1. GENETIQUE & Cancers de la prostate O. CUSSENOT Urologie Hôpital Tenon (AP-HP) / Université Paris 6

4. Adénocarcinome Micro-invasif Cancer latent Cancer Evolutif Cancer Métastatique & Réfractaire au Traitement Carcinogenèse Prostatique Croissance & maturation Prostatique Atrophie inflammatoire proliférative Néoplasie intraépithéliale Prostate adulte Prédisposition génétique Hormones stéroïdes Inflammation Stress oxydatif Enzymes et récepteurs stéroïdiens Récepteurs macrophages, cytokines… Carcinogènes 1 2 3

5. CHAINON MANQUANT Prolifération Prolifération Prolifération Différentiation Carcinogenèse Prostatique AR DHT TMPRSS2 ETS AR TMPRSS2 ETS * - ETS AR DHT TMPRSS2

7. How genetics can delimit high risk groups for prostate cancer? Behind usual risk factors: Familial history of cancer & African origin  Genetic markers of susceptibility

8. Segregation Dominant Autosomal --- X linked -- Recessive Predisposition locus 1956 1980 1996  1998  2000  2006  2011 Candidate Genes Genomewide association studies Markers of susceptibility Familial Prostate cancer A brief history BRCA2 PCaP HPC1 8q24

9. Epidémio-génétique « the Swedish Family-cancer database » « Czene et al, 2002 »

10. Bil-Axelson A et al. NEJM 2005 p<0,001 Importance des Formes à début précoce « Facteur de risque génétique » « The disease-specific mortality risk increase with early onset » Mortalité spécifique

11. J Clin Oncol. 2006 Urology 2006

12. BRCA2, PALB2...

13. Mutations BRCA 1 & 2 et progression fatale

14. Age at diagnosis for men with familial history of prostate cancer & BRCA2 mutation status Prevalence of BRCA2 mutation in a set men with early onset (<50 y.o.) prostate cancer BRCA2* 7% 98 men 49 yo 61 yo 69 yo

15. Genetic markers of susceptibility 3 Major Cases/Controls Studies Familial Prostate Cancer International Consortium for Prostate Cancer Genetics Sporadic Prostate Cancer Cancer Genetic Markers of Susceptibility US + French (all European ancestry) Cancer Research UK UK + Australian De Code Genetics Iceland + Afro-American

16. CGEMS ICPCG Cancer Genetic Markers of Susceptibility International Consortium for Prostate Cancer Genetics Aggressive disease Localised High Risk & Metastatic PROGENE (CeRePP) The French Prostate Cancer Cases / Controls Study (10,000 males) Began in 1994 Familial Prostate Cancer « Carter criteria » (200 families) Genetic markers of susceptibility

17. ICPCG

19. MSR1 CAPB RNASEL HPC20 HPCX ELAC2 Gènes & locus de prédisposition pour le cancer de la prostate familial & groupes de recherche européens du Consortium international ACTANE Finlande Suéde Allemagne Légende France GCT1 PCAP BRCA2 AR 8q24 NKX3.1 CHEK2 NBS1

20. Expression différentielle de RA et ERA chez des patients présentant une histoire familiale de cancer de prostate AR AR HPC HPC ERA ERA Spo Spo 2008 Héréditaire Sporadique AR (med) 90 (10-100%) 40% (0-90) p< 0.004 ERA (med) 10 + cellules/spot (0-100) 30 + cellules/spot (0-100) p< 0.03 Ki67 (med) 2% (0-13%) 1% (0-10%) p=0.2 5AR1 - (n=8), + (n=9), ++ (n=4) - (n=10), + (n=7), ++ (n=4) p=0.7 5AR2 - (n=3), + (n=3), ++ (n=10), +++ (n=5) - (n=3), + (n=8), ++ (n=5), +++ (n=4) p=0.3 Aromatase - (n=12), + (n=9), - (n=15), + (n=6), p=0.5 ERB - (n=4), + (n=17), - (n=7), + (n=14), p=0.5 Ce Re P P

21. Committed Studies CGEMS: Prostate Cancer PLCO: The Prostate, Lung, Colon and Ovarian, Cancer Screening Trial (155,000 men and women, U.S.). Began in 1993 . ACS: The American Cancer Society Cancer Prevention Study Nutrition Cohort (86,000 men and 97,000 women, U.S.) Began in 1992. HPFS: The Health Professionals Follow-up Study ( 51,529 U.S. male dentists, optometrists, osteopaths, podiatrists, pharmacists, and veterinarians. began in 1986. ATBC: The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. (29,133 Caucasian male smokers, Finland . Began in 1985. PROGENE (CeRePP): The French Prostate Cancer Case Control Study. (10,000 male Cases/Controls for Prostate Cancer), Began in 1994.

22. Prostate Cancer PSA or Prostate Cancer Type 2 Diabetes Results from the 3 main consortium CTBP2 11p15 THADA EHBP1 ITGA6 3p12.1 EEFSEC PDLIM5 TET2 SLC22A3 JAZF1 LMTK2 8p21 8q24.21(x5) MSMB/ NCOA4 11q13 (x3) HNF1B (x2) 17q24.3 19q13.2 KLK2/ KLK3 BIK NUDT10/ NUDT11 CGEMS CRUK deCODE

23. Region 1 Prostate Bladder Region 3 Prostate Colorectal Ovarian Region 2 Region 1 Region 3 Region 4 Region 4 Prostate Men of African Descent Region 2 Prostate Breast rs7008482 126,3 TCC Linkage 55% rs6983267 « G risk allele » rs1447295 « A risk allele » 40% 30% 10% 25% 10% rs7008482 « G risk allele » rs16901979 « A risk allele » 90% 28% 99% 2% 45% 30% 8q24

24. Results: Aggressive PRCA (2,338 v 2,623) 100,000 MC simulations SNP DATA General PRCA (meta) Aggressive PRCA (meta) Chr SNPs Region Gene CMH emp pvalue allele test OR allele test CI allele test emp pvalue allele test OR allele test CI 2 rs721048 2p15 EHBP1 <0.000010 1.26 1.16, 1.38 <0.000010 1.29 1.16, 1.43 3 rs2660753 3p12 0.0017 1.20 1.07, 1.34 0.012 1.19 1.04, 1.37 6 rs9364554 6q25 SLC22A3 0.0031 1.12 1.04, 1.21 0.016 1.12 1.02, 1.23 7 rs10486567 7p15 JAZF1 0.0023 1.14 1.05, 1.23 0.00028 1.22 1.10, 1.35 7 rs6465657 7q21 LMTK2 0.095 1.06 0.99, 1.14 0.27 1.05 0.96, 1.15 8 rs979200 8q24 (Salinas) 0.86 1.01 0.93, 1.09 0.39 1.04 0.95, 1.14 8 rs1016343 8q24 (Salinas) 0.000020 1.20 1.10, 1.31 0.00036 1.21 1.09, 1.33 8 rs13254738 8q24 (region 2) 0.078 1.07 0.99, 1.15 0.21 1.06 0.97, 1.16 8 rs6983561 8q24 (region 2) 0.000050 1.42 1.20, 1.67 0.0037 1.35 1.11, 1.65 8 rs16901979 8q24 (region 2) 0.000020 1.48 1.26, 1.75 0.00072 1.42 1.16, 1.74 8 rs6983267 8q24 (region 3) 0.000010 1.18 1.10, 1.27 0.00050 1.16 1.08, 1.28 8 rs7837328 8q24 (Salinas) 0.00055 1.14 1.06, 1.22 0.013 1.12 1.03, 1.22 8 rs7000448 8q24 (region 3) 0.048 1.08 1.00, 1.16 0.037 1.10 1.01, 1.20 8 rs1447295 8q24 (region 1) <0.000010 1.30 1.18, 1.44 <0.000010 1.42 1.26, 1.61 8 rs4242382 8q24 (region 1) <0.000010 1.28 1.15, 1.41 <0.000010 1.38 1.23, 1.57 8 rs10090154 8q24 (region 1) <0.000010 1.32 1.19, 1.46 <0.000010 1.41 1.25, 1.60 8 rs7005795 8q24 (Johanna) 0.99 1.00 0.93, 1.07 0.38 0.96 0.88, 1.05 9 rs1571801 9p13 DAB2IP 0.30 0.96 0.88, 1.04 0.29 0.95 0.86, 1.04 10 rs10993994 10q11 MSMB <0.000010 1.17 1.09, 1.25 0.00078 1.17 1.07, 1.27 10 rs4962416 10q26 CTBP2 0.16 1.06 0.98, 1.14 0.18 1.07 0.97, 1.18 11 rs10896449 11q13 0.00071 1.14 1.05, 1.22 0.00098 1.16 1.06, 1.27 17 rs11649743 17q12 (Sun) HNF1B 0.00085 1.16 1.06, 1.28 0.00082 1.22 1.09, 1.37 17 rs4430796 17q12 HNF1B 0.000040 1.16 1.08, 1.25 0.000050 1.20 1.11, 1.32 17 rs3737559 17q21 (BRCA1) BRCA1 0.76 1.02 0.91, 1.15 0.75 0.98 0.84, 1.14 17 rs1799950 17q21 (BRCA1) BRCA1 0.037 1.16 1.01, 1.33 0.12 1.15 0.96, 1.37 17 rs1859962 17q24 0.00055 1.14 1.05, 1.22 0.000020 1.20 1.11, 1.32 19 rs2735839 19q13 (KLK3) KLK3 0.010 1.14 1.03, 1.27 0.22 1.09 0.95, 1.23 23 rs5945619 Xp11 0.00012 1.23 1.11, 1.36 0.00026 1.27 1.12, 1.44

25. 8q24 Region 2 (rs16901979) Meta: PRCA allelic OR=1.48 (1.26, 1.75), p=0.00002

26. KARU-PROSTATE L. Multigner, P. Blanchet Région 4 Région 2 8q24 validation Ce Re P P

27. Men of African descent have a more aggressive disease PCa starts at the same age in men of African descent (A) & Caucasian (C) men (20-30 yo # A-8% / C-11%  70-79 yo # A-77%/ C-69%) But Incidence rate of clinical PC among (A) men is 60% higher than in (C) men mortality rate is 2.4-fold higher in (A) men than in (C) men Metastatis occurred at a 4:1 ratio i n (A) and (C) men I.J Powell et al. J. Urol. 2010 Age specific distant Pca incidence (1995-2004) per 100.000 men Age at Diag. EA rate AA rate Rate Ratio 40-49 0,6 2,9 4,9 50-59 3,8 15,7 4 60-69 16,8 60,3 3,6 70-79 38,7 119,5 3

28. Genome research 2010 PLOS Genetics 2011

29. Nature Biotechnology 2011 Région 4 Région 2

30. 17q12 HNF1B (rs4430796) Meta: PRCA allelic OR=1.16 (1.08, 1.25), p=0.00004

31. HUMAN HEREDITY 2010

32. TESTOSTERONE DHT AR OESTROGENES Catechols-estrogènes CYP1B1 CYP17 COMT CYP19 ER2 DHEA HSD17B2 HSD3B1/B2 « DNA-Adducts » INITIATION PROMOTION CARCINOGENESE PROSTATIQUE ER1 CYP3A4 SRDA2 VDR Vit D3 CYP27B1 CYP24 *

33. Expression of Estrogen Related Proteins in Hormone Refractory Prostate Cancer Cases: Association to Tumor Progression Shorter time to hormonal relapse was associated with high expression of CYP19 & BCAR1 on diagnostic biopsy , together with low staining for ESR1 in stromal cells

34. But predictive value of PSA test is limited by confusing factors related to PSA patho-biology PSA blood level is currently the main marker using in tools for…… Prediction of Prostate Biopsy outcomes Prediction of Radical Prostatectomy outcomes Genetic markers a nd PSA variability

35. Predictive value of PSA test is limited by confusing factors related to PSA patho-biology PSA is secreted by non cancerous and cancerous prostatic glands and PSA blood level correlate with prostatic epithelial volume Alteration of basal membrane & vascular permeability (such as cancer or inflammation) influence PSA blood level PSA gene arbors androgen response elements & PSA blood level correlates with androgenic activity Genetic polymorphisms of PSA correlates with PSA blood level Standardisation according individual environmental & genetic variability Involving PSA biology

36. T  DHT  AR  Androgen response elements  PSA 5  R 5ARI V89L/V89L genotype CGA repeat genotype E2 Aromatase activity CYP19 Genotype TTA repeat BMI ESR2 ESR2 genotype Factors of aggressiveness or unreliable low PSA Low Blood level Diagnosis! Prognosis!

37. Cumulative effect of five SNPs (KLK3/PSA) (rs2569729, rs266849, rs266870, rs2735839, rs1506684) PLCO-Trial 1,157 Controls men Prostate, Lung, Colorectal and Ovarian Cancer Screening % Variant allele carriers (9 & 10 did not exist) Genetic polymorphisms related to PSA secretion Cramer SD et al, JNCI 2003 T  DHT  AR  PSA 5  R

39. 10% 20% 50% 20% <1% <5% >50% Mutations Rares Variants génétiques communs Combinatoire Environnement Alimentation Chimioprévention Fréquence des allèles à risque Facteurs de risque génétiques

40. Familial or individual history of cancer Definition hereditary Definition aggressive disease (Critères de prédisposition héréditaire) Phénotype familial

42. Three at 8q24 and one each at 17q12 and 17q24.3 AUC= 63.3 (95% CI, 61.7 to 65.0) (age, region, family history, number the five SNPs)

43. Performances # Zheng PSA <10ng/ml AUC: 0,65 Pas ATCD Fam. 1 Parent 1° >1 Parent 1° 8q24 rs1447295 (CC) . 8q24 rs1447295 (AA/AC) Ce Re P P

44. The susceptibility SNPs for the Diabetes application were rs4430796 ( HNF1B ) and rs10486567 ( JAZF1 ). Values are given for ORs significant at the 5% level. The minor allele frequency of rs4810671 was 0.48. 2011

45. Prévention & 5ARi s  Sélection des cancers agressifs AR DHT 5  R1-2 T E2 ESR1 CYP19

46. Méthodes de dépistage Suivi des sujets à risque Au moins 1 critère  Positif (+) 40-70 ans (1 an) PSA sang (40 ans) >2,5 ng/ml (+20%/an) PSA T /Vol.Prostate (cc) + si ≥ 15% Rapport L/T + si ≤ 10% Marqueurs Urinaires (PCA 3) + si >35 IRM Perfusion/Diffusion & (Apparent Diffusion Coefficient) Nodule & chute ADC

47. Remerciements CGEMS ICPCG Cancer Genetic Markers of Susceptibility SJ. Chanock, G Thomas International Consortium for Prostate Cancer Genetics WB Isaacs, J.Xu KARU-PROSTATE L. Multigner, P. Blanchet Epidémio-génétique des cancers de la prostate O. Cussenot, G. Cancel-Tassin, G.Fromont PROGENE H. Sobol, F. Eisinger J. Muller, S. Gazut 1 9 9 5 Ce Re P P