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Update on Melanoma James M. Grichnik M.D. Ph.D.

Disclosures

• Galileo Group (Consulting)

• Canfield Scientific (Consulting)

• DigitalDerm (Founder, Major Shareholder)

• 12/2015 CaliberID (Equipment and meeting support)

Outline • Immune Regulation - Microbiome

• Targeted RX - Phenotype Switching

• UV – not trivial

• Genetics: Melanoma Patterns

• Melanoma - Radial Disparity

• Technology – Confocal

• What hasn’t significantly changed

- Dysplastic nevi vs Melanoma progression

- Sentinel node

Immune Regulation

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Checkpoint Inhibitors

Engl J Med. 2015 July 02; 373(1): 23–34. doi:10.1056/NEJMoa1504030

Microbiome Fecal Diversity

Gopalakrishnan et al., Science 359, 97–103 (2018)

Bacterial Types

Gopalakrishnan et al., Science 359, 97–103 (2018)

CD8+ density

Gopalakrishnan et al., Science 359, 97–103 (2018)

Transplantable

Gopalakrishnan et al., Science 359, 97–103 (2018)

Bacteriophages

Diagnostic Potential and Interactive Dynamics of the Colorectal Cancer Virome. Hannigan GD, Duhaime MB, Ruffin MT 4th, Koumpouras CC, Schloss PD. MBio. 2018 Nov 20;9(6). pii: e02248-18.

Human Virome and Disease: High-Throughput Sequencing for Virus Discovery, Identification of Phage-Bacteria Dysbiosis and Development of

Therapeutic Approaches with Emphasis on the Human Gut. Santiago-Rodriguez TM, Hollister

EB. Viruses. 2019 Jul 18;11(7). pii: E656.

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Opportunities

• Stool

• Blood

• Oral

• Weight

• Gender

#1

• Mom was right - eat your vegetables

Targeted RX

Development of encorafenib for BRAF-mutated advanced melanoma. Koelblinger P, Thuerigen O, Dummer R. Curr Opin Oncol. 2018 Mar;30(2):125-133

BRAF > Mesenchymal

https://www.embopress.org/doi/full/10.15252/emmm.201505971

DM1N DM3N DM2N

Nestin (red) / gp100 (green)

Melanoma Heterogeneity

Grichnik JM, Burch JA, Schulteis RD, Shan S, Liu J, Darrow TL, Vervaert

CE, and HF Seigler, Melanoma, a tumor based on a mutant stem cell?,

Journal of Investigative Dermatology, 126:143-153, 2006

PANX1 inhibition with probenecid down regulates MITF/gp100

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MITF (G) FSCN1 (R) DAPI (B)

SK

ME

L28

CO

NT

RO

L

SK

ME

L28 P

+

BB

G R

x

MITF FSCN1 Composite with DAPI

E-CADHERIN (R) N-CADHERIN (G) DAPI (B)

SK

ME

L28

CO

NT

RO

L

SK

ME

L28 P

+

BB

G R

x

E-Cadherin N-Cadherin Composite with DAPI

Dominant role of the niche in melanocyte stem-cell fate determination

Nishimura EK, Jordan SA, Oshima H, Yoshida H, Osawa M, Moriyama M, Jackson IJ, Barrandon Y, Miyachi Y, Nishikawa S. Nature. 2002 Apr 25;416(6883):854-60.

Low MITF/AXL ratio predicts early resistance to multiple targeted drugs in melanoma

Müller J, et al. Nat Commun. 2014 Dec 15;5:5712

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Low MITF/AXL ratio predicts early resistance to multiple targeted drugs in melanoma. Müller J, et al. Nat Commun. 2014 Dec 15;5:5712 Low MITF/AXL ratio predicts early resistance to multiple targeted drugs in melanoma. Müller J, et al. Nat Commun.

2014 Dec 15;5:5712

AXL Inhibitor

• TP-0903 is a novel oral inhibitor that targets AXL kinase and reverses the mesenchymal phenotype associated with advanced cancers.

• Preclinical studies have shown promising antitumor activity of TP-0903 as a single agent against a variety of tumor types in both in vitro and in vivo studies.

• Have BRAF-mutated melanoma that has not responded to immunotherapy or a combination BRAF/MEK inhibitor

• https://clinicaltrials.gov/ct2/show/NCT02729298?term=axl&draw=4&rank=12

#2

• To ensure elimination of a problem is to block the escape route

• Eliminate both E (TA) and M (stem) – then there maybe nowhere to hide

UV

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https://www.researchgate.net/publication/322902729_Melanin_distribution_in_human_epidermis_affords_localized_protection_against_DNA_photodamage_and_concurs_with_skin_cancer_incidence_difference_in_ex

treme_phototypes/figures?lo=1

Tumor evolution. High burden and pervasive positive selection of somatic mutations in normal human skin.

