NSCLC: diagnóstico molecular, pronóstico y seguimiento; CTC

Qué hay de nuevo en diagnóstico molecular, pronóstico
y seguimiento en NSCLC
Mauricio Lema Medina MD
Clínica de Oncología Astorga / Clínica SOMA, Medellín, Colombia
Medellín, 22.05.2018

Conflicts of interest for this lecture
Mauricio Lema
Lecture fees by: Boehringer-Ingelheim, BMS, MSD

Lung cancer: “relevant” subgroups
NSCLC SCLC
NSCLC with “Driver” NSCLC withoud “Driver”
10%
15% 75%
NSCLC (without
“driver”)
Squamous
25%
NSCLC (without
“driver”)
Non-squamous
50%
90%
EGFR: 10%
ALK/EML4: 4%
ROS1: 1%
Mostly, adenocarcinoma
Adenocarcinoma
Squamous
Large-cell

Extracellular
Domain
Transmembrane
Domain
Intracellular
Domain
EGF PATHWAY
EGFR: transmembrane protein
Tyrosine Kinase
Domain
Adapted from:
Ciardiello F, et al. N Engl J Med. 2008;358:1160-1174. www.clinicaloptions.com

Kinase domain N-lobe
EGFR mutations in human cancer
CR2
476-621
L1
1-163
N-lobe
686-769
L2
310-475
CRD
961-1211
CR1
164-309
TM
622-644
JM
645-685
C-lobe
773-960
L858R
lung
R108K
neuronal
L861Q
lung
Frequency of mutation:
≥40%
<5%
5-40%
Ligand bs Ligand bs
A1048V
stomach
R677H
neuronal
C624F
neuronal
P598V
glioblastoma,
neuronal
P596L
glioblastoma,
neuronal
R324L
neuronal
D1012H
lung
686 960
Kinase domain C-lobe
E709K
lung,
prostate
E709A
lung
E709G
lung
G719S
lung,
intestine
G719C
lung
G719A
lung
L833V
lung
T790M
lung,
neuronal,
oesophagus
L858R
lung
L858Q
lung
L858M
lung
H835P
breast
H835L
breast,
lung
T710I
breast
E872K
breast
E872X
oesophagus
L861Q
lung, neuronal
L861R
lung
L861V
lung
E866K
breast, lung
delL747-A751insP
lung
delL747-A751insS
lung
delL747-T751
lung
delL747-S752
lung
delE747-A750insP
lung
delL747-P753
lung
delL747-P753insQ
lung
delL747-P753insS
lung
delE746-T751insA
lung
delE746-T751insI
lung
delE746-A751
lung
delE746-T750insRP
lung
delK745-E749
lung
delE746-A750
lung
delE746-S752insA
lung
delE746-S752insV
lung
delE746-S752insVA
lung
EGFRvIII:
delV30-R297insG
glioblastoma,
lung, breast
Catalytic site
R108K
neuronal
T263P
glioblastoma,
neuronal
A289V
glioblastoma,
neuronal
A289D
glioblastoma,
neuronal
A289T
glioblastoma,
neuronal
delD770-N771insSVD
lung
delD770-N771insG
lung
delH773_V774insNPH
lung
delV774_C775insHV
lung
delV769-D770insASV
lung
S768I
lung, neuronal,
oesophagus
S768ins
lung
H774M
lung
H773R
lung

EGFR IN NSCLC: TWO DISTINCT PATHWAYS
Nucleus
Adaptor
Survival
PIP2
PI3K
PIP3
PTEN
AKT
Apoptosis
regulators
Proliferation
Adaptor
Transcription
factors
MAPK
MEK
RAFGTP-RASGDP-RAS
Sordella, et al. Science 2004
ATP ATP
● Greater signalling through the
MAPK pathway producing
excessive cell proliferation
● Higher affinity for ATP than
mutant receptor, so greater
competition with EGFR TKIs for
binding sites; higher
concentrations needed to inhibit
● Successful inhibition of wild-type
EGFR reduces proliferation and
halts tumour growth
● Higher incidence of stable disease
EGFR
wild-type

EGFR IN NSCLC: TWO DISTINCT PATHWAYS
ATP
Nucleus
Adaptor
Survival
PIP2
PI3K
PIP3
PTEN
AKT
Apoptosis
regulators
Proliferation
Adaptor
Transcription
factors
MAPK
MEK
RAFGTP-RASGDP-RAS
Sordella, et al. Science 2004
ATP
● Preferential signalling through the PI3K-
mediated anti-apoptotic pathway –
‘oncogene addiction’
● Reduced affinity for ATP means EGFR TKIs
have less competition for binding sites;
lower concentrations sufficient to inhibit
● Successful inhibition of mutated EGFR
produces ‘apoptotic shock’
● Higher incidence of complete or partial
response
EGFR
mutation
+ve

EGFR mutations
10% to 15% of patients in North America
and approximately 50% of patients in Asia
with advanced NSCLC have tumors
with EGFR gene mutations

EGFR sensitizing mutations
▪ Intracellular catalytic domain mutations
– Exon 19 deletions
– Exon 21 L858R
– Exon 20 T790M (resistance)

Tissue-based EGFR mutation testing
Cobas EGFR Mutation Test
This is a rapid, multiplex, real-time PCR assay designed to detect 41 mutations
in exons 18, 19, 20, and 21.[O’Donnell 2013]
Therascreen EGFR RGQ PCR Kit
This is an amplification refractory mutation detection system, which is able to
detect 29 mutations in exons 18, 19, 20, and 21 of the EGFR gene.

