梅奥(英文)：他莫昔芬、CYP2D6和他莫昔芬活性代谢产物Endoxifen：现状及未来研究方向

MatthewP.GoetzProfessorofOncologyProfessorofPharmacologyMayoClinicCP1229323-1Tamoxifenmetabolism:Arethehydroxylatedmetabolitesimportant?TamoxifenpharmacokineticsandpharmacogenomicsTheeffectsoftamoxifenandmetabolitesonestrogen-inducedproliferationandERgenestimulationClinical:effectsofCYP2D6onKi-67AssociationbetweenCYP2D6genotypeandtamoxifenoutcomes:ExtensivecontroversyRelevanceofCYP2D6testing:Whatlevelofevidenceisneeded?BackgroundTamoxifenBiotransformationMurdteretal.ClinPharTher2011ccCH3CH2OCH2CH2NCH3CH3CYP3A4CYP3A5TamoxifenCYP2D6CYP2C9CYP2C19CYP1A2CYP2D6CYP3A4CYP2B6CYP2C9CYP2C19CYP3A4ccCH3CH2OHOCH2CH2NCH3CH34-hydroxytamoxifenccCH3CH2OCH2CH2NCH3HN-desmethyltamoxifenCYP2D6CYP2B6CYP2C9CYP2C19ccCH3CH2OCH2CH2NCH3H4-hydroxy-N-desmethyltamoxifen(Endoxifen)OHSULT1A1UGTsSULT1A1UGTsTamoxifenBiotransformation5-10nM(average~7nM)5-60nM(average~30nM)150-500nM500-900nMCYP2D6geneEndoxifenandCYP2D6Genotype/PhenotypeMurdteretal.ClinPharTher2011EndoxifenConcentrationsandCYP2D6GenotypeExtensivevariabilityintheconcentrationoftamoxifenanditsmetabolitesCYP2D6isresponsibleforthehydroxylationofN-desmethyltamoxifenCYP2D6geneticvariationiscloselyassociatedwithendoxifenconcentrationsintamoxifentreatedpatientsDotheconcentrationsoftamoxifenanditsmetabolitesaffecttheestrogeninducedstimulationofbreastcancer?SummaryXianglinWuetal.CancerRes2009;69:1722-1727EffectsoftamoxifenandmetabolitesonER-stimulatedproliferationandtranscriptionPhilippY.Maximovetal.JNCIJNatlCancerInst2014;106:dju283Effectsof“postmenopausal”estrogenlevelsonER-stimulatedproliferationinthepresenceoftamoxifenandmetabolitesEffectsof“pre-menopausal”estrogenlevelsonER-stimulatedproliferationinthepresenceoftamoxifenandmetabolitesPhilippY.Maximovetal.BritishJournalofPharmacology2014Combo=7nM4-Hydroxytamoxifen+300nMTamoxifen+700nMN-DesmethyltamoxifenEffectsoftamoxifenandmetabolitesonEstrogen-stimulatedproliferationofMCF-7andMCF-7/HER2ReinickeetalunpublishedEndoxifenisacriticalmetabolitethatnecessaryforfullinhibitionofproliferationandERtranscriptioninER+cellsTheeffectsofendoxifenvarycomparingamountofestrogenusedtostimulatecellgrowthandcelllineTheimportanceofendoxifen(andthusCYP2D6genotype)onproliferationandERtranscriptionmaygreatestinpremenopausalwomenInanER+/HER2model,higherconcentrationsofendoxifenwerenecessarytoinhibitgrowth.SummaryKi-67

ChangeisCorrelatedwithClinicalOutcomeafterTamoxifenTherapyHigherKi-67expressionafter2weeksofendocrinetherapywassignificantlyassociatedwithlowerrecurrence-freesurvival(P=0.004)13JNCIAnnalsofOncology22-582-587,2011Ki-67isasurrogatemarkerfortheresponsetotamoxifentherapyKi-67changeafterTAMER(+)Her2(-)anyT,anyN,M0RadicalOperationNeoadjuvantTamoxifenTherapyFor2-4weeksPrimaryEndpoint：ChangeinKi-67Labelingindex(LI)SecondaryEndpoint:Tumorreduction(US)HistologicalresponseBreastconservativeoperationC-GENTstudy-ProspectiveClinicalStudytoClarifytheRelationshipbetweenCYP2D6GenotypeandtheTherapeuticEffectsofPreoperativeTamoxifenTherapy-CYP2D6genotypeAssociationStudyKi-67LabelingindexCoreneedlebiopsysampleKi-67LabelingindexSurgicallyresectedbreastcancertissue14ZembutsuAACR2016・SapporoMedicalUniversity・SaitamaCancerCenter・ShowaUniversity・SagaraHospital・YokohamaCityMinatoRedCrossHospital・YokohamaCityUniversity

