Types and sub-types of gastric carcinoma
•Adenocarcinoma•Adenosquamous carcinoma•Anaplastic carcinoma•Blue cell carcinoma•Carcinoma with lymphoid stroma•Carcinoma simplex•Desmoplastic carcinoma•Differentiated carcinoma•Diffuse carcinoma•Expanding carcinoma•Glandular carcinoma•Infiltrative carcinoma•Intestinal carcinoma•Intestinal cell type carcinoma•Linitis plastica•Lymphoepithelial carcinoma•Lymphoepithelioma-like carcinoma•Mixed carcinoma•Medullary carcinoma withlymphoid stroma
•Mucinous adenocarcino-ma•Mucoid carcinoma•Mucous cell type carcinoma•Nonglandular carcinoma•Papillary adenocarcinoma•Parietal cell carcinoma•Poorly-differentiated adenocarcinoma•Pyloric-cardiac cell carcinoma•Scirrhous carcinoma•Signet-ring cell carcinoma•Small cell carcinoma•Solid carcinoma•Solid medullary type•Squamous cell carcinoma•Tubular adenocarcinoma•Types I, II, III and ]IVof Goseki et al.•Unclassified carcinoma•Undifferentiated carcinoma
•Localization •Histotype
Ancient times 1800 Present day
Cancer of distal stomach (non-cardia)
Cancer of proximal stomach (cardia)
Incide
nce
Changing epidemiology
Morphologic heterogeneity
The stomach displays a diverse microbiota when H. pylori is absent or low in abundance
Resident or transient populations of ingested microbes??
Stomach H. pylori -
Stomach H. pylori +
Andersson et al., PLoS ONE 2008
• Helicobacter pylori infection• Diet• Smoking
Environment(Epi)Genetic alterations
Gastriccancer
Gene-environment interaction
Risk of gastric cancer developmentH. pylori virulent genotypes 15 to 17IL-1 gene polymorphism 3.3H. pylori virulence & IL-1B polymorphism 87
Machado et al. Gastroenterology 121: 823, 2001 Figueiredo et al, JNCI 94: 1680, 2002
• Polymorphisms: Mucin genes; Pro-inflammatory genes
• Mutations in “low” or “high”penetrant genes
Familial aggregation
Intestinal (glandular) carcinoma Diffuse (isolated cell-type) carcinoma
• Elderly patients, mainly males• Decreasing incidence everywhere• Blood-born metastases
• Young patients, mainly females• Familial/hereditary conditioning• Dissemination to the peritoneum
CIN (Chromosomal instability)-Aneuploidy# 3p, 7q, 13q (LOH)# 6q (LOH)# 1q, 5q, 17p (LOH)RAS (overexpression/mutation)ERBB-2 (amplification)TPR-MET (rearrangement)c-MET (6.0 Kb mARN)EGF (overexpression)TGF-a (overexpression)
p 53 (LOH, mutation)APC (LOH, mutation)DCC (LOH)p 16 (hypermethylation)
MSI (Microsatellite Instability)
S-Tn, T, S-TCDw75, S-LexLaminin, collagen IVu-PA, Cat-D NM 23 (loss)CD 44 (variants)
Diploidy# 3p, 7q, 13q (LOH)# 6q (LOH)
c-MET (6.0 Kb mRNA)
p 53 (LOH, mutation)
TGF-ß (overexpression)
K-SAM (amplification)E-cadherin (loss/mutation)
S-Tn, T, S-TCDw75, S-Lex
NM 23 (loss)CD 44 (variants)
Intestinal (glandular) carcinoma Diffuse (isolated cell) carcinoma
ERBB-2
PT NM LMMucosa
ERBB-2 amplification in intestinal carcinoma
David L, Seruca R, Nesland J, Soares P, Sansonetty F, Holm R, Borresen AL,Sobrinho-Simões M: c-erbB-2 expression in primary gastric carcinomas and their metastases. Mod Pathol 5:384, 1992
Blood born metastases Poor prognosis
ERBB-2 amplification in intestinal carcinoma
David L et al; Mod Pathol 5:384, 1992Barros-Silva J et al; Br J Cancer 100: 487,2009
ERBB-2In gastric carcinoma
ToGA TrialERBB2 overexpression in 22% of advanced gastric cancersSignificantly improved survival with trastuzumab
ASCO 2009 (LBA 4509)
ERBB-2
Prognostic factor YES (56%)(about 40 studies) NO (44%)
a
3’-UTR EGFR A13 REPEAT
20/63 (31.7%)
