Neoplasia Mary P. Bronner, MD Division Chief of Anatomic Pathology - - PowerPoint PPT Presentation

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Neoplasia Mary P. Bronner, MD Division Chief of Anatomic Pathology - - PowerPoint PPT Presentation

May 15, 2023 6 likes •599 views

Department of Pathology Inflammatory Bowel Disease Neoplasia Mary P. Bronner, MD Division Chief of Anatomic Pathology University of Utah Department of Pathology Neoplastic Progression in Chronic Inflammatory GI Dz Inflammation Dysplasia

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Department of Pathology

Inflammatory Bowel Disease Neoplasia

Mary P. Bronner, MD Division Chief of Anatomic Pathology University of Utah

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Department of Pathology

Neoplastic Progression in Chronic Inflammatory GI Dz

Inflammation Dysplasia Carcinoma

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Department of Pathology

Chronic Inflammatory GI Disease & Cancer

  • Barrett’s Esoph

Esoph CA

  • HP Gastritis

Gastric CA

  • Hepatitis B & C

HCC

  • Ch Pancreatitis

Panc CA

  • UC and Crohn’s

Intestinal CA

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Department of Pathology

Ulcerative Colitis: A Paradigm

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Department of Pathology

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Department of Pathology

Managing Cancer Risk in UC

  • Ignore it
  • “Prophylactic” colectomy
  • Colonoscopic surveillance for

dysplasia / early carcinoma

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Department of Pathology

Optimal Colonic Biomarker

  • Pancolonic distribution
  • Predate incurable cancer
  • Objective
  • Sensitive, Specific, PPV, NPV
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Gold Standard Biomarker: Dysplasia

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Department of Pathology

Dysplasia: Problems

  • Sampling
  • Distinction from reactive change
  • Observer variation
  • Natural history incompletely

understood

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Department of Pathology

Adequate Bx Sampling

Histology

From: Rubin CE, et al. Gastroenterology 1992;103:1611

Dysplasia Cancer

  • No. Bx’s for

90% confidence 33 34

  • No. Bx’s for

95% confidence 56 64

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Department of Pathology

UC Surveillance Protocol

10 cm 5 cm

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

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Department of Pathology

Rectosigmoid Predominance of Ulcerative Colitis Cancer

Location of Colorectal Carcinoma

RS D T A/C 52% 12% 21% 15%

Choi PM. Gastroenterology 1993;104:666 Summary of 5 Studies

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Department of Pathology

Dysplasia: Problems

  • Sampling
  • Distinction from reactive change
  • Observer variation
  • Natural history incompletely

understood

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Department of Pathology

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Department of Pathology

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Department of Pathology

Dysplasia: Problems

  • Sampling
  • Distinction from reactive change
  • Observer variation
  • Natural history incompletely

understood

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Department of Pathology

Outcome of 40 UC LGD Patients

  • 78% no progression, avg f/u 5y (1-13 y)
  • 22% HGD, avg f/u 1.5 y (1-3 y)
  • ≥3 LGD biopsies: 9x progression risk
  • 2 non-compliant patients developed

Dukes’ A cancer

Brentnall, Bronner, et al. Prospective study of progression of LGD in UC. Inflamm Bowel Dis 18:2240-6, 2012.

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Dysplastic Field: Limited

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Department of Pathology

Better Biomarkers of Cancer Risk Greatly Needed!

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Department of Pathology

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Department of Pathology

Chromosomal Instability?

  • FCM Aneuploidy - Detects gross

chromosomal instability

  • CGH - Detects clonal gains and losses
  • f chromosomal regions
  • FISH - Detects clonal and non-clonal

chromosomal abnormalities

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Department of Pathology

Biopsy Sampling: Flow Cytometry

Rubin CE, et al. Gastroenterology 1992;103:1611

Dysplasia Cancer

  • No. Bx for

90% confidence 20 8

  • No. Bx for

95% confidence 30 14

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Morphologic + DNA Ploidy Neoplastic Field: Larger

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Department of Pathology

Metaphase Comparative Genomic Hybridization in UC

39% (15/38) of diploid bx’s near dysplasia or cancer showed CGH detectable alterations

Performed in collaboration with

  • F. Waldman, UCSF
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Department of Pathology

Array-based Comparative Genomic Hybridization (CGH)

Chromosomes replaced by ordered array of targets Karyotyping of metaphase spreads not necessary Greatly increased resolution

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Department of Pathology

Array CGH in UC

  • 100% (9/9) UC-progressors

extensive chromosomal gains and losses

  • FISH and PCR targets identified

Bronner MP, Mod Pathol 2010;23:1624-33

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Department of Pathology

Ulcerative Colitis A-CGH

PROGRESSORS NON-PROGRESSORS

Gain Loss

Bronner MP, Mod Pathol 2010;23:1624-33.

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Department of Pathology

BAC CGH Whole Genome Log2-Ratio Plots of All Chromosomes

Normal Non-UC Control UC Non-progressor UC Progressor UC Progressor

Bronner MP, Mod Pathol 2010;23:1624-33.

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Morphology + DNA Ploidy + CGH Neoplastic Field: Larger Still

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Department of Pathology

Non-Clonal Change in UC: Wider Field?

  • DNA Flow & CGH detect clonally expanded

abnormalities only

  • Larger fields of non-clonal instability?

Detectable in negative biopsies, even from rectum?

  • Assessed by Fluorescence In Situ Hybridization

(FISH)?

