Molecular markers to aid in Molecular markers to aid in early diagnosis of early diagnosis of

pancreatic cancer pancreatic cancer Michael Goggins, MDMichael Goggins, MD

Professor of Pathology, Medicine and Professor of Pathology, Medicine and OncologyOncology

Johns Hopkins Medical Institutions, Johns Hopkins Medical Institutions, Baltimore, MDBaltimore, MD

“7th Annual Symposium on Gastrointestinal Cancers " St. Louis, Mo, 9/20/08

DisclosureDisclosure

Dr. Goggins has licensing agreements Dr. Goggins has licensing agreements with Oncomethylome sciences for several with Oncomethylome sciences for several DNA methylation markersDNA methylation markers

Early detection of Early detection of asymptomatic diseaseasymptomatic disease

Early diagnosis of Early diagnosis of symptomatic diseasesymptomatic disease

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positive margin

negative margin

poor or undifferentiated

well or moderate

no positive nodes

positive nodes

< 3 cm

≥ 3 cm

p<0.0001

p<0.0001

p<0.0001

p<0.0001

Survival for Ductal Pancreas AdenocarcinomaSurvival for Ductal Pancreas Adenocarcinoma

Tumor Diameter

Margin Status

Lymph Node Status

Histologic Grade

Early detection of small asymptomatic Early detection of small asymptomatic neoplasms may result in cureneoplasms may result in cure

Best outcome: 79 patients wth small, Best outcome: 79 patients wth small, asymptomatic, asymptomatic,

<< 1 cm cancers 1 cm cancers

5- year survival 100% after surgery if 5- year survival 100% after surgery if PC limited to duct epithelium (CIS?)PC limited to duct epithelium (CIS?)

Ariyama 1997

What is the natural history of What is the natural history of patients who present with patients who present with

symptoms and are ultimately symptoms and are ultimately diagnosed with pancreatic diagnosed with pancreatic

cancer?cancer?

We do not have much quantitative We do not have much quantitative information on the obstacles to information on the obstacles to

diagnosis for patients with diagnosis for patients with pancreatic cancerpancreatic cancer

When there are delays in When there are delays in diagnosis, what are their diagnosis, what are their

causes?causes?

Chari et al, AJR 2004;182:897

Pancreatic CT abnormalities up Pancreatic CT abnormalities up to 18 months prior to a to 18 months prior to a

diagnosis of pancreatic cancerdiagnosis of pancreatic cancer

How many patients would have How many patients would have a significantly improved a significantly improved

outcome if they were optimally outcome if they were optimally diagnosed as soon as diagnosed as soon as symptoms presented?symptoms presented?

Markers of Pancreatic Markers of Pancreatic NeoplasiaNeoplasia

What performance What performance characteristics are needed characteristics are needed

for a(serum) molecular for a(serum) molecular marker for the marker for the

DiagnosisDiagnosis of pancreatic of pancreatic cancercancer

The performance The performance characteristics of a marker characteristics of a marker often vary by population often vary by population

(disease stage, heterogeneity): (disease stage, heterogeneity): Ca19-9Ca19-9

0

35

70

105

140

175

210

0 1 2 3 4 5 6

panc ca

amp cbd ca

pancreatitis/panc cyst

islet cell neoplasm

healthy

PC AmpCA CP islet ca controls JHU unpublished

Sensitivity for resectable PC =65%

(Sensitivity for unresectable PC=80%)

900 (TP) 200 (FP)

100 (FN) 800 (TN)

Disease No Disease

Positive

Negative

Test Sensitivity: 90% Specificity: 80% (for cancer)

PPV: 900/1100=81% NPV: 800/900=91%1,0001,000

1,100

900

Disease prevalence 50% (e.g. pancreatic mass)

182 (TP) 360 (FP)

18 (FN) 1540 (TN)

Disease No Disease

Positive

Negative

Sensitivity: 90% Specificity: 80% (for resectable cancer)

PPV: 182/542=34% NPV: 1540/1558=98%

1,800200

542

1558

Disease prevalence ~10%, e.g. mid-back pain, wt loss

What performance What performance characteristics are needed characteristics are needed for a molecular marker forfor a molecular marker for

ScreeningScreening for pancreatic for pancreatic cancer?cancer?

