抗EGFR治疗结直肠癌疗效的潜在预测标记

抗抗EGFR治疗结直肠癌疗效的治疗结直肠癌疗效的潜在预测标记潜在预测标记浙江大学医学院附属第一医院浙江大学医学院附属第一医院 肿瘤中心肿瘤中心 化疗科化疗科 徐徐 农农肿瘤治疗肿瘤治疗疗效毒性选择EGFR状态作为结直肠癌的预后因素状态作为结直肠癌的预后因素l82%的结直肠癌EGFR有不同程度的表达肿瘤类型肿瘤类型与与RFS相关性相关性(%)与与OS相关性相关性(%)EGFR 作为强烈预后指标作为强烈预后指标 膀胱癌60(n=5)63(n=11)宫颈癌75(n=4)71(n=7)食管癌 0(n=1)69(n=13)头颈部肿瘤75(n=8)82(n=11)卵巢癌80(n=5)67(n=9)EGFR 作为中度预后指标作为中度预后指标 乳腺癌N/A55(n=11)结直肠癌结直肠癌N/A67(n=3)胃癌 N/A50(n=6)内膜癌N/A40(n=5)EGFR 作为轻度预后指标作为轻度预后指标 NSCLC20(n=10)10(n=10)Nicholson et al.Eur J Cancer 2001;37(Suppl.4):S915Frequency(%)of studies showing an association between increased EGFR level and decreased survival预测抗预测抗EGFR疗效指标疗效指标l皮疹 l检测 EGFR 状态EGFR蛋白表达IHC基因表达FISH 基因突变基因水平 基因考贝数l检测 EGFR 激活EGFR 配体EGFR 磷酸化 KRAS l其他信号通路lPTEN失活lVEGF基因表达lP21 丧失lSTAT3激活l胚系基因多态性lEGFR基因多态性CA双核苷酸重复序列 lFcR多态性FcRIIa131位点和FcRIIIa 158位点 lcyclin D1 A870G和EGF A61G的多态性lCox-2的G765C多态性 临床预测标记临床预测标记痤疮样皮疹l痤疮样皮疹是抗EGFR靶向药物常见的不良反响，并呈剂量依赖性。l抑制EGFR介导的信号通路l -抑制生长、促进凋亡、l -抑制细胞迁移l -增加细胞黏附和分化l -刺激炎症进而影响角质化细胞l导致特有的皮肤表现抗抗EGFR治疗治疗 所致皮肤反响所致皮肤反响 1 2 3 4 5 6 7 8 9抗抗EGFR治疗治疗 所致皮肤反响所致皮肤反响Descriptionof severe cases后炎症效应痤疮样皮疹甲沟炎皮肤枯燥Topical antiacnecreams(drying effect)tetracyclines antihistaminesPruritusPulse dye laserEmollients Hydrocolloid dressing or propylene glycol acetylsalicylAntiseptic soaks,silver nitrate(pyogenic granuloma)皲裂Segaert S,et al.Ann Oncol.2005;16:1425-1433.Therapy Suggestions西妥昔单抗治疗西妥昔单抗治疗 皮疹与生存期关系皮疹与生存期关系1.Saltz L,et al.Proc ASCO.2001.2.Saltz L,et al.J Clin Oncol.2004;22:1201-1208.3.Cunningham D,et al.N Engl J Med.2004;351:337-345.4.Van Cutsem E,et al.EORTC/NCI Geneva.2004.5.Xiong H,et al.J Clin Oncol.2004;22:2610-2616.6.Kies MS,et al.Proc ASCO.2002.0No reactionGrade 2Grade 1Grade 3Survival(Months)161284CRC9923Saltz(2001)1CRC0141Saltz(2004)2CRCBONDCunningham3CRCVan Cutsem(2004)4Pancreatic Xiong(2004)5SCCHNKies(2002)6*There were no grade 4 skin reactions.Van Cutsem E,et al.ASCO 2007.Abstract 4000.Skin reaction grade 0 or 1(n=244)0.02.55.07.510.012.515.017.520.0PFS Time(Months)1.000.750.500.250.00PFS EstimateSkin reaction grade 2(n=243)Skin reaction grade 3*(n=112)11.3 months5.4 months9.4 monthsCRYSTAL:PFS by On-Study Skin Reactions:Cetuximab+FOLFIRI皮肤毒性与肿瘤疗效的机理皮肤毒性与肿瘤疗效的机理l一些研究者提出假设，皮疹是西妥昔单抗与受体结合饱和程度的替代标志l获得所需皮肤毒性的靶向剂量就能进一步提高该药物的疗效l证实假说，进行了一项随机多中心I、II期研究EVEREST试验l另一种假说的解释是皮肤毒性的预测价值可能与个体间胚系遗传多态性有关Tejpar S,et al.ASCO 2007.Abstract 4037.Patients with EGFR-positive mCRC failing irinotecan-based therapy(N=166)Arm A:Irinotecan+standard-dose