New Insights on Merkel Cell Carcinoma€¦ · New Insights on Merkel Cell Carcinoma Emory Melanoma...

New Insights on Merkel Cell Carcinoma

Emory Melanoma / Skin Cancer Symposium

Saturday, Feb 27, 2016; Emory Conference Center35 min talk + 10 min questions

Clinic:

Seattle Cancer Care Alliance

Fred Hutchinson Cancer

Research Center

Paul Nghiem, MD, PhDProfessor & Head, UW Dermatology/Medicine & Pathology

George F. Odland Endowed Chair in Dermatology

Research:

Univ of WA

Lake Union Campus

UV DNA Damage/Cell cycle

Merkel cell carcinoma

Overview

• Pathogenesis & the Merkel polyomavirus– Risk factors

– Viral oncogenesis

Overview



• Tumor / viral immunity– Humoral and cellular immunity

Overview



• Tumor / viral immunity– Humoral and cellular immunity

• Therapy– Current & future immune-based therapies

Why is MCC important?

• More lethal than melanoma– ~40% mortality (~15% for melanoma)



• Reported incidence increasing– Quadrupled since 1986

– Currently ~2,000 new cases/yr in USA



• Reported incidence increasing– Quadrupled since 1986

– Currently ~2,000 new cases/yr in USA

• Optimal therapy is unique among skin CAs– Proper tx is relatively benign, effective

What is a Merkel Cell?Friedrich Merkel, 1875 Mechanoreceptors in basal

layer of epidermis?

What is a Merkel Cell?

copyright: Paul Nghiem & Paul Quade, www.EchoMedicalMedia.com

Friedrich Merkel, 1875 Mechanoreceptors in basal

layer of epidermis?

What is a Merkel Cell?

• Essential for light touchMaricich, et al, Science, 2009

• Derived from epidermis (not neural crest)

Van Keymeulen, et al, J Cell Biol, 2009

Morrison, et al, Dev Biol, 2009

copyright: Paul Nghiem & Paul Quade, www.EchoMedicalMedia.com

Friedrich Merkel, 1875 Mechanoreceptors in basal

layer of epidermis?

Merkel cell CA: clinical appearance (easy to miss)

Clinician’s Impression at the Time of

Bx in 106 MCC pts

BENIGN 56% • Cyst/Acneiform lesion 32%

• Lipoma 6%

• Dermatofibroma 5%

MALIGNANT 36% • Non-melanoma skin CA 19%

• Lymphoma 6%

• Metastatic Carcinoma 2%

• MCC 1%

Indeterminate 8% • "Nodule" Heath, JAAD, 2008

"Perinuclear dot pattern"

of cytokeratin-20

MCC Reported Incidence is Rising

1500 new

cases/yr

in USA

in 2005(NCDB data)

Lemos & Nghiem

JID 2007

CK20

antibody

Many cases

‘missed’

1600 new

cases/yr

in USA

in 2006

(SEER data)

Albores-Saavedra

J Cut. Path 2009

Increase in Risk Factors

• Prolonged sun exposure

– 98% Caucasian; Latitude associated; sun-

exposed skin

• Immune suppression (HIV, SOTR, CLL)

• Age > 50

Paulson & Nghiem,

unpublished

Clinical appearance (easy to miss)

Clinical Presentation

Generic description: "Firm papule / nodule, often red or purple"

We wanted more concrete data…

A: Asymptomatic

E: Expanding rapidly

I: Immune Compromised

O: Older than 50

U: UV-exposed, fair skin

89% of MCCs: ≥ 3 features

(sensitive, NOT specific!)

A: Asymptomatic

E: Expanding rapidly

I: Immune Compromised

O: Older than 50

U: UV-exposed, fair skin

89% of MCCs: ≥ 3 features

(sensitive, NOT specific!)

If red, rapidly growing,

non-tender nodule on

sun-exposed skin of

pt over 60:

? biopsy

MCC Presenting Site

In 138 patients

Heath, JAAD, 2008

Skin: Primary MCC (n=

123)

Nodal Presentation (n=15)

(no primary)

thought experiment...

Assuming there is palpable

nodal disease...

better to have a primary or not?

MCC Presenting Site

In 138 patients

Heath, JAAD, 2008

2010 AJCC

Staging System

Replaced 5

conflicting staging

systems...

How does one stage an MCC patient?

Bianca Lemos, MD

2010 AJCC

Staging System

Replaced 5

conflicting staging

systems...

How does one stage an MCC patient?

