Contributo della patologia nella diagnosi e nel trattamento del

Contributo della patologia nella diagnosi e
nel trattamento del melanoma
Opinioni a confronto in oncologia
Dr. S. Leoni-Parvex, Istituto cantonale di patologia, Locarno
Ospedale Italiano, Lugano, 18.02.2016
I.
Diagnosi istopatologica
i. Staging istologico
ii. Istotipo
II. Patologia molecolare
i.
Staging istologico
J Clin Oncol 29:2199-2205. © 2011
• Ulcera
• Breslow
• Mitosi
Linfonodo sentinella
Analisi istopatologica LNS
• Multiple sezioni seriate a 150 um di intervallo fino a esaurimento
• Per ogni livello : HE – S100 – Melan-A – 1 sezione non colorata (in riserva)
Colorazione HE
Melan-A
Nevo nodale : rischio di LNS falso positivo
Metastasi linfonodale
Melanociti grandi e atipici, nel parenchima
Identici ai melanociti del melanoma primario
2006 : primo studio multicentrico
randomizzato sull’efficacia del LNS
Donald L. Morton, MD, John Wayne Cancer Institute, Santa Monica
MSLT-I
MULTICENTER SELECTIVE LYMPHADENECTOMY TRIAL I
Wide excision alone
versus
SNB + Complete lymphadenectomy
15%
16%
di cui 25% in stadio N3
25% in stadio N3
3,4%
di cui 70% in stadio N1
Melanoma related survival (5-year):
72 % versus 90 % (SN negative)
Linfonodo sentinella
Terapeutico ??
•
Is SNB correlated with disease-free survival?
Yes
in patients with intermediate-thickness (P=0.0074) or thick (P=0.0358) lesions 5 year
disease-free survival was :
78 % in the SNB group, as compared with 73% in the observation group
•
Is SNB correlated with overall survival?
No
The third interim analysis of MSLT-I found that there was
no significant difference in overall survival for the entire population.
•
Does “watch and wait” increase the number of tumor-positive nodes
Yes, the mean total number of positive nodes (Sentinel plus Non-sentinel) was
1.4 ± 0.9 in the SNB group versus 3.2 ± 3.9 in the observation group (P=0.0001).
Asportazione LNS
(risultati di MSLT-I)
• Fattore prognostico indipendente
• Migliore controllo delle recidive loco-regionali
• Recidive linfonodali più rare
(3.4 % versus 15 %)
• Linfonodi coinvolti meno numerosi (1.4 versus 3.2)
• Lieve aumento DFS
MSLT-II
SNB + Complete lymphadenectomy
versus
SNB + Ultrasound observation
The use of ultrasound monitoring in MSLT-II is important because high-definition ultrasonography
has the potential to detect metastases as small as 4 millimeters in the regional nodes.
MSLT-II
SECOND MULTICENTER SELECTIVE LYMPHADENECTOMY TRIAL
The fact that 80% sentinel-node positive patients have no non-sentinel node
involvement, suggests that if nodal metastases are limited to 1 or 2 sentinel
nodes, then SNB might be therapeutic as well as diagnostic.
MSLT-II’s primary outcome is melanoma-specific survival.
Secondary outcomes include overall survival and disease-free survival,
prognostic accuracy of histopathology,
molecular and immunologic markers, and quality of life.
Indicazioni al linfonodo sentinella
nel melanoma sottile (< 1 mm)
• The procedure should be recommended selectively for patients with T1b melanomas.
•
Preliminary evidence from several other large studies suggests that T1 melanomas with a
mitotic rate of >= 1 mitosis/mm2 and a thickness of >= 0.76 mm are associated with an
approximately 10% risk of occult metastases in their sentinel lymph nodes
•
(J.Gershenwald, personal communication, March 2009).
AAD, 2011
Indicazioni per melanoma < 0.75 mm
Biopsia shave
possibile sottostima del Breslow
Indicazioni per melanoma 0.76 - 1 mm
Indicazioni per melanoma 0.76 - 1 mm + ulcera / mitosi
Fotografia di slides presentate al congresso
Verificare staging istologico
•
•
Ulcera versus erosione o trauma
Mitosi dermiche versus epidermiche
Indicazione LNS melanoma < 1mm
> 0.75 mm
• con ulcera o mitosi (T1b)
Proporre
• senza ulcera o mitosi
Discutere individualmente
< 0.75 mm
• con ulcera o mitosi (T1b)
• senza ulcera o mitosi
Non raccomandato
Breslow
< 0.5 mm
0.5 – 0.76
0.76 – 0.9
0.9 – 1mm
LNS +
0%
3.8 %
5.3 %
10.3 %
Rajmohan Murali.
