Molecular profiling of the tumor is a step towards personalized cancer treatment. Follicular thyroid cancer. Anaplastic thyroid cancer

Molecular pathology of lung cancer studies the totality of morphological and molecular genetic features of this tumor. At the same time, the most important aspects problems are the determination of biomolecular and histogenetic markers of cancer, as well as the pathology of apoptosis in lung cancer.

Biomolecular markers of lung cancer are diverse, apparently coincide with markers of non-radiation lung cancer and are represented by various genes, proteins, hormones and other molecules.

Cellular oncogenes in lung cancer. In the pathogenesis of lung cancer highest value have cellular oncogenes of four families: myc, ras, bcl, erb-B.

The myc family of cellular oncogenes - c-myc, L-myc, N-myc - is represented by immediately reacting genes and encodes cellular regulatory proteins that induce proliferation and suppress differentiation. It was found that in the absence of growth factors, an increase in c-myc expression does not lead to cell division, but to apoptosis, which can be inhibited by bcl-2. Amplification of c-myc is found in 10-25% of lung cancers, while L-myc and N-myc are found only in neuroendocrine lung tumors (10-30%). Determination of increased expression of myc oncoproteinins is recorded much more often.

L-myc expression is found only in the group of neuroendocrine lung tumors, and c-myc expression in both the group of small cell and non-small cell lung cancer. In the group of small cell lung cancer, a significant correlation of L-myc and c-myc expression with the presence of metastases and tumor size was established.

The ras family of cellular oncogenes often undergoes changes during tumor growth. The genes encode the synthesis of p21 proteins, which have GTPase activity and bind to GTP and thereby affect the transmission of the growth signal to the cell. Mutations that activate the ras genes and are localized in codons 12, 13, and 61 are described. Most often, K-ras mutations are found in lung cancer, which are inherent only in non-small cell lung cancer, in contrast to small cell lung cancer. The frequency of K-ras mutations in lung adenocarcinomas is up to 30%, and in squamous cell lung cancer only 3%. Communication shown K-ras mutations with smoking.

K-ras mutations were found in lung precancer - atypical hyperplasia of the alveolar epithelium. Expression of p53 has been described in the same foci. Correlations were found between higher expression of this oncoprotein with glandular differentiation of lung cancer. High expression of ras protein products was also recorded in foci of lung adenomatosis and in oval and slit-like epithelial structures in scars.

The bcl-2 family consists of bcl-2, bax, bak, bclXL, bclXS, protein products which are able to form homo- and heterodimers, which sometimes have a diametrically opposite effect on the proliferation and apoptosis of tumor cells. The most studied of this family, bcl-2, is localized on the inner membrane of mitochondria, as well as in the nucleus, stimulates cell proliferation and inhibits apoptosis, probably due to antioxidant activity. On the contrary, bax proteins, whose transcription and synthesis is regulated by p53, block proliferation and stimulate apoptosis of tumor cells. BclXL inhibits apoptosis and stimulates proliferation, while bclXS, on the contrary, induces apoptosis. Thus, the balance between the protein products bcl-2 - bax, bclXL-bclXS and determine the shift of the balance towards proliferation or apoptosis in the tumor.

Suppressor genes in lung cancer. The role of suppressor genes in the development of tumors is reduced to blocking apoptosis and removing their suppressive effect on cellular oncogenes, which ultimately ends with the activation of proliferation. To realize the effect of damage to suppressor genes, the changes must affect both alleles of the gene, since a mutated suppressor gene is always treated as intact as recessive to dominant. For example, a mutation or deletion of one of the alleles of a suppressor gene must be accompanied by a loss or change in the other allele.

Suppressor genes in lung cancer are relatively well understood. The most common chromosome deletions are known, affecting the following regions: 3p21-24, 17p13, 13q14, 9p21-22 and 5q21. The 3p21-24 deletion occurs most frequently: in small cell cancer - in 100% and in non-small cell - in 85% of cases. But not a single suppressor gene is localized in this zone. Other sites correspond to known suppressor genes. So, for example, p53 is localized in 17p13, the retinoblastoma gene is located in 13q14, p16 INK4B(MTS1) and p15 INK4B(MTS2) - 9p21-22. The functions of most of these genes are well known and are associated with the control of the G1 phase of the mitotic cycle and/or apoptosis. Their inactivation causes the development of apoptosis. The detection of genome damage in the area of ​​localization of suppressor genes at the stage of precancerous changes indicates the involvement of these genes in the early stages of tumor growth. Currently, a number of new suppressor genes have been described that appear to be important for the development of lung cancer and are localized on chromosomes 1 and 16.

The p53 gene is exposed to the most frequent changes with tumor growth. Wild-type p53 (natural) is a transcription factor with multiple functions, including regulation of cell transition from G1 to S-phase, DNA repair, and apoptosis following genome damage. A deletion of one of the alleles (17p13) in combination with a point mutation in the other allele is a genetic rearrangement observed in most malignant tumors. The mutated p53 actually acts as a cellular oncogene, stimulates the proliferation of tumor cells and induces the formation of antibodies that are detected in the blood of patients. The latter served as the basis for the development of immunodiagnosis and immunotherapy for lung cancer.

The mutation causes conformational changes in the p53 protein, and it accumulates in the cell nuclei, which makes it possible to determine it by immunohistochemical methods. On the contrary, wild-type p53 is considered to have a very short half-life (20 min) and therefore cannot be determined immunohistochemically. Inactivation of p53 in lung cancer occurs in about 70% of cases. Studies on the correlation of p53 expression with survival are controversial. In general, if such an action exists, it is very insignificant. The association of p53 with malignant transformation is also unclear. At the same time, experimental data show that upon activation of wild-type p53, growth slows down and apoptosis develops, which can lead to reversal of the malignant phenotype.

