New classification of gynecologic cancers

Transcription

1 Centre Jean Perrin Centre de Lutte contre le Cancer d'auvergne Clermont-Ferrand - France - New classification of gynecologic cancers Frédérique Penault-Llorca

2 Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012 Int J Cancer Mar 1;136(5):E

3 ENDOMETRIAL CARCINOMA

4 First of all: familial forms Familial Endometrial Carcinomas Lynch II (HNPCC) Mutations in DNA repair genes Endometrial carcinoma 15yrs earlier (46yrs old) Cumulated risk: 40 to 70% Family history should be explored for all endometrial K Screening and prophylactic hysterectomy Cowden PTEN Mutation Risk X 3 à 5 : cumulated risk: 28%

5 Endometrial carcinoma Lynch < 50 yrs Multifocal Uterine lower segment High grade endometrioid Heterogeneous tumors Non endometrioid < 60 yrs Lymphocytic stroma Invasive tumors, embolies Synchronous T ovaries/endometrium: CCC Screening by IHC MSH1, MLH2, MLH6, PMS2 when endometrial carcinoma is diagnosed in women under 60yrs regardless family history

6 Endometrial carcinoma <40yrs Endometroid G1-2 (80%) Stage I-II (90%) Good prognosis: 6% of mortality Synchronous T ovary/endometrium (13%): endometroid 16% MSI-H phenotype : worse prognosis (mortality 23% vs 6%) Don t forget the other causes: polycystic ovaries syndroma and granulosa cell tumor

7 IT WAS «ALMOST» SIMPLE

8 «ENDOCRINE» CLASSIFICATION

9 1-5% Type I hormono dependent 50 59yrs Hyperestrogeny Endometrial carcinoma Type II non hormono dependent 66 yrs (post menoposal) Absence of hyperestrogeny 5-10% 70-75%

10 Type I Endometrial carcinoma Bokhman Type II 77 to 80% Endometrioid Hyperplasia of endometrium Precursor : atypical hyperplasia 10 to 23% Serous and clear cell Atrophic endometrium precursor : EIC Intraepithelial carcinoma EIC (Bokhman, based on the pathology of Russian women in the 0 s, 0 s Other histotypes are excluded including Lynch

11 Dichotomic classification Type 1 Type 2

12 HISTO-MOLECULAR SUBTYPES OF ENDOMETRIAL CANCER Murali, Lancet Oncol 2014

13

14 TCGA endometroid carcinoma POLE (ultramuted) MSI (hypermuted) Copy number low ( endometroid ) Copy number high (Non endometroid) Log rank p = 0,02 POLE (ultramuted) MSI (hypermuted) Copy number low Copy number high ASCO 2013 Pashtan I, abstr actualisé Nature 2013;497:67-73

15 TCGA results for endometroid carcinomas POLE sub unit of ADN polymerase e => role in DNA replication, frequent mutations MSI (MLH1 promotor methylation, Lynch) KRAS, PTEN mutations Low copy number: MSS CTNNB1 mutations High copy number : P53+++ rares mutations of KRAS, PTEN [Nature 2013;497:67-73],

16 Frequency 8% 40% 28% 24% Bokman subtypes Molecular subtypes POLE Type I MSI Low copy number MSS Type II High copy number serous Histologic subtypes Grade Endometrioid I,II, III I,II, III I,II III Serous & endo Altered copy nbr Mutation rate PI3K alterations KRAS alterations P53 mut Pronostic 35% 5% 1% >90% Good Intermediate Poor

17 POLE MUTATIONS POLE : gene coding for DNA Polymerase E ENDOMETRIAL CANCER PROGNOSIS TISSUE GENOMICS EMERGING

18 Frequency 8% 40% 28% 24% Bokman subtypes Molecular subtypes POLE Type I MSI Low copy number MSS Type II High copy number serous Histologic subtypes Grade Endometrioid I,II, III I,II, III I,II III Serous & endo Altered copy nbr Mutation rate PI3K alterations KRAS alterations P53 mut Pronostic 35% 5% 1% >90% Good Intermediate Poor

19 Immunotherapy : strong rational for MSI and POLE tumors Nb élevés de néo-antignens et de Tils high levels of TILs and neoantigens

