89 Emerging Molecular Diagnostic Tests and Therapies for Melanoma. Aleodor Andea MD

Transcription

1 89 Emerging Molecular Diagnostic Tests and Therapies for Melanoma Aleodor Andea MD 2011 Annual Meeting Las Vegas, NV AMERICAN SOCIETY FOR CLINICAL PATHOLOGY 33 W. Monroe, Ste Chicago, IL 60603

2 89 Emerging Molecular Diagnostic Tests and Therapies for Melanoma Malignant melanoma is the leading cause of death among cutaneous neoplasms. The diagnosis and differentiation of melanoma from benign nevi is currently based on morphology however; in a significant number of cases a definitive diagnosis of melanoma is not possible. Recent molecular studies have revealed genomic differences between melanomas which harbor numerous chromosomal gains and losses and benign nevi which have no detectable chromosomal aberrations. Assays evaluating these abnormalities are ready to be implemented into clinical practice and could become important tools in the diagnosis of this deadly disease. On the therapy side, agents targeting specific pathways active in melanomas are being aggressively investigated with some, including BRAF inhibitors, getting ready for primetime. The session will focus on the utility of comparative genomic hybridization using metaphase chromosomes and microarrays as well as fluorescent in situ-hybridization in establishing a diagnosis of melanoma. In addition, data reflecting the efficacy of the newly FDA approved BRAF inhibitor (vemurafenib) in metastatic melanoma will be presented and the role of BRAF mutation testing discussed. Recognize the categories of melanocytic lesions for which an accurate histologic diagnosis is difficult. Determine appropriate ancillary studies that may help establish a correct diagnosis. Become familiar with new agents used for the treatment of melanoma. FACULTY: Aleodor Andea MD Practicing Pathologists Molecular Pathology Molecular Pathology 1.0 CME/CMLE Credit Accreditation Statement: The American Society for Clinical Pathology (ASCP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). Credit Designation: The ASCP designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. ASCP continuing education activities are accepted by California, Florida, and many other states for relicensure of clinical laboratory personnel. ASCP designates these activities for the indicated number of Continuing Medical Laboratory Education (CMLE) credit hours. ASCP CMLE credit hours are acceptable to meet the continuing education requirements for the ASCP Board of Registry Certification Maintenance Program. All ASCP CMLE programs are conducted at intermediate to advanced levels of learning. Continuing medical education (CME) activities offered by ASCP are acceptable for the American Board of Pathology s Maintenance of Certification Program.

3 Emerging Molecular Diagnostic Tests and Therapies for Melanoma Aleodor Andea, MD Associate Professor of Pathology and Dermatology Director of Dermatopathology Section University of Alabama at Birmingham Birmingham, USA Disclosure information I have no financial or industrial affiliation to disclose. Aleodor A Andea Overview 1. Problems in the diagnosis 2. Molecular alterations (with implications for diagnosis or treatment) 3. Diagnostic assays 4. New therapies 1

4 NEVI Melanoma diagnosis MELANOMA Small Symmetric Well-circumscribed Predominantly nested Uniform No No Present Absent Absent Absent Size Symmetry Circumscription Nested architecture Nests uniformity Pagetoid spread Confluent growth at DEJ Maturation Cytologic atypia Mitoses in dermis Atypical mitoses Large Asymmetric Poorly-circumscribed Predominantly single cells Irregular Prominent Present Absent Severe Present Present ~1 2 million bx/ year in US to rule out melanoma ~3% 6% of bx are melanomas In most cases dx can be made on histopathology 2.3% 25% of cases with diagnostic discrepancies (McGinnin et al, Arch Dermatol 2002, Corona et al, J Clin Oncol 1996, Farmer et al, Hum Pathol 1996, Lodha et al J Cutan Pathol 2008) Reasons for discrepancy Ambiguous lesions with overlapping criteria Atypical Spitz nevi Atypical blue nevi Recurrent melanocytic nevi Nevi in acral, genital or mammary line regions Nevoid melanoma Inter observer variability 2

