Clara MontagutServicio de Oncología Médica & Programa de Investigación en Cáncer

Hospital del Mar, Barcelona

Valor clínico de la biopsia líquida en cáncer de colon

Hospital del Mar, Barcelona

SEAP-IAP / SEOM, 27 Mayo 2016

Aplicaciones Clínicas de los Test de ADN tumoral

circulante (Cáncer Colorrectal)

Aplicaciones Clínicas de la biopsia líquidaen cáncer colorrectal

1. Determinación de RAS al diagnóstico

2. Monitorizar respuesta / resistencia al tratamiento antiEGFR

3. Monitorizar “tumor load”

Aplicaciones Clínicas de los Test de ADN tumoral

circulante (Cáncer Colorrectal)

Aplicaciones Clínicas de la biopsia líquidaen cáncer colorrectal

1. Determinación de RAS al diagnóstico

2. Monitorizar respuesta / resistencia al tratamiento antiEGFR

3. Monitorizar “tumor load”

Greater patient selection with RAS testing increases the survival benefit with cetuximab + FOLFIRI

HR 0.69 (0.54–0.88)p=0.0024

∆ = 8.2 months

HR=0.796 (0.67–0.95)p=0.0093

HR=0.878 (0.77–1.00)p=0.0419

∆ = 3.5 months∆ = 1.3 months

1.01.01.0

RAS wtKRAS exon 2 wtUnselected

Cetuximab + FOLFIRI (n=178)

FOLFIRI (n=189)

0.0

0.2

0.4

0.6

0.8

Months5442 48186 12 24 30 36

28.4

20.2

0Time (months)

5442 48

23.520.0

0.0

0.2

0.4

0.6

0.8

180 6 12 24 30 36Months

5442 480.0

0.2

0.4

0.6

0.8

180 6 12 24 30 36

OS

est

imat

e

19.9

18.6

Cetuximab + FOLFIRI (n=599)

FOLFIRI (n=599)

Cetuximab + FOLFIRI (n=316)

FOLFIRI (n=350)

Tissue RAS Result

Plasma Ras

Result

Positive Negative Total

Positive 25* 2 27

Negative 1 22 23

Total 26 24 50

Plasma/Tissue Correlation - H. del Mar Experience

Total 26 24 50

* 1 positive in tissue and plasma but in different codon

Positive Agreement: 25/26: 96.15%

Negative Agreement: 22/24: 91.66%

Overall Agreement: 47/50: 94%

Aplicaciones Clínicas de los Test de ADN tumoral

circulante (Cáncer Colorrectal)

Aplicaciones Clínicas de la biopsia líquidaen cáncer colorrectal

1. Determinación de RAS al diagnóstico

2. Monitorizar respuesta / resistencia al tratamiento antiEGFR

3. Monitorizar “tumor load”

Emergence of mutations of resistance

KRASKRAS

wtKRAS wt

Clonal dynamics during antiEGFR treatment in mCRC

wt

Response to anti-EGFR treatment

Progression to anti-EGFRtreatment

Basal tumor

wtKRAS wt

EGFR

Anti-EGFR treatment

KRAS

LIGANDS overexpressionAREG, HRG, TGFα

Cell membrane

EGFR HER2 ampl MET ampl

NRAS

1. Mutations in extracellulardomain of EGFR

Resistencia adquirida a tratamiento anti-EGFR

KRAS

BRAF

MEK-1

ERK

PI3-K

AKT

NRAS

2. Downstream mutationsor activation of alternativereceptors that converge in MEK activation

Montagut, Nat Med 2012; Misale, Nature 2012; Diaz, Nature 2012; Bardelli, Cancer Discov 2013; Troiani, CCR 2013; Misale, STM 2014; Hobor, CCR 2014; Arena, CCR 2015; Siravegna, Nat Med 2015; Russo, Cancer Discov 2016

Monitoring mutations of resistance in the blood of patients

Misale, Nature 2012; Diaz, Nature 2012; Bettegowda, STM 2014 ; Morelli, Ann Oncol 2015

Biopsia líquida recoge la heterogeneidad de todas las clonas de resistencia

Aim: To assess the clinical relevance of monitoring mutations in serial plasma samples from RAS wt mCRC patients treated with cetuximab-based therapy in 1st line

Diagnosis During treatm ent Progression Post -progression

Cetuximab-based treatment in 1st line

Diagnosis During treatm ent Progression Post -progression

Plasma

sample

Tumor sample

MonthlyBaseline +3 / +6 monthsEndof treatment

Biopsia liquida para guiar decisión terapéutica después de cetuximab/panitumumab

• rechallenge• segunda generación antiEGFR

Mutations in KRAS emerge during anti-EGFR treatmentand decline when treatment is suspendend

