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Dipartimento di Endocrinologia Università di Pisa
Pisa, Italia
Prof. Rossella Elisei
TUMORI MIDOLLARI E SINDROMI GENETICHE
RIUNIONE DEL GRUPPO (CSD) CHIRURGICO ONCOLOGICOGenova, 18 settembre 2009
TAVOLA ROTONDA: I TUMORI DELLA TIROIDE
THYROIDTHYROID:: 2 CELLULAR TYPES2 CELLULAR TYPES
C CELLS OR PARAFOLLICULAR CELLSC CELLS OR PARAFOLLICULAR CELLS1% OF THYROID CELLS1% OF THYROID CELLS
Parafollicularcells
Follicularcells
Colloid
Bloodvessel
Normal C Cells Diffuse HCC
Focal HCC Nodular HCCMedullary carcinoma
Slight HCC
Hypothesis of progression of the tumoral transformation of C Cells
EARLY DIAGNOSIS OF MTC BY MEANS OF
CALCITONIN ASSAY
Melvin KEW et al, N Engl J Med, 1971
CHROMOGRANIN +
CALCITONIN +
THYROGLOBULIN -
Routine measurement of serum calcitonin in nodular thyroid
diseases allows the preoperative diagnosis of
unsuspected sporadic medullarythyroid carcinoma.
Pacini F et al, JCE&M, 1994
70
%
PAPILLARY FOLLICULAR ANAPLASTIC LYMPHOMA0
10
20
30
40
50
60
MEDULLARY UNKNOWN
THYROID CANCER HISTOTYPETHYROID CANCER HISTOTYPE((DepartmentDepartment of of EndocrinologyEndocrinology, Pisa), Pisa)
55--10% of 10% of thyroidthyroid cancercancer
Surv
ival %
PTC
FTC
MTC
ATC
years
0
50
100
0 2 5 10 15 20
SURVIVAL vs HISTOTYPE (n=1150)SURVIVAL vs HISTOTYPE (n=1150)
%
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Lymph node mets.
Extrathyroidalinvasion
Distant mets.
Intrathyroidal
SURV
IVORS
SURVIVAL (years)
ABSENCE OF LYMPH NODES METASTASESABSENCE OF LYMPH NODES METASTASESIS AIS A POSITIVE PROGNOSTIC FACTORSPOSITIVE PROGNOSTIC FACTORS
(MAYO CLINIC)
PREVALENCE OF DIFFERENT FORMS OF MEDULLARY THYROID CARCINOMA
MTC
HEREDITARY 20%
SPORADIC 80%
MEN 2A 65%
MEN 2B 25%
FMTC 10%
Multiple Endocrine Neoplasia type 2A
Thyroid
Parathyroids
Adrenal glands
phoechromocytoma
Medullary carcinoma
Multiple adenomatosis
MTC CCHpheochromocytoma
HABITUS MARFANOIDE(100%)
MUCOSAL NEURINOMAS (100%)
TYPICAL “NON” ENDOCRINE DISEASES IN MEN 2B
MEGACOLON(80-90%)
CUTANEOUS AMILOIDOSIC LICHEN
“NON” ENDOCRINE DISEASE IN MEN 2A
Rare (10%) but specific
HEREDITARY MTC IS INHERITED AS AN AUTOSOMIC DOMINANT TRAIT
II
III
I
IV
MTC + PHEO MTC PHEO LCA
’80: MEN IIA SYNDROME LOCUS ON CHROMOSOME 10
CHROMOSOME LOCALIZATIONCHROMOSOME LOCALIZATION
10q11.210q11.2
1993RET AND MEN II !
