ca breast molecular biology
TRANSCRIPT
CA BREAST MOLECULAR BIOLOGY AND PATHOLOGY
DR SUHAS K R
Introduction • Breast cancer - extremely heterogeneous disease caused by
interactions of both inherited and environmental risk factors • Progressive accumulation of genetic and epigenetic changes
in breast cancer cells• Tumors with similar clinical and pathological presentations
may have different behaviors• Global gene expression profiling (GEP) studies - for
classifying breast cancer into distinct biological classes associated with patient survival, based on gene expression patterns
GENETICS
Genetics • Low penetrance high frequency breast cancer
predisposition genes o FGFR 2, LSP1, TOX3
• Moderate penetrance low frequency breast cancer predisposition genes o CHEK 2 ,BRIP1, ATM , PALB2
• High penetrance low frequency breast cancer predisposition genes o BRCA1, BRCA 2, TP53, PTEN, CDH 1, STK11/LKB1
BRCA -1Breast Cancer 1,Early onset ( Chr.17)
BRCA-2, Breast Cancer 2,Early onset( Chr.13)
p53( Chr.17) CHEK2( Chr. 22)
FUNCTIONS:1. Transcription2. DNA Repair
of double stranded breaks
3. Ubiquitination
4. Transcriptional regulation.
FUNCTIONS:1. Stability of
the human genome
2. DNA double strand break repair.
FUNCTIONS1. Cell cycle
control2. DNA
replication3. DNA repair4. Apoptosis.
FUNCTIONS1. Cell cycle
checkpoint kinase, recognition and repair of DNA damage.
2. Activates BRCA1 and p53 by phosphorylation
Germline point mutations/Deletions of BRCA1 gene Hereditary breast & ovarian cancers.
Mutations 20% Hereditary breast cancer, ovarian cancer, increased cancer risk in male carriers.
Mutations Sporadic breast cancers. Li fraumeni syndrome
Mutations - rare (<5%). Li fraumeni variantIncrease breast cancer risk after radiation exposure
Differential Chemotherapeutic Sensitivity for Breast Tumors With
BRCA• BRCA1 and BRCA2 germline mutations have an important role in
DSB repair of DNA
• Defective BRCA1 or BRCA2 functions and subsequently impair DNA repair capacity
• Differentially more sensitive to DNA-damaging chemotherapeutic agents
• Resistant to taxanes
PATHOGENESIS – HORMONAL FACTORS
• Hormones breast growth during puberty, menstrual cycles, pregnancy cycles of proliferation cells at risk for DNA damage.
• If premalignant or malignant cells are present, hormones - stimulate their growth + growth of normal epithelial and stromal cells tumour development.
• Metabolites of estrogen mutations / generate DNA-damaging free radicals.
CLASSIFICATION – BREAST CARCINOMA
NON-INVASIVE/IN SITU CARCINOMA
Intraductal carcinoma Lobular carcinoma in
situ
INVASIVE CARCINOMA
Infiltrating ( invasive ) duct carcinoma – NOS
Infiltrating ( invasive ) lobular carcinoma
Medullary carcinoma
Colloid (mucinous) carcinoma Papillary carcinoma Tubular carcinoma Adenoid cystic carcinoma Secretory carcinoma Inflammatory carcinoma Carcinoma with
metaplasia
PAGET’S DISEASE OF THE NIPPLE
DUCTAL CARCINOMA IN SITUMost DCIS detected by
calcifications on mammography/mammographic density - periductal fibrosis surrounding a DCIS/rarely palpable mass/ nipple discharge/incidental finding on a biopsy for another lesion.
Spreads through ducts & lobules extensive lesions entire sector of a breast.
DCIS – involves lobules – acini distorted, unfolded appear as small ducts.
DCIS – 5 Architectural subtypes
CRIBRIFORM
COMEDO CARCINOMA
PAPILLARY
MICROPAPILLARY
SOLID
ComedocarcinomaSolid sheets of pleomorphic
cells with high grade hyperchromatic nuclei.
Areas of central necrosis +nt.
Necrotic cell membranes – calcify clusters/linear & branching microcalcifications on mammography.
Periductal concentric fibrosis & chronic inflammation.
Extensive lesions – palpable as vague nodularity.
Noncomedo DCISMonomorphic cell population –
nuclear grades low to high.CRIBRIFORM DCIS Intra-epithelial spaces –evenly
distributed, regular in shape.
