TARGET THERAPY IN NON GLIOMA BRAIN TUMORS.

Transcription

1 TARGET THERAPY IN NON GLIOMA BRAIN TUMORS. Meduloblastoma and Sonic Hedgehog inhibitor Jordi Rodon Ana Garrido

2 TARGET THERAPY IN NON GLIOMA BRAIN TUMORS. Meduloblastoma and Sonic Hedgehog inhibitor

3 Medulloblastoma Most common malignant brain tumor in children (15 to 30 % of tumors in the CNS). In adults is quite rare, with important histologic and phenotypic differences. It has a 5-year survival of around 70% Histological subtypes (WHO2007): classic type, desmoplastic/nodular type, medulloblastoma with extensive nodularity, anaplastic medulloblastoma, large-cell medulloblastoma. Therapy: Maximal safe surgical resection Postoperative radiotherapy (entire craniospinal axis -3640Gy-, and a posterior fossa boost -to Gy) In adults, the role of chemotherapy is less clear but recommended. No strong evidence to support a specific chemotherapy regimen in adults

4 Chang Staging System Average-risk disease: T1, T2, T3a and M0 disease who undergo a total or neartotal resection (< 1.5 cm2) High-risk disease: T3b or T4 plus M1 to M3 disease plus postoperative residual tumours or unfavorable histology (large cell/anaplastic)

5 Hereditary syndromes

6 Genetic profiling of medulloblastoma Northcott P A et al. JCO 2011;29:

7 Children: 10% Adults: 15% Children: 30 % Adults: 60 % Children: 25 % Adults: 0-5 % Children: 35 % Adults: 25 %

8 EGL, external germinal layer VZ, subventricular zone CGNPs, cerebellar granule neuron precursors

9 Children: 10% Adults: 15% Anti WNT (LGK974, PRI-724, OMP-54F28) Children: 30 % Adults: 60 % Anti SMO (vismodegib, Sonidegib, LEQ506) Children: 25 % Adults: 0-5 % HDAC inhibitors Children: 35 % Adults: 25 %

10 Molecular subtypes and treatment

11 The Hedgehog (Hh) Pathway Hh signaling pathway now known to be essential in mammalian embryonic development and adult tissue homeostasis 1 Mechanism2,3 Target Genes PTCH inhibits SMO Binding of Hh ligand to PTCH relieves inhibition of SMO SMO signaling, via SUFU, activates Gli transcription factors Constitutive activation of the Hh pathway can result from mutations (PTCH, SMO or SUFU) or overexpression of the ligands 4 8 Hypermethylation of PTCH and the negative regulator HIP1 can also lead to pathway activation9,10 COS, conserved ortholog set; PTCH, patched; SMO, smoothened; SUFU, suppressor of fused 1. Jiang J, Hui C. Dev Cell 2008; 15: ; 2. Epstein EH. Nat Rev Cancer 2008; 8: ; 3. Xie J. Acta Biochim Biophys Sin (Shanghai) 2008; 40: ; 4. Slade I, et al. Fam Cancer 2011; 10(2):337-42; 5. Lee Y, et al. Cancer Res 2003; 63 (17): ; 6. Scott DK, et al. Cell Cycle 2006; 5(20):2381-9; 7. Zurawel RH, et al. Genes Chromosomes Cancer 2000;27:44-51; 8. Thompson MC, et al. JCO 2006;24 (12): ; 9. Shahi MH, et al. BMC Cancer 2010;10:614-34; 10. Shahi MH, et al. J Neurooncol 2011;103(2):

12 SHH-medulloblastoma Curious bimodal age distribution, accounting for the majority of both infant and adult medulloblastomas but for only a minority of childhood cases Desmoplastic (or nodular) histology is almost exclusively restricted to SHH medulloblastomas, whereas classic and large-cell or anaplastic (LCA) cases also occur, but they are not confined to this subgroup. Intermediate prognosis subgroup, OS~60-80% The SHH medulloblastoma genome contains substantially more regions of chromosomal gain and loss than WNT medulloblastoma Antagonists of SHH signalling, primarily those inhibiting the pathway at the level Somatic of PTCH1, occasionally components industry of the SHH of SMO, mutations are currently an areaand of active interestadditional in the pharmaceutical and pathway, as well as somatic copy number aberrations (SCNAs) affecting the SHH are in clinical trials for medulloblastoma. target genes MYCN and GLI family zinc finger 2 (GLI2), are typical of this subgroup.