KRASKRAS

wt wtKRAS wt

EGFR

Response to treatment Progression to treatmentBasal tumor

Off treatment

EGFR

Liquid biopsy for longitudinal monitoring of RAS mutations in blood of patientsRechallenge with cetuximab

Siravegna et al. Nat Med 2015

Rechallenge with anti-EGFR therapy

Cetuximab + FOLFIRI

R

FIRE-4 (Phase III, n=550)

Bevacizumab + FOLFOX/XELOX

Cetuximab + irinotecan/FOLFIRI

RegorafenibCetuximab + FOLFIRI

R

1st line 2nd line 3rd line

RAS wt

mCRCBevacizumab + FP maintenanceFOLFIRI

Liquid biopsy to track/identify resistance

• Primary endpoint: OS after randomization 2• Results expected: January 2022

FP maintenance

New generation anti-EGFR moAb

0.25

0.50

0.75

1.00

1.25CetuximabPanitumumabSym004

Det

ecte

d st

aine

d ce

lls(N

orm

aliz

ed to

EG

FR

WT

)

Sym004 is effective in colorectal cancer harbouring EGFR ECD mutations

Receptor binding

Sánchez-Martín et al. CCR 2016

0.00Empty EGFR WT S492R R451C K467T G465R

0

200

400

600

800

1000

1200

1400

1600

4 7

10

12

14

17

20

24

27

31

39

48

56

62

69

76

83

89

97

10

9

12

4

13

9

Tu

mo

r v

olu

me

(m

m3

)

Days

Control

Cetuximab

Sym004

S492R EGFR ECD mut

Liquid biopsyEGFR ECDRAS/RAF

mCRC patients withacquired resistance to

cetuximab/ panitumumab

Sym004EGFR ECD mut

MM-151 overcomes acquired resistance to cetuximab and panitumumab in CRC harbouring EGFR ECD mutations

Arena et al, STM 2015

Aplicaciones Clínicas de los Test de ADN tumoral circulante (Cáncer Colorrectal)

Aplicaciones Clínicas de la biopsia líquidaen cáncer colorrectal

1. Determinación de RAS al diagnóstico

2. Monitorizar respuesta / resistencia al tratamiento antiEGFRtratamiento antiEGFR

3. Rechallenge

4. Monitorizar “tumor load”

El ADN tumoral circulante predice la respuesta al tratamiento antes que las pruebas de

imagen

Evaluación precoz de respuesta a tratamiento con quimioterapia

8 semanas después

Tie et al. Ann Oncol 2015

1%

2%

3%

4%

5%

6%

7%

8%

Patient 1: NRAS 61

Patient 2: NRAS 61

Patient 3: KRAS 146

mut

ant

ctD

NA

frac

tion

Evaluación de respuesta a tratamiento con antiangiogénico

0%

Baseline CT scan: SD CT Scan: PDRA

S m

utan

t

BASELINE Stable Disease

Patient 1

Take-home message

• La detección de RAS en biopsia líquida ha demostrado altacorrelación con la determinación en tejido en pacientes con cáncer colorrectal metastásico

• La determinación de RAS en biopsias líquidas seriadas permitemonitorizar la dinámica clonal de los tumores, detectarprecozmente la aparición de resistencias y seleccionar el tratamiento adecuado en cada momento

• Ensayos clínicos con toma de decisiones basadas en biopsialíquida están en marcha

Graciascmontagut@hospitaldelmar.cat

5

10

50

100

150

tumor load (%)

Tu

mo

r lo

ad

(%

of

ba

seli

ne

)

NRAS p.Q61L

% m

uta

nt

all

ele

s

Detección de adquisición de mutaciones de RAS en sangre periféricamediante BEAMing en paciente tratado con anti-EGFR

0 0

Tu

mo

r lo

ad

(%

of

%

Baseline 1st CT scan PD

27-FEB-2012 01-MAY-2012

Last administration of anti-EGFR

CT scan: PR

*

22-DEC-201401-AGO-2013

FOLFOX+CETUX

*

FOLFIRI+Aflibercept

***

tumor load (%)

Tu

mo

r lo

ad

(%

of

ba

seli

ne

)

EGFR p.S492R

KRAS p.Q61H

% m

uta

nt

all

ele

s

Clonal dynamics in a CRC patient treated with anti-EGFR therapy

Baseline 1st CT scan1st line

1st line PD 2nd line PD1st CT scan2nd line

PANIT

25-JUN-2009 21-AGO-2009 17-MAY-2010

Last administration of anti-EGFR(1st line)

CT scan: PR

Last administration of anti-EGFR(2nd line)

CT scan: PR

9-DEC-2010 13-APR-20111-NOV-2010

First administration ofanti-EGFR (2nd line)

FOLFOX+CETUX

Joana Vidal.Unpublished data

Global implementation of RAS liquid biopsy* testing: Goals for 2016

*Launch of a CE-marked in vitro diagnostic for RAS, using liquid biopsies, by Sysmex Inostics, in collaboration with Merck is expected in 2016 (a ‘research use only’ kit is already available). Launch of a CE-marked in vitro diagnostic for RAS, using liquid biopsies, by Biocartis, in collaboration with Merck is expected in 2017.

