nouveaux outils en biologie et leur intérêt dans la...
TRANSCRIPT
Nouveaux outils en biologie et leur intérêt dans la physiopathologie, le diagnostic et le pronostic des
hémopathies malignes
Les Lymphomes : LNH et LH
Catherine Thieblemont
Hôpital Saint-Louis, Paris
DES le 16/01/2015
Plan Cancer 2014-2019
INCa - DGOS
Soutien de 28 plateformes hospitalières de génétique moléculaire en France pour
développer les tests déterminants pour les traitements des patients atteints de KC
dont les hémopathies malignes
En 2015
LLC Lymphomes
+ ACSé : mutation ALK dans L. Anaplasique + KC Bronchique (mutation exons 23 et 25) Traitement ciblé : Crizotinib (Xalkori) iTK -> ALK
FISH Caryotype CCND1 Clonalité ALK
Incidence 14 000 cas/an Incidence 5 000 cas/an
En pratique, pour les lymphomes en 2015
FISH Caryotype ? CCND1 Clonalité ALK
- réarrangement de BCL1 (BM, FISH) - Analyse de l’expression de la cycline D1 (IHC)
Analyse FISH BCL2, BCL6, MYC + IHC
* DLBLC tous? Ou critères? - 1ère ligne : COPADEM – High dose CHOP - EPOCH - Réfractaire: protocole ERLEM lysa * Burkitt
Clonalité Lésions / lymphomes cutanés Et pb diagnostique dans qqs lymphomes gg
BCL1; IgH t(11;14) BCL1 MTC-JH
CCND1
MYC tr MYC Amp MYC IHC
Lymphomes : maladie hétérogène
Incidence : 14 /100 000 –> 99 /100 000
Lymphome B à > 90%
Forme agressive dans 1/2 des cas Plus de 30 sous-types différents
Présentation clinique, réponse au
traitement et évolutions diverses
OMS 2008
Physiopathologie: Hétérogénéité moléculaire
Moelle osseuseMoelle osseuse SangSang Ganglion Ganglion
CSL
Lymphoblaste
LB naïf LB naïf
CB CC IB
LB mémoire
Plasmocyte
Lymphopoïèse BLymphopoïèse B
indépendante de l’antigèneindépendante de l’antigène
Lymphopoïèse BLymphopoïèse B
dépendante de l’antigènedépendante de l’antigène
B-cell differenciation
Moelle osseuseMoelle osseuse SangSang Ganglion Ganglion
CSL
Lymphoblaste
LB naïf LB naïf
CB CC IB
LB mémoire
Plasmocyte
Lymphopoïèse BLymphopoïèse B
indépendante de l’antigèneindépendante de l’antigène
Lymphopoïèse BLymphopoïèse B
dépendante de l’antigènedépendante de l’antigène
B-cell differenciation
- Hypermutation somatique - Switch isotypique
Instabilité génétique
Moelle osseuseMoelle osseuse SangSang Ganglion Ganglion
CSL
Lymphoblaste
LB naïf LB naïf
CB CC IB
LB mémoire
Plasmocyte
Lymphopoïèse BLymphopoïèse B
indépendante de l’antigèneindépendante de l’antigène
Lymphopoïèse BLymphopoïèse B
dépendante de l’antigènedépendante de l’antigène
DLBCL Follicular lymphoma Burkitt lymphoma Hodgkin lymphoma
Mantle cell lymphoma CLL
Marginal Zone lymphoma Waldenstrom Hairy Cell leukemia
Germinal Center Pre- GC Post GC
Chromosomal abnormality : one subytpe of lymphoma related to one differentiation stage
OMS 2001; 2008
What we have learned since 2000
• DNA: Structural abnormalities = structural genomics
CGH, SNP, sequencing (NGS), ChIP-CHIP
• RNA and protein : expression abnormalities = functionnal genomics
Gene expression profiling (GEP) , RNA-Seq
Proteomic profil, Tissu array
What we have learned since 2000 in lymphoma
- Gene expression profiling (GEP)
- Genome and exome sequencing
- Mutational profil of a selected genes set as biomarkers
Goal :
- Strategy to improve success for the use of novel agents
GEP in lymphoma
Fernandez V, et al.. Cancer Res 2010 Thieblemont C, e al. Blood 2004. Rosenwald et al., Cancer Cell, 2003
Dave et al.,NEJM 2004
iMCL cMCL
T cells
Macrophages
Alizadeh et al. Nature 2000; 403:503 Monti S, et al. (2005) Blood 105: 1851-61
MCL MZL
FL
DLBCL
Alizadeh et al. Nature 2000; 403:503
Cell lines patients
n = 40
Molecular Profil
The power of GCB / ABC classification
Lenz G, et al. NEJM 2008
Survival predictor score (n=394) in DLBCL treated by R-CHOP
• Angiogenesis
• Fibrosis
• Immune cells
Chromosomal imbalances in DLBCL
DLBCL : two distinct diseases
Jeelall YS et al. Immunol Cell Biol. 2011
NF-KB pathways
BCR signalling cascade is
generally antigen- dependent
Jeelall YS et al. Immunol Cell Biol. 2011
Hallmark of ABC-like DLBCL : constitutional NF-KB activation
Oncogenic gene mutation
•CARD11 10%
•CD79A/B 20%
•A20 30%
•MYD88 39%
Ngo VN, Nature 2006 - Lenz G, Science 2008 Davis RE, Nature 2010- Compagno M, Nature 2009
A subset of DLBCLs exhibits
coordinate overexpression of protein kinase
of the BCR signaling cascade
and BCR dependent survival signals
Inhibitors of Tyrosine kinases in DLBCL
Modified from Wiestner, JCO 2013. nucleus
Oral drug
Fostamatinib disodium R406 Rafetinib
dasatinib
IPI-145
iBTK
BTK inhibitor
Modified from Wiestner, JCO 2013.
iBTK
nucleus
Inhibiting BTK
Aalipour A et al. BJH 2013
Inhibiting BTK
Wilson W et al. 623 – ASH 2012
Ibrutinib : meaningful response rate in relapsed/refractory ABC DLBCL, but not in other molecular subtypes.