Blood-based Testing: What Is Circulating
DNA?
▪ In lung cancer patients with progressive disease, dying
tumor cells release small pieces of their DNA into the
bloodstream.1,2
▪ This DNA is called cell-free circulating tumour DNA
(ctDNA), which moves throughout the bloodstream.
▪ Identifying and analyzing cancer DNA from a blood
sample allows physicians to detect genetic changes in
the tumor that may help guide treatment.3
1. Diaz LA, et al. J Clin Oncol. 2014;32:579-586. 2. Kimura H, et al. Clin
Cancer Res. 2006;12:3915-3921. 3.Thress KS, et al. Lung Cancer. 2015;
90:509-515.

“Liquid biopsy” for mEGFR
Cobas EGFR Mutation Test V.2 as a blood-based companion diagnostic to
test for EGFR exon 19 deletions, T790M mutations, or L858R mutations.
Plasma testing using real time PCR for qualitative detection of EGFR exon 19
deletion or L858R mutation:
Positive in 76.7% of tissue-positive specimens
Negative in 98.2% of tissue-negative

Relative Frequencies of Acquired
Resistance Mechanisms to EGFR TKIs
Yu HA, et al. Clin Cancer Res. 2013;19:2240-2247.
T790M
60%
HER2
8%
Unknown
18%
HER2 + T790M
4%
MET
amplification
3%
Small cell + MET
1%
Small cell
1%
Small cell +
T790M
2%
MET + T790M
3%

Assessment of Plasma Testing for EGFR
T790M in Circulating DNA
▪ Likelihood of plasma EGFR T790M being positive is
higher in pts with stage M1B as compared to M1A
Gadgeel S, et al. EMSO 2015. Abstract 3088.
Tissue/Plasma Concordance for T790M Testing
Tissue, n
Positive Negative Inadequate
Tissue
Total
Plasma, n
Positive 155 23 12 190
Negative 37 12 8 57
Total 192 35 20 247

“Liquid biopsy” for mEGFR
Phase I/II TIGER-X trial with rociletinib
Compared T790M mutational status from tissue (real time PCR), plasma (digital PCR), and urine
(next-generation sequencing) in patients with EGFR-mutation positive advanced NSCLC (N = 181).
These plasma and urine assays are a highly specific means of detecting
EGFR and KRAS mutations in advanced NSCLC.
The T790M-positive percent agreement between tissue and plasma was 81.5% and 83.8%
between tissue and urine, with 57% positive by all 3 samples.

AURA 1/2: Osimertinib in Metastatic EGFR
T790M–Positive NSCLC
▪ Multicenter, open-label phase II trials
– AURA 1: N = 201; extension of phase I dose-escalation
study
– AURA 2: N = 210
▪ Primary endpoint: ORR (independent review)
Metastatic NSCLC
pts with confirmed
EGFR T790M
mutation, WHO PS
0-1, progressed on
prior therapy,
including EGFR TKI
Osimertinib 80 mg QD
Yang CH, et al. WCLC 2015. Abstract MINI16.06.
Mitsudomi T, et al. WCLC 2015. Abstract MINI16.08.

Response Rates of EGFR T790M–Positive
Cohorts to Osimertinib
▪ DCR (CR, PR, or SD): 90% (95% CI: 84-94); activity in LM
Jänne PA, et al. New Engl J Med. 2015;372:1689-1699. Jänne PA, et al. ELCC 2015; Abstract LBA3.
Yang, J C-H, et al. ASCO 2016. Abstract 9002.
n = 127 20 mg 40 mg 80 mg 160 mg 240 mg Total
n 10 32 61 41 13 157
ORR, % (95%
CI)
50
(19-81)
59
(41-76)
66
(52-77)
51
(35-67)
54
(25-81)
59
(51-66)
*Imputed values for pts who died within 14 wks (98 days) of start of treatment and had no evaluable target lesion
assessments. DStudy discontinuation. T790M mutation determined by central test.
40 mg
80 mg
160 mg
240 mg
20 mg
-100
-90
-80
-70
-60
-50
-40
-30
-20
-10
0
10
20
30
40
50
D
D*D*
D
D DD
D
D DD D
DD
D
DD
D
D
D
D D D
DD D D
D DD
D D D D D DDD
D D D D D
DD
D D
D D D D
D
D
D
D
D
D
D
Best % Change From Baseline in Target Lesion

