Molecular portrait of the tumor. Materials and methods. Differentiated thyroid cancer

"We can rarely give up our beloved
clinical hypothesis and continue to treat patients in such a way that
how they have been treated for many decades ...
Meanwhile, it is time to change the existing paradigms.”

Richard Schilsky, ASCO President

“For the most serious illnesses, the most strong medicines, accurately applied ... "
Hippocrates

The prognosis for cancer treatment depends on clinical stage disease (TNM), tumor biology and treatment. Modern achievements clinical oncology undeniable. And yet, despite the obvious progress in creating new anticancer drugs, every day, thousands of cancer patients take drugs that do not help them. For some patients, empiric treatment will be beneficial and safe. However, for many other patients, therapy can be both useless and toxic.

By the end of the 90s. XX Art. cytotoxic chemotherapy has reached its limit. The development of molecular biology and the focus on personalized medicine have led to a fundamentally new approach to treating patients using new generation molecular targeted drugs. Blockade of proliferation cancer cell was achieved by selective inhibition of its main signaling pathways - ligands, membrane receptors, intracellular proteins.
However, despite the obvious successes of the new approach, at the end of the first decade of the post-genomic era, there was an urgent need to revise this new therapeutic paradigm, which was due to large quantity clinical failures due to the development of acquired tumor resistance.

Targeted therapy targets and mechanisms of resistance
The most holistic view of the development and evolution of cancer was presented in two textbook articles by D. Hanaan and R. Weinberg (Cell, 2000, 2011). Based on the characteristics, the targets of therapy should not only be cancer cells with their unstable genome, special type metabolism, active neoangiogenesis, and the acquired ability to evade growth signals, circulate in the circulation, and metastasize. Therapy targets should also be the tumor microenvironment, cancer stem cells, and all components of the metastatic cascade.
Obviously, it is simply impossible to implement such a program within the framework of a treatment protocol for a particular patient, even when using a combination of several targeted drugs. A single drug, even with a unique molecular mechanism of action, cannot be effective in the treatment of a genetically heterogeneous progressive tumor in which multiple resistance mechanisms emerge and become established.
Particular mechanisms of resistance to various targeted drugs are well studied. These include activation of alternative EGFR pathways that promote cell survival in response to drug damage, formation of an oncogenic bypass and autocrine loop, loss of the extracellular domain of the membrane receptor (formation of a truncated receptor - truncated), kinome reprogramming, autophagy, epithelial-mesenchymal transition, epigenetic mechanisms, etc.
During progression and under the influence of therapy, additional oncogenic mutations appear in the tumor, its molecular landscape changes, and genome instability develops, which is commonly called genomic chaos today (W. George, Jr. Sledge, 2011).
Not only cancer cells are characterized by individuality and variability. In addition to epithelial cells, changes also occur in the tumor-associated stroma. Stromal cells are also subject to molecular evolution, although they are a genetically more stable component. solid tumor.
microenvironment of benign stromal cells immune system and inflammatory cells, also affects the evolution of the malignant clone and the formation of secondary resistance to therapy.

Heterogeneity as a reason for the ineffectiveness of anticancer therapy

The main reason for the low efficiency empirical therapy is tumor heterogeneity.
For decades, histologists have classified cancer according to morphological features describing different types cancer cells and their relationship with the tumor stroma.
Methods of molecular analysis, especially rapidly developing in the post-genomic era, have shown the true extent of tumor heterogeneity.

