M' Papotti, M' Volante Universit di Torino

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M. Papotti, M. VolanteUniversità di Torino
Tumori neuroendocrini Il ruolo dellanatomia
patologica
Corso AME Milano, 25 maggio 2007
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Caro Mauro, . Riguardo alla tua relazione,
considerato il titolo, avremmo piacere che tu
affrontassi nel tempo che hai a disposizione 20
min la classificazione del neuroendocrino, i
limiti della citologia in rapporto alle scelte
terapeutiche, il discorso dei recettori e della
loro utilità in pratica clinica. considera che
sarà un corso AME () con un taglio decisamente
pratico e questo anche per quanto riguarda
l'anatomia patologica.
Invito del dr R. Cozzi
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Different diagnostic criteria and classification
for

• Medullary thyroid carcinoma
• Pheochromocytoma/Paraganglioma
• Parathyroid adenoma/carcinoma
• Pituitary adenoma/carcinoma

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neuroendocrine tumor classificationMENU

• - History, Definition Glossary
• - Pathological classification
• ? pure NE tumors
• ? mixed NE/exocrine tumors
• - Further characterisation

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• History
• 1907 carcinoid term Oberndorfer
• 1930 carcinoid syndrome Cassidy
• 1940/50 helle zellen Feyrter
• 1952 serotonin discovery Erspamer Asero
• 1963 fore-, mid-, hind-gut carcinoids
  Williams Sandler
• 1965/70 APUD concept Pearse
• 1980 diffuse NE system WHO
• 1994 neuroendocrine tumor replaces carcinoid
  Capella et al
• 2000 classification of endocrine tumors WHO
  Solcia et al

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• History
• 1907 Karzinoid term Siegfried
  Oberndorfer

6 ileal tumors, slowly growing, no metastases
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NE TUMORS
Glossary Synonyms

• carcinoid, malignant carcinoid
• apudoma
• islet cell tumor
• adenoma / microadenoma vs carcinoma
• Kultchisky cell tumor / carcinoma
• endocrine carcinoma
• endocrine neoplasm
• hormone-oma (insulinoma, gastrinoma,..)
• pancreatic (A/B/D/PP)-cell tumor

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Neuroendocrine tumor classificationMENU

• - History, Definition Glossary
• - Pathological classification
• ? pure NE tumors
• ? mixed NE/exocrine tumors
• - Further characterisation

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THE BENIGN THE MALIGNANT THE CLINICALLY
AGGRESSIVE
Clinical Morphological Hormonal Ki67 Gene
expression
WHICH CLASSIFICATION CRITERION ????
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Clinical Morphological Hormonal Ki67 Gene
expression
Incidence, Localisation, Endocrine
function, Symptoms, Treatment, Behavior,
Survival
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Macro
Clinical Morphological Hormonal Ki67 Gene
expression
insulinoma
1 cm

• Single or multiple
• Well demarcated or invasive
• Size 0.5-15 cm.
• Cystic appearance
• Lymph node mets
• Distant mets

Gastric micro-carcinoids
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Micro
Tumor architecture
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Clinical Morphological Hormonal Ki67 Gene
expression
THE BENIGN THE MALIGNANT THE CLINICALLY
AGGRESSIVE

• Gross features and structure are not enough for
  the purpose of identifying homogeneous groups
  with clinical relevance

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CLASSIFICATION PROBLEMS
1994
2000
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2000 WHO CLASSIFICATION

• Introduces terms tumor/carcinoma (vs
  carcinoid) .LUNG EXCLUDED
• Replaces neuroendocrine with endocrine
• Incorporates hormonally active tumors
• (morpho-functional approach)
• Recognizes mixed exo-endocrine tumors
• Incorporates information on tumor grade
• Introduces criteria of malignancy
  (angioinvasion, Ki67 pancreas, only)

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• Microscopic features of malignancy
• Depth of invasion
• Size of tumor
• Angioinvasion
• High grade cellular atypia

