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8/6/2019 6a. Tumori Solidi
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TUMORI SOLIDI
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CA RCINOMA DEL POLMONE
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Angiogenesis
growth of new vessels from existing va scul a ture
P hysiologic a l wound he a ling, embryogenesis, menstru a tion
Pa thologic a l tumour growth, rheum a toid a rthritis, p sori a sis
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invasion angiogenesis intravasation
Adhesion to vesselwall in distant organ
micrometastasis metastasisExtravasation and migration
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S te p s in Angiogenesis
1. the rele a se of p rote a ses from "a cti va ted " endotheli a l cells
2. degr a d a tion of the b a sement membr a ne surrounding the existing vessel
3. migr a tion of the endotheli a l cells into the interstiti a l s pa ce
4. endotheli a l cell p rolifer a tion
5. lumen form a tion
6. gener a tion of new b a sement membr a ne with the recruitment of p ericytes
7. fusion of the newly formed vessels
8. initi a tion of blood flow.
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Hanahan and Folkman, 1996. Cell 86:353
The a ngiogenic switch hy p othesis - a b a la nce
between p ro - a nd a nti -a ngiogenic f a ctors
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The tumour a nd its surrounding en vironment a re known to p romote VEGF rele a se
IGF = insulin -like growth f a ctor; PDGF = p la telet -deri ved growth f a ctor; EGF = e p iderm a l growth f a ctor
EGF
Hyp oxi a PDGF
IL-8
b FGF
COX-2Nitric oxideOncogenes
VEGF rele a se Binding a nd a cti va tionof VEGF rece p tor -2
IGF- 1
P rolifer a tionS ur viva l Migr a tion
ANGIOGENESISP erme a bility
P P
PP
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The VEGF f a mily a nd its rece p tors
Migration, permeability, DNA synthesis, survival
Lymphangiogenesis
P PP
P
P P
PP
P P
PP
VEGF-A VEGF-B
PlGF
VEGF
receptor-1
VEGF-A
VEGFreceptor-2
VEGF-C VEGF-D
VEGFreceptor-3
Angiogenesis
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GR B2GR B2PL CKPL CK
p85p85
Ad ap ter molecule bindingAd ap ter molecule binding
Rece p tor dimeriz a tionAuto p hos p horyl a tionRece p tor dimeriz a tionAuto p hos p horyl a tion
VEGF R ece p tor Acti va tion
Lig a ndbindingLig a ndbinding
Dimeric VEGF lig a ndDimeric VEGF lig a nd
Tr a nscri p tionTr a nscri p tion
P erme a bility P rolifer a tion
Migr a tionAdhesionS ur viva l
P erme a bility P rolifer a tion
Migr a tionAdhesionS ur viva l
NucleusNucleus
Downstre a m sign a ling e vents Downstre a m sign a ling e vents
Endotheli a l cellEndotheli a l cell
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S tr a tegies to inhibit VEGF sign a lling
Ferrara & Kerbel Nature 438: 96797 4, 2005.
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Be va cizum a b (Ava stin)
VEGF isoforms recognised by hy p er va ria ble murine
a ntibody fr a gment
Hum a n Ig G-1
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Lanticor p o a nti -VEGF be va cizum a b blocc alinter a zione del VEGF con i suoi recettori
B evacizumab si lega alVEGF bloccando
linterazione con i recettorie lattivazione dellatrasduzione del segnale avalle
Il blocco del VEGFinduce la regressione dellavascolarizzazionetumorale
Bevacizumab
P P
PP
VEGF
X
Crescita
Proliferazione
Migrazione
Sopravvivenza
X
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mitogeno in vitro p er di versi tip i di cellule endoteli a li
induttore di a ngiogenesi in vivo
f a ttore di so p r avv ivenz a cellul a re in vitro
f a ttore di p erme a bilit va scol a re
stimol a la migr a zione cellul a re
inibisce lap o p tosi
Atti vit biologiche del VEGF
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The ErbB Fa mily
ErbB1 (HER 1, EGFR )
ErbB 2 (HER2 , neu)
ErbB 3 (HER3 )
ErbB 4 (HER4 )
4 ty p es of erbB rece p tor 4 ty p es of erbB rece p tor 11 Lig a nds e a ch with a common 11 Lig a nds e a ch with a common EGF like structureEGF like structure
EGF
EGF
TGF-a
Am p hiregulinBet a cellulin
Ep iregulin
HB-EGF
Ep igenNeuregulin 1 (NRG 1)
Neuregulin 2 (NRG2 )
Neuregulin 3 (NRG3 )
Neuregulin 4 (NRG4 )
ER B rece p tors
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Es p ressione di EGFR nei tessuti norm a li
Cute, appa r a to digerente, sistem a res p ir a torio, ghi a ndole m a mm a rie, appa r a to genit a le, appa r a to urin a rio, SN C, sistem a endocrino
E p resente sulle: cellule e p iteli a li cellule strom a li
cellule gli a li cellule muscol a ri lisce
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EGFR : FUNZIONE FISIOLOGI CA
Un a delle p rinci pa li vie molecol a ri a tti va te d a llEGFR q uell a di r a s. Ra s viene reclut a taa ttr av erso il leg a me con lamolecol a SOS .
