 Good morning everybody, and thanks for being here, and I thank Dr. Taikoti and the Kinnick Cancer Association for inviting me. Is it on? You can hear me, right? Okay. Yeah. All right. So I'm one of those behind the scene doctors that patients usually don't see me, but when the tumor comes out of your body and the surgeon will send the tissue to the laboratories and where we will render the diagnosis for the tumor, and then the doctors can decide what to do and how to treat you. So I work closely with the urologists, the surgeons, and medical oncologists. So as Dr. Taikoti said, I'm working in the pathology experiment, and I am a geneticist. Because in cancer, very much cancer is really a genetic disease because cancer is caused by aberrations of the genes or the genome. So overall though, most of the cancers are actually not necessarily hereditary. Hereditary cancer comes for less than 10% of all cancer, and most of them are actually sporadic. Familiar cancer, just because you see it in multiple people in a family doesn't necessarily mean it is hereditary. So for the majority of the time, those cancers are due to like somatic gene mutations, which we'll explain more. So they're like sporadic in nature, and they're not hereditary. So at this day and age, everybody already knows about, have heard of DNA. So we know we all have DNA, our genome is really the blueprint of who we are, and our genome influences our looks and health and behavior and everything. So they are pretty much it's a long stretch of ACGT, different way of organizing sequences that constitutes the whole human genome. And in our everybody's genome, there are like three billion base pairs of the nucleotide. So a pair is like A matched with T. So and then there are like among these three billion base pairs, about 10 billions are variant, like different from people to people. The majority of the genome are the same from people to people. And but those variants decide the differences basically, you know, how we are. Everybody was born with some kind of a genetic liability. For example, in the inherited form of those kidney cancers, like the Von Heppholing-Dau syndrome family, you already are born with this germline mutation of the Von Heppholing-Dau gene, so VH gene. And so then even some of us who appear to be normal, we probably have some predisposition of the genetic liability. Then over the time, after birth, we are generally healthy, but there are like other environmental factors or other things that will have additional insults to our genome. And later on with those multiple hits, at some point, when it reaches beyond the threshold, then we get sick. So that's kind of like largely the same, and as I mentioned earlier, about somatic mutations versus inheritable mutations. That's usually because, you know, everybody, we know we all, we come from a fertilized egg. So we have that, those are called zygotes, so mom will contribute the egg and dad will contribute the sperm. And we have starting with the zygotes and then those cells will divide, divide, divide it to make into different parts of our organ and bottom. And so some of the cells will make germline, so that becomes, burns an egg of our own. And those are called germline cells. And then the others form our body cells. And those body cells are called somatic cells. So like when you have mutations in the somatic cells, and mutations happen later, like in this stage, in the somatic cells only, that's what, and some of those kind of mutations will cause cancer. And so like kidney cancer, let's say these cells got mutated and they become kidney cancer. So those are all, those are called sporadic cancers. And they're caused by somatic mutations. But those, in those hereditary form of cancer, so the mutations actually happens in the germline cells, the germ cells. Or they're like starting with the zygote stage, they can be mutated. And then those mutations will be carried forward and inherited by the next generation. And then all the cells in the next generation, body cells, as well as germline cells are going to carry that mutation. So that's the difference between some germline versus somatic mutations. So we, the other term you sometimes might hurt here is constitutional. Constitutional abnormalities can affect both the germline and somatic cells. So all our genetic materials in everybody is packaged into those neatly, 46 neat bundles, which we call them chromosomes. So many of you probably know we have all together 46 chromosomes. And 22 pairs and the 23rd pair is the sex chromosome. So if you have the longer ones is the X chromosome, the shorter ones is the Y chromosome. So this is a male. So if you have two X chromosomes, then that's a female. So what is in a chromosome? So this is an electron microscopy photo of a chromosome. And so that's actually composed of DNA and proteins. And the most common proteins are histones. And there's some non-histone proteins as well. So when you look at these, we have like these are chromosomes are really long stretches of the DNA we mentioned earlier. And they got compacted and compacted and compacted and packaged into those kind of chromosomes, which you can see at certain stages of cell cycle. So there are many chromosome abnormalities and can cause disease. So