5 Need for a better test Prevent under/overtreatment of patients Reduce medical costs associated with unnecessary treatment Impact positively on patient care Most common reason for medical malpractice in pathology Kornstein, et al. Arch Pathol and Lab Med, 2007 Gerami, et al, Am J Surg Pathol, 2009 Molecular alterations in melanocytic neoplasms MAP kinase alterations Replicative senescence in melanocytic lesions GROWTH FACTORS MAP Kinase CY YTOPLASM RAS RAF MEK H-Ras, K-Ras, N-Ras A-Raf, B-Raf, C-Raf1 MEK-1, MEK-2 ERK ERK-1, ERK-2 NUCLEUS PROLIFERATION 3

6 GROWTH FACTORS MAP Kinase KIT mutations in 17% of melanomas RAS CY YTOPLASM RAF MEK ERK NUCLEUS PROLIFERATION Curtin et al., N Engl J Med, 2005 MAP Kinase pathway activation in melanocytic lesions GROWTH FACTORS CY YTOPLASM NRAS RAF MEK 30% of melanomas ERK NUCLEUS PROLIFERATION Albino et al., Oncogene 1989 MAP Kinase pathway activation in melanocytic lesions GROWTH FACTORS CY YTOPLASM HRAS RAF MEK Spitz s nevi ERK NUCLEUS PROLIFERATION Bastian B et al, Am J Pathol

7 MAP Kinase pathway activation in melanocytic lesions GROWTH FACTORS RAS CY YTOPLASM B-RAF MEK 40-60% of melanomas, 80% of nevi ERK NUCLEUS PROLIFERATION Davies et al, Nature 2002, Marcia et al. Cancer Res 2002, Curtin et al, N Engl J Med 2005, Pollock et al., Nat Genet 2002 B Raf mutations in melanocytic lesions Lesion % with B-Raf mutation Melanomas 56-80% Nevi Congenital 86% Intradermal 88% Compound 70% Clark s 52-80% Spitz 0% Spitzoid Melanomas 0% Replicative senescence in melanocytic lesions s are protected by telomeres and the enzyme telomerase Greider and Blackburn EH, Nature 1989 Szostak et al, Cell

8 T T T T Mitosis T T T Mitosis T T p53, P53, RB, p16 Checkpoint Cell cycle arrest (Senescence) T T T T Mitosis T T T Mitosis T T Mitosis T Mitosis p53, P53, RB, p16 T T T T T T T T T p53, P53, RB, p16 T Mitosis Mitosis DNA breaks, fusions Cell Crisis Gross chromosomal abnormalities Increase apoptosis Cell Death 6

9 Nevi T T T T Mitosis T T T MAPK -B-RAF -N-RAS -H-RAS Mitosis T T p53, RB, p16 Cell cycle arrest ( Oncogene- Induced Senescence) No chromosomal aberrations T T T T Mitosis Mitosis Mitosis T T T T T Mitosis Melanoma T Mitosis DNA breaks, fusions +/- p53, P53, RB, p16 MAPK -B-RAF -N-RAS -H-RAS Cell cycle arrest (Senescence) Cell Crisis -Re-stabilize telomeres -growth advantage Cell Death Melanoma Gross chromosomal abnormalities Molecular tests differentiating melanoma from nevi IHC Expression microarrays CGH FISH 7

10 Nevus (<5%) Ki 67 Melanoma (>5%) Spindle cell melanoma Ki 67 problems Indeterminate lesion HMB 45/ Cyclin D1 Nevus Melanoma 8

11 HMB 45 problems Combined Nevus Melanoma Spitz Nevus p16 Melanoma Positive in 100% of Spitz nevi Negative in 32-50% of melanomas Stefanaki et al, J Am Acad Dermatol 2007 Expression microarray 9

12 120 melanocytic lesions FFPE Combimatrix CustomArray Platform Hierarchical clustering Koh et al., Mod Pathol 2009 Melanomas (95%) Nevi (98%) Problems with tissue microarrays Expensive Require microdissection Difficult to reproduce results Multi marker assays Gene espression microarrays Small set of discriminant markers IHC 10