There is evidence for the significance of the p53 mutation in the early stages of lung carcinogenesis. Mutant forms of p53 are never detected in reserve basal cell hyperplasia or squamous metaplasia without signs of dysplasia. In p53 dysplasia, mutations are detected in 12-53% of cases, and in cancer in situ - 60-90% of cases in studies of tissue surrounding lung cancer. Detection of p53 in more than 20% of cells in dysplasia foci is a marker of irreversible precancerous changes. However, p53 mutation is not a necessary phenomenon in lung cancer, and therefore the absence of p53 is not a favorable prognostic factor. Moreover, neither the accumulation of p53 nor its mutation exhaust the molecular mechanisms through which p53 can be inactivated in tumors. Disruption of p53 function occurs when it interacts with other proteins that regulate the mitotic cycle - p21, Mdm2, bax.

The Rb gene is localized at the 13q14 site, which is deleted in 80% of small cell lung cancer cases (as often as in retinoblastoma), encodes a 110 kDa nuclear phosphoprotein, and controls the exit of the cell from the G1 phase. Hypophosphorylation of Rb leads to cell blockade at the G1 stage and apoptosis. Rb inactivation in tumors is achieved by loss of one of the alleles and mutation of the second allele of the gene.

Thus, inactivation of the p53 and Rb suppressor genes is more important for the development and progression of small cell lung cancer.

Growth factors, growth factor receptors and binding proteins in lung cancer. Growth factors play a role in the progression of lung cancer important role, providing tumor growth with the help of autocrine and paracrine stimulation.

Adhesive molecules and extracellular matrix in lung cancer. Adhesive molecules, integrin receptors and the extracellular matrix of lung cancer have a modulating effect on tumor cells and ensure the growth, invasion and metastasis of the tumor, as discussed in the previous sections of the lecture.

The first phase of tumor invasion is characterized by a weakening of contacts between cells, as evidenced by a decrease in the number of intercellular contacts, a decrease in the concentration of some adhesive molecules from the CD44 family, etc., and, conversely, an increase in the expression of others that ensure the mobility of tumor cells and their contact with the extracellular matrix. On the cell surface, the concentration of calcium ions decreases, which leads to an increase in the negative charge of tumor cells. The expression of integrin receptors, which provide attachment of the cell to the components of the extracellular matrix - laminin, fibronectin, and collagens, is enhanced. In the second phase, the tumor cell secretes proteolytic enzymes and their activators, which ensure the degradation of the extracellular matrix, thereby clearing the way for invasion. At the same time, the degradation products of fibronectin and laminin are chemoattractants for tumor cells that migrate to the degradation zone during the third phase of invasion, and then the process is repeated again.

Histogenetic markers of various types of lung cancer. Lung cancer is represented by tumors of various histogenesis. In recent years, all histological types of lung cancer are divided into small cell and non-small cell, which differ not only in morphological manifestations, but also clinically, response to chemotherapy and life prognosis of patients.

Small cell lung cancer is also characterized by specific biomolecular markers from the group of cellular oncogenes, suppressor genes, and growth factors. Besides, small cell carcinoma differs in signs of neuroendocrine differentiation. In more than 90% of cases, tumor cells express both chromogranin and pancytokeratins. Chromogranin is found in the form of granules in the cytoplasm of tumor cells. The number of chromogranin-positive cells and the level of expression varies depending on the degree of tumor maturity.

Non-small cell lung cancer is a heterogeneous group of tumors belonging to different histogenetic groups: squamous cell carcinoma (markers are cytokeratins and keratohyalin), adenocarcinoma (mucus cytokeratins, surfactant), as well as large cell carcinoma, which can be represented by both low-grade adenocarcinoma and low-grade squamous cell carcinoma. cancer.

Lecture equipment

Gross preparations: bronchiectasis and pneumosclerosis, chronic obstructive pulmonary emphysema, cor pulmonale, honeycomb lung in idiopathic fibrosing alveolitis, lung silicosis, central lung cancer, lung cancer metastases to the adrenal glands.

Micropreparations: chronic obstructive bronchitis, bronchiectasis and pneumosclerosis, chronic obstructive pulmonary emphysema, cor pulmonale, restructuring of the lung vessels in secondary pulmonary hypertension, idiopathic fibrosing alveolitis, sarcoidosis, lung silicosis, peripheral lung cancer, squamous cell lung cancer, lung adenocarcinoma, small cell lung cancer.

Electronograms: chronic obstructive pulmonary emphysema (obliteration of alveolar capillaries), lung adenocarcinoma, small cell lung cancer.

Republican Scientific and Practical Center of Oncology and Medical Radiology named after A.I. N. N. Alexandrova is currently carrying out 56 scientific projects, 23 of which are related to molecular genetic research. They are carried out at the Republican Molecular Genetic Laboratory of Carcinogenesis (oncology department of genetics, cellular and biochip technologies, virology, immunology and proteonics).

Traditional diagnostic tools are exhausting their potential, - says Deputy Director for scientific work Republican Scientific and Practical Center, Corresponding Member of the National Academy of Sciences of Belarus, Dr. med. sciences, professor Sergey Krasny. - It's time to use such a reserve as molecular genetic research. They make it possible to test tumors with high accuracy to determine chemosensitivity, to establish the hereditary nature of the disease by the patient's genetic portrait, and to purposefully act proactively by prescribing targeted treatment.

In 2016, about 10,000 patients passed through the Republican Scientific and Practical Center, approximately 7,000 of them underwent molecular biological studies; large-scale tumor profiling for individualization of therapy was carried out on about a hundred people. On the basis of molecular biological markers, tumors of the central nervous system, soft tissues and bones, lymphoma were diagnosed, studies were conducted to assess the hereditary risks of developing malignant neoplasms, monitoring the concentration of drugs in body fluids for individual dose adjustment of the drug, cell therapy technologies were developed and implemented.

