Molecular Genetics Mutations of Thyroid Cancer

dr. Eka Satyani Belina

04012722125005
Ilmu Bedah

Pembimbing
dr. Rachmat Hidayat, M.Sc

PROGRAM PENDIDIKAN DOKTER SPESIALIS

FAKULTAS KEDOKTERAN
UNIVERSITAS SRIWIJAYA

Molecular Genetics Mutations of Thyroid Cancer

Abstract
 The most common endocrine malignancy is thyroid cancer and
its incidence has continuously increased in all over the world, mostly because increased use of
diagnostic imaging and surveillance. Thyroid cancer represents approximately 1,5-2,1% of all
cancers worldwide and the sixth most common cancer in women. The incidence of thyroid
cancer in female is three times higher than in male. Thyroid cancer can occur in any age but
mostly in younger population. The incidence rate is 43% in patients between 46 and 64 years.
The changes of some genes and pathways associated with different forms of thyroid cancer.
Thyroid cancer is closely linked with mutation of BRAF (B-fast accelerated fibrosarcoma), RET
(rearranged during transfection), RAS , PPARG (peroxisome proliferator activated receptor
gamma), RET, NTRK1 that promote the activation of MAPK (mitogen-activated protein kinase)
and PI3K (phosphoinositide 3-kinase) signalling pathways. Mutation of BRAF and RAS, or gene
fusions of RET/PTC and TRK can initiate the activation of MAPK in papillary thyroid cancer.
On the other hand, the mutation of RAS, PIK3CA and AKT1 as well as inactivation of PTEN
can promote activation of PI3K/AKT in follicular thyroid cancer.

Abstrak

Keganasan endokrin paling sering adalah kanker tiroid dan angka insidensi kanker tiroid
terus meningkat di seluruh dunia, kebanyakan karena peningkatan pemeriksaan diagnostik dan
pengawasan ketat. Kanker tiroid menunjukkan 1,5-2,1% dari seluruh kanker di seluruh dunia dan
kanker nomor 6 yang paling sering terjadi pada wanita. Insidensi kanker tiroid pada wanita
adalah 3 kali lebih tinggi daripada pria. Kanker tiroid dapat terjadi pada semua umur, namun
lebih sering pada usia muda. Angka insidensi kanker payudara adalah 43% untuk pasien dengan
usia antara 46 dan 64 tahun. Perubahan gen dan jalur genetik berhubungan dengan tipe kanker
tiroid yang berbeda. Kanker tiroid berhubungan erat dengan mutasi dari BRAF (B-fast
accelerated fibrosarcoma), RET (rearranged during transfection), PPARG (peroxisome
proliferator activated receptor gamma), RET, NTRK1 yang memicu aktivasi jalur MAPK
(mitogen-activated protein kinase) dan PI3K (phosphoinositide 3-kinase). Mutasi dari BRAF dan
RAS, atau fusi gen dari RET/PTC dan TRK dapat meninisiasi aktivasi dari MAPK di kanker
tiroid tipe papiler. Sedangkan mutasi dari RAS, PIK3CA dan AKT1 serta inaktivasi PTEN dapat
menginisiasi aktivasi dari jalur PI3K/AKT di kanker tiroid tipe folikuler.
Keywords : Thyroid Cancer, Genetics, Mutation, PTC, FTC, BRAF, RET, RAS, PPARG,
TERT, TP53

1. Introduction

The most common endocrine malignancy is thyroid cancer and

its incidence has continuously increased in all over the world, mostly because increased use of
diagnostic imaging and surveillance(1)(2). Thyroid cancer represents approximately 1,5-2,1% of
all cancers worldwide and the sixth most common cancer in women. The incidence of thyroid
cancer in female is three times higher than in male(3). Thyroid cancer can occur in any age but
mostly in younger population. The incidence rate is 43% in patients between 46 and 64 years (4).
Thyroid cancer originates from follicular cells called Non-medullary thyroid cancer. This
type is responsible for ~95% of all cases. Non-medullary thyroid cancer is classified into well
differentiated which are papillary, follicular and hurthle, poorly differentiated and anaplastic
cancer(3). The most common subtype is papillary thyroid cancer (PTC) and has the best
prognosis. Parafollicular neuroendocrine cells of the thyroid can also be the origin of thyroid
cancer called medullary thyroid cancer. This cancer is uncommon, approximately 1–2% of all
thyroid cancers(2).
The understanding of the oncogenic pathways in thyroid cancer has led to specific
changes through the substansial improvement. The changes of some genes and pathways
associated with the different forms of thyroid cancer. Papillary thyroid cancer with mutations of
BRAF and RET, follicular thyroid cancer (FTC) with mutation of RAS and rearrangement of
PPARG, medullary thyroid cancer with mutation of RET, and anaplastic thyroid cancer with
mutations of TP53 and in the phosphatidylino- sitol 39-kinase (PI3K)/AKT1 pathway(5).
The pathogenesis of the development and progression of thyroid cancer is far from being
clear at present. Therefore, we have reviewed the literature and summarizes the current
knowledge about molecular genetics status of thyroid cancer. This review’s aim is to provide the
reader an overview of the main genetic that can influence the development of thyroid cancer.

