DIAPHRAGM. DIAgnostic and Prognostic biomarkers in the Rational Assessment of Mesothelioma

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1 DIAPHRAGM DIAgnostic and Prognostic biomarkers in the Rational Assessment of Mesothelioma Kevin Blyth Consultant Respiratory Physician, Southern General Hospital NRS Research Fellow & Honorary Clinical Senior Lecturer, University of Glasgow

2 An Introduction.. Consultant in Respiratory Medicine MD in MRI and other cardiorespiratory disease biomarkers (2007) Regional Pleural Service General Respiratory Clinic Thoracic Malignancy Service (Interventional Bronchoscopy, EBUS, Thoracoscopy) Research Program weighted towards Pleural Disease (Malignancy, Infection, PTX) Founder/Chair of the WoS Mesothelioma MDT

3 Plan Introduction Mesothelioma Research Program DIAPHRAGM Trial Design Research Questions Sample Collection & Storage Sample Timing Tumour & Host Covariates and Confounders

4 Epithelioid Sarcomatoid Biphasic Breathlessness & Pain (diffuse, refractory) Almost never metastasizes Unique nonspherical growth pattern Develops in unique physical environment with prolonged inflammatory prodrome Median Survival 9/12, but huge variation. Some patients survive for many years

5 The increasing Incidence of Mesothelioma Average latency between exposure and death is 41 (15 67) years Health and Safety Executive. Mesothelioma mortality in Great Britain. Estimating the future burden. National Sta

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7 Mesothelioma Incidence Peaks of UK incidence are in the West of Scotland Standardised Mortality Rate 200 to to to to to 80 0 to 40 Glasgow Newcastle Middlesbrough Stoke Swindon London Plymouth Portsmouth/ Southampton

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9 DIAPHRAGM DIAgnostic and Prognostic Biomarkers in the Rationale Assessment of Mesothelioma

10 DIAPHRAGM Milestones 2011: Conception and early design Feb 2012: IHTAB review March 2012: MRI Feasibility Study Funding Application Summer 2012: MRI Feasibility Opened Dec 2012: DIAPHRAGM Funding Application Nov 2013: DIAPHRAGM Fellow appointed Dec 2013: DIAPHRAGM Opened

11 Fibulin-3 Retrospective Study 92 Mesothelioma and 271 Asbestos Exposed/Other Controls Blood Fibulin-3 levels were significantly higher in patients with MPM compared with other cohorts. The inset shows the receiver operating characteristic (ROC) curve for patients with MPM vs. controls Pass HI et al. Fibulin-3 as a blood and effusion biomarker for pleural mesothelioma. NEJM 2012 Oct 11;367(15):

12 SOMAscan Proteomic Assay: Pilot Data Retrospective Study 117 Mesothelioma and 142 Asbestos Exposed Controls ROC curves for SOMAscan proteomic assay in classifier training (blue), blinded verification (purple) and validation (red) sets with corresponding AUC values and 95% confidence intervals RM Ostroff et al. Early Detection of Malignant Mesothelioma in Asbestos-exposed Individuals with a Noninvasive Proteomics-based Surveillance Tool. PLoS One 2012; 7(10): e46091

13 Gene Name Gene Id Protein Target SwissProt ID Function MM vs Asbestos* KS test p-value t test p-value APOA1 335 Apo A-I P02647 Lipid transport Down 2.99E E-11 C9 735 C9 P02748 Adaptive immune response CCL Ck-b-8-1 P55773 Cellular ion homeostasis, inflammatory response Up 6.47E E-07 Up 2.81E E-08 CDK5/ CDK5R1 1020/ 8851 CDK5/p35 Q00535/ Q15078 Cell morphogenesis Up 1.22E E-09 CXCL BLC O43927 Immune system development Up 1.67E E-08 F Coagulation Factor IX P00740 Coagulation cascade Up 2.46E E-09 FCN FCN2 Q15485 Immune effector Up 3.38E E-11 FN Fibronectin P02751 Cell morphogenesis Down 9.23E E-06 ICAM sicam-2 P13598 Cell adhesion Up 2.67E E-06 KIT 3815 SCF sr P10721 Immune system development, receptor tyrosine kinase MDK 4192 Midkine P21741 Regulation of cell division SERPINA Kallistatin P29622 Serine protease inhibitor TNFRSF8 943 CD30 P28908 Regulation of cytokines & cell proliferation * Up or down regulation in MM cases relative to controls. Down 3.83E E-08 Up 2.99E E-02 Down 2.05E E-07 Up 8.02E E-06

