Disclosures 9/25/2012. Emerging Biomarkers for Risk Stratification, Prognosis and Prediction of Treatment Responses in Colorectal Carcinoma (CRC)

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1 Emerging Biomarkers for Risk Stratification, Prognosis and Prediction of Treatment Responses in Colorectal Carcinoma (CRC) Disclosures 21 st ANNUAL SYMPOSIUM ON MOLECULAR PATHOLOGY Clinical Applications of Genomic Medicine September 19, 2012 I have no conflicts of interest Dhananjay Chitale, MD Division Head, Molecular Pathology and Genomic Medicine Director, Tissue Biorepository Senior Staff Surgical Pathologist Clinical Assistant Professor, Wayne State University School of Medicine Henry Ford Hospital, Detroit, MI Outline for today's talk 1. The epidemiology of colorectal cancer (CRC) 2. Understanding of CRC at molecular level a. Correlation with morphologic alterations in the course of the progression to malignancy 3. Global molecular alterations present in CRC a. Risk stratification, prognosis b. Predictive of treatment responses 4. Specific genetic alterations and signal pathway deregulation a. Risk stratification, prognosis b. Predictive of treatment responses 1. Potential utility in the management of patients using current adjuvant therapy (5FU/LV, Irinotecan, Oxaliplatin etc.) 2. Targeted therapy (KRAS, BRAF, PI3CA etc.) 5. Multigene signature assays 6. Pharmacogenomics (5FU/LV, Irinotecan, Oxaliplatin etc.) The 20 Most Commonly Diagnosed Cancers Worldwide, 2008 Estimates Cancer Research UK 2011 Registered charity in England and Wales ( ) and Scotland (SC041666) The 20 Most Common Causes of Death from Cancer Worldwide, 2008 Estimates 2010, American Cancer Society, Inc. Cancer Research UK 2011 Registered charity in England and Wales ( ) and Scotland (SC041666) 1

2 American Cancer society DATA SEER DATA Decreasing incidence of CRC attributed to colonoscopy, FOBT / FIT Conclusion from the American Cancer Society statistics Third in incidence as well as cancer related mortality for both men and women in most western countries. Incidence of CRC is declining due to screening (colonoscopy, Guaiac stool test etc) However, the long term survival has not changed significantly when compared stage to stage better understanding of the molecular biology and pathogenesis of CRC there is a need to identify molecular targets CRC facts CRC facts 65 85% are sporadic no family history Sporadic Hereditary Approximately 20% of patients present with metastatic disease Metastatic colon cancer 5 year survival rate of only 11%. An additional 30% to 40% develop metastasis during the course of their disease. 15% and 35% major hereditary component Strong CRC in first or second degree relatives fourth of these are highly penetrant (< 5%) Single gene mutation cancer syndrome CRC develops as multistep progression Genotypic and phenotypic (Vogelstein model) 65 85% 15 35% Overall 5 year survival: ~65% CRC not a single disease but heterogeneous complex of diseases Each CRC is caused by distinctive genetic/ epigenetic background 2

3 Risk stratification traditional. so how do we stratify risk? Clinical (proximal versus distal) Pathological Grade: well moderate versus poorly differentiated Mucinous versus nonmucinous Lymphovascular invasion, perineural invasion Pathological stage Clinical response to treatment is diverse, even if their clinicopathological parameters seems similar, especially early stage cancers pt1 pt2 pt3 pt4 Adenoma carcinoma Sequence Risk stratification molecular pathways and biomarkers Normal TVA HG dysplasia CA There is substantial evidence that treatment response is dependent on the aberrations in the tumor itself and genetic background of the individual (germline) as well. Adenoma carcinoma Sequence Molecular pathways and biomarkers Reflect underlying mechanisms of carcinogenesis which will help identify potential therapeutic targets Inactivation Mutations 18q loss TP53 of APC CIN defect: in KRAS DCC,DPC4 17q loss 5q loss Normal TVA HG dysplasia CA Genomic instability global cellular events such as Chromosomal instability (CIN) Micorsatellite instability (MSI) CpG island methylator phenotype (CIMP) Single molecular events for predicting response to targeted therapies against those molecules e.g. KRAS, BRAF, PI3KCA etc Non random Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic alterations during colorectal tumor development. N Engl J Med. 1988;319:

