Download O9.2 Metabolic targets in renal cell cancer

Metabolic Targets in Renal
Cell Carcinoma
Brian Shuch, MD
Assistant Professor of Urology and Radiology
Cancer Genetics and Prevention Program
Yale Cancer Center
Brian Shuch, MD Disclosures
1.
Company
Relationship: honoraria, speakers’ bureau, grants,
research support, stock, consultant, et cetera
Pfizer
Consultant
Overview
• Review the molecular genetics of RCC
• Discuss biology and therapeutic targets in HLRCC
• Discuss biology and therapeutic targets in ccRCC
Overview of Kidney Cancer
2013 (ISUP Vancouver Meeting)
Clear cell RCC
Multilocular clear cell RCC
Papillary I and II RCC
Chromophobe
Hybrid oncocytic/chromophobe
Collecting duct
Renal medullary carcinoma
Neuroblastoma associated
Mucinous tubular & spindle
cell
Tubulocystic RCC
Acquired cystic disease RCC
Clear cell papillary RCC
Unclassified RCC
MiT family translocation
HLRCC
• Clear cell kidney cancer represents 75% of RCC
• All the rest lumped into a basket considered “non-clear cell RCC”
Shuch, B., et al. (2014). Understanding Pathologic Variants of Renal Cell Carcinoma: Distilling Therapeutic Opportunities from Biologic Complexity. Eur Urol.
“Non-Clear Cell RCC”- Descriptive??
Phone Market
Sneaker Market
Lumping rare kidney cancer variants into a “non-clear cell” basket term has
led to trials not focusing on unique biology .
“The Genetic Basis of Hereditary RCC”
Clear Cell
Papillary Type 1
VHL
MET
Papillary Type 2
FH
Chromophobe
Oncocytoma
FLCN
• Different germline alterations lead to
different forms of kidney cancer
• Much of our understanding of sporadic
RCC comes from hereditary RCC
• However, sporadic forms significantly
more complex than previously thought
Genomic Alterations Differ by Subtype: Pan-RCC Analysis
• Distinct pattern of genetic mutations in kidney cancer
• However, several themes emerge common to several forms of kidney cancer
Chen, F., et al. (2016). Multilevel Genomics-Based Taxonomy of Renal Cell Carcinoma. Cell Reports. 2016
Genomic Alterations and Dysregulated Metabolism in RCC
Ricketts, C. J., et al. (2016). SnapShot: Renal Cell Carcinoma. Cancer Cell, 29(4), 610–610.e1.
Kidney Cancer
Metabolic Targets
• Shared mutations lead to activated
metabolic pathways
• Overlapping gene alterations in the
hypoxia pathway, PI3K/mTOR
pathway, chromatin regulation, cell
cycle control, and antioxidant
response
Durinck, S., et al. (2015). Spectrum of diverse genomic alterations define non-clear cell renal carcinoma
subtypes. Nat Genet, 47(1), 13–21.
Kidney Cancer Metabolic Targets
• Glycolysis and the Krebs cycle central to energy processing
• Dysregulated glucose metabolism common in RCC
• Understanding the metabolic and genetic basis of RCC will provide the
foundation for the further development of effective forms of therapy
High grade Clear cell/Chromophobe &Oncocytoma
FH/SDH Kidney Cancer and high grade pRCC
Kidney Cancer- Metabolic Targets
Hexokinase Inhibitors (2DG)
PKM2 Inhibitors
• Obligate metabolism
may lead to exquisite
sensitivity to inhibition
of specific pathways
• Carbon metabolism is
central to generation of
ATP and lipids
• Several enzymes have
been postulated as
therapeutic targets in
RCC
Hereditary Leiomyomatosis and Renal Cell Cancer
(HLRCC)
• Estimated incidence is 1 in 50,000-100,000
• Incidence likely significantly higher from our group’s estimates from EXAC/1000
genomes (~1/1500)
• Autosomal dominant inheritance pattern
• Linked to 1q42 and found to be Fumarate hydratase (FH) in 2002
• Behaves like classic tumor suppressor gene with LOH found in tumors
• Responsible for Krebs cycle enzyme that is responsible for oxidation of
fumarate to malate
Tomlinson, I. P., Alam, N. A., Rowan, A. J. et al.: Germline mutations in FH predispose to dominantly inherited
uterine fibroids, skin leiomyomata and papillary renal cell cancer. Nat Genet, 30: 406, 2002
Cutaneous Leiomyomas In HLRCC
Occur in 75% of individuals, generally in clusters.