GI NETS
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3 TIE SYSTEM for GI NETs
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PANCREATIC NETs
Microscopic features of malignancy

• Invasion of surrounding tissues
• Size of tumor
• (gt6 cm is suspected)
• High grade cellular atypia
• Focal or diffuse necrosis
• High mitotic index
• Blood or lymph vessel nerve invasion
• Ki67 gt 2

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3 TIE SYSTEM for pancreatic NETs
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Does this system fit with the clinical
practice? Is it easily applicable?
E. Bajetta, L. Catena, G. Procopio, E. Bichisao,
L. Ferrari, S. Della Torre, S. De Dosso, S.
Iacobelli, R. Buzzoni, L. Mariani and J. Rosai
Is the new WHO classification of neuroendocrine
tumours useful for selecting an appropriate
treatment? Ann Oncol 2005 161374
Problem of other non-carcinoid NETs (eg malignant
pheochromocytoma, MTC, parathyroid carcinoma,
Merkel cell carcinoma, etc)
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Does this system fit with the clinical
practice? Is it easily applicable?

• Benign vs uncertain behaviour in well
  differentiated pancreatic NETs
• Appendiceal NETs (small invasive?)
• Mixed endocrine exocrine tumors
• Use morphology or Ki67 first?
• The new TNM system for foregut NETs
• Extra GEP pulmonary NETs ? especially
  intermediate grades

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• BENIGN vs UNCERTAIN BEHAVIOR
• Benign Uncertain
• Extrapancreatic growth no no
• Angioinvasion no yes
• Size gt2 cm no yes
• Mitoses gt2 /10HPF no yes
• Ki67 gt2 no yes

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Resembles WD NET (benign), but in general size
gt3 cm, mitoses gt2, Ki67 gt5 but above all
unequivocal signs of malignancy must be present
LOCAL INVASION
LYMPHNODE
LIVER
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FOREGUT NET CLASSIFICATION
Recent proposal of a staging system for fore-gut
NETs and improvement of grading
system using mitoses Ki67
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SPECTRUM OF PULMONARY NETS
TC
SCLC
Difficulties in identifying the intermediate
entities
AC
LCNEC
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SPECTRUM OF PULMONARY NETS
TC AC SCLC
Indolent clinical behavior Aggressive clinical
behavior
Significantly different survival
Arrigoni et al 1972
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SPECTRUM OF PULMONARY NETS
TC AC LCNEC SCLC
lt2 mitoses 3-10 mitoses gt10 mitoses small
cells no necrosis or necrosis (necrosis)
(necrosis)
Significantly different survival plt0.0001
Significantly different survival plt0.0001
NO significantly different survival
Travis et al Am J Surg Pathol 22,934,1998
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SPECTRUM OF PULMONARY NETS
TC AC LCNEC SCLC
TC AC LCNEC
SCLC
NO significantly different survival
Asamura et al JCO 2470,2006
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Degree of differentiation
WELL DIFF.
POORLY DIFF.
LUNG
SMALL CELL/ LARGE CELL NE CARCINOMA
TYPICAL CARCINOID
ATYPICAL CARCINOID
MEEC
WELL DIFF. NE TUMOR benign/borderline
WELL DIFF. NE CARCINOMA
POORLY DIFF. NE CARCINOMA (small/large cell)
GEP
LOW GRADE
HIGH GRADE
Biological behaviour
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Neuroendocrine tumor classificationMENU

• - History, Definition Glossary
• - Pathological classification
• ? pure NE tumors
• ? mixed NE/exocrine tumors
• - Further characterisation

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2000 WHO CLASSIFICATION

• CATEGORIES RECOGNIZED
• 1 well differentiated endocrine tumor
• 2 well differentiated endocrine carcinoma
• 3 poorly differentiated endocrine carcinoma
• 4 mixed exocrine-endocrine tumor
• (5 tumor-like lesions)