4 Chromosomal instability (CIN) Chromosomal instability (CIN) Numerical chromosomal alterations are referred to CIN leading to carcinogenesis through loss of tumor suppressors genes loss of heterozygosity (LOH) the suppressor pathway copy number gains of oncogenes. CIN involves large proportion of CRC (~80 85%), mostly MSIstable tumors Causes of CIN are heterogeneous Chromosome cohesion e.g. Rad21/SCC1, SCC3, Securin Mitotic checkpoint defects e.g. Mutations in genes encoding mitotic checkpoint proteins such as BUB1 and BUB1B (BUBR1) Centrosome amplification, cytokinesis failure e.g. Amplification of AURKA (Aurora kinase A, STK15/BTAK), a centrosome associated serine threonine kinase Kinetochore microtubule attachment dynamics Dysregulation of cell cycle proteins e.g. Mdm2, TP53 1. Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic alterations during colorectal tumor development. N Engl J Med. 1988;319: Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10: Chromosomal Instability (CIN) Phenotype, CIN High or CIN Low, Predicts Survival for Colorectal Cancer.Watanabe et al J Clin Oncol 2012:30: Mechanisms of Chromosomal Instability. Current Biology 20, R285 R295, March 23, Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic alterations during colorectal tumor development. N Engl J Med. 1988;319: Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10: Chromosomal Instability (CIN) Phenotype, CIN High or CIN Low, Predicts Survival for Colorectal Cancer.Watanabe et al J Clin Oncol 2012:30: Mechanisms of Chromosomal Instability. Current Biology 20, R285 R295, March 23, 2010 Chromosomal instability (CIN) DNA Repair Defects Microsatellite instability Allelic losses are common in CRC with high frequencies, such as on chromosomes 17p p53 gene (75% CRC), other p53 allele had been inactivated by mutation 5q APC gene Allelic deletions in up to 50% of CRC and in about 30% of adenomas, respectively and truncating mutations are found in 63% and 60% of adenomas and carcinomas, respectively 18q Deleted in colorectal carcinoma gene (DCC)~70% SMAD 4 and SMAD 2 genes While looking for LOH events using microsatellite markers, a second completely unrelated type of genomic instability was detected This type of hypermutability, termed MSI or RER present in about 15% of all colorectal tumors Functional loss of MLH1 due to promoter methylation and gene silencing in sporadic CRCs Most near diploid in more than 90% of cancers in Lynch syndrome (~3% of all CRC) mutations in any of the mismatch repair genes, MSH2, MLH1, MSH6, PMS2 (less common PMS1, MSH3) 1. Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic alterations during colorectal tumor development. N Engl J Med. 1988;319: Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10: Chromosomal Instability (CIN) Phenotype, CIN High or CIN Low, Predicts Survival for Colorectal Cancer. Watanabe et al J Clin Oncol 30: Lengauer C, Kinzler KW, Vogelstein B. Genetic instabilities in human cancers. Nature. 1998;396: Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10:13 27; DOI: /jmoldx Chromosomal Instability (CIN) Phenotype, CIN High or CIN Low, Predicts Survival for Colorectal Cancer. Watanabe et al J Clin Oncol 30: DNA Repair Defects Microsatellite instability Aberrant DNA Methylation Epigenetic changes methylation of promotor MSI is the manifestation of the loss of protein function one or more DNA mismatch repair proteins (MMR proteins) MSI H >30% unstable loci in a panel of 5 10 loci (monodinucleotide) 5 mononucleotides (BAT 25, BAT 26, NR 21, NR 24, MONO 27) MSI leads to inactivation of tumor suppressor genes Clusters of cytosine residues followed by a guanosine (CpG), sequences are present in about 50 70% of promoters in the human genome Many genes are inactivated with transcriptional silencing by hypermethylation at CpG islands (1998) MLH1 was inactivated by epigenetic modification of its promoter in most of the sporadic tumors with MSI. Sinicrope F A, Sargent D J Clin Cancer Res 2012;18: Herman JG, Umar A, Polyak K, et al. Incidence and functional consequences of hmlh1 promoter hypermethylation in colorectal carcinoma. Proc Natl Acad Sci USA. 1998;95: Kane MF, Loda M, Gaida GM, et al. Methylation of the hmlh1 promoter correlates with lack of expression of hmlh1 in sporadic colon tumors and mismatch repair defective human tumor cell lines. Cancer Res. 997;57:

5 CIMP CpG island methylator phenotype Classifications CIMP CpG island methylator phenotype CIMP high colorectal tumors have a distinct clinical, pathological, and molecular profile associations with proximal tumor location, female sex, poor differentiation, MSI H high BRAF and low TP53 mutation rates The serrated pathway of tumorigenesis has been suggested in the development of CIMP high CRC 15% Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10:13 27; DOI: /jmoldx CIMP At the present time, the panel of methylation markers and the method of assessment of CIMP is not standardized Few sensitive and specific markers to identify CIMP high using MethyLight technology CACNA1G, CDKN2A, CRABP1, IGF2, MLH1, NEUROG1, RUNX3, and SOCS1 Several published studies have combined analysis of these genomic instability profiles to subclassify CRC Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10:13 27; DOI: /jmoldx MSI/CIMP classification Histopathologic changes in CRC carcinogenesis Sporadic MSI H pathways (CIMP) Sessile serrated polyp Carcinoma Sequence HNPCC/Lynch syndrome MLH1 methylation + BRAF V600E mutation Normal MLH1 methylation Dysplastic crypt APC β catenin AXIN2 BRAF mutations >KRAS) Mutational inactivation of genes with microsatellites: TGF βiir, BAX Sessile Serrated polyp/ Carcinoma adenoma Inactivation of tumor suppressor genes by promoter hypermethylation APC β catenin AXIN2 Mutational inactivation of genes with microsatellites: TGF βiir, BAX Normal Dysplastic crypt Tubular adenoma Carcinoma CIMP /MSI subtype is the most common Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10:13 27; DOI: /jmoldx MMR Mutational inactivation Familial MSI H pathways (HNPCC) KRAS mutations adenomatous polyp Carcinoma Sequence Adapted from The Molecular Basis of Cancer, Saunders, Elsevier, 3 rd edition P53 mutations 5

6 DNA Repair Defects Evolving concept of molecular pathways of CRC development Tumor suppressor pathway Hypermutator pathway Sinicrope F A, Sargent D J Clin Cancer Res 2012;18: Risk and prognostic stratification What do these global genomic changes mean in the grand scheme of risk and prognostic stratification? CIN high (especially 18q): worst survival 18qLOH/SMAD4 loss Poor prognosis in CIMP low patients regardless of MSI screening status Poor prognosis in CIMPhigh patients with MSS CIN low : better survival MSI+ cancers have a better prognosis 1. Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10: Chromosomal Instability (CIN) Phenotype, CIN High or CIN Low, Predicts Survival for Colorectal Cancer. Watanabe et al J Clin Oncol 30: The Role of the CpG Island Methylator Phenotype in Colorectal Cancer Prognosis Depends on Microsatellite Instability Screening Status. Anna M. Dahlin et al, Clin Cancer Res; 16(6); Prognostic biomarkers in CRC Predictive biomarkers in CRC Despite the clear association of MSI and CIN with prognosis, these markers have not yet been adopted into routine clinical decision making Colorectal cancer molecular biology moves into clinical practice, Colin C Pritchard,William M Grady Gut 2011;60:116e129. doi: /gut Colorectal cancer molecular biology moves into clinical practice, Colin C Pritchard,William M Grady Gut 2011;60:116e129. doi: /gut

