Oncology SpR training day 23 November Oesophageal cancer

Transcription

1 Oncology SpR training day 23 November 2015 Oesophageal cancer

2 Squamous Adenocarcinoma Adenosquamous Basaloid squamous Spindle cell squamous Verrucous Mucoepidermoid Adenoid cystic Undifferentiated WHO classification Neuroendocrine

3 WHO classification - mesenchymal Granular cell tumour Haemangioma Leiomyoma Lipoma GIST Kaposi sarcoma Leiomyosarcoma Rhabdomyosarcoma Synovial sarcoma Lymphoma Secondary tumours

4 Neuroendocrine classification Neuroendocrine tumour G1 G2 <2% Ki67 or 2mitoses/HPF >2%,ki67 >2mitoses/HPF Neuroendocrine carcinoma G3 large cell small cell invasion, mets, >30%Ki67 Mixed adeno-neuroendocrine carcinoma (MANEC) at least 30% of tumour is of one type

5 TNM 7 th edition A gastric tumour which has an epicentre within 5cm of the OG junction and which extends into the oesophagus is staged as an oesophageal tumour. If not extending into oesophagus, stage as gastric.

6 TNM 7 TH Edition new features OG junction and proximal 5cms stomach staged as oesophagus Tis carcinoma - incorporates in situ carcinoma and high grade dysplasia T4 sub-classified T4a pleura, pericardium, diaphragm (operable) T4b other adjacent structures aorta, vertebra, trachea

7 TNM Oesophagus 5 th edition 7 th edition T1 in situ carcinoma, lamina propria, submucosa Tis in situ ca/high grade dysplasia T1a lamina propria, muscularis propria T1b submucosa T2 muscularis propria T2 muscularis propria T3 adventitia T3 adventitia T4 adjacent structures N1 regional nodes M1 M1a coeliac nodes lower M1b other M1a cervical nodes upper M1b other M1a regional mid-thoracic M1b other T4a pleura, pericardium, diaphragm T4b aorta, vertebral body, trachea N1 1-2 regional nodes, N2 3-6 nodes N3 >6 nodes M1 distant metastases

8 O-G Junction Difficult to define junction precisely Proximal limit of gastric folds in most studies Debate over cardia is it normal or pathological Siewert classification Epidemiological data show rise in incidence of O-G Junction cancers similar to Barrett s and similar relationship to GORD, obesity and tobacco and inverse relationship to H.pylori

9 Stomach 5 th edition 7 th edition T1 lamina propria, submucosa T1a lamina propria, muscularis mucosae T1b submucosa T2a muscularis propria T2b serosa T2 muscularis propria T3 perforates serosa T3 subserosa T4 invades adjacent structures N1 1-6 nodes N N3 >15 T4a perforates serosa T4b invades adjacent structures N1 1-2 nodes N2 3-6 N3a 7-15 N3b >15

10 Oesophageal cancer CRUK website 4 th commonest cause of cancer death in men (6%) 6 th commonest in women (3%) Nearly 50% are >70 years old 5 year survival in men 15.5% women 12.4%

11 Squamous cell carcinoma Desmosomes between cells keratinisation CK5/6 Nuclear p63 CK immunos are useful for distinguishing spindle cell variant of SCC from a sarcoma

12 keratinisation

13 desmosomes

14 Adenocarcinoma Glandular architecture Cytoplasmic vacuoles Mucin stain diastase/pas CK7 + BerEP4 CEA

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16 Immunohistochemistry Endocrine markers: S100, Chromogranin, synaptophysin, CD56 and Ki67 for grading TTF-1 is a nuclear transcription factor expressed in lung and thyroid In lung cancer, most adenoca and small cell ca express TTF-1 and up to 10% of squamous cell cancers However oesophageal primary endocrine cancers often express TTF-1, therefore it is of no use for differentiating a primary oesophageal small cell carcinoma from metastatic small cell cancer from lung