13 SHH-medulloblastoma Curious bimodal age distribution, accounting for the majority of both infant and adult medulloblastomas but for only a minority of childhood cases Desmoplastic (or nodular) histology is almost exclusively restricted to SHH medulloblastomas, whereas classic and large-cell or anaplastic (LCA) cases also occur, but they are not confined to this subgroup. Intermediate prognosis subgroup, OS~60-80% The SHH medulloblastoma genome contains substantially more regions of chromosomal gain and loss than WNT medulloblastoma Antagonists of SHH signalling, primarily those inhibiting the pathway at the level Somatic of PTCH1, occasionally components industry of the SHH of SMO, mutations are currently an areaand of active interestadditional in the pharmaceutical and pathway, as well as somatic copy number aberrations (SCNAs) affecting the SHH are in clinical trials for medulloblastoma. target genes MYCN and GLI family zinc finger 2 (GLI2), are typical of this subgroup.

14 SHH-medulloblastoma Curious bimodal age distribution, accounting for the majority of both infant and adult medulloblastomas but for only a minority of childhood cases Desmoplastic (or nodular) histology is almost exclusively restricted to SHH medulloblastomas, whereas classic and large-cell or anaplastic (LCA) cases also occur, but they are not confined to this subgroup. Intermediate prognosis subgroup, OS~60-80% The SHH medulloblastoma genome contains substantially more regions of chromosomal gain and loss than WNT medulloblastoma Antagonists of SHH signalling, primarily those inhibiting the pathway at the level Somatic of PTCH1, occasionally components industry of the SHH of SMO, mutations are currently an areaand of active interestadditional in the pharmaceutical and pathway, as well as somatic copy number aberrations (SCNAs) affecting the SHH are in clinical trials for medulloblastoma. target genes MYCN and GLI family zinc finger 2 (GLI2), are typical of this subgroup.

15 ONE CASE MADE A DIFFERENCE

16 (SMO inhibitor) PTCH1 mutation (position 2720, resulting in a G C change) Skin Tumo r SMO mutation (position 473, resulting in a G C change) Robert L. Yauch, et al. Science 326, 572 (2009)

17 Phase I/Proof of mechanism (GDC-0449) Advanced Solid Tumors Adults Phase I NCT (GDC-0449) Recurrent Medulloblastoma Children Phase I NCT Sonidegib (LDE225) Sonidegib Advanced Solid Tumors Adults Phase I NCT Sonidegib (LDE225) Sonidegib Medulloblastoma, RB, NB, HB, HGGlioma Children Phase I/II NCT Sonidegib (LDE225) Sonidegib Advanced Solid Tumors (Asian) Adults Phase I NCT LEQ506 LEQ506 Advanced Solid Tumors Adults Phase I NCT Proof of concept (GDC-0449) V + TMZ vs TMZ Recurrent Medulloblastoma Adults Phase I/II IHC + NCT (GDC-0449) Recurrent Medulloblastoma Adults II IHC + (STRATIF) NCT (GDC-0449) Recurrent Medulloblastoma Children Phase II IHC + (STRATIF) NCT Adults Phase II/III 5-gene Hh signature assay NCT Phase III/ Proof of efficacy Sonidegib (LDE225) S vs TMZ Recurrent Medulloblastoma

18 (GDC-0449) Recurrent Medulloblastoma Adults II IHC + (STRATIF) NCT Stratum A (non-shh group); Stratum B (SHH tumors) and Stratum C (indeterminate). 32 patients [Stratum A (n = 8); Stratum B (n = 20); Stratum C (n = 4) No responses were observed in Strata A or C and the median duration of treatment was 1.5 months (range ). Three of 20 patients enrolled on Stratum B had sustained responses. The median duration of therapy for Stratum B patients was 2.76 months (range ). Six patients were on treatment for 6.44 months (GDC-0449) Recurrent Medulloblastoma Children Phase II IHC + (STRATIF) NCT Of the 7 patients with SHH medulloblastoma, 3 had evaluable disease: One patient had a complete response, which was not sustained for 8 weeks; the other 2 experienced no response.