7 CIN Can we use CIN, CIMP, MSI in clinical decision making? Lack of Gold Standard and Uniform Methods, Definition, and Criteria Limitations: 1. Markers and criteria for CIN have not been standardized 2. No conclusive studies predicting response rates based on CIN+/ status 1. Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10: Colorectal cancer molecular biology moves into clinical practice Colin C Pritchard,1 William M Grady Gut 2011;60:116e129. doi: /gut CIMP Limitations: 1. Lack of a universally accepted definition of the methylator phenotype Ogino CIMP Marker Panel (MLH1, p16, CRABP1, CACNA1G, and NEUROG1) Laird CIMP Marker Panel (CACNA1G, NEUROG1, IGF2, RUNX3, and SOCS1) 2. Considerable overlap between CIMP and sporadic MSI tumors adds to the challenge of incorporating CIMP status into clinical trials and clinical decision making MSI Limitations: 1. Despite the presence of the recommended panel of markers (the NCI panel) markers used for studies on MSI are still not uniform to draw reproducible conclusions. Moderate evidence: 1. Shown to predict adverse outcome with 5 FU 2. Improved outcome with Irinotecan Evidence not enough to recommend routine MSI testing as predictive marker 1. Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10: Colorectal cancer molecular biology moves into clinical practice Colin C Pritchard,1 William M Grady Gut 2011;60:116e129. doi: /gut Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10: Colorectal cancer molecular biology moves into clinical practice Colin C Pritchard,1 William M Grady Gut 2011;60:116e129. doi: /gut CIN+CIMP+MSI+ mutations Genomic instability Role of specific genetic alterations and signal pathway deregulation There is an accumulation of mutations in specific genes resulting in deregulation of specific cell signalling pathways differentiation apoptosis immortalisation angiogenesis invasion CIN CIMP MSI WNT TGF β PI3K RTK RAS TP53 7

8 Diversity and frequency of genetic changes leading to deregulation of signalling pathways in CRC. The Cancer Genome Atlas Network Nature 487, (2012) doi: /nature11252 The Cancer Genome Atlas Network Nature 487, (2012) doi: /nature11252 Non Hypermutated Preferred pathways Hypermutated (MSI H) Mutation frequencies in human CRC. WNT signaling 92% RTK RAS signaling 59% PI3K signaling 50% TGF β signaling 27% P53 signaling 64% WNT signaling 97% TGF β signaling 87% RTK RAS signaling 80% PI3K signaling 53% P53 signaling 47% The Cancer Genome Atlas Network Nature 487, (2012) doi: /nature11252 Mutation frequencies in human CRC. Evolving concept of molecular pathways of CRC development After removal of non expressed genes Hypermutated tumors (16%) ACVR2A 63% APC 51% TGFBR2 51% BRAF 46% MSH3, MSH6 40% MYO1B, TCF7L2 31% CASP8, CDC27, FZD3 29% MIER3, TCERG1 29% Non hypermutated tumors (84%) APC 81% TP53 60% KRAS 43% PIK3CA 18% FBXW 11% SMAD4 10% TCF7L2 9% NRAS 9% The Cancer Genome Atlas Network Nature 487, (2012) doi: /nature11252 Annu Rev Pathol MechDis 2011, 6: Molecular pathology of CRC 8

9 Can we use somatic mutation in clinical decision making? Somatic molecular alterations in cell signaling pathways provide opportunities for targeted therapy for personalized medicine and have been used successfully many tumors e.g. TKI Lung cancer Imatinib CML, GIST WNT pathway Small molecule inhibitors of this pathway are still in the preclinical setting Therefore, despite the critical and universal role of WNT, there is no clinical role for APC or CTNB1 mutation in treatment selection or prognosis The Cancer Genome Atlas Network Nature 487, (2012) doi: /nature11252 Colorectal cancer molecular biology moves into clinical practice, Colin C Pritchard,William M Grady Gut 2011;60:116e129. doi: /gut TGFβ pathway TP53 Deregulation of TGFβ signaling in many CRC Loss of SMAD4 tumor suppressor gene Lymph node metastasis Still, there is no definite clinical role for any genetic markers is in the TGFβ signaling 18qLOH associated with poor prognosis Role as predictive marker still in clinical trials (ECOG5202) MSI H TP53 mutations are noted in ~50% of all the CRC Like APC, key tumor suppressor gene No prognostic or predictive role in the clinical setting The Cancer Genome Atlas Network Nature 487, (2012) doi: /nature11252 The Cancer Genome Atlas Network Nature 487, (2012) doi: /nature

