Tumörmarkörer och klinisk relevans

SLMF:s
Vårmöte
Linköping
14‐16
april
2010
Tumörmarkörer
och
klinisk
relevans
Leif
Johansson
VO
Klinisk
Patologi
Universitetssjukhuset
Lund
Labmedicin
Skåne
Prognostiska faktorer vid NSCLC studerade i metaanalyser!
• • • • • • • • • SÄMRE PROGNOS
TTF1
Cox2
EGFR
Ras
Ki67
HER2
VEGF
Microvascular density
• • • P53
Aneuploidy
Survivin
• • BÄTTRE PROGNOS
Bcl-2
• De flesta av dessa markörer kan enkelt bestämmas med immunohistokem
Nya behandlingsmodaliteter och överlevnad vid
NSCLC
Morgensztern (#8078) ASCO 2009
• Tittade på förändring i överlevnad över tid i en databas med
127,816 patienter
• Signifikant förbättrad OS för stadie IV NSCLC patienter de
sista 8 åren
• Förändringen berodde huvudsakligen på förbättrad överlevnad
för patienter med adenocarcinom medan effekten var liten för
patienter med skivepitelcancer
• Man tillskrev detta fr a nya terapier såsom erlotinib och
gefitinib som huvudsakligen anses vara effektiva mot
adenocarcinom
• Kanske ännu ett skäl, förutom pemetrexed och bevacizumab,
att skilja skivepitelcencer från NSCLC-icke skivepitel!?
JMDB,
CP=cis/pemetrexed,
CG=
cis/gemcitabin
Pemetrexed
vs
Docetaxel
Results:
OS
100
PaIents
Randomized
to
Pemetrexed
100
PaIents
Randomized
to
Docetaxel
HR=0.48
P=0.001
50
Non‐squamous:
Median
=
8.2
Percent
Surviving
Percent
Surviving
Non‐squamous:
Median
=
9.2
Squamous:
Median
=
7.4
Squamous:
Median
=
6.2
0
NS
50
0
Overall
Survival
(months)
Overall
Survival
(months)
WCLC
2007
–
Peterson
P
et
al.,
Abstract
#
P2‐328
Chemotherapy
and
NSCLC
Chemotherapy
Type
of
Chemotherapy
NSCLC,
non
squamous
Pemetrexed
(Alimta®)
AnUfolate
agent
Yes
NSCLC,
Squamous
cell
carcinoma
No
(Docetaxel)
Bevacizumab
(AvasUn®)
Angiogenesis
inhibitor
Yes
ContraindicaUon
Immunohistochemistry
of
lung
cancer
Johansson L. Histopathological classification of lung cancer: relevance of cytokeratin
and TTF-1 immunophenotyping. Ann Diagn Pathol 2004;8:259-267.
Histological n CK5 CK7 CK20 CAM5.2 TTF-1
Type
SCLC 13
2
11
2
13
13
SQCC 12
12
4
1
12
0
AC 11
1
11
1
11
11
LCC 9
1
8
0
9
5
Total
45
16
34
4
45
29
SCLC
=
small
cell
lung
carcinoma,
SQCC
=
squamous
cell
carcinoma,
AC
=
adenocarcinoma,
LCC
=
large
cell
carcinoma,
CK5
=
cytokeraUn
5,
CK7
=
cytokeraUn
7,
CK20
=
cytokeraUn
20,
CAM5.2
=
CK8
(CK7),
TTF‐1
=
Thyroid
TranscripUon
Factor‐1
Downey
P
et
al.
If
it's
not
CK5/6
posiIve,
TTF‐1
negaIve
it's
not
a
squamous
cell
carcinoma
of
lung.
APMIS.
2008
Jun;116(6):526‐9.
• Novel
targeted
treatment
of
NSCLC
requires
accurate
classificaUon
of
NSCLC
as
SCC
and
AC
• This
study
details
the
CK5/6
and
TTF‐1
immunoprofile
of
surgical
resecUons
of
45
NSCLCs
(24
ACs
and
21
SCCs)
in
Ussue
microarrays
• All
SCC
were
CK5/6
posiUve,
TTF‐1
negaUve
• 20
of
24
adenocarcinomas
had
the
reverse
pacern
• In
conclusion,
all
SCCs
in
this
study
were
CK5/6
posiUve
and
TTF‐1
negaUve,
and
therefore
tumours
that
do
not
display
this
phenotype
are
unlikely
to
be
SCCs
• CK5/6
and
TTF‐1
is
therefore
a
pracUcal
panel
for
the
disUncUon
between
pulmonary
SCC
from
AC
in
rouUne
histopathology
pracUce
Squamous
cell
carcinoma
CK5+
CK7-
ADENOCARCINOMA
CK7+
CK5‐
Kamal,
N.
