CURSO DE PATOLOGÍA GINECOLÓGICA II

Actualizaciones en patología cervical y endometrial

Avances en la

Patología Molecular del

Cáncer de Endometrio

José Palacios

Hospital Universitario Ramón y Cajal. Madrid

p53ER

ER p53

NONENDOMETRIOID CARCINOMA

ENDOMETRIOID CARCINOMA

ENDOMETRIAL CARCINOSARCOMA (MMMT)

UNDIFFERENTIATED ENDOMETRIAL CARCINOMA

NORMAL

EPITHELIUM

Simple Hyperplasia Atrophic endometrium

(AE)

Complex Atypical

Hyperplasia

ENDOMETRIOID

CARCINOMA

(EEC)

Endometrial

Intraepithelial Carcinoma

NON-ENDOMETRIOID

CARCINOMA

(NEEC)

PROGRESSION MODEL FOR ENDOMETRIAL CARCINOMA

Prolif Secretory

K-Ras/PTEN

ββββ-catenin/

MSI/PI3KCA/

FGFR2

P53/CIN/?

p53

hMLH1 promoter hypermethylation

NON-CODING SEQUENCES

(BAT25, BAT26,...)

CODING SEQUENCES

PTEN, BAX, hMLH6, hMSH3, TGFββββ-RII, CASP-5, BCL10

RER+ phenotype

MSI

U M

EC1

U M

EC2

U M

EC3

U M

EC4

hMLH1 hMHS2

BAT25

TNN

T

CASP-5 (A10) BCL10 (A8) RAD50 (A9)

TP53 MUTATION

CHROMOSOME INSTABILITY

ANEUPOIDY

STK15, CCNE1, CCND1, HER2

ONCOGENE AMPLIFICATION LOH TSG

CHROMOSOME INSTABILITY

CDH1

CELL CYCLE ALTERATIONS

INVASION AND METASTASIS

ALLELIC IMBALANCES

Serous endometrial carcinoma

Reduced E-cadherin

T

N

D16S496

CCNE1Cyclin E

Nature, 2013

GENE FREQUENCY GENE FREQUENCY

PTEN * 77.7% MLL4 9.1%

PIK3CA 53.1% BCOR 8.0%

PIK3R1 37.1% ATR 6.9%

CTNNB1 36.6% CCND1 5.7%

ARID1A 35.4% SPOP 5.7%

KRAS 24.6% SIN3A 5.7%

CTCF 20.6% MKI67 5.7%

RPL22 12.6% FBXW7 5.1%

TP53 11.4% FOXA2 5.1%

FGFR2 10.9% NRAS 2.9%

ARID5B 10.9%

Gene mutations in endometrioid endometrial carcinoma

TCGA; Nature 2013

*62/136 (45.5%) tumors with PTEN mutations has > 2 mutations

GENE Grade 1 Grade 2 Grade 3

CTNNB1 47.7% 36.8% 17.9%

TP53 0 11.8 30.8%

Gene mutations in endometrioid endometrial carcinoma

CTNNB1 PTEN RAS MSI

AH (11) 1 (9%) 4 (36%) 4 (36%) 1(9%)

AHWSM (14) 7 (50%) 0 0 0

Molecular alterations in

atypical endometrial hyperplasia

Bratchel, et al.; Am J Surg Pathol 2005

GENE FREQUENCY GENE FREQUENCY

TP53 90.7% PRPF18 7%

PIK3CA 41.9% SPOP 7%

FBXW7 30.2% CDH19 7%

PPP2R1A 36.6% FGFR2 7%

CHD4 16.3% ARID1A 7%

CSMD3 11.6% FOXA2 4.6%

COLA11 11.6% USP36 4.6%

TAF1 (30%), EP300 (8%), TSPYL2 (6%), MAP3K4 (6%) and ABCC9 (6%).

Gene mutations in serous endometrial carcinoma

TCGA; Nature 2013

Khun et al; J Natl Cancer Inst 2012.

Le Gallo et al; Nat Genet 2012;

Zhao et al; PNAS 2013.

Cluster 1 tumours were nearly devoid of broad SCNAs, averaging less than 0.5% genome alteration, with no significant recurrent events. Tumours also had significantly increased non-synonymous mutation rates compared to all others .

Clusters 2 and 3 consisted mainly of endometrioid tumours, distinguished by more frequent 1q amplification in cluster 3 than cluster 2 (100% of cluster 3 tumours versus 33% of cluster 2 tumours) and worse progression-free survival

Somatic copy number alterations (SCNA)

TCGA; Nature 2013

Cluster 4 included 95% serous tumours and 12% of endometrioid tumours (24% of grade 3 and 5% of grade 1 or 2).

Recurrent previously reported focal amplifications of the oncogenes MYC(8q24.12), ERBB2 (17q12) and CCNE1 (19q12)13.

SCNAs previously unreported in endometrial cancers: FGFR3 (4p16.3) and SOX17 (8q11.23).

Frequent TP53 mutations (90%),

Somatic copy number alterations (SCNA)

TCGA; Nature 2013

GENE FREQUENCY

PIK3CA 52%

CCNE1 48%

ERBB2 44%

MYC 40%

CHD4 28%

Zhao et al; PNAS 2013

Molecular subtypes of endometrial cancer

TCGA; Nature 2013

•Mutations in the exonuclease domain of POLE

•POLE is a catalytic subunit of DNA polymerase epsilon involved in nuclear DNA replication and repair.

•Hotspot mutations in POLE at Pro286Arg and Val411Leu

present in 76% of ultramutated samples.

•Increased frequency of C to A transversion.

•Increased mutations in PTEN (94%), PIK3R1 (65%), PIK3CA

(71%); FBXW7 (82%), KRAS (53%).

•Improved progression-free survival.

Endometrial cancer: ultramutated group (7%)

TCGA; Nature 2013

TCGA; Nature 2013

Molecular alterations in the PI(3)K pathway

TCGA; Nature 2013

Molecular alterations in the RTK/RAS/ββββ-catenin pathway

TCGA; Nature 2013

Zhao et al; PNAS 2013

<5% of all endometrial carcinomas

Overal survival: 35%�Stage I: 50%�Estadio >II: 0-25%

Endometrial carcinosarcoma

Author p53 +De Jong et al. 2011 17/37

Keeling et al. 2011 12/12

Kanthan et al. 2010 15/23

Buza et al. 2009 18/30

Horn et al. 2009 1/1

Semczuk et al. 2008 0/1

Robinson-Bennett et al. 2006 4/5

Taylor et al. 2006 15/26

Kounelis et al. 1998 25/32

Iwasa et al. 1998 7/25

Abeln et al. 1997 3/4

Nicotina et al. 1997 4/10

Swisher et al. 1996 6/20

Mayall et al. 1994 5/17

Liu et al. 1994 17/23

This study 51/76

ALL STUDIES175/310 (56.5%)

p53 expression in endometrial carcinosarcoma

Van de Vijver e al; in preparation

p53

p16

TP53 mutations in endometrial carcinosarcoma

Author Total Jin et al. 2003 3/12

Watanabe et al. 2001 1/1

Soong et al. 1999 11/24

Kounelis et al 1998 9/9

Abeln et al. 1997 4/4Wada et al. 1997 8/25

Liu et al. 1994 17/23

ALL STUDIES53/99

(53.5%)

Van de Vijver e al; in preparation

Oncogene mutations in carcinosarcoma

Biscuola et al; Hum Pathol 2013

Oncogen Previous studies Present series Total

PI3KCA 12/49 (24.5%) 6/34 (17%) 18/83 (21.7%)

AKT ND 1/34 (2.9%) 1/34 (2.9%)

KRAS 15/73 (20.5%) 3/34 (8.8%) 18/104 (17.3%)

NRAS 1/31 (3.2%) 2/34 (5.8%) 3/65 (4.6%)

BRAF 0/18 1/34 (2.9%) 1/52 (2%)

CTNNB1 1/31 (3.2%) 0/18 1/49 (2%)

PDGFRA 0/25 4/34 (11.7%) 4/59 (6.8%)

KIT 0/55 2/34 (5.9%) 2/89 (2.3%)

MET ND 2/34 (5.9%) 2/34 (5.9%)

EGFR 0/18 2/34 (5.9%) 2/52 (3.8%)

Oncogene mutations in carcinosarcoma

Biscuola et al; Hum Pathol 2013

OncogenAmpl. Previous studies Present series Total

EGFR ND 15/76 (19%) 15/76 (19%)

HER2 19/142 (13.4%) 1/76 (1.3%) 20/218 (9.2%)

ALK ND 1/76 (1.3%) 1/76 (1.3%)

Oncogene amplifications in carcinosarcoma

Biscuola et al; Hum Pathol 2013

HER2EGFR

EGFR

SarcomaCarcinoma

EMT inducers and miRNAs in carcinosarcoma

SNAI1

SNAI2

ZEB1

LOXL2

miR-200fmiR-203miR-205miR224miR-133

Castilla et al; J Pathol 2011

Diaz et al; in preparation

HMGA2/ECS HMGA2/ECS

*

*

let7a let7a Lin28B

HM

GA

2

HM

GA

2

Lin

28B

EEC: 3%

ESC: 45%

ECS: 54%

Romero-Pérez et al; Hum Pathol 2013

HMGA2 IN ENDOMETRIALCARCINOSARCOMA

• Tumor composed of medium or large size cells with a

complete absence of glandular differentiation, and with absent or minimal (<10%) neuroendocrine differentiation.

• UEC represents about 9% of all ECs.

• Some UECs develop as undifferentiated solid areas associated with grade 1 or 2 endometrioid carcinomas

(dedifferentiated carcinomas)

• UEC remains under-recognized and it is often classified as

FIGO grade 3 endometrioid adenocarcinoma.

• UECs have a more aggressive phenotype than grade 3 EECs.

Undifferentiated endometrial carcinomas

MARKER G3 EEC UEC SEC

MLH1 (-) 42% 30% 4%

LYNCH ¿? 21% 10% 19%

p53 27% 33% 52%

E-CDH (0) 20% 66% 40%

ZEB 1 0 62% 7%

HMGA2 0 24% 25%

N-CDH 13% 50% 11%

Cyt. p120 0 40% 0

Undifferentiated endometrial carcinomas

Romero-Pérez et al; Mod Pathol in press

p53

ZEB1

ZEB1 overexpression is associated with down-regulation of E-cadherin and microRNA-200 expression in UEC

Romero-Pérez et al; Mod Pathol in press

•Most endometrioid carcinomas had few copy number alterations or

TP53 mutations, but frequent mutations in PTEN, CTNNB1, PIK3CA, KRAS and mutations in the SWI/SNF chromatin remodelling complex

(ARID1A, ARID5B).

•Uterine serous carcinomas and 25%of high-grade endometrioid

carcinomas had extensive copy number alterations and frequent TP53mutations and cell cycle alterations. A significant proportion of serous

carcinomas have mutations in chromatin-remodeling genes and

ubiquitin ligase complex genes.

•From a molecular point of view endometrial cancer can be classified into four categories: POLE ultramutated, microsatellite instability

hypermutated, copy-number low, and copy-number high.

•Carcinosarcomas and undifferentiated carcinomas are characterized

by a EMT molecular phenotype.

Conclusions