explored in testicular germ cell tumors (TGCTs) MGC course - - PowerPoint PPT Presentation

Hallmarks of Cancer explored in testicular germ cell tumors (TGCTs)

MGC course 07-10-2018 Wolter Oosterhuis

Hallmarks of cancer (Hanahan and Weinberg, Cell 2000)

Hallmarks of cancer (Hanahan and Weinberg, Cell 2011)

▪ Figure 3 (page 658)

Oosterhuis and Looijenga, Springer 2017

Type GCT Age (years) Sex Anatomical site Phenotype/developme ntal potential Developmental state Precursor cell Genomic imprinting; methylation Karyotype Animal model Neonates F/M Retroperitoneum/ sacrum/skull/hard palate Included and parasitic twins 2C-state (omnipotent) Blastomere Biparentental Normal diploid Not available I Neonates and children < 6; rarely beyond childhood F/M Testis/ovary/sacral region/ retroperitoneum/ anterior mediastinum/ neck/midline brain/other rare sites (Immature) teratoma (TE)/yolk sac tumor (YST) Primed-state (pluripotent) PGC/gonocyte before start of global demethylation Biparental partially erased Diploid (TE)/ aneuploid (YST): gain: 1q,12(p13),20q loss: 1p,4,6q Mouse teratoma II After start of puberty. In disorders of sexual developm., Klinefelter’s- and Down’s syndrome rarely before puberty >>M Dysgenetic gonad/testis/ovary/ anterior mediastinum (thymus)/midline brain (pineal gland) Seminoma/ dysgerminoma/ germinoma reprogrammed to non-seminoma/ non-dysgerminoma/ non-germinoma Naïve-state (totipotent) PGC/gonocyte undergoing global demethylation Erased Aneuploid (+/- triploid) gain: X,7,8,12p,21 loss: Y,1p,11,13,18 in mediastinum and midline brain also (near)diploid and (near)tetraploid with gain

• f 12p

Not available III Older men, usually > 55 M Testis Spermatocytic tumor Spermatogonium to premeiotic spermatocyte Spermatogonium/ spermatocyte Partially- completely paternal Gain: 9 Canine seminoma IV After puberty F Ovary Dermoid cyst Maternally imprinted 2C-state Oogonia/oocyte (gynogenote) Partially- completely maternal (Near) diploid diploid/tetraploid peritriploid gain: X,7,12,15 Mouse gynogenote V After puberty F Placenata/uterus Molar pregnancy Paternally imprinted 2C-state Empty ovum/ spermatozoa (androgenote) Completely paternal Diploid (XX and XY) Mouse androgenote VI Older age, usually > 60 F/M Atypical sites for GCT Resembling type I or non-seminoma components of type II Primed state or non-seminoma lineages of naïve- state Somatic cell induced to pluripotency Imprinting pattern of

• riginating cell

Depending on precursor cell Xenografts derived from iPSC

Characteristics of seven defined types of germ cell tumors (GCT)

Oosterhuis and Looijenga, Springer 2017

Type GCT Age (years) Sex Anatomical site Phenotype/developme ntal potential Developmental state Precursor cell Genomic imprinting; methylation Karyotype Animal model Neonates F/M Retroperitoneum/ sacrum/skull/hard palate Included and parasitic twins 2C-state (omnipotent) Blastomere Biparentental Normal diploid Not available I Neonates and children < 6; rarely beyond childhood F/M Testis/ovary/sacral region/ retroperitoneum/ anterior mediastinum/ neck/midline brain/other rare sites (Immature) teratoma (TE)/yolk sac tumor (YST) Primed-state (pluripotent) PGC/gonocyte before start of global demethylation Biparental partially erased Diploid (TE)/ aneuploid (YST): gain: 1q,12(p13),20q loss: 1p,4,6q Mouse teratoma II After start of puberty. In disorders of sexual developm., Klinefelter’s- and Down’s syndrome rarely before puberty >>M Dysgenetic gonad/testis/ovary/ anterior mediastinum (thymus)/midline brain (pineal gland) Seminoma/ dysgerminoma/ germinoma reprogrammed to non-seminoma/ non-dysgerminoma/ non-germinoma Naïve-state (totipotent) PGC/gonocyte undergoing global demethylation Erased Aneuploid (+/- triploid) gain: X,7,8,12p,21 loss: Y,1p,11,13,18 in mediastinum and midline brain also (near)diploid and (near)tetraploid with gain