Individual (intertumoral) heterogeneity
Microchip technology for analyzing the level of expression of thousands of genes made it possible at the beginning (2000) to classify cancer mammary gland(BCG) to luminal A, luminal B, HER/2 and basal. Somewhat later, a refinement of molecular taxonomy with an emphasis on basal crayfish revealed additional subtypes. Among them, there are such as Claudin-low (characterized by gene expression similar to breast stem cells), subtypes of mesenchymal tumors (genes that regulate the epithelial-mesenchymal transition), subtypes of apocrine tumors with androgen receptor expression and activation of the corresponding signaling pathway, subtypes with activity genes that regulate the immune response.
Further molecular studies of breast cancer were associated with the implementation of the METABRIC (Molecular Taxonomy of Breast Cancer International Consortium) project. It has been found that molecular events such as point mutations, insertions, deletions, amplifications, duplications, translocations, and inversions can influence the tumor genomic landscape. It turned out that somatic mutations can occur both in genes not associated with carcinogenesis and in genes whose mutations occur frequently during cancer development (GATA3, TP53, and PIK3CA). In addition to genome damage in breast cancer, various epigenomic disorders (DNA methylation), damage at the level of transcription and microRNA were found. As a result of these studies, only in the luminal A subtype, another 10 different molecular integrative clusters were classified that affect the outcome of the disease. It has also been established that all four "main" subclasses and new "additional" molecular subtypes of BC have different sensitivity profiles to anticancer drugs.
Molecular genetic classifications that affect the characteristics of treatment are being created for gastric cancer, colorectal carcinoma, ovarian cancer and other localizations.

Intratumoral (intratumoral) heterogeneity
A much greater fundamental problem of oncology is intratumoral heterogeneity. The coexistence of several subclones in a tumor with different sets of molecular aberrations and different drug sensitivities makes it ineffective to suppress one cell fraction against the entire tumor. Additional unfavorable factor is a change in the biology of the tumor during its development.
Intratumoral heterogeneity is usually divided into spatial (geographic) and temporal (evolutionary).
Spatial heterogeneity suggests the presence of molecular genetic differences in certain regions of the tumor, genetic differences between the primary tumor and its metastases, as well as differences between metastases of different anatomical locations.
Depending on the level of genetic heterogeneity, monogenomic (the same genetic profiles in different geographical areas) and polygenomic tumors (different subclonal populations of cells in different departments) are observed.
Fundamental changes in the genome during tumor development occur at three time points: at the moment of transition of cancer in situ to invasive cancer, during the slow evolution of primary invasive cancer and during metastatic progression.
There are many reasons to believe that cancer behaves like an open, unstable ecosystem that depends on the pressures of environmental factors such as the immune system and hypoxia to develop. The formation of evolutionary (temporal) heterogeneity of the primary tumor is also actively influenced by ongoing antitumor treatment.
In a solid tumor, there is always a rare subclone of cells of critical importance that determines the final outcome of the disease. The death of a patient is most often observed as a result of exposure to the organism of that clone of cells, which at the moment primary diagnosis was not dominant and represented no more than 1% of all tumor cells. The presence of such cells has been proven in the example of malignant myeloma, cancer prostate and in tumors of other localizations. Analysis of serial biopsies performed multiple times throughout the history of the disease (from the moment primary diagnosis until the death of the patient) showed that the clone of cells that survived as a result of therapy was not dominant at the beginning and developed after drug elimination of other, “basic”, rapidly proliferating clones.
The identification and eradication of this deadly cell clone leading to the death of patients is a necessary therapeutic strategy.

Tumor heterogeneity at the cell level
Majority contemporary research molecular aberrations was carried out on cells representing the main tumor population. At the same time, structural changes in DNA that occur on early stages tumor development and leading to outbreaks of genomic evolution (the so-called "big mutational clock"). The disadvantage of these methods was that the research process did not take into account the presence of rare subclones with unique genetic mutations hidden in total mass main cells. It is in these cells that a gradual accumulation of point mutations occurs, contributing to extensive subclonal genetic divergence (“small mutational clocks”).
Currently, attempts are being made to overcome this shortcoming (study of the tumor at the level of one leading malignant clone). Modern methods of molecular profiling make it possible to do this. It was found that the tumor contains the so-called. driver mutations and passenger mutations. Driver mutations confer a selective growth advantage on cells carrying such mutations. Passenger mutations do not have this effect.
Typically, only driver mutations have been studied as therapeutic targets. However, passenger mutations have also recently attracted the attention of researchers, since such effects as the induction of an immune response and proteotoxic stress depend on them. Passenger mutations can also be the target of anticancer strategies.
The accumulation of numerous mutations, which is characteristic of tumors with genomic and chromosomal instability, may result in a mutational crisis. When the optimal threshold of genomic instability is exceeded, there is a violation of viability and a decrease in the number of elements of the entire system.

