Objectives. Terminology 03/11/2013. Pitfalls in the diagnosis of Gastroenteropancreatic Neuroendocrine Tumors. Pathology Update 2013

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1 Pitfalls in the diagnosis of Gastroenteropancreatic Neuroendocrine Tumors Pathology Update 2013 Ozgur Mete, MD Consultant in Endocrine Pathology, Department of Pathology, University Health Network Assistant Professor, Department of Laboratory Medicine and Pathobiology, University of Toronto Objectives To review the terminology of neuroendocrine tumors To review the current classification systems To review pitfalls in the diagnosis of neuroendocrine tumors To review the role of ancillary tools To discuss the grading system To be aware of site-specific and grade-dependent staging systems of neuroendocrine tumors Terminology 1

2 Terminology Carcinoid tumor Siegfried Oberndorfer, 1907 No longer acceptable Islet cell tumor No longer acceptable APUDoma No longer acceptable Neuroendocrine tumor/neoplasm Endocrine tumor Neuroendocrine carcinoma Carcinoid, 1907 Carcinoma-like Siegfried Oberndorfer Original sections showing ileal carcinoids from the collection of Siegfried Oberndorfer, obviously provided in 1907 by Robert Rössle ( ). Kloppel et al. Virchows Arch. 2007;451 (Suppl 1): S3-7 Kloppel et al. Virchows Arch. 2007;451 (Suppl 1): S3-7 2

3 Arch Surg 2007;142: WHO 2010 (GEPNET) Neuroendocrine tumor (NET) -NET Grade 1 (ICD-O 8240/3) -NET Grade 2 (ICD-O 8249/3) Neuroendocrine carcinoma (NEC) (ICD-O 8246/3) -Large cell NEC, Grade 3 (ICD-O 8013/3) -Small cell NEC, Grade 3 (ICD-O 8041/3) Morphologic Diagnosis 3

4 How do we diagnose neuroendocrine tumors morphologically? -Growth Patterns -Nuclear Features salt&pepper -Sometimes cytoplasmic granularity and -NEUROENDOCRINE MARKERS Morphologic Features of NETs Histological Growth Patterns Solid/nesting pattern Trabecular/gyriform Glandular Tubular-acinar Cystic Papillary Angiomatoid Mixed patterns Histological patterns are NOT specific for Tumor type or Functional status Exception-Amyloid deposition Insulinoma Exception-Psammoma bodies with glandular structures Somatostatinoma (duodenal) 4

5 Cytological Features of NETs Cytology Usual Salt&Pepper Nuclei Oncocytic and clear cell Spindle cell Rhabdoid Large cell Small cell 1111 Confirm Neuroendocrine and Epithelial differentiation Neuroendocrine Differentiation Synaptophysin Chromogranins *poorly differentiated can be negative *rectal NETs can be negative for chr-a *circulating tumor marker PGP 9.5, CD56, CD57 NESP-55 Histidine decarboxylase, NSE Chromogranin-A Epithelial Differentiation AE1/AE3 CAM5.2 EMA, other keratins.. CAM5.2 Immunohistochemical Diagnosis of NETs Hormones Glucagon, insulin, somatostatin, PP Serotonin, Gastrin, VIP, somatostatin PYY, glucagon like peptide 1, PP Inhibin, bombesin, ACTH, GHRH, CRH, and other ectopic hormones Proliferation Rate Ki67 (MIB-1), phospho-histone3 Predictive Markers DAXX, ATRX, menin: pancreas CK19, CD117: pancreas E cadherin, beta catenin, CEACAM1 mtor pathway Factors that help to characterize Site of Origin TTF 1 in lung, thyroid and others poorly diferantiated neuroendocrine carcinomas PDX 1, islet 1 (Isl 1), and Pax 6/Pax 8 in pancreas Islet 1 (Isl 1) and Pax 8 in rectal NETs CDX 2 in small bowel and pancreas Xenin in duodenum Pit 1, T pit, SF 1 in pituitary Tyrosine hydroxylase in paraganglioma and pheochromocytoma 5

6 The role of Immunohistochemistry in the Diagnosis of GEP-NETs 1. Confirm neuroendocrine differentiation 2. Confirm epithelial differentiation 3. Hormones -Determine the peptide profile -Define precursor lesions -Help to determine certain cell types 4. Determine the cell origin (transcription factors) 5. Determine the proliferative rate 6. Prognosticators Hormone and Transcription Factor e.g. Diffuse CDX 2 and Serotonin in a metastatic small bowel NET SEROTONIN CDX 2* Positive for chromogranin A Positive for synaptophysin Negative for keratins (in this case) Negative for tyrosine hydroxylase Positive for CDX 2 Positive for Serotonin MIB 1 LI is 4% * Nuclear The possibility of a paraganglioma should be excluded in a keratin-negative neuroendocrine tumor Neuroendocrine Tumor, Grade 2 (WHO 2010) or Paraganglioma Clinical management is different for paragangliomas Unlike other NETs, paragangliomas are MIBG-avid Criteria of malignancy in paragangliomas 6