EGFR mutations in sporadic gastric carcinoma
3’-UTR EGFR A13 REPEAT
EGFR mutations 2/77 cases
EGFR amplification 4/30 cases
15-30% of the cases
Peltomäki P et al. Cancer Res 53:5853, 1993Seruca R et al. Int J Cancer 64:32, 1995Santos NR et al. Gastroenterology 110:38, 1996
Microsatellite Instability (MSI) in gastric cancer
Survival of patients
Multivariate analysis• Staging (pTNM) (p< 0.0008)• Venous invasion (p= 0.004)• Histological classification (p=0.08)• Microsatellite instability (p=0.04)
Seruca R et al. Int J Cancer 64: 32, 1995Santos N et al. Gastroenterology 110: 38, 1996 Oliveira C et al. Am J Pathol 153: 1211, 1998
MSI is a molecular marker of good prognosis
in sporadic gastric cancer
Univariate analysis
Unmethylated MethylatedMSI-H 25% 75%MSS 100% -
MLH
1 met
hylation
hMLH1 promoter hypermethylation is the main mechanism underlying MSI in SGC
Mismatch Repair (MMR) gene mutations are rare in sporadic gastric carcinomas
(Do not explain most of the MSI cases)
MSI status
K-RAS Exon 1
BRAF Exon 15
MSI-H 10/36 (28%) 0/38 (0%)
MSS 0/46 (0%) 1/139 (0.72%)
p=0.0001 NP
KRAS and BRAF in sporadic gastric carcinoma
Oliveira et al, Oncogene 22: 9192, 2003Brennetot C et al, Gastroenterology 125, 2003
V600E
S-Le x
Orcein staining
Venous invasion High expression of S-Lex
Absent 5.6%Present 94.4%
p=0.0025
Amado et al. Gastroenterology 114: 462, 1998
High S-Lex expression is a marker of poor prognosisin sporadic gastric cancer
Histotype cases (n) CD44v6 overexpression (%)
Intestinal 14 7 (50.0)
Diffuse 13 10 (76.9)
Mixed 16 10 (62.5)
TOTAL 43 27 (62.8)
CD44v6 in sporadic gastric carcinoma
Normal mucosa
IM (complete)
Dysplasia (low grade)
Hyperplastic polyp
IM (incomplete)
Dysplasia (high grade)
CD44v6 in precursor lesions of gastric carcinoma
What about diffuse carcinoma?
CIN & Aneuploidy# 3p, 7q, 13q (LOH)# 6q (LOH)# 1q, 5q, 17p (LOH)RAS (overexpression/mutation)ERBB-2 (amplification)TPR-MET (rearrangement)c-MET (6.0 Kb mARN)EGF (overexpression)TGF-a (overexpression)
p 53 (LOH, mutation)APC (LOH, mutation)DCC (LOH)p 16 (hypermethylation)
MSI
S-Tn, T, S-TCDw75, S-Lex
Laminin, collagen IVu-PA, Cat-D NM 23 (loss)CD 44 (variants)
Diploidy# 3p, 7q, 13q (LOH)# 6q (LOH)
c-MET (6.0 Kb mRNA)
p 53 (LOH, mutation)
TGF-ß (overexpression)
K-SAM (amplification)E-cadherin (loss/mutation)
S-Tn, T, S-TCDw75, S-Lex
NM 23 (loss)CD 44 (variants)
E-cadherin gene (CDH1) plays the major role
Intestinal (glandular) carcinoma Diffuse (isolated cell) carcinoma
E-cadherin gene alterations in sporadic gastric carcinoma
Machado JC et al. Oncogene 20:1525, 2001
MutationLOH
Promoter methylation
“2nd HIT”“1st HIT”
met unmet
Mixed gastric carcinomas show similar chromosomal aberrations in both their diffuse and glandular components
Diffuse component
Intestinal component
Carvalho B et al. Cellular Oncology 28:283, 2006
E-cadherin mutations in mixed gastric carcinomas
”Intestinal” component 17%”Diffuse” component 83%
Machado JC et al: E-cadherin gene mutations provide a genetic basis for the phenotypic divergence of mixed gastric carcinomas
Lab Invest 79: 459, 1999
Histological type
Glandular (n=89)Isolated cell (n=14)Solid (n=28)Mixed (n=82)
5-year survival rate
52%67%48%16%
Carneiro F et al. Pathol Res Pract 191: 571, 1995
4-1-02 - ICD-O Code
Adenocarcinoma 8140/3 Papillary adenocarcinoma 8260/3 Tubular adenocarcinoma 8211/3 Mucinous adenocarcinoma 8480/3 Signet-ring cell carcinoma 8490/3
WHO – 3rd Edition
Signet ring cell ca? Mixed ca?
