分子标记物指导下的结直肠癌治疗课件.ppt

1、北京大学肿瘤医院北京大学肿瘤医院 消化肿瘤内科消化肿瘤内科王晰程王晰程分子标记物指导下的结直肠治分子标记物指导下的结直肠治疗疗 氟氟尿嘧啶类（尿嘧啶类（5FU Cape5FU Cape）奥沙利奥沙利铂、伊立铂、伊立替替康康含奥沙利铂的方案含奥沙利铂的方案 FOLFOXFOLFOXBevBev/cetcet XELOXXELOXBevBev FOLFOXIRIFOLFOXIRIBevBev含伊立替康的方案含伊立替康的方案 CPT-11CPT-11 XELIRIXELIRI FOLFIRIFOLFIRICetCet/Bev/Bev 西妥昔、西妥昔、帕尼单抗帕尼单抗 贝伐珠单抗贝伐珠单抗其它：瑞格菲

2、尼其它：瑞格菲尼细胞毒药物 分子靶向药物Catalano V,Loupakis F,Graziano F,et al.Br J Cancer.2009 Mar 24;100(6):881-7.不同原发肿瘤部位患者的PFS及OSFOLFIRI+西妥昔单抗(A组)FOLFIRI+贝伐珠单抗(B组)PFS时间(月)左侧(n=127)中位PFS=10.5个月右侧(n=39)中位PFS=8.8个月P=0.065HR=0.69 (0.47-1.03)OS时间(月)左侧(n=127)中位OS=28.0个月右侧(n=39)中位OS=22.7个月P=0.034HR=0.63 (0.41-0.97)1.000.7

3、50.500.250.001224364860721.000.750.500.250.00122436486072PFS时间(月)左侧(n=137)中位PFS=10.8个月右侧(n=30)中位PFS=6.9个月P0.0001HR=0.35 (0.23-0.53)OS时间(月)左侧(n=137)中位OS=38.7个月右侧(n=30)中位OS=16.1个月P0.0001HR=0.26 (0.16-0.42)1.000.750.500.250.001224364860721.000.750.500.250.00122436486072Heinemann V,et al.2014 ASCO Abstr

4、act 3600.西妥昔单抗、贝伐单抗一线治疗，KRAS野生型的左半结肠患者OS明显优于右半结肠患者传统治疗个体化治疗Kalia M.Metabolism.2013;62 Suppl 1:S11-S14.结直肠癌患者结直肠癌患者治疗治疗有效有效无效无效副作用副作用大大组织、血液、组织、血液、DNA、核酸分析、核酸分析治疗治疗有效有效标记物蛋白功能CRC中的缺陷发生率作用EGFR跨膜酪氨酸激酶受体蛋白表达突变拷贝数增加25-90%极少见0-50%与抗EGFR单抗疗效不相关尚未知是否与抗EGFR单抗疗效相关不确定是否与抗EGFR单抗疗效相关KRASGDP-/GTP-结合蛋白，促进配体依赖的信号转导

5、激活突变（密码子12,13,61,146）；导致MAPK信号通路的激活30-40%若是突变的话，会对抗EGFR单抗治疗无反应NRASEGFR信号传导通路中的蛋白突变（密码子12、13、59、61、117、146）3-5%若是突变的话，会对抗EGFR单抗治疗无反应BrafKras下游丝氨酸-苏氨酸蛋白激酶激活突变（V600E）5-12%突变者预后差，Crystal/OPUS荟萃分析发现应用爱必妥治疗可能获益PTEN蛋白酪氨酸磷酸酶；灭活PI3K通路蛋白表达丢失；突变；杂合性缺失13-19%预后差，可能会对抗EGFR单抗治疗无反应上皮调节蛋白，双调蛋白（高表达）EGFR配体，与EGFR结合激活下游

6、通路50-60%高表达者，应用爱必妥治疗可能获益更多1.Krasinskas AM.Patholog Res Int.2011 Feb 14;2011:932932.2.Luo HY,Xu RH.World J Gastroenterol.2014;20(14):3858-3874.标记物标记物蛋白功能蛋白功能CRC中的缺陷中的缺陷发生率发生率作用作用EGFR跨膜酪氨酸激酶受体蛋白表达突变拷贝数增加25-90%极少见0-50%与抗EGFR单抗疗效不相关尚未知是否与抗EGFR单抗疗效相关不确定是否与抗EGFR单抗疗效相关KRASGDP-/GTP-结合蛋白，促进配体依赖的信号转导激活突变（密码子1

