07 Marsoni

09,00 – 13,40
I Sessione
Moderatori:
Giordano Beretta, Roberto Labianca
11,00 – 11,20
Ca colon retto:
prospettive di ricerca
Silvia Marsoni
Ca Colon-retto: prospettive di ricerca
SilviaMarsoni,MD
Director Clinical Research Office,FPO-IRCCSCandiolo,Italy
CRC is a ‘difficcult’ tumor for precision medicine
•
The 2 more frequently mutated genes - KRAS and NRAS - are un-targetable
•
Pts with the targetable BRAF V600Emut do NOT respond to BRAF inhibitors
•
The only targeted gene – EGFR - is NOT mutated NOR amplified g ORR < 20%
The only tumor type in which target therapy
is prescribed by subtraction!
…NOT in KRAS… NOT in NRAS… NOT in RAF …
Targeting primary and secondary resistances in mCRC
Livio Trusolino
Andrea Bertotti Fed Dinicolantonio
ESTABLISH
Renzo
Cappussotti
patient- derived
xenografts
(n ~500 patients)
MINE
Drivers of
PRIMARY RESISTANCE in PDXs
VALIDATE
DRIVERS as TARGETS
In PDX trials
Sal Siena
GO to BENCH
GO to CLINIC
With new hypotheses
generated
by clinical data
PROOF of CONCEPT
TRIALS
PM Comoglio
in target-enriched patients
The mCRC AIRC team
MEASURE
ctDNA to understand
SECONDARY RESITANCE in MAN
Alberto Bardelli
Silvia Marsoni
MINIG the xenopatients (PDX) for new targets in mCRC
Placebo
Evaluation time-point at
three weeks
Cetuximab
20 mg/kg twice-weekly
Evaluation time-points at
three and six weeks
Placebo
Evaluation time-point at
three weeks
p0
Cetuximab
engraftment
(2 mice)
SURGERY
p1
expansion
(4-8 mice)
p2
treatment
(12-24 mice)
Livio Trusolino and Andrea Bertotti
20 mg/kg twice-weekly
Evaluation time-points at
three and six weeks
Primaryresistance
HER2amplification
Effect of cetuximab treatment on growth of in mCRC PDXs
tumours with different somatic alterations
HER2amplification
HER2 amplification
In xenopatients…..
Complete disappearance of tumor
with a combination of
Lapatinib and trastuzumab (but
not either drug alone)
In patients…..
70% Disease control rate
30% Objective Response rate (1 CR)
Long lasting responses in heavily pre-treated
chemorefractory, CET resistant PTS
HERACLES next steps (1)
3. Optimizing the anti HER2 strategy by combining
anti-HER2 target therapy to HER2-directed chemotherapy
Xenopatient CRC0186
TreatmentStart
The HERACLES B trial
TreatmentStart
TreatmentEnd
Bertotti and Trusolino
pertuzumab + T-DM1
in HER2+ 2nd line mCRC
Start June 2016
HERACLES next steps (2)
……..
and including HER2 mutations
NTRK traslocations
Basket trial by Ignita
In TRK,ALK,ROS traslocated PTS
START JUNE 2016
FUNNELmCRC-OncoCarta
LivioTrusolino,AlbertoBardelli,SilviaMarsoni
THEFUNNEL
TRIAL
HER2
Mult WT
ROS-TRK-ALK
IGF2
Funnel (1) a precision medicine platform for
molecular-driven trials
LiquidBiopsy
Clinical Data
Radioimaging
POCtrial
forX
Mutation X
Funnel sorting
at metastatic disease
diagnosys
POCtrial
forK
Amplification K
Mutation Y
POCtrial
forY
POCtrial
forT
Amplification T
Deletion Z
POCtrial
forZ
TIME:lines oftreatment
Funnel (2) a precision medicine platform for
translational discovery
OUTLIERS
TUMOR HETEROGENEITY
TUMOR EVOLUTION
Secondary resistance
HER2
RAS
Patients progressing under anti HER2 therapy are still HER2 positive
Before
HERACLES
pt.121019
Biopsy
at relapse
#121001
Lung mts 40x
Liver mts 200X
Liver mts 40X
Cerebellum mts 100X
#121003
HER2amplification inplasmadetected byddPCR
HER2detection withIHC(VENTANA®)intumoursamples
before andafter lapatinibandtrastuzumab
Courtesy ofL.BandieraandE.Valtorta
HER2 secondary resistance
2. Precision chemotherapy to overcome secondary
resistance in HERACLES progressing patients
HER2+tumoractsas‘molecularsponge’for
HER2immunoconjugates (T-DM1)
PDXderivedfrombiopsyofprogressingliver
lesionofHERACLESpt.#121001
TheHERACLESRESCUE trial:T-DM1inHERACLESnonresponders
withdocumentedplasmaHER2positivectDNA
Startedwinter2016– Firstpatiententered=PR
RAS mediated secondary resistance to anti EGFR
Heat map of acquired
resistance mutations to
EGFR blockade in ctDNA
from patients with metastatic
CRC originally responding to
cetuximab
Bettegowda etal
Sci Transl Med2014
Siena & Bardelli 2014
20
Dual vertical targeting of the EGFR to ERK axis
CRC tumors resistant to anti-EGFR therapy show a characteristic
mutation pattern and respond to combined EGFR-MEK inhibition.