AJCC MCC Staging System (2009)

– Stage I: Local, ≤ 2cm

• Ia: Nodes negative by path exam

• Ib: Nodes not clinically detectable

– Stage II: Local, > 2cm

• IIa: Nodes negative by path exam

• IIb: Nodes not clinically detectable

• IIc: Primary tumor invading bone/muscle/fascia/cartilage

– Stage III: Regional Nodal Disease

• IIIa: Nodes pos by path exam and not clinically detectable

• IIIb: Nodes clinically detectable; in-transit metastasis

– Stage IV: Distant Metastatic Disease

How predictive was the

7th Edition system?

Analysis with an

independent

(subsequent) cohort

Can we make it better?

published 2009

0

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10 11

Local disease (n=213; MCC-specific survival)M

CC

-specific

surv

ival (%

)

Time from diagnosis (years)

IA (n=112)

IB (n=48)

IIA (n=32)

IIB (n=21)

0

25

50

75

100

0 1 2 3 4 5 6 7 8

Nodal and distant disease (n=215; MCC-specific survival)M

CC

-specific

surv

ival (%

)


IIIA (n=78)

IV (n=26)

IIIB (n=111)

0

25

50

75

100

0 1 2 3 4 5 6 7 8

Nodal and distant disease (n=215; MCC-specific survival)M

CC

-specific

surv

ival (%

)


IIIA (n=78)

IV (n=26)

IIIB (n=111)

known or unknown primary?

0

25

50

75

100

0 1 2 3 4 5 6 7 8

MC

C-s

pecific

surv

ival (%

)


IIIB Known Primary Lesion

(n=49)

IIIB Unknown Primary Lesion

(n=62)

Univariate analysis by competing risks regression:

HR 0.31; p<0.01; 95% CI 0.16 – 0.60

Multivariate analysis by competing risks regression:

(controlling for age at dx, sex, and immune suppression)

HR 0.43; p=0.04; 95% CI 0.20 – 0.94

IIIB Patients by Primary Lesion Status (n=111; MCC-specific survival)

0

10

20

30

40

50

60

70

80

2 year overall survival(Tarantola et al; n=50)

5 year MCC-specific survival(Seattle; n=104)

5 year MCC-specific survival(Busam et al; n=115)

% S

urv

ival

Unknown primary(57%)


Known primary(36%) Known primary

(33%)

“Unknown primary” lesion better survival across independent cohorts


Known primary(28%)

Positive lymph node

Poorly functioning immune cells cannot eliminate the primary tumor

Primary tumor

Positive lymph node

Poorly functioning

immune cells

Among Stage IIIB Patients the Presence or Absence of a Primary Matters

Known primaries

Functional killer T cells secrete effector cytokines or molecules to destroyed the primary tumors.

These patients do much better!!

Unknown primaries

Positive lymph node

Poorly functioning immune cells cannot eliminate the primary tumor

Primary tumor

PrimaryTumorgone

Positive lymph node

Positive lymph node

Poorly functioning

immune cells

Highly functioning

immune cells

Among Stage IIIB Patients the Presence or Absence of a Primary Matters

Known primaries

The immune system likely mediates

regression of primary tumors

0%

20%

40%

60%

80%

100%

Immune Suppressed(n = 11 )

Not ImmuneSuppressed

(n = 92)

% w

ith

Un

kn

ow

n P

rim

ary

p < 0.0001(Fisher’s exact)

66%

0%!!

IIIb cases:

Bottom line on initial therapy...

Surgery & radiation:

>95% of patients ‘free of

detectable disease’...

but

MCC recurs in nearly half

Bottom line on initial therapy...

Surgery & radiation:

>95% of patients ‘free of

detectable disease’...

but

MCC recurs in nearly half

Metastatic MCC chemotherapy (‘small cell regimen’)

- shrinks MCC in most cases

- over half progress by 3 mos...

Chemotherapy & metastatic MCC

53% of patients ‘respond’...

Half progress by 93 days after starting chemo

(Quite toxic therapy...unsatisfactory results...need options!)

Iyer, et al, in preparation

PFS after 1st line chemo

Given links to immune suppression, UV...

how does MCC arise?

Moore/Chang

(KSHV)

Present in 8/10

MCCs

Validated in

dozens of studies

Virus (MCPyV) is

extremely

common!

Schematic ofMCPyV genome

A new human virus that causes cancer (in 2008)

Adapted from Bhatia/Afanasiev, et al, Curr Oncol Rep, 2011

Virus on us all yet only

1 in 3000 will get MCC…how?

Adapted from Bhatia/Afanasiev, et al, Curr Oncol Rep, 2011

What are mutation patterns in virus-pos vs virus-neg tumors?

Virus on us all yet only

1 in 3000 will get MCC…how?

