Personalised Medicine and the Future of Tissue Pathology Manuel Salto-Tellez Professor and Chair of Molecular Pathology Queen’s University Belfast BASIC SCIENCE MACRO HISTO/ CYTO DIAGNOSTICS IHC/ ICC IN SITU HYBRIDIZATIONS PCR BASIC SCIENCE DIAGNOSTICS LACK OF KNOWLEDGE LACK OF ROBUST TECHNOLOGY LACK OF ROBUST RESEARCH DESIGN (CLINICAL TRIALS) BOTTLENECK DIAGNOSTIC & CLINICAL APPLICATIONS Molecular Tissue Pathology and Personalised Medicine DEFINITIONS TESTS – strengths and challenges RELEVANCE TO TRADITIONAL TISSUE DIAGNOSTICS DIAGNOSTIC & CLINICAL APPLICATIONS Molecular Tissue Pathology and Personalised Medicine DEFINITIONS TESTS – strengths and challenges RELEVANCE TO TRADITIONAL TISSUE DIAGNOSTICS DIAGNOSTIC & CLINICAL APPLICATIONS Association Molecular (AMP) of molecular Molecularfor diagnosis is Pathology the application biology techniques and knowledge of the molecular mechanisms of disease to diagnosis, prognostication and treatment of diseases. HAEMATOONCOLOGY INFECTIOUS DISEASES Molecular Diagnostics SOLID TUMORS IDENTITY TESTING GENETIC DISEASES Diagnostic Molecular Oncology Association for Molecular Pathology (AMP) Diagnostic Molecular Histopathology & Cytopathology is the application of molecular diagnosis to those samples that are firstly analysed by histopathologists and cytopathologists: FFPE Materials FNAs, effusion and exfoliative cytology Diagnostic Molecular Histopathology / Cytopathology Molecular Tissue Pathology and Personalised Medicine DEFINITIONS TESTS – strengths and challenges RELEVANCE TO TRADITIONAL TISSUE DIAGNOSTICS DIAGNOSTIC & CLINICAL APPLICATIONS Diagnostic Value Translocations in sarcomas Translocations in sarcomas Tumor Ewing’s sarcoma Peripheral PNET Myxoid liposarcoma Translocation t(11;22) t(21;22) t(12;16) t(12;22) Alveolar Rhabdomyosarcoma t(2;13) t(1;13) Clear cell sarcoma t(12;22) Desmoplastic small round t(11;22) cell tumor Synovial sarcoma t(X;18) Myxoid chondrosarcoma t(9;22) Dermatofibrosarcoma t(17;22) protuberans Infantile fibrosarcoma t(12;15) Fusion Product EWS-FL11 EWS-ERG TLS-CHOP EWS-CHOP PAX3-FKHR PAX7-FKHR EWS-ATF1 EWS-WT1 SYT-SSX1/ SYT-SSX2 EWS-CHN COL1A1-PDGFB STRONG DIAGNOSTIC VALUE ETV6-NTRK3 Diagnostic t(11;22)(p13;q12) translocation characteristic of DSRBCT Pang B, Leong CC, Salto-Tellez M, Petersson F. ApplImmunohistochem Mol Morphol. 2011 Jan;19(1):70-5 Haemato-oncology Lymphomas CLONALITY STUDIES All lymphomas IgH receptor and TCR gene rearrangement TRANSLOCATIONS c-ski (1q23); c-ets (11q23-24); bcr-abl Precursor B-ALL t(1;19), t(4;11), del(6q), t(9;22) B-CLL / SLL del(13); trisomy 12 Mantle cell lymphoma t(11;14) Cyclin D1 Follicular lymphoma t(14;18) Bcl-2 Extranodal marginal zone B-cell lymphoma t(11;18) API2/ML1 Splenic Marginal zone B cell lymphoma del(7), del(10) Lymphoblastic lymphoma (immunocytoma) t(9;14) PAX-5 Diffuse large B-cell lymphoma t(3;14) & t(14;18) Bcl-6 & Bcl-2 Burkitt lymphoma t(8;14), t(2;8), t(8;22) c-myc Plasmacytoma t(4;14) & t (6;14) FGFR3 & MUM1/IRF 4 T-cell prolymphocytic leukemia Inv(14) TCL-1 Angioimmunoblastic T cell lymphoma +3, +5, +X Anaplastic large cell lymphoma t(2;5) Hepatosplenic γδ i(7) (adapted from Ng, Lee and Salto-Tellez EOMD 2008) NMP/ALK Dec ‘02 Bladder biopsy – T-cell Lymphoma Jan ‘03 First gastric biopsy – T-cell lymphoma Jan ‘04 Lymphocytic gastritis-like biopsy Thyroid Pathology B-Raf mutations Malignant Melanoma Therapeutics GSK2118436 PLX4032 Diagnostics Thyroid Cancer Colon cancer MSI and HNPCC & KRAS = Prognostic and ?Therapeutics Gliomas Courtesy of Brendan Pang Diagnostic Value Genetic Value Diagnostic Value Genetic Value Therapeutic Value Selected target therapeutics in the routine