PDX derived from a liver biopsy of a
mCRC patient progressing after response to cetuximab
Misale etAl.Sci Transl Med 2014
control
CET
MEKI
combo
21
SEMIRAMIS trial – preventing RAS mediated resistance
mCRC chemo-resistant, quintuple-negative EGFR naïve patients.
basal
2WKS
…TumorassessmentRECISTq8WKS…
4WKS
8WKS
16WKS
24WKS
32WKS
N..WKS
Informedconsent
Imagingguided
biopsy
if possible
ETSlandmarkassessment
Imagingguided
biopsy
if possible
MEKi +cetuximab
All
Patientwithanytumorshrinkageonly*
PD
MARKERS
BLOOD:ctDNA (q2Wks)
BLOOD:PKfortroughlevel(cycle1day15)
FFPE ofTumorand/orMetastases(includingprimary):
Mutations:KRAS;NRAS;BRAF;PIK3CA;Amplifications:KRAS,MET&HER2
Planned START November 2016
Marsoni, Siena, Sartore-Bianchi, Bardelli 2015
Exploiting RAS ctDNA findings as a rationale for
cetuximab re-challenge in ‘multiple WT’ mCRC
CHRONOS trial
anti EGFR rechallenge in multiple WT patients
developping RAS mediated resistance
Planned START
October 2016
Marsoni, Siena, Sartore-Bianchi, Bardelli 2016
BRAFMUT
HER2MUT
HER2AMPL
MODUL
3° line
RASextended MUT
2° line
Funnel sorting
at mDiagnosis
1° line
Funnel-embedded trials
ARETHUSA
NEDD8
VEMURAFENIB
HERACLES3
(>2)HERACLESB HERACLESR
ROS/ALK/TRK
STARTRK2
MULTIPLEWT
SEMIRAMIS
MULTIPLEWT
IFIGENIA
MULTIPLEWT
CHRONOS
Next …
Precision immunotherapy
Pembrolizumab (anti PD1) is active
only in in MMR deficient patients
Le et Al. NEJM (2015)
High mutational load only in MMR
deficient tumors
The Cancer Genome Atlas Network
Nature 487, 330-337 (2012)
Less than 5% of mCRC patients is MMR deficient (MSI-H)
Can we make MMR proficient tumor become MMR deficient?
We are working on it! Stay tuned…..
Conclusions
In colorectal cancer: yes, we can!
TheScientists
Thewhoiswho
ofthemCRCresistancesprojects
The‘services’back-bone
CTU- Candiolo
SilviaMarsoni
CosimoMartinoPM
AntonellaBalsamoPM
MarioSpionePM
Marilì VitielloDM
Genetic Lab– Vicenza
Translational Cancer Med.