To implement the achievements of molecular biology in the domestic clinic, the first international certificates have already been received, modern equipment has been purchased for performing fluorescent in situ hybridization, molecular sequencing, polymerase chain reaction (PCR), immunohistochemistry, chromato-mass spectrometry, flow cytometry, enzyme immunoassay.

Biologist Victoria Mayorova prepares samples for PCR reaction.

New developments

Forecast evaluation method clinical course bladder cancer through a comprehensive analysis of the clinical and morphological parameters of the tumor and the molecular genetic status of the FGFR3 gene.

Based on this analysis, a model of molecular pathways for the pathogenesis of bladder cancer was created. Depending on the presence of a certain mutation, pathology can develop in two ways: the so-called superficial cancer, characterized by low malignancy and a favorable prognosis (mutations in the FGFR3 and HRAS genes); a more aggressive muscle-invasive cancer that metastasizes early and is characterized by a poor prognosis (mutations in the TP53 and RUNX3 genes).

Using this method, a group of patients with a very high risk of disease progression, who had mutations in the TP53 and RUNX3 genes, was identified. This is important for predicting the course of the disease and determining the degree of aggressiveness of treatment. Knowing that the patient's tumor will develop as a superficial one, after treatment, the bladder will be mainly controlled.

If the progression of the disease is expected, then in relation to metastasis, the state of other internal organs will be monitored. In addition, patients may be identified who must immediately undergo a radical removal of the bladder, otherwise metastases will develop.

Non-invasive complex method of molecular genetic and radiation diagnostics of prostate cancer.

Such an examination should be carried out when a patient with high level prostate-specific antigen (PSA) in the blood, a primary biopsy was performed, which turned out to be negative. Usually, another biopsy is performed six months later, followed by another (and so on 10-15 times), but this is an aggressive study, so a solution was required that would allow limiting ourselves to only one such intervention. Scientists have found a way. By detecting the expression of the PCA3 oncogene and the chimeric TMPRSS2-ERG gene in urine, it is possible to isolate patients who really need to undergo a biopsy (the rest can be delayed).

Development and implementation of a method for transplantation of tissue-engineered respiratory tracts with their lesions of tumor or cicatricial etiology.

We are talking about the category of patients who die within 2-5 months. A method was proposed for decellularization of the cadaveric trachea, in fact, with the preparation of a matrix, then populating it with chondrocytes and after that with epithelial cells. In addition, the technology provides for tracheal revascularization with subsequent transplantation to patients. All this is done in order to replace the defect of the trachea after removal of the tumor or scar. Currently, 3 surgeries have been performed. All patients have been living for more than six months - this is considered an encouraging result.

Laboratory diagnostics doctor Irina Vladimirovna Stukalova and senior laboratory assistant Natalia Zakharovna Pishchik are preparing the analyzer for the isolation of human papillomavirus DNA.

Together with the Institute of Genetics and Cytology of the National Academy of Sciences of Belarus, the topic “Proteomic and molecular genetic studies of tumor stem cells (SSC) of colorectal cancer for the development of new methods of targeted cell therapy” is planned (program of the Union State “ stem cell- 2").

Using a model of a 5-fluorouracil-resistant colorectal cancer cell line, it is planned to study the role of COCs in the mechanisms of tumor progression and to select possible molecular targets for direct action on COCs using vaccine-based cell therapy methods using dendritic cells and/or dendritic cells and lymphokine-activated killers. . This will be a new stage in the immunotherapy of malignant tumors.

Biologist Igor Severin in the cryobank of tumor cell lines.

Another project is “Development of risk identification technology oncological diseases based on molecular-genetic and epigenetic markers” (program of the Union State “DNA-identification”). It is planned to develop an innovative DNA technology to identify molecular genetic and epigenetic markers of the risk of recurrence or progression of the disease in patients with colorectal cancer. According to experts, the new technology will allow timely preventive treatment and prevent the appearance of metastases.

A promising area of ​​research is the study of epigenetic mechanisms of regulation, i.e., processes that do not affect the structure of genes, but change their level of activity. One of them is RNA interference - a mechanism for suppressing gene expression at the stage of translation, when RNA is synthesized, but does not manifest itself in a protein. And if a high level of expression of some microRNA is detected, it can be assumed that there is a problem in this organ.

The miRNA gene family makes up slightly more than 1% of the entire human genome, but regulates the expression of almost a third of all genes. A number of ongoing scientific projects are devoted to the study of miRNAs in various tumors. The department is developing a non-invasive diagnostic method germ cell tumors testis, based on the determination of the expression of a microRNA panel in the blood. The same family of molecules, in addition to diagnosing diseases, is used to predict the course of oncological diseases and to select individual drug therapy.

The task of the study is to identify markers poor prognosis(you can select a group of such patients and select additional treatment). It is also important to determine the miRNA spectrum. It will indicate sensitivity to certain chemotherapy regimens (we are talking about breast cancer, for which a panel of markers was found).

By studying the molecular characteristics during treatment, it is possible to adjust the treatment regimen when additional mutations appear. The method is called a “liquid” biopsy: a blood test can monitor genetic changes and suggest the progression of the disease much earlier.

Drugs for therapy are expensive and highly toxic, so it is important to determine drug resistance at an early stage and find a replacement.

Molecular profiling involves the determination of genetic disorders characteristic of each specific tumor, since it is known that the same nosological forms differ in molecular characteristics. Knowing the molecular portrait of a tumor is also necessary for predicting the course of the oncological process and individualizing treatment. A personalized approach to prescribing cytotoxic drugs and targeted therapy in cancer patients, taking into account molecular biomarkers of sensitivity and toxicity, provides the most accurate selection of drugs.

As part of molecular profiling On the basis of a large-scale analysis of data from world publications, multiplatform panels of biomarkers for breast cancer, ovarian cancer, colorectal cancer, non-small cell lung cancer, and melanoma have been developed, designed to select systemic antitumor therapy.

