Download Serum biomarkers in pre-operative triage

Biomarkers and Molecular
Pathways in Endometrial Cancer
Donal Brennan
Queensland Centre for Gynaecological Cancer
Plan
• Why we need biomarkers in EAC
• Serum biomarkers in pre-operative triage
• The rationale for targeted therapeutics in
advanced / recurrent disease
Plan
• Why we need biomarkers in EAC
• Serum biomarkers in pre-operative triage
• The rationale for targeted therapeutics in
advanced / recurrent disease
Type 1 v’s Type 2 endometrial cancer
Loss of PTEN
KRAS mutations
MSI
p53 mutations
Genomic instability
Type 1
G1/2 EAC
Risk Factors
Excess Estrogen – endogenous and exogenous
Tamoxifen
Diabetes
Nulliparity
Type 2
G3 EAC
Serous
Clear Cell
Risk Factors
Age
Obesity
?BRCA
Pre-operative triage
Increasing incidence of endometrial cancer in women < 50 years old
Arora et al . Best Pract Res Clin Obstet Gynaecol. 2012 Jun;26(3):311-24.
Plan
• Why we need biomarkers in EAC
• Serum biomarkers in pre-operative triage
• The rationale for targeted therapeutics in
advanced / recurrent disease
Biomarkers in EAC
• Limited use
• None utilised for triage of patients as diagnosis
• CA-125 associated with extra-uterine disease
– Lacks sensitivity and specificity
– Threshold – 35 v’s 65 iu
– NPV < 90%
• MRI to assess myometrial invasion
– Cost issues, access issues, inter-observer variability
• Lymph nodes?????????
Predicting Extra-Uterine Disease
Salvesen HB et al Lancet Oncol 2012 8(13) e353 - e361
HE4 in endometrial cancer
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Identified in Human Epididymis
Secreted protein
? role in innate immunity
Upregulated in a number of
cancers – ovary, endometrial,
lung
• FDA approved in EOC
• HE4 is increased in EC compared
to normal endometrium
• A number of single institution
retrospective studies have
demonstrated HE4 associated
with
– advanced stage
– myometrial invasion
– poor prognosis
• No data from population based
studies
Australian National Endometrial Cancer Study (ANECS)
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Population based, case control study
1497 patients recruited between 2005 and 2007
Peri-operative serum available for 373 patients
CA-125 and HE4 quantified using Abbott Architecture kits
Analysis performed in clinically accredited lab
Non-parametric Mann Whitney U test, ROC analysis,
Kaplan Meier and Cox Porportional Hazards applied.
ANECS HE4 study
Manuscript submitted
Association with Clinicopathological Factors
Median HE4 (IQR)
[pmol/L]
P Value
Median CA125 (IQR)
[U/ml]
P Value
All women
FIGO Stage (2009)
Stage I & II (n =339)
Stage III & IV (n=30)
72·7 (53·2-106·3)
134·6 (83-237·7)
<0·001 14·9 (11-23)
29·4 (15·1-76·5)
<0·001
Grade
Grade I & II (n=291)
Grade III (n=76)
73·1 (53·5-114·7)
82·7 (53·3-113·4)
0·572
15·4 (11·1-24·1)
15·5 (11·3-28·5)
0·431
Endometrioid Histology
Non Endometrioid (n=57)
Endometrioid (n=316)
81·8 (56·0-110·7)
73·7 (53·6-113·4)
0·765
14·9 (11-30·5)
15·5 (11·2-24·2)
0·496
LVSI
Absent (n=276)
Present (n=57)
74·2 (53·1-111·2)
77·9 (51·8-114·3)
0·908
14·9 (11·2-24·8)
15·4 (9·9-25·9)
0·853
Myometrial Invasion
≤ 50% (n=289)
> 50% (n=84)
68·0? (52-93·6)
115·3 (81·7-178·9)
<0·001 14·6 (11·1-21·8)
25·1 (11·8-43·5)
<0·001
Age
< 62 (n=184)
≥62 (n=189)
64·0 (48·1-91·2)
85·2 (61·8-136·2)
<0·001 15·5 (11·6-26·1)
15·2 (10·5-26)
0·295
BMI (kg/m2)
< 30 (n=184)
>/= 30 (n=189)
68·4 (52·5-101·3)
81·6 (55·1-122)
0·024
15·0? (10·9-26·8)
15·6 (11·4-24·2)
0·723
Diabetes
No (n=309)
Yes (n=64)
73·1 (53·2-106·5)
91·1 (57·3-152·3)
0·023
15·4 (11·2-26)
15·9 (11·8-26·3)
0·781
Hypertension
No (n=231)
Yes (n=137)
69·8 (50-101·6)
82·7 (60-131·1)
0·001
15·2 (11·2-24·9)
15·8 (11·6-26·6)
0·653
Manuscript submitted
Predicting Outer Half Myometrial Involvement