AURA: Adverse Events
Causally-related adverse events
occurring in ≥ 15% of pts overall, n
(%)
AURA Phase I: 80 mg (n
= 63)
AURA Pooled Phase II:
80 mg (n = 411)
Any Gr Gr ≥ 3 Any Gr Gr ≥ 3
Rash (grouped terms) 23 (37) 0 167 (41) 3 (<1)
Diarrhea 22 (35) 1 (2) 157 (38) 2 (<1)
Paronychia (grouped terms) 18 (29) 1 (2) 118 (29) 0
Dry skin (grouped terms) 14 (22) 0 125 (30) 0
Fatigue 10 (16) 0 NR NR
Select adverse events
Interstitial lung disease (grouped
terms)
1 (2) 1 (2) 12 (3) 8 (2)
Hyperglycemia 0 0 1 (<1) 0
QT prolongation 1 (2) 1 (2) 14 (3) 4 (1)
Slide credit: clinicaloptions.com
Jänne PA, et al. New Engl J Med. 2015;372:1689-1699.
Jänne PA, et al. ELCC 2015; Abstract LBA3.

Mechanism of Action of ALK, ROS1 and RET
Fusion Oncogenes
• All three are receptor tyrosine
kinases (RTK)
• ALK and RET are capable of
homodimerization and self (ligant
independend) activation
• Mechanism of self activation of
ROS1 is being debated
• Downstream signaling via RAS/ERK
(proliferation), and PI3K/AKT and
JAK/STAT( resistance to apoptosis)

ALK rearrangement
• Results in ALK fusion oncogenes
• Occurs in 2% to 7% of NSCLC tumors;
• Detected via FDA-approved FISH assay
• Required for treatment with crizotinib, brigatinib, alectinib, or
ceritinib

“Liquid biopsy” for ALK/EML4 mutation
Proof-of-concept data for detecting ALK rearrangements have also shown high specificity in plasma samples correlated
with tissue-based FISH assays.
In a study of 77 patients with NSCLC, analysis of EML4-ALK rearrangements by real time PCR in platelets, plasma, and
exosomes isolated from blood samples demonstrated 65% sensitivity and 100% specificity in platelet samples.
In a separate study, next-generation sequencing of cell-free DNA from blood to matched tissue in 386 solid-tumor patients
(37% with lung cancer) showed that when abnormalities in ALK, ROS1, and others were detected in blood, the mutations
were also detected in 94% to 100% of tissue samples, depending on the specific mutation
Neelson RJ, Oncotarget, 2016
Zill OA, Proc ASCO, 2016

Mutated BRAF (V600E): constituvely activated

clinicaloptions.com/oncology
Dabrafenib/Trametinib in BRAF+ NSCLC
Dabrafenib + Trametinib in BRAF V600E–
Mutant NSCLC: Background
▪ BRAF V600E accounts for ~ 2% of NSCLC mutations and
associated with poorer outcomes on platinum regimens
▪ Dabrafenib: reversible, small molecule inhibitor of BRAF V600
kinase
– Single-agent activity in BRAF V600E–mutant NSCLC[1]
▪ Trametinib: reversible, small molecule inhibitor of MEK1/MEK2
– Addition to dabrafenib more active than monotherapy in
melanoma[2,3]
▪ Current study (BRF113928) evaluated safety and efficacy of
dabrafenib + trametinib in BRAF V600E–mutant advanced
NSCLC[4]
1. Planchard D, et al. ESMO 2014. Abstract LBA38_PR. 2. Long GV, et al. N Engl J Med. 2014;371:1877-
1888. 3. Robert C, et al. N Engl J Med. 2015;372:30-39. 4. Planchard D, et al. ASCO 2015. Abstract 8006.

Dabrafenib + Trametinib in Previously
Treated NSCLC With a BRAF Mutation
▪ BRF113928: Single-arm, multicenter, open-label phase II trial
▪ Interim analysis with N = 33 (safety population)
– 24 pts evaluated for efficacy
▪ Primary endpoint: ORR (by investigator); secondary endpoints: PFS,
OS, DoR, safety, tolerability, PK
Dabrafenib 150 mg BID +
Trametinib 2 mg QD
(n = 20)
Pts with progressing
stage IV BRAF V600E–
mutant NSCLC after 1-
3
prior regimens (≥ 1
platinum-based)
ECOG PS 0-2
(N = 40)
Planchard D, et al. ASCO 2015. Abstract 8006.
Dabrafenib 150 mg BID +
Trametinib 2 mg QD
(n = 20)
If ≥ 6
responses
Stage 1 Stage 2

BRF113928: Pt Population
Characteristic
All Treated (N = 33)
Male, % 36
Median age, yrs (range) 66 (49-88)
ECOG PS 0/1 at baseline, % 94
Smoking history, %
▪Never
▪≤ 30 pack-yrs
▪> 30 pack-yrs
27
39
30
No. of prior regimens for metastatic disease, %
▪1
▪2
▪3
58
18
15

BRF113928: Responses With Dabrafenib +
Trametinib
▪ Median time on study treatment (dabrafenib and trametinib) = 108 days (range, 1 to 244 days)
Planchard D, et al. ASCO 2015. Abstract 8006. Reprinted with permission.
IndividualPatients
0 1 2 3 4 5 6 7 8 9
Treatment Duration (Mos)
*1st-line patient (protocol deviation)
Best Confirmed Response
Partial Response
Stable Disease
Progressive Disease
Not Evaluable
Not Available
First Partial Response
Disease Progressed
Still on Study Treatment

