Untersuchungen zur Therapieentscheidung bei Brustkrebs Institut f. Pathologie Dr. Beate Richter-Sadocco Berliner Allee 48 30175 Hannover info@hannover-pathologie.de

Therapieentscheidung Morphologie und Stadieneinteilung Molekulare Biomarker Proteasen Therapieentscheidung

Morphologie

Histologie

WHO Die neue Serie der Weltgesundheitsorganisation (WHO) standardisiert die Klassifikation von Tumoren nach deren histologischen Typ. 4. Edition, 2012

WHO - Klassifikation 2012

Tumor - Grading Die histologische Graduierung invasiver Brustkarzinome wird routinemäßig angewandt nach der Bloom & Richardson - Methode und modifiziert nach Elston & Ellis. WHO, 2012

International Union Against Cancer Das TNM-System zur Klassifikation maligner Tumoren wurde 1943-1952 entwickelt und dient der klinischen Stadieneinteilung sowie Ihrer statischen Erfassung.

TNM 2012

Tumorstadium I-II TNM Staging Atlas, second edition 2012

Tumorstadium III-IV TNM Staging Atlas, second edition 2012

Operative Therapieentscheidung Indikation für BET Günstige Relation von Tumorgröße und Brustvolumen Keine ausgedehnte Hautinfiltration des Tumors Keine ausgedehnte Infiltration in den Pectoralismuskel BET-Wunsch der Patientin Indikation für Ablatio Multizentrische Karzinome Inflammatorisches Karzinom (cutane Lymphangiosis carcinomatosa) T4 – Karzinome Ausgedehnte in situ – Tumorkomponente Tumorentfernung auch mit Nachresektion nicht im Gesunden möglich

Operative Therapieentscheidung Fazit der ACOSOG Z0011 – Studie Kein Vorteil der lokalen und regionalen Rezidivrate Kein signifikanter Unterschied des Gesamtüberlebens Giuliano et al, Ann.Surg. 2010

Molekulare Biomarker In den histopathologischen Routineuntersuchungen werden 3 relevante molekulare Biomarker als immunhistochemische Reaktionen eingesetzt: Oestrogenrezeptor (ER), Progesteronrezeptor (PR) und Her-2/neu. Ggf. wird eine in situ – Hybridisierung für die Bestimmung einer Her-2/neu – Gen Amplifikation durchgeführt.

Molekulare Biomarker (IHC) Progesteron Oestrogen Her-2/neu

Molekulare Biomarker (ISH) Her-2/neu – Gen nicht amplifiziert Her-2/neu - Gen amplifiziert

Molekulare Subtypen N Engl J Med, 2009; 360:790-800

Oncotype DX® Recurrence Score berechnet aus 21 verschiedenen Genen 16 KREBS ASSOZIIERTE GENE Estrogen Proliferation HER2 Invasion Others ER PR Bcl2 SCUBE2 Ki-67 STK15 Survivin Cyclin B1 MYBL2 GRB7 HER2 Stromelysin 3 Cathepsin L2 CD68 GSTM1 BAG1 The final gene set used for the Oncotype DX™ assay includes the 16 cancer genes identified in the clinical trials: 5 genes are in the proliferation group, 2 in the HER2 group, 4 in the estrogen receptor group, 2 in the invasion group, and 3 are unaligned. Some of the genes are well known in the breast cancer literature; others are relatively new. The 5 reference genes are used for normalizing the expression of the cancer-related genes. As was previously stated, it is important to note that there are other genes linked to breast cancer (e.g., the 250 candidate genes from which the 16 genes were selected). The 16 genes presented in this slide were selected for the Oncotype DX assay based on the three clinical trials, which demonstrated a consistent statistical link between these genes and distant breast cancer recurrence and the most robust predictive power across the three studies. Additional information on some of the 16 cancer related genes: MYBL2: The protein encoded by this gene, a member of the MYB family of transcription factor genes, is a nuclear protein involved in cell cycle progression. The encoded protein is phosphorylated by cyclin A/cyclin-dependent kinase 2 during the S-phase of the cell cycle and possesses both activator and repressor activities. It has been shown to activate the cell division cycle 2, cyclin D1, and insulin-like growth factor-binding protein 5 genes. Transcript variants may exist for this gene, but their full-length natures have not been determined. STK15: The protein encoded by this gene is a cell cycle-regulated kinase that appears to be involved in microtubule formation and/or stabilization at the spindle pole during chromosome segregation. The encoded protein is found at the centrosome in interphase cells and at the spindle poles in mitosis. This gene may play a role in tumor development and progression. A processed pseudogene of this gene has been found on chromosome 1, and an unprocessed pseudogene has been found on chromosome 10. Multiple transcript variants encoding the same protein have been found for this gene. Scube2 can modulate the long-range action of Bmp-dependent Hedgehog signaling in the neural tube and somites. STMY3 (MMP11): Proteins of the matrix metalloproteinase (MMP) family are involved in the breakdown of extracellular matrix in normal physiological processes, such as embryonic development, reproduction, and tissue remodeling, as well as in disease processes, such as arthritis and metastasis. Most MMP's are secreted as inactive proproteins which are activated when cleaved by extracellular proteinases. However, the enzyme encoded by this gene is activated intracellularly by furin within the constitutive secretory pathway. Also in contrast to other MMP's, this enzyme cleaves alpha 1-proteinase inhibitor but weakly degrades structural proteins of the extracellular matrix CL2: The protein encoded by this gene, a member of the peptidase C1 family, is a lysosomal cysteine proteinase that may play an important role in corneal physiology. This gene is expressed in colorectal and breast carcinomas but not in normal colon, mammary gland, or peritumoral tissues, suggesting a possible role for this gene in tumor processes. GSTM1: Cytosolic and membrane-bound forms of glutathione S-transferase are encoded by two distinct supergene families. At present, eight distinct classes of the soluble cytoplasmic mammalian glutathione S-transferases have been identified: alpha, kappa, mu, omega, pi, sigma, theta and zeta. This gene encodes a glutathione S-transferase that belongs to the mu class. The mu class of enzymes functions in the detoxification of electrophilic compounds, including carcinogens, therapeutic drugs, environmental toxins and products of oxidative stress, by conjugation with glutathione. The genes encoding the mu class of enzymes are organized in a gene cluster on chromosome 1p13.3 and are known to be highly polymorphic. These genetic variations can change an individual's susceptibility to carcinogens and toxins as well as affect the toxicity and efficacy of certain drugs. Null mutations of this class mu gene have been linked with an increase in a number of cancers, likely due to an increased susceptibility to environmental toxins and carcinogens. Multiple protein isoforms are encoded by transcript variants of this gene. BAG1: The oncogene BCL2 is a membrane protein that blocks a step in a pathway leading to apoptosis or programmed cell death. The protein encoded by this gene binds to BCL2 and is referred to as BCL2-associated athanogene. It enhances the anti-apoptotic effects of BCL2 and represents a link between growth factor receptors and anti-apoptotic mechanisms. At least three protein isoforms are encoded by this mRNA through the use of alternative translation initiation sites, including a non-AUG sit 5 Referenzgene Beta-actin GAPDH RPLPO GUS TFRC 21 Paik et al. N Engl J Med. 2004;351:2817-2826. 21 21

EndoPredict® - EP-Score als molekularer Fingerabdruck 23

Molekulare Diagnostik Ärzteblatt, Okt. 2012

Proteasen (2001) Mithilfe der Invasionsfaktoren uPA/PAI-1 kann das Rezidivrisiko für Patientinnen mit Nodal-negativem Mammakarzinom besser abgeschätzt werden.

Proteasen

Systemische Therapieentscheidung pT2 N0 M0 G2 Stadium IIA HR pos. Her-2/neu neg. Ki-67 < 15% HR pos./ neg. Her-2/neu pos. Ki-67 < 15% endokrine Therapie Chemotherapie ? Chemotherapie Herceptin Oncotype Dx oder Endopredict uPA/ PAI-1

Systemische Therapieentscheidung pT1c N1a M0 G2 Stadium IIA HR pos. Her-2/neu neg. Ki-67 < 15% HR pos./ neg. Her-2/neu pos. Ki-67 < 15% endokrine Therapie Chemotherapie ? Chemotherapie Herceptin Oncotype Dx oder Endopredict

Systemische Therapieentscheidung pT1a N0 M0 G3 Stadium IA HR neg. Her-2/neu neg. Ki-67 >30% HR pos./ neg. Her-2/neu pos. Ki-67 >30% Chemotherapie Chemotherapie Herceptin ?

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