molecular progression of thyroid lesionsapoptotic-pathway - adhesive and migration affect line the...
TRANSCRIPT
Molecular progressionof thyroidlesions
Molecular progressionof thyroidlesions
Dr. Peter Lakatos1st Department of Medicine
Semmelweis University, Budapest
Dr. Peter Lakatos1st Department of Medicine
Semmelweis University, Budapest
Thyroid nodules
• Population: 4-7% with thyroid nodules
• More frequent in women
• Incidence increasing with age
• Malignancy: 5-10% of cold nodules
Basic question: Which nodule will become malignant?
Thyroid cancer
• Thyroid cancer: 1.5% of all malignancies
• Incidence increasing during the last 25 years:
4.8→ 8.0 /100,000
11.7 women, 4.2 men /100,000
History
1. Characteritics of the nodule
2. Other symptomsA.) hyperthyroidism/hypothyroidism
B) compression
3. Familiy history� MEN
4. Neck irradiation
Physical examination
• Size
• Nodule consistency, multiple, solitary
• Fixed or mobile
• Cervical lymph nodes
• Quickly enlarging nodule• Stiff, fixed nodule• Swelling cervical lypmh node• Hoarse voice, swallowing difficulty• Previous neck irradiation• Age: <20 yrs or >70 yrs• Male sex• Familiy history of medullary cancer• Familiy history of MEN-2
Signs indicating increasedrisk for malignancy inpatients with thyroid nodules
• Identifying further nodules
• Determining the size of the nodules
• Looking for malignancy signs
• Guidance of FNAB
US indication in case of thyroidnodule
• hypodensity• microcalcification• hypervascularization• solitary nodule• irregular borderline• lack of halo
The more signs are noted, the higher the risk.
Risk of thyroid cancer in a solitary nodule withmicrocalcification is 70%.
US and thyroid cancer
Thyroid Imaging Reporting and Data System (TIRADS)
Horvath E et al, JCEM 2009. 94:1748-1751.
FNAB• FNAB is the most reliable test• Results in classes:
- non-diagnostic- benign- follicular lesion- suspicious for malignancy- malignant
• Limitations of FNAB:– No differentiation between benign follicular or Hürthle-
cell adenoma and malignant forms (capsular and/orvascular invasion)
– No result in 15%• False negative: < 5%
Classificationof thyroid cancers
Follicular cells• Differentiated
– Papillary 80%– Follicular 10%– Hürthle-cell 3-5%
• Non-differentiated– Anaplastic 1-2%
Parafollicular cells– Medullary 5%
Papillary cancer
• Responsible for 90% of radiation-induced cancers
• Subclassification:: microcarcinoma, intrathyroidal, extrathyroidal– Histology variants: high-cell, clear-cell, columnar,
diffuse sclerotizing
• Multiple nodules in 30-50%
• Lymphatic spreading
• Lymph mets in 20-50%
Follicular cancer• More frequent in iodine-deficient areas• Diagnosis: vascular and/or capsular invasion• Subclassification:: minimally or extremely invasive
– Vascular invasion→ more aggressive compared to capsular invasion
• Rarely multiple nodules• Hematogenous spreading• Frequent lung and bone mets.
Hürthle -cell cancer
• Frequent mets.
• Iodine uptake in less than 10%
• Frequent recurrence
• High mortality – 30% / 10 yrs
Anaplastic cancer
• Decreasing frequency
• Rapid progression >60 yrs
• Frequent mets. at the time of dg.
• Limited surgical solutions
• Irradition or chemo not effective
• Average survival: ~ 4 - 6 months
Medullar y cancer
• Origin: parafollicular C-cells
• Calcitonin and CEA elevation in the circulation(50%)
• Sporadic: 80%
• At the time of dg.: 75%met. and 20% distantmet.
Medullar y cancer• MEN IIA �
– MC (100%), pheo (40%), hyperparathyroidim (35%)– AD trait– Missense mutation in the RET protoonkogene (extracell. cytein)– Surgery recommended before 6 yrs of age
• MEN IIB �– MC (100%), pheo (50%), mucosal ganglioneuromas (100%),
Marfan sy– AD trait– Missense mutation in the RET tirozine-kinase domain– Recommended surgery in infant age
• Familial MC
Differentiated thyroid cancers
● PTC and FTC comprise 90% of all thyroid malignancies.● PTC is the most common histological type of all thyroid malignancies (60-
80%). Somatic mutations are found in more than 40-70% of papillary carcinoma cases.
