PATOLOGIA MOLECULAR DEL

CANCER DE ORIGEN

DESCONOCIDO?

Xavier Matias-Guiu

Hospital Universitari Arnau de Vilanova,

Universitat de Lleida, IRBLLEIDA.

CANCER UNKNOWN PRIMARY

• 3-5 % of diagnosed cancers

• Variability depending of centers

• 50% adenocarcinomas

• Immunohistochemistry helps in 30-85%

• Metastases to liver (25%) and bone (25%)

• Prognosis depends of identification of

primary site or actionable genomic

alterations.

CANCER UNKNOWN ORIGIN

(Pathology)

• Adenocarcinoma (50%)

• Poorly Differentiated Carcinomas(35%)

• Squamous Cell Carcinoma (10%)

• Undifferentiated Carcinoma (5%)

CANCER UNKNOWN ORIGIN

(Immunohistochemistry)

• Cytokeratins

• Organo-specific markers (PSA,

Thyroglobuline, GCDFP-15)

• Non-organ-specific markers (CEA, p63,

ER/PR)

CANCER UNKNOWN ORIGIN

(Cytokeratins 7 + 20 -)

• Breast Ca

• Lung, nonsmall cell ca (90%)

• Ovarian serous ca (90%)

• Mesothelioma

• Endometrial Ca

CANCER UNKNOWN ORIGIN

(Cytokeratins 7 - 20 +)

• Colon Ca (75-95%)

CANCER UNKNOWN ORIGIN

(Cytokeratins 7 + 20 +)

• Transitional Cell Ca

• Ovarian mucinous ca

• Pancreatic Ca

CANCER UNKNOWN ORIGIN

(Cytokeratins 7 - 20 -)

• Hepatocellular Ca (70- 90%)

• Renal cell ca (70 – 90%)

• Prostatic Ca

• Neuroendocrine Ca

• Squamous cell Ca

CANCER UNKNOWN ORIGIN

(Breast cancer markers)

• GCDFP-15 (sensitivity, 55%; highest in lobular and apocrine; independent of grade, ER status, mitotic index; also expressed in vulva, eyelid; never expressed in lung, colon, ovary)

• Mamaglobin (sensitivity 46,6%,

combined with GCDFP-15,

sensitivity 69%)

• ER, PR

GCDF-15 Mamoglobin

CANCER UNKNOWN ORIGIN

(GI tract markers)

• Villin (sensitive for colon ca; 5% lung

adenoca)

• CDX-2 (sensitive for colon ca; occasionally

positive in mucinous obvarian or bladder

adenoca)

• CK7 / CK20

Villin CDX-2

TTF-1

• 38 kd member of the NKx-2 family of

transcription factors

• Thyroid, respiratory epithelium and

diencephalon

• Lung tumors (highest in neuroendocrine

and bronchioloalveolar; lowest in

squamous and mucinous)

• Occasional rectal and ovarian adenoc.

• Positive in thyroid and neuroendocrine

tumors

WT-1

• Tumor suppressor gene in 11p13

• Mesangial cells, Sertoli cells, ovarian stroma

and surface epithelium, mesothelium

• Marker of serous ovarian cancer (97%

specificity, 91% sensitivity)

CANCER UNKNOWN ORIGIN

(Renal Cell Ca)

• CK7-/CK20-

• Vimentin

• CD-10

• PAX-2

MOLECULAR APPROACHES IN

TUMORS OF UNKNOWN ORIGIN

• ONE GENE

• MULTIPLE GENES

LUNG CANCER AND EGFR

MUTATIONS

• 83 year old man

• Disseminated cancer (liver and lung). Pleural Effusion

• Pleural Cytology: Positive for malignancy, consistent with adenocarcinoma. TTF-1 negative

Clinical History

EGFR exon 19 E746-A750 del 15pb

Diagnosis

Pleural metastasis from pulmonary

adenocarcinoma with EGFR mutations.

Treatment with EGFR inhibitors.

ASSESSMENT OF PRIMARY

ORIGIN IN PATIENTS WITH A

PREVIOUS HISTORY OF CANCER

Independent vs Metastatic Tumors

(clonality)

• Cromosome X (HUMARA)

• LOH

• Mutation analysis

• Viral Detection

N T

T1

T2

T3

T4

T5

T6

T2

T7

T8

T9

T10

T11

T12

T13

T14

T2

T8

T15

T16

T11

T17

T18

Primary Tumor

Metastasis

• 71 year old woman

• Cervical cancer, two years ago.

• Adrenal Tumor

Clinical History

Diagnosis

Cervical Carcinoma metastatic to

the adrenal gland

• A 50 year old woman.

• Pseudomyxoma peritonei

• Ovarian Tumor

• Appendiceal Mucocele

Clinical History

Diagnosis

Appendiceal mucinous tumor with

ovarian metastasis

Cuatrecasas M, Matias-Guiu X, Prat J: Synchronous mucinous tumors of

the ovary and appendix. A clinico-pathologic study with analysis of K-RAS

mutations.