3 studies in late 2015...

genetic mutations in virus-pos & virus-neg MCC...

49 MCCs...

Goh, et al. 2015.

Oncotarget

“MCC-Low”“MCC-High”

Goh, et al. 2015.

Oncotarget

Viral status

greatly affects

mutation

frequency

Goh, et al. 2015.

Oncotarget

Viral status

greatly affects

mutation

frequency

100-fold

difference

between

MCC-Lo &

MCC-Hi

Goh, et al. 2015. Oncotarget

Virus-negative MCCs ‘neoantigens’

PDL1-pos (‘immune visible’) tumors

have more mutations

Wong, et al. 2015.

Cancer Res.

PDL1-pos (‘immune visible’) tumors

have more mutations

Wong, et al. 2015.

Cancer Res.

Virus-neg tumors

may be

immunogenic...

We will return to

this!

Humoral immunity: a powerful biomarker

Kelly Paulson, MD, PhD Will Simonson,MD, PhDMark Wener, MDDenise Galloway, PhD Jody Carter, PhD

Antibodies to T-Ag (not capsid) fall after tx

Antibodies to T-Ag (not capsid) fall after txCapsid antibodies:>60% of us have them!

T-Ag antibodies:<1% of 530 population controls~50% of newly diagnosed MCCs

Antibodies to T antigen reflect disease burden

Paulson, Carter, et al, CA Research, 2010

“This could be clinically useful...”

Detecting MCC

recurrences using

serology

Paulson, et al, submitted

PPV = 66%

NPV = 97%

Oncoprotein Ab Positive (n = 114)

Oncoprotein Ab Negative (n = 105)

Competing-risks Regression

Controlling for: Age, Stage, and Sex

p = 0.037

Hazard Ratio = 0.46

95% CI = 0.224 – 0.955

Time after Diagnosis (Days)

MC

C s

pe

cif

ic S

urv

iva

l (%

)MCC Specific Survival by Oncoprotein Ab Titer

590 1 2 3 4 5

0

25

50

75

100


Oncoprotein Ab Positive (n = 114)

Oncoprotein Ab Negative (n = 105)

Competing-risks Regression

Controlling for: Age, Stage, and Sex

p = 0.037

Hazard Ratio = 0.46

95% CI = 0.224 – 0.955

Time after Diagnosis (Days)

MC

C s

pe

cif

ic S

urv

iva

l (%

)MCC Specific Survival by Oncoprotein Ab Titer

600 1 2 3 4 5

0

25

50

75

100

Sero-neg patients:

follow with scans


Assay ‘live’ (available) as of January 2014...Run by UW Lab Medicine (50 ul serum)

Cost $200 (very modest vs CT scan)Helps both virus-pos and virus-neg patients...

Antibodies are useful for tracking MCC...

What are T cells good for?

Antibodies are useful for tracking MCC...

What are T cells good for?

Survival!!

If CD8+ T cells are moderate or high within tumor,survival is 100% (n=146 patients + n=150 patients)

killer CD8 T cell

MCC cell

expressing MCPyV protein

How do CD8 T

cells recognize

their target?

Finding MCPyV-specific T cells

x

xx

x

MCPyVproteome

map

MCPyV-Antigen source

Jayasri Iyer

David Koelle


x

xx

x

MCPyVproteome

map


95 peptides: covering 389 AA

Persistently expressed in MCCs

Jayasri Iyer

David Koelle

T cell source


x

xx

x

MCPyVproteome

map



Blood “TIL”Persistently expressed in MCCs

Jayasri Iyer

David Koelle

T cell source

Antigen presenting cells


x

xx

x

MCPyVproteome

map



Blood “TIL”

Assay: T cells produce IFN-γ if recognize peptide


Jayasri Iyer

David Koelle


x

xx

x

MCPyVproteome

map

MCPyV


First 26 MCPyV epitopes identified from blood and MCC tumors

epitopesdiscovered

‘Tools’ for MVPyV-specific T cell study

Iyer/Afanasiev et al, CCR, 2011; Afanasiev et al, submitted

Iyer, et al, Clin Ca Res, 2011

‘Tools’ for MVPyV-specific T cell study

Iyer/Afanasiev et al, CCR, 2011; Afanasiev et al, submitted

Control subjects

(n=10)

% s

ub

jects

with

te

t+T

ce

lls

MCC patients

(n=9)

0%

Iyer, et al, Clin Ca Res, 2011

Jim Dowdalls/Photo Researchers, Inc

Why do virus-positive tumors grow if patients have virus-specific T cells??

Virus infected cell

CD8T cell

Are virus-specific T cells dysfunctional?