oncology practice Targeted therapeutics Target Tumor Trastuzumab Her-2 Breast Ca Rituximab CD20 B-Cell Lymphoma Cetuximab EGFR/KRAS CRC & HN Ca Bevacizumab VEGF Breast Ca / CRC / NSCLC Panitumumab EGFR CRC Imatinib c-kit / BCR-ABL GIST and CML Gefitinib EGFR Lung Ca Erlotinib EGFR NSCLC & Pancreatic Ca Lapatinib Her-2 & EGFR Breast Ca Sorafenib VEGFRs/PDGFR/RAF HCC & RCC Sunitinib VEGFRs/PDGFR/RET RCC & GIST Tensirulimus / Everolimus mTOR RCC Bortezomib Proteasome MM & MCL VorinostatBortezomib HDAC Cutaneous TCL Antibodies Small Molecule Inhibitors From: Quek, Yan, Yong and Salto-Tellez. Personalized Medicine (2009) 6(5),465-468 Selected target therapeutics in the routine oncology practice Targeted therapeutics Target Tumor Trastuzumab Her-2 Breast Ca Rituximab CD20 B-Cell Lymphoma Cetuximab EGFR/KRAS CRC & HN Ca Bevacizumab VEGF Breast Ca / CRC / NSCLC Antibodies Drugs in theEGFR pipeline inCRC 2010 = 850 Panitumumab Small Molecule Inhibitors Imatinib c-kit / BCR-ABL and CML Source – AACR 2010 internalGIST statistics Gefitinib EGFR Lung Ca Erlotinib EGFR NSCLC & Pancreatic Ca Lapatinib Her-2 & EGFR Breast Ca Sorafenib VEGFRs/PDGFR/RAF HCC & RCC Sunitinib VEGFRs/PDGFR/RET RCC & GIST Tensirulimus / Everolimus mTOR RCC Bortezomib Proteasome MM & MCL VorinostatBortezomib HDAC Cutaneous TCL From: Quek, Yan, Yong and Salto-Tellez. Personalized Medicine (2009) 6(5),465-468 Molecular diagnostics and personalised / predictive medicine Gastrointestinal stromal tumour Br J Cancer 2007;96:776–82 Cytopathology 2009;20:297–303 Mod Pathol 2003;16:79–85 Hum Pathol 2003;34:362–8 J Clin Pathol2010;63:839–42 J Clin Pathol 2011; July 14th Arch Pathol Lab Med 2011; 135(6):693-5 C-kit mutations Imatinib HER2-neu FISH Breast cancer Trastuzumab Lapatinib Gastric cancer Lung cancer Clin Chem 2007;53:62–70 J Thorac Oncol 2011, on line EGFR mutations EML4-ALK Colon cancer J Mol Diagn 2009;11:543–52 Pathology 2008;40:295–8 Cytopathology 2010; Oct 4th Int J Colorectal Dis 2010; Dec 3th Erlotinib Gefitinib ALK inhibitor PF-02341066 Cetuximab K-Ras mutations Pathology 2008;40:295–8 Cytopathology 2010; Oct 4th B-Raf mutations Malignant Melanoma GSK2118436 PLX4032 Modern pathology must be a synergy of morphology, IHC and molecular Dx Colon cancer J Mol Diagn. 2009; 11:543-52 Pathology 2008;40:295–8 Cytopathology 2010, Oct 4, in press Int J Colorectal Dis. 2010 Dec 3. KRAS mutations B-Raf mutations K-Ras mutations Cetuximab Journal of Molecular Diagnostics 2009, Vol. 11, No. 6 DOI: 10.2353/jmoldx.2009.090057 A Multicenter Blinded Study to Evaluate KRAS Mutation Testing Methodologies in the Clinical Setting Vicki Whitehall* et al (Salto-Tellez M, Iacopetta B) Pyrosequencing DNA sequencing Tib-MolBiol kit DxS SSCP HRM 2009 – 2010 N = 1,555 12% 189 31% 483 18% 285 Molecular testing as a revenue generator? 108 212 7% 14% Clinical trials NUH Private Singapore 278 18% Industry Sponsored Re-structured Hospitals Overseas Lung cancer Clin Chem 2007;53:62–70 JTO 2011, accepted EGFR mutations EGFR mutations EML4-ALK Erlotinib Gefitinib ALK inhibitor PF-02341066 Sharma et al. Nat Rev Cancer 2007 IPASS (Mok T, et al. 2009) EGFR Testing 1. 2. 3. 4. 5. 