Cetuximab 250 mg/m2/weekArm B:Irinotecan+dose-escalated*Cetuximab dose increases of 50 mg/m2 q2w up to maximum 500 mg/m2/wkArm C:Irinotecan+standard-dose Cetuximab 250 mg/m2/week Day 1Day 22 Grade 1 rash(n=89)Grade 2 rash(n=77)*Dose escalated by 50 mg/m2/week until grade 2 toxicity,tumor response,or dose reaches 500 mg/m2.EVEREST:Study Design Cetuximab 400 mg/m2 initial dose then 250 mg/m2/wk+Irinotecan(180 mg/m2 q2w)Not eligible for randomization randomizationTejpar S,et al.ASCO 2007.Abstract 4037.Arm C(Standard Dose)Arm C(Standard Dose)Response RatePFSMonthsResponse(%)Arm A(Fixed Dose)Arm B(Dose Escalation)Arm A(Fixed Dose)Arm B(Dose Escalation)051015202530350123456EVEREST Phase I/II Cetuximab in mCRC Study:Preliminary ResultsEGFR表达状态表达状态EGFR表达表达(IHC)抗EGFR药物EGFR表达有效率%西妥昔单抗Cunningham等2EGFR表达细胞10%7（4/56）020%31（5/16）2035%0(0/7)35%9(3/32)EGFR 染色强度微弱5（1/21）弱或中度13（7/55）强12（4/34）Saltz等9EGFR状态1+6（2/35）2+13（4/30）3+0（0/10）帕尼单抗 Hecht等15EGFR表达细胞1%6(2/35)1-9%8(4/51)9%7(6/89)Berlin等1610%8(3/39)EGFR 突变突变l与NSCLC相反,体细胞EGFR基因突变在结直肠癌患者中罕见l不管EGFR基因状态是野生型还是突变型,抗EGFR治疗都有效Khambata-Ford S,et al.J Clin Oncol.2007;25:3230-3237.Tsuchihashi Z,et al.N Engl J Med.2005;353:208-209.EGFR 基因拷贝数基因拷贝数lMetastatic colorectal cancer patients treated with cetuximab or panitumumab(N=31)screened for EGFR copy number and mutation profileObjective response(n=10)Stable or progressive disease(n=21)Moroni M,et al.Lancet Oncol.2005;6:279-286.89.94.8020406080100Objective respondersNonrespondersIncreased EGFR Copy Number by FISH(%)P 0.0001EGFR FISH表达表达lRetrospective analyses suggest a correlation between anti-EGFR therapy and EGFR gene copy numbers by FISH 2,3lMethodology issues for translation into clinical practice4Cetuximab Treatment of mCRC(n=85)11.Cappuzzo F,et al.Ann Oncol.2007;Epub.2.Moroni M,et al.Lancet 2005;6:279-286.3.Sartore-Bianchi A,et al.J Clin Oncol.2007;25:3238-3245.4.Personeni N,et al.J Clin Oncol.2007;25:18S.Abstract 10569.6.611.33.58.50481216TTPOSMonthsEGFR FISH+EGFR FISH-P=.02P=.81007030020406080100 2.47 2.47CR+PRPD+SD10032020406080100 43%43%68P=.0009P=.0007Patients(%)Patients(%)EGFR gene copy number Chromosome 7 polysomyor amplificationEGFR 基因拷贝数基因拷贝数Sartore-Bianchi A,et al.J Clin Oncol.2007;25:3238-3245.lSurvival,response outcomes on panitumumab associated with EGFR gene copy number EGFR 磷酸化激活磷酸化激活Measuring EGFR phosphorylation by immunohistochemistry may predict higherresponse rates Major