Melanoma e carcinoma pancreatico · 2010-12-01 · Polygenic inheritance, small number of low penetrance genes Possible there are other genes responsible for melanoma in a small proportion

TUMORI EREDITARI: dalla biologia molecolare al trattamentoModena 18-19 novembre 2010

Melanoma e carcinoma pancreatico

Giovanna Bianchi-ScarràDipartimento di Oncologia Biologia e GeneticaUniversità di Genova /Genetica dei tumori ereditari rariAzienda Ospedale San Martino

TUMORI EREDITARI: dalla biologia molecolare al trattamento

Melanoma: the general picture

Malignant melanoma is an often fatal form of skin cancer that arises from the malignant transformation of cutaneous melanocytes.

Melanoma accounts for roughly 48,000 deaths worldwide annually (World Health Organization, 2006).

Incidence rates have been steadily rising in many Western countries; the highest are generally observed where fair-skinned populations are exposed to high levels of solar UV radiation (Parkin et al., 2005)

Intensive surveillance aiming at early diagnosis is recommended (National Comprehensive Cancer Network NCCN 2010).


Who is at risk ?

Sun-sensitive skin type

Eye and hair color

Excessive sun exposure

Blistering sunburnsduring childhood

High nevus density

Familiality


Melanoma Risk Factors

EnvironmentPhysical Traits

High-Risk Genes

Sun exposure

Skin type, hair color,moles

genes


Today’s focus will be on:

The general framework

The shared Italian approach and the international approach to genetic counseling and DNA testing in

hereditary melanoma families

Underlying issues + future directions


The Framework

Genetic Susceptibility

Susceptibility to melanoma is an autosomal dominant trait with incomplete penetrance and variable expressivity

As many as 40% of melanoma kindreds carry mutations in the major susceptibility genes (Miller & Mihm, 2006); (Molven et al., 2005).


The Framework

Hereditary melanoma

P.CNod.

SS

Inheritance : autosomal dominant trait

incomplete penetrance and variable

expressivity

ND


The Framework

Major susceptibility genesCDKN2A (9p21), CDK4 (12q13)


The Framework

The CDKN2A locus

CDKN2A-arf CDKN2A

1 1 2 3

p14ARF

132 aa

p16

156 aa

Cen TelP P

p15

138 aa

1 2

CDKN2B


The Framework

The CDKN2A locus

CDKN2A-arf CDKN2A

1 1 2 3

p14ARF

132 aa

p16

156 aa

Cen Tel

P

P P

p15

138 aa

1 2

CDKN2B


The Framework

The CDKN2A locus

CDKN2A-arf CDKN2A

1 1 2 3

p14ARF

132 aa

p16

156 aa

Cen Tel

P

P P

p15

138 aa

1 2

CDKN2B


The Framework

Heterogeneity of family size


The Framework

Heterogeneity of family size

Arg24Pro (CDKN2A) kindreds of Italian origin living

in Australia and in Liguria

Pancreatic cancer !!


The Framework

GenoMELGENOMEL EU FP6 Network of Excellence, 2005-2010

“Genetic and environmental risk factors for melanoma:

translation into behavioural change”

•Identify new melanoma susceptibility genes

•Assess the risk of melanoma and other cancers associated with the impairment of these genes

•Evaluate gene – environment interactions


The Framework: Development of internationalconsensus on clinical testing Kefford et al., 1999: “It is premature to offer DNA testing

outside of defined research protocols, except in rare circumstances and only after careful genetic counseling …”

Kefford et al., 2002: “In countries of low melanoma incidence, or where founder mutations are prevalent and contribute to the observed familial clusters (…) DNA testing may improve compliance with sun protection and surveillance in mutation carriers”

Italy and the Netherlands have prevalent founder mutations and amongst GenoMEL were among the first to start with clinical testing


The Framework: Towards genetic counseling in Dutchmelanoma families

Psycho-oncological study

Distress levels were associated with worriesand anxiety over pancreatic cancer, but were low compared to those reported after counselingfor treatable cancers in other syndromes.


Who should be referred for genetic counseling for melanoma in Italy ?

2004 SIGU-ONC recommendations

for genetic counseling and testing

for hereditary melanoma

Protocol shared by genetic services in Italy

Key point:

genetic testing can be offered after counseling to

families with at least 2 affected members.


MILANO

TORINOBOLOGNA

FIRENZE

NAPOLI

PADOVA

ROMA

BARI

MESSINA

GENOVA

PALERMO

RAGUSA

Nine medical genetics

services/hereditary tumor

centers offer counseling,

some also testing – others

send samples to Genoa.

