NO DISCLOSURES. 1. Incipient neoplasia: Dysplasia/Tis NEUROENDOCRINE TUMORS OF THE GI AND PANCREATOBILIARY TRACT

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1 3002: CYTO- HISTOLOGY OF NEUROENDOCRINE NEOPLASMS OF LUNG, GASTROINTESTINAL TRACT AND PANCREAS Momin Siddiqui, MD, FIAC Professor Divisional Director and Chief of Cytopathology Emory University Hospital Atlanta, GA Michelle Reid, MD, MSc Associate Professor Director of Cytology Services Emory University Hospital- Midtown Atlanta GA NO DISCLOSURES In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation. NEUROENDOCRINE TUMORS OF THE GI AND PANCREATOBILIARY TRACT 1. Incipient neoplasia: Dysplasia/Tis 2. Well differentiated neuroendocrine tumors (WHO Grade 1 and 2) 3. Poorly differentiated (WHO Grade 3) 4. Hybrid tumors or misfits Grade- discordant NETs Composite carcinoma- neuroendocrine (MANEC) Carcinoma ex- goblet cell carcinoid 1

2 1. Incipient neuroendocrine neoplasia Also known as microadenoma, hyperplasia or dysplasia Incidental microscopic small lesions Counterpart of pulmonary tumorlets or thyroid- medullary C- cell hyperplasia Typically occur secondary to a syndrome (Z- E syndrome) or medical disorder (autoimmune gastritis) Stomach- Enterochromaffin- like cell lesions Etiology Atrophic/autoimmune gastritis Drugs Gastrin- producing tumor Hypo or achlorhydria Sustained hypergastrinemia Genetic factors? ELC Hyperplasia ELC Dysplasia ELC NET (carcinoid) Enterochromaffin- like cell lesions in the stomach Hyperplasia à Rare cells Linear Micronodular 2

3 ECL Dysplasia Micronodule formation ENETS /TNM proposal: Tis (In- situ tumor/dysplasia); Vanoli et al, Human Pathol, Reporting of Incipient NE Neoplasia Stomach, bx: If composed of tiny clusters only: ELC- cell proliferation in a background of atrophic gastritis If conglomerates or large clusters Minute WDNET of type A arising in the background of ELC proliferation and atrophic gastritis à Type A or type 1 Gastric NET 3

4 NEUROENDOCRINE TUMORS OF THE GI AND PANCREATOBILIARY TRACT 1. Incipient neoplasia: Dysplasia/Tis 2. Well differentiated neuroendocrine tumors (WHO Grade 1 and 2) 3. Poorly differentiated (WHO Grade 3) 4. Hybrid tumors or misfits Grade discordant NETs Composite carcinoma- neuroendocrine (MANEC) Carcinoma ex- goblet cell carcinoid 2. WDNETs Terminology and concepts WHO Terminology Neuroendocrine (not endocrine) Tumor (not neoplasm) NET 1/2 Carcinoid à (WD) neuroendocrine tumor Pancreatic endocrine neoplasm (PEN) à (WD) Pancreatic neuroendocrine tumor (PanNET) Carcinomaà (PD) neuroendocrine carcinoma 4

5 Well differentiated NETs are now in the Neoplastic; other category WDNET: Classic nested morphology WDNETs: Ribbon- like or trabecular pattern 5

6 WDNET, bland plasmacytoid chromogranin+ cells Well Differentiated Neuroendocrine Tumor FNA Plasmacytoid cells D Well Differentiated Neuroendocrine Tumor - FNA D Salt-n-pepper chromatin, small nucleoli 6

7 FNA Biopsy Well Differentiated Neuroendocrine Tumor FNA Pseudorosettes are seen on smears WDNET- cell block Keratin Pseudorosettes are seen on cell block Synaptophysin Morphologic Repertoire and Potential Diagnostic Pitfalls in Well- Differentiated NETs 7

8 WDNET Diagnostic problems Artifacts Atypical morphologic patterns Chromogranin- A negativity (common in appendiceal and rectal NETs) Degeneration (cystic) Problem: Limited bx - Mucosal component can be small - Artifacts common Ampullary NET: Original diagnosed as adenoca. Pitfall: Glandular patterns 8

