluorescente-in-situ-hybridizatie
Geen amplificatie Mutaties in KRAS-gen
DNA amplificatie
Patiënten met deze tumoren hebben GEEN voordeel van EGFR-targeted therapie Interfase kern Interfase kernen metafase
Rosell NEJM 2009, Mok NEJM 2009, Capuzzo JNCI 2005
= EGFR gen (1 kopie)
Detectie van EGFR amplificatie/polysomie mbv fluorescente-in-situ-hybridizatie
= cen 7 controle (1 kopie)
= cen 7 controle (1 kopie) metafase
= EGFR gen (1 kopie)
Detectie van EGFR amplificatie/polysomie mbv fluorescente-in-situ-hybridizatie
Geen amplificatie Geen amplificatie
FISH
Polysomie
Interfase kern Interfase kern
Interfase kern
metafase
metafase = cen 7 controle (1 kopie)
metafase = cen 7 controle (1 kopie) = EGFR gen (1 kopie)
= EGFR gen (1 kopie) = cen 7 controle (1 kopie)
cen7 Normaal EGFR
= EGFR gen (1 kopie)
9
Colorado criteria: 1. Normaal
FISH-negatief
2. Lage polysomie
FISH-negatief
3. Hoge polysomie
FISH-positief
4. Amplificatie
FISH-positief
DNA amplificatie
Disomy: ≤2 kopieën in >90% van de cellen
FISH
Laag polysomie: ≥4 kopieën in 10%-40% van de cellen
FISH EGFR Amplificatie
Interfase kernen
Amplificatie EGFR
Hoog polysomie: ≥4 kopieën in ≥40% van de cellen
cen7
= cen 7 controle (1 kopie) = EGFR gen (1 kopie)
metafase
Laag trisomy: ≤2 kopieën in ≥40% van de cellen 3 kopieën in 10%–40% van de cellen >4 kopieën in <10% van de cellen Hoog trisomy: ≤2 kopieën in ≥40% van de cellen 3 kopieën in ≥40% van de cellen ≥4 kopieën in <10% van de cellen)
Detectie van mutaties in EGFR Detectie van mutaties in EGFR
Waar zitten de mutaties ?
Hoe detecteren we mutaties ? hotspots Golden standard: directe (bidirectionele) sequentie analyse (op paraffinemateriaal) 18
P- loop
Extracellular
EGFR Exon 21
domain 19
EGFR Exon 19 Wild type
Deletions 45-50%
αC- helix Transmembrane region ATP binding
N-lobe
del746-750
Duplications/
20
Insertions (9%)
TK
cleft C-lobe
domain
Regulatory
Y845
A- loop
21
domain EGFR-EIWIT-MOLECULE
Deletie van 5 amimozuren
L858R 35-45% Substitution T>G Leucine to Arginine
Sequist JCO 2007, 25; 587
EGFR-GEN en EXONEN
10
Amplification of EGFR detected by fluorescence in-situ hybridisation
EGFR mutaties • EGFR mutaties worden gevonden in 4 exonen van het EGFR gen; exon 18 tot 21 Tyrosine Kinase Domein Exon 18-24 EGFR Gen
Exon 18 G719C G719S G719A
5%
Exon 19 Del E746-A750 Del E746_S752>V Del E746_T751>A Del E746_T751 Del L747_A750>P Del L747_E749 Del L747_P753>Q Del L747_P753>S Del L747_S752 Del L747_T751>P Del L747_T751 Del S752_I759 & additional deletions
Exon 20
Exon 21
T790M D770_N771 (ins NPG) D770_N771 (ins SVQ) D770_N771 (insG) S768I
L858R L861Q
~45%
~5% Lynch et al., 2004 Paez et al., 2004 Sharma et al., 2007 Hirsch and Bunn, 2009
~45%
Samenvatting biomarkers
Pooled analysis (any line of therapy) Pooled median PFS (95% accuracy interval)
• TS • ERCC1 – Platinum resistentie
• RRM1 – Gemcitabine resistentie
• EGFR – EGFR TKI gevoeligheid
• Genomische strategie? – Voorspelt recidief en potentieel voordeel van adjuvante chemotherapie
Pooled studies
– Fluoropyrimidine/antifolate resistentie ERLOTINIB n = 365
