Rare tumours: some recent data and ideas

Part two – endometriosis associated cancer

David G. HuntsmanBC Cancer Agency Vancouver General Hospital University of British Columbia

Canada Research Chair in Molecular and Genomic Pathology

Clear cell and endometrioid ovarian carcinoma represent around 20% of cases in North America

Treated as one disease despite different clinical presentation and survival

Clinical disease heterogeneity

MP10

In retrospective cohorts expect up to a 20% misclassification in chart based pathology

F Kommoss 2002 << F Kommoss 2014 = B Gilks 2014

<<< =

• 300 cases centrally reviewed in 2002

• Reviewed again by same pathologist using 2014 WHO criteria : 54% concordance

• New histotypes showed 98% concordance with second reviewer and stronger associations with outcome and biomarkers

Impact of histotype changes

Clear cell carcinoma of the ovary

• 2nd most common ovarian carcinoma subtype in NA (12%) and more frequent in Asia

• Do not respond to standard ovarian chemotherapy

• No other treatments available

• May respond to radiotherapy

• Molecular basis little understood

• Weird cousins of renal CCC

ARID1a mutations• Common in OCCC, Endometrioid of ovary and uterus and MSI

positive gastric cancers

• Found in cancer types without tp53 mutations

• Occur in precancerous lesions but may not be initiating events

• Not prognostic

• Apart from association with PIK3Ca mutations no reproducible evidence that ARID1a mutant ovarian cancers are different from non mutant cases of the same type

• Specific targeting of ARID1a mutant cancers has been challenging

ARID1AClear cell ovarian carcinoma

2010 NEJM Wiegand K, et al.; 2010 Science Jones S, et al.

Genomic perspectiveClear cell ovarian carcinoma

ERBB2 overexpressed and amplified Pro-oncogenic/transforming growth factor receptorMET overexpressed and amplified Pro-oncogenic/transforming growth factor receptor

…and more recently highlighted…

2010 GynOnc Anglesio M, et al.

Activated pathways in OCCC

Anglesio et al 2011. Clin Can Res

IL6 STAT3 HIF1A & HIF2A(EPAS1)(activation of hypoxia-related survival pathways)

Elevated levels:IL6(Activated) STAT3(Nuclear) HIF1AHIF2A (EPAS1)

Nuclear HIF1a in OCCC

Genomic disruptionsClear cell ovarian carcinoma

Anglesio 2011

Tan 2011

METERBB2HNF1B

Endometrioid carcinomas

• Almost all are low grade yet some progress to higher grade cancers

• Stage 1 low grade endometrioid carcinomas of ovary have a very good prognosis

• Higher grade endometriod carcinomas and recurrent low grade need new treatment approaches

• POLE mutations in 5% of cases, MSI in >20%

• Beta catenin mutations in 50% of cases

• Often present with synchronous uterine carcinoma

Synchronous uterine and ovarian carcinomas

• Up to 50% of low grade endometrioid carcinomas

• Most are low grade and T1a

• Due to excellent prognosis are considered to be separate primaries

• Genomic and data molecular studies low resolution and interpreted as supporting separate primaries

• Data to be shown non-validated comparisons of somatic mutations

SEO_VAN_65

SEO_TBG_

22

150

125

SEO_VAN_43

SEO_VAN_22

SEO_VAN_27

SEO_VAN_29

SEO_VAN_14

SEO_VAN_54

SEO_TBG_

15

SEO_VAN_58

SEO_VAN_56

SEO_VAN_60

SEO_TBG_

31

SEO_VAN_04

SEO_VAN_07

SEO_VAN_08

SEO_VAN_33

SEO_VAN_40

Endometriosis?

Ovarian

Endometrial

In almost all cases the uterine and ovarian cancers share somatic mutations

Anglesio JNCI 2016

Copy number plots showing clonality

Data and Conclusions • Clonal relationships between the endometrial and

ovarian cancers seen in but one of 20 cases studies so far

• Analysis of endometriosis and normal endometrium should inform whether these are metastatic cancers or whether a mutant field defect leads to both uterine cancer and ovarian cancer through endometriosis

• Are these true metastasis?

Endometriosis: the main risk factor for CCC and ENOC

• First described by Sampson in 1925.

Pearce et al Lancet Oncology 2012

• 13,226 controls, 7,919 cases including 674 CCC and 1220 endometrioid

Are these uterine cancers in the wrong place?

Gounaris et al, J Pathology 2011

MET (HGFR) amplification and overexpression in OCCC?