S.,
J.
C.
Soria,
et
al.
(2010).
"MutS
homologue
2
and
the
long‐term
benefit
of
adjuvant
chemotherapy
in
lung
cancer."
Clin
Cancer
Res
16(4):
1206‐1215.
• RESULTS: MSH2 levels were low in 257 (38%) and high in 416
(62%) tumors
• There was a trend for chemotherapy to prolong overall survival
when MSH2 was low but not when MSH2 was high
• When combining MSH2 with ERCC1 and P27 the benefit of
chemotherapy decreased with the number of markers expressed at
high levels (p = 0.01, p=0.01)
• Chemotherapy prolonged overall survival in the MSH2-/ERCC1subgroup (P = 0.01) and in the MSH2-/P27- subgroup (P = 0.01)
• CONCLUSIONS: MSH2 expression is a borderline significant
predictor of a long-term benefit from adjuvant cisplatin-based
chemotherapy in patients with completely resected lung cancer.
MSH2 combined with ERCC1 or P27 may identify patients most
likely to benefit durably from chemotherapy
Epidermal
growth
factor
receptor
(EGFR)
• First
idenUfied
as
a
candidate
for
cancer
therapy
more
than
two
decades
ago
• Expressed
in
most
NSCLC;
has
a
role
in
– Cellular
proliferaUon
– InhibiUon
of
apoptosis
– Angiogenesis
– MetastaUc
potenUal
– Chemoresistance
PredicIve
EGFR
Test
Methods,
Immunohistochemistry
(IHC)
• IHC has been used for many years, but for most of the
markers, no objective standardized assessment methods
have been established
• This might contribute to the fact that the methodology
has not been given much credit for predictive
performance
• Platforms have been developed for objective, automated
staining and interpretation
• Studies are undergoing for validation of EGFR
expression and other proteins related to targeted
therapies in lung cancer
EGFR
IHC
3+
PredicIve
EGFR
Test
Methods,
Gene
copy
number
• Based
on
experience
with
HER2
in
breast
cancer,
the
FISH
technology
has
been
the
most
prevalent
method
• New
technologies
have
emerged,
such
as
the
non‐
fluorescence
Silver
in
situ
HybridizaUon
(SISH)
technique
assessable
in
bright‐light
microscopy
with
preservaUon
of
the
cell
morphology.
Thus,
the
specimens
are
stable
and
can
be
revisited
for
years
• The
technology
has
been
introduced
for
HER2
determinaUon
in
breast
cancer,
but
clinical
validaUon
for
other
markers
(i.e
IGF‐1R)
in
lung
cancer
has
just
been
iniUated
(Wynes
et
al.
2009)
EGFR
FISH
amplifiering,
cytologi
EGFR
amplifiering,
dual
color
SISH
PredicIve
EGFR
Test
Methods,
MutaIon
analyses
• Tissue-based DNA sequencing remains the most commonly used
technique
• More sensitive PCR-based methodologies have emerged (i.e. high
resolution melt curve analysis; Scorpion-ARMS using the DXS
system)
• Multigene high- throughput approaches such as the Sequenom
technique
• Large scale sequencing as done in the Tumor Sequencing Project
(TSP) for lung adenocarcinomas by integrating different methods
• Mutation-specific antibodies for immunohistochemistry have recently
been developed (i.e. EGFR antibodies) with very encouraging
results*
* Yu, J., S. Kane, et al. (2009). "Mutation-specific antibodies for the detection of EGFR mutations in non-small-cell lung
cancer." Clin Cancer Res 15(9): 3023-3028.
Yu,
J.,
S.
Kane,
et
al.
(2009).
"MutaUon‐specific
anUbodies
for
the
detecUon
of
EGFR
mutaUons
in
non‐small‐cell
lung
cancer."
Clin
Cancer
Res
15(9):
3023‐3028.