Sentinel Lymph Node Biopsy in Patients With Thin Primary Cutaneous Melanoma.
Ann Surg 2011;00:1–6.
Annals of Surgery: January 2012 - Volume 255 - Issue 1 - p 128–133
Linfadenectomia complementare
Cause:
•
•
•
•
Rifiuto da parte del paziente
Età > 75 anni
Comorbidità
Stazione inguinale / o linfonodi testa e collo
• Melanoma Thin & Thick
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York
• The data described in this study do not support routine CLND in all
patients with positive SLN.
• (…) there seems to be at least a subgroup of patients with positive SLN
who do not require CLND.
•
Selection criteria for this subgroup are not firmly established. For example,
should it be patients with thin melanomas with micrometastases, at low risk
for regional failure ?
• With appropriate prerandomization stratification, MSLT II should shed
light on these questions.
• Until those results are available, nodal observation may be a reasonable
alternative to the informed patient who does not want to participate in
MSLT II or who does not have access to participation in MSLT.
THM - Staging istologico
I.
Microstaging: Spessore Breslow / Ulcera / Mitosi
II. Linfonodo sentinella
• Fattore prognostico e migliore controllo delle recidive loco-regionali
• Indicazioni:
• >= 1mm : raccomandato
• < 1mm : solo con fattori aggravanti (ulcera o mitosi o > 0.75 mm)
III. Linfadenectomia complementare
•
Valutare individualmente in funzione del contesto clinico-oncologico
i.
Staging istologico
ii. Istotipo
Classificazione Istologica
Melanoma a diffusione superficiale (SSM)
•
•
•
•
•
Cute a esposizione solare intermittente
Paziente giovane
Molti nevi / nevi atipici
Fase di crescita radiale
Rischio di melanoma metacrono
Melanoma nodulare
•
•
•
•
•
Paziente anziano
Con pochi nevi
Testa - collo - schiena
Fase di crescita verticale dall’inizio
Melanoma aggressivo
Lentigo maligna melanoma
•
•
•
•
Cute a esposizione solare cronica (viso e braccia)
Paziente anziano (8 decade)
Fase di crescita radiale lenta
Margini mal definiti (clinicamente e all’istologia)
•
Slow Mohs
Melanoma acrale lentigginoso
•
•
•
•
•
Cute glabra e letto ungueale
Paziente anziano (65 anni)
Diagnosi tardiva
Aggressivo
Margini mal definiti / field cells
Our finding of isolated melanocytes with amplifications up to 3 mm beyond the
histologically recognizable extent of the tumors is the first direct demonstration of the
presence of such cells.
It seems likely that insufficient removal of field cells could lead to local recurrences.
We have begun to collect tissues of recurrent AMs for this purpose. The first case we
examined, which recurred three times over a period of 3 years, showed field cells at
the margins of all but the final excision (data not shown).
70% dei melanomi diagnosticati sono melanomi sottili (< 1mm) di tipo SSM
With more than 20 years of follow-up data for a cohort of 26,736 people
in the Australian state of Queensland diagnosed with thin melanomas,
we show that the long-term survival is 96%.
The major feature that independently has the most severe detrimental effect on
overall long-term survival from thin invasive melanoma was
Tumor thickness > = 0.75mm
The next most influential factor determining survival, was a diagnosis of
NodularMelanoma,
which continued to be disproportionately associated with ongoing deaths after 15 years.
Also influential in determining survival was
Patient age > 65 years
Melanoma on scalp or neck
Male sex
patients older than age 65 years with thin melanomas had an almost three-fold increase in
risk of dying from their melanoma.
In conclusion
1. We have confirmed that the outlook for patients with thin invasive melanoma is
generally extremely positive, with only 4 patients in 100 dying of their disease.
2. These data provide more solid justification for continuing efforts to
improve early detection through clinical surveillance and public education,
particularly among older people for whom both the risk of melanoma and the risk of dying
from that melanoma are comparatively high.