• f 12p

Not available III Older men, usually > 55 M Testis Spermatocytic tumor Spermatogonium to premeiotic spermatocyte Spermatogonium/ spermatocyte Partially- completely paternal Gain: 9 Canine seminoma IV After puberty F Ovary Dermoid cyst Maternally imprinted 2C-state Oogonia/oocyte (gynogenote) Partially- completely maternal (Near) diploid diploid/tetraploid peritriploid gain: X,7,12,15 Mouse gynogenote V After puberty F Placenata/uterus Molar pregnancy Paternally imprinted 2C-state Empty ovum/ spermatozoa (androgenote) Completely paternal Diploid (XX and XY) Mouse androgenote VI Older age, usually > 60 F/M Atypical sites for GCT Resembling type I or non-seminoma components of type II Primed state or non-seminoma lineages of naïve- state Somatic cell induced to pluripotency Imprinting pattern of

• riginating cell

Depending on precursor cell Xenografts derived from iPSC

Characteristics of seven defined types of germ cell tumors (GCT)

Type II, erased, pluripotent (dys/ger)SEMINOMA NON(dys/ger)SEMINOMA

embryonal carcinoma teratoma yolk sac tumor choriocarcinoma

carcinoma in situ (CIS) intratubular germ cell neoplasia unclass. (ITGCNU)

germ cell diff.

it Sem it non-Se

reprogramming default

germ cell neoplasia in situ (GCNIS) embryoid body

Type II testicular germ cell tumor, histopathology

Intratubular seminoma

• Intratub. non-seminoma

intermediate stages between precursor and invasive cancer GCNIS → intratubular seminoma → seminoma GCNIS → intratubular non-seminoma → non-seminoma Reprogramming occurs also within seminiferous tubules

TGCTs: bell-shaped age distribution Median age at presentation (lump in testis) of seminoma (35) non-seminoma (25) (intratub. reprogamming) combined tumors (30) (reprogramming of invasive seminoma, or two separate tumors)

NS S CT

TGCTs: Clinical presentation, diagnosis, treatment ▪ Rare, but most frequent cause of death due to malignancy in age range 17- 45, despite high curability ▪ Serum tumor markers AFP (yolk sac tumor) HCG (choriocarcinoma) (> 85% one or both positive), and specific micro RNA’s (100% positive) ▪ Combined treatment: surgery (orchidectomy) followed by irradiation (seminoma) or cisplatin-based chemotherapy (non-seminoma) if necessary followed by removal of metstatic residual masses (usually retroperitoneal)

TGCTs: famous survivor Lance Amstrong, lucky to have the most curable solid cancer you can have; even with metastases cure rate >80%

Epidemiology: rise of incidence, decline sperm quality

▪ Rising incidence of TGCTs in affluent Western societies ▪ Decline of sperm quality in affluent Western societies ▪ Common cause? Hypovirilizing factors in environment? Xeno-estrogens?

TGCTs origin, testicular dysgenesis syndrome (TDS) ▪ Characteristics of TDS: features of hypo-virilization

▪ Hypospadias ▪ Cryptorchidism ▪ Small testis ▪ infertility ▪ Microlithiasis (ultra-soundpicture) ▪ Histology: features of hypo-virilisation as in partial androgen insensitivity (Sertoli cell only nodules; suboptimal spermatogenesis) ▪ Increased risk of TGCTs

▪ TGCT is developmental cancer: initiation in primordial germ cells due to disturbed embryonic development; somatic mutations play minor role.

Hallmark: replicative immortality

Telomerase is ON in normal primordial germ cells, GCNIS, seminoma, normal ES cells, embryonal carcinoma, and other tumors, and OFF in normal somatic tissue and mature teratoma

Albanell et al, JNCI 1999

Hallmark: sustaining proliferative signaling (I) ▪ Lowest mutation rate of solid cancers in adults ▪ Only driver mutations (initiating event): ▪ cKIT mutations in bilateral testicular cancer (genetic mechanism) ▪ KRAS (downstream from cKIT) ▪ Accounting for about 2% of TGCT; rest due to disturbed embryonal development

Hallmark: sustaining proliferative signaling (II) ▪ delayed maturation (epigenetic mechanism) ▪ window for co-expression of OCT3/4 (survival factor) and TSPY (stimulating cell cycle) and SCF ▪ autocrine loop SCF and cKIT (SCF receptor) expressed by GCNIS cells ▪ role of variants in cKIT that are associated with higher risk for TGCT? (GWAS-studies Rapley et al.)

