Kathleen D. Danenberg Response Genetics, Inc. Predictive and Prognostic Markers for Gastric Cancer.
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Transcript of Kathleen D. Danenberg Response Genetics, Inc. Predictive and Prognostic Markers for Gastric Cancer.
Kathleen D. DanenbergResponse Genetics, Inc.
Predictive and Prognostic Markers for
Gastric Cancer
ERCC1
Why would a predictive test for
platinum efficacy be desirable?
Dank et al. Randomized phase III study comparing irinotecan combined with 5-fluorouracil and folinic acid to cisplatin combined with 5-fluorouracil in chemotherapy naive patients with advanced adenocarcinoma of the stomach or esophagogastric junction. Annals of Oncology. 2008; 19:1450-1457.
IF (n=170): irinotecan, folinic acid 5-fluorouracil;CF (n=163): cisplatin and 5-fluorouracil
Median TTPIF: 5.0 monthsCF: 4.2 months
Median OS:IF: 9.0 monthsCF: 8.7 months
Non-platin and platin therapy have similar outcomes
Irinotecan-5-FU Cisplatin-5-FU
Toxic deaths 0.6% 3%
Discontinuation for toxicity
10% 21%
Neutropenia gr. 3-4 25% 52%
Fever or infection 4.8% 10.2%
Thrombocytopenia 1.8% 11.7% (p=0.0003)
Diarrhea 21.6% 7.2%
Stomatitis 2.4% 16.9%
Neurotoxicity 5.4% 22.9%
Cardiovascular toxicity
2.4% 6.0%
…but non-platin treatment is less toxic: Comparative toxicity profiles
of CF and IF
Dank et al. Annals of Oncology. 2008; 19:1450-1457.
• “… Irinotecan/5-fluorouracil (IF) is a platinum-free regimen that has similar efficacy to cisplatin/5-fluorouracil (CF) but with improved tolerance.
• As such, IF could represent a potential platinum-free alternative backbone to be combined with new targeted agents to be explored for the treatment of metastatic gastric cancer.
Dank et al. Annals of Oncology. 2008; 19:1450-1457.
Conclusions
The platins react with DNA to form inter- and intra-strand
crosslinks
ERCC1 is part of the nucleotide excision repair complex that repairs platin crosslinks in DNA
30
40
50
60
70
80
90
% cell viability
cisplatin (4uM)
oxali (2 uM) carbo (20 uM)
control
siRNA
Pre-clinical studies show ERCC1 to be a direct determinant of
cisplatin efficacyERCC1 small interfering RNA expression reduces ERCC1 expression and sensitizes the cells to platinum-containing chemotherapeutic agents.
Youn et al. Oncogenic H-Ras Up-Regulates Expression of ERCC1 to Protect Cells from Platinum-Based Anticancer Agents Cancer Res 2004:64, 4849-4857.
ERCC1 gene expression in gastric cancer cells negatively correlates with
sensitivity to cisplatin.
ERCC1 mRNA expression levels and sensitivity to cisplatin in cells from malignant effusions collected from untreated gastric cancer patients (P= 0.014, r = 0.685).
Wang et al. ERCC1 and BRCA1 mRNA expression levels in metastatic malignant effusions is associated with chemosensitivity to cisplatin and/or docetaxel. BMC Cancer 2008;8:97.
Clinical Study
ERCC1 Threshold for Platin Sensitivity: Response Genetics
Scale
Percent Patients with Low
ERCC1 Benefit Ref
NSCLC: GILT (Platin Doublets) ERCC1<1.7 53 RR=53% Cobo et al JCO 2007
NSCLC: MADeIT (Platin Doublets) ERCC1<1.44 50
RR=44%, Increased Survival Sim et al JCO 2007
CRC: FOLFOX ERCC1<1.7 80
Increased Survival
and Response Shirota et al JCO 2001
CRC: FOLFOX Validation ERCC1<1.7 80
Increased Survival Lenz et al ASCO 2008
Gastric: 5-FU/Cis ERCC1<1.46 50Increased Survival Metzger et al JCO 1998
Gastric: FOLFOX ERCC1<1.79 64Increased Survival J Wei et al ASCO 2007
Gastric: FOLFOX ERCC1<2.2 80Increased Survival
J Wei et al British J of Cancer 2008
Gastric: Platin (S-1/Oxaliplatin) ERCC1<1.85 67
Increased RR and Survival
Matsubara et al British J of Cancer 2008
ERCC1 thresholds and benefit of low
ERCC1 from platin therapy
ERCC1 mRNA levels and response in gastric cancer patients receiving FP
Metzger R, et al. J Clin Oncol. 1998;16:309-316.
p=0.004 by Kruskal-Wallis test.
