An unusual superficial small round cell sarcoma

Transcription

1 An unusual superficial small round cell sarcoma - Diagnostic problems - Differential diagnosis Antonio Llombart Bosch Isidro Machado Dep. Pathology Univ. Medical School Valencia, Institute of Oncology IVO

2 Clinical record A 19 year-old man was admitted to the hospital with a large superficial mass involving the right gluteus. The tumor had been detected by the patient one year earlier The physical examination revealed a large ulcerated tumor located in the medial area of the right gluteus. Magnetic resonance imaging (MRI) showed an eccentric mass (160 x 135 x 88mm) located mainly in the right gluteus. An abdominal-thoracic tomography (CT) revealed a small, unspecific nodule in the lung and enlarged lymph nodes in the right inguinal and iliac areas. A right external iliac lymph node (11mm) was observed. Complete surgical resection of the primary tumor was performed.

3 MRI

4 CT SCANN

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6 PATHOLOGY

7 PATHOLOGY Sections (4 μm thick) were cut for hematoxylin/eosin (H/E), immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) studies. Positive nuclear staining was considered for Fli-1, INI-1, S100, Tdt, myogenin and Ki-67. Cytoplasmic and/or membranous staining was considered for CD99, CAV-1, HNK-1, LCA, actin, SMA, CD20, CD3, CD30, CD138, CD8, CD4, c-kit, CK (AE1/AE3), CK20, EMA, desmin, vimentin, synaptophysin, chromogranin-a, HMB-45, Melan-A, and CD34.

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13 PAS 20X

14 CD 99 10X CD 99 40X

15 AE1 AE3 AE1 AE3

16 KI 67 40X INI-1 40X

17 PATHOLOGY: FISH FISH was performed on paraffin-embedded tumors in whole sections and EWSR1 (22q12) (Vysis, Abbott, IL, USA) a break-apart probe was used for the analysis.

18 Molecular biology MOLECULAR BIOLOGY The primer sets :EWS/Fli1, EWS/ERG, EWS/ETV1, EWS/E1AF, EWS/FEV, BCOR/CCNB3PAX3/FOX01A, PAX7/FOX01A, EWS/WT1, SYT/SSX1, SYT/SSX2, SYT/SSX4, FUS/FEV and EWS/NFATc2 were used for (RT- PCR) All resulted negative

19 MOLECULAR BIOLOGY Primers and probe for CIC/DUX4 detection PCR product with positive result for CIC/DUX4

20 MOLECULAR BIOLOGY DNA Sequence Analysis showing gene fusion (CIC/DUX4)

21 Differential Diagnosis: small round cell tumors in bone or soft tissue Atypical Es/PNET Microcellular osteosarcoma Myxoid chondrosarcoma Mesenchymal chondrosarcoma Undifferentiated synovial sarcoma Malignant non-hodgkin Lymphoma Neuroblastoma Primitive sarcoma of bone

22 ESFT. Histological Subtypes (Atypical)

23 TFSE. Molecular Genetics Cromosoma 22 Aurias A, Rimbaut C, Buffe D, Dubousset J, Mazabraud A. [Translocation of chromosome 22 in Ewing's sarcoma]. C R Seances Acad Sci III. 1983;296(23): EWSR1 intacto

24 Chromosomal translocations and gene fusions described in ESFT Cytogenetic alteration Fusion gene Incidence t(11;22)(q24;q12) EWSR1/FLI % t(21;22)(q22;q12) EWSR1/ERG 5-10% t(7;22)(p22;q12) EWSR1/ETV1 <1% t(17;22)(q12;q12) EWSR1/ETV4 <1% t(2;22)(q33;q12) EWSR1/FEV <1% t(6;22)(p21;q12) EWSR1/POU5F1 <1% t(1;22)(q36.1;q12) EWSR1/PATZ1 <1% t(2;22)(q31;q12) EWSR1/SP3 <1% t(20;22)(q13;q12) EWSR1/NFATc2 <1% t(16;21)(p11;q22) FUS/ERG <1% t(2;16) (q33;p11) FUS/FEV <1% t(15;19)(q14;p13.1) BRD4/NUT <1% t(4;19)(q35;q13) CIC/DUX4 <1% Ordóñez JL, Osuna D, Herrero D, de Alava E, Madoz- Gúrpide J. Advances in Ewing's sarcoma research: where are we now and what lies ahead? Cancer Res Sep 15;69(18): Pinto A, Dickman P, Parham D. Pathobiologic markers of the ewing sarcoma family of tumors: state of the art and prediction of behaviour. Sarcoma. 2011;2011: Sumegi J, Nishio J, Nelson M, Frayer RW, Perry D, Bridge JA. A novel t(4;22)(q31;q12) produces an EWSR1-SMARCA5 fusion in extraskeletal Ewing sarcoma/primitive neuroectodermal tumor. Mod