General Population: Age 65: 5 year RiskGeneral Population: Age 65: 5 year Risk

PPV

NPV

Surveillance Epidemiology and End Result

18 (TP) 396 (FP)

2 (FN) 1584 (TN)

Disease No Disease

Positive

Negative

Sensitivity:90% Specificity: 80%PPV: 18/414=4.3% NPV: 1584/81856=99.8%

1,98020

1586

414

Disease prevalence, 1%

New Onset Diabetics: 3 yr PC riskNew Onset Diabetics: 3 yr PC risk

PPV

NPV

Chari et al. Gasto 2005

Family Hx PC 3 1Family Hx PC 3 1stst-degree relatives: 3-yr PC risk-degree relatives: 3-yr PC risk

PPV

NPV

Klein et al. Cancer Research 2004

PPV

NPV

Klein et al. Cancer Research 2004

Family Hx PC 2 1Family Hx PC 2 1stst-degree relatives: 3-yr PC risk-degree relatives: 3-yr PC risk

Is this the right question to Is this the right question to ask of our markers?ask of our markers?

What performance What performance characteristics are needed for characteristics are needed for a molecular marker to Screen a molecular marker to Screen

for pancreatic cancer?for pancreatic cancer?

What about the performance What about the performance characteristics for a characteristics for a molecular marker of molecular marker of

neoplastic precursors?neoplastic precursors?

95 10

5 90

Disease No Disease

Positive

Negative

Test: Sensitivity: 95% Specificity: =90% (EUS or MRI)

PPV: 95/105=91% NPV: 90/95=95%

100100

105

95

Strong Family Hx of PC, prevalence: 10% (IPMN)

Cancer of the Pancreas Cancer of the Pancreas ScreeningScreening

(CAPS) clinical trials(CAPS) clinical trialsWho are we screening?Who are we screening?

Asymptomatic High risk individuals with a Asymptomatic High risk individuals with a strong family history of pancreatic cancer strong family history of pancreatic cancer and certain germline mutation carriersand certain germline mutation carriers

CAPS1:1999CAPS1:1999

CAPS2: 2001CAPS2: 2001

CAPS3: 2006CAPS3: 2006

CAPS4: 2008CAPS4: 2008

Familial PC Screening ProgramsFamilial PC Screening ProgramsPopn Screening

TestsDiagnostic

Yield (IPMN/PC)

Canto, CGH 2004,n=36

FPC (> 3)

PJS

EUS 5.8%

Canto, CGH 2006,n=78

FPC (> 3)

PJS

EUS + CT 10.2%

Kurtz, DDW 2007,n=66

FPC CT/MRI

+/- EUS

7.6%

Poley, DDW 2007,n=46

FPC, PJS, FAMM,

BRCA1/2

EUS 23.9%

Other studies ongoing, eg. Brentnall et al (Seattle), Europac, U Pitt, Zubarik et al, (Vt)

Cancer of the Pancreas Screening Cancer of the Pancreas Screening Study (CAPS) 3Study (CAPS) 3

CAPS 3 – 1CAPS 3 – 1stst national American multicenter national American multicenter screening studyscreening study

EUS/CT/MRI + biomarkers (juice)EUS/CT/MRI + biomarkers (juice) Hopkins, Mayo, MDACC, Dana Farber, Hopkins, Mayo, MDACC, Dana Farber,

UCLAUCLA www.clinicaltrials.gov Email: caps3@jhmi.eduEmail: caps3@jhmi.edu lizst.onc.jhmi.edu/caps3lizst.onc.jhmi.edu/caps3

CAPS 4CAPS 4

Single center, long-term screening and Single center, long-term screening and surveillance (V foundation)surveillance (V foundation)Evaluate expanded eligibility Evaluate expanded eligibility – 1 FDR, 1 SDR (eg. parent and 1 FDR, 1 SDR (eg. parent and

grandparent)grandparent)– BRCA2 mutation carriersBRCA2 mutation carriersBiomarker discoveryBiomarker discovery

3 months10 mm

12 months18 mm

baseline

Lobular CP like changes on EUSLobular CP like changes on EUS

Extensive PanINExtensive PanINLobulocentric Lobulocentric atrophyatrophy

Brune et al, AJSP, 2006

Is the identification of IPMNs Is the identification of IPMNs and PanINs in asymptomatic and PanINs in asymptomatic individuals justified when we individuals justified when we

have not proven that have not proven that surveillance of these lesions surveillance of these lesions leads to improved outcome?leads to improved outcome?

What molecular markers are What molecular markers are on the horizon and can they on the horizon and can they

help identify cancer or help identify cancer or advanced neoplasia?advanced neoplasia?

