2/20/13 BRAF Gene Mutation Tests

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BRAF Gene Mutation Tests

Author: Sherilyn Alvaran Tuazon, MD; Chief Editor: Eric B Staros, MD more...

Updated: Dec 12, 2012

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BRAF gene mutation testing has emerged as an important tool for diagnosis, prognosis, treatment, and predicting
patient outcome in response to targeted therapy for multiple cancer types.

The BRAF gene mutation test result is positive (ie, a mutation is present) if V600E is found in the BRAF gene.
V600E is the most common gene mutation for the BRAF gene and is the most common mutation tested for in
clinical laboratories.

Interpretation
BRAFand melanoma

Approximately 40-60% of cutaneous melanomas carry mutations in the BRAF gene.About 90% of these mutations
are found to be V600E.[1]

Vemurafenib (PLX4032) is a highly selective and potent inhibitor of BRAF V600E. It has marked antitumor effects
against melanoma cell lines with the BRAF V600E mutation but not against cells with wild-type (non-mutated)
BRAF. Evidence exists that vemurafenib improves overall and progression-free survival in patients with advanced
melanoma with the V600E mutation.[2] Thus, establishing whether BRAF mutations exist in melanoma is now of
critical therapeutic importance.[3]

BRAFand colorectal cancer

BRAF mutation testing will likely be increasingly used in the management of colorectal cancer, as more evidence
emerges regarding its usefulness. Some indication exists that BRAF mutation testing may be used to evaluate the
likelihood of having hereditary nonpolyposis colorectal carcinoma (HNPCC) or Lynch syndrome versus sporadic
colorectal cancer. Distinguishing HNPCC from sporadic colon cancer with MSI-H is important because patients
with HNPCC and their family members can be offered genetic counseling and provided with opportunities to prevent
such second cancers through close surveillance and prophylactic surgery.[4]

The presence of microsatellite instability (MSI) is one of the major mechanisms of disease in HNPCC; however,
MSI-high (MSI-H) is also found in approximately 12% of sporadic cases of colorectal cancer.[5] Full gene
sequencing, albeit expensive, can detect all of the defective mismatch repair genes in HNPCC. Preliminary tests,
such as BRAF mutation testing, may be useful in determining which patients are likely to benefit from full gene
sequencing[4] Approximately 91% of sporadic colorectal cancers harbor BRAF mutation, whereas BRAF is almost

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never mutated in colorectal cancers that arise as a consequence of Lynch syndrome.[6] Thus, persons with
colorectal cancers with the BRAF mutation may be unlikely to have HNPCC, and further testing with full gene
sequencing is probably unwarranted.

Some evidence indicates that the presence of BRAF mutation may render colorectal cancer resistant to epidermal
growth factor (EGFR)-inhibitors, such as cetuximab and panitumumab. K-ras, which lies upstream of BRAF, is
mutated in 30-50% of colorectal cancersand is predictive of unresponsiveness to EGFR-inhibitor targeted therapy.
Although not yet standard of practice, there is some suggestion that BRAF mutation testing may be a useful
adjunct to k -ras testing, since the presence of mutated BRAF likewise confers resistance to anti-EGFR
treatment[7]

In addition, the presence of BRAF mutation may possibly serve as a useful prognostic marker, as one study
reported its significant association with decreased progression-free and overall survival in colorectal cancer[8]

BRAFand thyroid cancer

The V600E BRAF mutation is the most common genetic alteration involved in the most prevalent type of thyroid
cancer, papillary thyroid cancer (PTC), with an overall prevalence of 45% [9]

Some studies indicate that the presence of the BRAF gene mutation may potentially be a putative prognostic
marker of papillary thyroid cancer[8, 10] A systematic review and meta-analysis reported that BRAF mutation was
significantly associated with recurrence, lymph node metastases, extrathyroidal extension, and advanced stage in
papillary thyroid cancer[10]

BRAF gene mutation testing has also been reported as a specific marker for papillary thyroid carcinoma when
used in conjunction with fine-needle aspiration biopsy (FNAB). Mutated BRAF has been demonstrated to occur
exclusively in papillary thyroid cancer and PTC-derived anaplastic thyroid cancer[11] and is virtually absent in
follicular, Hurthle cell, medullary carcinomas, and in benign thyroid tumors.[8]

BRAFand other cancers

The BRAF mutation may be a potential diagnostic tool to distinguish Hairy-cell leukemia (HCL) from other B-cell
lymphomas with similar clinical and morphologic features, such as the HCL-variant and splenic marginal zone
lymphoma. A study by Tiacci et al demonstrated that BRAF mutation was present in all patients with HCL but not
in other peripheral B-cell lymphomas or leukemia, which implicates the potential usefulness of BRAF mutation
testing in diagnosis of HCL.