Martincorena I, Roshan A, Gerstung M, Ellis P, Van Loo P, McLaren S, Wedge

DC, Fullam A, Alexandrov LB, Tubio JM, Stebbings L, Menzies A, Widaa S, Stratton MR, Jones PH, Campbell PJ.

Science. 2015 May 22;348(6237):880-6.

• Sun-exposed eyelid

skin

• 2-6 mutations/MB/cell

• Positively selected

‘driver’ mutations were

found in 18-32% of

normal skin cells at a

density of ~140/cm2

http://www.weather.com/health/secret-sun-damage-20130516

Science. 2015 May 22; 348(6237): 880–886. 13.2/MB

P53, NOTCH1/2/HRAS

61.2/MB

K15, PTCH1 / p53

75.8/MB

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Frequent clones of p53-mutated keratinocytes in normal human skin

• Patients w/o h/o skin cancer • Tissue from cosmetic procedures • P53 mutated clones, arising from

DEJ, 60-3,000 cells in size • Present at frequencies exceeding

40 cells per cm2 • Together involve as much as 4%

of the epidermis • More frequent in sun exposed

areas

Proc. Natl. Acad. Sci. USA Vol. 93, pp. 14025–14029, November 1996

#3

• You really are getting toasted

• UV is rewriting your skin’s genetic code – not trivially but extensively

• It’s the combination of mutations that matter

• Of course need the right cell type and in correct state as well.

https://www.pinterest.com/pin/508625351636016300/

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#4

• Declining death rate

Probability (%) of Developing Invasive Cancer during

Selected Age Intervals by Sex, US, 2012-2014

Cases and Incidence of

Melanoma by age 2014-

2016, UK #5

• It is the old white guys that are the biggest problem.

Genetics / Patterns

Spitz

HRAS

Blue

GNAQ

Lentigo

Congenital

NRAS

Acquired

BRAF

Reed

Combined

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Melanoma Dermoscopic Patterns

Sanchez MI et al. JAMA Dermatology 150:633-639, 2014

Rhomboidal – Wild type NRAS BRAF GNAQ

HRAS KIT

KIT

Dark Homogenous Streak Pattern

HRAS

GNAQ BRAF

NRAS

#6

• Germline may define mutations that develop

• Mutations drive growth pattern

• Paucity of genetic data for thin low risk tumors

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https://www.mattek.com/products/human-melanocytes/

Melanoma - Radial Disparity

KIT

AF CA AS

WT

AF CA AS

NRAS

AF CA AS

BRAF

AF CA AS

Ethnic prevalence of germline SNPs over represented in specific melanoma mutations

0%

10%

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30%

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60%

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90%

100%

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100%

0%

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70%

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90%

100%

0%

10%

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KIT

NRAS BRAF

WT

#7

• Melanoma is racially biased

• Prevention approaches may need to be modified on germline as well as environment.

Dermoscopy

Technology

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Challenges with

Melanoma Diagnosis

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Visualizing Melanoma Cells and Image Stacks in 3D

Cell is segmented Dendritic Melanoma

Cell identified Reconstruction Registration

3D

reconstructions

#8

• Confocal helps with those difficult dermoscopic diagnoses

• May help studying melanocyte/melanoma biology

Meiomitosis

• Hallmark is genomic instability

• CT antigens….meiosis proteins

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#9

• Meiotic protein expression can’t be good during mitosis.

What hasn’t changed

• Dysplastic nevi

• Sentinel node / Staging

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https://img.grepmed.com/uploads/3509/oncology-melanoma-pathophysiology-model-clark-original.png

Melanocytes

Benign Nevi

Melanomas

Melanocytic “stem cell” JID 2006;126:142-53

Melanomas do not

require pre-existing nevi

Lucas CR, Sanders LL, Murray JC, Myers SA,

Hall RP, and JM Grichnik, Early melanoma detection: non-uniform dermoscopic features and

growth, Journal of the American Academy of

Dermatology, 48(5):663-671, 2003

Dermoscopy Baseline TBP Clinical

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Dermoscopy

Baseline TBP Clinical

Melanomas are growing,

unusual and progressively

more non-uniform

Lucas CR, Sanders LL, Murray JC, Myers SA, Hall RP, and JM Grichnik, Early

melanoma detection: non-uniform dermoscopic features and growth, Journal of the

American Academy of Dermatology, 48(5):663-671, 2003

Title of Invention: Methods and systems for the detection of malignant melanoma

First named inventor: James M Grichnik

Application number: 10/858,941

Filing Date: 6/02/2004

Status: Notice of Allowance (4/18/2008)

Sentinel node Summary

• Immune Regulation - Microbiome

• Targeted RX - Phenotype Switching

• UV – not trivial

• Genetics: Melanoma Patterns

• Melanoma - Radial Disparity

• Technology – Confocal

• What hasn’t significantly changed

- Dysplastic nevi vs Melanoma progression

- Sentinel node

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