GCNIS Stem cell factor-receptor (cKIT) OCT3/4 TSPY SCF

Cryptorchid testis: normal germ cell development H & E TSPY OCT3/4 SCF

H & E TSPY OCT3/4 SCF cryptorchid testis: delayed maturation

H & E TSPY OCT3/4 SCF Cryptorchid testis: pre-GCNIS

GCNIS Stem cell factor-receptor (cKIT) OCT3/4 TSPY SCF

In bilateral testicular GCT c-KIT mutations do play a role, and problably take place before the migrating primordial germ cells reach the genital ridges Migrating primordial germ cells depend on KIT-signalling for survival and proliferation

Enabling characteristicsustaining proliferative signaling (III) ▪ polyploidization ▪ in itself advantageous? (compare: polyploidization of plant cells in stressful conditions) ▪ causing chromosomal instability by asymmetrical distribution of chromosomes over daughter cells ▪ resulting in extra copies of #12 and 12p (mainly as i(12p)) convey survival and growth advantage

Peri

Gain of 12p in human type II TGCT Banding Schematic FISH CGH

ITGCN invasive Rosenberg et al., 2000; Summersgill et al. 2001

amplicon on12p11.2-2.1 i(12p)

GCNIS

Hallmark: resisting cell death ▪ Anti-apoptotic genes ▪ GCNIS and seminoma ▪OCT3/4 ▪ Seminoma and non-seminoma ▪Genes on 12p ▪BCAT1, EKI1

Sertoli cell-independence versus invasive growth

ITGCN invasive Rosenberg et al., 2000; Summersgill et al. 2001

Emerging hallmark: avoiding immune destruction ▪ TGCTs originate in the seminiferous tubules, which are an immune-privileged site ▪ Innate and adaptive immune cells only appear after invasive growth, probably in particular in seminoma ▪ GCNIS adjacent to non-seminoma largely lacks lymphocytic infiltration ▪ GCNIS adjacent to seminoma is infiltrated and attacked by lymphocytes

Seminoom

seminoma

Peri- and intratubular lymphocytic infilatrates involving GCNIS (and ISE), typically in parenchyma adjacent to Se.

Emerging hallmark: deregulation of cellular energetics ▪ GCNIS cells are packed with glycogen

Enabling characteristic: tumor promoting inflammation ▪ Intratubular hypoxia ▪ necrosis of intratubular non-seminoma ▪ upregulation of cMET ▪ inducing inflammatory response, including angiogenesis and angioinvasion?

HvN, 02-10-08

Pluripotent EC– cells only differentiate upon invasion

Intratubular non- seminoma is always undifferentiated. Hypoxia induced factors (cMET) trigger infiltrative growth, and angioinvasion. Differentiation only upon invasion

TGCTs: treatment sensitivity ▪ Seminoma cell (neoplastic counterpart of primordial germ cell) and of EC-cell (counterpart of ES cell, and stem cell of non-seminoma) inherently sensitive due to ▪ wt P53; hypersensitive DNA damage response ▪ absence of p21-induced cell cycle arrest ▪ Apoptosis proneness

(Nature rather destroys these cells than running the risk of transmitting mistakes in DNA-repair to the next generation or the developing embryo)

▪ the adult stem cells of the mature somatic tissues the produce are, on the contrary, resistant cells

Hallmark: evading growth suppressors: induces treatment resistance ▪ Somatic derivatives of EC ▪ Secondary non-germ cell malignancies ▪ Late appearing (glandular) YST ▪ Original and acquired resistance in EC ▪ Microsatellite instability ▪ BRAF mutations (V600E) ▪ P53 mutation ▪ MDM2 amplification

TGCTs: promise of cancer stem cell therapy

Case history

▪ May 1990, orchidectomy for primary non-seminoma; ▪ October 1990, 1st recurrence, retroperitoneal and retro-crural; chemotherapy; ▪ February 1991, resection of retroperitoneal residual mass (not retro- crural): RMT; ▪ Novermber 1991, retro-crural: 2nd recurrence; ▪ April 1992, resection of retro-crural (mediastinal) lymph nodes; RMT and, upon revision, low grade leiomyosarcoma with angio-invasion; ▪ September 2009, 3rd recurrence; very large retroperitoneal mass (size 13 cm) causing pain; resection: RMT, low grade leiomyosarcoma, and intestinal type adenocarcinoma; one cycle of BEP; ▪ Present, residual mass of less than 2 cm, retroperitoneal, in area of

• peration.

Summary of the most relevant histological findings in the primary tumor. Diagnosis: non-seminoma (Type II) with EC, teratoma, YST, trophoblastic giant cells, GCNIS, intratubular NS, angio-invasion

Overview of the gradual progression

• f the smooth muscle component.

Only in the second recurrence the criteria for a secondary somatic type malignancy are met:

• expansive growth (> LPF, x 40)
• Invasive growth (angio-invasion)
• nuclear atypia

Overview of the gradual progression of the nuclear atypia in the smooth muscle component, and the sudden progression of the nuclear atypia in the epithelial component.

TGCTs: promise of cancer stem cell therapy

Or: remaining tumor cells regain clonogenic potential and progress

Hallmarks of cancer (Hanahan and Weinberg, Cell 2000)

Hallmarks of cancer (Hanahan and Weinberg, Cell 2011)

▪ Figure 3 (page 658)