Acute antigen

exposure

Activated cells, characterized by expression of:

CD28 Co-stimulatory receptor (ligand: B7); required for T cell activation

CD69 Earliest inducible cell surface glycoprotein during T cell activation; plays a role in T cell proliferation

CD137 (4-1BB)

Member of TNF-receptor family; induced by T cell activation; important in T cell proliferation, cytokine secretion and cytotoxicity

CD38 Cyclic ADP ribose hydrolase; marker of T cell activation; functions in cell adhesion, signal transduction and calcium signaling

HLA-DR MHC class-II surface receptor that is upregulated with T cell activation

T cell surface receptor phenotype

reveals functional profile

Adapted from Afanasiev, Nghiem, MCC book chapter

Chronic antigen

exposure

Acute antigen

exposure




CD137 (4-1BB)




Exhausted T cells, characterized by prolonged expression of:

PD-1 Programmed death-1; inhibitory T cell receptor (ligands: PD-L1 (B7-H1), PD-L2 (B7-DC)); reduces T cell proliferation and effector functions

CTLA-4 (CD152)

Cytotoxic T-Lymphocyte Antigen 4; inhibitory receptor (ligand:B7); effectively competes for ligands with CD28 (which has lower avidity than CTLA-4), preventing T cell activation

Tim-3 T cell Immunoglobulin Mucin-3; inhibitory T cell receptor (ligand: galactin-9); leads to decrease in effector T cell function

T

cell




Chronic antigen

exposure

Acute antigen

exposure




CD137 (4-1BB)




Exhausted T cells, characterized by prolonged expression of:

PD-1 Programmed death-1; inhibitory T cell receptor (ligands: PD-L1 (B7-H1), PD-L2 (B7-DC)); reduces T cell proliferation and effector functions

CTLA-4 (CD152)

Cytotoxic T-Lymphocyte Antigen 4; inhibitory receptor (ligand:B7); effectively competes for ligands with CD28 (which has lower avidity than CTLA-4), preventing T cell activation

Tim-3 T cell Immunoglobulin Mucin-3; inhibitory T cell receptor (ligand: galactin-9); leads to decrease in effector T cell function

Recently activated T cells, characterized by expression of:

Combination of activation and inhibition markers via appropriate immunoregulatory feedback mechanisms

T

cell




Are the ‘brakes’ ON in MCC-specific T cells? (compared to other viral responses)

PD-1 Tim-3

Examined ‘exhausted’ PD1+/Tim-3+ cells


Afanasiev et al, Clin Ca Research 2013

PD

1+T

im3

+ (%

po

siti

ve c

ells

)PD-1 Tim-3

(Data from 4-7 MCC patients)



PD

1+T

im3

+ (%

po

siti

ve c

ells

)PD-1 Tim-3





PD

1+T

im3

+ (%

po

siti

ve c

ells

)PD-1 Tim-3



PD-1 & PDL-1 trials

are beginning...


Clinical Trial Indication Target Patient characteristic

Status

IL-12(Oncosec)

Local Injection of IL-12 gene

Injectable lesion Complete

GLA(Immune Design)

Local Toll-like receptor agonist

Injectable lesion Complete

PD-1(Merck)

Metastatic 1st line

PD-1 on T cell No prior systemic therapy

Recruiting

PD-L1(EMD Serono)

Metastatic 2nd line

PD-L1 on Tumor

Progressed after receiving chemo

Recruiting

T cell + PD-L1(EMD + Pfizer)

Metastatic Infuse Virus specific T cells

Virus + MCC ?

4-1BB(Pfizer)

Metastatic CD-137 on T cell

+/- chemo or immune therapy

closed

MCC Clinical Trials Overview

PDL1 (2nd line) MCC trial:

55 yo woman; primary lesion on chest x 1 year (had metastases at dx)

Failed chemotherapy (Carbo + etoposide)

Large liver mets: 2 x 11 cm

MCPyV-negative

After 4 weeks (2 doses) of PDL1

Activity of PD-1 blockade with pembrolizumab as first systemic therapy in patients with advanced

Merkel cell carcinoma

Paul Nghiem1,2, Shailender Bhatia1,2, Adil Daud3, Philip Friedlander4, Harriet Kluger5, Holbrook Kohrt6, Ragini Kudchadkar7, Evan Lipson8, Lisa Lundgren2,

Kim Margolin6, Sunil Reddy6, Erica Shantha1, William Sharfman8, Elad Sharon9, John Thompson1,2, Suzanne Topalian8, Mac Cheever1,2

