Molecular markers to aid in early diagnosis of pancreatic cancer Michael Goggins, MD Professor of Pathology, Medicine and Oncology Johns Hopkins Medical Institutions, Baltimore, MD “7th Annual Symposium on Gastrointestinal Cancers " St. Louis, Mo, 9/20/08
Disclosure Dr. Goggins has licensing agreements with Oncomethylome sciences for several DNA methylation markers
Early detection of asymptomatic disease Early diagnosis of symptomatic disease
positive margin negative margin poor or undifferentiated well or moderate no positive nodes positive nodes < 3 cm ≥ 3 cm p< Survival for Ductal Pancreas Adenocarcinoma Tumor Diameter Margin Status Lymph Node Status Histologic Grade
Early detection of small asymptomatic neoplasms may result in cure Best outcome: 79 patients wth small, asymptomatic, < 1 cm cancers 5- year survival 100% after surgery if PC limited to duct epithelium (CIS?) Ariyama 1997
What is the natural history of patients who present with symptoms and are ultimately diagnosed with pancreatic cancer? We do not have much quantitative information on the obstacles to diagnosis for patients with pancreatic cancer
When there are delays in diagnosis, what are their causes?
Chari et al, AJR 2004;182:897 Pancreatic CT abnormalities up to 18 months prior to a diagnosis of pancreatic cancer
How many patients would have a significantly improved outcome if they were optimally diagnosed as soon as symptoms presented?
Markers of Pancreatic Neoplasia What performance characteristics are needed for a(serum) molecular marker for the Diagnosis of pancreatic cancer
The performance characteristics of a marker often vary by population (disease stage, heterogeneity): Ca19-9 PC AmpCA CP islet ca controls JHU unpublished Sensitivity for resectable PC =65% (Sensitivity for unresectable PC=80%)
900 (TP)200 (FP) 100 (FN)800 (TN) DiseaseNo Disease Positive Negative Test Sensitivity: 90% Specificity: 80% (for cancer) PPV: 900/1100=81% NPV: 800/900=91% 1,000 1, Disease prevalence 50% (e.g. pancreatic mass)
182 (TP)360 (FP) 18 (FN)1540 (TN) DiseaseNo Disease Positive Negative Sensitivity: 90% Specificity: 80% (for resectable cancer) PPV: 182/542=34% NPV: 1540/1558=98% 1, Disease prevalence ~10%, e.g. mid-back pain, wt loss
What performance characteristics are needed for a molecular marker for Screening for pancreatic cancer?
General Population: Age 65: 5 year Risk PPV NPV Surveillance Epidemiology and End Result
18 (TP)396 (FP) 2 (FN)1584 (TN) DiseaseNo Disease Positive Negative Sensitivity:90% Specificity: 80% PPV: 18/414=4.3% NPV: 1584/81856=99.8% 1, Disease prevalence, 1%
New Onset Diabetics: 3 yr PC risk PPV NPV Chari et al. Gasto 2005
Family Hx PC 3 1 st -degree relatives: 3-yr PC risk PPV NPV Klein et al. Cancer Research 2004
PPV NPV Klein et al. Cancer Research 2004 Family Hx PC 2 1 st -degree relatives: 3-yr PC risk
Is this the right question to ask of our markers? What performance characteristics are needed for a molecular marker to Screen for pancreatic cancer?
What about the performance characteristics for a molecular marker of neoplastic precursors?
DiseaseNo Disease Positive Negative Test: Sensitivity: 95% Specificity: =90% (EUS or MRI) PPV: 95/105=91% NPV: 90/95=95% Strong Family Hx of PC, prevalence: 10% (IPMN)
Cancer of the Pancreas Screening (CAPS) clinical trials Who are we screening? Asymptomatic High risk individuals with a strong family history of pancreatic cancer and certain germline mutation carriers CAPS1:1999 CAPS2: 2001 CAPS3: 2006 CAPS4: 2008
Familial PC Screening Programs PopnScreening Tests Diagnostic Yield (IPMN/PC) Canto, CGH 2004,n=36 FPC (> 3) PJS EUS 5.8% Canto, CGH 2006,n=78 FPC (> 3) PJS EUS + CT10.2% Kurtz, DDW 2007,n=66 FPCCT/MRI +/- EUS 7.6% Poley, DDW 2007,n=46 FPC, PJS, FAMM, BRCA1/2 EUS 23.9% Other studies ongoing, eg. Brentnall et al (Seattle), Europac, U Pitt, Zubarik et al, (Vt)
Cancer of the Pancreas Screening Study (CAPS) 3 CAPS 3 – 1 st national American multicenter screening study EUS/CT/MRI + biomarkers (juice) Hopkins, Mayo, MDACC, Dana Farber, UCLA lizst.onc.jhmi.edu/caps3
CAPS 4 Single center, long-term screening and surveillance (V foundation) Evaluate expanded eligibility –1 FDR, 1 SDR (eg. parent and grandparent) –BRCA2 mutation carriers Biomarker discovery
3 months 10 mm 12 months 18 mm baseline
Lobular CP like changes on EUS
Extensive PanIN Lobulocentric atrophy Brune et al, AJSP, 2006
Is the identification of IPMNs and PanINs in asymptomatic individuals justified when we have not proven that surveillance of these lesions leads to improved outcome?
What molecular markers are on the horizon and can they help identify cancer or advanced neoplasia?
Molecular alterations in pancreatic cancer DNA: Somatic mutations Aberrant DNA methylation Chromosomal losses/gains RNAs: RNAs and microRNAs Proteins Peptides, glycopeptides Other eg. Autoantibodies Infiltrating pancreatic ca
Normal Duct PanIN 1APanIN 1B PanIN 2PanIN 3 Invasive AdenoCa Intraductal Papillary Mucinous Neoplasm (IPMN) Mucinous Cystic Neoplasm (MCN) Cystic Lesion AdenomaCarcinoma in situ Invasive AdenoCa
Research Activity Time Candidate Markers Pancreatic cancer research: Era of systematic discovery Translational Evaluation of markers 100% 0% Systematic Discovery (“Omics”)
The Pancreatic Cancer Genome
Data figure on the pc genome Number of somatic mutations in pancreatic cancer
Walter et al, Cancer Biol Ther, 2008 Gains Losses Pancreatic cancer chromosomal gains + losses
Quantifying mutant KRAS in Pancreatic juice: LigAMP Shi et al, Cancer Biol Ther, 2008 PC CP
Discovering the cancer methylome Methylome = genome wide DNA methylation patterns
Chr1 Chr2 Chr3 Chr4 Chr5 Chr6 Chr7 Chr8 Chr9 Chr10 Chr11 Chr12 Log ratio
Hong et al, Modern Path in press Aberrant DNA methylation in IPMNs %
Quantitative Methylation analysis of ERCP Brushings of common bile duct strictures
QMSP ≥1 gene + 3 gene panel, >3% conc.n Sens (CI)Spec (CI)Accuracy (CI) Pancreatic adenocarcinoma (58-84) a 86.4 (7-24) 81 (73-88) i Biliary tract cancer1080 (49-94) b 86.4 (7-24)86 (76-92) Cytology Pancreatic adenocarcinoma (14-34) c 100 (95-100) 69 (60-77) Biliary tract cancer1030 (11-60) d 100 (95-100)92 (84-96) Cytology + QMSP Pancreatic adenocarcinoma4176 (61-76) e 86.4 (7-24)82 (74-88) h Biliary tract cancer1090 (60-96) f 86.4 (7-24)88 (79-94) QMSP of biliary and Pancreatic duct Brushings performed to diagnose strictures Parsi et al, Clin Gastro Hep, 2008
Pancreas juice sampling for markers
Quantifying pancreatic juice DNA methylation alterations 5 gene panel, quantified by QMSP, CAPS2 study population Cancer Res 2006:66:1208
Marker Discovering Pancreatic cancer expression patterns
Clin Cancer Res 2006;12:442 Candidate pancreatic cancer markers: Serum Macrophage inhibitory cytokine-1 (MIC-1) PC=pancreatic cancer CP=chronic pancreatitis Nl=normal ELISA
MicroRNA alterations in pancreatic cancer Hahn et al, Oncogene 2007;264442