1、抗EGFR治疗结直肠癌疗效的 潜在预测标记,浙江大学医学院附属第一医院 肿瘤中心 化疗科 徐 农,肿瘤治疗,疗效,毒性,选择,EGFR状态作为结直肠癌的预后因素,82%的结直肠癌EGFR有不同程度的表达,Nicholson et al. Eur J Cancer 2001;37(Suppl. 4):S915,Frequency(%) of studies showing an association between increased EGFR level and decreased survival,预测抗EGFR疗效指标,皮疹 检测 EGFR 状态 EGFR蛋白表达IHC 基因表达FISH
2、 基因突变 基因水平 基因考贝数 检测 EGFR 激活 EGFR 配体 EGFR 磷酸化 KRAS,其他信号通路 PTEN失活 VEGF基因表达 P21 丢失 STAT3激活 胚系基因多态性 EGFR基因多态性（CA双核苷酸重复序列） FcR多态性（FcRIIa131位点和FcRIIIa 158位点） cyclin D1 A870G和EGF A61G的多态性 Cox-2的G765C多态性,临床预测标记,痤疮样皮疹,痤疮样皮疹是抗EGFR靶向药物常见的不良反应，并呈剂量依赖性。 抑制EGFR介导的信号通路- 抑制生长、促进凋亡、- 抑制细胞迁移- 增加细胞黏附和分化- 刺激炎症进而影响角质化细胞
3、 导致特有的皮肤表现,抗EGFR治疗 所致皮肤反应,1 2 3 4 5 6 7 8 9,抗EGFR治疗 所致皮肤反应,Description of severe cases,后炎症效应,痤疮样皮疹,甲沟炎,皮肤干燥,Topical antiacne creams (drying effect) tetracyclines antihistamines,Pruritus,Pulse dye laser,Emollients,Hydrocolloid dressing or propylene glycol acetylsalicyl,Antiseptic soaks, silver nitrat
4、e (pyogenic granuloma),皲裂,Segaert S, et al. Ann Oncol. 2005;16:1425-1433.,Therapy Suggestions,西妥昔单抗治疗 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. 200
5、4. 5. Xiong H, et al. J Clin Oncol. 2004;22:2610-2616. 6. Kies MS, et al. Proc ASCO. 2002.,0,No reaction,Grade 2,Grade 1,Grade 3,Survival (Months),16,12,8,4,CRC 9923 Saltz (2001)1,CRC 0141 Saltz (2004)2,CRC BOND Cunningham3,CRC Van Cutsem (2004)4,Pancreatic Xiong (2004)5,SCCHN Kies (2002)6,*There we
6、re no grade 4 skin reactions.,Van Cutsem E, et al. ASCO 2007. Abstract 4000.,Skin reaction grade 0 or 1 (n = 244),0.0,2.5,5.0,7.5,10.0,12.5,15.0,17.5,20.0,PFS Time (Months),1.00,0.75,0.50,0.25,0.00,PFS Estimate,Skin reaction grade 2 (n = 243),Skin reaction grade 3* (n = 112),11.3 months,5.4 months,9
7、.4 months,CRYSTAL: PFS by On-Study Skin Reactions: Cetuximab + FOLFIRI,皮肤毒性与肿瘤疗效的机理,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 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 证实假说，进行了一项随机多中心I、II期研究（EVEREST试验） 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 irin
8、otecan-based therapy (N = 166),Arm A: Irinotecan + standard-dose Cetuximab 250 mg/m2/week,Arm B: Irinotecan + dose-escalated* Cetuximab dose increases of 50 mg/m2 q2w up to maximum 500 mg/m2/wk,Arm C: Irinotecan + standard-dose Cetuximab 250 mg/m2/week,Day 1,Day 22, Grade 1 rash (n = 89), Grade 2 ra
9、sh (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 dosethen 250 mg/m2/wk + Irinotecan (180 mg/m2 q2w),Not eligible for randomization,randomization,Tejpar S, et al. ASCO 2007. Abstract 4037.
