Xét nghiệm đột biến EGFR trong ung thư phổi không tế bào nhỏ & vai trò của nhà giải phẫu bệnh trong kỷ nguyên điều trị ứng hợp

Xét nghiệm đột biến EGFR trong ung thư phổi không tế bào nhỏ & vai trò của nhà giải phẫu bệnh trong kỷ nguyên điều trị ứng hợp

SỞ Y TẾ TP HỒ CHÍ MINH BỆNH VIỆN UNG BƯỚU HỘI Y HỌC TP HỒ CHÍ MINH

HOI UNG THU

XÉT NGHIỆM DOT BIEN EGFR TRONG UNG THU PHO! KHONG TE BAO NHỎ

VAI TRO CUA NHA GIAI PHAU BENH TRONG KY NGUYEN DIEU TR| UNG HOP

TP Hô Chí Minh, Chủ nhột, ngòy 23 thang 06 nam 2013

HỘI THẢO KHOA HỌC

XÉT NGHIEM DOT BIEN EGFR TRONG UNG THƯ PHÔI KHÔNG TẾ BÀO NHỎ: VAI TRÒ CỦA NHÀ GIẢI PHẪU BỆNH

TRONG KỶ NGUYÊN ĐIÊU TRỊ ỨNG HỢP

08:30, Chủ Nhật, ngày 23 tháng 06 năm 2013

KS Nikko, 235 Nguyễn Văn Cừ, Quận 1, TP Hồ Chí Minh

Chủ tọa

GS BS Nguyễn Chấn Hùng Chủ tịch Hội Ung Thư Việt Nam CHƯƠNG TRÌNH

nguyên điều trị ứng hợp PGS TS Brendan Pang Giám đốc phòng thí nghiệm,

TT chẩn đoán phân tử học ung thư Khoa Giải phẫu bệnh - Đại học Quốc gia Singapore 10:00 - 10:50 Lựa chọn các phương pháp xét nghiệm đột biến EGFR

TS BS Guanshan Zhu Trưởng Đơn vị Nghiên cứu Di truyền học Ung thư Trung tâm Nghiên cứu Phát minh AstraZeneca Thượng Hải

10:50 - 12:00 Thao luận

Tiệc trưa

AstraZeneca?

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Center China

EGFR Mutation Testing:

An Update and Experience Sharing

Mike Zhu, MD/PhD

Principal Scientist of Tumour Genetics Translational Science of Asia & EM iMed AstraZeneca R&D

dun22"4/23'4, 2013 at Ha Noi / HCM, Vietnam

@ Understanding of EGFR mutations

@ Understanding of tumour and DNA

@ Process for EGFR mutation testing

@ Choice of testing methods

@ Surrogate samples for tumour mutation testing

@ Experience from mainland China

@ Online training resource about EGFR mutation testing

EGFR activating mutations in NSCLC SF

@ 437 patients with samples evaluable for

EGFR mutation screening

in Asia Center China

»>Frozen tumor from China

Branchiotaveolar carcinoma (BA\ 7 3

‘Squamous cell carcinoma “4 1 0.02

Mutation type vs sensitivity to Gefitinib .°

Sensitivity to

1 ean o deletions; ~90% Sensitive

Sample collection/preparation vs

DNA quality/quantity

Choice of methods

@ QPCR method recommended for quality check if the DNA is derived from FFPE tissue

The amount of tumour cells in bronchial biopsy

samples is variable and relatively low wee

h Tumour

These samples would require enrichment for

tumour cells prior to EGFR mutation analysis,

and/or a sensitive EGFR mutation testing

method used to ensure low level EGFR

mutations are not missed

Pathology review lên

ey

formalin fixed paraffin sections in tubes, cores extraction to ensure tumour

* To ensure the tumor tissue used for mutation detection is NSCLC

* To ensure tumor percentage is qualified for mutation screening and data analysis

(>40% for sequencing; much less for ARMS)

+ To ensure the tumor cell number is enough for detection

(at least 100 tumor cells should be included in the tissue)