LivioTrusolino
AndreaBertotti
Oncogenomic
EnzoMedico
ClaudioIsella
7 Core centers
Molecular Oncology
AlbertoBardelli
GiuliaSiravegna,
SandraMisale
Cancer Epigenetics
FedericaDiNicolantonio
LudovicBarault
TheClinical
Network
Chair: Salvatore Siena
AnatomiaPatologica
AnnaSapino
MassimoTruini (NCC)
SandroVeronese(NCC)
PaolaCassoni(Molinette)
Radiomics
ChirurgiaOncologica
DanieleRegge
MicheleDeSimone
AngeloVanzulli (ONCG)
AndreaMuratore
AlessandroFerrero(Mauriziano)
LASCandiolo
Structure-informatics
AlexFiore
TheBIG Candiolo
(Bionformatics)
NiguardaCancer Center
AndreaSartore-Bianchi
Molinette
PatriziaRacca
FPO-IRCCs
FrancescoLeone
IOV-Padova
VittorinaZagonel
SaraLonardi
Bologna
AndreaArdizzone
Roma
GiuseppeTonini
Napoli
FortunatoCiardiello
6
Associated
centers
backups
FUNNELbackbone
Metastatic
disease
diagnosis
Time course of disease in each patient
*if possible,original primary tumourFFPEmustalso berecovered
§ NOTMANDATORY
FUNNELdesign:S.Marsoni,A.Bertotti,A.Bardelli,L.Trusolino
FUNNELdesign:S.Marsoni,A.Bertotti,A.Bardelli,L.Trusolino
Overexpressedkinasegenesare
therapeutictargetsinCRC
Overcoming acquired resistance to Lapatinib and Trastuzumab
RR251239
DM240847
RR251239
DM 240847
V e h ic le
) ±S E M
800
T ra s tu z u m a b -L a p a tin ib
3000
3
T u m o r V o lu m e ( m m
T u m o r V o lu m e ( m m
V e h ic le
4000
T ra s tu z u m a b -L a p a tin ib
3
) ±S E M
1000
600
400
200
0
2000
1000
0
0
1
2
3
4
w e e ks
5
6
7
8
0
1
2
3
4
5
6
7
8
w e e ks
Alessandro Magrì and Alberto Bardelli
What next?
Stay tuned…..
T-DM1 is effective in overcoming acquired resistance to lapatinib
and trastuzumab in two HERACLES-patient derived xenografts
pt.121001
pt.121003
RR251239
DM 240847
V e h ic le
) ±S E M
800
T ra s tu z u m a b -L a p a tin ib
3000
3
T u m o r V o lu m e ( m m
T u m o r V o lu m e ( m m
V e h ic le
4000
T ra s tu z u m a b -L a p a tin ib
3
) ±S E M
1000
600
400
200
0
2000
1000
0
0
1
2
3
4
w e e ks
5
6
7
8
0
1
2
3
4
w e e ks
5
6
7
8
Therapeuticinterventioninpreclinicaltrials
toovercomeresistancetoanti-EGFRantibodyblockade
HERACLES as an example of Precision Medicine in CRC
PDXMolecularscreening
Retrospectivevalidation
Functionalvalidation
HER2+DiagnosticCriteria
HERACLEStrialinHER2
amplifiedmCRCpatients
SomeCET-resistant tumorsareHER2amplified
HER2isamplifiedinCETresistantPTS
HER2NOTamplifiedinCETresponders
HER2+PDXsrespondtolapatinib+
trastuzumab,butnottoeitheragentalone
InKRASWTmCRCHER2isamplified in≈5%
HER2+casesareIHC3+/FISH+in>50%ofcells
30%ORR(1CR,2.5+yrs)inHER2patients
resistanttochemotherapy,bevacizumab&
cetuximab
Harness
vital tumors
from CRC pts
The precision medicine cycle in mCRC
The PROFILING
traslational platform
Establish
a LARGE PDX colony
MINE PDX
for putative drivers
Enrich the colony with
2ND resistance PDX
VALIDATE
drivers as targets
in driver-enriched
PDX
NGS of ctDNA
for drivers of
aquired resistance
5 Ongoing/planned PoC trials
1 translational trial
Bardelli, Marsoni, Siena, Trusolino - 2015
Proof of concepts
TRIALS
In target enriched
populations
GENOTYPE
PATIENTS with
mCRC
ONCOCharta
The FUNNEL
Traslational platform
Funnel backbone
Time course of disease in each patient
Metastatic
disease
diagnosis
FUNNELIC
&registration
Any metastatic firstline
New
treatment
commence
CR/PRor
SD>4mos
relapse
Newsurgery or
biopsy
(if clinically indicated)
FFPE*
ü
PLASMA
New
treatment
commence
CR/PRor
SD>4mos
relapse
After
3rd
line
Death
ü
FUP
q6mos.
