Rilevanza dell’innovazione tecnologica per la ricerca traslazionale e la terapia in oncologiaricerca traslazionale e la terapia in oncologia

Ruggero De Maria

Dipartimento di Ematologia Oncologia e Medicina Molecolare, 

Istituto Superiore di Sanità

Translational research: the central role of biotechnologiesthe central role of biotechnologies

Bench scientists Clinical scientistsClinicians Bench scientists Clinical scientistsClinicians

PathophysiologyDiseases

GenomicsProteomics

Clinical trialsDiseasesNew infections Stem cells

Transgenic/knockoutsStructuralStructuralbiology/Imaging

Clinical problem ClinicalClinical applicationapplication

Association of molecular markers with toxicity outcomes in a randomized trial of chemotherapy for advanced colorectal cancer: the FOCUS trialpy

How Could Molecular Markers InfluenceHow Could Molecular Markers Influence Treatment Decisions?

Treatment Clinical Genomic Impact

“Sparing” Yes No ↓ Unnecessary Therapy

“Selection” No Yes ↑ CurabilityAvoid undertreatment

“Direction” Equipoise Yes or no More appropriate treatment choices

“Confirmation” Yes No

YesNo

Confirm clinical decision

Innovative screening tools: BRCA1/2 mutation screening for hereditary Breast and Ovarian Cancer syndromehereditary Breast and Ovarian Cancer syndrome 

Lifetime risk estimates of developing breast and ovarian cancer among 

h h dwomen with inherited BRCA1 or BRCA2 mutations

Reduction of cancer incidence with surgical and nonsurgical interventions

Roukos DH. Nat Clin Pract Oncol. 2007

Association of molecular markers with toxicity outcomes in a randomized trial of chemotherapy for advanced colorectal cancer: the FOCUS trial

Marker/Function Variant At Risk GT Drug EffectedHypothesized Impact

Activity Toxicity Other

py

ABCB1/cellular efflux 3435 C to T TT Irinotecan ↓ ↑ ↓ clearance

DPYD/detoxification IVS14 + 1G to A (*2A) Variants Fluorouracil ↓ ↑ ↑ active metabolite

ERCC2/DNA repair 35 931 A to C CC Oxaliplatin ↓ ↑ ↓ DNA repairERCC2/DNA repair 35,931 A to C CC Oxaliplatin ↓ ↑ ↓ DNA repair

GSTP1/detoxification 313 A to G AA Oxaliplatin ↓ ↑ ↓ detoxification

MLH1/DNA repair -93 G to A AAFluorouracilIrinotecan Oxaliplatin

↓ ↑ ↓ DNA repairOxaliplatin

MTHFR/folate pool, modifies FU response 667 C to T TT Fluorouracil ↓ ↑ --

TYMS/target for FU metabolite

1494: 6 bp insertion +/+ Fluorouracil -- ↑ ↓ expressionmetabolite ER: VNTR 28 bp 2R/2R Fluorouracil -- ↑ ↓ expression

UGT1A1/detoxification VNTR: 6 or 7 TA repeats (*28) 7/7 Irinotecan ↓ ↑ ↓ detoxification

XRCC1/DNA repair 23 885 G to A AA Irinotecan ↓ ↑ ↓ DNA repairXRCC1/DNA repair 23,885 G to A AA Oxaliplatin ↓ ↑ ↓ DNA repair

Individuals who are homozygous for the UGT1A1*28 allele are at increased risk for neutropenia following initiation of irinotecan treatment

Braun MS, et al. J Clin Oncol. 2009 

p g

Molecular profiling for individual risk assessment :MammaPrint® (70 genes involved in cancer biology)( g gy)

Van ‘t Veer et al, Nature2002

MicroRNAs are endogenous non coding single-stranded RNAs of ~ 22nt that play important roles in

animals and plants by targeting 3’UTR of mRNAs for cleavage or translational repression

MiRNAs may thus represent one of the largest class of gene regulators

They are implicated in a variety of processes, such as development, organogenesis,

stemness and differentiation, growth control and programmed cell death

Relationship between the expression levels of 9 MicroRNAs and time from diagnosis to initial therapy in patients with chronic lymphocytic leukemia (CLL)

(P<0.01)

Calin GA et al. N Engl J Med 2005

( )

Present and future of targeted therapy

Siena S et al,JNCI 2009

Biomarkers discovery: predictive value of EGFR‐activating mutations for anti‐EGFR therapy (lung cancer)

EGFRMutation Positive EGFRMutation Negative

HR: 0.48 ty of P

FS

1.0

0.8

0.6 ty of P

FS

1.0

0.8

0.6

EventsGefitinib: 97 (73.5%)Pac/carbo: 111 (86.0%)

EventsGefitinib: 88 (96.7%) Pac/carbo: 70 (82.4%)

(95% CI: 0.36‐0.64; P < .001)

