Pathology in Gynecologic Cancer –all what you want to know as a PhD scientist

Ie-Ming Shih, MD, PhD

http://pathology2.jhu.edu/shihlab/index.cfm

Gross anatomy of female genital organs

Squamous intraepithelial lesion

Squamous carcinoma

Endometrial hyperplasia

Endometrioid carcinoma

LeiomyomaLeiomyosarcoma

“Ovarian” cancer:Primary carcinomaMetastatic carcinomaStromal tumorGerm cell tumor

HPV

estrogen

?

Chorio-carcinoma

mole

Placenta can give rise to a variety of trophoblastic tumors including choriocarcinoma

EVT (IT) atchorion laeve

EVT (IT) atimplantation site

CT

Placental plate

Histology

Leiomyoma, the most common benign uterine tumor in women

Endometrioid carcinoma of the uterus

Courtesy of Dr. Russell Vang

Gestational Trophoblastic Diseases

Lesions of fetal origin

Maternal Fetus Paternal

Homozygous complete mole- 80-90%

Empty Egg

23X

46XX

46XX

46XX

PaternalChromosomes

Only

23X

23Y

23X

23Y46XY

46XY

46XY

Dispermy

Diploid androgeniccells

Heterozygous complete mole-< 20%

PaternalChromosomes

Only

23Y

69XXY

69XXY

69XXY

23X 23X

23Y Triploid 69XXY Cells

Maternal Chromosomeswith Paternal Extra Set

23X

23X

Dispermy Diandry

Choriocarcinoma can occur in any pregnancy events

(Hertig, 1956)

CHM

Abortion

TermPregnancy

ChoriocarcinomaInvasive pushing borderCentral massive necrosis/hemorrhageLack of angiogenesisDimorphic appearance- syncytiotrophoblast

alternating with mononucleate trophoblastNo chorionic villi or fetal partsOccasional mixed with PSTT or ETT

β-hCG stain

Rapid progression of choriocarcinoma if untreated

one month

Gestational trophoblastic disease

GTD is a semi-allogenic tissue to the patient: abnormally formed placenta (molar pregnancy) neoplasms (choriocaricnoma, PSTT and others)

Reproductive ages- symptoms or signs related to an (antecedent) pregnancy

CHM is a risk factor for choriocarcinoma which is highly aggressive and fatal if untreated

With chemotherapy (MTX), all choriocarcinomas are curable

β-hCG is the gold standard surrogate serum marker for follow-up BUT NOT FOR DIAGNOSIS

The fact of ovarian cancer• Ovarian carcinoma is the major disease of

cancer mortality in women (20,180 new cases 15,310 new deaths in 2006)

• Molecular etiology is poorly understood • Patients are usually on death roll if tumors recur• A peritoneal disease, ideal for i.p. therapy

Issues of borderline tumors

Prediction of outcome in SBT, invasive vs non-invasive implants

Pathogenesis of high-grade serous carcinomaTarget-based therapy in recurrent tumors

Several others…

Ovarian cancers include:

“Aggressive scale” of ovarian epithelial tumors

Serous Endometrioid Clear cell Mucinous Transitional

Carcinoma

Borderline tumor(LMP)

Adenoma

H L

Ovarian Epithelial Tumors- Type I and Type II (the dualistic pathway)Ovarian Epithelial Tumors- Type I and Type II (the dualistic pathway)

Serous Endometrioid Clear cell Mucinous Transitional

Carcinoma

Borderline tumor(LMP)

Adenoma

H L

Type I Low-grade serous CA + endometrioid CA + clear cell CA

Type II High-grade serous CA + some other types

Serous borderline tumor

Morphological continuum of low-grade serous carcinoma:

cystadenoma- SBT- intraepithelial LG CA- invasive LG CA

Genes involved:KRASBRAFERBB2 (Her2/neu)

Her2

Mutual exclusive mutation in ERBB2 (Her2)/KRAS/BRAF

cyclin D1

(Am J Pathol, 160:1223, 2002)(J Natl Cancer Inst, 95:484, 2003)(Cancer Res, 54:6915, 2004)