Messina, Ragusa, Palermo

to start counseling

Italy

Aim:

CDKN2A mutation frequency in Italy

The Framework

The shared Italian approach


CDKN2A mutations


Comment

No significant difference in mutation rate

between the families with 1 and families with 2

tested cases* as expected in a country of low

incidence such as Italy where the likelihood of

chance clustering of cases in a family is low

Implications for genetic testing

selection criteria !!

* confirmed melanomas



skin screening twice

yearly

The shared Italian approach

Mutation-positive

family member

Mutation-negative

family member

skin screening

as

recommended

by dermatologist

Follow up in CDKN2A/CDK4- negative families

Follow up in CDKN2A/CDK4-positive families


The International Approach

Selection criteria for genetic assessment

of patients

with familial melanoma

J Am Acad Dermatol. 2009 Oct;61(4):677.e1-14.

S A Leachman, J Carucci, W Kohlmann, M M Asgari, W Bergman, G Bianchi-Scarrà, T Brentnall, B Bressac-de Paillerets, W Bruno, C Curiel, F A. de Snoo, T Debniak, MF Demierre, D Elder, A

Goldstein, J Grant-Kels, A C Halpern, C Ingvar, R Kefford, J Lang, R M MacKie, G Mann, K Mueller, J Newton-Bishop, H Olsson, GM Petersen, S Puig, D Rigel, S Swetter, M Tucker, E

Yakobson, JA Zitelli, H Tsao


The International Approach

The data gathered in this paper will aid clinicians in the identification of:

The melanoma patients that are most likely to benefit from referral to a clinical genetics service for discussion of their melanoma risk

Higher rates of CDKN2A/p16 positivity



The Issues Future Directions

MPM and CDKN2A mutation*

CDKN2A and PC risk – internationally and in Italy

Mutations with unknown functional significance*

Wild-type families

Behavioral studies*

b)


MPM and CDKN2A mutation*

New criterion for access to genetic testing?


MPM in north-western Italy

L. Pastorino et al. Pigment Cell Melanoma Res.2008

Hospital-based case-case study comparing frequency of CDKN2A and MC1R mutations in MPM and single primary melanoma (SPM) cases

CDKN2A mutation frequency

32.6% in MPM (31 ⁄ 95)

vs

11.1% (44 ⁄ 398) in SPM patients

(OR = 4.27; 95% CI 2.43–7.53)


MultiMEL projectMain objectives

Identify the frequency of mutations in CDKN2A and CDK4 in MPM patients on a national basis to establish whether MPM may be added as a new criterion for genetic testing for hereditary melanoma

Define the role of modifier genes, especially variants of the MC1R gene, in the development of MPM.


Methods Study design: case-case-control, multicentric, retrospective, hospital-

based.

N. of subjects: at least 20 cases of MPM and 20 cases of SPM (or multiples of 20) and associated controls for each participating center (minimum 200 MPM)

Population: MPM and SPM patients.

Length: End of enrollment: December 2011

End of molecular analyses: June 2012

End of statistical analyses: December 2012


Preliminary results : (151 patients )

34% of MPM cases carry CDKN2A mutations, regardless of family history (51/151) :

- 19% of non-familial MPM patients are mutation positive (19/100)

-18.6% of patients with two melanomas (14/75) need to confirm

- 45.5 % patients who developed 3 or more melanomas have a mutation frequency of (5/11) too soon


CDKN2A and PC risk - internationally and in Italy

GenoMEL data: ≈ 28% of CDKN2A mutation positive families (3 affecteds) have ≥ 1 case of PC (453)

“Since the association between some mutations and PC is still unclear, and could depend on other co-factors, counseling on PC risk should be managed carefully”



0

1

2

3

4

5

6

7

8

39 49 59 69 74age at diagnosis (yrs)

cum

ulat

ive

risk

of p

ancr

eatic

can

cer p16(+) p16(-) General Population

(RR 9.4 fold-% CI 2.7-33.4) (Ghiorzo et al. 2004)

Understanding individual risk of PC requires that studies be carried out in which individuals rather than families be classified according to their mutational status

Cumulative risk of pancreatic cancer according to p16 (G101W) status in Ligurian f amilies


Hospital-based case-control research project

PCCR Questionnaire including accurate family history confirmed through cancer registry

Molecular analyses (CDKN2A; BRCA1 e 2; STK11; MLH1, MSH2, MSH6; palladin; PALB2) sequencing and MLPA

Study aim

Improve our ability to identify individuals who are at high risk of

developing pancreatic cancer because of their genetic background.