COOKIE CUTTER – LIKE
• SOLID DCIS Completely fills the involved
spaces.
Noncomedo DCISPAPILLARY DCIS Grows into spaces along
fibrovascular cores lack myoepithelial cell layer.
• MICROPAPILLARY DCIS Bulbous protrusions without a
fibrovascular core arranged in complex intraductal patterns.
Calcifications – assoc.with necrosis/form on intraluminal secretions.
PAGET’S DISEASE OF NIPPLE• Malignant cells/PAGET
CELLS Extend from DCIS within ductal system – via lactiferous sinuses nipple skin without crossing the BM.
• Tumour cells – disrupt tight squamous epithelial barrier – ECF seeps out onto nipple surface oozing scaly crust.
• Paget’s cells – detected by nipple Bx/cytological preparation of the exudate.
• Poorly differentiated, ER Negative, HER2/neu overexpression.
• Prognosis – depends on features of underlying Ca.
PAGET’S DISEASE OF NIPPLE
MANAGEMENT AND PROGNOSIS OF DCISMajor risk factors for recurrence:1. Grade2. Size3. Margins
In ER + ve DCIS Post-op. radiation + Tamoxifen recurrence risk – low.
LOBULAR CARCINOMA IN SITUIncidental biopsy finding -no
calcifications /stromal reactions mammographic densities.
Bilateral - 20% to 40% .
Young women.
Loss of expression of E-cadherin(transmembrane cell adhesion protein cohesion of normal breast epithelial cells).
LOBULAR CARCINOMA IN SITU - MORPHOLOGY• Dyscohesive round cells
with oval or round nuclei and small nucleoli. Absence of atypia, pleomorphism, mitoti activity, necrosis.
Involved acini – recognizable as lobules.
Mucin-positive signet-ring cells.
ER and PR +ve.
Invasive Carcinoma, No Special Type (NST; Invasive
Ductal Carcinoma)Majority (70% to 80%).
Gross appearance: Most tumors - firm to hard ,irregular border . Less frequently - well-circumscribed border , softer consistency.
When cut / scraped characteristic grating sound d/t small, central pinpoint foci or streaks of chalky-white elastotic stroma and occasional small foci of calcification.
Invasive Carcinoma – NST- HPE
Features Well diff. Ca Mod. diff.Ca Poorly diff. Ca.Tubule
formationProminent Less,solid
clusters/single infiltrating cells
Ragged nests/solid
sheets of cellsNuclei Small,round,mo
nomorphicGreater nuclear pleomorphism
Nuclei – enlarged,irregul
ar.Mitotic figures Rare Present NumerousProliferation
rate- - High
Tumour necrosis - - Present
INVASIVE LOBULAR CARCINOMAWell-differentiated and
moderately differentiated carcinomas diploid, ER positive, HER2/neu overexpression - rare
Poorly differentiated carcinomas aneuploid, lack hormone receptors, may overexpress HER2/neu.
Different pattern of metastasis than other breast cancers. Metastasis peritoneum ,retroperitoneum, the leptomeninges (carcinoma meningitis), the gastrointestinal tract, ovaries and uterus.
MEDULLARY CARCINOMAMC - 6th decade.
May closely mimic a benign lesion clinically and radiologically/ present as a rapidly growing mass.
MORPHOLOGY : Well – circumscribed,soft,fleshy mass - little desmoplasia more yielding on palpation and cutting. (medulla =>“marrow”).
MEDULLARY CARCINOMA - HPE1. Solid, syncytium-like sheets of
large cells with vesicular, pleomorphic nuclei, prominent nucleoli > 75% of the tumor
2. Frequent mitotic figures; 3. Moderate to marked
lymphoplasmacytic infiltrate surrounding and within the tumor.
4. Pushing (noninfiltrative) border• Poorly differentiated.
MEDULLARY CARCINOMAHigh nuclear grade, aneuploidy,
hormone receptors - nt, HER2/neu overexpression –nt.
Lymph node metastases -
infrequent.
Syncytial growth pattern and pushing borders - d/t overexpression of adhesion molecules intercellular cell adhesion molecule and E-cadherin limit metastatic potential.
MUCINOUS/COLLOID CARCINOMA
Older women (median age 71) grow slowly - many years.
Morphology: Tumor – soft/rubbery . Consistency & appearance of pale gray-blue gelatin. Borders - pushing / circumscribed.