17 HER2 testing Epidermal growth factor receptors (EGFR) bind EGF and TGFα (transforming growth factor) Family of four membrane receptors with intrinsic tyrosine kinase activity Best known are EGFR1 or ERB1 EGFR2 or ERB2 or (HER2/Neu)

18 HER-2 testing Gastric and oesophageal adenocarcinomas 20-30% over-express HER2 worse prognosis more heterogenous staining in gastric cancer so sampling problem in small biopsies (6+ biopsies advised) much greater rate of positivity in intestinal than in diffuse gastric cancer Trastuzamab improves survival in gastric cancers, oesophageal under trial

19 HER-2 testing Immunohistochemistry using monoclonal antibody slightly different scoring from breast must be done by a CPA/ISO accredited lab

20 Pattern No reactivity or membranous reactivity in <10% of cells Score/Classification 0/negative Faint/barely perceptible membranous reactivity in >10% of cells; cells are reactive only in part of their membrane 1+/negative Weak/moderate complete or basolateral membranous reactivity in >10% of cells Moderate /strong complete or basolateral membranous reactivity in >10% of cells Biopsy samples with cohesive IHC3+ or FISH+ clones, irrespective of size (even if <10%) 2+/equivocal 3+/positive 3+/positive

21 Negative /IHC 0 Equivocal /IHC 2+ HER2 IHC IHC 3+/positive

22 HER-2 testing by FISH FISH for equivocal IHC probe for HER2 gene, and probe for centromere of chromosome 17 to adjust for aneuploidy In normal cells, there should be equal numbers of both probes centromere and HER2

23 HER-2 testing by FISH FISH needs dark room and special microscope the image rapidly fades interpretation is difficult in a dark field with loss of landmarks FISH is being replaced by chromogen in situ hybridisation (CISH) and dual colour CISH

24 FISH Fluorescent probes against dark field Dako-DuoCISH Dye labelled probes against counterstain

25 Squamous cell carcinoma Pathogenesis Squamous cell - alcohol (spirits especially) and smoking Can occur anywhere along whole length of oesophagus May be associated with oral and laryngeal cancer p53 mutations - occur early % of tumours - not same mutations as tobaccoassociated lung cancers

26 Squamous cell carcinoma Other causes of SCC Achalasia Oesophageal webs and iron deficiency anaemia Plummer-Vinson syndrome Lye stricture (caustic NaOH and Na2CO3) Diverticulum Tylosis

27 Squamous cell carcinoma Oesophageal carcinoma belt Turkey, Iran, Kazakhstan to Northern China 80% of world SCC oesophagus are in the developing world Dietary deficiency? vitamins, selenium, zinc HPV Candida oesophagitis in China Tobacco products, opium dross

28 Squamous cell carcinoma Dysphagia Odynophagia Weight loss Ulceration leading to haemorrhage, mediastinal sepsis, aspiration pneumonia, trachea-oesophageal fistula

29 Squamous cell carcinoma Upper oesophagus (10%) Middle (65%) Lower (25%) Usual type well to moderately differentiated Some poorly differentiated Other types: Verrucous very bland cytology, warty architecture Basaloid like basal cell carcinoma Spindle cell may be mistaken for sarcoma but CK positive

30 Squamous cell oesophagus Rich sub-mucosal lymphatic network Lateral and longitudinal spread Intra-mucosal cancers have <5% risk of nodal metastasis Sub-mucosal 45% Early nodal spread Upper oesophageal to cervical nodes Middle to pulmonary hilar nodes Lower to gastric and coeliac nodes

31 Squamous cell carcinoma mutation methylation p53 FHIT oesophagitis LGD amplification Cyclin D1 HGD amplification EGFR cmyc INVASION

32 Adenocarcinoma Seven times commoner in men Highest incidence in Western world Rapid increase since 1970 In USA 3.6/million population in 1970 to 25.6/million in 2006 Parallels a rise in incidence of Barrett s oesophagus Linked to gastro-oesophageal reflux disease, obesity, smoking (but not alcohol)