BRF113928: Safety With Dabrafenib +
Trametinib
▪ Most common AEs: pyrexia, diarrhea, nausea, vomiting, decreased
appetite, asthenia, cough, peripheral edema, rash
▪ 1 death due to pleural effusion and disease progression
AE, % All Treated (n = 33)
Any AE 88
Any grade ≥ 3 AE 45
Any serious AEs
Serious AEs ≥ 2 pts
▪Pyrexia
▪Confusional state
▪Hyponatremia
42
18
6
6
AE leading to discontinuation 6

BRF113928: Conclusions
▪ Dabrafenib + trametinib active in small cohort of pretreated
pts with BRAF V600E mutation–positive advanced
NSCLC[1]
– ORR (63%) and disease control rate (88%) higher than
previously reported for dabrafenib monotherapy (32% and
56%, respectively)[2]
▪ Manageable safety profile with few grade ≥ 3 events[1]
▪ Currently recruiting third cohort to evaluate combination in
previously untreated BRAF V600 mutation–positive
advanced NSCLC
1. Planchard D, et al. ASCO 2015. Abstract 8006. 2. Planchard D, et al. ESMO 2014. Abstract LBA38_PR.

BRAF mutation
Oncomine Dx Target Test, a next-generation sequencing test to detect
multiple gene mutations for lung cancer in a single test from a single tissue
specimen.
This test detects the presence of BRAF, ROS1, and EGFR gene mutations or
alterations in tumor tissue of patients with NSCLC.
This test can be used to select patients with NSCLC with the BRAF V600E
mutation.
Neelson RJ, Oncotarget, 2016
Zill OA, Proc ASCO, 2016

NSCLC without
actionable mutations

Inmunología tumoral
Célula tumoral
PD-1
PD-L1
PD-L2
Receptor de células T
MHC-1
CD28
Shp-2
B7.1
Célula
Dendrítica
Antígeno tumoral
Linfocito T
CD8+/Citotóxico

Célula tumoral
PD-1
PD-L1
PD-L2
MHC-1
CD28
Shp-2
B7.1
Célula
Dendrítica
Antígeno tumoral
Linfocito T
CD8+/Citotóxico
Receptor de célula T (TCR) MHC II y antígeno
MHC II: Major histocompatibility complex

Cebado
(priming) y
activación de las
células T
Célula tumoral
PD-1
PD-L1
PD-L2
MHC-1
CD28
Shp-2
B7.1
Célula
DendríticaLinfocito T
CD8+/Citotóxico
Co-estimuladora CD28 Co-estimuladora B7.1

En la
periferia...
Mientras tanto...

Célula tumoral
PD-1
PD-L1
PD-L2
MHC-1
CD28
Shp-2
B7.1Antígeno + MHC-1

Activación de la
respuesta
inmunológica
CD8 efectora
Célula tumoral
PD-1
PD-L1
PD-L2
MHC-1
CD28
Shp-2
B7.1
Linfocito T
CD8+/Citotóxico
Antígeno + MHC-1
Receptor de células T (TCR)
+++
Respuesta inmune antitumoral
Presente

Las células
tumorales
expresan PD-
L1 (PD-L2)
cuando hay
estimulación
continuada del
IFN-Gamma,
"apagando" al
linfocito T
Célula tumoral
PD-1
PD-L1
PD-L2
MHC-1
CD28
Shp-2
B7.1
Linfocito T
CD8+/Citotóxico
IFN-γ
IFN-γR
PD-L1
PD-1
- - -
Respuesta inmune antitumoral
Frenada

Tumor Cell
Cytotoxic T8
Lymphocyte
PD-L1
PD-1
- - -
Tumor Cell
Cytotoxic T8
Lymphocyte
- - -
Tumor Cell
Cytotoxic T8
Lymphocyte
+ + +

Examples of PD-L1 IHC Staining of NSCLC Samples Using
the Clinical Trial Assay
Brown: PD-L1
staining
Blue color:
HNE
counterstain
PS < 1% PS 1% to 49% PS ≥ 50%
5 x
magnification
40 x
magnification
Garon EB, et al. N Engl J Med. 2015;372:2018-2028. Image courtesy of E. Garon. Slide credit: clinicaloptions.com

Blueprint PD-L1 IHC Assay Comparison Project: Phase 1
▪ Analytical comparison of % tumor
cell staining (tumor proportion
score), by case (n = 39), for each
assay
▪ Data points represent the mean
score from 3 pathologists for each
assay on each case
▪ No clinical diagnostic cutoff applied
▪ Conclusion: 3 of 4 assays are
analytically similar for tumor cell
staining
22C3 (pembrolizumab), 28-8 (nivolumab), and
SP263 (durvalumab)
SP142 (atezolizumab)
Hirsch FR et al. J Thorac Oncol. 2017;12:208-222. Slide credit: clinicaloptions.com
100
80
60
40
20
0
1 3 5 7 9 11 13 15 17 19
%TumorCellStaining
23 25 27 29 31 33 35 3721 39
22C3
28-8
SP142
SP263

