Rafael Rosell,

Cancer Research Laboratory, Dr. Rosell

Germans Trias i Pujol Research Institute and Hospital

Badalona, Barcelona, España

Predicting post-operative recurrence of NSCLC

In partnership with

Chairpersons: Luis Léon & Jorge García Scientific Organizer: Rafael López López

Each metastasis is a disease on its own (Angelova et al Cell 2018)

What to do in the clinical practice? • Bespoke Oncoprint

-Acquired SETD2 mutations to cisplatin -Acquired KEAP mutations to EGFR TKI

• Clearance of lung cancer- NKG2D-activating receptor on NK cells

• Low frequency of early resected NSCLC

• Limited efficacy of adjuvant therapies Chemotherapy

Promotes metastasis via MENAINV

Promotes HIF1α, CD47

EGFR TKIs Promotes STAT3, SRC, FAK and YAP1 Promotes ALDH+ cancer cells

ICB

Lack of effect in tumor re-population cells o IDO-kynurenine-AhR metabolic circuitry o Natural killers expressing NKG2D, NKP46

• Bespoke Oncoprint

KRAS wtLKB1 -> ICB EGFR -> combinatory therapy BRAF - > combinatory therapy Driver fusions - > combinatory therapy Others (without LKB1 or KEAP mutations) - > ICB + CDK4/6 inhibitors ICB + chemotherapy? Avoid, if possible

All lung cancer patients are at risk for recurrence following complete surgical resections. Risk increases with stage. The most frequent & concerning form of recurrence after complete resection is metastasis. Therapies to prevent recurrence must address the threat of metastasis. Cisplatin-based chemotherapy administered either before or after surgery improves survival. Cisplatin-based chemotherapy administered before surgery does not enhance resectability or permit lesser resections. Radiation combined with cisplatin-based chemotherapy does not likely enhance resection rates or survival beyond chemotherapy alone and adds toxicity. Radiation combined with cisplatin-based chemotherapy may provide benefits based on stage and the location of the tumor. Immune checkpoint blockade and oncogene-targeted drugs are appropriate for investigation as neoadjuvant therapies because of their established efficacy and safety in the metastatic setting, and preliminary signals of activity in earlier stages. Perioperative collection and storage of blood, high resolution CT and PET/CT images, and digital pathologic images are important for studying emerging technologies using artificial intelligence

Blumenthal et al JTO 2018, Rockville Consensus Meeting, March, 2018

See also“..Major changes on eighth edition cancer staging..” Rami-Porta, Asamura, Travis and Rusch, CA Cancer J Clin 2017

Navani et al, on behalf of the NSCLC collaborative Group CHEST 2018

Provisos and limitations of adjuvant therapies

Rosell and Karachaliou EbioMedicine 2018

Chemotherapy can promote metastasis

C. Codony-Servat Oncotarget 2017

Pennell et al (Sequist) JCO 2018 Zhong et al (Wu) Lancet Oncology 2018

Adjuvant erlotinib in EGFR mutant NSCLC Adjuvant/CTONG1104

Somatic mutations in lung adenocarcinoma: Co-mutation plot

The Cancer Genome Atlas Research Network, Nature 2014

Park et al FASEB 2018 EGFR TKI resistance mediated by KEAP1 mutations

Zebrafish (Danio rerio) injected with HCC827GRKU cells labeled with the flourescent cell tracker CM-Dil

Bespoke Oncoprint in plasma DNA of early resected NSCLC

Nature thanks S. Lippman, R. Rosell and the other anonymous reviewer(s) for their contribution to the peer review of this work.

Abbosh et al Nature 2017

Bespoke multiplex-PCR panels were synthesized for each patient targeting clonal and sub-clonal SNVs

Chaudhuri et al (Diehn) Cancer Discov 2017

ctDNA detection preceded radiographic progression in 72% of patients by a median of 5.2 months. 53% of patients had ctDNA mutation profiles linked with favorable response to TKIs or ICB.

