The Warburg Effect: How Does it Benefit Cancer Cells?

Cancer is a dynamic disease. During the course of disease, cancers generally become more heterogeneous. As a result of this heterogeneity, the bulk tumour might include a diverse collection of cells harbouring distinct molecular signatures with differential levels of sensitivity to treatment. This heterogeneity might result in a non-uniform distribution of genetically distinct tumour-cell subpopulations across and within disease sites (spatial heterogeneity) or temporal variations in the molecular makeup of cancer cells (temporal heterogeneity). Heterogeneity provides the fuel for resistance; therefore, an accurate assessment of tumour heterogeneity is essential for the development of effective therapies. Multiregion sequencing, single-cell sequencing, analysis of autopsy samples, and longitudinal analysis of liquid biopsy samples are all emerging technologies with considerable potential to dissect the complex clonal architecture of cancers. In this Review, we discuss the driving forces behind intratumoural heterogeneity and the current approaches used to combat this heterogeneity and its consequences. We also explore how clinical assessments of tumour heterogeneity might facilitate the development of more-effective personalized therapies.

Tumour heterogeneity and resistance to cancer therapies

Treatment options for patients with metastatic melanoma, and especially BRAF-mutant melanoma, have changed dramatically in the past 5 years, with the FDA approval of eight new therapeutic agents. During this period, the treatment paradigm for BRAF-mutant disease has evolved rapidly: the standard-of-care BRAF-targeted approach has shifted from single-agent BRAF inhibition to combination therapy with a BRAF and a MEK inhibitor. Concurrently, immunotherapy has transitioned from cytokine-based treatment to antibody-mediated blockade of the cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and, now, the programmed cell-death protein 1 (PD-1) immune checkpoints. These changes in the treatment landscape have dramatically improved patient outcomes, with the median overall survival of patients with advanced-stage melanoma increasing from approximately 9 months before 2011 to at least 2 years - and probably longer for those with BRAF-V600-mutant disease. Herein, we review the clinical trial data that established the standard-of-care treatment approaches for advanced-stage melanoma. Mechanisms of resistance and biomarkers of response to BRAF-targeted treatments and immunotherapies are discussed, and the contrasting clinical benefits and limitations of these therapies are explored. We summarize the state of the field and outline a rational approach to frontline-treatment selection for each individual patient with BRAF-mutant melanoma.

/pdf/targeted-agents-and-immunotherapies-optimizing-outcomes-in-5a2hkcogzr.pdf

Targeted agents and immunotherapies: optimizing outcomes in melanoma.

Immune checkpoint blockade produces clinical benefit in many patients. However, better biomarkers of response are still needed, and mechanisms of resistance remain incompletely understood. To address this, we recently studied a cohort of melanoma patients treated with sequential checkpoint blockade against cytotoxic T lymphocyte antigen-4 (CTLA-4) followed by programmed death receptor-1 (PD-1) and identified immune markers of response and resistance. Building on these studies, we performed deep molecular profiling including T cell receptor sequencing and whole-exome sequencing within the same cohort and demonstrated that a more clonal T cell repertoire was predictive of response to PD-1 but not CTLA-4 blockade. Analysis of CNAs identified a higher burden of copy number loss in nonresponders to CTLA-4 and PD-1 blockade and found that it was associated with decreased expression of genes in immune-related pathways. The effect of mutational load and burden of copy number loss on response was nonredundant, suggesting the potential utility of a combinatorial biomarker to optimize patient care with checkpoint blockade therapy.

/pdf/integrated-molecular-analysis-of-tumor-biopsies-on-31xm2s4v5v.pdf

Integrated molecular analysis of tumor biopsies on sequential CTLA-4 and PD-1 blockade reveals markers of response and resistance

Emerging Roles of Cell-free Tumor DNA in Oncology The capacity to detect new cancers, treatment-resistant variants, and tumor heterogeneity by noninvasive technology on the basis of tumor DNA in th...