Immunohistochemical
staining
of
xenograds.
Control
EGFR
anIbody
stains
all
six
cell
lines
(top).
L858R‐specific
anIbody
stains
only
the
cancer
cells
with
the
L858R
point
mutaIon
(H1975
and
H3255;
middle).
dEGFR‐specific
anIbody
stains
only
the
cancer
cells
with
the
exon
19
deleIon
(H1650
and
HCC827;
bogom).
Vilka
evidens
finns
för
ac
testen
fungerar?
Gupta, R., et al., The predictive value of epidermal growth
factor receptor tests in patients with pulmonary
adenocarcinoma: review of current "best evidence" with
meta-analysis. Hum Pathol, 2009. 40(3): p. 356-65.
Ohe,
Y.,
Y.
Ichinose,
et
al.
(2009).
"Phase
III,
randomized,
open‐label,
first‐line
study
of
gefiUnib
(G)
versus
carboplaUn/paclitaxel
(C/P)
in
selected
paUents
(pts)
with
advanced
non‐small‐cell
lung
cancer
(NSCLC)
(IPASS):
EvaluaUon
of
recruits
in
Japan.
."
J
Clin
Oncol
27((suppl;
abstr
8044^)
):
15s.
• Background: IPASS demonstrated superiority of gefitinib vs C/P in
1,217 clinically selected chemonaïve pts in Asia with advanced
NSCLC
• Chemonaïve, never/light ex-smokers with stage IIIB/IV NSCLC and
adenocarcinoma histology were randomized to gefitinib or C/P
• Primary objective was PFS, Secondary endpoints were overall
survival (OS)
• Results: gefitinib demonstrated superior PFS compared with C/P
(HR 0.69; 95% CI 0.51-0.94; p=0.0191)
• Preliminary OS (25% maturity; follow-up ongoing) was similar for
gefitinib and C/P (HR 0.89; 95% CI 0.53-1.48)
• There were no deaths due to ILD-type events (frequency 1.8%
[gefitinib] vs 0% [C/P])
• Conclusions: gefitinib demonstrated improved PFS but similar OS
"GefiUnib
or
carboplaUn‐paclitaxel
in
pulmonary
adenocarcinoma."
Mok,
T.
S.,
Y.
L.
Wu,
et
al.
(2009).
N
Engl
J
Med
361(10):
947‐957.
• Phase III study, chemonaive patients (asians, adenocarcinoma,
nonsmokers, former light smokers)
• Gefitinib (609 patients) or carboplatin/paclitaxel (608 patients)
• PFS gefitinib 24.9%, carboplatin-paclitaxel 6.7%, (HR 0.74; P<0.001)
• 261 mut+ patients; PFS gefitinib versus carboplatin-paclitaxel (HR
0.48; P<0.001)
• 176 mut- patients; PFS gefitinib versus carboplatin-paclitaxel (HR
2.85; P<0.001)
• CONCLUSIONS: Gefitinib is superior to carboplatin-paclitaxel for
adenocarcinoma among nonsmokers or former light smokers
• Mut+ is a strong predictor of a better outcome with gefitinib
Slutliga
biomarkördata
från
BR.21,
(Zhu,
da
Cunha
Santos
et
al.
2008)
• Behandlingssvar på erlotinib för mut- var 7% och för mut
+ 27% (p=.03)
• Behandlingssvar för FISH- var 5% och för FISH+ 21%
(p=.02)
• Skillnaden i total överlevnad för mut+ var inte signifikant
medan FISH+ hade signifikant överlevnadsvinst
(HR=0.43, p=.004)
• Vid multivariat analys var endast FISH+ signifikant (p=.
005)
• Detta talar starkt för en behandlingsvinst för FISH+
patienter, åtminstone i andra linjen
ASCO
2009,
erloUnib
• Cappuzzo
(#8001)
och
Brugger
(#8020)
rapporterade
kliniska
data
och
biomarkördata
från
SATURN;
• PaUenter
som
ej
progredierat
eser
fyra
cykler
KT
randomiserades
Ull
erloUnib
eller
placebo
• Totalt
1,949
paUenter
i
KT
fasen,
889
randomiserades
Ull
erloUnib
(n=438)
eller
placebo
(n=451)
• Ökad
PFS
oberoende
av
EGFR
FISH,
IHK,
mut
eller
KRAS
mut
status
(OS?)
