Download Moehler et al.. Ann Oncol. 2010 Nov 30.

Predictive and Prognostic
Markers for Gastric Cancer
Kathleen D. Danenberg
Response Genetics, Inc.
ERCC1
Why would a predictive test for
platinum efficacy be desirable?
Non-platin and platin therapy have
similar outcomes
IF (n=170): irinotecan, folinic acid 5-fluorouracil;
CF (n=163): cisplatin and 5-fluorouracil
Median TTP
IF: 5.0 months
CF: 4.2 months
Median OS:
IF: 9.0 months
CF: 8.7 months
Dank et al. Randomized phase III study comparing irinotecan combined with 5-fluorouracil and folinic acid to cisplatin
combined with 5-fluorouracil in chemotherapy naive patients with advanced adenocarcinoma of the stomach or
esophagogastric junction. Annals of Oncology. 2008; 19:1450-1457.
…but non-platin treatment is less toxic:
Comparative toxicity profiles of CF and IF
Irinotecan-5-FU
Cisplatin-5-FU
Toxic deaths
0.6%
3%
Discontinuation for
toxicity
10%
21%
Neutropenia gr. 3-4
25%
52%
Fever or infection
4.8%
10.2%
Thrombocytopenia
1.8%
11.7% (p=0.0003)
Diarrhea
21.6%
7.2%
Stomatitis
2.4%
16.9%
Neurotoxicity
5.4%
22.9%
Cardiovascular
toxicity
2.4%
6.0%
Dank et al. Annals of Oncology. 2008; 19:1450-1457.
Conclusions
• “… Irinotecan/5-fluorouracil (IF) is a platinum-free
regimen that has similar efficacy to cisplatin/5fluorouracil (CF) but with improved tolerance.
• As such, IF could represent a potential platinum-free
alternative backbone to be combined with new
targeted agents to be explored for the treatment of
metastatic gastric cancer.
Dank et al. Annals of Oncology. 2008; 19:1450-1457.
The platins react with DNA to form
inter- and intra-strand crosslinks
ERCC1 is part of the nucleotide excision repair
complex that repairs platin crosslinks in DNA
Pre-clinical studies show ERCC1 to be a
direct determinant of cisplatin efficacy
ERCC1 small interfering RNA expression reduces ERCC1 expression and sensitizes
the cells to platinum-containing chemotherapeutic agents.
90
80
70
% cell
viability
60
control
siRNA
50
40
30
cisplatin (4
uM)
oxali (2 uM)
carbo (20 uM)
Youn et al. Oncogenic H-Ras Up-Regulates
Expression of ERCC1 to Protect Cells from
Platinum-Based Anticancer Agents Cancer Res
2004:64, 4849-4857.
ERCC1 gene expression in gastric cancer cells
negatively correlates with sensitivity to cisplatin.
ERCC1 mRNA
expression levels and
sensitivity to cisplatin
in cells from
malignant effusions
collected from
untreated gastric
cancer patients
(P= 0.014, r = 0.685).
Wang et al. ERCC1 and BRCA1 mRNA expression levels in metastatic malignant effusions
is associated with chemosensitivity to cisplatin and/or docetaxel. BMC Cancer 2008;8:97.
ERCC1 thresholds and benefit of low
ERCC1 from platin therapy
Clinical Study
NSCLC: GILT (Platin
Doublets)
NSCLC: MADeIT (Platin
Doublets)
CRC: FOLFOX
CRC: FOLFOX Validation
Gastric: 5-FU/Cis
Gastric: FOLFOX
Gastric: FOLFOX
Gastric: Platin
(S-1/Oxaliplatin)
ERCC1 Threshold for Platin
Sensitivity: Response
Genetics Scale
Percent
Patients
with Low
ERCC1
Benefit
Ref
ERCC1<1.7
53
RR=53%
Cobo et al JCO 2007
50
RR=44%,
Increased
Survival
Sim et al JCO 2007
80
Increased
Survival and
Response
Shirota et al JCO 2001
80
Increased
Survival
Lenz et al ASCO 2008
50
Increased
Survival
Metzger et al JCO 1998
64
Increased
Survival
J Wei et al ASCO 2007
80
Increased
Survival
J Wei et al British J of Cancer
2008
67
Increased
RR and
Survival
Matsubara et al British J of
Cancer 2008
ERCC1<1.44
ERCC1<1.7
ERCC1<1.7
ERCC1<1.46
ERCC1<1.79
ERCC1<2.2
ERCC1<1.85
ERCC1 mRNA levels and response in
gastric cancer patients receiving FP
20
ERCC1 Expression
16
12
p=0.004 by KruskalWallis test.