● FTC is the second most common histological type with a frequency is 10-15%. Mutation is present in 30-50%.
Benvenga, S., Horm Metab Res, 2008. 40(5): p. 323-8.Woodruff, S.L., et al., Am J Surg, 2010. 200(4): p. 462-6.Schlumberger, M., Ann Endocrinol (Paris), 2007. 68(2-3): p. 120-8.Cheng, S.P., et al., Langenbecks Arch Surg, 2008. 393(5): p. 729-32.
Albarel F, Conte-Devolx B, Oliver C.,Ann Endocrinol (Paris). 2012. Apr. 13. [Epub aheadof print]
Genetic alterations and PTC
PTC frequently carries- BRAF (v-raf murine sarcoma viral oncogene homolog B1) - RET/PTC (RET tyrosine-kinase protooncogene / papillary thyroid
carcinoma) - RAS (rat sarcoma viral oncogene homolog) mutations
BRAF mutation has been associated with more aggressive tumor behavior:- extrathyroidal extension- lymph node involvement- resistance to radioactive iodine- tumor recurrence
BRAF gene mutation is an oncogenic mutation influencing the mitogen-activated protein kinase (MAPK) signaling pathway.
THERAPEUTIC INTERVENTION!
Targeted therapy in the BRAF pathway
Cantwell-Dorris ER et al, Mol Cancer Ther; 2011. 10(3) DOI:10.1158/1535-7163.MCT-10-0799
Albarel F, Conte-Devolx B, Oliver C.,Ann Endocrinol (Paris). 2012. Apr. 13. [Epub aheadof print]
Genetic alterations and FTCFTC is prone to have
- RAS- RET/PTC - PAX8/PPAR-gamma mutations
These alterations have been identified in approximately 30-80 % of the tumors.
RAS family activates three cascades: - MAP-kinase-pathway- phosphatidilinozitol-3-kinase/protein-kinase-b (PI3K/AKT)
apoptotic-pathway- adhesive and migration affect line
The altered RAS proteins bind with major affinity to a GTP and activate GTPase effect, thus these proteins maintain constitutive activation of proliferation in follicular cells. Therefore genomic instability and increased proliferative potential will be the consequence in these cells.
Albarel F, Conte-Devolx B, Oliver C.,Ann Endocrinol (Paris). 2012. Apr. 13. [Epub aheadof print]
More genetic alterations recognizedRET proto-oncogene is a tyrosine-kinase transmembrane receptor and encoded on chromosome X. Occurence of frequent alterations in sporadic papillary cancer has been established.
- RET/PTC1 fusion protein is associated with less malignancy- RET/PTC2 is infrequent- RET/PTC3 marks more aggressive tumors and exhibits bad prognosis.
PAX8 (paired box 8) gene is encoding a transcription factor that has a role in tissue differentiation in embryonic age. The PAX8/PPAR-gamma-1 rearrangement may appear in follicular thyroid cancer.
Thyroid receptors as well as micro-RNAs might also contribute to the pathological processes resulting in malignant transformation of the thyroid.
THERAPEUTIC INTERVENTION!
Kim WG, Cheng S, Biochim. Biophys. Acta (2012), doi:10.1016/j.bbagen.2012.04.002
Thyroid carcinogenesis
de la Chapelle A, Jazdzewski K., JCEM 2011. 96:3326-36.)
Regulation of PTEN/PI3K/AKT pathway by microRNAs
Gene Cancer type Prevalence (%)
BRAF PTC 45
not well-differentiated cancer 20
anaplastic carcinoma 20
RAS anaplastic carcinoma 50
FTC 45
not well-differentiated cancer 35
PTC 10
RET medullary carcinoma 50-95
RET/PTC PTC 20
PAX8-PPARγ FTC 35
TP53 anaplastic carcinoma 70
not well-differentiated cancer 20
Genetic alterations inthyroid cancers
Age
men (n=40) 52.2 ± 13.2
women (n=85) 51.5 ± 14.2
number of DNA samples BRAF HRAS KRAS NRAS
papillary cc. 106 40 (37.7%) 1 (0.9%) 1 (0.9%) 1 (0.9%)
follicular cc. 12 2 (16.7%) 1 (8.3%) 0 3 (25.0%)
other cc.* 7 0 0 0 1 (14.3%)
normal tissue 121 0 0 0 0
summ 246
number of RNA samples
RET/PTC1 RET/PTC3
papillary cc. 59 5 (8.5%) 1 (1.7%)
follicular cc. 12 0 0
other cc.* 7 0 0
normal tissue 78 0 0
summ 156
*: anaplastic thyroid carcinomas, follicular adenomas and follicular neoplasia
Genetic alterations in thyroid cancers in Hungary
Balla B et al, Thyroid 2011. 21(4):459-460.