Chemist Olga Konstantin Kolos launches the synthesis of oligonucleotides.

Is it necessary to expand the geography of research?

Anna Portyanko,

head of the Republican

molecular genetic

laboratory of carcinogenesis,

doctor med. Sciences:

At the present stage, from the group of glioblastomas, variants have been identified that are characterized by a different prognosis. From a morphological point of view, it is easy to confuse glioblastoma and anaplastic oligodendroglioma: when stained with hematoxylin-eosin, they look almost the same. But thanks to genetic tests, we find differences. Moreover, it is routinely performed in our pathology department.

In a similar way, lymphomas also “multiplied”. For example, several lymphomas have been isolated from Hodgkin's lymphoma through molecular genetic testing. Previously, based on hematoxylin-eosin histology, they were classified as Hodgkin's lymphoma, and when molecular genetic analysis for the T-cell receptor appeared, it turned out that this was follicular T-cell lymphoma.

How does this affect treatment? First of all, it is possible to give a more accurate forecast. If a person has glioblastoma, then the median survival is 1 year, and if we are talking about anaplastic oligodendroglioma, then 10 years.

We develop contacts with foreign experts from the best European scientific centers. Together with colleagues from Germany, we are trying to develop important areas of proteomics - the analysis of not just one protein, but the proteome as a whole. The whole cycle has been created, starting from a cytological preparation, there is a laser microdissection system based on a microscope, which allows you to isolate tumor cells from a large tumor, then do mass spectrometry and determine the spectrum of all proteins in this tumor.

Is it necessary to expand the geography of research? I think that it is enough for the country to have one such center - the Republican Molecular Genetic Laboratory of Carcinogenesis, where you can quickly perform all the necessary molecular biological studies (including histological material obtained from regions).

We have the opportunity to carry out not only histological diagnostics, but also preliminary diagnostics using a flow cytometer. Literally within an hour after a person's lymph nodes have been removed, we can preliminarily tell if there is a lymphoma (and if so, which one). This is a great help for clinicians.

Biologist Anastasia Pashkevich loads samples into a genetic analyzer.

What was Angelina Jolie afraid of?

We study genetic damage that occurs during the development of a tumor, - says Elena Suboch, head of the oncological department of genetics of the Republican Molecular Genetic Laboratory of Carcinogenesis. - The current direction is the assessment of hereditary risks of developing oncological diseases. Hereditary forms of tumors account for 1–2% of all oncopathologies, and here special treatment and surgical regimens should be applied. An important goal of identifying familial tumor syndromes is to identify still healthy relatives of the patient who have pathogenic mutations. As a result, it is possible to develop a set of measures aimed at preventing an unfavorable outcome of oncopathology.

An example is heard: American actress Angelina Jolie, who has a mutation in the BRCA1 gene that increases the risk of developing breast cancer, went for a radical operation to prevent the occurrence of a malignant tumor.

Scientists of the Republican Molecular Genetic Laboratory of Carcinogenesis are working on this pathology.

On a grant from the Belarusian Republican Fund fundamental research in 2015–2017, the work “The system of allelic discrimination of the mutational status of the BRCA1 and BRCA2 genes in malignant neoplasms of the human breast” was completed. A population study was conducted, and it turned out that the frequency of mutations in the BRCA1 and BRCA2 genes is approximately 2.5% among women (the frequency spectrum of mutations differs from that observed in residents of neighboring countries).

Each population has its own spectrum of genetic disorders. Knowing the characteristic mutations, you can first test them, and then look for other options. The result of the scientific project was the development of a system for allelic discrimination of the mutational status of the BRCA1/BRCA2 genes using real-time polymerase chain reaction. 5 main mutations that are found in Belarusian women have been identified.

Specialists of the Oncology Department of Genetics are also testing a large panel of markers to assess the risk of developing ovarian, endometrial, thyroid, kidney, colorectal cancer, melanoma, and polyposis syndromes.

Today there are new international classifications brain tumors and lymphomas requiring mandatory molecular genetic studies. Therefore, in the departments of genetics and cellular technologies, an algorithm for diagnosing such diseases using biomarkers is being developed.

In recent years, methods of molecular and genetic research malignant cells. These studies allow us to determine the degree of aggressiveness of the tumor and, as a result, the appointment of the most appropriate cancer treatment in Germany.

In some cases, it is worth limiting only surgical intervention and the disease will not return even without the use of chemotherapy and radiation. It is also possible to analyze certain cancer cell growth receptors, blocking which with special antibodies can prevent their further reproduction.

In addition, in modern oncology, it is possible to determine mutations (genetic damage) in the enzymes of tumor cells, which are responsible for whether a given tumor is amenable to certain chemotherapy or not.

We offer you to send us by mail a block with the pathology of your biopsy or operation even without coming to Israel or Germany. On the basis of the ‹‹Genomics›› laboratory, we carry out genetic and molecular analysis of the material, after which, based on the nature of the tumor, leading oncologists in Israel and Germany will provide you with specific recommendations in the treatment of cancer to achieve the most effective result with the least harm to the body.

‹‹OncotypeDX›› is not an experimental study. The results of these tests are based on observation of patients over 8 years. They are widely used in the largest cancer centers in the world and have saved hundreds of thousands of people from the use of ineffective chemotherapy.

What tests exist and who are they suitable for?

Oncotype DX for Breast (Breast) Cancer

1.a) Oncotype DX ® breast

‹‹Oncotype DX ® breast›› is a diagnostic test that is performed after surgical treatment of breast cancer. Suitable for postmenopausal women with invasive breast cancer, estrogen receptor positive (ER+) and HER 2 negative tumors with intact lymph nodes.

The ‹‹Oncotype DX breast›› test provides Additional information, with which doctors apply the decision on the course of further treatment.