7、2,13,61,146）；导致MAPK信号通路的激活30-40%若是突变的话，会对抗EGFR单抗治疗无反应NRASEGFR信号传导通路中的蛋白突变（密码子12、13、59、61、117、146）3-5%若是突变的话，会对抗EGFR单抗治疗无反应BRAFKras下游丝氨酸-苏氨酸蛋白激酶激活突变（V600E）5-12%突变者预后差，Crystal/OPUS荟萃分析发现应用爱必妥治疗可能获益PTEN蛋白酪氨酸磷酸酶；灭活PI3K通路蛋白表达丢失；突变；杂合性缺失13-19%预后差，可能会对抗EGFR单抗治疗无反应上皮调节蛋白，双调蛋白（高表达）EGFR配体，与EGFR结合激活下游通路50-60%高

8、表达者，应用爱必妥治疗可能获益更多KRAS是第一个被证实预测抗EGFR单抗疗效的生物标记物*KRAS-WT exon 2 subset全RAS检测需包括6个外显子1。ASCO GI 2014 2。N Engl J Med 2013;369:1023-1034 3。Bokemeyer,et al.ASCO 2014.Abstract 3505 4。Ciardiello,et al.ASCO 2014.Abstract 3506 5。ESMO 2013 0%2.0%3.8%NRAS12 1312 136114659 61117 146EXON 2EXON 3EXON 4EXON 2EXON 3EX

9、ON 4FIRE346%0%PRIME35%2.8%0.9%CRYSTAL3.5%5.1%0.8%OPUS6.8%5.8%0%PEAK5.4%4.3%4%3.3%5.9%4%4.9%67%5.6%9.3%7.6%FIRE3PRIMECRYSTALOPUSPEAKKRASKRAS WTKRAS MUT:codons 12,13TreatmentFOLFOX(N=331)Panitumumab+FOLFOX(N=325)FOLFOX(N=219)Panitumumab+FOLFOX(N=221)PFS,mosHR(95%CI)P value8.6100.80(0.67-0.95)0.019.27.

10、41.27(1.04-1.55)0.02OS,mosHR(95%CI)P value19.723.90.88(0.73-1.06)0.1719.215.51.17(0.95-1.45)0.15ORR,*%(95%CI)48(42-53)57(51-63)41(34-48)40(33-47)Odds ratio (95%CI)1.47(1.07-2.04)P=0.020.98(0.65-1.47)P=0.92Douillard JY,et al.Presented at ASCO 2011(abstr 3510).Siena S,et al.Presented at ASCO GI.2011(a

11、bstr3510).RAS WT aRAS MUT bTreatmentFOLFOX(N=253)Panitumumab+FOLFOX(N=259)FOLFOX(N=276)Panitumumab+FOLFOX(N=272)PFS,mosHR(95%CI)P value7.910.10.72(0.58 0.90)0.018.77.31.31(1.07 1.60)0.01OS,mosHR(95%CI)P value20.226.00.78(0.62 0.99)0.0419.215.61.25(1.02 1.55)0.04a WT in KRAS and NRAS exons 2,3,and 4.

12、b.MUT in any KRAS or NRAS exon 2,3,or 4 17%of patients with non-mutated KRAS exon 2 had other RAS mutations 52%of all patients had some RAS mutationN Engl J Med 2013;369:1023-34Roth AD,et al(2010)J Clinical OncologyII期和III期结直肠癌术后BRBRAFKRAS 结直肠癌中，结直肠癌中，BRAF BRAF 突变率约为突变率约为5%-10%5%-10%。导致信号通路活化和肿瘤细胞增殖

13、导致信号通路活化和肿瘤细胞增殖 与与KRASKRAS突变相互排斥突变相互排斥 提示预后不良提示预后不良 BRAFBRAF抑制剂单独使用无效抑制剂单独使用无效RasRaf*MEKERKProliferationSurvivalTherapeutic inhibitors for BRAF mutant cancers in trials:PLX-4032 in BRAF mutated melanoma Flaherty et al ASCO 200970%objective response PLX-4032 in BRAF mutated colorectal cancer Kopetz e

