Hedgehog pathway inhibitors (HPI) inactivating SMO 1, have become first line treatment for patients with locally advanced BCC (laBCC). HPI safety and efficacy have been shown in clinical trials2,3. Nevertheless, common adverse events lead to treatment discontinuation

Basset-Seguin, N

Battistella, M

Benfodda, M

Bouquet, F

Dumaz, N

Ighilahriz, M

Mourah, S

Nikolaev, S

Savina, A

Sharpe, H

Soufir, N

English

Crossref

Vismodegib resistant mutations are not selected in multifocal relapses of locally advanced basal cell carcinoma after vismodegib discontinuation

Apollo (Cambridge)

1  JEADV-2019-0507 1 Vismodegib resistant mutations are not selected in multifocal relapses of locally 2 advanced basal cell carcinoma after vismodegib discontinuation 3 Key words:  4 Basal cell carcinoma, vismodegib, resistance, multifocal relapses, SMO mutations 5 Manuscript word count : 585words 6 Table and figure count : 1 figure and 1 table 7 M.Ighilahriz1, M.Benfodda1,6, H.Sharpe7, N.Soufir1,2,6, S.Mourah1,2, N.Dumaz1,2, 8 M.Battistella3, A.Savina4, F.Bouquet4, S.Nikolaev 1,2,  N.Basset-Seguin1, 2,3 9  10 1 Institute of Skin Research, INSERM U 976, Saint Louis Hospital, Paris, F-75010, France 11 2 Université Paris-Diderot, Sorbonne Paris Cité, Paris, F-75013, France 12 3 AP-HP, Hôpital Saint-Louis, Department of Dermatology, Paris, F-75010, France 13 4  Institut Roche, Boulogne-Billancourt, France 14 5 AP-HP, Saint Louis University Hospital, Pharmacology-Biologic Laboratory, Paris, France 15  6 AP-HP, Hôpital Bichat Claude Bernard, Département de Génétique, Paris, F-75018, France 16 7 University of Cambridge, Cambridge Institute for Medical Research, Cambridge Biomedical 17 Campus  18 2   1 Corresponding author: Nicole Basset-Seguin (MD, PhD) 2 Address : Hôpital Saint Louis, Dermatology, 1 Avenue Claude Vellefaux. Paris 75010.France 3 Telephone number: 0033612973131 4 Fax number: +33142385310 5 Email address: nicole.basset-seguin@aphp.fr 6 Conflict of interest:  7 Nicole  Basset Seguin is an investigator and a consultant for Roche laboratories  8 Ariel Savina  and Fanny Bouquet  are employees of Roche Laboratories 9 Meriem Benfodda, Hayley Sharpe, Nadem Soufir, Samia Mourah, Nicolas Dumaz, Maxime 10 Battistella and Sergey Nikolaev have no conflict of interest to declare. 11 Funding/Support:  12 Nicole  Basset Seguin and Meriem Ighilahriz have received research funding from Roche 13 laboratories 14  15  16  17  18 19 3  To the editor,  1 Hedgehog pathway inhibitors (HPI) inactivating SMO 1, have become first line treatment for 2 patients with locally advanced BCC (laBCC). HPI safety and efficacy  have been shown in 3 clinical trials2,3. Nevertheless, common adverse events lead to treatment discontinuation. 4 Some laBCC develop acquired resistance (AR) to HPI, illustrated by tumor regrowth under 5 treatment after an initial response. AR  is explained by the presence of SMO mutations  6 affecting the binding of the drug or conferring constitutive activation of SMO , (acquired de 7 novo or present before treatment at low frequency and selected during its course) 4,5. LaBCC 8 patients who discontinued vismodegib after achieving complete remission (CR) frequently 9 develop multifocal relapses, which could harbor vismodegib resistant mutations6. We 10 hypothesized that vismodegib resistant clones could lie dormant and regrow after drug 11 withdrawal.  