Elsevier

The Lancet Oncology

Volume 16, Issue 8, August 2015, Pages 937-948
The Lancet Oncology

Articles
Analysis of circulating DNA and protein biomarkers to predict the clinical activity of regorafenib and assess prognosis in patients with metastatic colorectal cancer: a retrospective, exploratory analysis of the CORRECT trial

https://doi.org/10.1016/S1470-2045(15)00138-2Get rights and content

Summary

Background

Tumour mutational status is an important determinant of the response of metastatic colorectal cancer to targeted treatments. However, the genotype of the tissue obtained at the time of diagnosis might not accurately represent tumour genotype after multiple lines of treatment. This retrospective exploratory analysis investigated the clinical activity of regorafenib in biomarker subgroups of the CORRECT study population defined by tumour mutational status or plasma protein levels.

Methods

We used BEAMing technology to identify KRAS, PIK3CA, and BRAF mutations in DNA obtained from the plasma of 503 patients with metastatic colorectal cancer who enrolled in the CORRECT trial. We quantified total human genomic DNA isolated from plasma samples for 503 patients using a modified version of human long interspersed nuclear element-1 (LINE-1) quantitive real-time PCR. We also measured the concentration of 15 proteins of interest—angiopoietin 2, interleukin 6, interleukin 8, placental growth factor, soluble TIE-1, soluble VEGFR1, VEGF-A, VEGF-C, VEGF-D, VEGF-A isoform 121, bone morphogenetic protein 7, macrophage colony-stimulating factor, stromal cell-derived factor-1, tissue inhibitor of metalloproteinase 2, and von Willebrand factor—in plasma samples from 611 patients. We did correlative analyses of overall survival and progression-free survival in patient subgroups based on mutational status, circulating DNA concentration, and protein concentrations. The CORRECT trial was registered with ClinicalTrials.gov, number NCT01103323.

Findings

Tumour-associated mutations were readily detected with BEAMing of plasma DNA, with KRAS mutations identified in 349 (69%) of 503 patients, PIK3CA mutations in 84 (17%) of 503 patients, and BRAF mutations in 17 (3%) of 502 patients. We did not do correlative analysis based on BRAF genotype because of the low mutational frequency detected for this gene. Some of the most prevalent individual hot-spot mutations we identified included: KRAS (KRAS G12D, 116 [28%] of 413 mutations; G12V, 72 [17%]; and G13D, 67 [16%]) and PIK3CA (PIK3CA E542K, 27 [30%] of 89 mutations; E545K, 37 [42%]; and H1047R, 12 [14%]). 41 (48%) of 86 patients who had received anti-EGFR therapy and whose archival tumour tissue DNA was KRAS wild-type in BEAMing analysis were identified as having KRAS mutations in BEAMing analysis of fresh plasma DNA. Correlative analyses suggest a clinical benefit favouring regorafenib across patient subgroups defined by KRAS and PIK3CA mutational status (progression-free survival with regorafenib vs placebo: hazard ratio [HR] 0·52, 95% CI 0·35–0·76 for KRAS wild-type; HR 0·51, 95% CI 0·40–0·65 for KRAS mutant [KRAS wild type vs mutant, pinteraction=0·74]; HR 0·50, 95% CI 0·40–0·63 for PIK3CA wild-type; HR 0·54, 95% CI 0·32–0·89 for PIK3CA mutant [PIK3CA wild-type vs mutant, pinteraction=0·85]) or circulating DNA concentration (progression-free survival with regorafenib vs placebo: HR 0·53, 95% CI 0·40–0·71, for low circulating DNA concentrations; HR 0·52, 95% CI 0·40–0·70, for high circulating DNA concentrations; low vs high circulating DNA, pinteraction=0·601). With the exception of von Willebrand factor, assessed with the median cutoff method, plasma protein concentrations were also not associated with regorafenib activity in terms of progression-free survival. In univariable analyses, the only plasma protein that was associated with overall survival was TIE-1, high concentrations of which were associated with longer overall survival compared with low TIE-1 concentrations. This association was not significant in multivariable analyses.

Interpretation

BEAMing of circulating DNA could be a viable approach for non-invasive analysis of tumour genotype in real time and for the identification of potentially clinically relevant mutations that are not detected in archival tissue. Additionally, the results show that regorafenib seems to be consistently associated with a clinical benefit in a range of patient subgroups based on mutational status and protein biomarker concentrations.

Funding

Bayer HealthCare Pharmaceuticals.

Introduction

Standard treatment for metastatic colorectal cancer includes drugs that target the molecular drivers of colorectal cancer pathogenesis, such as VEGF and EGFR. These drugs have improved overall survival, progression-free survival, and response in metastatic colorectal cancer.1, 2, 3, 4, 5, 6, 7, 8, 9

Tumour genotype plays an important part in drug resistance in patients with metastatic colorectal cancer. For example, use of anti-EGFR-antibody treatment is restricted to patients with RAS-wild-type tumours, some of whom acquire RAS mutations during treatment as a mechanism of drug resistance.10, 11 Genotyping of tumour tissue can help with the selection of patients with tumours amenable to treatment; however, the value of testing a tumour sample is limited by intertumour and intratumour heterogeneity. Moreover, archival tissue will not show genotypic changes that have occurred since the sample was obtained.

Regorafenib is a multikinase inhibitor that inhibits various protein kinases implicated in oncogenesis, angiogenesis, and the tumour microenvironment.12 Treatment with regorafenib has shown significant benefits for overall survival and progression-free survival in patients with previously treated metastatic colorectal cancer in two placebo-controlled phase 3 trials, CORRECT13 and CONCUR.14

Investigation of the effect of genotype on treatment outcomes in patients treated with regorafenib is important in view of the association between tumour genotype and response to treatment that exists with other drugs used for metastatic colorectal cancer. In this retrospective exploratory analysis, we investigated the clinical activity of regorafenib in biomarker subgroups of the study population of CORRECT, as defined by tumour mutation status, plasma DNA concentration, or plasma protein concentrations.

Section snippets

Study design and participants

CORRECT13 was an international, multicentre, randomised, placebo-controlled phase 3 study in patients with histologically or cytologically documented metastatic adenocarcinoma of the colon or rectum who had received all approved standard therapies available locally (including a fluoropyrimidine, oxaliplatin, irinotecan, bevacizumab, and, if appropriate, cetuximab or panitumumab), with disease progression during, or within 3 months after the last administration of the last standard therapy. 760

Results

In CORRECT, 760 patients were randomly assigned (2:1) to receive treatment with regorafenib (505 patients) or placebo (255 patients) between April 30, 2010, and March 22, 2011. The trial was stopped by the data monitoring committee at the second planned interim analysis on Oct 22, 2011, after 432 deaths, because the hazard ratio (HR) for overall survival for regorafenib versus placebo crossed the prespecified overall survival efficacy boundary (HR 0·77, 95% CI 0·64–0·94, one-sided p=0·0052).

Discussion

Our analysis shows that regorafenib provides a consistent overall and progression-free survival benefit in a range of subgroups of patients with metastatic colorectal cancer based on tumour mutation status and plasma protein biomarker concentrations. Furthermore, our results support the use of circulating tumour DNA to establish tumour genotype at the time of treatment.

To our knowledge, this is the largest study published so far to address the genetic evolution of metastatic colorectal cancer

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