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Old 08-06-2013, 06:06 PM   #1
gdpawel
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Functional Profiling Leads to Identification of Accurate Genomic Findings

Robert A. Nagourney, M.D.
Medical & Laboratory Director
Rational Therapeutics

The 2013 American Society of Clinical Oncology annual meeting, held May 31 – June 1, in Chicago, afforded the opportunity to report three studies.

The first, “An examination of crizotinib activity in human tumor primary culture micro-spheroids isolated from patients with advanced non-small cell lung cancer,” reports our experience using the EVA-PCD platform to examine the drug crizotinib. This small molecule originally developed as an inhibitor of the oncogenic pathway MET, was later found to be highly active in a subset of cancer patients who carried a novel gene rearrangement for anaplastic lymphoma kinase (ALK). It was this observation that lead to the drug (sold under the name Xalkori) being approved for the treatment of advanced ALK positive lung cancer. The subsequent observation that this same drug inhibited yet another gene target known as ROS-1 found in a subset of lung cancer patients, has led to its use in this patient population.

Our exploration of crizotinib activity identified a series of patients who received the drug and responded dramatically. This included both ALK positive and ROS-1 positive patients. One patient however, appeared highly sensitive to the drug in our studies, but was found negative for the ALK gene rearrangement by genomic analysis. We repeated our functional analysis only to the find again, the same high degree of crizotinib sensitivity. I felt confident the patient should receive crizotinib, but at the time the drug was not yet commercially available and he didn’t qualify for the protocols, as he was ALK negative.

I scoured the country looking for a way to get the patient treated with crizotinib. From Sloan Kettering to UCLA, no one could help. And then, in collaboration with my abstract co-author Ignatius Ou from UC Irvine, we decided to repeat the ALK analysis. That proved to be a very good idea. For the patient was indeed positive for ALK gene rearrangement by second analysis and subsequently responded beautifully to a treatment for which he would not otherwise qualify. Once again, phenotype trumped genotype.

A final patient in the series represented a particularly interesting application of functional analysis. The patient, a young woman with an extremely rare pediatric sarcoma, had failed to respond to multiple courses of intensive chemotherapy and her family was desperate. As she approached the end of her third year in high school, it looked unlikely that she would reach her senior year. A portion of her tumor was submitted for analysis. The results confirmed relative resistance to chemotherapeutics, many of which she had already received and failed, but showed exquisite sensitivity to crizotinib. Indeed, our inclusion of crizotinib in the analysis reflected our intense effort to identify any activity for this previously refractory patient.

We reported our findings to the pediatric oncologist and encouraged them to consider an ALK rearrangement analysis, despite this particular pathway not being on anyone’s radar prior to our study. The result – a positive gene rearrangement. This led to a successful petition to the drug company for the use of this agent for an off-label indication. The response was prompt and dramatic, and remains durable to this day, nearly a year later. Again, the phenotypic analysis guided us to the correct genomic finding.

Note: Another of the functional cytometric profiling labs has reported out positive for Xalkori (crizotinib) killing tumor cells and killing endothelial cells, with absolutely brilliant responses, in some ALK translocation negative lung cancer patients.
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Old 08-06-2013, 06:11 PM   #2
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Physiology Trumps Informatics

According to laboratory oncologists, much like genomics aims to unravel the structure of the genome, metabolomics focuses on understanding the many small molecule metabolites that result from a cell's metabolic processes.

There are an estimated 5,000 - 20,000 endogenous human metabolites, and analysing their production gives an accurate picture of the physiology of a cell at a given moment in time.

Whereas the cell’s genotype can predict its physiology to a limited extent, metabolomics also takes phenotype – and therefore environmental conditions – into account, allowing a more precise measure of actual cell physiology.

For research, the study of metabolomics provides the means to measure the effects of a variety of stimuli on individual cells, tissues, and bodily fluids.

By studying how their metabolic profiles change with the introduction of chemicals or the expression of known genes, for example, researchers can more effectively study the immediate impact of disease, nutrition, pharmaceutical treatment, and genetic modifications while using a systems biology approach.