MEN IIA
MEN IIBFMTC
MTC sporadic*
MEN IIA (1)(MTC + PHEO + HYPERP)
MEN IIA (2)(MTC + PHEO)
MEN IIA (3)(MTC + HYPERP)
Involved codons609 611 618 620 634 768 804 918
6% 2% 92%
3% 4% 13% 80%
8% 15% 8% 69% 97%
7% 3% 33% 17% 30% 3%95%*
* Somatic mutations are found in 40% of sporadic MTC
RET MUTATIONS AND PHENOTYPES (INTERNATIONAL RET CONSORTIUM, 1994)
CYS
TEIN
RIC
HD
OM
AIN
TYR
OSI
NE
KIN
ASE
DO
MA
IN
2006 GENOTYPE-PHENOTYPE ACCORDING TO KNOWN MUTATIONS
point mutationsdeletions/insertion
Dupl E529-C531 8 FMTC
10Del G592-G607 MTCDel F612-C620 MTC
11Del D631-L633 MTCDel E632-C634 MTCDel C630-D631 MTCDel E632-L633 MTCDel E632-L633 MTCDel E632-A640 + insVRP MTCC634-insH/E/L/C-R635 MEN2A
15Del D898-E902 MTC
EXONS PHENOTYPEMUTATED CODONS EXONS PHENOTYPE
883891
918
15
16
MEN 2BFMTC
MEN 2B
912 16 FMTC
MUTATED CODONS
768790-1
13 FMTCFMTC
15
804 14 FMTC
630
634
11 FMTC
MEN 2A
632/633/634 MEN 2A634/635 MEN 2A
609611618620
10FMTC-MEN 2AFMTC-MEN 2AFMTC-MEN 2AFMTC-MEN 2A
603 FMTC
533 8 FMTC
EXTR
AC
ELLU
LAR
D
OM
AIN
Data from Santoro M and Carlomagno F, Nature Clin Pract Endocrinol & Metab, 2006
exon 13
exon 10exon 11
exon 14
exon 16exon 15
Cys 609 (1%) 5 22Cys 611 (3%) 7 30Cys 618 (7%) 7 29 41Cys 620 (7%) 6 22
Cys 630 (1%) 1 32
Cys 634 (68%) 1.1 12 10
Glu 768 (1%) 22 59Leu 790 (5%) 10 28Tyr 791 (2%) 21 38 38
Val 804 (2%) 6-12 28-33
Ser 891 (2%) 13 52 10Met 918 (3%) 0.75 12
Earliest age of manifestation (yr)
MTC(95%)
PCC(50%)
phPT(10-30%)
adapted from Machens and Dralle 2006
CODON SPECIFIC AGE RELATED PROGRESSION IN MEN 2
MEN 2B918883
804+806804+904
609611618620
634790791
V804L891
MEN 2A634635637
FMTC
532533630768
V804M844912
CORRELATION BETWEEN RET MUTATION AND THE PHENOTYPIC PRESENTATION OF HEREDITARY MTC
Kouvaraki et al, 2005
CLINICAL APPLICATIONS
a) EASY IDENTIFICATION OF HEREDITARY MTC CASES (20%)
b) IDENTIFICATION OF GENE CARRIERS AMONG FIRST DEGREE RELATIVES
DEFINITIVE CURE
EARLY DIAGNOSIS AND TREATMENT
! !
BLOOD AND/OR BLOOD AND/OR TUMORAL TISSUETUMORAL TISSUE
GENOMIC DNA
SEQUENCE ANALYSIS AND/OR RESTRICTION ANALYSIS
GENETIC ANALYSIS OF RET GENEGENETIC ANALYSIS OF RET GENE““METHODSMETHODS””
PCR WITH SPECIFIC PRIMERS FOR EXONS 10-11-13-14-15-16
RET MUTATION GENETIC SCREENING Dept. Endocrinology, Pisa, 1995 -2005
754 screened subjects
CLINICAL PRESENTATION
306 patients with family history of MEN II
448 apparently MTC sporadic cases
RE-CLASSIFICATION OF “APPARENTLY SPORADIC”AFTER RET GENE SCREENING
(Dept. Of Endocrinology, Pisa)
448 sporadic cases
Identification of a germlinemutation
38 hereditary cases6 MEN IIA (1 "de novo")
32 FMTC (unknown)(8.4%)
CONCLUSIONS: RET genetic screening in hereditary cases...
