Homotypic Cell Cannibalism and Cannibalism Index-A Four Year Study in In ltrating Ductal Carcinoma Breast 1* 1 1

Transcription

1 ISSN ORIGINAL ARTICLE Homotypi Cell Cannibalism and Cannibalism Index-A Four Year Study in In ltrating Dutal Carinoma Breast 1* 1 1 Alok Mohan, Pradeep Kr. Sharma, R.K. Thakral 1 Department of Pathology, Muzaffarnagar Medial College and Hospital, Muzaffarnagar (Uttar Pradesh) India Abstrat : Bakground: Homotypi ell annibalism is a hallmark of malignant lesions. It serves as an emerging indiator of both the anaplasti grade and invasiveness. Aim and Objetives: The present study was onduted to orrelate tumour ytologial grade with the inidenes of ell annibalism. Material and Methods: Three stained smears per ase were submitted for ytologial grading. The smears were then submitted for visually ounting the number of examples of ell annibalism and the annibalism index was alulated. Results: Seventy ytologial diagnosed ases of breast malignanies were assessed for the presene of ell annibalism. The results were orrelated with the ytologial grade of arinoma. The study revealed that ell annibalism was enountered in 68.57% ases of breast arinoma. 44.4% of grade I, 71.4% of grade II and 100% of grade III tumours grade. It was observed that grade I tumours had mean annibalism per smear of 1.62/1000 tumour ells smear, grade II mean annibalism per smear of 2.50/ 1000 tumour ells and grade III mean annibalism per smear 4.90/1000 tumour ells. Tumour diathesis and metastasis were also found more in annibalism positive ases. Conlusion: The phenomenon of ell annibalism was enountered more in high grade tumours. Thus it an be designated as an emerging marker of anaplasia and aggressive tumour behaviour. Keywords: Cytology, Carinoma, Cannibalism Index, Breast, Malignany Introdution: Cell-in-ell phenomenon refers to formation of ell-in-ell strutures due to the entering of one or more living ells into another ell. This is an old biologial phenomenon whih was traed bak about one hundred years ago. Reently, ell-inell has attrated attention of pathologists beause of its lose relationship in understanding linial pathogenesis [1]. Cell-in-ell strutures our in vitro or in vivo, either homotypially or heterotypially, thus representing unique interellular interations of different ells [2]. Mostly homotypi type of ell-in-ell interations our between sibling tumour ells, whereas heterotypi type of ell-in-ell strutures are found in-between the immune ells and tumour or various tissue ells [3]. Cannibalism is desribed to be a proess in whih metastati tumour ells undergo starvation and exhibit their ability to atively take or eat other homotypi or heterotypi live or dead ells. Degradation of effetor ells inside annibalisti ells relies on the aidi digestive mahinery in avesomes that requires saffolding proteins like aveolin-1 or ezrin as well as ativation of proteolyti enzymes. This ell-in-ell death supplies nutrients in starvation. Moreover, this mehanism saves the tumour ells from immune attak [4-6]. 61

2 Cellular annibalism was first desribed by Leyden in He used the name bird's eye ells for annibalisti ells [7].It is defined as the ability of a ell to phagoytose another ell. The ingested ell is ontained in a vauole that pushes the nuleus of the annibal ell to the periphery of the ell. This appearane gave rise to the names suh as bird's eye ells or signet-ring ells [8]. The feature of ell annibalism has been identified in various tumours in vivo as well as in vitro [9].In metastati melanoma, tumour annibalism was observed in vivo, and onfirmed in vitro as a feature of metastati lesions. However, it was not found in primary tumour site [5]. Many workers have reognized this morphologial phenomenon in several tumour types e.g.; arinoma breast, giant ell arinoma of lung, small ell arinoma of lung, endometrial stromal saroma, but they have referred to this phenomenon by different names suh as ellular phagoytosis of tumour ell by another tumour ell, ell-in ell appearane or bird's eye ells [10-13]. Cannibalism index refers to the number of examples of ell-annibalism per 1000 tumour ells [14]. This is alulated for the quantitative assessment of ell annibalism phenomenon. Cell annibalism positive ytologial smears of malignant lesions are subjeted to mirosopi examination. This parameter is introdued to maintain uniformity in ounting and to derease the observer bias. Cannibalism index of high grade tumours tends to be high. Hetero-annibalism means eating up of non-self ells, mostly leuoytes. Many past studies have desribed the features of hetero-annibalism [15, 16]. In 2008, few studies have suggested that hetero-annibalism an be explained as an exaerbation of self annibalism and may be a survival strategy for aner ells [17].The ability for phagoytosis ould be used as a marker for the malignant potential of the tumour ells [16]. With these onsiderations, the present study was undertaken to evaluate the presene of ell annibalism in ytogially diagnosed breast malignanies and to orrelate the ourrene of ell annibalism with ytologial grading of malignant tumour. Material and Methods: The present study was onduted on the ytology samples olleted from the ytology laboratory in department of Pathology in Muzaffarnagar Medial College and Hospital, Muzaffarnagar. Meerut from August 2011 to July The ases studied were of Fine Needle Aspiration Cytology (FNAC) and nipple disharge ytology, with a ytologially diagnosed breast malignany. 1. Three smears per ase, stained with the MGG were submitted for ytologial grading with the referene to ytologial riteria laid down by Robinson et al. 2. The smears were firstly submitted for visually ounting the number of examples of ell annibalism in 20 high power fields (X40) objetive. The ounting was done by two pathologists individually (AM and PS). Then the mean per smear was alulated. This redued observer bias. Smears showing ell annibalism were labeled as annibalism positive. 3. Cell annibalism positive smears were then expressed as number of examples of annibalism per 1000 tumour ells (i.e. annibalism index). 62

