colon cancer can be prevented normal epithelium adenoma carcinomametastases early detection improves...

Colon Cancer can be preventedColon Cancer can be prevented

Normal epithelium Adenoma Carcinoma Metastases

Early detection improves prognosisEarly detection improves prognosis

Multistep processMultistep process

Multitarget Stool DNA

Testing for CRC Screening

(NEJM 3.2014)Aspirin reduced risk for

CRC - CAPP1, 2, 3..

Cancer Hub 3/2014

All tumors are ‘genetic’Chromosomal instability (CIN).

Microsatellite instability (MSI).

<20% of tumors are inherited

Normal epithelium Adenoma Carcinoma Metastases

Inherited CRCInherited CRCA relatively large number of monogenic syndromes

associated with a high lifetime risk of CRC.

2004 - Inherited CRC

HNPCCFAP (APC)

Rare Polyposis Syndromes •Cowden's disease (PTEN)•PJS (STK11)•JPS (SMAD4, BMPR1A)

Adapted from Burt RW et al. Prevention and Early Detection of CRC. 1996

Cancer Hub 3/2014

2014 - Inherited CRC

HNPCC - Lynch / Syndrome X

FAP (APC)

Rare Polyposis Syndromes •Cowden's disease (PTEN)•PJS (STK11)•JPS (SMAD4, BMPR1A)•HMPS

MAP (MutYH)

Adapted from Burt RW et al. Prevention and Early Detection of CRC. 1996

PPAP (POLE POLD1)

Cancer Hub 3/2014

Gene Disease Association or Cancer Risk

Complete Sequencing

Del/Dup Added

MLH1 Lynch, Muir-Torre Yes Yes November 2011

MSH2 Lynch, Muir-Torre Yes Yes November 2011

MSH6 Lynch Yes Yes November 2011 PMS2 Lynch Yes Yes November 2011 EPCAM Lynch Yes Yes November 2011 APC FAP, Turcot Yes Yes November 2011 MUTYH MAP Yes Yes November 2011 CDH1 HDGC Yes Yes June 2012

PTEN Cowden Yes Yes June 2012

STK11 Peutz-Jeghers Yes Yes June 2012 TP53 Li-Fraumeni Yes Yes June 2012 SMAD4 Juvenile Polyposis Yes YesJanuary 2013 BMPR1A Juvenile Polyposis Yes Yes January 2013

POLE Colon, endometrial cancer Yes Yes NEW October 2013

POLD1 Colon cancer Yes Yes NEW October 2013

GALNT12 Colon cancer Yes Yes NEW October 2013

GREM1 Polyposis Yes Yes NEW October 2013

AKT1 Breast, thyroid cancers, macrocephaly

Yes Yes NEW October 2013

PIK3CA Breast, thyroid cancer, macrocephaly


COLOSEQ NGS PANEL (UW)COLOSEQ NGS PANEL (UW)

Next-Generation Sequencing (NGS) ERA:Next-Generation Sequencing (NGS) ERA:

Analyze entire human genome in a clinically useful time frame

Faster & cheaper generation of data , increased accuracy Sufficient for clinical application

NGS does not cover variety of complex genetic aberrations :NGS does not cover variety of complex genetic aberrations :CNVs, structural changes, epigenomic changes CNVs, structural changes, epigenomic changes

post-sequencing analysis Bioinformatics


Complete Sequencing

Del/Dup Added














COLOSEQ NGS PANEL (UW)COLOSEQ NGS PANEL (UW)


Complete Sequencing

Del/Dup Added














COLOSEQ PANELCOLOSEQ PANEL

Three pathways involved in the repair of baseThree pathways involved in the repair of basepair-level mutations can predispose to CRCpair-level mutations can predispose to CRC

Peutz Jeghers Syndrome GI polyposis & mucocutaneous

pigmentation• Polyps are most prevalent in the small intestine • Mucocutaneous hyperpigmentation in

childhood:around the mouth, eyes, nostrils, perianal area, buccal mucosa.

• Hyperpigmented macules on the fingers (may fade in puberty and adulthood)

Females:– risk for sex cord tumors with annular

tubules (SCTAT)– adenoma malignum of the cervix.