10 Overlapping mutations Mutually exclusive EGF signaling ERBB2/RAS/RAF/RAF/MAPK Constitutive activation by KRAS mutations codons 12,13 40% BRAF mutations codons % MSI H Prognostic biomarkers in CRC EGF signaling PI3K/Akt pathway PIK3CA mutations 20% PTEN loss 30% The Cancer Genome Atlas Network Nature 487, (2012) doi: /nature11252 Colorectal cancer molecular biology moves into clinical practice, Colin C Pritchard,William M Grady Gut 2011;60:116e129. doi: /gut Predictive biomarkers in CRC EGF signaling Mechanism of action anti EGFR Four large phase III randomized trials established the association of KRAS mutation and lack of benefit from anti EGFR therapy in metastatic CRC Colorectal cancer molecular biology moves into clinical practice, Colin C Pritchard,William M Grady Gut 2011;60:116e129. doi: /gut Gut 2011;60:116e129. doi: /gut Predictive markers currently in clinical practice mcrc First negative predictor for a targeted therapy 1. Testing for mutations in KRAS codon 12, 13 in exon 2 negative predictor to anti EGFR therapy CLIA certified lab, no specific methodology recommended, performed on FFPE or fresh tissues 2. BRAF mutations negative predictor to anti EGFR therapy (insufficient evidence) CLIA certified lab, no specific methodology recommended, performed on FFPE or fresh tissues 3. MSI testing should be considered CRC patients <50 yrs. or with stage II disease Stage II may have good prognosis and do not benefit from 5 FU neoadjuvant therapy Benefit from Irinotecan containing regimens NCCN Clinical Practice Guidelines for Oncology: Colon Cancer v

11 A C B D 9/25/2012 K ras testing Formalin fixed, paraffin embedded tissue Fresh frozen tissue HFH experience: KRAS codon 12,13+ CRC: 41% (212/512) No significant ethnic difference FFPE tissue Fresh frozen tissue B raf testing HFH MSI BRAF+ KRAS+ hmlh1 H+ AA (19) CA(19) Others(4) Total(42) Most MSI H tumors were sporadic CRC with frequent BRAF mutations, hmlh1 M and occurred in RC of elderly CA women Forward 34G>T; G12C 1799T>A; V600E Reverse Reverse Forward Testing methodologies and sensitivity MSI H Direct sequencing (Sanger sequencing) ~25% Locked Nucleic acid PCR sequencing ~1% (Arcila M, et al. J Mol Diagn 13:64 73, 2011 BAT 26 NR 21 BAT 25 MONO 27 Tumor NR 21 BAT 26 BAT 25 MONO 27 Normal NR 24 NR 24 ARMS Amplification Refractory Mutation System Qiagen FDA approved test ~1% Sequenom based assays (MALDI TOF) ~5 10% H & E Loss of MSH2 Colonic adenocarcinoma IHC Multigene signature assays guiding selection for current adjuvant therapy in early stage colorectal cancers (stage II: T3 T4, N0,M0) Currently not in NCCN recommendation Loss of MSH6 Positive MLH1 NCCN Clinical Practice Guidelines for Oncology: Colon Cancer v