10、,Arm C (Standard Dose),Arm C (Standard Dose),Response Rate,PFS,Months,Response (%),Arm A (Fixed Dose),Arm B (Dose Escalation),Arm A (Fixed Dose),Arm B (Dose Escalation),0,5,10,15,20,25,30,35,0,1,2,3,4,5,6,EVEREST Phase I/II Cetuximab in mCRC Study: Preliminary Results,EGFR表达状态,EGFR表达(IHC),EGFR 突变,与N
11、SCLC相反,体细胞EGFR基因突变在结直肠癌患者中罕见 不论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,Metastatic colorectal cancer patients treated with cetuximab or panitumumab (N = 31) screened for EGFR copy number and
12、 mutation profile Objective response (n = 10) Stable or progressive disease (n = 21),Moroni M, et al. Lancet Oncol. 2005;6:279-286.,89.9,4.8,0,20,40,60,80,100,Objective responders,Nonresponders,Increased EGFR Copy Number by FISH (%),P 0.0001,EGFR FISH表达,Retrospective analyses suggest a correlation b
13、etween anti-EGFR therapy and EGFR gene copy numbers by FISH 2,3 Methodology issues for translation into clinical practice4,Cetuximab Treatment of mCRC (n = 85)1,1. 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;25:3
14、238-3245. 4. Personeni N, et al. J Clin Oncol. 2007;25:18S. Abstract 10569.,6.6,11.3,3.5,8.5,0,4,8,12,16,TTP,OS,Months,EGFR FISH+,EGFR FISH-,P = .02,P = .8,100,70,30,0,20,40,60,80,100, 2.47, 2.47,CR + PR,PD + SD,100,32,0,20,40,60,80,100, 43%, 43%,68,P = .0009,P = .0007,Patients (%),Patients (%),EGFR
15、 gene copy number,Chromosome 7 polysomy or amplification,EGFR 基因拷贝数,Sartore-Bianchi A, et al. J Clin Oncol. 2007;25:3238-3245.,Survival, response outcomes on panitumumab associated with EGFR gene copy number,EGFR 磷酸化（激活）,Measuring EGFR phosphorylation by immunohistochemistry may predict higher respo
16、nse rates Major methodological issues for translation into clinical practice,pEGFR 7 (n = 7),pEGFR 7 (n = 13),0,20,40,60,80,100,Disease Control Rate (%),100,54,P = 0.05,Level of EGFR Phosphorylation,Personeni N, et al. Semin Oncol. 2005;32:S59-S62.,EGFR 配体表达: A Predictor for Increased PFS?,EGFR Liga
17、nd Expression,High,Low,0,20,40,60,80,100,120,140,Median PFS (Days),103.5 days,115.5 days,57 days,57 days,EREG (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 wit
18、h the baseline expression level of epiregulin (EREG),Van Cutsem E, et al. WCGIC 2007. Abstract 0034.,EVEREST 研究: 表皮调节素,PFS,Survival,High Low,1.0 0.8 0.6 0.4 0.2 0.0,0 100 200 300 400 500,0 200 400 600 800,High Low,P = .013,P = .00033,Time (Days),Time (Days),Proof of PFS,Proof of OS,1.0 0.8 0.6 0.4 0
19、.2 0.0,KRAS突变,预测西妥昔单抗疗效的生物学指标,RAS是细胞内信号传导途径中的“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,K-RAS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 西妥昔单抗治疗 生存期明显缩短,30 mCRC patients treated with cetuximab 43% with KRAS mutation KRAS mutation observed in 0% of 11
20、 responders 68% of 19 nonresponders P = .0003,Lievre A, et al. Cancer Res. 2006;66:3992-3995.,6.3,16.9,0,5,10,15,20,Median Survival (months),Mutated KRAS,Wild type KRAS,P = .016,Predictive Role of KRAS in CRC,P = .003,Khambata-Ford S, et al. J Clin Oncol. 2007;25:3230-3237.,11,51,89,46,0,20,40,60,80
