Maria Chiara Zatelli Sezione di Endocrinologia Dip. di Scienze Biomediche e Terapie Avanzate...
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Transcript of Maria Chiara Zatelli Sezione di Endocrinologia Dip. di Scienze Biomediche e Terapie Avanzate...
Maria Chiara ZatelliMaria Chiara ZatelliSezione di EndocrinologiaSezione di Endocrinologia
Dip. di Scienze Biomediche e Terapie AvanzateDip. di Scienze Biomediche e Terapie Avanzate Università di FerraraUniversità di Ferrara
Direttore: Prof. Ettore degli UbertiDirettore: Prof. Ettore degli Uberti
Analisi genetica del nodulo Analisi genetica del nodulo tiroideo:tiroideo:
implicazioni per l’esecuzione del implicazioni per l’esecuzione del linfonodo sentinellalinfonodo sentinella
Ferrara, 20 gennaio 2012Ferrara, 20 gennaio 2012
……molecular marker…?molecular marker…?
……a molecular marker (genetic marker) is a DNA a molecular marker (genetic marker) is a DNA sequence associated to a part of the genome, used in sequence associated to a part of the genome, used in molecular biology and biotechnology experiments to molecular biology and biotechnology experiments to identify a very highly specific DNA sequence…identify a very highly specific DNA sequence…
What relevance in thyroid nodules?What relevance in thyroid nodules?
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Fine-needle aspiration biopsy (FNAB) is Fine-needle aspiration biopsy (FNAB) is currently the most sensitive and specific currently the most sensitive and specific
tool tool for the presurgical differential diagnosis of for the presurgical differential diagnosis of
thyroid malignancythyroid malignancy
butbut
has also substantial limitationshas also substantial limitationsEszlinger et al. Mol Cell Endocrinol 2010;322:29
thyroid surgerythyroid surgery
75% benign 75% benign lesions lesions
5% malignant 5% malignant lesionslesions
20% follicular proliferation 20% follicular proliferation
FAFA FTCFTC fvPTCfvPTC
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
MOLECULAR BIOLOGYMOLECULAR BIOLOGY
study of biology at molecular levelstudy of biology at molecular level
pathologypathology
Does it improve Does it improve cytological fine needle cytological fine needle aspiration diagnosis of aspiration diagnosis of thyroid nodules?thyroid nodules?
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
RNARNA DNADNA
cytologycytology
somatic somatic mutation mutation analysisanalysis
rearrangemenrearrangement studiest studies
BRAFBRAFN-RASN-RASH-RAS H-RAS K-RASK-RAS
RET/PTC1 RET/PTC1 RET/PTC3 RET/PTC3
PPARPPAR/PAX8/PAX8
Highly feasible Highly feasible in clinical in clinical settingssettings
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
PAPILLARY CARCINOMAPAPILLARY CARCINOMA
DNADNA
BRAF V600E point mutationBRAF V600E point mutation
[K601E and V599Ins][K601E and V599Ins]
45-80% of PTC, mainly tall cell and 45-80% of PTC, mainly tall cell and classic hystology classic hystology
extrathyroidal invasion extrathyroidal invasion
higher stagehigher stage
recurrence (with reduced I up-take)recurrence (with reduced I up-take)
de-differentiationde-differentiation
resticted to PTCresticted to PTCNikiforova et al. Exp Rev Mol Diagn 2008, 8: 83
Lupi et al. J Clin Endocrinol Metab. 2007;92:4085
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
• do they improve diagnosis?do they improve diagnosis?genetic tests genetic tests
Kim et al. J Clin Endocrinol Metab, 2011, 96:658
BRAFV600E BRAFV600E molecular molecular
testtestCytologyCytology BRAFBRAF Cytology + BRAFCytology + BRAF
SensitivitySensitivity 100100 77.377.3 89.689.6 64.064.0 89.689.6 86.786.7
SpecificitySpecificity 36.436.4 98.898.8 95.595.5 100100 95.595.5 98.898.8
PPVPPV 92.992.9 92.192.1 99.499.4 100100 99.499.4 92.992.9
NPVNPV 100100 95.995.9 52.552.5 93.793.7 52.552.5 97.597.5
AccuracyAccuracy 93.393.3 95.495.4 90.290.2 95.495.4 90.290.2 96.996.9
K valueK value 0.510.51±±0.0.1111
0.810.81±±0.00.022
0.630.63±±0.00.077
0.760.76±±0.00.055
0.630.63±±0.00.077
0.880.88±±0.010.01
Zatelli et al . Eur J Endocrinol 2009, 161:467
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Kim et al. J Clin Endocrinol Metab, 2011, 96:658
• do they improve diagnosis?do they improve diagnosis?genetic tests genetic tests
BRAFV600E BRAFV600E molecular testmolecular test
BRAF mutation analysis BRAF mutation analysis may help especially in may help especially in