14 Gene Name Gene Id Protein Target SwissProt ID Function MM vs Asbestos* KS test p-value t test p-value APOA1 335 Apo A-I P02647 Lipid transport Down 2.99E E-11 C9 735 C9 P02748 Adaptive immune response CCL Ck-b-8-1 P55773 Cellular ion homeostasis, inflammatory response Up 6.47E E-07 Up 2.81E E-08 CDK5/ CDK5R1 1020/ 8851 CDK5/p35 Q00535/ Q15078 Cell morphogenesis Up 1.22E E-09 CXCL BLC O43927 Immune system development Up 1.67E E-08 F Coagulation Factor IX P00740 Coagulation cascade Up 2.46E E-09 FCN FCN2 Q15485 Immune effector Up 3.38E E-11 FN Fibronectin P02751 Cell morphogenesis Down 9.23E E-06 ICAM sicam-2 P13598 Cell adhesion Up 2.67E E-06 KIT 3815 SCF sr P10721 Immune system development, receptor tyrosine kinase MDK 4192 Midkine P21741 Regulation of cell division SERPINA Kallistatin P29622 Serine protease inhibitor TNFRSF8 943 CD30 P28908 Regulation of cytokines & cell proliferation * Up or down regulation in MM cases relative to controls. Down 3.83E E-08 Up 2.99E E-02 Down 2.05E E-07 Up 8.02E E-06

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17 Diagnostic Biomarker Performance Patients with Suspected Pleural Malignancy Target n= 600, 6 diagnostic pleural centres (Thoracoscopy) 120 patients with MPM 20%) Asbestos Exposed Controls Target n =109, recruited in Glasgow via CAA Cross-sectional Substudy Contrast enhanced MR imaging and paired blood: pleural fluid biomarker levels prior to Thoracoscopy Prognostic Biomarker Performance MPM patients will have repeat biomarker levels at 3 months Follow-up until death, or 2 years

18 DIAPHRAGM Recruitment January February March April May June July Aug Sep Oct Per month Cumulative Target July August September October 0 SGH VIC GRI/STOB GGH

19 DIAPHRAGM: Samples & Storage Serum, Plasma and DNA (cell pellet) in 120 patients with Mesothelioma 480 patients with non-mesothelioma Pleural Effusion 109 Asbestos-exposed Controls Paired Pleural Fluid samples in 50 Stored at -80 C, within 2 hours of sampling Fluid in 250 μl aliquots

20 DIAPHRAGM: Sample Timing & Covariates Tight, pre-defined early sampling when the patient presents with suspected pleural malignancy Must be prior to any significant pleural intervention that may affect biomarker levels: pleural biopsy, intercostal drain, pleurodesis Recording of covariates/confounders at each blood draw Inflammatory biomarkers, medications, renal function, BMI

21 DIAPHRAGM: Tumour & Host Determinants Tumour Tumour volume using Pleural MRI in 50 patients recruited in Glasgow Tumour vascularity based on contrast kinetic MRI data Host Tumour microenvironment (acute, chronic inflammation, stromal composition) Systemic Inflammatory Response

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23 Conclusion DIAPHRAGM is a multicentre observational study Funded by CSO (Project Grant and NRS Fellow) Trial Management by CR-UK Glasgow CTU Testing the utility and basis of novel biomarkers Determinants (disease, host) Confounders (organ dysfunction, host, drugs..) Anatomical and Functional Imaging Blood and Pleural Fluid Banking built-in

24 Comments & Questions