14、t al ASCO 2010,Abstr 353421 patients1 partial response(5%)and 4 minor responsesReactivation of EGFR signaling upon BRAF inhibition Signaling in BRAF CRCPartial inhibition of MAPK pathway signaling with inhibition of BRAF and EGFRUpdated modelRobust inhibition of MAPK pathway signaling with inhibitio

15、n of BRAF,MEK,EGFRMaximum Percent ReductionFrom Baseline MeasurementUnconfirmed responses(CR+PR):4(11%)2 confirmed responses(1 CR and 1 PR)Unconfirmed minor responses:8(22%)Corcoran et al ASCO 2013!100!80!60!40!20!020406080100Best Unconfirmed ResponseComplete responseProgressive diseasePartial respo

16、nseNot evaluableStable diseaseBars are grouped by best unconfirmed response.*Indicates maximum reduction from baseline is 0%.a Denotes that subject received prior anti-EGFR therapy.b denotes progressive disease secondary to presence of new lesion.c Patient had a 30%reduction in target lesions but wa

17、s deemed to have PD due to presence of one new lesion.Johanna C.Bendell MD,2014 ASCOAbstract 351580%16%4%Died despite maximal treatmentCured by the addition of chemotherapyCured by surgery aloneIs treating 100 patients with essentially good prognosis(as a whole population)with potentially toxic chem

18、otherapy for 6 months justified to cure an extra 4 patients?dMMR leads to accumulation of mutations and therefore tumorigenesis and to the characteristic finding of MSIPCR on tumor DNA for MSI(microsatellite instability)IHC for MMR protein statusMLH1+MSH2+MLH1-MSH2-SourceStage/TreatmentEndpointdMMR

19、vs pMMRHR(95%CI);p-valueRibic et al1II/IIISurgery aloneOverall survival0.31(0.14-0.72)p=0.004Sargent et al2II/IIISurgery aloneDisease-free survivalOverall survival0.46(0.22-0.95);p=0.030.51(0.24-1.10);p=0.06Gray et al3(QUASAR)IISurgery aloneRecurrence-free interval0.31(0.15-0.63)p0.001Roth et al4(PE

20、TACC-3)II5FU irinotecanRelapse-free survival0.30 p=0.0041.Ribic CM,et al.N Engl J Med.2003;349:247-257.2.Sargent DJ,et al.J Clin Oncol.2010;28:3219-3226.The 15%of stage II colon cancer patients with dMMR tumors have been found consistently to have a lower risk of recurrence and/or death3.Gray R,et a

21、l.J Clin Oncol.In press.4.Roth AD,et al.J Clin Oncol.2009;27:abstract 288.Colon Cancer Technical FeasibilityDevelopment StudiesSurgery AloneNSABP C-01/C-02(n=270)Cleveland Clinic(n=765)Selection of Final Gene List&AlgorithmDevelopment Studies Surgery+5FU/LVNSABP C-04(n=308)NSABP C-06(n=508)Clinical

22、Validation Study Stage II Colon CancerQUASAR(n=1,436)Test Prognosis and Treatment BenefitDevelopment and ValidationStandardization and Validation of Analytical MethodsKerr et al.,ASCO 2009,#4000 Colon Cancer Recurrence Score from Development StudiesCELL CYCLEKi-67C-MYCMYBL2ATP5EGPX1PGK1UBBVDAC2GADD4

23、5BRecurrence ScoreSTROMALFAPINHBABGNReference GenesRS=0.15 x Stromal Group -0.30 x Cell Cycle Group +0.15 x GADD45B in Pre-specified Recurrence Risk GroupsComparison of High vs.LowRecurrence Risk Groups using Cox Model:HR=1.47(p=0.046)Recurrence Risk GroupRange of RSProportion of patientsLow3043.7%I

24、ntermediate30-4030.7%High4125.6%22%(16%-29%)18%(13%-24%)12%(9%-16%)Kaplan-Meier Estimates(95%CI)of Recurrence Risk at 3 yearsYearsRecurrence Risk GroupHighIntermediateLowProportion Event Free0.00.20.40.60.81.0012345n=711Resected stage II colon cancerT stage,MMR statusT3 and dMMRlow riskT3 and pMMRst