Am J Surg Pathol 1996 20:739-746

MOLECULAR APPROACHES IN

TUMORS OF UNKNOWN ORIGIN

• ONE GENE

• MULTIPLE GENES

Commercial Tests for Cancer of

Unknown Origin

• Quest-Lab Corp (92 gene PCR test for 39 cancer types)

• Agendia (microarray-based test for 43 cancer types)

• Pathworks Diagn (microarray-based test for 15 cancer types,

representing 60 different morphologies)

• Veridex ( PCR-based test for 6 cancer types)

• Epitype ( Methylation-based assay)

• CancerTYPE-bioTheranostics (PCR-based test for 39 cancer

types)

• Rosetta Genomics (PCR-based test on miRNA for 25 cancer

types)

Cancer metastático de origen

desconocido

(Inmunohistoquímica versus Patología

Molecular en 73 casos)

• 73 casos, que se presentan como metástasis de cáncer de

origen incierto o controvertido (103 casos evaluados)

• Pathwork Tissue of Origin Test en tejido congelado

• Immunohistoquímica (CK7, CK20, CK19, PSA, Thyrogl,

TTF1, GCDF-15, Mamoglobin, ER, PR, WT1, CDX2, villin,

PAX2, HepPar 1, Glypican, CD-10, Inhibin, S-100, Melan-A,

HMB-45)

Cancer metastático de origen

desconocido

(Inmunohistoquímica versus Patología

Molecular en 73 casos)

Los principales problemas a los que se plantea la técnica molecular son:

1) Dificultades técnicas inherentes al sistema de microarrays

2) Dificultad de trabajar con muestras congeladas

3) Problemas de “ruido de fondo” por la población normal acompañante

4) Metástasis de cánceres primarios, que no están incluidos entre los que

el sistema evalúa

5) Problemas específicos en tipos histológicos precisos.

Metastatic carcinoma to the

peritoneum and the ovaries

(Inmunohistochemistry versus Gene

expression microarray in 32 cases)

29 cases with known primary tumor after follow-up:

IHC : 22/ 29

Pathwork: 25/29

IHC + Pathwork: 26/ 29

3 cases without known primary tumor after follow-up:

In the 3 cases concordance IHC and Pathwork (colon, stomach, amd

colon versus stomach)

• 69 year old woman

• Unilateral ovarian tumor

• Colon cancer, several years ago

Clinical History

CK 7 CK 20 CK 7 CK 20

Villin CDX 2

Diagnosis

Colon carcinoma metastatic to the

ovary

• 64 year old woman

• Breast Cancer, several years ago

• Peritoneal Carcinomatosis

Clinical History

ER WT-1

Mamoglobin GCDF-15

Diagnóstico

Metastatic ovarian carcinoma

(serous type)

• 59 year old man.

• Brain tumor

Clinical History

TTF-1 CK-7

CK-20

Diagnosis

Metastatic carcinoma of pancreatic

origin.

• A 37 year old patient.

• Unilateral ovarian tumor

Clinical History

• Gastroscopy negative

• Gastric biopsies: Adenocarcinoma with signet ring cells

Follow up

Diagnosis

Gastric carcinoma metastatic to the

ovary

• 64 year old woman

• Bilateral ovarian tumors

Clinical History

CK 7 negative; CK 20 positive

• Gastroscopy: negative

• Gastric biopsies: negative

Follow-up

Diagnosis

Gastric carcinoma metastatic to the

ovaries

• 50 year old woman.

• Vaginal Bleeding

• Endometrial Biopsy

• Bilateral Ovarian tumors

Clinical History

AEI-AE3 +

CK7 –

CK 20 +

ER, PR –

Vimentin –

CDX-2 +

Villin +

Diagnosis

Metastatic adenocarcinoma (signet-

ring features) of unknown origin

involving the endometrium and the

ovaries

Estudio Molecular Cancer Origen Desconocido

Last generation sequenciacing

(Ion Torrent, Miseq)

Actionable genomic alteration rather than site of origin for

personalized therapy

Targeted next generation sequencing of adenocarcinoma of

unknown primary site reveals frequent actionable genomic

abnormalities and new routes to targeted therapies

J Ross, K Wang, GO Otto, PG Palmer, R Yelensky, D Lipson, J

Chmielecki, SM Ali, D Morosini, VA Miller, PJ Stephens

USCAP 2014, San Diego, abstract # 2163

236 cancer-related genes (3,769 exons) and 47

introns of 19 genes commonly rearranged.

127 cancers of unknown origin

Liver (24%) lymph nodes (23%), peritoneum

(16%), pleura (6%), bone (5%), brain (4%)

Next generation sequencing for Actionable

Mutations

484 alterations (3.8 per tumor)

115 cases (91%) showed at least one actionable

mutation

The most common actionable mutations were:

KRAS (23%), CDKN2A (23%), MCL1 (11%),

ERBB2 (9%), PTEN (8%), PIK3CA (7%), EGFR

(7%), BRAF (6%)

69% of tumors has an actionable mutation in

RTK/RAS pathway.

Estudio Molecular Cancer Origen Desconocido

Last generation sequenciacing

• Conventional pathology and IHC solves 85% of cases

• Combination of Conventional pathology, IHC and gene expression assays solves more than 95% of cases

• Gene expression tests should be interpreted in the appropriate pathological context.

• Last generation sequencing is an alternative that offers identification of actionable genomic alterations regarless the site of origin

Take Home Messages

PATOLOGIA MOLECULAR DEL

CANCER DE ORIGEN

DESCONOCIDO?

Xavier Matias-Guiu

Hospital Universitari Arnau de Vilanova,

Universitat de Lleida, IRBLLEIDA.