ER
CC
1 E
xp
ressio
n
20
16
12
8
4
0
Response No Response
ERCC1 mRNA levels and survival of advanced gastric cancer patients treated
with a FOLFOX regimen
Conclusion: “In patients with high mRNA levels of ERCC1, alternative chemotherapy regimens should be
considered.”
p<0.0001
Wei J et al. Br J Cancer. 2008;98:1398-402.
ERCC1 mRNA
Hazard ratio
Low (<0.47)
1
High (>0.47)
9.4 (p<0.0001)
Effect of ERCC1 protein expression on survival in FOLFOX chemotherapy of advanced gastric cancer
Overall survival curve according to ERCC1 expression measured by IHC (P
= 0.0396).
ERCC1 was the only significant independent prognostic factor impacted on OS (hazard ratio 1.91, P = 0.037).
Kwon et al. Ann Oncol. 2007;18:504-9.
Low ercc1
High ercc1
P value Hazard
Adjuvant therapy
47 mos. 7 mos. 0.01 2.77
Surgery only
12 mos. 33 mos. 0.038
Low ercc1
High ercc1
P value Hazard
Adjuvant therapy
undefined
13 mos. 0.007 2.68
Surgery only
21 mos. 43 mos. 0.004 0.18
Median RFS
Median OS
Yiu et al. ASCO 2010 abstract 29
Prediction of survival by ERCC1 expression in gastric cancer treated with surgery followed by FOLFOX or receiving surgery alone.
PELF = cisplatin (P), epirubicin (E), leucovorin (L), 5-fluorouracil (F)
Conclusion: “IHC studies for ERCC1 might be useful to predict the clinical outcome in MGC patients treated with PELF regimen.”
Median overall survival
low ERCC1 13 months
high ERCC1 9 months Log rank p=0.018
1-year survival rate
low ERCC1 62%
High ERCC1 21%
Natoli et al. J Clin Oncol 28, 2010 (suppl; abstr e14603)
ERCC1 expression and activity of PELF regimen as first-line treatment of metastatic gastric cancer.
Br J Cancer. 2008; 98: 832–839. Matsubara et al.
ERCC1expression and outcomes of advanced gastric cancer patients treated with cisplatin and S-1.
0.0
0.2
0.4
0.6
0.8
1.0
0 12 24 36 48 60 72 84 96
log-rank P < .001
Months since start of 1st-line chemotherapy
Pro
bab
ilit
y o
f su
rviv
al
Low ERCC1 and low DPD expression: median survival time, 15.5 monthsAny high expression: median survival time, 10.2 months
Impact of low ERCC1 and DPD on the outcomes of advanced gastric cancer.
Br J Cancer. 2008; 98: 832–839. Matsubara et al.
ASSIGNMENT
RANDOM
n=200, Endpoints: feasibility and increase of PFS
Genotypic Arm: ERCC1 Selection
High ERCC1: CPT11/docetaxel
Low ERCC1: FOLFOX
ASSIGNMENT
RANDOM
High ERCC1:FOLFOX
Low ERCC1: CPT11/docetaxel
SWOG proposed prospective trial using ERCC1to select CPT11/docetaxel or FOLFOX
EGFR expression
Chemotherapy with EGFR-targeted agents: KRAS and EGFR mutations are rare in gastric adenocarcinoma• Mammano E etal. Anticancer Res. 2006;26:3547-50.
– in 49 gastric adenocarcinomas, no specific EGFR gene mutations were detected.