13 Multi marker assays Gene espression microarrays Small set of discriminant markers IHC ARPC2 FN1 RGS1 SPP1 WNT2 Kashani-Sabet et al. PNAS 2009, Haqq et al. PNAS 2005 IHC Top: 0, 1+, 2+, 3+ Algorithm for discrimination 95% specificity 91% sensitivity Bottom: 0, 1+, 2+, 3+ Kashani-Sabet et al. PNAS 2009 Kashani-Sabet et al. PNAS

14 Comparative Genomic Hybridization Screens the entire genome for gains and losses in DNA material in one experiment Variants: Conventional CGH Array based CGH Conventional CGH The ratio of green:red signals along each chromosome is determined 12

15 Array CGH Arrays of genomic bacterial artificial chromosome (BAC) clones CGH in Melanocytic lesions 54 benign nevi 27 Spitz nevi 19 Blue nevi 7 Congenital nevi 132 MM 22 Acral location 108 non Acral Bastian B et al, Am J Pathol

16 Gains: 6p Losses: Gains: 11p: 11% Losses: 1q 7p 7q 8q 9p 9q 10q 10p 7q: 2% 0% 17q 20q 6q 11q The 7 cases were all Spitz nevi (no progression to MM at 7 yrs FU) 96% of cases Bastian B et al, Am J Pathol 2003 Conclusion Potential diagnostic test for ambiguous melanocytic lesions. Chromosomal Aberrations in Ambiguous Melanocytic Lesions Spitz nevi: no abnormalities gains on 11p (12 18%) 18%) Congenital nevi: no abnormalities Cellular blue nevi: no abnormalities Maize Jr, JC et al, Am J Surg Pathol 2005 Bastian B et al, Am J Pathol 2000 Bastian B et al, J Invest Pathol 1999 Bastian B et al, Am J Pathol

17 Disadvantages of CGH Requires 30 50% pure tumor cells Does not allow histologic correlation Cannotdetecttumor tumor subpopulations FISH 15

18 CGH date from melanomas Gerami et al. Am J Surg Pathol q31 (COX2) 4q12 (KIT) 7q34 (BRAF) 6p35 (RREB1) 6q23 (MYB1) 6 cen 7 cen 9p31 (p16) 10 cen 11q13 (CCND1) 17q25 (TK1) 17q21 (RARA) 17 cen 20q13 (ZNF217) Training cohort 301 melanocytic tumors 148 melanomas 153 nevi Validation cohort Unequivocal lesions: 83 melanomas 86 nevi 27 ambiguous cases with clinical follow up 6 cases developed metastases 21 free of disease at > 5 years follow up Gerami et al. Am J Surg Pathol 2009 Gerami et al. Am J Surg Pathol

19 Validation cohort: 72 of 83 melanomas FISH positive 87% sensitivity 82 of 86 nevi FISH negative 95% specificity 4 nevi were FISH positive Gerami et al. Am J Surg Pathol cases with indeterminate histology 6 developed metastases, all FISH positive 100% sensitivity 21 disease free at > 5 years, 15 FISH negative 71% specificity Gerami et al. Am J Surg Pathol Nevi 20 Melanomas 19/20 negative Specificity 95% 18/20 positive Sensitivity 90% 17

20 Superficial Lentigo Nodular Acral Spreading Maligna N=22 lentiginous N=70 N=28 N=3 Sensitivity 81% 82% 91% 100% Most common alteration 6p25 gain (RREB1) 73% 6p25 gain (RREB1) 68% 6p25 gain (RREB1) 82% 6p25 gain (RREB1) 100% 22 total lesions - Sensitivity: 60% - Specificity: 33% 12 ambiguous lesions FISH worked in 8 cases -5 malignant (3 FISH positive) -3 benign (1 FISH negative) Other potential applications Nevoid melanomas vs Mitotically active nevi 18

21 Mitotically active nevus N=10 Nevoid melanoma N=10 10/10 cases FISH negative 10/10 cases FISH positive Gerami et al. Am J Surg Pathol 2009 Other potential applications Nevoid melanomas vs Mitotically active nevi Intranodal nevus vs Metastatic Melanoma Metastatic melanoma N=24 Nodal nevus N=17 FISH status 20 cases FISH positive 16 cases FISH negative Sensitivity 83% Specificity 94% 4 FISH negative metastases In 2 the primary melanoma was also FISH negative 1 FISH positive nevus Scott et al. Am J Surg Pathol

