Nieuwe targets en cfDNAdr. A.J. van der Wekken

Universitair Medische Centrum Groningen

Leek meeting 2017

Disclosure

• Advisory board: • Lilly• Boehringer-Ingelheim• Pfizer• AstraZeneca• MSD

• Lectures:• Lilly• Boehringer-Ingelheim• Pfizer• AstraZeneca• BMS

InhoudNieuwe inzichten bekende targets

Nieuwe targets

cfDNA

ALK / ROS1

Study design

Retrospective study at Massachusetts General Hospital (MGH) and University of California-Irvine (UCI)

Advanced ALK+ NSCLC patients with a ALK variant, treated with ≥1 ALK

Records reviewed to extract data on clinicopathologic characteristics, treatment outcomes, and post-ALK TKI biopsy genotyping

ALK+ NSCLC patients evaluated between

1/2008 – 1/2017n = 380

Known ALK fusion variant based on genotyping

n = 137

Treated with at least one ALK TKI

n = 129

Cohort flow chart

4.7%

0.8%

3.9%

2.3%

6.2%

Non-EML4-ALK

v7

v5'

v5

v3a/b

v2

v1

Distribution of ALK variants (n = 129)

Final analysis set

Kinase

Kinase

Kinase

Kinase

Kinase

Kinase

EML4 ALK

E20

E2

E18

E14

A20

A20

A20

A20

A20

A20

E13

E6

Coiled-coil region, EML4

TAPE domain, EML4

MA 07.07: Clinical outcomes and ALK resistance mutations according to EML4-ALK variantLin JJ et al.

WT34%

T1151KI1171N/S9%

V1180L3%

G1202R37.5%

G1202R+L1196M3%

G1202R+F1174L3%

I1171N+C1156Y3%

V1180L+G1202del+C1

156Y3%

Variant 1 (n = 14) Variant 3 (n = 12)

WT86%

L1196M7%

E1210K7%

WT67%

C1156Y9%

I1171T8%

F1174V8%

S1206Y8%

Variant 1 (n = 19) Variant 3 (n = 32)

WT58%

I1171T5%

F1174C11%

L1196M11%

G1202del5%

E1210K+S1206C6%

E1210K+D1203N6%

Post-crizotinib biopsies Post- second generation ALK TKI biopsies

v1 v3 P

ALK mutations 14 33 0.365

G1202R 0 0 1

v1 v3 P

% ALK mutations 42 66 0.145

% G1202R 0 44 0.001

MA 07.07: Clinical outcomes and ALK resistance mutations according to EML4-ALK variantLin JJ et al.

Progression-free survival on ALK TKIs based on EML4-ALK variant 1 vs variant 3(A) Crizotinib as first -line therapy (B) Second-generation TKI as post-crizo tinib

therapy(C) Lorlatinib as post-crizotinib and post- secondgeneration TKI therapy

v1 v3

27 28

Median PFS 8.8 mos 5.6 mos

1.52 [95% CI 0.85-2.72]p = 0.153

v1 v3

n 37 40

Median PFS 12.6 mos 8.1 mos

HR 1.44 [95% CI 0.86-2.40]p = 0.164

v1 v3

n 11 17

Median PFS 2.6 mos 7.1 mos

HR 0.18 [95% CI 0.05-0.67]p = 0.004

0.0

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60Time (months)

variant 1variant 3

0.0

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60Time (months)

variant 1variant 3

0.0

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60Time (months)

variant 1variant 3

MA 07.07: Clinical outcomes and ALK resistance mutations according to EML4-ALK variantLin JJ et al.

Design of TPX- 0005: Systematically Overcoming Resistance Mutation s ATP & Crizotinib

solvent front mutations

ATP & Ceritinib

ATP & Alectinib

ATP & TPX-0005

ATP & Lorlatinib

ATP & Brigatinib

4

TPX-0005 IC50 (nM) at 10 µM ATP

ALK 1.04NPM-ALK 1.23ALK(T1151M) 0.49ALK(1151T Ins) 2.16ALK(L1152R) 1.23ALK(C1156Y) 0.93ALK (F1174L) 1.46ALK(F1174S) 1.02ALK (L1196M) 1.08ALK (G1202R) 1.21ALK(S1206R) 0.53ALK(G1269A) 5.5ALK(G1269S) 14.1ALK(R1275Q) 2.79

TPX-0005: Potent Inhibitor against Wildtype and Mutant ALKs

MW 355.3

Ba/F3 EML4-ALK Cells IC50 (nM)

Inhibitor WT G1202R

TPX-0005 17.8 20.5

Crizotinib 74.8 359.4

Ceritinib 2.1 388

Alectinib 18.9 607

Brigatinib 11.8 399

Lorlatinib 0.7 NA

Ba/F3 EML4-ALK G1202R xenograft model

11

Ba/F3 Cell Proliferation IC 50 (nM)

CD74-ROS1 LMNA-TRKA ETV6-TRKB ETV6-TRKC

Inhibitor WT G2032R WT G595R G639R G623R

TPX-0005 <0.2 8.4 <0.2 0.4 0.6 3.0

Crizotinib 18.4 1402

Lorlatinib 0.2 262.4

Cabozantinib 0.5 60.7

Brigatinib 34.5 1385

Ceritinib 70.9 2000

Entrectinib 11.3 2404 0.3 705 1384 1000

Larotrectinib NA NA 3.5 1024 3000 1500

Ba/F3 CD74-ROS1 G2032R xenograft model

TPX-0005 Potently Inhibited Wildtype and Solvent Front Mutated ROS1 and TRKs

NIH3T3 LMNA-TRKA G595R xenograft model

RET en partners

Yoh et al, Lancet Resp Med, 2017

Vandetanib in patients with previously treated RET-rearranged advanced

non-small-cell lung cancer (LURET): an open-label, multicenter phase 2 trial

9 PR and ORR 53% (90% CI, 31 to 74)

in 17 eligible cases13

NRG1-CD74 fusie

NRG1/Neuregulin Fusion in Invasive Mucinous Adenocarcinoma

Lapatinib Afatinib

0

10

20

30

40

50

60

70

80Vector

CD74-NRG1 (C8;N6)

CD74-NRG1 (C6;N6)

Me

an

nu

mb

er

of

colo

nie

s

M)

(Nakaoku et al., Clin Cancer Res, 2014; Murayama, Nakaoku et al., Cancer Res, 2015)

CD74-NRG1 - + +

0

0,05

0,1

0,15

0,2

0,25

0,3

0,35

0,4

0,45

Vector CD74-NRG1

(C6;N6)

CD74-NRG1

(C8;N6)

N.T. IGF-2 NAb

Sphere formationCancer stem cell markerNIH3T3 colonies

cfDNA

Crowley et al., Nat Rev Cancer 2013

Norton Clin Biochem 2013

“Technical” hemolysis: the effect on DNA content upon storage of bloodtubes (EDTA vs BCT/Streck) before processing plasma.

DNA content upon storage in time in EDTA tubes DNA content upon storage in time in BCT tubes

Adapted from Diaz, J Clin Oncol 2014

Example of plasma cfDNA mutation levels of druggable (line) and new resistant EGFR mutation (broken)

Oxnard CCR 2014

Detection of new EGFR-T790M mutation upon progressionmight be reason for changing treatment

Conclusie

• Mogelijk invloed van varianten op respons

• ALK

• RET

• cfDNA wordt belangrijker voor analyse en behandelstrategie

• Plasma

• Urine (ucfDNA)

??? VRAGEN ???