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Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Molecular Cancer Therapeutics Molecular Medicine in Practice Molecular Profiling of Patients with Colorectal Cancer and Matched Targeted Therapy in Phase I Clinical Trials Rodrigo Dienstmann1, Danila Serpico1, Jordi Rodon1, Cristina Saura1, Teresa Macarulla1, Elena Elez1, nchez-Olle 2, Claudia Aura3, Maria Alsina1, Jaume Capdevila1, Jose Perez-Garcia1, Gessamí Sa 3 3 3 ndez-Losa , Ana Vivancos4, and Josep Tabernero1 Ludmila Prudkin , Stefania Landolfi , Javier Herna Abstract Clinical experience increasingly suggests that molecular prescreening and biomarker enrichment strategies in phase I trials with targeted therapies will improve the outcomes of patients with cancer. In keeping with the exigencies of a personalized oncology program, tumors from patients with advanced chemorefractory colorectal cancer were analyzed for specific aberrations (KRAS/BRAF/PIK3CA mutations, PTEN and pMET expression). Patients were subsequently offered phase I trials with matched targeted agents (MTA) directed at the identified anomalies. During 2010 and 2011, tumor molecular analysis was conducted in 254 patients: KRAS mutations (80 of 254, 31.5%), BRAF mutations (24 of 196, 12.2%), PIK3CA mutations (15 of 114, 13.2%), KRAS and PIK3CA mutations (9 of 114, 7.9%), low PTEN expression (97 of 183, 53.0%), and high pMET expression (38 of 64, 59.4%). In total, 68 patients received 82 different MTAs: phosphoinositide 3-kinase (PI3K) pathway inhibitor (if PIK3CA mutation, n ¼ 10; or low PTEN, n ¼ 32), PI3K pathway inhibitor plus MEK inhibitor (if KRAS mutation, n ¼ 10; or BRAF mutation, n ¼ 1), second-generation anti-EGF receptor monoclonal antibodies (if wild-type KRAS, n ¼ 11), anti-hepatocyte growth factor monoclonal antibody (if high pMET, n ¼ 10), mTOR inhibitor plus anti-insulin-like growth factor-1 receptor monoclonal antibody (if low PTEN, n ¼ 5), and BRAF inhibitor (if BRAF mutation, n ¼ 3). Median time-to-treatment failure on MTA was 7.9 versus 16.3 weeks for their prior systemic antitumor therapy (P < 0.001). Partial response was seen in 1 patient [1.2%, PI3K inhibitor with PIK3CA mutation] and stable disease >16 weeks in 10 cases (12.2%). These results suggest that matching chemorefractory patients with colorectal cancer with targeted agents in phase I trials based on the current molecular profile does not confer a significant clinical benefit. Mol Cancer Ther; 11(9); 2062–71. 2012 AACR. Introduction Colorectal cancer is the third most common cancer worldwide, accounting for approximately 10% of total cancer incidence and mortality (1). In the last decade, a multidisciplinary approach to the treatment of metastatic colorectal cancer along with the introduction of new cytotoxic drugs and the addition of targeted therapies directed against angiogenesis (bevacizumab, aflibercept, and regorafenib) and the EGF receptor (EGFR) pathway (cetuximab and panitumumab) have improved survival endpoints considerably. Nevertheless, the prognosis in metastatic colorectal cancer remains poor, and other than the negative predictive effect of KRAS mutations for Authors' Affiliations: 1Molecular Therapeutics Research Unit, Medical Oncology Department, 2Database Management Office, 3Molecular Pathology Lab, and 4Cancer Genomics Lab, Vall d'Hebron Institute of Oncology, noma de Barcelona, Vall d'Hebron University Hospital, Universitat Auto Barcelona, Spain Corresponding Author: Josep Tabernero, Vall d'Hebron University Hos noma de Barcelona, P. Vall d'Hebron 119-129, pital, Universitat Auto Barcelona 08035, Spain. Phone: 3493-489-4301; Fax: 3493-274-6059; E-mail: [email protected] doi: 10.1158/1535-7163.MCT-12-0290 2012 American Association for Cancer Research. 2062 response with EGFR-targeted agents, efficacious personalized treatment of metastatic colorectal cancer remains an unmet need in clinical oncology. Aberrant activation of the RAS/RAF/MEK and PI3K/ mTOR/AKT pathways, either by upstream EGFR stimulation or downstream mutations or deregulations, occurs in virtually all colorectal tumors. Mutations in KRAS, frequently found in codons 12 and 13, occur in as many as 40% of patients with colorectal cancers and are strongly associated with resistance to anti-EGFR monoclonal antibodies (mAb) as a result of constitutive pathway activation. Because cetuximab and panitumumab are not effective in all patients with wild-type (wt) KRAS metastatic colorectal cancers, molecular markers downstream of EGFR, namely, mutations in NRAS, BRAF, PIK3CA and PTEN loss-of-function, may also predict lack of response to anti-EGFR therapies in colorectal cancers (2). BRAF mutations in colorectal cancers are mainly located in a hotspot region in exon 15 (V600E) and occur in 5% to 15% of the tumors. NRAS mutations are frequently found in codon 61 and have been identified in as many as 5% of colorectal cancer samples. KRAS, NRAS, and BRAF mutations are, however, mutually exclusive. Mutations in PIK3CA, which encodes the catalytic p110a kinase subunit, have been reported in 15% of patients with colorectal Mol Cancer Ther; 11(9) September 2012 Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Colorectal Cancer Patients in Phase I Trials of Targeted Agents cancers. As many as 70% involve the exon 9 helical domain (such as E542K or E545K) or the exon 20 kinase domain (such as H1047R; ref. 3). Loss-of-function mutations, deletions, or epigenetic silencing by promoter methylation of PTEN, a negative regulator of phosphoinositide 3-kinase (PI3K), have also been linked to resistance to antiEGFR mAbs in colorectal cancers (4–6). Loss of PTEN expression, assessed by immunohistochemistry, is found in as many as 40% of colorectal cancer tumors (4–6). Importantly, the RAS/RAF/MEK and PI3K/AKT/ mTOR pathways also interact extensively: (i) each shows activation of upstream receptor tyrosine kinases; (ii) mutations in KRAS or BRAF and PIK3CA coexist in a significant percentage of colorectal tumors; and (iii) complex networks allow compensatory parallel signaling when one or the other pathway is inhibited (7). Complex cross-talk involving EGFR and other pathways has also been identified in the past few years. Mesenchymal–epithelial transition (MET) activation, for example, occurs in 50% to 80% of colorectal tumors with both mutant and wt KRAS (8). Preclinical cellular models show cooperation between MET and KRAS to enhance colorectal cancer tumorigenicity (9, 10). In addition, MET hyperactivation, secondary to increased expression of the MET receptor or its ligand [hepatocyte growth factor (HGF)], may have a role in resistance to anti-EGFR therapies (11). The same is true for the insulin-like growth factor-1 receptor (IGF1R) as well as HER2 and HER3 upregulation (12–14). Multiple novel targeted agents have entered clinical development. These include innovative mAbs targeting EGFR, EGFR/HER3, MET (or HGF), and IGF1R, as well as kinase inhibitors downstream of these pathways, mainly BRAF, MEK, PI3K, mTORC1/2, and AKT. These agents are being investigated in phase I trials using biomarker enrichment strategies. Their study designs are based on preclinical and early clinical response data showing the potential predictive value of specific molecular aberrations. Examples include PIK3CA-activating mutations and loss of PTEN expression and benefit with PI3K pathway inhibitors (15, 16), synergistic antitumor activity with combination blockade of mTOR and IGF1R signaling (17, 18), RAS/RAF mutations and response to PI3K pathway inhibitors plus MEK inhibitors (19–21), BRAF mutations linked to antitumor activity of selective BRAF inhibitors (22, 23), and MET hyperactivation and benefit with MET/ HGF targeting agents (24, 25). Molecular biomarker–based patient selection in early clinical trials has many putative advantages over an unselected population-based approach. These include (i) early clinical qualification of potential predictive biomarkers for molecularly targeted agents; (ii) further delineating underlying cancer biology; (iii) providing clinically relevant therapeutic opportunities for patients with advanced-stage cancer; and (iv) impacting novel drug development by assisting in go versus no go decisions and changing drug approval registration strategies for promising agents. A caveat is, however, that finding a www.aacrjournals.org potential target in a patient’s tumor does necessarily correlate with response to a therapeutic agent directed toward the target. Early clinical validation is, therefore, a key component of the drug development process (26). Recent studies have examined the feasibility of using a real-time molecular profile of patient tumors and matching the identified aberration(s) with treatments targeted to the specific aberration(s). Von Hoff and colleagues and Tsimberidou and colleagues showed that patients who received MTAs had better response rates and improved time to treatment failure (TTF; ref. 27, 28). As part of our personalized oncology program, tumors from patients with advanced chemorefractory metastatic colorectal cancer were analyzed for specific molecular aberrations [KRAS/ BRAF/PIK3CA mutations, PTEN, and phosphorylated MET (pMET) expression] in the Vall d’Hebron Molecular Pathology and Cancer Genomics Labs (Barcelona, Spain). Patients with advanced cancer were then offered enrollment on a molecularly appropriate phase I trial with an MTA based on the hypothesis that biomarker enrichment strategies might improve their outcomes. We retrospectively evaluated the benefit of MTA only in patients with metastatic colorectal cancers, unlike studies enrolling patients with any advanced tumor type (27, 28). Our primary objective was to compare time TTF using a therapy selected by the molecular profile of a patient’s tumor with the TTF for the most recent unmatched therapy on which the patient had experienced progression. We also describe the clinical benefit rate with an MTA in patients with metastatic colorectal cancers treated in phase I clinical trials. Patients and Methods Patients and matched targeted therapy All patients with pathologically confirmed metastatic colorectal cancers refractory to standard therapy referred to phase I clinical trials at the Molecular Therapeutic Research Unit of Vall d’ Hebron Institute of Oncology during 2010 and 2011 had archived formalin-fixed, paraffin-embedded (FFPE) tumor samples analyzed for specific molecular aberrations. Informed consent was obtained at baseline. In total, 254 patients/tumor samples were analyzed, and 68 patients were enrolled on specific first-inhuman phase I trials based on the results of tumor genetic alterations/protein expression levels as well as logistic factors, including study availability and eligibility criteria. If more than one molecular deregulation was identified or 2 different matched targeted therapies were available for one specific aberration, patients could receive more than one MTA. These included second-generation anti-EGFR mAbs [if (wt) KRAS], PI3K pathway inhibitors (if PIK3CA mutation or low PTEN expression), mTORC1 inhibitor plus anti-IGF1R mAb (if low PTEN expression), PI3K pathway inhibitors plus MEK inhibitors (if KRAS or BRAF mutation), BRAF inhibitor (if BRAF mutation) and anti-HGF mAb (if high pMET expression). All phase I studies were conducted in accordance with the guidelines of the Vall d’ Hebron Institute of Oncology Institutional Review Board. Mol Cancer Ther; 11(9) September 2012 Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. 2063 Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Dienstmann et al. Tissue samples and molecular analyses PTEN and pMET expression levels were assessed by immunohistochemistry using a histopathologic scoring (H-score) system, which is based on a sum of the proportion of stained cells multiplied by the staining reactivity [H-score ¼ (0 % staining cells negative) þ (1 % staining cells weakly positive) þ (2 % staining cells moderately positive) þ (3 % staining cells strongly positive); ref. 29]. An anti-PTEN antibody (Cell Signaling Technologies, clone 138G6, cat# 9559) was used in a 1:100 dilution and incubated at room temperature for 60 minutes. We considered low PTEN expression when there was an absence of immunostaining (PTEN-null) or PTEN H-score 50 (range, 0–300) compared with the internal control. The subgroup with PTEN-null expression (H-score ¼ 0) is described separately. Paraffin-embedded cell pellets were used as controls in each run (MDA231 and PC3 as positive and