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A su a v olt a , r a s determin alatti va zione dell a
serin a/ treonin a chin a si r a f, delle MAPKK 1 e 2 e delle MAPK ERK 1 e 2.
EGFR : FUNZIONE FISIOLOGI CA
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Il risult a to dell atti va zione di q uest a v ia molecol a re les p ressione di va rie p roteine nucle a ri, inclus a la ciclin a D 1 (necess a ria p er il pa ss a ggio G
1-S nel ciclo cellul a re).
EGFR : FUNZIONE FISIOLOGI CA
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TKTK
S ur viva l(a nti -ap o p tosis)
PI3-K
STAT3
AKTPTEN
MEK
Gene tr a nscri p tionMAPK
P rolifer a tion /m a tur a tion
Chemother ap y /
r a diother ap yresist a nce Angiogenesis Met a st a sis
pY
pY RAS R AFSOS
GR B2pY
G1
SM
G 2
Anticor p i monoclon a li
P iccole molecole a nti -TK
S tr a tegie a nti -EGFR
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Ty rosine KinaseDomain
Ligand
Ligand bindingDomain
P PP85
P100
PI 3 Kinase
Extr a cellul a r
GROWTH, DIFFERENTIATION, APOPTOSIS ETC
Membr a ne
Intr a cellul a r
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Su mmar y of EGFR m u tations (PNA S 2004 101 13306)
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7 28 8 7 57 617 29688 8248237 62
A review of 3016 cases from the literature.Chan , Hill and Gullick EJC 2006 42 17.
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Mut a tions a re a ssoci a ted with N e ver -S mo kers, gender a nd Histologic a l subty p es
Mut a tions a re more common in Ea st Asi a ns (30 .6% th a n in
Ca uc a si a ns (7 .6% ) p
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Hepatocellular 0/7 3 Lee et al. 2005
Pancreatic 2/55 ( 4%) Kwak et al. 2006
EsophagealB arrets
2/17 (12 %)3/21 (14%)
Kwak et al. 2006Kwak et al. 2006
Colon 0/9 8 Lee et al. 2005
B reast 0/ 42
0/150/111/9 3
Generali et al. 2007
Lynch et al. 200 4B argava ert al. 2005Lee et al. 2005
Head & Neck 17/10 8 (16 %)1/100 (1 %)
3/41 (7%)
Na et al. 2007Leoffler-Ragg et al.2005Lee et al. 2005
Cholangeocarcinoma 3/22 (14%) Gwak et al. 2005
A cute A dult Leukaemia 0/ 88 Lee et al. 2005
Gastric 0/1 85 Lee et al. 2005
Other 9/566 (2 %) S ihto et al. 2005
Incidence of Kinase Mutations in Other Tumour T ypes
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Current receptor inhibitors
Monoclonalantibodies
S mall moleculeRTK inhibitors
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K
R
K
R
K
Tumor res p onseTumor res p onse
Ova ryP rost a te
Lung
Colon
Ga stric
Bre a st
m A bm A b
S m a ll mol.S m a ll mol.