Tratamiento Anti-EGFR

TejidoWT

cáncer colorrectal metastásico

Estado de la mutación RAS

Anti-EGFR

Quimioterapia,antiangiogenico

MUT

Pre-Treatm

entP

ost-Treatment

Patient #

KRAS exon 2

KRAS exon 3

KRAS exon 4

NRAS exon 2

NRAS exon 3

NRAS exon 4

BRAF exon 15

PIK3CA exon 9

PIK3CA exon 20

EGFR exon 12

KRAS exon 2

KRAS exon 3

KRAS exon 4

NRAS exon 2

NRAS exon 3

NRAS exon 4

BRAF exon 15

PIK3CA exon 9

PIK3CA exon 20

EG

FR

exo

n1

2

R451C

S464L

G465R

K467T

I491M

S492R

45811

13

15

16

Em

ergence of mutations of resistance

during cetuximab

treatment in colorectal cancer

16

17

18

20

21

23

26

27

31

33

34

35

36

37

Montagut et al. N

atMed

2012A

rena&B

ellosilloet al. C

linC

ancerR

es 2015

Sym004Phase I clinical trial in patients progressing to cetuximab

EGFR G465R mutation EGFR S492R mutation

Dientsmann. Cancer Discov 2015 Sánchez-Martín et al. CCR 2016

Monitorización de recaída tras cirguía

Diehl et al. Nat Med 2008

Before surgery(mutant DNA 13%)

d+3 after surgery(mutant DNA 0.01%)

d+48 after surgery(mutant DNA 0.1%)

d+244 after surgery(mutant DNA 0.66%)

Monitorización de recaída tras cirugía

Diehl et al. Nat Med 2008

Coexistance of mutations of resistance

Patient TreatmentKRAS

mutationNRAS

mutationEGFR

mutationRespon

sePFS (w)

2 FOLFIRI cetuximab G465R SD 63

4 FOLFIRI cetuximab Q61H; V114I S464L; I491M SD 39

8 IRINO cetuximab G12S PR 55

9 FOLFIRI cetuximab G12V PR 41

10 IRINO cetuximab G60R SD 24

12 IRINO cetuximab G12V CR 48

13 IRINO cetuximab Q61H SD 20

16 FOLFOX cetuximab G12S SD 24

18 IRINO cetuximab G12A Q61H PR 25

19 FOLFIRI cetuximab G12V SD 23

20 IRINO cetuximab A146T SD 51

21 FOLFOX cetuximab S492R PR 42

Supplementary Table 1

22 FOLFOX cetuximab Q61L S492R PR 60

24 FOLFIRI cetuximab Q61L SD 26

25 FOLFOX cetuximab S492R PR 44

29 IRINO cetuximab K467T PR 52

32 IRINO cetuximab V114I Q61K SD 21

33 IRINO cetuximab G12D; G60D R451C SD 22

39 IRINO cetuximabG12C; G12D; G12A; G12V

S464L; G465E; G465R

PR 61

42 IRINO cetuximab G465R PR 45

43 IRINO cetuximab S464L PR 69

44 panitumumab G465R; G465E PR 39

45 IRINO panitumumab Q61H Q61H G465R; S464L SD 32

46 panitumumab Q61H SD 26

47 FOLFIRI cetuximab G12D G465R; S464L PR 17

53 FOLFIRI cetuxi Q61H S464L PR 67

59 panitumumab Q61H PR 37

EGFR ECD mut Clinical work Frequency % median

G465R / G465E Arena. STM 2016 3/11 3%

4%

Bertotti. Nature 2015 2/22 1%

Sanchez. CCR 2016 1/13 8%

Non-published data 3/20 3%

S464L Arena. STM 2016 1/11 9%5%

Non-published data 3/20 2%

EGFR ECD mutations. Prevalence in patients

Mutations of resistance. Clinical implications 1

Non-published data 3/20 2%

K467T Arena. CCR 2015 1/37 3% 3%

I491M Non-published data 1/20 <1% 1%

R451C Arena. CCR 2015 1/37 3%3%

Heracles study 1/?

S492R Montagut. Nat Med 2012 2/10 20%

11%

Morelli. Ann Oncol 2015 5/62 8%

Dienstmann. Can Discov 2015 1/26 1%

Newhall, WCGIC 2014 46/258 16%

27%Total frequency (median)