6. EGFR mutation testing model EGFR mutation testing methodology EGFR mutation testing materials EGFR mutation testing turnaround time EGFR mutation testing reporting EGFR mutation testing – single biomarker versus multiple biomarkers 7. Conclusions The story of 1960’s - Isolation of a protein that induced epithelial growth 1970’s - Discovered specific binding receptors for EGF on target cells 1980’s - Modification of proteins by phosphorylation on tyrosine residues might be a critical step in tumorigenesis BIOMARKER VALIDATION PATHOLOGY DIAGNOSTICS TECHNOLOGY TRANSFER (MOLECULAR & IHC) VALIDATION OF CLINICAL MOLECULAR DIAGNOSTIC TESTS RESEARCH (clinical trials) TRANSLATIONAL RESEARCH BASIC RESEARCH 1987 1992 BASIC SCIENCE 2002 2004 2006-7 CLINICAL COST Phase I Phase II Phase III Adapted from: Phasing out phase III trials? How much evidence do we need if the target is clearly hit? Jaap AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics November 12-16, 201 Lung cancer ClinChem 2007;53:62–70 J ThoracOncol 2011; accepted EGFR mutations Gefitinib Erlotinib Colon cancer 6. LUNG CANCER single biomarker versus multiple biomarkers Breast Cancer (DNA microarrays of Q RT-PCR): •70-gene profile MammaPrint •21-gene recurrence score Oncotype DX •76-gene outcome Rotterdam signature Colon Cancer: •12-gene expression signature: independent predictor of recurrence in stage II disease AML: •133-gene signature in adult AML of normal karyotype: prognostic information Concerns: 1. Is this evidence supported by solid, randomized, prospective clinical trials? 2. Are single-lab results reproducible if the test is done in different centres? Molecular classification of lung adenocarcinoma Molecular classification of lung adenocarcinoma LUNG ADENOCA EGFRmut LUNG ADENOCA EGFR wt Molecular classification of lung adenocarcinoma LUNG ADENOCA EGFR mut LUNG ADENOCA MET ampl LUNG ADENOCA KRASmut LUNG ADENOCA EML4-ALKpos Pathology sequence – reflex testing (ver 2) Diagnostic material (bronchoscopic, needle core or cytology) SCLC NSCLC EGFR exons 18–21 mutation detection EGFR mut EGFR wt KRAS Ex 2 & 3 KRAS mut? KRAS wt? EML4-ALK EGFR-TKI treatment KRAS-related treatment? EML4-ALK AMP EML4-ALK not AMP ALK inhibitors? Other treatments Other treatments Molecular Diagnostics and the Taxonomy of Cancer DIRECTOR'S CHALLENGE: TOWARD A MOLECULAR CLASSIFICATION OF TUMORS Release Date: January 20, 1999 RFA: CA-98-027 P.T. National Cancer Institute PURPOSE - The Director of the National Cancer Institute (NCI) challenges the scientific community to harness the power of comprehensive molecular analysis technologies to make the classification of tumors vastly more informative. This challenge is intended to lay the groundwork for changing the basis of tumor classification from morphological to molecular characteristics. Dr Harold Varmus, 1999 Every year there are more samples coming into Pathology Departments New molecular diagnostic approaches and classifications are based on very solid morphological interpretations – Phenotype and Genotype are not mutually exclusive, but are complementary WHO classification of lung adenocarcinoma 1.3.3. Adenocarcinoma 1.3.3.1. Acinar 1.3.3.2. Papillary 1.3.3.3. Bronchioloalveolar carcinoma 1.3.3.3.1. Non-mucinous (Clara / pneumocyte type II) 1.3.3.3.2. Mucinous 1.3.3.3.3. Mixed mucinous and non-mucinous or intermediate cell type 1.3.3.4. Solid adenocarcinoma with mucin 1.3.3.5. Adenocarcinoma with mixed subtypes 1.3.3.6. Variants 1.3.3.6.1. Well-differentiated fetaladenocarcinoma 1.3.3.6.2. Mucinous ("colloid") adenocarcinoma 1.3.3.6.3. Mucinouscystadenocarcinoma 1.3.3.6.4. Signet-ring adenocarcinoma 1.3.3.6.5. Clear cell adernocarcinoma Travis et al. J ThoracOncol 2011 1.3.3. Adenocarcinoma 1.3.3.1. Acinar 1.3.3.2. Papillary 1.3.3.3. Bronchioloalveolar carcinoma 1.3.3.3.1. Non-mucinous (Clara / pneumocyte type II) 1.3.3.3.2. Mucinous 1.3.3.3.3. Mixed mucinous and non-mucinous or intermediate cell type 1.3.3.4. Solid adenocarcinoma with mucin 1.3.3.5. Adenocarcinoma with mixed subtypes 1.3.3.6. Variants 1.3.3.6.1. Well-differentiated fetal adenocarcinoma 1.3.3.6.2. Mucinous ("colloid") adenocarcinoma 