2. Thyroid Cancer and Gene Mutations

The changes of some genes and pathways associated with different forms of thyroid
cancer. Thyroid cancer is closely linked with mutation of BRAF (B-fast accelerated
fibrosarcoma), RET (rearranged during transfection), RAS , PPARG (peroxisome proliferator
activated receptor gamma), RET, NTRK1 that promote the activation of MAPK (mitogen-
activated protein kinase) and PI3K (phosphoinositide 3-kinase) signaling pathways. Mutation of
BRAF and RAS, or gene fusions of RET/PTC and TRK can initiate the activation of MAPK in
papillary thyroid cancer. On the other hand, the mutation of RAS, PIK3CA and AKT1 as well as
inactivation of PTEN can promote activation of PI3K/AKT in follicular thyroid cancer(6).
 Mutations of RET/PTC occur in papillary thyroid cancer, approximately 10-20% of
sporadic PTC cases. BRAF mutation often found in PTC cases and associated with poor
prognosis. The incidence of PTC with BRAF mutation are approximately 29-69% of all PTC
cases. Activating mutations of RAS are seen in 40-53% of cases of FTC. The mutations of
PPARG is also seen in FTC, approximately 60% of cases of FTC. RET rearrangement is seen in
about 88-95% of hereditary cases and in 40-50% of cases of sporadic medullary thyroid cancer.
Aplastic thyroid cancer often associated with mutations of TP53 tumour suppressor gene or
PI3K/AKT1(5).

Thyroid Malignancy Common Molecular Alteration Site MTT

(Penetrance)
PTC BRAF (40%-45%) Sorafenib,* vemurafenib,
dabrafenib
RET(10%-20%) Vandetanib
FTC RAS (40%-53%) Tipifarnib
PAX8/PPARG translocation (30%- PPARG agonist
60%)
MTC RET (sporadic, 40%-50%; Vandetanib*
familial,>95%)
ATC TP53 (50%-60%) Gene therapy
CTNNB1 (5%-60%) None
PI3K/AKT1 pathway (5%-20%) mTOR inhibitor

Table 1. Genomic Taxonomy of Thyroid Cancers(5)

2.1 BRAF

BRAF is a part of the raf family of serine/threonine protein kinases. BRAF is a

proto-oncogene which encodes protein that regulating MAPK (mitogen-activated protein
kinase) signaling pathway. Activating of mutations of BRAF mostly located in in the
glycine-rich P loop (residues 462–471) and activation segment (residues 593–622)(1).
High kinase activity group consist of mutations of Glu586Lys, Val600Glu,
Val600Asp, Val600- Lys, Val600Arg and Lys601Glu, while intermediate kinase activity
consist of Gly464Glu, Gly464Val, Gly466Ala, Gly469Glu, Asn581Ser, Phe595Leu,
Leu597Val, Leu597Arg and Thr599Ile mutations. Mutations of Gly466Glu, Gly466Val,
Gly596Arg and Asp594Val have been classified as a low kinase activity group(1).
BRAF mutation often found in PTC cases and associated with poor prognosis. The
incidence of PTC with BRAF mutation are approximately 29-69% of all PTC cases(5).

Substitution of glutamine for valine at amino acid codon 600 (Val600Glu, BRAF V600E) is a
result of BRAF mutations in T1799A and occurs over 90%, while other BRAF mutations are
rarely reported. (maha rebai, 2016). BRAFV600E is a risk biomarker in papillary thyroid
cancer(3). This biomarker was associated with high risk characteristics such as invasion to
extrathyroid, lymph node metastasis, and advanced tumour stage(1). Mutation of BRAFV600E
has a high specificity and high positive predictive value (PPV) for cancer. Many thyroid
cancer are marked by other mutations, testing for mutation of BRAF does not provide
sufficiently high negative predictive value (NPV) to avoid cancer with no BRAF
mutation(7).

2.2 RET
The Rearranged During Transfection (RET) is a proto-oncogene that encodes tyrosine
kinase involved in the cellular signaling of members of the glial-cell derived neurotrophic
factors (GDNF) family(3).
RET is associated mostly with medullary thyroid cancer. Medullary thyroid cancer
divided into 2, familial (25%) or sporadic (75%)(6). RET rearrangement is seen in about 88-
95% of hereditary cases and in 40-50% of cases of sporadic medullary thyroid cancer(5).
RET is also associated with PTC. Rearrangement of RET in PTC (RET-PTC) is an early
event of carcinogenesis, with 10-20% of RET fusions found in patient with PTC(3). RET
fusions are linked with diagnose at younge age but not with risk of recurrence. There are
many types of RET-PTC rearrangements, at least 30. The most common rearrangements are
RET/PTC1 (fusion CCDC6 and RET) and RET/PTC3 (fusion NCOA4 and RET). RET-PTC
rearrangements are frequently detected in radiation-induced tumours, but can be found in
sporadic papillary thyroid cancer(1).
Both extracellular and intracellular domains is affected by RET gene point mutations,
inducing different effects. A ligand-independent constitutive dimerization induced by
intracellular mutations. It promotes the activation of the tyrosine kinase receptor. While
extracellular domain induce ligand and dimerization independent. In medullary thyroid
cancer cases, activating mutations of different RET domains induce different clinical
features. They are divided into 2 groups, MEN2A syndrome and MEN2B syndrome. Men2A
syndrome is divided into 3 based on clinical characteristics, which are MEN2A with
cutaneous lichen amyloidosis (CLA), MEN2A with Hirschprung Disease (HD), and familial
medullar thyroid cancer (FMTC)(6).

2.3 RAS
RAS is a proto-oncogene that promoted the activation of PI3K and MAPK signaling
pahways. Substitution can occur in codons G12, G13 and Q61 and may incude one of the
three RAS genes (KRAS, HRAS, and NRAS). RAS is locked in its active GTP-bound form
as the effect of these mutations. RAS mutation mainly found in FTC(8). Activating
mutations of RAS are seen in 40-53% of cases of FTC(5). RAS mutation can also found in
follicular adenoma, PTC (0-20%), fyPTC (17-25%), and poorly differentiated and anaplastic
thyroid cancer (20-60%). Activating mutations of RAS followed by mutation of TERT
(C228T and C250T) have been associated with reccurent thyroid tumor, more aggressive
tumor and patient mortality(9).

2.4 PAX8/PPARG
PAX8/PPARG is a fusion protein and the product of a t(2;3)(q13;p25) chromosomal
translocation and associated with FTC(3). PAX8/PPARG is a gene fusion between paired
box 8 (PAX8) and peroxisome proliferator activated receptor γ (PPARG). PAX8/PPARG
mutation mostly found in FTC(1). The mutations of PPARG is also seen in FTC,
approximately 60% of cases of FTC.(5) Some studies said that the occurrence of the
rearrangements of PAX8/PPARG in the PTC, typically with low frequency (1-5%)(1).

2.5 TERT
Ribonucleoprotein polymerase that maintains telomere repeat TTAGGG at the ends
of chromosomes known as Telomerase Reverse Transcriptase (TERT). It also consists of a
protein component with reverse transcriptase activity and RNA component that serves as a
template. Many malignancies including thyroid cancer have reported highly frequent
mutations in the promoter region of TERT. Mutations occur in 2 positions , located at -124
bp and -146 bp upstream from the ATG start site.
Based on Cancer Genome Atlas Project, activating mutations of TERT have been
identified in 9,4% of the informative papillary tumours with 7% of C228T, 0,3% for C228A
and 2,1% for C250T substitutions(1). The mutation of TERT have been linked with disease
specific mortality. It’s also an indicator of clinically aggressive tumours, distant metastases,
higher stage and persistent disease. The mutation of TERT have been associated with older
age and a higher risk of reccurence(1). The prognostic value of TERT mutations is
significantly stronger than BRAF(10).

2.6 TP53
Transcription factor that regulates the expression of target genes as a response of
celluler stresses is called Tumour suppressor protein 53 (TP53). Activating mutations of
TP53 gene are rare in well differentiated thyroid cancer (PTC or FTC). Mutation of TP53
gene are frequent in more advanced forms of carcinoma. TP53 mutations are common in
poor differentiated thyroid cancer (DTC) and anaplastic thyroid cancer. The prevalence of
TP53 mutations in poor DTC are 27%, and 48% in anaplastic TC. The mutation of TP53 are
found in between exons 5 and 9(1).

3. Discussion
Thyroid is the most common endocrine malignancy. Thyroid follicular cells may
transform to differentiated or undifferentiated thyroid cancer. Molecular genetics mutation
have been linked with specific stages, from well differentiated thyroid cancer (DTC) to
undifferentiated thyroid cancer derived from follicular cell(6).
Well differentiated thyroid carcinoma are the most common type of TC, around 90%
of TC. Well DTC can be divided into papillary thyroid cancer (PTC) and follicular thyroid
cancer (FTC). Poor differentiated TC and anaplastic TC are rare but more aggressive.
Medullary TC are also rare and came from parafollicular C cells(6).
As the mechanisms of thyroid cancer increases, molecular markers for diagnosis,
prognosis , and treatment are becoming more important(11). The explanation of molecular
mechanisms underlying thyroid cancer has been developed because of the progress of
genome sequence. The molecular genetics of thyroid cancer involves dysregulation of
MAPK and PI3K signalling pathways. MAPK signalling pathway is responsible for initiation
of PTC, through the mutation of BRAF and RAS genes or the fusion of RET/PTC and TRK.
PI3K/AKT pathway is responsible for FTC, through activating mutations of RAS, PIK3CA
and AKT1(6).
TERT mutation have been found in all histological thyroid cancer type. Its mutation
have been associated with aggressive and undifferentiated tumours. Mutation of RET
account for medullary thyroid cancer(6).
The development of molecular genetic science has enhanced 2 concepts about
thyroid tumors. The first concept is the development and progression of thyroid cancer.
Many cancers started from a benign tumor to malignant tumor through genetic mutations. In
thyroid cancer, the implementation of this concept is the progression of follicular adenoma to
follicular carcinoma, but not for PTC. This concept can’t be applied in the progression of
PTC. Recently, a precancer lesion has been found as the precursor for invasive forms of PTC,
called noninvasive follicular thyroid neoplasm with a features look like papillary (NIFTP).
The second concept is how to differentiate benign thyroid tumors from hyperplastic
nodules by using genetic analysis. The enhancement of multiple cell proliferation cause
hyperplastic nodules. This nodules is not a neoplasm but may increase in size. This nodules
has lower risk of progression to malignancy. On the other hand, benign thyroid tumors is a
clonal neoplasm. It originates from a single cell that multiplied itself to hundreds or
thousands of times.
The explanation of molecular mechanisms underlying thyroid cancer has been
developed because of the progress of genome sequence(6). A material taken from thyroid
nodule showed point mutations or gene fusions and first demonstrated in 1990s. But BRAF
mutations is identified in early 2000s. Activating mutations of BRAF, typically BRAF V600E
are the most common genetic mutation in thyroid cancer. The mutation found in 40-454% of
PTC. Mutation of BRAFV600E has a high specificity and high positive predictive value (PPV)
for cancer. In the late 2000s, other common genes mutation in thyroid cancer has tested, such
as NRAS, HRAS, and KRAS, and gene fusions, RET/PTC1, RET/PTC3 and
PAX8/PPARG(7)
4. Summary and Discussion

As the mechanisms of thyroid cancer increases, molecular markers for diagnosis,

prognosis , and treatment are becoming more important(11). The explanation of molecular
mechanisms underlying thyroid cancer has been developed because of the progress of
genome sequence(6). The molecular genetics of thyroid cancer involves dysregulation of
MAPK and PI3K signalling pathways. MAPK signalling pathway is responsible for initiation
of PTC, through the mutation of BRAF and RAS genes or the fusion of RET/PTC and TRK.
PI3K/AKT pathway is responsible for FTC, through activating mutations of RAS, PIK3CA
and AKT1(6).
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