Nauji glioblastomų molekuliniai žymenys. Vilnius, 2015
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1 Nauji glioblastomų molekuliniai žymenys Vilnius, 2015
2 Planas Molekulinio kariotipavimo principai Trumpas įvadas į citogenetiką Citogenetiniai žymenys
3 Molekulinis kariotipavimas
4 Įvadas į citogenetiką 1p/19q codelecija delecija 1 os chromsomos trumpajame (p) petyje + delecija 19 os chromosomos ilgajame petyje (q) +7 trisomija 7 os chromosomos padvigubėjimas 10 monosomija tik viena 10 a chromosoma 9p delecija (loss) 9 os chromosomos trumpojo peties (p) delecija 4q duplikacija (gain) 4 os chromosomos ilgojo peties (q) padvigubėjimas
5 Citogenetiniai žymenys 1p/19q co deletion Detected in 70% of histologically defined oligodendrogliomas. Tumors that lack the co deletion are often observed to have ATRX and TP53 mutations. The 1p/19q loss may be itself a mechanism of inactivation of CIC and FUBP1 genes. Profiling studies show that FUBP1 and CIC mutations occur simultaneously with IDH mutations, creating a unique molecular profile for oligodendrogliomas. A 1p19q co deletion is associated with improved prognosis in low grade gliomas (LGGs) and predictive of improved outcomes with chemotherapy and radiation.
6 Citogenetiniai žymenys Isolated 1p and 19q deletions 1p and 19q deletions alone were not found to improve survival of patients with GBM; However, when adjusted for age, sex, and chemotherapy, 19q deletions seem to negatively impact survival (komentaruose). 1p isolated deletion 15 25% astrocytomas. On multivariate analyses, chromosome 1p was a prognostic factor for prolonged PFS (HR = 1.75, P = 0.03) and OS (HR = 3.59, P = 0.02) in grade 2 gliomas but not for grade 3 (HR = 0.81, P = 0.7 for PFS; HR = 1.31, P = 0.7 for OS) (208 patients with WHO grade 2 and 3 gliomas). Kaneshiro et al Iwamoto et al. 2008
7 Citogenetiniai žymenys +7 trisomy and 10 monosomy EGFR gene in chromosome 7 PTEN gene in chromosome 10 EGFR amplifications are seen in 30 40% of GBMs and are strongly associated with poor prognosis and progression (trisomy 7 amplification of EGFR). PTEN deletions are seen in a much higher proportion (approximately 80%) of GBMs (monosomy 10 deletion of PTEN). Gains of 7 and losses of 10 are associated with EGFR amplification and PTEN loss seen similarly in GBM and associated with equally poor prognosis. The accumulation of cytogenetic abnormalities and particularly gain of chromosome 7 and loss of chromosome 10 are indicators of likely transformation to WHO grade IV tumors, also known as GBM. Trisomy 7 and monosomy 10 have been found to be frequently associated. The combination of both anomalies is probably important in the tumorigenesis of glioblastoma.
8 Citogenetiniai žymenys +7 trisomy and 10 monosomy HOXA locus 7p15.2 in glioblastoma. Hypermethylation of HOXA is associated with a gain of chromosome 7, a hallmark of glioblastoma, and may compensate for tumor driven enhanced gene dosage as a rescue mechanism by preventing undue gene expression. Aberrant expression of a HOX gene dominated stem cell signature in glioblastoma has been linked with increased resistance to chemo radiotherapy and sustained proliferation of glioma initiating cells. Kurscheid et al. 2015
9 Citogenetiniai žymenys 4q aberrations (PDGFRA gene) High level PDGFRA expression (gain/amplification 4q) are associated with IDH1 mutation, higher frequency of deletions at 1p and 19q, lower frequency of EGFR amplification (+7 trisomy), younger age at diagnosis and better patient's survival.
10 9p deletion (CDKN2A/B gene) Citogenetiniai žymenys The Kaplan Meier estimates for overall survival indicate that the patients with losses of 9p and 10q had significantly longer overall survival rates under TMZ treatment.
11 Citogenetiniai žymenys 22q deletion/loh Loss of 22q was more frequent in astrocytic tumors (37%) compared to mixed or oligodendroglial tumors (21%) (P = 0.02). Loss of 22q was correlated to 10q loss but not to 1p or 9p loss. Taken together, these data suggest that loss of 22q is an alteration associated with malignant progression of gliomas (Donadey et al., 2006).
12 Citogenetiniai žymenys Hyperdiploidic karyotype (>46 chromosomes) Hyperdiploidy is the main chromosomal characteristic of malignancy and aggressiveness of gliomas tumors and is often associated with a non response to treatment (Gadji et al., 2008). Hyperdiploid cells are resistant to conventional therapy, in part due to infrequent cell division due to a delay in the G₀/G₁ phase of the cell cycle. Hyperdiploid tumor cells are significantly larger and more metabolically active than euploid cancer cells (Donovan et al., 2014).
13 Aberacija Dažniausiai nustatoma Įtaka prognozei 1p/19q co delecija Izoliuota 1p arba 19q delecija Oligodendrogliomos (rečiau glioblastomos) 1p delecija 15 25% astrocytomas. Geresnė prognozė LGGs (glioblastomose neįtakoja) Geresnė prognozė Grade II gliomose +7 trisomija/10 monosomija +7 trisomy glioblastomas (30 40%) 10 monosomy glioblastomas (80%) Blogesnė prognozė 4q duplikacija Geresnė prognozė 9p delecija Geresnė prognozė gydant TMZ 22q delecija/loh Astrocytic tumors (37%) Mixed or oligodendroglial tumors (21%) Ligos progresija Hiperdiploidinis kariotipas Blogesnė prognozė
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16 Idėjos mokslui?