negative controls, respectively) and also considered as internal positive controls were nerve sheaths and vessels. An antibody against pMET (pMET Tyr1349; Epitomics, EP2367Y, cat# 2319-1) was used in a 1:100 dilution and incubated at room temperature for 60 minutes. Positive expression was defined as H-score >30 (range, 0–300; ref. 30). For mutation detection, KRAS and PIK3CA were initially assessed by real-time PCR using a DxS Scorpions technology (TheraScreen KRAS Mutation Kit and DxS PI3K Mutation Test Kit; DxS). In this technique, allele- or mutation-specific amplification is achieved by ARMS (amplification refractory mutation system) technology and its detection is conducted using Scorpions (bifunctional molecules containing a PCR primer covalently linked to a probe; ref. 31). The following mutations were evaluated: KRAS G12A, G12D, G12R, G12C, G12S, G12V, G13D and PIK3CA H1047R, E542K, E545D, E545K. Standard Sanger sequencing of exons 9 or 20 of the gene confirmed each PIK3CA mutation. Sanger sequencing was also used to assess BRAF mutations in exon 15. Later on, tumor genetic analyses by PCR-based and deep sequencing techniques were substituted by the OncoCarta Panel v 1.0, a multigene panel with 19 key oncogenes and 238 mutations, via the MassARRAY System (Sequenom, Inc.). The MassARRAY System involves the following steps: multiplex PCR of gene exons of interest, primer extension reactions using IPLEX chemistry, and analysis of primer extension products by matrix-assisted laser desorption/ ionization—time-of-flight (MALDI-TOF) mass spectrometry. A Vall d’Hebron pathologist evaluated total tumor area in the tissue block, and a minimum 30% tumor content was required for further processing. DNA was extracted from five 10-mm slices of FFPE tumor samples using the RecoverAll Total Nucleic Acid Isolation Kit (Ambion). DNA was quantified with nanodrop (ND1000), 260:280 and 260:230 ratios were used for quality control (QC) of sample purity. Additional QC was obtained in low concentration samples by quantitative PCR of 100-bp long amplicons in AKT1 (exon 1), KRAS (exon 1), and PIK3CA (exon 20), dsDNA quantification 2064 Mol Cancer Ther; 11(9) September 2012 with Quant-iT DNA BR (Invitrogen) and lab-on-a-chip using High Sensitivity DNA Chips (Agilent). The full mutation panel is not available for all patients included in this study. This is because the prescreening program was initially constructed on the basis of the clinical trials available at the time of screening and their inclusion criteria (i.e., there were no trials focused on patients with PIK3CA- or BRAF-mutated tumors actively recruiting in early 2010). In addition, we gradually added new technologies (OncoCarta Panel v 1.0 via the MassARRAY System) to simultaneously assess multiple mutations. Treatment evaluation We reviewed the electronic medical records of patients enrolled in clinical trials according to molecular prescreening results, sex, age, Eastern Cooperative Oncology Group performance status at the beginning of treatment and detailed information on prior treatments. The formulation of the patient database and collection of data for the purpose of this study were conducted retrospectively. Previous therapies were classified into different groups according to National Comprehensive Cancer Network (NCCN) guidelines: (i) standard regimens, including capecitabine/5-fluorouracil, oxaliplatin, irinotecan, bevacizumab, and cetuximab (monotherapies or combinations) or (ii) nonstandard, if not an approved chemotherapy regimen (such as single-agent gemcitabine or pemetrexed used off-label, or mitomycin or capecitabine after progression to regimens containing infusional 5-fluorouracil) or an unmatched agent in another earlyphase clinical trial. Treatment on phase I studies continued until disease progression or death or unacceptable toxicity occurred and was carried out according to the specific requirements of each protocol. Efficacy was assessed routinely by computed tomographic scans and/or MRI at baseline before treatment initiation and then every 2 cycles (6–8 weeks) as per each phase I study protocol. In accordance with Response Evaluation Criteria in Solid Tumors (RECIST) v. 1.0 or 1.1 (depending on study protocol), tumor responses were classified as complete response, partial response, stable disease, or progressive disease. TTF was defined as the time interval from the start of a therapy to its discontinuation for any reason, including disease progression, treatment toxicity, or death, whichever occurred first. Patients with TTF on MTA longer than 16 weeks (>2 radiologic RECIST assessments) were described separately. In addition, if the TTF on MTA/TTF on prior therapy ratio was 1.3, then the matched targeted therapy selected was defined as having benefit for the patient (27). Statistical analysis Survival analyses were conducted using the Kaplan– Meier method and compared with a log-rank test (TTF with MTA vs. previous unmatched therapy). Subgroup analysis was conducted considering standard versus nonstandard previous therapy. Exact 2-sided 95% confidence Molecular Cancer Therapeutics Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Colorectal Cancer Patients in Phase I Trials of Targeted Agents Table 1. Molecular profile of patients with colorectal cancer referred to phase I clinical trials No. (%) Tested 175/79 (68.9/31.1) 173/81 (68.1/31.9) 254 254 0 0 Analysis of single aberrations KRAS mutation Unknowna G12D G12V G13D G12C G13V G12F/G12S/K61H/K61L BRAF mutation V600E K601E PIK3CA mutation E542K/E545K Q546K E110K/H1047L/R88Q PTEN-low PTEN-null pMET high 80 (31.5) 17 20 15 9 6 2 1 24 (12.2) 23 1 15 (13.2) 5 2 1 97 (53) 45 (24.6) 38 (59.4) 254 0 196 58 114 140 183 71 64 190 Analysis of double aberrations KRAS wild-type and PIK3CA mutation KRAS mutation and PIK3CA mutation KRAS mutation and PTEN-low KRAS mutation and PTEN-null BRAF mutation and PIK3CA mutation BRAF mutation and PTEN-low BRAF mutation and PTEN-null PIK3CA mutation and PTEN-low PIK3CA mutation and PTEN-null pMET high and KRAS mutation pMET high and BRAF mutation pMET high and PIK3CA mutation pMET high and PTEN low 6 (5.3) 9 (7.9) 38 (20.8) 14 (7.6) 0 (0) 4 (3.1) 2 (1.5) 4 (3.6) 1 (0.9) 16 (25) 2 (6.3) 2 (5.6) 4 (6.6) 114 114 183 183 92 130 130 