20 Endometrial Cancer (EC) Four molecular subtypes<br />(Integrated genomic, transcriptomic and proteomic characterization)

21 Parp inhibitors and endometrial carcinoma: strong rational Defect in homologous recombination in serous tumors (type2) TCGA Group 4 Similar evolution to high serous ov Ca BRCA : mutations in ~ 10% but probably underestimated Activity of Parp inhibitors in case of Pten inactivation or Arid1A alterations TCGA group 2 and 3 Leary, Current opinion Oncol 2016, Prurdle, Modern Pathol 2017

22 E N D O M E T R I A L K Not routinely performed nowadays PolE sequencing Group 1 POLE mutated IHC MMR MSH6, PMS2, MLH1, MSH2 Group 2 MSI IHC P53 Non mutated MMR Non mutated POLE mutated MSI profile P53 mut 0 or>75% Group 3 MSS P53 wild type Copy number low Group 4 P53 mutated Copy number high

23 E N D O M E T R I A L K PolE sequencing Group 1 POLE mutated IHC MMR MSH6, PMS2, MLH1, MSH2 Group 2 MSI IHC P53 Non mutated MMR Non mutated POLE mutated MSI profile P53 mut 0 or>75% Group 3 MSS P53 wild type Copy number low Immuno? Parp inh? Other? Group 4 P53 mutated Immuno? Immuno? Parp Inh? Combo Immuno-Parp? Copy number high Parp Inh?

24 Conclusion Uterine carcinoma : determination of the proper histologic subtype is of paramount importance for treatment strategies Grade 3 endometrial carcinoma of good prognosis (POLE mutation) not routine yet Emerging potential targets Familial forms: systematic LYNCH screening for tumors before 60yrs old

25 OVARIAN EPITHELIAL TUMORS

26 Ovarian cancer mortality

27 WHO, 2014 Ovarian Epithelial Tumors Serous 50% (transitional cell carcinoma) rare Endometrioid 20% Mucinous (intestinal) 15% Sero-mucinous (endocervical) rare Clear cell 5% Brenner 5% Indifferenciated 5-7%

28 Risk factors for EOC Predispositions: 5-10% Hereditary monogenic Multifactorial Susceptibilities:10-30% Hereditary multigenic Multifactorial Sporadic: 60-85% Multifactorial

29 Possible genetic context Family aggregations of ovarian cancer (frequent): - breast cancers (man-woman) / ovary BRCA genes - colon / endometrium / ovaries (Lynch) MMR genes - ovaries only BRCA & MMR + other genes... - ovarian cancers - 1 ovarian cancer <60 years Hereditary diseases with associated clinical signs (rare): associated genes Non-epithelial tumors Peutz-Jegher, Swyer, familial gonadal neoplasia, Carney... Epithelial tumors Gorlin, A.T., Maffucci, Gardner, Werner, SLF, Cowden, Bloom...

30 First of all: familial forms Genetic risk: 3 principal syndromes Ovarian cancer site specific: familial: >3 cases of OvCa, Mean age 49 yrs old, RR 40 if BRCA1 and 12% if BRCA2 BRCA1:Mutation 75% of the cases Breast/ovaries syndrome: familial: >3 cases of breast Ca and > 2 OvCa, Mean Age= 52 yrs, RR X 50%=> RR 60% if BRCA1 vs RR 30% if BRCA2 Mutation BRCA 1/2: 95% of the cases Ford et al, 1994 Dauplat et al, 1998

31 Age: Predicted BRCA1 and BRCA2 carrier probability for breast and ovarian cancer cases Age at onset (years) Breast cancer Ovarian cancer BRCA1 BRCA2 BRCA1 BRCA % 5.0% 0.6% 0.8% % 2.0% 8.2% 0.4% % 1.5% 1.8% 1.6% % 1.2% 1.3% 0.8% % 0.8% 0.1% 0.1% Among ovarian cancer cases diagnosed at 40 years, the probability of BRCA1/2 germline mutation is 8.6% Among ovarian cancer cases diagnosed at 70 years, the probability of BRCA1/2 germline mutation is 0.2%, a figure similar to general population Antoniou et al, Br J Cancer, 2004