CT-SCAN
CLINICALDATA
TISSUEBIOPSY§
Any metastatic second line
andsoon..
ü
*if possible,original primary tumourFFPEmustalso berecovered
§ NOTMANDATORY
FUNNELdesign:S.Marsoni,A.Bertotti,A.Bardelli,L.Trusolino
TheWHOisWHOof
mCRCAIRC5x1000projects
The‘services’back-bone
CTU- Candiolo
SilviaMarsoni
CosimoMartinoPM
AntonellaBalsamoPM
MarioSpionePM
Marilì VitielloDM
Genetic Lab– Vicenza
AnatomiaPatologica
AnnaSapino
MassimoTruini &SandroVeronese (NCC)
PaolaCassoni(Molinette)
ChirurgiaOncologica
AndreaMuratoreIRCC
AlessandroFerrero
(Mauriziano)
Radiomics
DanieleRegge
AngeloVanzulli (NCC)
LASCandiolo
Structure-informatics
AlexFiore
TheBIG Candiolo
(Bionformatics)
GiorgioCorti
TheScientists
Translational
CancerMedicine
LivioTrusolino
AndreaBertotti
Molecular Oncology
AlbertoBardelli
GiuliaSiravegna
Oncogenomic
EnzoMedico
ClaudioIsella
Cancer Epigenetics
FedericaDiNicolantonio
LudovicBarault
7 Core Centers
Chair: Salvatore Siena
TheClinical
Network
NiguardaCancer Center
AndreaSartore-Bianchi&AlessioAmatu
Molinette
PatriziaRacca
FPO-IRCCs
FrancescoLeone
IOV-Padova
VittorinaZagonel
SaraLonardi
Bologna
AndreaArdizzone
Roma
GiuseppeTonini
Napoli
FortunatoCiardiello
6
Associated
centers
Colon Cancer is a diseases of many genes
Before: one disease
Today: many different forms of colon cancer
driven by different molecular defects – with
more to be identified
Colorectal
cancer
41
Frommantomouse
Schematicdiagramofintegratedgenomicandtherapeutic
analysesinmCRCpatient-derivedxenografts
Diversityandfrequencyofgeneticchangesleadingto
deregulationofsignallingpathwaysinCRC.
The Cancer Genome Atlas Network Nature 487, 330-337 (2012) doi:10.1038/nature11252
Oncogenicaddiction
Mechanismsofsecondaryresistance
Next Generation Precision Medicine
studies in mCRC patients
targets
HER2
HERACLE S- R
FPI 8/2015
HERACLES B
Waiting approval
MEK
IGF2
EGFR
In all WT
tumors
CET naive
5 Negative
tumors
SD after CET
Rechallenge
in extended
RAS aquired
resistance
ERMES
IFIGENIA
YO-YO
Waiting
approval
In design
4 Precision Medicine trials
Waiting
approval
ctDNA
MethctDNA
CORNUCOPIA
FPI march 2015
CASTORE
In approval
2 Hypothesis Generating trials
Identificationofoutlierkinasegenesin
151CRCcelllines.
HER2 is an actionable biomarker of primary resistance
Quadruple WT
HER2 amplification
Patient
Xenopatient
FISH
HER2
CEP17
Waterfall plot in mCRC PDX treated with Cetuximab
New markers of resistance and sensitivity to antiEGFR
therapy in KRAS-WT mCRC xenopatients
Bertotti et al, Nature 2015
CetuximabscreeningonCRCcelllines.
Effect of anti-HER2 therapies in cetuximab-resistant, HER2-amplified
metastatic colorectal cancer xenopatients.
The combination, but not either drug alone, is effective
Bertotti A et al. Cancer Discovery 2011
FUNNEL is not just another Umbrella trial.
FUNNEL is a ‘backbone research omnibus’ in which each patient is genotyped at
diagnosis of metastatic disease, and then ‘biologically’ monitored via liquid biopsy
and radioimaging at therapeutic checkpoints (response/progression) until death.
FUNNEL is structured to:
• Collect longitudinally biological samples throughout the patient life-time.
• Embed independent or pharma sponsored trials for any line of treatment.
• Allow patients to hop-on and hop-off from back-bone to trial(s) and back.