7 Tyrosine Hydroxylase Tyrosine hydroxylase The role of Immunohistochemistry in the Diagnosis of GEP-NETs 1. Confirm neuroendocrine differentiation 2. Confirm epithelial differentiation 3. Hormones -Determine the peptide profile -Define precursor lesions -Help to determine certain cell types 4. Determine the cell origin (transcription factors) 5. Determine the proliferative rate 6. Prognosticators Hormone Immunohistochemistry Assessment of cellular origin of neuroendocrine cell proliferations PPI-related G cell hyperplasia (illustrations) ECL cell hyperplasia, D cell hyperplasia, L cell NET Gastrin Mete & Asa. Pathology 2013; 45(3):

8 Hormone Immunohistochemistry Assessment of Precursor lesions e.g. islet dysplasia, pancreatic endocrine microadenomas Glucagon Insulin Somatostatin PP Glucagon Dysplasia Insulin Dysplasia Somatostatin Dysplasia PP Dysplasia Mete & Asa. Pathology 2013; 45(3): The role of Immunohistochemistry in the Diagnosis of GEP-NETs 1. Confirm neuroendocrine differentiation 2. Confirm epithelial differentiation 3. Hormones -Determine the peptide profile -Define precursor lesions -Help to determine certain cell types 4. Determine the cell origin (transcription factors) 5. Determine the proliferative rate 6. Prognosticators Is this neuroendocrine tumor functional? No clinical evidence of symptoms (surgeon says) Biochemically high PP levels Pancreatic Polypeptide 8

9 Clear cell change: VHL syndrome Rarely in MEN1 syndrome and sporadic NETs inhibin Gucer H et al. Virchows Arch 2013; 463(4): The assessment of the non-tumorous parenchyma can provide critical information! NESIDIOBLASTOSIS (DUCTULO-INSULAR COMPLEXES) Type 1 gastric NET PELIOSIS ECL cell hyperplasia ECL cell hyperplasia Mete & Asa. Pathology 2013; 45(3): Grading & Staging in Gastroenteropancreatic NETs 9

10 Grading of Neuroendocrine Tumors GEP-NETs Tumor grade refers to the degree of biologic aggressiveness and is also related to differentiation but different Tumor differentiation refers to the extent of resemblance to the normal cellular counterpart Grading-GEPNET G1 G2 G3 Mitotic activity <2/10HPF 2-20/10HPF >20/10 HPF Ki-67 index <3% 3-20% >20% Neuroendocrine tumors are malignant!! G1 G2 G3 To count or not to count is not the question, but rather how to count Counting vs eyeballing Manual counting Digital image analysis Ki67 LI assessment percent of 2000 cells in areas of hot spot nuclear labeling tumor heterogeneity Mitotic counting at least 50HPF in areas at highest mitotic density 10

11 Staging of Neuroendocrine Tumors Tumor Stage refers to the extent of the spread of the tumor. The size of the tumor The extent of invasion into the organ of origin The involvement of lymph nodes The involvement of distant sites are crital factors The AJCC/IUCC has recently provided in 2010 the new TNM staging for GEP NETs of different anatomical sites TNM Staging of PETs (G1, G2, G3) TNM T primary tumor (For any T, add (m) for multiple tumors) TX T0 T1 T2 T3 Primary tumor cannot be assessed No evidence of primary tumor Tumor limited to the pancreas and size <2 cm Tumor limited to the pancreas and size >2 cm Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery T4 Tumor involves the celiac axis or the superior mesenteric artery (unresectable) N regional lymph nodes NX Regional lymph node cannot be assessed N0 N1 No regional lymph node metastasis Regional lymph node metastasis M distant metastases MX M0 M1 Distant metastasis cannot be assessed No distant metastases Distant metastasis (indicates the presence of any single or multiple metastases at any distant anatomical site including nonregional nodes) Stage Ia Stage Ib Stage IIa Stage IIb Stage III Stage IV T1,N0 T2,N0 T3,N0 T1-3,N1 T4, Any N, M0 Any T, N M1 AJCC/IUCC 7 th edition 2010 TNM Staging of Gastric NETs (G1, G2) TNM T primary tumor (For any T, add (m) for multiple tumors) TX T0 Tis T1 T2 T3 Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ/dysplasia (tumor size < 0.5 mm), confined to mucosa Tumor invades lamina propria or submucosa and 1 cm Tumor invades muscularis propria or tumor size >1 cm Tumor penetrates subserosa T4 Tumor invades visceral peritoneum (serosal) or other organs or adjacent structures N regional lymph nodes NX Regional lymph node cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M distant metastases MX Distant metastasis cannot be assessed M0 No distant metastases M1 Distant metastasis Stage 0 Stage Ia Stage IIa Stage IIb Stage IIIa Stage IIb Stage IV Tis, NO T1,N0 T2,N0 T3,N0 T4,N0 AnyT, N1, M0 Any T, Any N, M1 AJCC/IUCC 7 th edition