+ To mark the tumor rich area for macro-disection when needed

Critical step for the success of EGFR mutation testing

Could be a limiting step for the turn around time (TAT) of the testing

* No PCR product within the DNA extraction area

* Change gloves and blades frequently

* Clean the bench before and after

„jïả"HHBBBBBBBBBBBBBBBBBBBBBBBBBBBNBBEBkE

= OD value(260, 260/280): concentration and purity

= Fluo dye: concentration only

* qPCR: concentration of amplifiable DNA and potential PCR inhibitors |

6 = Transfer product /add reagent/ open tube 20~30%

0.1%

ARMS vs DNA sequencing Center China SF

ARMS kit DNA sequencing

EGFR mutation type coverage 29 types of common mutations any known and unknown mutation ; Lower limit of detection <1% 20%

70-75%

Mutants detected >95% (estimated to be associated with 25-30%

‘mutation unknown’ results’) Amplicon size ~100bp >200bp

Procedure time (ex DNA ext") <h 1 day

High

lexi (multi-step complex analysis requiring

Camapenty bow highly skilled and experienced

technicians) Result output Objective Subjective Commercial kit

1 F Hirsch, et al JCO 2006

2 C Zhu, etal JCO 2008

EGFR RGQ i EGFR Mutation Clamp —- PCR Kit i it Detection Kit

Pleural Effusion for EGFRmtesing _.S2

* Kimura et al Cancer Sci 2006; 7 (7):642-648 “Zhang et al Lung Cancer 2008; 60:175-182

@ EGFRm can be detected from pleural effusion

@ Sensitive methods are needed

Innovation

valued surrogate samples for EGFRm detection !2'7

@ Data from paired samples: tissue vs MPE, tissue vs plasma

@ Determined by Amoy Dx ARMS kit

MPE + - _ Total Plasma _ + - _ Total

Total 12 16 28 Total 69 76 145

sensitivity: 83.3% sensitivity: 59.4%

@ Cytology samples: ready to @ Plasma samples: need

promote for EGFRm testing further study

| i Unpublished data, for reference only

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2, Tumor content of the sample

3, DNA extraction method and results

4, EGFRm testing method and results

5, Clinical indication of the EGFRm status

EGFRm testing in mainland China in 2009

® 9 hospital-based labs

@2 with ARMS method

97 with sequencing

@ A few service CROs by sequencing

@<1% patients with NSCLC tested

@ ~24% mutation positive rate

@ Clinicians & pathologists short of

awareness of the testing methods

®@ >16% patients with NSCLC tested

@ 30-32% mutation positive rate

@ Clinicians & pathologists aware of the testing methods

For reference only

Good collaboration of Clinician-Pathologist-TestingLab

is the most important factor for success !

Tissue availability and quality control

Interpretation of testing results Turn around time (TAT)

‘This website is an international information resource intended for international healthcare professionals with an interest in epidermal

growth factor receptor (EGFR) mutation testing and the treatment of advanced non-small cell ung cancer (NSCLC) Please choose

which website you require

While the intemet serves a global community, the pharmaceutical industry is subject to country-specific regulatory considerations

This means that the registration status and approved product labels may not be the same in different countries Please refer to your

local Prescribing Information for full details of products referred to in this website

Access to the International egfr-rutation.com website for healthcare professionals 3

Policy

Information for patients and members of the press

‘PATIENTS: This website is intended for PRESS: if you are a member of the press, you

intemational healthcare professionals only If you should visit the AstraZeneca Press Office @

are a patient, please click ‘len! formavon

Lssfst (PIL), which has been written for patients

and provides information about taking or using this medicine For Summary of Product Characteristics

(SPC) please click here

information in your local country for specific

For more information on AstraZeneca’s products,

please click ' :-

-35-

ae

MUTATION This website is intended for Healthcare Professionals only, if you are a patient please click here Astrazenecs?