All Patients (n=373)
AUC
HE4 – 0.76 (0.70-0.81)
CA-125 – 0.65 (0.57-0.72)
Endometrioid Histology, Grade 1 and 2 (n = 280)
Endometrioid Histology (n = 316)
AUC
AUC
HE4––0.76
0.77(0.70-0.83)
(0.70-0.83)
HE4
CA-125––0.62
0.64(0.53-0.71)
(0.55-0.73)
CA-125
Applying 70pmol/L as a threshold
Manuscript submitted
HE4 as a Prognostic Marker
P = 0.05
P = 0.001
Manuscript submitted
Multivariate Analysis of RFS
Manuscript submitted
HE4 Summary
• Largest study of HE4 in EC to date
• First population based study
• Elevated HE4 is associated with an aggressive phenotype
• HE4 is a superior to CA125 in predicting outer-half
myometrial invasion
– HE4 < 70 pmol/L, ? avoid lymphadenectomy
• HE4 is an independent predictor of OS and RFS
Manuscript submitted
Where next?
• What is the functional role of HE4 in endometrial cancer.
• What effect does progesterone treatment have on HE4?
• Can HE4 be used to monitor patients on hormonal therapy
• Are
age-specific
references needed?
HE4
may be beneficial
in pre-operative triage
weelevated
apply targeted
in advanced /
• Can
Is HE4
in recurrenttherapeutic
disease ?
recurrent disease
– Particularly if it was normal at initial presentation
• Can HE4 be used to monitor for recurrence?
Plan
• Why we need biomarkers in EAC
• Serum biomarkers in pre-operative triage
• The rationale for targeted therapeutics in
advanced / recurrent disease
Historical Perspective
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18th century – Biology
19th century – Chemistry
20th century – Physics / Computer Science
21st century – Molecular Medicine
Principles of Molecular Medicine
• Successful new therapies will be based on a
foundation of precise molecular understanding of
disease
• Translational science must adopt a multidisciplinary
approach that requires substantial infrastructure
• Human subjects are an essential early component in
the evaluation of new drug candidates
Charles Sawyers J Clin Invest 2009
The Targeted Therapeutic Era to Date
• Molecular Diagnostics are urgently required
• Oncogene addiction
– Only relevant in certain tumour types
• Repeat analysis during treatment
– Inclusion of translational arm in early phase trials
– Pathway diagnostics
Somatic Mutations in Endometrial Cancer
Adv Genomics Genet. ; 2012(2): 33–47
Classification of EAC based on somatic mutation profiling
Type 1 – PTEN,
KRAS common
TypePI3K,
1
Type 2
Grade III – higher incidence of p53 and PI3K mutations , less CTNNB1, KRAS
Type II – p53 mutations common, PTEN mutations rare
Alterations in PI3K pathway seen in 80% of endometrioid cancers
Loss of MMR protein expression associated with higher mutation prevalence
Cheung L W et al. Cancer Discovery 2011;1:170-185
Somatic Mutations in Endometrial Cancer
Type 1
Type 2
FGFR2
Her2
PI3K
KRAS
PI3K
PTEN
CTNNB1
p53
What does and unsupervised approach add ?
• Similar mutation frequencies for normal
candidates - PTEN, p53, PI3K, CTNNB1
• 10 novel tumour suppressor genes –
ARID1A, INHBA, KMO, TTLL5, GRM8,
IGFBP3, AKTIP, PHKA2, TRPS1, and
WNT11
• 2 novel oncogenes – ERBB3 and RPS6KC1
Liang H et al. Genome Res. 2012;22:2120-2129
Wu J N , and Roberts C W Cancer Discovery 2013;3:35-43
Loss of ARID1A expression in primary human cancers
? Haploinsufficient effect
ARID1A regulates PI3K activity in Endometrial Cancer
Liang H et al. Genome Res. 2012;22:2120-2129
RAS and PI3K pathways
www.biooncology.com
Downstream Effects of PI3K and KRAS mutations
Distinct downstream signaling events are activated in PI3K pathway- and
KRAS-mutant EC
Cheung L W et al. Cancer Discovery 2011;1:170-185
KRAS as a therapeutic target
• Best molecular targets are
aberrantly activated kinases that
are inhibited by selective smallmolecule inhibitors.