• Biomarkördata
är
de
mest
omfacande
som
rapporterats
i
en
randomiserad
studie
• IHK+
84%
(n=742),
FISH+
48%
(n=488),
mut+
11%
(n=377),
KRAS+
18%
(n=494)
ASCO
2009,
erloUnib
• Spanska lungcancergruppen, Massuti (#8023); starkt signikant
fördel för EGFR mut+ patienter behandlade med erlotinib
• Hirsch (#8026); EGFR mut+ korrelerade med ökad 6 mån PFS i 1st
line terapi med erlotinib. EGFR FISH+ och KRAS– visade trend
• En stor fransk kohort, Cadranel (#8079), konfirmerade det
oberoende värdet av flera prognostiska faktorer vid behandling med
erlotinib vid avancerad NSCLC; EGFR IHK, FISH och mut samt
KRAS mut
• Jackman (#8065); kliniska parametrar kan användas för att
selektera till behandling med erlotinib om EGFR genotyp inte är
känd
• Yoshioka (#8067); prospektiv biomarkörstudie som visade att
erlotinib till tidigare behandlade EGFR mut- patienter är lika effektiv
och säker som standard docetaxel [Shepherd JCO 2000].
"Screening
for
Epidermal
Growth
Factor
Receptor
MutaUons
in
Lung
Cancer."
Rosell,
R.,
T.
Moran,
et
al.
(2009).
N
Engl
J
Med.
Epub
2009/08/2
• Methods
• Lung cancers from 2105 patients in Spain were screened for EGFR
mutations
• Patients with tumors carrying EGFR mutations were eligible for erlotinib
treatment.
• Results
• EGFR mutations were found in 350 of 2105 patients (16.6%); women
(69.7%), never smoked (66.6%), adenocarcinomas (80.9%) (P<0.001 for all
comparisons)
• The mutations were deletions in exon 19 (62.2%) and L858R (37.8%)
• Median PFS and OS for 217 patients who received erlotinib, in first or
second line, were 14 months and 27 months, respectively
• Conclusions
• Large-scale screening of patients with lung cancer for EGFR mutations is
feasible and can have a role in decisions about treatment
• The results were similar in first and second line treatment
"First‐
or
second‐line
therapy
with
gefiUnib
produces
equal
survival
in
non‐
small
cell
lung
cancer."
Wu,
J.
Y.,
C.
J.
Yu,
et
al.
(2008).
Am
J
Respir
Crit
Care
Med
178(8):
847‐853.
• 328 patients (Taipei, Taiwan); stage IIIb or IV NSCLC, were
sequenced for EGFR mutations (192 mut+)
• 152 exon 19 deletions or L858R were receiving gefitinib
• Classified as chemonaive (91) or chemotherapy-treated (61).
• Neither OS after the start of therapy nor PFS after gefitinib therapy
was significantly different between these two groups (P = 0.207 and
0.804, respectively)
• OS; clinical response to gefitinib (P = 0.001)
• CONCLUSIONS: This study suggests that gefitinib is effective in
patients with EGFR mutations. The gefitinib response rate in
chemonaive patients is higher than in chemotherapy-treated patients;
however, there is no difference in OS
ASCO
2009,
cetuximab
• O'Byrne
(#8007);
KRAS
mut
predikterar
inte
för
effekt
med
cetuximab
i
kombinaUon
med
first
line
KT
vid
avancerad
NSCLC,
medan
rash
av
varje
grad
är
associerat
med
bäcre
effekt
• Khambata‐Ford
(#8021);
ingen
korrelaUon
mellan
behandlingssvar
på
cetuximab
och
KRAS
mut,
EGFR
mut,
EGFR
IHC
eller
EGFR
FISH
• Mack
(#8022);
KRAS
ingen
predikUv
roll
• SLUTSATS:
EGFR
relaterade
biomarkörer
faller
inte
ut
vid
behandling
med
cetuximab
vid
lungcancer
• Deca
i
motsats
Ull
colorektal
cancer
där
KRAS
mut+
anses
utesluta
de
som
ej
skall
ha
behandling
RIKTLINJER
FÖR
BIOMARKÖRANALYSER
INFÖR
BEHANDLING
MED
TYROSINKINASHÄMMARE
(TKI)
VID
AVANCERAD
ICKE
SMÅCELLIG
LUNGCANCER
(NSCLC)
SVENSKA
LUNGCANCER
STUDIEGRUPPEN
(SLUSG)
Leif
Johansson
Simon
Ekman
Mikael
Johansson
Karl
Köhlbäck
Första
linjens
behandling
• • • • EGFR mutationsanalys rekommenderas i första hand
1. icke-rökare
2. adenocarcinom
3. alla patienter med NSCLC för att vinna erfarenhet och kunskap
• • • • • Vävnad för EGFR mutationsanalys
Formalinfixerat paraffin inbäddat material
1. bronkbiopsi, mellannål, VATS biopsi, operationsmaterial
2. cellblock preparerat från pleuravätska
3. cellblock preparerat från bronkborstar, nålbiopsier m.m. avsköljt i
cytolyt
Bakgrund
och
slutsats
första
linjens
behandling
• EGFR
mut+
paUenter
har
bäcre
behandlingssvar
och
ökad
PFS
(Mok,
Wu
et
al.