methodological issues for translation into clinical practicepEGFR 7(n=7)pEGFR 7(n=13)020406080100Disease Control Rate(%)10054P=0.05Level of EGFR PhosphorylationPersoneni N,et al.Semin Oncol.2005;32:S59-S62.EGFR 配体表达配体表达:A Predictor for Increased PFS?EGFR Ligand ExpressionHighLow020406080100120140Median PFS(Days)103.5 days115.5 days57days57daysEREG(P=.0002)AREG(P=.0002)n=110,cetuximab monotherapy.Khambata-Ford S,et al.J Clin Oncol 2007;25:3230-3237.EREG:epireulin 表皮调节素AREG:amphiregulin 双调蛋白Association of PFS and OS with the baseline expression level of epiregulin(EREG)Van Cutsem E,et al.WCGIC 2007.Abstract 0034.EVEREST 研究研究:表皮调节素表皮调节素PFSSurvivalHighLow1.00.80.60.40.20.00 100 200 300 400 5000 200 400 600 800HighLowP=.013P=.00033Time(Days)Time(Days)Proof of PFSProof of OS1.00.80.60.40.20.0KRAS突变突变预测西妥昔单抗疗效的生物学指标 RAS RAS是细胞内信号传导途径中的是细胞内信号传导途径中的“下游区的一种信号传导下游区的一种信号传导 蛋白，对细胞的生长，存活和分化等功能具有重要影响蛋白，对细胞的生长，存活和分化等功能具有重要影响K-RAS基因基因KRAS 基因突变时，不管EGFR是否活化，KRAS 蛋白p 21 ras激活KRAS 基因突变是早期事件，结直肠患者发生率4045%KRAS 突变总体与预后差有关KRAS突变患者突变患者西妥昔单抗治疗西妥昔单抗治疗 生存期明显缩短生存期明显缩短l30 mCRC patients treated with cetuximab43%with KRAS mutationlKRAS mutation observed in0%of 11 responders68%of 19 nonrespondersP=.0003Lievre A,et al.Cancer Res.2006;66:3992-3995.6.316.905101520Median Survival(months)Mutated KRASWild type KRASP=.016Predictive Role of KRAS in CRCP=.003Khambata-Ford S,et al.J Clin Oncol.2007;25:3230-3237.11518946020406080100DiseaseControl GroupPatients(%)Mutant at KRAS codon 12 or 13Wild-type KRASNonrespondersTreatment(Panitumumab or Cetuximab)No.of Patients(WT:MT)Objective Responsen(%)WTMTBenvenuti et al(Cancer Res,2007)Pmab or cmab or cmab+CT48(32:16)10(31)1(6)Capuzzo,et al(Ann Oncol.2007;Epub)Cmab CT81(49:32)13(26)2(6)Di Fiore,et al(Br J Cancer.2007)Cmab+CT59(43:16)12(28)0(0)Khambata-Ford,et al(J Clin Oncol.2007)Cmab80(50:30)5(10)0(0)De Roock,et al(Ann Oncol.2008)Cmab or cmab+irinotecan113(67:46)27(40)0(0)Livre et al(J Clin Oncol.2008)Cmab CT114(78:36)34(44)0(0)Single-Arm Studies:KRAS as a Biomarker for EGFR InhibitorsKRAS Status and Response to Panitumumab:Phase III Trial AnalysisAmado RG,et al.GI Cancers Symposium 2021.Abstract 278.J Clin Oncol 2021,26,1626Panitumumab 6 mg/kg every 2 weeks+Best Supportive Care(n=231)Best Supportive Care*(n=232)Colorectal cancer patients stratified by ECOG 0-1 vs 2 and region(N=463)*Optional crossover to panitumumab upon disease progression.PFS by KRAS Status and