13.2 (12.0–14.7)
GEFITINIB n = 1071
9.8 (9.3–10.4)
CHEMOTHERAPY n = 375
5.9 (5.3–6.5)
0
6
12 PFS (months)
18
24
Permutation test for estimated pooled median PFS (1,000 iterations) EGFR TKI vs. chemotherapy p=0.000 (two-sided) Mok T, et al. J Thoracic Oncol 2009;4(9;Suppl 1):Abstract B9.7
11
Mechanisms of Action of Anti-EGFR Drugs in Cancer Cells
BIBW 2992 (Tovok™)*: A novel, potent and irreversible dual inhibitor of EGFR and HER2*
*
Ciardiello F and Tortora G. N Engl J Med 2008;358:1160-1174
Clustering of Mutations in the EGFR Gene at Critical Sites within the ATP-Binding Pocket Mechanisms of Action of Anti-EGFR Monoclonal Antibodies in Cancer Cells
Ciardiello F and Tortora G. N Engl J Med 2008;358:1160-1174 Lynch T et al. N Engl J Med 2004;350:2129-2139
12
Introducing BIBW 2992
Dual targeting of EGFR and HER2 broadens the reach of erbB kinase receptor family inhibition
• BIBW 2992: – a novel representative of the new-generation tyrosine kinase inhibitors – a potent, irreversible dual inhibitor of EGFR and HER21–3 – one of the most advanced inhibitors of this type in development – active in NSCLC cells harbouring EGFR activating and/or resistance mutations3
1. Eskens FALM et al. Br J Cancer 2008; 98:80–85. 2. Solca F et al. AACR-NCI-EORTC Proceedings, AACR-NCIEORTC International Conference on Molecular Targets and Cancer Therapeutics. 2005;118 (Abstract A244). 3. Solca F et al. AACR-NCI-EORTC Proceedings, AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics. 2005;118 (Abstract A242)
BIBW 2992 blocks all cancer-relevant EGFR and HER2 dimers
Dual targeting of EGFR and HER2 broadens the reach of erbB kinase receptor family inhibition
13
BIBW 2992 blocks all cancer-relevant EGFR and HER2 dimers
BIBW 2992 is an irreversible dual EGFR/HER2 inhibitor • Dual EGFR and HER2 inhibitory activity is expected to1– 3: – Maximize inhibition of signaling by erbB receptors – Result in improved efficacy across more cancer types • Irreversible binding1–3: – Provides a sustained blockade of receptors and may improve inhibition of tumour cell proliferation – Provides activity against receptors that are resistant to first-generation inhibitors (e.g. EGFRL858R/T790M mutants) 1. Eskens FALM et al. Br J Cancer 2008; 98:80–85. 2. Solca F et al. AACR-NCI-EORTC Proceedings, AACR-NCIEORTC International Conference on Molecular Targets and Cancer Therapeutics. 2005;118 (Abstract A244). 3. Solca F et al. AACR-NCI-EORTC Proceedings, AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics. 2005;118 (Abstract A242)
BIBW 2992 has a good safety profile • Tolerability: – BIBW 2992 was well tolerated and comparable with other agents in this class in terms of dose-limiting toxicities such as rash and diarrhoea1,2 – No non-mechanism-related toxicities are evident to date1–8
BIBW 2992 has been designed to irreversibly inhibit the EGFR and HER2 kinases Structural model of BIBW 2992 in the EGFR kinase domain: BIBW 2992 F
BIBW 2992 was designed to covalently bind to EGFR and the related HER2 receptor
N
Cl
N
N N
N O
O
O
S N F
O
Cl
N N
N N
O
N O
S N