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CGA
Exocrine
Endocrine
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NE differentiation in colon cancer
1995
CGA
mucin
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..ANY BIOLOGICAL and/or CLINICAL SIGNIFICANCE??
pure non-NE ca.
non-NE ca.
focal NE
BREAST and COLORECTAL CANCERS
NO
Non-NE carcinomas with NE differentiation
Y/N ?
NSCLC
STOMACH PROSTATE CANCERS
YES
Breast (WHO2004) Lung (WHO2004) GI tract
(WHO2003) Prostate (WHO2003)
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gt5 NE cells
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Am J Surg Pathol August 2006
LCNEC of the stomach are significantly more
aggressive than conventional ADC. ADC-NED have
also a worse prognosis than conventional ADC
(borderline significance)
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CGA increase during progression
Reduced survival of CGA cases
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CASE REPORT
April 2007
July 1996 Nov 1997 Oct 1999 May 2000
Rectal polyp, cancerised
Local recurrence
Pelvic recurrence
Stable disease
Rectum resection
Radical Surgery
FNAB
ADC stage B1

• ChTx 1 5-FU folic acid (6x)
• RT 50 Grey
• ChTx 2 oxaliplatin 5-FU folic acid (12x)

CgA
CgA
CgA
Oncologia Prof Dogliotti dr Tampellini
ChTx 1
RT
ChTx 2
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pure NE tum.
pure non-NE ca.
NE tum.
non-NE ca.
mixed (intermingled)
mixed (collision)
focal non-NE
focal NE
0
100
30
non-NE
NE
100
30
0
Mixed NE/non-NE carcinomas
WDET - TC WDEC - AC PDEC SCLC/LCNEC
Non-NE carcinomas with NE differentiation
Breast (WHO2004) Lung (WHO2004) GI tract
(WHO2003) Prostate (WHO2003)
WHO 2000 Endocrine tumors
WHO 2000 Endocrine WHO 2004 lung
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Degree of differentiation
WELL DIFF.
POORLY DIFF.
LUNG
SMALL CELL/ LARGE CELL NE CARCINOMA
TYPICAL CARCINOID
ATYPICAL CARCINOID
Mixed Endo-Exocrine Ca
WELL DIFF. NE TUMOR benign/borderline
WELL DIFF. NE CARCINOMA
POORLY DIFF. NE CARCINOMA (small/large cell)
GEP
LOW GRADE
HIGH GRADE
Biological behaviour
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HOW TO BREAK THE ARROW?
TYPICAL CARCINOID
LUNG
LUNG
WELL DIFF. NE TUMOR benign/borderline
GEP
ATYPICAL CARCINOID
MEEC
SMALL CELL/ LARGE CELL NE CARCINOMA
WELL DIFF. NE CARCINOMA
POORLY DIFF. NE CARCINOMA (small/large cell)
Light microscopy ??
GEP
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Neuroendocrine tumor classificationMENU

• - History, Definition Glossary
• - Pathological classification
• pure NE tumors
• mixed NE/exocrine tumors
• - Further characterisation

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• Further characterisation
• hormonal
• Ki 67
• receptors
• molecular

THE BENIGN THE MALIGNANT THE CLINICALLY
AGGRESSIVE
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Chromogranins Synaptophysin N-CAM Cytoker.
34bE12 NSE, VMAT PGP9.5 Neurofilaments
MARKERS
SSTR2
Hormones calcitonin, bombesin, insulin,
glucagon, somatostatin, gastrin, PP, VIP, ACTH,
serotonin, NEW ghrelin, cortistatin,
obestatin, secretagogin Virch Arch 449, 402,
Oct 2006
CGA
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• Further characterisation
• Ki 67 proliferation index