CYP24A1 has beenidentified in PTC
• CYP24A1 is the calcitriol-neutralizing enzyme• Increased expression has been shown in colon cc and liver cc
Changes of relative CYP24A1 gene expression in 51 human papillary tumors vs.
control thyroid tissues.
Patients’ number
CYP24A1 mRNA expression was markedly increased in 31 cases (61%) of the examined papillary cancer compared with that
of normal thyroid tissue, sometimes reaching over 106-fold elevation. We measured lower CYP24A1 transcription level in
12 tumor tissues (23.5%). There was no variation in CYP24A1 gene expression between 2 tumor and healthy control tissue,
and CYP24A1 specific mRNA was not detected in the thyroid samples of 6 patients.
Component143210-1-2-3-4
Com
pone
nt2
4
3
2
1
0
-1
-2
-3
-4
20
30
38
39
26
1
31
11
6
8
40
19 18
21
17
10
13
12
32
34
149
37
41
25
22
29
5
42
35
4
23
333
272
7
28
24
36
16 44
15 43
Tumorlocalization 1
Winter
Lymph node metastasis
PTC oncocyter variant
CCDC6/RET
Hashimoto
Hyperthyreosis
CYP24A1 RATIOKRAS
Vascularization
Spring
Hypothyreosis
No other thyroid disease
DIRECTION
BRAFTumor size Hyperplasia
Age
ELE1/RET Tumor localization 2
Lymphocytas thyreoiditisSex
No PTC subtype/variation
Fall
HRAS
Tumor localization 3
Struma
Summer
PTC follicular variant
PTC hyalinized variant
Principal component analysis
Component143210-1-2-3-4
Com
pone
nt2
4
3
2
1
0
-1
-2
-3
-4
Tumorlocalization 1
Winter
Lymph node metastasis
PTC oncocyter variant
CCDC6/RET
Hashimoto
Hyperthyreosis
CYP24A1 RATIOKRAS
Vascularization
Spring
Hypothyreosis
No other thyroid disease
DIRECTION
BRAFTumor size Hyperplasia
Age
ELE1/RETTumor localization 2
Lymphocytas thyreoiditisSex
No PTC subtype/variant
Fall
HRAS
Tumor localization 3
Struma
Summer
PTC follicular variant
PTC hyalinized variant
Principal component analysis
HMGA2 (high mobility group AT-hook 2): RAS-regulatedcell proliferationpancreatic ductal adenocarcinoma, papillary serous carcinoma
MRC2 (mannose receptor, C type 2, also known as Endo 180)tumor cell migration
SFN/14-3-3r (stratifin)tumor suppressor genelung cancer, squamous cell carcinoma, pancreatic cancer,endometrial carcinoma, cervical cancer, colorectal carcinoma
Prasad NB et al, Thyroid, 2012. 22(3):275-284.
Three-Gene Molecular Diagnostic Modelfor Thyroid Cancer
Specificity: 100%Sensitivity: 80%
Follow-up study
● FNAB samples collected● Planned: 800, accomplished to date: 710● At least 3 yrs of follow-up planned● Frequency of genetic alterations, incidence of malignancies recorded● Can genetic alterations predict malignancy?
Genetic alteration Frequency
BRAF 4
NRAS 1
HRAS 7
KRAS 0
RET/PTC3 1
One year follow-up of 231 subjects
13
Malignant samples (cytology)
Follicular adenoma (4)
PTC 14
Medullary 1
15 (19)
malignant non-malignant
+ -
Geneticalteration
+ 5 8
- 10 223
231
4 BRAF and 1 RET/PTC3
Melck AL, Yip L, HEAD & NECK—2011, DOI 10.1002/hed.21818.
University of Pittsburgh’s current algorithm for the evaluation of thyroid nodules
Contribution of molecular information to thyroiddiagnostics and therapy
● Additional information to FNAB or histology
● Individual treatment options (e.g. thyrosine kinase inhibition)
● Prediction of malignancy in thyroid nodules
Thank you foryour attention!