Cílená léčba v onkologii Vladimír Rak Prerekvizity ... • Organizmy z buněk • Chování určené proteiny • Proteiny určené geny (DNA) • Nádory z buněk • Změněné chování oproti normálním somatickým buňkám • Změny v DNA (mutace) → nádory Specifické! Prerekvizity ... Nádorové buňky jsou trochu jiné než ostatní somatické buňky protože mají specifické změny v DNA „Cancers don’t invent new things, they co-opt processes, functions that are used in development in normal homeostasis, but they subvert them for their own purposes“ - Douglas Hanahan Myšlenka dne • Možná kdybychom ovlivnili specificky ty funkce, kterými se nádorové buňky liší od normálních buněk, tak vyléčíme nádor a nepoškodíme člověka Proč to dělat? Proč vůbec potřeba? • Standardní léčba: • Nevyléčí 100% lidí • Toxická Proč vůbec potřeba? • Standardní léčba: • Nevyléčí 100% lidí • Toxická Proč vůbec potřeba? • Nevyléčí 100% lidí – jícen adenoCa spinoCa N2 Proč vůbec potřeba? • Nevyléčí 100% lidí – plíce Stádium 5-leté přežití IA1 92% IA2 83% IA3 77% IB 68% IIA 60% IIB 53% Stádium Median OS IV CHT 9-10 měs. Cíl. léčba ≈ 25 měs.* Proč vůbec potřeba? • Nevyléčí 100% lidí – krk - tonzila The length of time from either the date of diagnosis or the start of treatment for a disease, such as cancer, to the date of death from the disease. Patients who die from causes unrelated to the disease are not counted in this measurement. In a clinical trial, measuring the causespecific survival is one way to see how well a new treatment works. Also called CSS. Proč vůbec potřeba? • Nevyléčí 100% lidí – ledvina Proč vůbec potřeba? • Nevyléčí 100% lidí – CNS (GBM) Proč vůbec potřeba? • Standardní léčba: • Nevyléčí 100% lidí • Toxická • Chirurgie • Radioterapie • Chemoterapie Proč vůbec potřeba? • Toxická • Chirurgie • Radioterapie • Chemoterapie + CNS, pankreaty, HNSCC, ... Proč vůbec potřeba? • Toxická • Chirurgie • Radioterapie • Chemoterapie Akutní / pozdní Proč vůbec potřeba? • Toxická • Chirurgie • Radioterapie • Chemoterapie FOLFIRINOX versus Gemcitabine for Metastatic Pancreatic Cancer „klasická“ léčba • Toxická • Nedostatečně účinná Čas ji zahodit a začít používat něco „modernějšího“? První krůčky • Chronická myeloidní leukemie • U těcho nádorů je častá specifická translokace mezi 9. a 22. chromozomem • Vzniká fůzní gen bcr-abl • Je to příčina tohoto onemocnění • cDNA → retrovirus → myš → CML • ABL – protoonkogen • Tyrosin kináza, buněčná diferenciace, dělení, adheze, odpověď na stres • Pokud spojený s BCR (breakpoint cluster region) • Zvýšená aktivita fůzního genu První krůčky • Ovlivňuje • RAS • PI3k – Akt/PKB • Jak-STAT • Jun, Myc, ... • ... • Pokud ale porušíme tyrosin kinázovou funkci → ztráta maligního chování • První cílený lék – imatinib mesylate (gleevec) • Vážena se na a inaktivuje Bcr - Abl • (relativně specifický – inaktivuje 4 TK) Skoro vše První krůčky První krůčky • relativně specifický – inaktivuje 4 TK • Kit se vyskytuje u přibližně % GIST • Solidní nádor – horší výsledky (větší genetická heterogenita?) Další je Kit Hallmarks Hallmarks Hallmarks Typy léků TKIs • Pozice TKs: • Na povrchu (EGFR, ) • V cytoplazmě (Raf, ) • Uvnitř jádra • Cíle TKs: • Serin/threonin • Tyrozin ... intrinsic and acquired resistance are major clinical challenges that limit the effectiveness of this drug class: • secondary mutations in the kinase that prevent or alter drug binding • co-mutations or adaptive changes involving parallel signaling pathways that reduce dependence on the target kinase TKIs The mitogen-activated protein kinase and phosphatidylinositol 3kinase (PI3K) signaling pathways. Major signaling nodes are shown as well as select kinase inhibitors