MUCINOUS CARCINOMA - HPETumor cells - arranged in
clusters and small islands within large lakes of mucin.
Mucinous carcinomas diploid, well to moderately differentiated, and ER positive.
Lymph node metastases - uncommon.
Overall prognosis is slightly better.
INVASIVE PAPILLARY & MICROPAPILLARY CARCINOMA
Rare - 1% or fewer of all invasive cancers.
More commonly seen in DCIS.INVASIVE PAPILLARY CA.ER positive.Favorable prognosis. INVASIVE MICROPAPILLARY
CA.ER negative,HER2 positive. Lymph node metastases - very
commonPrognosis is poor.
METAPLASTIC CARCINOMA Includes a variety of rare types of
breast cancer (<1% of all cases) matrix-producing carcinomas, squamous cell carcinomas, and carcinomas with a prominent spindle cell component.
ER-PR-HER2/neu “triple negative”.
Lymph node metastases - infrequent.
Prognosis - poor.
TUBULAR CARCINOMA• Uncommon.
• Morphology: Well-formed tubules + nt, myoepithelial cell layer, BM - nt tumor cells in direct contact with the stroma. Apocrine snouts - typical.Calcifications - within the lumens.
• > 95% of all tubular carcinomas - diploid, ER + ve,HER2/neu –ve .
• Well differentiated. Excellent prognosis.
INFLAMMATORY CARCINOMATumors swollen,
erythematous breast - caused by extensive invasion and obstruction of dermal lymphatics by tumor cells.
Underlying carcinoma - diffusely infiltrative - does not form a discrete palpable mass confusion with true inflammatory conditions a delay in diagnosis.
Many patients metastases at diagnosis / recur rapidly.
Overall prognosis poor.
Disease patterns in ER +ve
• Have better outcomes
• Potential for recurrence over a long period (half recurrences in between 6 to 15 years )
• Better survival even in a recurrence or a metastatic setting
• predilection for osseous metastasis – women who relapse after a decade do so in bones in majority of cases
Impact of histology • Invasive ductal vs invasive lobular • Invasive lobular associated with older age at presentation ,
larger tumors of lower grade with less LVI • ILC more likely to be bilateral and multicentric and
exclusively ER PR positive and HER 2 negative• ILC tend to be mammographically occult • ILC more likely to involve bone, ovary and the body cavities • Rare sites like skin, adrenal, GB, pancreas more often with ILC Loss of
CDH
Impact of histolgy
HER2/neu• Human Epidermal growth factor Receptor 2
• Member of ErbB protein family.
• HER2 is a cell membrane surface-bound receptor tyrosine kinase - normally involved in signal transduction pathways cell growth and differentiation.
• Approximately 30 % of breast cancers amplification of the HER2/neu gene/ overexpression of its protein product.
HER 2 status • More likely to be detected symptomatically • Younger age, high nuclear grade, more LN and negative
hormone status • Inferior OS • Following BCS locoregional recurrence rates are higher and
re excision rates are higher • Distant mets to liver and lungs • CNS acts as a sanctuary site present in more than 50 %
with mets
Triple negative status • 15% of the breast cancers • Relatively younger population • Larger tumors, mostly grade 3, aggressive phenotype,
less likely to have lymph nodes • Overall poorer prognosis • OS from diagnosis of mets - 7- 12 months • OS from diagnosis of CNS disease - 4 -5 months
Breast cancer subtypes
ER status
Negative
Basal like
Normal like
Positive
Luminal type
Luminal like • ER-positive group - relatively high expression of many
genes expressed by breast luminal cells (ER-responsive genes, luminal cytokeratins and other luminal associated markers)
• Luminal A - 50- 60 % of all breast types
• low histological grade, low degree of nuclear pleomorphism, low mitotic activity (low Ki 67)and include special histological types (i.e., tubular, invasive cribriform, mucinous and lobular) with good prognosis.
• Luminal B 15- 20 % - • increased expression of proliferation-related genes
FGFR1, PI3K
• ER-positive, HER2-negativeand Ki 67 high or ER and HER-2 positive tumors
• more aggressive phenotype, higher histological grade, proliferative index and a worse prognosis
• Ki 67 cut off 14% differentiates the two
Basal like • 8- 37% of all breast cancers • Most of these tumors are infiltrating ductal tumors with
solid growth pattern, aggressive clinical behavior and high rate of metastasis to the brain and lung
• Express high levels of basal myoepithelial markers, such as CK5, CK 14, CK 17 and laminin, triple-negative.
