Histology in the Decision-making Process Giorgio V. Scagliotti University of Torino Department of Clinical & Biological Sciences giorgio.scagliotti@unito.it Lung Cancer Four Main Histological Subtypes Squamous Cell Carcinoma Adenocarcinoma Large Cell Carcinoma Small Cell Carcinoma Travis WD et al. WHO Classification of Lung Tumors 2004 1
Lung Cancer Clinical Distinction for Therapy Non-Small Cell Lung Cancer Squamous Cell Carcinoma Adenocarcinoma Large Cell Carcinoma Small Cell Lung Cancer Lung Cancer Clinical Distinction for Therapy Non-Small Cell Lung Cancer Similarities in Biological Behaviour & Clinical Outcomes Same Chemotherapy Options Squamous Cell Carcinoma Adenocarcinoma Large Cell Carcinoma Small Cell Lung Cancer 2
Relative Contribution of Prognostic Factors in NSCLC Prognostic Information I=Institution; H=Histology; TS=Tumor size WL=Weight loss; ED=Extent of disease; PS=Performance Status Stanley KE JNCI 1980; 65:25 Efficacy Plateau of Cytotoxic Chemotherapy in NSCLC Study Drugs # Pts %, St. IV %, ORR MST %, 1-YS Kelly,2001 SWOG 9503 Vnr/Cis Tax225/Cb 202 208 88 89 28 25 8 8 33 36 Schiller,2002 ECOG 1594 Tax135/Cis Gem/Cis Txt/Cis Tax225/Cb 292 288 293 290 89 86 86 86 21.3 21 17.3 15.3 8.1 8.1 7.4 8.3 31 36 31 35 Scagliotti,2002 ILCP Vnr/Cis Gem/Cis Tax225/Cb 201 205 201 81 81 82 30 30 32 9.5 9.8 9.9 37 37 43 Belani,2002 TAX 326 Vnr/Cis Txt/Cis TxT/Cb 404 408 402 67 67 67 25 32 24 10.1 11.3 9.4 41 46 38 3
Scagliotti G et al. J. Thorac. Oncol. 2009;4:1568 Retrospective Analysis of a 3-Arm Randomized Trial Pairwise Comparisons for Survival (P-values) Squamous Adenocarcinoma Large cell Other Squamous (N=187) - 0.0021 0.1607 0.9724 Adenocarcinoma (N=310) - 0.6953 0.0239 Large cell (N=45) - 0.2090 Other (N=65) - Squamous histology was associated with longer overall survival than adenocarcinoma To a lesser extent, other histology was associated with longer survival than adenocarcinoma Scagliotti G et al. J. Thorac. Oncol. 2009;4:1568 4
Retrospective Analysis by Histology in ECOG 1594 Regardless of histology types, overall survival and progression-free survival were similar in chemo-naive patients treated with standard platin-based doublets involving paclitaxel, docetaxel or gemcitabine Tien H, Dahlberg S, Schiller J, Johnson DJ., J. Thorac. Oncol. 2009; 4 (9 suppl.):s493 Prognostic & Predictive Role of Histology in Advanced NSCLC A literature search of the last 25 years of publications in NSCLC including phase II-III clinical trials, meta-analyses and retrospective reviews revealed : 11 reports found some degree of association between histology and prognosis In 7 reports histology predicted outcomes in patients treated with specific chemotherapeutic agents A prognostic/predictive role of histology was reported in 12 studies with EGFR TKis Hirsch F., Novello S. et al. JTO 2009 5
Critical Issues with Lung Cancer Histology Relevance of histopathological subtyping of lung cancer Subtyping problems in small samples (biopsies or FNA cytology) Role of immunohistochemical markers Tissue identification of prognostic and predictive factors (potentially useful for selecting therapy) Critical Issues with Lung Cancer Histology Relevance of histopathological subtyping of lung cancer Subtyping problems in small samples (biopsies or FNA cytology) Role of immunohistochemical markers Tissue identification of prognostic and predictive factors (potentially useful for selecting therapy) 6