MedicalCenter・SapporoBreastSurgicalClinic・KoikiMonbetsuHospitalSingapore:・NationalUniversityofSingapore・KotoniBreastClinic・NakagamiHospital・NipponMedicalSchool・Higashi-SapporoHospitalC-GENTcollaborativestudygroup(17sites)15・HirosakiMunicipalHospital・StMariannaUniversity・TanTockSengHospital・TokyoMedicalUniversity16Ki-67changeafterneoadjuvanttamoxifentherapypre-TAMpost-TAMKi-67(%)Ki-67(%)pre-TAMpost-TAMP=2.4x10-109.95(%)4.79(%)Med.Reductionrate52%N=273Level1datathat…..CYP2D6geneticvariationisassociatedwithendoxifenconcentrationsCYP2D6genotype(*10/*10)affectsKi-67labelingchangeina2-weekwindowstudyWhatisthelevelofevidencefortheuseofCYP2D6genotypingforpatientswithER+breastcancer?SummaryStudyCohort Totalof1580patients(GermanandUSorigin)Inclusioncriteria Histologicallyprovenbreastcancer Nopreviouschemotherapyorendocrinetreatment otherthanadjuvanttamoxifen Nometastaticdiseaseatdiagnosis Steroidreceptorpositivity(ER+and/orPgR+)Pharmacogeneticanalysiswith1361eligiblepatientsmedianfollow-upof6.3years95.4%postmenopausalSchroth,Goetzetal.,JAMA2009CYP2D6PolymorphismandTamoxifenOutcomeStuttgart/MayoStudyTime-To-RecurrenceEvent-Free-Survival151296301.0.8.6.4.20.0151296301.0.8.6.4.20.0EMhetEM/IMPMP<0.001ProportionofpatientsFollow-up(years)EMhetEM/IMPMP=0.0029Schroth,Goetzetal.,JAMA2009Numberofpatients:132546%48%6%46%48%6%CYP2D6PolymorphismisaDeterminantofTamoxifenResponseinEarlyBreastCancerInternationalTamoxifenPharmacogenomicsConsortium.4,973tamoxifen-treatedpatientsUsingclinicaltrialeligibility(Criterion1:n=1,996)(postmenopausalER+-positive,20mg/daytamoxifenfor5years,standardfollow-up),CYP2D6PMassociatedwithIDFSandBCFI:HR1.25;(1.06,1.47;p=0.009).AdditionalDataSupportiveofCYP2D6Province,M;GoetzMPetal.ClinPharmacolTher.2014Feb;95(2):216–227Simon/Hayes/PaikCriteriaCategoryA:ProspectiveClinicalTrial(PCT)designedtoaddresstumorbiomarkerCategoryB:PCTnotdesignedtoaddressbiomarker,butdesignaccommodatestumormarkerutilityCategoryC:ProspectiveObservationalRegistry,treatmentandfollow-upnotdictatedCategoryD:NoprospectiveaspecttostudySimon,R.M.,S.Paik,Hayesetal.(2009).JournaloftheNationalCancerInstitute101(21):1446-1452.PostmenopausalWomenwithER+BreastCancer:BIG1-98:Tamoxifenorletrozole(5yrs)DNAderivedfromFFPETumorCoresATAC:Tamoxifenoranastrozole(5yrs)DNAderivedfromFFPETumorCoresABCSG8:Tamoxifen(5yrs)orTamoxifen(2yrs)followedbyanastrozole(3yrs)DNAderivedfromFFPEtissuesectionsenrichedfornormaltissueCYP2D6Genotype:ResultsfromtheAdjuvantTamoxifenandAITrials(CategoryB)Reganetal.JNationalCancInstitute2012RaeetalJNationalCancInstitute2012Goetzetal.ClinCancResearch2013“Prospective-retrospective"designusingarchivedspecimens---SecondaryanalysesofphaseIIItrials(CategoryB)"adequateamountsofarchivedtissuemustbeavailableforstatisticalpower”Recommend2/3ofsamplespatientsstudiedmustberepresentativeofpatientsinthetrialtestshouldbeanalyticallyandpre-analyticallyvalidatedforusewitharchivedtissueDidATAC,BIG1-98,andABCSG-8fulfillthesecriteria?ParadigmforBiomarkerStudyDesignSimon/Paik/HayesCriteriaSimon,R.M.,S.Paik,Hayesetal.(2009).JournaloftheNationalCancerInstitute101(21):1446-1452.ReganetalJNCI2012BIG1-98:OutcomebyCYP2D6PhenotypeCYP2D6PhenotypeNObserved(%)Expected(%)Poor(PM)23695-7Intermediate(IM)7162755-65Extensive(EM)15855930-35***HardyWeinbergequilibrium:CYP2D6*4:X2testPvalue=1x10-92CYP2D6*41:X2testPvalue=2x10-174;BIG1-98:ObservedvsExpectedCYP2D6Alleles---excesshomozygotesanddeficiencyofheterozygotesReganetal.JNatlCancerInst2012StantonVJr:JNatlCancerInst104:1265-1266;authorreplyNakamuraY,RatainMJ,CoxNJ,etal.JNatlCancerInst104:1264;authorreply

