Updates and news from the Gastrointestinal Cancers ...
Transcript of Updates and news from the Gastrointestinal Cancers ...
Colon cancer: critical review
AIOM POST-ASCO G.I. 2017 Review
Updates and news from the Gastrointestinal Cancers Symposium in San Francisco, CA,USA
Roma, 10-11 Febbraio 2017
Carmelo Pozzo
Oncologia Medica
Fondazione Policlinico Gemelli
UCSC - Roma
What’s new in colon cancer at ASCO G.I. 2017?
• Colorectal Cancer Heterogeneity
• Role of molecular subtypes, molecular markers and genetic testing in clinical practice
• Immune Checkpoint inhibitors in mCRC
• Nivo +/- ipilimumab
• Sidedness matters
• Molecular subtypes and “surrogate” markers in metastatic and early CRC
• Mature data from some important studies
• IRI+CET +/- vemurafenib in BRAF mut (SWOG S1406)
• Triplet + beva vs FOLFIRI +beva (CHARTA)
• Role of bacteria (microbiota) in colorectal carcinogenesis
• Pro e Contra HIPEC, hyperthermic intraperitoneal chemotherapy
What’s new in colon cancer at ASCO G.I. 2017?
• Colorectal Cancer Heterogeneity
• Role of molecular subtypes, molecular markers and genetic testing in clinical practice
The Role of Molecular Subtypes for Prediction and Prognosis of Colorectal Cancer
Presented By Sabine Tejpar at 2017 Gastrointestinal Cancers Symposium
Outcome of the Different Molecular Subgroups
Presented By Sabine Tejpar at 2017 Gastrointestinal Cancers Symposium
Role of molecular subtypes in CRC
• Numerosi studi per caratterizzare e quantificare l’eterogenietà cellulare nel CRC e proporre dei modelli
• Tumore colorettale: 4 gruppi molecolari o qualcosa di più complesso? Quali i limiti dell’analisi molecolare e del clustering?
• Capacità predittiva ancora in corso di validazione in studi retrospettivi
• “Supervised Pathway Signature” utilizzati nella stratificazione di nuovi trial clinici
• Ancora lontani dall’impiego per una valutazione del rischio e della prognosi (Oncotype DX, Mammaprint etc?)
The Role of Molecular Markers in Clinical Trials
Presented By Sebastian Stintzing at 2017 Gastrointestinal Cancers Symposium
When to obtain tissue material
Presented By Sebastian Stintzing at 2017 Gastrointestinal Cancers Symposium
Role of molecular markers in trials (and in clinical practice?)
• Ruolo prognostico ben definito : RAS, BRAF, MSI, meno definito per altri Pi3K, HER-2, CSM and molecular subtypes
• Solo pochi di essi derivano da mutazioni “actionable” o sono “druggable” driver:
• RAS e inibitori EGFR: SI
• MSI e inibitori immunocheckpoint SI
• BRAF e vemurafenib? FORSE
• HER-2 e trastuzumab? FORSE
• Ancora pochissimi gli esempi di “Basket Trial” o “Umbrella Study” nel CRC
Utilization of Genetic Testing in Clinical Practice
Presented By Elena Stoffel at 2017 Gastrointestinal Cancers Symposium
Screening of CRC Tumors for Mismatch Repair Deficiency (MMRd)*
Presented By Elena Stoffel at 2017 Gastrointestinal Cancers Symposium
Screening for Genetic Predisposition
Presented By Elena Stoffel at 2017 Gastrointestinal Cancers Symposium
Role of genetic testing in clinical practice
• Tutti i tumori colorettali dovrebbere essere testati per MMR deficiency o solo in base al rischio personale (giovane età: < 50 anni) o familiare?
• Il test genetico in presenza di MMRd o mutazione somatica di BRAF deve prevedere anche la ricerca di mutazioni della linea germinale: BRCA 1-2, APC, MUTYH, ATM, NBN, VUS?
• Molte varianti incerte e mutazioni a penetranza variabile “not actionable”
• Potential for anxiety/distress…
What’s new in colon cancer at ASCO G.I. 2017?
• Immune Checkpoint inhibitors in mCRC
• Pembro
• Nivo
• Nivo +/- ipilimumab
• Atezolizumab
• Atezolizumab +/- cometininb
Nivolumab in Patients With DNA Mismatch Repair Deficient/Microsatellite Instability High Metastatic Colorectal Cancer: Update From CheckMate 142
Presented By Michael Overman at 2017 Gastrointestinal Cancers Symposium
Best Reduction in Target Lesion Size <br />in Patients With MSI-H
Presented By Luis Diaz at 2017 Gastrointestinal Cancers Symposium
Investigator-Assessed PFS in Patients With MSI-H<br />Nivolumab ± Ipilimumab in Metastatic CRC
Presented By Luis Diaz at 2017 Gastrointestinal Cancers Symposium
Clinical activity and safety of cobimetinib and atezolizumab in colorectal cancer
Presented By Luis Diaz at 2017 Gastrointestinal Cancers Symposium
Efficacy: Change in Tumor Burden Over Time
Presented By Luis Diaz at 2017 Gastrointestinal Cancers Symposium
Is immunotherapy in colon cancer holding the promise?
