Current Diagnostic Tests

for Colorectal Cancer

Evlina Suzanna, MD, Path

Chairman of Medical staff of Anatomical Pathologist
Dharmais National Cancer Hospital
NCC Indonesia
 Terminology-Istilah
INTERNIS. PET SCAT Gynaecologist
Paediatrician Surgical oncologist
Endokrinology RADIOTERAPI
Neurologist Psychiatrist
Oncologist Haematologist
Tumor Marker, .>>>> Terapi target
Dll..... GERIATRY ? ? Pathologist
 Definisi
Neoplasia new growth/neoplasm.
Tumor Swelling Inflammation non-neoplastic.
Neoplasm Swelling.
Tumor (non-neoplastic) ~ Neoplasm.

Oncology ( Greek oncos = tumor) is the study of

tumors or neoplasms.
Cancer (?/Latin = crab cancer) : Malignant
tumors.
proses terjadinya kanker : Carcinogenesis
Mekanisme karsinogenesis dapat merupakan defek pada berbagai
tingkat pengaturan siklus proliferasi sel.
 Cellular Basis of Cancer
Cancer is a collection of diseases
characterized by abnormal and
uncontrolled growth

Cancer arises from a loss of normal

growth control

In normal tissues, the rates of new

cell growth and old cell death are
kept in balance

In cancer, this balance is disrupted

This disruption can result from

1) uncontrolled cell growth or
2) loss of a cell's ability to undergo
apoptosis
 Classification guideline

etc

http://w2.iarc.fr/en/publications/list/bb/index.php
http://training.seer.cancer.gov/modules_site_spec.html
 Coding guideline
ICD-O-3 : International Classification of Diseases (ICD)
for Oncology 3rd revision
Subset of ICD 10th revision (ICD-10)
Specific code set for neoplasms
Coding system for primary site and cell type
ICD-O-3 updates (in english) : September 2011
www.who.Int/classifications/icd/updates/ICDO3Updates.pdf

Multiple tumors are defined differently by various

registries, and specific solutions to all problems cannot be
given here.
A working party of IARC recommended definitions of
multiple neoplasm for the purpose of incidence reporting
for international comparison
http://www.iacr.com.fr/MPrules_july2004.pdf
http://www.iacr.com.fr/TechRep42-MPrules.pdf
 Staging guideline
AJCC CANCER STAGING MANUAL TNM SYSTEM
Edge, S.B.; Byrd, D.R.; Compton, C.C.; Fritz, A.G.; Greene, F.L.;
Trotti, A. (Eds.)

7th ed. 2010, X, 646p. 130 illus.. With CD-ROM.

http://www.springer.com/medicine/surgery/cancer+
staging?SGWID=0-40654-0-0-0
SEER SUMMARY STAGING MANUAL 2000
Summary staging is the most basic way of categorizing how far a
cancer has spread from its point of origin. Summary staging has also
been called General Staging, California Staging, and SEER Staging. The
2000 version of Summary Stage applies to every anatomic site,
including the lymphomas and leukemia. Summary staging uses all
information available in the medical record; in other words, it is a
combination of the most precise clinical and pathological
documentation of the extent of disease.
http://seer.cancer.gov/tools/ssm/
 Staging guideline
FIGO/IGCS STAGING

Staging system for gynecological cancer

http://www.igcs.org/files/TreatmentResources/FIGO_IGCS_staging.pdf

ANN ARBOR STAGING

Staging system for lymphoma

CLARK AND BARSLOW STAGING

Staging system for melanoma

DUKES STAGING

Staging classification for colorectal cancer

 Pendahuluan
Sel
Suatu struktur dan fungsi pada hewan, tumbuhan
dan manusia yang merupakan satuan hidup yang
paling kecil yang sanggup hidup mandiri.

Sejarah
Robert Hooke 1665 Jaringan gabus rongga rongga
kosong.