The case of PD-L1
expression in 1L

Pembrolizumab in NSCLC (KEYNOTE-001 Cohort): OS by
PD-L1 Expression
Pts at Risk, n
119 92 56 22 5 4 3 0
161 119 58 15 6 4 0 0
76 55 33 8 0 0 0 0
100
80
60
40
20
0
0 4 8 12 16 20 24 28
OS(%)
Mos
PS 1-49%
PS < 1%
PS ≥ 50%
PS
Median OS, Mos
(95% CI)
≥ 50% NR (13.7-NR)
1-49% 8.8 (6.8-12.4)
< 1% 8.8 (5.5-12.0)
Garon EB, et al. N Engl J Med. 2015;372:2018-2028. Garon EB, et al. AACR 2015. Abstract CT04. Slide credit: clinicaloptions.com

Reck M, et al. N Engl J Med. 2016;375:1823-1833.
Pembro
(n = 154)
CT
(n = 151)
Median PFS, mos 10.3 6.0
HR (95% CI) 0.50 (0.37-0.68; P < .001)
KEYNOTE-024: PFS
0
10
20
30
40
50
60
70
80
90
100
0 3 6 9 12 15 18
104 89 44 22 3 1154
151 99 70 18 9 1 0
Mos
PFS(%)
Pts at Risk, n
62%
50%
48%
15%
mNSCLC 1L PD-L1 ≽50%

For the 30% with PD-L1 expression
≽50%, anti-PD1 (Pembrolizumab)
is indicated in 1L
-Level 1-
KEYNOTE 24

Nivolumab
Chemotherapy
CheckMate-026: OS in Pts With ≥ 5% PD-L1
Nivolumab
(n = 211)
Chemotherapy
(n = 212)
Median OS, mos
(95% CI)
14.4
(11.7-17.4)
13.2
(10.7-17.1)
1-yr OS rate, % 56.3 53.6
All randomized pts (≥ 1% PD-L1+) HR: 1.07 (95% CI: 0.86-1.33)
HR: 1.02 (95% CI: 0.80-1.30)
▪ 60.4% in the chemotherapy arm had
subsequent nivolumab therapy
▪ 43.6% in the nivolumab arm had
subsequent systemic therapy
Socinski M, et al. ESMO 2016. Abstract LBA7_PR.
Mos
OS(%)
2421181512963 27
100
80
60
40
0
20
0 30
mNSCLC 1L PD-L1 ≽5%

Signatures of mutational processes in human cancer
Alexandrov, L. B., Nik-Zainal, S., Wedge, D. C., Aparicio, S. A. J. R., Behjati, S., Biankin, A. V., … Stratton, M. R. (2013). Signatures of mutational processes
in human cancer. Nature, 500(7463), 415–421. https://doi.org/10.1038/nature12477

Tumor Mutational Burden and Response Rate to PD-1 Inhibition
Yarchoan, NEJM, 2017

Tumor Mutational Burden and Response Rate to PD-1 Inhibition
Yarchoan, NEJM, 2017
Our linear correlation formula — objective response
rate=10.8×loge(X)−0.7, where “X” is the number of
coding somatic mutations per megabase of DNA

CheckMate 227: Nivolumab plus Ipilimumab
in Lung Cancer with a High Tumor
Mutational Burden
eanu, T.-E., Pluzanski, A., Lee, J. S., Otterson, G. A., Audigier-Valette, C., … Paz-Ares, L. (2018). Nivolumab plus Ipilimumab in Lung Cancer with a High Tumor Mutational Burden. https://doi.org/10.1056/NEJMoa1801946. https://doi.org/10.10
Untreated metastatic squamous and
Non-squamous NSCLC
No untreated brain metastasis.
No drug sensitive EGFR/ALK
mutations
No autoimmune disease
PD-L1 ≥1%
Nivolumab + Ipilimumab
Platinum doublet
Nivolumab
Stratification: Squamous vs Non-squamous
R
Untreated metastatic squamous and
Non-squamous NSCLC
No untreated brain metastasis.
No drug sensitive EGFR/ALK
mutations
No autoimmune disease
PD-L1 <1%
Nivolumab + Ipilimumab
Platinum doublet +
Nivolumab
Platinum doublet
Stratification: Squamous vs Non-squamous
R
Endpoints:
High TMB: PFS Nivo + Ipi vs Chemo
PD-L1≥1%: OS Nivo + Ipi vs Chemo

CheckMate 227 - Part 1: Nivolumab plus Ipilimumab in
Lung Cancer with a High Tumor Mutational Burden
Hellmann, M. D., Ciuleanu, T.-E., Pluzanski, A., Lee, J. S., Otterson, G. A., Audigier-Valette, C., … Paz-Ares, L. (2018). Nivolumab plus Ipilimumab in Lung Cancer with a
High Tumor Mutational Burden. https://doi.org/10.1056/NEJMoa1801946. https://doi.org/10.1056/NEJMOA1801946
Nivo + Ipi Arm
Nivolumab: 3 mg/kg q2w
Ipilimumab: 1 mg/kg q6w
Nivolumab Arm
Nivolumab: 240mg q2w
Nivo + Chemo Arm
Nivolumab: 360mg q3w
Platinum doublet