Immunosorting

Minced to small fragments and collagenase digestion

Trypsin digestion

SBT HG tumor

37oC

Primary culturePrimary culture

ImmunosortingImmunosorting

Minced to small fragments and collagenase digestion

Trypsin digestion

SBT HG tumor

37oC37oC

Primary culturePrimary culture

10 20 30 40 50 60

0

2

4

6

8

10

12

Ch 19

10 20 30 40 50 60

0

2

4

6

8

10

12

Ch 19

**

(Cancer Biol Ther, 5:779, 2006)

0 10 20 30 40 50 60 70 80 90 100 110

OVCAR3SKOV3CAOV3

OVPC-8OVPC-7OVPC-6OVPC-5OVPC-4OVPC-3OVPC-2OVPC-1MPSC1Stroma

OSEwt wtwt wtwt mutmut wtwt mutmut wtwt mutwt wtwt wtwt wtwt wtwt wtwt wtwt wt

KRAS BRAF

Cell number (% of DMSO controls)

Mutation status

SBT/LG

HG

SBTs with KRAS/BRAF mutations are more sensitive to theMEK inhibitor in vitro than the conventional HG carcinomas

(Cancer Res, 65:1994, 2005)

Tumor progression model in ovarian endometrioid carcinoma

Endometriosis Endometrioid borderline tumor Endometrioid carcinoma

Genes involved:

PTENCTNNB1 (β-catenin)PIK3CAp53 (in high-grade CA)

Transgenic mice with PTEN and β-cateninmutations give ovarian endometrioid carcinoma. (Cho et al, Cancer Cell, in press)

Transvaginal ultrasound studies

Konishi et al. Gyn Oncol, 88:309, 2003

cystno cyst

Borderline tumorsClear cell carcinomaEndometrioid carcinom

High-grade serous carcinoma

A 38-year-old, infertile woman October 1989, a 5-cm endometriotic cyst. In 1995, she was given hormonal treatment.In December 1998, the cyst re-increased in size, and the solid portion appeared.Laparotomy revealed stage-Ia clear cell carcinoma.

(Gyn Oncol, 88:309, 2003)

A 51-year-old woman with annual checkup for 7 years.Last examination in July 1998 showed that both ovaries were normal-appearing. In July 1999, a large cystic tumor with solid components was detected by. Laparotomy revealed stage IIIc, high-grade serous carcinoma

(Gyn Oncol, 88:309, 2003)

New hypothesis- fallopian tube origin of “ovarian” (pelvic) serous carcinoma

Fallopian tube

Tumor celldissemination

Most Type I ovarian cancers can be early detected… because of indolent tumor progression from precursors

Time

Not curable stageMetastatic disease

Detection pointBiomarker/imagingTu

mor

load

Early stagePre-neoplasticstage

Late stage

Does early cancer detection work at all for Type II CA?Does stage I high-grade serous CA exist?

Pre-neoplasticstage

Tum

or lo

ad

Time

Not curable stageMetastatic disease

Detection pointBiomarker/imaging

Early stage Late stage

Type I

Type II

Stepwiseprecursor

“de novo”(tubal origin)

relatively indolent

highly aggressive

better OS

poor OS

Mutation in KRAS, BRF, β-cat, PTEN, PIK3CA

p53 mutation (CIN)

CLINICAL IMPLICATIONS

Type I

Type II

Early detection

Treatment of recurrent DxMolecular predictors

Kinase inhibitors

Suppress underlying genetic instability

Aggressive CAVery CINfulp53 mutationsUnique gene

expression

Indolent tumorLess CINfulKRAS/BRAF

mutationsLOH Ch1p+Ch19qUnique gene

expression

(Am J Pathol; 164:1511, 2004)(Clin Cancer Res; 11:7274, 2005)

Predicting Suboptimal SurgeryCase Study

Now what?Now what?

Advanced Ovarian Cancer• United States: 14,000 new cases annually• Long-term survival 25% to 50%• Important Prognostic Factors: - Age

- Performance status- FIGO stage- Ascites volume- Tumor grade/subtype- Chemosensitivity- Residual disease

Advanced Ovarian Cancer:WHY does the surgeon make a difference?WHY does molecular genetics make a difference?

Radical Oophorectomy

Sigmoid Sigmoid TumorTumor

Left OvaryLeft Ovary

Right OvaryRight OvaryUterusUterus

Bladder TumorBladder Tumor

Bristow et al. J Am Coll Surg 2003; 197: 565.