TreatmentAmado RG,et al.GI Cancers Symposium 2021.Abstract 278.J Clin Oncol 2021,26,1626The relative effect of panitumumab vs best supportive care was significantly greater in patients with WT vs mutant KRASThe quantitative-interaction test comparing the magnitude of the relative treatment effect on PFS between WT and mutant KRAS was statistically significant(P .0001)PFS was significantly greater for panitumumab treatment compared with best supportive care in the WT KRAS group(stratified log-rank test:P .0001).Mutant KRASWT KRASPmab+BSCBSC alone7.47.3HR:0.99(95%CI:0.73-1.36)Proportion Event FreeWeeks00.10.20.30.40.50.60.70.80.91.0048 12 16 20 24 28 32 36 40 44 48 52HR:0.45(95%CI:0.34-0.59)Stratified log-rank test:P grade 2 toxicity,tumor response,or dose reaches 500 mg/m2.EVEREST:Study Design Cetuximab 400 mg/m2 initial dose then 250 mg/m2/wk+Irinotecan(180 mg/m2 q2w)Not eligible for randomization randomizationEVEREST:PFS(ITT Population)00.20.40.60.81.00200400600DaysPFS Estimate800P .0001KRAS mutantWT KRASKRAS mutation present83 days(95%CI:75.9-90.2)173 days(95%CI:141.3-204.7)Tejpar S,et al.ASCO 2021.Abstract 4001.Reproduced with permission.EVEREST:PFS by Treatment Group and KRAS Status0.00.20.40.60.81.002004006008000.00.20.40.60.81.002004006008000.00.20.40.60.81.00200400600800DaysDaysDaysKRAS mutantWT KRASControlKRAS mutation presentP=.014KRAS mutantWT KRASDose EscalationKRAS mutation presentKRAS mutantWT KRASNonrandomizedKRAS mutation presentP .001P=.020Tejpar S,et al.ASCO 2021.Abstract 4001.Reproduced with permission.PFS EstimatePFS EstimatePFS EstimateCAIRO2 Study of the Dutch Colorectal Group(DCCG):SchemaStratified by previous adjuvant chemotherapy,serum LDH,number of affected organs,and institutionPatients with advanced colorectal cancer,with no previous systemic treatment for advanced disease,and WHO performance score 0-1(N=755)Arm ACycles 1-6Capecitabine 1000 mg/m2 BID on Days 1-14+Oxaliplatin 130 mg/m2 on Day 1+Bevacizumab 7.5 mg/kg on Day 1Cycles 7 and beyondCapecitabine 1250 mg/m2 BID on Days 1-14+Bevacizumab 7.5 mg/kg on Day 1(n=368)Arm B*Capecitabine,Oxaliplatin,Bevacizumab as above+Cetuximab 400 mg/m2 initial dose then 250 mg/m2 weekly(n=368)Punt,et al.ASCO 2021.Abstract 4011.Primary endpoint:PFSSecondary endpoints:OS,response rate,toxicity,quality of life*3-wk cycles.CAIRO2:Impact of KRAS on PFS/OS 野生型野生型 突变型突变型 P值值 PFSCapeOx+Bev 10.7 12.5 0.92CapeOx+Bev+C 