GI-Oncology Wiesbaden 5-7-2014 Molekular-diagnostische Algorithmen beim Sporadischen und Hereditären Kolorektalen Karzinom: Was ist wann zu tun ? Reinhard Büttner Institut für Pathologie Universität Köln CIO Köln Bonn [email protected] 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 I. Sporadische Kolonkarzinome number of polyps predictive biomarkers II. Familiäre Kolonkarzinome 1. HNPCC - Lynch Syndrom I, II 2. FAP 2.5 % - Muir-Torre-Syndrom 0.5 % - Klassische Formen - Atypische Form, MAP 1 1 3. Nichtadenomatöse Polyposis % % 0.1 % - Peutz-Jeghers - Juvenile Polyposis - Cowden Syndrom III. Kolonkarzinome bei CED time, activity HNPCC Diagnostische Algorithmen Hereditary non-Polyposis Colorectal Cancer (HNPCC)  revised Bethesda Criteria 2004 Steinke V et al, Int J Cancer. 2014 Jul 1;135(1):69-77. 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 1st degree relative with CRC or HNPCCassociated tumor < 50 years of age 5) Patients with CRC and two or more 1st or 2nd degree relatives with CRC or HNPCC-acssociated tumor If one of these criteria is positive, MSI analysis should be performed ! 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 HNPCC – Genetics Monogenetic dominant trait with defect in one of DNA mismatch repair gene 42 J, CRC Gebärmutterkrebs 33 J. "Leber-CA" 40 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 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 Agarosegelelektrophorese Tumor 1 BAT26 Normal 2 MSS MSI-H Langzeitstudie der DKH-Zentren für erblichen Darmkrebs no Amsterdam-II or Bethesda ? yes no positive Microsatellite Analysis / Immunhistochemistry? yes Amsterdam-II ? no MMR Mutation yes / no yes DGVSrecommendations HNPCC-specific surveillance BRAF Mutation no 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) The German HNPCC Consortium Klinische Zentren Biometrie und zentrale Datenbank Referenzpathologie Referenzgastroenterologie seit 1999 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 München Reference Pathology: Reinhard Büttner, Köln Efficacy of Surveillance Internationaler Vergleich: Stadienverteilung 80,0 70,0 60,0 3 Kohortenstudien % all CRCs 50,0 Engel (Germany) Järvinen (Finland) Vasen (Netherlands) 40,0 30,0 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 Sporadische CRCs Biomarker Diagnostik im Netzwerk Genomische Medizin Personalized clinical trials Gastric+ GEJ PIK3CA mut/amp  BYL719 + AUY922 ERBB2 amp  TDM1 / BYL719+AU MET amp  AMG337 FGFR2 amp  BGJ398 KRAS mut other Esophageal cancer SQ: PIK3CA mut FGFR1 amp  BYL719  BGJ398 Colorectal Cancer: BRAF mut  LGL818 + BYL719+ Cetuximab  CGM097 TP53 wt Previous wo Somatic gene alterations Personalized treatment in GI cancer: targets and proof of principle 1,3 Do we hit the right Target ??? 5 Entity % with actionable genomic alterations esophageal / cervical SQ1 32 Esophageal AD2 48 Gastric AD3 46 Colorectal AD4 51 TCGA 2013, 2 Dulak Nature 2013, 4 TCGA Nature 2012, 5 Bang Lancet 2010 Buettner et al, JCO 2013 Introducti Enrichment 50 microsatellites Network Genomic Medicine Gastrointestinal cancer: P.I. Thomas Zander Dep. Pathology Köln GCGC Study Center Initiation Q1/13 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 MSI ... Allocation of pts. to personalized trials Molecular epidemiology Evaluation personalis. Therapy - Outcome - Cost Cancer Registry CIO Cancer Registry NRW NGS – Datenauswertung: Filemaker 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 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 Institute of Pathology, Cologne Peter Nürnberg Janine Altmüller Kerstin Becker Christian Becker Cologne Center for Genomics (Cologne) Roman Thomas Martin Peifer Institute of Genomics (Cologne) Thomas Henkel Katrin Stamm Targos (Kaseel) DDR2 mutations occur in a higher frequency in Adeno compared to SCC revealed by NGS Thomas Zander, Jürgen Wolf Center for Integrated Oncology Cologne/ Bonn GI- Cancer Group Cologne