… is the most specific and sensitive test for the diagnosis of MEN II
… allows the early treatment of MTC that is fundamental for its definitive cure. In particular, according with the guidelines for the treatment of MEN gene carriers (BRANDI M ET AL, JCE&M, 2001), thyroidectomy isrecommended
as soon as possible (< 2 yrs) in MEN IIB 5 yrs of age in MEN IIA or before if MTC suspected< 10 yrs in FMTC or when Pg test is positive
... identifies gene carriers and non gene carriers: non gene carriers willnever develop MTC during their life and can avoid any other clinicalinvestigation.
… gene carriers must be also investigated for the presence of pheochromocytoma and/or hyperparathyroidism
23-38 Cys 609 1 0 123-38 Cys 611 3 3 123-38 Cys 618 7 9 723-38 Cys 620 7 8 4
57 Cys 630 1 1 3113 Cys 634 68 37 23
7 Glu 768 1 2 3Leu 790 5 10 1Tyr 791 2 7 0
7 Val 804 2 4 14? Met 848 0 0 1
18 Ser 891 2 0 6? Ala 883 Thr 0 0 1? Ser 904 Thr 0 0 1
141 Met 918 3 19 5
ex 13
In vitroTransforming
ActivityN of foci
RETgene
RET mutation
% of RET familiesEUROMEN 1993-2001
N=102
Halle1994-2003
N=100
Pisa1994-2006
N=72
ex 15
ex 16
ex 14
ex 13
ex 11
ex 10
1 no mutMod
ified
from
Mac
hens
and
Dra
lle,
Molec
ular
End
ocrino
logy
, 20
06
index case
Ex 15: GCT883->ACT
consanguineous
not mutated
Homozygous + MTCHeterozygous
not screened no mutationj
Heterozygousmutation
Homozygousmutation
Identification of a novel point mutation in the RET gene (Ala883Thr), which isassociated with MTC phenotype only in homozygous condition
Elisei R, Romei C, Cosci B et al JCE&M, 2004
… Our functional characterization of the R833C substitution suggests that, like the V804M and S891A mutations, this thyrosine kinase mutation confers a weak activating potential upon RET.
Craston A,…, and Bongarzone I, Molecular Endocrinology, 2006
A novel Activating Mutation [R833C] in the RET Tyrosine Kinase Domain Mediates Neoplastic Transformation
Late-onset Medullary carcinoma of the thyroid: need for genetic testing and prophylactic thyroidectomy in adult family members.
Shaha A et al, The laryngoscope, 2006
Female 47 yrs with V804M Ret mutation: undetectable Basal CT, only CCH at histology
Male 45 yrs with V804M Ret mutation: undetectable Basal CT, only CCH at histology
0
10
20
30
40
50
60
70
80
918 634 689 804 611 618 620 790 891 912 630 791 768
AGE(YRS)
Intracellular domain
Extracellular domain
EARLIEST REPORTED AGE OF MTC DIAGNOSIS ACCORDING TO RET MUTATIONS
REPORTED MUTATIONS
GAGEL R, PERSONAL COMUNICATION, ATA MEETING PALM BEACH, 2003
AGGRESSIVENESS OF MTC AND RET MUTATION
MEN 2BMEN 2BMEN 2AMEN 2AFMTCFMTC
UnclassifiedUnclassified
MEN 2AMEN 2AFMTCFMTC
UnclassifiedUnclassified
ClinicalClinical phenotypephenotype
883, 918883, 918611, 618, 611, 618, 620, 634620, 634
609, 768, 790, 609, 768, 790, 791, 804, 891791, 804, 891
RET RET MutationMutation
HighestHighest riskrisk,,LevelLevel 33
HigherHigher riskrisk,,levellevel 22
High High riskrisk,,levellevel 11
Kouvaraki et al 2005
OPEN QUESTIONS ON RET GENE CARRIERS:1) At what age must they be operated on?
2) Should they be operated on the basis of age or taking into account the type of RET mutation?
3) Is the basal and stimulated calcitonin importantin taking the decision to operate the child?
4) Should the total thyroidectomy be associated tothe central neck compartment dissection?