33 Barrett s squamous GOJ

34 squamous adenocarcinoma Barrett s stomach

35 Adenocarcinoma Occur in distal third reflux zone Dysphagia, odynophagia, weight loss, haematemesis Local, peri-gastric and coeliac nodes Intra-mucosal cancer has <5% risk of nodal involvement Sub-mucosal >30%

36 Role of obesity Increased incidence of Barrett s Mechanical effect increasing reflux Cytokines visceral fat inflamed, macrophages produce proinflammatory cytokines including IL-6 Role of H.pylori Improved hygiene Use of antibiotics Less gastritis therefore more acid producing mucosa CagA type more protective as more virulent

37 Barrett s metaplasia with no dysplasia. Goblet cells, brush border cells and Paneth cells are visible

38 Adenocarcinoma Pathogenesis Barrett s oesophagus due to acid/bile reflux Acid causes inflammation and ulceration, leading to increased cell proliferation Mutagens: Regenerating epithelium is exposed to neutrophil products like oxygen free radicals, peroxides Nitric oxide from salivary nitrates + acid Bile acids - especially DCA Tobacco

39 Barrett s Survival for adenoca is around 15% at 5 years Regular screening of Barrett s patients has been proposed However, up to 33% UK population get regular dyspepsia and 10% of these develop Barrett s metaplasia Most Barrett s patients don t know they have it

40 Screening Mass screening to detect cases of Barrett s: Cyto-sponge and Immunohistochemistry for Trefoil factor 3 There would need to be a risk stratification to concentrate resources on those most at risk of progression A huge effort has been made to find molecular biomarkers of progression to cancer but without notable success so far

41 Progression to cancer Original life time risk was estimated as 1:20 (over 20 years this is 0.25% per annum, 30 years 0.17% per annum) Current estimates for individuals % per annum, over 20 years = % which is greater than 1:50, i.e. over 49 patients need to be scoped every 3 years for 20 years to detect one cancer.

42 From Cameron et al % Italian GOSPE study(1991) Cameron at al 0% Age related incidence of Barrett s in patients undergoing endoscopy for GI symptoms

43 Screening Between 1 in 20 to 1 in 50 develop cancer over their lifetime, so low pick-up, high wastage of resources Surgery is complex and risky Subjects have many co-morbidities due to age, smoking, obesity Metastases occur early, so chance of cure is low Endoscopy service could not cope

44 Lead time bias Tumour excised Death from disseminated cancer Screening visits metastases Initiating mutation Survival time screened case Survival time symptomatic case Tumour excised Screening discovered cancer vs symptomatic discovered case

45 Stratification of risk

46 Progression of metaplasia to cancer Genetics: Mutations Deletions Amplifications Translocations Copy number variation Epigenetics: micrornas from non-coding regions (junk DNA) Chromatin acetylation, histidinylation Hyper- and hypo-methylation

47 Adenocarcinoma oesophagitis Methylation LOH mutation p16 p53 METAPLASIA LGD over-expression EGFR ERBB2 HGD INVASION EGFR amplified in 30-60%

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49 Progression to cancer Established risk factors Length of segment Presence of high grade dysplasia Aneuploidy

50 Segment length The more Barrett s mucosa, the greater the chance of a mutation Once formed, Barrett s segments stay the same length Medical treatment has no significant effect on length

51 Prague nomenclature In this case C4 M7 M-=7cm C=4cm

52 Dysplasia Vienna Classification I no dysplasia II indefinite for dysplasia III low grade IV high grade including carcinoma in situ, intra-mucosal carcinoma, suspicious of invasion V invasive carcinoma, sub mucosal or beyond

53 LGD

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55 Complexity of a Barrett s segment

56 Detecting dysplasia and invasion Seattle protocol: quadrantic biopsies at 1 or 2 cm intervals a long segment results in an awful lot of biopsies! Targeted biopsies makes more efficient use of pathologist: Use of dyes (chromo-endoscopy) methylene blue, acetic acid Narrow band imaging NBI Optical coherence tomography OCT Confocal laser endoscopy Molecular imaging