CISCA - IPD Meta-analysis Ardizzoni A. et al. JNCI 2007;99:847 Histological Subtype of NSCLC and Chemotherapy Selection Adenocarcinoma Pemetrexed (non-squamous) UFT (adenocarcinoma) EGFR TKIs (?papillary & BAC ) Squamous cell carcinoma IGFR inhibitors Bevacizumab contraindicated 7
Carboplatin + Paclitaxel ± Bevacizumab in Advanced NSCLC (ECOG 4599): Survival by Histology Subtype Baseline characteristics Total N PC (n=444) N Median (months) PCB (n=434) N Median (months) HR 95% CI All patients 878 444 10.3 434 12.3 0.80 0.69 0.93 Histologic type Adenocarcinoma 602 302 10.3 300 14.2 0.69 0.58 0.83 Large cell 48 30 8.7 18 10.0 1.15 0.60 2.24 Squamous 3 2 12.3 1 22.4 0.00 0.00 BAC 23 11 17.7 12 10.0 1.48 0.57 3.69 NSCLC, NOS 165 86 10.0 79 9.5 1.16 0.84 1.61 Other 34 11 12.6 23 8.4 0.92 0.43 1.98 BAC = brochioalveolar carcinoma; NOS = not otherwise specified; PC = paclitaxel + carboplatin; PCB = paclitaxel + carboplatin + bevacizumab Sandler A, et al. Proc IASLC Chicago 2008 Study Design Stage IIIB/IV NSCLC PS 0-1 No prior chemo Randomization: gender, PS, stage, histo vs cyto dx, brain mets R Pemetrexed 500 mg/m 2 + Cisplatin 75 mg/m 2 day 1 Primary objective: Overall Survival 15% Non-inferiority margin (HR 1.17) N = 1700 Patients, Power 80% Gemcitabine 1250 mg/m 2 + Cisplatin 75 mg/m 2 day 1; Gemcitabine 1250 mg/m 2 day 8 B12, folate, and dexamethasone given in both arms Scagliotti GV et al. JCO 2008; 26:3543 8
Pre-Specific Subset Analyses Randomization Factors plus.. Age Group Ethnicity Smoking Status Histology 17 Thymidilate Synthase Expression in Normal Lung Tissue & Lung Cancer Snap Frozen Tissues FFPE Tissues TS mrna levels Significantly Higher in Lung Cancer than in normal lung tissue Significantly Higher in Squamous Cell Carcinoma of the Lung Ceppi P. et al. Cancer 2006 9
Cis/Pem vs. Cis/Pem : Subgroup Analyses Scagliotti GV et al. JCO 2008; 26:3543 Efficacy by Histology in Pemetrexed Studies NSCLC Histologic Group Second-line Pem vs. Docetaxel First-line Pem/Cis vs. Gem/Cis Maintenance Pem vs. Placebo Pem Doc Cis/Pem Cis/Gem Pem Placebo Non-squamous n=205 n=194 n=618 n=634 n=325 n=156 Median OS, months 9.3 8.0 11.0 10.1 15.5 10.3 Adjusted HR (95% CI) P value 0.78 (0.61 1.00) 0.048 0.84 (0.74 0.96) 0.011 0.70 (0.56 0.88) 0.002 Squamous n=78 n=94 n=244 n=229 n=116 n=66 Median OS, months 6.2 7.4 9.4 10.8 9.9 10.8 Adjusted HR (95% CI) P value 1.56 (1.08 2.26) 0.018 1.23 (1.00 1.51) 0.050 1.07 (0.77 1.50) 0.678 Non-squamous = adenocarcinoma, large cell carcinoma, and other/indeterminate NSCLC histology Scagliotti GV, et al. Oncologist 2009 10
Meta-Analysis of Postoperative Adjuvant CT with Tegafur-Uracil in NSCLC Hamada C. et al. JCO 2005; 23:4999 Critical Issues with Lung Cancer Histology Relevance of histopathological subtyping of lung cancer Subtyping problems in small samples (biopsies or FNA cytology) Role of immunohistochemical markers Tissue identification of prognostic and predictive factors (potentially useful for selecting therapy) 11
Biopsy Techniques in Lung Cancer Diagnosis Sputum cytology Bronchial brushings and washings Fluids FNA cytology primary or mets Transbronchial biopsy Bronchial biopsy Core biopsy primary or mets Liver biopsy Mediastinoscopy Lymph node excision VATS biopsy / resection Thoracotomy & tumour excision Increase in Cell number and Tissue architecture Kerr K., 2008 Critical Issues with Lung Cancer Histology Relevance of histopathological subtyping of lung cancer Subtyping problems in small samples (biopsies or FNA cytology) Role of immunohistochemical markers Tissue identification of prognostic and predictive factors (potentially useful for selecting therapy) 12