Males:• Calcifying Sertoli cell tumors of the

testes, (gynecomastia)

FAP (Familial Adenomatous polyposis)• Autosomal Dominant• 75-80% have an affected parent.• 3 per 100,000 people • 1% of CRC

• 100-1000s precancerous colonic polyps.• Mean age of 16 years (7-36y)• By 35 years - 95% have polyps. • Mean age of CRC is 39 years (range 34-43y)• CRC is inevitable without colectomy.

AFAP• Fewer colonic polyps (average of 30) • Age of CRC diagnosis is 50-55y

The APC gene(Adenomatous Polyposis

Coli)Normal product: homodimerize and bind to other

proteins (b, g-catenin, tubulin)

Involved in:– cell adhesion & intracellular signal transduction.– normal apoptosis & proliferation (Wingless-Wnt

signaling)

Plays a role in:– chromosome segregation & chromosomal instability, – cell migration up the colonic crypt – cell adhesion – cell polarity

FAP (Familial Adenomatous polyposis)Extra colonic manifestations:

– polyps of the gastric fundus and duodenum,

– osteomas,

– dental anomalies, – hypertrophy of the retina pigment epithelium (CHRPE),

– soft tissue tumors,

– desmoid tumors,

– associated cancers

FAP - Lifetime Risk of Extra-Colonic Cancer

Site Type of Cancer Risk of Cancer

Small bowel: duodenum or periampulla Carcinoma

4-12%

Small bowel: distal to the duodenum Rare

Stomach Adenocarcinoma 0.5%Pancreas ~2%

ThyroidPapillary thyroid

carcinoma~2%

CNSUsually

medulloblastoma<1%

Liver Hepatoblastoma 1.6%) children <age 5 years (

Bile ductsAdenocarcinoma Low, but increased

Adrenal gland

APC Polymorphism I1307K (Ashkenazi Jews) – Increased risk for CRC

• A neutral variant - does not alter the function of the APC protein.

• 6% of Ashkenazi Jews and a smaller proportion of other Jews.

• Has not been seen in non-Jews. (Israeli Arabs)

• Carriers have approximately twice the risk of colorectal cancer

• Penetrance – 10-20%

E1317Q mutation

MAP - MYH-associated polyposis - The MYH Gene:

The MYH Gene initiates base excision repair

Preventing G:C to T:A transversion caused by oxidative stress.

APC: G→T → Stop codon

Tumors from MAP patients:•Somatic G:C to T:A mutations: ↑G→T; C→A

mutations•No- MSI

MUTYH-associated polyposis (MAP)

MUTYH - a post-replicative DNA glycosylase

Base excision repair (BER) repairs the majority of endogenous DNA damages (deaminations, depurinations, alkylations & oxidative damages)

A signature of a defect in MUTYH is high proportion of GC→TA transversions in tumor target genes

APC & KRAS

Cancer Hub 3/2014

MUTYH-associated polyposis (MAP)

Autosomal recessive CRC

• 2002 - Germline bi-allelic mutations in MYH predispose to multiple adenoma or polyposis coli.

• Phenotype is similar to attenuated FAP

Cancer Hub 3/2014

100 years for Lynch Syndrome

• 1913 - Warthin’s report on ‘‘Cancer Family Syndrome’’ • 1960 – Henry Lynch re-identifying the syndrome

1993 – The genetics behind

Cancer Hub 3/2014

100 years for Lynch Syndrome

• 1913 - Warthin’s report on ‘‘Cancer Family Syndrome’’ • 1960 – Henry Lynch re-identifying the syndrome

LS is seriously under-diagnosed. LS is seriously under-diagnosed.

<5 % of high risk patients received LS testing<5 % of high risk patients received LS testing

1:10001:1000 1:370Hampel, H. & A. de la Chapelle, Cancer prevention research, 2011. 4(1): p. 1-5

18,800,000 carriers worldwide

61,700 newly diagnosed Lynch related CRC worldwideJemal, A., et al., Cancer statistics, 2010. CA Cancer J Clin, 2010. 60(5): p. 277-300.

Cross et al, Genet Med. 2013

Cancer Risks in Carriers by 70y Compared to the General Population

CancerGeneral population

risk

Lynch

Risks Mean Age of Onset

Colon 5.5% 80% 44 years

Endometrium 1.5-2.7% <60% 46 years

Stomach <1%11-

19%56 years

Ovary 1-1.6% 9-12% 42.5 years

Hepatobiliary tract <1% 2-7% Not reported

Urinary tract <1% 4-5% ~55 years

Small bowel <1% 1-4% 49 years

Brain/central nervous system

<1% 1-3% ~50 years

Diagnostic Criteria

Amsterdam (1991, 1998)

≥ 33 relatives with Lynch tumors* and:

≥ 22 generations;

≥ 11 case of CRC diagnosed before 50 years.