• S.W. Han et al. Br J Cancer 2009;100:298-304. – In 38 gastric patients, no EGFR
amplification or K-ras mutations were observed.These findings suggest a priori that:
a)due to lack of EGFR mutations, gastric tumors will not be very sensitive to EGFR-directed TKI’s (e.g., gefitinib and erlotinib)
b) however, due to the lack of KRAS mutations, they may be sensitive to EGFR-directed antibodies
EGFR Tyrosine Kinase Inhibitors: Phase II, Adenocarcinoma
Gastric Number Patients
% Response
Dragovich (Erlotinib)
25 0%
Doi (Gefitinib) 75 1%
GE Junction
Ferry (Gefitinib)
27 11%
Janmaat (Gefitinib)
26 0%
Tew (Erlotinib) 17 0%
Dragovich(Erlotinib)
43Total: 7/113
9%6%
Doi 1036 Proc ASCO 22, 2003; Ferry Clin Can Res 132:5869; 2007 Janmaat JCO 24: 1612; 2006;Tew GI ASCO 2005; Dragovich JCO 24: 4922; 2006
Bouche O et al. J Clin Oncol 2004;22:4319-4328.
PFS and OS with “classical chemotherapy”
Survival LV5FU2 (n=45)
LV5FU2-cisplatin (n=44)
LV5FU2-irinotecan
(n=45)
OS, months 6.8 9.5 11.3
1-yr OS, % 31 43 43
PFS, months 3.2 4.9 6.9
Abbreviations: LV5FU2), leucovorin-5-FU; OS, overall survival; PFS, progression-free survival
Moehler et al.. Ann Oncol. 2010 Nov 30.: Patients with a complete response (CR) or partial response (PR) had significantly longer OS times and PFS times than patients with SD or PD.
Median PFS(months)
Median OS(months)
LV-5-FU-irinotecan
6.9 11.3
+ cetuximab 9.0 16.5
Median PFS(months)
Median OS(months)
CR + PR 10.6 19.1
SD + PD 6.0 12
p value 0.001 0.041
Moehler et al.. Ann Oncol. 2010 Nov 30.
PFS and OS are increased by addition of cetuximab
Bouche et al.. J Clin Oncol 2004;22:4319-4328
Predicting cetuximab activity
• Since KRAS mutations and EGFR mutations are rare in gastric tumors, can EGFR expression levels predict response to cetuximab?
-For EGFR (+) patients, both TTP (median 7.2 vs 5.0 months, P=0.020) and OS (not reached vs 7.6 months, P=0.013) were significantly longer after adjusting for clinical factors.S.W. Han et al Br J Cancer. 2009;100:298-304.
Phase II study and biomarker analysis of cetuximab combined with modified FOLFOX6 in
advancedgastric cancer.
Response
Overall (n=38)
50%
EGFR(+), low serum ligands (n=11)
100%
Remainder (n=27)
37%
-but tumor EGFR expression did not correlate with PFS
(log-rank P = 0.567) or OS (log-rank P = 0.663).
Response rate relationship to EGFR expression
EGFR(+) 19/26 (73%)
EGFR(-) 3/13 (23%)
EGFR (+) frequency
Responding tumors
16/19 (84%)
Non-responding tumors
10/20 (50%) P=0.041
Moehler et al. Ann Oncol. 2010 Nov 30.
Cetuximab with irinotecan, folinic acid and 5-FU as first-line treatment in advanced gastroesophageal cancer: a prospective multi-center biomarker-oriented phase II study.
-EGFR expression did not significantly correlate with ORRPinto et al. Phase II study of cetuximab in combination with FOLFIRI in patients with untreated advanced gastric or gastroesophageal junction adenocarcinoma (FOLCETUX study). Ann Oncol 2007;18:510-517.
Phase II study of cetuximab plus FOLFIRI in patients with untreated advanced gastric or GE junction adenocarcinoma (FOLCETUX study).
