Molekular-diagnostische Algorithmen beim Sporadischen und Hereditären Kolorektalen Karzinom: Was ist wann zu tun?

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1 Reinhard Büttner Institut für Pathologie Universität Köln CIO Köln Bonn GI-Oncology Wiesbaden Molekular-diagnostische Algorithmen beim Sporadischen und Hereditären Kolorektalen Karzinom: Was ist wann zu tun?

2 Offenlegung potentieller Interessenkonflikte 1. Anstellungsverhältnis oder Führungsposition Direktor des Instituts für Pathologie, Universität zu Köln Gründer, Miteigentümer und Scientific CEO Targos Molecular Pathology GmbH, Kassel, Köln & San Francisco 2. Beratungstätigkeit SAB AstraZeneca, BeyerHealthcare, BMS, Boehringer-Ingelheim, Merck-Serono, MSD, Novartis, Pfizer, Roche 3. Aktienbesitz none 4. Honorare Für SABs (s.o.) 5. Finanzierung wissenschaftlicher Untersuchungen DFG, Deutsche Krebshilfe, BMBF, Pfizer (ROS, ALK Diagnostik) 6. Gutachtertätigkeit DFG, Krebshilfe, Wilhelm-Sander-Stiftung, Marlene Porsche Stiftung, Rüdiger Stiftung, Vladimir Totovic Stiftung 7. Andere finanzielle Beziehungen keine

3 I. Sporadische Kolonkarzinome number of polyps predictive biomarkers II. Familiäre Kolonkarzinome 1. HNPCC - Lynch Syndrom I, II 2.5 % - Muir-Torre-Syndrom 0.5 % 2. FAP - Klassische Formen 1 % - Atypische Form, MAP 1 % 3. Nichtadenomatöse Polyposis 0.1 % - Peutz-Jeghers - Juvenile Polyposis - Cowden Syndrom III. Kolonkarzinome bei CED time, activity

4 HNPCC Diagnostische Algorithmen

5 Hereditary non-polyposis Colorectal Cancer (HNPCC) revised Bethesda Criteria 2004 Steinke V et al, Int J Cancer Jul 1;135(1): Evaluating the performance of clinical criteria for predicting mismatch repair gene mutations in Lynch syndrome. 1) All patients with CRC < 50 years of age 2) Patients with syn- or metachronous CRC or HNPCC-associated tumor 3) Patients with CRC revealing MSI-H histology < 60 years of age 4) Patients with CRC and 1 st degree relative with CRC or HNPCCassociated tumor < 50 years of age 5) Patients with CRC and two or more 1 st or 2 nd degree relatives with CRC or HNPCC-acssociated tumor If one of these criteria is positive, MSI analysis should be performed!

6 HNPCC Genetics Function: repair of small replication errors in the daughter strand Identification of errors Heterodimer formation (MSH2 + MSH6 or MSH2 + MSH3) Tetramer formation with PMS2 + MLH1 or PMS1 + MLH1 Exonuclease recruitment Repair synthesis, ligation

7 HNPCC Genetics Monogenetic dominant trait with defect in one of DNA mismatch repair gene 42 J, CRC "Leber-CA" 40 J. Gebärmutterkrebs 33 J. 40 & 53 J. CRC 59 J. Talgdrüsenadenome 71 J. Duodenal-Ca 41 & 54 J. CRC 32 J. CRC 36 J. CRC Genetics follows Two-Hit hypothesis nach (A. Knudson): hereditary defect is compensated by second wild-type allele any secondary somatic mutation leads to complete loss of MMR-proficiency

8 Microsatellite Instability Analysis 1 AT AT AT AT AT AT AT AT AT AT AT AT AT AT AT 2 AT AT AT AT AT AT AT BAT26 Tumor Agarosegelelektrophorese 1 2 BAT26 Normal MSS MSI-H

9 Langzeitstudie der DKH-Zentren für erblichen Darmkrebs no no Amsterdam-II or Bethesda? yes positive Microsatellite Analysis / Immunhistochemistry? yes BRAF Mutation no no Amsterdam-II? yes MMR Mutation yes / no DGVSrecommendations HNPCC-specific surveillance

