SANAC El papel de la biopsia líquida en el diagnóstico y seguimiento del cáncer. Emilio Alba

Transcripción

1 El papel de la biopsia líquida en el diagnóstico y seguimiento del cáncer Emilio Alba UGCI Oncología Médica. Hospital Universitario Regional y Virgen de la Victoria Departamento de Medicina. Universidad de Málaga. IBIMA

2 Bettegowda, C., et al Sci. Trans. Med., (2014) vol 6

3 LOAD Detection of cancers in high-risk population/early diagnosis Monitoring for minimal residual disease PROFILE Detection of response/resistance to therapy Choice of targeted agent CONCLUSIONS TOPICS

4 LOAD Detection of cancers in high-risk population/early diagnosis Monitoring for minimal residual disease PROFILE Detection of response/resistance to therapy Choice of targeted agent CONCLUSIONS TOPICS

5 Analytic Platform Digital PCR (Beaver 2014) BEAMing (Bettegowda 2014) SCODA (Kidess 2015) Selected Studies of ctdna detection Molecular Alteration Patients Tumor Stage Sensitivity SNV (PIK3CA) 14 Breast I-II 93% SNV (structural variants) SNV (Kras, BRAF, PIK3CA, EGFR) 7 Bladder Localized 57% 19 Breast Localized 53% 40 CCR Localized 78% 14 Gastric-E Localized 57% 9 Ovarian Localized 89% 121 Pancreatic Localized 50% 10 CCR I-II 60% Beaver JA, Clin Cancer Res 2014 Bettegowda C, Sci Transl Med 2014 Kidess E, Oncotarget 2015

6 LOAD Detection of cancers in high-risk population/early diagnosis Monitoring for minimal residual disease PROFILE Detection of response/resistance to therapy Choice of targeted agent CONCLUSIONS TOPICS

7 CTCs in Localized Disease Tumor Patients Method Results Prostate (Khurana 2013) CRC (Tsai 2016) CRC (Bork 2015) 12 Cell Search Inconclusive 95 CMx Platform > 5CTC = DFS 239 Cell Search 1 CTC = DFS, OS Khurana KK, 2013 Tsai WS, Sci Rep 2016 Bork U, Br J Caancer 2015

8 Presence of CTCs and clinical outcome in early breast cancer Banys-Paluchowski M. Front Oncol 2016

9 Presence of persistent CTCs and outcome in early breast cancer Banys-Paluchowski M. Front Oncol 2016

10 ctdna as Diagnostic Tool Biopsy NGS: 10 gens more frecuently mutated (Illumina/BEAMING) Correlation Mx: BIRADS 4a - 5 Blood ctdna

11 What s Spotlight 59 Targeted amplification / library preparation Amplicon panel; 277 amplicons across 59 genes Sample tracking ID panel (104 amplicons) Sequencing adaptors / barcodes (Illumina) Analysis: ERASE-Seq cloud bioinformatic solution Complete; from fastq to vcf generation HIPAA compliant (encrypted data transfer, storage) The workflow enables calling variants down to 0.1% AF with over < 0.3 FP calls per 10kB No restriction of search space (full panel)

12 Detection of Residual Disease after Surgery (ctdna) Method Tumor Patients Results Chromosomal Rearrangement (Olsson 2015) NGS (Tie 2016) Digital PCR (Garcia Murillas 2015) Breast 20 CRC 178 ctdna : Recurrence 0 / 6 ctdna + : Recurrence 13/14 ctdna + : Recurrence 11 / 14 ctdna : Recurrence 16/164 Breast 37 ctdna + v : HR: 25.1 Olsson E, EMBO Mol Med 2015 Tie J, Sci Transl Med 2016 García Murillas J, Sci Transl Med 2015

13 Monitoring ctdna Olsson E EMBO Mol Med 2015

14 En pacientes con el tumor primario intervenido (n=14) observamos una disminución del % de MAF al compararlo con los pacientes que no han sido intervenidos (n=10). Vemos un aumento en la media del % de MAF del 4,37 en los pacientes sin cirugía del tumor primario Las diferencias de % de MAF dependiente de la presencia del tumor primario, aunque no sean estadísticamente significativas, podría deberse a que éste acumula un volumen mutacional mayor que las metástasis o que, al no estar presente el tumor primario, hubiera un déficit de células que vertieran ctdna al torrente sanguíneo.

15 Analizando los resultados de un paciente con mutación en KRAS, exón 2, Cd12 en diferentes procesos clínicos, podemos observar en las gráficas que en la intervención del primario hay una disminución del % del MAF presente antes de ella. Cuando comienza el tratamiento, baja el % de MAF hasta el límite donde la técnica determina como wildtype. BEAMing-1: 01/06/2016 pre-cx KRAS-2, cd12 MAF: 1,71% BEAMing-2: 20/06/2016 post-cx Cx primario y hepática: 02/06/2016 Tumor primario: KRAS-2, cd12 KRAS-2, cd12 MAF: 0,198% BEAMing-3: 22/08/2016 En curso de Xelox adyuvante WT MAF: 0,006% El BEAMing podría ser una excelente técnica para monitorizar la enfermedad, ya que a través de la sangre obtendríamos una representación de lo que ocurre en ese momento concreto de la evolución tumoral o de la respuesta del paciente al tratamiento.

