Tumörmarkörer och klinisk relevans

Transkript

1 SLMF:s Vårmöte Linköping april 2010 Tumörmarkörer och klinisk relevans Leif Johansson VO Klinisk Patologi Universitetssjukhuset Lund Labmedicin Skåne

2 Prognostiska faktorer vid NSCLC studerade i metaanalyser! SÄMRE PROGNOS TTF1 Cox2 EGFR Ras Ki67 HER2 VEGF Microvascular density P53 Aneuploidy Survivin BÄTTRE PROGNOS Bcl-2 De flesta av dessa markörer kan enkelt bestämmas med immunohistokem

3 Nya behandlingsmodaliteter och överlevnad vid NSCLC Morgensztern (#8078) ASCO 2009 Tittade på förändring i överlevnad över tid i en databas med 127,816 patienter Signifikant förbättrad OS för stadie IV NSCLC patienter de sista 8 åren Förändringen berodde huvudsakligen på förbättrad överlevnad för patienter med adenocarcinom medan effekten var liten för patienter med skivepitelcancer Man tillskrev detta fr a nya terapier såsom erlotinib och gefitinib som huvudsakligen anses vara effektiva mot adenocarcinom Kanske ännu ett skäl, förutom pemetrexed och bevacizumab, att skilja skivepitelcencer från NSCLC-icke skivepitel!?

4 JMDB, CP=cis/pemetrexed, CG= cis/gemcitabin

5 Pemetrexed vs Docetaxel Results: OS 100 PaIents Randomized to Pemetrexed 100 PaIents Randomized to Docetaxel Non squamous: Median = 9.2 Non squamous: Median = 8.2 Percent Surviving 50 Squamous: Median = 6.2 HR=0.48 P=0.001 Percent Surviving 50 Squamous: Median = 7.4 NS 0 0 Overall Survival (months) Overall Survival (months) WCLC 2007 Peterson P et al., Abstract # P2 328

6 Chemotherapy and NSCLC Chemotherapy Pemetrexed (Alimta ) Type of Chemotherapy NSCLC, non squamous NSCLC, Squamous cell carcinoma AnUfolate agent Yes No (Docetaxel) Bevacizumab (AvasUn ) Angiogenesis inhibitor Yes ContraindicaUon

7 Immunohistochemistry of lung cancer Johansson L. Histopathological classification of lung cancer: relevance of cytokeratin and TTF-1 immunophenotyping. Ann Diagn Pathol 2004;8: Histological n CK5 CK7 CK20 CAM5.2 TTF-1 Type SCLC SQCC AC LCC Total SCLC = small cell lung carcinoma, SQCC = squamous cell carcinoma, AC = adenocarcinoma, LCC = large cell carcinoma, CK5 = cytokeraun 5, CK7 = cytokeraun 7, CK20 = cytokeraun 20, CAM5.2 = CK8 (CK7), TTF 1 = Thyroid TranscripUon Factor 1

8 Downey P et al. If it's not CK5/6 posiive, TTF 1 negaive it's not a squamous cell carcinoma of lung. APMIS Jun;116(6): Novel targeted treatment of NSCLC requires accurate classificauon of NSCLC as SCC and AC This study details the CK5/6 and TTF 1 immunoprofile of surgical resecuons of 45 NSCLCs (24 ACs and 21 SCCs) in Ussue microarrays All SCC were CK5/6 posiuve, TTF 1 negauve 20 of 24 adenocarcinomas had the reverse pacern In conclusion, all SCCs in this study were CK5/6 posiuve and TTF 1 negauve, and therefore tumours that do not display this phenotype are unlikely to be SCCs CK5/6 and TTF 1 is therefore a pracucal panel for the disuncuon between pulmonary SCC from AC in rouune histopathology pracuce

9 Squamous cell carcinoma CK5+ CK7-

10 ADENOCARCINOMA CK7+ CK5

11 Kamal, N. S., J. C. Soria, et al. (2010). "MutS homologue 2 and the long term benefit of adjuvant chemotherapy in lung cancer." Clin Cancer Res 16(4): RESULTS: MSH2 levels were low in 257 (38%) and high in 416 (62%) tumors There was a trend for chemotherapy to prolong overall survival when MSH2 was low but not when MSH2 was high When combining MSH2 with ERCC1 and P27 the benefit of chemotherapy decreased with the number of markers expressed at high levels (p = 0.01, p=0.01) Chemotherapy prolonged overall survival in the MSH2-/ERCC1- subgroup (P = 0.01) and in the MSH2-/P27- subgroup (P = 0.01) CONCLUSIONS: MSH2 expression is a borderline significant predictor of a long-term benefit from adjuvant cisplatin-based chemotherapy in patients with completely resected lung cancer. MSH2 combined with ERCC1 or P27 may identify patients most likely to benefit durably from chemotherapy