22 Other potential applications Nevoid melanomas vs Mitotically active nevi Intranodal nevus vs Metastatic Melanoma Blue nevus vs Blue nevus like metastatic melanoma Blue nevus like metastatic melanoma N=10 Blue nevus N=10 FISH status 9 cases FISH positive 10 cases FISH negative Sensitivity 90% Specificity 100% 6p25 gains Pouryazdanparast et al. Am J Surg Pathol 2009 Other potential applications Nevoid melanomas vs Mitotically active nevi Intranodal nevus vs Metastatic Melanoma Blue nevus vs Blue nevus like metastatic melanoma Micro staging in melanomas with associated nevi 20

23 Conclusion FISH provide additional criteria to help diagnose histologically ambiguous cases This test should be performed in conjunction with standard histopathologic evaluation How to use molecular testing Not in all cases! Only when histology is ambiguous Clinically relevant Trust your clinical judgment Is this final? Sensitivity not great Interpretation is labor intensive Technically challenging Expensive More probes/cutoff points need to be evaluated 21

24 Melanoma treatment FDA approved therapy High dose interleukin 2 Dacarbazine Response rates: 7 20% No improvement in survival New FDA approved drugs Ipilimumab (YERVOY) FDA approval: 3/25/2011 Vemurafenib (ZELBORAF) FDA approval: 8/17/2011 /

25 Ipilimumab Blocks cytotoxic T lymphocyte associated antigen 4 (CTLA4) APC MHC TCR Ag T-cell CD80/86 CD28 Melanoma APC MHC TCR Ag T-cell CD80/86 CTLA-4 Melanoma 23

26 APC MHC TCR Ag T-cell CTLA-4 CD80/86 Anti CTLA-4 AB Melanoma Ipilimumab phase 3 trial Hodi et al. N Eng J Med, 2010, Ipilimumab phase 3 trial Robert et al. N Eng J Med, 2011, 24

27 BRAF V600E inhibitor Vemurafenib MAP Kinase pathway activation in melanocytic lesions GROWTH FACTORS RAS CY YTOPLASM B-RAF MEK 40-60% of melanomas, 90% is V600E ERK NUCLEUS PROLIFERATION MAP Kinase pathway activation in melanocytic lesions GROWTH FACTORS RAS CY YTOPLASM B-RAF MEK Vemurafenib ERK NUCLEUS PROLIFERATION 25

28 PLX4032 (Vemurafenib) Phase I : Complete or partial tumor regression 81% Phase II (BRAF Inhibitor in 2 (BRIM2)): Single arm study 132 patients 2% complete response 53% show a >30% tumor reduction 30% stable disease Flaherty et al. N Eng J Med, 2010, PLX4032 (Vemurafenib) Phase III (BRIM3): 675 patients Vemurafenib vs Dacarbazine 63% reduction in risk of death 74% reduction in risk of death and disease progression Vemurafenib phase 3 trial 26