as I mentioned earlier, they're constitutional type and their somatic type. And then there's in terms of the specific types of chromosome abnormalities, they're often gains and losses or losses, we also call them deletions. So there could be gains of chromosomes part part of a chromosome or a whole stretch of the chromosome. So they're also gene rearrangements, which means it could be specific segments of the chromosomes are inverted or translocated to other chromosomes, other kinds of things we call them rearrangements. So how do we study chromosomes? So in the for 50 years, what we've been doing is we grow the cells in test tubes, trying to grow them in test tubes, and then they will, we will try to harvest them and put them on two microscope slides and we look at them under the microscope. And so later on, we use the computer to help with the microscope examination. And we will digest away some of the proteins using specific enzymes so that the chromosomes will show those kind of a banding, we call it G banded structures, you see the band that kind of adds a face to every chromosome so we can recognize. And then we align them up as from longest to the shortest and number them. And that way, that's how we can recognize them. And then in the 90s, we started to have this so called molecular cytogenetics technique that fluorescence inside hybridization abbreviated as fish. So we basically use synthetic DNA, so a short stretch of DNA made we made into a we call it probes. So the fish and we label them using fluorescence. And so that when we put them into the cell and try to let them hybridize with match, basically, they go find the matching sequences on the chromosome. And then we will be able to visualize using fluorescence signal, look at in the cell on the chromosomes where these genes are and whether there's any abnormalities of these genes. So of course, then you can also pseudo color those and to make them into distinguish distinct colors and to look at the chromosomes to help with the recognition of the chromosomes. Then the newer in these recent years, we started to have this array based technology. So it's just like using the previously in the fish analysis, you have those one synthetic DNA that you match with your chromosome sequences. And now you're making millions of those and array them onto a kind of little, little kind of microscopic slide called chips. So you package all those arrayed sort of fish probe synthetic probe into a chip. And then you'll be able to also they're all fluorescent labeled and then use modern scanning techniques. This is a scanner that we use. And then we can visualize them in a different way. So using that technology. So Dr. Ticody mentioned earlier, we use this on co scan technology. This can actually put together 200,000 probes fish probes onto this little chip. And the chip is actually I should have brought one it's like half of the size of your palm. And then it covers the whole genome. And especially for cancer diagnosis is really helpful because it gives you very high resolution for about 1000 or 900 cancer genes, in addition to other non cancer genes. So this is a busy slide. But the bottom line is that we can have like in every 2500 base pairs of the DNA, we can have a probe to cover in those regions. So that then it'll usually you need 20 probes to make a very confident call of an abnormality. So the resolution becomes very high. And it's very sensitive as well. So okay, so now the to look at it. So to look at the abnormalities of that, the genome, the 46 chromosomes, now instead of looking at them, like standing up chromosomes and banded, now we're like looking at it as if they're lying down, you put them lie down, and then they link them head to head. So comes on one, two, three, four, all the way to 22. And then x and y chromosomes are on the right. And as Dr. Ticoli mentioned earlier that you can see the baseline the two. So the normal line would be the two copy line. And then x and y in a normal male would be just one copy. So you see lower than the two copy line. That's the one copy line. And if there's anything gain, you will see a a increase. So in this case, like from chromosome one, you have a one q, the long arm of one has gained. So have three copies instead of two copies. So anything that's dropping, then that's one copy. So and in this case, you also see that y chromosome was further lost. So that actually has also a loss of y chromosome. So that's how you can also look at your different colors of different chromosomes. And that allows us to have a very nice genomic overview of a patient's tissue sample. So these are looking at the kidney tissue. So we're looking at somatic abnormalities. And so you can have small deletions or gains and you can have large like on chromosome three short arm, you have the loss and gain and multiple chromosomes. As you can see, these genomes can often be very complex. Multiple multiple chromosomes are involved in gains and losses or rearrangements. So and that gives us a hint as to what kind of tumor suppressors or the oncogenes are actually inactivated or activated. So you can also when we put all the kidney cancer patients together and get an overview, you can see very frequently the three p like in on chromosome