12 To this end, we studied three laBCC patients who achieved clinically and histologically CR 13 with vismodegib and relapsed after treatment discontinuation. All patients gave their written 14 informed consent for the study, including a non-opposition note and signed agreement for 15 genetic analysis. Frozen or formalin-fixed paraffin-embedded (FFPE) tumor tissue was 16 obtained before vismodegib treatment and after relapse for DNA extraction. DNA sequencing 17 of 21 cancer genes (CDKN2A, CTNNB1, DHH, FBXW11, GLI1, GLI2, GLI3, GSK3B, 18 HHIP, HRAS, IHH, NRAS, PIK3CA, PTCH1, PTCH2, SHH, SMO, STAT5B, STK36, 19 SUFU, TP53) (in-house microarray) was performed using Next Generation Sequencing 20 4  (NGS) on PGM sequencer and ThermoFisher technology (Ion PGM™ Hi-Q™ View Chef 1 Kit, ThermoFisher). The preparation of amplicon libraries was made by AmpliSeq. Average 2 sequencing depth was 1125X, and 95% of the target regions were covered. Detection of 3 variants was performed with integrated software dedicated to Ion Torrent technology (Torrent 4 browser and Ion Reporter). Only variants with a high-quality score (p value <0.001) and 5 allelic frequency of a least 0.05 of variant reads were retained.  6 Multifocal relapses from three laBCC patients who achieved CR with vismodegib and 7 discontinued treatment (Fig.1) were studied.  Driver mutations in HP genes were identified:  8 Loss-of-Function PTCH1 mutations in patients 1 and 2 and Gain-of-Function  SMO W535L 9 mutation in patient 3 (Table1). That latter was shown to confer partial drug resistance to 10 vismodegib 5. However CR observed in this patient 3 as well as in 2 other patients with SMO 11 W535L tumors  treated in our clinic (data shown) suggest another yet unidentified genomic 12 variants could be implicated in the resistance. TP53 mutations were also observed in patients 13 2 and 3 (Table 1). All identified mutations are most likely somatic, as they are present in only 14 a fraction of cells (Variant Allele Frequency < 35%), and they inactivate the tumor suppressor 15 gene PTCH1 or are reported as cancer mutations in the COSMIC database. Another variant 16 not described in BCC was detected in patient 2 in gene hFU (STK36), a positive regulator of 17 the GLI zinc-finger transcription factors 7. We found no significant differences in the coding 18 regions of sequenced genes in relapsed tumors compared to pre-treatment tumors, especially, 19 no additional SMO mutations (Table1).  20 5  Our results suggest that in laBCC, multifocal relapses after vismodegib discontinuation harbor 1 the same mutational pattern than the baseline tumor. These results are interesting as BCCs are 2 amongst the most highly mutated human cancers and could be expected to select drug 3 resistant clones. This suggests that residual disease, after treatment cessation, regrows without 4 the need to acquire further genetic alterations  and could be eligible for treatment rechallenge. 5 Accordingly, two of our patients who presented multifocal relapses after treatment 6 discontinuation including the one bearing a SMO mutation were again subjected to 7 vismodegib and achieved apparent clinical CR. 8  9  10  11  12  13 References: 14  15 1.  LoRusso PM, Rudin CM, Reddy JC, Tibes R, Weiss GJ, Borad MJ, et al. Phase I trial of 16 hedgehog pathway inhibitor vismodegib (GDC-0449) in patients with refractory, locally 17 advanced or metastatic solid tumors. Clin Cancer Res Off J Am Assoc Cancer Res. 15 avr 18 2011;17(8):2502‑11.  