small nodulessmall nodulesEFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Section of EndocrinologySection of EndocrinologyUniversity of FerraraUniversity of Ferrara
(1436 (1436 ♀♀; ; 420420 ♂♂))age 52 age 52 ±± 0,32 (12-73) 0,32 (12-73)
2421 FNAs2421 FNAs
Biomolecular Biomolecular analysisanalysis
PathologyPathology
US & clinical evaluationUS & clinical evaluation
1856 pz1856 pz
suspected: 829suspected: 829
NON suspected: 1529NON suspected: 1529
BRAFV600E BRAFV600E molecular molecular
testtest
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
cytologycytology SS %% NSNS %%
tottot 829829 34,234,2 15921592 65,765,7
Malignant Malignant raterate 115115 13,913,9 103103 6,56,5
PTC/PTC/malignantmalignant 112112 97,497,4 9898 95,195,1
BRAF +BRAF + 6464 7,77,7 5050 3,13,1
BRAF +/BRAF +/MalignantMalignant
64/1164/1155
55,755,7 50/10350/103 48,548,5
FNAB per se detects FNAB per se detects a high percentage of a high percentage of malignant lesions in malignant lesions in unsuspected nodulesunsuspected nodules
Martina Rossi et al. submitted
All nodules should undergo FNABAll nodules should undergo FNAB
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
BRAFV600E BRAFV600E molecular testmolecular test CytologyCytology BRAFBRAF Cytology + Cytology +
BRAFBRAF
SS NSNS SS NSNS SS NSNS
SensitivitySensitivity 76,76,88
69,469,4 56,656,6 5151 92,92,99
84,784,7
SpecificitySpecificity 99,99,77
99,999,9 100100 100100 99,99,77
99,999,9
PPVPPV 97,97,77
98,698,6 100100 100100 98,98,11
98,898,8
NPVNPV 96,96,55
9898 93,693,6 96,996,9 98,98,99
9999
AccuracyAccuracy 96,96,66
98,198,1 94,194,1 9797 98,98,88
9999
BRAF testing BRAF testing
significantly significantly
increases FNAB increases FNAB
sensitivity also in sensitivity also in
nodules clinically nodules clinically
non suspectednon suspected
BRAFV600E molecular test increases BRAFV600E molecular test increases diagnostic sensitivity for PTCdiagnostic sensitivity for PTC
15 PTC patients “rescued” 15 PTC patients “rescued” by BRAF analysisby BRAF analysis
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Martina Rossi et al . submitted
BRAFV600E BRAFV600E molecular molecular testtest
SS %% NSNS %%
ACUSACUS 2266
3,13,1 7878 4,94,9
PTCPTC 66 75,075,0 1010 37,37,00
BRAF +BRAF + 55 19,219,2 00 0,00,0
FNFN 3355
4,24,2 6262 1,21,2
PTCPTC 55 25,025,0 9923,23,77
BRAF +BRAF + 22 5,75,7 66 9,79,7
BRAF testing identifies BRAF testing identifies
as malignant 10% of FNas malignant 10% of FN
Indication to total Indication to total thyroidectomythyroidectomy
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Martina Rossi et al . submitted
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Thyroid molecular markers increase Thyroid molecular markers increase diagnostic sensitivity of cytology for diagnostic sensitivity of cytology for
PTCPTCandand
influence surgical approachinfluence surgical approach
CONCLUSION -1CONCLUSION -1
• any prognostic any prognostic value?value?
genetic tests genetic tests
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Xing et al. J Clin Oncol. 2009;27:2977-82
BRAFV600E BRAFV600E molecular testmolecular test
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
BRAFV600E BRAFV600E molecular testmolecular test
PTCPTCpersistence/recurrence predictionpersistence/recurrence prediction
All PTCAll PTC Conventional Conventional PTCPTC
sensitivity sensitivity 68%68% 79%79%
specificity specificity 66%66% 60%60%
PPVPPV 36%36% 34%34%
NPVNPV 88%88% 92%92%Xing et al. J Clin Oncol 2009; 27:2977-82
BRAF mutation–positive patients BRAF mutation–positive patients are are significantly more likely to have PTC significantly more likely to have PTC
persistence/recurrencepersistence/recurrence
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
significantly reduced disease-free probability significantly reduced disease-free probability in BRAF+ patientsin BRAF+ patients
Xing et al. J Clin Oncol. 2009;27:2977-82
BRAF V600E genetic testBRAF V600E genetic test
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
significantly increased mortalitysignificantly increased mortalityin BRAF+ patientsin BRAF+ patients
Elisei et al. J Clin Endocrinol Metab. 2008;93:3943
BRAF V600E genetic testBRAF V600E genetic test
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Thyroid molecular markers may predict Thyroid molecular markers may predict patients outcomepatients outcome
CONCLUSION -2CONCLUSION -2
• any surgical any surgical relevance ?relevance ?
