Rilevanza dell innovazione tecnologica per la

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1 Rilevanza dell innovazione tecnologica per la ricerca traslazionale e la terapia in oncologia Ruggero De Maria Dipartimento di Ematologia Oncologia e Medicina Molecolare, Istituto Superiore di Sanità

2 Translational research: the central role of biotechnologies Clinicians Benchscientists Clinical scientists Pathophysiology Diseases New infections Genomics Proteomics Stem cells Transgenic/knockouts Structural biology/imaging Clinical trials Clinical problem Clinical application

3 Association of molecular markers with toicity outcomes in a randomized trial of chemotherapy for advanced colorectal cancer: the FOCUS trial

4 How Could Molecular Markers Influence Treatment Decisions? Treatment Clinical Genomic Impact Sparing Yes No Unnecessary Therapy Selection No Yes Curability Avoid undertreatment Direction Equipoise Yes or no More appropriate treatment choices Confirmation Yes No Yes No Confirm clinical decision

5 Innovative screening tools: BRCA1/2 mutation screening for hereditarybreastandovariancancer and syndrome Lifetime risk estimates of developing breast and ovarian cancer among women with inherited BRCA1 or BRCA2 mutations Reduction of cancer incidence with surgical and nonsurgical interventions Roukos DH. Nat Clin Pract Oncol. 2007

6 Association of molecular markers with toicity outcomes in a randomized trial of chemotherapy for advanced colorectal cancer: the FOCUS trial Hypothesized Impact Marker/Function Variant At Risk GT Drug Effected Activity Toicity Other ABCB1/cellular efflu 3435 C to T TT Irinotecan clearance DPYD/detoification IVS14 + 1G to A (*2A) Variants Fluorouracil active metabolite ERCC2/DNA repair 35,931 A to C CC Oaliplatin DNA repair GSTP1/detoification 313 A to G AA Oaliplatin detoification Fluorouracil MLH1/DNA repair -93 G to A AA Irinotecan DNA repair Oaliplatin MTHFR/folate pool, modifies FU response 667 C to T TT Fluorouracil -- TYMS/target for FU 1494: 6 bp insertion +/+ Fluorouracil -- epression metabolite ER: VNTR 28 bp 2R/2R Fluorouracil -- epression UGT1A1/detoification VNTR: 6 or 7 TA repeats (*28) XRCC1/DNA repair 23,885 G to A AA 7/7 Irinotecan detoification Irinotecan Oaliplatin DNA repair Individuals who are homozygous for the UGT1A1*28 allele are at increased risk for neutropenia following initiation of irinotecan treatment Braun MS, et al. J Clin Oncol. 2009

7 Molecular profiling for individual risk assessment : MammaPrint (70 genes involved in cancer biology) Van t Veer et al, Nature2002

8

9 MicroRNAs are endogenous non coding single-stranded RNAs of ~ 22nt that play important roles in animals and plants by targeting 3 UTR of mrnas for cleavage or translational repression MiRNAs may thus represent one of the largest class of gene regulators They are implicated in a variety of processes, such as development, organogenesis, stemness and differentiation, growth control and programmed cell death

10

11 Relationship between the epression levels of 9 MicroRNAs and time from diagnosis to initial therapy in patients with chronic lymphocytic leukemia (CLL) (P<0.01) Calin GA et al. N Engl J Med 2005

12 Present and future of targeted therapy Siena S et al,jnci 2009

13 Biomarkers discovery: predictive value of EGFR activating mutations for anti EGFR therapy (lung cancer) EGFR Mutation Positive EGFR Mutation Negative Probabilit ty of PFS Paclitael/ carboplatin Events Gefitinib: 97 (73.5%) Pac/carbo: 111 (86.0%) HR: 0.48 (95% CI: ; P <.001) Gefitinib Mos Since Randomization ty of PFS Probabili Gefitinib Events Gefitinib: 88 (96.7%) Pac/carbo: 70 (82.4%) Paclitael/ carboplatin Mos Since Randomization ORR, % Gefitinib Paclitael/ P Value Carboplatin Overall population <.001 EGFR mutation positive <.001 EGFR wild type Mok TS, et al. NEJM 2009

14 Biomarkers discovery: predictive value of K ras status for anti EGFR therapy (CRYSTAL trial) Influence of KRAS status on efficacy of cetuimab plus FOLFIRI Normanno N et al. Nat. Rev. Clin. Oncol 2009

15 Translational Potential of Protein Microarrays for Routine Use in Clinical Research Specimens Tumor biopsy Microdissection Protein Microarray Data Analysis Patient/Tumor Specific Signaling Network Profile Tailored targeted therapy

16 Patient A Patient B Patient A Patient B

17 Pathology Report of the Future: Individualized Protein Pathway Activation Maps GlioblastomaMulitformePatient 1 GlioblastomaMulitformePatient 2

18

19 Symmetric division Asymmetric division Tumorigenic cancer stem cells Non tumorigenic transient amplifying progenitors Non tumorigenic differentiated cell Old view New view Non Metastatic Potentially metastatic Non Metastatic

20 Symmetric division Asymmetric division Tumorigenic cancer stem cells Non tumorigenic transient amplifying progenitors Non tumorigenic differentiated cell Old view New view Non Metastatic Potentially metastatic Non Metastatic

21 Symmetric division Asymmetric division Tumorigenic cancer stem cells Non tumorigenic transient amplifying progenitors Non tumorigenic differentiated cell Old view New view Non Metastatic Potentially metastatic Non Metastatic

22 Colon cancer spheres are tumorigenic and reproduce the original tumor even after long term epansion Volume (cm m 3 ) spheres 50 spheres 10 6 adherent cells Time (weeks) CDX2 beta-catenin CK 20 patient mouse patient mouse mouse after ½ year mouse after 1 year H&E Ricci-Vitiani et al. Nature 445:111, 2007

23 Need for more reliable animal models: CSC derived vs cell line derivedenografts Cancer stem cells NCI 60 cell lines RPPM

24 ISS has the largest collection of cancer stem cells MRI Diagnosis and tissue banking Tumor database Tumor dissociation H&E Stem cell culture and epansion Cancer stem cell banking Tumor Type Histotype Total available Tumor Type Histotype Total available Colorectal Colon 18 Glioblastoma 32 Rectum 8 Melanoma 9 Squamous 7 Ovary 3 Adenocarcinoma 8 Breast Infiltrating ductal 9 Lung Large Cell 5 Infiltrating lobular 1 Small Cell 2 Carcinoid 1 TBD 3 Thyroid Anaplastic 4 Papillary 8 Follicular 6

25 Translating the CSC concept into clinical studies Banking and characterization of CSCs Identification of druggable pathways Test of pathway targeted t t dinhibitors through high throughput technologies on CSC derived enografts (i.e. RPPM): in vitro drug screening Clinical studies: Retrospective Rt ti (biomarkers validation) Prospective (adaptive trials)

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