This is due to the fact that the results of the study determine the degree of aggressiveness of the tumor, the chance of recurrence and the need for chemotherapy.

The ‹‹Oncotype DX›› test provides essential information in addition to standard tumor characterization measurements such as tumor size, tumor grade, and lymph node status, which are traditionally used by clinicians for evaluation. In the past, based on these parameters, a decision was made on the tactics of further treatment. With the advent of the test for 21 genes - ‹‹Oncotype DX breast››, physicians have an effective tool that indicates the degree of effectiveness of chemotherapy or hormonal treatment.

To date, the results of the Oncotype test are the most important in deciding whether to use chemotherapy in the treatment of breast cancer, it fundamentally changes the decision compared to what was used in the past without its use. Since the types of tumors are different for everyone, it sometimes happens that a small tumor with unaffected lymph nodes can be very aggressive. Therefore, intensive chemotherapy is necessary. On the other hand, in cases where this is not the case, with the ‹‹Oncotype›› test, you can save yourself from unnecessary chemotherapy and the side effects associated with it.

Below we present the stories of several patients who have benefited from the ‹‹Oncotype DX›› test.

Susan, aged 59, a routine mammogram revealed cancer.

After surgery to remove the tumor and biopsy of the lymph nodes, Susan underwent a series of examinations, including PET/CT, to assess the extent of the spread of the cancer. She was relieved when all those tests came back negative, but Susan wanted to make sure her illness wouldn't come back. After hearing about ‹‹Oncotype DX ®›› from a friend, Susan asked her doctor if the test was right for her. The initial tumor findings were suitable for the test, as her tumor was estrogen receptor positive and lymph node negative. Susan's doctor was very surprised when he saw the result of ‹‹Oncotype DX››, it was - 31, which indicates high risk cancer recurrence, and chemotherapy is necessary additional treatment in this case. Based on her ‹‹Oncotype DX›› test result, Susan's doctor recommended several rounds of chemotherapy, which she started immediately to avoid a possible recurrence of the disease. Before the test, Susan's doctor was sure that chemotherapy was not needed, but after learning about the high risk of a return of the disease, he changed his mind.

A commercial airline pilot with 27 years of experience, Diana, 50, discovered a small lump in her left breast during a self-examination.

A tissue biopsy confirmed her worst fears. Diana's cancer took the form of multiple small tumors scattered across her breasts. She was immediately operated on - the entire breast was removed. Although the tumors themselves were very small, Diana's doctor could not confidently rule out the need for chemotherapy based on standard measures such as tumor size and stage. Diana was worried about her future health and work safety. "Because I'm small, there has been concern that I'm less able to withstand the severe side effects of chemotherapy," Diana said. "In addition, the airline has been vigilant about the health of its pilots, and a cancer diagnosis could mean a permanent suspension from flying."

Seeking information, Diana's doctor turned to Oncotype DX for a genomic analysis of her illness. About a week later, Diana learned that her score was 13, suggesting that she had more low risk relapse (return of the disease). During the conversations with her doctor, she felt confident that she could avoid chemotherapy and her side effects without increasing the likelihood of recurrence of the disease, and she was able to continue her career and active lifestyle. In addition, she was able to keep her long hair, which she raised from the age of 23. "Thirteen is mine lucky number currently," Diana said.

The test is suitable for menopausal women with invasive breast cancer, estrogen receptor positive (ER+) and HER-2 negative tumors, with normal lymph nodes. It is performed on a tissue sample of a removed tumor during surgery.

1.b) Immunohistochemical test of ER, PR, HER-2 receptors in tumor cells

Genetic analysis Fish-response to the antibody ‹‹Trastuzumab›› (Herceptin).

Immunohistochemical study: checking the tumor for special proteins - receptors located on the surface of tumor cells and being a target for drugs.

Analysis of estrogen, progesterone, HER-2 receptors allows us to establish their sensitivity to hormone therapy and to a specific antibody (biological drug, not chemistry, a new generation of oncological drugs).

A tumor DNA test that tests genes in tumor cells for antibody susceptibility. Herceptin (Fish reaction) is suitable in 20-25% of breast cancer patients. This medicine significantly increases life expectancy in metastatic disease and prevents the return of the disease after surgery.

The above tests are suitable for both primary tumors at any stage and metastatic tumors.

1.c) CYP2D6 test

After the operation, many women are shown prophylactic treatment to prevent further relapse. If there are estrogen receptors and progesterone receptors in the tumor tissues, then menopausal patients are often prescribed hormone therapy, Tamoxifen tablets for 5 years.

Recent studies have found a specific enzyme in liver cells that activates the drug ‹‹Tamoxifen›› into the active substance ‹‹Endoxifen››, which destroys cancer cells.

Therefore, the effectiveness of the drug is largely determined by the degree of activity of the liver enzyme CYP2D6, and the activity of the enzyme is determined by the genes of the patient.

The genetic test detects mutations in genes associated with the CYP2D6 enzyme, and allows you to accurately assess the degree of enzyme activity and the degree of effectiveness of the drug ‹‹Tamoxifen››.

Determination of the CYP2D6 genetic code helps in choosing the right hormonal treatment and provides an opportunity to predict the effectiveness of the use of ‹‹Tamoxifen›› individually for each patient.

From the medical literature it is known that 7-10% of the population of Europe and the USA have an ineffective enzyme, in these cases ‹‹Tamoxifen›› is an ineffective medicine.
It is very important to find those women for whom ‹‹Tamoxifen›› treatment is not suitable due to inefficient drug metabolism caused by low CYP2D6 enzyme activity. These patients are at an increased risk of recurrence of breast cancer when taking ‹‹Tamoxifen››, and they need to take other hormonal drugs.

The test is intended for patients who are expected to be prescribed ‹‹Tamoxifen››, at an early or metastatic stage of the disease. The analysis is carried out using the patient's saliva.