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18 PSO 2007 gliomų klasifikacija Tipas Laipsnis Vidutinis išgyvenamumas (metais) Astrocitoma II 6 8 Oligodendroglioma II 12 Oligoastrocitoma II 3 iki >10 Anaplastinė astrocitoma/oligodendroglioma III 3 Glioblastoma IV 1 2 WHO Classification of Tumours of the Central Nervous System 2007
19 Nauji gliomų žymenys Tipas IDH1/2 (izocitratdehidrogenazėsgeno) mutacijos 1p19q TERTp (telomerazės atvirkštinės transkriptazės promotoriaus regiono) mutacijos MGMT (O6 metilguanino DNR metiltransferazės) promotoriaus metilinimas +7/ 10, chromosomų heterozigotiškumo praradimas (LOH, ang. loss of heterozygosity) ATRX (ang. α thalassemia/mental retardation syndrome X linked) geno mutacijos TP53 geno mutacijos Vigneswaran et al. Ann Transl Med 2015;3(7):95
20 Žemo laipsnio gliomos Tipas ATRX/p53 mutacijos 1p19q kodelecija IDH1/2 mutacija Astrocitoma: išgyvenamumas >7 m. Oligodendroglioma: išgyvenamumas >12 m. IDH laukinis tipas Astrocitoma: išgyvenamumas <5 m. Reta Vigneswaran et al. Ann Transl Med 2015;3(7):95
21 PSO III laipsnio gliomos Tipas +7 +7/ 10q IDH1/2 mutacija Anaplastinė astrocitoma: išgyvenamumas >5 m. IDH laukinis tipas Anaplastinė astrocitoma: progresavimas iki antrinės glioblastomos <2 m. Anaplastinė oligodendroglioma: išgyvenamumas >10 m. Antrinė glioblastoma: išgyvenamumas <2 m. Vigneswaran et al. Ann Transl Med 2015;3(7):95
22 Glioblastomos Pirminės (90 proc.) IDH laukinis tipas, EGFR, PTEN mutacijos Blogesnis išgyvenamumas Antrinės (10 proc.) IDH, TP53, ATRX mutacijos Geresnis išgyvenamumas Vigneswaran et al. Ann Transl Med 2015;3(7):95
23 Klasifikacija pagal molekulinius žymenis Trigubai teigiami TERT ir IDH mutacija Tik IDH mutacija Trigubai neigiami Tik TERT mutacija II ir III laipsnis IV laipsnis II IV laipsnis Paplitimas (%) Eckel Passow et al. N Engl J Med 2015;372:
24 Gliomos diagnozės vidutinis pacientų amžius pagal molekulines grupes Amžius, kai nustatyta diagnozė Mayo klinika UCSF suaugusiųjų gliomos tyrimas Vėžio genomo atlasas Trigubai teigiami TERT ir IDH mutacija Tik IDH mutacija Trigubai neigiami Tik TERT mutacija Eckel Passow et al. N Engl J Med 2015;372:
25 Gliomų molekulinių grupių bendro išgyvenamumo koreguotos Kaplan Meier vertės II ir III laipsnis TERT ir IDH mutacijos (n=31) IV laipsnis Išgyvenamumas (%) Tik IDH mutacijos (n=275) Trigubai teigiami (n=181) Trigubai neigiami (n=40) Išgyvenamumas (%) Trigubai neigiami (n=80) Tik IDH mutacijos (n=32) TERT ir IDH mutacijos (n=11) Tik TERT mutacijos (n=59) metai Tik TERT mutacijos (n=347) metai Eckel Passow et al. N Engl J Med 2015;372:
26 Molekulinių žymenų reikšmė
27 Molekulinių žymenų reikšmė Išgyvenamumas (%) Laikas (dienomis) Laikas (dienomis) Laikas (dienomis) Žemo laipsnio gliomos Anaplastinės gliomos Glioblastomos Boots Sprener et al. Mod Pathol 2013;26(7):922 9
28 Molekulinių žymenų reikšmė Išgyvenamumas (%) Laikas (dienomis) Laikas (dienomis) Laikas (dienomis) Žemo laipsnio gliomos Anaplastinės gliomos Glioblastomos Boots Sprener et al. Mod Pathol 2013;26(7):922 9
29 Laikas (dienomis) Laikas (dienomis) Laikas (dienomis) Išgyvenamumas (%) Laikas (dienomis) Laikas (dienomis) Boots Sprener et al. Mod Pathol 2013;26(7):922 9
30 Ar teisingai interpretuojame? Aponienė IDH1/IDH2, ATRX+, MGMT+, 1p/19q co del, 10, +7; vidutinės rizikos? suderinamos su PCV/radioterapijos arba Temozolomido/radioterapijos algoritmais (?) GBM Oligoastrocitoma???
31 Išvados Molekuliniai žymenys svarbūs gaunant prognostinę/predikcinę informaciją, tačiau... Individualiam pacientui ši informacija turi būti vertinama atsargiai, atsižvelgiant į kitus kriterijus (amžius, histopatologinė diagnozė)! Boots Sprener et al. Mod Pathol 2013;26(7):922 9
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