19 2.  Basset-Seguin N, Hauschild A, Grob J-J, Kunstfeld R, Dréno B, Mortier L, et al. Vismodegib 20 in patients with advanced basal cell carcinoma (STEVIE): a pre-planned interim analysis 21 of an international, open-label trial. Lancet Oncol. juin 2015;16(6):729‑36.  22 3.  Migden MR, Guminski A, Gutzmer R, Dirix L, Lewis KD, Combemale P, et al. Treatment 23 with two different doses of sonidegib in patients with locally advanced or metastatic 24 basal cell carcinoma (BOLT): a multicentre, randomised, double-blind phase 2 trial. 25 Lancet Oncol. juin 2015;16(6):716‑28.  26 4.  Sharpe HJ, Pau G, Dijkgraaf GJ, Basset-Seguin N, Modrusan Z, Januario T, et al. Genomic 27 analysis of smoothened inhibitor resistance in basal cell carcinoma. Cancer Cell. 9 mars 28 2015;27(3):327‑41.  29 6  5.  Atwood SX, Sarin KY, Whitson RJ, Li JR, Kim G, Rezaee M, et al. Smoothened variants 1 explain the majority of drug resistance in basal cell carcinoma. Cancer Cell. 9 mars 2 2015;27(3):342‑53.  3 6.  Herms F. Follow-up of patients with complete remission of locally advanced basal cell 4 carcinoma treated with vismodegib after treatment discontinuation: A retrospective 5 multicentric French study. J Clin Oncol. supple. 2017;9535.  6 7.  Murone M, Luoh S-M, Stone D, Li W, Gurney A, Armanini M, et al. Gli regulation by the 7 opposing activities of Fused and Suppressor of Fused. Nat Cell Biol. mai 2000;2(5):310‑2.  8   9 Tables and figures legends: 10 Patients Patient 1+ Patient 1 ++ Patient 2++ Patient 3+ Mutations Baseline R 1 R 2 Baseline R 3 R 4 Baseline R Baseline R SMO (NM_005631.4)                 c.1604G>T  (p.Trp535Leu) c.1604G>T  (p.Trp535Leu)                 33% 13% PTCH1 (NM_000264.4)  c.1189G>T (p.Glu397*)  c.1189G>T (p.Glu397*)  c.1189G>T (p.Glu397*)  c.1189G>T (p.Glu397*)  c.1189G>T (p.Glu397*)  c.1189G>T (p.Glu397*)         12% 20% 10% 14% 7% 4% c.3306+1G>T  c.3306+1G>T      c.3153G>A (p.Trp1051*) c.3153G>A (p.Trp1051*) c.3153G>A (p.Trp1051*) c.3153G>A (p.Trp1051*) c.3153G>A (p.Trp1051*) c.3153G>A (p.Trp1051*) 11% 16%     11% 22% 10% 15% 4% 4%         STK36 (NM_015690.5)             c.1915-1G>A c.1915-1G>A                 12% 7%     P53 (NM_000546.5)             c.853G>A (p.Glu285Lys)  c.853G>A (p.Glu285Lys)  c.855_856 delinsAA (p.Glu286Lys) c.855_856 delinsAA (p.Glu286Lys)             12% 15% 34% 15%  11  12  13 Table 1 : NGS analysis of patient’s tumor at baseline and at relapse after drug 14 discountinuation. 15  * =  Stop codon, +Frozen biopsy, ++ FFPE biopsy, R=Relapse. The percentages (%) 16 correspond to the presence of mutation in the tumor 17   18 7   1 Figure 1: 2  Illustration of a laBCC and its multifocal relapses in one of the studied patients, a)- Baseline 3 invasive basal cell carcinoma of the upper right eyelid, b)- Complete tumoral remission after 4 12 months of Vismodegib treatment, c)- Multifocal relapses (indicated by arrows) 1 year after 5 treatment discontinuation..  6  7  8 

Vismodegib resistant mutations are not selected in multifocal relapses of locally advanced basal cell carcinoma after vismodegib discontinuation.

https://www.repository.cam.ac.uk/bitstream/handle/1810/294698/Ighilahriz%20et%20al%282019%29.pdf?sequence=1&isAllowed=y

Vismodegib resistant mutations are not selected in multifocal relapses of locally advanced basal cell carcinoma after vismodegib discontinuation.

Abstract

Similar works

Full text

Available Versions

Crossref

Apollo (Cambridge)