Melanoma nodulare
Advanced thickness of NM at presentation
• Delayed diagnosis
• Unique phenotype that fails the ABCD categorization
Nodular / non pigmented
• Rapid growth
• Median: 5 months for NM vs 9 months for SSM as assessed by patient
Opportunistic screening by physicians may have
the potential to reduce NM associated mortality.
THM - Istotipo
•
SSM
• Paziente giovane con molti nevi
• Sorveglianza per ulteriori melanomi metacroni
• NM
• Paziente anziano / Diagnosi tardiva
• Screening opportunistico dal medico generalista
• ALM
• Margini ma definiti e «field-effect»
• Rischio recidiva
• LMM
• Margini mal definiti
• Slow Mohs
I.
Diagnosi istopatologica
i. Staging istologico
ii. Istotipo
II. Patologia molecolare
Patologia molecolare
Markers predittivi per terapia a bersaglio molecolare
Mutazioni di BRAF / NRAS / c-KIT
Schema tratto da : J Clin Oncol 2006 (24):4340-4346
John A. Curtin, Klaus Busam, Daniel Pinkel, and Boris C. Bastian.
N Engl J Med 2005;353:2135-47.
CSD : chronic sun-induced damage
• Non-CSD melanomas (SSM & Nodular)
• high frequency of BRAF or NRAS mutations
• CSD melanomas (LMM)
• Acral, and Mucosal melanomas
• high frequency of mutations of c-KIT, amplifications of cyclin D1 &
CDK4-genes.
• 50% BRAF-mutation
•
V600E (75%), > V600K (20%) > V600R
• Vemurafenib / Dabrafenib
• SSM > NM (ALM 15%)
• 20% NRAS-mutation
• associated with a worse prognosis
•
MEK inhibition - Trametinib
• NM > SSM (ALM 15%)
• 15% KIT mutations
•
KIT-inhibitors: Sunitinib, Dasatinib, Imatinib
• Acral & LLM
Uguen et al. Diagnostic Pathology (2015) 10:121
Blocco paraffina
PCR
BRAF and NRAS testing can also be done
by immunohistochemistry (IHC).
• IHC with SP174-antibody (NRAS-Q61R)
• Sensitivity :100 % ; specificity 99 %
• IHC with VE1-antibody (BRAF-V600E)
• Sensitivity 100 % ; specificity 95 %.
The currently available antibody only allows for the testing of BRAF-V600E
mutations and NRAS-Q61R , thus they should only be used as a screening
method, combined with a molecular testing if negative.
False negative: BRAFV-600K / -600R / -600D
NRAS-Q61L / - Q61K
False positive : tumor heterogeneity / low tumor cells densitiy
Uguen et al. Diagnostic Pathology (2015) 10:121
• This work identified significant correlations between :
• BRAF mutations and SSM (superficial spreading mel.) on one hand, and
• NRAS mutations and Nodular melanoma on the other hand.
• It confirms the link between melanoma with BRAF-mutation and a
• more aggressive phenotype, with (..)
• early lymph node involvement and perhaps brain metastasis.
• Younger age at diagnosis of primary melanoma was significantly linked to
BRAF mutations.
PDL-1
PD-1 (a receptor expressed on T cells) binds to PD-L1(expressed on cancer cell) and
induces exhaustion of a cytotoxic immune response by causing T-cell apoptosis
PD-L1 is expressed on approximately 40–50% of melanomas.
PDL-1 - Analisi Immunoistochimica
• These treatments are superior to chemotherapy, but still, they do not work for
all patients.
• ORR of 34.1% (95% CI 27.6–41.3%) in the PD-L1 positive population
• ORR of 19.9% (95% CI 15.4–25.3%) in the PD-L1 negative population
• None of the three FDA approvals mention expression of PD-L1 as a prerequisite for
prescribing these drugs.
• There is a lack of defined criteria about what ‘PD-L1-positive tumor’ in a
tumor biopsy
• In trials of nivolumab, the cutoff used is 1% to 5% of positive cells in a biopsy.
• Different companies use PD-L1 reagents from different commercial sources
and, without doubt, these different reagents have different sensitivities.
• The most confounding factor is that PD-L1 expression in tumors is not stable:
not only can it be confined to different parts of tumors, but it can appear and
disappear, depending on treatments and other poorly understood influences.