and antireceptor antibodies. Funguje pouze u nádorů co mají danou mutaci / jsou závislé na určité signalizaci (crizotinib, vemurafenib ...) TKIs OncoKB level 1 mutations represent established FDA-recognized biomarkers of response to an FDA-approved drug being used in the FDA-approved cancer indication +sorafenib, sunitinib TKIs – ALK (anaplastic lymphoma kinase) • Orphan receptor (insuline kinase family) • Role při vývoje nervového systému • Fúze z jinými geny (EML4) → ligand-nezávislá signalizace • U přibližně 4-5% NSCLC (mladší muži nekuřáci adenoCa) • Nebývá zároveň s EGFR nebo KRAS mutacemi We conducted a phase 3, open-label trial comparing crizotinib with chemotherapy in 347 patients with locally advanced or metastatic ALK-positive lung cancer... TKIs – ALK (anaplastic lymphoma kinase) • The median progression-free survival was 7.7 months in the crizotinib group and 3.0 months in the chemotherapy group (hazard ratio for progression or death with crizotinib, 0.49; 95% confidence interval [CI], 0.37 to 0.64; P<0.001) Among 80 patients who had received crizotinib previously, the response rate was 56% (95% CI, 45 to 67). Responses were observed in patients with various resistance mutations in ALK and in patients without detectable mutations. Among patients with NSCLC who received at least 400 mg of ceritinib per day, the median progression-free survival was 7.0 months TKIs – BRAF V600E (vemurafenib, dabrafenib) • Mutace přítomná u ≈50 - 60% melanomů • Nebývá při mutaci Ras (stejný efekt) • Pokud RAF wt → TKI aktivují (místo inhibice) downstream ERK signální dráhu RAF TKI (vemurafenib, dabrafenib) A 38-year-old man with BRAF-mutant advanced melanoma with widespread subcutaneous tumor nodules. A: Prior to initiation with vemurafenib. B: After 15 weeks of therapy with vemurafenib. C: At progression, after 23 weeks of therapy. A post-progression biopsy was sequenced and revealed a BRAF V600E mutation and a concomitant MEK1 C121S activating resistance mutation. (Reproduced from Wagle N, Emery C, Berger MF, et al. Dissecting therapeutic resistance to RAF inhibition in melanoma by tumor genomic profiling. J Clin Oncol 2011;29[22]:3085–3096.) • Jak moc je v nádoru buněk? • 1buňka ≈10 μm • Jak moc je v nádoru buněk? • 1buňka ≈10 μm • 1 mm^3 = 100x100x100 buněk = 10^6 buněk • 1 cm^3 = 10^9 buněk • Rozlišovací mez zobrazovacích metod je v rámci milimetrů • To že po léčbě není nikde vidět žádný nádor znamená, že v těle může být něco mezi 0 a asi 10^7 buněk Multi TKIs – sorafenib, sunitinib • Sorafenib • VEGFR, PDGFR, RAF, FLT3, KIT, RET inhibitor Multi TKIs – sorafenib, sunitinib • Sunitinib • VEGFR, PDGFR, FGFR, FLT3, KIT, RAF, FMS • Pazopanib • VEGFR, PDGFR, KIT • Cabozantinib • VEGFR, AXL, MET, KIT, TIE2, FLT3, RET CDK4/6 TKIs (palbociclib, ribociclib, abemaciclib) Co tuto signalizaci porušuje? CDK4/6 TKIs (palbociclib, ribociclib, abemaciclib) In this double-blind study, we randomly assigned, in a 2:1 ratio, 666 postmenopausal women with ER-positive, HER2-negative breast cancer, who had not had prior treatment for advanced disease, to receive palbociclib plus letrozole or placebo plus letrozole. mTOR inhibitory ..... • Součást PIK3, reguluje především růst a přežití buněk • Serin / threonin kináza • Everolimus, sirolimus, ... TKIs závěr • DeVita 2018: Although often effective initially, both intrinsic and acquired resistance to kinase inhibitors is the rule rather than the exception. In many cases, resistance is the result of selection for cells with a co-mutation in a second targetable kinase. In others, “adaptive” resistance due to activation of parallel kinase pathways is the basis for treatment