110 110 64 32 36 61 140 140 71 71 172 124 124 144 144 190 222 218 193 Analysis of 3 mutations No mutation (KRAS, BRAF, and PIK3CA wild-type) Mutation in 1 gene (KRAS, BRAF, or PIK3CA) Mutation in 2 genes (KRAS or BRAF and PIK3CA) 36 (39.1) 47 (51.1) 9 (9.8) 92 92 92 172 172 172 Biopsy site (primary/metastasis) Mutation detection technique (DxS Scorpions or sequencing/MassARRAY system) a Not tested Total 254 254 KRAS mutation detected outside Vall d'Hebron Labs and tumor tissue left was not sufficient for confirmation on site. intervals (CI) were calculated. All tests were 2-sided, and P < 0.05 was considered statistically significant. All statistical analyses were conducted using SPSS v.15.0 software (SPSS). Results Molecular prescreening During 2010 and 2011, we analyzed tumor samples from 254 patients with metastatic colorectal cancers referred to phase I trials at our institution. Archived www.aacrjournals.org biopsy specimens were the only source of tissue used for analysis. The median age of patients was 61.9 years (range, 32.8–85.1) and 65% were men. Detailed molecular profiles of patients’ tumors are presented in Table 1. KRAS, BRAF, and PIK3CA mutation rates are similar to previous reports (3). PTEN expression was evaluated as being low in 53% (97 of 183) of tumor samples. Of these, 46.4% (45 of 97) had PTEN-null expression. The coexistence of KRAS mutations and PIK3CA mutations (7.9%) or KRAS mutations and PTEN-low/null expression (20.8%/7.6%) confirms Mol Cancer Ther; 11(9) September 2012 Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. 2065 Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Dienstmann et al. 254 patients/ tumor samples analyzed 68 patients selected for phase I trials based on molecular profile 82 matched targeted therapies Figure 1. Study diagram and illustration of the primary analysis (TTF comparisons). In example 1, patient received an MTA after progression to one nonstandard chemotherapy (CT) regimen. In example 2, patient received 2 consecutive MTAs after progression to standard CT regimens. MTA, matched targeted agent; TTF, time to treatment failure. TTF comparisons Example 1: Standard CT Standard CT Nonstandard CT MTA Example 2: Standard CT Standard CT MTA the frequent parallel activation of RAS/RAF/MEK and PI3K/AKT/mTOR pathways in colorectal cancers. Compared with (wt) KRAS patients, those harboring a KRAS mutation did not have a significantly higher prevalence of PIK3CA mutations (7.9% vs. 5.3%, P ¼ 0.5). In addition, approximately 60% of the tumors analyzed had high pMET expression according to the cutoff value for inclusion on the anti-HGF trial. This aberration was not mutually exclusive with KRAS, BRAF, or PIK3CA mutations. Matched targeted therapy Sixty-eight patients were enrolled in 15 different phase I clinical trials. There were a total of 82 matched targeted therapies, with 8 patients participating in 2 clinical trials and 3 who were enrolled in 3 clinical trials, as shown in Fig. 1. Table 2 presents patients’ demographics and clinical characteristics. Phase I trials included PI3K pathway inhibitors (National Clinical Trial numbers: NCT01115751, NCT01219699, NCT01090960, NCT00940498, NCT01058707, NCT00620594, NCT01068483, NCT01449370), PI3K pathway inhibitors plus MEK inhibitors (NCT01363232, NCT01155453), second-generation anti-EGFR mAbs (NCT01207323, NCT01117428), anti-HGF mAb (NCT00969410), mTORC1 inhibitor plus anti-IGF1R mAb (NCT00730379), and BRAF inhibitor (NCT01143753). Detailed descriptions of matched targeted therapies, dose levels, and patient outcomes are presented in Table 3. Time to treatment failure on MTA Median TTF on MTA was 7.9 weeks (95% CI, 7.6–8.1) compared with 16.3 weeks (95% CI, 13.9–18.7) with the 2066 Mol Cancer Ther; 11(9) September 2012 MTA prior systemic antitumor therapy (P < 0.001). As shown in Fig. 2, analysis according to type of previous therapy showed that if it was considered nonstandard (n ¼ 39), TTF with MTA was 7.0 weeks (95% CI, 5.7–8.3) and TTF with prior therapy was 8.7 weeks (95% CI, 7.3–10.1). Nonstandard therapy was another phase I trial with unmatched agent in 21 patients and off-label chemotherapy regimens Table 2. Patient demographics and clinical characteristics No. (N ¼ 68), % Characteristic Sex Male Female Age, y Median Range Number of prior treatment regimens (metastatic) Median 1–3 4–7 ECOG performance status 0 1 Tumor type Colon Rectum 43 (63.2) 25 (36.8) 62.8 37.2–82.6 3 52 (76.5) 16 (23.5) 23 (33.8) 45 (66.2) 41 (60.3) 27 (39.7) Abbreviation: ECOG, Eastern Cooperative Oncology Group. Molecular Cancer Therapeutics Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. www.aacrjournals.org Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. BRAF mutation BRAF inhibitor (n ¼ 3) Abbreviations: PR, partial response; SD, stable disease. PTEN low mTORC1 inhibitor plus anti-IGF1R mAb (n ¼ 5) 3 2 PTEN-low and KRAS mutation PTEN-low and KRAS wild-type 3 1 pMET high and BRAF mutation BRAF mutation 4 pMET high and KRAS wild-type pMET high Anti-HGF mAb (n ¼ 10) 1 5 5 5 KRAS wild-type KRAS wild-type and PTEN-low KRAS wild-type þ BRAF mutation KRAS wild-type Second-generation anti-EGFR mAb (n ¼ 11) 1 1 6 3 4 pMET high and KRAS mutation KRAS mutation KRAS mutation and PTEN-null KRAS mutation and PIK3CA mutation BRAF mutation and PTEN-null KRAS or BRAF mutation PI3K pathway inhibitor plus MEK inhibitor (n ¼ 11) 10 PTEN-low and KRAS mutation PIK3CA mutation and KRAS wild-type PIK3CA mutation and KRAS mutation 6 22 PTEN-low and KRAS wild-type PTEN low or PIK3CA mutation PI3K pathway inhibitor (n ¼ 42) No. Molecular profile Rationale Targeted therapy <1/3 MTD: 1 MTD: 2 MTD: 5 <1/3 MTD: 1 1/3 to <MTD: 4 MTD: 5 MTD: 11 1/3 to <MTD: 6 MTD: 5 <1/3 MTD: 5 1/3 to <MTD: 1; MTD: 36 Dose level PR: 0 SD >16 wks: 0 PR: 0 SD >16 wks: 1 (20%) PR: 0 SD >16 wks: 1 (10%) PR: 0 SD >16 wks: 3 (27.3%) PR: 0 SD >16 wks: 0 PR: 1 (2.4%) SD >16 wks: 5 (11.9%) Response rate Need for combination therapy. Wrong biomarker? Target or pathway redundancy? Wrong biomarker? Need for combination therapy. Treatment at biologically inactive doses. Presence of downstream pathway aberrations (PTENlow and BRAF mutation). Acquired resistance to antiEGFR mAbs Treatment at biologically inactive doses. Wrong biomarker? Need for