9 Ampullary somatostatinoma ( GLANDULAR psammomatous carcinoid ) Intraluminal mucin but no convincing intracytoplasmic mucin Ampullary somatostatinoma Glandular psammomatous carcinoid Glandular pattern Psammoma bodies Neurofibromatosis LN metastasis in 50-70% (despite their small size ) Ileal WDNET 9

10 PanNETs: Nucleoli may be prominent in some WDNETs Prominent nucleoli and pseudoacini D Lipid- rich PanNETs: Cytoplasmic droplets present in both histology and cytology Oncocytic PanNETs: Probably more aggressive Liver mass FNA 10

11 Pleomorphic Variant of PanNET: Has no clinical significance Note single plasmacytoid cells and cells with focal degenerative endocrine atypia Paraganglioid NET: Note distinct nesting pattern PanNET, tubular sclerosing pattern 11

12 PanNET, tubular sclerosing pattern Chromogranin Benign ducts can be prominent in PanNETs Ductulo- insular NET, no clinical significance, NOT MANEC CK 19 + ducts Cystic Degeneration in a PanNET: 12

13 Cyst lumen Cyst wall Cystic PanNET: 37 Same Cystic PanNET on EUS- FNA Tumor cells have round nuclei with coarse chromatin, focal prominent nucleoli. Paucicellular sample with abundant debris and rare clusters of epithelial cells. 38 Low cellularity limits IHC panels; Grading could not be done in this cystic NET Synaptophysin Chromogranin 39 13

14 WDNETs Determinants of outcome Determinants of Biologic Behavior in WDNETs of GIT 1. Location 2. Cell type 3. Clinical setting 4. Size (stage) 5. Grade 6. Adjunct histologic/biologic parameters Location Most appendiceal classical WDNETs (carcinoid) are asymptomatic Most are microscopic 2% of autopsies Most rectal ones are non- metastatic Most < 1 cm Ileal or colonic WDNETs: Mets are common, often advanced at diagnosis 14

15 Determinants of Biologic Behavior in GI NETs 1. Location 2. Clinical setting 3. Cell type 4. Size (stage) 5. Grade 6. Adjunct histologic/biologic parameters Predicting Behavior in NETs The importance of clinical setting Example: Gastric NETs Type I: Autoimmune/atrophic gastritis- related Compensatory hypergastrinemia è ECL proliferation à Typically benign course Type II (Zollinger- Ellison or MEN syndrome) Type III (sporadic NETs) à Typically aggressive Determinants of Biologic Behavior in NETs 1. Location 2. Clinical setting, syndromic background 3. Cell type 4. Size (stage) 5. Grade 6. Adjunct histologic/biologic parameters 15

16 Predicting Behavior in NETs The importance of cell type 3. Cell type/hormonal status Most insulinomas are benign Often small at diagnosis (> 70% are < 1 cm) Present earlier because of Whipple triad Fasting Hypoglycemia with symptoms relieved by IV glucose Most glucagonomas are malignant Often higher stage (large; >3 cm) at diagnosis Determinants of Biologic Behavior in GI- PB Tract NETs 1. Location 2. Cell type 3. Clinical setting 4. Stage (depth of invasion, size and metastasis) 5. Grade 6. Adjunct histologic/biologic parameters Staging of Ampullary NETs Stage AJCC ENETS T1 Ampulla of Vater or sphincter of Oddi Lamina propria, submucosa; < 1 cm T2 Duodenal wall Muscularis propria, subserosa; > 1 cm T3 Pancreas Pancreas or retroperitonal invasion T4 Peri- pancreatic soft tissues or other adjacent organs The invasion of the peritoneum or other organs 16

17 Staging of Pancreatic NENs Stage AJCC ENETS T1 Confined, < 2 cm Confined < 2 cm T2 Confined, > 2 cm Confined, 2-4 cm T3 Beyond pancreas Confined, > 4 cm, CBD or duodenum T4 Adjacent organ Adjacent organ Determinants of Biologic Behavior in GI NETs 1. Location 2. Cell type 3. Clinical setting 4. Size (stage) 5. Grade 6. Adjunct histologic/biologic parameters 5. WDNET- 3 vs PDNEC?? 17

