VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
Discover Personalized Medicine: Gordon Mills, PD, PhD
1. Sheikh Khalifa bin Zayed Al
Nahyan Institute for
Personalized Cancer Therapy
John Mendelsohn Gordon Mills
Funda Meric-Bernstam Kenna Mills Shaw
DELIVERING ON THE PROMISE OF PERSONALIZED
MOLECULAR MEDICINE IN OVARIAN CANCER
2. Targeted Therapy For Cancer
Tumor
Capitalizing on the vulnerabilities (Achilles Heel) of cancer
3. Ovarian Cancer
Karst and Drapkin et al
Faculty 1000 Medicine
High Grade Serous
Ovarian Cancer
Is Probably Fallopian
Tube Cancer
• 22,000 new cases and 15,500 deaths in the USA
• Low grade and high grade tumors have distinct genomic
aberrations
• Low grade and high grade tumors do not interconvert
• HGSEOC is the most common and aggressive form of
ovarian cancer
4. DIFFERENT HISTOLOGICAL SUBTYPES OF OVARIAN
CANCER INDICATE DIFFERENT THERAPEUTIC
OPPORTUNITIES
Serous
Endometrioid
Mucinous
Clear cell
High grade low grade
High grade low grade
Low grade serous
KRAS
Clear Cell
PIK3CA mutations
Endometrioid
ARID1A mutation and deletion
PARP inhibitors
Mucinous
Probably metastatic colon
High grade serous
p53, BRCA1/2 copy number
long tail of actionable mutations
Targeted agents
Bevaczumib
PARP inhibitors have now been
FDA approved
5. Interstrand crosslink
Double-strand break
DNA alkylation
O 6-alkylguanine
Uracil
Abasic site
8-Oxoguanine
Single-strand break
Ionising radiation
Antitumour agents Alkylating agents
Ionising radiation
Oxygen radicals
Spontaneous reactions
Antitumour agents
(6-4)PP
Bulky adduct
CPD
UV light
Polycyclic aromatic
hydrocarbons
Replication
errors
A-G mismatch
T-C mismatch
Insertion
Deletion
Me
Recombinational
repair (HR, NHEJ)
Direct reversal
(AGT, MGMT)
Base excision
repair
Nucleotide
excision repair
Mismatch
repair
Modified from Hoeijmakers, J. H. (2001) Nature 114, 366-374.
MAJOR MECHANISMS OF DNA DAMAGE AND
REPAIR
O6BG
PaTrin
PARPi
DNA PKi
ATMi
6. Normal Cells
DNA Damage
HR
mediated-repair
BRCA1
Unknown
factors
Rad51
RPA
Others
factors
Death
DSB SSB
PARP
mediated repair
BRIT1
ATM
PARP
Others
factors
HR-deficient Cancer Cells
x
x
BRCA1
BRCA2
PARP inhibitors induce synthetic lethality in
HR-deficient cancer cells
PARPness: Can we identify patients likely to benefit from PARP inhibitors
BRCA1/BRCA2 mutations
Germline Somatic
BRCA1/2 loss
Other members of complex
PTEN loss?