2009)
(Ohe,
Ichinose
et
al.
2009)
(Mitsudomi,
Morita
et
al.
In
Press,
Corrected
Proof.).
Data
angående
OS
är
foryarande
ofullständiga
men
ec
par
studier
tyder
på
bäcre
OS
för
mut+
paUenter
med
såväl
erloUnib
(Rosell,
Moran
et
al.
2009)
som
gefinib
(Wu,
Yu
et
al.
2008).
I
båda
dessa
studier
var
OS
samma
i
first
och
second
line.
• • Mot
bakgrund
av
deca
rekommenderas
i
första
hand
EGFR
mutaUonsanalys
inför
första
linjens
behandling
om
EGFR
TKI
är
ec
alternaUv
för
behandling.
Andra
linjens
behandling
Om
EGFR
mutaUonsanalys
ej
är
uyörd
inför
första
linjens
behandling
• 1. EGFR mutationsanalys och/eller EGFR FISH
• 2. EGFR immunohistokemi betraktas tills vidare som rådgivande inför behandling
tillsammans med
• 3. kliniska markörer (kvinna, icke-rökare, adenocarcinom, asiatiskt ursprung)
• • • • • • • • • Vävnad för EGFR analys inför andra linjens behandling
Formalinfixerat paraffin inbäddat material
1. bronkbiopsi, mellannål, VATS biopsi, operationsmaterial
2. cellblock från pleuravätska
3. cellblock preparerat från bronkborstar, nålbiopsier m.m. avsköljt i cytolyt
För FISH även lufttorkat cytologiskt material (+/- tidigare Giemsa färgning)
1. pleuravätska
2. bronkborstar
3. nålbiopsier m.m.
Bakgrund
och
slutsats
andra
linjens
behandling
• En
meta‐analys
(Gupta,
Dastane
et
al.
2009)
talar
för
ac
immunohistokemi
+,
FISH+,
och
mut+
predikterar
behandlingssvar
på
gefiUnib
för
paUenter
med
adenocarcinom.
Biomarkördata
från
BR.21
(Zhu,
da
Cunha
Santos
et
al.
2008)
talar
starkt
för
en
behandlingsvinst
av
erloUnib
för
FISH+
paUenter
i
andra
linjen.
SATURN
studien
visar
signifikant
ökad
PFS
för
erloUnib,
fr.a.
för
EGFR
mut+
paUenter,
men
även
för
FISH+
och
immunohistokemi+
paUenter
(Cappuzzo,
Ciuleanu
et
al.
2009).
Slutligen,
mut+
paUenter
behandlade
med
erloUnib
visade
en
OS
på
27
mån,
vilket
är
mycket
bäcre
än
historiska
kontroller
(Rosell,
Moran
et
al.
2009).
• • Inför
andra
linjens
behandling,
om
EGFR
mutaUonsanalys
ej
är
uyörd
Udigare,
rekommenderas
EGFR
mutaUonsanalys
och/eller
EGFR
FISH
.
EGFR
IHK
och
kliniska
markörer
rekommenderas
i
andra
och
tredje
hand.
EGFR
FISH,
Polysomy
EGFR
FISH,
Amplified
EGFR
MUTATIONS
IN
LUNG
CANCER
Tack
för
er
uppmärksamhet!