19 Phase I/Proof of mechanism (GDC-0449) Advanced Solid Tumors Adults Phase I NCT (GDC-0449) Recurrent Medulloblastoma Children Phase I NCT Sonidegib (LDE225) Sonidegib Advanced Solid Tumors Adults Phase I NCT Sonidegib (LDE225) Sonidegib Medulloblastoma, RB, NB, HB, HGGlioma Children Phase I/II NCT Sonidegib (LDE225) Sonidegib Advanced Solid Tumors (Asian) Adults Phase I NCT LEQ506 LEQ506 Advanced Solid Tumors Adults Phase I NCT Proof of concept (GDC-0449) V + TMZ vs TMZ Recurrent Medulloblastoma Adults Phase I/II IHC + NCT (GDC-0449) Recurrent Medulloblastoma Adults II IHC + (STRATIF) NCT (GDC-0449) Recurrent Medulloblastoma Children Phase II IHC + (STRATIF) NCT Adults Phase II/III 5-gene Hh signature assay NCT Phase III/ Proof of efficacy Sonidegib (LDE225) S vs TMZ Recurrent Medulloblastoma

20 LDE225: Preclinical Summary Ptch +/-, p53 -/- MB model Tumor volume (mm3) mean ± SEM LDE225 Gli-1 mrna (human) Luciferase (mouse) Gli-1 promoter Assay Cell Line IC50 (nm) Shh-induced Gli-1 mrna Human HEPM 13 Shh-induced Gli-1 Luciferase Mouse TM Vehicl e 5mg/kg 10 mg/kg 20 mg/kg Days 2 post-implantation LDE225 is a novel oral inhibitor of Smo that potently inhibits Smo-dependent proliferation in vivo in preclinical studies Gli, glioma-associated oncogene homolog zinc finger protein; MB, Medulloblastoma; Shh, Sonic Hedgehog Dorsch, M et al. AACR Abstract #1976.

21 Sonidegib (LDE225), a Smoothened (Smo) antagonist: Phase I safety and pharmacologic results in patients with advanced solid tumors O CF 3 H N O N N O Maximum tolerated dose for oral LDE225 was 800 mg QD LDE225 was generally well tolerated at doses of mg daily The most frequent toxicities were gastrointestinal (nausea/vomiting, disgeusia) and muscular (muscle cramps), but mild (grade 1 and 2). High systemic drug exposure was associated with increased risk of CK elevation Rodon et al. CCR 2014

22 Sonidegib (LDE225), a Smoothened (Smo) antagonist: Phase I safety and pharmacologic results in patients with advanced solid tumors O CF 3 H N O N N O Maximum tolerated dose for oral LDE225 was 800 mg QD LDE225 was generally well tolerated at doses of mg daily LDE225 exhibits exposure-dependent target The mosttreatment frequent toxicities were gastrointestinal (nausea/vomiting, disgeusia) and (muscle cramps), butexpression mild (grade 1in and 2). inhibition as muscular measured by Gli-1 mrna biopsies of High systemic drug exposure was associated with increased risk of CK normal skin elevation Rodon et al. CCR 2014

23 Sonidegib (LDE225), a Smoothened (Smo) antagonist: Phase I safety and pharmacologic results in patients with advanced solid tumors O CF 3 H N O N N O Tumor responses in MB and BCC patients were observed with well tolerated doses/exposures of LDE225 Maximum tolerated dose for oral LDE225 was 800 mg QD LDE225 was generally well tolerated at doses of mg daily LDE225 exhibits exposure-dependent target The mosttreatment frequent toxicities were gastrointestinal (nausea/vomiting, disgeusia) and (muscle cramps), butexpression mild (grade 1in and 2). inhibition as muscular measured by Gli-1 mrna biopsies of High systemic drug exposure was associated with increased risk of CK normal skin elevation Rodon et al. CCR 2014

24 Sonidegib (LDE225), a Smoothened (Smo) antagonist: Phase I safety and pharmacologic results in patients with advanced solid tumors O CF 3 H N O N N O Tumor responses in MB and BCC patients were observed with well tolerated doses/exposures of LDE225 Maximum tolerated dose for oral LDE225 was 800 mg QD LDE225 was generally well tolerated at doses of mg daily LDE225 exhibits exposure-dependent target The mosttreatment frequent toxicities were gastrointestinal (nausea/vomiting, disgeusia) and (muscle cramps), butexpression mild (grade 1in and 2). inhibition as muscular measured by Gli-1 mrna biopsies of High systemic drug exposure was associated with increased risk of CK normal skin elevation Rodon et al. CCR 2014

25 Sonic Hedgehog inhibitor LDE225 and meduloblastoma DEVELOPMENT OF A SELECTION BIOMARKER

26 Development of a selection biomarker Platform selection: Sensitivity Scope Robustness Cost Sample: tumor content Sample: best source Sample: archival material