Chaudhuri et al (Diehn) Cancer Discov 2017

Lam et al (Heymach) WCLC, Toronto, 2018

20

32

18

25

7

30

4

47

94

94

53

7

79

0

85

2

12

12

13

04

13

67

15

84

17

01

18

50

20

54 20

61

21

64

21

85

22

50

22

72

22

72

0 500 1000 1500 2000

Nonsense

Synonymous

Missense

Frameshift

ARID1A = 2285 aa

ARID domainaa 1016-1124

HIC1 binding domainaa 1355-1424

GR binding domainaa 1635-2285

Karachaliou, Bracht, Rosell, J Thor Oncol, Dec, 2018

0

1

2

3

4

5

6

7

8

NCI-H460 A549 Hs746T NCI-H596

Rel

ativ

e A

RID

1A

mR

NA

ex

pre

ssio

n

KRAS-mutated cell lines

MET exon 14-mutated cell lines

**

0,0

0,5

1,0

1,5

1 2

Co

mb

inat

ion

Ind

ex

1.5

1.0

0.5

0.0

AZD6738+ Tepotinib Selumetinib

NCI-H460Hs746T

Oncoprint in Squamous cell carcinoma of the lung

Lack of studies in plasma DNA

Teixeira et al Nat Med 2019

Lung carcinoma in situ (CIS) lesions precursor to LSCC

Circos diagram comparing CIS genomic profiles with TCGA LSCC data

Teixeira et al Nat Med 2019

TP53, CDKN2A, SOX2 and AKT2 FAT1, KMT2D, KEAP1, EGFR and NOTCH1

LSCC

Dotto and Rustgi Cancer Cell 2016

Li et al..Baselga, Cancer Cell 2018

Genomic alterations causing YAP activation leads to CDK6-mediated resistance. FAT1 deletion and truncated mutations – PFS of 2.4 months in patients receiving CDK4/6i.

Cristescu et al Science 2018

KEYNOTE Clinical data sets, Merck

Predicting immunotherapy response

Niemeijer et al Nat Comm 2018 Tumor PDL1 expression < 1%. Heterogeneous tracer uptake in the tumor with 89Zr-nivolumab PET

Mayo de las Casa et al (Molina-Vila) Trans Cancer Res 2019

Mayo de las Casa et al (Molina-Vila) Trans Cancer Res 2019

Conclusions

Provisos in early stage NSCLC • TNM is relevant • Adjuvant chemotherapy could be noxious

SETD2 mutations MENAINV

• Adjuvant single EGFR TKI Enrichment of cancer stem cells Cancer cell rewiring

• Adjuvant immunotherapy: NKG2D and other receptors on NK cells is promising

Monitoring plasma DNA warranted, according to bespoke Oncoprint

• NGS and Nanostring

BACK UP

Patchwork plots from each donor in a 1-cm square area of normal esophageal epithelium from each donor. A number of samples from the donor were selected to amount to 1cm2 of tissue.

Martincorena et al Science 2019

Rustgi and Serag NEJM 2014

Pennell et al (Sequist) JCO 2018

Kadi et al (Hassan) Cancer Res 2018

Activation-induced cytidine deaminase (AICDA) generates T790M mutations

Martin et al, Nat Comm 2018

Thousand-and-one amino acid kinase (TAOK)

(Han et al Oncogene 2018)

See also: Lin et al Carcinogenesis 2018

KD of PKCι increases YAP binding to AMOT (Justilien et al, Oncogene 2017)

Abbosh et al Nature 2017

Nature thanks S. Lippman, R. Rosell and the other anonymous reviewer(s) for their contribution to the peer review of this work.