As mentioned, BRAF mutations are found to occur in many other cancer types, such as lung cancer, glioma,
Ependymoma, non-Hodgkin lymphoma, acute lymphoblastic leukemia, liver cancer, stomach cancer, and
esophageal cancer, although at a low frequency (1-3%). However, the clinical implication and utility of BRAF gene
mutation testing in these types of cancers have yet to be determined.

Collection and Panels

The test for BRAF mutation can be applied to fresh, frozen or, more commonly, formalin-fixed, paraffin embedded
(FFPE) tumor.[4] The V600E mutation is the primary mutation tested for commercially. The most commonly used
technique to identify BRAF mutation is real-time polymerase chain reaction (PCR).

A more comprehensive evaluation of BRAF genotypes can be accomplished using DNA sequencing methods,
including traditional Sanger sequencing or newer methods, such as pyrosequencing.[4] Although sequencing is
considered the criterion standard, real-time PCR can perform as well at identifying the most common BRAF
mutation, V600E, with a reported sensitivity and specificity of 100% in one study.[12] Moreover, real-time PCR has
the advantages of reduced labor, faster turnaround, and lower cost.[12]

Background
Description

The BRAF gene is located on chromosome arm 7q34. It encodes B-raf, a serine-threonine kinase that is part of
the Ras-Raf-Mek-Erk-MAPK (mitogen-activated protein kinase) signaling cascade (see the illustration below).[13]
Activation of this pathway has been implicated in promoting growth, proliferation, and differentiation of cells.
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Ras-Raf-Mek-Erk MAP kinase Pathw ay

Three functional RAF proteins exist in humans, ARAF, BRAF, and CRAF.[3] Among them, BRAF has the highest
basal kinase activity, and is the most potent activator of the MAPK pathway.[14]

The BRAF gene is composed of 18 exons, and the most common activating mutation is found in exon 15 at
nucleotide position 1799, involving a transversion of thymine to adenine.[4] This results in a substitution of glutamic
acid for valine at position 600, which is designated as V600E. This mutation occurs within the kinase domain of
the B-raf protein and is reported to have 10 times more kinase activity than its normal counterpart.[1] It therefore
acts as an oncogene, promoting cell growth, differentiation, and survival.

More than 30 different BRAF mutations have been identified.[15] However, V600E accounts for about 90% of all the
BRAF mutations, and is the mutation commonly tested for in clinical laboratories.[14]

The BRAF gene mutation is found in many different cancers, with various frequencies reported. The highest
incidence is found in malignant melanoma (27–70%), papillary thyroid cancer (36–53%), colorectal cancer (5–
22%) and serous ovarian cancer (30%). However, it can also occur at a low frequency (1-3%) in other cancers,
including lung cancer, glioma, ependymoma, non-Hodgkin's lymphoma, acute lymphoblastic leukemia, liver
cancer, stomach cancer, and esophageal cancer.[16]

Indications/Applications

BRAF gene mutation testing has emerged as an important tool for diagnosis, prognosis, treatment, and predicting
patient outcome in response to targeted therapy.[17]

Evidence indicates BRAF gene mutation testing has a role in the following:

Differentiating papillary thyroid cancer from other types of thyroid cancer and benign thyroid nodules
Differentiating sporadic colorectal cancer with microsatellite instability-high (MSI-H) from hereditary
nonpolyposis colorectal carcinoma (HNPCC) or Lynch syndrome
Differentiating hairy cell leukemia from other B-cell lymphomas with similar clinical and morphologic
features
Determining prognosis, as cancers with BRAF mutation are found to be more aggressive than their
counterparts without the mutation, particularly in papillary thyroid carcinoma and colorectal carcinoma
In treatment decisions, because in patients with advanced colorectal cancer, BRAF mutation testing has
been suggested since its presence confers resistance to epidermal growth factor inhibitors (cetuximab and
panitumumab), when k-ras is not mutated
In therapeutic targeting, because the presence of mutated BRAF has been a valuable therapeutic target,
particularly in metastatic melanoma

Considerations

Studies continue to be published regarding the usefulness of detecting BRAF in various tumors in clinical practice.
However, at present, BRAF mutation testing is only widely accepted for use in targeted therapy for advanced
malignant melanoma. As more evidence emerges, BRAF mutation testing may become standard of care in the
diagnosis and management of other cancers.