8
4
0
Response
No Response
Metzger R, et al. J Clin Oncol. 1998;16:309-316.
ERCC1 mRNA levels and survival of advanced gastric
cancer patients treated with a FOLFOX regimen
Wei J et al. Br J Cancer. 2008;98:1398-402.
p<0.0001
ERCC1
mRNA
Hazard
ratio
Low (<0.47) 1
High
(>0.47)
9.4
(p<0.0001)
Conclusion: “In patients with high mRNA levels of ERCC1, alternative
chemotherapy regimens should be considered.”
Effect of ERCC1 protein expression on survival in
FOLFOX chemotherapy of advanced gastric cancer
ERCC1 was the only
significant independent
prognostic factor
impacted on OS (hazard
ratio 1.91, P = 0.037).
Overall survival curve according to ERCC1
expression measured by IHC (P = 0.0396).
Kwon et al. Ann Oncol.
2007;18:504-9.
Prediction of survival by ERCC1 expression in gastric
cancer treated with surgery followed by FOLFOX or
receiving surgery alone.
Median RFS
Adjuvant
therapy
Surgery
only
Median OS
Low ercc1 High
ercc1
P value
Hazard
47 mos.
7 mos.
0.01
2.77
12 mos.
33 mos.
0.038
Low ercc1 High
ercc1
P value
Hazard
Adjuvant
therapy
undefined 13 mos.
0.007
2.68
Surgery
only
21 mos.
0.004
0.18
Yiu et al. ASCO 2010 abstract 29
43 mos.
ERCC1 expression and activity of PELF regimen as
first-line treatment of metastatic gastric cancer.
PELF = cisplatin (P), epirubicin (E), leucovorin (L), 5-fluorouracil (F)
Median overall survival
low ERCC1
13 months
high ERCC1
9 months
1-year survival rate
low ERCC1
High ERCC1
Log rank
p=0.018
62%
21%
Conclusion: “IHC studies for ERCC1 might be useful to
predict the clinical outcome in MGC patients treated with
PELF regimen.”
Natoli et al. J Clin Oncol 28, 2010 (suppl; abstr e14603)
ERCC1expression and outcomes of advanced gastric
cancer patients treated with cisplatin and S-1.
Matsubara et al. Br J Cancer. 2008; 98: 832–839.
Impact of low ERCC1 and DPD on the
outcomes of advanced gastric cancer.
Low ERCC1 and low DPD expression:
median survival time, 15.5 months
Any high expression:
median survival time, 10.2 months
Probability of survival
1.0
0.8
0.6
log-rank P < .001
0.4
0.2
0.0
0
12
24
36
48
60
72
84
Months since start of 1st-line chemotherapy
Matsubara et al. Br J Cancer. 2008; 98: 832–839.
96
SWOG proposed prospective trial using ERCC1
to select CPT11/docetaxel or FOLFOX
R
A
N
D
O
M
A
S
S
I
G
N
M
E
N
T
R
A
N
D
O
M
A
S
S
I
G
N
M
E
N
T
High ERCC1:
CPT11/docetaxel
Genotypic
Arm: ERCC1
Selection
High ERCC1:
FOLFOX
n=200, Endpoints: feasibility and increase of PFS
EGFR expression
Chemotherapy with EGFR-targeted agents:
KRAS and EGFR mutations are rare in gastric adenocarcinoma
• Mammano E etal. Anticancer Res. 2006;26:3547-50.
– in 49 gastric adenocarcinomas, no specific EGFR
gene mutations were detected.
• S.W. Han et al. Br J Cancer 2009;100:298-304.
– In 38 gastric patients, no EGFR amplification or
K-ras mutations were observed.