Virchow 1885 Semua sel berkembang dari sel

yang telah ada.
Sel : Inti dan Sitoplasma
Mengandung organel cell
Sel epitel torak dan skuamosa normal
Rasio inti : sitoplasma = 1 :4
Struktur Sel darah merah /Eritrosit
Tanpa inti sel : Tidak membawa sifat genetik
 Genome
Genome complete set of hereditary information for
any organism

Chromosome a discrete unit of genome carrying many

genes

Consists of long duplex DNA molecule and proteins

Chromosomes Organization
 Genes
Gene segment of DNA that codes for a
polypeptide chain

Includes Exons and Introns

Transcriptome the complete set of genes

expressed under particular conditions
Gene Structure
 What is Molecular Pathology?
o Pathology: is the study of diseases.
o Molecular biology: the study of molecules
in biological systems that are responsible for
normal biological traits or behaviors i.e.:
DNA replication, transcription and
translation in normal cells.
o Molecular pathology: an evolving field that
examines and identifies the molecules
involved in specific diseases.
Integrates knowledge and techniques applied in
molecular biology to pathology.

Molecular Basis
Of Diseases
Environment
And genes
Growth regulation
e.g.Rb causing
Retinoblastoma etc
Changes in structural
Proteins
1.e.g. collagen, Deletions
Or point mutation that
Produce reduced amount
Of normal collagen or
Normal amounts of mutant
Collagen. Causing
Osteogenesis imperfecta
2.e.g cell membrane Fibrillin
Missense mutations causing
Marfan syndrome
Or deletion of dystrophin gene
Causing Duchene muscular
Dystrophy
Changes an Enzyme
e.g. Phenylalanine hydroxylase
Splice site mutation leading to reduced amount
Causing phenylketonuria
Changes an Enzyme inhibitor
e.g. 1-Antitrypsin
Missense mutation that impair secretion from liver
To serum causing Emphysema and Liver disease
Changes a receptor
e.g. Low density lipoprotein receptor
Deletion or point mutation that reduce synthesis,
Or transport to the cell surface or binding to low
density lipoprotein
Causing Familial hypercholesterolemia
Change a transport or carrier protein
1.e.g. Haemoglobin
Mutations in splice sites (commonest) leading to
Reduced -globin.causing -Thalassemia in
-Thalassemia the -globin gene is usually deleted
2.e.g. Cystic fibrosis transmembrane conductance
Regulator. Deletions or point mutation causing
Cystic fibrosis.
Changes in Hemostasis
e.g. Factor VIII deletions, insertions, nonsense
Mutation reduce synthesis or abnormal factor VIII
Causing Hemophilia A.
 Proliferasi sel
Definisi : Pertumbuhan jaringan- penambahan
ukuran dan jumlah Sel.

Bayi 3 4x.1015
Dewasa balance 1012
Kematian sel degenerasi
Penambahan sel pertumbuhan

Siklus sel
Cell cycle clock siklin/cdk
Checkpoint faktor ekstra selular, intraselular
Protoonkogenes >< Tumor supressor genes
 Mekanisme siklus sel normal
Teratur dan terkontrol 2 sel
Daugther cell
anak identik

Mitosis Gateway
Phase G0 : Anti mitogenig signal
Phase G1 (Gap 1) : Tidak
Growth
Factors reproduktif
Phase G2(Synhesa) : DNA
duplikasi/ Replikasi
CELL CYCLE Phase G2( Gap 2) : Persiapan
DNA replication mitosis-DNA 2X normal.
Phase M (mitosis ) : Pembelahan
Cell cycle
diri.
inhibitors

Control Point
WSGI :8 jam 100 hari (usus
hepatosit)

Whole system genomic inisiative/wsgi

1 fertilized egg
50x1012

1016 cell divisions/lifetime

Proliferation Differentiation Death

 Cellular equilibrium
Proliferation Differentiation Death

Transit
Renewing
Proliferating

Exiting
Mekanisme siklus sel normal-abnormal
 Sel Jaringan Organ System
Fisik/ Raga/ Tubuh : 12 Sistem
1. Jantung dan Pembuluh Darah
2. Sal Nafas Atas & Bawah/Paru
3. Pencernaan Atas &Bawah
4. Ginjal, Saluran Kemih
5. Genitalia Pria & Wanita/System Reproduksi
6. Syaraf Pusat & Syaraf Tepi
Diferensiasi
7. Panca Indera
8. Jaringan lunak dan Tulang
9. Darah & Retikuloendotel/Immunitas
10. Kulit dan Adneksa
11. Endokrin/hormon(Gondok, Hypofise)
12. Hati dan Empedu
Struktur sel-jaringan : Kulit, Payudara
 Cancer: disruption of
cellular equilibrium