1.3.3.6.3. Mucinous cystadenocarcinoma 1.3.3.6.4. Signet-ring adenocarcinoma 1.3.3.6.5. Clear cell adernocarcinoma Objectivity Reproducibility Clinical Relevance Affordability Mod Pathol 2003;16:79–85 Hum Pathol 2003;34:362–8 JCP2010;63(9):839-42 JCP 2011, accepted Archives Path Lab Med 2001, in press HER2-neu FISH Breast cancer Gastric cancer Her-2/neu amplification Trastuzumab Lapatinib 54 | 1.1 Topic goes here | Project number | 14.12.08 Copyright © 2008 National University Health System American Society of Clinical Oncology/College of American Pathologists Guideline Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer - Antonio C. Wolff AC et al. JCO Jan 1 2007: 118-145. HER2-neu FISH C-erbB2 IHC OR SCORE 0, 1+ 0R 3+ SCORE 2+ HER2-neu FISH Final Report 4 signals or 1.8 ratio 1.8 to 2.2 ratio > 6 signals or >2.2 ratio C-erbB2 IHC Final Report Guidelines for Human Epidermal Growth Factor Receptor 2 Testing: Biologic and Methodologic Considerations Guido Sauter, James Lee, John M.S. Bartlett, Dennis J. Slamon, Michael F. Press JCO Mar 10 2009: 1323-1333. Table 3. FISH in Central Laboratory and IHC With DAKO Herceptest in Local/Community Hospital Laboratories FISH in Central Laboratory IHC With DAKO Herceptest in Local/Community Hospital Labs (No. of samples) 0 1+ 2+ 3+ Total Positive 11 (a) 8 (b) 21 (c) 204 (d) 244 (e) Negative 296 (f) 142 (g) 103 (h) 57 (i) 598 (j) Sauter, G. et al. J Clin Oncol; 27:1323-1333 2009 Copyright © American Society of Clinical Oncology Table 3. FISH in Central Laboratory and IHC With DAKO Herceptest in Local/Community Hospital Laboratories FISH in Central Laboratory Positive IHC With DAKO Herceptest in Local/Community Hospital Labs (No. of samples) 0 1+ 2+ 3+ Total 11 (a) 8 (b) 21 (c) 204 (d) 244 (e) 103 (h) 57 (i) 598 (j) 7.8% Negative 296 (f) Sauter, G. et al. J Clin Oncol; 27:1323-1333 2009 Copyright © American Society of Clinical Oncology 142 (g) Table 3. FISH in Central Laboratory and IHC With DAKO Herceptest in Local/Community Hospital Laboratories FISH in Central Laboratory Positive IHC With DAKO Herceptest in Local/Community Hospital Labs (No. of samples) 0 1+ 2+ 3+ Total 11 (a) 8 (b) 21 (c) 204 (d) 244 (e) 103 (h) 57 (i) 598 (j) 7.8% Negative 296 (f) Sauter, G. et al. J Clin Oncol; 27:1323-1333 2009 Copyright © American Society of Clinical Oncology 142 (g) 9.6% From: Jared N. Schwartz, MD, PhD, FCAP Director, Pathology & Lab Medicine Presbyterian Healthcare Charlotte, Past President, College of American Pathologists Correlation between HER2 IHC and ISH (CISH and SISH) show a significant number of false positive and false negative results, confirming the decision for mandatory ISH testing to determine HER2 status in Australia. There were insufficient data to correlate CISH or SISH with FISH but laboratories should validate CISH and SISH testing as specified by the HER2 Advisory Board. Copyright © American Society of Clinical Oncology Her2 and Gastric Cancer Lancet. 2010 Aug 28;376(9742):687-97. Epub 2010 Aug 19. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastrooesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial. Bang YJ, Van Cutsem E, Feyereislova A, Chung HC, Shen L, Sawaki A, Lordick F, Ohtsu A, Omuro Y, Satoh T, Aprile G, Kulikov E, Hill J, Lehle M, Rüschoff J, Kang YK; ToGA Trial Investigators. Her2 and Gastric Cancer J Clin Pathol. 