• Oncogenic Ras proteins have
reduced GTPase activity
• Restoring enzymatic function is a
major challenge
• Prognostic relevance of KRAS
mutation remains inconsistant
• MEK inhibitors have shown some
promise in other tumour types
PI3K Pathway as a therapeutic target
Salvesen H B et al. PNAS 2009;106:4834-4839
Slomovitz B M , and Coleman R L Clin Cancer Res 2012;18:5856-5864
How do we define activity of PI3K pathway?
• Major issue for trial design
• Clinically valid molecular diagnostic is urgently required
• Options include
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PTEN IHC
pAKT
Stathmin IHC
Sequence based assay
Combination assay
Djordjevic et al Mod Pathology 2012
Targeting PI3K / AKT / mTOR
Slomovitz B M , and Coleman R L Clin Cancer Res 2012;18:5856-5864
Temsirolimus in recurrent o4 metastatic EAC
62 patients, weekly temsirolimus 25mg
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Chemo-Naïve group (Group A)
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Chemo-treated group (Group B)
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48% SD or better
Median PFS 3.2 months
Toxicity
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69% SD or better
Median PFS – 9.7 months
Rash, fatigue, mucositis, pneumosisitis
Higher dose reduction in chemo-treated group
Unable to identify any predictor of
response
Oza A M et al. JCO 2011;29:3278-3285
Phase 1 and phase 2 trials of targeted therapies for endometrial cancer
>100 trials registered investigating PI3K inhibition
26 trials open in endometrial cancer
4 are biomarker enriched
Rapalogues / PI3K inhibitors in breast and gynae cancers
Combined with various other regimens
Response rate 30% in patients with PI3KCA mutation
Response rate 10% in patients with wild type PI3KCA
Predicting response to PI3K inhibition
PI3K inhibitors
p85
p110
PTEN
AKT inhibitors
AKT
mTORC2
Rapalogs
mTORC1
Dual mTOR
Inhibitors
4EBP1
S6K
Approach to identify predictive biomarkers
Coexistent KRAS mutation predicts resistance
Coexistent Her2 amplifcation predicts response
PTEN mutant cells are sensitive to PI3Kb inhibitors
PTEN loss may predict response to AKT inhibitors
Must identify addicted v’s dependent populations
Brennan et al Nat Rev Cancer 2010
Future for Targeted Therapies in Endometrial Cancer
• Biomarker enriched, adaptive trial design
• Repeat biopsy
• Tumour heterogeneity
• Circulating free DNA
• Confirmation of pathway inhibition
• Identify mechanisms of resistance
• Combination therapy
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Vertical – RAF / MEK inhibition in melanoma
Horizontal – MEK + PI3K / PI3K + PARP
Endocrine therapy
Cytotoxics
Leary et al Sci Tran Med 2012
ER Signalling
E2
Growth Factor
e.g. EGF or IGF-1
ER
MISS
MAP Kinase
Activation
Classical Ligand
Dependent Pathway
Ligand Independent
Pathway
P
P
mRNA
Protein
ER ER
ERE
Genomic
Pathway
ER Responsive Gene
Tissue
Response
P
ER
Fos
mRNA
Protein
Jun
AP-1
Target Gene
Brennan et al Oncogene 2012
Rationale for combining PI3K inhibition and endocrine therapies
IGF 1/II
P
IGF-R
PTEN
PI3K
LKB1
E2
AKT
AMPK
Metformin
mTOR
p-S6K
ER
PR
ER response genes
PR, PS2
PR response genes
Inhibition of proliferation
Conclusions
• Why we need biomarkers in EAC
• Fertility sparing therapy,
• Obesity
• Serum biomarkers in pre-operative triage
• HE4 shows some promise
• The rationale for targeted therapeutics in
advanced / recurrent disease
• PI3K inhibitors are unlikely to have a role as single
agents
• Combination, biomarker enriched studies may offer
best chance of clinical response