Sarah Watson

Influence of geriatric consultation with comprehensive geriatric assessment on final therapeutic decision in elderly cancer patients.

Elderly patients represent a heterogeneous population in which decisions on cancer treatment are often difficult. The present study aims to report a 2-year period of the activity of geriatric assessment consultations and the impact on treatment decisions. Since January 2007, we have systematically carried out geriatric consultations, using well-known international scales, for elderly patients in whom treatment decisions appear complex to oncologists. From January 2007 to November 2008, 161 patients (57 men, 104 women; median age 82.4 years, range 73-97) were seen at geriatric consultations. Most of the patients (134/161) were undergoing first-line treatment and cancer was metastatic in 86 patients (53%). Geriatric assessment found severe comorbidities (grade 3 or 4 in CIRS-G scale) in 75 patients, dependence for at least one activity of daily living (ADL) in 52 patients, cognitive impairment in 42 patients, malnutrition in 104 patients (65%) and depression in 39 patients. According to the oncologists prior decisions, there were no changes in treatment decisions in only 29 patients. Cancer treatment was changed in 79 patients (49%), including delayed therapy in 5 patients, less intensive therapy in 29 patients and more intensive therapy in 45 patients. Patients for whom the final decision was delayed or who underwent less intensive therapy had significantly more frequent severe comorbidities (23/34, p<0.01) and dependence for at least one ADL (19/34, p<0.01). In this study, we have found that comprehensive geriatric evaluation did significantly influence treatment decisions in 82% of our older cancer patients.

Pragmatic issues in biomarker evaluation for targeted therapies in cancer

Predictive biomarkers are becoming increasingly important tools in drug development and clinical research. The importance of using both guidelines for specimen acquisition and analytical methods for biomarker measurements that are standardized has become recognized widely as an important issue, which must be addressed in order to provide high-quality, validated assays. Herein, we review the major challenges in biomarker validation processes, including pre-analytical (sample-related), analytical, and post-analytical (data-related) aspects of assay development. Recommendations for improving biomarker assay development and method validation are proposed to facilitate the use of predictive biomarkers in clinical trials and the practice of oncology.

SMARCA4 inactivation defines a group of undifferentiated thoracic malignancies transcriptionally related to BAF-deficient sarcomas

While investigating cohorts of unclassified sarcomas by RNA sequencing, we identified 19 cases with inactivation of SMARCA4, which encodes an ATPase subunit of BAF chromatin-remodeling complexes. Clinically, the cases were all strikingly similar, presenting as compressive mediastino-pulmonary masses in 30- to 35-year-old adults with a median survival time of 7 months. To help define the nosological relationships of these tumors, we compared their transcriptomic profiles with those of SMARCA4-mutated small-cell carcinomas of the ovary, hypercalcemic type (SCCOHTs), SMARCB1-inactivated malignant rhabdoid tumors (MRTs) and lung carcinomas (of which 10% display SMARCA4 mutations). Gene profiling analyses demonstrated that these tumors were distinct from lung carcinomas but related to MRTs and SCCOHTs. Transcriptome analyses, further validated by immunohistochemistry, highlighted strong expression of SOX2, a marker that supports the differential diagnosis of these tumors from SMARCA4-deficient lung carcinomas. The prospective recruitment of cases confirmed this new category of SMARCA4-deficient thoracic sarcomas as readily recognizable in clinical practice, providing opportunities to tailor their therapeutic management.

ETV4 is a useful marker for the diagnosis of CIC -rearranged undifferentiated round-cell sarcomas: a study of 127 cases including mimicking lesions