LOW
HIGH
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KI-67 DIAGNOSTIC USE
2000
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KI-67 PROGNOSTIC USE
OS
KI-67 in WD NE carcinoma
P 0.017
Prognostic value if groups are homogeneous (eg
all WDCA or PDCA). Otherwise possible bias due to
tumor differentiation
TTP
P 0.043
Brizzi et al, 2007 (submitted)
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KI-67 USE for Tx STRATEGY
10 to 15 cut-off levels according to therapy
modalities
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SEQUENTIAL STEPS in the DIAGNOSTIC PROCESS of
the PATHOLOGIST 1 Use morphology (histopathology
markers) to enter each NET case into
homogeneous groups (eg WHO classification
criteria) 2 Within each group, analyse known (eg
Ki67) or new prognostic markers 3 Analyse
molecules useful for targeted therapy, if
requested
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SOMATOSTATIN RECEPTORS (SSTR)

• The pathologist has to search for SSTR presence
  in a tumor (YES/NO) and, if YES, provide
  information on SSTR subtype

PROBLEM 1 What to search for?
selective SRIF analogs for single SSTR
subtypes vs universal analog for all SSTR
subtypes
PROBLEM 2 How to identify SSTRs?
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How to identify SSTRs?
1 Autoradiography 2 RT-PCR / ISH
3 Immunohistochemistry

• Accessible to all laboratories
• Low cost
• Commercial antibodies ??
• Applicable on archival tissues
• Applicable on biopsies and FNAs
• Identifies SSTR type (1-5) ??
• Need to standardize interpretation

sst2
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Which SSTR antibodies for IHC ??
predominant membrane staining for SSTR2
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Main goal of SSTR localisation provide
information correlated with clinical data
Correlation SSTR-IHC with Octreotide scintigraphy
sst2
Surgical samples (lung) 88 (22/25 cases)
bronchial biopsy
Surgical specimen
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Collaborative project on SSTR2A IHC in
correlation with in vivo data

• 107 cases of NET with variable degrees of
  differentiation and different locations, all with
  Octreoscan and/or information on clinical
  response to SS analogues (from Universities of
  Turin, Varese and Naples)

• Complete clinico-pathological data
• IHC for SSTR2A using 3 different commercial
  polyclonal Abs

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Proposed IHC score for SSTR2 (based on staining
pattern)
Case 2187A/2187B
NE tumor
1 or /-
2
2
3
2.5?
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Score 0
Score 1
Score 2
Score 3
SUBCELLULAR PATTERN
(Negative)
Pure cytoplasmic
Membranous circumferential
Membranous incomplete
EXTENSION OF POSITIVE TUMOR CELL POPULATION
(Absent)
1-100
lt50
gt50
CONCORDANCE WITH OCTREOSCAN DATA
50
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87
94
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Correlation SSTR2 IHC with in vivo data
IHC score 0 totally negative 1 cytoplasmic 2
focal membrane 3 diffuse membrane
107 cases 70 WD NET/CA 18 PD NE CA 9 MTC 10
others
-

Concordance IHC/Octreoscan 77 (82/107 cases)
61 IHC/OS 21 IHC-/OS-
(19/25 discrepant cases being IHC-/Octreoscan)
Concordance IHC/SS analogue response 81 (21/26
cases)
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Thank you!!!
University of Turin at San Luigi Hospital,
Orbassano
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NSGMUC
NSG
MUC
Amphicrine cell
Pure non-NE cell (i.e. mucinous)
Pure NE cell
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sst in endothelia, necrosis and intra-tumoral
lymphocytes
SqCa
sst3
LCNEC
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SUMMARY OF OBSERVED STAINING PATTERNS IN sst IHC
sst2 predominant membrane (cytoplasmic possible,
if weaker than membrane )
sst3 cytoplasmic (with membrane increase)
sst5 membrane and cytoplasmic
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sst2A IHC expression in 71 NE tumors of the lung
Typical carcinoid (24) score 0/1 4
score 2/3 20 (83) Atypical carcinoid
(20) score 0/1 8 score 2/3 12
(60) LCNEC (17) score 0/1 7 score 2/3
10 (59) SCLC (10) score 0/1
4 score 2/3 6 (60)