(PowerPoint)

The Clinical Implications of Treating Patients with

Li-Fraumeni Syndrome

Julie Kanter, MD

Case Presentation: HPI: __ is a 6½ year old male who presented

to his PCP for a check-up. He was noticed to be pale in color with multiple bruises on his legs. His parents also noted some decreased energy at home. PCP sent the child to an outpatient lab where a CBC was notable for +blasts, Hgb 7.2, and plt count of 17. __ was diagnosed with AML the following day after

a bone marrow exam. LP was negative for any CNS disease

Case Presentation: Past medical history: patient was

diagnosed with a stage III embryonal rhabdomyosarcoma of his R thigh in 2/2002. He underwent treatment with chemotherapy, brachytherapy, external radiation, and surgical excision. He had been off-therapy for 4 years at the time of current presentation.

Case Presentation: Family History:

Pt’s father, was diagnosed with a fibrous histiosarcoma in 1991 at the age of 25

Pt’s uncle (father’s brother) was diagnosed with metastatic melanoma in 2006

Pt’s paternal grandfather was diagnosed with a histiosaromca in 1996 and later acute leukemia

Pt’s maternal grandfather and great-grandfather had prostate cancer

Pt’s mother is healthy with no problems Pt’s 9 year old brother is healthy with no problems

Case Presentation: New diagnosis AML FAB M7-acute megakaryoblastic leukemia Flow cytometric analysis revealed 21% in the blast gate

that express CD33, CD34, CD41 (partial), CD61 (partial), and CD117. Cells do not express CD13, CD14, CD56, or CD64

Bone Marrow biopsy: extensive fibrosis with >90% cellularity and minimum of 20% blasts with increased megakaryocyte numbers with hyperchromasia

Cytogenetics: Highly complex 36-44XY, del(2)(q3),del(5q),

+8,+12,add(12),der(13)t(12;13),add(17)(p12),-18,-20,+mar(2)/38

amp(p53)(19/2000)

add(17)(p?12)

Note the amplification (4~6 signals) of P53

Normal 17

Abnormal 17P53Control probe (D17Z1)

Li-Fraumeni syndrome A cancer predisposition syndrome Individuals with LFS are at increased risk for

developing multiple primary cancers Age-specific cancer risks have been calculated Inherited in an autosomal dominant manner Highly penetrant cancer syndrome: segregation

analysis of families with LFS, revealed a 50% chance of cancer before age 40 and up to 90% by age 60 (Lustbader et al, 1992)

Occurs in approximately 1/50,000 individuals Two forms exist: classic Li-Fraumeni syndrome (LFS) and Li-Fraumeni-like syndrome (LFL)

Clinical Criteria for Classic LFS 1. A proband with a sarcoma

diagnosed at less than 45 years of age AND

2. A first degree relative with any type of cancer less than 45 years of age AND

3. First or second degree relative with any cancer at less than 45 years of age OR a sarcoma at any age.

Criteria for Li-Fraumeni-like syndrome (LFL)-two definitions Birch et al 1994

Proband with any childhood cancer or sarcoma, brain tumor, or adrenal cortical tumor diagnosed before age 45 AND

First or second-degree relative with a typical LFS cancer (sarcoma, breast cancer, brain cancer, adrenal cortical tumor, or leukemia)

Eeles’ 1995 Two first or second-degree relatives with

typical LFS-related malignancies at any age

P53 TP53 gene: Recognized as the most

common gene mutated in sporadic cancers Well known that tumor suppressor genes

need both copies of the gene to be inactivated to cause tumor

However…this gene is unique in that it does not always obey the classical 2-hit hypothesis

This property of the TP53 gene is a dominant negative effect: a mutation of one copy of the gene will lead to inefficient protein formation

LOH: loss of heterozygosity Loss of Heterozygosity: Accepted model for

tumor suppressor gene mechanism in which there is a mutation in one allele and the secondary loss of the remaining wild type allele

Less than 50% of tumors from members of LFS families show the LOH

Supports the theory of a dominant negative effect

AML and p53 10% of leukemias contain mutant p53 in their

malignant chromosomes (in contrast to solid tumors) In AML, the deletion or rearrangement of p53 occurs

in about 17% of patients In pts without LFS who have p53 abnormalities-most

common observation is the loss of p53 In LFS, most common observation is a missense

mutation at p53 Therapy-related AML and MDS is also associated

with p53 alterations in addition to deletion of chromosome 5/5q or 7/7q in >50% of patients

Mutation of p53 is significantly associated with deletion of 5q (p<0.0001) while deletion of 7q was not significant

Li-Fraumeni (as discussed by Dr. Li and Dr. Fraumeni in 1988)

1969: Described four families with autosomal dominant pattern of soft tissue sarcoma, breast cancer, and other neoplasms in children and young adults

1988: Analyses of 24 families and further defining the component neoplasms

Cancer developed in 151 blood relatives, 79% prior to 45 years of age

Majority of cancers: 50 bone and soft tissue sarcomas of diverse histological subtype and 28 breast cancers

Additional cancers in excess: brain tumors (14), leukemia (9), and adrenocoritcal carcinoma (4 cases)

15/151 blood relatives had a secondary malignancy, 73% of which were in the above categories

6/15 patients had second cancers linked to radiotherapy

Molecular genetics P53 gene has been mapped to

chromosome 17p13 It is 20kb in length, comprises 11 exons

and encodes a 393 amino acid protein It has been called “guardian of the

genome” because of its role in the cellular response to DNA damage

Molecular testing In patients with classic LFS, approximately 50-60% will

have a genetically detectable p53 mutation In patients with LFL, 22% of families defined by Birch’s

definition will have an identifiable mutation Of those, 95% can be detected by sequence analysis of

exons 4 through 9. Why not more?

The methods used to detect p53 mutations neglect the regulatory region of the gene

P53 protein may undergo faulty regulation at the protein level by interacting with other cellular proteins

LFS could result from germline defects in other genes that participate in the p53 cell cycle regulatory pathway

Relative frequency of cancers in carriers of germline p53 mutations Birch J et al: Cohort of individuals from 28

families with LFS (with p53 mutation identified)

Relative frequency of cancers in carriers of germline p53 mutations The previous analyses identified seven cancer types

as being strongly associated with germline TP53 mutations

Carcinoma of the female breast, tumors of the brain and spinal cord, soft tissue sarcoma, osteosarcoma, and adrenocortical carcinoma (of the original group defined by Li in 1988)

Wilms’ Tumor and phyllodes tumor Moderate association: Carcinoma of the pancreas Weak association: Leukemia and neuroblastoma Cancers that did not occur in excess: lung, colon,

bladder, prostate, cervix, and ovary TP53 mutations have tissue specific effects with

regard to their increased cancer risk

Incidence of multiple primary cancer in patients with LFS Hisada et al reviewed the data from the original 24

families discussed by Li and Fraumeni and quantified the risk for secondary malignancy

200 cancer patients in 24 families were eligible for study

These 200 patients accumulated 1142 person-years of follow-up before diagnosis of second primary cancer (30 patients), death (120 patients), loss to f/u (2 patients)

30/200 patients had a second cancer occurrence with range in time b/n 1-27 years (median 6 years). 9 of these patients had received radiotherapy

8/30 developed a third cancer and 4/8 developed a 4th cancer

Incidence of multiple primary cancer in patients with LFS Cumulative second cancer probability of 57% at 30

years of follow up Cumulative probability was highest among patients

initially diagnosed with a soft tissue sarcoma Rate was highest among those patients with cancer

initially diagnosed before age 20 years and declined with age at initial dx

RR of second cancer differed markedly by age at first cancer

Patients with LFS who had cancer after 45 years of age had no increased RR of secondary cancer

Genotype vs Phenotype Total of 494 tumors identified in

individuals who were confirmed TP53 carriers or with LFS or LFL (Olivier M, et al)

Study done to further examine the tumor spectrum in LFS families with TP53 mutation versus a clinical background of LFS or LFL

Genotype vs Phenotype

Age in years at time of diagnoses

Tumor type, age at onset, and gender distribution in TP53 germ-line mutation carriers from LFS/LFL families

*Most frequent cancer is breast cancer (30.6%) followed by STS at (17.8%).

*A group of “less prevalent” tumors including lung, hematopoietic, stomach, colorectal , ovary, and melanoma account for 15%

Risk of Developing Second Cancers among survivors of childhood soft tissue sarcomas

Cohen R, et al evaluated 1499 children (age<18yrs) who survived >1 year after diagnosis with STS to assess the risk of developing a SMN in patients treated for RMS, fibromatous neoplasms, and other STS

27 children developed 28 second primary malignancies vs 4.5 expected malignancies. Increased risk for a second solid tumor, AML, cutaneous melanoma, oral cancers, and female breast cancer

Relative Risk of developing a SMN was highest during the first 5 years after initial treatment

4 patients with AML developed cancer within 29 months of treatment Risk by Initial Treatment for RMS

Combined radiotherapy with chemotherapy was associated with significantly higher risk than surgery alone

Initial tx with chemotherapy OR radiation therapy was not associated with a significantly increased risk for SMN

Fibromatous Neoplasms Combined radiotherapy and chemotherapy was associated with >70fold

increased risk for developing second cancer Radiation alone was associated with increased risk over chemotherapy alone

Observed excess of AML in these trials was attributed to therapy with alkylating agents and topoisomerase II inhibitors

How to avoid a second primary cancer in patients with LFS?

Uncertainty exist regarding strategies to reduce second cancer morbidity and mortality in families with LFS.

Ionizing radiation is a known risk factor with dose-dependent effects

Chemotherapy alone or surgery alone when feasible for treatment

Second cancers can arise in diverse organs and anatomic sites regardless of the first tumor type or the family’s germline p53 gene status (identifiable p53 mutation did not correlate with

increased risk of second malignancy)

Mechanisms for surveillance in patients with LFS Main recommendation: Earlier and more

frequent breast cancer screening for women There are no other universally agreed upon

surveillance recommendations for most LFS-associated malignancies

Other possible recommendations: Annual CBC with slide review Annual physical exam Annual Urinary analyses with micro/macro Healthy lifestyle Avoid environmental carcinogens

Treatment implications Increased sensitivity to DNA damaging

agents (XRT) commonly used to treat the type of cancers seen in LFS can pose a major risk

In addition, these tumors are commonly radioresistant

Radiation therapy should be avoided whenever there are other feasible treatment options

For breast cancer patients with LFS:

Urgent TP53 testing if patient is <30yrs old Mastectomy vs conservative therapy with xrt Response to systemic therapy

hormonal therapy vs nonanthracycline containing therapy vs anthracycline containing therapy

Chemoprevention for recurrence of breast cancer and for occurrence of contralateral breast cancer with Tamoxifen when possible (as used in BRCA mutation carriers)

Ethical Dilemma: Who do you screen? The overall lifetime risk of cancer is high (80-

90%) but the variable expressivity and penetrance and diversity of tumor spectrum render clinical surveillance and genetic testing a difficult test

What about the children or siblings of patients with LFS?

When a child is not competent to give consent, the main consideration in genetic testing should be the welfare of the child

Cornerstone of this process: “informed consent” or at least assent

Ethical Dilemma: Who do you screen? LFS screening is presymptomatic genetic

testing: testing a healthy person with no features or symptoms of a disease caused by a specific gene

This testing is only justifiable when the test result will change medical care (especially in childhood). Specific syndromes that apply incl: Familial adenomatous poposis, Multiple endocrine

neoplasia I, Multiple endocrine neoplasia II, Von Hippel-Lindau, Retinobastoma, Neurofibromatosis

Ethical Question: Do we test JM for Li-Fraumeni syndrome Will it change our current treatment for

this patient? TBI based transplant regimen

Will it change future management for this patient and his family??

Once an individual is diagnosed with LFS and the TP53 mutation is identified, predictive testing for yet unaffected relatives is easier

Ethical Question: Do we test JM’s brother for Li-Fraumeni syndrome Potential loss of autonomy for the child.

When the child who has been tested matures, the right of that person to decline testing or the possibility of withholding genetic test results has been effectively lost

Potential inability to minimize the risk of stigmatization and discrimination in later life

Disruption in family dynamics. If the sibling of a proband is negative, feelings of guilt may be overwhelming to the child

Evaluation of a decision aid for families considering p53 genetic counseling and testing (Peterson S, et al)

Study population of 57 adults from 13 kindreds who had previously participated in research regarding the genetics of LFS at MD Anderson

Eligibility criteria: donated a blood sample before clinical testing for p53 mutation was available, having at least 25% carrier risk, 18+ yrs of age, speaking English. Individuals with and without personal dx of cancer were eligible to participate

No one had undergone genetic counseling or p53 clinical testing in anyway

Evaluation of a decision aid for families considering p53 genetic counseling and testing (Peterson S, et al)

Outcomes were evaluated by questionnaires after the administration of a video-based decision aide to enhance the understanding of the clinical and psychosocial aspects of LFS and facilitate informed decision making

Results: Knowledge scores increased in both men and women from

baseline to post-DA assessment Perceived risk of developing cancer and cancer worries

decreased significantly Participants intention to have genetic testing did not change

following the use of the DA Participants did report lower levels of decisional conflict post-DA,

suggesting that it may have helped reduce uncertainty and improve perceived effectiveness of genetic counseling and testing decisions

96% reported they would recommend the DA to others who were considering the genetic counseling and testing

Ethical questions continue: American Society of Clinical Oncology

(ASCO) does consider LFS as a syndrome for which predictive testing should be considered.

In these publications, predictive testing for TP53 mutations is included amount “tests for hereditary syndromes with a high probability of linkage to known cancer susceptibility genes, and for which the medical benefit of the identification of a carrier is presumed but not established.”

The clinical value and reliability of the test is based on research studies.

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Li-Fraumeni Syndrome. Journal of the NCI, vol 90 (8), 1998 Tischkowitz M, Rosser E. Inherited cancer in children: practical/ethical problems and

challenges. Eur Jour of Cancer 40 (2004) 2459-2470 American Society of Clinical Oncology policy statement update: genetic testing for cancer

susceptibility. J Clin Oncol 2003: 21:2397-406 Birch J, Alston R, McNally R, et al. Relative frequency and morphology of cancers in

carriers of germline TP53 mutations. Oncogene (2001) 20:4621-28 Li F, Fraumeni J, et al. A Cancer Family Syndrome in Twenty-four Kindreds. Cancer

Research 48, 5358-5362 Garber J, Golstein A, Kantor A, et al. Follow-up study of twenty-four families with LI-

Fraumeni Syndrome. Cancer Research 51, 6094-97 Heyn R, Haeberlen V, Newton W. Second Malignant Neoplasms in children Treated for

Rhabdomyosarcoma. Jour Clin Onco, vol 11, No 2, 1993:262-270 Cohen R, Curtis R, Inskip P. The Risk of Developing Second Cancers among Survivors

Childhood Soft Tissue Sarcoma. Cancer, 2005. Vol 103. Number 11 Moule RN, Jhavar SG, Eeles R. Genotype phenotype correlation in Li-Fraumeni syndrome

kindreds and its implications for management. Fam Cancer 2006. 5:129-133 Olivier M, Goldgar D, and Sodha N, et al. Li-Fraumeni and Related syndromes: correlation

between tumor type, family structure, and TP53 genotype. Cancer Research, 2001, 63:6643

Boyapati A, Kanbe E, Zhang D, p53 Alterations in Myeloid leukemia. Acta Haematologica 2004; 111:100-106