HER f a mily: ta rgeted app ro a ches
Extern a l dom a inExtern a l dom a in
Intern a l dom a inIntern a l dom a in
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Res p onses in pa tients with or without mut a tions
Howe ver 12.3% of pa tients with mut a tions p rogress on TKIs a nd 86 .8% a chie ving st a ble dise a se p ossess wt EGFR
Pa tients with NS CLC res p onsi ve to gefitinib or erlotininb a re more likely to h a rbour mut a tions th a n
not (76 .7% v s 23 .3% )
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Associ a tion of S ite of Mut a tion a nd S ensiti vity to TKI tre a tment
Riel y et al. Clin Cancer Res 2006 12 72 32
85-90 %Total
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De velo p ment of Drug Resist a nce
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EML4-ALK fusion in N S CLC
N termin a l p ortion of EML4 w a s
fused to the intr a cellul a r kin a se
dom a in of ALK
Both m ap to the short a rm of
chromosome 2 (2p2 1 a nd 2p23
res p ecti vely)
Soda et al. Nature (2007) 448: 561-6
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ALK
ALK is a tyrosin -k in a se rece p tor
ALK is ex p ressed in br a in a nd testis
ALK w a s identified a s a fusion pa rtner of NP M1 in
a n ap la stic la rge -cell lym p hom a with t(2 ;5)
S ince then fusion genes in vol ving ALK h av e been
described in ALCL, infl a mm a tory myofibrobl a stic
tumors a nd neurobl a stom a s
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EML4-ALK
W ild -ty p e ALK is thought to be a cti va ted in res p onse to binding of a s p ecific lig a nd
EML4ALK is oligomerized via the coiled coil dom a in (CC) of EML4
Resulting in p ersistent mitogenic sign a ling th a t le a ds to m a lign a nt tr a nsform a tion.
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Tr a nsforming a bility of EML4-ALK
Exp ression p la smids for EML4 ALK
Introduced it into mouse 3T3 fibrobl a sts
S ubcut a neous injection
of the tr a nsfected 3T3cells into nude mice formed tumors
Soda et al. Nature (2007) 448: 561-6Soda et al. PNAS (2008) 106:19893-7
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Conclusion
EML4- ALK fusion is r a re e vent in NS CLC (5- 10% )
P resent in both Asi a ns a nd North
Americ a n /E uro p e a n p o p ul a tionExclusi ve to NS CLC
More common in ne ver smo kers
ALK inhibitors m a y h av e a role in the tre a tment of NS CLC with EML4- ALK fusion
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CA RCINOMA DELL A MAMMELL A
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Role of HER2 in bre a st c a ncer Role of HER2 in bre a st c a ncer
HER2 gene a m p lific a tion or rece p tor o verex p ression occurs in app roxim a tely 30% of met a st a tic bre a st c a ncers
HER2-p ositi ve tumours a re a ssoci a ted with p oor p rognosis a nd shortened dise a se -free /o ver a ll sur viva l
HER2 rece p tor p ro vides a n extr a cellul a r ta rgetfor no vel a nd s p ecific a ntic a ncer tre a tment
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Tr a nsmembr a ne structure of Tr a nsmembr a ne structure of HER2 monomer HER2 monomer
Extr a cellul a r dom a in(632 a mino a cids)Lig a nd -binding site
Intr a cellul a r dom a in(580 a mino a cids)Tyrosine kin a se a cti vity
Tr a nsmembr a ne dom a in(22 a mino a cids)
Cyto p la sm
P la sm amembr a ne
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Indic a tors of incre a sed HER2 p roductionIndic a tors of incre a sed HER2 p roduction