Radical Oophorectomy

Culdesac TumorCuldesac Tumor

Distal SigmoidDistal Sigmoid CervixCervix

UterusUterus

Bladder TumorBladder Tumor

Bristow et al. J Am Coll Surg 2003; 197: 565.

For Type II OVCA- focus on recurrent tumors?

Eventually, all chemotherapyfails in recurrent tumors…

Recurrent tumors are always inevitable…

Gene discovery

High-throughput nucleotide sequencing

Digital Karyotyping

SNP array

LongSAGE (Serial Analysis of Gene Expression)

http://www.digitalkaryotyping.org/

Proteomics

CIN at molecular genetic levelsDigitalkaryotyping

SNP array 1

2

3

4

5

6

7

89

1011

13141516171819

x

202122

12

chro

mos

ome

LG HG

(Nakayama et al, Int J Cancer, in press)(Shih et al. PNAS, 102: 14004, 2005)

Amplicons in ovarian serous carcinomas

AKT2 Cyclin E1 Notch3

Cyclin E1 Notch3 AKT2 Rsf-1 PIK3CA

NormalGain Amp

Total

NormalGainAmp

Total

47(56.6)* 47(58.1) 70(79.5) 73(82.1) 56(75.7) 6(7.2) 16(19.8) 6(6.8) 2(2.2) 10 (13.5)

30(36.1) 18(22.1) 12(13.6) 14(15.7) 8(10.8)

83 81 88 89 74

26(100) 22(91.7) 24(100) 25(100) 20(100)0 2(8.3) 0 0 0 0 0 0 0 0

26 24 24 25 20

* Percentage of cases in parenthesis. Amp: amplification

Notch3 Rsf-1

FISH validation

HG CA

LG CA

Digital karyotypingSNP arrays

Prioritize amplicons

FISH on TMA

p = 0.03

0 40 80 120 160 2000

20

40

60

80

100

Not amplifiedAmplified

Overall survival (months)

Perc

ent S

urvi

val

Johns Hopkins Hospital(primary solid tumors, FISH)

0 20 40 60 80 100 120

OP bis Todeszeitpunkt

0,0

0,2

0,4

0,6

0,8

1,0

Kum

. Übe

rlebe

n

Univ. Muenster Hospital(primary solid tumors, FISH)

Amp

Amp

p = 0.012

p = 0.015

p = 0.03

0 20 40 60 80 1000

20

40

60

80

100

Low expressionHigh expression

Overall survival (months)

Perc

ent S

urvi

val

Norwegian Radium Hospital(primary effusion samples, real-time PCR)

p = 0.037

Vancouver General Hospital(primary solid tumors, FISH)

p = 0.026

Amp

High

Things to remember…

1. All the female reproductive tract and organs including placenta can give rise to neoplastic diseases. Some are common and some are rare!

2. The most common neoplasm among gynecologic tumors is leiomyoma (smooth muscle tumors from myometrium in the uterus) which causes pain, bleeding and infertility in women. Not much research is going on.

3. Endometrioid carcinoma is the most common malignant tumors in the uterus. Most of cases are at early stages and prognosis is excellent. This type of cancer arises from precursors, endometrial hyperplasia and is characterized by defined mutations in PTEN and beta-catenin genes.

Things to remember…

4. Ovarian “cancer” is a heterogeneous group of tumors and can be broadly classified into primary epithelial, stromal, germ cell and metastatic tumors.

5. Within the primary epithelial tumors, they can be classified into different histologic subtypes and each subtype can have benign, borderline or malignant categories.

6. Different histologic subtypes have unique molecular pathways for their development and progression. So, study of ovarian cancer should separate different histological types.

Things to remember…7. Based on clinical and molecular studies, ovarian epithelial

neoplasms can be viewed as two groups- type I and type II for research purposes.

8. The high-grade serous carcinoma is what has been referred as “ovarian cancer”. It is the most common and lethal type of all ovarian neoplasms.

9. The origin of “ovarian” cancer is still not known. Increased ovulation (causes surface inclusion bodies) is a risk factor…A new hypothesis of tubal origin has been recently proposed.

10. Early detection of type II tumor may not work… Focus on the studies of recurrent tumors may likely have a translational impact.