6a. Tumori Solidi

8/6/2019 6a. Tumori Solidi

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TUMORI SOLIDI


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CA RCINOMA DEL POLMONE


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Angiogenesis

growth of new vessels from existing va scul a ture

P hysiologic a l wound he a ling, embryogenesis, menstru a tion

Pa thologic a l tumour growth, rheum a toid a rthritis, p sori a sis


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invasion angiogenesis intravasation

Adhesion to vesselwall in distant organ

micrometastasis metastasisExtravasation and migration


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S te p s in Angiogenesis

1. the rele a se of p rote a ses from "a cti va ted " endotheli a l cells

2. degr a d a tion of the b a sement membr a ne surrounding the existing vessel

3. migr a tion of the endotheli a l cells into the interstiti a l s pa ce

4. endotheli a l cell p rolifer a tion

5. lumen form a tion

6. gener a tion of new b a sement membr a ne with the recruitment of p ericytes

7. fusion of the newly formed vessels

8. initi a tion of blood flow.


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Hanahan and Folkman, 1996. Cell 86:353

The a ngiogenic switch hy p othesis - a b a la nce

between p ro - a nd a nti -a ngiogenic f a ctors


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The tumour a nd its surrounding en vironment a re known to p romote VEGF rele a se

IGF = insulin -like growth f a ctor; PDGF = p la telet -deri ved growth f a ctor; EGF = e p iderm a l growth f a ctor

EGF

Hyp oxi a PDGF

IL-8

b FGF

COX-2Nitric oxideOncogenes

VEGF rele a se Binding a nd a cti va tionof VEGF rece p tor -2

IGF- 1

P rolifer a tionS ur viva l Migr a tion

ANGIOGENESISP erme a bility

P P

PP


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The VEGF f a mily a nd its rece p tors

Migration, permeability, DNA synthesis, survival

Lymphangiogenesis

P PP

P

P P

PP

P P

PP

VEGF-A VEGF-B

PlGF

VEGF

receptor-1

VEGF-A

VEGFreceptor-2

VEGF-C VEGF-D

VEGFreceptor-3

Angiogenesis


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GR B2GR B2PL CKPL CK

p85p85

Ad ap ter molecule bindingAd ap ter molecule binding

Rece p tor dimeriz a tionAuto p hos p horyl a tionRece p tor dimeriz a tionAuto p hos p horyl a tion

VEGF R ece p tor Acti va tion

Lig a ndbindingLig a ndbinding

Dimeric VEGF lig a ndDimeric VEGF lig a nd

Tr a nscri p tionTr a nscri p tion

P erme a bility P rolifer a tion

Migr a tionAdhesionS ur viva l

P erme a bility P rolifer a tion

Migr a tionAdhesionS ur viva l

NucleusNucleus

Downstre a m sign a ling e vents Downstre a m sign a ling e vents

Endotheli a l cellEndotheli a l cell


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S tr a tegies to inhibit VEGF sign a lling

Ferrara & Kerbel Nature 438: 96797 4, 2005.


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Be va cizum a b (Ava stin)

VEGF isoforms recognised by hy p er va ria ble murine

a ntibody fr a gment

Hum a n Ig G-1


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Lanticor p o a nti -VEGF be va cizum a b blocc alinter a zione del VEGF con i suoi recettori

B evacizumab si lega alVEGF bloccando

linterazione con i recettorie lattivazione dellatrasduzione del segnale avalle

Il blocco del VEGFinduce la regressione dellavascolarizzazionetumorale

Bevacizumab

P P

PP

VEGF

X

Crescita

Proliferazione

Migrazione

Sopravvivenza

X


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mitogeno in vitro p er di versi tip i di cellule endoteli a li

induttore di a ngiogenesi in vivo

f a ttore di so p r avv ivenz a cellul a re in vitro

f a ttore di p erme a bilit va scol a re

stimol a la migr a zione cellul a re

inibisce lap o p tosi

Atti vit biologiche del VEGF


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The ErbB Fa mily

ErbB1 (HER 1, EGFR )

ErbB 2 (HER2 , neu)

ErbB 3 (HER3 )

ErbB 4 (HER4 )

4 ty p es of erbB rece p tor 4 ty p es of erbB rece p tor 11 Lig a nds e a ch with a common 11 Lig a nds e a ch with a common EGF like structureEGF like structure

EGF

EGF

TGF-a

Am p hiregulinBet a cellulin

Ep iregulin

HB-EGF

Ep igenNeuregulin 1 (NRG 1)

Neuregulin 2 (NRG2 )



ER B rece p tors


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Es p ressione di EGFR nei tessuti norm a li

Cute, appa r a to digerente, sistem a res p ir a torio, ghi a ndole m a mm a rie, appa r a to genit a le, appa r a to urin a rio, SN C, sistem a endocrino

E p resente sulle: cellule e p iteli a li cellule strom a li

cellule gli a li cellule muscol a ri lisce


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EGFR : FUNZIONE FISIOLOGI CA

Un a delle p rinci pa li vie molecol a ri a tti va te d a llEGFR q uell a di r a s. Ra s viene reclut a taa ttr av erso il leg a me con lamolecol a SOS .


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A su a v olt a , r a s determin alatti va zione dell a

serin a/ treonin a chin a si r a f, delle MAPKK 1 e 2 e delle MAPK ERK 1 e 2.



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Il risult a to dell atti va zione di q uest a v ia molecol a re les p ressione di va rie p roteine nucle a ri, inclus a la ciclin a D 1 (necess a ria p er il pa ss a ggio G

1-S nel ciclo cellul a re).



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TKTK

S ur viva l(a nti -ap o p tosis)

PI3-K

STAT3

AKTPTEN

MEK

Gene tr a nscri p tionMAPK

P rolifer a tion /m a tur a tion

Chemother ap y /

r a diother ap yresist a nce Angiogenesis Met a st a sis

pY

pY RAS R AFSOS

GR B2pY

G1

SM

G 2

Anticor p i monoclon a li

P iccole molecole a nti -TK

S tr a tegie a nti -EGFR


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Ty rosine KinaseDomain

Ligand

Ligand bindingDomain

P PP85

P100

PI 3 Kinase

Extr a cellul a r

GROWTH, DIFFERENTIATION, APOPTOSIS ETC

Membr a ne

Intr a cellul a r


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Su mmar y of EGFR m u tations (PNA S 2004 101 13306)


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7 28 8 7 57 617 29688 8248237 62

A review of 3016 cases from the literature.Chan , Hill and Gullick EJC 2006 42 17.


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Mut a tions a re a ssoci a ted with N e ver -S mo kers, gender a nd Histologic a l subty p es

Mut a tions a re more common in Ea st Asi a ns (30 .6% th a n in

Ca uc a si a ns (7 .6% ) p


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Hepatocellular 0/7 3 Lee et al. 2005

Pancreatic 2/55 ( 4%) Kwak et al. 2006

EsophagealB arrets

2/17 (12 %)3/21 (14%)

Kwak et al. 2006Kwak et al. 2006

Colon 0/9 8 Lee et al. 2005

B reast 0/ 42

0/150/111/9 3

Generali et al. 2007

Lynch et al. 200 4B argava ert al. 2005Lee et al. 2005

Head & Neck 17/10 8 (16 %)1/100 (1 %)

3/41 (7%)

Na et al. 2007Leoffler-Ragg et al.2005Lee et al. 2005

Cholangeocarcinoma 3/22 (14%) Gwak et al. 2005

A cute A dult Leukaemia 0/ 88 Lee et al. 2005

Gastric 0/1 85 Lee et al. 2005

Other 9/566 (2 %) S ihto et al. 2005

Incidence of Kinase Mutations in Other Tumour T ypes


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Current receptor inhibitors

Monoclonalantibodies

S mall moleculeRTK inhibitors


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K

R

K

R

K

Tumor res p onseTumor res p onse

Ova ryP rost a te

Lung

Colon

Ga stric

Bre a st

m A bm A b

S m a ll mol.S m a ll mol.

HER f a mily: ta rgeted app ro a ches

Extern a l dom a inExtern a l dom a in

Intern a l dom a inIntern a l dom a in


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Res p onses in pa tients with or without mut a tions

Howe ver 12.3% of pa tients with mut a tions p rogress on TKIs a nd 86 .8% a chie ving st a ble dise a se p ossess wt EGFR

Pa tients with NS CLC res p onsi ve to gefitinib or erlotininb a re more likely to h a rbour mut a tions th a n

not (76 .7% v s 23 .3% )


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Associ a tion of S ite of Mut a tion a nd S ensiti vity to TKI tre a tment

Riel y et al. Clin Cancer Res 2006 12 72 32

85-90 %Total


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De velo p ment of Drug Resist a nce


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EML4-ALK fusion in N S CLC

N termin a l p ortion of EML4 w a s

fused to the intr a cellul a r kin a se

dom a in of ALK

Both m ap to the short a rm of

chromosome 2 (2p2 1 a nd 2p23

res p ecti vely)

Soda et al. Nature (2007) 448: 561-6


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ALK

ALK is a tyrosin -k in a se rece p tor

ALK is ex p ressed in br a in a nd testis

ALK w a s identified a s a fusion pa rtner of NP M1 in

a n ap la stic la rge -cell lym p hom a with t(2 ;5)

S ince then fusion genes in vol ving ALK h av e been

described in ALCL, infl a mm a tory myofibrobl a stic

tumors a nd neurobl a stom a s


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EML4-ALK

W ild -ty p e ALK is thought to be a cti va ted in res p onse to binding of a s p ecific lig a nd

EML4ALK is oligomerized via the coiled coil dom a in (CC) of EML4

Resulting in p ersistent mitogenic sign a ling th a t le a ds to m a lign a nt tr a nsform a tion.


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Tr a nsforming a bility of EML4-ALK

Exp ression p la smids for EML4 ALK

Introduced it into mouse 3T3 fibrobl a sts

S ubcut a neous injection

of the tr a nsfected 3T3cells into nude mice formed tumors

Soda et al. Nature (2007) 448: 561-6Soda et al. PNAS (2008) 106:19893-7


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Conclusion

EML4- ALK fusion is r a re e vent in NS CLC (5- 10% )

P resent in both Asi a ns a nd North

Americ a n /E uro p e a n p o p ul a tionExclusi ve to NS CLC

More common in ne ver smo kers

ALK inhibitors m a y h av e a role in the tre a tment of NS CLC with EML4- ALK fusion


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CA RCINOMA DELL A MAMMELL A


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Role of HER2 in bre a st c a ncer Role of HER2 in bre a st c a ncer

HER2 gene a m p lific a tion or rece p tor o verex p ression occurs in app roxim a tely 30% of met a st a tic bre a st c a ncers

HER2-p ositi ve tumours a re a ssoci a ted with p oor p rognosis a nd shortened dise a se -free /o ver a ll sur viva l

HER2 rece p tor p ro vides a n extr a cellul a r ta rgetfor no vel a nd s p ecific a ntic a ncer tre a tment


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Tr a nsmembr a ne structure of Tr a nsmembr a ne structure of HER2 monomer HER2 monomer

Extr a cellul a r dom a in(632 a mino a cids)Lig a nd -binding site

Intr a cellul a r dom a in(580 a mino a cids)Tyrosine kin a se a cti vity

Tr a nsmembr a ne dom a in(22 a mino a cids)

Cyto p la sm

P la sm amembr a ne


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Indic a tors of incre a sed HER2 p roductionIndic a tors of incre a sed HER2 p roduction

Am p lific a tion /o verex p ression

1

2

3

4

1 = o gene co p y number 2 = o m RN A tr a nscri p tion3 = o cell surf a ce rece p tor p rotein ex p ression4 = o rele a se of rece p tor extr a cellul a r dom a in

A = HER2 DN AB = HER2 RN AC = HER2 rece p tor p rotein

Norm a l

Nucleus

Cyto p la sm

Cyto p la smicmembr a ne

C

B

A


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HER2 technic a l app ro a chesHER2 technic a l app ro a ches

Gene a m p lific a tion

FISH/ CISH

P rotein o ver -ex p ression

immunohistochemistry


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HER2HER2--p ositi ve IHC st a inp ositi ve IHC st a in

2+ 3+3+0 1+


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Du a lDu a l--color FISHcolor FISH


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No a m p lific a tion Am p lific a tionAm p lific a tion

HER2 a m p lific a tion by FISHHER2 a m p lific a tion by FISH


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Her2 testing algorithmHer2 testing algorithm

Pa tient tumour s a m p le

IHC FISH

2+ 3+ +

Retest withFISH

Tr a stuzum a bTr a stuzum a bther ap yther ap y


+



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Tr a stuzum a b: Tr a stuzum a b: hum a nised a ntihum a nised a nti --HER2 monoclon a l a ntibodyHER2 monoclon a l a ntibody

B ersaglio : loncoproteina HER2

A lta affinita (Kd=0.1nM )

e specificita

95 % umano , 5% murino D iminuito potenziale

immunogeno A umentato potenziale per

arruolare meccanismieffettori immuni


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P iccole molecole a d a tti vit a nti -tirosinchin a si che blocc a HER 1 ed HER2


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Erlotinib Gefitinib Lapa tinib

S mall head group quinazolines Large head group quinazoline

Inibitori tirosin -chin a sici

NN

O O

NH

O ON

O

NN

O O

NH

Cl F

NH

S

O

NN

NH

Cl

OO

O

F


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70-80% s p or a dici

15-20% f a mili a ri

5-10% eredit a ri

Bre a st Ca ncer Bre a st Ca ncer


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Condizione di p redis p osizione eredit a ria :

p i c a si di c a rcinom a a lla m a mmell a in pa renti di p rimo gr a do

so p r a ttutto in gio va ne et o con un coin volgimento di

entr a mbe le m a mmelle

c a rcinom a dell o va io in f a mili a ri di p rimo gr a do

c a si di c a rcinom a dell a m a mmell a m a schile (BRCA2)

TUMORE DELL A MAMMELL A FAMILIARE


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Nel 1 994- 1995 sono st a ti identific a ti duegeni res p ons a bili dell a suscettibilit a lc a ncro dell a m a mmell a : BRCA1, sulcromosom a 17, e B RCA2 sul cromosom a13.

Gli indi vidui p ort a tori di mut a zioni a c a ricodi uno dei due geni h a nno un rischiom a ggiore di insorgenz a di tumore a llam a mmell a o tumore o va rico a d un certo

p unto dell a loro vita .

TUMORE DELL A MAMMELL A FAMILIARE


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inibiscono l a crescit a delle ghi a ndole m a mm a rie

inter a giscono con le p roteine RAD (p roteine del ri pa ro)

regol a no l atti vit di a ltri geni (p2 1) (p rotein a regol a trice dell atr a scrizione del DNA

gioc a no un ruolo fond a ment a le nell embriogenesi

BRCA1 /BRCA 2

FUNZIONI

B RCA1 (17q2 1) e B RCA2 (13q 12) sono colleg a te ed integr a te in a lcuni

fond a ment a li pa thw a y di ris p ost a a l da nno del DNA.

ON COSOPPRESSORI


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S ono st a te identific a te oltre 600 mut a zioni (p roteinetronche, in a tti va zione genic a ) in B RCA1 e B RCA2

BRCA1 /BRCA2

ANALISI MUT AZION ALE DI TUTT A LA SEQUENZ A GENI CA

BRCA1: 24 esoni (ATG in ex 2)

BRCA2: 27 esoni (ATG in ex 2)

Test di a gnostico:

Ca m p ione di P B

BRCA1 /17q2 1BRCA1 /17q2 1


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BRCA1 /17q2 1BRCA1 /17q2 1

BRCA2/13q 12BRCA2/13q 12


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P edigree of a f a mily with germline BRCA2: 6503 del TT mut a tion

f ather mother

proband

BRCA2 mut


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Clinic a l P resent a tion

Ea rlier th a n av er a ge a ge of onset me a n 45

Pa ttern of p rim a ry c a ncers segreg a ting in f a milyDistinguishing pa thologic a l fea tures

CRC usu a lly in vol ves the p roxim a l colon

Incre a sed incidence of synchronous a nd met a chronous C RC

S ur viva l r a te for C RC app e a rs better th a n th a t of i t s s p or a dicva ria nt

Extr a colonic c a ncers (Lynch II)

HNP CC: CARCINOM A DEL COLON .-RETTO F AMILIARE NONPOLIPOSI CO


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Pa thology

P oorly differenti a ted, mucinous a nd incre a sed incidence of signet

cells

Dip loid, p eritumor a l lym p hocyte infiltr a tion a nd Crohn s li ke re a ction

Adenom a s found in 20% of colons in HNP CC pa tients with C RC

Colonic a denom a s tend to occur e a rlier, a re l a rger a nd more often

villous with more high gr a de dys p la si a

Acceler a ted r a te of a denom a to c a rcinom a

HNP CC: CARCINOM A DEL COLON-RETTO F AMILIARE NONPOLIPOSI CO


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1. Ep itelio p rolifer a nte mut a zioni in A P C

Cromosom a 5

Le cellule e p iteli a li sfuggono pa rzi a lmente a l controllo del

ciclo cellul a re

Le cellule si di vidono p er form a re un p iccolo cluster che

p ort a a d un p oli p oGli indi vidui eterozigoti ne form a no d a 100 a 1000

FAP : Fa mili a l Adenom a tous P oly p osis

2. Adenom a intermedio - Mut a zioni dell oncogene r a s

Cromosom a 12

Crescit a m a ggiore e p rotrusioni a form a di dit a

3. Adenom a ava nz a to D CC /18q - deleted in colon c a ncer

4. Adenoc a rcinom a - P erdit a o in a tti va zione di TP53/ 17p 13


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MODELLO MULTI-HIT


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GENI DI RISPOST A AL D ANNO DEL DN A

Ripa r a no i d a nni del DNA

La p erdit a dell a loro funzione determin a laccumulo di mut a zioni in a ltri geni cruci a li

Consider a ti un gru pp o di GENI SOPPRESSORI

HNP CC: CARCINOM A DEL COLON .-RETTO F AMILIARE NONPOLIPOSI CO

Germline mut a tion in DNA mism a tch re pa ir genes resulting in

micros a tellite inst a bility

Inherited in A D m a nner

Accounts for 1 -3% of a ll c a ses of C RC (b a sed on detection of

germline mut a tions)


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HNP CC


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Micros a tellite Inst a bility Pa thw a y

Va rious re pa ir mech a nisms a re ava ila ble to correct a ny errors occurring

during DNA re p lic a tion

One ty p e of error c a lled sli ppa ge c an occur during the re p lic a tion of

micros a tellite se q uences by DNA p olymer a se

Micros a tellite DNA se q uences a re defined a s short dinucleotide or

mononucleotide re p e a ts

These se q uences a re usu a lly within non coding regions a lthough some

genes cont a in micros a tellites within coding regions (e.g., TGF- rece p tor

II, Insulin li ke growth f a ctor II rece p tor, regul a tors of the cell cycle e.g.

E2F4 , regul a tors of ap o p tosis e.g.B AX

a nd e ven the MMR genesthemsel ves )


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Ea rly di a gnosis of heredit a ry of colorect a l c a ncer

AP C mut a tions MLH1(51%), MSH6(45% )MSH2 , PMS 1 a nd PMS2(3% ) mut a tions

Familial adenomatous pol yposis Hereditar y non-pol yposis colon cancer

>25 : a nnu a l colonsco p y

>35 : a nnu a l colonsco p y, CA -125 , gynecologicex a min a tion, tr a ns va gin a l ultr a sonogr ap hy

>45 : BSO ( bil a ter a l s a lp ingo -oo p horectomy)p refer a bly with LAVH (lapa rosco p ic tr a ns -va gin a l histerectomy)

>1 5: a nnu a l colonsco p y

>25 : a nnu a l upp er g a strointestin a lendosco p ies

No s p ecific a d vice for a slithly higher ris k of he pa tobl a stom a ( in childhood) a nd pap illa rythyroid c a ncer (in young women)

6a. Tumori Solidi

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