Immunohistochemistry of Lung Cancer IHC is the most rapid (1 day) and less expensive method (2-8 euro x reaction) to display cell differentiation when morphology cannot distinguish clear-cut criteria IHC TTF-1 + Poorly-differentiated NSCLC??? Poorly-differentiated adenocarcinoma Immunohistochemistry of Lung Cancer TTF-1 Surfactant Apoproteins (A & B) Napsin A p63 HMWCK (CK5-6, 34βE12) Desmocollin 3 CK 7 ADENOCARCINOMA SQUAMOUS CELL CARCINOMA 13
H&E TTF-1 p63 NSCLC on H&E ê SQC at IHC NSCLC on H&E ê ADC at IHC Lung Cancer Diagnosis (Bx and/or Cx) (1999/2004) Malignant Cancer NSCLC (2009) NSCLC SCC Poorly diff. NSCLC ADC If clinically relevant - IHC (CK5/6, 34bE12, p63, DSC-3, TTF-1) - (Mucin stain) - Expert referral - Another sample TTF-1, (mucin +ve), others ve.. favours ADC TTF-1, (mucin ve), others +ve.. favours SQC Architecture (pap/acinar/solid) Grade CLINICAL DATA IMAGING DATA 14
Critical Issues with Lung Cancer Histology Relevance of histopathological subtyping of lung cancer Subtyping problems in small samples (biopsies or FNA cytology) Role of immunohistochemical markers Tissue identification of prognostic and predictive factors (potentially useful for selecting therapy) Inhibition of Folate Enzymes by Pemetrexed, Raltitrexed, and Methotrexate Compound TS (nm) DHFR (nm) GARFT (nm) Pemetrexed 109 ±9.0 7.0 ±1.9 9,300 ±690 Pemetrexed Glu5 1.3 ±0.3 7.2 ±0.4 65 ±16 Raltitrexed 6.0 ±0.9 45 ± 3 424,000 Raltitrexed Glu5 1.4 ±0.1 30 ± 3 132,000 Methotrexate 13,000 0.004 80,000 MTX Glu5 47 0.004 2,500 Shih et al. Cancer Res 57:1116-1123, 1997 Chabner et al. J Clin Invest, 76:907-912, 1985 15
Classification of Human Lung Carcinomas by mrna Expression Profiling Reveals Distinct Adenocarcinoma Subclasses SCLC Very High TS ; Squamous Intermediate TS, Adenocarcinoma Low TS Bhattacharjee A et al. PNAS 2001; 98:13790 TS mrna Expression in Lung Cancer (n=146) 5 TS relative mrna levels 4 3 2 1 0 ADC SCC non-ne LCC LCNEC SCLC Scagliotti GV et al. Poster Discussion ASCO 2009 - Abstract # 7521 16
Correlations Between DSC3 Staining and TS Expression Levels in Large Cell Carcinoma of the Lung 100 P=0.018 90 TS protein expression levels 80 70 60 50 40 30 20 10 0 Negative Positive DSC3 protein expression Phase III Study ED-SCLC Pemetrexed/Carboplatin vs Etoposide/ Carboplatin Socinski MA. JCO 2009;27:4787 17
TS Immunoreactivity in Cytological NSCLC-NOS Cytological sample Histological sample TS negative TS positive Gene Expression According to Histology Squamous Cell Carcinoma Median (range) Adenocarcinoma Median (range) P value ERCC1 1.41 (0.45-7.34) 0.72 (0.23-2.45) 0.0001 MZF1 0.62 (0.06-6.72) 0.25 (0.03-1.49) 0.0001 Twist 10.37 (0.30-76.01) 2.50 (0.14-19.16) 0.0001 RRM1 2 (0.6-6.9) 1.2 (0.4-2.9) 0.0001 TRX 2.13 (0.40-11.88) 0.91 (0.31-7.94) 0.0001 Tpd1 1.7 (0.6-7.3) 1.3 (0.1-2.6) 0.02 NFAT 0.4 (0.1-2.3) 0.5 (0.1-1.8) 0.65 BRCA1 4.26 (0.55-18.48) 1.50 (0.09-8.08) 0.0001 BubR1 16.3 (1.4-90) 7 (0.8-25) 0.0001 Rosell R. et al. PLoS ONE 2:e1129 18