Analysis Methods tumor tissue
The methods of molecular analysis of tumor tissue are extremely diverse and are far beyond the limits of classical histology. Today, these methods include: microarray, Southern blot, Northern blot, Western blot, in situ hybridization, polymerase chain reaction(PCR), real-time reverse transcriptase PCR, immunohistochemistry, immunofluorescence microscopy, maldi-mass spectrometry.
Tumor cell analysis can be performed at the genome level (fluorescence in situ hybridization, spectral karyotyping, comparative genomic hybridization), transcription (microarray technology: gene and RNA expression profiling), proteome (2D gel electrophoresis, mass spectrometry, surface-enhanced laser desorption ionization in TOF mode: matrix technology + mass spectrometry).
Molecular tomography of tumor tissues makes it possible to visualize the spatial distribution of proteins, peptides, drug compounds, metabolites, as well as predictive molecular biomarkers.
Molecular analysis should include primary solid tumor tissues, tissues of realized hematogenous metastases (rapidly growing and clinically significant), as well as circulating tumor cells and circulating tumor DNA (an indicator of the presence of "dormant" metastases). Tumor and metastasis biopsies should be taken from different geographic locations of the same solid tumor. It is believed that a liquid biopsy is more informative (and safer).

From empiric to personalized therapy
The tumor, being an open unstable biological system, not only demonstrates individual heterogeneity, but also changes its molecular characteristics throughout evolution, and especially during metastatic progression. Both the main and non-dominant clones of solid tumor cells, as well as cells of the tumor microenvironment, undergo changes.
To suppress the proliferation of all tumor cells, a strategy is used combination therapy. The concept of combined (simultaneous or sequential) treatment was first proposed by Goldie and Coldman more than 30 years ago. The concept united such concepts as tumor growth, an increase in the frequency of mutations in it, the emergence of resistant cell clones and the development of resistance.
Today strategy modern therapy cancer involves the use of combinations of cytostatics, cytostatics and targeted drugs, and even a combination of two targeted drugs (tyrosine kinase inhibitors and monoclonal antibodies). This strategy is based on tumor suppression by medicines affecting the pool of basic, rapidly proliferating cells. Life cycle of these cells is determined by the activity of driver mutations. In general, the stability of the system is explained by many factors, including the activity of passenger mutations, the role of which is not taken into account in therapeutic protocols.
The strategy of personalized therapy, which is today the main paradigm of anticancer treatment, takes into account the constantly changing landscape of the entire "tumor field": the heterogeneity of primary solid tumor clones, the heterogeneity of circulating tumor cells, as well as the phenotypic and metabolic heterogeneity of "dormant" cancer cells in numerous metastatic niches. bone marrow and visceral organs.