Subsets of primitive round-cell sarcomas remain difficult to diagnose and classify. Among these is a rare round-cell sarcoma that harbors a CIC gene rearrangement known as CIC-rearranged undifferentiated round-cell sarcoma, which is most commonly fused to the DUX4 gene. Owing to its aggressive clinical behavior and potential therapeutic implications, accurate identification of this novel soft tissue sarcoma is necessary. Definitive diagnosis requires molecular confirmation, but only a few centers are as yet able to perform this test. Several studies have shown that PEA3 subfamily genes, notably ETV4 (belonging to the family of ETS transcription factors), are upregulated in CIC-rearranged undifferentiated round-cell sarcomas. We performed a detailed immunohistochemical analysis to investigate ETV4 expression in CIC-rearranged undifferentiated round-cell sarcomas and their potential mimics (especially Ewing sarcomas). The study cohort included 17 cases of CIC-rearranged undifferentiated round-cell sarcomas, and 110 tumors that morphologically mimic CIC-rearranged undifferentiated round-cell sarcomas: 43 Ewing sarcomas, 25 alveolar rhabdomyosarcomas, 20 poorly differentiated round-cell synovial sarcomas, 10 desmoplastic round-cell tumors, 5 BCOR-CCNB3 sarcomas, 5 lymphoblastic lymphomas, and 2 rhabdoid tumors. All CIC-rearranged undifferentiated round-cell sarcomas (on core needle biopsies and open biopsies) were ETV4-positive with a strong diffuse nuclear pattern. Among the other 110 tumors, only six cases (four Ewing sarcomas, one alveolar rhabdomyosarcoma, and one desmoplastic round-cell tumor) showed focal (<5% of tumor cells) and very weak nuclear expression of ETV4; all other tumors were completely negative for ETV4. We conclude that systematic immunohistochemical analysis of ETV4 makes it possible to diagnose undifferentiated round-cell sarcomas (with no molecular markers for sarcoma-associated translocation) such as CIC-rearranged undifferentiated round-cell sarcoma.

Transcriptomic definition of molecular subgroups of small round cell sarcomas: Molecular classification of sarcoma subtypes

Sarcoma represents a highly heterogeneous group of tumours. We report here the first unbiased and systematic search for gene fusions combined with unsupervised expression analysis of a series of 184 small round cell sarcomas. Fusion genes were detected in 59% of samples, with half of them being observed recurrently. We identified biologically homogeneous groups of tumours such as the CIC‐fused (to DUX4, FOXO4 or NUTM1) and BCOR‐rearranged (BCOR–CCNB3, BCOR–MAML3, ZC3H7B–BCOR, and BCOR internal duplication) tumour groups. VGLL2‐fused tumours represented a more biologically and pathologically heterogeneous group. This study also refined the characteristics of some entities such as EWSR1–PATZ1 spindle cell sarcoma or FUS–NFATC2 bone tumours that are different from EWSR1–NFATC2 tumours and transcriptionally resemble CIC‐fused tumour entities. We also describe a completely novel group of epithelioid and spindle‐cell rhabdomyosarcomas characterized by EWSR1– or FUS–TFCP2 fusions. Finally, expression data identified some potentially new therapeutic targets or pathways. Copyright

MET : nouvelle cible, nouvelles approches combinatoires

The MET tyrosine-kinase receptor is implicated in embryonic development and tissue repair. It appears to be a key of tumour development since it drives cell migration and invasion and can induce the conversion from an epithelial to a mesenchymal phenotype. Aberrant signaling of the MET pathways is associated with an aggressive prognosis and a poor outcome. Preliminary clinical results of several MET inhibitors have been encouraging particularly in tumours in which MET was amplified or mutated. MET inhibition could be especially interesting in association with others drugs since activation of MET is a secondary event induced by hypoxia, inflammatory cytokines or HER inhibitors that could exacerbate the malignant properties of transformed cells. Molecular targeted therapies against MET could therefore be effective as a combination approach.

PAX3-FOXO1 transgenic zebrafish models identify HES3 as a mediator of rhabdomyosarcoma tumorigenesis

Alveolar rhabdomyosarcoma is a pediatric soft-tissue sarcoma caused by PAX3/7-FOXO1 fusion oncogenes and is characterized by impaired skeletal muscle development. We developed human PAX3-FOXO1 -driven zebrafish models of tumorigenesis and found that PAX3-FOXO1 exhibits discrete cell lineage susceptibility and transformation. Tumors developed by 1.6–19 months and were primitive neuroectodermal tumors or rhabdomyosarcoma. We applied this PAX3-FOXO1 transgenic zebrafish model to study how PAX3-FOXO1 leverages early developmental pathways for oncogenesis and found that her3 is a unique target. Ectopic expression of the her3 human ortholog, HES3, inhibits myogenesis in zebrafish and mammalian cells, recapitulating the arrested muscle development characteristic of rhabdomyosarcoma. In patients, HES3 is overexpressed in fusion-positive versus fusion-negative tumors. Finally, HES3 overexpression is associated with reduced survival in patients in the context of the fusion. Our novel zebrafish rhabdomyosarcoma model identifies a new PAX3-FOXO1 target, her3/HES3, that contributes to impaired myogenic differentiation and has prognostic significance in human disease.