Fig 1 from Yamamoto et al, 2012. Mod Path

In second study by Yamamoto et al. MET overexpression and copy number changes were also correlated with atypical endometriosis that was synchronous with OCCC

Endometriosis

Adjacent atypicalendometriosis

Regions of endometriosis that are synchronous to OCCC

Features found in OCCC can be found in adjacent endometriosis

H&E IHC CISH

VOA1048Adjacent Atypical Endometriosis vs. OCCC

21

DAH145 - VOA1048 (in some cases the adjacent atypical endometriosis is essentially cancer

22

1:22408228:CDC42:coding:snvs:DAH145

15:100890253:AC015723.8:coding:snvs:DAH145

19:50840381:NAPSB:coding:snvs:DAH145

20:46386033:SULF2:coding:snvs:DAH145

1:6266355:C1orf188:coding:snvs:DAH145

1:29631897:PTPRU:coding:snvs:DAH145

1:46105922:GPBP1L1:coding:snvs:DAH145

1:89523838:GBP1:coding:snvs:DAH145

1:109197458:C1orf59:coding:snvs:DAH145

1:186324779:TPR:coding:snvs:DAH145

2:211085473:ACADL:coding:snvs:DAH145

2:219602546:TTLL4:coding:snvs:DAH145

3:132172461:DNAJC13:coding:snvs:DAH145

3:149700912:C1orf37:coding:snvs:DAH145

3:184580707:VPS8:coding:snvs:DAH145

4:187629068:FAT1:coding:snvs:DAH145

5:524228:SLC9A3:coding:snvs:DAH145

5:127681270:FBN2:coding:snvs:DAH145

5:140615717:PCDHB18:coding:snvs:DAH145

5:168180893:SLIT3:coding:snvs:DAH145

6:7246723:RREB1:coding:snvs:DAH145

6:74073560:OOEP:coding:snvs:DAH145

7:101944369:AC005088.3−2:coding:snvs:DAH145

8:113301714:CSMD3:coding:snvs:DAH145

9:2718192:KCNV2:coding:snvs:DAH145

9:130270400:LRSAM1:coding:snvs:DAH145

10:95069866:MYOF:coding:snvs:DAH145

10:102566211:PAX2:coding:snvs:DAH145

10:104130515:GBF1:coding:snvs:DAH145

11:45907403:CRY2:coding:snvs:DAH145

11:55135884:OR4A15:coding:snvs:DAH145

11:56143251:OR8U8:coding:snvs:DAH145

11:125853858:CDON:coding:snvs:DAH145

12:6078430:VWF:coding:snvs:DAH145

12:57586646:LRP1:coding:snvs:DAH145

12:101682807:UTP20:coding:snvs:DAH145

12:102053560:MYBPC1:coding:snvs:DAH145

13:23906156:SACS:coding:snvs:DAH145

13:73539509:PIBF1:coding:snvs:DAH145

14:92548659:ATXN3:coding:snvs:DAH145

16:4016933:ADCY9:coding:snvs:DAH145

16:22825976:HS3ST2:coding:snvs:DAH145

16:30980953:SETD1A:coding:snvs:DAH145

17:18226316:SHMT1:coding:snvs:DAH145

17:42284886:UBTF:coding:snvs:DAH145

17:68129103:KCNJ16:coding:snvs:DAH145

17:73499325:KIAA0195:coding:snvs:DAH145

18:9859309:RAB31:coding:snvs:DAH145

19:814453:PTBP1:coding:snvs:DAH145

20:25263878:PYGB:coding:snvs:DAH145

22:24829598:ADORA2A:coding:snvs:DAH145

22:37447918:7SK:coding:snvs:DAH145

22:39884587:MGAT3:coding:snvs:DAH145

X:8764386:FAM9A:coding:snvs:DAH145

X:37026831:FAM47C:coding:snvs:DAH145

X:117043429:Y:RNA:coding:snvs:DAH145

X:117540879:WDR44:coding:snvs:DAH145

X:153187162:ARHGAP4:coding:snvs:DAH145

X:153219079:HCFC1:coding:snvs:DAH145

VOA1048.A15

atypical endometriosis−adjacent

VOA1048.A6

Left Ovary CCC

VOA1048.B6

Endometrial Polyp

VOA1048.T

Left Ovary CCC

value

SOMATIC

UNDETERMINED

WILDTYPE

CCC (3a) AT-E-osis (3b) E-osis (3e) E-osis (3f)

Fig 3

A

B

Anglesio J Path 2015

DAH72 – VOA734

24

ARID1A

Conclusions• Adjacent atypical endometriosis can have a near

complete complement of mutations -final transformation events may not be mutations

• So far no explanation for why endometriosis can lead to two such distinct cancers

• Are there more sensitive clonal marks for tracking relatedness

• Is there a screening window ?• What about endometriosis not associated with

cancer?

