clinical relevance of liquid biopsy in cancer...
TRANSCRIPT
Dr Catherine Alix-Panabières, MCU-PHUniversity Medical Centre Montpellier
FRANCEFEDER
Clinical relevance of Liquid Biopsy in cancer patients
2013
2010
March 2018
Complementary circulatingbiomarkers
22 337 articles
4 000 articles 3 288 articles
LIQUID BIOPSYNovember 2018
Clinical Trials - CTCs and ctDNA in ClinicalTrial.Gov
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completed active
CTC ctDNA
Nu
mb
er
of
Clin
ical
Tri
als
TNM 2010: CTCs in new cM0(i+) Classification
Epithelial-to-mesenchymal transitionAnoikis resistance
Homing & metastasis-initiating potential
Genomic heterogeneity
Invasion/Intravasation ability (single CTCs and/or clusters)
Phenotypic diversity
... ...
Liquid phase of tumor progression
Alix-Panabieres & Pantel, Nature Rev. Cancer 2014
The technical challenge:
Finding one tumor cell in 106 – 108 normal blood cells
Principle of CTC assays:
CTC enrichment followed by CTC detection
CTC Enrichment
Alix-Panabières & Pantel
Nat Rev Cancer
2014
Detection of CTCsAlix-Panabières & Pantel, Nat Rev Cancer 2014
EPISPOT assay
DNA
mRNA
secreted proteins by
VIABLE cells
Detection of Functional CTC/DTC
2002
2005
1rst
2016
2017
EpiDrop
EPIDROP technology
EpiDrop
LNCaP : PSA secretion and EpCAM staining
EpCAM+/-
+/- PSA Secretion
=> PSA release in 1h
Prostate Cancer Patients (N = 100)
Healthy Controls (N=50)
EpiDrop
Clinical Trial
CTCs & ctDNA (cfmiRNA, platelets and
exosomes) provide
complementary information for
Liquid Biopsy
Assays need to be validated by
independent expert groups (Ratner, Nature Biotech 2018)
Interventional clinical studies are
required to demonstrate clinical
utility of Liquid Biopsy(Merker et al. JCO 2018)
! Therapy must work !
Alix-Panabieres & Pantel, Cancer Discovery 2016
CLINICAL RELEVANCE IN EARLY STAGE
CANCER PATIENTS
(TNM-STAGE M0)
CTCs in Neoadjuvant Breast Cancer Therapy
CTC counts provide prognostic information independent from pathological complete response (pCR)
Validated by an international meta-analysis of 2,156 individual patients “21 studies & 16 centers” (Bidard, Pantel et al. JNCI 2018)
2017
CTCs before Neoadjuvant Cancer Therapy & Overall Survival in Breast Cancer
Stratified p value <.0001
N pts % events Hazard Ratio
0 CTC 1175 9.8% 1
1 CTC 199 10.6% 1.09 [0.65-1.69]
2 CTCs 59 23.7% 2.63 [1.42-4.54]
3-4 CTCs 47 29.8% 3.84 [2.08-6.66]
≥ 5 CTCs 93 46.2% 6.25 [4.34-9.09]
months
Surv
ivalfr
act
ion
Bidard, Pantel et al. JNCI 2018
<1 CTC/sample
> 5 CTCs/sample
DETECTION OF MINIMAL RESIDUAL DISEASE
(POST-TREATMENT SURVEILLANCE)
CTCs in high-risk early breast cancer patients during follow-up
Trapp, Janni, Pantel et al. (SUCCESS study group), JNCI 2018
CTCs detected 2 years after adjuvant chemotherapy
CLINICAL RELEVANCE IN METASTATIC PATIENTS
DETECTION & MONITORING OF CTCS
CTC CHARACTERIZATION (DNA, RNA, PROTEINS)
THERAPEUTIC TARGETS (HER2, ER, PD-L1)
RESISTANCE MECHANISMS (AR-V7)
2015
Deactivation
Activation
Antibodies targeting the PD-1/PD-L1
checkpoint have shown dynamic and durable
tumor regressions
→ suggesting a rebalancing of the host–
tumor interaction.
Cancer uses a sort of “cellular camouflage”
Mazel et al., Mol Oncol 2015
(Editorial by R. David in Lancet Oncol. 2015)
Metastatic Breast Cancer Patients
PD-L1PE
William Jacot
PD-L1 is frequently expressed on CTCs (> 60% of patients) in metastatic breast cancer
patients
2017
2014
- 17 centres provided data for 1944 eligible patients from 20 studies
- Meta-analysis on raw data.
Clinical Validity !