Caris Molecular Intelligence Services
The idea of ​​identifying individual predictive tumor markers that could predict the results of antitumor therapy arose in 2008, when Professor Daniel D. Von Hoff created the unique Caris Molecular Intelligence Services (USA) laboratory. Today, for molecular profiling of tumor tissues in the laboratory, a combination of methods is used - IHC, CISH, FISH, Next-Generation Sequencing, Sanger Sequencing, Pyro Sequencing, PCR (cobas ®), Fragment Analysis.
For several years, molecular tomography in this laboratory has been performed on 65,000 patients with more than 150 histopathological subtypes malignant tumors. A complex approach based on the use of not one method (for example, only immunohistochemical), but a combination of molecular methods, allows you to identify individual predictive tumor markers of a particular patient and, based on this analysis, make decisions about personalized therapy.
The expression of some proteins (or gene amplification) requires the prescription of appropriate drugs, the expression of other proteins excludes the prescription of a particular drug. Thus, TOPO1 expression is preferable for prescribing irinotecan, RRM1 expression is preferable for prescribing gemcitabine, MGMT expression is the basis for prescribing temozolomide or dacarbazine, TOPO2A expression with simultaneous amplification of HER2 allows for therapy with doxorubicin, liposomal doxorubicin, and epirubicin.
To prescribe trastuzumab, in addition to detecting HER/2 expression/amplification, in order to predict drug resistance, it is necessary to study PTEN (IHC) and PIK3CA (NGS).
On the other hand, TS expression requires the avoidance of fluorouracil, capecitabine, pemetrexed; Expression of SPARC (IHC), TLE3 (IHC), Pgp (IHC) requires the avoidance of docetaxel, paclitaxel, nab-paclitaxel.
With such a combination of tumor markers as ER (IHC), HER2 (IHC), HER2 (CISH), PIK3CA (NGS), everolimus and temsirolimus should not be prescribed.
Combination modern methods biological imaging makes it possible to identify molecular predictive tumor markers for each known cytosatic or targeted drug used today in clinical oncology. Such an approach, based first on conducting molecular profiling of tumor tissues, identifying individual predictive tumor markers in it, and only then on developing a treatment strategy plan, has received evidence in a number of ways. clinical research. One of them is the Bisgrove Study, which included TGen, Scottsdale Healthcare and Caris Dx.
The design of this study was revolutionary. Given the fact that each tumor is individual, the authors of the study design refused to randomize patients into multiple groups, based on anatomical localization tumor or only one immunohistochemical feature. AT this study there were no comparison groups - each patient acted as his own control.
In total, 66 patients from 9 US cancer centers participated in the study: 27% - breast cancer, 17% - CRC, 8% - OC, 48% - other localizations. All patients were treated for metastatic cancer according to generally accepted standards - only from 2 to 6 lines. After the last progression continued therapy based on molecular profiling.
The results of the study showed that the time to progression in patients with BC increased by 44%, with CRC - by 36%, with OC - by 20%, with other localizations - by 16%. It should be noted that all patients at the time of inclusion in the study developed secondary resistance to drug therapy, and generally accepted recommendations for their further treatment did not have. Thus, it is concluded that for aggressive, rare tumors, as well as progressive tumors with developed resistance, there is no alternative to molecular profiling and treatment personalization.

Changing the design of clinical trials
Separately, it should be noted that the paradigm of personalized therapy in oncology is actively changing the generally accepted design of clinical trials. There are growing voices that the results of clinical trials based on randomization and stratification of patients into multiple populations and cohorts should be reconsidered to account for individual intra- and intertumoral heterogeneity. As a result, the design of modern clinical trials is becoming increasingly personalized.
An example of such latest modern designs are Master protocols, Basket trials, Adaptive trial design and, finally, N-of-1 studies. The main idea behind the new designs is as follows. The sponsors of the study are simultaneously several pharmaceutical companies that have drugs with different targets and different molecular mechanisms of action for the treatment of cancer of this localization. Patients are included in the study after a possibly complete molecular profiling of the tumor. Participating in one study, the patient, depending on the availability of appropriate target proteins, can alternately receive the most effective drugs. During therapy, an individual adaptation of the drug according to the dose can be carried out or a cocktail mix from a combination can be used. various drugs, the need for which arose during treatment. Tumor progression and toxicity are not grounds for stopping treatment, but only for changing the type of therapy. The clinical decision is influenced by the results of molecular profiling of the tumor, which is carried out immediately after tumor progression or the next course of therapy. Thus, during the study, the patient may receive a completely different drug that was originally prescribed to him.
Finally, there are already trials for only one patient - N-of-1 studies. This design is most suited to the personalized therapy paradigm. Such an approach will allow in the near future to create individual preparations for cancer therapy.
However, even today, personalized therapy protocols based on molecular profiling of the tumor are widely used in clinical practice leading cancer centers in the USA, Europe, Japan, allowing you to receive clinical results new level. Such global centers include Memorial Sloan-Kettering Cancer Center, Center for Personalized Genetic Medicine at Harvard, Institute for Personalized Medicine at MD Anderson, Center for Personalized Health Care at the Ohio State University.
Since January 2014, molecular profiling of tumor tissues based on the Caris Molecular Intelligence Services platform has been available in Ukraine. This became possible thanks to AmaxaPharma, which is the official partner of Caris Life Sciences in the field of molecular profiling of tumor tissue in Eastern Europe. Since January 2014, thanks to this collaboration, dozens of patients with rare tumors for which there are no standards of therapy, as well as cancer patients with primary and acquired chemoresistance, have already undergone Molecular Intelligence molecular profiling in Ukraine. The first results are obtained, which differ significantly from the results of the empirical approach.
The possibility of implementing molecular profiling in our country has made it possible to come close to solving the problem of personalized cancer treatment.