32 Danish study in population-based series of patients with newly diagnosed ovarian cancer (MALOVA study) 10% had 1 family history of breast/ovarian cancer» Invasive epithelial ovarian cancer (N=445) BRCA mutations 5.8% (BRCA1: 22 patients; BRCA2: 5 patients) Serous Endometrioid Mucinous Clear cell Undifferentiated Other 62% 13% 10% 7% 2% 7% BRCA mutations 5.4% BRCA mutations 5.4% BRCA mutations 0% BRCA mutations 9.1% BRCA mutations 12.5% BRCA mutations 13.3% No tumours from BRCA mutation carriers were mucinous Soegaard M, et al. Clin Cancer Res 2008;14(12):

33 First of all: familial forms Genetic risk: 3 principal syndromes Lynch (HNPCC Hereditary non-polyposis colorectal carcinoma) familial: >3 cases of CRC (one before 50 yrs), endomerium, biliary tract, urinary tract, ovaries, Mean age: 45 yrs, RR 10%, Microsatellite instability: MSH1, MSH2, PMS1, PMS2, MLH1 (MSH2: RR 38 MLH1: RR20 MSH6: RR1) Other Syndromes : Peutz Jegher Syndrome: STK11 (ch19) mutation; Prevalence: 1/10.000, hamartomatous Polyposis of the digestive tract, CRC (60%), Breast (32-54%), ovaries (20%), uterus (10%), pancreas Lynch et al, 1986 Chabbert-Buffet et al, 2012

34 IT WAS «ALMOST» SIMPLE

35 Ovarian Oncogenesis Kurman 2008 Type I 25% Stade I Slow evolution Mutations BRAF, KRAS, PTEN, b catenin Precursor : Endometriosis Borderline T Endometrioid Serous low grade Mucinous Clear cell carcinoma Type II 75% > stade I Rapid evolution P53 Mutations Genetic instability De novo ut STIC High grade serous Undifferenciated carcinoma Carcinosarcoma (MMMT)

36 A dual origin? 60%? 40%? Dysplasie Tube dysplasia tubaire Dysplasie Ovarian dysplasia ovarienne Crum et al, 2010

37 Ovarian tumors linked to endometriosis Endometriosis is precursor for CCC, endometroid and seromucinous ARID 1A - ARID 1A + ARID 1A 20% of endometrioid ovarian endometrioma

38 BUT.

39 HISTO-MOLECULAR SUBTYPE OVARIAN CANCER 90% 10% Banerjee S & Kaye SB, Clin Cancer Res DIFFERENT EPITHELIAL OCs (EOCs) high-grade serous (HGSOC) low-grade serous (LGSOC) mucinous clear cell endometrioid Prat J, Virchow s Archive 2012

40 Ovarian carcinoma 5 distinct diseases HG serous LG serous mucinous Endome trioid Clear cell Frequency 70% <5% 3% 10% 5-10% Risk factor BRCA1/2?? HNPCC HNPCC+/- Precursor STIC LMP serous LMP mucinous Endome triosis Endome Triosis Mol Biol P53/BRCA BRAF KRAS PTEN HNF1b KRAS HER2 ARD1A ARD1A PIK3CA ChimioSens High Intermediate Weak High Low Prognosis Poor Intermediate Good Good Intermediate to poor

41 Banerjee S, and Kaye S B Clin Cancer Res 2013

42 Loss of expression of BAF250a* Chimioresistance MEK inhibitors? TZB? (HER2 amplification) 42 PI3K mtor? Inhibitors of ARID1A Type I ARIDIA PI3KCA ZNF217 PPP2RIA Mutation CTNNBI PTEN PIK3CA PPP2RIA Mutation Endometrioid Clear cell KRAS BRAF ERBB2 PIK3CA Mutation HER2 KRAS Mutation Mucinous TP53 mutation Cromosomal instability High-grade serous Inactivation of BRCA 1/2 (Mutation or hypermethylation) Parp Inhibitors Platinium salts Type II BRAF inhibitors TZB? Double inhibition : PI3K & MEK inhibitors fromwiegand K et al J Pathol 2011 Mc Conechy M et al J Pathol 2012