10 Categories for Microsatellite Reporting (NIH-panel) MSS (microsatellite stabile tumors) all 5 loci are stabile: no indication for HNPCC MSI-L (low microsatellite instability) 1/5 loci instabile: analyse second panel MSI-H (high microsatellite instability) 2 or more loci instabile: HNPCC suspicious Immunohistochemistry B-RAF (Kuan SF, Hum Pathol 2012)

11 The German HNPCC Consortium seit 1999 Klinische Zentren Biometrie und zentrale Datenbank Referenzpathologie Referenzgastroenterologie Speaker: Peter Propping, Bonn Bochum Düsseldorf Köln Bonn Leipzig Dresden Clinical centers: Elke Holinski-Feder, München/Regensburg Magnus von Knebel Doeberitz, Heidelberg Markus Nöthen, Bonn Brigitte Royer-Pokora, Düsseldorf Hans-Konrad Schackert, Dresden Wolff Schmiegel, Bochum Data Storage and Biometry: Markus Löffler / Christoph Engel, Leipzig Heidelberg Regensburg Reference Pathology: Reinhard Büttner, Köln München

12 % all CRCs Efficacy of Surveillance Internationaler Vergleich: Stadienverteilung 80,0 70,0 60,0 50,0 40,0 30,0 3 Kohortenstudien Engel (Germany) Järvinen (Finland) Vasen (Netherlands) Kolo jährlich Kolo alle 3 J. Kolo alle 1-2 J. 20,0 10,0 0,0 n.s. 0 I II III IV UICC Stage Engel et al, CGH 2010, Järvinen et al, JCO 2009, Vasen et al, Gastroenterology 2010

13 Sporadische CRCs Biomarker Diagnostik im Netzwerk Genomische Medizin

14 Previous wo Personalized clinical trials Gastric+ PIK3CA mut/amp BYL719 + AUY922 GEJ ERBB2 amp TDM1 / BYL719+AU MET amp AMG337 FGFR2 amp BGJ398 KRAS mut other Esophageal PIK3CA mut BYL719 cancer SQ: FGFR1 amp BGJ398 Colorectal BRAF mut LGL818 + BYL719+ Cancer: Cetuximab TP53 wt CGM097

15 Somatic gene alterations Personalized treatment in GI cancer: targets and proof of principle Do we hit the right Target??? Entity esophageal / cervical 32 SQ 1 Esophageal AD 2 48 Gastric AD 3 46 Colorectal AD 4 51 % with actionable genomic alterations 5 1,3 TCGA 2013, 2 Dulak Nature 2013, 4 TCGA Nature 2012, 5 Bang Lancet 2010 Buettner et al, JCO 2013 Introducti

16 Enrichment 50 microsatellites

17 Network Genomic Medicine Gastrointestinal cancer: P.I. Thomas Zander Initiation Q1/13 Dep. Pathology Köln GCGC Study Center Hospitals Office-based Medical Oncologists Genetic profile FFPE-samples Local Pathologists FGFR1 amp DDR2 mut PIK3CA mut ERBB2 amp EGFR amp MET amp PIK3CA mut KRAS mut NRAS mut BRAF mut TP53 mut Allocation of pts. to personalized trials Molecular epidemiology Evaluation personalis. Therapy - Outcome - Cost MSI... Cancer Registry CIO Cancer Registry NRW

18 NGS Datenauswertung: Filemaker

19

20 The value of genomic sequencing > higher sensitivity > correct histotyping > pretherapeutic diagnostics of Lynch Syndrome patients > staging of multiple tumors > comprehensive biomarker testing > co-occurrance of genotypes and therapy response Combined Histology and Molecular Diagnostics

21 Institute of Pathology, Cologne DDR2 mutations occur in a higher frequency in Adeno compared to SCC revealed by NGS Lukas Heukamp Margarethe Odenthal Claudia Vollbrecht Sabine Merkelbach-Bruse Jana Fassunke Michaela Ihle Helen Künstlinger Carina Heydt Theresa Buhl Ursula Rommerscheidt-Fuss Alexandra Florin Frank Ueckeroth Michael Kloth Michal R Schweiger Peter Nürnberg Janine Altmüller Kerstin Becker Christian Becker Roman Thomas Martin Peifer Thomas Henkel Katrin Stamm Cologne Center for Genomics (Cologne) Institute of Genomics (Cologne) Targos (Kaseel) Thomas Zander, Jürgen Wolf Center for Integrated Oncology Cologne/ Bonn GI- Cancer Group Cologne