Proliferation Differentiation Death

Struktur sel normal - tumor
 TUMOR SUPPRESSOR GENES
Disorders in which gene is affected

Gene (locus) Function Familial Sporadic

DCC (18q) cell surface unknown colorectal

interactions cancer

WT1 (11p) transcription Wilms tumor lung cancer

Rb1 (13q) transcription retinoblastoma small-cell lung

carcinoma

p53 (17p) transcription Li-Fraumeni breast, colon,

syndrome & lung cancer

BRCA1(17q) transcriptional breast cancer breast/ovarian

tumors
BRCA2 (13q) regulator/DNA repair
IMPORTANCE OF DNA REPAIR
GENETIC
ALTERATIONS
IN CANCER
 Mekanisme kontrol
Faktor ekstraseluler
1. Faktor pertumbuhan (GF)
2. Reseptor faktor pertumbuhan (GFR)
3. Sitokin ( Interleukin, interferon, CSF)
4. JAK (STAT dari Tirosin. DNA intranukleus)

Faktor intraseluler
1. Kompleks siklin/cdks
2. Proto onkogenes (Kontrol positif proliferasi sel)
3. Tumor supressor genes (TSGs) (kontrol negatif
proliferasi sel).
 Tumor Progression
Cellular
Multiple mutations lead to colon cancer
Genetic changes --> tumor changes
Stem cells as the target of carcinogens
Stem cell Post mitotic
Differentiated Normal
senescent
differentiated
cell

Benign tumor

Grade 2
malignancy

Grade 3 or 4
malignancy
Karsinogenesis- Waktu terjadinya kanker
 KARSINOGENESIS

Average age (years)

Screening here Screening here has

encounters the maximum
Dysplasia swamp cost-effectiveness
~8% of cancers ~92% of cancers
COLORECTAL CANCER /CRC
Cancer Epidemiology
 Trend of cancer cases in Dharmais National Cancer Hospital

Laki-laki Perempuan Total 2371 2387

2110
1930
1663 1653 1674 1606
1612 1569
1462 1508 1474
1354 1345 1392
1257
1098 1049 1079
1002 1016
910 902 848 958
841
705
392 718 802 781
606 610 647 673
604 595
513 552 393
497 516
263
129

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
1993-1997 1998-2002 2003-2007
 Distribution of Colorectal Cancer by Age Group
in Dharmais Cancer Hospital 1993-2007

18
16
14
12
10 1993-1997

8 1998-2002
2003-2007
6
4
2
0
5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75+

Peak in 1998-2007 : 50- Peak in 1993-1997 : 55-

 Background
Distribution of basis of diagnosis of Colon Cancer
in Dharmais Cancer Hospital, NCC Indonesia
Clinical only Radiology Tumor Marker Microscopic
1993-1997 3,73 % 8,07 % 0,00 % 88,20 %
1998-2002 3,70 % 5,56 % 2,31 % 88,42 %
2003-2007 2,08 % 7,29 % 1,74 % 88,89 %

Distribution of basis of diagnosis of Rectum, Rectosigmoid, and Anal Cancer

in Dharmais Cancer Hospital, NCC Indonesia

Clinical only Radiology Tumor Marker Microscopic

1993-1997 3,55 % 6,38 % 0,71 % 89,36 %
1998-2002 3,47 % 1,74 % 0,43 % 94,35 %
2003-2007 5,30 % 4,67 % 0,00 % 90,03 %

Courtesy : Dharmais Cancer Registry Subdivision

 The Comparison of Top 10 Malignancy
between Dharmais HB Cancer Registry
and Jakarta PB Cancer Registry
MALE FEMALE
Dharmais 03-07 Jakarta 05-07 Dharmais 03-07 Jakarta 05-07
Pharynx Bronchus and Lung Breast Breast
Bronchus and Lung Colorectum Cervix Uteri Cervix Uteri
Colorectum Hepar Ovary Ovary
Leukemia Pharynx Colorectum Colorectum
Lymph Nodes Prostate Gland Thyroid Gland Bronchus and Lung
Hepar Leukemia Pharynx Thyroid Gland
Prostate Gland Lymph Nodes Leukemia Corpus Uteri
Oral Cavity Renal pelvis -bladder Bronchus and Lung Pharynx
Skin Skin Lymph Nodes Leukemia
Soft Tissue CNS Corpus Uteri Hepar
Anatomy of Colorectal
 Diagnostic test for colorectal cancer
Triple Diagnostic : 1. Blood Test
1. Clinical 2. Tumor marker
2. Radiology 3. Sigmoidoscopy
3. Laboratory 4. Colonoscopy
Clinical Pathology 5. Imaging
Anatomical Pathology 6. Biopsy
7. H & E (routine)
8. Immunohistochemistry
9. Molecular Pathology
1. Blood test
Fecal occult blood test
It is to test the presence of microscopic or invisible blood in the stool, or feces.
Complete blood count
It is to test the anemia. Some people with colorectal cancer become anemic because of prolonged
bleeding from the tumor.
Liver Enzyme
It is to check liver function, because colorectal cancer can spread to the liver.