2. Oncotype DX ® colon for colon cancer

2A. Oncotype DX®colon is a diagnostic test that is performed after the surgical removal of colon cancer. The ‹‹Oncotype DX colon›› test helps men and women with colon cancer learn more about the biological characteristics of the tumor and determine the likelihood of recurrence. Combined with other pieces of information, the results of the ‹‹Oncotype DX colon›› trials can help patients and their physicians make personalized decisions about whether or not to use chemotherapy in complex treatment colon cancer.

One of the main problems in the treatment of patients with colon cancer is to determine the risk of recurrence of the disease after surgery and assess the need for postoperative chemotherapy in order to reduce the chance of recurrence.

Oncotype DX provides a new way to assess the risk of recurrence in stage 2 colon cancer (without lymph node involvement) and enhances the ability to make informed decisions on an individual basis.

You have recently been diagnosed with stage II colon cancer without lymph node involvement and have undergone surgical resection. Do you and your doctor have to make a decision about chemotherapy?

The ‹‹Oncotype DX›› test provides the necessary, additional information based on the genomic features of the tumor, which doctors use when making decisions about treatment tactics. It also indicates the likelihood of recurrence. The ‹‹Oncotype DX colon›› test provides information in addition to the standard data such as tumor stage and lymph node status that physicians and their patients traditionally use to assess whether the disease is likely to recur. In 15% of cases, the tumor of the colon is absolutely non-aggressive, and in this case, chemotherapy only brings harm to the body, because. the disease will never return.

Below are answers to the most frequently asked questions about the ‹‹Oncotype DX colon››

1. What is the ‹‹Oncotype DX colon›› test?

‹‹Oncotype DX colon››- tests colon cancer cells by looking at the activity of 12 human genes in order to assess the likelihood of the return of colon cancer in patients with early stage colon cancer with intact lymph nodes.

2. Who is the ‹‹Oncotype DX colon›› suitable for?

Men and women with newly diagnosed stage II colon cancer.

3. How does the ‹‹Oncotype DX colon›› test work?

The DNA that makes up the cell is extracted from tumor samples and then analyzed to determine the degree of activity of each of the 12 genes. The results of the analysis are calculated using a mathematical equation to convert the value into a numerical result.
This result corresponds to the probability of colon cancer recurrence within 3 years of initial diagnosis among individuals with early stage(second stage) colon cancer who underwent surgery to remove the primary tumor.

4. How long does testing take?

It usually takes 10 to 14 calendar days from the time the pathology arrives at the laboratory. The results of the study come in the form of a number on a scale from 0 to 100, and indicate the degree of likelihood of a relapse.

The ‹‹Oncotype DX colon›› is the doctor's advanced tool for assessing the severity of colon cancer and assisting in personalized treatment.

2B. Mutation testing in the K-RAS-Test is suitable for patients with metastatic colon and rectal cancer

One receptor that is characteristic of colon tumors is the epithelial growth factor receptor or epidermal growth receptor EGFR. These growth factors with a specific growth receptor trigger a chain of reactions that promote the development and division of the tumor cell. Changes, mutations (genetic failures of the code that determines the structure of the receptor), activation of EGFR receptors, can lead to constant uncontrolled cell division - these are necessary prerequisites for the appearance of malignant tumors. Determination of the EGFR receptor (a gene that can lead to cancerous transformation) is the target receptor for targeted treatment of tumors of the colon and rectum.

The drug - the antibody ‹‹Erbitux›› (Setuximab) blocks these receptors and thus prevents further division and growth of malignant cells.

What is K-RAS?

One of the "actors" involved in the chain of events. The action occurs after the activation of the EGFR family protein. The K-RAS receptor, this protein is a link in the chain of division signals in cells, which ends in the cell nucleus.

When there is a mutation in the K-RAS receptor, even if the EGFR receptor is blocked by the Erbitux›› antibody, it will still occur chain reaction cell division, bypassing the EGFR receptor link, in other words, the antibody will be absolutely ineffective.

On the other hand, if there is no mutation in K-RAS, then the biological drug ‹‹Erbitux›› gives a statistically significant improvement in the survival of patients with metastatic disease. In 55-60% of cases, no mutation is observed, that is, it is possible to treat with an antibody.

Complex treatment with ‹‹Erbitux›› in combination with chemotherapy allows to reduce metastases, and in the future, in some cases, it is possible to remove them surgically, which can lead to complete recovery.

If 10 years ago, patients with the fourth metastatic stage of colon disease lived an average of a year, now they live 3-5 years, and in 20-30% of cases a complete recovery is possible.

Thus, the test for the presence of a mutation in K-RAS helps to assess the degree of effectiveness of treatment with biological drugs in metastatic colon cancer.

The test is suitable for patients with metastatic colon and rectal cancer.

To conduct the test, you need a block with tissue from a biopsy tumor or a sample from a removed tumor.

3. Checking for EGFR mutations - non-small cell lung cancer

On tumor cells of non-small cell lung cancer, there are growth receptors responsible for the process of cell division.

Special enzymes that transmit signals for cell division are called tyrosine kinase.
Tyrosine-Kinase inhibitors are targeted drug therapies that block signals that promote tumor growth. These new drugs, small molecule tyrosine kinase and epidermal growth factor receptor (EGFR) inhibitors (Erlotinib (Erlotinib), Gefitinib (Gefetinib) were originally developed for use as second-line therapy after chemotherapy failure.

Under these conditions, Erlotinib showed an increase in survival rate, with an outcome magnitude similar to second-line chemotherapy, but without severe side effects. Since this is a targeted therapy, specific cancer cells are affected without harming normal cells, thereby not harming the body.