These findings suggest a priori that:
a) due to lack of EGFR mutations, gastric tumors will not be
very sensitive to EGFR-directed TKI’s (e.g., gefitinib and
erlotinib)
b) however, due to the lack of KRAS mutations, they may be
sensitive to EGFR-directed antibodies
EGFR Tyrosine Kinase Inhibitors: Phase II,
Adenocarcinoma
Gastric
Number Patients
% Response
Dragovich
(Erlotinib)
25
0%
Doi (Gefitinib)
75
1%
27
11%
GE Junction
Ferry (Gefitinib)
Janmaat (Gefitinib) 26
0%
Tew (Erlotinib)
17
0%
Dragovich
(Erlotinib)
43
Total: 7/113
9%
6%
Doi 1036 Proc ASCO 22, 2003; Ferry Clin Can Res 132:5869; 2007 Janmaat JCO 24: 1612; 2006;Tew GI ASCO 2005; Dragovich
JCO 24: 4922; 2006
PFS and OS with “classical chemotherapy”
Survival
LV5FU2
(n=45)
LV5FU2cisplatin
(n=44)
LV5FU2irinotecan
(n=45)
OS, months
6.8
9.5
11.3
1-yr OS, %
31
43
43
PFS, months
3.2
4.9
6.9
Abbreviations: LV5FU2), leucovorin-5-FU; OS, overall survival; PFS, progression-free
survival
Bouche O et al. J Clin Oncol 2004;22:4319-4328.
PFS and OS are increased by addition of
cetuximab
Median PFS
(months)
Median OS
(months)
LV-5-FUirinotecan
6.9
11.3
Bouche et al.. J Clin
Oncol 2004;22:4319-4328
+ cetuximab
9.0
16.5
Moehler et al.. Ann Oncol.
2010 Nov 30.
Median PFS Median OS
(months)
(months)
CR + PR
10.6
19.1
SD + PD
6.0
12
p value
0.001
0.041
Moehler et al.. Ann Oncol.
2010 Nov 30.: Patients
with a complete response
(CR) or partial response
(PR) had significantly
longer OS times and PFS
times than patients with
SD or PD.
Predicting cetuximab activity
• Since KRAS mutations and EGFR mutations are rare
in gastric tumors, can EGFR expression levels predict
response to cetuximab?
Phase II study and biomarker analysis of cetuximab
combined with modified FOLFOX6 in advanced
gastric cancer.
Response
Overall (n=38)
50%
EGFR(+), low
serum ligands
(n=11)
100%
Remainder
(n=27)
37%
-For EGFR (+) patients, both TTP (median 7.2 vs 5.0 months,
P=0.020) and OS (not reached vs 7.6 months, P=0.013) were
significantly longer after adjusting for clinical factors.
S.W. Han et al Br J Cancer. 2009;100:298-304.
Cetuximab with irinotecan, folinic acid and 5-FU as first-line
treatment in advanced gastroesophageal cancer: a
prospective multi-center biomarker-oriented phase II study.
Response rate relationship to EGFR expression
EGFR(+)
19/26 (73%)
EGFR(-)
3/13 (23%)
EGFR (+) frequency
Responding
tumors
Non-responding
tumors
16/19 (84%)
10/20 (50%)
P=0.041
-but tumor EGFR expression did not correlate with PFS
(log-rank P = 0.567) or OS (log-rank P = 0.663).
Moehler et al. Ann Oncol. 2010 Nov 30.
Phase II study of cetuximab plus FOLFIRI in patients with
untreated advanced gastric or GE junction adenocarcinoma
(FOLCETUX study).
-EGFR expression did not significantly correlate with ORR
Pinto et al. Phase II study of cetuximab in combination with FOLFIRI in patients with untreated
advanced gastric or gastroesophageal junction adenocarcinoma (FOLCETUX study). Ann Oncol
2007;18:510-517.
Discrepant results for EGFR expression level as a
predictive factor for cetuximab therapy
EGFR associated with:
Response
Survival
Han et al
yes
yes
Moehler et al
yes
no
Pinto et al
no
-
HER2 status
HER2 inhibitors trastuzumab and lapatinib
in gastric cancer
• ASCO 2008, Abstr 4526, Bang, et al.
– Analysis of 2484 gastric cancer samples from the Ph III
ToGA trial
– 21.9% HER2 positivity
• ASCO 2009, Abstr LBA 4509, ToGA Trial
– Rand Ph III, HER2+ gastric cancer
– 5-FU/capecitabine + cisplatin +/- trastuzumab
– RR 47.3 vs. 34.5%, OS 13.5 vs. 11.1 mo (p = 0.0048)
– HR 0.74 (0.60-0.91)
– Practice changing!!!