Some shortcomings:
4-1 Gastric carcinoma Gregory Y. Lauwers Fátima Carneiro David Y. Graham Maria-Paula Curado Silvia Franceschi Elizabeth Montgomery Masae Tatematsu Takenori Hattori
4-1-02 - ICD-O Code Adenocarcinoma 8140/3 Papillary adenocarcinoma 8260/3 Tubular adenocarcinoma 8211/3 Mucinous adenocarcinoma 8480/3 Poorly cohesive carcinomas (including signet ring cell 8490/3 carcinoma and other variants)Mixed carcinoma 8255/3
WHO – 4th Edition, 2010
Major histological
types
• pTNM• Venous invasion
• Sialyl-Lex
• ERBB-2• E-cadherin
• Microsatellite instability
Poor prognosis
Good prognosis
Normal mucosa: neg
Intestinal metaplasia & dysplasia: pos
Sporadic gastric carcinoma
MSIIntestinal GC, older age
MLH1 methylation
Good prognostic biomarker
Oncogenic Mutations
KRAS negative
BRAF negative
EGFR positive
Biomarker for targeted therapy (EGFR inhibitors?)
CD44v6
New diagnostic biomarker
E-cadherin
Poor prognostic biomarkerLOH+ Mut
Nodal metastization, Advanced stage
Gastric cancer in hereditary cancer syndromes
Syndromes Genetic alterations
• Lynch syndrome (HNPCC) MMR• Li-Fraumeni syndrome TP53• Peutz-Jeghers syndrome STK1• Familial adenomatous polyposis APC
Sporadic (90%)
Familial Aggregation (10%)Familial Gastric Cancer (FGC)Familial Intestinal Gastric Cancer (FIGC)Familial Diffuse Gastric Cancer (FDGC)
Hereditary (1%)Hereditary Diffuse Gastric Cancer (HDGC)
GASTRIC CARCINOMA
Maori kindred
Guilford P et al. Nature 392:402,1998
E-cadherin gene(CDH1) germline
mutations
Hereditary DiffuseGastric Cancer
1999
E-cadherin changes in familial gastric cancer
2001
2003
Familial gastric cancer: overview and guidelines for management.
Prophylactic gastrectomies in asymptomatic carriers of germ-line E-cadherin mutations
Functional analyses of E-cadherin (CDH1)germline missense mutations
Model of development of HDGC2004
Cleft lip/palate and CDH1 mutations in families with HDGC
2006
2005 Report of the first Portuguese family with HDGC J Med Genet 36: 873, 1999
N Engl J Med 344:1904, 2001 Gastroenterol Clin Biol 25: 931, 2001 Hum Mutat 19:510, 2002 Hum Mol Genet 12: 575, 2003Hum Mol Genet 12: 3007, 2003 Oncogene 22:5716, 2003 J Pathol 203: 681, 2004Virchows Arch 446: 18, 2005 Clin Cancer Res 11:5401, 2005J Med Genet 43:138, 2006J Mol Med 84:1023, 2006 Hum Mol Genet15:1704, 2006 Hum Mutat 28:203, 2007Oncogene 27: 4255, 2008 J Clin Pathol 61:25, 2008 J Pathol 216:295, 2008 Gastroenterology 136:2137, 2009J Med Genet 47: 436, 2010
2007Novel germline CDH1 mutations
Experimental model in Drosophila
2008NMD mRNA surveillance downregulates aberrantCDH1 transcripts
Second hit of CDH1 inactivation
2009
2010
CLINICALHISTORY
HISTOLOGICALCLASSIFICATION
MOLECULAR CLASSIFICATION
IDENTIFICATION OF FAMILIAL CASES
The story of hereditary diffuse gastric carcinoma
HEREDITARY – Germline mutations
SPORADIC – Somatic mutations
E-cadherin mutations in diffuse gastric cancer
HEREDITARY – Germline mutations
Missense mutations (20%)
Functional Assays in CHO cells (aggregation & collagen
invasion assays)
Missense mutations affect cell-cell adhesion, motility and invasion
T340A, A634V, W409R,V832M, E757K
A617T, ….