Clinical studies have shown a correlation between the presence, activation of specific mutations in the T3 region of the EGFR receptor, and an increase in the activity of small molecule drugs - Erlotinib and Gefitinib. The presence of a mutation was found in 15-17% of patients, and instead of heavy chemotherapy with side effects, an antibody in tablets is suitable for them. The antibody can be given as the first line of treatment for metastatic disease. This drug can inhibit the growth of a tumor for years, as it blocks the tumor growth receptor.

The test is suitable for patients with non-small cell lung cancer with metastases, both before the start of any chemotherapy, and when the disease progresses during treatment. It is carried out on the biopsy block or on the material obtained during the operation.

4. New survey - Target Now (Target check)

Just as there is a difference between different people, there is also a difference between different malignant tumors, even if they are of the same origin, from the same organ.
So, for example, breast cancer may respond to hormone treatment in one woman, and another woman will not respond to them. Today, with the development of medicine, tests have been developed that help doctors choose treatment individually for each patient, thereby significantly increasing the effectiveness of treatment and reducing the risk of unwanted side effects.

What is Target Now?

This is a study conducted on the material of cancerous tissue removed during an operation or biopsy.

The study is testing potential targets in tumor cells for various drugs.
In accordance with these goals (the presence or absence of certain receptors, mutations or their absence) allow the doctor to choose one or another drug that kills a specific tumor.

The test detects a large number of molecules in cancer cells that can be used as a site of action or target, chemicals and/or various biological antibodies. Molecular changes may indicate the expected good efficacy or ineffectiveness of a given treatment.

The results of this study were published in 2009 at the annual meeting of the American Association for Cancer Research. The test was conducted on 66 patients suffering from metastatic cancer. According to the results of the Target Now test (Target check), patients were selected for the necessary treatment after the standard treatment used for their disease turned out to be ineffective.

The study found that molecular targets can be detected in 98% of cases.

In addition, adjusted treatment based on the results of the ‹‹Target Now›› test in one third of patients was found to prolong the time to disease progression by 30% compared with past treatment before the Target Test. Many patients have been extended life for many months and even years. It must be emphasized that we are talking about patients who were not helped by many drugs prescribed according to the scheme generally accepted for their disease.

From the results of Targeted Testing, it was found that their particular tumor is often treated with drugs that are not usually suitable for their type of cancer in the general group.

This study indicates that the Target Now test can detect drugs that are personally appropriate for a given tumor, which is difficult to determine in any other way today. A targeted test now allows for optimal adjustment of individual drugs before starting cancer treatment.

This study is suitable for patients with metastatic disease of any organ who have not responded to previous treatment.

To conduct the study, it is necessary to have tissue from a biopsy or after surgery.

5. Mamma Print - a test to determine the risk of breast cancer recurrence

MammaPrint is a diagnostic test to assess the likelihood of recurrence, which can predict the possible occurrence of breast cancer recurrence within 10 years after treatment of the primary tumor.

MammaPrint is the only test of its kind that received FDA approval in February 2007.

The results of this test allow you to choose a technique after surgical treatment. If there is a high risk of recurrence, chemotherapy is indicated.

According to FDA guidelines, this test is indicated for patients under 61 years of age, without affected lymph nodes, with a tumor size of less than 5 cm. MamaPrint is also effective in hormone-dependent breast cancer and in other types of malignant tumors.

This test is based on the analysis of 70 oncogenes associated with breast cancer. The analysis of these genes makes it possible to predict with great accuracy how a particular malignant tumor will behave in the future, this will allow the attending physician to choose the necessary treatment with great accuracy.
The test is performed on tumor tissue taken during a biopsy or after surgical removal.

MamaPrint is the first highly individualized diagnostic test.
Today this method is very popular, for the sake of diagnostics with its use, many patients from the CIS countries come to Israel.
To take this test, you need to come to Israel for a few days, undergo a biopsy or surgical operation as the test requires fresh tissue samples. After that, you can go home or wait for the diagnostic results in Israel. It will take about 10 days to wait.

Treatment in Israel with the "Cancermed" center is the organization of high-quality medical care.

We are completing a series of articles on oncological diseases.
Today I will tell you in detail what molecular testing is and how it affects the diagnosis.

In the photo: Vladislav Mileiko, head of the department,
biomedical holding "Atlas".

To understand how molecular diagnostics works and what place it occupies in oncology, one must first understand the mechanisms that occur in a tumor.

Molecular processes in a tumor

Mutations in proto-oncogenes and suppressor genes responsible for cell division and death cause the cell to stop following instructions and synthesize proteins and enzymes incorrectly. Molecular processes are out of control: the cell is constantly dividing, refusing to die, and accumulating genetic and epigenetic mutations. Therefore, malignant neoplasms are often called a disease of the genome.

Hundreds of thousands of mutations can occur in tumor cells, but only a few contribute to tumor growth, genetic diversity, and development. They are called drivers. The remaining mutations, "passenger" (passenger), in themselves do not make the cell malignant.

Driver mutations create different populations of cells, which provides tumor diversity. These populations or clones respond differently to treatment: some are resistant and relapse. In addition, the different sensitivity of clones to therapy can lead to a radical change in the molecular profile during treatment: even cells that are insignificant at the beginning of the population can gain an advantage and become dominant at the end of treatment, which will lead to resistance and tumor development.

Molecular Diagnostics

Driver mutations, changes in the number or structure of proteins are used as biomarkers - targets for which treatment is selected. The more targets are known, the more accurate the selection of potentially effective treatment regimens can be.

It is not easy to separate driver mutations from the rest and determine the molecular profile of the tumor. For this, the technology of sequencing, fluorescence in situ hybridization (FISH), microsatellite analysis and immunohistochemistry is used.

Next-generation sequencing methods can identify driver mutations, including those that make a tumor sensitive to targeted therapy.