PharoahPD,AbrahamJ,CaldasC:JNatlCancerInst104:1263-1264;authorreply

“ExcessofhomozygotesanddeficiencyofheterozygotesattributabletouseoftumorDNAgivenlossofheterozygosity(LOH)involvingchromosome22q13.1(locationofCYP2D6)1`-3Useofnon-standardPCRtechniques(>60PCRcycles)anadditionalcontributortoseveregenotypingerror1BIG1-98CYP2D6analysesrecommendedforforretraction2StantonVJr:JNatlCancerInst104:1265-1266;authorreplyNakamuraY,RatainMJ,CoxNJ,etal:JNatlCancerInst104:1264;authorreply

PharoahPD,AbrahamJ,CaldasC:JNatlCancerInst104:1263-1264;authorreply

BIG1-98:ReasonsforGenotypingErrorTCGA:LossofHeterozygosity(LOH)attheCYP2D6Locus(chromosome22q13.1)>40%ofER+BCHeterozygotesmislabeledashomozygotesComparingpurifiedER+tumorDNA(FFPEtumorcores)vsgermline(buccalcells),CYP2D6*4genotypediscordantin6/31(19.4%)Conclusion:TumorDNAshouldnotbeusedtodeterminegermlineCYP2D6genotypewithoutsensitivetechniquestodetectlowfrequencyallelesandqualitycontrolproceduresappropriateforsomaticDNA.CYP2D6LOHandGenotypingErrorGoetzetal.JNatlCancerInst.2014

Rae,J.M.ATAC:CYP2D6ScoreDoesNotPredictRecurrenceinTamoxifenArmIMEMPMIMIMOverallPforTrend=0.107YearsPhaseIIIBiomarkerStudyDesignMissingdataATACanalysisofCYP2D6represented18%oftamoxifen-treatedpts(missingdatain>80%)Significantdifferences(P<0.001)comparinggenotyped/non-genotypedgroupsforradiotherapy,chemotherapy,mastectomy,grade,nodalstatus,hormonereceptorstatus,tumorsize,anddeathGenotypedatafortheCYP2D6*4allelein588breastcancerpatientsnotinHWE(χ2=18.1,P=.000021).Regan,M.M.,B.Leyland-Jones,etal.(2012).JournaloftheNationalCancerInstitute104(6):441-451.Rae,J.M.,S.Drury,etal.(2012).JournaloftheNationalCancerInstitute104(6):452-460.ABCSGTrial8:CYP2D6PM/PMvsEM/EMPrimary