Deep infiltrating endometriosis

• Will other clinically relevant forms of endometriosis have somatic mutations as have been seen in endometriosis associated with cancer

? Is endometriosis a partially competent neoplasm

Deep Infiltrating Endometriosis“Case 2”

NTC CTRLG12V CTRLCASE2(LCM) NormalTissue

CASE2

Endometriosis (LCM)

KRAS Double-mutation positive

G12V

G12A

WT

Endometriosis, CCOC and ENOCa

?

How do two such different cancers arise from the same precursor?

How do different cancers arise from the same precursor? Do distinct mutations drive distinct oncogenic pathways

?

ENOCA and CCC: commonly mutated genes

Summary of specific genomic findings

• No single feature exclusive to endometrioid or CCC discovered

• No feature seen exclusively in ARID1a wild type cancers seen

• KMT2B (MLL4) the most commonly mutated “new” gene of interest

Landscapes: Can the genomic landscape inform our understanding of the pathogenesis of these cancers

• Higher level view of cancer genome enables identification of signatures that point to mutational process

• ENOCa and CCC compared to GCT and HGSCa

Copy number changes

GCT<<ENOCa<CCC<<HGSCa

Signatures as well as specific mutations track with cancer types

Signatures of mutational processes in human cancers: Alexandrov et al Nature 2014

ENOCA and CCC: genomic landscapes

ENOCA and CCC: genomic landscapes

APOBECMMR AGE

How do different cancers arise from the same precursor?

?

Although differences no mutation is exclusive to these cancer types some landscape features are enriched Cancer associated mutations may precede transformation process (Anglesio)

Cysteine Biosynthetic Pathway

Methionine Homocysteine Cystathionine CysteineCBS

CTH

Glutathione

Higher in clear cell

CCOCENOCHGS

CTH is Highly Expressed in Clear Cell Ovarian Cancer

CTH and CBS Expression in Cell Lines

CTH

CBS

a-Tubulin

A2

78

0

IGR

OV

1

TOV

11

2D

20

08

JHO

C5

JHO

C7

JHO

C9

OV

ISE

OV

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NA

OV

TOKO

RM

G2

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CaO

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Hey

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CA

R 3

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CA

R 4

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R 5

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SAYO

ENOC CCC HGS

Homocysteine Cystathionine CysteineCBS CTH

The Origins of Endometriosis Associated Ovarian Cancer?

Cell of Origin forEndometrioid

Ovarian Cancer?

Cell of Origin forClear Cell

Ovarian Cancer?

CCOC and EndoCa and the ovary• Both cancers are associated with endometriosis

• Although cancer associated mutations occur in endometriosis at other sites, transformation occurs almost exclusively within ovarian endometriomas

• CCOC and EndoCa look similar to their endometrial counterparts and have similar mutations – do these cancers arise from different cells of origin?

• The IL6 pathway is dominant in OCCC, whereas ARID1A/PIK3CA mutation occurs in approximately 50% of cases

• Is OCCC more than on disease and if so what marks each type (proteomics screen)

Thanks• My lab:, Niki Boyd ,Michelle Woo, Leah Prentice, Melissa

McConechy, Winnie Yang, Sarah Mains-Bandiera, Clara Salamanca, Michael Anglesio, Alicia Tone, Hector Li Chang, Yemin Wang, Jay Chen, Tony Karnezis,, Madlen Maassen and Janine Senz

• Sohrab Shah -- Bioinformatics: Jairhu Ding, Yikan Wang, Ali Bashashati, Gavin Ha, Andrew McPherson, Gavin Ha

• GSC: Marco Marra, Martin Hirst, Gregg Morin• Collaborators: Stefan Kommoss, M Kobel, Blaise Clarke, J

Brenton, AM Mes-Masson, D Bowtell, B Vanderhyden, A Okamoto and Sam Aparicio

• OvCaRe BC: Blake Gilks, Dianne Miller, Ken Swenerton, Paul Hoskins, YZ Wang, Nelly Auersperg, Brad Nelson, Cal Roskelly, Tom Ehlen, Anna Tinker, Jessica McAlpine