12 Epidermal growth factor receptor (EGFR) First idenufied as a candidate for cancer therapy more than two decades ago Expressed in most NSCLC; has a role in Cellular proliferauon InhibiUon of apoptosis Angiogenesis MetastaUc potenual Chemoresistance

13 PredicIve EGFR Test Methods, Immunohistochemistry (IHC) IHC has been used for many years, but for most of the markers, no objective standardized assessment methods have been established This might contribute to the fact that the methodology has not been given much credit for predictive performance Platforms have been developed for objective, automated staining and interpretation Studies are undergoing for validation of EGFR expression and other proteins related to targeted therapies in lung cancer

14 EGFR IHC 3+

15 PredicIve EGFR Test Methods, Gene copy number Based on experience with HER2 in breast cancer, the FISH technology has been the most prevalent method New technologies have emerged, such as the nonfluorescence Silver in situ HybridizaUon (SISH) technique assessable in bright light microscopy with preservauon of the cell morphology. Thus, the specimens are stable and can be revisited for years The technology has been introduced for HER2 determinauon in breast cancer, but clinical validauon for other markers (i.e IGF 1R) in lung cancer has just been iniuated (Wynes et al. 2009)

16 EGFR FISH amplifiering, cytologi

17 EGFR amplifiering, dual color SISH

18 PredicIve EGFR Test Methods, MutaIon analyses Tissue-based DNA sequencing remains the most commonly used technique More sensitive PCR-based methodologies have emerged (i.e. high resolution melt curve analysis; Scorpion-ARMS using the DXS system) Multigene high- throughput approaches such as the Sequenom technique Large scale sequencing as done in the Tumor Sequencing Project (TSP) for lung adenocarcinomas by integrating different methods Mutation-specific antibodies for immunohistochemistry have recently been developed (i.e. EGFR antibodies) with very encouraging results* * Yu, J., S. Kane, et al. (2009). "Mutation-specific antibodies for the detection of EGFR mutations in non-small-cell lung cancer." Clin Cancer Res 15(9):

19 Yu, J., S. Kane, et al. (2009). "MutaUon specific anubodies for the detecuon of EGFR mutauons in non small cell lung cancer." Clin Cancer Res 15(9): Immunohistochemical staining of xenograds. Control EGFR anibody stains all six cell lines (top). L858R specific anibody stains only the cancer cells with the L858R point mutaion (H1975 and H3255; middle). degfr specific anibody stains only the cancer cells with the exon 19 deleion (H1650 and HCC827; bogom).

20 Vilka evidens finns för ac testen fungerar? Gupta, R., et al., The predictive value of epidermal growth factor receptor tests in patients with pulmonary adenocarcinoma: review of current "best evidence" with meta-analysis. Hum Pathol, (3): p

21 Ohe, Y., Y. Ichinose, et al. (2009). "Phase III, randomized, open label, first line study of gefiunib (G) versus carboplaun/paclitaxel (C/P) in selected pauents (pts) with advanced non small cell lung cancer (NSCLC) (IPASS): EvaluaUon of recruits in Japan.." J Clin Oncol 27((suppl; abstr 8044^) ): 15s. Background: IPASS demonstrated superiority of gefitinib vs C/P in 1,217 clinically selected chemonaïve pts in Asia with advanced NSCLC Chemonaïve, never/light ex-smokers with stage IIIB/IV NSCLC and adenocarcinoma histology were randomized to gefitinib or C/P Primary objective was PFS, Secondary endpoints were overall survival (OS) Results: gefitinib demonstrated superior PFS compared with C/P (HR 0.69; 95% CI ; p=0.0191) Preliminary OS (25% maturity; follow-up ongoing) was similar for gefitinib and C/P (HR 0.89; 95% CI ) There were no deaths due to ILD-type events (frequency 1.8% [gefitinib] vs 0% [C/P]) Conclusions: gefitinib demonstrated improved PFS but similar OS