2. Tumor marker
Colorectal cancer cells sometimes make substances that are released into the bloodstream :
CEA, CA 19-9
Uses : to monitor patients who already have been diagnosed with or treated for colorectal cancer, to
show how well treatment is working or provide an early warning of a cancer that has returned.

3. Sigmoidoscopy
It is used to evaluate gastrointestinal symptoms, such as abdominal pain, rectal bleeding, or changes in
bowel habits and also for screening

4. Colonoscopy
A procedure using a long flexible tube with the aim of examining the entire rectum and colon. If found
polyps in the colon, it is usually removed using a colonoscope and sent to a pathologist for later
examined the type of cancer
5. Imaging
CT Scan
CT with portography : to look for spread from colorectal cancer to liver
CT-guided needle biopsy: to to guide a biopsy needle precisely into the suspected area. A fine-needle biopsy sample (tiny fragment
of tissue) or a core needle biopsy sample (a thin cylinder of tissue) is then removed and looked at under a microscope
USG
Endorectal ultrasound : to see how far through the rectal wall a cancer may have penetrated and whether it has spread to nearby
organs or tissues such as lymph nodes.
Intraoperative ultrasound : It is done during surgery after the surgeon has opened the abdominal cavity. The transducer can be
placed against the surface of the liver, making this test very useful for detecting the spread of colorectal cancer to the liver.
MRI
To look at abnormal areas in the liver that might be due to cancer spread
To help determine if rectal cancers nearby structure
Chest X-Ray
This test may be done after colorectal cancer has been diagnosed to see if cancer has spread to the lungs.
PET Scan
A PET scan can help give the doctor a better idea of whether an abnormal area seen on another imaging test is a tumor or not.
For patients who have already been diagnosed with cancer, it is to to see if the cancer has spread to lymph nodes or other parts of
the body.
A PET scan can also be useful if the doctor thinks the cancer may have spread but doesn't know where.
Special machines are able to perform both a PET and CT scan at the same time (PET/CT scan). This allows the doctor to compare
areas of higher radioactivity on the PET with the more detailed appearance of that area on the CT.
Angiography
Angiography is an x-ray procedure for looking at blood vessels.
Angiography can be useful in showing the arteries that supply blood to tumors in the liver. This can help surgeons decide whether a
cancer can be removed and if so, it can help in planning the operation
Double-contrast barium enema (DCBE)
In this test, a series of colon and rectum X-rays are taken. The patient is given an enema with a barium solution, and air is pumped
into the rectum. The barium and air outline the colon and rectum on the X-rays. It detects approximately 30% to 50% of the cancers
found with standard colonoscopy, and may miss small polyps.
6. Biopsy/Resection
Usually if a suspected colorectal cancer is found by any diagnostic
test, it is biopsied during a colonoscopy.
In a biopsy, the doctor removes a small piece of tissue with a special
instrument passed through the scope.
Less often, part of the colon may need to be surgically removed to
make the diagnosis.

Cellular Multiple mutations lead to colon cancer

Genetic changes --> tumor changes
MUTASI BERULANG SEBAGAI PENYEBAB KANKER

Sel normal
Mutasi
pertama
Mutasi
kedua
Mutasi
ketiga

Mutasi
keempat
MUTASI BERULANG SEBAGAI PENYEBAB KANKER

Sel normal
Mutasi
pertama
Mutasi
kedua
Mutasi
ketiga

Mutasi
keempat
MUTASI BERULANG SEBAGAI PENYEBAB KANKER

Sel normal
Mutasi
pertama
Mutasi
kedua
Mutasi
ketiga

Mutasi
keempat
MUTASI BERULANG SEBAGAI PENYEBAB KANKER

Sel normal
Mutasi
pertama
Mutasi
kedua
Mutasi
ketiga

Mutasi
keempat
MUTASI BERULANG SEBAGAI PENYEBAB KANKER

Sel normal
Mutasi
pertama
Mutasi
kedua
Mutasi
ketiga
Mutasi keempat

Mutasi
keempat
MUTASI BERULANG SEBAGAI PENYEBAB KANKER

Sel normal
Mutasi
pertama
Mutasi
kedua
Mutasi
ketiga

Mutasi
keempat
Sel-sel ganas
 The progression of mutations that commonly
lead to colorectal cancer

The fatal metastasis is the last of six serial changes that the epithelial cells lining the rectum
undergo. One of these changes is brought about by mutation of a proto-oncogene, and three of
them involve mutations that inactivate tumor-suppressor genes.
Prognostic marker
A marker that provides information
about the natural history of the
disease.

Predictive marker
A marker that provides information
about the likelihood of response to
a treatment.
 Prognostic determinants
Category I Category IIA Category IIB Category III Category IV
Local tumor Tumor grade Histologic type DNA content Prognostic
extent Circumferential Mismatch repair All other molecular
Regional nodes (radial) margin deficiency and molecular profiles
Mesenteric Tumor tumor markers
nodules regression after infiltrating K-ras and
Nodal micro- neo-adjuvant lymphocytes benefit from
metastases therapy 18q deletions EGFR-targeted
Vascular Tumor border treatments
invasion Perineural Microvessel
Residual tumor invasion density
Serum CEA Cell surface
molecules
Peritumoral
fibrosis and
inflammatory
response
Focal
http://www.uptodate. neuroendocrine
com/contents/patholo
differentiation
gy-and-prognostic-
determinants-of- Proliferative
colorectal-cancer activity
 Classification of Tumor in Colorectal (WHO)
Epithelial tumours Non-epithelial tumours
Adenoma 8140/0 Lipoma 8850/0
Tubular 8211/0 Leiomyoma 8890/0
Villous 8261/0 Gastrointestinal stromal tumour 8936/1
Tubulovillous 8263/0 Leiomyosarcoma 8890/3
Serrated 8213/0 Angiosarcoma 9120/3
Intraepithelial neoplasia (dysplasia) Kaposi sarcoma 9140/3
associated with chronic inflammatory diseases Malignant melanoma 8720/3
Low-grade glandular intraepithelial neoplasia Others
High-grade glandular intraepithelial neoplasia Malignant lymphomas
Carcinoma Marginal zone B-cell lymphoma 9699/3
Adenocarcinoma 8140/3 of MALT Type
Mucinous adenocarcinoma 8480/3 Mantle cell lymphoma 9673/3
Signet-ring cell carcinoma 8490/3 Diffuse large B-Cell Lymphoma 9680/3
Small cell carcinoma 8041/3 Burkitt lymphoma 9687/3
Squamous cell carcinoma 8070/3 Burkitt-like /atypical Burkitt-lymphoma 9687/3
Adenosquamous carcinoma 8560/3 Others
Medullary carcinoma 8510/3
Undifferentiated carcinoma 8020/3 Secondary tumours
Carcinoid (well diff endocrine neoplasm) 8240/3
EC-cell, serotonin-producing neoplasm 8241/3
L-cell, glucagon-like peptide and PP/PYY Polyps
producing tumor Hyperplastic (metaplastic)
Others Peutz-Jeghers
Mixed carcinoid-adenocarcinoma 8244/3 Juvenile
Others
 epithelial tumor
Epithelial tumours invasive non-epithelial tumor
6.1%
Carcinoma
Adenocarcinoma 8140/3
Mucinous adenocarcinoma 8480/3
Signet-ring cell carcinoma 8490/3
93.9%
Small cell carcinoma 8041/3
Squamous cell carcinoma 8070/3
Adenosquamous carcinoma 8560/3
Medullary carcinoma 8510/3
Undifferentiated carcinoma 8020/3

25.7%

74.3%

Adenocarcinoma Others type

Specimen Macroscopic
 Grade of colorectal cancer
Grade : a description of how closely the cancer looks like normal
colorectal tissue when seen under a microscope.
The scale used for grading colorectal cancers :
Low grade (G1 or G2)
G1 : the cancer looks much like normal colorectal tissue
High grade (G3 or G4)
G4 : cancer looks very abnormal
Low-grade cancers tend to grow and spread more slowly than
high-grade cancers.
Most of the time, the outlook is better for low-grade cancers
than it is for high-grade cancers of the same stage.
Grade is useful to decide whether a patient should get additional
(adjuvant) treatment with chemotherapy after surgery
 Immunohistochemistry
Colorectal cancer progresses in a step-wise histological pattern with molecular
and genetic correlates at each step. As cellular atipya increases, there is
deregulation of cellular maturation and apoptosis. Loss of apoptotic control leads
to the accumulation of cells with genetic abnormalities that enhance cell
proliferation

Normal Hyperplastic Tubular Villous

Marker colon cancer
colon polyp adenoma adenoma
p53 negative negative neg/focal + focal +/++ +/+++
bcl-2 neg/focal focal + ++ +++ ++/+++
bax ++/+++ ++ ++/+++ +++ ++/+++

p53, bcl-2 and bax immunohistochemistry in colorectal carcinogenesis: immunohistochemical markers for colorectal
cancer chemoprevention trials
Rebecca Cody, Sarah Whaley, George Youngberg, Koyamangalath Krishnan, James H. Quillen VA Medical Center and East Tennessee State
University, Johnson City, TN.
Staging System
UICC / Dukes Astler
TNM Coller
O - -
I A A, B1
IIA B B2
IIB B B2
IIC B B3
IIIA C C1
IIIB C C1, C2
IIIC C C2, C3
IV - D
Gene mutations that cause colon cancer
 Hallmarks Of Cancer

Hanahan & Weinberg,Cell 2011

 Therapeutic Implication

Hanahan & Weinberg,Cell 2011

Pathologist expertise is essential to quality KRAS testing and effective metastatic CRC patient
treatment determination for the following reasons.
Identification of the right cells for assay analysis. KRAS mutations are detected on DNA from
tumor sections. A pathologists evaluation of the tissue section used for DNA extraction is
required to ensure that tumor cells are present in the specimen and that tumor cells are
present in adequate quantity/concentration for the KRAS test that is utilized by the lab.
Consultation with oncologists and other members of the treatment team. The pathologist
can assist oncologists in the appropriate use of this test and guide the interpretation of
results. Even if local pathologists are not performing the test in their own laboratory, they
should understand the clinical significance of KRAS test results.
Reference laboratory selection. Pathologists who utilize reference laboratories for this testing
should be able to carefully evaluate the KRAS testing technology utilized and quality
processes employed to ensure confidence in the results.
Technology selection. Directors of molecular diagnostic laboratories will need to determine
the best method for KRAS mutation detection in their environment.
sequence of sense strands of exon 1 (codons 11-13) of the K-ras gene
from the six pancreatic cancer cell lines. K-ras has the GGTGTT
mutation at codon 12, but has wild-type GGC at codon 13. The
negative control BXPC-3 is shown to be wild-type at codons 12 and 13.
Bottom: sequence of antisense strands of exon 1 of the K-ras gene
from the six pancreatic cancer cell lines. K-ras codon 12 has the
ACCAAC mutation at codon 12, but has wild-type GCC at codon 13.
BXPC-3 is shown to be wild-type at codons 12 and 13.

Gene segment of DNA that codes for a

polypeptide chain
Includes Exons and Introns
Transcriptome the complete set of genes
expressed under particular conditions
KRAS
KRAS can harbor oncogenic mutations that yield a constitutively active protein in
approximately 40% of CRC tumors.
Most KRAS mutations occur in codon 12 or 13 of the gene.
Recent studies have indicated that the presence of KRAS mutations in codon 12 or
13 is associated with a lack of response to EGFR inhibitors.
The presence of KRAS mutations in the tumor is generally associated with a worse
prognosis.
KRAS mutations are also found in many other common tumor types beyond CRC,
but their impact on anti-EGFR therapies have not yet been studied thoroughly.
Patients with cancers with mutations in KRAS do not benefit from treatment with
certain anti-cancer drugs such as cetuximab and panitumumab.

BRAF
Patients with cancers with mutations in BRAF do not benefit from treatment
with certain anti-cancer drugs such as cetuximab and panitumumab.
BRAF mutations, such as V600E, are responsible for an additional 12-15% of
patients who fail to respond to anti-EGFR treatment
BRAF is a downstream molecule from KRAS in a signaling pathway involved in
cell cycling
 Two commonly used methods to evaluate
samples for KRAS mutations are:
Real-Time PCR. In real-time PCR, fluorescent probes specific
for the most common mutations in codons 12 and 13 are
utilized. When a mutation is present, the probe binds and
fluorescence is detected.
Direct Sequencing Analysis. KRAS mutations can also be
identified using a direct sequencing method of exon 2 in
the KRAS gene. This technique identifies all possible
mutations in the exon. Direct sequence analysis has lower
analytical sensitivity than some of the real time PCR assays.
However, the clinical relevance of a small percentage of
cells with mutant KRAS has not been established.
Non-Epithelial tumours

Gastrointestinal stromal tumour 8936/1

Leiomyosarcoma 8890/3
Adverse prognostic indicators in stromal tumors
(Weiss and Goldblum 2000)

Parameter Stomach Duodenum Jejunum/ colon rectum extraGI

Ileum
High celularity + + + + + +
Mitosis/hpf >10/50 >2/50 >5/50 high >2/50
100%met
Size >6cm >4,5cm >9cm >5cm
Necrosis +
Mucosal inv + + +
Infiltration of
Musc propria +
Growth pattern nonorganoid epiteloid (>50%)

DNCC : Gross specimen >10 cm

BIOLOGIC BEHAVIOR : LOW RISK and HIGH RISK
 Kit in Malignancy
The Kit receptor tyrosine kinase is not limited to normal tissues; it
is detected in various cancers, including

GIST
Small-cell lung cancer (SCLC)
Neuroblastoma
Testicular cancer/seminoma
Myeloid leukaemia (including CML and AML)
 Schematic Structure of Kit
The portion of the Kit receptor outside the cell binds its ligand, stem
cell factor (SCF), which under normal conditions activates signalling
pathways
The portion of Kit inside the cell has the tyrosine kinase activity, and is
where Glivec binds and blocks Kit activation
 Molecular Pathology of GISTs

The majority of GISTs (~90%) express the product

of a mutated c-kit gene
Mutations are heterozygous1 normal, 1 mutated
allele
c-kit oncogenic mutations:
Exon 11
Exon 9
Exon 13
Exons 17 and 2
 Histopathology of GIST: Biological Markers Used
in Diagnosis of GIST
GISTs positive for
CD117 (c-Kit receptor tyrosine
kinase)
Positive in >95%
CD34
(mesenchymal/haematopoietic
precursor cell marker)
Positive in 60% to 70%
Vimentin and smooth muscle actin
Positive in 15% to 60%
GISTs do not express
Desmin and S-100
CD117 (c-Kit)positive
staining GIST
 Microscopic Appearance of GIST
and Normal Small Intestine

H+E Stain CD117 IHC Stain

GIST

Normal
Small
Intestine

CDM Fletcher, MD
GI Leiomyoma

Desmin

c-Kit

SD Nelson,MDPath
 Mesenchymal tumors ( spindle and epiheloid
cell) of the Digestive tract
Smooth muscle - leiomyoma/sarcoma >> oesophagus
actin , SMA +, CD117-
desmin :varying
expression.
Pheripheral nerve sheath
(PNS) - schwannoma >>stomach, S100 +
Interstitial cells of Cajal phenotype CD117+,CD34 80%+
-GI wall - GIST
-adjacent soft tissue -extraGIST omentum and
mesenterium 80%,
peritoneum 20%
5% of ICC-phenotype
tumors.
Autonomic nerve (neural) Gastrointestinal autonomic
nerve tumor (GANT)
- diagnosis by EM
 Malignant Potential of GIST: Defining Risk of
Aggressive behaviour
Size Mitotic count

Very low risk <2 cm <5 per 50 HPF

Low risk 2-5 cm <5 per 50 HPF

Intermediate risk <5 cm 6-10 per 50 HPF

5-10 cm <5 per 50 HPF
High risk >5 cm >5 pr 50 HPF
>10 cm Any mitotic rate
Any size >10 per 50 HPF
HPF: high-powered field, 400x (high magnification microscopy).

Fletcher C et al. 2002 (In press)