Prob

abilit

GefitinibPaclitaxel/carboplatin

0.4

0.2

0

Prob

abili

Gefitinib

Paclitaxel/carboplatin

0.4

0.2

0

Mos Since Randomization

00 4 8 12 16 20 24

Mos Since Randomization

00 4 8 12 16 20 24

ORR, % Gefitinib Paclitaxel/ P ValueORR, % Gefitinib Paclitaxel/Carboplatin

P Value

Overall population 43.0 32.2 < .001EGFR mutation positive 71 2 47 3 < 001EGFR mutation positive 71.2 47.3 < .001EGFR wild type 1.1 23.5 .001

Mok TS, et al. NEJM 2009

Biomarkers discovery: predictive value ofK‐ras status for anti‐EGFR therapy (CRYSTAL trial)K ras status for anti EGFR therapy (CRYSTAL trial)

Influence of KRAS status on efficacy of cetuximab plus FOLFIRINormanno N et al. Nat. Rev. Clin. Oncol 2009

Translational Potential of Protein Microarraysfor Routine Use in Clinical Research Specimens

Tumor biopsy MicrodissectionTumor biopsy Microdissection

Protein Microarray

Data AnalysisData Analysis

Patient/Tumor‐SpecificSignaling Network Profile

Tailored targeted therapy

Patient A Patient B

Patient A

Patient B

Pathology Report of the Future: 

Glioblastoma Mulitforme Patient 1 Glioblastoma Mulitforme Patient 2

Individualized Protein Pathway Activation Maps

Glioblastoma Mulitforme Patient 1 Glioblastoma Mulitforme Patient 2

Symmetricdivision

Asymmetricdivisiondivision division

Non tumorigenicdifferentiated cell

Non tumorigenic transient amplifying progenitors

Tumorigeniccancer stem cells

Non

Old view New view

x Non

New view

xPotentially

Metastatic

xx

Potentially

Metastatic

xx

metastatic

NonMetastatic

xxxxx x

xmetastatic

NonMetastatic

xxxxx xx

xMetastaticx x

xxxx

xxx

Metastaticx xxxxx

xxx xxxx xxxx

Symmetricdivision

Asymmetricdivisiondivision division

Non tumorigenicdifferentiated cell

Non tumorigenic transient amplifying progenitors

Tumorigeniccancer stem cells

Non

Old view New view

x Non

New view

Potentially

Metastatic

xx

Potentially

Metastatic

metastatic

NonMetastatic

xxxxx x

xmetastatic

NonMetastaticxx

xxx x Metastaticx xxxxx

xxx

Metastaticx xxxxx xxxx xxx

Symmetricdivision

Asymmetricdivisiondivision division

Non tumorigenicdifferentiated cell

Non tumorigenic transient amplifying progenitors

Tumorigeniccancer stem cells

Non

Old view New view

x Non

New view

xPotentially

Metastatic

xx

Potentially

Metastatic

xx

metastatic

NonMetastatic

xxxxx x

xmetastatic

NonMetastatic

xxx

xxx x Metastaticx xxxxx

xxx

Metastatic

xxxxx x

xxxx xxxx

xx xxx

Colon cancer spheres are tumorigenic and reproduce the original tumor even

CDX2 beta-catenin CK 20

after long term expansion

patient

50 spheres106 adherent cells

500 spheres

m3 )

2.0

2.5

Volu

me

(cm

0 5

1.0

1.5

mouse

Time (weeks)

V

0

0.5

0 2 4 6 8 10 12 14

patient mouse mouse after ½ year mouse after 1 year

( )

H&E

Ricci-Vitiani et al. Nature 445:111, 2007

Need for more reliable animal models: CSC‐derived vs cell line‐derived xenograftsCSC derived vs cell line derived xenografts

Cancer stem cellsNCI 60 cell lines

RPPM

MRI

ISS has the largest collection of cancer stem cellsMRI

Tumor database

Diagnosis and tissue banking

Tumor dissociation

H&E

Cancer stem cellbanking

dissociationStem cell cultureand expansion

g

Tumor Type Histotype Total availableGlioblastoma ‐ 32

Tumor Type Histotype Total availableColorectal Colon 18 Glioblastoma ‐ 32

Melanoma ‐ 9Ovary ‐ 3Breast Infiltrating ductal 9

Infiltrating lobular  1

Colorectal Colon 18Rectum 8Squamous 7Adenocarcinoma 8

Lung Large Cell 5

ThyroidAnaplastic 4Papillary  8Follicular 6

Small Cell 2Carcinoid 1TBD 3

Translating the CSC concept into clinical studies

Banking and characterization of CSCs

Identification of druggable pathways T t f th t t d i hibitIdentification of druggable pathways through high‐throughput technologies (i.e. RPPM): in vitro drug screening

Test of pathway‐targeted inhibitors on CSC‐derived xenografts

Clinical studies:

R t ti (bi k lid ti )‐Retrospective (biomarkers validation)

‐Prospective (adaptive trials)