Am p lific a tion /o verex p ression
1
2
3
4
1 = o gene co p y number 2 = o m RN A tr a nscri p tion3 = o cell surf a ce rece p tor p rotein ex p ression4 = o rele a se of rece p tor extr a cellul a r dom a in
A = HER2 DN AB = HER2 RN AC = HER2 rece p tor p rotein
Norm a l
Nucleus
Cyto p la sm
Cyto p la smicmembr a ne
C
B
A
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HER2 technic a l app ro a chesHER2 technic a l app ro a ches
Gene a m p lific a tion
FISH/ CISH
P rotein o ver -ex p ression
immunohistochemistry
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HER2HER2--p ositi ve IHC st a inp ositi ve IHC st a in
2+ 3+3+0 1+
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Du a lDu a l--color FISHcolor FISH
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No a m p lific a tion Am p lific a tionAm p lific a tion
HER2 a m p lific a tion by FISHHER2 a m p lific a tion by FISH
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Her2 testing algorithmHer2 testing algorithm
Pa tient tumour s a m p le
IHC FISH
2+ 3+ +
Retest withFISH
Tr a stuzum a bTr a stuzum a bther ap yther ap y
Tr a stuzum a bTr a stuzum a bther ap yther ap y
+
Tr a stuzum a bTr a stuzum a bther ap yther ap y
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Tr a stuzum a b: Tr a stuzum a b: hum a nised a ntihum a nised a nti --HER2 monoclon a l a ntibodyHER2 monoclon a l a ntibody
B ersaglio : loncoproteina HER2
A lta affinita (Kd=0.1nM )
e specificita
95 % umano , 5% murino D iminuito potenziale
immunogeno A umentato potenziale per
arruolare meccanismieffettori immuni
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P iccole molecole a d a tti vit a nti -tirosinchin a si che blocc a HER 1 ed HER2
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Erlotinib Gefitinib Lapa tinib
S mall head group quinazolines Large head group quinazoline
Inibitori tirosin -chin a sici
NN
O O
NH
O ON
O
NN
O O
NH
Cl F
NH
S
O
NN
NH
Cl
OO
O
F
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70-80% s p or a dici
15-20% f a mili a ri
5-10% eredit a ri
Bre a st Ca ncer Bre a st Ca ncer
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Condizione di p redis p osizione eredit a ria :
p i c a si di c a rcinom a a lla m a mmell a in pa renti di p rimo gr a do
so p r a ttutto in gio va ne et o con un coin volgimento di
entr a mbe le m a mmelle
c a rcinom a dell o va io in f a mili a ri di p rimo gr a do
c a si di c a rcinom a dell a m a mmell a m a schile (BRCA2)
TUMORE DELL A MAMMELL A FAMILIARE
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Nel 1 994- 1995 sono st a ti identific a ti duegeni res p ons a bili dell a suscettibilit a lc a ncro dell a m a mmell a : BRCA1, sulcromosom a 17, e B RCA2 sul cromosom a13.
Gli indi vidui p ort a tori di mut a zioni a c a ricodi uno dei due geni h a nno un rischiom a ggiore di insorgenz a di tumore a llam a mmell a o tumore o va rico a d un certo
p unto dell a loro vita .
TUMORE DELL A MAMMELL A FAMILIARE
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inibiscono l a crescit a delle ghi a ndole m a mm a rie
inter a giscono con le p roteine RAD (p roteine del ri pa ro)
regol a no l atti vit di a ltri geni (p2 1) (p rotein a regol a trice dell atr a scrizione del DNA
gioc a no un ruolo fond a ment a le nell embriogenesi
BRCA1 /BRCA 2
FUNZIONI
B RCA1 (17q2 1) e B RCA2 (13q 12) sono colleg a te ed integr a te in a lcuni
fond a ment a li pa thw a y di ris p ost a a l da nno del DNA.
