patologia molecular del cancer de origen desconocido?€¦ · metastatic carcinoma to the...
TRANSCRIPT
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PATOLOGIA MOLECULAR DEL
CANCER DE ORIGEN
DESCONOCIDO?
Xavier Matias-Guiu
Hospital Universitari Arnau de Vilanova,
Universitat de Lleida, IRBLLEIDA.
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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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CANCER UNKNOWN ORIGIN
(Pathology)
• Adenocarcinoma (50%)
• Poorly Differentiated Carcinomas(35%)
• Squamous Cell Carcinoma (10%)
• Undifferentiated Carcinoma (5%)
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CANCER UNKNOWN ORIGIN
(Immunohistochemistry)
• Cytokeratins
• Organo-specific markers (PSA,
Thyroglobuline, GCDFP-15)
• Non-organ-specific markers (CEA, p63,
ER/PR)
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CANCER UNKNOWN ORIGIN
(Cytokeratins 7 + 20 -)
• Breast Ca
• Lung, nonsmall cell ca (90%)
• Ovarian serous ca (90%)
• Mesothelioma
• Endometrial Ca
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CANCER UNKNOWN ORIGIN
(Cytokeratins 7 - 20 +)
• Colon Ca (75-95%)
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CANCER UNKNOWN ORIGIN
(Cytokeratins 7 + 20 +)
• Transitional Cell Ca
• Ovarian mucinous ca
• Pancreatic Ca
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CANCER UNKNOWN ORIGIN
(Cytokeratins 7 - 20 -)
• Hepatocellular Ca (70- 90%)
• Renal cell ca (70 – 90%)
• Prostatic Ca
• Neuroendocrine Ca
• Squamous cell Ca
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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
GCDF-15 Mamoglobin
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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
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Villin CDX-2
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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
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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)
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CANCER UNKNOWN ORIGIN
(Renal Cell Ca)
• CK7-/CK20-
• Vimentin
• CD-10
• PAX-2
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MOLECULAR APPROACHES IN
TUMORS OF UNKNOWN ORIGIN
• ONE GENE
• MULTIPLE GENES
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LUNG CANCER AND EGFR
MUTATIONS
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• 83 year old man
• Disseminated cancer (liver and lung). Pleural Effusion
• Pleural Cytology: Positive for malignancy, consistent with adenocarcinoma. TTF-1 negative
Clinical History
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EGFR exon 19 E746-A750 del 15pb
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Diagnosis
Pleural metastasis from pulmonary
adenocarcinoma with EGFR mutations.
Treatment with EGFR inhibitors.
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ASSESSMENT OF PRIMARY
ORIGIN IN PATIENTS WITH A
PREVIOUS HISTORY OF CANCER
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Independent vs Metastatic Tumors
(clonality)
• Cromosome X (HUMARA)
• LOH
• Mutation analysis
• Viral Detection
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N T
T1
T2
T3
T4
T5
T6
T2
T7
T8
T9
T10
T11
T12
T13
T14
T2
T8
T15
T16
T11
T17
T18
Primary Tumor
Metastasis
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• 71 year old woman
• Cervical cancer, two years ago.
• Adrenal Tumor
Clinical History
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Diagnosis
Cervical Carcinoma metastatic to
the adrenal gland
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• A 50 year old woman.
• Pseudomyxoma peritonei
• Ovarian Tumor
• Appendiceal Mucocele
Clinical History
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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 1996 20:739-746
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MOLECULAR APPROACHES IN
TUMORS OF UNKNOWN ORIGIN
• ONE GENE
• MULTIPLE GENES
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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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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)
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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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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)
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• 69 year old woman
• Unilateral ovarian tumor
• Colon cancer, several years ago
Clinical History
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CK 7 CK 20 CK 7 CK 20
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Villin CDX 2
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Diagnosis
Colon carcinoma metastatic to the
ovary
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• 64 year old woman
• Breast Cancer, several years ago
• Peritoneal Carcinomatosis
Clinical History
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ER WT-1
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Mamoglobin GCDF-15
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Diagnóstico
Metastatic ovarian carcinoma
(serous type)
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• 59 year old man.
• Brain tumor
Clinical History
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TTF-1 CK-7
CK-20
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Diagnosis
Metastatic carcinoma of pancreatic
origin.
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• A 37 year old patient.
• Unilateral ovarian tumor
Clinical History
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• Gastroscopy negative
• Gastric biopsies: Adenocarcinoma with signet ring cells
Follow up
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Diagnosis
Gastric carcinoma metastatic to the
ovary
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• 64 year old woman
• Bilateral ovarian tumors
Clinical History
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CK 7 negative; CK 20 positive
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• Gastroscopy: negative
• Gastric biopsies: negative
Follow-up
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Diagnosis
Gastric carcinoma metastatic to the
ovaries
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• 50 year old woman.
• Vaginal Bleeding
• Endometrial Biopsy
• Bilateral Ovarian tumors
Clinical History
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AEI-AE3 +
CK7 –
CK 20 +
ER, PR –
Vimentin –
CDX-2 +
Villin +
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Diagnosis
Metastatic adenocarcinoma (signet-
ring features) of unknown origin
involving the endometrium and the
ovaries
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Estudio Molecular Cancer Origen Desconocido
Last generation sequenciacing
(Ion Torrent, Miseq)
Actionable genomic alteration rather than site of origin for
personalized therapy
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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
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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
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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.
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Estudio Molecular Cancer Origen Desconocido
Last generation sequenciacing
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• 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
Take Home Messages
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PATOLOGIA MOLECULAR DEL
CANCER DE ORIGEN
DESCONOCIDO?
Xavier Matias-Guiu
Hospital Universitari Arnau de Vilanova,
Universitat de Lleida, IRBLLEIDA.