12 Stage II Colon Cancer Which patient should receive adjuvant chemotherapy? The 12 Gene Oncotype DX Colon Cancer Recurrence Score Assessment of recurrence risk following surgery Identification of patients who would benefit from 5FU/LV Independent clinical value in the context of other measures such as T stage and MMR Optimized for FFPE colon tumor tissue High risk for recurrence Benefit from chemorx Kerr et al., ASCO 2009, #4000 Recurrence Score STROMAL FAP INHBA BGN GADD45B CELL CYCLE Ki 67 C MYC MYBL2 RS = 0.15 x Stromal Group 0.30 x Cell Cycle Group x GADD45B Reference Genes ATP5E GPX1 PGK1 UBB VDAC2 O Connell et al JCO 28:3937 Kerr et al., ASCO 2009, #4000 Oncotype DX Colon Cancer Assay Patient Report QUASAR Validation Study Clinical validation study analyzed 1,436 patients with stage II colon cancer The Recurrence Score is a validated multi gene RT PCR clinical assay which independently and quantitatively predicts individual recurrence risk The continuous RS will have the greatest clinical utility for T3, MMR proficient patients, who constitute the majority of stage II colon cancer (~70% of pts) Prognostic assay for assessing risk of recurrence O Connell MJ, Lavery I, Yothers G, et al. Relationship between tumor gene expression and recurrence in four independent studies of stage II/III colon cancer patients treated with surgery alone or surgery plus adjuvant 5 FU/LV. J Clin Oncol. 2010; 28: Oncotype DX Colon Cancer Assay Predictive? The treatment score was not predictive of chemotherapy benefit Not ready for predicting treatment response ColoPrint 18 gene signature based assay for CRC 18 gene set to predict high vs low recurrence risk patients. MCTP1, LAMA3, CTSC, PYROX D1, EDEM1, IL2RB, ZNF697, SLC6A11, IL2RA, CYFIP2, PIM3, LIF, PLIN3, HSD3B1, ZBED4, PPARA, THNSL2, CA4388O2 Requires fresh frozen samples Able to predict the development of distant metastasis in stage II CRC patients Facilitates the identification of patients who may be safely managed without chemotherapy No studies on predicting response yet J Clin Oncol. 2011;35: J Clin Oncol. 2011;29: Independent validation of a prognostic genomic profile (ColoPrint) for stage II colon cancer (CC) patients. J Clin Oncol 29: 2011 (suppl 4; abstr 358) 12

13 Previstage Guanylyl Cyclase C test for staging CRC 25 30% of pn0 patients develop recurrent disease Likely due to sampling limitations in histology examination underestimating occult lymph node metastasis GCC (GUCY2C) is expressed in primary and metastatic CRC Expression of GCC by qrt PCR to detect occult lymph node metastases in FFPE tissues Prospective study of 257 patients with pn0 CRC showed expression of GUCY2C in histologically negative lymph nodes independently associated with time to recurrence and disease free survival in patients with pn0 colorectal cancer Previstage Guanylyl Cyclase C test for staging CRC 241 patients with stage II colon cancer without adjuvant chemotherapy RT qpcr for GCC mrna in FFPE lymph node tissues Preliminary results detection of GCC mrna in LNs associated with risk of disease recurrence in patients with untreated stage II CRC No studies on predicting response yet 1. Previstage GCC test for staging patients with colorectal cancer. Expert Rev Mol Diagn September ; 8(5): Association of GUCY2C Expression in Lymph Nodes With Time to Recurrence and Disease Free Survival in pn0 Colorectal Cancer. JAMA. 2009;301(7): Evaluation of Guanylyl Cyclase C Lymph Node Status for Colon Cancer Staging and Prognosis. Ann Surg Oncol (2011) 18: Pharmacogenomics (PG) Heritable traits related to drug delivery and drug action Pharmacogenomics The therapeutic drug level affected by Pharmacokinetics What body does to drugs? (drug delivery) Clearance Half Life Bioavailability Metabolism PK PG Polymorphisms in enzymes / binding proteins required for transporting, metabolizing, excreting the drug PD Pharmacodynamics What drugs do to the body (drug action) Most drug actions mediated via receptors binding proteins enzymes. 1. Renal or hepatic impairment 2. Polymorphic metabolism 3. Environmental influences Pharmacogenomics (PG) Heritable traits related to drug delivery and drug action Polymorphisms & irinotecan Drug metabolizing enzyme UGT1A1 Inactivates SN 38, the active species derived from irinotecan Reduced activity of UGT1A1 causes toxicity FDA APPROVED PG Polymorphisms & 5 FU Folate metabolism Pharmacogenomics in treatment of CRC PK PD Polymorphisms & Oxaliplatin Pharmacogenomics in colorectal cancer: The first step for individualized therapy World J Gastroenterol 2007 November 28; 13(44): Pharmacogenomics in colorectal cancer: The first step for individualized therapy World J Gastroenterol 2007 November 28; 13(44):