ON COSOPPRESSORI
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S ono st a te identific a te oltre 600 mut a zioni (p roteinetronche, in a tti va zione genic a ) in B RCA1 e B RCA2
BRCA1 /BRCA2
ANALISI MUT AZION ALE DI TUTT A LA SEQUENZ A GENI CA
BRCA1: 24 esoni (ATG in ex 2)
BRCA2: 27 esoni (ATG in ex 2)
Test di a gnostico:
Ca m p ione di P B
BRCA1 /17q2 1BRCA1 /17q2 1
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BRCA1 /17q2 1BRCA1 /17q2 1
BRCA2/13q 12BRCA2/13q 12
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P edigree of a f a mily with germline BRCA2: 6503 del TT mut a tion
f ather mother
proband
BRCA2 mut
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Clinic a l P resent a tion
Ea rlier th a n av er a ge a ge of onset me a n 45
Pa ttern of p rim a ry c a ncers segreg a ting in f a milyDistinguishing pa thologic a l fea tures
CRC usu a lly in vol ves the p roxim a l colon
Incre a sed incidence of synchronous a nd met a chronous C RC
S ur viva l r a te for C RC app e a rs better th a n th a t of i t s s p or a dicva ria nt
Extr a colonic c a ncers (Lynch II)
HNP CC: CARCINOM A DEL COLON .-RETTO F AMILIARE NONPOLIPOSI CO
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Pa thology
P oorly differenti a ted, mucinous a nd incre a sed incidence of signet
cells
Dip loid, p eritumor a l lym p hocyte infiltr a tion a nd Crohn s li ke re a ction
Adenom a s found in 20% of colons in HNP CC pa tients with C RC
Colonic a denom a s tend to occur e a rlier, a re l a rger a nd more often
villous with more high gr a de dys p la si a
Acceler a ted r a te of a denom a to c a rcinom a
HNP CC: CARCINOM A DEL COLON-RETTO F AMILIARE NONPOLIPOSI CO
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1. Ep itelio p rolifer a nte mut a zioni in A P C
Cromosom a 5
Le cellule e p iteli a li sfuggono pa rzi a lmente a l controllo del
ciclo cellul a re
Le cellule si di vidono p er form a re un p iccolo cluster che
p ort a a d un p oli p oGli indi vidui eterozigoti ne form a no d a 100 a 1000
FAP : Fa mili a l Adenom a tous P oly p osis
2. Adenom a intermedio - Mut a zioni dell oncogene r a s
Cromosom a 12
Crescit a m a ggiore e p rotrusioni a form a di dit a
3. Adenom a ava nz a to D CC /18q - deleted in colon c a ncer
4. Adenoc a rcinom a - P erdit a o in a tti va zione di TP53/ 17p 13
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MODELLO MULTI-HIT
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GENI DI RISPOST A AL D ANNO DEL DN A
Ripa r a no i d a nni del DNA
La p erdit a dell a loro funzione determin a laccumulo di mut a zioni in a ltri geni cruci a li
Consider a ti un gru pp o di GENI SOPPRESSORI
HNP CC: CARCINOM A DEL COLON .-RETTO F AMILIARE NONPOLIPOSI CO
Germline mut a tion in DNA mism a tch re pa ir genes resulting in
micros a tellite inst a bility
Inherited in A D m a nner
Accounts for 1 -3% of a ll c a ses of C RC (b a sed on detection of
germline mut a tions)
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HNP CC
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Micros a tellite Inst a bility Pa thw a y
Va rious re pa ir mech a nisms a re ava ila ble to correct a ny errors occurring
during DNA re p lic a tion
One ty p e of error c a lled sli ppa ge c an occur during the re p lic a tion of
micros a tellite se q uences by DNA p olymer a se
Micros a tellite DNA se q uences a re defined a s short dinucleotide or
mononucleotide re p e a ts
These se q uences a re usu a lly within non coding regions a lthough some
genes cont a in micros a tellites within coding regions (e.g., TGF- rece p tor
II, Insulin li ke growth f a ctor II rece p tor, regul a tors of the cell cycle e.g.
E2F4 , regul a tors of ap o p tosis e.g.B AX
a nd e ven the MMR genesthemsel ves )
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Ea rly di a gnosis of heredit a ry of colorect a l c a ncer
AP C mut a tions MLH1(51%), MSH6(45% )MSH2 , PMS 1 a nd PMS2(3% ) mut a tions
Familial adenomatous pol yposis Hereditar y non-pol yposis colon cancer
>25 : a nnu a l colonsco p y
>35 : a nnu a l colonsco p y, CA -125 , gynecologicex a min a tion, tr a ns va gin a l ultr a sonogr ap hy
>45 : BSO ( bil a ter a l s a lp ingo -oo p horectomy)p refer a bly with LAVH (lapa rosco p ic tr a ns -va gin a l histerectomy)
>1 5: a nnu a l colonsco p y
>25 : a nnu a l upp er g a strointestin a lendosco p ies
No s p ecific a d vice for a slithly higher ris k of he pa tobl a stom a ( in childhood) a nd pap illa rythyroid c a ncer (in young women)