25 Evolution of EWSR1 gene Möller E, Stenman G, Mandahl N, Hamberg H, Mölne L, van den Oord JJ, Brosjö O, Mertens F, Panagopoulos I. POU5F1, encoding a key regulator of stem cell pluripotency, is fused to EWSR1 in hidradenoma of the skin and mucoepidermoid carcinoma of the salivary glands. J Pathol May;215(1): Brandal P, Panagopoulos I, Bjerkehagen B, Heim S. t(19;22)(q13;q12) Translocation leading to the novel fusion gene EWSR1-ZNF444 in soft tissue myoepithelial carcinoma. Genes Chromosomes Cancer Dec;48(12): Shao L, Singh V, Cooley L. Angiomatoid fibrous histiocytoma with t(2;22)(q33;q12.2) and EWSR1 gene rearrangement. Pediatr Dev Pathol Mar-Apr;12(2): Kim S, Lim B, Kim J. EWS-Oct-4B, an alternative EWS-Oct-4 fusion gene, is a potent oncogene linked to human epithelial tumours. Br J Cancer Jan 19;102(2): Malone VS, Dobin SM, Jones KA, Donner LR. CD99-positive large cell neuroendocrine carcinoma with rearranged EWSR1 gene in an infant: a case of prognostically favorable tumor. Virchows Arch Sep;457(3): Antonescu CR, Zhang L, Chang NE, Pawel BR, Travis W, Katabi N, Edelman M, Rosenberg AE, Nielsen GP, Dal Cin P, Fletcher CD. EWSR1- POU5F1 fusion in soft tissue myoepithelial tumors. A molecular analysis of sixty-six cases, including soft tissue, bone, and visceral lesions, showing common involvement of the EWSR1 gene. Genes Chromosomes Cancer Dec;49(12): El-Kabany M, Al-Abdulghani R, Ali AE, Francis IM, Hussein SA. Soft tissue high grade myoepithelial carcinoma with round cell morphology: Report of a newly described entity with EWSR1 gene rearrangement. Gulf J Oncolog Jan;1(9):73-7.

26 MICROCELULAR OSTEOSARCOMA H/E H/E CD99 HNK-1

27 MYXOID CHONDROSARCOMA H/E H/E H/E S100

28 MESENCHYMAL CHONDROSARCOMA H/E H/E CD99 SOX-9

29 UNDIFFERENTIATED SYNOVIAL SARCOMA H/E H/E CD99 EMA

30 BONE LYMPHOMA H/E H/E CD20 CD68

31 NEUROBLASTOMA H/E H/E NB84 CD99

32 PRIMITIVE BONE SARCOMA H/E H/E HNK-1

33 Differential Diagnosis: Superficial small round cell tumors Ewing/PNET Merkel cell tumor Lymphoma Metastatic carcinoma Small cell melanoma

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36 SUPERFICIAL EWING SARCOMA A B CD99 CD99 FISH EWSR1

37 MERKEL CELL CARCINOMA A B C CK20 CK20

38 UNDIFFERENTIATED SYNOVIAL SARCOMA A B C CK EMA BLC2 FISH SYT

39 EPITHELIOID SARCOMA A B C VIM CK CD34

40 MALIGANT RHABDOID TUMOR INI1

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44 High Prevalence of CIC Fusion with Double-Homeobox (DUX4) Transcription Factors in EWSR1-Negative Undifferentiated Small Blue Round Cell Sarcomas A Italiano, Y Shao Sung, L Zhang, S Singer, R G.Mak,JMCoindre, and C R. Antonescu Genes Chromosomes Cancer. 2012,51(3): Some EWSR1-negative SBRCT carry rearrangements for FUS and CIC genes Tumors positive for CIC-DUX4 fusion occurred mainly in male young adult patients (median age: 29 years), with the extremities being the most frequent location Microscopically, tumors displayed a primitive, round to oval cell morphology with prominent nucleoli, high mitotic count and areas of necrosis. CD99 expression was variable, being either diffuse or patchy and tumors mostly lacked other differentiation markers Screening for these two genes. CIC rearrangements by FISH were detected in 15/22 (68%), while none showed FUS abnormalities. RACE, RT-PCR and/or long range DNA PCR performed in two cases with frozen material showed that CIC was fused to copies of the DUX4 gene on either 4q35 or 10q26.3 Subsequent FISH analysis confirmed fused signals of CIC with either 4q35 or 10q26.3 region in six cases each. CIC-DUX4 resulting in a t(4;19) translocation has been described in primitive sarcomas. Present results suggest the possibility of a newly defined subgroup of primitive round cell sarcomas characterized by CIC rearrangements, distinct from Ewing sarcoma family of tumors.

