MSI and other molecular markers: how useful are they? Daniela E. Aust, Institute for Pathology, University Hospital Dresden, Germany

MSI and other molecular markers: how useful are they? Daniela E. Aust, Institute for Pathology, University Hospital Dresden, Germany

Disclosure slide I Member of advisory boards for AMGEN, ROCHE I Speaker honoraria from FALK Pharma, Pfizer, Lilly and ROCHE I Third party funds from MERCK for immunohistochemistry in a clinical trial

What can (molecular) pathology offer for clinical decisions in colorectal cancer? Better understanding of the disease Prognostic markers Predictive markers

Therapeutic Targeting of the Hallmarks of Cancer Weinberg R & Hanahan D, 2011

GOAL:

Predictive markers I MSI for 5-FU, irinotecan, immune checkpoint therapy? I RAS for anti-egfr-therapy I TS, TP, DPD for 5-FU-therapy I ERCC1 for oxaliplatin

MSI and 5-FU I Several studies showed the absence of benefit for adjuvant chemotherapy in MSI-H patients Ribic et al. N Engl J Med 2003 570 cancers, 95 (16,7 %) with MSI-H. Interaction chemotherapy*msi status p=0.009 Jover et al. Gut 2006 505 patients stage II-III 125 stages II (42.2%) 135 stages III (64.5%) with adjuvant chemotherapy Interaction chemotherapy*msi status p=0.007

Dan Sargent et al. 1027 patients included in trials demonstrating the effect of FU in adjuvant settings MSI + (dmmr) 185 pts (18%) No chemotherapy 5FU chemotherapy Dan Sargent et al, JCO 2010

Stage II Stage III MSI MSS Dan Sargent et al, JCO 2010

Chemotherapy 5FU No chemotherapy Lynch syndrome Sporadic MSI 2141 patients, 344 MSI + (16%) ; positive effect limited to the group of lynch syndrome

To cut the long 5 FU-story short (from A. Zaanan) References Type of study Number of patients Number of MSI tumours (%) Tumour stage Survival Number of patients receiving adjuvant CT Stratification analysis criteria Survival results for MSI patients 5-fluorouracil-based adjuvant chemotherapy Elsaleh et al, 2000 [19] Hemminki et al, 2000 [20] Ribic et al, 2003 [30] Carethers et al, 2004 [22] de Vos Tot Nederveen Cappel et al, 2004 [23] Benatti et al, 2005 [24] Westra et al, 2005 [21] Jover et al, 2006 [25] Lanza et al, 2006 [26] Kim et al, 2007 [27] Lamberti et al, 2007 [28] R 656 56 (8.5) III 272 MMR 5 yr-os Longer survival P / NR 95 11 (12) III 95 MMR 3 yr-rfs Longer survival R from RCT 570 95 (16.7) II + III 283 MMR and CT 5 yr-dfs 5 yr-os R 204 36 (17.6) II + III 66 CT OS No benefit R 92 92 (100) b III 28 CT 5 yr-os No benefit R 1263 256 (20.3) All stages 304 CT 5 yr-os No benefit R from RCT No benefit or detrimental a 273 44 (16) III 273 MMR 5 yr-dfs Longer survival c P / NR 754 66 (8.8) All stages 260 CT OS No benefit R 718 114 (15.9) II + III 193 MMR and CT 6 yr-os No benefit R from RCT 542 98 (18) II + III 369 MMR 5 yr-rfs/os No significant difference d P / NR 416 52 (13) All stages 89 e MMR OS No significant difference Sargent et al, 2010 [31] Hutchins et al, 2011 [29] R from RCT R from RCT 457 70 (15) II + III 229 No benefit 5 yr-dfs MMR and CT 1027 f 5 yr-os 165 (16) II + III 512 No benefit or detrimental 1913 218 (11.4) II (90%) 924 MMR and CT 2 yr-rfs No benefit

KRAS und BRAF beim Kolorektalkarzinom NO-147 Right colon Left colon The prognostic impact of MMR depended on tumor site. The interaction is highly significant p=0.009. Validated on CALGB 88903

Defective mismatch repair as a prognostic marker in UICC stage III colon cancer with adjuvant FOLFOX Zaanan et al., Clin Cancer Res. 2011

From A. Zaanan To cut the long oxaliplatin/irinotecan-story short. References Type of study 2011 [29] RCT Number of patients Number of MSI tumours (%) Tumour stage Survival Number of patients receiving adjuvant CT Stratification analysis criteria Survival results for MSI patients Oxaliplatin-containing adjuvant chemotherapy Kim et al, 2010 [38] Des Guetz et al, 2010 [39] Zaanan et al, 2010 [40] Zaanan et al, 2011 [41] R 135 12 (8.8) All stages FOLFOX, n=121 MMR 3 yr-dfs 3 yr-os No significant difference R 105 19 (18) II + III FOLFOX, n=105 MMR DFS Longer survival R 233 32 (14) III 5FU, n=124 FOLFOX, n=109 CT 3 yr-dfs Longer survival with FOLFOX R 303 34 (11.2) III FOLFOX, n=303 MMR 3 yr-dfs Longer survival Irinotecan-containing adjuvant chemotherapy Bertagnolli et al, 2009 [44] R from RCT 702 96 (13) III 5FU, n=348 5FU + IRI, n=354 MMR and CT 5 yr-dfs Longer survival with IRI Tejpar et al, 2009 [45] R from RCT 1254 188 (15) II + III 5FU, n=633 5FU + IRI, n=621 MMR and CT RFS OS No significant difference