18 Well- Differentiated NET Poorly- Differentiated NEC Cells are bland, have abundant cytoplasm, low N/C, no necrosis, few mitoses Cells have scant cytoplasm, high N/C, areas of necrosis, numerous mitoses Grade (subclassification terminology ) in WDNETs Based on 2010 WHO NET 1 NET 2 NET 3/ CA Mitoses (10 HPF) < >20 Ki- 67 proliferation index (%) >20 WHO 2010 NET Terminology But what about cases with Ki- 67 index 2-3%? ~15% of PanNETs fall within 2-3% range. 18

19 Grade (subclassification) of NETs, 2010 Based on ENETS proposal NET 1 NET 2 NET 3 Mitoses/10 HPF < >20 Ki- 67 proliferation index (%) 3 (2) 3-20 >20 NANETS regards Ki- 67% index between 2% and 3 % as G1 and changed the upper limit to 3 19

20 WDNET PDNEC Cell Block Ki-67 stain index 3% G1 Ki-67 stain index 80% G3 Current Concepts and Controversies In Grading Grading methodologies, old and new I. Problems with Ki- 67: How to Count? 1. Refusing to count is no longer an option 2. Eyeballing 1

21 Results of eye- balling of Ki67 index by 18 observers in 45 cases illustrates striking inter- observer variability (as well as grade variability) 2

22 37 (pos) (37 pos neg) Ki- 67 index = 10% Ki-67 heterogeneity 66 cases K-67-LI (%) Areas Mean High positive area 5.3 At random Ki-67 (%) Case High positive area At random 3

23 Intratumoral Ki-67 heterogeneity 66 cases K-67-index (%) Ki-67 (%) Areas Mean Highest positive area (HOT SPOT) 5.3 At random 2.5 The final grade was different in 30% of the cases with random- area vs hot- spot counting Case High positive area At random Reid et al. (Abstract) Mod Pathol January. We asked a panel of 40 expert pancreatobiliary pathologists to grade this PanNET based on this image using an audience response system. Q16b: My count of Ki67 positive cells in this highlighted area is? A.<3 B.4-6 C.7-10 D.>10 4

24 NEUROENDOCRINE TUMORS OF THE GI AND PANCREATOBILIARY TRACT 1. Incipient neoplasia: Dysplasia/Tis 2. Well differentiated neuroendocrine tumors (WHO Grade 1 and 2) 3. Poorly differentiated (WHO G3) 4. Hybrid tumors or misfits Grade discordant NETs Composite carcinoma- neuroendocrine Carcinoma ex- goblet cell carcinoid 3. PDNECs (Poorly differentiated NE carcinomas, small cell or large cell type) Poorly diff NEC (Grade 3 NET ), small cell type 5

25 Poorly diff NEC ( NET 3 ), large cell type Cells have high N/C, areas of necrosis, numerous mitoses Poorly differentiated NECs of GI/PB tract Often (30%) a/w conventional adenocarcinoma and adenomatous component (MANEC) Aggressive behavior (worse than ordinary carcinomas of respective sites) Small cell ca. therapy protocol may work better than ordinary adenoca. protocols (inadequate data) For Pancreatic NEC always exclude metastasis first (esp from lung) NEUROENDOCRINE TUMORS OF THE GI AND PANCREATOBILIARY TRACT 1. Incipient neoplasia: Dysplasia/Tis 2. Well differentiated neuroendocrine tumors (WHO Grade 1 and 2) 3. Poorly differentiated (WHO Grade 3) 4. Misfits or hybrid tumors 1. Grade discordant NETs Composite carcinoma- neuroendocrine Carcinoma ex- goblet cell carcinoid 6

26 4. Misfits 1. Grade- Discordant NETs WDNET (G1/2) by morphology but G3 by Ki67 WHO 2010 Neuroendocrine tumor (NET 1) Neuroendocrine tumor (NET 2) Neuroendocrine carcinoma (NET 3/NEC) 3. NET- 3 (Ki67> 20) becomes a mixed bag of: I. Mitotically active conventional NET II. Pulmonary type HGNEC (small cell ca, large cell NEC) Well- differentiated NET (2 examples) 7

