Liquid biopsies to track clonal evolution and resistance to EGFR inhibition in mcrc Alberto Bardelli Candiolo Cancer Center IRCCs University of Torino - Medical School
Disclosures Horizon discovery Biocartis Trovagene Relationship SAB SAB SAB
Tumor evolution in the blood of patients
Colorectal cancer as a model system for liquid biopsies Adenomatous Polyps Severe Dysplasia Adenocarcinoma Hepatic Metastasis Early Adenoma Hyperproliferation
Actionable targets in CRC
Liquid biopsies of actionable targets in CRC crizotinib MET ALK Lapatinib trastuzumab HER2 cetuximab panitumumab EGFR TRKA entrectinib Wnt 1 Porcupine inhibitor Anti RSPO Ab RSPO LRP5/6 Frizzled LGR4-6
Publication First clinical response (PR) 2011 2012 2013 2014 Validation in animal models First patient treated (Niguarda Hospital) Clinical trial HERACLES
HER2+ mcrc xenopatients are sensitive to dual HER2 blockade with lapatinib and trastuzumab vehicle trastuzumab lapatinib HER2+ mcrc PDX or xenopatients lapatinib and trastuzumab Bertotti A. et al, Cancer Discovery 2012
HER2 amplification in CRC IHC 0 IHC 1+ IHC 2+ IHC 3+ HER2 IHC 10X 10X 10X 10X 10X 10X 10X 10X 20X 20X 20X 20X 10X 10X 10X 10X 40X 40X 40X 40X FISH 100X 100X 100X 100X Positive tumor cells > 50% Eligible for HERACLES Trial
Patient # 121023 Patient # 121016 Representative CE-CT scans of 2 responders baseline Week 8 - PR Week 54 - PR + baseline Week 8 - PR Week 24 - PR + 10
Change in target lesion from baseline (%) Change in target lesion from baseline (%) Response and resistance to HER2 blockade Waterfall plot Spaghetti plot HER2 3+ HER2 2+ Patients on treatment PD NEW LESION 11 *3 patients are not shown: 122026 (IHC 2+), not assessed yet; 121011 (IHC 3+) and 121013 (IHC 3+) early clinical PD. Sartore-Bianchi et al., Lancet Oncology 2016
E R B B 2 C N V o r G E * 1 0 ^ -3 / m l p la s m a o r H E R 2 E C D (n g / m l) % P IK 3 C A o r T P 5 3 m u t a t e d a lle le s HER2 blockade secondary resistance 2 0 0 G E * 1 0 ^ -3 / m l p la s m a E R B B 2 C N V Patient 1 2 1 0 0 6121006 -P O Z Z I 5 0 H E R 2 E C D P IK 3 C A H 1 0 4 7 R 4 0 T P 53 R 17 5H 1 5 0 3 0 2 0 1 0 0 1 0 4 3 5 0 2 1 0 0 2 4 6 1 0 1 2 1 4 1 6 1 9 2 1 2 3 2 4 2 5 2 7 2 9 3 2 3 8 4 0 4 2 4 4 4 6 4 8 5 0 5 2 5 4 5 6 5 8 N G S 6 0 6 2 0 Siravegna et al., Unpublished
HER2 CNA or ERBB3 % mutated alleles TP53 % mutated alleles or GE*10^-3/ml plasma HER2 blockade secondary resistance 16 14 12 10 ERBB2 CNV GE*10^-3/ml plasma ERBB3 L652W ERBB3 E928G TP53 G105V Patient 122025 100 90 80 70 60 8 50 6 4 2 40 30 20 10 0 0 4 6 8 10 12 14 16 18 20 22 24 28 30 32 36 38 40-PD 42-PD weeks of Trastuzumab+lapatinib treatment 0 Siravegna et al., Unpublished
Actionable targets in CRC crizotinib MET ALK Lapatinib trastuzumab HER2 cetuximab panitumumab EGFR TRKA entrectinib Wnt 1 Porcupine inhibitor Anti RSPO Ab RSPO LRP5/6 Frizzled LGR4-6
CRC patient: ALK translocated 4X 20X 60X CRC patient: NTRK1 translocated 4X 20X 60X Medico et al., Nature Commun 2015
Targeting translocated NTRK1 in CRC B LMNA-NTRK1 Sartore-Bianchi et al., JNCI 2016
Monitoring NTRK1 blockade in cfdna Russo et al., Cancer Discovery 2016
TRKA resistance mutations
Cetuximab Panitumumab Anti EGFR therapy in colorectal cancer Ligand EGFR EGFR/ErbB2/ ErbB3/ErbB4 P P Cytoplasm RAS PI3K RAF AKT MEK ERK Cell Proliferation Survival Migration Nucleus
% mutated alleles Monitoring EGFR blockade in cfdna Misale et al., Nature 2012 Siravegna et al., Nat Med 2015
Mechanism (1) Downstream signaling reactivation EGFR p.v600e p.g12d p.g13d p.g12r p.g12c p.k117n p.a146t BRAF KRAS NRAS p.g12d p.g13d p.g12c p.q61r MEK p. K57N Approx 70% of patients ERK
Mechanism (2) Mutations of the target: EGFR ECD EGFR S492R EGFR R451C EGFR S464L EGFR G465R EGFR K467T EGFR I491M S492K467 I491 G465 S464 R451 EGFR Approx 30% of patients
Resistance to EGFR blockade drives lesion-specific responses in colorectal cancer
MAP2K1 K57T emerges during to EGFR blockade TP53 p.e171* MAP2K1 p.k57t TISSUE SAMPLES TP53 RAS/RAF MAP2K1 Primary Tumor, 2011 Liver metastasis (pre-cetux), 2012 Post-cetux progression liver biopsy, 2014 p.e171* WT WT p.e171* WT WT p.e171* WT p.k57t
Clonal evolution and lesion-specific responses Panitumumab + trametinib (5 months) MEK1 p.k57t? Russo et al., Cancer Discovery 2016
Clonal evolution and lesion specific response in cfdna
Tracing cancer s evolutionary trees with liquid biopsies Russo and Bardelli submitted
What are we up against?