Molecular alterations in pancreatic Molecular alterations in pancreatic cancercancer

DNA: DNA:

Somatic mutationsSomatic mutations

Aberrant DNA methylationAberrant DNA methylation

Chromosomal losses/gainsChromosomal losses/gains

RNAs:RNAs:

RNAs and microRNAsRNAs and microRNAs

ProteinsProteins

Peptides, glycopeptidesPeptides, glycopeptides

Other Other

eg. Autoantibodieseg. Autoantibodies

Infiltrating pancreatic ca

Normal Duct PanIN 1A PanIN 1B PanIN 2 PanIN 3 Invasive AdenoCa

Intraductal Papillary Mucinous Neoplasm (IPMN)

Mucinous Cystic Neoplasm (MCN)

Cystic Lesion

Adenoma Carcinoma in situ

Invasive AdenoCa

ResearchActivity

Time

1985 1990 1995 2000 2005 2010 2015 2020

CandidateMarkers

Pancreatic cancer research:Pancreatic cancer research:Era of systematic discoveryEra of systematic discovery

TranslationalEvaluation of markers

100%

0%

Systematic Discovery(“Omics”)

The Pancreatic Cancer Genome

Data figure on the pc genomeData figure on the pc genome

Number of somatic mutations in pancreatic cancer

Walter et al, Cancer Biol Ther, 2008

Gains

Losses

Pancreatic cancer chromosomal gains + losses

Quantifying mutant Quantifying mutant KRASKRAS in in Pancreatic juice: LigAMPPancreatic juice: LigAMP

Shi et al, Cancer Biol Ther, 2008

PC

CP

Discovering the cancer Discovering the cancer methylomemethylome

Methylome = genome wide Methylome = genome wide DNA methylation patternsDNA methylation patterns

Chr1

Chr2

Chr3

Chr4

Chr5

Chr6

Chr7

Chr8

Chr9

Chr10

Chr11

Chr12

Log

ratio

Hong et al, Modern Path in press

Aberrant DNA methylation in IPMNs

%

Quantitative Methylation analysis of Quantitative Methylation analysis of ERCP Brushings of common bile ERCP Brushings of common bile

duct stricturesduct strictures

QMSP   ≥1 gene +  

3 gene panel, >3% conc. n Sens (CI) Spec (CI) Accuracy (CI)

Pancreatic adenocarcinoma 41 73.2 (58-84)a 86.4 (7-24) 81 (73-88) i

Biliary tract cancer 10 80 (49-94)b 86.4 (7-24) 86 (76-92)

Cytology   

Pancreatic adenocarcinoma 41 19.5 (14-34)c 100 (95-100) 69 (60-77)

Biliary tract cancer 10 30 (11-60)d 100 (95-100) 92 (84-96)

     

Cytology + QMSP    

Pancreatic adenocarcinoma 41 76 (61-76)e 86.4 (7-24) 82 (74-88) h

Biliary tract cancer 10 90 (60-96)f 86.4 (7-24) 88 (79-94)

QMSP of biliary and Pancreatic duct Brushings QMSP of biliary and Pancreatic duct Brushings performed to diagnose stricturesperformed to diagnose strictures

Parsi et al, Clin Gastro Hep, 2008

Pancreas juice sampling for markersPancreas juice sampling for markers

Quantifying pancreatic juice DNA methylation alterationsQuantifying pancreatic juice DNA methylation alterations5 gene panel, quantified by QMSP, CAPS2 study population

Cancer Res 2006:66:1208

B .

Hs766T

MiaPaca2

Panc1

PL45

PL 12

PL 1

BxP

C3

CAPAN1

CFPA

C1

CAPAN2

PL 8

PL 11

Su86.86

AsP

C1

PL 3

PC 16

PC 17

PC 15

PC 12a

PC 11

PM 1

Normal 1

Normal 2

Normal 3

Marker

Discovering Pancreatic cancer expression patterns

MIC-1

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

0 0 .5 1 1 .5 2 2 .5 3 3 .5

PC CP Nl

S e rie s1

Clin Cancer Res 2006;12:442

Candidate pancreatic cancer Candidate pancreatic cancer markers: markers: Serum Macrophage Serum Macrophage inhibitory cytokine-1 (MIC-1)inhibitory cytokine-1 (MIC-1)

PC=pancreatic cancer CP=chronic pancreatitis Nl=normal

ELISA

MicroRNA alterations in pancreatic cancer

Hahn et al, Oncogene 2007;264442