43 FOCUS ON BRCANESS IN HIGHGRADE SEROUS CARCINOMAS

44 Serous carcinomas Low grade: Extremely rare High grade: Common

45 HISTO-MOLECULAR SUBTYPE High-Grade Serous OC (HGSOC) (70% of primary EOCs) OVARIAN CANCER PROGNOSIS / PREDICTION TISSUE MORPHO + IHC + GENOMICS EMERGING Gurung A et al, Histopathology 2013 HALLMARK GENOMIC INSTABILITY DRUGS PLATINUM SALTS PARP INHIBITORS Prat J, Virchow s Archive 2012

46 Presence of a BRCA mutation Allows the possibility of a very effective treatment in case of late relapse

47 WHAT PATIENTS TO TEST?

48 ?? 3 2?

49 Only patients with a family history? Percentage of BRCA Mutation Carriers Who Lack a Family History Walsh et al 27% Family history is not a sufficient Soegaard et al 54% Malander et al 8% criterion! Risch et al 37% Alsop et al 44% Song et al 39% Between 35% to 40% of patient with BRCA1/2 Do NOT have a family history Walsh T, et al. Proc Natl Acad Sci U S A. 2011;108: ; Soegaard M, et al. Clin Cancer Rev. 2008;14: ; Malander S, et al. Eur J Cancer. 2004;40: ; Risch HA, et al. J Natl Cancer Inst. 2006;98: ; Alsop K, et al. J Clin Oncol. 2012;30: ; Song H, et al. Hum Mol Genet. 2014;23(17):

50 Only young patients? BRCA1/2 - BRCA1 + BRCA2 + Alsop et al 60 y 53 y 60 y Soegaard et al 61 y 49 y Age Risch et is al not a 56 sufficient y 51 y criterion! 57 y Malander et al 59 y 57 y Song et al 59 y 52y 57y At least 25% of pts with BRCA1/2 Mutations are older than 60 yrs Alsop K, et al. J Clin Oncol. 2012;30: ; Soegaard M, et al. Clin Cancer Rev. 2008;14: ; Risch HA, et al. J Natl Cancer Inst. 2006;98: ; Malander S, et al. Eur J Cancer. 2004;40: ; Song H, et al. Hum Mol Genet. 2014;23:

51 Only pts with a high grade serous carcinoma? Frequency of germline BRCA mutation Total population Serous Endometrioid Clear Cell Histological type (except Mucinous Alsop et al 14.1% 16.6% 8.4% 6.3% NA mucinous) is not a sufficient Risch HA et al 13.2% 18.0% 7.1% 7.1% 0% Soegaard M et al 5.8% 5.4% 5.4% 9.1% 0% criterion! Jacobi CE et al 13.9% 10.8% 0% 0% 0% Malander S et al 8% 7.6% 13.0% 12.5% 0% Alsop K, et al. J Clin Oncol 2012;30: ; Risch HA, et al. J Natl Cancer Inst 2006;98: ; Soegaard M, et al. Clin Cancer Rev. 2008;14: ; Jacobi CE, et al. Genet Med 2007;9: ; Malander S, et al. Eur J Cancer. 2004;40: ; Pennington KP et al. Clin Cancer Res. 2014;20:

52 French guidelines (st Paul de Vence) for BRCA mutation testing (2018) BRCA mutation testing must be proposed To all patients with high grade, undifferentiated, carcinosarcoma or clear cell ovarian (or primary peritoneal) serous or endometrioid cancer. Whatever the age or family history

53 How to look at BRCA mutations Germinal: hereditary family implication On blood or sputum Somatic: acquired tumor alterations no family implications test on the tumor

54 Diagnosis Oncogenetic counselling gbrca 14-20% French INCa guidelines 2017 Positive result Negative result sbrca 5-11% Positive result Negative result

55 Frequency of BRCA somatic mutations Hennessy et al TCGA network Alsop et al Population 235 unselected epithelial ovarian cancers 489 high-grade serous ovarian cancers 1001 nonmucinous ovarian cancers Frequency of somatic mutations 5% 6.3% 6% Pennington et al 390 ovarian carcinomas 7% Ledermann et al 265 high-grade, recurrent ovarian carcinomas, platinum-sensitive 7% Hennessy BT, et al. J Clin Oncol. 2010;28: ; The Cancer Genome Atlas Research Network. Nature. 2011;474: ; Alsop K, et al. J Clin Oncol. 2012;30: ; Pennington P, et al. Clin Cancer Res. 2014;20: ; Ledermann J, et al. Lancet Oncol. 2014;15:

56 Context Tumor Type: high-grade epithelial ovarian, fallopian tube, or primary peritoneal cancer Analysis of germline BRCA1/2 (blood) at the initial diagnosis of the tumor after oncogenetics consultation Analysis of somatic BRCA1/2 (the tumor): at the first platinosensitive relapse if BRCA1/2 germinal mutation negative (~7% extra positive cases) or if not tested at baseline

57 Somatic BRCA testing Requirements Adequate quantity of tumor material (FFPE) Control of pre-analytical steps (optimal quality) NGS (Next Generation Sequencing) with external quality control Timing => Results: 2 to 3 weeks Major limitations Tissue is the issue! Quantity of tissue available Quality of tissue available Complexity of NGS data analysis Validation of the results (Sanger) Turnaround time (costs if non-pooled tests) FFPE: formalin-fixed, paraffin-embedded

58 MOLECULAR TESTING ACCURACY DEPENDS UPON PATHOLOGISTS.AND SURGEONS

59 Type of samples

60 QUANTITY

61 Mc Cluggage Mod Pathol 2015 Type of samples

62

63 Initial diagnosis: OK but beware of necrosis Optimal and quick fixation Peritoneal biopsies => guidelines for surgeons 6 biopsies 5-10mm Beware of electrocoagulation

64 Examples of unsuitable samples Many samples do not have enough tumor Early discussion with surgeons or pathologists would have led to different specimens Low tumor content (post neoadjuvant) or diffuse necrosis Tiny biopsies despite huge peritoneal mets

65 Examples of unsuitable samples Many samples do not have enough tumor Early discussion with surgeons or pathologists would have led to different specimens pcr: pathological complete response Post neoadjuvant Low tumor residual content or pcr

66 Example of adequate samples Tumor content and surface area are the key! Cellularity > 20% Surgical specimen Many small biopsies with dense tumor

67 ANALYTICAL

68 NGS for BRCA1/2 Goals Exhaustive coverage of BRCA1/2 genes Acceptable sensitivity Germinal: 30X Somatic: 100 to 300X Limits BRCA1/2: large genes, no hot spots Diversity of mutations (SNP, ins/del, RGT) Quantity of material Quality of samples and design Detection of large rearrangments (10% BRCA1, 2% BRCA2) Del: deletion; ins: insertion; NGS: next generation sequencing; SNP: single-nucleotide polymorphism; RGT: rearrangement

69 POST-ANALYTICAL: INTERPRETATION

70 Clinical report Suitability of tumor sample Target analysed: examined genes (i.e. BRCA1 or BRCA2) Region of interest: the regions covered for each gene (e.g. coding region only or intronic and exonic regions) Overall results: either pathogenic/deleterious variant present or absent Mutation details (when present)

71 Clini al report ont Reference sequence Summary/interpretation: Pathogenic or likely pathogenic classification of the identified variants Non-pathogenic variants should not be reported, (laboratory may keep a record) Variants of unknown significance should be reported separately and clearly indicate the lack of sufficient clinical or biological evidence

72 CONCLUSION

73 Conclusion Ovarian carcinoma : determination of the proper histologic subtype is of paramount importance for treatment strategies (exclude metastasis for bilateral non serous tumors) Always question the pathologist in case of bilateral non serous carcinoma Specific mutations for granulosa cell tumors (FOXL2) and Sertoli cell tumors (DICER) Familial forms

74 Conclusion The spectrum of ovarian carcinoma shows heterogeneous disease with different biology and putative targets Emerging potential targets (BRCA, PIK3CA, ARID A, HER + immunotherapy With the advent of parp inhibitors, the pathologists role in the management of high grade serous tumors has changed

75 Important take home messages EVERY women with a epithelial non mucinous ovarian cancer should be tested for BRCA 1 &2 Every women <60 years with an endometrial cancer should be tested for MSI Time as come to incorporate genetics to oncology