Outline enhanced diagnostics and potential treatment strategies - PowerPoint PPT Presentation

5/25/2018 Pathognomonic mutations in rare gynecologic cancers: from discovery to Outline enhanced diagnostics and potential treatment strategies • To understand rare cancers as histo- molecular entities • Pathognomonic mutations: where diagnostic is prognostic and predictive • FOXL2, DICER, SMARCA4 and other David G. Huntsman examples BC Cancer Agency Vancouver General Hospital University of British Columbia Research into rare cancers Almost every type of ovarian joys and challenges cancer is a rare disease • Direct benefit to those who have them • Forme Fruste models to understand common cancers • Satisfaction of rapid knowledge translation • Limited shots on goal need for better pre- clinical research 1

5/25/2018 ETV3-NTRK3 fusions : the poster child for generalizability of discoveries from rare cancers • Fusion discovered in extremely rare sarcoma (1998) • Fusion found in vanishingly rare breast cancer subtype • Fusion found in rare kidney cancer • Fusion found rarely in AML and other common cancers Celluar Acute Congenital Secretory mesoblastic myeloid fibrosarcoma carcinoma nephroma leukaemia Drilon et al NEJM 2018 Histomolecular entity versus molecular subtypes What is the value of diagnosis in of a common cancer: the mountain analogy a post genomic era • Histomolecular entity • Molecular subtypes of • A useful diagnosis common cancer must be Diagnostic – Clinically relevant gravity – Biologically plausible – Reproducible • A histologic or Need for other genomic feature biomarkers alone does not make Single pathogenetic Multiple pathogenetic a diagnosis pathway and dominant pathways and treatment treatment options 2

5/25/2018 What about diagnostic biomarkers US National Research Council, Nov 2 nd 2011 3

5/25/2018 FOXL2 mutation 4 granulosa cell tumors of the ovary V V O O A A 4 1 9 1 9 V V O O A A 1 2 5 9 9 2 Shah et al (2009) NEJM 4

5/25/2018 FOXL2 IHC and mutational analysis as a Cross-cancer mutation summary for FOXL2 (147 studies ) standard diagnostic (Kommoss et al Mod None of the cancers included in c-bioportal had the C134W Path2013) mutation as none were GCT Confirmation of FOXL2 aGCT specific c.402C>G mutation by Sanger Sequencing *No mutations at C134W Missense Mutations Truncating Mutations Question : what does a cancer specific mutation mean to patients TaqMan based digital mutation 18 assay for FOXL2 aGCT specific What does getting the correct diagnosis mean to patients c.402C>G mutation 3 European Centers (n =336) Melissa McConechy Winnie Yang Finland, The Netherlands & Germany Blake Gilks Aline Talhouk Anniina Färkkilä Mikko Anttonen Markku Heikinheimo Leila Unkila-Kallio Hugo Horlings Hannah van Meurs Maaike Bleeker Stefan Kommoss Sarah Brucker McConechy, Färkkilä, Horlings et al JNCI 2016 5

5/25/2018 • Patient’s disease relapsed after 2.6 years and died of disease 3 years from Diagnosis • She had been misdiagnosed as GCT – personal opportunity cost Overall survival of women with molecularly define AGCT is not distinct from population based controls 6

5/25/2018 Why is the recurrent FOXL2 mutation so FOXL2 in Ovarian and Mullerian Stroma specific for adult type GCT Ovary Fallopian tube Endometrium Endocervix In adults expression is restricted to specialized stroma of ovary, uterus and fallopian tube Image from protein atlas Other targets What else The FOXL2 mutation is diagnostic for aGCT is going on in GCT and its oncogenicity linked to granulosa cell pathophysiology genomes? Follicle Corpus luteum • TERT promoter mutations in 1/3 • Smattering of other cancer Ovulation mutations including targetable PIK3CA pathway mutations • LOH of chromosome 22 AGCT Granulosa cell Luteinized granulosa cell FOXL2-mutant granulosa cell Theca cell Oocyte 7

5/25/2018 Molecularly defined AGCT SCLT Background The power of a correct diagnosis • Rare histologicially diverse mixed sex • Prior studies overestimated death from disease due to contaminating misdiagnosed cases. cord-stromal tumour • Missed diagnosed cases dominate early relapses and likely past trials studied in clinical • Mostly sporadic • Usually an indolent disease or managed well by primary and secondary surgeries • Occasionally in setting of DICER1 • Treatment needed for inoperable cases of molecularly defined AGCT Syndrome • Medium time to relapse >7 years therefore current follow-up strategy Well differentiated (5) Moderately diff. (34) Poorly diff. (7) likely useless – needs testing • Cell free DNA could be used as an adjunct to monitor patients in trials • If no means of targeting FOXL2 derived then analysis for other targetable mutations through inclusion in a basket type trial may be feasible Heterologous diff (8*) Retiform (2*) FOXL2 (100% positive) Recurrent DICER1 somatic mutations in ovarian sex cord-stromal tumors • mutations at four metal binding sites in RnaseIII b domain. • High frequency in Sertoli-Leydig cell tumor (SLCT). • Often present in tumors related to DICER1 syndrome (such as PPB, SLCT), a condition caused by germline DICER1 Heravi-Moussavi A. NEJM. 2012 haploinsufficiency. Gyne Onc 2011 8