45 High Prevalence of CIC Fusion with Double-Homeobox (DUX4) High Prevalence of CIC Fusion with Double-Homeobox (DUX4) Transcription Factors in EWSR1-Negative Undifferentiated Small Transcription Factors in EWSR1-Negative Undifferentiated Small Blue Round Cell Sarcomas Blue Round Cell Sarcomas A Italiano, Y Shao Sung, L Zhang, S Singer, R G.Mak,JMCoindre, and C R. Antonescu A Italiano, Y Shao Sung, Genes L Zhang, Chromosomes S Singer, Cancer. R G.Mak,JMCoindre, 2012,51(3): and C R. Antonescu Genes Chromosomes Cancer. 2012,51(3):

46 High Prevalence of CIC Fusion with Double-Homeobox (DUX4) High Prevalence of CIC Fusion with Double-Homeobox (DUX4) Transcription Factors in EWSR1-Negative Undifferentiated Small Small Blue Round Cell Sarcomas A Italiano, A Italiano, Y Shao Y Shao Sung, Sung, L L Zhang, Zhang, S Singer, Singer, R R G.Mak,JMCoindre, G.Mak,JMCoindre, and and C R. C Antonescu R. Antonescu Genes Chromosomes Cancer. 2012,51(3): Genes Chromosomes Cancer. 2012,51(3): CIC gene rearrangements and fusion with candidate genes on 4q35 and 10q26.3 by FISH.

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52 Undifferentiated Small Round Cell Sarcoma With t(4;19)(q35;q13.1) CIC-DUX4 Fusion:A Novel Highly Aggressive Soft Tissue Tumor With Distinctive Histopathology. Choi EY, et al. Departments of Pathology, University of Michigan, Ann Arbor, MI. Am J Surg Pathol Sep;37(9): A subset of small round cell sarcomas remains difficult to classify -Four cases of CIC-DUX4 sarcoma-associated translocation. -No EWS or SYT rearrangements were detected by RT-PCR or FISH. -The tumors had small round cell morphology -Only focal staining for CD99 was present in each tumor. -Two had very focal cytokeratin staining. -All were negative for desmin, myogenin,tle-1, and S100 protein, -The tumors were highly aggressive, and all patients died of disseminated disease within 16.8 months. CIC-DUX4 sarcoma represents a novel translocation-associated sarcoma with distinctive histopathologic features and rapid disease progression.

53 FINAL DIAGNOSIS Superficial undifferentiated small round cell sarcoma with CIC/DUX4 gene fusion. A new subtype of Ewing-like tumors with locoregional lymph node metastasis.

54 NO: DOES IT NOT EXISTS!!!!

55 REFERENCES 1: Choi EY et al. Undifferentiated Small Round Cell Sarcoma With t(4;19)(q35;q13.1) CIC-DUX4 Fusion: A Novel Highly Aggressive Soft Tissue Tumor With Distinctive Histopathology. Am J Surg Pathol Sep;37(9): : Kajtár B et al. CD99-positive undifferentiated round cell sarcoma diagnosed on fine needle aspiration cytology, later found to harbour a CIC-DUX4 translocation: a recently described entity. Cytopathology Jul 3. 3: Italiano A et al. High prevalence of CIC fusion with double-homeobox (DUX4) transcription factors in EWSR1-negative undifferentiated small blue round cell sarcomas. Genes Chromosomes Cancer Mar;51(3): : Graham C et al. The CIC-DUX4 fusion transcript is present in a subgroup of pediatric primitive round cell sarcomas. Hum Pathol Feb;43(2): : Yoshimoto M et al. Detailed cytogenetic and array analysis of pediatric primitive sarcomas reveals a recurrent CIC-DUX4 fusion gene event. Cancer Genet Cytogenet Nov;195(1):1-11 6: Kawamura-Saito M et al. Fusion between CIC and DUX4 up-regulates PEA3 family genes in Ewing-like sarcomas with t(4;19)(q35;q13) translocation. Hum Mol Genet Jul 1;15(13):

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