Just as a cancer genome refers to the complete set of genes, the metabolome refers to the complete set of metabolites in a given tumor. You may need to have the metabolome as well as the genome.

There are many reasons why cancer cures remain out of reach, but several changes could be implemented immediately to increase the rate of success. One of them is the need to redouble the efforts in the study of basic metabolism and the growing field of metabolomics (the metabolome).

Sweeping Study Of Cancer Metabolism Identifies Hundreds Of Alterations And Potential

http://cancerfocus.org/forum/showthread.php?t=3952
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Old 08-06-2013, 06:16 PM   #3
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Conducting more predictive screens with 3D micro-spheroid cultures

Tissue-mimicking 3D micro-spheroids have been shown to have more physiologically relevant responses to compounds than traditional 2D cultures, bridging the gap between 2D cell cultures and animal and human trials when it comes to screening drugs for cancer.

Three-dimensional (3D) cell culture is already making a big impact on cancer therapy. Rational Therapeutics, based in Long Beach, CA, and the Weisenthal Cancer Group, based in Huntington Beach, CA, are using 3D micro-spheroid culture to provide laboratory-based treatments for cancer patients.

How does it work? First, tumor samples are collected from qualified patients and maintained as micro-spheroids that mimic the body’s environment. The tumor micro-spheroids are then exposed to different drugs and combinations to identify treatments that are most effective at killing the cancer cells. Finally, based on analysis of the results, treatment recommendations are made to help the patients and their physicians determine the best treatment regimens.

According to Rational Therapeutics, the 3D tumor micro-spheroids reflect the complex elements of the body’s cellular environment. The ability to maintain the cells in their native state, where cell-to-cell interactions and heterogeneous cell populations are preserved, has proven critical for the accurate prediction of clinical response.

At the American Association for Cancer Research (AACR) meeting in April 2011, Dr. Robert Nagourney, medical director at Rational Therapeutics and instructor in Pharmacology at the University of California, Irvine School of Medicine, presented findings based on results obtained from primary culture of human tumor micro-spheroids.

Specifically, Dr. Nagourney reported that cancer drugs that target different pathways are more effective when used in combination than alone. By targeting more than one pathway, cancer cells are trapped and killed more easily. The results also demonstrate that biological signals measured from functional cytometric profiling are more powerful and useful than DNA indicators in generating compelling data to aid cancer drug selection.

Sources:
Rational Therapeutics http://www.rational-t.com/
Weisenthal Cancer Group http://weisenthalcancer.com/Home.html
Medicine News Today http://www.medicalnewstoday.com/articles/220677.php
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Old 08-06-2013, 06:21 PM   #4
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Accuracy and clinical utility of in vitro cytometric profiling to personalize chemo

This study published by ASCO was a collaborative effort with SageMedic of Larkspur, CA, The Ludwig Maximilians University Munich, Germany and the Weisenthal Cancer Group. The study was a meta-analyses that examined the sensitivity and specificity of human tumor primary culture studies and the efficacy of drug therapies selected, based on laboratory findings. In aggregate there were 28 retrospective and 15 prospective trials included.

The overall sensitivity was 0.92 (95 percent C.I. 0.89 – 0.95), and specificity of 0.72 (95 percent C.I. 0.67 – 0.77) with an area under the curve for the ROC of 0.893 (SE = 0.023, p < 0.001). When clinical outcomes were examined, it revealed a two-fold improvement for assay-guided therapy for standard of care (odds ratio 2.04, 95 percent C.I. 1.62 – 2.57, p < 0.001). Finally, the one-year survival rate for assay-guided therapy proved superior (OR 1.44, 95% C.I. 1.06 – 1.95, p= 0.02).

As can be seen from this well conducted meta-analysis, there is a wealth of evidence to support the use of human tumor primary cultures for the selection of chemotherapy.

Accuracy and clinical utility of in vitro cytometric profiling to personalize chemotherapy: Preliminary findings of a systematic review and meta-analysis.