5/25/2018 Mutations impact critical aspartic acids DICER1 in the RNase IIIb domain mutations • In presence of germline truncating mutations the hotspot mutations are a specific somatic second hit Moussavi, Anglesio and Cheng et al NEJM 2011 Moussavi, Anglesio and Cheng NEJM 2012 Mutations at DICER1 Hotspots Mutations at DICER1 Hotspots lead to global loss of 5p lead to global loss of 5p miRNAs miRNAs SLCT miRNA-seq mES cell model-Nanostring miRNA profiling Wang et al. Neoplasia 2015 Anglesio MS. J Path. 2012 Anlglesio et al J Path 2012 9

5/25/2018 Analyzing miRNA biogenesis defects in DICER1 hotspot mutations in oSLCTs (FFPE) by miRNA sequencing SLCT • Kato et al Human Path 2017 -6 of 10 –association SLCT (no DICER1 hotspot mutation): 8 with androgenic effects SLCT (with DICER1 hotspot mutation): 4 • De Kock – AJSP 2017 all of 30 mod or high grade cases had hotspot mutations DICER1 status 5p 3p total reads 5p% YW_1 no hotspot 15689 17151 32840 47.775 • Conlon – Mod Path 2015 20/32 cases had hotspot YW_2 no hotspot 3001 5114 8114 36.979 mutation no associations YW_3 no hotspot 11556 6804 18360 62.940 YW_4 no hotspot 12762 8186 20948 60.922 YW_5 no hotspot 34054 18029 52083 65.385 YW_6 no hotspot 9971 3415 13386 74.487 YW_7 no hotspot 12391 6056 18447 67.173 YW_8 D1709N 2327 7155 9483 24.544 • Larger studies with consistent mutation detection YW_9 D1810H 1400 5750 7150 19.582 approaches will be required to determine the YW_10 D1810Y 2339 5734 8073 28.968 frequency of these mutations in SLCT and other YW_11 D1810Y 915 4942 5858 15.623 YW_12 no hotspot 79437 23398 102835 77.247 tumors and whether there is diagnostic utility P < 0.001 Wang et al Neoplasia 2015 Do SLCT represent three diseases Mutation Distribution by Patient Age • DICER1 mutant (younger, more androgenic P = 0.005 symptoms, moderately/poorly differentiated, P < 0.0001 • 45 cases reviewd by 100 P = 0.0003 retiform or heterologous elements), 90 Gilks, Kommoss and 80 Clement 70 • FOXL2 mutant (postmenopausal, abnormal • Tested for Dicer1 & 60 bleeding, moderately/poorly differentiated, no Foxl2 hotspot Age 50 retiform or heterologous elements) mutations and FOXL2 40 by IHC 30 20 • DICER1 / FOXL2 wild type (intermediate age, no 10 retiform or heterologous elements, including all 0 A Karnezis et al, submitted DICER1 FOXL2 WT/WT well differentiated tumors). 41% 22% 37% A Karnezis et al, submitted 10

5/25/2018 A proposed model for DICER1 mutation in How do miRNA processing defects ovarian SLCT development: way too complex – lead to cancer in other contexts animal models will be required to sort this out SMARCA4 inactivating mutation- the only recurrent Small cell carcinoma of the ovary, somatic mutation in SCCOHT hypercalcemic type (SCCOHT) SMARCA4 Germline • Described by Scully 1 QLQ HSA BRK DEXDc SNF2_N HELICc Bromo 1,647 a.a. 1979 • A rare disease in Somatic young women, Nonsense mutation Missense mutation Splice site mutation mean age 22 Kupryjanczyk et al. Polish J Patho l 2013. • Sometimes familial Ramos, Karnezis et al. Nature Genetics 2014. Witkowski et al. Nature Genetics 2014. • Undifferentiated Jelinic et al. Nature Genetics 2014 Ramos et al. Rare diseases 2014 small cells 100 • Elevated serum pLDpuro-GFP calcium level (60%) pLDpuro-SMARCA4 80 % cell confluence • Very lethal 35% 2yr 60 survival 40 20 0 0 24 48 72 96 120 144 168 Time (hours) 11