https://www.nejm.org/doi/pdf/10.1056/NEJMra1706174

Application of Cell-free DNA Analysis to Cancer Treatment

BackgroundThe pathogenic mutations in melanoma have been largely catalogued; however, the order of their occurrence is not known. MethodsWe sequenced 293 cancer-relevant genes in 150 areas of 37 primary melanomas and their adjacent precursor lesions. The histopathological spectrum of these areas included unequivocally benign lesions, intermediate lesions, and intraepidermal or invasive melanomas. ResultsPrecursor lesions were initiated by mutations of genes that are known to activate the mitogen-activated protein kinase pathway. Unequivocally benign lesions harbored BRAF V600E mutations exclusively, whereas those categorized as intermediate were enriched for NRAS mutations and additional driver mutations. A total of 77% of areas of intermediate lesions and melanomas in situ harbored TERT promoter mutations, a finding that indicates that these mutations are selected at an unexpectedly early stage of the neoplastic progression. Biallelic inactivation of CDKN2A emerged exclusively in invasive melanomas. PTEN...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1502583

The Genetic Evolution of Melanoma from Precursor Lesions

The pathogenic mutations in melanoma have largely been catalogued, but the order of their occurrence is not known. We identified 82 cases of melanocytic neoplasia with two or more histopathologically distinct precursor and descendent portions. These portions spanned several histopathologic stages including benign nevi, intermediate neoplasms such as dysplastic nevi, melanoma in situ, invasive melanoma, and metastatic melanoma. In total, 277 histopathogically distinct areas were microdissected and sequenced using a panel of several hundred cancer-genes at an average of 275-fold coverage. In all cases precursor lesions harbored mutations known to activate the MAPK pathway, most commonly affecting BRAF or NRAS, and thus these were considered initiating mutations. TERT promoter mutations were the earliest secondary mutations to occur, emerging in intermediate neoplasms and in situ melanomas. Bi-allelic CDKN2A mutations and/or deletions arose predominantly at the transition to invasive melanoma. TP53 and PTEN mutations occurred comparatively later in thicker primary melanomas. In the 12 cases in which matched primaries and metastases were sequenced, no pathogenic mutations were specifically associated with the transition to metastatic melanoma, suggesting that metastatic capability was already present in the primary tumors. Unequivocally benign neoplasms, which mostly consisted of conventional nevi, disproportionately harbored BRAFV600E mutations as the only apparent pathogenic alteration. Lesions that were histopathologically intermediate, such as dysplastic nevi, had two or more pathogenic mutations and were enriched for NRAS mutations. These findings provide genetic support for the existence of an intermediate stage of melanocytic neoplasia, resolving a long-standing controversy. We also found that melanomas with different initiating mutations evolve through distinct evolutionary trajectories linked to specific histopathologic precursors. A mutational signature of UV-radiation-induced DNA damage predominated in lesions from all histopathologic stages, implicating UV-radiation in both the initiation and progression of melanoma. The point mutation burden increased steadily from one progression stage to the next, stabilizing once melanomas became invasive. By contrast, copy number alterations only became prevalent at the transition to invasive melanoma. Melanomas evolve from benign lesions linearly, whereas, they show patterns of branched evolution when they evolve from intermediate lesions; this indicates that evolution may accelerate once a melanocytic neoplasm reaches an intermediate stage. In summary, our study outlines a framework of the genetic evolution of melanocytic neoplasms from precursor lesions and unveils the rate-limiting homeostatic factors that become disrupted as neoplasms progress from one stage to the next, as well as the pathogenic factors driving this evolution. Citation Format: Alan H. Shain, Richard Yu, Iwei Yeh, Jamal Benhamida, Ivanka Kovalyshyn, Aravindhan Sriharan, Eric Talevich, Reinhard Dummer, Jeffrey North, Laura Pincus, Beth Ruben, William Rickaby, Corrado D’Arrigo, Alistair Robson, Robert Judson, Nancy Joseph, Boris Bastian. The genetic evolution of melanoma. [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 2372.

Abstract 2372: The genetic evolution of melanoma

We report two cases of fibrous histiocytoma (FH) associated with discrete nodular aggregates of Langerhans cells (LCs) resembling Langerhans cell histiocytosis (LCH). In addition, the LCs showed positivity for BRAF V600E immunohistochemistry, a finding reported in neoplastic but not reactive LCs 1. To our knowledge, these cases represent the first published association of FH and LCH.

This article is protected by copyright. All rights reserved.

Two cases of benign fibrous histiocytomas (dermatofibromas) associated with Langerhans cell histiocytosis

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The Genetic Evolution of Melanoma from Precursor Lesions

Abstract 2372: The genetic evolution of melanoma

Two cases of benign fibrous histiocytomas (dermatofibromas) associated with Langerhans cell histiocytosis