ATA Guidelines for the management of MTC, Thyroid 2009
UNIVERSITY OF HALLE ALGORITHM OF OPERATIVE INTERVENTION IN RET GENE CARRIERS
(Machens A. and Dralle H: Surgery, 2006)
Stimulated serum calcitonin
Increased Not increasedRisk category:codon
Thyroidectomy at age:
Lymph node dissection:
central compartment
lateral compartments
any
immediately
synchronously
tumor>10mmor node positive
highest high least-high
6-12mo 5yrs 5-10yrs
no
DEPT. OF ENDOCRINOLOGY, UNIVERSITY OF PISA, ALGORITHM OF OPERATIVE INTERVENTION IN RET GENE
CARRIERS AND UNDETECTABLE LEVELS OF SERUM CT
Stimulated serum calcitonin
Increased Not increasedRisk category:codon
Thyroidectomy at age:
any
immediately*
highest high least-high
Lymph node dissection:
central compartment
lateral compartments
synchronously
node positive
*After analysing pheo and hyperparat
when Pg test for serum CT is positive
synchronously
node positive
Genecarriers(n=29)
Screening Iperp/Pheo
Thyroidnodules
(eco)
CT pg/mlbasal/peak
dopo PgSyndrome Thyroid
ectomyn=17
n=64=MEN2A
2=FMTC
Mean age(aa)
28.7
66.5YES Pos/Pos 2Pos/1Pos n=6
n=92=MEN2A
7=FMTC
13.5
45NO Neg/Pos Neg/Neg n=7
n=143=MEN2A
11=FMTC
16.5NO Neg/Neg Neg/Neg n=4
CLINICAL FEATURES OF MEN 2/FMTC “GENE CARRIERS”
22
PATHOLOGICAL FEATURES OF“GENE CARRIERS” SUBMITTED TO
THYROIDECTOMY
MTCSize of the tumor
(range)
MEN 2An=7
FMTCn=10
7/7
9/10*
5-18 mm
2-25 mm
TNM
7=T1N0M02=T2bN1M0
4=T1N0M03=T2bN1M0
operatedgene
carriers17/29
*1/10 C cell hyperplasia 12/17(71%) cured
Prophylactic Thyroidectomy in Multiple Endocrine Neoplasia Type 2A <19 years
Skinner MA,…. Wells S. New Engl. J of Med, 2005
44/50 (88%) gene carriers treated by surgery, were definitively cured
after a 5-10 years follow up
27/50 with elevated serum CT after Pg stimulation (median age: 11yrs)
23/50 with undetectable CT after Pg stimulation (median age: 7 yrs)
RET mutations in codons at “high risk” *
* 19=634, 16=620,11=618,3=609,1=611
TYROSINETYROSINE--KINASE INHIBITORS: RATIONALEKINASE INHIBITORS: RATIONALE
StopStopPhosphorylationPhosphorylation
Stop Stop signalsignaltrasmissiontrasmission
ACTIONACTION
InhibitionInhibition cellularcellulargrowthgrowth
MUTATED RET
AMG 706: AMG 706: MotesanibMotesanib
North America S Sherman (18), L Wirth (11), R Martins (9), S Agarwala (5), J Barrera (5), R Boccia (4), K Burman (3), J Jakub (3), Z Nahleh (3), L Rosen (3), K Ali (2), O Clark (2), T Davis (2), G Srkalovic (2), J Stephenson (2), R Bukowski (1), R Mena (1), N Tchekmedyian (1)
M Schlumberger (15), A Pinchera/R Elisei (12), L Bastholt (10), JP Droz (10), M Hofmann (8), L Licitra (8), F Pacini (7), C Daumerie (6), BN Bui (5), B Jarzab (4), S Jansson (3), C Schvartz (3), ML Brandi (2), B Conte-Devolx (2), G Lundell (2), J Philippe (2), F Orlandi (2), P Lind (1), C Pirich (1), K Racz (1), V Rohmer (1), J Sowinski (1), I Szabolcs (1)
Study 20040273 Participating Investigators (Total No. of MTC Patients Enrolled = 91)
Europe
Final resultsFinal results