Phase II study of Ibrutinib, a BTK inhibitor
in De novo R/R DLBCL
• R/R DLBCL • n=70 • GEP of FFPE biopsy (Affymetrix) • Sanger sequencing CD79B and MYD88 mutations • Assessment every 2 cycles of 28 d
Ibrutinib
560 mg/j
Phase Ib study : Ibrutinib + R-CHOP in patients with CD20-positive B-cell NHL
• Résults (in10 patients after 6 cycles)
– ORR : 100 %
– RC : 70 %
Younes A, Thieblemont C, et al. Lancet Oncol 2014
Good tolerance profil
• CD20+ B-cell lymphoma
• untreated
n = 17
Ibrutinib + R CHOP
Ibrutinib : dose escalation : 280 - 420 - 560 mg/j
R-CHOP : standard doses
Toxicity > 20% of the patients
Neutropenia 77 %
Thrombopenia 65 %
Vomiting 59 %
Diarrhea 24 %
constipation 24 %
Fatigue 35 %
Ibrutinib 560 mg/j
+ R-CHOP
Phase III : Ibrutinib + R-CHOP
in patients with non-GC DLBCL (PHOENIX)
Currently ongoing
• Primary Objective : EFS
• duration from the date of randomization to the date of disease progression,
• relapse from CR as assessed by the investigator
• initiation of subsequent treatment therapy
• death
Phase III : Ibrutinib + R-CHOP
in patients with non-GC DLBCL (PHOENIX)
Surrogate Methods for classifying GC / ABC DLBCL
Hans C.P. et al. (2004)
Blood 103: 275-282
Germinal center
Non-Germinal center
CD10 + - Bcl–6 + - MUM1 - +
152 samples
IHC
NGS : Next generation sequencing
Lawrence MS, et al Nature 2014
Genome of DLBCL are highly mutated
Analysis of somatic point mutations in exomes sequences from 4,742 cancers (with matched normal-
tissue) accross 21 cancer types
Median somatic mutation per Mb : 3,3 mutations
less than lung cancer and melanoma (~10)
More than 200
DLBCL
exomes
published
F. Jardin Lysa
Genes mutations in DLBCL : cell functions and signaling pathways
GCB-related DLBCL
JAK-STAT Pathway
Epigenetic regulation
PI3K/mTOR/AKT pathway
Apoptosis
Immunity
BCR/NFKB pathway
Genes mutations and cell functions in DLBCL
Jardin F. Discov Med 2014,
ABC-related DLBCL
Recurrent mutated genes in DLBCL : Common and specific signaling pathways in GCB-like and ABC-like DLBCL
Pasqualucci L. Curr Opinion Hematol 2013
EZH2 : exclusively mutated in GCB
Morin DM et al. Nat Genet 2010
Phase II trial: NCT01897571 and NCT02082911
NGS : Genetic lesions in Lymphoma
Rossi et al. 2013
NGS : Genetic lesions in Lymphoma
Rossi et al. 2013
Help for diagnosis and for therapeutic target :
Hairy cell leukemia : Targeting BRAF
Tiacci E et al. NEJM 2014; Tiacci E et al; ASH 2014
BRAF V600F mutation Phase II trial Vemurafenib 28 BRAF-V600E+ HCL patients
Biomarkers in lymphoma
Strategies to improve success for the use of novel agents
Standard CHOP +/-R ABVD
New agents Brentuximab AMM 2013 Ibrutinib AMM 2014 Idelalisib AMM 2014 Revlimid AMM 2015 Inhibiteur EZH2 Inhibiteur bcl2 Anti PDL1/L2 – PD1 antibromodomain …
Check Hayden E, Nature March 2014; 507 : 273 -4
The $1,000 genome is fast approaching
Biomarkers in lymphoma
Strategies to improve success for the use of novel agents
… …
LYSA
DLBCL - Ibrutinib + Chemo in front line - Anti-PD1
Marginal Zone lymphoma - Ibrutinib : anti-BTK, in front line Mantle cell lymphoma - ABT : anti-bcl2 - Ibrutinib : anti-BTK Associated with chemo Hodgkin’s Lymphoma - Brentuximab + Chemo - Anti-PD1
Trials Biology
F. Jardin Lysa
Hemato-oncology C. Thieblemont P. Brice S. Amorin S. Harel Pathology J. Brière A. Janin Biology K. Beldjord K. Diaz D. Geromin ME. Noguera W. Cuccuini Genomic, Nancy R. Houlgatte J. Broseus S. Hergalant
Lymphoma TEAM Saint-Louis Hospital –University Paris – Sorbonne Paris Cité VII
Radiology E. De Kerviler C. De bazelaire Nuclear Medecine P. Merlet D. Lussato Pharmacists I. Madelaine P. Faure
Jardin F. Discov Med 2014,
En pratique : NGS : Genetic lesions in Lymphoma