Molekular-diagnostische Algorithmen beim

Sporadischen und Hereditären Kolorektalen Karzinom:

Was ist wann zu tun ?

Reinhard Büttner

Institut für Pathologie Universität Köln

CIO Köln Bonn

Reinhard.Buettner@uk-koeln.de

GI-Oncology Wiesbaden 5-7-2014

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

Offenlegung potentieller Interessenkonflikte

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

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 HNPCC-

associated 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

42 J, CRC

"Leber-CA" 40 J. Gebärmutter-

krebs 33 J.

40 & 53 J. CRC

71 J. Duodenal-Ca

59 J. Talgdrüsenadenome 41 & 54 J. CRC

32 J. CRC

36 J. CRC

HNPCC – Genetics

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

Monogenetic dominant trait with defect in one of DNA mismatch repair gene

40 & 53 J. CRC

71 J. Duodenal-Ca

59 J. Talgdrüsenadenome

AT AT AT

AT AT AT

1

Microsatellite Instability Analysis

Agarosegelelektrophorese

1 2

AT AT AT AT

AT AT AT AT AT

AT AT AT

AT AT AT AT 2

BAT26 Tumor

BAT26 Normal

MSS MSI-H

positive Microsatellite

Analysis /

Immunhistochemistry?

Amsterdam-II or

Bethesda ?

yes

MMR Mutation

yes / no Amsterdam-II ?

no

DGVS-

recommendations

HNPCC-specific

surveillance

no

no

yes

Langzeitstudie der DKH-Zentren für erblichen Darmkrebs

yes 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)

München

Heidelberg

Düsseldorf

Bonn

Dresden Bochum

Regensburg

Leipzig

seit 1999

Klinische Zentren

Biometrie und zentrale Datenbank

Referenzpathologie

Speaker:

Peter Propping, Bonn

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

Reference Pathology:

Reinhard Büttner, Köln

The German HNPCC Consortium

Köln

Referenzgastroenterologie

n.s. 0 I II III IV

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

Engel (Germany)

Järvinen

(Finland)

Vasen

(Netherlands)

UICC Stage

% a

ll C

RC

s

Engel et al, CGH 2010, Järvinen et al, JCO 2009, Vasen et al, Gastroenterology 2010

Kolo jährlich

Kolo alle 3 J.

Kolo alle 1-2 J.

Efficacy of Surveillance

Internationaler Vergleich: Stadienverteilung

3 Kohortenstudien

Sporadische CRCs

Biomarker Diagnostik im

Netzwerk Genomische Medizin

Personalized clinical trials

Esophageal PIK3CA mut BYL719

cancer SQ: FGFR1 amp BGJ398

Colorectal BRAF mut LGL818 + BYL719+

Cancer: Cetuximab

TP53 wt CGM097

Gastric+ PIK3CA mut/amp BYL719 + AUY922

GEJ ERBB2 amp TDM1 / BYL719+AUY922

MET amp AMG337

FGFR2 amp BGJ398

KRAS mut

other

Previous work

Personalized treatment in GI cancer: targets and

proof of principle

Do we hit the right Target ???

Entity % with

actionable

genomic

alterations

esophageal / cervical

SQ1

32

Esophageal AD2 48

Gastric AD3 46

Colorectal AD4 51

Som

atic

gen

e al

tera

tions

1,3 TCGA 2013, 2 Dulak Nature 2013, 4 TCGA Nature 2012, 5 Bang Lancet 2010

Buettner et al, JCO 2013

5

Introduction

Enrichment

50 micro-

satellites

Hospitals

Office-based Medical Oncologists

FGFR1 amp DDR2 mut PIK3CA mut ERBB2 amp EGFR amp MET amp PIK3CA mut KRAS mut NRAS mut BRAF mut TP53 mut MSI ...

Local Pathologists

Dep. Pathology Köln GCGC Study Center

Molecular epidemiology

Allocation of pts. to personalized trials

Evaluation personalis. Therapy - Outcome - Cost

Cancer Registry CIO

Network Genomic Medicine Gastrointestinal cancer:

P.I. Thomas Zander Initiation Q1/13

FFPE-samples

Cancer Registry NRW

Genetic profile

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

DDR2 mutations occur in a higher

frequency in Adeno compared to SCC

revealed by NGS

Lukas Heukamp Institute of Pathology, Cologne

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 Cologne Center for Genomics (Cologne)

Janine Altmüller

Kerstin Becker

Christian Becker

Roman Thomas Institute of Genomics (Cologne)

Martin Peifer

Thomas Henkel Targos (Kaseel)

Katrin Stamm

Thomas Zander, Jürgen Wolf

Center for Integrated Oncology Cologne/ Bonn

GI- Cancer Group Cologne