Study design


Variants with unknown functional significance

Functional analysis for novel missense mutations

I. p16-CDK binding assay

II. Growth inhibition assay

III. Subcellular micro-localization

GenoMEL Referral laboratory (prof. Mann - Sydney )

(dr. Scaini - Padova )


Functional analysis for

CDKN2A 5’UTR variants

reporter assays

polysomal profiling as a means to determine the relative

impact of the 5’-UTR variants on mRNA translation efficiency

starting from heterozygous patients’ cells. (-21,-25,-57-64).

Referral Laboratory (prof. G.Bianchi Scarrà )


Wild-type families


Wild-type families


Where are all the other melanoma predisposition genes?

High risk: 1p22 locus associated with early onset melanoma families

There is another gene responsible for late age of onset or the majority of families that show later onset are clusters of cases that do not share a Mendelian gene defect predisposing them to melanoma?

Polygenic inheritance, small number of low penetrance genes

Possible there are other genes responsible for melanoma in a small proportion of families but because of their small overall effect and locus heterogeneity for melanoma suscepibilty, it would be difficult to identify such families through conventional linkage

Revert to candidate gene approaches (as for CDK4)


Where are all the other melanoma predisposition genes?

Low risk: several candidate genes, no replication, gene haplotypes not covered fully, bias towards positive findings

Notable exception: association between functional variants ofthe melacortin 1 receptor MC1R and melanoma (one of the most replicated case-control associations in all of biology)


9p21,16q24,11q14-21

9p21

Adjacent MTAP

flanking CDKN2A

11q14-21

TYR

16q24

MC1R

Despite variation in allele frequencies

these variants show omogenity of

effect across pop of European

ancestry living at different latitudes


Future directions

GenoMEL Behavioral studies –

How do melanoma families perceive geneticresearch & testing?

Ongoing study

Questionnaire developed in English and translated into ten different languages

Administered on-line or in person to all available and consenting members of GenoMEL families


Future directions

GenoMEL Behavioral studies

Melanoma risk factors, perceived threat and intentional tanning: an international online survey

Eur J Cancer Prev. 2010 May;19(3):216-26.

Bränström R, Chang YM, Kasparian N, Affleck P, Tibben A, Aspinwall LG, Azizi E, Baron-Epel O, Battistuzzi L, Bruno W, Chan M, Cuellar F, Debniak T, Pjanova D, Ertmaoski S, Figl A, Gonzalez M, Hayward NK, Hocevar M, Kanetsky PA, Leaf SL, van Nieuwpoort FA, Heisele O, Palmer J, Peric B, Puig S, Ruffin AD, Schadendorf D, Gruis NA, Brandberg Y, Newton-Bishop J.


Future directions

GenoMEL Behavioral studies

Predictors of sun protection behaviors and severe sunburn in an international online study.

Cancer Epidemiol Biomarkers Prev. 2010 Sep;19(9):2199-210.

Bränström R, Kasparian NA, Chang YM, Affleck P, Tibben A, Aspinwall LG, Azizi E, Baron-Epel O, Battistuzzi L, Bergman W, Bruno W, Chan M, Cuellar F, Debniak T, Pjanova D, Ertmanski S, Figl A, Gonzalez M, Hayward NK, Hocevar M, Kanetsky PA, Leachman SA, Heisele O, Palmer J, Peric B, Puig S, Schadendorf D, Gruis NA, Newton-Bishop J, Brandberg Y.


Thank you


AcknowledgementsDipartimento di Oncologia, Biologia e Genetica - Università degli Studi di Genova

Dr.P.Ghiorzo, Dr.L.Pastorino, Dr.W.Bruno, Dr. S.Gargiulo , Dr.S.Nasti, Dr.P.Origone

I.S.T.

Dr.P.Queirolo

Prof. P.L.Santi, Dr.S.Gliori, Dr.M.Adami, Dr.M.Muggianu

Prof. M.Sertoli

Azienda Ospedaliera Universitaria San Martino

Clinica Dermatologica (prof A.Parodi)

Dermatologia ospedaliera (dott G.Ghigliotti )

Collaborations:

GenoMEL-European Network of Excellence (2005-2010)

IMI -Italian Melanoma Intergroup

Dr.A.Goldstein. Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA

Dr S.Leachman. Huntsman Cancer Institute, University of Utah, Salt Lake City, USA

Prof.J.Newton Bishop. ICRF Genetic Epidemiology Laboratory, St. James’ University Hospital, Leeds, England

Documents

Melanoma e carcinoma pancreatico · 2010-12-01 · Polygenic inheritance, small number of low penetrance genes Possible there are other genes responsible for melanoma in a small proportion