DERİN KÖSEBAY OTURUMU - file.trsgo.orgfile.trsgo.org/pdf/2018/kongre2018/14.pdf · Endometrial Ca: Molecular vs ... Uterine cervix squamous carcinoma adenocarcinoma ... Endometrioid/Undiff

DERİN KÖSEBAY OTURUMU

The reflection of the New Molecular and Morphological Classification of Endometrial Cancer to the Clinical

Practice Ayse AYHAN, MD. PhD

Retired Professor, Hacettepe University, Faculty of Medicine, TurkeyAdjunct Professor, Johns Hopkins University Department of Gynecologic Pathology, Baltimore, MD, USA

Adjunct Professor, Hiroshima and Hamamatsu University Faculty of Medicine, Japan

Consultant Pathologist, Seirei Mikatahara Hospital, Hamamatsu, Japan www.ayseayhan.com

http://pathology2.jhu.edu/department/index.cfm

http://pathology2.jhu.edu/department/index.cfm

Endometrial Ca:

Molecular vs Pathological Diagnostics

• Endometrial cancer Classification :

• Histopathological Classification

• Molecular Classification

• The impact of molecular classification on

routine practice:

• The role of the Pathologist-Molecular Tx

Endometrial Ca:






routine practice:


Characteristics Type I (80%) Type II(20%)

Age 55-65 65-75

Clinical Setting Unopposed E Atrophy

Obesity, Ht, DM None

Morphology Endometrioid Non-Endometrioid

Precursor EIN / Hyperplasia EGD?

Behaviour Indolent Aggressive

Characteristics of Type I and Type II Endometrial Cancer

Genetic Alteration Type I Ca (%) Type II Ca(%)

PTEN inactivation 50-80 10

KRAS mutation 15-30 0-5

-catenin mutation 25-40 0-3

Microsatellite Instability 20-40 0-5

ARID1A alterations 40-60 0

P53 mutation 10-20 80-90

HER2/neu 10-30 40-80

P16INK4A inactivation 10 40

E-cadherin 10-20 60-90

PPP2R1A 5-7 20-40

Endometrial Cancer Molecular Subsets

CLASSICAL ENDOMETRIOD CA

MSIPTEN (77%)

CTNNB1 (53%)

KRAS (24%)PIK3CA (55%)ARID1A (35%)

Molecular Alterations in Type I

(Endometrioid) Endometrial Ca

• Immunoreactivity was not detected in 36 (3.6%) of 995 tumors

• Uterine low-grade endometrioidcarcinomas had a high frequency of loss of ARID1A expression: 15/58 (26%) were negative

• There was no ARID 1A loss on serous type uterinecarcinomas.

ARID1A Expression Loss in Endometrioid Carcinomas

Tumor total no. IHC(-) %of IHC(-)

Immunohistochemical study of ARID1A on 995 carcinomas

Hepatocellular carcinoma Bile duct carcinomaLung

adenocarcinomasquamous carcinoma

Renal cell carcinomaBreast carcinomaOvary

high-grade serous carcinomalow-grade serous carcinomamucinous carcinoma

Uterine cervixsquamous carcinomaadenocarcinoma

Uterine corpusendometrioid carcinomaserous carcinoma/MMMT

Trophoblastic tumorchoriocarcinomaplacental site trophoblastic tumorepithelioid trophoblastic tumor

Prostate carcinomaColon carcinomaGastric carcinomaPancreatic carcinomaOral squamous carcinomaIHC: Immunoreactivity of ARID1A

4127

42107391

2211536

11411

5817

356

1735494548

4

02

1101

00 0

21

150

00002540

07.4

2.410

01.1

000

1.89.1

260

0000

4.111

8.30

AJSP 35:625, 2011

Endometrioid Ca Serous CaEndometrium

AH / EIN with loss of PTEN and/or ARID1A

Co-loss of ARID1A & PTEN was highly significant and nonrandom (p=0.0003)

All AH / EIN areas with ARID1A loss were geographically nested within the areas

of PTEN loss. A significant increase in Ki67 in areas with concurrent PTEN and

ARID1A co-loss compared to adjacent AH / EIN areas showing only PTEN loss.