Are Other Genomic Markers Differentially Expressed in NSCLC? Author Squamous Adenocarcinoma P Value Olauseen, NEJM 2006 ERRC1 Positive * 70% 45% ERCC1 Negative * 21% 40% Zheng, NEJM 2007 Median ERCC1** 56.8 (1.9-178.7) Median RRM1 ** 62.3 (13.2-96.2) 68.0 (6.6-153.1) 40.5 (8.3-95.1) 0.001 * H Score (semiquantitative IHC) ; ** AQUA Scores Five Gene Signature and Outcome in NSCLC High-risk Low-risk P value Original Cohort (n=101) Adenocarcinoma 61% 36% 0.03 Squamous Cell Ca. 32% 47% Others 7% 17% Validation Cohort (n=60) Adenocarcinoma 32% 50% 0.19 Squamous Cell Ca. 59% 42% Others 9% 8% Chen HY et al. NEJM 2007; 356:11 19
hsa-mir-205 Expression Distinguishes Squamous From Non-Squamous NSCLC MicroRNA expression levels in 122 adenocarcinoma and squamous cell carcinoma qrt-pcr platform in an independent dataset of 20+27 NSCLC FFPE samples Assay validated in a blinded cohort of 79 NSCLC FFPE samples Hsa-miR-2005 highly specific marker for SCC of the lung Cut-off score of 2.5, sensitivity 96%, specificity 90% Lebanovy D et al. JCO2009; 27:2030-37 Conclusion Histologic subtyping should be taken into account in making treatment decisions WHO classification should remain the common language for exchanging information and treatment decision. There are cheap ways to separate squamous from non squamous histology also in limited cytological samples. The use of pharmacogenomic markers holds the promise to improve results of cytotoxic chemotherapy Mandatory need of histology (pharmacogenomic) - driven prospective trials in any stage of NSCLC 20
Biomarkers, Prognostication and Prediction EGFR gene mutations BRCA1 mrna PCR TS protein IHC RRM1 mrna PCR EGFR amplification FISH Selected gene Expression signatures ERCC1 mrna PCR p27kip1 protein IHC ERCC1 protein IHC KRAS gene mutation What s Next? TS mrna PCR SerpinB3 protein IHC EGFR protein IHC cmet amplification FISH P53 protein IHC RRM1 protein IHC SerpinB3 mrna PCR Cis/Pem vs. Cis/Pem : Overall Survival Scagliotti GV et al. JCO 2008; 26:3543 21
Second -Line Study of Pemetrexed vs. Docetaxel : Efficacy by Histology Non-squamous group Pemetrexed (n=205) Docetaxel (n=194) Squamous group Pemetrexed (n=78) Docetaxel (n=94) % ECOG PS 2 12.5 10.1 8.3 17.4 % TSPC <3 months 51.0 51.0 48.7 41.9 % Stage IV 81.5 78.9 57.7 66.0 % Male 60.5 69.1 89.7 88.3 Median OS, months 9.3 8.0 6.2 7.4 Adjusted OS HR (95% CI) 0.778 (0.607, 0.997) 1.563 (1.079, 2.264) Median PFS, months 3.1 3.0 2.3 2.7 Adjusted PFS HR (95% CI) 0.823 (0.664, 1.020) 1.403 (1.006, 1.957) Treatment by Histology Interaction: Survival Adjusted for Cofactors (p=0.001) Peterson P. et al. 12 th World Conference on Lung Cancer 2007 Double-blind, Placebo-controlled Phase III Trial of Maintenance Pemetrexed : Efficacy by Histologic Groups Median PFS, mos CR+PR+SD*, % Prelim Median OS, mos Pem Plac p-value Pem Plac p-value Pem Plac p-value Nonsquamous (n=482) Adeno (n=329) Large cell (n=20) Other (n=133) Squamous (n=181) 4.37 1.84 <0.00001 54.3 26.6 <0.001 14.4 9.4 0.005 4.60 2.66 <0.00001 58.2 29.6 <0.001 16.4 11.7 0.091 4.53 1.45 0.104 30.0 25.0 0.999 9.1 5.5 0.154 4.11 1.58 0.0001 47.5 18.9 0.004 11.3 7.0 0.005 2.43 2.50 0.896 33.3 34.5 0.999 9.6 11.9 0.231 * Clinical response (CR+PR+SD) was significantly improved with pemetrexed vs placebo in the intent-to-treat population (49% vs 29%, p <0.001). Ciuleanu T. et al. Proc. ASCO 2008 22
Carbo/Etoposide vs. Carbo/Pemetrexed in ED-SCLC: Interim PFS Analysis Probability Without Event Median (95% CI) Pem-Cb: 3.68 (3.38, 4.2) Eto-Cb: 5.32 (5.03, 5.85) Log rank p<.0001 PFS HR = 1.79 (90% CI: 1.49, 2.15) Patients at risk Pem-Cb: 364 199 92 21 6 1 0 Eto -Cb: 369 220 140 52 13 1 0 Socinski M. et al. Proc. ASCO 2008 23