Renal Cell Carcinoma – Detection of PRCC-TFE3 and Alpha-TFEB Gene Fusions Using RT-PCR on Tissues (Odes 60153 and 60154) Notice of Assessment
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Renal Cell Carcinoma – Detection of PRCC-TFE3 and Alpha-TFEB Gene Fusions Using RT-PCR on Tissues (odes 60153 and 60154) Notice of Assessment June 2013 DISCLAIMER: This document was originally drafted in French by the Institut national d'excellence en santé et en services sociaux (INESSS), and that version can be consulted at http://www.inesss.qc.ca/fileadmin/doc/INESSS/Analyse_biomedicale/Juin_2013/INESSS_Analyse_15.pdf http://www.inesss.qc.ca/fileadmin/doc/INESSS/Analyse_biomedicale/Juin_2013/INESSS_Analyse_16.pdf It was translated into English by the Canadian Agency for Drugs and Technologies in Health (CADTH) with INESSS’s permission. INESSS assumes no responsibility with regard to the quality or accuracy of the translation. While CADTH has taken care in the translation of the document to ensure it accurately represents the content of the original document, CADTH does not make any guarantee to that effect. CADTH is not responsible for any errors or omissions or injury, loss, or damage arising from or relating to the use (or misuse) of any information, statements, or conclusions contained in or implied by the information in this document, the original document, or in any of the source documentation. 1 GENERAL INFORMATION 1.1 Requestor: Centre hospitalier universitaire de Québec (CHUQ). 1.2 Application Submitted: August 1, 2012. 1.3 Notice Issued: April 12, 2013. Note: This notice is based on the scientific and commercial information (submitted by the requestor[s]) and on a complementary review of the literature according to the data available at the time that this test was assessed by INESSS. 2 TECHNOLOGY, COMPANY, AND LICENCE(S) 2.1 Name of the Technology Reverse transcription of messenger RNA and amplification (RT-PCR). 2.2 Brief Description of the Technology RT-PCR is used here to detect the production of chimeric messenger RNA generated from a chromosomal translocation. The technique comprises the following four steps: i) the isolation of total RNA from the suspected renal tumour; ii) the reverse transcription of messenger RNA and the synthesis of complementary DNA; iii) amplification by PCR with primers in each of the fusion genes (the PCR product spans the fusion junction); iv) the analysis of amplification products by agarose or polyacrylamide gel electrophoresis. 2.3 Company or Developer In-house protocol from Argani et al. (2002) (PRCC-TFE3) and Kuiper et al. (2003) (Alpha-TFEB)1. Test kits (PRCC-TFE3): . FFPE RNA kit (Roche Diagnostics) or RNeasy Plus (QIAGEN) . Transcriptor Reverse Transcriptase (Roche Diagnostics) . Taq DNA Polymerase (QIAGEN) Test kits (Alpha-TFEB): . QIAamp Mini Kit (QIAGEN) . Taq DNA Polymerase (Roche Diagnostics) 2.4 Licence(s): Not applicable. 2.5 Patent, If Any: Not applicable. 2.6 Approval Status (Health Canada, FDA) Not applicable; the kits used have not been approved by Health Canada. 1 Personal electronic communication with Dr. Chantal Courtemanche from the CHU de Québec (March 1, 2013). 1 2.7 Weighted Value 284.0 (PRCC-TFE3) and 263.0 (alpha-TFEB). Several similar tests were identified in the 2012-2013 Index, representing approximately 30 different codes (translocations associated with lymphomas, leukemias, sarcomas, and other diseases; the weighted values range between 20.0 and 324.0). 3 CLINICAL INDICATIONS, PRACTICE SETTINGS, AND TESTING PROCEDURES 3.1 Targeted Patients Individuals with renal cell carcinoma (RCC) whose tumour histopathology suggests the presence of a translocation with TFE3 or TFEB gene fusion. 3.2 Targeted Diseases(s) 3.2.1 Biology Several subtypes of adult RCCs can be distinguished based on histological criteria, the most common being clear cell renal cell carcinoma (CCRCC) (75%). In 2004, the World Health Organization (WHO) established an RCC subtype—based on histological and cytogenetic criteria— bearing an Xp11 translocation (Xp11 translocation RCC) (DeLellis et al., 2004). Xp11 translocation RCCs typically have papillary architecture and are composed of large, clear to eosinophilic cells and medium- or large-sized nuclei with prominent nucleoli. They also show stromal changes such as the presence of psammoma bodies (stratified calcifications) and hyaline nodules. The most commonly observed Xp11 translocations cause the regulating centres of the PRCC and ASPL2 genes to fuse with the coding regions of the ubiquitously expressed transcription factor E3 (TFE3). Another translocation, t(6;11)(p21q12), which generates the Alpha-TFEB3 fusion protein, was described for the first time in 2001, (Argani et al., 2001b). TFEB and TFE3 are members of the MiTF (microphthalmia-associated transcription factor) family (Kuiper et al., 2003). 