ASK A QUESTION

mutation testing expert a question about EGFR mutation testing

EGFR, the epidermal growth factor receptor, is a cellular transmembrane receptor.’ This receptor xpressed Evidence for personalised

across a number of different tumour types, including non-small cell lung cancer (NSCLC).1 treatment

Mutations in the tyrosine kinase jain of the EGFR gene increase the activity of pro-survival intracellular Expert opinions

signalling cascad

Survival and his results in the dependence of certain cancer cells on EGFR for proliferation, invasion

tetastasis, and the stimulation of tumour-induced angiogenesis >

EGFR mutations are present in approximately 30-40% of Asian and approximately 10-12% of non-Asian patients

with advariced NSCLC 4.5.5

A patient's EGFR mutation status — positive or negative — can be confirmed by performing a diagnostic EGFR

mutation test to look for the presence or absence of mutations in tumour DNA encoding the EGFR gene

itation testing in advanced NSCLC patients helps physicians to prescribe the most appropriate

each patient

References

Wells A EGF receptor nt / Biochem Cell Biol 1999; 31: 637-643

2 Gazdar AF, Shigematsu H, Herz J, Minna JD Mutations and addiction to EGFR: the Achilles ‘heal’ of lung

cancers? Trends Mol Med 2004; 10: 481-486

3 Mendelsohn J, Baselga J The EGF receptor family as targets for cancer therapy Oncogene 2000; 19: 6550—

6565

4 Tokumo M, Toyooka S, Kiura K ef al The relationship between epidermal growth factor receptor mutations

ang clinicopathologic features in non-small cell lung cancers Clin Cancer Res 2005; 11: 1167-1173

5 Yoshida k, Yatabe Y, Park J ef al Prospective validation for prediction of gefitinib sensitivity by epidermal

growth factor receptor gene mutation in patients with non-small cell lung cancer J Thorac Oncol 2007; 2: 22—

28

6 Cortes-Funes H, Gomez C, Rosell R et al Epidermal growth factor receptor activating mutations in Spanish

| gefitinid-treated non-small-cell lung cancer patients Ann Oncol 2005; 16: 1081-1086

i EGFR mutation test results

Approximately 10-12% of Caucasian patients and 30-40% of Asian patients with advanced ne cancer (NSCLC) have epidermal growth factor receptor (EGFR) mutation-positive tumours.*

improved progression-tree survival and objective response rates when treated with firstii

inhibitors (EGFR-TKis) compared with standard doublet chemotherapy 42*.7£

There is a large amount of data supporting sensitivity to EGFR-TK therapy in patients whose tumours harbour the common exon 19 deletions and L85BR point mutations, which make up about 90% of all EGFR

therapy based on clinical tnals or individual case reports may be limited or absent

Effective interpretation of EGFR mutation test results will help physicians to prescride the most appropriate treatment for each patient

1 Cortes-Funes H, Gomez C, Rosell R et a/ Epidermal growth factor receptor activating mutations in Spanish

Qefitinio-treated non-small-cell lung cancer patients Ann Onco! 2005; 16: 1081-1086

2 Yoshica K, Yatabe Y, Park J et al Prospective validation for prediction of gefitiniy sensitivity by epidermal

growth factor receptor gene mutation in patients with non-small cell lung cancer J Thorac Onaco/ 2007; 2: 22—

Trandomised phase 3 trial Lancet Onco! 2010; 14: 121-128

7 Zhou C, Wu YL, Chen G etal Erlotinid versus chemotherapy as first-line treatment for patients with advanced

m EGFR mutation-positive non-small-cell lung cancer (OPTIMAL, CTONG-0802): a mullicentre, open-1abel,

randomised, phase 3 study Lancet Oncol 2011; 12: 735-742

i Glossary | ,AA | Advance search S4R°

MUTATION This website Is intended for Healthcare Professionals only, ifyou are a patient please click here Astrazeneca 2

Q

Access multimedia resources on epidermal growth factor receptor (EGFR) mutation testing and relevant » Congress information

congress presentations below

Expert training

Watch how-to videos that explain each step of the EGFR mutation testing process

Gefitinib mechanism of action

Ashort video showing the mechanism of action of gefitinib

Congress information

Watch video presentations from key congresses

Expert information documents

Aseries of documents describing several aspects of EGFR mutation testing, including suitable samples