surgeryRandomizeAnastrozole

(3years)Tamoxifen

(2years)Tamoxifen

(3years)Tamoxifen

(2years)Primaryendpoint:event-freesurvivalCYP2D6CYP2D6CYP3A4/5OR:2.40OR:0.28OR:2.60OR:2.54P=0.04P=0.46CYP2D6*4;withinHWECYP2D6geneticvariationandendoxifenconcentrations(datanotshown)areassociatedwithrelapsefreesurvivalintamoxifentreatedpatientsinsomestudiesSignificantmethodologyissuesinBIG-98andATACpreventinterpretationofthesedatasetsCYP2D6accountsforonly30-50%ofthevariabilityinendoxifenconcentrationsStillgreatcontroversyintheU.SandEuropeonhowCYP2D6genotypeshouldbeusedtoselectpatientsforthetreatmentofbreastcancerSummarySubstituteAIfortamoxifen1SubstituteanotherSERM(toremifene)Increasethedoseoftamoxifen(40-60mg/day)2-4DirectlyadministerendoxifenWaystoovercomeCYP2D6metabolisminTamoxifentreatedpatientsSchroth,Goetzetal.,JAMA2009Hertzetal.Oncologist2016Foxetal.ClinCancRes2016DezentjeBreastCancerResTreat2015Nointellectualproperty:Therefore,limitedabilitytodevelopendoxifenVisittoNCIin1/09forrequestNCIsupportforendoxifendrugdevelopmentMarch2,2009ApprovaltoproceedwithEndoxifenDrugDevelopment,IncludingNCIProductionofClinicalGradeEndoxifen,PreclinicalToxicology/PharmacologyStudiesandMaterialsforINDSubmissionbyNCI2009:Novelformulation:EndoxifenHCLCanEndoxifenbeDevelopedasaDrug?InvivoPKEffectsonEREffectsonMembraneinitiatedSteroidSignalingGeneregulationKeydifferencesbetweenTamoxifenandEndoxifenMultipledosepharmacokineticsofEndoxifen:plasmaconcentration4hoursafterasingleor5dailydoses

DailydosesDose(mg/kg)152552.4±27.2ng/mL(140±27nM)73.1±16.8ng/mL(196±45nM)1001130±330ng/mL(3020±890nM)1700±60ng/mL(4550±160nM)ReidJ,GoetzMP,etal.CancerChemotherPharmacol.2014Dec;74(6):1271-8.EndoxifenandLetrozoleinMCF7/AC1XenograftsEndoxifenDrugDevelopmentTimeline 2009 2010 2011 2015 PreclinicalpharmacologyandtoxicologyNCIandMayocompletepreclinicalToxicology;FDAINDapplicationPhaseIIstudiesHumanphaseIstudybegins

FinalresultsofaFirst-in-humanPhaseIStudyoftheTamoxifen(TAM)Metabolite,Z-EndoxifenHydrochloride

(Z-Endx)inWomenwithAromataseInhibitor(AI)RefractoryMetastaticBreastCancer(MBC)(NCT01327781)

MatthewP.Goetz;VeraJSuman;JoelM.Reid;DonW.Northfelt;MichaelA.Mahr;TravisDockter;MaryKuffel;AndrewT.Ralya;SarahBurhow;StephanieSafgren;ReneeMcGovern;JerryCollins;HowardStreicher;ZacharyR.Chalmers;GarrettFrampton;JohnR.Hawse;TufiaHaddad;CharlesErlichman;MatthewM.Ames;andJamesN.Ingle

MayoClinic,Rochester,MNandScottsdale,AZ;FoundationMedicine,Cambridge,MA

CP1229323-1SanAntonioBreastCancerSymposium,December8-12,2015GoetzSABC2015MTDnotdeterminedOnecycle1DLT(Grade3PE)atthe60mg/daydoselevel.NoadditionalDLT’sobservedOnegrade4hypertriglyceridemia(aftercycle1)Grade2hotflashesobservedatalldoselevelsDilatedeyeexams(baseline,2m,6m,12m)noeyetoxicityToxicitySummaryGoetzSABC2015Z-EndoxifenPharmacokineticsSummaryDose(mg)20406080100120160Day128128128128128128128Tmax(h)4.01.83.42.65.25.44.03.019.52.210.02.73.76.0Cmax(ng/ml)66.7258143346286547228849460128042012606351950C24h(ng/ml)34.114667.32481193791386021949263578133