• LOGIC Trial
– Rand Ph III, HER 2+ gastric cancer
– Capecitabine + oxaliplatin +/- lapatinib
The ToGA trial: Primary end point- OS
Event
Median
Events OS
HR
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
FC + T
FC
11.1
0
2
4
167
182
13.8
11.1
95% CI
p value
0.74 0.60, 0.91
13.8
6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Time (months)
No.
at
risk
294
290
T, trastuzumab
246 209 173 147 113
223 185 143 117 90
90
64
71
47
56
32
43
24
30
16
21
14
13
7
12
6
6
5
4
0
1
0
0
0
0.0046
HER2 assay by IHC for gastric cancer required
a different set of guidelines than for breast
.
Rüschoff et al. Virchows Arch. 2010 457:299-307
Sources of HER2 Testing Variation with IHC
Pre-analytic
Time to fixation
Method of tissue processing
Time of fixation
Type of fixation
Analytic
Assay validation
Equipment calibration
Use of standardized laboratory
procedures
Training and competency assessment
of staff
Type of antigen retrieval
Test reagents
Use of standardized control materials
Use of automated laboratory methods
Post-analytic
Interpretation criteria
Use of image analysis
Reporting elements
Quality assurance procedures
Laboratory accreditation
Proficiency testing
Pathologist competency
assessment
Wolff et al. American Society of Clinical Oncology/College of American Pathologists
guideline recommendations for human epidermal growth factor receptor 2 testing in
breast cancer. J Clin Oncol. 2007;25:118-45.
HER-2 mRNA expression by PCR correlates
with HER-2 FISH (r=0.83) and IHC (r=0.72)
Press et al. HER-2 Gene Amplification, HER-2 and Epidermal Growth Factor Receptor mRNA
and Protein Expression, and Lapatinib Efficacy in Women with Metastatic Breast Cancer. Clin
Cancer Res 2008; 14: 7861
Comparison of HER2 expression and amplification in primary
breast tumors (T) and corresponding lymph node metastases
(N) determined with IHC, FISH, and quantitative RT-PCR
IHC
HER2 expression scored
as 0 and 1+ (=negative) or
2+ and 3+ (=positive) is
indicated.
FISH analysis:
red, HER2 signals; green,
centromere 17 signals. +,
specimens harboring a
HER2 amplification; −,
nonamplified specimens.
Quantitative RT-PCR:
red line, the cutoff
between high (scored as
HER2 positive) and low
relative expressions of
HER2.
Vinatzer et al. Clin Cancer Res 2005;11:8348-8357
PCR quantitation of HER2 expression gives the
same clinical information as IHC and FISH
Quantitative RT-PCR:
-simple, cost-effective,
-rapidly produces quantitative, numerical, and
reproducible results.
-easily amenable to standardization, insensitive
to inter-observer variability
-results are a number, which can be either above
or below a predetermined threshold.
IHC
-interpretation of IHC results is inherently
difficult and time-consuming, requires
experienced pathologists
-is influenced by use of different antibodies,
fixatives, staining protocols, and inter-observer
variability.
FISH
-is quantitative and reproducible but results are
more difficult to interpret than those of
quantitative RT-PCR.
-time-consuming, and requires specialized
expertise and equipment.
Vinatzer et al. Clin Cancer Res 2005;11:8348-8357
Her2 gene expression associated with OS in patients with
metastatic gastric cancer treated with lapatinib
Overall Survival
by Her2 Expression Level
100%
Above Median
Below Median
N
17
17
Events
12
15
Median in months
6
3
P = .005
80%
60%
40%
20%
0%
0
6
12
Months After Registration
18
24
Chang H et al,Journal of Clinical Oncology, 2007 ASCO Annual Meeting Proceedings Part I. Vol 25, No.
18S (June 20 Supplement), 2007: 4647
Summary and conclusions
• ERCC1 mRNA expression appears to be a viable
predictive marker for platin therapy.
• The jury is still out on EGFR expression as a
predictive marker for cetuximab therapy.
• The IHC and FISH-based assay of HER2 has many
issues so PCR should be investigated as an additional
tool or as an alternative.