Biomarker for Response and Resistance in Ovarian Cancer

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1 2016 대한부인종양학회제 31 차춘계학술대회 New Trends in Translational Research Biomarker for Response and Resistance in Ovarian Cancer Shin-Wha Lee, M.D., Ph.D. Department of Obstetrics and Gynecology ASAN Medical Center

2 CONTENTS Response and Recurrence in Ovarian Cancer Proposed Biomarker: Predictive and Prognostic Molecular Profile: Predictive and Prognostic Biomarker of Precision Medicine

3 Ovarian Carcinoma: Clinical Course No Prognostic Biomarkers Progression Diagnosis Interval Cytoreduction Second-Look Progression Secondary Surgeries Secondary Cytoreduction Death Consolidation/ Maintenance Symptoms Chemo #1 Chemo #2 Chemo #3+ Platinum + Taxol Staging Primary cytoreduction Cure Patients living with disease Supportive Care Current Surveillance Strategy: CA-125, CT / PET, Clinical Exam

4 When Does Ovarian Cancer Recur? Population Study Treatment PFS Optimal St III GOG 114 IV Carb & Pac, IP Cis 28 mos GOG 172 IV Pac, IP Cis & Pac 24 mos GOG 158 IV Pac & Carb 21 mos GOG 114 IV Pac & Cis 22 mos GOG 158 IV Pac & Cis 19 mos GOG 172 IV Pac & Cis 18 mos Suboptimal III & IV GOG 111 IV Pac & Cis 18 mos GOG 162 IV Pac Cis 12 mos GOG 152 IV Pac Cis 11 mos Stage IC-IV SCOTROC Doc Carbo 15 mos Stage IC-IV SCOTROC Pac Carbo 15 mos All Stage III & IV GOG 182 IV Pac/Carbo x 8 16 mos Carb = carboplatin; Cis = cisplatin; Doc = docetaxel; pac = paclitaxel; GOG = Gynecologic Oncology Group; IP = intraperitoneal; Pac = paclitaxel

5 Platinum Sensitivity in HGSOC SCOTROC1 data from Jim Paul Stage III/IV HGSOC (n=258) CCNE1, URI, MYC, RAS, other? BRCA1/2 HRD?

6 Pénzváltó et al. Current Cancer Drug Targets, 2014

7 Investigating Chemo-Response/Resistance Assays Scientifıc weak points of chemoresponse testing Changes in tissue that must be expanded in culture for testing The use of surrogate tissues such as blood Intratumoral heterogeneity Elise C. Kohn, asco.org/edbook

8 Proposed Biomarkers of Resistance Against Platinum and Taxanes Reduction of intracellular drug concentration Changes in the target molecules Alterations in cellular response Pénzváltó et al. Current Cancer Drug Targets, 2014

9 Molecular Subsets of HGSOC C3 C2 C1 C4 C3 C2 C1 C4 C1 Differentiated C2 Immune C3 Mesenchymal C4 Proliferative Tothill et al, Clin Can Res 2008 TCGA, Nature 2011 Verhaak et al, J Clin Invest. 2013

10 Altered Pathways in HGSOC TCGA, Nature 2011

11 Molecular Descriptions of Ovarian Cancer Types and Potential Therapeutic Leads Pénzváltó et al. Current Cancer Drug Targets, 2014

12 Homologous Recombination Deficiency as a Clinically and Molecularly Relevant Subclassification of HGSC Homologous Recombination Pathway wild type Other 33% BRCA1 germline 9% Homologous Recombination Pathway mutation BRCA2 germline 6% BRCA1 somatic 4% BRCA1 methylation 10% BRCA2 somatic 3% CCNE1 amplification 18% Other HR pathway 11% PTEN loss 6% Platinum/PARPi resistant Platinum/PARPi responsive

13 What Constitutes HR Pathway Inactivation? Other 33% BRCA1 germline 9% BRCA2 germline 6% BRCA1 somatic 4% BRCA2 somatic 3% BRCA1 methylation 10% Functional Assay for HR Status CCNE1 amplification 18% Other HR pathway 11% PTEN loss 6% CHEK2 mutation BRIP1 mutation RAD51 mutation RAD51C methylation PALB2 mutation FANC mutation EMSY amplification? Asima Mukhopadhyay et al. Clin Can Res 2010

14 HRD score, as a Predictor of Response to PARPi

15 PRECISION MEDICINE in CANCER TREATMENT Unique Therapies that treat an Individual s Cancer based on the Specific Genetic Abnormalities of Person s Tumor Combination of target drugs and immunotherapeutic drugs are important in future precision medicine

16 HETEROGENEITY of CANCER Inter-patient: population subtypes Intra-patient: spatial, temporal Intra-tumor: tissue Intra-tumor: genetic Universal biomarker for response and resistance Specific, Personalized Biomarker Molecular profile from 1 time or 1 site Serial sample, Multiple biopsy Well-known, small number of molecular profile Diverse molecular target, Ultra-sensitive technology

17 What are the Clinical Implications? Second-Look Progression Secondary Cytoreduction Consolidation/ Maintenance Symptoms Drug #1 Drug #2 Drug #3 Drug #4 Drug #5+ Staging Primary cytoreduction Cure Personalized Biomarker: Individual, Tumor-specific biomarkers 1. Liquid Biopsy Biopsy: Figure out invasiveness & heterogeneity 2. Biomarker-driven Clinical Trial