57 Cellular molecular targets Over-expressed Underexpressed EGFR ERBB2 C-MET FGR1 FGR2 Glycans Proteins detected by monoclonal antibodies. Glycans detected by by lectins

58 Improving diagnosis of dysplasia by immunohistochemistry Often poor agreement between pathologists, especially at lower end: reactive indefinite low grade dysplasia Diagnosis may be enhanced using: Ki67 proliferative marker P53 AMACR (α-methyl acyl co-enzyme racemase)

59 Ki67 No dysplasia

60 Ki67 HGD

61 NS EMR Removes mucosa and sub mucosa (? ER a more accurate description as not just mucosa sampled) More accurate evaluation of dysplasia and its grading Confirmation of invasion: T1a vs T1b Measures depth of invasion Think of it as a Big biopsy as well as a treatment

62 EMR Pathology is important, mainly to confirm or refute the presence of malignancy if present, depth of malignancy But also, If invasive, any vascular invasion present? Status of deep margin lateral margin not as important Margin involvement by adenocarcinoma is followed by recurrence in 37-50% Deep margin more important than lateral for treatment

63 EMR In many Barrett segments there is duplication of the muscularis mucosae Submucosal invasion T1b is when tumour penetrates through the deep layer

64 NS An EMR specimen

65 Many Barrett s segments show duplication of the muscularis propria. Cancer must pass through the deep layer to constitute submucosal invasion. 1 2

66 NS Uses of EMR in the Upper GI tract good-sized biopsy of a lesion which may have yielded difficult/equivocal pathological results in previous repeated standard biopsy procedures. Better agreement between pathologists. complete excision of benign tumorous nodules with ability to judge completeness of excision (instead of multiple biopsy chews) complete excision and complete pathological assessment of early gastric cancers to provide definitive pathology and thus a guide to further management of neoplastic lesions of the oesophagus

67 Aneuploidy Early changes in Barrett s include Aneuploidy telomerase shortening and global genomic hypomethylation

68 Aneuploidy is present in up to 90% of samples of non-dysplastic Barretts

69 TRISOMY 20 TETRASOMY 8 MONOSOMY 20 HYPERPLOIDY 8 DNA probes for sequences specific to individual chromosome s centromeres. Diploid cells will have two of each colour.

70 Flow cytometry: showing progression to cancer depending on ploidy of index biopsy aneuploid diploid

71 Aneuploidy The degree of clonal diversity n a segment i highly predictive of progression A panel of p53 LOH, p26 LOH and aneuploidy or increased tetraploidy is highly predictive of progression but not practical for routine use Flow cytometry on biopsies is technically difficult

72 Progression to cancer Danish study 11,028 Barrett s patients: 66% of cancers were found within 1 year of index endoscopy 1099 veterans with Barrett s: cancer within 2 years of index endoscopy Majority of Barrett s maintain relative somatic chromosomal stability Progressors show a very rapid increase in somatic chromosomal alterations

73 Progression to cancer Non-progressors: small localised deletions involving fragile sites and 9p loss/copy neutral LOH that generate little genetic diversity and remain stable over long periods Progressors, as they approach cancer, develop chromosome instability, gains and losses, genomic diversity, selection of chromosomal abnormalities and catastrophic doublings within a 4 year period

74 Therapies for Barrett s metaplasia and dysplasia Medical PPI /fundo-plication (open/laparoscopic) Elimination of Barrett s mucosa by - LASER and photo-dynamic therapy - RFA radio frequency ablation - Cryo-spray using liquid nitrogen or CO2 endoscopically - Followed by PPI acid suppression to allow new squamous epithelium to form Long term risk of buried dysplasia under the resurfaced squamous epithelium. Also, PPI cause hypergastrinaemia which stimulates cell proliferation, could promote dysplasia EMR (ER) endoscopic mucosal resection

75 No dysplasia endoscopy every 3 years LGD 6 months, 12 months then annually HGD 3 months CT, EUS EMR to assess depth HGD/Intramucosal carcinoma EMR no submucosal disease Submucosal disease or vascular invasion Ablate remainder of Barrett s by RFA or similar method oesophagectomy