В представленный обзор включены основные этапы формирования анти-HER2-терапии рака молочной железы (РМЖ). До 30% опухолей молочной железы гиперэкспрессируют рецепторы эпидермального фактора роста HER2/neu, и именно данная экспрессия коррелирует с неблагоприятным течением и прогнозом заболевания. Определение HER2-статуса при РМЖ является обязательным для всех стадий заболевания, что необходимо для оценки прогноза и выработки оптимального лечебного алгоритма. Первым таргетным препаратом, разработанным в 1992 г. для лечения HER2-положительного РМЖ, стал трастузумаб (Герцептин). Уникальный механизм действия Герцептина (таргетная блокада HER-зависимого сигнального каскада, блокада активации сигнальных каскадов PI3K и MAPK, активация антителозависимой клеточно-опосредованной цитотоксичности
и др.) и высокая эффективность препарата позволили существенно изменить прогноз при HER2-положительном РМЖ. В серии крупных международных исследований (HERA, NSABP B-31, NCCTG 9831 и BCIRG 006) показана важная роль адъювантной терапии Герцептином в течение года в снижении риска развития рецидива (до 50%) и смерти (до 30%) при HER2-положительном РМЖ. Эффективность неоадъювантной химиотерапии с трастузумабом была изучена в серии крупных рандомизированных исследований (NOAH, GeparQuattro, GeparQuinto), в которых было показано преимущество Герцептина в достижении полного морфологического регресса опухоли и существенном улучшении показателей выживаемости. В ряде крупных исследований (М7701, HO648g, BCIRG 007, HERNATA и др.) показана эффективность Герцептина при метастатическом HER2-положительном РМЖ. Появление пертузумаба открыло новые перспективы для лечения: препарат ингибирует процесс димеризации HER2-рецепторов с другими рецепторами семейства HER и блокирует HER-опосредованные сигнальные пути, активирует антителозависимую клеточную цитотоксичность. Комбинация пертузумаба и трастузумаба обеспечивает блокаду большего количества HER2-опосредованных внутриклеточных сигнальных каскадов, чем каждый из препаратов в отдельности, что ведет к более выраженному противоопухолевому эффекту. В крупном рандомизированном исследовании CLEOPATRA показаны беспрецедентные результаты лечения метастатического и рецидивирующего РМЖ: увеличение медианы общей выживаемости до 56,5 мес вне зависимости от возраста, расы, полученного ранее лечения, статуса рецепторов стероидных гормонов и локализации метастазов. Показано преимущество пертузумаба у пациенток пожилого возраста, больных с метастазами в головной мозг, а также значимое увеличение медианы времени без прогрессирования. Для противоопухолевой терапии HER2+ РМЖ появился новый класс лекарственных агентов – конъюгаты. Трастузумаб эмтанзин (T-DM1) – первый конъюгат таргетного моноклонального антитела трастузумаба, цитотоксического химиопрепарата (DM1) и связывающего агента (линкера); механизм противоопухолевого действия T-DM1 складывается из эффектов трастузумаба (который связывается с HER2-рецептором и осуществляет весь спектр противоопухолевого действия) и адресной доставки высокоэффективного цитостатика DM1, вызывающего гибель клетки за счет нарушения полимеризации микротрубочек и остановки клеточного цикла. Эффективность T-DM1 показана в увеличении безрецидивной выживаемости, уровне и длительности ответа на лечение и повышении общей выживаемости у больных HER2+ распространенным РМЖ, предлеченных таксанами и Герцептином (исследование EMILIA). Современные варианты терапии HER2-положительного РМЖ прекрасно сочетают высокую эффективность, безопасность лечения и сохранение качества жизни больным.
This review includes the main steps of anti-HER2-therapy for breast cancer (BC). Up to 30% of breast tumors overexpress epidermal growth factor receptor HER2/neu, and this expression is correlated with poor prognosis and course of the disease. Determination of HER2-status in BC is mandatory for all stages, it is necessary to evaluate the prognosis and development of optimal therapeutic algorithm. The first targeted therapy developed in 1992 for the treatment of HER2-positive BC, has become trastuzumab (Herceptin). The unique mechanism of Herceptin (targeted blockade of HER-dependent signaling pathway, the blockade of the activation of PI3K and MAPK signaling pathway, activation of antibody-dependent cellular cytotoxicity, etc.) and high efficiency have significantly changed the prognosis of HER2-positive BC. The important role of 1-year adjuvant therapy with Herceptin has showed in large international trials (HERA, NSABP B-31, NCCTG 9831, BCIRG 006) for reducing the risk of recurrence (50%) and death (30%) in HER2-positive BC. Neoadjuvant chemotherapy with trastuzumab has studied in the large randomized trials (NOAH, GeparQuattro, GeparQuinto), which has been shown to benefit of Herceptin in the rate of pathological complete response and significant improvement of survival. The effectiveness of Herceptin in metastatic HER2-positive BC has showed in the large studies (M7701, HO648g, BCIRG 007, HERNATA, etс.) The advent of pertuzumab opened new perspectives for the treatment BC: pertuzumab inhibits HER2-receptor dimerization with other HER-receptors (HER1-3) and blocks the HER-mediated signaling pathways, activates of antibody-dependent cellular cytotoxicity. The combination of pertuzumab and trastuzumab blockade provides more HER2-mediated intracellular signaling pathways than either drug alone, which leads to a more pronounced anticancer response. In a large randomized study CLEOPATRA had shown unprecedented results of treatment of metastatic or recurrent BC: the increasing median of overall survival up to 56,5 months, regardless of age, race, the prior treatment, hormone receptor status and location of metastases. The benefit of pertuzumab has shown in old patients, patients with brain metastases, as well as a significant increase in progression-free survival. The new class of anti-HER2-agent – conjugates, appeared last time. Trastuzumab emtanzin (T-DM1) – the first conjugate the targeted monoclonal antibody trastuzumab, cytotoxic chemotherapy agent (DM1) and linker. Antitumor effect of T-DM1 sum of the effects of trastuzumab (targeted blockade of HER-dependent signaling pathway) and targeted delivery of high effective agent (DM1), which causes cell death by disrupting microtubule polymerization and cell cycle arrest. Efficiency T-DM1 has shown to increase disease-free survival, rate and duration of response and overall survival in patients with HER2-positive advanced BC pretreated with taxanes and Herceptin (EMILIA trial). Modern treatment options in HER2-positive BC perfectly combine high efficiency, safety and saved the quality of life.
Key words: breast cancer, HER2-positive status, Herceptin, adjuvant and neoadjuvant anti-HER2-therapy, pertuzumab, T-DM1.
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Авторы
И.В.Колядина, И.В.Поддубная
ГБОУ ДПО Российская медицинская академия последипломного образования Минздрава России, Москва;
ФГБНУ Российский онкологический научный центр им. Н.Н.Блохина, Москва
________________________________________________
I.V.Kolyadina, I.V.Poddubnaya
Department of Oncology, Russian Medical Academy of Postgraduate Education, Ministry of Health of Russia, Moscow;
N.N.Blokhin Russian Cancer Research Center (RCRC) (115478, Kashirskoe shosse, 24, Moscow, Russia)