27 Medulloblastoma Most common malignant brain tumor in children. Long-term survival in high-risk disease ~ 65% Gene expression profiling reveals 4-7 molecular subtypes of MB> Up to 30% of MBs are Hh-pathway activated but application of gene expression analysis as a pre-selection tool faces challenges: For Affymetrix platform, fresh frozen specimens Up to 25% of all medulloblastomas have mutations in PTCH (~15%), SMO (~2%) and SUFU (~8%) Screening for mutations (via direct sequencing) is a challenge: Large genes (35 exons to screen) No clear correlation between SHH-gene expression signature and mutations in PTCH1, SMO and SUFU (~8%) Thompson MC, JCO 2006, Cho JCO 2011, Northcott JCO 2011, Robinson Nature 2012

28 Medulloblastoma Most common malignant brain tumor in children. Long-term survival in high-risk disease ~ 65% Gene expression profiling reveals 4-7 molecular subtypes of MB> Up to 30% of MBs are Hh-pathway activated but application of gene expression analysis as a pre-selection tool faces challenges: For Affymetrix platform, fresh frozen specimens Up to 25% of all medulloblastomas have mutations in PTCH (~15%), SMO (~2%) and SUFU (~8%) Screening for mutations (via direct sequencing) is a challenge: Large genes (35 exons to screen) No clear correlation between SHH-gene expression signature and mutations in PTCH1, SMO and SUFU (~8%) Thompson MC, JCO 2006, Cho JCO 2011, Northcott JCO 2011, Robinson Nature 2012

29 Development of an assay No clear correlation between SHH-gene expression signature and mutations in PTCH1, SMO, and SUFU Gen expression assays capture SHHdependent tumors Set up a gene signature test predictive of Hh activation, applicable to FFPE and measurable by routine RT-PCR Run clinical trial testing the test/drug in patients with SHH+ MB

30 Development of the 5-gene Hh Signature Candidate gene selection (combined analysis of 3 datasets) Assay Optimization (Selection of differentially expressed target genes in RTPCR assays, optimized for FFPE samples) Model Building (Predictive multi-gene model building using the elastic net method using 40 MB FFPE tumor samples and a 5-fold cross-validation) Independent Validation of the 5-gene Hh Signature Agreement between Hh status determined by gene expression profiling and the 5-gene Hh signature (in paired samples fresh/ffpe) Clinical validation of the 5-gene Hh Signature Clinical data and tumor biopsies from patients with recurrent MB from 3 phase I trials (X2101 Adults with advanced solid tumors; X1101 Asian adults with advanced solid tumors; X2104 Children with advanced solid tumors Shou et al.ccr 2014 (in press)

31 Development of the 5-gene Hh Signature Candidate gene selection (combined analysis of 3 datasets) Assay Optimization (Selection of differentially expressed target genes in RTPCR assays, optimized for FFPE samples) Model Building (Predictive multi-gene model building using the elastic net method using 40 MB FFPE tumor samples and a 5-fold cross-validation) Independent Validation of the 5-gene Hh Signature Agreement between Hh status determined by gene expression profiling and the 5-gene Hh signature (in paired samples fresh/ffpe) Clinical validation of the 5-gene Hh Signature Clinical data and tumor biopsies from patients with recurrent MB from 3 phase I trials (X2101 Adults with advanced solid tumors; X1101 Asian adults with advanced solid tumors; X2104 Children with advanced solid tumors Shou et al.ccr 2014 (in press)

32 Development of an assay No clear correlation between SHH-gene expression signature and mutations in PTCH1, SMO, and SUFU Gen expression assays capture SHHdependent tumors Set up a gene signature test predictive of Hh activation, applicable to FFPE and measurable by routine RT-PCR NCT A Phase II Study of Oral LDE225 in Patients With Hedge-Hog (Hh)-Pathway Activated Relapsed MB

33 Technological evolution MiSeq (Illumina) NGS platforms capable of sequencing No clear correlation between SHH-gene genes in FFPE samples expression signature and mutations in PTCH1, SMO, and SUFU ncounter (Nanostring) Gen Nanostring expression ncounter assays capture capableshhof characterizing dependent gene expression tumors profiles in FFPE tissue Set up a gene signature test predictive of Hh activation, applicable to FFPE and measurable by routine RT-PCR NCT A Phase II Study of Oral LDE225 in Patients With Hedge-Hog (Hh)-Pathway Activated Relapsed MB

34 Genome Sequencing of SHH Medulloblastoma Predicts Genotype-Related Response to Smoothened Inhibition Cancer Cell 25, , March 17, 2014

35 Thanks!