3.2.2 Epidemiology In children and adolescents, Xp11 translocation RCCs account for approximately 50% of all renal tumours, or between 20% and 70% depending on the authors (Kuroda et al., 2012; Geller et al., 2008; Bruder et al., 2004). In middle-aged adults, Xp11 translocation RCCs are estimated to account for 1.6% of all renal tumours and 15% of the CCRCC subtype (Komai et al., 2009). However, these values are underestimated, as translocations have not been systematically researched (Argani et al., 2007). Some authors suggest that exposure to cytotoxic agents during childhood could significantly increase the risk of developing Xp11 translocation RCC (Argani et al., 2006; Ramphal et al., 2006). As RCCs with t(6;11) rarely occur, only some 30 documented cases exist. 3.2.3 Treatments The first line of treatment involves a radical nephrectomy, or partial nephrectomy if the tumour is superficial. A regional lymphadenectomy is performed when lymph nodes have been affected or when the risk of recurrence is high. For advanced stages of the disease, the first line of treatment is immunotherapy with cytokines (interferon/interleukin-2). If treatment fails, targeted therapies 2 PRCC (papillary renal cell carcinoma) and ASPL (alveolar soft part sarcoma locus) genes are involved in cell cycle control. 3 The function of the Alpha gene, which lacks intron sequences, is unknown. 2 such as sunitinib or sorafenib4, VEGF (vascular endothelial growth factor) inhibitors, or temsirolimus5, an mTOR kinase inhibitor, may yield a complete response (Kuroda et al., 2012; CEPO, 2010). 3.2.4 Prognosis The prognosis for Xp11 translocation RCCs is not clearly defined and is more dependent on the stage of the disease at the time of diagnosis. Among younger people, Xp11 translocation RCCs appear to be indolent, even in cases of lymph node involvement with no distant metastasis (Armah et al., 2009; Geller et al., 2008; Ramphal et al., 2006). However, the tumours appear to be more aggressive in adults (Argani et al., 2007; Meyer et al., 2007). Xp11 translocation RCCs with ASPL- TFE3 fusions are associated with more advanced stages than are PRCC-TFE3 fusions (Komai et al., 2009; Camparo et al., 2008). However, as Xp11 translocation RCCs with PRCC-TFE3 fusions present a higher risk of recurrence, longer term follow-ups are required (Kuroda et al., 2012). 3.3 Number of Patients Targeted The requestor reports an estimated total volume of 20 tests over the next three years and declares not having conducted any tests (the two translocations combined) from 2011 to 2012. 3.4 Medical Specialties Involved (and Other Professions, If Any) Surgery, oncology, and anatomic pathology. 3.5 Testing Procedure The test is performed on RNA isolated from a biopsy or a formalin-fixed and paraffin-embedded resection of the tumour tissue. 4 TECHNOLOGICAL BACKGROUND 4.1 Nature of the Diagnostic Technology Complementary (confirmation of uncertain cases). 4.2 Brief Description of the Current Technological Context Analytical algorithms leading to the detection of gene translocations may comprise various steps, depending on the clinical and histological characteristics observed. Indeed, on a histological basis alone, the subtle morphological variations and the confusion surrounding the use of descriptive terms in literature can complicate the diagnosis. (Hintzy et al., 2008). Therefore, histopathological diagnoses are strengthened by using IHC to assess specific markers (TFE3 and TFEB). A number of authors consider the combination of histology and IHC to be sufficient, as it has been described as very sensitive and specific (Argani et al., 2007). Karyotyping continues to be the gold standard for detecting chromosomal translocations. FISH has also proven effective and is increasingly used (Zhong et al., 2010). The diagnosis of renal cell carcinomas that generate gene fusions with TFE3 or TFEB relies on the detection of chimeric messenger RNA by RT-PCR or by sequencing of genomic DNA junctions combined with protein overexpression by IHC. 4 Sunitinib is registered on the list of medications published by the RAMQ, but sorafenib is not. Its therapeutic value was rejected in February 2010. 5 Temsirolimus has been registered on the exceptional medications list published by the RAMQ since February 2012. 3 4.3 Brief Description of the Advantages Cited for the New Technology The RT-PCR technique is widely used, especially in cases of leukemia or sarcoma involving translocations. Indeed, there is a high risk that the junction between the fusion genes will be located inside the long intron sequences. Consequently, fusion genes are more easily detected using messenger RNA, given their smaller size6. It is therefore possible to identify the junction point by using a few primer combinations located within the coding sequences (exons) of the hypothetically fused genes (Argani and Ladanyi, 2005). However, fusions