ARID1A
HRD genomic scaring assay
regional loss of heterozygosity
CLIA assay in development
HRD RNA predictor
HRD protein predictor
PARP
inhibitors
x
x
PARP
inhibitors
x
x
DNA Damage
HR
mediated-repair
BRCA1
BRIT1
ATM
Unknown
factors
Rad51
RPA
Others
factors
Survival
DSB SSB
PARP
mediated repair
BRCA2
PARP
Others
factors
7. Aberrations in BRCA1/2 HR pathway in HGSOC (86% of 574 cases)
ATR, ATM, BRCA1/2 are needed for efficient repair
Loss of TP53BP1 reverses HR defect induced by BRCA1
deficit and protects from effects of DNA damage
TP53BP1 is downregulated by PI3K pathway inhibition
(RPPA arrays)
C11ORF30 = EMSY EMSY decreases BRCA2
PTEN contributes to HR and PARP sensitivity
0 50 100 150
020406080100
Months Survival
%Surviving
Gene Set Not Altered
Gene Set Altered
Logrank test p−value: 0.000042
BRCA1, BRCA2, ATR ATM: homdel exp<-1 mut
C11ORF30: amp exp>1
PTEN: homdel, exp<-1 prot<-1 mut
TP53BP1: homdel mut exp<-1 prot<-1
8. Samples with BRCA1, BRCA2, or RAD51C deficiency
Samples with BRCA1 mutations
Samples with BRCA2 mutations
Samples with BRCA1 low expression or promoter methylation
Samples with RAD51C promoter methylation
Samples with intact BRCA1, BRCA2, and RAD51C
HRD-LOH score
HRD genomic scarring
LOH Loss of heterozygosity Telomeric Allelic Imbalance
Large scale transitions
Myriad Hennessey
9. Abkevich et al, BJC, 2012
4.1 years
3.1 years
TCGA dataset
median dicotomized
p = 0.00006
HRD prognosticates overall survival
10. HRD score predicts PARPi response
ARIEL2 Rucaparib
HRD
Subgroup
Median PFS, mo (90%
CI)
BRCAmut 9.4 (7.3, Not Reached)
HRD positive 7.1 (3.7, 10.8)
Biomarker
Negative
3.7 (3.5, 5.5)
Subgroup
Comparison
Hazard Ratio (90% CI)
BRCAmut vs
Biomarker
Negative
0.47 (0.35, 0.64)
HRD vs
Biomarker
Negative
0.61 (0.41, 0.92)
PFS by HRD biomarker status
Biomarker Negative
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Time (months)
PFS
McNeish and colleagues
ARIEL2
HRD positive
BRCAmut
11. UNEXPECTED HIGH RATE
OF FAILURE OF TARGETED
THERAPEUTICS
Even for patients with the
biomarker only subpopulations of
patients benefit:
Usually short term
Three resistance mechanisms
Intrinsic (Genetic)
Selected (Genetic)
Adaptive (Homeostatic loops, cross talk
and bypass)
Rationale combinatorial therapy
Systems are robust to single
perturbations. Tumors exhibit
decreased robustness and may
be more sensitive to multiple
perturbations
Yarden and Lander
CHALLENGES TO
PERSONALIZED
TARGETED THERAPY
12. Combination of a PI3Ki and a PARPi
Gerburg Wulf and SU2C PI3K in Women’s Cancer Team
13. Ovarian Cancer
Breast Cancer
PI3K Dream Team
http://pi3k.org
77% OvCa gBRCA
57% BrCa gBRCA
Non mutant BRCA1/2 2 PR
One biopsy: ATR mutant
N=46
N=24
BKM and Olaparib
demonstrate marked
responses
15. 15
COTI-2: A novel and effective p53
normalizing agent
N
N
N
H
S
N
N
N
• Novel small molecule
o Formula = C19H24N6S
o 3rd generation Thiosemicarbazone
• Discovered in a NSCLC screen
• Simple 3 step synthesis
• Active in >10 xenografts
• IND Approved
• Phase I trial pending
• NSC319726 p53 normalizer is a
thiosemicarbazone
• NSC319726 is a Zn chelator and
transporter allowing refolding of a
subset of p53 mutations
16. TP53 is the most
commonly mutated
gene in the human
genome
R273
R248
R175
R220
Ovary
Lung
17. COTI-2 is active in naturally
occurring p53 mutant lines in vivo
Intravenous Oral
Established OVAR3 Ovarian Cancer Cell Line (R248Q)
75-100mm3 3xper week
18. COTI2 TP53 mutations in ovarian cancer
R248
G245
R273
Y220C
I195FR175H
C242
R273P/G
G245C/V
R175H/L
R248Q/W
C275S/F
C275