1) University of Washington 2) Fred Hutchinson Cancer Research Center 3) Univ of California San Francisco 4) Mt Sinai Medical Center 5) Yale University

6) Stanford University 7) Emory University 8) Johns Hopkins University

9) NCI-Cancer Therapy Evaluation Program

European Cancer Congress / ESMO Vienna, Austria

Sunday, September 27th, 2015

85

Metastatic MCC platin + etoposide

Initial responses common (53%) poor durability:

>50% of patients progress by 3 months

>90% of patients progress by 10 months

Iyer, et al, J Clin Oncol 32:5s, 2014 (suppl; abstr 9091)

Miller, et al, Curr Treat Options Onc, 2013

Median survival = 9.6 months

n = 179

Trial design: pembrolizumab in MCC

• Strong rationale for anti-PD1 in MCC

– tumor-specific T cells are PD1+, Tim3+

– PDL1 frequent in MCC tumors

• Multi-center (7 sites), single arm, open label, Phase II trial of first systemic therapy

• Primary endpoint: response rate (RECIST 1.1)

86

Interim results9/18/15

• 24 patients had received at least one dose of pembrolizumab

• 14 patients had at least one post-treatment scan

Response in MCC target lesions(At first scan, RECIST 1.1 as of 9/18/15 data export)

n = 14

% C

han

ge

in

targ

et

lesio

ns

at

1s

tscan

Progressive disease:

target lesion f/u data

initially not available =

*Complete responses (RECIST 1.1) occurred in lymph nodes that regressed to < 10 mm.

Progression based

on new lesions

Partial Response: 1st

scan data initially not

available, at 2nd scan

was -70% =

* *

Activity of MK-3475 in patients with advanced MCC(RECIST 1.1 data as of 9/18/15)

Key:

n = 14 includes 2 patients who have PD based only on new

lesions (no f/u data on target lesions currently)

Stable Disease =

Progressive Disease =

Partial Response =

Complete Response =

Progressive disease:

target lesion f/u data

not available =

*Complete responses (RECIST 1.1) occurred in lymph nodes that regressed to < 10 mm.

Baseline

Response to anti-PD1

Baseline:

- Bulky tumors in pelvis: bladder compression

- Subcutaneous metastases on R leg

Baseline 3 wks after pembrolizumab

Response to anti-PD1

Baseline:

- Bulky tumors in pelvis: bladder compression

- Subcutaneous metastases on R leg

After 1 dose:

- SQ lesion barely palpable at 3 weeks; biopsy showed. . .

What happened in the SQ tumor?

Pathologic CR after single dose of pembrolizumab

What happened in the SQ tumor?

Bladder symptoms resolved

Continues on trial (week 34)

No side effects

Tumors continue to shrink

Partial response on pembrolizumab

Baseline 1st scan (13 wks) after PD1

Bulky pelvic disease:

Conclusions: Pembrolizumab in MCC

• Responses (RECIST 1.1) in 10 of 14 patients (71%)

– More durable than chemotherapy (historical)

• Biomarker studies will address:

– Virus-pos vs. virus-neg MCC responses?

– Does PD-1 increase the number and/or function of preexisting virus-specific T cells in blood/tumor?

(possible in 5 of 15 cases thus far)

• Expansion plans underway...for first line & relapsed disease

Vision for future MCC management

1. Minimize recurrences

- best initial management (surgery, RT)

- immune-stimulation in ‘adjuvant’ setting...

Vision for future MCC management

1. Minimize recurrences

- best initial management (surgery, RT)

- immune-stimulation in ‘adjuvant’ setting...

2. If recurrence:

- find early by serology or scans

- reduce tumor & reverse immune evasion

- immune-therapy for long-lasting control...

Thanks to funding sources

Michael Piepkorn Endowment

Bezos Immune Therapy Fund

Research scientists: Dafina Ibrani, Lola Yelistratova, Chris Lewis, Ryan Doumani

Undergraduate research assistants & students: Jamil Qazi, Hannah Thomas, Austin Anderson, Christine Ma, Kaushik P, Seesha T, Tessa Marx

Masaoki Kawasumi, Kaifeng HungUV & DNA repair

Lab Team Research fellows:

Jayasri Iyer Erica Shantha Candice Church

Graduate and medical students/doctors: Ata Moshiri, Olga Afanasiev, Natalie Miller, Kelly Paulson, Natalie Vandeven

New Insights on Merkel Cell Carcinoma€¦ · New Insights on Merkel Cell Carcinoma Emory Melanoma...

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Transcript of New Insights on Merkel Cell Carcinoma€¦ · New Insights on Merkel Cell Carcinoma Emory Melanoma...