25、andard riskT4 and pMMRhigh riskConsider observationOncotype DXColon Cancer AssayConsider chemotherapydMMR,mismatch repair deficient;pMMR,mismatch repair proficient阿司匹林治疗的潜在靶点15-20%15-20%结直肠癌存在结直肠癌存在PIK3CA PIK3CA 基因突变。基因突变。突变多见于外显子突变多见于外显子9 9 和外显子和外显子2020。PIK3CA PIK3CA 突变的患者可能从阿司匹林的治疗中获益。突变的患者可能从阿司匹林

26、的治疗中获益。Liao X et al(2009)NEJM氟尿嘧啶类药物通过氟尿嘧啶类药物通过DPDDPD酶代谢酶代谢从体内降解。从体内降解。DPDDPD酶的部分或全部缺乏可加重酶的部分或全部缺乏可加重5-Fu5-Fu相关不良反应，严重时可导致相关不良反应，严重时可导致死亡。死亡。DPDDPD酶是否缺乏可通过检测酶是否缺乏可通过检测DPDDPD酶酶的活性或的活性或DPDDPD基因的测序来预测。基因的测序来预测。DPDDPD基因突变的位点和频率在不基因突变的位点和频率在不同人种间存在较大差别。同人种间存在较大差别。Saif MW.(2013)Cancer Genom&ProteomiUGT1A1

27、UGT1A1是伊立替康代谢的是伊立替康代谢的关键酶。关键酶。UGT1A1UGT1A1多态性可能与伊立多态性可能与伊立替康的毒性相关。替康的毒性相关。UGT1A1 UGT1A1*28 28 和和UGT1A1 UGT1A1*6 6 在人种间具有差异性。在人种间具有差异性。Derwinger K,Gustafson.Anticancer Res.2011 Jun;31(6):2347-50.*28 40%vs 15%hetero 10%vs 5%homo*6?vs 28%hetero?vs 7%homoPalomaki GE et al(2009)Genetics Med Severe Diarrh

28、eaSevere NeutropeniaHeterozygous mutationHeterozygous mutationHomozygous mutationHomozygous mutationCheng L.et al(2014)Cancer Chemother Pharmacol Severe DiarrheaSevere NeutropeniaHeterozygous mutationHeterozygous mutationHomozygous mutationHomozygous mutationKE Caudle et al(2013)Clini Pharm TheraRAS

29、RAS基因的检测缩小了治疗人群，但目标人群的生存受益更为显基因的检测缩小了治疗人群，但目标人群的生存受益更为显著。著。BRAFBRAF、PIK3CAPIK3CA突变如何选择更适宜的治疗仍在探索当中。突变如何选择更适宜的治疗仍在探索当中。IIII期结直肠癌的期结直肠癌的MISMIS状态结合分子水平的基因表达谱可更好地筛状态结合分子水平的基因表达谱可更好地筛选高危复发人群。选高危复发人群。UGT1A1UGT1A1和和DPDDPD基因的多态性与药物不良反应存在一定相关性，应基因的多态性与药物不良反应存在一定相关性，应进一步研究如何提高其预测的准确性。进一步研究如何提高其预测的准确性。大数据时代的结直

30、肠癌再分型？大数据时代的结直肠癌再分型？CMS：Concensus Molecular Subtype Dienstmann,et al.ASCO 2014.Abstract 3511CMS114%超突变,BRAF mut,MSI,免疫通路活化/表达,右侧肿瘤,诊断时年龄更大,女性CMS241%EGFR 扩增/过表达,CIN高表达,MSS,强WNT/MYC通路,左侧肿瘤,TP53 mut,CMS38%KRAS mut,CIN低表达,适度WNT/MYC 通路活化,PIK3CA mut,IGFBP2过表达CMS420%CIN/MSI 异质性,间质/TGF-beta活化,诊断时年龄更轻,NOTCH3

31、/VEGFR2过表达生存时间一般生存时间更好生存时间一般生存时间最差Greystoke A et al.(2012)Gastroenterol Res Prct不同不同研究的研究的RAS突变率：突变率：BEAMING焦磷酸测序双脱氧测序/WAVE双脱氧测序/WAVEBEAMING1。ASCO GI 2014 2。N Engl J Med 2013;369:1023-1034 3。Bokemeyer,et al.ASCO 2014.Abstract 3505 4。Ciardiello,et al.ASCO 2014.Abstract 3506 5。ESMO 2013 mCRC生物制剂十年发展 2

