Was liefert der Pathologe? Was wollen der Chirurg und der Onkologe von ihm wissen?
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Transcript of Was liefert der Pathologe? Was wollen der Chirurg und der Onkologe von ihm wissen?
PathologieStephan Dirnhofer
GIST: Pathologie
12. Treffen der GIST-Gruppe SchweizZürich, 26. April, 2015
Epidemiology
• Clinical GIST: – Incidence: 15/million – Prevalence 150/million
• (Incidental) Micro-GIST: – 2-10% of Population (500 000 in CH)– Incidentally detected– KIT/PDGFRA-mutation
Münst, 2011; Nilsson 2005; Mazzola 2008; Liang 2010
When and why clinically relevant?
GIST: role of pathology
Diagnostic
Prognostic
Predictive
Follow`up
GIST-Diagnosis
Kindblom, 2005
GIST
CD117 (Kit)
Kindblom, 2004GIST
ICC
GIST- Diagnosis
Prognostic factors
• Size
• Site
• Mitosis/50hpf
• Tumor rupture
• Mutational status
Fletcher (NCI 2002)
Risk stratification by NCI, NCCN
• about 50% locally advanced and/or metastasied
Extracellular domain
Cell membrane
Juxtamembrane domain
Tyrosine kinase domain
KIT and PDGFRA mutations in GIST
TK1 domain
TK2 domain
Kinase insert
Regulation of dimerization
Ligand-binding domain
KIT ex 9 (10%)
KIT ex11 (70%) / PDGFRA ex12 (1%)
KIT ex13 (1%) / PDGFRA ex14 (1%)
KIT ex17 (1%) / PDGFRA ex18 (6%)
80-82 % 5-8 %
Mutually exclusive
Genotype is diagnostic for GIST
Genotype is prognostic for tumor recurrence
Genotype predictive for TKI-response
Genotype identifies primary resistance (D842V)
Genotype determines dose selection
Genotype associated with TKI resistance
Genotype is cost-effective
Genotype is recommended (ESMO, NCCN, CH)
GIST- Genotyping: Why?
„wild-type“ GIST
Courtesy: Prof. E. Wardelmann, Münster
„wild-type“ GIST
AlterationHäufigkeit (in der wt-Gruppe)
Referenzen
BRAF Mutation < 7% Agaram et al. Genes Chromosomes Cancer. 2008;47(10):853-859
KRAS Mutation <1% Heinrich and Corless, unpublished
Erhöhte IGF1R Expression 50% Tarn et al. PNAS. 2008;105(24):8387-8392
SDHA, SDHB, SDHC or SDHD Keimbahnmutation*
~12%Janeway et al. PNAS. 2011;108(1):314-318Pantaleo et al. J Natl Cancer Inst. 2011;103(12):983-7
Verlust der SDHB Expression häufig Janeway et al. PNAS. 2011;108(1):314-318
NF1 Keimbahnmutation selten Andersson et al. Am J Surg Pathol. 2005; 29:1170-1176
Courtesy: Prof. E. Wardelmann, Münster
GIST-Immunophenotype
• CD117(KIT) 95 %• DOG1 90-95% (1/3 of CD117 neg cases)
• CD34 70 %• SMA 25%• S100 <10%• Desmin <5%
• Most sarcomas (and other tumors) CD117 negative!
Hornick, 2002, Dirnhofer 2006
DOG1
Gastrointestinal Stromal Tumours (GIST)
• Most common non-epithelial neoplasm of the GI-tract
• Similar male-to-female ratio
• Highest incidence in 5th to 7th decades
• Rare in children/young adults
• “Molecular” subtypes
• Tumorgenotype is diagnostic, prognostic and predicitive
• Model for targeted therapy in solid tumors
GIST: Involved Sites
Occur anywhere in GI tract/abdomen
Site Incidence
Gastric 60%–70%
Small Intestine 20%–30%
Colon <5%
Other (omentum, mesentery, oesophagus)
<5%
• 578 consecutive autopsies – 17 „Mikro-“ GIST (3%)– 11 KIT-, 1 PDGFRA-Mutation– all benign
• 69 GISTS (39 KIT-mut, 2 PDGFRA-mut, 28 wt)• BRAF and KRAS mutation
• BRAF (V600E) in 2/28 wt GIST (7%)• KRAS wt• BRAF-mut: rare alternative molecular pathway
J Clin Pathol 2009
Succinate dehydrogenase (SDH)-complex
• SDH-complex: 4 subunits (SDH-A, B, C, D)
• Kebs cycle
• Ubiquitously present in mitochondria
• Tumor suppressor function
• HIF-pathway
• Hypermethylation
• Loss of function of SDH-complex in subset of GIST
Succinate dehydrogenase (SDH)-deficient GIST
• Clinical features:
• Children & young adults
• Chronic course (metastasis after 40 yrs!)
• Low rate of mortality
• Associated with paraganglioma
• Carney-Stratakis-Syndrome (CSS): GIST, Paraganglioma
• Carney Triad (CT): GIST, Paraganglioma, Chondroma
Succinate dehydrogenase (SDH)-deficient GIST
• Pathologic features:•Subset of gastric GIST (7-8%)
•Multinodular/plexiform growth pattern
•Epitheloid cytology
•KIT & DOG1+ (CD34 +/-), SDH-negative
•KIT & PDGFRA wt
•SDH-mutations (germline and sporadic)
•Prognosis unpredictable by standard parameters
•Lymph node matastasis
Am J Surg Pathol 2011
Miettinen 2011
SDH-negative cases
SDH-positive cases
Miettinen 2011
Programm
• Introduction
• Epidemiology
• Pathology
• Genetics
• Mutational analysis
• Subtypes (BRAF, SDH)
• Summary
Summary• Clinical GIST rare, incidental GIST common
• Pathology central
• for accurate diagnosis
• for accurate risk assessment
• for accurate molecular status
• KIT & PDFRA- mutations
• first oncogenic event (“drivers“)
• prognostic for tumor recurrence
• predictive for TKI sensitivity
• causes for TKI resistance
• Molecular subtypes (BRAF, SDH)
• Molecular status before systemic therapy