27 (Morphologically) Well- differentiated but Ki67 > 20% Diagnosis: Well- differentiated PanNET, grade 3 of 3 by Ki67 proliferation index Comment: NOT a PDNEC Reference: Basturk et al, Am J Surg Pathol, 2014 Basturk et al, Am J Surg Pathol, 2015 Poorly differentiated NE carcinoma PD NE carcinoma (ki67 typically > 50%) Diagnosis: Poorly differentiated neuroendocrine carcinoma Reference: Basturk et al, Am J Surg Pathol, 2014 Basturk et al, Am J Surg Pathol,

28 Patients with Ki % had a significantly longer survival vs those > 55% (14 vs 10 m, p<0.05). PDNEC Group with Ki67 index >55 had a much better response to cis- platinum Grade discordant G3 WDNETs Grade 3 NE Neoplasms (Ki67 > 20 %) are a Dichotomy 1. NET- 3 w WDNET morphology (Ki %): 2. NET- 3 w PDNEC- morphology (Ki- 67 > 55%): 9

29 NET- 3 (Ki- 67 > 20 %) : Our current practice NET- 3 w WDNET morphology (Ki % ): Differentiated NET, grade 3 of 3 by proliferation index Basturk et al NET- 3 w PDNEC- morphology (Ki67 > 55% ): Poorly differentiated neuroendocrine carcinoma Sorbye et al 4. Misfits 2. WDNETs with a Morphologically High- Grade Component 10

30 Ambiguous morphology : WD? PD? Ki % 2. WDNETs with a Morphologically High- Grade Component May represent progression of WDNET to high- grade PDNEC component Rare occurrence High- grade component is either in the primary (48%) tumor or the metastasis (52%) Median survival is much better (55 mths) vs 11 mths for pure PDNECs Clin Cancer Res 2016 Feb 15. Misfits: NET- 3 (Ki- 67 > 20 %) : Maybe the dichotomy is a trichotomy 1. NET- 3 w WDNET morphology (Ki % ): Differentiated NET, grade 3 of 3 by proliferation index Basturk et al 2. Ambiguous category in between 3. NET- 3 w PDNEC- morphology (Ki67 > 55% ): Poorly differentiated neuroendocrine carcinoma Sorbye et al 11

31 Loss of RB, +p53 IHC PDNEC (RB, P53) If there is loss of ATRX/DAXX IHC WDNET Rb loss Tang et al, Am J Surg Pathol Jun 1 NEUROENDOCRINE TUMORS OF THE GI AND PANCREATOBILIARY TRACT 1. Incipient neoplasia: Dysplasia/Tis 2. Well differentiated neuroendocrine tumors (WHO Grade 1 and 2) 3. Poorly differentiated (WHO Grade 3) 4. Hybrid tumors or misfits 1. Grade discordant NETs 2. Composite/mixed adeno- neuroendocrine carcinoma(manec) 3. Carcinoma ex- goblet cell carcinoid Case for Presentation Liver mass FNA 12

32 Liver core biopsy done at time of FNA Ki67 index 17% DX; Metastatic WDNET, Grade 2 Follow- up: Colon mass - Mixed Adenocarcinoma and NEuroendocrine Carcinoma of colon (MANEC): Dx requires 30% NE component Ki67 index = 58% = G3, NEC Should the diagnosis on the patient s prior liver core biopsy be amended? Ki67 index 17% = WDNET, Grade 2 13

33 Diagnosing NET in Liver Diagnosis is dependent on tumor grade: NOT on site of involvement (liver met) NOT based on evaluation of the primary tumor The term neuroendocrine carcinoma/nec G3 should be reserved for tumors with Ki67 index >20% and small/large cell morphology Mixed neuroendocrine- acinar carcinoma with a distinct NE component CHROMOGRANIN Should Ki67 index be calculated on cytology samples? Yes. This example has >500 cells WHO requires that cells be counted Add a comment on specimen cellularity. State that final grade may increase on resection specimen. Fung et al. Acta Cytol. 2013; 57(5): Ki-67 stain index 4% 14