32、01420082012200420062011西妥昔单抗+伊立替康2L贝伐珠单抗+化疗1L贝伐珠单抗+化疗2L西妥昔单抗仅用于既往伊立替康治疗失败的KRAS WT（2L）帕妥木单抗+FOLFOX1L帕妥木单抗+FOLFIRIKRAS WT2L瑞戈非尼2L+贝伐珠单抗跨线阿柏西普+FOLFIRI 2L帕妥木单抗以及西妥昔单抗不能用于RAS MT或RAS未知帕妥木单抗+FOLFOXKRAS-WT(US)自2004年以来，多个mCRC靶向药物获得FDA批准2013Budinska E et al Asco 2012 5 clusters with sufficient sample size wer

33、e retained as CRC subtypes A,B,C,D and E.原发肿瘤部位定义 右侧CRC(“中肠”)：盲囊肝曲 左侧CRC(“中肠”)：直肠结肠脾曲 排除横结肠肿瘤(n=9)统计学 分别采用双侧Fishers精确和log-rank检验方法评估两组间缓解率(ORR)和生存期(PFS/OS)的差异 根据后向消除设计，采用COX回归方法对基线特征、BRAF和PIK3CA突变进行分析FIRE-3研究中右侧与左侧原发肿瘤分布3%*44%20%77%*进一步分析排除了横结肠肿瘤 33%Heinemann V,et al.2014 ASCO Abstract 3600.1.Van Cu

34、tsem E,et al.JCO 2011;29:2011-2019.2.Forbes SA,et al.Nucleic Acids Res 2011;39:D945-950.Derwinger K,Gustafson.Anticancer Res.2011 Jun;31(6):2347-50.Weiss JM,Pfau PR,OConnor ES,et al.J Clin Oncol.2011 Nov 20;29(33):4401-9.allStage IStage IIIStage IIP=0.001P0.0012014200420082000200720112013Venook12Sal

35、tz1Goldberg3Saltz6Bokemeyer7Saltz1Douillard2Hurwitz4Falcone5Douillard2Douillard9Van Cutsem8Falcone11Heinemann100102025总生存(月)1553035FOLFIRI+安维汀 TRIBE25.85-FU/LV 推注12.6FOLFOX19.5FOLFOX+安维汀 NO1696621.2FOLFOX+西妥昔单抗 OPUS 22.8*IFL14.85-FU/LV 静注14.1IFL+安维汀 AVF2107g20.3FOLFOXIRI 意大利GONO研究 22.6FOLFIRI17.4FOL

36、FOX+帕妥木单抗 PRIME23.9*FOLFIRI+西妥昔单抗 CRYSTAL23.5*化疗+西妥昔单抗 CALGBFOLFIRI+安维汀 FIRE-325.0*FOLFIRI+西妥昔单抗 FIRE-328.7*FOLFOXIRI+安维汀 TRIBE 31.0化疗+安维汀 CALGB29.0*29.9*靶向治疗组化疗组*KRAS野生型肿瘤；注：此图中的数据比较并非来自头对头的临床研究野生型肿瘤；注：此图中的数据比较并非来自头对头的临床研究.1.Saltz LB,et al.N Engl J Med 2000;343:905-914.2.Douillard JY,et al.Lancet 2

37、000;355:1041-1047.3.Goldberg RM,et al.J Clin Oncol 2004;22:23-30.4.Hurwitz H,et al.N Engl J Med 2004;350:2335-2342.5.Falcone A,et al.J Clin Oncol 2007;25:1670-1676.6.Saltz LB,et al.J Clin Oncol 2008;26:2013-2019.7.Bokemeyer C,et al.Ann Oncol 2011;22:1535-1546.8.Van Cutsem E,et al.J Clin Oncol 2011;29:2011-2019.9.Douillard JY,et al.2011 ASCO Abstract 3510.10.Heinemann V,et al.2013 ASCO Abstract LBA3506.11.Falcone A,et al.2013 ASCO Abstract 3505.12.Venook A,et al.2014 ASCO Abstract LBA3.13.Aprile G,et al.World J Gastroenterol 2013;19(46):8474-8488.