Contributor Information and Disclosures

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2/20/13 BRAF Gene Mutation Tests

Author
Sherilyn Alvaran Tuazon, MD Clinical Instructor/Hospitalist, Bone Marrow Transplant Unit, Department of
Medical Oncology, Thomas Jefferson University Hospital

Sherilyn Alvaran Tuazon, MD is a member of the following medical societies: Philippine Medical Association

Disclosure: Nothing to disclose.

Chief Editor
Eric B Staros, MD Associate Professor of Pathology, St Louis University School of Medicine; Director of
Clinical Laboratories, Director of Cytopathology, Department of Pathology, St Louis University Hospital

Eric B Staros, MD is a member of the following medical societies: American Medical Association, American
Society for Clinical Pathology, Association for Molecular Pathology, and College of American Pathologists

Disclosure: Nothing to disclose.

References

1. Davies H, Bignell GR, Cox C, Stephens P, Edkins S, Clegg S. Mutations of the BRAF gene in human
cancer. Nature. Jun 27 2002;417(6892):949-54. [Medline].

2. Chapman PB, Hauschild A, Robert C, Haanen JB, Ascierto P, Larkin J. Improved survival with vemurafenib
in melanoma with BRAF V600E mutation. N Engl J Med. Jun 30 2011;364(26):2507-16. [Medline].

3. Govender D, Chetty R. Gene of the mont. BRAF. J ClinPathol. 2012;00:1-3.

4. Sharma SG, Gulley ML. BRAF mutation testing in colorectal cancer. In: Archives of Pathology &
Laboratory Medicine. 134, No. 8. August 2010:1225-1228.

5. Jensen LH, Lindebjerg J, Byriel L, Kolvraa S, Crüger DG. Strategy in clinical practice for classification of
unselected colorectal tumours based on mismatch repair deficiency. Colorectal Dis. Jun 2008;10(5):490-
7. [Medline].

6. National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline in Oncology. See guidance
for colon/rectal cancer. www.nccn.org.

7. Di Nicolantonio F, Martini M, Molinari F, Sartore-Bianchi A, Arena S, Saletti P. Wild-type BRAF is

required for response to panitumumab or cetuximab in metastatic colorectal cancer. J Clin Oncol. Dec 10
2008;26(35):5705-12. [Medline].

8. Cohen Y, Xing M, Mambo E, Guo Z, Wu G, Trink B. BRAF mutation in papillary thyroid carcinoma. J Natl
Cancer Inst. Apr 16 2003;95(8):625-7. [Medline].

9. Tufano RP, Teixeira GV, Bishop J, Carson KA, Xing M. BRAF Mutation in Papillary Thyroid Cancer and
Its Value in Tailoring Initial Treatment: A Systematic Review and Meta-Analysis. Medicine (Baltimore).
Sep 2012;91(5):274-86. [Medline].

10. Xing M. BRAF mutation in thyroid cancer. Endocr Relat Cancer. Jun 2005;12(2):245-62. [Medline].

11. Tiacci E, Trifonov V, Schiavoni G, Holmes A, Kern W, Martelli MP. BRAF mutations in hairy-cell
leukemia. N Engl J Med. Jun 16 2011;364(24):2305-15. [Medline].

12. Benlloch S, Paya A, Alenda C, Bessa X, Andreu M, Jover R. Detection of BRAF V600E mutation in
colorectal cancer: comparison of automatic sequencing and real-time chemistry methodology. J Mol
Diagn. Nov 2006;8(5):540-3. [Medline].

13. Dhomen N, Marais R. New insight into BRAF mutations in cancer. Curr Opin Genet Dev. Feb
2007;17(1):31-9. [Medline].

14. Wan PT, Garnett MJ, Roe SM, Lee S, Niculescu-Duvaz D, Good VM. Mechanism of activation of the
RAF-ERK signaling pathway by oncogenic mutations of B-RAF. Cell. Mar 19 2004;116(6):855-67.
[Medline].

emedicine.medscape.com/article/2045309-overview#showall 4/5
2/20/13 BRAF Gene Mutation Tests

15. Bamford S, Dawson E, Forbes S, Clements J, Pettett R, Dogan A. The COSMIC (Catalogue of Somatic
Mutations in Cancer) database and website. Br J Cancer. Jul 19 2004;91(2):355-8. [Medline].

16. Garnett MJ, Marais R. Guilty as charged: B-RAF is a human oncogene. Cancer Cell. Oct 2004;6(4):313-
9. [Medline].

17. Ziai J, Hui P. BRAF mutation testing in clinical practice. Expert Rev Mol Diagn. Mar 2012;12(2):127-38.
[Medline].

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