CTCs vs. conventional tumor markers (PFS, p values) in
metastatic breast cancer patients receiving chemotherapy
Model
used as
referen-
ce
(
baseline 3-5 weeks 6-8 weeks
CTCBL CA15-3BL CEABL CTC3-5
CA15-3
BL +
CA15-3 3-
5
CEABL +
CEA 3-5CTC6-8
CA15-3
BL +
CA15-3 6-
8
CEABL +
CEA 6-8
N patients 1193 914 593 436 357 289 279 215 170
CP 6 E-10 .10 .04
CP
+CTCBL.32 .12 5 E -05 .25 .35 9 E-05 .40
Few
events
CP
+CTCBL
+ CTC3-5
.26 .41
CP
+CTCBL
+ CTC6-8
.36Few
events
Bidard, Pierga, Michels, Pantel et al, Lancet Oncology 2014, European Pooled
Analysis of CTCs in metastatic BC (n=1944)
Androgen Receptor Variant 7 (AR-V7) Expression in CTCs: Predictive marker for Abiraterone or Enzalutamide Therapy in Prostate Cancer
Antonarakis et al. J. Clin. Oncol. 2017
Good Response Moderate Response Poor Response
INTERVENTIONAL STUDIES BASED ON LIQUID BIOPSY
→ CLINICAL UTILITY
STIC CTC METABREAST
A randomized study to assess
« Circulating Tumor Cells » count at baseline
as a tool to choose between
HormonoT vs ChemoT
in HR(+) M(+) breast cancer patients
J-Y PiergaF-C Bidart
Clinical Utility !
Standard arm N=497 CTC arm N=497
≥5 CTC/7.5ml<5 CTC/7.5ml
CTC-driven decision
Hormone T. ChemoT
Clinician choice
unfavorablefavorable
M+ HR+ breast cancer patients before any treatmentwho can be treated either by HormoneT or chemoT.
Randomizationstratified on center & PS and metastasis-free interval
Hormone T. ChemoT
Endpoints
Medical : PFS (non-inferiority), quality of life, toxicity, OS
Economics : differential costs per life year without disease progression, global costs
Baseline CTC count
blinded
Baseline CTC count
disclosed
Tumor evaluation until progression
Oral Presentation
San Antonio
Breast Cancer
Symposium
12 / 2018
Personalized Treatment of Metastatic castrate-resistant prostate
cancer according to CTC kinetic during chemotherapy:
TACTIK Project
Chemotherapy will be
given or not according
to the investigator’s
decision
N=792 mCRPC patients
to ensure that 396
patients will present >= 5
CTC before initiation of
chemotherapy.
S. Culine
Circulating Cell-free DNA in Blood
Schwarzenbach, Hoon, Pantel, Nature Rev. Cancer 2011
LOW CTDNA CONCENTRATION AS ANALYTICAL CHALLENGE
ctDNA analyses require sensitive technologiesCAPP-Seq: 0.00025 % (Newman et al. Nature Biotech. 2016)
Tumor-associated mutations in ageing individuals
(clonal hematopoiesis, benign tumors)
Low concentration of ctDNA and high background of non-tumor cfDNA
-> need for very sensitive methods
with changes from Cabel L. et al. EJSO 2017
Liquid Biopsy to Stratify NSCLC Patients for EGFR-targeted therapy
Douillard et al. Br J Cancer 2014
N Rate (%) 95% CI
Concordance 652 94.3 92.3-96.0
Sensitivity 105 65.7 55.8-74.7
Specificity 547 99.8 99.0-100
PPV 70 98.6 92.3-100
NPV 582 93.8 91.5-95.6
FDA Approval: June 2016
“… if such mutations are not detected in the
blood, then a tumor biopsy should be
performed to determine if the NSCLC
mutations are present….”
Phallen et al. Science TM 2017: 155 / 216 (72%) alterations were identical in both
plasma and tumor samples (100 pats, various tumor types)
EGFR mutations in tumors and blood plasma:
L858R, exon 19 deletions [19 different mutations] and T790M
• High specificity and sensitivity for ovarian cancer
• Detection of early cancer stages and some tumor types (breast cancer) is still a challenge
In vitro expansion of colon cancer CTCs
Thibaut
Mazard
Laure
Cayrefourcq
2015
AACR AWARD 2017
Cell line from human circulating colon cancer cells- SUMMARY
- Stable for 5 years
- Shares important features of the tumor cells in the patient with colon cancer (primary
tumor/metastasis: KRAS wt; BRAF mutated)
- Showed an intermediate epithelial/mesenchymal phenotype (EM Plasticity) with stem cell–like
characteristics (e.g., growth as microspheres and expression of cancer stem cell markers)
- Induced in vitro angiogenesis
- Induced tumors in immunodeficient mice.
CTC-MCC-41
We have established a cell line with important properties relevant for the development and
progression of metastatic disease.