22 "GefiUnib or carboplaun paclitaxel in pulmonary adenocarcinoma." Mok, T. S., Y. L. Wu, et al. (2009). N Engl J Med 361(10): Phase III study, chemonaive patients (asians, adenocarcinoma, nonsmokers, former light smokers) Gefitinib (609 patients) or carboplatin/paclitaxel (608 patients) PFS gefitinib 24.9%, carboplatin-paclitaxel 6.7%, (HR 0.74; P<0.001) 261 mut+ patients; PFS gefitinib versus carboplatin-paclitaxel (HR 0.48; P<0.001) 176 mut- patients; PFS gefitinib versus carboplatin-paclitaxel (HR 2.85; P<0.001) CONCLUSIONS: Gefitinib is superior to carboplatin-paclitaxel for adenocarcinoma among nonsmokers or former light smokers Mut+ is a strong predictor of a better outcome with gefitinib

23 Slutliga biomarkördata från BR.21, (Zhu, da Cunha Santos et al. 2008) Behandlingssvar på erlotinib för mut- var 7% och för mut + 27% (p=.03) Behandlingssvar för FISH- var 5% och för FISH+ 21% (p=.02) Skillnaden i total överlevnad för mut+ var inte signifikant medan FISH+ hade signifikant överlevnadsvinst (HR=0.43, p=.004) Vid multivariat analys var endast FISH+ signifikant (p=. 005) Detta talar starkt för en behandlingsvinst för FISH+ patienter, åtminstone i andra linjen

24 ASCO 2009, erlounib Cappuzzo (#8001) och Brugger (#8020) rapporterade kliniska data och biomarkördata från SATURN; PaUenter som ej progredierat eser fyra cykler KT randomiserades Ull erlounib eller placebo Totalt 1,949 pauenter i KT fasen, 889 randomiserades Ull erlounib (n=438) eller placebo (n=451) Ökad PFS oberoende av EGFR FISH, IHK, mut eller KRAS mut status (OS?) Biomarkördata är de mest omfacande som rapporterats i en randomiserad studie IHK+ 84% (n=742), FISH+ 48% (n=488), mut+ 11% (n=377), KRAS+ 18% (n=494)

25 ASCO 2009, erlounib Spanska lungcancergruppen, Massuti (#8023); starkt signikant fördel för EGFR mut+ patienter behandlade med erlotinib Hirsch (#8026); EGFR mut+ korrelerade med ökad 6 mån PFS i 1 st line terapi med erlotinib. EGFR FISH+ och KRAS visade trend En stor fransk kohort, Cadranel (#8079), konfirmerade det oberoende värdet av flera prognostiska faktorer vid behandling med erlotinib vid avancerad NSCLC; EGFR IHK, FISH och mut samt KRAS mut Jackman (#8065); kliniska parametrar kan användas för att selektera till behandling med erlotinib om EGFR genotyp inte är känd Yoshioka (#8067); prospektiv biomarkörstudie som visade att erlotinib till tidigare behandlade EGFR mut- patienter är lika effektiv och säker som standard docetaxel [Shepherd JCO 2000].

26 "Screening for Epidermal Growth Factor Receptor MutaUons in Lung Cancer." Rosell, R., T. Moran, et al. (2009). N Engl J Med. Epub 2009/08/2 Methods Lung cancers from 2105 patients in Spain were screened for EGFR mutations Patients with tumors carrying EGFR mutations were eligible for erlotinib treatment. Results EGFR mutations were found in 350 of 2105 patients (16.6%); women (69.7%), never smoked (66.6%), adenocarcinomas (80.9%) (P<0.001 for all comparisons) The mutations were deletions in exon 19 (62.2%) and L858R (37.8%) Median PFS and OS for 217 patients who received erlotinib, in first or second line, were 14 months and 27 months, respectively Conclusions Large-scale screening of patients with lung cancer for EGFR mutations is feasible and can have a role in decisions about treatment The results were similar in first and second line treatment

27 "First or second line therapy with gefiunib produces equal survival in nonsmall cell lung cancer." Wu, J. Y., C. J. Yu, et al. (2008). Am J Respir Crit Care Med 178(8): patients (Taipei, Taiwan); stage IIIb or IV NSCLC, were sequenced for EGFR mutations (192 mut+) 152 exon 19 deletions or L858R were receiving gefitinib Classified as chemonaive (91) or chemotherapy-treated (61). Neither OS after the start of therapy nor PFS after gefitinib therapy was significantly different between these two groups (P = and 0.804, respectively) OS; clinical response to gefitinib (P = 0.001) CONCLUSIONS: This study suggests that gefitinib is effective in patients with EGFR mutations. The gefitinib response rate in chemonaive patients is higher than in chemotherapy-treated patients; however, there is no difference in OS