First cell: 4 billion years Mass extinction events Bottlenecks
Tumor evolution and targeted therapies Response to therapy Resistance to therapy
Liquid biopsies to monitor cancer evolution 1. Exploiting clonal evolution 2. Therapies that adapt to tumor evolution
-1- Exploiting clonal evolution
% mutated alleles What happens to resistant clones upon progression? Baseline Par al Response Progressive disease
KRAS clones decline upon withdrawal of EGFR antibodies Siravegna et al., Nature Medicine 2015
When KRAS clone decline in blood, re-challenging with anti-egfr antibodies can be clinically effective CHRONOS
% mut RAS clones CHRONOS 1 st line including anti-egfr RAS Baseline 2 nd line rechallenge Mutational Load (BML) RAS Intermediate Mutational Load (IML) RAS Rechallenge Mutational Load (RML) time Tumor sensitivity to anti-egfr sensitive resistant Andrea Sartore Bianchi, Salvatore Siena, Silvia Marsoni
-2- Therapies that adapt to tumor evolution
EGFR ECD resistant mutations EGFR S492R EGFR R451C EGFR S464L EGFR G465R EGFR K467T EGFR I491M S492K467 I491 G465 S464 R451 EGFR Sabrina Arena and Clara Montagut Approx 30% of patients
Emergence of RAS or EGFR extracellular domain mutations and duration of response to EGFR blockade All (N=27) EGFR only (N=7) RAS only (N=13) EGFR + RAS (N=7) Male Sex (%) 13 (48%) 5 (71%) 6 (46%) 2 (29%) Age (median, range) 60 (31-81) 64 (44-78) 59 (42-81) 55 (31-78) Anti-EGFR drug Cetuximab 23 (85%) 6 (86%) 11 (85%) 6 (86%) Panitumumab 4 (15%) 1 (14%) 2 (15%) 1 (14%) Irinotecan -based 20 (74%) 4 (57%) 10 (77%) 6 (86%) Chemotherapy Oxaliplatin -based 4 (15%) 2 (29%) 1 (8%) 1 (14%) None 3 (11%) 1 (14%) 2 (15%) 0 1st 5 (19%) 2 (29%) 1 (8%) 2 (29%) Line of treatment 2nd 9 (33%) 2 (29%) 6 (46%) 1 (14%) > 3rd 13 (48%) 3 (42%) 6 (46%) 4 (57%) Best Response Stable Disease >16w 12 (44%) 1 (14%) 8 (62%) 3 (43%) Response 15 (56%) 6 (86%) 5 (38%) 4 (57%) Progression Free Survival Median (weeks; 95% CI) 39.1 (33-46) 45 (42-48) 25.6 (24-27) 38.7 (21-56) Clara Montagut
Emergence of RAS or EGFR extracellular domain mutations and duration of response to EGFR blockade Van Emburgh et al submitted
EGFR ECD mutations appear after K-RAS clones during EGFR blockade Van Emburgh et al submitted
Dynamics of RAS and EGFR-ECD clonal evolution in cancer cells populations Baseline 1 Month 2 Months 3 Months 4 Months 6 Months NRAS G12C NRAS G12C+EGFR S492R 0.5-5% <0.5%
MM-151 and EGFR ECD mutations Arena et al., Science Transl Med 2016
MM-151 on patient s avatar
MM-151 and EGFR ECD mutations EGFR ECD TRIAL
In blood veritas DiAGNOSIS: genotyping cfdna in the blood to determine the tumor profile SURGERY: tumor cfdna is not present, the patient is disease free RESISTANCE: emergence of genetic alterations associated with drug resistance MINIMAL RESIDUAL DISEASE: tumor cfdna is still present in the circulation FOLLOW UP: patient monitoring throughout the treatment course to assess response and resistance TREATMENT: analysis tumor cfdna for real time monitoring of response to treatment
Monitoring tumor evolution Russo and Bardelli
Josep Tabernero Ryan Corcoran Silvia Marsoni Cosimo Martino Salvatore Siena Andrea Sartore Bianchi Mauro Truini Emanuele Valtorta Federica Di Nicolantonio Livio Trusolino Andrea Bertotti Enzo Medico Clara Montagut Beatriz Bellosillo Gary Li Sabrina Arena Giulia Siravegna Benedetta Mussolin Carlotta Cancelliere Simona Lamba Luca Lazzari Giovanni Germano Beth Van Emburgh Giorgio Corti Ciovanni Crisafulli Michela Buscarino Alice Bartolini Mariangela Russo Sandra Misale