1. Update on Cholangiocarcinoma: What we have learned from the International Hepatobiliary Neoplasia Biorepository Roon Chaiteerakij, MD Mayo Clinic, Rochester, MN Chaiteerakij.roongruedee@mayo.edu

2. Outline International Hepatobiliary Neoplasia Biorepository (IHNB) Studies on cholangiocarcinoma How we use liver tissues collected from the IHNB to conduct research

3. ©2013 MFMER | 3299636-3 The IHNB Collects Data and Samples of Patients with Liver, Bile duct and Gallbladder Cancer and Controls Cancer cases Benign Liver Disease controls Healthy controls Blood DNA plasma & serum Urine, Stool & Bile Tumor & Benign tissue Questionnaire Clinical data

4. ©2013 MFMER | 3299636-4 Hepatobiliary cancer Tumor Biology Novel therapeutics Early diagnosis Epidemiology study Personalized oncology Clinical outcome Our Goal is to Improve Prevention, Diagnosis and Treatment of Liver, Bile Duct and Gallbladder Cancers

5. ©2013 MFMER | 3299636-5 Cholangio carcinoma Tumor Biology Novel therapeutics Early diagnosis Epidemiology study Personalized oncology Clinical outcome Epidemiology: Understanding the Risk Factors for Hepatobiliary Cancers

6. ©2013 MFMER | 3299636-6 Epidemiology Studies use Clinical Data, Risk Factor Questionnaires, and Blood Samples Cancer cases Healthy controls Blood DNA plasma & serum Urine, Stool & Bile Tumor & Benign tissue Questionnaire Clinical data Benign Liver Disease controls

7. Current Epidemiology Studies on Cholangiocarcinoma (CCA) Classification of CCA Incidence of CCA Clinical risk factors for CCA Genetic risk factors for CCA

8. Classification of CCA CCA is not a single disease but a group of three separate diseases The three have similarities, but also distinct differences

9. 103 iCCA (intrahepatic) 71 pCCA (perihilar) 22 dCCA (distal) Image Courtesy of Dr. Gregory Gores Gallbladder Cystic duct Pancreas Classification of Cholangiocarcinoma (CCA)

10. The Incidence Rate of Intrahepatic Cholangiocarcinoma in Olmsted County, MN, US has Increased 7-fold Incidence rates (Per 100,000 person-year) 1976-19901991-2000 2001-2008 2.1 Yang JD, et al. Am J Gastro 2012 P trend = 0.02 Year 0.3 0.8

11. 103 iCCA (intrahepatic) 71 pCCA (perihilar) 22 dCCA (distal) Image Courtesy of Dr. Gregory Gores Gallbladder Cystic duct Pancreas Classification of Cholangiocarcinoma (CCA)

12. 1976-19901991-2000 2001-2008 2.1 iCCA Year 1.3 1.5 2.2 1.9 1.4 dCCA The Incidence Rate of Distal CCA has Decreased by 35% 0.8 0.3 0.6 pCCA Incidence rates (Per 100,000 person-year) Yang JD, et al. Am J Gastro 2012

13. Demographics of 1267 CCA Patients Data from IHNB iCCA pCCA dCCA Distribution of location Proportion of Males (%) iCCA pCCAdCCA 50% 60% 63% Mean age(Year) iCCA pCCAdCCA 61 62 67

14. Factors associated with iCCA development Risk (fold) PSC Chaiteerakij, et al. Hepatology. 2013 Cirrhosis Diabetes Hepatitis CSmoking 82 8 4 3 1.5 Primary Sclerosing Cholangitis

15. Factors associated with iCCA development Risk (fold) PSCCirrhosis Diabetes No Metformin use 82 8 4 3 1.5 Metformin use was associated with 60% reduction in risk for iCCA Chaiteerakij, et al. Hepatology. 2013 Diabetes Metformin use 5 2

16. Study of Effect of Metformin Treatment on Cholangiocarcinoma in Mice Control Metformin Manuscript, in preparation

17. Epidemiologic study Current classification of CCA Clinical risk factors for CCA Genetic risk factors for CCA Planned GWAS for CCA Future directions