28 ASCO 2009, cetuximab O'Byrne (#8007); KRAS mut predikterar inte för effekt med cetuximab i kombinauon med first line KT vid avancerad NSCLC, medan rash av varje grad är associerat med bäcre effekt Khambata Ford (#8021); ingen korrelauon mellan behandlingssvar på cetuximab och KRAS mut, EGFR mut, EGFR IHC eller EGFR FISH Mack (#8022); KRAS ingen predikuv roll SLUTSATS: EGFR relaterade biomarkörer faller inte ut vid behandling med cetuximab vid lungcancer Deca i motsats Ull colorektal cancer där KRAS mut+ anses utesluta de som ej skall ha behandling

29 RIKTLINJER FÖR BIOMARKÖRANALYSER INFÖR BEHANDLING MED TYROSINKINASHÄMMARE (TKI) VID AVANCERAD ICKE SMÅCELLIG LUNGCANCER (NSCLC) SVENSKA LUNGCANCER STUDIEGRUPPEN (SLUSG) Leif Johansson Simon Ekman Mikael Johansson Karl Köhlbäck

30 Första linjens behandling EGFR mutationsanalys rekommenderas i första hand 1. icke-rökare 2. adenocarcinom 3. alla patienter med NSCLC för att vinna erfarenhet och kunskap Vävnad för EGFR mutationsanalys Formalinfixerat paraffin inbäddat material 1. bronkbiopsi, mellannål, VATS biopsi, operationsmaterial 2. cellblock preparerat från pleuravätska 3. cellblock preparerat från bronkborstar, nålbiopsier m.m. avsköljt i cytolyt

31 Bakgrund och slutsats första linjens behandling EGFR mut+ pauenter har bäcre behandlingssvar och ökad PFS (Mok, Wu et al. 2009) (Ohe, Ichinose et al. 2009) (Mitsudomi, Morita et al. In Press, Corrected Proof.). Data angående OS är foryarande ofullständiga men ec par studier tyder på bäcre OS för mut+ pauenter med såväl erlounib (Rosell, Moran et al. 2009) som gefinib (Wu, Yu et al. 2008). I båda dessa studier var OS samma i first och second line. Mot bakgrund av deca rekommenderas i första hand EGFR mutauonsanalys inför första linjens behandling om EGFR TKI är ec alternauv för behandling.

32 Andra linjens behandling Om EGFR mutauonsanalys ej är uyörd inför första linjens behandling 1. EGFR mutationsanalys och/eller EGFR FISH 2. EGFR immunohistokemi betraktas tills vidare som rådgivande inför behandling tillsammans med 3. kliniska markörer (kvinna, icke-rökare, adenocarcinom, asiatiskt ursprung) Vävnad för EGFR analys inför andra linjens behandling Formalinfixerat paraffin inbäddat material 1. bronkbiopsi, mellannål, VATS biopsi, operationsmaterial 2. cellblock från pleuravätska 3. cellblock preparerat från bronkborstar, nålbiopsier m.m. avsköljt i cytolyt För FISH även lufttorkat cytologiskt material (+/- tidigare Giemsa färgning) 1. pleuravätska 2. bronkborstar 3. nålbiopsier m.m.

33 Bakgrund och slutsats andra linjens behandling En meta analys (Gupta, Dastane et al. 2009) talar för ac immunohistokemi +, FISH+, och mut+ predikterar behandlingssvar på gefiunib för pauenter med adenocarcinom. Biomarkördata från BR.21 (Zhu, da Cunha Santos et al. 2008) talar starkt för en behandlingsvinst av erlounib för FISH+ pauenter i andra linjen. SATURN studien visar signifikant ökad PFS för erlounib, fr.a. för EGFR mut+ pauenter, men även för FISH+ och immunohistokemi+ pauenter (Cappuzzo, Ciuleanu et al. 2009). Slutligen, mut+ pauenter behandlade med erlounib visade en OS på 27 mån, vilket är mycket bäcre än historiska kontroller (Rosell, Moran et al. 2009). Inför andra linjens behandling, om EGFR mutauonsanalys ej är uyörd Udigare, rekommenderas EGFR mutauonsanalys och/eller EGFR FISH. EGFR IHK och kliniska markörer rekommenderas i andra och tredje hand.

34 EGFR FISH, Polysomy

35 EGFR FISH, Amplified

36 EGFR MUTATIONS IN LUNG CANCER

37 Tack för er uppmärksamhet!