21、,100,Disease Control Group,Patients (%),Mutant at KRAS codon 12 or 13,Wild-type KRAS,Nonresponders,Single-Arm Studies: KRAS as a Biomarker for EGFR Inhibitors,KRAS Status and Response to Panitumumab: Phase III Trial Analysis,Amado RG, et al. GI Cancers Symposium 2008. Abstract 278.J Clin Oncol 2008,
22、26,1626,Panitumumab 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 Treatment,Amado RG, et al. GI Canc
23、ers Symposium 2008. Abstract 278. J Clin Oncol 2008,26,1626,The relative effect of panitumumab vs best supportive care was significantly greater in patients with WT vs mutant KRAS The quantitative-interaction test comparing the magnitude of the relative treatment effect on PFS between WT and mutant
24、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 KRAS,WT KRAS,Pmab + BSC,BSC alone,7.4,7.3,HR: 0.99 (95% CI: 0.73-1.36),Proportion Event Free,Weeks,
25、0,0.1,0.2,0.3,0.4,0.5,0.6,0.7,0.8,0.9,1.0,0,4,8,12,16,20,24,28,32,36,40,44,48,52,HR: 0.45 (95% CI: 0.34-0.59) Stratified log-rank test: P .0001,Proportion Event Free,Weeks,0,0.1,0.2,0.3,0.4,0.5,0.6,0.7,0.8,0.9,1.0,0,4,8,12,16,20,24,28,32,36,40,44,48,52,Pmab + BSC,BSC alone,12.3,7.3,Median PFS,Median
26、 PFS,OS by KRAS Status and Treatment,Amado RG, et al. GI Cancers Symposium 2008. Abstract 278. . J Clin Oncol 2008,26,1626,Median OS (Months),8.1,7.6,4.9,4.4,0,2,4,6,8,10,WT KRAS,WT KRAS,Mutant KRAS,Mutant KRAS,Pmab,BSC,Pmab,BSC,FOLFIRI 5-FU bolus 400 mg/m2, 46-hr infusion 2400 mg/m2 + Irinotecan 18
27、0 mg/m2 + Leucovorin 400 mg/m2 every 2 wks,Patients with previously untreated EGFR-expressing metastatic colorectal cancer (N = 1217),FOLFIRI + Cetuximab 5-FU bolus 400 mg/m2, 46-hr infusion 2400 mg/m2 + Irinotecan 180 mg/m2 + Leucovorin 400 mg/m2 every 2 wks + Cetuximab 400 mg/m2 initial dose, then
28、 250 mg/m2 wkly,Van Cutsem E, et al. ASCO 2008. Abstract 2.,CRYSTAL Trial FOLFIRI Cetuximab: Study Schema,Patients stratified by region and ECOG performance score Safety population: n = 1202 ITT population: n = 1998,ITT人群与KRAS不同状态患者疗效数据对比,KRAS 突变率 35.6%（192/540）,FOLFOX4,Patients with previously untr
29、eated EGFR-detectable mCRC (N = 237),FOLFOX4 + Cetuximab,Van Cutsem E, et al. ASCO 2008. Abstract 2.,OPUS Trial FOLFOX Cetuximab: Study Schema,Patients stratified by region and ECOG performance score Safety population: n = 1202 ITT population: n = 1998,Cetuximab 400 mg/m2 initial dose, then 250 mg/m
30、2 wkly,ITT人群与KRAS不同状态患者疗效数据对比,KRAS 突变率 42.5%（99/233）,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/week,Arm B: Irinotecan + dose-escalated* Cetuximab dose increases of 50 mg
31、/m2 q2w up to maximum 500 mg/m2/wk,Arm C: Irinotecan + standard-dose Cetuximab 250 mg/m2/week,Day 1,Day 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 initi
32、al dosethen 250 mg/m2/wk + Irinotecan (180 mg/m2 q2w),Not eligible for randomization,randomization,EVEREST: PFS (ITT Population),0,0.2,0.4,0.6,0.8,1.0,0,200,400,600,Days,PFS Estimate,800,P .0001,KRAS mutant,WT KRAS,KRAS mutation present,83 days (95% CI: 75.9-90.2),173 days (95% CI: 141.3-204.7),Tejp
33、ar S, et al. ASCO 2008. Abstract 4001. Reproduced with permission.,EVEREST: PFS by Treatment Group and KRAS Status,0.0,0.2,0.4,0.6,0.8,1.0,0,200,400,600,800,0.0,0.2,0.4,0.6,0.8,1.0,0,200,400,600,800,0.0,0.2,0.4,0.6,0.8,1.0,0,200,400,600,800,Days,Days,Days,KRAS mutant,WT KRAS,Control,KRAS mutation pr