combination therapy. Resistance to monotherapy in the presence of KRAS mutations. Reasons for lack of response Table 3. Matched targeted therapies in phase I clinical trials based on molecular profile, dose level, and patient outcome Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Colorectal Cancer Patients in Phase I Trials of Targeted Agents Mol Cancer Ther; 11(9) September 2012 2067 Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Dienstmann et al. 7.9 (95%CI, 7.6–8.1) Overall (n = 82) 16.3 (95%CI, 13.9–18.7) 7.0 (95%CI, 5.7–8.3) Prior therapy nonstandard regimen as per NCCN (n = 39) Figure 2. Comparisons of TTF on MTA (light gray bars) and prior unmatched therapy (dark gray bars). Subgroup analysis according to type of prior therapy. NCCN, National Comprehensive Cancer Network; MTA, matched targeted agent; TTF, time to treatment failure. MTA 8.7 (95%CI, 7.1–10.1) Prior unmatched therapy 8.1 (95%CI, 7.2–9.1) Prior therapy standard regimen as per NCCN (n = 43) 21.9 (95%CI, 15.0–28.7) 0 5 10 15 20 25 TTF (wk) in 18 patients. On the other hand, if previous therapy was an approved standard regimen (n ¼ 43), TTF with MTA was 8.1weeks (95% CI, 7.2–9.1) and TTF with prior therapy was 21.9 weeks (95% CI, 15.0–28.7). Overall, 64 patients (78%) received maximum tolerated doses (MTD) or recommended phase 2 doses (RP2D), 9 patients (11%) had doses lower than one third of the MTD and 9 patients (11%) received intermediate doses (that ranged from one third to less than the MTD). In total, 10 matched therapies had to be discontinued because of adverse events (12.2%). Tumor response and clinical benefit with MTA One patient whose tumor harbored PIK3CA R88Q and KRAS G12C mutations (detected using the MassARRAY system) had a confirmed partial response to a specific PI3K-a inhibitor as monotherapy. This is the only patient who has continued on treatment for longer than 24 weeks. Stable disease longer than 16 weeks was seen in 10 cases (12.2%): 2 patients on specific PI3K-a inhibitor (both with PIK3CA mutations), 2 patients on PI3K/mTOR inhibitors, and one patient on mTORC1/2 inhibitor [all with low PTEN and a (wt) KRAS/BRAF/PIK3CA profile], one patient on mTORC1 inhibitor plus anti-IGF1R mAb (PTEN-null and KRAS mutant), 3 patients on secondgeneration anti-EGFR mAb [all with (wt) KRAS/BRAF profiles and refractory to cetuximab or panitumumab], and one patient on anti-HGF mAb [the one with the highest pMET H-score (200) plus (wt) KRAS status; only 2 patients had an H-score < 100]. None of the 11 patients who received a PI3K pathway inhibitor plus an MEK inhibitor had disease stabilization for longer than 16 weeks (3 had a simultaneous KRAS mutation and PTEN-null expression, one had a KRAS mutation plus a PIK3CA mutation, and one had a BRAF mutation and PTEN-null expression). A TTF ratio 1.3 was achieved in 13 of the 82 matched therapies (15.9%). There was no difference in terms of TTF on MTA according to site of mutation analysis [primary (n ¼ 53) vs. metastasis (n ¼ 29); 7.9 weeks in both subgroups], number of previous lines of chemotherapy [1–3 (n ¼ 52) vs. 4 (n ¼ 30); 7.9 and 8.0 weeks, respectively], number of molecular aberrations 2068 Mol Cancer Ther; 11(9) September 2012 [0 or 1 (n ¼ 44) vs. 2 (n ¼ 38); 8.4 and 6.1 weeks, respectively], and dose level [MTD (n ¼ 64) vs. lower than MTD (n ¼ 18); 7.9 weeks in both subgroups]. Discussion Our results suggest that matching patients with chemorefractory metastatic colorectal cancers with targeted agents in early clinical trials based on their current molecular profiles does not result in longer TTF compared with their prior systemic therapy. In addition, only a small percentage of study patients derived benefit in tumor response or disease stabilization, comparable with statistics reported in the literature of patients treated on phase I trials without molecular selection (32). These findings are disparate from those in a recently published series of patients with PIK3CA mutant breast and gynecologic malignancies enrolled in phase I trials with PI3K/mTOR inhibitors (33). However, all responses in this study were observed in patients treated with combination therapies, mainly mTORC1 inhibitors plus cytotoxic agents or bevacizumab. Some caveats deserve consideration when looking at the results of this study. First, it is a retrospective study in a single institution. Despite the homogeneous patient population, the mechanisms of action of the targeted agents are heterogeneous. Notably, the biomarkers selected for enrichment of the phase I trials were primarily exploratory. Different techniques (DxS Scorpions, sequencing, MassARRAY system) with different sensitivities were used to identify the most frequent mutations in KRAS, BRAF, and PIK3CA (of note, all PIK3CA mutations detected by DxS Scorpions or the MassARRAY system were confirmed by Sanger sequencing). In addition, analyzing archival tumor samples from the time of diagnosis may not reflect the molecular aberrations that drive metastatic disease as a result of clonal evolution and selection pressure from previous treatments (34). This is particularly true in regard to protein expression levels, such as PTEN (5). Furthermore, a limitation inherent to all phase I clinical trials is that patients may have been treated at nonbiologically active doses, even though 78% received MTD/RP2D doses and were treated in the expansion Molecular Cancer Therapeutics Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Colorectal Cancer Patients in Phase I Trials of Targeted Agents cohorts of each protocol. Finally, the timing of tumor assessment during a phase I trial (every 6–8 weeks) is usually shorter than restaging intervals for patients receiving standard therapies (every 8–12 weeks), which is another possible bias. Many patients in our series received PI3K pathway inhibitors based on PTEN expression levels, irrespective of coexisting oncogenic aberrations (e.g., KRAS mutations). The predictive value of PTEN expression for determining response to PI3K pathways inhibitors in colorectal cancer is, however, still pending. Moreover, the optimal method for assessing PTEN loss of function has not yet been established, that is, a cutoff point to define positive and negative expression levels according to