Abstract NG03: Zebrafish models of PAX3-FOXO1 pathogenesis reveal novel targets in human rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children, and is associated with a misregulation of skeletal muscle developmental pathways. Of the two histological subtypes, embryonal (ERMS) and alveolar (ARMS), ARMS is more aggressive and prone to metastases. The majority of ARMS cases have a defining t(1;13) or t(2;13) chromosomal translocation and a fusion of either PAX3 or PAX7 with FOXO1, creating a transcriptionally active chimeric protein in which the PAX DNA binding domain is juxtaposed with the transactivation domain of FOXO1. PAX3-FOXO1 is the most prevalent ARMS chromosomal translocation, and is associated with reduced overall survival. However, the biological impact of this PAX3-FOXO1 fusion oncogene and its gain of function activities remains to be fully understood, and the fusion has been intractable to target therapeutically. Remaining questions include understanding how PAX3-FOXO1 initiates and drives ARMS tumorigenesis in the context of a vertebrate developmental system, including susceptible cell types and targeted signaling pathways, with the aim of guiding therapeutic strategies. We are implementing human PAX3-FOXO1 transgenic zebrafish models to address these remaining questions. Previously, we demonstrated that the introduction of human fusion oncogenes, such as EWS-FLI1, in developing zebrafish initiates tumor formation that faithfully recapitulates the human disease (Leacock et al, 2012). Here, we use a transposon-based system to express the human PAX3-FOXO1 fusion during embryonic development, and find that PAX3-FOXO1 is active in a zebrafish system, functions to induce early embryonic defects, such as cyclopia, and is tumorigenic. These developmental phenotypes and tumor formation are unique to PAX3-FOXO1, as over-expression of the normal PAX3 gene in this context does not have the same effect. To identify the developmental signaling pathways PAX3-FOXO1 is leveraging to induce these distinct phenotypes, we FACS sorted cells expressing GFP tagged PAX3 or PAX3-FOXO1 from embryos, and performed a microarray gene expression analysis. Contrasting PAX3 and PAX3-FOXO1 revealed distinct gene expression signatures and aberrant developmental signaling pathways likely responsible for PAX3-FOXO1 driven cell transformation. Of the identified up-regulated genes, the most up-regulated PAX3-FOXO1 target is hairy-related 3 (her3), which we validate as being both unique to and dependent on PAX3-FOXO1 expression. The human homolog of her3 is HES3, which is a basic helix-loop-helix transcription factor that is activated by Notch signaling. To determine its relevance in the human disease, we compared HES3 expression from RNAseq data derived from PAX3/7-FOXO1 fusion positive RMS patient tumors, and found that HES3 is over-expressed in fusion-positive RMS as compared to the fusion-negative RMS subtype. Furthermore, the expression status of HES3 is predictive of overall survival. Over-expression of HES3 predicts reduced overall survival only in the context of the PAX3/7-FOXO1 fusion, and not for embryonal or fusion negative RMS, suggesting this gene and related signaling pathways are down-stream targets of PAX3-FOXO1 that likely contribute to its pathogenesis. These data highlight the utility of zebrafish developmental assays to identify new oncogenic targets in a whole animal context that are relevant in the human disease. Our findings identify a new PAX3-FOXO1 target gene, and implicate Notch signaling as a contributor to PAX3-FOXO1 pathogenesis. We are currently applying these transgenic zebrafish models, in parallel to human cell models and primary patient genomic data, to determine the mechanisms underlying her3/HES3 over-expression and its potential for therapeutic targeting. Overall, an ARMS transgenic zebrafish model with embryonic phenotypes that are informative and predictive of tumorigenesis has relevance ranging from studying ARMS biology to translational applications, including in vivo drug discovery. Citation Format: Genevieve Kendall, Sarah Watson, Lin Xu, Franck Tirode, Olivier Delattre, James Amatruda. Zebrafish models of PAX3-FOXO1 pathogenesis reveal novel targets in human rhabdomyosarcoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr NG03.