Conclusion
Tumor heterogeneity has deep clinical implications for cancer patients. To make the right clinical decisions, it is necessary to have the most complete picture of the biology of the cancer cell and its microenvironment. Molecular profiling primary tumor tissues, hematogenous metastases, circulating tumor cells, and metastatic niche cells allows us to take a big step towards the implementation of a program of personalized cancer treatment.

STATS BY TOPIC Oncology and Hematology

06.01.2019 Oncology and hematology Promeneva diagnosis of ovarian cancer: Possibility of current diagnostic images Application of micafungin in hematology

Invasive fungal infections(IGI) increase morbidity, mortality, duration of hospitalization and associated costs in hematological patients with severe immunodeficiency. These patients have a large number of interrelated risk factors for IHI, such as impaired anatomical barriers, suppression of the immune response, chemotherapy-induced neutropenia, renal or liver failure, hyperglycemia, and graft-versus-host disease, as well as antibiotic treatment a wide range action or corticosteroids, placement of central venous catheters....

06.01.2019 Oncology and hematology Resolution of the meeting for the sake of experts on the problem of thrombocytopenia in practice of oncologists and hematologists

Thrombocytopenia is a group of illnesses and syndromes, united by a common sign: the manifestation of a hemorrhagic syndrome, which develops as a result of a decrease in the number of blood platelets in peripheral blood<150×109/л....

As a result of the progress of new scientific areas of molecular biology, molecular genetics and genetic engineering, a huge step forward has been made, which now makes it possible to ask nature questions that were previously impossible to ask. We are talking about understanding the most fundamental foundations of such phenomena as cell division and differentiation, as well as the reasons for the mechanism of their violations.

In a concrete application to one of the most topical and exciting problems facing humanity - the problem of malignant tumors - we can talk about the emergence of a new science - molecular oncology. Her striking success in the field of studying the molecular mechanisms of oncogenesis and the molecular basis of the cancer phenotype is associated with the use of unique research methods inherent in her.

The book "Molecular Oncology", which is being published and is offered to readers, is devoted to summing up the first results and presenting the achievements of this young science. It clearly traces the continuity of the basic principles and postulates of classical theoretical oncology, primarily in the main issues: the polyetiology of the onset of tumors and the multi-stage nature of this process.

However, solutions are already given at another level of organization of living matter - the molecular one. This book is the first and only one so far in our country. It was written by authors who are directly and actively working in this field, which predetermined the depth of understanding of the given specific facts and the constructiveness of generalizations. The idea of ​​the universality of the molecular mechanisms of oncogenesis runs throughout the book.

This idea naturally follows from the authors' analysis of the latest studies of the main types of carcinogenesis: chemical, physical, biological, the basis of which, as the authors convincingly show, is one and can be expressed in fundamentally general molecular terms.

Separate chapters are devoted to each of these types of oncogenesis. Chapter 1 turns the reader to the origins of theoretical oncology, to its classic studies of the beginning of this century. Chapters 2 and 3 are devoted to the molecular mechanisms of chemical and viral carcinogenesis, respectively.

The first three chapters mentioned logically precede the final chapters 4 and 5, the true core of the book.

It is in these chapters that facts and ideas are presented in a concentrated form, symbolizing the essence and spirit of modern theoretical oncology - molecular oncology. Her achievements inspire confidence in the final victory of the human mind over a serious illness.

"Molecular Oncology"
I.F. Seitz, P.G. Knyazev

To a critically thinking observer, modern theoretical oncology may appear to be a flowering tree, but not a fruitful one. Such an impression is to some extent justified and is due to a clear imbalance of huge intellectual efforts and material investments, on the one hand, and modest practical outputs, on the other. Still remain unclear both the nature of malignant neoplasms and the primary stimulus that initiates the inevitable chain ...