immunohistochemical assay results. Preclinical experiments showed that PIK3CA mutations and PTEN aberrations render tumors sensitive to PI3K pathway inhibitors, whereas simultaneous mutations in the mitogen-activated protein kinase (MAPK) pathway (KRAS, BRAF) can mediate resistance to therapy (35, 36). Preliminary clinical data suggested a negative predictive role for tumors harboring KRAS mutations in response to mTORC1 inhibitors (37). Nevertheless, efficacy of mTORC1/2 inhibitors was observed in KRAS/BRAF-mutant colorectal cancer xenograft models, and PI3K/mTOR inhibitors induced tumor regressions in genetically engineered (wt) PIK3CA mouse models (38, 39). Interestingly, the only patient with colorectal cancer achieving a partial response in our series had a molecular profile with a simultaneous PIK3CA and KRAS mutation. PI3K pathway inhibitors have also shown activity in KRAS-mutant breast and ovarian cancer (33, 40). Despite this positive result, most of our patients with PI3K pathway activation treated with single-agent kinase inhibitors did not derive benefit from therapy, especially those with low PTEN expression and coexisting KRAS mutations. It is possible that a treatment approach with a combination of agents could overcome resistance to PI3K pathway inhibitors in colorectal cancers. In preclinical models, inhibiting the PI3K pathway showed synergy with cytotoxic agents, enhancing its efficacy by potentiating apoptosis (41). In addition, dual inhibition of the RAF/MEK and PI3K/AKT/mTOR pathways seems to be required for complete abrogation of downstream effectors in RASmutant tumors (19–21). PIK3CA and PTEN mutations strongly reduce the sensitivity of RAS-mutant cells to MEK inhibitors (42). Preclinical studies provide a clear rationale for the coinhibition of these frequently co-activated pathways, and many early clinical trials testing this hypothesis are underway. The clinical impact of such a parallel pathway blockade remains unclear, but none of the 11 patients treated with PI3K pathway inhibitors plus MEK inhibitors in our series had benefit in terms of response or disease stabilization. A recently published large data set reported similarly disappointing results, with no partial responses or disease stabilizations for more than 16 weeks in 16 patients with metastatic colorectal cancers treated using the same approach (43). www.aacrjournals.org Remarkably, as in our series, some patients who received PI3K pathway inhibitors plus MEK inhibitors had simultaneous RAS/RAF and PI3K/AKT/mTOR activation. It is also important to highlight the fact that the use of full doses of both targeted agents was rarely achieved because of overlapping toxicities. Interestingly, in patient-derived metastatic colorectal cancer xenografts exhibiting KRAS and BRAF mutations, concomitant inhibition of PI3K/ mTOR and MEK pathway activity proved to be more effective than single pathway inhibition, although the best response was limited to tumor growth arrest rather than overt tumor regression (21). This observation is potentially important for further drug development in RAS/RAFmutant colorectal cancers. Regarding BRAF inhibitors in BRAF-mutant colorectal cancers, none of the 4 patients treated in our series with selective BRAF inhibitors or PI3K pathway inhibitors plus MEK inhibitors had signs of antitumor activity. In an expansion cohort of the phase I study with vemurafenib at the RP2D, only 1 of 19 patients had a confirmed partial response (44). These findings support preclinical data suggesting that BRAF-mutant colorectal cancers might respond to combined targeted therapy with BRAF and EGFR inhibitors (45). A combination strategy also appears hopeful when agents targeting the MET/HGF pathway are used. Preliminary clinical data suggest that adding an MET tyrosine kinase inhibitor or an anti-HGF mAb to an approved anti-EGFR mAb might increase the response rate in (wt) KRAS metastatic colorectal cancer (46, 47). Interestingly, the patients who had the greatest benefit with a MTA in our data set had a molecular profile with (wt) KRAS/BRAF and received second-generation anti-EGFR mAbs (3 of 11 patients refractory to cetuximab or panitumumab had stable disease for more than 16 weeks). These retrospective data, while not definitive, are certainly hypothesis-generating. With the switch from histology- to molecular-driven therapy, phase I trials in clinical oncology are providing an arena for early hypothesis testing. The one-size-fits-all approach for drug development of molecular targeted agents in solid tumors has yielded disappointing results, and patients with metastatic colorectal cancers enrolled in biomarker-driven early clinical trials do not appear to derive significant benefit. A strong biologic hypothesis, solid preclinical data on the mechanisms of primary/ acquired resistance and tumor models that better mimic the clinical disease are needed to further drug development. Our data confirm that prescreening strategies for early clinical trials and molecular profiling in patients with metastatic colorectal cancers are feasible. For personalized therapy to become a reality for these patients, a more comprehensive analysis of molecular aberrations appears to be critically important. Disclosure of Potential Conflicts of Interest J. Tabernero has had a role as consultant/advisor for Amgen, Genentech, Merck-Serono, Novartis, Roche, and Sanofi-Aventis. No potential conflicts of interest were disclosed by the other authors. Mol Cancer Ther; 11(9) September 2012 Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. 2069 Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Dienstmann et al. Authors' Contributions Conception and design: R. Dienstmann, D. Serpico, J. Rodon, C. Saura, E. Elez, J. Tabernero Development of methodology: R. Dienstmann, D. Serpico, J. Rodon, M. Alsina, G. Sanchez-Olle, J. Hernandez-Losa, A. Vivancos, J. Tabernero Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): R. Dienstmann, J. Rodon, C. Saura, T. Macarulla, E. Elez, M. Alsina, J. Capdevila, G. Sanchez-Olle, C. Aura, L. Prudkin, S. Landolfi, J. Hernandez-Losa, A. Vivancos, J. Tabernero Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): R. Dienstmann, J. Rodon, M. Alsina, G. S anchez-Olle, A. Vivancos, J. Tabernero Writing, review, and/or revision of the manuscript: R. Dienstmann, D. Serpico, J. Rodon, C. Saura, E. Elez, J. Capdevila, J. Perez-Garcia, J. Hern andez-Losa, A. Vivancos, J. Tabernero Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): R. Dienstmann, D. Serpico, G. Sanchez-Olle Study supervision: R. Dienstmann, J. Rodon, M. Alsina, J. Tabernero Acknowledgments The authors thank Debora Moreno and Nuria Murtra from Database Management Office, Jose Jimenez from Molecular Pathology Lab of Vall d’Hebron Institute of Oncology, and Joann Aaron, MA, for editorial support. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Received March 21, 2012; revised May 14, 2012; accepted May 23, 2012; published OnlineFirst June 21, 2012. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 2070 Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010;60:277–300. Dienstmann R, Vilar E, Tabernero J. Molecular predictors of response to chemotherapy in colorectal cancer. Cancer J 2011;17:114–26. De Roock W, Claes B, Bernasconi D, De Schutter J, Biesmans B, Fountzilas G, et al. Effects of KRAS, BRAF, NRAS and PI3KCA mutations on the efficacy of cetuximab plus chemotherapy in chemotherapy-refractory metastatic colorectal cancer: a retrospective consortium analysis. Lancet Oncol 2010;11:756–62. Frattini M, Saletti P, Romagnani E, Martin V, Molinari F, Ghisletta M, et al. PTEN loss of expression predicts cetuximab efficacy in metastatic colorectal cancer patients. Br J Cancer 2007;97: 1139–45. Loupakis F, Pollina L, Stasi I, Ruzzo A, Scartozzi M, Santini D, et al. PTEN expression and KRAS mutations on primary tumors and metastases in the prediction of benefit from cetuximab plus irinotecan for patients with metastatic colorectal cancer. J Clin Oncol 2009;27: 2622–29. Sartore-Bianchi A, Di Nicolantonio F, Nichelatti M, Molinari F, De Dosso S, Saletti P, et al. Multi-determinants analysis of molecular alterations for predicting clinical benefit to EGFR-targeted monoclonal antibodies in colorectal cancer. PLoS One 2009;4:e7287. Janku F, Lee JJ, Tsimberidou AM, Hong DS, Naing A, Falchook GS, et al. PIK3CA mutations frequently coexist with RAS and BRAF mutations in patients with advanced cancers. PLoS One 2011;6: e22769. Kammula US, Kuntz EJ, Francone TD, Zeng Z, Shia J, Landmann RG, et al. Molecular coexpression of the c-Met oncogene and hepatocyte growth factor in primary colon cancer predicts tumor stage and clinical outcome. Cancer Lett 2007;248:219–28. Long IS, Han K, Li M, Shirasawa S, Sasazuki T, Johnston M, et al. Met receptor over-expression and oncogenic Ki-ras mutation cooperate to enhance the tumorigenicity of colon cancer cells in vivo. Mol Cancer Res 2003;1:393–401. Seiden-Long IM, Brown KR, Shihn W, Wigle DA, Radulovich N, Jurisica I, et al. Transcriptional targets of hepatocyte growth factor signaling and K-ras oncogene activation in colorectal cancer. Oncogene 2006;25:91–102. €ler J, Hofman M, Giesemann T, Fiebig HH, Beckers Krumbach R, Schu T. Primary resistance to cetuximab in a panel of patient-derived tumor xenograft models: activation of MET as one mechanism of drug resistance. Eur J Cancer 2011;47:1231–43. Scartozzi M, Mandolesi A, Giampieri R, Pierantoni C, Loupakis F, Zaniboni A, et al. Insulin-like growth factor 1 expression correlates with clinical outcome in K-RAS wild type colorectal cancer patients treated with cetuximab and irinotecan. Int J Cancer 2010;127:1941–7. Bertotti A, Migliardi G, Galimi F, Sassi F, Torti D, Isella C, et al. A molecularly annotated platform of patient-derived xenografts ("xenopatients") identifies HER2 as an effective therapeutic target in cetuximab-resistant colorectal cancer. Cancer Discov 2011;1:508–23. Mol Cancer Ther; 11(9) September 2012 14. Beji A, Horst D, Engel J, Kirchner T, Ullrich A. Toward the prognostic significance and therapeutic potential of HER3 receptor tyrosine kinase in human colon cancer. Clin Cancer Res 2012;18:956–68. 15. Serra V, Markman B, Scaltriti M, Eichhorn PJ, Valero V, Guzman M, et al. NVP-BEZ235, a dual PI3K/mTOR inhibitor, prevents PI3K signaling and inhibits the growth of cancer cells with activating PI3K mutations. Cancer Res 2008;68:8022–30. 16. Wallin JJ, Edgar KA, Guan J, Berry M, Prior WW, Lee L, et al. GDC-0980 is a novel class I PI3K/mTOR kinase inhibitor with robust activity in cancer models driven by the PI3K pathway. Mol Cancer Ther 2011;10:2426–36. 17. O'Reilly KE, Rojo F, She QB, Solit D, Mills GB, Smith D, et al. mTOR inhibition induces upstream receptor tyrosine kinase signaling and activates Akt. Cancer Res 2006;66:1500–8. 18. Naing A, Kurzrock R, Burger A, Gupta S, Lei X, Busaidy N, et al. Phase I trial of cixutumumab combined with temsirolimus in patients with advanced cancer. Clin Cancer Res 2011;17:6052–60. 19. Engelman JA, Chen L, Tan X, Crosby K, Guimaraes AR, Upadhyay R, et al. Effective use of PI3K and MEK inhibitors to treat mutant Kras G12D and PIK3CA H1047R murine lung cancers. Nat Med 2008;14:1351–6. 20. Jaiswal BS, Janakiraman V, Kljavin NM, Eastham-Anderson J, Cupp JE, Liang Y, et al. Combined targeting of BRAF and CRAF or BRAF and PI3K effector pathways is required for efficacy in NRAS mutant tumors. PLoS One 2009;4:e5717. 21. Migliardi G, Sassi F, Torti D, Galimi F, Zanella ER, Buscarino M, et al. Inhibition of MEK and PI3K/mTOR suppresses tumor growth but does not cause tumor regression in patient-derived xenografts of RASmutant colorectal carcinomas. Clin Cancer Res 2012;18:2515–25. 22. Yang H, Higgins B, Kolinsky K, Packman K, Bradley WD, Lee RJ, et al. Antitumor activity of BRAF inhibitor vemurafenib in preclinical models of BRAF-mutant colorectal cancer. Cancer Res 2012;72:779–89. 23. Flaherty KT, Puzanov I, Kim KB, Ribas A, McArthur GA, Sosman JA, et al. Inhibition of mutated, activated BRAF in metastatic melanoma. N Engl J Med 2010;363:809–19. 24. Spigel DR, Ervin TJ, Ramlau R, Daniel DB, Goldschmidt JH, Blumenschein GR, et al. Final efficacy results from OAM4558g, a randomized phase II study evaluating MetMAb or placebo in combination with erlotinib in advanced NSCLC. J Clin Oncol 29: 2011 (suppl; abstr 7505). 