CheckMate 227: Nivolumab plus Ipilimumab
in Lung Cancer with a High Tumor
Mutational Burden
eanu, T.-E., Pluzanski, A., Lee, J. S., Otterson, G. A., Audigier-Valette, C., … Paz-Ares, L. (2018). Nivolumab plus Ipilimumab in Lung Cancer with a High Tumor Mutational Burden. https://doi.org/10.1056/NEJMoa1801946. https://doi.org/10.10
1004 patients with evaluable TMB
444 patients with at least 10 mutations / MB by FoundationOne
High TMB (44.2%)
139 assigned to Nivo + Ipilimumab 160 assigned to Chemotherapy

CheckMate 227 - Part 1:
Nivolumab plus Ipilimumab
in Lung Cancer with a High
Tumor Mutational Burden
Hellmann, M. D., Ciuleanu, T.-E., Pluzanski, A., Lee, J. S., Otterson, G. A., Audigier-
Valette, C., … Paz-Ares, L. (2018). Nivolumab plus Ipilimumab in Lung Cancer with a
High Tumor Mutational Burden. https://doi.org/10.1056/NEJMoa1801946.
https://doi.org/10.1056/NEJMOA1801946

In Low TMB:
PFS Nivo + Ipi: 3.2 mo
PFS Chemo: 5.5 mo

Among patients with a high tumor
mutational burden, the benefit of
nivolumab plus ipilimumab over
chemotherapy was similar in patients
with a PD-L1 expression level of at
least 1% and those with a level of less
than 1%.

Combination biomarker selection for 1st line NSCLC
TMB
high
TMB low
PD-L1
high
PD-L1
low
PD-L1
high
PD-L1
low
Pembrolizumab Nivolumab + Ipilimumab Pembrolizumab Chemotherapy
Rivzy, AACR, Chicago, 2018

Conclusions 1
• “Liquid biopsies” may detect “actionable” resistance mutations (ie,
T760M) in TKI-treated mEGFR NSCLC patients
• T760M EGFR mutation can be treated with Osimertinib
• “Liquid biopsies” less developed in other settings
• Conventional, tissue-based, biopsy continues to provide the highest
yield for mutational analysis in mNSCLC.
• This field is evolving at a staggering pace…

Conclusions 2
• Actionable mutations other than EGFR may provide “relatively”
effective treatment options for patients with mNSCLC
• ALK/EML4 (Crizotinib, Alectinib, Ceritinib, etc).
• ROS1 (Crizotinib)
• BRAF (Dabrafenib + Trametinib)

Conclusions 3
• 1st-line Pembrolizumab is very active in mNSCLC with high tumor
expression of PD-L1 (≥ 50%)
• Tumor mutation burden (TMB) is evolving as a IO biomarker.
• But the whole story of both may end soon…

Impacto Pronóstico de las Células Tumorales Circulantes en NSCLC
Mauricio Lema Medina MD
Clínica de Oncología Astorga / Clínica SOMA, Medellín, Colombia
Medellín, 22.05.2018

81
Increased Prediction
Disease recurrence Survival Treatment response
Imaging
CTCs

A subset of tumor cells with the ability to escape
from the primary site, intravasate (blood &
lymphatic vessels); survive in the blood;
extravasate in distant sites; and form micro-
metastases
Circulating Tumor Cells - CTCs
Joose et al, 20015

1 mL of blood
1000,000,000 cells
Detection threshold: 1-10 CTC/mL

CTC technology
• Label-dependent methods
• Surface markers
• Immunomagnetic (ie, EpCAM or CD45)
• Label-independent
• Physical properties
• Cell size
• Density
• Deformability
• Dielectric properties
• Combinations

CTC process
Blood sample (ie, 7.5-10 mL)
CTC enrichment (remove plasma, and other non-
CTC cells)
CTC cell sorting (immunomagnetic, density, size…)
CTC measurement

CellSearch™
FDA approved for Breast Cancer

https://www.youtube.com/watch?v=9AoFNT5vjmM

7.5 mL of
Peripheral blood
Centrifuged
Plasma is
removed
Re-suspension
in buffer
CTCs enriched
with EpCAM Ab
ferrofluid

Epithelial cells display cell membrane EpCAM proteins (Positive identification)

Ferro-EpCAM-Ab-labeled cells are magnetically separated from the other cells

Cytokeratin monoclonal antibody staining (positive identification of epithelial cells)

CD45 Ab is used to distinguish contaminating white blood cells (negative
identification)

DAPI (a DNA stain) is added

Ferrofluid EpCAM Ab
Nanoparticles and
Citokeratin stains and CD45
Ab and DAPI
Magnest incubation in the
dark x20 min