O
1. Eskens FALM et al. Br J Cancer 2008; 98:80–85. 2. Plummer R et al. Eur J Cancer Suppl 2006;4(12):173–174. 3. Agus DB et al. J Clin Oncol 2006:24(18S);2074. 4. Mom CH et al. J Clin Oncol 2006;24(18S):3025. 5. Shaw H et al. J Clin Oncol 2006;24(18S): 3027. 6. Eskens FA et al. Proceedings, AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics. November 2005. 116 (Abstract A235). 7. Plummer R et al. Proceedings, AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics. November 2005. 81–82 (Abstract A105). 8. Marshall JL et al. Proceedings, AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics. November 2005. 168 (Abstract B161)
O
Solca F et al. Presented at AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics, Philadelphia, 14–18 Nov 2005
14
EGFR mutations in NSCLC •
EGFR mutations are over-represented in responders to EGFR inhibitors These mutations include: – exon 19 small in-frame deletions – exon 21 point mutations e.g. EGFR L858R Mutations known to cause resistance to first-generation EGFR include: – exon 20 in-frame insertions – exon 20 point mutations (e.g. T790M)
•
•
Extracellular ligand-binding domain
Deletions (vIII) ~ 1%
TM
Dual-target EGFR drugs in the pipeline • Agent
Target
Sponsor
Status
•
Lapatinib
EFGR,HER2
GlaxoSmithKline
Phase III breast, kidney cancer
•
ZD6474
EGFR, HER2, VEGFR
AstraZeneca
Phase III, NSCLC; phase II, medullary thyroid carcinoma
•
HKI-272
EGFR, HER2
Wyeth
Phase II, breast, NSCLC
•
BIBW-2992
EGFR, HER2
Boehringer-Ingelheim Planning for phase II in
Exon 18
breast, prostate, and ovarian cancer
19 20 21
Tyrosine kinase domain
• • • •
AEE788 BMS-599626 CI-1033 XL-647
EGFR, HER2, VEGFR Novartis Phase I solid tumor EGFR, HER2 Bristol-Myers Squibb Phase I for solid tumors EGFR, HER2, HER4 Pfizer Phase II breast, NSCLC EGFR, HER2, VEGFR2, EphB4 Exelixis Phase I completed; phase II
22
planned fo rNSCLC
23 24
Sharma et al. Nature Rev Cancer 2007;7;169 Ji et al. Proc Natl Acad Sci USA 2006;103;7817 Stephens et al. Nature 2004;431:525
•
Phase II Single Arm BIBW 2992 in NSCLC With EGFR Activating Mutations The primary objective of this open-label, single arm Phase II trial is to explore the efficacy of BIBW 2992 defined by the objective response rate (CR, PR) as determined by RECIST (R010754) in patients with advanced NSCLC Stage IIIB or IV whose tumors harbor activating mutations within exon 18 to exon 21 of EGFR and who have progressed or relapsed after one prior cytotoxic chemotherapy regimen. www.clinicaltrials.gov
Pharmacokinetics • At BIBW 2992 70 mg/day: – Exposure: AUC0- and AUC ,ss 82–2080 ng·h/mL – Peak plasma concentrations: Cmax and Cmax,ss range 7–150 ng/mL. – Volume of distribution; Vz/F 800–2900 L. – Median tmax values 1–4 h. – terminal t1/2 13–32 h. – Accumulation ratio based on AUC: 2–2.9 • Mom C.H. et al. JCO, 2006
15
Efficacy of Erlotinib in Chemotherapy-Refractory Non-Small-Cell Lung Cancer
Beeldvormend onderzoek juni 2006
Ciardiello F and Tortora G. N Engl J Med 2008;358:1160-1174
Activerende mutaties - Deletie in exon 19 - L858R in exon 21
16
