ESMO Preceptorship Programme › content › download › ... · The ASCRS Textbook of Colon and...
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ESMO Preceptorship Programme
A case of right-sided colonic adenocarcinoma with pulmonary metastases and an unusual molecular profile
Myrto KastrisiouUniversity Hospital of Ioannina, Greece
Colorectal Cancer– Lugano – 15-16.11.2019
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ESMO PRECEPTORSHIP PROGRAMME
Disclosure of interest None
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ESMO PRECEPTORSHIP PROGRAMME
Case presentation Jan 2019:
– Feeling of tiredness and weakness
Image from hasshe.com
76-year-old ♀ Never-smoker Arterial hypertension Family history of cancer
(brother and sister)
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ESMO PRECEPTORSHIP PROGRAMME
Diagnostic work-up
4. Thorax CT scan 17 spiculate nodular lesions disseminated in both lungs (0.5–1.8 cm)
1. CBC anaemia (Hg=10.3 g/dL); CEA=18.72. Colonoscopy diverticulae of left colon and sigmoid3. Abdominal CT scan luminal stenosis of the right colon
above the cecum extending for 7 cm and a renal lesion
5. GI MDT Discussion6. Fit, w/o curative intent –
disease control
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ESMO PRECEPTORSHIP PROGRAMME
Histology & Molecular findings Feb 2019: right hemicolectomy Histology report: low-grade adenocarcinoma at 3 cm from
ileocecal valve (5.5 cm X 5 cm)– Infiltration of pericolic adipose tissue: T3– 1/18 LN +ve: N1a– Multiple pulmonary lesions on CT scan of the thorax: M1
Tissue NGS (23-gene panel): KRASQ22K, BRAFG466E, also SMAD and TP53 mutations
MSI testing: MSS
Plasma BEAMing Digital PCR (research protocol):KRAS and NRAS exons 2, 3, 4codons 12, 13, 59, 61, 117, 146 No mutation detected
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ESMO PRECEPTORSHIP PROGRAMME
Treatment & ResponseFeb–Aug 2019:
8 cycles of CapOx + Bev(well tolerated)
Sep 2019–present:Maintenance Cap
+ Bev
Re-evaluation CT scan PR
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Food for thought… Why did a non-rectal
tumour spread to the lunghaving skipped the liver?
What is the biologicalimpact of the rare KRAS and BRAF mutations observed in this tumour?
How to explain co-existenceof mutually exclusive KRASand BRAF mutations?
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Lung-only colorectal cancer metastases
Hugen N, van de Velde CJ, de Wilt JH, Nagtegaal ID. Metastatic pattern in colorectal cancer is stronglyinfluenced by histological subtype. Ann Oncol. 2014;25(3):651–657. doi:10.1093/annonc/mdt591
66%5%
23%
6%
No lungLung onlyLung and liverLung and other
The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham (2016)
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ESMO PRECEPTORSHIP PROGRAMME
KRAS Q22K Activating mutation of the Ras pathway in vitro
anti-EFGR resistance In CRC, 0.009% or 7/73000 (COSMIC) JM Loree (2017): 8609 mCRC cases: 0.2%
Schubbert S et al. Nat Rev Cancer (2007).
RAS wild-type50,7%
Typical RAS mutations
48%
Atypical RAS mutations other than Q22K
1,1%KRAS Q22K
0,2%
RAS mutant49,3%
RAS wild-type Typical RAS mutations Atypical RAS mutations other than Q22K KRAS Q22K
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ESMO PRECEPTORSHIP PROGRAMME
BRAF G466E
Yao Z et al. Nat (2017)
In CRC, 2/73000 (COSMIC)
Belongs to Class 3 of BRAF mutants with low/absent kinase activity– Co-exist with aberrations in upstream molecules of the Ras pathway such as
• RAS, NF1 or receptor tyrosine kinases (RTK)
Promise for response to therapeutic inhibition of the Ras/Raf pathway
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ESMO PRECEPTORSHIP PROGRAMME
Take-home message
The existence of rare KRAS and BRAF mutations in a
patient with colorectal cancer points to the limitations of
hotspot mutation analysis, as such mutations may have
implications in the patient’s treatment and clinical course.
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ESMO Preceptorship Programme
Thank you for your attention!