2017
CTC-MCC LINES
D1
CTC-MCC-41 No colosphere No colosphereCTC-MCC-41.5
A, B, C, D, E, F, G
D30 D60
C1
D15 D45DIAGNOSTIC
in vitro CTC
culture
Patient 044
1rst Line 2nd Line
No treatment
RELAPSE
D75 D90 D105 D165
CTC-MCC-41.4
D158
DEATH
C2 C3 C4 C5 C1 C2 C3
RELAPSE RECHUTE
Blood samples
EDTA tubes
30295 ND
3278
286
CTC-MCC-41 CTC-MCC-41.2 CTC-MCC-41.3 CTC-MCC-41.4 CTC-MCC.41.5
CTC
count
CellSearch
Soler et al. Sci Rep. 2018
Cayrefourcq et al, Cancer Res 2015
Alix-Panabières et al, Clin Chem 2017
2018
Comprehensive outlook on the molecular events involved in colon
cancer progression and provides potential CTC biomarkers that may
help developing new therapies
…to specifically target CTCs with stem cell properties that cause
metastases and tumor relapse in patients with colon cancer.
2017
Platelets
Platelets
KEY AIM: COMBINED ANALYSIS OF CTCS AND CFDNA
Prostate Cancer
(CTCs)
PHRC
Merkel Carcinoma
(CTCs, circulating nucleic acids)
Prostate Cancer
(CTCs, ctDNA & exosomes)
Transcan ‘PROLIPSY’
Lung Cancer
(CTCs, ctDNA, miRNA, exosomes, platelets)
Marie Curie
Breast & pancreas Cancer: AXL
(CTCs, exosomes, plasma proteins)
FUI ‘PANTHER’
Breast & lung Cancers
(CTCs, ctDNA, exosomes)
IMI CALL
CURRENT PROJECTS
Head & Neck Cancer
(CTCs)
CIRCUTEC
Colon Cancer
(CTCs)
COLOSPOT
Cancer-ID is a project funded by the Innovative Medicines Initiative Joint Undertaking (IMI JU) under grant agreement nr. 115749.
Academia, EFPIA
European
Liquid
Biopsy
Society (ELBS)
…European Liquid Biopsy Society (ELBS)
46
Academia, EFPIA, patient organisations, health insurance and
reimbursementorganisations
Coordination
UKE, Prof. Klaus Pantel
Executive Board
Individual Partners
Individual Partners
Individual Partners
Individual Partners
Individual Partners
Individual Partners
Individual Partners
Individual Partners
Individual Partners
ELBS structure
Key Objective:
Foster the
introduction of
liquid biopsy into
clinical practice
Laboratory „Detection Rare Human Circulating Cells“
A big thank you to the patients for donating blood
Magali Boyer
Alexe
Soler
Françoise GarimaMartine MazelLaure CayrefourcqCatherine
Alix-Panabières
Zahra Eslamisamarin
Luis Cortez Hernandez
Léa Sinoquet
Sarah Francini
Renaud Garrel
Jean-Michel Fabre
Eric Assenat
Olivier Dereure
Vincent Foulongne
Valérie Costes
Jean-Louis pujol
Pascal Pujol
Rodolphe Thuret
Delphine Topart
MONTPELLIER
COLLABORATIONS
Laurent Meunier
Stéphane Droupy
NIMES
Xavier Rebillard
MONTPELLIER
William jacot
David Azria
Thibault Mazard
Marc Ychou
Amélie Darlix
Didier Cupissol
Pierre-E. Colombo
Céline Bourgier
Xavier Quentin
Philippe Rouanet
MONTPELLIER
Pierre-Jean Lamy
MONTPELLIER
Sandrine Moutel
Franck Perez
Jean-Yves Pierga
François-Clément Bidard
PARIS
Fabienne Thomas
Etienne Chatelut
Jean-Pierre Delord
TOULOUSE
Paul Hofman
NICE
Jean-Marc Lacorte
PARIS
Philippe Clézardin
Edith Bonnelye
Martine Crozet
LYON
Dominique Heymann
NANTES
Klaus Pantel
Anna Babayan
Simon Joosse
HAMBURG
Klaus Eyer
Guilhem Chenon
Andrew Griffiths
Jérôme Bibette
Jean Baudry
PARIS
Evi Lianidou
ATHENS
Maciej Zabel
Joanna Budna
POZNAN
Angel Carracedo
Ceres Fernadez Rozadilla
Jesus Hita Millan
Angel Diaz-Lagares
SANTIAGO DEL COMPOSTELLA
Hugh Fan GAINSVILLE
Bruce Zetter BOSTON
Hans Lilja NEW-YORK
Sendurai Mani HOUSTON
SUPPORTS
FP6 EU STREP ‘DISMAL’TRANSCAN ‘CTCSCAN’ 2012 TRANSCAN ‘PROLIPSY’ 2016IMI ‘CANCER-ID’ 2015Marie Curie ‘ELBA’ 2017
FUI PANTHER 2016INCa – ARC - La Ligue Fondation de France – MINEFI –SIRIC
MENARINI/ROCHE
Sandrine Dabernat
Etienne Buscail
BORDEAUX
Tom Würdinger
AMSTERDAM
FEDER
Thank you foryour attention !