three, there is a big segment that's often lost. And you can also also see like on some seven can be frequently gained. So this gives an gives us an overview of what the possible common abnormalities are in kidney cancer patients. So as Dr. Takati also mentioned earlier, kidney cancer is not a single disease. There are many different histological subtypes. And every kind of histological subtypes have very distinct disease courses. And their outcome is different as well. And you would require a different kind of treatment. So it's very important up front to diagnose accurately what kind of histological subtypes. So you already heard about this before the most common type is the clear cell renal cell carcinoma CCRCC, like 65 to 75% and then followed by the papillary type and chromophob type oncocytoma, which is a relatively benign tumor that does not metastasize. And then there's a translocation type of tumor and that accounts for about 50%. And then there's also upward to five or 6% of unclassified tumors. And usually the sporadic form of tumor kidney cancer would be like you will call it you only one side happens on one side of the unilateral and unifocal. So usually it's just single locus. And whereas the inherited forms are bilateral, affecting both sides of the tumor kidney, and then multifocal. So that's usually the situation. And this is from a relatively new recent summary of the different types of human renal epithelial neoplasms, kidney cancer. So they're like, we already know all the inherited form of lung hyperlinda or all the inherited form of the kidney cancer has the bone hyperlinda gene mutation. And the majority of the clear cell RCC also has the VHL mutations. But there are also the other kind, the PBR, PBMR1. And then the papillary types, the common type type type one usually has the met mutation that's an actually an amplification of the met one gene. And many of our hereditary type of kidney cancer allows allow us to see the different mutations that also occur in sporadic tumors. So they're like in chromophob and oncocytoma and even hybrid it oftentimes the FLCN genes are mutated. And the papillary type two, it's usually the FH gene. So translocation tumor, these are the transcription three most commonly involved transcription factors that are translocated into other chromosomes onto other chromosomes. And there's some other types. So that's really helpful. But still a lot of times we may not be very clear about the histological subtypes. So when to how does genomics come into play with a diagnosis, it really helps a great deal with subtype classification. So we have certainly you don't need to remember this gives you an impression that for each sub type of those histologic subtypes, we have specific more specific kinds of chromosomal gains and losses and rearrangements that will allow us to know this is more likely clear cell RCC. The other is like for example, if you see very much of these kinds of gains, we'll know it's more papillary RCC and not necessarily without the three P deletion and it's not clear cell. And chromophob it's usually loss of crumbs of monosomia means only one copy. So there's only one copy of all those chromosomes. So that's how we can look at the whole genome and understand what kind of histological subtypes it should be, especially in those cases that are unclassified by histology. And so for that reason, there's a recent algorithm, genomic algorithm for classifying unclassifiable common RCCs. And so that's proposed by the Memorial Sloan Kettering Institute. And I certainly don't mean to have you read in these cases, but we can actually start with looking at whether there's like asking if we see three P deletion, then next, if we don't, so you know, decision arms, and then you can classify them into different subtypes. So that helps a great deal. And then as I mentioned earlier, for the oncocytoma, it's important to identify them and distinguish them from the chromo, the type, the malignant type. So there's one specific abnormality called CCND when cycling D1 gene mutation rearrangements. This is actually quite unique to oncocytoma. If you can detect that it happens to these kind of patients, if you can detect cycling D1 gene rearrangements, you can be pretty comfortable in calling those cancers as oncocytoma. So we can use the fish technology to look at individual cells. So in this case, you know, this is a normal cell because the CCND1 gene, it's supposed to be intact. So we label like the beginning portion of the gene and the later portion of the gene with different color, green and red. And so they're supposed to be all together, like in this case. And when they are separated, that means they're rearranged. They're not supposed to be separated. But so they somehow you know, the beginning portion and the latter portion got divorced. So that's a bad thing. So you know, that's rearranged about then it gives you the diagnosis of confirming oncocytoma. So in addition to helping with the diagnosis, it also is very helpful with the prognostication. So for example, this is a summary of the genomic aberration seen in CCRCC, clear cell, renal cell carcinoma. And then if you see in these cases, when you see 3p deletion loss, that's actually a good thing. The patient survived better. But