Pharmacogenetics of the VEGF pathway. Federico Innocenti, MD, PhD University of North Carolina Chapel Hill, NC, USA

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1 Pharmacogenetics of the VEGF pathway Federico Innocenti, MD, PhD University of North Carolina Chapel Hill, NC, USA

2 Angiogenesis o Angiogenesis an important process for tumor biology o Tumor growth and distant spread o VEGF family and its receptors o Angiogenesis is a hostmediated process

3 VEGF-pathway inhibitors o Antibody and fusion protein o Tyrosine kinase inhibitors o Approved in several diseases o Wide inter-individual variability in response o Hypothesis o Germline DNA variation: associate with extent of vascularization and response to therapy

4 Personalized therapy with VEGF-pathway inhibitors? o We still do not have a way to guide drug and dose selection of anti-angiogenesis drugs o Different types of biomarkers in many correlative studies o Imaging o Laboratory alterations o Circulating proteins o Germline and somatic changes o Inconsistent results for association with survival, often not replicated

5 Studies o VEGFR-2 sequencing in germline DNA and functional validation o GWAS in pancreatic cancer patients treated with chemotherapy plus bevacizumab o Candidate gene study in RCC patients treated sorafenib vs. placebo o Candidate gene study in early stage NSCLC

6 Studies o VEGFR-2 sequencing in germline DNA and functional validation o GWAS in pancreatic cancer patients treated with chemotherapy plus bevacizumab o Candidate gene study in RCC patients treated sorafenib vs. placebo o Candidate gene study in early stage NSCLC

7 Resequencing of VEGFR-2 (KDR) and functional studies o Resequencing in different ethnic groups o Functional validation of SNPs o Testing their effect on vascularization and gene expression in lung cancer specimens

8 VEGFR-2 amino acid changes Increased phosporylation NH R106W (AA-0.021) V297I (CA-0.083, AS-0.188, AA-0.125) E372D (AA-0.083) Q472H (CA-0.354, AS-0.521, AA-0.104) C482R (CA-0.083, AS-0, AA-0) E673D (AA-0.021) Increased microvessel density in lung cancer 789 TK P839L (AS-0.021) V952I (AA-0.021) TK COOH 1357 Glubb et al., Clin Cancer Res 2011 P<0.05

9 Q472H and increased NSCLC response to bevacizumab-based therapy? o Complete response A B C o Partial response D E F Courtesy of Mark Socinsky, MD, U Pittsburgh

10 Studies o VEGFR-2 sequencing in germline DNA and functional validation o GWAS in pancreatic cancer patients treated with chemotherapy plus bevacizumab o Candidate gene study in RCC patients treated sorafenib vs. placebo o Candidate gene study in early stage NSCLC

11 GWAS in advanced pancreatic cancer CALGB R A N D O M I Z A T I O N Gemcitabine 1000 mg/m 2 D 1, 8, 15 Bevacizumab 10 mg/kg D 1, 15 Gemcitabine 1000 mg/m² D 1, 8, 15 Placebo D 1, 15 Kindler et al., J Clin Oncol 2010

12 GWAS in advanced pancreatic cancer patients: acknowledgements o RIKEN/CGM (Japan) o Michiaki Kubo, Taisei Mushiroda, Yusuke Nakamura, Hitoshi Zembutsu o Alliance for Clinical Trials in Oncology o Donna Hollis, Hedy Kindler, Chen Jiang, Kouros Owzar, Paula Friedman, Richard Schilsky o University of North Carolina at Chapel Hill o Dan Crona, Zhen Hu, Dylan Glubb, Amy Etheridge, Howard McLeod o University of Chicago o Nancy Cox, Patrick Evans, Anuar Konkashbaev, Mark Ratain

13 Overall Survival, both arms, n=294 IL17F Innocenti et al., Clin Cancer Res 2012

14 IL17F amino acid changing variant o o o Increased angiogenesis in cellular studies Worse survival No interaction with bevacizumab

15 Studies o VEGFR-2 sequencing in germline DNA and functional validation o GWAS in pancreatic cancer patients treated with chemotherapy plus bevacizumab o Candidate gene study in RCC patients treated sorafenib vs. placebo o Candidate gene study in early stage NSCLC

16 Pharmacogenetics of sorafenib, a VEGFpathway inhibitor o o o Renal cancer (clear cell) is driven by angiogenesis o VHL inactivation TARGET: 294 mrcc patients, sorafenib vs. placebo o Escudier et al., NEJM 2007 Association with OS o Dan Crona, PharmD (UNC), Andrew Skol, PhD (U of C)

17 1,500 SNPs, 50 genes, mostly related to angiogenesis

18 Rs in VEGFA and association with overall survival (both arms) HR=7.14 (95% CI: ) p=7.9x10-8 (passed FDR) Minor Allele Frequency 0.18 C allele = reduced OS C allele = increased luciferase activity in two cell lines Crona et al., EORTC/NCI/AACR 2012

19 Studies o VEGFR-2 sequencing in germline DNA and functional validation o GWAS in pancreatic cancer patients treated with chemotherapy plus bevacizumab o Candidate gene study in RCC patients treated sorafenib vs. placebo o Candidate gene study in early stage NSCLC

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21 FDR-adjusted associations with PFS Concordance with luciferase assays

22 Rs in FLT1 was replicated for PFS in an independent replication cohort REPLICATION COHORT BOTH COHORTS COMBINED N=142 HR=1.69 [0.99 to 2.89], p=0.027 N=292 HR=1.76 [1.31 to 2.47], p=0.0001

23 Validation of clinical utility of the FLT1 variant in early stage NSCLC o ECOG 1505 o Funding application National Institutes of Health (NIH) National Cancer Institute (NCI) Funding Opportunity Title Activity Code Announcement Type Validation of Molecular Diagnostics to Predict Patient Outcomes Using Specimens from Multi-Site Cancer Trials (R01) R01 Research Project Grant Reissue of PA

24 Randomized studies for bevacizumab pharmacogenomics o All phase III, randomized to bevacizumab, placebo controlled o o Pancreatic cancer, gemcitabine +/- bevacizumab o ~300 patients, all GWASed o o HRPC, prednisone+docetaxel +/- bevacizumab o ~900 patients, all GWASed o o Colorectal cancer, chemotherapy + either cetuximab or bevacizumab o ~2,000 patients (800 already GWASed)

25 Considerations on the pharmacogenetics of VEGF-pathway inhibitors o Germline genome might not be just background for cancer genome sequencing o Might germline variants modulate tumor biology and response to therapy with VEGF-pathway inhibitors? o Functional validation + powered testing in clinical trials

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27 Normalized Luciferase Expression Molecular phenotypes of VEGFA SNPs 2.0 HEK293 All Clones (embryonic All Repskidney) 1.5 A498 (renal carcinoma) All Clones all reps Wild Type rs rs Variant ID C allele rs Triple Mutant 0.0 Wild Type rs rs rs Triple Mutant C allele Crona et al., EORTC/NCI/AACR 2012

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