Discrepant results for EGFR expression level as a predictive factor for cetuximab therapy
EGFR associated with: Response Survival
Han et al yes yes
Moehler et al yes no
Pinto et al no -
HER2 status
HER2 inhibitors trastuzumab and lapatinib in gastric cancer
• ASCO 2008, Abstr 4526, Bang, et al.– Analysis of 2484 gastric cancer samples from
the Ph III ToGA trial– 21.9% HER2 positivity
• ASCO 2009, Abstr LBA 4509, ToGA Trial– Rand Ph III, HER2+ gastric cancer– 5-FU/capecitabine + cisplatin +/- trastuzumab– RR 47.3 vs. 34.5%, OS 13.5 vs. 11.1 mo (p =
0.0048)– HR 0.74 (0.60-0.91)– Practice changing!!!
• LOGIC Trial– Rand Ph III, HER 2+ gastric cancer– Capecitabine + oxaliplatin +/- lapatinib
The ToGA trial: Primary end point- OS
Time (months)
294290
246223
209185
173143
147117
11390
9064
7147
5632
4324
3016
2114
137
126
65
40
10
00
No. at risk
11.1 13.8
0.00.10.20.30.40.50.60.70.80.91.0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Event
FC + TFC
Events
167182
HR
0.74
95% CI
0.60, 0.91
p value
0.0046
MedianOS
13.811.1
T, trastuzumab
Rüschoff et al. Virchows Arch. 2010 457:299-307.
HER2 assay by IHC for gastric cancer required a different set of guidelines
than for breast
Sources of HER2 Testing Variation with IHC
Pre-analytic Time to fixation Method of tissue processing Time of fixation Type of fixationAnalytic Assay validation Equipment calibration Use of standardized laboratory
procedures Training and competency assessment of staff Type of antigen retrieval Test reagents Use of standardized control materials Use of automated laboratory methods
Post-analytic Interpretation criteria Use of image analysis Reporting elements Quality assurance procedures Laboratory accreditation Proficiency testing Pathologist competency
assessment
Wolff et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol. 2007;25:118-45.
Press et al. HER-2 Gene Amplification, HER-2 and Epidermal Growth Factor Receptor mRNA and Protein Expression, and Lapatinib Efficacy in Women with
Metastatic Breast Cancer. Clin Cancer Res 2008; 14: 7861
HER-2 mRNA expression by PCR correlates with HER-2 FISH (r=0.83)
and IHC (r=0.72)
Comparison of HER2 expression and amplification in primary breast tumors (T) and corresponding lymph node metastases (N) determined with IHC, FISH, and
quantitative RT-PCR
Vinatzer et al. Clin Cancer Res 2005;11:8348-8357
IHCHER2 expression scored as 0 and 1+ (=negative) or 2+ and 3+ (=positive) is indicated.
FISH analysis:red, HER2 signals; green, centromere 17 signals. +, specimens harboring a HER2 amplification; −, nonamplified specimens.
Quantitative RT-PCR:red line, the cutoff between high (scored as HER2 positive) and low relative expressions of HER2.
PCR quantitation of HER2 expression gives the same clinical information as IHC and FISH
Vinatzer et al. Clin Cancer Res 2005;11:8348-8357
Quantitative RT-PCR: -simple, cost-effective, -rapidly produces quantitative, numerical, and reproducible results. -easily amenable to standardization, insensitive to inter-observer variability-results are a number, which can be either above or below a predetermined threshold.
IHC-interpretation of IHC results is inherently difficult and time-consuming, requires experienced pathologists-is influenced by use of different antibodies, fixatives, staining protocols, and inter-observer variability.
FISH-is quantitative and reproducible but results are more difficult to interpret than those of quantitative RT-PCR.-time-consuming, and requires specialized expertise and equipment.
Her2 gene expression associated with OS in patients with metastatic gastric cancer treated with lapatinib
Overall Survivalby Her2 Expression Level
0%
20%
40%
60%
80%
100%
0 6 12 18 24Months After Registration
Above MedianBelow Median
N1717
Events1215
Median in months63
P = .005
Chang H et al,Journal of Clinical Oncology, 2007 ASCO Annual Meeting Proceedings Part I. Vol 25, No. 18S (June 20 Supplement), 2007: 4647
Summary and conclusions
• ERCC1 mRNA expression appears to be a viable predictive marker for platin therapy.
• The jury is still out on EGFR expression as a predictive marker for cetuximab therapy.
• The IHC and FISH-based assay of HER2 has many issues so PCR should be investigated as an additional tool or as an alternative.