Functional Irrelevant
“so-called variants”
Functional Relevant
Adhesion, Motility, Invasion
Suriano G et al. Hum Mol Genet 12:3007, 2003
Familial gastric cancer: overview and guidelines for management
(International Gastric Cancer Linkage Consortium)
Carriers of germline E-cadherin truncating mutations
Caldas C, Carneiro F, Lynch H et alEur J Genet 36: 873, 1999
Intensive screeningProphylactic gastrectomy
Carneiro F et al: J Pathol 203:68, 2004
In 9 prophylactic gastrectomies from North America
(Huntsman et al, 2001 and Chun et al, 2001),
all exhibited foci of intramucosal diffuse carcinoma
Hereditary diffuse gastric cancer (HDGC)
E-cadherin germline mutations in HDGC
G62V
T118RP172R L214P
G239R
D244GA298T
T340A
W409RI415L
P429S
V487A
A592T
T599S
A617T
A634V R732Q P799R
V832M
TRUNCATING
MISSENSE
In vivo validation of in vitro assays of CDH1 missense mutations
Barber M et al J Pathol 216:295, 2008
Barber M et al J Pathol 216:295, 2008
The highest number of foci was found in the fundus (44.7%) followed by the body (40.2%).
Rogers W et alAm J Surg Pathol 32:799, 2008
70% of the total signet ring cell foci were locted within the proximal 1/3 of the stomach
Gastrectomies in New Zealand in CDH1 carriers
Charlton A et al: Hereditary diffuse gastric cancer: predominance of multiple foci of signet ring cell carcinoma in distal stomach and transitional zone. Gut 53;814-820, 2004
Total gastrectomies in asymptomatic CDH1 mutation carriers (n=96)(prophylactic gastrectomies & gastrectomies for early carcinoma)
• Intramucosal SRC carcinoma 87 (91%)
• Total gastrectomies studied under research protocol 73• Number of cases with intramucosal SRC carcinoma 70* (96%)
* 2/3 cases negative for SRC intramucosal carcinoma displayed in situ carcinoma
In situ (signet ring cell) carcinoma
Pagetoid spread of signet ring cells:
Two-layer structure: an inner layer composed of benign mucous cells
and an outer layer of signet ring cells.
In situ (signet ring cell) carcinoma Pagetoid spread of signet ring cells:Two-layer structure: an inner layer composed of benign
mucous cells and an outer layer of signet ring cells.
Mucosa
Muscularis mucosa
Submucosa
T1aTisTNM stage
A B
Carneiro F, Charlton A, Huntsman D4th Edition of WHO book , 2010
Non-neoplastic mucosawith foveolar hyperplasia
In situ signet ring cellcarcinoma
In situ signet ring cellcarcinoma and pagetoid spread
CDH1 germline mutation
Inactivation of second allele of CDH1
?
Pagetoid spread of signetring cell carcinoma
Early invasive (intramucosal)signet ring cell carcinoma
C D EA B
Development model of HDGC
Carneiro F et alJ Clin Pathol 61:25, 2008
CLINICALHISTORY
HISTOLOGICALCLASSIFICATION
MOLECULAR CLASSIFICATION
First Portuguese HDGC Family (Porto)
Second Portuguese HDGC Family (Coimbra)
Genetics, Pathology and Clinics of Familial Gastric Cancer
The story of Hereditary Diffuse Gastric Cancer (HDGC)
Methylation
DNA demethylating agents
Gene structure alterations
Partners of E-cadherin signalling
2nd HIT of CDH1 silencing?
ModulatorsE-cadherin expression
Carla Oliveira Gianpaolo SurianoJosé Carlos MachadoCéu FigueiredoPaulo FerreiraRita MateusRachid KaramHerculano MoreiraManuel Cardoso de OliveiraFátima CarneiroRaquel SerucaManuel Sobrinho-Simões
Paul PharoahCarlos Caldas
Department of Oncology, University of Cambridge UK
David HuntsmanDavid Owen
Thomas Smyrk
J. van KriekenJ de Bruin
Hospitais da Universidade de Coimbra
Augusta CiprianoMário Rui Silva
VU University Medical CenterBeatriz CarvalhoGerrit Meijer
Academic Medical CenterJohan OfferhausAnya Milne
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