Immune checkpoint inhibitors Sunshine et al, Current Opinion in Pharmacology 2015 15

Immune checkpoint inhibition Guillebon et al, WJGO 2015 16

Mismatch repair deficiency predicts response to pembrolizumab (Le et al, NEJM 2015) I Phase II-study with 41 patients: 11 mismatch repair deficient CRC 10 mismatch repair deficient non-crc 21 mismatch repair proficient CRC I Primary endpoints: Immune-related response Immune related progression free survival I Significant difference in immune-related response and immune- related progression-free survival between mismatch repair deficient and mismatch repair proficient CRC I Whole exome sequencing revealed 1782 somatic mutations in mismatch repair deficient tumors and 73 in mismatch repair proficient tumors 17

Immune-checkpoint-inhibitors for mismatch-repair- deficient colorectal cancer But: only 4% of mcrc are mismatch repair deficient! Kelderman, Cancer Cell 2015 18

RAS-/RAF-pathway

KRAS-mutation as a negative predictor for anti-egfr-treatment KRAS mutation 32% NRAS mutation 3% BRAF + PIK3CA mutation 2% KRAS, BRAF, NRAS, PIK3CA wild type, no PTEN loss I Respons BRAF mutation 5% KRAS + PIK3CA mutation 8% PIK3CA mutation / PTEN loss Molecular aberration to be identified 12% 23%

KRAS and NRAS Mutations in Colorectal Cancer KRAS 1 2 3 4 5 6 exon 12/13 59/61 117/146 mutation position NRAS 40% 4% 6% frequency (Amgen) 43-49% TCGA 1 2 3 4 5 6 7 exon 12/13 59/61 117/146 mutation position 3.5% 4% 0% frequency (Amgen) 5-9% TCGA non-coding exon coding exon

Douillard JY & Oliner KS et al, NEJM 2013

Workflow erweiterte RAS-Testung Hausfälle generell /K-Fälle nach Anforderung Anforderung KRAS KRAS 12/13 KRAS WT KRAS Mut KRAS 59/61/117/146 Ende KRAS Mut KRAS WT Ende NRAS 12/13/59/61 NRAS Mut NRAS WT Ende NRAS 117/146 23 Ende

Extended RAS-Analyses WT Mut KRAS Fälle 01.07.2013-01.09.2013 KRAS Analysen 01.07.2013-01.09.2013

From Tissue to biomarker External quality control!

Summary predictive markers I MSI-H tumors (UICC II) do not benefit from 5-FU treatment, but do benefit from FOLFOX or FOLFIRI I Impact of MSI-H is dependent on tumor location and hereditary background I KRAS- and NRAS-mutations are negative predictors of response to anti-egfr-therapy, but I Other members of the pathway may also contribute to non-response: PI3K, PTEN, EGFR, etc. I Biomarker testing needs rigorous quality control

Molecular signatures in CRC do we need them? YES To select stage II patients who are at risk of recurrence (~15%) To select stage III patients who are at low risk of recurrence (~50%) To select stage II and III patients who will benefit from adjuvant chemotherapy

UICC Stage II and Stage III prognosis I Inside each tumour stage the risk of recurrence is depending of various risk factors I For UICC stage II : obstruction/ perforation, emergent admission, T4 stage, high-grade, less than 12 LN are indicative of poor prognosis I For stage III the number of positive lymph-nodes are associated with the risk of recurrence I The only validated prognostic biomarker is the MSI status in stage II patients O Connor J Clin Oncol 2011;29:3381-88 Weisser J Clin Oncol 2011; 29:4796-802 Roth J Cin Oncol 2009; 28:466-74

International Colorectal Cancer Subtyping Consortium ICCSC Bionetwork Sage initiative (Justin Guinney Steven Friend) +TCGA COLON DATA + AGENDIA Unpublished

TCGA MSI/CIMP CIN Invasive Group F Netherlands 1.1. 1.2 1.3 2.1. 2.2. Group D Swiss Inflammatory Goblet Transit Amplifying Stem-like Enterocyte Group A Petacc3 Surface crypt Lower crypt CIMP+ Mesenchymal Mixed Group E AMCAJCCII CCS1 CCS2 CCS3 Group B French CIN immune down dmmr KRASm CSC CIN Wnt up CIN normal Group C Agendia A-type B-type C-type Rodrigo Dienstmann (version 3, Jan 3rd 2013)

Consensus molecular subtypes of CRC Guinney et al., Nature Medicine 2015 31

Consensus molecular subtypes of CRC Guinney et al., Nature Medicine 2015 32

Concensus molecular subtypes of CRC Guinney et al., Nature Medicine 2015 33

Conclusion I CRC is a comlex disease with several subentities derived through different pathways I dmmr colon tumors are clearly a subgroup of colon cancer with specific behavior I The division of CRC in various subentities generates the necessity of multicenter trials, since subgroups will be small I FFPE-material should be collected in these trials and investigated for potential prognostic and predictive markers I The addition of molecular data will hopefully allow the development of a more personalized treatment of CRC

HE I: label tumor area HE II: check for tumor FFPE tumor block gdna MSI block adequate on entry? (samples) microstallelite instability (MSI) adequate for analysis (FFPEQ) tumor cell content etc. (DNA) amount DNA

Thank you for your attention. 36