16 Most frequent mutated and methylated genes Ciriello G Nat Genetics 2014

17 LOAD Detection of cancers in high-risk population/early diagnosis Monitoring for minimal residual disease PROFILE Detection of response/resistance to therapy Choice of targeted agent CONCLUSIONS TOPICS

18 Tissue NGS vs. Plasma Cell-Free NGS on 165 Paired Samples from Five Centers Cell-free DNA vs. Tissue NGS SENSITIVITY SPECIFICITY DIAGNOSTIC ACCURACY I I I I I Tissue vs. Cell-free DNA NGS SENSITIVITY SPECIFICITY DIAGNOSTIC ACCURACY 85.0% (78.9%-89.7%) 99.6% (99.4%-99.7%) 99.3% (99.1%-99.4%) 80.7% (74.4%-85.8%) 99.7% (99.5%-99.8%) 99.3% (99.1%-99.4%) I I I I I Cell-free DNA sensitivity may be limited when tumor DNA is not shed into circulation. Tissue DNA sensitivity may be limited because samples fail to capture tumor heterogeneity. All sequencing (both tissue and cfdna) on Illumina HiSeq Lanman et al PLOS One

19 Concordancia tejido/plasma en CCR diseminado Concordancia global 25/28 89,2% Concordancia nativos 9/12 75% Concordancia mutados 16/16 100%

20 Concordance tissue/blood in a clinical trial Lebofsky R Mol Oncol 2014

21 BELLE-2: Efficacy by PIK3CA Mutation in ctdna PIK3CA mutation analysis in ctdna by BEAMing method (N = 587 pts) Buparlisib + fulvestrant extended PFS in pts with PIK3CA mutations vs fulvestrant alone Median PFS, Mos (95% CI) ctdna PIK3CA mutant (n = 200)* Buparlisib + Fulvestrant Placebo + Fulvestrant HR (95% CI) P Value 7.0 ( ) 3.2 ( ) 0.56 ( ) <.001 ctdna PIK3CA non-mutant (n = 387) 6.8 ( ) 6.8 ( ) 1.05 ( ).642 *n = 87 buparlisib + fulvestrant; n = 113 placebo + fulvestrant. n = 199 buparlisib + fulvestrant; n = 188 placebo + fulvestrant. ORR higher with buparlisib + fulvestrant in pts with PIK3CA mutations vs fulvestrant alone (18.4 % vs 3.5%) but similar in pts with non-mutant PIK3CA (11.6% vs 10.6%) Baselga J, et al. SABCS Abstract S6-01.

22 Erlotinib Carboplatin with docetaxel or gemcitabine A - EGFR L858R or exon 19 Del Measured in Tissue (N = 86) Median PFS (95% CI): Erlotinib arm 10.4 mos ( ) Chemotx arm 5.1 mos ( ) B - EGFR L858R or exon 19 Del Measured in Plasma (N = 49) Median PFS 995% CI) by qpcr or TaqMan: Erlotinib arm 12.3 mos ( ) Chemotx arm 5.5 mos ( ) Whether measured in tissue or blood, EGFR L858R and ex19 deletions responded to erlotinib. This is intuitive since the mutations in the blood come from the tissue. Karachaliou et al EURTAC trial JAMA Oncology

23 Gastric Cancer (N = 78) NSCLC (N = 72) ctdna matched Therapies (n) Therapeutic Targets ERBB2 amplification (6) PIK3CA mutation (2) FGFR2 amplification (1) MET amplification (1) EGFR mutation (8) EGFR T790M mutation (8) EML4-ALK fusion (1) Results 1 PD, 1 CR, 5 PR, 3 SD 1 PD, 1 SD, 15 PR Response Rate (PR+CR) 60% 88% Disease Control Rate (PR+CR+SD) 90% 94% Kim et al ASCO Abstract J Clinical Oncology 34;15_suppl

24 LOAD Detection of cancers in high-risk population/early diagnosis Monitoring for minimal residual disease PROFILE Detection of response/resistance to therapy Choice of targeted agent CONCLUSIONS TOPICS

25 EGFR T790M Mutations Respond to Osimertinib When Measured in Plasma (ddpcr) There was no difference in PFS between plasma-detected and tissue-detected EGFR T790M, the median response duration was 9.7 months (95% CI, 8.3 to 11.6) in the osimertinib group and 4.1 months (95% CI, 3.0 to 5.6) in the platinum pemetrexed group. Kim et al ASCO Abstract J Clinical Oncology 34;15_suppl

26 Proyecto de utilidad clínica de la biopsia líquida no invasiva (Guardant 360) en pacientes con NSCLC no escamosos en estadios avanzados

27 Resultados: 9 Pacientes había recibido tto previo con Qt. 5 no De los 13 resultados disponibles, 2 pacientes (15,88%) se están tratando en base a resultados: 1 EGFR mutado (L858R) y 1 FGFR +

28 CONCLUSIONS FACTS CTCs ARE PROGNOSTIC MARKERS IN EARLY AND METASTATIC DISEASE CTCs AND ctdna DETECT MRD HIGH CONCORDANCE TISSUE/BLOOD PREDICTIVE FACTORS FOR SOME ANTITARGET THERAPY PROMISES ctdna AS SCREENING TOOL CTCs AND ctdna AS SURROGATE MARKERS OF ALL TUMOR POPULATIONS (heterogeneity) CLINICAL UTILITY OF EARLY DIAGNOSIS OF MRD CLINICAL UTILITY AS PREDICTIVE FACTORS