Corcoran and Chabner NEJM 2018

NGS analysis of early stage surgical biopsy samples

EC

(n=50)

CRC

(n=12)

Patient number

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19EGFR

KRAS

BRAF

PIK3CA

NRAS

KIT

PDGFRA

ALK

ERBB2

ERBB3

ESR1

RAF1

Patient number

1 2 3 4 5 6 7 8 9 10 11 12EGFR

KRAS

BRAF

PIK3CA

NRAS

KIT

PDGFRA

ALK

ERBB2

ERBB3

ESR1

RAF1

Patient number

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

EGFR

KRAS

BRAF

PIK3CA

NRAS

KIT

PDGFRA

ALK

ERBB2

ERBB3

ESR1

RAF1

NSCLC

(n=19)

KRAS

hotspot mutation

Non hotspot mutation

hotspot and non-hotspot mutations

PIK3CA

hotspot mutation

Non hotspot mutation

hotspot and non-hotspot mutations

Molina-Vila 2019

Gwinn et al Cancer Cell 2018

SLC7A11 induced by NRF2

Iyer et al Cell 2018 Liu et al Nat Comm 2017

Hunger and Mullighan NEJM 2015

Overall survival among children with ALL

Bases of Bespoke Oncoprint (Abbosh et al Nature 2017) Relapse of ALL. Subclones with acquired mutations confer resistance to chemotherapy (Hunger and Mullighan NEJM 2015).

Sayar et al Ann Thorac Surg 2004

Perineural invasion in Stage I NSCLC

Depression related to cancer observational study: DeCa

Protocol Number: Version Number: 1.0

Version Date: 2018-07-09 Principal Investigator

Rafael Rosell MD Institute of Oncology Rosell

Co-Investigators Manuel Fernandez-Bruno

Niki Karachaliou

ELBA

European

Liquid Biopsies

Academy

Patient Health Questionnaire

(PHQ)-9

ADRB2

norepinephrine

ERK

NGFBDNF

PKA

IL6

STAT3

paxillin/FAK

epinephrine

Exosomes released in BLOOD

TRK receptorsNGF

BDNF

PSYCHOLOGICAL DISTRESS

nerve

Blood vessels

axonogenesis

tumor cell

Exosomes released in URINE

300 METASTATIC CANCER PATIENTS

100 EARLY-STAGE CANCER PATIENTS

CON

TRO

LS

Tissueif available

FIRST VISIT

100 metastatic lung cancer patients

PHQ-9

Bas

elin

e ti

ssu

e

if a

vaila

ble

Baseline, at best response, at the time of progression

At the first visit

NCounter (custom-designed 200 gene panel)

ADRB2, NGF, BDNF, TrkB, FAK, etc

No depression

Mild depression

Moderate depression

Moderately severe depression

Severe depression

High expressors

Moderate expressors

Low expressors

Covariates to be adjusted: smoking, exercise, food, alcohol

sele

ctio

n o

f b

iom

arke

rs

Depression related

Non-depression related

Transfection of Ba/F3 cell lines with the 2 groups of genes

Identification of genes with oncogenic potential/drug testing

(e.g TPX-0005)

Targeted gene expression in zebrafish→ metastasis, migration,

invasion/therapies

In culture

In vivo

24 mo 36 mo

MSK-IMPACT in 860 LUADs

Jordan…Drilon…Baselga Cancer Discov 2017

Paired blood, lavages and tumor surgical samples

Molina-Vila 2019

Hotspot variants detected by PNA Taqman Assay in blood versus pleural or peritoneal lavages

N= 6 Detected

Detected 2 (33.3%)

No detected 4

Detected 1 (16.7%)

No detected 5

Surgery biopsy LC samples

Plasma (cfDNA)

Pleural lavage (cfDNA)

Molina-Vila 2019

N= 19 Detected

Detected 9 (47,4%)

No detected 10

Detected 2 (10,5%)

No detected 17

Peritoneal lavage (cfDNA)

Plasma (cfDNA)

Hotspots in Surgery biopsy EC samples

N=7 Detected

Detected 2 (28.6%)

No detected 5

Detected 1 (14.3%)

No detected 6

Hotspots Surgery biopsy CRC patients

Peritoneal lavage (cfDNA)

Plasma (cfDNA)

André et al Cell 2018

Shi et al PNAS 2018 Deng et al Science 2015

NKG2D promotes NK activation and tumor rejection (Guerra et al Immunity 2008)