• 15% dei carcinomi colorettali dMMR alla diagnosi, ma solo 4-5% nella malattia metastatica
• Percentuale molto piccola di mCRC (si… ma l’incidenza del CRC è molto elevata!) che presenta mutazioni “actionable” (i.e. dMMR, POLE, POLD)
• PD-L1 non è utlizzabile come biomarker nel CRC
• Con la combinazione risposte più durature (dati ancora preliminari)
• Come incrementare l’immunogenicità o il numero dei tumori CRC immunogenici?
• Cosa fare in seguito a progressione dopo una prolungata risposta a inibitori immunocheckpoint?
What’s new in colon cancer at ASCO G.I. 2017?
• Sidedness matters
• Molecular subtypes in metastatic CRC
• “Surrogate” markers in early CRC
Continuum of molecular alterations from right to left<br />
Presented By Sabine Tejpar at 2017 Gastrointestinal Cancers Symposium
Molecular Variances Between Rectal <br />and Left-Sided Colon Cancers
Presented By Mohamed Salem at 2017 Gastrointestinal Cancers Symposium
Frequency of microsatellite instability in left-sided CRC
Presented By Mohamed Salem at 2017 Gastrointestinal Cancers Symposium
Her2/Neu : Overexpression and Amplification
Presented By Mohamed Salem at 2017 Gastrointestinal Cancers Symposium
Sidedness matters: right-sided vs left-sided vs rectal
• Migliore conoscenza degli aspetti molecolari: si, ma quale impatto clinico?
• Prognosi peggiore nell’ordine per: colon destro > retto > colon sinistro?
• Le classificazioni molecolari (CMS 1-2-3-4 e TGCA) e alcune mutazioni (RAS, BRAF) o overespressioni (HER2) non sono sufficienti a spiegare la differente prognosi, indipendentemente dalla sede?
• Quanto è “actionable” questa migliore conoscenza biomolecolare del CRC?
• Dati sufficienti per evitare gli inibitori EGFR nel colon destro?
NCCN: si AIOM: no (o ni)
• Reale beneficio del beva nel colon destro o è sufficiente la sola chemioterapia…?
• Reale beneficio di anti EGFR in 2a linea (Pani) o in 3a (Cetux) nel colon destro… ?
• E la tripletta sempre nel colon destro come ‘a vedi..?
Primary Tumor Location and Potential
Treatments
MSI-H
HER2+ BRAF MT
Bevacizumab + CT
Left-sided Right-sided
Anti-EGFRs + CT
Anti-PD1
Bev + Triplet CT HER2-targeted agents
↑KRAS MT ↑KRAS WT
↑AREG/EREG
Bufill JA. Ann Intern Med. 1990;113:779-788; Missiaglia E, et al. ASCO 2013. Abstract 3526; Brule SY, et al. ASCO 2013. Abstract
3528; The Cancer Genome Atlas Network. Nature. 2012490:61-70; Bendardaf R, et al. Anticancer Res. 2008;28:3865-3870.
• Impact of CHARTA (phase 2 !!!) with FOLFOXIRI /BEVA vs FOLFIRI/BEVA:
• None or… finally we know that oxaliplatin is effective but can also be
omitted!
• I am still a little confuse… with regards to the best treatment sequence sin mCRC
and for what patients??
• Chemo mono + bio 1st line
• Chemo doublet 1st line
• Chemo doublet + bio 1st line
• Chemo triplet alone 1st line
• Chemo triplet + bio 1st line
• Chemo + same or other bio 2nd line
• Immunotherapy 2nd or 3rd line
• Bio mono 2nd or 3rd line
• Chemo mono 3rd or 4th or
• De-potentiation
• Maintenance with bio or with chemo mono, etc…
What’s new in CRC at ASCO G.I. 2017? Little steps and many open questions…
• Impact of SWOG S1406 (phase 2 !!) with vemurafenib + Cet + IRI vs Cet + IRI:
• Potentially strong impact… for an off-label use of vemurafenib in BRAF+
• BRAF “druggable” also in CRC or just anti EGFR resistance reversal?
• BRAF blockade to overcome the gap of anti EGFR treatment in right-sided
CRC?
• Is mCRC ready for a “precision medicine” approach?
• Many “not actionable” mutations and “not druggable” drivers
• Few basket and/or umbrella trials ongoing in mCRC
• Strong regulatory issues: i.e. HER-2 iand trastuzumab, BRAF and vemurafenib
MGMT mutation, other potential driver
What’s new in CRC at ASCO G.I. 2017? Little steps and many open questions…