One first-degree relative of the other two.

Limited sensitivity (61-70%)

* (endometrial, ovarian, small bowel, ureter or renal pelvis)

The Bethesda guidelines (1997, 2003)

Any of:• CRC < age of 50 years.CRC < age of 50 years.• Synchronous / metachronous LS-related tumors

regardless of age. • Tumor with a MSI-H histology < 60 years.• CRC with ≥ 1 first-degree relatives with LS-related

tumor (<50) or adenoma (< of 40) • CRC with ≥ 2 relatives with LS-related tumors,

regardless of age.

>2005> - 4 Algorithms & Models for LS prediction

LS - Diagnostic Algorithm

Clinical criteria (Amsterdam, Bethesda )

Tumor testing

Gene testing

sequencing

MLPA

Mutation testing (Familial; Founder)

Negative

HNPCC unlikely

Positive

a

a’

b

b’

MSI

IHC

BRAF/Methylation

MLH1

Negative

Reflex Reflex ScreeningScreening

HNPCC - Surveillance for Cancer

All: <20-25y:• 21-40 every 2 years; <40 Annual full colonoscopy

(Prophylactic colectomy?)

Females: <25-30y:• Annual pelvic examination • Annual transvaginal ultrasonography • Annual endometrial aspiration • Annual CA-125 screening.(Burke et al 1997, Brown et al 2001, National comprehensive Cancer Network 2003)

(prophylactic TAH & BSO?)

Other Extracolonic:• Recommendations depend on family history!

Benefit of Surveillance (Jervinen 1995, 2000)

2-3y surveillance intervals

A 63% reduction in the incidence of CRC

A 65% reduction in overall mortality

Screening for MMR is cost-effectiveness Cancer Prev Res (Phila). 2011 (Vasen et. al)

Gastroenterology. 2010 (Vasen et. al)

A cumulative risk of 6% after 10-years.

Risk for advanced cancer was 0.6% after 10-yearsRisk for advanced cancer was 0.6% after 10-years

https://pob.hadassah.org.il/owa/redir.aspx?C=7b205028bfea41aebb5be5cfb8def6bd&URL=http://www.ncbi.nlm.nih.gov/pubmed/20206180

The Genetics behind:

In 1993:A link between

The malfunction of post-replicative DNA

mismatch repair

&

HNPCC

The mismatch-repair (MMR) system

Genomic instability in colon cancer:

85% - Chromosomal instability (CIN).

15% - Microsatellite instability (MSI).

Genomic instability in CRC:

85% - Chromosomal instability (CIN).

15% - Microsatellite instability (MSI).

"אונקולוגיה בעידן הגנום – תורת המידות"

1993 - MMR- Mutation Mismatch Repair

MMR proteins recognize and repair base pair mismatches that occur during DNA replication - “DNA caretakers”

MLH1 PMS2

MSH6MSH2MMR-work in pairs

Cancer Hub 3/2014

MMR Loss

IDLs

Microsatellite instability

Genes with microsatellites in coding regions are at ‘risk’

Target genes*:TGFBRII (PolyA 10)

BAX (G8)IGFRIIR (G8)MSH3 (A)8

MSH6TCF4

Microsatellite instability (MSI)

Cancer Hub 3/2014

LOHLOH

Cancer Hub 3/2014

CarrierCarrier

Tumor Testing – Surrogate Biomarker

MSI

Cancer Hub 3/2014

LOHLOH Mechanisms for LOHMechanisms for LOH??

Cancer Hub 3/2014

Intervention

Intervention

Toledano, Goldberg, et al. FamCan. 2009

Colon Cancer

Carrier of c.686_687delCT mutation in PMS2

8

Endometrial Cancer

Bladder Cancer

MMR-D

2

CMMR-DAutosomal recessive LS

LOHLOH

Cancer Hub 3/2014

CarrierCarrier

Lynch

Cancer Hub 3/2014

childchild ParentParent

Thank you

colon cancer can be prevented normal epithelium adenoma carcinomametastases early detection improves...

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