25. Catenacci DVT, Henderson L, Xiao S-Y, Patel P, Yauch RL, Hegde P, et al. Durable complete response of metastatic gastric cancer with anti-Met therapy followed by resistance at recurrence. Cancer Discov 2011;1:573–9. n J, Saura C, Dienstmann R, Vivancos A, Cajal SR, Baselga J, 26. Rodo et al. Molecular prescreening to select patient population in early clinical trials. Nat Rev Clin Oncol 2012;9:359–66. 27. Von Hoff DD, Stephenson JJ Jr, Rosen P, Loesch DM, Borad MJ, Anthony S, et al. Pilot study using molecular profiling of patients tumors to find potential targets and select treatments for their refractory cancers. J Clin Oncol 2010;28:4877–83. 28. Tsimberidou AM, Iskander NG, Hong DS, Wheler JJ, Fu S, Piha-Paul SA, et al. Personalized medicine in a phase I clinical trials program: The Molecular Cancer Therapeutics Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Colorectal Cancer Patients in Phase I Trials of Targeted Agents 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. M. D. Anderson Cancer Center initiative. J Clin Oncol 29: 2011 (suppl; abstr CRC2500). Kirkegaard T, Edwards J, Tovey S, McGlynn LM, Krishna SN, Mukherjee R, et al. Observer variation in immunohistochemical analysis of protein expression, time for a change? Histopathology 2006;48: 787–94. ~adas I, Arumí-Uría M, Do mine M, Lopez-Vilarin ~o JA, Arpí Arriola E, Can O, et al. MET phosphorylation predicts poor outcome in small cell lung carcinoma and its inhibition blocks HGF-induced effects in MET mutant cell lines. Br J Cancer 2011;105:814–23. rez-Gauthier A, Conde E, Angulo B, García-García E, Martínez R, Sua Hidalgo M, et al. A commercial real-time PCR kit provides greater sensitivity than direct sequencing to detect KRAS mutations: a morphology-based approach in colorectal carcinoma. J Mol Diagn 2010; 12:292–9. Horstmann E, McCabe MS, Grochow L, Yamamoto S, Rubinstein L, Budd T, et al. Risks and benefits of phase 1 oncology trials, 1991 through 2002. N Engl J Med 2005;352:895–904. Janku F, Wheler JJ, Westing SN, Moulder SL, Naing A, Tsimberidou AM, et al. PI3K/AKT/mTOR inhibitors in patients with breast and gynecologic malignancies harboring PIK3CA mutations. J Clin Oncol 2012;30:777–82. Gasparini G, Longo R. The paradigm of personalized therapy in oncology. Expert Opin Ther Targets 2012;16 Suppl 1:S7–16. Ligresti G, Militello L, Steelman LS, Cavallaro A, Basile F, Nicoletti F, et al. PIK3CA mutations in human solid tumors: role in sensitivity to various therapeutic approaches. Cell Cycle 2009;8:1352–8. Ihle NT, Lemos R Jr, Wipf P, Yacoub A, Mitchell C, Siwak D, et al. Mutations in the phosphatidylinositol-3-kinase pathway predict for antitumor activity of the inhibitor PX-866 whereas oncogenic Ras is a dominant predictor for resistance. Cancer Res 2009;69:143–50. Di Nicolantonio F, Arena S, Tabernero J, Grosso S, Molinari F, Macarulla T, et al. Deregulation of the PI3K and KRAS signaling pathways in human cancer cells determines their response to everolimus. J Clin Invest 2010;120:2858–66. Roper J, Richardson MP, Wang WV, Richard LG, Chen W, Coffee EM, et al. The dual PI3K/mTOR inhibitor NVP-BEZ235 induces tumor www.aacrjournals.org 39. 40. 41. 42. 43. 44. 45. 46. 47. regression in genetically engineered mouse model of PIK3CA wildtype colorectal cancer. PLoS One 2011;6:e25132. Bhagwat SV, Gkhale PC, Crew AP, Cooke A, Yao Y, Mantis C, et al. Preclinical characterization of OSI-027, a potent and selective inhibitor of mTORC1 and mTORC2: distinct from rapamycin. Mol Cancer Ther 2011;10:1394–406. Bendell JC, Rodon J, Burris HA, de Jonge M, Verweij J, Birle D, et al. Phase I, dose-escalation study of BKM120, an oral pan–class I PI3K inhibitor, in patients with advanced solid tumors. J Clin Oncol 2012;30: 282–90. Mallon R, Feldberg LR, Lucas J, Chaudhary I, Dehnhardt C, Santos ED, et al. Antitumor efficacy of PKI-587, a highly potent dual PI3K/mTOR kinase inhibitor. Clin Cancer Res 2011;17:3193–203. Wee S, Jagani Z, Xiang KX, Loo A, Dorsch M, Yao YM, et al. PI3K pathway activation mediates resistance to MEK inhibitors in KRAS mutant cancers. Cancer Res 2009;69:4286–93. Shimizu T, Tolcher AW, Papadopoulos KP, Beeram M, Rasco D, Smith LS, et al. The clinical effect of the dual-targeting strategy involving PI3K/AKT/mTOR and RAS/MEK/ERK pathways in patients with advanced cancer. Clin Cancer Res 2012;18:2316–25. Kopetz S, Desai J, Chan E, Hecht JR, O'Dwyer PJ, Lee RJ, et al. PLX4032 in metastatic colorectal cancer patients with mutant BRAF tumors. J Clin Oncol 28: 2010 (suppl; abstr 3534). Prahallad A, Sun C, Huang S, Di Nicolantonio F, Salazar R, Zecchin D, et al. Unresponsiveness of colon cancer to BRAF(V600E) inhibition through feedback activation of EGFR. Nature 2012;483:100–3. Eng C, Van Cutsem E, Nowara E, Swieboda-Sadlej A, Tebbutt NC, Mitchell EP, et al. A randomized, phase Ib/II trial of rilotumumab (AMG 102; ril) or ganitumab (AMG 479; gan) with panitumumab (pmab) versus pmab alone in patients with wild-type KRAS metastatic colorectal cancer. J Clin Oncol 29: 2011 (suppl; abstr 3500). Bessudo A, Bendell JC, Gabrail N, Kopp MV, Mueller L, Hart LL, et al. Phase I results of the randomized, placebo controlled, phase I/II study of the novel oral c-MET inhibitor, ARQ 197, irinotecan, and cetuximab in patients with wild-type KRAS metastatic colorectal cancer who have received front-line systemic therapy. J Clin Oncol 29: 2011 (suppl; abstr 3582). Mol Cancer Ther; 11(9) September 2012 Downloaded from mct.aacrjournals.org on April 29, 2017. © 2012 American Association for Cancer Research. 2071 Published OnlineFirst June 21, 2012; DOI: 10.1158/1535-7163.MCT-12-0290 Molecular Profiling of Patients with Colorectal Cancer and Matched Targeted Therapy in Phase I Clinical Trials Rodrigo Dienstmann, Danila Serpico, Jordi Rodon, et al. Mol Cancer Ther 2012;11:2062-2071. Published OnlineFirst June 21, 2012. Updated version Cited articles Citing articles E-mail alerts Reprints and Subscriptions Permissions Access the most recent version of this article at: doi:10.1158/1535-7163.MCT-12-0290 This article cites 42 articles, 19 of which you can access for free at: http://mct.aacrjournals.org/content/11/9/2062.full.html#ref-list-1 This article has been cited by 9 HighWire-hosted articles. Access the articles at: /content/11/9/2062.full.html#related-urls Sign up to receive free email-alerts related to this article or journal. 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