Subcategory: Molecular Diagnostics and Imaging

Session Type and Session Title: This abstract will not be presented at the 2013 ASCO Annual Meeting but has been published in conjunction with the meeting.

Abstract Number: e22188

Citation: J Clin Oncol 31, 2013 (suppl; abstr e22188)

Author(s):

Christian Apfel, Kimberly Souza, Cyrill Hornuss, Larry Weisenthal, Robert Alan Nagourney; SageMedic, Inc, Larkspur, CA; Ludwig Maximilians University of Munich, Munich, Germany; Weisenthal Cancer Group, Huntington Beach, CA; Rational Therapeutics, Long Beach, CA

Background:

Cytometric analysis, or in-vitro functional profiling, has been developed as a method to predict tumor response to different drugs with the premise to personalize chemotherapy and improve patient outcomes.

Methods:

We performed a systematic review and a meta-analysis a) of correlative studies using cytometric profiling that reported diagnostic accuracy (sensitivity and specificity) and b) of effectiveness studies comparing patient outcomes when allocated to treatment guided by a cytometric assay versus population-based standard of care. We used Meta-DiSc software to find pooled sensitivity and specificity and analyze the summary receiver operating characteristic (sROC) curve and used Review Manager 5.1 to generate forest plots on overall tumor response (50% or greater decrease in tumor diameter) and on 1-year overall survival.

Results:

We included 28 mostly retrospective trials (n=664) reporting accuracy data and 15 prospective trials (n=1917) reporting therapeutic efficacy data. The accuracy of correlative study revealed an overall sensitivity of 0.922 (95% confidence interval 0.888 to 0.948), specificity of 0.724 (95% CI 0.669 to 0.774) and an area under the sROC curve of 0.893 (SE=0.023, p<0.001). Studies comparing the clinical utility revealed a two-fold overall tumor response for an assay-guided therapy versus standard of care therapy (odds ratio 2.04, 95% CI 1.62 to 2.57, p<0.001). Similarly, patients who received assay-guided therapy compared to those who received standard of care or physician’s choice had a significantly higher 1-year survival rate (OR 1.44, 95% CI 1.06 to 1.95, p=0.02).

Conclusions:

Despite various limitations of individual studies, the aggregate and fairly consistent evidence of these data suggests cytometric profiling to be accurate, to improve overall tumor response, and to increase 1-year patient survival. Given the enormous potential for our society, a well-designed and sufficiently-powered randomized controlled trial is urgently needed to validate these results.

http://meetinglibrary.asco.org/content/118466-132
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Old 08-06-2013, 06:25 PM   #5
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Clinical application of human tumor primary culture analyses

The study reviewed the results of 67 patients from institutions across Brazil. Tumor samples were transported by overnight courier to California for drug response profiling. A broad array of tumors were included. The overall success rate provided actionable results in 62 of 67 patients (92 percent). More than 75 percent of the studies provided results for between 8 and 16 drugs and combinations with a median of 12 reported. Several strikingly good responses were observed, including novel combinations identified in the laboratory. This study confirms the feasibility of international collaboration and reflects the globalization of medical care delivery.

International collaboration in personalized medicine for the treatment of advanced and drug-refractory cancers: Clinical application of human tumor primary culture analyses.

Subcategory: Cytotoxic and Other Novel Agents

Session Type and Session Title: This abstract will not be presented at the 2013 ASCO Annual Meeting but has been published in conjunction with the meeting.