failure. Achieving the promise of precision oncology will thus require the development of combination therapies that can prevent or delay the emergence of drug resistance. Such combinations have been difficult to develop to date due to the diversity of co-mutation patterns observed in lung cancer, melanoma, and other common cancer types. The additive toxicity associated with the use of multiple agents is also a hurdle in the development of effective combination regimens. One can, however, envision a future in which broad prospective tumor molecular profiling and the availability of more selective inhibitors will allow for the personalized selection of kinase inhibitor combinations. Achieving this vision will require close collaboration between clinical and laboratory researchers focused on identifying the biologic basis for drug response in parallel with the development of less toxic, more selective kinase inhibitors. PARPi (olaparib, veliparib, rucaparib, ...) • Oprava SSBs • Pokud porucha DSBs opravy a nárůst SSBs → problém • „BRCAness“ • Syntetická letalita Potenciální otázky: Proč dojde ke smrti buňky, když NHEJ je pořád funkční? A je NHEJ opravdu tak špatné? PARPi (olaparib, veliparib, rucaparib, ...) Between April 7, 2014, and July 19, 2016, we randomly allocated 564 patients: 375 (66%) to rucaparib and 189 (34%) to placebo Eligible patients were aged 18 years or older, had a platinum-sensitive, high-grade serous or endometrioid ovarian, primary peritoneal, or fallopian tube carcinoma, had received at least two previous platinumbased chemotherapy regimens, had achieved complete or partial response to their last platinum-based regimen, had a cancer antigen 125 concentration of less than the upper limit of normal, had a performance status of 0–1, and had adequate organ function. 6 12 18 24 30 36 Imunitní systém • Nádory mají neoantigeny (mutované geny), které imunitní systém bere jako cizí • Imunitní dohled – především T lymfocyty a NK buňky Většinou passenger mutace Málo MHC-1„cizí“ epitopy na MHC-1 Neoantigeny Fetální antigeny Antigeny ze specif. míst (testis) CEA T lymfocyty = CD8+ CTLs Imunitní systém Imunitní systém „...Immune response in cancer reflects a series of carefully regulated events that may be optimally addressed not singly but as a group.“ Imunitní systém Makroskopické nádory se už imunitě úspěšně vyhly Imunitní systém – obrana nádorů CTLA-4 PD-1 Nenastává u myší s poruchou adaptivní imunity Blokují aktivaci CTLs Imunitní systém Blokování CTLs „Chechpoint inhibitory“ („matoucí“ termín) CTLA-4 je inhibiční receptor na povrchu T lymfocytů Funkce: limitace imunitní reakce Protilátky proti CTLA-4 (ipilimumab) Protilátky proti CTLA-4 (ipilimumab) A total of 676 patients with unresectable stage III or IV melanoma, whose disease had progressed while they were receiving therapy for metastatic disease, were randomly assigned to .... The median overall survival was 10.0 months among patients receiving ipilimumab plus gp100, as compared with 6.4 months among patients receiving gp100 alone (hazard ratio for death, 0.68; P<0.001) Blokování CTLs „Chechpoint inhibitory“ („matoucí“ termín) PD-1 je inhibiční receptor na povrchu T lymfocytů Protilátky proti PD-1 / PD-L1 Protilátky proti PD-1 / PD-L1 Protilátky proti PD-1 / PD-L1 Protilátky proti PD-1 / PD-L1 Protilátky proti PD-1 / PD-L1 Imunoterapie CTLA-4 PD-1 CAR-T cells (Chimeric Antigen Receptor) „Choosing the most appropriate antigen is extremely critical, as CARs will essentially kill any cell expressing its target antigen.