2011 Jul 14. [Epub ahead of print] Her2 and Gastric Cancer Her2 and Gastric Cancer Molecular Tissue Pathology and Personalised Medicine DEFINITIONS TESTS – strengths and challenges RELEVANCE TO TRADITIONAL TISSUE DIAGNOSTICS DIAGNOSTIC & CLINICAL APPLICATIONS ANATOMICAL DIMENSION OF PATHOLOGY ANATOMICAL / CLINICAL DIMENSION OF PATHOLOGY (HISTOLOGY AND CYTOLOGY) “… transforming pathology of the dead into pathology of the living.” Lauren V. Ackerman Gordon Signy K Shanmugaratnam ANATOMICAL -CLINICAL DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS Paediatric Sarcomas Colorectal Cancer Lympho – proliferative Disorders Lung Cancer Breast Cancer Gastrointestinal Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 ANATOMICAL -CLINICAL DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS SURG PATH Diagnosis of Paediatric Sarcomas SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders SURG PATH Diagnosis of Lung Cancer SURG PATH SURG PATH Diagnosis of Diagnosis of Gastrointestinal Breast Cancer Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 ANATOMICAL / CLINICAL DIMENSION OF PATHOLOGY Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 ANATOMICAL / CLINICAL / MOLECULAR DIMENSION OF PATHOLOGY Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 MACRO HISTO/ CYTO IHC/ ICC MACRO HISTO/ CYTO IHC/ ICC IN SITU HYBRIDIZATIONS PCR ANATOMICAL -CLINICAL DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS SURG PATH Diagnosis of Paediatric Sarcomas SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders SURG PATH Diagnosis of Lung Cancer SURG PATH SURG PATH Diagnosis of Diagnosis of Gastrointestinal Breast Cancer Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 ANATOMICAL -CLINICAL DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS Molecular Detection of Translocations SURG PATH Diagnosis of Paediatric Sarcomas KRAS/BRAF Mutation Analysis Specific translocations Microsatellite Instability Analysis B & T cell rearrangements SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders Analysis of EGFR Mutations SURG PATH Diagnosis of Lung Cancer HER2-neu Status Analysis of C-kit Mutations SURG PATH SURG PATH Diagnosis of Diagnosis of Gastrointestinal Breast Cancer Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 A N A T O M I C A L - C L I N I C A L – MO L E C U L A R DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS Multiple Biomarker Analysis Molecular Detection of Translocations SURG PATH Diagnosis of Paediatric Sarcomas KRAS/BRAF Mutation Analysis Specific translocations Microsatellite Instability Analysis B & T cell rearrangements SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders Analysis of EGFR Mutations SURG PATH Diagnosis of Lung Cancer HER2-neu Status Analysis of C-kit Mutations SURG PATH SURG PATH Diagnosis of Diagnosis of Gastrointestinal Breast Cancer Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 A N A T O M I C A L - C L I N I C A L – MO L E C U L A R DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS Pharmacogenomics Multiple Biomarker Analysis Molecular Detection of Translocations SURG PATH Diagnosis of Paediatric Sarcomas KRAS/BRAF Mutation Analysis Specific translocations Microsatellite Instability Analysis B & T cell rearrangements SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders Analysis of EGFR Mutations SURG PATH Diagnosis of Lung Cancer HER2-neu Status Analysis of C-kit Mutations SURG PATH Diagnosis of Breast Cancer SURG PATH Diagnosis of Gastrointestinal Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 Selected targeted therapeutics in routine oncology practice Targeted therapeutics Target Tumour Trastuzumab Her-2 Breast Ca Rituximab CD20 B-Cell Lymphoma Cetuximab EGFR/KRAS CRC & HN Ca Bevacizumab VEGF Breast Ca / CRC / NSCLC Panitumumab EGFR CRC Imatinib c-kit / BCR-ABL GIST and CML Gefitinib EGFR NSCLC Erlotinib EGFR NSCLC & Pancreatic Ca Lapatinib Her-2 & EGFR Breast Ca Sorafenib VEGFRs/PDGFR/RAF HCC & RCC Sunitinib VEGFRs/PDGFR/RET