HLRCC Kidney Cancer
• 15-30% of patients with HLRCC
• Tumors are very aggressive/infiltrative
• Can metastasize even when tumors 1-2 cm
• ~70% of patients present with Stage III/IV disease
• Over 50% of individuals with HLRCC kidney cancer had died of disease
• Patients with limited treatment options and those with metastatic
disease classically have lived ~12 months
• Resistant to classic forms of kidney cancer therapy
Grubb et al. Hereditary leiomyomatosis and renal cell cancer: a syndrome associated with an aggressive
form of inherited renal cancer. J Urol vol. 177 (6) pp. 2074-9
Renal Manifestations: 46 year old man with hematuria
HLRCC and Exquisite Sensitivity to Withdrawal of Glucose
HLRCC
Sporadic Papillary Type II
Relative Cell Growth
(% of growth with normal glucose)
120%
100%
80%
60%
40%
20%
0%
UOK262
LABAZ1
HRC86T2
MDACC-55
Glucose
• Cell lines incredibly sensitive to glucose withdrawal (12 hours)
• Blocking glucose uptake postulated to be therapeutic strategy
Shuch, B. et al In Preparation
• Knock down of FH similarly leads to
HIF accumulation
• Addition of fumarate/succinate lead
to HIF accumulation
• HIF1a known to lead to GLUT-1
upregulation
• Targeting downstream pathways on HLRCC proven
modestly effective with bevacizumab/erlotinib
combination
• Single arm phase II study
– VEGF tx targeting angiogenesis and EGFR perhaps impairing glucose uptake
• Arm 1: HLRCC
-overall response rate was 65% (all PR)
-Median PFS was 24.2 months
-some with durable response for >3 years
• Arm 2: Sporadic pRCC
-29% response rate (all PR)
-Median PFS of 7.4 months
•
NRF2 can protect cancer cells from oxidative stress and promote cell
proliferation.
• Recent studies reveal that activation of the Nrf2 pathway is critical for
resistance to chemotherapeutic agents
• Small molecule inhibitors of NRF2 have been recently described
• Treatment with NRF2 inhibitors has been shown to re-sensitize nonsmall cell lung ca to platinum based therapy, may
Fumarate levels cause cysteine
residues to succination alters Keap1
And prevents NRF2 binding and
ubiquitination
• C13 Radiolabeled Glucose assessed in cells with altered Krebs cycle/ETC,
most citrate contained no C13 (m+0), indicating suppressed entry of
glucose into Krebs Cycle
• Reductive Glutamine metabolism allows generation of AKG and the Krebs
Cycle can reverse to allow citrate generation
• Galactose oxidation produces no ATP- common in glycolytic cells
• Glutamine in FH (-/-) cell line cells cannot grow without carbon source
LDH catalyzes the reversible reduction of
lactate to pyruvate.
LDH-A is upregulated in solid tumors
reliant on glycolysis, inhibition of this
enzyme has been shown to inhibit
growth both in vitro and in vivo
Metabolic Targets in HLRCC/HLRCC-like Kidney Cancer
Summary of the Mechanism of Tumorigenesis in HLRCC
Ub
Decreased
HR repair
αKG-dependent
dioxygenase(s)
Fumarate
HPH
X
HIFα
C
TeT proteins
KEAP1
NRF2
5hmC
5mC
αKG
succinate
Regulation of DNA methylation
Loss of miR200EMT
C
S
C
KEAP1
C
HIFα
HIFα
HIFα
HIFα
HIFα
S
NRF2
Anti-Oxidant
Response
Angiogenesis
Proliferation
Glucose Transport
Principle Component Analysis:
Comparing Papillary I/II RCC to HLRCC
HLRCC
Pap I
Pap II
Published CEL files assessing mRNA using Affymetric HG 133 U Plus 2
Shuch, B ASCO GU 2012
Altered Metabolism of HLRCC
140
Oxygen Consumption
Extracellular Acidification
OCR (O2/min/ug of prot)
ECAR (mpH/min/ug of prot)
180
120
100
80
60
40
20
160
140
120
100
80
60
40
20
0
LABAZ
HRC86T2
MDA55
UOK262
UOK262 had significantly high amounts of
extracellular acidification/glycolysis
Shuch, B ASCO GU 2012
0
LABAZ
HRC86T2
MDA55
UOK262
The sporadic papillary lines have normal
oxygen consumption while UOK262 has none
Dysregulated Glucose Metabolism Gene Expression
***Gene expression for Glycolysis, Krebs Cycle, PPP, glycogen, pyruvate pathways
Shuch, B ASCO GU 2012
Applicability to Sporadic Papillary RCC
Identification of CIMP Cluster/Warburg Class of Tumors Similar to HLRCC
• CpG Island Methylated Phenotype cluster:
• Germline FH alterations and other mechanisms such as
CDKN2A loss, and alterations in NRF2/KEAP1 pathway
• Awful prognosis
• CIMP phenotype may be interesting population to
target with inhibitors of DNA methylation, CDK4/6
inhibitors, or glycolytic inhibitors (Warburg effect)
Altered Metabolism in the HLRCC-like CIMP cohort
Aggressive type 2 pRCC can have a similar metabolic phenotype to HLRCC
How common this is in advanced pRCC is unknown, but will be investigated in S1500
SWOG trial, n=180 metastatic pRCC patients
Clear Cell Kidney Cancer
• VHL loss (mutation/hypermethylation) in >80% of clear cell RCC
• 95% of clear cell RCC demonstrate 3p loss, leading to LOH
• VHL dysregulation central to hypoxia pathway
• Hypoxia adaptive changes include upregulation of glycolysis
• Accounts for 90% of metastatic RCC
• Loss of VHL and resultant
downsteam changes including
upregulation of the VEGF pathway
have led to our current systemic
therapy approaches to treatment
• Over 100 other downstream targets
of HIF which may also be
therapeutic targets in ccRCC
• VHL also has HIF independent
functions and loss has not been a
focus on research
Shuch, B., et al. (2014). Understanding Pathologic Variants of Renal Cell Carcinoma: Distilling Therapeutic
Opportunities from Biologic Complexity. Eur Urol.