34 NEUROENDOCRINE TUMORS OF THE GI AND PANCREATOBILIARY TRACT 1. Incipient neoplasia: Dysplasia/Tis 2. Well differentiated neuroendocrine tumors (WHO Grade 1 and 2) 3. Poorly differentiated (WHO Grade 3) 4. Hybrid tumors or misfits 1. Grade discordant NETs 2. Composite/mixed adeno- neuroendocrine carcinoma(manec) 3. Carcinoma ex- goblet cell carcinoid Appendiceal tumor: relatively intact wall; layers preserved A subtle infiltrate of very well- formed glandular units 15

35 Classical Goblet cell carcinoid Previous names: Crypt cell adenocarcinoma; Adenocarcinoid Is it really a carcinoid? Chromogranin only focal Ordinary carcinoid pattern is rarely seen If low- grade/low- stage (confined to the appendix),behaves like a carcinoid (prognosis is good) Composed of goblet cells; very similar to colonic crypts THIS CASE ALSO SHOWED Compressed, ill- defined, irregular glandular units Stromal mucin associated with disorganized neoplastic cells 16

36 CHROMOGRANIN CASE - Diagnosis ADENOCARCINOMA EX- GCC APPENDICEAL CRYPT CELL ADENOCARCINOMA WHO: Mixed GCC- adenocarcinoma Reid MD et al. Mod Pathol PMID:

37 Distinctive features of dedifferentiated GCC (adenoca ex GCC) allow it to be recognized as an appendiceal primary even in metastatic sites: 1. Goblet cells (with voluminous pale- basophilic cytoplasm) 2. Crypt like structures 3. Small goblet cell clusters 4. Microglandular units Signet- ring like cells with voluminous cytoplasm, in small clusters: Most likely appendiceal (less likely gastric) Especially if they form small, round glandular elements 18

38 NKX6-1 Is a Novel Immunohistochemical Marker for Pancreatic and Duodenal Neuroendocrine Tumors Tseng et al. Am J Surg Pathol. 39(6), June 2015 CONCLUSION NE tumors of pancreas and GIT are a mixed bag of well and poorly differentiated neoplasms Prognosis is mainly dependent on grade Location and functionality play a lesser role Grade- discordant NETs must be clearly reported Associated w/ increased aggression relative to G1/2 tumors New molecular/ihc markers (p53, Rb, DAXX, ATRX) can help with classification Determining the site of origin of a NET Often not possible; lots of overlaps Often not necessary WD- NET is a perfectly adequate diagnosis Don t be cornered by your clinicians to commit Imaging studies (octreotide scan and PET) and serologic studies (serotonin etc) are very successful in identifying the primary Having said that, few site- specific patterns do exist 19

39 THANK YOU 20

40 Cytohistology of Neuroendocrine Neoplasms of Lung, Gastrointestinal Tract and Pancreas: Review of Current Trends and Practical Approach to Diagnosis American Society of Clinical Pathology Annual Meeting, Las Vegas, September Momin T. Siddiqui M.D. Director of Cytopathology Emory University Hospitals, Atlanta, USA Professor of Pathology and Laboratory Medicine Emory University School of Medicine, Atlanta, USA

41 Conflict of Interest No conflict of interest to declare

42 Learning Objectives Discuss cytohistologic features of pulmonary neuroendocrine tumors Classification of neuroendocrine tumors Carcinoid tumor, atypical carcinoid tumor, small cell neuroendocrine carcinoma, large cell neuroendocrine carcinoma

43 Introduction Neuroendocrine tumors develop from primitive cells in the neural crest These neural crest cells have ability for active amine precursor uptake and decarboxylation, which form biologically active amines Kulchitsky or K cell is thought to be the APUD cell of origin for PNEN K cells found widely in the tracheobronchial tree Chemoreceptors that sense oxygen and carbon dioxide levels and help regulate air flow K cells? of endodermal origin

44 Cytologic Sampling and Evaluation Play a greater role in diagnosing these tumors in comparison to transbronchial biopsy Bronchial brushings sample a wider area Fine needle aspirates can be EBUS directed or CT scan directed and dependent on the location of the tumor mass Well sampled fine needle aspirates are hypercellular and effectively diagnose these tumors Fine needle aspirate yield is operator dependent