RCC & GIST Temsirolimus/ Everolimus mTOR RCC Bortezomib Proteasome MM & MCL Vorinostat HDAC Cutaneous TCL Antibodies Small molecule inhibitors Adapted from: Quek et al. (Salto-Tellez M). Personalized Medicine 2009 A N A T O M I C A L - C L I N I C A L – MO L E C U L A R DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS Pharmacogenomics Multiple Biomarker Analysis Molecular Detection of Translocations SURG PATH Diagnosis of Paediatric Sarcomas KRAS/BRAF Mutation Analysis Specific translocations Microsatellite Instability Analysis B & T cell rearrangements SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders Analysis of EGFR Mutations SURG PATH Diagnosis of Lung Cancer HER2-neu Status Analysis of C-kit Mutations SURG PATH Diagnosis of Breast Cancer SURG PATH Diagnosis of Gastrointestinal Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 A N A T O M I C A L - C L I N I C A L – MO L E C U L A R DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS Pharmacogenomics Multiple Biomarker Analysis Molecular Detection of Translocations SURG PATH Diagnosis of Paediatric Sarcomas KRAS/BRAF Mutation Analysis Specific translocations Microsatellite Instability Analysis B & T cell rearrangements SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders Analysis of EGFR Mutations SURG PATH Diagnosis of Lung Cancer HER2-neu Status Analysis of C-kit Mutations SURG PATH Diagnosis of Breast Cancer SURG PATH Diagnosis of Gastrointestinal Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 A N A T O M I C A L - C L I N I C A L – MO L E C U L A R DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS Pharmacogenomics Multiple Biomarker Analysis Molecular Detection of Translocations SURG PATH Diagnosis of Paediatric Sarcomas KRAS/BRAF Mutation Analysis Specific translocations Microsatellite Instability Analysis B & T cell rearrangements SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders Analysis of EGFR Mutations SURG PATH Diagnosis of Lung Cancer HER2-neu Status Analysis of C-kit Mutations SURG PATH Diagnosis of Breast Cancer SURG PATH Diagnosis of Gastrointestinal Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 A N A T O M I C A L - C L I N I C A L – MO L E C U L A R DIMENSION OF PATHOLOGY TREATMENT AND/OR PROGNOSIS Pharmacogenomics Multiple Biomarker Analysis Molecular Detection of Translocations SURG PATH Diagnosis of Paediatric Sarcomas KRAS/BRAF Mutation Analysis Specific translocations Microsatellite Instability Analysis B & T cell rearrangements SURG PATH Diagnosis of Colorectal Cancer SURG PATH Diagnosis of Lympho – proliferative Disorders Analysis of EGFR Mutations SURG PATH Diagnosis of Lung Cancer HER2-neu Status Analysis of C-kit Mutations SURG PATH Diagnosis of Breast Cancer SURG PATH Diagnosis of Gastrointestinal Stromal Tumours Salto-Tellez M. Clinical Chemistry 2007 Jul;53(7):1188-90 Molecular Pathology in Contemporary Diagnostic Pathology Laboratory An Opinion for the Active Role of Surgical Pathologists Gregory Y Lauwers, Stephen Black-Schaffer, and Manuel Salto-Tellez Am J SurgPathol. 2010 Jan;34(1):115-7 To maintain its central role in the evaluation of patients, surgical pathology will need completely to incorporate the molecular diagnostic for the understanding and characterization of diseases. If surgical pathologists attempt, even passively, to resist this change, it could have 3 hugely significant consequences: 1) inviting others to perform molecular testing of surgical pathology samples, moving the central role of tissue-based diagnosis out of the field of pathology 2) compromising the strategic position of our discipline at the crossroads between the clinical practice