Dr Brendan Pang, MBBS, FRCPath (UK)

Director DMOC; enes inst Associate, Cancer

Science Institute

Discovered specific receptor for

EGF on target cells 10 years later

The HER Family of Receptors

EGFR "eu

Roskoski Biochem Biophys Res Commun 2004;319:1; Rowinsky Annu Rev Med 2004;55:433

EGFR mutation causes conformational

change and increased activation

Wild Type EGFR Mutant EGFR Ligand ——> (@D) @

EGFR signals for longer

at the cell membrane

Arteaga 2006, Gadzar et al 2004, Hendricks et al 2006, Sordella et al 2004

EGFR internalisation Degradation/recycling

Epidermal growth factor receptor expression in

human lung carcinomas defined by a monoclonal

antibody

rita RW, Hofeditz C, Masui H, Fairshter R, Rovston 1

SCIENCE VOL 304 4 JUNE 2004

EGFR Mutations in Lung Cancer:

Correlation with Clinical Response to Gefitinib Therapy

J Gulllerme Peas,'* Pasi A Jinne.'2* Jøffrey C- Lao,»

Katsuhiko Naoki’ Hidefumi Sasaki” Yoshitaka Fujii”

Bruce E Johnson,'*} Matthew Meyerson’ ?*

CLINICAL

an of MEDICINE th NEW ENGLAND

{CANCER RESEARCA 5, 587-507 Never 199)

Receptor Underlying Responsiveness of Non-Small-Cell

Lung Cancer to Gefitinib

Cann Dagens

Detection of Epidermal Growth Factor Receptor Variations by Partially Denaturing HPLC

Epidermal Growth Factor Receptor Monoclonal Antibody Inhibits Constitutive

Receptor Phosphorylation, Reduces Autonomous Growth, and Sensitizes

Androgen-independent Prostatic Carcinoma Cells to Tumor Necrosis

Factor a!

‘ChavsJye Fong, Edward R Sherwood,’ John Mendelsohn, Chung Lee, and James M Keztowshi

SCHR MEARE, 397 Croke 369

ZD1839 (Iressa): An Orally Active Inhibitor of Epidermal Growth Factor Signaling

with Potential for Cancer Therapy

Alan E Wakeling Simon P Guy, Jim R Woodburn, Susan E Ashton, Brenda J Curry, Andrew J, Barker, and

Keith H Gibson

Epidermal Growth Factor Receptor Mutation Testing

in the Care of Lung Cancer Patients

Timeline: Discovery of EGFR biomarkers during the

Gefitinib development programme

EGFR gene copy number line setting

Thatcher et al 2005, Kim et al 2008, Mok et al 2009, Fukuoka 2009

* The study exceeded its primary objective and demonstrated superiority of

Gefitinib relative to carboplatin / paclitaxel in terms of PFS

—- however, the effect was not constant over time, initially favouring carboplatin /

paclitaxel and then favouring Gefitinib, potentially driven by differences in PFS outcomes for parents with EGFR mutation positive (Gefitinib benefit) and negative in litaxel benefit) tumours

— EGFR mutation = was a strong predictive biomarker for the effect of

Gefitinib compared with carbo} / paclitaxel

* Objective response rate was superior for Gefitinib compared with

carboplatin / paclitaxel

* Overall survival was similar for both treatments (survival follow-up is ongoing

and survival may be influenced by subsequent treatments)

* Gefitinib had a more favourable tolerability profile than carboplatin /

: EGFR Chemo- EGFR Chemo-

Population TKI therapy TKI therapy HR

a Mok T, et al N Eng! J Med 2009;361:947-957; b Han JY, et al J Clin Oncol 2012;30:1122-1128;

2010;11:121-128; e Zhou C, et al J Clin Oncol 2011;29; f Rosell R, et al Lancet Oncol

2012;13:239-246.