18 1. Liquid Biopsy 2. Biomarker-driven Clinical Trial Initial surgery and chemotherapy ctdna, CTC, Exosome TUMOR Tumor-specific DNA mutation De novo DNA mutation RELAPSE Tumor burden Needs for assessment of resistance in real time and relapse

19 Clinical Uses of ctdna 1. Detection of minimal residual disease 2. Disease monitoring 3. Detection of new mutations Aparicio S, N Engl J Med 2013

20 Obvious Application in HGSOC Estimated levels of cell-free circulating DNA fragments/ml Estimated half-life 114 min Circulating tumor cells are infrequent in HGSOC TP53 mutations are ubiquitous Cancer Diagnosis Treatment Relapse Earlier diagnosis? Personalized patient monitoring Detection of minimal residual disease Mechanisms of resistance Detection of revertant mutation: BRCA1/2 How important is genetic heterogeneity? Swisher et al, Am J Obstet Gynecol 2005; Ahmed et al, J Path 2010

21 Personalized circulating tumor DNA biomarkers dyna mically predict treatment response and survival in gynecologic cancers. JOHN A. MARTIGNETTI, MD, PhD ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI DEPARTMENTS OF GENETICS AND GENOMIC SCIENCES, OBSTETRICS/GYNECOLOGY & REPRODUCTIVE SCIENCES, PEDIATRICS AND ONCOLOGICAL SCIENCES

22 ctdna analysis pipeline: digital PCR Extreme sensitivity 6 logs dynamic range: 3 1x10 6 copies Highly reproducible Identify tumor-specific mutations and translate into t umor-specific probes for detecting ctdna. 5 picoliter partitions ctdna Oil/surfactant Fluorescent detection Wild type ctdna Background ddpcr Sensitivity 0.01% or lower Create 10M dro plets per sampl e (30 min) PCR (2 hr) Read 10M dropl ets per sample ( 4 hr) RainDance Technologies Analyze result s

23 On average, ctdna had a predictive lead time of 7 months over CT imaging

24 ctdna levels at completion of primary therapy are associated with survival Sensitivity of each assay 0.01% or lower. Each assay could detect < 3 copies of ctdna / ml of blood.

25 ctdna Platform using TP53 Mutation To investigate TP53 mutation in primary tumor tissue and ctdna in patients with high grade serous carcinoma of ovary (HGS-OC) To assess the clinical efficacy of ctdna monitoring in the management of ovarian cancer Patient Enrollment (from July 2013) Identification of TP53 mut in Cancer Tissue Isolation and Purification of ctdna Analyzing ctdna Detection and Quantification Sanger Sequencing QIAmp Circulating Nucleic Acid Kit Digital PCR: droplet digital PCR (QX200) Average conc ± 0.59 ng/ml Monitoring ctdna (compared with CA-125 and imaging)

26 TP53 mut : 80.9 % in HGSOC Tumor Tissue 83 women with ovarian tumor SURGERY Tumor tissue collected Serial blood samples collected Exclusion Criteria Identification of somatic genomic mutations : Direct sequencing of TP53 mutations in 59 women 43 had mutations (72.8 %) 38 of 47 HGS-OC had TP53 mutations (80.9 %) 26 patients being monitored TP53 mut ctdna

27 1. Liquid Biopsy 2. Biomarker-driven Clinical Trial Randomize-all-design Interaction (biomarker-stratified) Randomized design

28 Towards a Multimarker Clinical Trial in HGSOC Biomarker driven clinical trial Molecular Evaluation of Primary Tumor BRCA or CCNE1 WT BRCA1/2 mutation Cyclin E1 amplification Biopsy 1 Immune Checkpoint Inhibitor HR and Immune Checkpoint CDK2i Replicative stress Biopsy 2/3 Molecular subtype TP53 Angiogenic adaptation

29 HGSOC Umbrella Trial Neoadjuvant First Line or First Recurrence? First line Diagnostic biopsy at presentation Standard adjuvant chemotherapy Debulking surgery Molecular assay Targeted agent Stratify patients Measure pathological response PRO Treatment naïve when targeted agent used Post-treatment sample obtained easily at surgery CON Biopsy required at diagnosis Molecular assay must be performed fast to assign unwell patients in real time hard to adopt at multicenters Ethics of modifying standard first line treatment when known response rates are high (70-80%)

30 HGSOC Umbrella Trial Neoadjuvant First Line or First Recurrence? Recurrent disease Standard first line surgery and chemotherapy Standard second line adjuvant chemotherapy Targeted agent Confirmatory biopsy? PRO More time to perform molecular profiling Patients treated on a rising CA-125 Less interference with standard (first line) care Access diagnostic blocks Molecular assay Stratify patients First relapse CON Prior chemotherapy and development of resistance may obscure drug impact Pre-treatment DX sample may differ to recurrent disease (confirmatory relapse biopsy additional cost) Matching post-treatment sample requires additional biopsy

31 SUMMARY: Biomarker for Response and Resistance in Ovarian Cancer Homologous Recombination Pathway as a Clinically and Molecularly Relevant Subclassification of HGSOC Wild type: Platinum/PARPi responsive Inactivation type: Platinum/PARPi resistant Personalized Biomarker Liquid biopsy ctdna Biomarker-driven clinical trial

32 ACKNOWLEDGEMENT

ACRIN Gynecologic Committee

ACRIN Gynecologic Committee ACRIN Gynecologic Committee Fall Meeting 2010 ACRIN Abdominal Committee Biomarkers & Endpoints in Ovarian Cancer Trials Robert L. Coleman, MD Professor and Vice Chair, Clinical Research Department of Gynecologic

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