• Around time of discovery of
VHL, team from JHU
discovered that HIF1 was a
major regulator of glycolytic
enzymes
• HIF1a responsible for
transcriptional regulation of
most of the enzymes
regulating glycolytic flux
• HIF1a and HIF2a with similar actions bind to HIF1b to form a heterodimer
and bind to same HRE
• Inducible HIF1a/HIF2a Lead to transcription of many of the same genes
• However they play non-redundant roles, and activation of each one
results in a distinctly different phenotype.
• HIF2 DOESN’T REGULATE GLYCOLYSIS
• Two “flavors” of VHL (-/-) kidney cancer, HIF1/2 vs HIF2
• Metabolism very different, HIF1/2 tumors with high expression of
glycolysis genes
• Perhaps different therapeutic response to anti-metabolic therapy
• Oxygen is the ultimate electron acceptor for mitochondrial respiration, a
process catalyzed by cytochrome c oxidase (COX), the terminal enzyme on ETC
• HIF1a leads to downregulation of mitochondrial respiration via COX regulation
ultimately suppressing the Krebs cycle/oxidative phosphorylation
• ccRCC has fundamental shift towards Warburg biology
• Hypoxia/HIF1 upregulation leads to glycolysis
• C13 analysis demonstrates reductive carboxylation in
hypoxic cells resulting in shuttling of glutamine into
Krebs cycle for carbon intermediates
• VHL (-/-) lines in normoxic conditions share a similar
phenotype due to HIF dysregulation.
• HIF1a K.D. reverses phenotype
• Metabolic findings supported in
ccRCC
• Suppression of Krebs cycle
enzymes observed in the TCGA
ccRCC analysis of 412 tumors
• Evidence of other dysfunctional
pathways including upregulation
of Oxidative Pentose Phosphate
Pathway and Fatty Acid Synthesis
Cancer Genome Atlas Research Network. (2013). Comprehensive molecular characterization of clear cell renal cell
carcinoma. Nature, 499(7456), 43–49.
• Later MSKCC group matched
tumor/normal kidney pairs
(n=138) and performed mass
spec for metabolites, RNAseq,
and pathway analysis
• Other dysregulated pathways
included PPP and lipid
metabolism
• Tumor progression associated
with metabolite increases in
glutathione and
cysteine/methionine metabolism
Hakimi, A. A., Reznik, E., Lee, C.-H., Creighton, C. J., Brannon, A. R., Luna, A., et al. (2016). An Integrated Metabolic Atlas of Clear Cell Renal
Cell Carcinoma. Cancer Cell, 29(1), 104–116.
Targeting Lipid Metabolism in ccRCC
• Clear cell is “clear” due to lipid accumulation
• Reductive carboxylation through glutaminase
for citrate source for lipogenesis
• ccRCC with overexpression of FASN have
significantly worse outcome
Albiges, L., et al. (2016). Body Mass Index and Metastatic Renal Cell Carcinoma:
Clinical and Biological Correlations. JCO. 34, 30 (October 2016) 3655-3663.
•
•
FASN inhibitor C75 was studied in ccRCC models
Lead to growth inhibition in cell culture and xenografts.
• FASN inhibitors have made it into clinical development for cancer
• ccRCC may be an interesting tumor to study similar agents due to role of
FASN/lipid metabolism
Conclusions
• Renal cell carcinoma (RCC) is a heterogenous group of cancers however
common dysregulated pathways lead to similar metabolic phenotype
• HLRCC and related tumors have an extreme Warburg phenotype, reliance
on glutamine metabolism, and are driven through dysregulation of
metabolites (oncometabolites).
• ccRCC, due to VHL loss have similar metabolic properties including
upregulation of glycolysis, Krebs cycle depression, and reductive
carboxylation.
• Complete reliance on these pathways may make them exquisitely
vulnerable to novel metabolic strategies currently in early clinical
development.
Questions?
[email protected]