10.5 8.6 0.47 P值值 0.10 0.043OSCapeOx+Bev 23 24.9 0.90CapeOx+Bev+C 22.2 19.1P值值 0.49 0.35KRAS 突变率 39.1%196/501其他信号通路其他信号通路PTEN磷酸酯酶和肿瘤抑癌蛋白磷酸酯酶和肿瘤抑癌蛋白l调节PI-3K-Akt信号通路l40%的结直肠癌PTEN表达下降，与PTEN突变或缺失有关Romagnani et al.Gastrointestinal Cancers Symposium 2007 abstract 427n=10n=17020406080100有效PTEN表达P=0.001Patients(%)无效35100上调上调VEGF和其他血管发生介质和其他血管发生介质lA431鳞状细胞癌移植瘤模型EGFR过表达的体内实验提示，通过增加EGFR产物能够诱导西妥昔单抗的获得性耐药lCiardiello等提示对西妥昔单抗或吉非替尼耐药的结肠癌细胞株活化的磷酸MAPK、COX-2表达和VEGF增高510倍lVallbohmer的研究也说明，在39例转移性结直肠中，用定量PCR检测发现，肿瘤内VEGF基因低表达与西妥昔单抗治疗疗效有关Viloria-Petit et al.Cancer Res 2001;61:50905101Ciardiello et al.Clin Cancer Res 2004;10:784793Vallbohmer et al.J Clin Oncol 2005;23:35363544.p21lOgino的研究提示结直肠癌p21表达，尤其伴有p53突变，是预测化疗加吉非替尼耐药的指标Ogino et al.Clin Cancer Res 2005;11:66506656020406080100有效率有效率(%)2567020406080100Patients(%)968P=0.05p21丧失p21表达阳性P=0.005p21表达丧失伴野生型p53p21表达伴p53突变STAT3激活激活l在EVEREST研究中，用IHC检测pSTAT3，初步结果显示西妥昔单抗治疗有效患者的STAT磷酸化程度轻度升高Spano et al.Eur J Cancer 2006;42:26682670.胚系基因多态性预测指标胚系基因多态性预测指标EGFR基因多态性基因多态性 EGFR G+497A EGF A+61G 00.40.81.22PFS(月月)1.31.800.40.81.21.621.21.4P=0.0017EGFR G+497AEGFR+497 GGP=0.042EGF+61 GG EGF+61 A-allelePFS(月月)1.6Lurje et al.submitted for publication130例 MCRC患者 cetuximab 治疗 回忆研究(IMCL-0144)FcR多态性多态性l39例转移性CRC患者lIgG1 mAb的片段c 能诱导ADCCZhang W,et al.J Clin Oncol.2007;25:3712-3718.Log-rank P=0.004FCGR2A H/H or H/R and FCGR3A F/F or F/V(n=22)FCGR2A R/R or FCGR3A V/V(n=13)PFS for patients with metastatic colorectal cancer receiving cetuximab by fragment c receptor(FCGR)polymorphisms.3.71.10246810Median PFSPFS(months)Cyclin D1 A870GEGF A61G 多态性多态性Zhang W,et al.Pharmacogenet Genomics 2006;16:475483.0246810Survival(月月)2.38.702468104.412P=0.019A870G AG/GGA870G AAP=0.004预后良好基因型 预后不良基因型EGF的A等位基因和cyclin D1的G等位基因预后良好基因型 预后不良基因型EGF的GG基因型和cyclin D1的AA基因型Survival(月月)Cox-2 G765C多态性多态性启动子区域启动子区域+8473多态性多态性l环氧化酶-2Cox-2 EGFR通路限速因素l体外试验 Cox-2的G765C多态性 启动子活性减弱30%0246810PFS(月月)1.35.902468101.43.8P=0.032G765C CCG765C G-alleleP=0.003+8473 CC +8473 T-allelePFS(月月)Lurje et al.submitted for publication预测抗预测抗EGFR疗效指标疗效指标-小结小结l皮疹 l检测 EGFR 状态EGFR蛋白表达IHC基因表达FISH 基因突变基因水平 基因考贝数l检测 EGFR 激活EGFR 配体EGFR 磷酸化 KRAS l其他信号通路lPTEN失活lVEGF基因表达lP21 丧失lSTAT3激活l胚系基因多态性lEGFR基因多态性CA双核苷酸重复序列 lFcR多态性FcRIIa131位点和FcRIIIa 158位点 lcyclin D1 A870G和EGF A61G的多态性lCox-2的G765C多态性 biomarker validation study未来方向未来方向Large prospectice clincal trials are needed to confirm and validate the predictive value of these molecular markers