Uterine Serous Carcinoma –Prototype of Type II EmCa

TP53 (>90%)

PPP2R1A (37%)HER2/neuIGFIImRNABP(IMP3)p16INK4AChromosome Instability(CIN)

Molecular Alterations in Type II

(Non-Endometrioid) Endometrial Ca

Endometrioid Adenoca• Variants (sq. diff; villoglandular, Secretory)

Mucinous Adenoca

Serous Intraepithelial Carcinoma

Serous Adenoca

Clear Cell Adenoca

Neuroendocrine tumors (Low/High)

Mixed Cell Adenocarcinoma

Undifferentiated Carcinoma

Dedifferentiated Carcinoma

Endometrial Adenocarcinoma (WHO, 2014)

Serous Intraepithelial Carcinoma

Squamous Cell Ca & TCC

Neuroendocrine tumors (Low/High)

Undifferentiated Ca

Dedifferentiated Ca

Endometrial Ca:






routine practice:


n=373, array, seq based

Endometrial Carcinoma (TCGA)

7% 28% 39% 26%


1

2

3 3


MSIPTEN (77%)

CTNNB1 (53%)


Molecular Alterations in Type I

(Endometrioid) Endometrial Ca

Recurrently mutated genes are different between the four groups

POLE-MutatedEEC, G1-3, <10%

PTEN (94%)


MSI-High mutEEC, G1-3, 30%

MSI

PTEN (88%)



Copy LOWEEC, G1-2, 30%

PTEN (77%)

CTNNB1 (52%)PIK3CA (53%)ARID1A (42%)

Copy HIGH-SLSerous(94%,Mx 30%)

P53 (92%)

PPPR1A (22%)PIK3CA (47%)CIN, amplifications


• Clinical Heterogeneity: Due to molecular ?

• TCGA clasification :

• Subtypes can be reliably delineated

• Prognostic / predictive information:

• Embracing and incorporating them into clinical

practice is thus attractive.

• Integration of molecular features into current

classification systems is not without obstacles.

Endometrial Carcinoma Molecular Diagnostics

• Improve risk stratification systems by combining traditional

clinico-pathological parameters

• How molecular classification can be optimally utilized to direct patient care.

Pathologists and clinicians caring for women with

endometrial cancer need to engage with and understand

the possibilities and limitations of this new approach,

because integration of molecular classification of

endometrial cancers is anticipated to become an

essential part of pathology practice.



1

2

3

PROactive Molecular rISc classifyer EmCa

Henry T. Lynch, MD.

A.S. Warthin,MD. PhDArch. Int. Med, 1913

10children. 6 cancer, He died of cancer at 60.

Third generation, 33/70 cancer : Uterine – Gastric - Colon

1985 : H. Lynch : Hereditary Nonpolyposis Colorectal Ca2005 Douglas (Mishigan-AnnArbor). MSH2 is the genetic defect

Subsequent Cancers

•Garg K, Soslow RA. J Clin Pathol 2009; 62: 679. Kwon JS, J Clin Oncol, 2011, Surgery, 2010

Co

rrelatio

ns: M

MR

deficien

t, LG: IT-P

T TIL’s

⚫ Microsatellites are polymorphic repetitive short non-coding DNA sequences – widely dispersed throughout the genome

⚫ Repetitive nature cause “REPLICATION ERRORS” (RER)

⚫ DNA repair mechanisms

⚫ Effectively represent the defects in MMR

genes rather than mutation spesific

⚫ Microsatellite Instability occurs in >20% of sporadic endometrioidendometrial carcinomas.

⚫ Most frequent causes⚫ MLH1 inactivation by epigenetic silencing

⚫ MSH2, MSH6, PMS2 mutation and expression loss

⚫ MI occurs as an early event in endometrioid endometrial cancer.

“MSI” in Endometrioid Endometrial Cancer

Endometrial Ca:






routine practice:


After TCGA: Pathology Correlations

• TCGA + Age + LVSI + DOI incorportaion

• POLE mutant: HGEEC:

• Superficial broad inv, TILs, (ambiguous)

• MSI : MLH1, PMS2, MSH2 and MSH6 partly Lynch synd

• Challenges to overcome :

• Multiple classifyers

• additional (Er, PgR, LCAM, b-catenin..)

Integrated TCGA Molecular & Clinicopathologic

TCGA : Molecular Classes of Endometrial Ca

TCGA : Molecular Classes of Endometrial Ca

Pathology-Molecular Correlations

Histopathology+IHC/ISH Molecular Management

Lower Uterine LocationEndometrioid/UndiffMucinousTIL?

Endometrioid HG, LVSI,CCC, undiff PROMINANT TILAmbiguous/bizarre/giantnuclei

MMR-D:MLH1MSH2PMS2MLH1 promotor

POLE mutations

• Genetic Counseling

• Screening• Consider Tx:

PD1/PDL1• CHKPT inh for

reccurrences

• AVOID overtreatment in adjuvant setting

Immune-Editing, Immune-Escape, Immune Checkpoint Regulation

• Currently, the single approved marker-driven treatment :

pembrolizumab (immune checkpoint inhibitor) for tumors

with defective MMR (abnormal IHC findings).