29 Rash Photosensitivity Hair loss Joint pain Liver problems Arrhythmias Allergic reactions Cutaneous SCC (26%) Side effects Cobas 4800 BRAF V600 Mutation Test FDA approved companion diagnostic test Detects BRAF V600E mutation Real time PCR References Molecular alterations in melanoma 1. Albino AP, Nanus DM, Mentle IR, Cordon Cardo C, McNutt NS, Bressler J et al. Analysis of ras oncogenes in malignant melanoma and precursor lesions: correlation of point mutations with differentiation phenotype. Oncogene 1989;4: Bastian BC, LeBoit PE, Pinkel D. Mutations and copy number increase of HRAS in Spitz nevi with distinctive histopathological features. Am J Pathol 2000;157: Curtin JA, Busam K, Pinkel D, Bastian BC. Somatic activation of KIT in distinct subtypes of melanoma. J Clin Oncol 2006;24: Curtin JA, Fridlyand J, Kageshita T, Patel HN, Busam KJ, Kutzner H et al. Distinct sets of genetic alterations in melanoma. N Engl J Med 2005;353: Davies H, Bignell GR, Cox C, Stephens P, Edkins S, Clegg S et al. Mutations of the BRAF gene in human cancer. Nature 2002;417: Haqq C, Nosrati M, Sudilovsky D, Crothers J, Khodabakhsh D, Pulliam BL et al. The gene expression signatures of melanoma progression. Proc Natl Acad Sci U S A 2005;102: Jaeger J, Koczan D, Thiesen HJ, Ibrahim SM, Gross G, Spang R et al. Gene expression signatures for tumor progression, tumor subtype, and tumor thickness in laser microdissected melanoma tissues. Clin Cancer Res 2007;13: Kashani Sabet M, Rangel J, Torabian S, Nosrati M, Simko J, Jablons DM et al. A multi marker assay to distinguish malignant melanomas from benign nevi. Proc Natl Acad Sci U S A 2009;106: Koh SS, Opel ML, Wei JP, Yau K, Shah R, Gorre ME et al. Molecular classification of melanomas and nevi using gene expression microarray signatures and formalin fixed and paraffin embedded tissue. Mod Pathol 2009;22: Pollock PM, Harper UL, Hansen KS, Yudt LM, Stark M, Robbins CM et al. High frequency of BRAF mutations in nevi. Nat Genet 2003;33:

30 CGH/ FISH in melanoma References 1. Bastian BC, LeBoit PE, Pinkel D. Mutations and copy number increase of HRAS in Spitz nevi with distinctive histopathological features. Am J Pathol 2000;157: Bastian BC, Olshen AB, LeBoit PE, Pinkel D. Classifying melanocytic tumors based on DNA copy number changes. Am J Pathol 2003;163: Bastian BC, Wesselmann U, Pinkel D, Leboit PE. Molecular cytogenetic analysis of Spitz nevi shows clear differences to melanoma. J Invest Dermatol 1999;113: Bastian BC, Xiong J, Frieden IJ, Williams ML, Chou P, Busam K et al. Genetic changes in neoplasms arising in congenital melanocytic nevi: differences between nodular proliferations and melanomas. Am J Pathol 2002;161: Bauer J, Bastian BC. Distinguishing melanocytic nevi from melanoma by DNA copy number changes: comparative genomic hybridization as a research and diagnostic tool. Dermatol Ther 2006;19: Dalton SR, Gerami P, Kolaitis NA, Charzan S, Werling R, LeBoit PE et al. Use of fluorescence in situ hybridization (FISH) to distinguish intranodal nevus from metastatic melanoma. Am J Surg Pathol 2010;34: Gaiser T, Kutzner H, Palmedo G, Siegelin MD, Wiesner T, Bruckner T et al. Classifying ambiguous melanocytic lesions with FISH and correlation with clinical long term follow up. Mod Pathol 2010;23: Gerami P, Jewell SS, Morrison LE, Blondin B, Schulz J, Ruffalo T et al. Fluorescence in situ hybridization (FISH) as an ancillary diagnostic tool in the diagnosis of melanoma. Am J Surg Pathol 2009;33: Gerami P, Mafee M, Lurtsbarapa T, Guitart J, Haghighat Z, Newman M. Sensitivity of fluorescence in situ hybridization for melanoma diagnosis using RREB1, MYB, Cep6, and 11q13 probes in melanoma subtypes. Arch Dermatol 2010;146: CGH/ FISH in melanoma References 10. Gerami P, Wass A, Mafee M, Fang Y, Pulitzer MP, Busam KJ. Fluorescence in situ hybridization for distinguishing nevoid melanomas from mitotically active nevi. Am J Surg Pathol 2009;33: Maize JC, Jr., McCalmont TH, Carlson JA, Busam KJ, Kutzner H, Bastian BC. Genomic analysis of blue nevi and related dermal melanocytic proliferations. Am J Surg Pathol 2005;29: Moore SR, Persons DL, Sosman JA, Bobadilla D, Bedell V, Smith DD et al. Detection of copy number alterations in metastatic melanoma by a DNA fluorescence in situ hybridization probe panel and array comparative genomic hybridization: a southwest oncology group study (S9431). Clin Cancer Res 2008;14: Morey AL, Murali R, McCarthy SW, Mann GJ, Scolyer RA. Diagnosis of cutaneous melanocytic tumours by four colour fluorescence in situ hybridisation. Pathology 2009;41: Newman MD, Lertsburapa T, Mirzabeigi M, Mafee M, Guitart J, Gerami P. Fluorescence in situ hybridization as a tool for microstaging in malignant melanoma. Mod Pathol 2009;22: Newman MD, Mirzabeigi M, Gerami P. Chromosomal copy number changes supporting the classification of lentiginous junctional melanoma of the elderly as a subtype of melanoma. Mod Pathol 2009;22: Pouryazdanparast P, Newman M, Mafee M, Haghighat Z, Guitart J, Gerami P. Distinguishing epithelioid blue nevus from blue nevus like cutaneous melanoma metastasis using fluorescence in situ hybridization. Am J Surg Pathol 2009;33: Ipilimumab References 1. Hodi FS, O'Day SJ, McDermott DF, Weber RW, Sosman JA, Haanen JB et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med 2010;363: Robert C, Ghiringhelli F. What is the role of cytotoxic T lymphocyte associated antigen 4 blockade in patients with metastatic melanoma? Oncologist 2009;14: Robert C, Thomas L, Bondarenko I, O'Day S, M DJ, Garbe C et al. Ipilimumab plus dacarbazine for previously untreated metastatic melanoma. N Engl J Med 2011;364:

31 References Vemurafenib 1. Arkenau HT, Kefford R, Long GV. Targeting BRAF for patients with melanoma. Br J Cancer 2011;104: Capper D, Preusser M, Habel A, Sahm F, Ackermann U, Schindler G et al. Assessment of BRAF V600E mutation status by immunohistochemistry with a mutation specific monoclonal antibody. Acta Neuropathol 2011;122: Chapman PB, Hauschild A, Robert C, Haanen JB, Ascierto P, Larkin J et al. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med 2011;364: FlahertyKT KT, Puzanov I, KimKB KB, RibasA A, McArthur GA, SosmanJA etal al. Inhibition of mutated, activated BRAF in metastatic melanoma. N Engl J Med 2010;363: Nazarian R, Shi H, Wang Q, Kong X, Koya RC, Lee H et al. Melanomas acquire resistance to B RAF(V600E) inhibition by RTK or N RAS upregulation. Nature 2010;468: Ribas A, Kim KB, Schuchter LM, et al. BRIM 2: an open label, multicenter phase II study of vemurafenib in previousl treated patients with BRAFV600E mutationpositive melanoma. J Clin Oncol 2011; 29:Suppl:8509. abstract. 7. Vultur A, Villanueva J, Herlyn M. Targeting BRAF in advanced melanoma: a first step toward manageable disease. Clin Cancer Res 2011;17: References Other 1. Corona R, Mele A, Amini M, De Rosa G, Coppola G, Piccardi P et al. Interobserver variability on the histopathologic diagnosis of cutaneous melanoma and other pigmented skin lesions. J Clin Oncol 1996;14: Farmer ER, Gonin R, Hanna MP. Discordance in the histopathologic diagnosis of melanoma and melanocytic nevi between expert pathologists. Hum Pathol 1996;27: Greider CW, Blackburn EH. A telomeric sequence in the RNA of Tetrahymena telomerase required for telomere repeat synthesis. Nature 1989;337: Kornstein MJ, Byrne SP. The medicolegal aspect of error inpathology: a searchof jury verdicts and settlements. Arch Pathol Lab Med 2007;131: Lodha S, Saggar S, Celebi JT, Silvers DN. Discordance in the histopathologic diagnosis of difficult melanocytic neoplasms in the clinical setting. J Cutan Pathol 2008;35: Lundblad V, Szostak JW. A mutant with a defect in telomere elongation leads to senescence in yeast. Cell 1989;57: McGinnis KS, Lessin SR, Elder DE, Guerry Dt, Schuchter L, Ming M et al. Pathology review of cases presenting to a multidisciplinary pigmented lesion clinic. Arch Dermatol 2002;138: