Successful use of next generation genomic sequencing (NGS)-directed therapy of clear cell carcinoma of the ovary (CCCO) with trametinib and metformin in a patient with chemotherapy-refractory disease
© Castro et al. 2015
Received: 1 June 2015
Accepted: 18 August 2015
Published: 28 August 2015
Compared to other subtypes of epithelial ovarian cancer, clear cell carcinoma of the ovary bears an ominous reputation for chemotherapy resistance, increased relapse rate, and diminished survival. Among patients with distinct histopathologic subtypes, molecular analyses have identified a variety of known drivers of the malignant behavior, and depict a striking heterogeneity.
A patient with rapidly metastatic CCCO that was refractory to taxane, platinum, pemetrexed, and bevacizumab-based strategies underwent molecular profiling which disclosed dual MAPK and PI3K/AKT/mTOR pathway mutations.
Combined targeted therapy with trametinib and metformin resulted in a dramatic disease regression without toxicity.
The case highlights the utility of precision medicine combining individual molecular diagnosis with rational therapeutic intervention with targeted agents.
KeywordsOvarian cancer Clear cell carcinoma Molecular profiling Targeted therapy PIK3CA mutation KRAS mutation Trametinib Metformin Precision medicine Personalized medicine Genomic Next generation sequencing
Clear cell carcinoma of the ovary (CCCO) represents a distinct histopathologic subtype  comprising 3.7–12.1 % of epithelial ovarian carcinoma (EOC). In general, CCCO has earned notoriety for being a particular challenge for management characterized by higher recurrence rates among patients with early stage disease, poor responsiveness to chemotherapy, especially platinum [2–7], de novo drug resistance, and inferior survival compared to other subtypes of EOC . In light of these characteristics, many investigators have opined that CCCO deserves a unique treatment strategy as a distinct disease entity. Nevertheless, current guidelines recommend similar adjuvant treatment regimens as used for other EOC histologies.
Molecular studies have demonstrated differences in the genomic characteristics of CCCO compared to other histological subtypes of EOC and suggest it may be amenable to different therapeutic approaches. In addition, individual differences have been observed between patients despite the common clear cell histology. In a recent study of 69 CCCO’s patients analyzed by next generation sequencing (NGS), PIK3CA was the most common mutation (52 vs. 8 % in all EOCs and 14 % in mixed CCCO’s), followed by TP53 (16 %) and KRAS (11 %). Mutations in FBXW7 (10 %), APC (7 %), and ATM (6 %) were observed at a higher rate than in other EOCs. Among 33 with PIK3CA mutations, 4 (12 %) had co-existing mutations in KRAS and 2 (6 %) had TP53 mutations while 70 % (23/33) over-expressed cMET and 12 % had a loss of PTEN . Relative cyclin E mRNA expression is often significantly higher in the CCCO’s , Hepatocyte nuclear factor-1 beta has also been identified as a molecular marker and touted as a possible molecular target for intervention .
We describe the application of DNA sequencing to identify known molecular drivers of malignancy in a patient with chemotherapy-refractory metastatic CCCO. The use of off-label, NGS-directed therapy led to meaningful disease regression and control.
The patient is a 40-year old woman with a history of endometriosis and infertility. In the spring of 2014 she developed pelvic pain. Trans-vaginal ultrasound revealed endometriosis and a complex cystic mass of the right ovary consistent with possible malignancy. The CA-125 was 32. She was taken to the operating room for a laparoscopic right ovarian cystectomy. Based on visible tumor within the ovary at surgery, the operation was converted to a staging laparotomy with traditional cytoreductive surgery with total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymph node dissection, peritoneal biopsies, and peritoneal washings. No residual disease remained after surgery. Pathology disclosed clear cell carcinoma of the right ovary. Examination of the uterus revealed adenomyosis and endometriosis with focal clear cell carcinoma near the parametrial margin; 13 pelvic and para-aortic lymph nodes from the right and 15 from the left side showed no evidence of metastatic disease. The omentum contained a small focus of malignant cells, however the remainder of samples from the pelvis, paracolic gutters, and the undersides of the diaphragms revealed no cancer. She was staged as having FIGO stage IIIA2 clear cell carcinoma of the ovary.
Beginning in June 2014 she was treated with post-operative, adjuvant, dose dense paclitaxel and carboplatin x 6 cycles, which were completed in October 2014. A post-treatment PET scan in October 2014 revealed metastatic progression with hypermetabolic metastatic disease in the liver and multiple sites of hypermetabolic lymphadenopathy throughout the pelvis including the vaginal cuff. Chemotherapy utilizing pemetrexed and bevacizumab was administered the following week for three treatment cycles until December 2014. In January 2015, another PET scan disclosed new hypermetabolic disease in the left lung measuring 8 mm, additional new hypermetabolic lymph nodes in the left iliac chain, and progression in the liver with multiple metastases.
FoundationOne™ genomic testing identified three driver mutations, of which two were actionable with available drugs
FDA-approved therapies for ovarian cancer
FDA-approved therapies for other tumor types
Promoter 124 C > T
The MEK inhibitor, trametinib (2 mg daily) and metformin (850 mg q12hr) which activates AMPK and also inhibits the AKT-mTOR pathway, were instituted 3 weeks later. The patient was not a participant on any active research protocol. Trametinib was obtained through Tripler Medical Center which does not restrict the use of off-label medicine or require insurance pre-authorization. The selection of metformin in lieu of a standard mTOR inhibitor, such as everolimus, was made because of the failure of the phase I effort to define a safe combination of trametinib and everolimus for phase II testing .
This case of clear cell carcinoma of the ovary depicts the notorious problems of chemotherapy resistance and early relapse. In just 6 months, her outlook evolved from a hope for cure to imminent death with tumor growth on both adjuvant taxane-platinum and pemetrexed-bevacizumab combinations. Her cancer possesses a PIK3CA mutation, a finding in 34 % of CCCO (http://cancer.sanger.ac.uk/cosmic/search?q=PIK3CA+ovarian), causing upregulation of the AKT pathway, which is frequently associated with de novo resistance to platinum combinations . In the sister disease, clear cell carcinoma of the kidney, molecular aberrations in the AKT pathway have also been reported in 20 % of patients , and have been successfully treated with MTOR inhibitors. A KRAS mutation was also identified in this patient’s cancer, a finding present in 14 % of CCCO patients . These mutations suggested a dual strategy of MEK and AKT pathway inhibition.
Derangement in the MAP kinase pathway plays a central role in the proliferation and progression of many cancers. Trametinib is an FDA-approved allosteric inhibitor of MEK1 and MEK2 capable of inhibiting cancers with KRAS mutations by producing downstream blockade. Metformin has been shown to alter AMPK, a protein kinase that directly and indirectly regulates mTOR signaling via phosphorylation of Raptor and TSC2, respectively. Proof of concept studies of metformin have been reported, including regression of breast  and pancreatic cancers . This approach, employing simultaneous blockade of AKT and MAPK pathways, has produced durable responses [18, 19]. In patients with KRAS-mutant ovarian cancer, MEK and PI3K inhibitors have provided response rates of 50–75 % [20–22]. Additionally, KRAS G12V mutation, which was present in this case, is a marker for responsiveness to MEK inhibition in patients with low grade serous ovarian cancer . Even though efforts to combine MEK inhibitors with PI3K/AKT/m-TOR inhibitors have thus far been plagued by the inability to identify a tolerable, safe dose for phase II testing , remarkably this patient experienced no toxic effects from the combination of trametinib and metformin.
This patient’s success validates the strategy of dual pathway inhibition as an approach to cancer with mutations in both the MAPK and AKT pathways. It highlights the potential safety of combining metformin and trametinib. This case also demonstrates the utility of linking molecular diagnosis with therapeutic decision-making for patients with advanced, chemotherapy-refractory disease. As such, the use of precision medicine to provide driver-drug strategies offers hope for patients with CCCO and other malignancies with this molecular etiology. This process is a promising, rational method for replacing the genomically-naïve approach to treatment that still dominates the standard of care for the entire spectrum of epithelial ovarian cancer.
This patient was fortunate to gain access to a drug that is usually unavailable to ovarian cancer patients due to strict payor policies that follow the drug license to the letter. However, over-zealous regulatory behavior and wholesale restriction of physician prescribing can deprive patients of life-saving medicines. In an era when molecular insights have theranostic value that can outperform the limitations of standard therapeutic options, molecular tumor boards to determine the appropriateness of novel therapies could help patients access breakthrough approaches whose availability is hampered by the regulatory mechanism, but which are nevertheless readily available and tailor made for their individual cancers.
Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The views expressed in this abstract/manuscript are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Pectasides D, Pectasides E, Psyrri A, Economopoulos T. Treatment Issues in Clear Cell Carcinoma of the Ovary: A Different Entity? The Oncologist November 2006 vol. 11 no. 10 1089-1094
- Kennedy AW, Biscotti CV, Hart WR, Webster KD. Ovarian clear cell adenocarcinoma. Gynecol Oncol 1989;32:342–349.
- Omura GA, Brady MF, Homesley HD, Yordan E, Major FJ, Buchsbaum HJ, et al. Long-term follow-up and prognostic factor analysis in advanced ovarian carcinoma: the Gynecologic Oncology Group experience. J Clin Oncol 1991;9:1138–1150.
- Sugiyama T, Kamura T, Kigawa J, Terakawa N, Kikuchi Y, Kita T, et al. Clinical characteristics of clear cell carcinoma of the ovary: a distinct histologic type with poor prognosis and resistance to platinum-based chemotherapy. Cancer 2000; 88:2584–2589.
- Goff BA, Sainz de la Cuesta R, Muntz HG, Fleischhacker D, Ek M, Rice LW, Nikrui N, et al. Clear cell carcinoma of the ovary: a distinct histologic type with poor prognosis and resistance to platinum-based chemotherapy in stage III disease. Gynecol Oncol 1996;60:412–417.
- Pectasides D, Fountzilas G, Aravantinos G, Kalofonos C, Efstathiou H, Farmakis D, et al. Advanced stage clear-cell epithelial ovarian cancer: the Hellenic Cooperative Oncology Group experience. Gynecol Oncol 2006;102:285–291.
- Recio FO, Piver MS, Hempling RE, Driscoll DL. Lack of improved survival plus increase in thromboembolic complications in patients with clear cell carcinoma of the ovary treated with platinum versus nonplatinum-based chemotherapy. Cancer 1996;78:2157–2163.
- Kennedy AW, Markman M, Biscotti CV, Emery JD, Rybicki LA, et al. Survival probability in ovarian clear cell adenocarcinoma. Gynecol Oncol 1999;74:108–114.
- Friedlander M, Russell K, Millis S, Gatalica Z, Voss A. Molecular profiling of clear cell ovarian carcinoma. J Clin Oncol 32:5s, 2014 (suppl; abstr 5516).
- Tsuda H, Bandera CA, Birrer MJ, Hashiguchi Y, Berkowitz RS, Mok SC. Cyclin E amplification and overexpression in clear cell adenocarcinoma of the ovary. Oncology 2004;67:291–299.
- Tsuchiya A, Sakamoto M, Yasuda J, Chuma M, Ohta T, Ohki M, Yasugi T, et al. Expression profiling in ovarian clear cell carcinoma: identification of hepatocyte nuclear factor-1 beta as a molecular marker and a possible molecular target for therapy of ovarian clear cell carcinoma. Am J Pathol. 2003 Dec;163(6):2503–12.
- Tolcher AW, Bendell JC, Papadopoulos KP, Burris HA 3rd, Patnaik A, Jones SF, et al. A phase IB trial of the oral MEK inhibitor trametinib (GSK1120212) in combination with everolimus in patients with advanced solid tumors. Ann Oncol (2015) 26 (1): 58–64.
- Mabuchi S, Kawase C, Altomare DA, Morishige K, Sawada K, Hayashi M, et al: mTOR is a promising therapeutic target both in cisplatin-sensitive and cisplatin-resistant clear cell carcinoma of the ovary. Clin Cancer Res 15:5404–13, 2009.
- Brugarolas J. Molecular genetics of clear-cell renal cell carcinoma. J Clin Oncol. 2014;32(18):1968–76.PubMed CentralView ArticlePubMedGoogle Scholar
- Zannoni GF, Improta G, Chiarello G, Pettinato A, Petrillo M, Scollo P, et al. Mutational status of KRAS, NRAS, and BRAF in primary clear cell ovarian carcinoma. Virchows Archiv 2014;465(2):193–8.
- Zakikhani M, Blouin MJ, Piura E, Pollak MN. Metformin and rapamycin have distinct effects on the AKT pathway and proliferation in breast cancer cells. Breast Cancer Res Treat. 2010;123(1):271–9. doi:10.1007/s10549-010-0763-9.View ArticlePubMedGoogle Scholar
- Soares HP, Ni Y, Kisfalvi K, Sinnett-Smith J, Rozengurt E. Different patterns of Akt and ERK feedback activation in response to rapamycin, active-site mTOR inhibitors and metformin in pancreatic cancer cells. PLoS One. 2013;8(2):e57289.
- Shimizu T, Tolcher AW, Papadopoulos KP, Beeram M, Rasco DW, Smith LS, et al. The clinical effect of the dual-targeting strategy involving PI3K/AKT/mTOR and RAS/MEK/ERK pathways in patients with advanced cancer. Clin Cancer Res. 2012 Apr 15;18(8):2316–25.
- Tolcher AW, Khan K, Ong M, Papadimitrakopoulou V, Gandara DR, Patnaik A, et al. Antitumor activity in RAS-driven tumors by blocking AKT and MEK. Clin Cancer Res. 2015 Feb 15;21(4):739–48.PubMed CentralView ArticlePubMedGoogle Scholar
- Mabuchi S, Kuroda H, Takahashi R, Sasano T The PI3K/AKT/mTOR pathway as a therapeutic target in ovarian cancer. Gynecol Oncol. 2015 Apr;137(1):173–9.
- Banerji U, Smith AD, Zivi A, Lorente D, Rihawi K, Tunariu N, et al. Dual targeting of RAF-MEK-ERK and PI3K-AKT-mTOR pathways in RAS-mutant cancers: Preclinical insights and institutional experience from a clinical trial of binimetinib (MEK162) plus BYL719. J Clin Oncol 32, 2014 Abstract e13559.
- Juric D, Soria JC, Sharma S, Banerji U, Azaro A, Desai J. et al. A phase 1b dose-escalation study of BYL719 plus binimetinib (MEK162) in patients with selected advanced solid tumors. J Clin Oncol 32:5s2014; Abstract 9051.
- Tsang YT, Deavers MT, Sun CC, Kwan SY, Kuo E, Malpica A,et al. KRAS (but not BRAF) mutations in ovarian serous borderline tumour are associated with recurrent low-grade serous carcinoma.J Pathol. 2013 Dec;231(4):449–56.