18. Is genetic variation associated with risk of CCA development? Cancer cases Healthy controls A Single nucleotide polymorphism (SNP) G * *

19. Is genetic variation associated with risk of CCA development? A Single nucleotide polymorphism (SNP) T C G G C G C C G G C Adenine (A) – Thymine (T) Cytosine (C) – Guanine (G)

20. Is genetic variation associated with risk of CCA development? Cancer cases Healthy controls Blood DNA (N = 370) (N = 740) A Single nucleotide polymorphism G * *

21. Genetic Variation in COX-2 Gene is Associated with CCA Risk Manuscript, submitted % Increases in Risk 300% 40% 50% rs2143417 rs689466both

22. Epidemiologic study Current classification of CCA Clinical risk factors for CCA Genetic risk factors for CCA Planned GWAS for CCA Future directions Genome Wide Association Study (GWAS)

23. GWAS for CCA (N = 2000) Cancer cases Healthy controls Blood DNA (N = 4000) * * * * * * * * * * * * * * * * * * * *

24. Accrual for Phase I (n=1974) MD Anderson Cancer Center (739) Mayo Clinic Rochester (728) Mayo Clinic Arizona (200) Mayo Clinic Florida (12) University of California, San Francisco (18) National Cancer of Institute Alberta Health Services (44) University Health Network (62) Imperial College, UK (140) Biodonostia Research Institute, Spain (31)

25. Future Directions of Genetic Risk Studies in CCA 2014 GWAS Discovery phase: Complete accrual, Grant application Validation phase: Begin accrual Whole exome sequencing 2015 2016 2018 2017 Genetic risk study in young-onset CCA GWAS Validation phase: Genotyping 18.4%17.3% 11.5% Proportion of CCA patients aged < 50 iCCA pCCAdCCA

26. Summary Genetic susceptibility for CCA remains poorly understood Findings from GWAS of CCA will improve our understanding of genetic predisposition pathogenesis New information will support efforts at prevention, diagnosis and treatment

27. ©2013 MFMER | 3299636-27 Cholangio carcinoma Tumor Biology Novel therapeutics Early diagnosis Epidemiologic study Personalized oncology Clinical staging system Clinical Outcomes study: Developing a New Clinical Staging System for pCCA

28. Stage I Single mass ≤ 3 cm

29. Stage II Vascular encasement Single mass ≤ 3 cm

30. Stage III Intrahepatic and/or lymph node metastasis Mass > 3 cm

31. Stage IV Peritoneal metastasis

32. ©2013 MFMER | 3299636-32 Stage I: 45.7 months (n=57) Stage II: 13.8 months (n=89) Stage III: 8.0 months (n=79) Stage IV: 2.1 months (n=38) Survival of pCCA Patients Classified by the New Staging System P<0.0001 Years Survival (%) Manuscript, submitted

33. Cancer cases Healthy controls Blood DNA plasma & serum Urine, Stool & Bile Tumor & Benign tissue Questionnaire Clinical data The International Hepatobiliary Neoplasia Biorepository Collects Liver Tissues Benign Liver Disease controls

34. Complete response Partial response No response Best candidate drug is used for clinical therapy of the patient Cancer tissue Implant into mice Next Generation Sequencing Key driver mutations in CCA genome are identified Candidate targeted drugs are tested in mice * * *

35. ©2013 MFMER | 3299636-35 Cholangio carcinoma Novel gene mutations Targeted therapies Clinical & genetic risk factors Genetic markers and biomarkers Patient- derived xenograft mouse model Clinical staging system Summary of Current Projects in the International Hepatobiliary Neoplasia Biorepository

36. Acknowledgements Mayo Genome Consortia Dr. Manal Hasan, MD Anderson Cancer Center Dr. Mitesh J. Borad, Mayo Clinic, Scottdale, ARZ Dr. Tushar C. Patel, Mayo Clinic, Jacksonville, FL Dr. R. Kate (Katie) Kelley, University of California San Francisco Dr. Oliver Bathe, Alberta Health Service, Canada Dr. Sean Kelly, University Health Network, Canada Dr. Shahid Khan, Imperial College, UK Dr. Jesus Banales, Biodonostia Research Institute, Spain All CCA patients and family members