Over time, the identification of the carcinogenic properties of chemical agents has become only a matter of technology, and there has been a clear shift in research focus from routine testing for carcinogenicity to the study of the mechanism of oncogenic action. In this case, along with significant successes, considerable difficulties were revealed. Successes concerned the purely chemical side of the problem: the need for activation of the original carcinogens was established, metabolism, interactions were studied ...

How does the invasion of fragments of chemical carcinogens into DNA result in uncontrolled growth and transformation of cells? The theory of chemical carcinogenesis, in order to take a new and decisive step forward, needs some kind of scientific event, similar in significance to the discovery of reverse transcriptase in oncovirology. In the theory of chemical carcinogenesis, such an event has not yet occurred. However, you can expect…

The main success of oncovirology today should be considered the discovery of oncogenes - discrete material genetic elements in the DNA structure of cells responsible for the induction of malignant tumors in humans and animals. This line of research is the most promising in modern theoretical oncology. Oncogenes have been found in the genomic DNA of not only animals, but also humans, and the likelihood of their involvement in tumor induction…

Even I. M. Sechenov in 1860, in the theses of his doctoral dissertation, wrote that in the present state of the natural sciences, the only possible principle of pathology is molecular. Now one can only marvel at this providence. Today, molecular oncology stands at the threshold of the mysteries of cancer. It is she who owns the most outstanding successes in the field of theoretical oncology in recent years. These include the following…

If molecular biology in the most concise interpretation can be characterized as a science that expresses and explains complex general biological phenomena in terms of the properties and interactions of molecules, then molecular oncology, of course, is designed to reveal the molecular mechanisms of the process of carcinogenesis and the characteristics of tumors. This book attempts to summarize the progress of this young science. All the greatness of progress in the knowledge of tumors in our ...

The use of gene transfer and molecular cloning techniques has made it possible to establish some of the most important, central determinants of the cancer process. These determinants are oncogenes and their products are oncoproteins that act both on the structure and functions of cells and affect the regulatory mechanisms of biochemical reactions. Many of these functions of oncogenes and oncoproteins are still unknown, however, with the current level of knowledge, they ...

The oncoprotein p21cras during the process of cell transformation, apparently, significantly affects the bioenergetics of the cell and the transmission of the regulatory signal from the cell membrane to the nucleus. There is also no doubt that the p2jcras oncoprotein in its multifunctional action in the process of malignancy of the target cell cooperates with the functions of other activated proto-oncogenes. For some steroid hormones, such as glucocorticoids, a mechanism has been established for transmitting their information from a specific ...

Source: Proceedings of the third annual Russian Cancer Conference
November 29 - December 1, 1999, St. Petersburg

PROSPECTS FOR MOLECULAR DIAGNOSIS IN ONCOLOGY. K.P. Hanson
Research Institute of Oncology. prof. N.N. Petrova

Achievements in genetics and molecular biology in recent decades have had a huge impact on understanding the nature of the initialization and progression of malignant tumors. It has been finally established that cancer is a heterogeneous group of diseases, each of which is caused by a complex of genetic disorders that determine the property of uncontrolled growth and the ability to metastasize. This modern knowledge has opened fundamentally new possibilities in the diagnosis and treatment of malignant neoplasms.

The influence of specific genetic disorders underlying tumor growth made it possible to detect specific molecular markers and develop tests for early tumor diagnosis based on them.

It is known that neoplastic transformation of cells occurs as a result of the accumulation of inherited (germinal) and acquired (somatic) mutations in proto-oncogenes or suppressor genes. It is these genetic disorders that can first of all be used to detect malignant cells in clinical material.

The most suitable substrate for molecular diagnostics is DNA, because it is stored for a long time in tissue samples and can be easily propagated using the so-called. polymerase chain reaction (PCR). This allows diagnostics to be carried out even in the presence of a minimum amount of the test material.

In addition to determining mutations in oncogenes and suppressor genes, for diagnostic purposes, changes are used that are detected in repetitive DNA sequences, the so-called. micro satellites.