45 Clinical Symptoms of PNEN Tumor size, location and biologic activity Cough, wheezing and hemoptysis Obstruction of bronchial lumen can cause difficulty in breathing Paraneoplastic syndromes secondary to aberrant expression of peptide hormones Cushing s Syndrome, syndrome of inappropriate secretion of anti-diuretic hormone

46 Classification of PNEN Dresler, et al Grade 1 Grade 2 Grade 3 Grade 3 Neuroendocrine carcinoma Neuroendocrine carcinoma Neuroendocrine carcinoma, small cell type Neuroendocrine carcinoma, large cell type Warren, et al Carcinoid tumor Well differentiated neuroendocrine carcinoma Travis, et al Carcinoid tumor Atypical carcinoid tumor Small cell carcinoma Small cell neuroendocrine carcinoma Intermediate differentiated neuroendocrine carcinoma Large cell neuroendocrine carcinoma

47 Carcinoid Tumor Account for 2-3% of all lung tumors White adults, equal sex distribution Not related to smoking history 75% are central Well circumscribed Carcinoid syndrome Low metastatic potential 5 year survival ranges from % Siddiqui MT. Pulmonary Neuroendocrine Neoplasms: A Review of Clinicopathologic and Cytologic Features. Diagnostic Cytopathology 2010;38:

48 Carcinoid Tumor Rosette Formation Plasmacytoid Cells

49 Carcinoid Tumor Organoid Pattern Salt and pepper chromatin Synaptophysin

50 Carcinoid Tumor Central/well circumscribed Organoid pattern with fibrovascular septa

51 Carcinoid Tumor Trabecular/ organoid Fibrovascular septa Rosettes Plasmacytoid cells Scant cytoplasm Eccentrically placed nuclei No nuclear molding Salt and pepper chromatin Inconspicuous nucleoli Rare mitosis No necrosis

52 Atypical Carcinoid Tumor Males, years Peripheral location History of cigarette smoking Multiple endocrine neoplasia syndrome Aggressive behavior Metastatic potential is high 5 year survival rate is approximately 70% Siddiqui MT. Pulmonary Neuroendocrine Neoplasms: A Review of Clinicopathologic and Cytologic Features. Diagnostic Cytopathology 2010;38:

53 Atypical Carcinoid Tumor

54 Atypical Carcinoid Tumor

55 Atypical Carcinoid Tumor

56 Atypical Carcinoid Tumor

57 Atypical Carcinoid Tumor

58 Atypical Carcinoid Tumor

59 Atypical Carcinoid Tumor Patterns Organoid Trabecular Nested Necrosis Inflammation Well circumscribed mass

60 Atypical Carcinoid Tumor Organoid pattern Cell block Organoid pattern

61 Atypical Carcinoid Tumor Pleomorphism Rosettes, acinar structures, palisading Oval, round, spindle, plasmacytoid cells Larger than CT/SCNC Moderate cytoplasm Variable sized nuclei Coarsely granular salt and pepper chromatin Prominent nucleoli Mitotic activity

62 Atypical Carcinoid Tumor Central camedo type tumor necrosis is a key feature!

63 Atypical Carcinoid Tumor Lymphovascular invasion is another key feature!!

64 Small Cell Neuroendocrine Carcinoma Account for 20-25% of lung cancers 90% are centrally located and rapidly growing Male smokers account for 80% of the cases Widespread metastasis Treated with chemotherapy/radiation 5 year survival is less than 5% Siddiqui MT. Pulmonary Neuroendocrine Neoplasms: A Review of Clinicopathologic and Cytologic Features. Diagnostic Cytopathology 2010;38:

65 Small Cell Neuroendocrine Carcinoma Small groups Nuclear Molding Hypercellular with crush artifact

66 Small Cell Neuroendocrine Carcinoma Round, oval or spindle cells 2-3 times the size of mature lymphocyte with rare intermediate size cells (3-4 times larger) Scant cytoplasm Round to oval nuclei Dense coarse chromatin Nucleoli generally absent or inconspicuous

67 Small Cell Neuroendocrine Carcinoma Centrally located tumor Diff Quik stain Papanicolaou stain Crush artifact and necrosis

68 Small Cell Neuroendocrine Carcinoma Increased mitotic activity Nuclear molding Crush artifact Necrosis IHC analysis Chromogranin Cell block