With the help of FISH technology, sections of chromosomes on which a certain gene is located are tinted. Two connected multi-colored dots are a chimeric or fused gene: when, as a result of rearrangement of chromosomes, sections of different genes are joined together. This can lead to the fact that the oncogene will fall under the influence of the regulation of another more active gene. For example, the fusion of the EML4 and ALK genes is of key importance in the case of lung cancer. The proto-oncogene ALK is activated under the influence of its rearrangement partner, which leads to uncontrolled cell division. The oncologist, given the rearrangement, may administer a drug that targets the activated ALK gene product (crizotinib).

Fluorescent in situ hybridization (FISH).

Microsatellite analysis shows the degree of damage to the DNA repair system, and immunohistochemistry - protein biomarkers located on the surface, in the cytoplasm and nuclei of tumor cells.

All of these studies are included in New Product biomedical holding "Atlas" - Solo test. With this test, the oncologist obtains information about the molecular profile of the tumor and how it affects the potential efficacy of a wide range of anticancer drugs.

Solo experts are examining up to 450 genes and biomarkers to evaluate how a tumor might respond to more targeted cancer drugs. For some of them, biomarker analysis is dictated by the manufacturer. For others, they use data from clinical trials and recommendations from international communities of oncologists.

In addition to selecting targets for targeted therapy, molecular profiling helps to detect mutations that, on the contrary, make a tumor resistant to a particular treatment, or genetic features that are associated with increased toxicity and require an individual selection of a drug dose.

For research, biopsy material or paraffinized blocks of postoperative material are used.

Molecular profiling provides additional information about the disease, but it is not always applicable to the choice of treatment. For example, in situations where standard therapy is sufficiently effective or indicated surgery. It is possible to identify clinical situations where such a study may be most useful:

• A rare type of tumor;
• Tumors with an unidentified primary focus (it is not known where the tumor that metastasized originally appeared);
• Those cases where a choice of several options for the use of targeted therapy is required;
• The possibilities of standard therapy have been exhausted and experimental treatment or inclusion of the patient in clinical trials is required.

Solo project specialists consult oncologists or patients and suggest whether a test is needed in this case.

Precision Medicine and Clinical Research

Usually in medical practice, general strategies are used to treat patients with a specific diagnosis. For small cell lung cancer, one strategy is used, for non-small cell lung cancer, another. For oncological diseases, this method is not always suitable. Due to differences at the molecular level, even with the same type of tumor, patients may receive ineffective or unnecessary treatment.

With the increase in research and the invention of targeted drugs, the approach to cancer treatment has begun to change. To increase the relapse-free period and life expectancy of the patient, it is necessary to take into account the molecular profile of the tumor, the body's response to medications and chemotherapy (pharmacogenomics), to know the main biomarkers.

Precision medicine can significantly improve the prognosis of a particular patient, avoid serious side effects of oncological drugs and significantly improve the patient's quality of life. But this method also has disadvantages.

Targeted drugs are on the rise and have two main limitations: most molecularly targeted agents provide only partial suppression of signaling pathways, and many are too toxic to be used in combination.

Imagine that you are an architect of Moscow. Standing in front of you not an easy task- Solve the problem of traffic jams during rush hour by building one bridge. Molecular mechanisms can be compared with the movement of machines, and the bridge - main drug which should solve the underlying problem. It seems that several drugs (a series of bridges) targeting the major molecular disturbances may solve this problem. But the toxicity of drugs increases and can be unpredictable.

We have gained a better understanding of the molecular processes of malignant tumors, but the current methods of introducing precision oncology into clinical practice are far behind. To speed up the study of targeted therapy, scientists have developed two new approaches - Basket and Umbrella.

The essence of the Basket method is that patients with a certain biomarker are selected for the study, regardless of the location and name of the tumor. In May 2017, the FDA approved such a treatment for a biomarker called high microsatellite instability (MSI-H) or mismatch repair defect (dMMR).

Molecular disorders differ not only in different patients, but also within the same tumor. Heterogeneity - a big problem in oncology, for which the Umbrella study design was developed. For the Umbrella method, patients are first selected according to the type of malignant neoplasms, and then genetic mutations are taken into account.

Such studies help not only to collect information about the effects of targeted drugs - sometimes this is the only option for patients who do not respond to standard treatment with registered drugs.

Clinical example

We decided to give an illustrative example of what the use of advanced molecular profiling might look like.

A patient with skin melanoma and liver metastases consulted an oncologist. The doctor and the patient decided to do molecular profiling in order to get more full information about the disease. The patient was biopsied and tissue samples sent for analysis. As a result of diagnostics, several important genetic disorders were found in the tumor:

• Mutation in the BRAF gene. Indicates activation of the RAS-RAF-MEK oncogene signaling pathway, which is involved in cell differentiation and survival.
• Mutation in the NRAS gene. Indicates additional activation of the RAS-RAF-MEK signaling cascade.
• An inherited variant of the TPMT gene. Indicates the features of metabolism anticancer drug"Cisplatin".

Based on the results of clinical studies and recommendations, we can come to the following conclusions:

• Drugs of the BRAF inhibitor class (Vemurafenib) can be potentially effective, moreover, the presence of an NRAS mutation can serve as an additional reason for prescribing a double blockade of the signaling cascade - a combination with MEK inhibitors (Trametinib).
• Although there is no approved therapy that directly targets the NRAS oncogene, mutations in it are known to increase the chance of successful treatment with immunotherapy (ipilimumab and pembrolizumab).
• The hereditary genetic variant in the TPMT gene indicates an increased individual toxicity of Cisplatin, which requires dose adjustment when prescribing platinum-containing therapy regimens.

Thus, the doctor gets the opportunity to navigate among the possible treatment options, starting not only from the clinical parameters of the patient, but also taking into account the molecular characteristics of the tumor.

Molecular diagnostics is not a panacea for all cancers. But this is an important tool for the oncologist, which allows you to approach the treatment of malignant tumors from a new perspective.

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