When comparing paired samples of tumor and normal tissues, the loss of one of the alleles in the tumor (loss of heterozygosity (LH)) can be detected, which reflects the presence of chromosomal deletions underlying the inactivation of suppressor genes.

In recent years, methods for the molecular and genetic study of malignant cells have been developed and put into practice. 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 yourself to 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 that physicians can use to inform treatment decisions.

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 ‹‹Oncotype DX›› result, which was 31, indicating a high risk of cancer recurrence, and chemotherapy is a 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 result was 13, suggesting that she has a lower risk of relapse (return of the disease). During the conversations with her doctor, she felt confident, she was able to avoid chemotherapy and its side effects without increasing the likelihood of a 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 grew from the age of 23. "Thirteen is my lucky number at the moment," 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 you 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.

This genetic test detects mutations in genes associated with the CYP2D6 enzyme, and allows you to accurately assess the degree of enzyme activity and the 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 as part of a comprehensive treatment for 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 likelihood 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, a chain reaction of cell division will still occur, 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 the FDA recommendations, 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 effective in hormone-dependent breast cancer and 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 surgery, 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.

Molecular medicine in cancer treatment

The creation of drugs based on marker genes and marker proteins makes it possible, acting only on them, to selectively destroy their carriers without giving side effects. This is molecular or genetic medicine.

In the coming years of the 21st century, this medicine should replace the existing one, which is now called "old". Indeed, with the "old" medicine, the medicine is created by the method of "trial and error", therefore they often cause severe side effects in patients. In this sense, standard cancer chemotherapy is in a difficult position today.
The main reasons for this are: 1) a cancer cell is a eukaryote among the normal cells of the human body, also eukaryotes; 2) the backlog of science until recent years about the sources of carcinogenesis and its molecular causes.

Standard chemotherapy drugs alone cannot distinguish between a cancer cell and normal cells, and aim to kill the too-rapidly dividing cells that each cancer cell was assigned to.

It has recently been found that carcinogenesis comes from two sources: 1) from a normal tissue cell that has become a stem cell, or 2) from a tissue stem cell.

It also turned out that in the composition of cancer cells, the cells are not the same:

The bulk of the cells are non-cancerous cells: they rapidly divide and, after performing the functions of the tissue, they themselves die through apoptosis; it is these cells that are targets for standard chemotherapy drugs;
- a much smaller part is made up of cancer cells: these are cancer stem cells that copy themselves by asymmetric division and generate non-cancerous cells as part of cancer cells.

At the same time, cancer stem cells divide rarely and slowly. This is the reason why conventional chemotherapy drugs are ineffective against cancer stem cells (J.E. Trosko et al., 2005).
Until now, patients with symptoms of cancer predominate in clinical practice, and patients with cancer are extremely rare - "in situ", i.e. in place.

It is already too late to start treatment for cancer with symptoms. After all, cancer cells begin to spread throughout the body when the size of cancer in the tissue of any organ is only 2 mm in diameter, i.e. with the onset of angiogenesis and lymphangiogenesis in the nodule.

Now, when eramolecular medicine has come, the patient will be treated even before the first symptoms of the disease, including cancer, appear: at the very beginning - at the level of the first cancer cell and its first descendants, and even before it begins - at the level precancerous cells.

Having determined the marker gene of the disease, it is possible to determine which protein causes it, which means that it is necessary to create a medicine against this protein or its gene - this is the “magic bullet” that P. Ehrlich so dreamed of. This is what the pharmacology of the future will be based on.
New drugs and drugs based on marker genes and marker proteins for a specific disease will target only defective cells, destroying them without damaging healthy cells. Hence - there will be no side effects from drugs in the patient.

Cancer stem cell arises from a normal cell or tissue stem cell due to derepression of fetal protein genes in it and simultaneous repression of suppressor genes by methylation of the CpG dinucleotides of the promoter of these genes or mutations in the genes. At the same time, it becomes more tenacious than a normal cell of the same type.
A cancer cell carries a number of tricks that make it invulnerable and capable of independent existence in the patient's body. Those. this defective cell is not just a cell, but a whole unicellular organism.

1. Predisease.

Any disease begins with a pathology of a cell or cells. Changes in a particular gene or genes of a cell are not a diagnosis of a disease, but only an establishment of a probable predisposition to it.
With such changes in the germ cell, the term is used - a predisposition to the disease, and in the somatic cell, they often say - predisease.
In pre-illness, such a gene does not yet manifest itself, since there is no synthesis of the gene product, proteins, in the cell yet. When such changes in genes occur in a normal cell, this is a precancerous cell.
"Repair" of such a gene or genes, or its replacement in a cell with a normal gene, "switching off" the genes of the properties of a cancer cell eliminate the predisease.

2. Illness.

When in a cell under the control of a gene or genes there is already a synthesis of its product - proteins, then this is a sign that the gene has already begun destructive work in the cell, leading to disease.
Here, changes in the gene or genes are the root cause of the disease of the cell, and changes in the properties of the cell are caused by the product of the gene, i.e. its proteins. These properties then form the symptoms of a particular disease.
The cause gene in the cell is the marker gene, and its protein is the marker protein. Inhibition of the causative gene and its products, the proteins in the cell, can stop the disease.

3. Early diagnosis of the disease.

Until now, many diseases, including severe ones, including cancer, are diagnosed at the stage of their symptoms. Treatment of many diseases at this stage is extremely difficult in terms of cure or even impossible.
Now the diagnosis of any disease, including the most dangerous disease - cancer, will become possible in the presymptomatic period.

"Before the beginning". This will be done by detecting in a cell or cells in a patient a marker gene for a specific disease. In relation to cancer, this would be the diagnosis of a pre-cancerous cell or cells.

"From the very beginning". This will be done by detecting in a cell or cells not only a marker gene, but also a marker protein for a specific disease. In relation to cancer, this will be the detection in the patient's body of the first cancer cell and its close descendants.
Materials for these studies can be: tissue samples of the background process of the corresponding organ - a biopsy, as well as blood and other biological fluids from the patient.

At any localization of cancer in a patient, due to the mosaicity of the capillaries of the cancer nodule, both cancer cells themselves and their markers can be detected in the blood: marker genes in blood plasma, and marker proteins from cancer stem cells in blood serum.
There may be marker genes from precancerous cells in blood plasma, as well as marker genes from cancer cells, but it is almost impossible to distinguish between them.
Theoretically, these differences can be found using MS-PCR and PCR-MMC and protein microarrays.

If marker genes characteristic of a cancer cell are found in the blood plasma from a patient, and the corresponding marker proteins are absent in the serum of the same blood sample, this could indicate the presence of precancerous cells.
The detection of marker genes from a cancer cell in the blood plasma from a patient could be referred to as level I of early cancer diagnosis, since gene disorders are the root cause of the transformation of a normal cell into a cancer cell. Then the detection of marker proteins from cancer cells in the patient's blood serum is the II level of early cancer diagnosis, since the marker protein is a gene product.

4. Treatment of the disease.

To do this, marker genes and cell marker proteins for each disease will be used as targets for drugs and drugs.
These are new drugs and agents that will target only defective cells, and for cancer, these are cancer stem cells, while not affecting normal stem cells. That is, these medicines and drugs will be selective and individual for a particular patient (A.I. Archakov, 2000).

5. Criteria for curing the disease and control.

Marker genes and marker proteins will make it possible to detect defective cells in any disease when they cannot yet be detected in the patient's body by any other methods.
They will make it possible to detect cancer in a patient with a size of a nodule of cancer cells in tissue with a diameter of 2 mm (A.S. Belokhvostov, 2000).
The amount or titer of marker genes and marker proteins in the blood from defective cells of a particular disease or from cancer stem cells will allow monitoring the process of treating a disease and the result of a patient's treatment.
If the titer of markers does not decrease during treatment, the treatment tactics should be changed. The complete absence of markers two to three weeks after the end of treatment is a sign that the patient has recovered from the disease.

It will be very convenient to carry out such control using biochips: DNA chips for marker genes, and protein chips for marker proteins of defective cells of a particular disease and cancer stem cells.