69 LCNEC: Clinical and Radiologic Features Initially described in 1991by Travis et, al.* Male patients over 60 years of age History of smoking CT scan: Well demarcated and lobulated mass Size ranges from 2-5 cm Lacks internal calcifications Moderate enhancement which is more than the chest wall muscle Lymphadenopathy in ipsilateral hilar and mediastinal areas *Travis WD et, al. Neuroendocrine tumors of the lung with proposed criteria for large cell neuroendocrine carcinoma: An Ultrastructural, immunohistochemical, and flow cytometric study of 35 cases. Am J Surg Pathol 1991;15:

70 Large Cell Neuroendocrine Carcinoma

71 Large Cell Neuroendocrine Carcinoma

72 Large Cell Neuroendocrine Carcinoma

73 Large Cell Neuroendocrine Carcinoma

74 Cytologic Features of LCNEC Tissue fragments Cellular clusters Rosettes Single cells Necrosis

75 Cytologic Features of LCNEC Tumor cells are > 3 times the tumor cells in small cell carcinoma

76 Cytologic Features of LCNEC Moderate amount of cytoplasm Round to oval nuclei with thin membranes Finely granular chromatin Nucleoli are common and are large and single

77 Cytologic Features of LCNEC Nuclear molding Naked nuclei, nuclear crush artifact and extensive necrosis

78 Histologic Features of LCNEC Large confluent organoid nests of tumor cells The tumor cells are separated by thin septa of fibroconnective tissue

79 Histologic Features of LCNEC Palisading of tumor cells Rosette like structures Necrosis

80 Histologic Features of LCNEC Individual tumor cells are large with moderate cytoplasm Nuclei have large nucleoli Mitotic counts are high Large zones of necrosis are common IHC confirmation of neuroendocrine differentiation

81 Mitotic Activity and Ki-67 PI CT AC SCNEC LCNEC Mitoses per 2 mm > 10 (median of 80) > 10 (median of 70) Ki-67 PI Upto 5% Upto 20% % 4-80% TTF-1 Mostly negative Mostly negative Positive 85% Positive 50% Synaptophysin/ chromogranin Positive Positive Positive (80-90%) Positive (80-90%) CD56 Positive Positive Positive (80-90%) Positive (80-90%) WHO Classification of Tumors of the Lung, Pleura, Thymus and Heart. Travis WD, editor, 2015

82 Poorly Differentiated Squamous Cell Carcinoma Diff-Quik Stain FNA Infiltrating Squamous Cell Carcinoma

83 SQCC: Immunohistochemistry CK5/P63 P40 Fatima N, Cohen C, Siddiqui MT, Combined Double CK5/P63 Stain: Useful Adjunct Test for Diagnosing Pulmonary Squamous Cell Carcinoma. Diagn Cytopathol 2012;40: Vogt AP, Cohen C, Siddiqui MT. p40 Is More Specific Than p63 and Cytokeratin 5 in Identifying Squamous Cell Carcinoma of Bronchopulmonary Origin. Diagn Cytopathol 2014;42:

84 Poorly Differentiated Adenocarcinoma Diff Quik FNA Infiltrating Adenocarcinoma

85 ADC: Immunohistochemistry TTF-1/Napsin A Johnson H, Cohen C, Siddiqui MT. TTF-1 & Napsin A Double Stain: A Comparison of Vendor Antibodies for Diagnosing Lung Adenocarcinoma. Acta Cytol 2012;56:

86 Differential Cytologic Features Cytologic Features LCNEC PDSQCC* PDADC* Cell Size Mostly Large Small to intermediate Mostly Large Single Cells Prominently Present Present Rarely Present Cellular Fragments Present Present Present Naked Nuclei Prominently Present Rarely Present Rarely Present Nuclear Molding Prominently Present Rarely Present Rarely Present Crush Artifact Present Rarely Present Rarely Present Rosettes Present Absent Absent Cytoplasm Moderate Scant Abundant Nuclear Membrane Thin Thick Thick Chromatin Fine Dense Fine Nucleoli Present Rare Present *PDSQCC-Poorly differentiated squamous cell carcinoma *PDADC-Poorly differentiated adenocarcinoma