34、esent,P = .014,KRAS mutant,WT KRAS,Dose Escalation,KRAS mutation present,KRAS mutant,WT KRAS,Nonrandomized,KRAS mutation present,P .001,P = .020,Tejpar S, et al. ASCO 2008. Abstract 4001. Reproduced with permission.,PFS Estimate,PFS Estimate,PFS Estimate,CAIRO2 Study of the Dutch Colorectal Group (D
35、CCG): Schema,Stratified by previous adjuvant chemotherapy, serum LDH, number of affected organs, and institution,Patients with advanced colorectal cancer, with no previous systemic treatment for advanced disease, and WHO performance score 0-1(N = 755),Arm A Cycles 1-6 Capecitabine 1000 mg/m2 BID on
36、Days 1-14 + Oxaliplatin 130 mg/m2 on Day 1 + Bevacizumab 7.5 mg/kg on Day 1 Cycles 7 and beyond Capecitabine 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)
37、,Punt , et al. ASCO 2008. Abstract 4011.,Primary endpoint: PFS Secondary endpoints: OS, response rate, toxicity, quality of life,*3-wk cycles.,CAIRO2: Impact of KRAS on PFS/OS,KRAS 突变率 39.1%（196/501）,其他信号通路,PTEN 磷酸酯酶和肿瘤抑癌蛋白,调节PI-3K-Akt信号通路 40%的结直肠癌PTEN表达下降，与PTEN突变或缺失有关,Romagnani et al. Gastrointesti
38、nal Cancers Symposium 2007 abstract 427,n=10,n=17,0,20,40,60,80,100,有效,PTEN表达,P =0.001,Patients (%),无效,35,100,上调VEGF和其他血管发生介质,A431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 Ciardiello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 Vallbohmer的研究也表明，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
39、抗治疗疗效有关,Viloria-Petit et al. Cancer Res 2001;61:50905101 Ciardiello et al. Clin Cancer Res 2004;10:784793 Vallbohmer et al. J Clin Oncol 2005;23:35363544.,p21,Ogino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;11:66506656,0,20,40,60,80,100,有效率 (%),25,67,0,20,40,60,80,100
40、,Patients (%),9,68,P =0.05,p21丢失,p21表达阳性,P =0.005,p21表达丢失伴野生型p53,p21表达伴p53突变,STAT3激活,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,EGFR基因多态性 EGFR G+497A EGF A+61G,0,0.4,0.8,1.2,2,PFS (月),1.3,1.8,0,0.4,0.8,1.2,1.6,2,1.2,1.4,P =0.0017,E
41、GFR G+497A,EGFR +497 GG,P =0.042,EGF +61 GG,EGF +61 A-allele,PFS (月),1.6,Lurje et al. submitted for publication,130例 MCRC患者 cetuximab 治疗 回顾研究 (IMCL-0144),FcR多态性,39例转移性CRC患者 IgG1 mAb的片段c 能诱导ADCC,Zhang W, et al. J Clin Oncol. 2007;25:3712-3718.,Log-rank P =0.004,FCGR2A H/H or H/R and FCGR3A F/F or F/V
42、 (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.,3.7,1.1,0,2,4,6,8,10,Median PFS,PFS (months),Cyclin D1 A870G EGF A61G 多态性,Zhang W, et al. Pharmacogenet Genomics 2006;16:475483.,0,2,4,6,8,1
43、0,Survival (月),2.3,8.7,0,2,4,6,8,10,4.4,12,P =0.019,A870G AG/GG,A870G AA,P =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),Cox-2 G765C多态性 启动子区域 +8473多态性,环氧化酶-2（Cox-2） EGFR通路限速因素 体外试验 Cox-2的G765C多态性 启动子活性减弱30%,0,2,4,6,8,10,PFS (月),1.3,5.9,0,2,4,
44、6,8,10,1.4,3.8,P =0.032,G765C CC,G765C G-allele,P =0.003,+8473 CC,+8473 T-allele,PFS (月),Lurje et al. submitted for publication,预测抗EGFR疗效指标-小结,皮疹 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 检测 EGFR 激活 EGFR 配体 EGFR 磷酸化 KRAS,其他信号通路 PTEN失活 VEGF基因表达 P21 丢失 STAT3激活 胚系基因多态性 EGFR基因多态性（CA双核苷酸重复序列） FcR多态性（FcRIIa131位点和FcRIIIa 158位点） cyclin D1 A870G和EGF A61G的多态性 Cox-2的G765C多态性,