Abstract 4190: Expression of a human CIC-DUX4 fusion is sufficient to induce malignant small round blue cell tumors in zebrafish: a new model of CIC-DUX4 sarcoma for translational research

Proceedings: AACR 107th Annual Meeting 2016; April 16-20, 2016; New Orleans, LAnnCIC-DUX4 sarcomas are aggressive soft-tissue malignancies characterized by frequent metastases and uniformly poor survival. Histologically, CIC-DUX4 sarcomas resemble Ewing sarcomas but do not express EWS-FLI1 or other FET-ETS fusion genes typical of Ewing sarcoma. The molecular origins of these tumors began to be clarified with the discovery that they harbor characteristic t(4; 19) or t(10; 19) chromosomal translocations that fuse the transcriptional repressor CIC with the homeodomain-containing protein DUX4. The resulting CIC-DUX4 fusion protein acts as an aberrant transcription factor. However, the critical targets of CIC-DUX4 have been only partly described, the cell of origin and mechanism of transformation are unknown and animal models of the disease are lacking. Owing to this lack of biologic understanding, patients with CIC-DUX4 sarcomas are treated with the same regimens used for classical Ewing sarcoma, despite generally poor outcomes.nnTo comprehensively address these problems we are taking a cross-species comparative oncology approach via analysis of human CIC-DUX4 sarcomas and genetically engineered in vivo zebrafish models. To study in vivo effects of CIC-DUX4, we used highly efficient Tol2 transposon-based transgenesis techniques to induce tumors in the zebrafish. In the absence of a known cell of origin for CIC-DUX4 sarcoma, we used a variety of ubiquitous promoters to induce mosaic expression of human CIC-DUX4 in zebrafish, along with GFP or mCherry fluorophores to mark transgenic cells. CIC-DUX4 exerted stong effects on zebrafish embryonic development. In particular, expression of CIC-DUX4 was prominent in the developing vasculature including hemogenic endothelium, indicating that the endothelial environment is favorable to the expression of CIC-DUX4. Beginning at 5 weeks of age, almost 40% of injected animals developed invasive, rapidly-growing tumors. Similar to human CIC-DUX4 sarcomas, tumors in the zebrafish occurred in soft tissues including the trunk musculature, the ventral abdominal tissue and the head and neck. The tumors exhibited histologic features of small round blue cells, identical to the appearance of human CIC-DUX4 sarcomas. Zebrafish CIC-DUX4 sarcomas were readily transplantable as allografts into recipient zebrafish. To further understand the molecular mechanisms of tumorigenesis, and to establish aspects of CIC-DUX4 function common to human and zebrafish tumors, we are carrying out detailed molecular analysis of the zebrafish tumors including RNASeq and whole-exome sequencing. Taken together these findings demonstrate that CIC-DUX4 expression is sufficient to promote the development of SRBCT, give insight into the cellular origins of CIC-DUX4 sarcomas and provide a valuable new animal model for translational research in this disease.nnCitation Format: Sarah Watson, Genevieve Kendall, Olivier Delattre, Franck Tirode, James F. Amatruda. Expression of a human CIC-DUX4 fusion is sufficient to induce malignant small round blue cell tumors in zebrafish: a new model of CIC-DUX4 sarcoma for translational research. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4190.

Antiangiogéniques: les anciens et les nouveaux

Angiogenesis constitutes a major process in cancer progression, especially by promoting the growth of malignant cells and dissemination of metastases. The development of anti-angiogenic targeted therapies has made significant progress over the last decade. Since the discovery of bevacizumab, numerous therapies have been designed. Among them, small molecules that inhibit the tyrosine-kinase activity of pro-angiogenic receptors such as VEGFR, are the most studied today. Current research focuses on the development of new targeted-therapies, able to inhibit the activity of several receptors at the same time and with a greater affinity. This article reviews the data on anti-angiogenic targetedtherapies, from available molecules to drugs still in the process of development.RésuméL’angiogenèse constitue un processusmajeur de la progression tumorale, en particulier en favorisant la croissance des cellules malignes et leur dissémination sous forme de métastases. Depuis une dizaine d’années, le développement de thérapies ciblées antiangiogéniques connaît un grand engouement. Depuis la découverte du bevacizumab, de nombreuses autres thérapies ont été développées. Parmi elles, les inhibiteurs de l’activité tyrosinekinase des récepteurs proangiogéniques comme le VEGFR sont aujourd’hui les plus étudiés. La recherche actuelle est basée sur le développement de nouvelles thérapies ciblées pouvant inhiber l’activité de plusieurs récepteurs avec une grande affinité. Cette revue reprend les données actuelles sur les thérapies ciblées antiangiogéniques disponibles et en cours de développement.