PATOLOGIA MOLECULAR DEL CANCER DE ORIGEN DESCONOCIDO? Xavier Matias-Guiu Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLLEIDA.
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1 PATOLOGIA MOLECULAR DEL CANCER DE ORIGEN DESCONOCIDO? Xavier Matias-Guiu Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLLEIDA.
2 CANCER UNKNOWN PRIMARY 3-5 % of diagnosed cancers Variability depending of centers 50% adenocarcinomas Immunohistochemistry helps in 30-85% Metastases to liver (25%) and bone (25%) Prognosis depends of identification of primary site or actionable genomic alterations.
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4 CANCER UNKNOWN ORIGIN (Pathology) Adenocarcinoma (50%) Poorly Differentiated Carcinomas(35%) Squamous Cell Carcinoma (10%) Undifferentiated Carcinoma (5%)
5 CANCER UNKNOWN ORIGIN Cytokeratins (Immunohistochemistry) Organo-specific markers (PSA, Thyroglobuline, GCDFP-15) Non-organ-specific markers (CEA, p63, ER/PR)
6 CANCER UNKNOWN ORIGIN Breast Ca (Cytokeratins ) Lung, nonsmall cell ca (90%) Ovarian serous ca (90%) Mesothelioma Endometrial Ca
7 CANCER UNKNOWN ORIGIN (Cytokeratins ) Colon Ca (75-95%)
8 CANCER UNKNOWN ORIGIN (Cytokeratins ) Transitional Cell Ca Ovarian mucinous ca Pancreatic Ca
9 CANCER UNKNOWN ORIGIN (Cytokeratins ) Hepatocellular Ca (70-90%) Renal cell ca (70 90%) Prostatic Ca Neuroendocrine Ca Squamous cell Ca
10 CANCER UNKNOWN ORIGIN (Breast cancer markers) GCDFP-15 (sensitivity, 55%; highest in lobular and apocrine; independent of grade, ER status, mitotic index; also expressed in vulva, eyelid; never expressed in lung, colon, ovary) Mamaglobin (sensitivity 46,6%, combined with GCDFP-15, sensitivity 69%) ER, PR Mamoglobin GCDF-15
11 CANCER UNKNOWN ORIGIN (GI tract markers) Villin (sensitive for colon ca; 5% lung adenoca) CDX-2 (sensitive for colon ca; occasionally positive in mucinous obvarian or bladder adenoca) CK7 / CK20
12 Villin CDX-2
13 TTF-1 38 kd member of the NKx-2 family of transcription factors Thyroid, respiratory epithelium and diencephalon Lung tumors (highest in neuroendocrine and bronchioloalveolar; lowest in squamous and mucinous) Occasional rectal and ovarian adenoc. Positive in thyroid and neuroendocrine tumors
14 WT-1 Tumor suppressor gene in 11p13 Mesangial cells, Sertoli cells, ovarian stroma and surface epithelium, mesothelium Marker of serous ovarian cancer (97% specificity, 91% sensitivity)
15 CANCER UNKNOWN ORIGIN (Renal Cell Ca) CK7-/CK20- Vimentin CD-10 PAX-2
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17 MOLECULAR APPROACHES IN TUMORS OF UNKNOWN ORIGIN ONE GENE MULTIPLE GENES
18 LUNG CANCER AND EGFR MUTATIONS
19 Clinical History 83 year old man Disseminated cancer (liver and lung). Pleural Effusion Pleural Cytology: Positive for malignancy, consistent with adenocarcinoma. TTF-1 negative
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21 EGFR exon 19 E746-A750 del 15pb
22 Diagnosis Pleural metastasis from pulmonary adenocarcinoma with EGFR mutations. Treatment with EGFR inhibitors.
23 ASSESSMENT OF PRIMARY ORIGIN IN PATIENTS WITH A PREVIOUS HISTORY OF CANCER
24 Independent vs Metastatic Tumors (clonality) Cromosome X (HUMARA) LOH Mutation analysis Viral Detection
25 Primary Tumor T1 T5 T6 T13 T14 N T T2 T2 T2 T3 T7 T8 T8 T4 T9 T10 T11 T15 T16 T11 T12 T17 T18 Metastasis
26 Clinical History 71 year old woman Cervical cancer, two years ago. Adrenal Tumor
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29 Diagnosis Cervical Carcinoma metastatic to the adrenal gland
30 Clinical History A 50 year old woman. Pseudomyxoma peritonei Ovarian Tumor Appendiceal Mucocele
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35 Diagnosis Appendiceal mucinous tumor with ovarian metastasis Cuatrecasas M, Matias-Guiu X, Prat J: Synchronous mucinous tumors of the ovary and appendix. A clinico-pathologic study with analysis of K-RAS mutations. Am J Surg Pathol :
36 MOLECULAR APPROACHES IN TUMORS OF UNKNOWN ORIGIN ONE GENE MULTIPLE GENES
37 Commercial Tests for Cancer of Unknown Origin Quest-Lab Corp (92 gene PCR test for 39 cancer types) Agendia (microarray-based test for 43 cancer types) Pathworks Diagn (microarray-based test for 15 cancer types, representing 60 different morphologies) Veridex ( PCR-based test for 6 cancer types) Epitype ( Methylation-based assay) CancerTYPE-bioTheranostics (PCR-based test for 39 cancer types) Rosetta Genomics (PCR-based test on mirna for 25 cancer types)
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46 Cancer metastático de origen desconocido (Inmunohistoquímica versus Patología Molecular en 73 casos) 73 casos, que se presentan como metástasis de cáncer de origen incierto o controvertido (103 casos evaluados) Pathwork Tissue of Origin Test en tejido congelado Immunohistoquímica (CK7, CK20, CK19, PSA, Thyrogl, TTF1, GCDF-15, Mamoglobin, ER, PR, WT1, CDX2, villin, PAX2, HepPar 1, Glypican, CD-10, Inhibin, S-100, Melan-A, HMB-45)
47 Cancer metastático de origen desconocido (Inmunohistoquímica versus Patología Molecular en 73 casos) Los principales problemas a los que se plantea la técnica molecular son: 1) Dificultades técnicas inherentes al sistema de microarrays 2) Dificultad de trabajar con muestras congeladas 3) Problemas de ruido de fondo por la población normal acompañante 4) Metástasis de cánceres primarios, que no están incluidos entre los que el sistema evalúa 5) Problemas específicos en tipos histológicos precisos.