A piezo-magnetic effect attracts and attaches labeled cells to the
surface

Sample is scanned by the fluorescent optical system

CTCs are positive for EpCAM and DAPI, but negative for CD45

Cut-off
≥5 CTCs/7.5 mL
CellSearch

Circulating Tumor Cells Identify Early Recurrence in
Patients with Non-Small Cell Lung Cancer Undergoing
Radical Resection.
• 56 patients
• Resectable NSCLC
• CTCs before and one month post-surgery
• CTC technology: CK+/EGFR+ CTCs were identified by immunocytochemical methods and
visualized under a direct light microscope to perform the combined cytomorphological and
immunophenotypic assessment
• Cut-off
• Post-op CTC (> 1 CTCs/10mL)
Bayarri-Lara C, PLoS One (2016)

Fig 1. Image galleries after isolation, cytomorphological analysis, and detection of cytokeratin-positive (CK+)
cells (red staining) and epidermal growth factor receptor (EGFR).
Bayarri-Lara C, Ortega FG, Cueto Ladrón de Guevara A, Puche JL, Ruiz Zafra J, et al. (2016) Circulating Tumor Cells Identify Early Recurrence in
Patients with Non-Small Cell Lung Cancer Undergoing Radical Resection. PLOS ONE 11(2): e0148659.
https://doi.org/10.1371/journal.pone.0148659
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0148659

Circulating Tumor Cells Identify Early Recurrence in
Patients with Non-Small Cell Lung Cancer Undergoing
Radical Resection.
Bayarri-Lara C, PLoS One (2016)
Before surgery After surgery

Table 6. Multivariate analysis of risk factors for disease-free survival (DFS).
Bayarri-Lara C, Ortega FG, Cueto Ladrón de Guevara A, Puche JL, Ruiz Zafra J, et al. (2016) Circulating Tumor Cells Identify Early Recurrence in
Patients with Non-Small Cell Lung Cancer Undergoing Radical Resection. PLOS ONE 11(2): e0148659.
https://doi.org/10.1371/journal.pone.0148659
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0148659

Circulating Tumor Cells Detected in the Tumor-Draining
Pulmonary Vein Are Associated with Disease Recurrence after
Surgical Resection of NSCLC
• 30 patients undergoing a curative-intent operation for stage I to IIIA NSCLC
• 10 mL before surgery and during surgery (pulmonary venous blood)
• Cut-off
• > 1 CTCs / 7.5 mL
• Circulating tumor microemboli (a cluster of 3 or more CTCs)
• Results
• Decreased DFS
• Decreased OS
• HR: 5.2 (Univariate)
• HR: 3.7 (Multivariate)
Crosbie PAJ JTO (2016)

Circulating Tumor Cells Detected in the Tumor-Draining
Pulmonary Vein Are Associated with Disease Recurrence after
Surgical Resection of NSCLC
Crosbie PAJ JTO (2016)
OS
Pulmonary vein CTC status
DFS
Peripheral vein CTC status
DFS
OS
High-risk vs Low-risk
DFS
OS

Circulating tumor cells in peripheral and pulmonary venous
blood predict poor long-term survival in resected non-small
cell lung cancer patients.
• 23 patients with resected stage I-IIIa NSCLC
• CTCs in peripheral and pulmonar veins
• 5yr follow-up
• Technique
• Investigator-developed magnetic-activated cell sorting (MACS) and
flow cytometry, termed the FAMCell System
• Cut-off
• Peripheral CTC > 5 CTCs / 15 mL
• Pulmonary vein CTC > 25 CTCs / 15 mL
Li Y, Sci Rep (2017)

Circulating tumor cells in peripheral and pulmonary venous
blood predict poor long-term survival in resected non-small
cell lung cancer patients.
Li Y, Sci Rep (2017)

Evaluation and prognostic significance of circulating
tumor cells in patients with non-small-cell lung cancer
• 101 chemo naive stages III/IV
• Locally-advanced NSCLC
• CTC before and after cycle 1 chemotherapy
• Technology: CellSearch™
• Cut-off
• CTC > 5 CTCs / 7.5 mL
Krebs MG, JCO (2011)

Evaluation and prognostic significance of circulating tumor cells in
patients with non-small-cell lung cancer

Evaluation and prognostic significance of circulating tumor cells in
patients with non-small-cell lung cancer
Stage IV disease

Evaluation and prognostic significance of circulating
tumor cells in patients with non-small-cell lung cancer
• 101 chemo naive stages III/IV
• Locally-advanced NSCLC
• CTC before and after cycle 1 chemotherapy
• Cut-off
• CTC > 5 CTCs / 7.5 mL
• Results
• High baseline CTC correlated with PFS / OS
• Decreased interval CTC correlated with better PFS / OS

High definition imaging of circulating tumor cells and associated
cellular events in non-small cell lung cancer patients; a
longitudinal analysis
• 28 metastatic NSCLC
Nieva J. Phys Biol. (2012)
High CTC
Low CTC

Clinical Significance of Circulating Tumor Cells
and Free DNA in Non-small Cell Lung Cancer
• 24 TKI-resistant EGFR+ metastatic NSCLC
• Correlation of CTC and cfDNA
• CellSearch and cfDNA for mEGFR
Isobe, Anticancer Research (2012)