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Department of Pathology

UC FISH

Hypothesis:

UC progressors differ from UC non-progressors using non-clonal genomic instability biomarkers on single negative rectal biopsies

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Department of Pathology

FISH

  • Interphase nuclear suspensions placed
  • n glass slide
  • Locus specific probes (Chrom 8, 11, 17,

18) & centromeres (green and red)

  • Red and green FISH spots counted per

100 nuclei

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Normal Cells

Abnormal Cells

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Department of Pathology

Control Normal Colon FISH Chrom11 Probe Set

Red and Green Signal Counts % of Nuclei 0r2g 1r1g 1r2g 1r3g 2r1g 2r2g 2r3g 2r4g 3r2g 3r3g 1 1 2 2 2 2 20 40 60 80 100

90

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Department of Pathology

Diploid Neg Rectal Bx UC Progressor Chrom11 Probe Set

Red and Green Signal Counts % of Nuclei

0r2g 1r1g 1r2g 1r3g 2r1g 2r2g 2r3g 2r4g 3r2g 3r3g 4 2 1 1 8 11

74

20 40 60 80 100

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Department of Pathology

FISH in Ulcerative Colitis

% cells with FISH abnormalities Arm loss 2 4 6 8 10 Arm gain Centromere loss Centromere gain p0.001 p0.001 p=0.001 p0.001 Non-UC controls N=10 UC non-progressors N=18 UC progressors N=12 Bronner MP, et al. Am J Pathol 2008;173:1853.

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Department of Pathology

8q: c-myc Specificity Sensitivity

0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0

11q: CyclinD1

0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0

17p: p53 Specificity Sensitivity

0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0

1-Specificity 1-Specificity Sensitivity 18q: DCC Sensitivty

0.0 0.2 0.4 0.6 0.8

1.0

0.0 0.2 0.4 0.6 0.8 1.0

1-Specificiy

ROC Analysis of FISH Biomarkers

Bronner MP, et al. Am J Pathol 173:1853-1860, 2008

1-Specificity

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Department of Pathology

All 4 chromosomes combined

1-Specificity Sensitivity

0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0

Bronner MP, et al. Am J Pathol 2008;173:1853.

ROC Analysis of FISH Biomarkers

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Department of Pathology

Consequences of Shortened Telomeres

  • Sticky chromosomal ends
  • Bridge-breakage-fusion cycles
  • Chromosomal arm losses/gains

and dicentrics

Studied by peptide nucleic acid (PNA) probe ISH or RT PCR

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Department of Pathology

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Department of Pathology

Telomere Shortening in UC

Epithelial: Stromal Telomere Ratio

1.4 Non-UC control 1.2 1.0 0.8 0.6 0.4 0.2 Non- progressors Progressors p=0.08 p=0.001 p=0.02 O’Sullivan J, et al. Nat Genet 2002;32:280-284.

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Anaphase Bridges in UC

% Anaphase Bridges

0.03

Non-UC control

0.025

Non- progressors Progressors p=0.011 p=0.0002

0.02 0.015 0.01 0.005

Bronner MP, et al. Am J Pathol 173:1853-1860, 2008

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Department of Pathology

NGS miRNA bioclassifier of UC patients at increased risk of colon cancer

  • Why miRNAs?

–Small size (~21nt) more stable, less ribonuclease degradation –Readily detectable in FFPE and stained slides –Important roles in immune regulation

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Department of Pathology

miRNAs misregulation in UC-P, UC-NP

  • Linear discriminant

analysis to predict UC-P

  • vs. UC-NP
  • Robust candidate panel

selected for RT-PCR & additional cohort validation

UC-NP vs. nl (26 miRNAs) UC-P vs. nl (29 miRNAs)

11

18 15

Normalized Read count

100 1000 UC_NP+UC_P

mir

UC_NP UC_P

UC-NP 9/10 UC-P 10/10

miRNA Panel

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Histology + DNA Ploidy + CGH +FISH +Telomeres +Ana Bridges +miRNA Neoplastic Field: Entire Colon

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Department of Pathology

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Department of Pathology

UC Polypoid Dysplasia You’re dalmed if you do, and dalmed if you don’t Teri Brentnall,MD

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Department of Pathology

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Department of Pathology

Dysplasia in UC vs Adenoma

  • No clinical features
  • No endoscopic features
  • No pathologic features
  • No molecular tests
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Department of Pathology

HOWEVER

  • If the lesion can be demonstrably

completely removed endoscopically

  • Has only Low-Grade Dysplasia
  • There is no other dysplasia on

adequate sampling

  • Then, careful follow-up may be

considered

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Department of Pathology

UC Dysplasia Management

Continue Surveillance with adequate sampling: –Single site LGD while in surveillance –Indefinite of negative for dysplasia

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Department of Pathology

UC Dysplasia Management

Consider Colectomy: –Multiple LGD sites –LGD on more than one endoscopy –LGD at initial colonoscopy –Excessive inflammatory polyps

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Department of Pathology

Inflammatory Polyps

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Department of Pathology

UC Dysplasia Management

Colectomy Indicated: –HGD –Endoscopically unresectable dysplastic lesion

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Department of Pathology

Conclusions

  • Molecular alterations are widespread in

UC, CD, CP, HP, HCV

  • Single non-dysplastic bx alterations show

promise for reducing sampling error

  • Paradigm for cancer in chronic

inflammatory disease

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Department of Pathology

Further Work:

  • Reproducibility
  • Longitudinal analyses
  • Prospective validation
  • High throughput
  • Reduced numbers of markers
  • Mechanism: why progressors?
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Department of Pathology

Thanks To My Colleagues: Bonnie Shadrach Teri Brentnall Peter Rabinovitch Ru Chen David Crispin Rosana Risques Jacintha O’Sullivan Noah Welker Keith Lai Danielle Elsberry Ryan O’Connell June Round John Valentine

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Department of Pathology