“ ...Upon encountering the antigen of interest, all necessary costimulation occurs and the T cell can eliminate the encountered cell... CAR-T cells (Chimeric Antigen Receptor) Vhodný antigen? • CD19 (B-cell ALL a B lymfomy) • BCMA (mnohočetný myelom) • CD30 (Hodgkin lymphoma) • FLT3 (AML) „Choosing the most appropriate antigen is extremely critical, as CARs will essentially kill any cell expressing its target antigen.“ „human epidermal growth factor receptor 2 (HER2)-targeted CAR that caused fatal pulmonary toxicity, potentially due to low levels of HER2 expression in the lungs“ CAR-T cells (Chimeric Antigen Receptor) Large B-cell lymphomas, including diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, and transformed follicular lymphoma, are treated with combination chemoimmunotherapy at diagnosis. Patients who have a relapse with chemotherapy-sensitive disease may be treated with high-dose chemotherapy followed by autologous stem-cell transplantation. However, patients who have disease that is resistant to primary or salvage chemoimmunotherapy or who have had a relapse after transplantation have an extremely poor prognosis. Recently, in a large, international, retrospective research study involving patients with non-Hodgkin’s lymphoma (SCHOLAR-1), investigators found an objective response rate of 26%, a complete response rate of 7%, and a median overall survival of 6.3 months with existing therapies among patients who had aggressive Bcell lymphoma that was resistant to chemotherapy or who had a relapse within 12 months after autologous stem-cell transplantation. CAR-T cells (Chimeric Antigen Receptor) ...objective response rate of 26%, a complete response rate of 7%... CAR-T cells (Chimeric Antigen Receptor) ...median overall survival of 6.3 months... CD20 • Receptor na povrchu B-lymfomů • Rituximab • induces lymphoma cell lysis through: • complement-mediated cytolysis • Antibody dependent cell cytotoxicity • induction of apoptosis • acts synergistically with chemotherapy Vývoj a dozrávání B lymfocytů „CD20 function is not fully understood, although it is known to be involved in the calcium flux. Recent studies suggested that raft-associated CD20 constitutes a component of a storeoperated calcium entry pathway activated by BCR“ (2015) CD20 (rituximab) • 399 previously untreated patients, age 60 to 80 years, with diffuse large B-cell lymphoma. • Patients received eight cycles of classical CHOP (cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, vincristine 1.4 mg/m2, and prednisone40 mg/m2 for 5 days) every 3 weeks. • In R-CHOP, rituximab 375 mg/m2was administered the same day as CHOP. Survivals were analyzed using the intent-to-treat principle. Celkové přežití ErbB rodina • Receptory na povrchu buněk • Přenos signálu přes buněčnou membránu • Tyrozin-kinázová funkce • Protoonkogeny HER2 • Receptor na povrchu buněk, součástí ErbB rodiny • Tyrozin-kináza • Trastuzumab, pertuzumab, ... In 1987, amplification of the ERBB2 gene, which encodes the HER2 transmembrane receptor tyrosine kinase, was identified in a subset of breast cancers Problémy • Resistence • Genetická instabilita • Intranádorová heterogenita – obrázek prso geny • Limitace cílů Nature - Vol 458j9 April 2009 doi:10.1038/nature07943 Problémy Nature - Vol 458j9 April 2009 doi:10.1038/nature07943 Problémy The advent of molecularly targeted agents, as discussed in the following sections, has not changed a widespread consensus among drug developers: monotherapies involving either low–molecularweight drugs or biological molecules are unlikely to cure most types of cancer, and effective multi-agent therapies must be devised if definitive, durable clinical responses are to be achieved in the future. Biology of cancer 2014, weinberg