In this study of patients with advanced MTC, In this study of patients with advanced MTC, motesanibmotesanibdiphosphatediphosphate demonstrated an encouraging demonstrated an encouraging clinicialclinicial benefit benefit raterate
–– overall, clinical benefit was PR (2%) + durable SD overall, clinical benefit was PR (2%) + durable SD ≥≥ 24 24 weeks (47%)weeks (47%)
–– 21% of patients with 21% of patients with prestudyprestudy PD achieved durable SD PD achieved durable SD ≥≥24 weeks24 weeks
–– 4848--week progressionweek progression--free survival was 49%free survival was 49%
1 Sherman et al, New England Journal of Medicine, 2008
ZD6474=VANDETANIB=ZACTIMAZD6474=VANDETANIB=ZACTIMA
Study D4200C00058Study D4200C00058Study D4200C00068 Study D4200C00068
N
HN
NO
O
F Br
N
Adapted from Wedge SR et al. Cancer Res 2002;62:4645–4655
ZD6474 (ZD6474 (VandetanibVandetanib, , ZactimaZactima) selectively targets ) selectively targets VEGFR, EGFR and RET tyrosine VEGFR, EGFR and RET tyrosine kinasekinase activityactivity
>200>200IGFIGF--1R1R>100>100AKTAKT
>20>20cc--kit, erbB2, FAK, kit, erbB2, FAK, PDK1PDK1
>10>10MEK, CDK2MEK, CDK2
>1>1VEGFRVEGFR--1 (Flt1 (Flt--1), 1), PDGFRPDGFR--β, β, TieTie--2, 2, FGFR1FGFR1
0.500.50EGFREGFR0.130.13RETRET0.110.11VEGFRVEGFR--3 (Flt3 (Flt--4)4)0.040.04VEGFRVEGFR--2 (KDR)2 (KDR)
ICIC5050 ((μμMM))KinaseKinase
PHASE II STUDY: Patient 001:PHASE II STUDY: Patient 001:Liver Metastasis of thyroid cancerLiver Metastasis of thyroid cancer
Kindly provided by Dr Wells S, Duke University, USA
PHASE II STUDY: Patient 001:PHASE II STUDY: Patient 001:Lymph Node Metastasis of thyroid cancerLymph Node Metastasis of thyroid cancer
Kindly provided by Dr Wells S, Duke University, USA
Lesion atLesion atBaselineBaseline 3 Months3 Months 7 Months7 Months
PHASE II STUDY: Patient 002:PHASE II STUDY: Patient 002:Breast Metastasis of thyroid cancerBreast Metastasis of thyroid cancer
Kindly provided by Dr Wells S, Duke University, USA
Study 58 DesignStudy 58 Design
Double-Blind
Optional Open-Label
Randomization 2:1
ZD6474 300mg
Placebo
PROGRESSION
DEATH
Survival follow-up
(all subjects)
232 MTC both sporadic and hereditary
77 subjects
155 subjects
ZD6474 300mg
ZD6474 300mg
EnrolmentHereditary MTC only
ZD6474 100mg Survival follow-up up to death
Study 68 DesignStudy 68 Design
2 Multicentric randomised international clinical trialsInternational Coordinating Investigator: Samuel Wells, MD
Study 58: subjects screened n= 32 subjects enrolled n= 24
Study 68: subjects screened n= 7subjects enrolled n= 4
Opened 12 February 2007, closed 19 October 2007
Final Results in 12 monthsVERY GOOD PRELIMINARY RESULTS
TOTAL ENROLLED in PISA: N= 28
Clinical trials are not open to MTC patients <18aa
Only one trial with ZACTIMA is currently open at NIH (Bethesda, Washington) for children with MTC (both sporadic and hereditary)
At present, only 6 children have been enrolledfrom all over the world (1 Italian girl 8 years oldwith MEN IIB with bilateral laterocervical metastaticlymph nodes and lung metastases): VERY GOOD RESULTS!!!!
Children can be enrolled through our center.