14 Take home message CIN+ cancers are associated with worse prognosis, MSI+ cancers have a better prognosis 18q LOH + tumor also have a worse prognosis Key pathways that drive colorectal cancer WNT signalling TGFβ signalling EGFR signaling Ras/Raf/MAPK and phosphatidylinositol 3 kinase (PI3K) Take home message Currently, only KRAS mutations in codon 12/13 are the highly validated predictive marker for resistance to anti EGFR drugs in treating CRC BRAF V600E mutation is likely to be a second predictive marker. MSI H shown to predict adverse outcome with 5 FU, improved outcome with Irinotecan Currently there are no predictive multi gene assays available The role of CRC molecular biomarkers in clinical decision making is likely to expand as more targeted drugs become available. Pharmacogenomics will likely play a role in selection and dosing of chemotherapeutic agents Personalized predictive pathology Beyond morphology, margins and staging Morphogenomics and Morphoproteomics A Role for Anatomic Pathology in Personalized Medicine. Robert Brown Arch Pathol Lab Med Vol 133, April 2009 References 1. The Molecular Basis of Cancer, Saunders, Elsevier, 3rd edition Association of GUCY2C Expression in Lymph Nodes With Time to Recurrence and Disease Free Survival in pn0 Colorectal Cancer. JAMA. 2009;301(7): Chromosomal Instability (CIN) Phenotype, CIN High or CIN Low, Predicts Survival for Colorectal Cancer. Watanabe et al J Clin Oncol 30: Colorectal cancer molecular biology moves into clinical practice, Colin C Pritchard,William M Grady Gut 2011;60:116e129. doi: /gut Comprehensivemolecular characterization of human colon and rectal cancer Nature 487, (2012) doi: /nature Evaluation of Guanylyl Cyclase C Lymph Node Status for Colon Cancer Staging and Prognosis. Ann Surg Oncol (2011) 18: Herman JG, Umar A, Polyak K, et al. Incidence and functional consequences of hmlh1 promoter hypermethylation in colorectal carcinoma. Proc Natl Acad Sci USA. 1998;95: Independent validation of a prognostic genomic profile (ColoPrint) for stage II colon cancer (CC) patients. J Clin Oncol 29: 2011 (suppl 4; abstr 358) 9. J Clin Oncol. 2011;29: J Clin Oncol. 2011;35: Kane MF, Loda M, Gaida GM, et al. Methylation of the hmlh1 promoter correlates with lack of expression of hmlh1 in sporadic colon tumors and mismatch repair defective human tumor cell lines. Cancer Res. 997;57: Kerr et al., ASCO 2009, # Lengauer C, Kinzler KW, Vogelstein B. Genetic instabilities in human cancers. Nature. 1998;396: Molecular Classification and Correlates in Colorectal Cancer. Ogino S, Goel A. J Mol Diagn 2008, 10:13 27; DOI: /jmoldx Molecular Genetics of Colorectal Cacner, Fearon. Annu Rev Pathol MechDis 2011, 6: Molecular pathology of CRC 16. Morphogenomics and Morphoproteomics A Role for Anatomic Pathology in Personalized Medicine. Robert Brown Arch Pathol Lab Med Vol 133, April NCCN Clinical Practice Guidelines for Oncology: Colon Cancer v1.2013, O Connell et al JCO 28:3937, Kerr et al., ASCO 2009, # O Connell MJ, Lavery I, Yothers G, et al. Relationship between tumor gene expression and recurrence in four independent studies of stage II/III colon cancer patients treated with surgery alone or surgery plus adjuvant 5 FU/LV. J Clin Oncol. 2010; 28: Pharmacogenomics in colorectal cancer: The first step for individualized therapy World J Gastroenterol 2007 November 28; 13(44): Previstage GCC test for staging patients with colorectal cancer. Expert Rev Mol Diagn September ; 8(5): Sinicrope F A, Sargent D J Clin Cancer Res 2012;18: The Role of the CpG Island Methylator Phenotype in Colorectal Cancer Prognosis Depends on Microsatellite Instability Screening Status. Anna M. Dahlin et al, Clin Cancer Res; 16(6); Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic alterations during colorectal tumor development. N Engl J Med. 1988;319: