Uniquely amongst the major tumor types, the premalignant state in colorectal cancer (CRC) is readily detectable and diagnosed. Indeed, a multi-step process of CRC genesis was defined by the seminal work of Vogelstein et al, who described the mutational events leading from adenoma to adenocarcinoma. In addition to genetic aberrations, recent evidence has highlighted the importance of the gut microbiome and associated inflammation in predicting CRC progression. To date however, these insights have not led to significant changes in the treatment paradigm because efforts continue to be focused on the later stages of disease.

We believe CRC presents an exceptional opportunity for disease interception but to design effective interventional strategies, the exact sequence of molecular events underlying progression needs to be better defined and understood. To address these needs, we have assembled a clinically annotated sample database encompassing all stages of CRC (healthy colon, adjacent mucosa, adenomas, high-grade dysplasia, primary CRC and liver metastases), including samples from the conventional, microsatellite stable subtype, as well as from the serrated, microsatellite instable pathway. The progression status of each sample was characterized using standard pathology criteria. In addition, molecular progression was determined by targeted mutation profiling and targeted copy number profiling, as well as genome-wide expression profiling.

This analysis confirms previous observations of early mutational events at the adenoma stage, including known tumor suppressor and oncogene driver mutations, e.g. KRAS G12 and G13 are mutated in 15% of the conventional adenomas but not in sessile serrated adenomas, as well as in 23% of the colorectal tumors. Copy number aberrations were observed at the adenoma and carcinoma stage, but with a lower prevalence then somatic mutations.

Furthermore, genome wide expression analysis indicates that several pathways known to be affected in colorectal cancer are already disregulated at the adenoma stage. These pathways include Wnt signaling, mucosal barrier defects, bile acid metabolism, and several immune respons genes, again fingerpointing at the interplay between local inflammation, the microbiome, and epithelial events. In addition, we observed that while genetic events are very dissimilar between the serrated/MSI and conventional/MSS pathway, the transcriptional regulation has many similarities, indicating at a possibility at targeting these disease subtypes using the same therapeutics.

These initial findings provide rational avenues to intercept CRC at the adenoma stage and efforts are now focused on exploring the added role of the colonic microbiota and immune system modulation. A more comprehensive and integrated view of the changes associated with disease initiation will lead to the identification of new paths for prevention, interception and cure.

Citation Format: Joke Reumers, Liesbeth Van Wesenbeeck, Eric Ciamporcero, Gerald Chu, Stan Gaj, Emanuele Palescandolo, Carl Van Hove, Karin Verstraeten, Gary Borzillo, Dianna Wu, Pieter Peeters, Janine Arts. Characterisation of molecular events across the colorectal cancer progression axis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4388. doi:10.1158/1538-7445.AM2017-4388