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50 Metastatic carcinoma to the peritoneum and the ovaries (Inmunohistochemistry versus Gene expression microarray in 32 cases) 29 cases with known primary tumor after follow-up: IHC : 22/ 29 Pathwork: 25/29 IHC + Pathwork: 26/ 29 3 cases without known primary tumor after follow-up: In the 3 cases concordance IHC and Pathwork (colon, stomach, amd colon versus stomach)
51 Clinical History 69 year old woman Unilateral ovarian tumor Colon cancer, several years ago
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54 CK 7 CK 7 CK 20 CK 20
55 Villin CDX 2
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58 Diagnosis Colon carcinoma metastatic to the ovary
59 Clinical History 64 year old woman Breast Cancer, several years ago Peritoneal Carcinomatosis
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61 ER WT-1
62 Mamoglobin GCDF-15
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64 Diagnóstico Metastatic ovarian carcinoma (serous type)
65 Clinical History 59 year old man. Brain tumor
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67 TTF-1 CK-7 CK-20
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69 Diagnosis Metastatic carcinoma of pancreatic origin.
70 Clinical History A 37 year old patient. Unilateral ovarian tumor
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75 Follow up Gastroscopy negative Gastric biopsies: Adenocarcinoma with signet ring cells
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77 Diagnosis Gastric carcinoma metastatic to the ovary
78 Clinical History 64 year old woman Bilateral ovarian tumors
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80 CK 7 negative; CK 20 positive
81 Follow-up Gastroscopy: negative Gastric biopsies: negative
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83 Diagnosis Gastric carcinoma metastatic to the ovaries
84 Clinical History 50 year old woman. Vaginal Bleeding Endometrial Biopsy Bilateral Ovarian tumors
85 AEI-AE3 + CK7 CK 20 + ER, PR Vimentin CDX-2 + Villin +
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87 Diagnosis Metastatic adenocarcinoma (signetring features) of unknown origin involving the endometrium and the ovaries
88 Estudio Molecular Cancer Origen Desconocido Last generation sequenciacing (Ion Torrent, Miseq) Actionable genomic alteration rather than site of origin for personalized therapy
89 Targeted next generation sequencing of adenocarcinoma of unknown primary site reveals frequent actionable genomic abnormalities and new routes to targeted therapies J Ross, K Wang, GO Otto, PG Palmer, R Yelensky, D Lipson, J Chmielecki, SM Ali, D Morosini, VA Miller, PJ Stephens USCAP 2014, San Diego, abstract # 2163
90 236 cancer-related genes (3,769 exons) and 47 introns of 19 genes commonly rearranged. 127 cancers of unknown origin Liver (24%) lymph nodes (23%), peritoneum (16%), pleura (6%), bone (5%), brain (4%) Next generation sequencing for Actionable Mutations
91 484 alterations (3.8 per tumor) 115 cases (91%) showed at least one actionable mutation The most common actionable mutations were: KRAS (23%), CDKN2A (23%), MCL1 (11%), ERBB2 (9%), PTEN (8%), PIK3CA (7%), EGFR (7%), BRAF (6%) 69% of tumors has an actionable mutation in RTK/RAS pathway.
92 Estudio Molecular Cancer Origen Desconocido Last generation sequenciacing
93 Take Home Messages Conventional pathology and IHC solves 85% of cases Combination of Conventional pathology, IHC and gene expression assays solves more than 95% of cases Gene expression tests should be interpreted in the appropriate pathological context. Last generation sequencing is an alternative that offers identification of actionable genomic alterations regarless the site of origin
94 PATOLOGIA MOLECULAR DEL CANCER DE ORIGEN DESCONOCIDO? Xavier Matias-Guiu Hospital Universitari Arnau de Vilanova, Universitat de Lleida, IRBLLEIDA.
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