Abstract Number: e13562

Citation: J Clin Oncol 31, 2013 (suppl; abstr e13562)

Author(s):

Fabricio Colacino Silva, Fernando C. Maluf, Antonio C. Buzaid, Robert Alan Nagourney, Nise Hitomi Yamaguchi, Paulo D'Amora, Steven Evans, Paula J Bernard, Federico Francisco; Hospital do Cancer Alfredo Abrao, Campo Grande, Brazil; Hospital Sirio-Libanes, São Paulo, Brazil; Hospital São José, São Paulo, Brazil; Rational Therapeutics, Long Beach, CA; Institute of Advances in Medicine and Hospital Albert Einstein, Sao Paulo, Brazil; Centro de Genomas, Sao Paulo, Brazil

Background:

Personalized oncology has advanced through genomic and proteomic platforms. BCR-abl; EGFr and ALK have provided drug-able targets and companion diagnostics in several diseases, yet many transforming events in humans are polygenic, complex and incompletely understood at a genomic level. Recognition that oncogenesis reflects changes in the cell and its micro environment has renewed interest in whole cell experimental models that capture native-state cell-cell, -stroma and -vascular signaling. Ex vivo analysis of programmed cell death (EVA/PCD) has been shown to correlate significantly with response, time to progression and survival (Nagourney, R. Curr. Treat Op Oncol, 2006).To explore EVA/PCD functional profiling in Brazil, hospital-based investigators, Centro de Genomas and Rational Therapeutics coordinated the transport of 67 surgical specimens for analyses.

Methods:

Dose-response curves using metabolic (ATP-content, mitochondrial) and morphologic endpoints, interpolated to LC50's and synergy by median-effect, were compared with databases to identify patient-specific profiles for cytotoxics, targeted agents and combinations. Reports provided day 7.

Results:

62/67 (92%) provided adequate tumor for analysis; 39 male (58%); 28 (42%) female; 6 chemo-naive and 61 previously treated. Results provided for < 8 drugs in 14/62 (22%); 8-16 drugs in 34/62 (54%) and > 16 drugs in 14/62 (22%). Of 22 tumor types, breast (8); Melanoma (8); NSCLC (8); ovary (7); pancreas (7) and sarcoma (4) predominated. EVA/PCD was used to select the most active combinations. Agents selected, response rates and durations are being tabulated and will be reported.

Conclusions:

The transport, processing and reporting of human tumor primary culture analyses is feasible, providing results in 92% of specimens and median of 12 drugs evaluated (range 4-32). Preliminary outcomes in these drug-refractory patients reveal that novel, often unexpected drug combinations (Everolimus and Lapatinib in triple negative breast) were identified and provided objective tumor responses, supporting EVA/PCD in therapy selection (personalized therapy) and drug development.

http://meetinglibrary.asco.org/content/117655-132
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Old 08-07-2013, 11:24 AM   #6
'lizbeth
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Re: Functional Profiling Leads to Identification of Accurate Genomic Findings

GDP,

thank you for posting this. I remember several years ago I was interested in autologous fat transfer for a revision. My very conservative plastic surgeon was not a fan of it.

Now a few years later I see Catia posting about a very satisfactory results from Dr. Khouri with the Brava bra. He was going against the tide of public opinion. Most US plastic surgeons were not embracing the concept. I watched as the concept was more established in Europe. Finally he is making progress in the US.

I think it will be the same for this concept. Its better. You know it is a better approach. I trust it is a better approach. But it is like turning the Titanic. So many researcher trying to grab the brass ring. They need to step back and look at the big picture. Instead of going full steam ahead. Patients are hitting icebergs and sinking to their deaths. When medicine could just slow down, do a functional test and increase the chances of disease free survival or overall survivor.

I think Nagourney is right. The answer is behind us, and functional testing needs to be integrated into the standard of care for patients with tumor samples large enough to be tested.
__________________
Diagnosed 2007
Stage IIb Invasive Ductal Carcinoma, Pagets, 3 of 15 positive nodes

Traditional Treatment: Mastectomy and Axillary Node Dissection followed by Taxotere, 6 treatments and 1 year of Herceptin, no radiation
Former Chemo Ninja "Takizi Zukuchiri"

Additional treatments:
GP2 vaccine, San Antonio Med Ctr
Prescriptive Exercise for Cancer Patients
ENERGY Study, UCSD La Jolla

Reconstruction: TRAM flap, partial loss, Revision

The content of my posts are meant for informational purposes only. The medical information is intended for general information only and should not be used in any way to diagnose, treat, cure, or prevent disease
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