• 24 TKI-resistant EGFR+ metastatic NSCLC
• Correlation of CTC and cfDNA
• CellSearch and cfDNA for mEGFR
• Results
• CTC+: 8/24
• cfDNA EGFR: 6/24
• cfDNA+ correlated with ≥ 2 CTCs

Evaluation of Circulating Tumor Cells and Related Events as Prognostic
Factors and Surrogate Biomarkers in Advanced NSCLC Patients Receiving
First-Line Systemic Treatment
• 43 stage IIIB/IV NSCLC,
• About to undergo 1st-line chemotherapy
• Platinum doublet (86%)
• CTC before chemotherapy cycle 1, cycle 2, and cycle 5
• Intact CTC were considered as cells with nucleus >4 µm and
CK+ CD45− cytoplasm
• Cut-off:
• Baseline ≥ 5 CTCs / 7.5 mL
• Afterwards ≥ 2 CTCs / 7.5 mL
Muinelo-Romay L, Cancers (Basel) (2014)

• 43 stage IIIB/IV NSCLC,
• About to undergo 1st-line chemotherapy
• Platinum doublet (86%)
• CTC before chemotherapy cycle 1, cycle 2, and cycle 5
• Intact CTC were considered as cells with nucleus >4 µm and CK+ CD45− cytoplasm
• Cut-off:
• Baseline ≥ 5 CTCs / 7.5 mL
• Afterwards ≥ 2 CTCs / 7.5 mL
• Results
• Baseline CTC correlates with PFS / OS.
• Increased levels of CTC during the treatment demonstrated lower OS and PFS rates

Circulating Tumor Cells Predict Prognosis Following Tyrosine Kinase
Inhibitor Treatment in EGFR-Mutant Non-Small Cell Lung Cancer Patients.
• 107 TKI treated (gefitinib/erlotinib) EGFR+ mNSCLC
• CTC on d0, d28
• Cut-off:
• ≥ 5 CTCs / 7.5 mL
• Results
• Baseline CTC
• High CTC PFS: 6.8
• Low CTC PFS: 11.1
Yang B, Onc Res (2017)

A prospective examination of circulating tumor cell profiles
in non-small-cell lung cancer molecular subgroups.
• 125 mNSCLC
• Technology: CellSearch™ and Vimentin assay (to assess EMT).
• Cut-off:
• ≥ 5 CTCs / 7.5 mL
• Results
• 51/125 (40.8%) had high CTC
• 26/125 (20.8%) had Vim+ CTC
• Increased CTC correlated with worse OS (HR: 0.55)
Lindsay CR, Ann Oncol (2017)

A prospective examination of circulating tumor cell profiles
in non-small-cell lung cancer molecular subgroups.
Lindsay CR, Ann Oncol (2017)
High CTC
Low CTC

Preoperative circulating tumor cell detection using the isolation
by size of epithelial tumor cell method for patients
with lung cancer is a new prognostic biomarker.
• 208 operable stage I-IV
• Technology: ISET™
• Cut-off:
• ≥ 50 CTCs / 10 mL
• Results
• 76/208 CTCs positive
• Increased CTC decreases DFS / OS
• High risk of recurrence in stage I and II
Hofman V, Clin Cancer Res (2011)

Preoperative circulating tumor
cell detection using the
isolation by size of
epithelial tumor cell method
for patients with lung cancer is
a new prognostic biomarker.
Hofman V, Clin Cancer Res (2011)

Detection of circulating tumor cells as a prognostic factor in patients undergoing
radical surgery for non-small-cell lung carcinoma: comparison of the efficacy of the
CellSearch Assay™ and the isolation by size of epithelial tumor cell method.
• 210 operable stage I-IV
• Technology: ISET™ and CellSearch™
• Cut-off:
• ISET ≥ 50 CTCs / 10 mL
• CellSearch > 5 CTCs / 7.5 mL
• Results
• CTC count was the strongest predictor of DFS (better than
histology / TNM)
Hofman V, International Journal of Cancer (2011)

Detection of circulating
tumor cells as a prognostic
factor in patients undergoing
radical surgery for non-
small-cell lung carcinoma:
comparison of the efficacy of
the CellSearch Assay™ and
the isolation by size of
epithelial tumor cell method.
Hofman V, International Journal of Cancer (2011)

CTC significantly correlates with survival end-points
in different NSCLC settings
Conclusion

Farace F, Br J Cancer, 2011
EpCAM-based
(CellSearch)
Size-based
(ISET)
Concordance in NSCLC:
4/20
A direct comparison of CellSearch and ISET for circulating tumour-cell
detection in patients with metastatic carcinoma

Epithelial Mesenchymal
Transition (EMT)
Bronte G, Biol Rev (2018)

So What?
What should we do with it?
We can predict the future, and we don’t like it…

NSCLC: diagnóstico molecular, pronóstico y seguimiento; CTC

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to NSCLC: diagnóstico molecular, pronóstico y seguimiento; CTC

Similar to NSCLC: diagnóstico molecular, pronóstico y seguimiento; CTC (20)

More from Mauricio Lema

More from Mauricio Lema (20)

Recently uploaded

Recently uploaded (20)

NSCLC: diagnóstico molecular, pronóstico y seguimiento; CTC

Editor's Notes