•
•
PD-L1 expression was frequently discordant between primary tumors and metastases and
between intra-patient metastases
PD-L1 was associated with higher TIL grade
The results reported herein show that patients affected by melanoma,
NSCLC and genitourinary with positive PD-L1 may have a
Higher chance of response to nivolumab, pembrolizumab,
And MPDL3280A in comparison to PD-L1 negative tumor.
• This study shows that PD-L1 is an independent negative prognostic factor in
melanoma patients
•
In agreement with a negative prognostic role for PD-L1, our study shows that MM
express PD-L1 in significantly higher proportions than primary lesions (40.3% versus
14%) suggesting that PD-L1 expression is acquired during disease progression.
• The second result of this work is that PD-L1 expression appears to correlate
with shorter OS during BRAF-i treatment.
• Our results suggest that PD-L1 is not mechanistically responsible for the
more aggressive phenotype in melanoma cells.
•
PD-L1 expression marks a subset of melanoma cells characterized by a specific gene
expression profile and by increased growth and aggressiveness.
Molte terapie a bersaglio molecolare
potenziali in futuro
THM - Biomarker predittivi
• Analisi PCR per mutazione di BRAF, NRAS e c-KIT su exeresi cutanea o
metastasi di melanoma è predittiva di risposta ai farmaci a bersaglio
molecolare.
• BRAF e NRAS : espressi principalmente in SSM e NM.
• C-KIT : principalmente in ALM e LMM.
• Determinazione immunoistochimica di espressione di PDL-1 nelle cellule
di melanoma è predittiva di una maggiore probabilità di risposta al
Nivolumab, ma non è una contro-indicazione al suo utilizzo.
Contatto:
[email protected]
Presentazione in PDF su:
Istituto Cantonale di Patologia
6600 Locarno
Biomarkers prognostici/di screening
LDH:
• LDH is elevated in advanced disease.
• It seems to be particularly elevated in liver metastases for which no clear
explanation can be given (Finck et al, 1983; Heimdal et al, 1989; Sirott et al, 1993).
• LDH level was integrated into current staging system AJCC 2009
M1c.
S100B
• Preliminary multivariate data indicates that lower S100B concentrations
(<0.15 ug/l) at baseline and during follow-up are associated with significantly
better overall survival (J. M. Kirkwood, personal communication).
• However the sensitivity of S100B is low for stage I/II:
• 0–9% in stages I/II,
• 5–98% in stage III,
• 40–100% in stage IV
Kruijff et al., 2009
• Swiss and German guidelines recommend determination of S100B in serum of
patients with Breslow >1 mm lesions every 3–6 months
• S100B is tissue specific :
• neural crest derived : glial cells of the brain & melanocytes
• Specifico ma poco sensibile in stadio precoce
• LDH is expressed ubiquitously in tissues :
• In cell lysis : after myocardial infarction, haemolysis, in different tumors
(specially necrotic fast-growing tumors).
• Più sensibile in stadio precoce ma poco specifico
EBioMedicine 2 (2015) 671–680
To date, there are no circulating biomarkers that are
sensitive or specific enough to be beneficial for
early detection of melanoma (all stages).
• Micro-RNAs are small non-coding RNAs which regulate gene expression
and are released into the circulation by tumor cells.
• In recent years, circulating microRNAs (miRNAs) have been studied for
their utility as biomarkers in a wide range of malignancies and disorders
(Allegra et al., 2012; De Guire et al., 2013).
• Due to the ‘encapsulation’ of these miRNAs in serum or plasma they are
highly resistant to degradation by RNAses.
• In comparison with serum LDH and S100B, expression levels of the
‘MELmiR-7’ panel performed better than both markers in predicting
overall survival.
• The ‘MELmiR-7’ panel has the potential to be used as a primary
screening tool for clinically undetected metastatic melanoma due to its
high sensitivity (93%) and specificity(≥82%)
This panel would therefore be suited to monitor tumor burden
during routine follow-up
after primary excision of melanoma
MicroRNAs offer an attractive option as stable biomarkers for cancer
detection, diagnosis, and prognosis assessment in both the tumor tissue
and circulation.
It will be important to carry out prospective trials
in well-defined, large patient groups.
THM - Markers prognostici
• Micro-RNA
• Superiori a S100 e LDH per monitorare il paziente
dopo terapia chirurgica del melanoma per l’
identificazione precoce delle recidive.
• Sono necessari ulteriori studi con ampi gruppi ben
definiti di pazienti.