• There is promise for targetting specific mutations/defects for

advanced stage endometrial cancers:

• PIK3CA pathway (PIK3CA or mTOR inhibitors),

• ER/PR (hormonal therapy),

• PTEN mutations (mTOR inhibitors or PARP inhibitors),

• ARIDIA mutations (EZH2 inhibitors, or PARP inhibitors)

• VEGF inhibitor(??) for recurrent ?

• Trials in recurrent Emca (GOG-86P and MITO END-2 trials)

• Bevacizumab (VEGF inhibitor) or temsirolimus (mTOR

inhibitor) with chemotherapy (stage III, Stage IVA, Stage IVB or

recurrent).

• PFS :19.6 months in patients with p53 loss of function (null) for

bevacizumab+paclitaxel+carboplatin compared to 12.2 months

PFS in the p53 wild-type group

• The group treated with temsirolimus did not show any effect

P53 MUTANTS??

A.R.Mallen, V.L. Filiaci, D.A. Levine, K. Thiel, C.A. Aghajanian, X.Meng, E. Devor,

K.N. Moore, M.A. Powell, A.A. Secord, K.S. Tewari, D.P. Bender, A.R. Stuckey, J.M.

Fowler, S.B. Dewdney, K.K. Leslie, Evidence for synthetic lethality between

bevacizumab and chemotherapy in advanced, p53 null endometrial cancers, 49th

Annual Meeting of the Society of Gynecologic Oncology. New Orleans, LA, 2018.

What do new techniques bring us?

Euphoria

Disappointment

Reality

PATHOLOGY

CLASSICAL

MOLECULAR

CLINICIAN

PATIENT

genetic

immunology

molecular

biology

biochemistry

biophysics

histology

anatomy

PATHOLOGYPATHOLOGYPATHOLOGYPATHOLOGYPATHOLOGY

Tesekkurler………………[email protected]

mutation

deletion

amplification

translocation

Genomic studies will offer pathologistsan unprecedented opportunity to bridgebasic research and clinical science

Application of genomic data and incorporate those to pathology practice will re-define the roles of pathologists in the patient care

Pathology will be the critical profession that advances future translational genomic research and providing new information beyond morphology

Nanopore sequencing-Towards the 15-minute genomeGenetics: Pulling strands of DNA through nanopores could dramatically speed up the sequencing of human genomes

Nanopore

(a-hemolysin)

Mar 10th 2011

… It is now possible to sequence

a human genome in about eight

days, at a cost of around $10,000.

But researchers dream of being

able to complete the process in a

matter of hours, or even minutes,

for less than $1,000.

Thank You…[email protected]

DISEASES

Congenital

have genetic basis

• Pathologic presence:infectious diseases

• Abnormal gene expression

• Aberrant gene creation

Acquired

Normal endometriumARID 1A expression

Low-grade Endometrioid Endometrial Carcinoma:ARID 1A loss

Serous endometrial CarcinomaNo ARID 1A loss

AJSP 35:625, 2011

Low-grade Endometrioid Endometrial Carcinoma:ARID 1A loss

Serous endometrial CarcinomaNo ARID 1A loss

Mapping the distribution of PTEN, ARID1A and MIB1

All AH / EIN areas with ARID1A loss were geographically nested within the areas

of PTEN loss. A significant increase in Ki67 in areas with concurrent PTEN and

ARID1A co-loss compared to adjacent AH / EIN areas showing only PTEN loss.

AR

ID1

A a

nd

PT

EN

co

-loss : b

lack d

ash

ed

line. O

nly

PT

EN

loss : g

reen

dash

ed

line.

PPP2R1A mutations occur frequently in

uterine serous but not endometrioid CA

Fadare & Zheng, 2009

Comprehensive and coordinated effort to accelerate our understanding of :

• Cancer etiology & pathogenesis

• Through the application of genome analysis technologies.

• The goal is to improve our ability to diagnose, treat and prevent cancer.

The study of DISEASE, addressing

• Etiology

• Pathogenesis

• Morphologic changes :

Structural, biochemical, and

functional changes in cells,

tissues and organs

• By means of molecular /microbiologic, immunologic & morphologic… techniques

• Providing a rational basis for clinical care and therapy

Documents

DERİN KÖSEBAY OTURUMU - file.trsgo.orgfile.trsgo.org/pdf/2018/kongre2018/14.pdf · Endometrial Ca: Molecular vs ... Uterine cervix squamous carcinoma adenocarcinoma ... Endometrioid/Undiff