• They also overexpress P-cadherin, fascin, caveolins 1 and 2, alphabeta crystallin and epidermal growth factor receptor (EGFR).
Basal like • triple-negative and basal-like are not completely
synonymous• frequent mutations in the tumor protein 53 (TP53)
gene, retinoblastoma (Rb)
• constitute approximately three quarters of breast
cancer 1 (BRCA1) gene related breast cancers.
Normal breast-like• 5%-10% of all breast carcinomas.• clinical significance remains undetermined• negative for CK5 and EGFR otherwise similar to basal
type on expression of various markers • intermediate prognosis between luminal and basal-like
cancers and usually do not respond to neoadjuvant chemotherapy
TNBC status• Higher loco regional recurrence rates • Significant excess visceral involvement – pulmonary
and CNS • metastatic TNBC - 33- 46 % CNS • Rarely there is a recurrence after 5 years compared to
other subtypes with recurrence even at 17 years • Triple-negative breast cancer is highly responsive to
primary anthracycline and anthracycline/taxane chemotherapy
• A more profound initial response to chemotherapy compared with other phenotypes despite poorer overall survival
CLINICAL GENE EXPRESSION BASEDASSAYS
• PAM 50 –
• a 50 gene expression assay based on microarray and quantitative real time (qRT)-PCR
• provide a risk of relapse score that predicts relapse-free survival for node-negative breast cancer patients who had not received adjuvant systemic therapy
MammaPrint• a microarray based gene expression profiling
assay• The genes that comprise the MammaPrint assay
are proliferation genes and genes associated with invasion and angiogenesis
• 70-gene signature• Stage Ⅰ/Ⅱ, 5 cm, ER (+), Node (-)/[1-3 Node (+)]• FDA approved - Yes
Oncotype DX• most widely used prognostic and predictive• 21 gene qRT-PCR based assay• hormone receptor positive, node-negative breast cancer• 21 selected genes essentially related to proliferation, ERand
HER2 signaling • absolute clinical benefit of adjuvant chemotherapy in lymph
node negative (N-) breast cancer is modest, estimated absolute benefit of 4% in terms of 10-year distant recurrence
• The Trial Assigning IndividuaLized Options for Treatment (Rx)
• GENOMIC GRADE INDEX
• MapquantDx is defines the tumoral histological grade by gene expression features, used to assign a grade index to ER-positive breast cancers in attempt to refine their molecular classification.
• to classify grade 2 tumors into low and high genomic grades
• BREAST CANCER INDEX• the likelihood of distant recurrences in patients diagnosed with
ER-positive, node-negative breast cancer.
THERAPEUTIC TARGETS
Therapeutic targets • Estrogen signalling - therapeutic success story • SERMs, aromatose inhibitors and ovarian ablation • Highly effective and have a made a significant impact
on breast cancer mortality and morbidity • Oncotype DX - adds additional insight
Growth factor receptor pathways
• HER2 (EGFR 2 or Erb2 ) - • HER2 amplification is associated with deregulation of
G1/S phase cell cycle control via up-regulation of cyclins D1, E, and cdk6, as well as p27 degradation
Trastuzumab- • disrupts heterodimeric interaction of HER2 with other
EGFR family members• modulate host immunity, activating natural killer cells
involved in antibody-dependent cellular cytotoxicity• decrease tumor-associated microvessel density
• Lapatinib - inhibits tyrosine phosphorylation of both EGFR and HER 2 which in turn inhibits the activation of proproliferative kinases ERK1/2 and AKT
• IGF – 1R - primary response mediator for IGF
• PI3-K Pathway – central signalling pathway downstream of tyrosine kinases and regulates cell growth and proliferation
Rapamycin - m TOR inhibitors
Raf inhibitor - sorafenib
Angiogenesis • VEGFR 2 mediates most of the functions• Bevacizumab - humanized monoclonal antibody • First line metastatic setting Multi targeted agents Sunitinib - VEGFR, PDGFR and c- kit Sorafenib - VEGFR, RAF kinase
Summary • The histological appearance of the tumors may not be
sufficient to establish the underlying complex genetic alterations and the biological events involved in cancer development and progression
• Defining more detailed biological characteristics to improve patient risk stratification and to ensure the highest chance of benefit and the least toxicity from a specific treatment modality
Thank you