if you see the 9p deletion that is represented in the blue color, that's actually a bad thing. The patient will survive much shorter time. Also like 14 q deletion that conveys a poor prognosis as well. So in those cases, it's really helpful for the physicians to know these kind of genomic abnormalities and to know how we can manage the patient, whether I should be more aggressive in treating patients, monitor them more frequently, or I could just, you know, do nothing and just observe. So that that's the reason we at CCM Fred Hudson University of Washington, we formed this multidisciplinary team to study these tissues and to look at manage these patients together. So this overall development of using the genomic analysis was have the clinical participants with urologists and oncologists, Dr. Takodi, and pathologist Dr. Tretia Kova. And so in our lab, we have together with me, we have clinical development scientists and technologists and we have fabulous administrative support to this kind of initiative. So the whole reason is that, you know, as you heard from Dr. Takodi back in the old days, it was one pill, one size filled, you know, fits all types of medication, chemotherapy in the beginning, which was not very effective, but then now with the help of the genetics and genomics era, we can identify subgroups and we can identify what kind of aberrations and will require specific type of treatment. We're not quite there yet, but that's the goal. So in terms of we know that laboratory tests account for only 3% of medical costs, but really makes, affects 70% of the medical decision making. So that's why that's important, especially in these days, the cost of sequencing and the genomic analysis have dropped precipitously, as you can see in recent years, it just drops like significantly. So really the goal of like even holding on sequencing costing less than $1,000 is within reach, really. So in that, with that, we'll be able to reach a very accurate diagnosis and that will help with targeted treatment and ultimately result in improved health outcome. So when we have those clinically available information to feed into our knowledge network, that'll help us with new classifications and better patient management in outcome. So Dr. Takodi and Dr. Gore, our surgeon urologist came up with those proposed testing schemes. So like localized renal tumor accounts for like more than 50% of all the kidney cancer patients. So that's actually really the most important group that we would like to have the genomic testing applied to, because like for regardless of pre-surgery or post-surgery, you can look at those tissues either through corneal biopsy or using the recession specimen tissue to look at a genome and then decide clinically whether we wanted to observe versus surgical removal in the pre-operation setting and then post-operation setting, we can tailor the intensity of surveillance and for evaluation. And in a metastatic setting, we like we use like before the IL-2 therapy, hydro therapy, those kind of prognostic marker information will also help us to decide whether we want to put the patient onto hydro therapy or not. So and then in other cases, I mentioned this metgene in the commonly seen in papillary RCC. And if you see the see metgene amplification, there is actually a specific drug you can use and that's very effective. So that's so called the predictive therapy. So if we're able to have the predictive marker, like in this case met one, we know this therapy is going to be very effective for that patient. So that would be the best case scenario, but we're still working on that. Then in terms of unclassified or completely sarcomatoid metastatic tumors, we can impact the choice of systemic therapy. So that's in our center right now. That's how we're trying to have this diagnostic algorithm. So patient comes comes with their disease diagnosis and the urologist will have surgical resection. So in that in this step, we could also have, as I mentioned earlier, have fine needle core needle biopsy to evaluate the tissue for the genomics. And then it's sent to histology review evaluation. And we do the CTGAD analysis, that's the chromosome genomic array testing using on co scan. And and then we sometimes we can clearly have a diagnosis result. Sometimes it's more complex and we work with the histological evaluation and kind of render a more accurate diagnosis. And then we'll go back and work with the oncologist to put the patient on to the correct arm of the therapy, either standard therapy or clinical trial protocols. So yeah, so with that, I'll close I we work very closely with our colleagues at both Fred Hutch University Washington and Seattle Cancer Care Alliance. And the testing of the genomic testing is performed at the SCCA cytogenetics laboratory. And it was developed, validated by this clinical laboratory scientist, shall you choose and do routinely performed by these technologists, and among others. And also our lab is always very interested in patient advocacy. That's them doing the pink glove dance for breast cancer advocacy. So I noticed the kidney cancer association has this orange symbol, right? So maybe we'll do orange glove dance someday. Okay. All right, that's yeah, that's concludes. Thank you very much.