Prospective Validation of a DNA Damage Repair-Hippo Pathway Signature in Patients With Advanced Gastric Cancer

We envisioned a scenario where the interaction between the ATM-Chk2/ATR-Chk1 pathways and Hippo enables GC cells to overcome chemotherapy-induced death stimuli. First, ATM-Chk2 and ATR-Chk1 were found to be activated across all the GC molecular subtypes. Moreover, a number of genes associated with their basal activation are recurrently mutated or amplified.

Thus, we retrospectively characterized a cohort of GC patients treated with first-line therapy for DDR- and Hippo-related markers, identifying a signature predicting inferior PFS and OS. This exploratory analysis provided the necessary information (frequency of candidate biomarkers and effect difference between groups) for a prospective study with validation purposes, which is the main goal of this trial.

Study Overview

• Status: Active, not recruiting
• Conditions: Gastric Cancer; DNA Damage
• Intervention / Treatment: Diagnostic test: investigated biomarkers regarding the efficacy of first-line chemotherapy

Detailed Description

This prospective, multicenter, non-interventional trial is designed for prospectively validating the DDR-Hippo signature as a predictor of inferior PFS in patients with inoperable locally advanced or metastatic GC receiving first-line therapy. Patients will be evaluated for response to chemotherapy every two cycles by current RECIST criteria. PFS will be defined as the time elapsing between the initiation of chemotherapy until objective tumor progression or death, and OS as the time elapsing between the initiation of chemotherapy until death from any cause. All molecular analyses will be centralized at the coordinating center. Investigators performing molecular analyses will be masked to clinical outcomes. Centralized radiological review is planned. The study will be conducted in accordance with the Declaration of Helsinki and adheres to the REMARK criteria.

The second task is designed for exploring genetic events functionally related to the DDR and Hippo pathways that may modify the predictive significance of the signature. These genes are schematically clustered on the basis of the expected alteration in: i) Mutated genes (cluster 1) to be evaluated by targeted DNA-Seq and amplified genes (cluster 2) to be evaluated by FISH/CISH. Cluster 1 includes TP53 (defective cell cycle progression and apoptotic response, aberrant TAZ/YAP-mediated transcription), KRAS (oncogene-induced replication stress and activation of cell cycle checkpoints to avoid apoptosis and senescence), BRCA1 and BRCA2 (defective homologous recombination repair), ARID1A, ATR and ATM (altered ATM/ATR-initiated DNA repair), RHOA (G-protein coupled receptor-mediated activation of TAZ/YAP), CTNNB1, APC and FBXW7 (Wnt-mediated control of TAZ/YAP). Cluster 2 encompasses MYC and KRAS (oncogene-induced replication stress), CCNE1, CCND1 and CDK6 (dysfunctional G1-S transition requiring compensatory activation of intra-S and G2/M checkpoints).

The present study is designed to generate prospective evidence on the ability of the investigated biomarkers to predict the efficacy of first-line chemotherapy in GC patients. The identification of patients who derive marginal benefit from chemotherapy holds the potential to expedite a wave of interventional trials with agents targeting the DDR-Hippo network (e.g. PARP inhibitors and ATR-Chk1 and ATM-Chk2 inhibitors), as well as to delineate the target population for studies with other compounds, such as immune checkpoint inhibitors. Overall, the experimental approach we propose is expected to culminate in the generation of a new tool to be used on a routine basis.

• Study Type: Observational
• Enrollment (Estimated): 167

Contacts and Locations

Study Locations

• Italy
  • Rome, Italy, 00144
    • "Regina Elena" National Cancer Institute

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

Patients with inoperable locally advanced or metastatic GC who are candidates for first-line chemotherapy treatment and meet the following criteria will be included in the study

Description

Inclusion Criteria:

• Age >18 years;
• Histologic diagnosis of locally advanced or metastatic gastric carcinoma (GC) or gastroesophageal junction carcinoma (EJC);
• Biological material adequate for molecular analysis to be performed, taken (at surgery or by biopsy) prior to the administration of any anti-tumor treatment (chemotherapy and/or radiotherapy);
• ECOG PS 0-2;
• Adequate hematologic, hepatic, and renal function;
• Measurable disease according to RECIST criteria;
• Written informed consent.

Exclusion Criteria:

• Previous chemotherapy for metastatic disease;
• Comorbidities not controlled with appropriate medical therapy;
• Brain metastasis;
• Patient unable to give adequate consent for the study

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Popolation	Diagnostic test: investigated biomarkers regarding the efficacy of first-line chemotherapy; The present study was designed to generate solid evidence on the predictivity of the investigated biomarkers regarding the efficacy of first-line chemotherapy in patients with GC

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Identify new biomarkers that predict the activity of first-line chemotherapy, in order to achieve better patient selection.	Computational enrichment analysis will be carried out to test whether tumors of patients with shorter PFS contain a higher-than-randomly-expected representation of a specific pathway/function. Special emphasis will be placed on, but not limited to, the DDR-Hippo-Wnt pathways. For multiple hypothesis testing a Benjamini-Hochberg False Discovery Rate correction will be applied (<5%). For clinical data analysis, the Pearson's Chi-squared test of independence (2-tailed) and the Pearson's correlation coefficient will be used to assess the relationships between categorical and continuous variables, respectively.	Three years
Identify additional genetic events molecularly linked to the DDR-Hippo signature and potentially improve its predictive ability.	RNA and DNA will be extracted from 5µm FFPE tissue sections using the AllPrep DNA/RNA FFPE kit (Qiagen). Libraries for RNA-Seq will be prepared using the TruSeq Stranded Total RNA kit with an initial ribosomal depletion step (Illumina). Targeted DNA-Sequencing will be conducted by designing a custom amplicon panel with DesignStudio and employing the TruSeq Custom Amplicon Low Input Kit (Illumina). RNA will be analyzed with our cloud pipeline (RAP, available at https://bioinformatics.cineca.it/rap/) that employs the Tuxedo Suite (Tophat, Cufflinks, Cuffdiff). For DNA analysis, applications available on Basespace (Illumina) will be used. Sequencing will be performed on our NextSeq500	Three years
Investigate pathways of interest at a deeper level, as well as identify other potential pathways/functions impacting clinical outcomes.	Clinical, pathological and molecular variables will be tested in univariate Cox analysis. A multivariate Cox proportional hazard model for PFS will be build with variables testing significant at the univariate assessment, and the related estimates reported as HR and 95%CI.	Three years

Collaborators and Investigators

• Sponsor: Regina Elena Cancer Institute
• Collaborators: Fondazione Policlinico Universitario Agostino Gemelli IRCCS; University of Roma La Sapienza; Campus Bio-Medico University; Azienda Ospedaliera "Sant'Andrea"; Azienda Sanitaria Locale n. 2 - Lanciano Vasto Chieti; Azienda Ospedaliero Universitaria Policlinico Modena

Study record dates

Study Major Dates

• Study Start (Actual): October 26, 2018
• Primary Completion (Actual): August 30, 2023
• Study Completion (Estimated): August 30, 2024

Study Registration Dates

• First Submitted: March 28, 2023
• First Submitted That Met QC Criteria: January 11, 2024
• First Posted (Actual): January 12, 2024

Study Record Updates

• Last Update Posted (Actual): January 18, 2024
• Last Update Submitted That Met QC Criteria: January 16, 2024
• Last Verified: January 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Neoplasms; Neoplasms by Site; Gastrointestinal Neoplasms; Digestive System Neoplasms; Gastrointestinal Diseases; Stomach Diseases; Stomach Neoplasms
• Other Study ID Numbers: RS1043/18

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No