genetic tests genetic tests
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
BRAF mutationBRAF mutation
0
10
20
30
40
50
60
BRAF (+)34
BRAF (-)69
n.
of
PTC
LN met (+) LN met (-)
20/26 BRAF+ LN
is a significant risk is a significant risk factor for locoregional factor for locoregional lymph node metastasislymph node metastasis
Kim et al. Ann Surg 2006;244: 799
is not necessary for is not necessary for locoregional lymph node locoregional lymph node
metastasismetastasis
lymph node metastases lymph node metastases may show may show de novode novo
mutationsmutations
Vasko et al. J Clin Endocrinol Metab 2005; 90: 5265
103 PTC
!! also in microPTC !!!! also in microPTC !!Lin et al. Ann Surg Oncol 2010;17:3294
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
extrathyroidal invasionextrathyroidal invasionlymph node lymph node metastasismetastasis
local neck recurrence local neck recurrence PTC recurrencePTC recurrencecomplicationscomplications
surgical strategysurgical strategylobectomylobectomy
total thyroidectomytotal thyroidectomy
lymph node dissectionlymph node dissection no dissectionno dissection
BRAF mutationBRAF mutation
High prognostic impactHigh prognostic impact
Xing Endocrine Reviews 2007; 28: 742
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
BRAF mutationBRAF mutation
Indication for sentinel lymphnodeIndication for sentinel lymphnode
Yip et al Surgery 2009; 146: 1215
PREDICTOR OF LYMPHNODE METASTASESPREDICTOR OF LYMPHNODE METASTASES
decision decision makingmaking
BRAFV600E BRAFV600E molecular testmolecular test more aggressive more aggressive
surgerysurgery
neck lymph node neck lymph node dissectiondissection
less less aggressive aggressive
surgerysurgery
+-
BRAF mutation-basedBRAF mutation-based
risk stratificationrisk stratification
PTC managementPTC management
Xing et al. J Clin Oncol. 2009;27:2977-82
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
Positivity of thyroid molecular markers Positivity of thyroid molecular markers as indication for sentinel lymphnode as indication for sentinel lymphnode
procedureprocedure
CONCLUSION -3CONCLUSION -3
May address patients with May address patients with
persistent/recurrent disease persistent/recurrent disease
to therapy withto therapy with
BRAF-specific inhibitorsBRAF-specific inhibitors
Cantwell-Dorris et al. Mol Cancer Ther 2011, 10: 385
BRAF V600E genetic testBRAF V600E genetic test
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
EFE 2012EFE 2012
Thyroid molecular markers & sentinel lymphnodeThyroid molecular markers & sentinel lymphnode
CONCLUSIONSCONCLUSIONS
increase cytology diagnostic sensitivity for PTC increase cytology diagnostic sensitivity for PTC
may predict patients outcomemay predict patients outcome
influence surgical approachinfluence surgical approach
their positivity is an indication for sentinel lymphnode their positivity is an indication for sentinel lymphnode
procedureprocedure
Thyroid molecular markers Thyroid molecular markers
THANKSTHANKS
Ettore degli UbertiEttore degli Uberti
Section of EndocrinologySection of EndocrinologyDept. of Biomedical Sciences and Advanced TherapiesDept. of Biomedical Sciences and Advanced Therapies
University of FerraraUniversity of Ferrara
Laboratorio di Laboratorio di Fisiopatologia Fisiopatologia
EndocrinaEndocrina
Ambulatorio Ambulatorio Ecografia/Ecografia/
AgoaspiratiAgoaspirati
Personale Personale MedicoMedicoTecnicoTecnico
InfermieristicoInfermieristico
Assegnisti di Assegnisti di ricercaricerca
DottorandiDottorandiStudentiStudenti
DegenzaDegenzaDay HospitalDay HospitalAmbulatoriAmbulatori