12 TNM Staging of Small Bowel NETs (G1, G2) TNM T primary tumor (For any T, add (m) for multiple tumors) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tumor invades lamina propria or submucosa and size 1 cm or less (small intestinal tumors); T1 tumor 1 cm or less (ampullary tumors) Tumor invades muscularis propria or tumor size >1 cm (small intestinal tumors); T2 tumor size >1 cm (ampullary tumors) Tumor invades through the muscularis propria into subserosal tissue without penetration of T3 overlying serosa (jejunal or ileal tumors) or invades pancreas or retroperitoneum (ampullary or duodenal tumors) or into non-peritonealized tissues T4 Tumor penetrates visceral peritoneum (serosa) or invades other organs N regional lymph nodes NX Regional lymph node cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M distant metastases MX Distant metastasis cannot be assessed M0 No distant metastases M1 Distant metastasis Stage Ia Stage IIa Stage IIb Stage IIIa Stage IIb Stage IV T1,N0 T2,N0 T3,N0 T4,N0 AnyT, N1, M0 Any T, Any N, M1 AJCC/IUCC 7 th edition 2010 TNM Staging of Large Bowel NETs (G1, G2) TNM T primary tumor (For any T, add (m) for multiple tumors) TX T0 T1 T1a T1b T2 Primary tumor cannot be assessed No evidence of primary tumor Tumor invades lamina propria or submucosa and size 2 cm Tumor size <1 cm in greatest dimension Tumor size 1 to 2 cm in greatest dimension Tumor invades muscularis propria or size > 2 cm with invasion of lamina propria or submucosa Tumor invades through the muscularis propria into the subserosa, or into non-peritonealized T3 pericolic or perirectal tissues T4 Tumor invades peritoneum or other organs N regional lymph nodes NX Regional lymph node cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M distant metastases MX Distant metastasis cannot be assessed M0 No distant metastases M1 Distant metastasis Stage Ia Stage IIa Stage IIb Stage IIIa Stage IIb Stage IV T1,N0 T2,N0 T3,N0 T4,N0 Any T, N1, M0 Any T, Any N, M1 AJCC/IUCC 7 th edition 2010 TNM Staging of Appendiceal NETs (G1, G2) TNM T primary tumor (For any T, add (m) for multiple tumors) TX T0 T1 T1a T1b T2 T3 T4 Primary tumor cannot be assessed No evidence of primary tumor Tumor invades lamina propria or submucosa and size 2 cm Tumor size <1 cm in greatest dimension Tumor size 1 to 2 cm in greatest dimension Tumor > 2 cm but 4 cm or with extension to the cecum Tumor > 4 cm or with extension to the ileum Tumor directly invades other adjacent organs or structures, eg, abdominal wall, skeletal muscle N regional lymph nodes NX Regional lymph node cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis M distant metastases MX Distant metastasis cannot be assessed M0 No distant metastases M1 Distant metastasis Stage Ia Stage II Stage III Stage IV T1,N0 T2 or T3,N0 T4,N0 or Any T, N1, M0 Any T, Any N, M1 AJCC/IUCC 7 th edition

13 Conclusions NETs are clinically & pathologically heterogeneous. Functionality depends on the presence of clinical symptoms. However, hormone immunohistochemistry can provide important information. Long term follow-up data indicates that all neuroendocrine tumors are malignant. Grading and Staging are important factors, and they are still evolving in neuroendocrine tumors Grading: Ki67: at least 2000 cells, hot spots Mitotic count: at least 50 HPF, hot spots Staging (TNM): extent of spread of the tumor The status of differentiation should be present in the report. Rule out paraganglioma when dealing with a keratin- and transcription factor-negative NET! Beware of wolves in sheep s clothing in NETs 13

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