of medicine and the scientific understanding of diseases 3) Loosing on revenue: molecular diagnostics is the fastest growing area of medicine, moving a budget of many billions of dollars, and a share of it should justifiably find it way to divisions of anatomic pathology, where it has the potential best to be understood and most appropriately integrated. Lauwers, Black-Schaffer, Salto-Tellez Am J Surg Pathol 2010;34:115-117 (Humble) recommendations: 1) now is the time for surgical pathology eagerly to embrace molecular pathology 2) actively to petition for its integration, when indicated, into daily clinical practice at sign out 3) vigorously to revisit and ensure its teaching in our residency programs all of this building on the role of board-certified molecular pathologists as invaluable bridges between pathologists’ roles as responsible diagnosticians and as clinical scientists Lauwers, Black-Schaffer, Salto-Tellez Am J Surg Pathol 2010;34:115-117 INTEGRATION LEADING TO FULL DIAGNOSTIC, PROGNOSTIC AND THERAPEUTIC OPINION CLINICO-PATHOLOGICAL INTEGRATION MORPHO-MOLECULAR INTEGRATION TRADITIONAL INTEGRATION Pulmonary pathology Urological Pathology CNS Pathology Lymphoreticular Pathology Gynaecological Pathology Gastrointestinal Pathology Soft Tissue Pathology Breast Pathology Lauwers, Black-Schaffer, Salto-Tellez Am J Surg Pathol 2010;34:115-117 EGFR Mutations I M M U N O H I S T O C H E M I S T R Y E L E C T R O N Various Chromosomal Abnormalities (BC) 1p 19q LOH (Gliomas) B- and T-cell receptor gene rearrangements Clinical History and Clinical Presentation Multiple translocations M I C R O S C O P Y HPV Subtype Identification Other Laboratory Investigations KRAS/BRAF mutations (CRC) MSI analysis c-kit mutation (GIST) Her-2/neu amplification (GC) Diagnostic Imaging Multiple translocations Her-2/neu amplification TOP 2A amplification Multiple gene amplification FINAL PATHOLOGICAL DIAGNOSTIC OPINION The increasingly important role of pathologists in personalised medicine Selected targeted therapeutics in routine oncology practice Targeted therapeutics Target Tumour Trastuzumab Her-2 Breast Ca Rituximab CD20 B-Cell Lymphoma Cetuximab EGFR/KRAS CRC & HN Ca Bevacizumab VEGF Breast Ca / CRC / NSCLC Panitumumab EGFR CRC Imatinib c-kit / BCR-ABL GIST and CML Gefitinib EGFR NSCLC Erlotinib EGFR NSCLC & Pancreatic Ca Lapatinib Her-2 & EGFR Breast Ca Sorafenib VEGFRs/PDGFR/RAF HCC & RCC Sunitinib VEGFRs/PDGFR/RET RCC & GIST Temsirolimus/ Everolimus mTOR RCC Bortezomib Proteasome MM & MCL Vorinostat HDAC Cutaneous TCL Antibodies Small molecule inhibitors Adapted from: Quek et al. (Salto-Tellez M). Personalized Medicine 2009 Molecular diagnostics and personalised / predictive medicine Gastrointestinal stromaltumour Br J Cancer 2007;96:776–82 Cytopathology 2009;20:297–303 C-kit mutations Imatinib Mod Pathol 2003;16:79–85 Hum Pathol 2003;34:362–8 J ClinPathol2010;63:839–42 J ClinPathol 2011; July 14th Breast Arch Pathol Lab Med 2011; 135(6):693-5 cancer HER2-neu FISH Trastuzumab Lapatinib Gastric cancer Lung cancer ClinChem 2007;53:62–70 J ThoracOncol 2011, on line EGFR mutations EML4-ALK Colon cancer J Mol Diagn 2009;11:543–52 Pathology 2008;40:295–8 Cytopathology 2010; Oct 4th Int J Colorectal Dis2010; Dec 3th Erlotinib Gefitinib ALK inhibitor PF-02341066 Cetuximab K-Ras mutations Pathology 2008;40:295–8 Cytopathology 2010; Oct 4th B-Raf mutations Malignant Melanoma GSK2118436 PLX4032 Modern pathology must be a synergy of morphology, IHC and molecular Dx From: Jared N. Schwartz, MD, PhD, FCAP Director, Pathology & Lab Medicine Presbyterian Healthcare Charlotte, Past President, College of American Pathologists