3 4. Finally, the index was orrelated with the ytologial grading of malignany, in order to explore the relation between ell annibalism, grading and aggressive tumour behaviour. 5. Presene of metastasis in lymph nodes, body fluids and other organs along with tumour diathesis was studied to establish the aggressiveness of malignany in order to assess the behaviour of malignany. Results: A total of seventy ases of breast tumours were studied, inluding 68 females and 02 males. The mean age of the ases studied was 52 years. Invasive dutal arinoma, Not Otherwise Speified (NOS) formed the major group with 65 ases (92.85%). In 61 ases FNAC was done from the palpable mass, while in 04 ases disharge from nipple was taken for smear preparation as no well defined mass was observed on palpation. There were two ases of medullary arinoma breast (2.86%), and one ase eah of tubular arinoma breast, invasive papillary arinoma and metaplasti arinoma of breast (eah 1.43 %).(Table 1) Aording to Robinson's grading [18], 18 were grade I (25.71%), 42 were grade II (60%) and 10 were grade III tumours (14.28%). Cell annibalism was demonstrated in 48 (68.57%) ases out of 70 ases of infiltrating dutal arinoma of breast not otherwise speified. It was positive in 44.4% of grade I, 71.4% of grade II (Fig.1) and 100% of grade III arinomas (Fig.2). On omparison of tumour grade and annibalism index, it was observed that grade I tumours had a mean of 1.62/1000 tumour ells, grade II (Fig. 1) with a mean of 2.50/1000 tumour ells and grade III (Fig.2) with a mean of 4.90/1000 tumour ells (Table 2). It was also observed that tumour diathesis and metastasis were ommonly enountered in annibalism positive ases. Table 1: Distribution of 70 Cases of Carinoma Breast Types of Carinoma In ltrating Dutal Carinoma (NOS) Number of Cases Medullary Carinoma Papillary Carinoma Tubular Carinoma Metaplasti Carinoma Robinson's grade Cases Table 2: Grade wise Cannibalism Positivity Cannibalism Positivity Total Example of Cell Cannibalism per 1000 Malignant Cells among Positives Numbers Perent Numbers Perent Numbers Mean Cannibalism Index Grade I Grade II Grade III

4 Fig. 1 & 2: Photomirograph of Aspiration Smear Showing Cell Cannibalism in Grade II Breast Carinoma (PAPX400) Fig.3 & 4: Photomirograph of Aspiration Smear Showing Cell Cannibalism in Grade III Breast Carinoma (GIEMSA X400) Disussion: Cellular annibalism is an important feature to distinguish benign from malignant lesions. The presene of annibalism besides being an indiator of malignany is also related with the aggressiveness of the malignany. It is mainly in the last two deades that the role of ell annibalism is reognized and researhed in relation to tumour behaviour. It is regarded as an exlusive harateristi of malignant tumour ells, and this phagoyti behaviour is orrelated with the degree of malignany [19]. Formation of endosomes seems to be the driving struture of annibalism. The endosomes ontain onstitutively ativated and highly ef ient aidi digestive system. This allows the tumour ells to 64

5 endoytose and digests other ells without the need for spei reeptor-ligand interations. An intat membrane-to- ytosol framework, inluding a dynami link between aveolin-1, ezrin, and atin seem to be neessary for the formation of annibalisti vauole. Downregulation of any of these leads to substantial inhibition of annibalisti ativity [4]. Cannibalism by tumour ells an ontribute to their survival and proliferation. Phagoytosis of other tumour ells resemble autophagi digestion of ell organelles under starvation thus ful lling feeding requirements under adverse onditions while ingestion of immune ells (neutrophils and lymphoytes) leads to esape from immune system mehanisms. Cannibalisti ells are resistant to aidi environment, while marophages or other tumour ells die in that environment [19]. Several steps have been proposed to desribe the proess of ell annibalism. At rst, the annibalisti ell engulfs the free ell with hange in shape of the nuleus from irular to semilunar. The nulear shape of the interiorized ell remains unhanged. In the ourse of time, the interiorized ell is ompletely enirled and dies off. The death of the interiorized ell is apparently due to lak of nutrition, rather than due to effet of lysosomal enzymes. This was onluded as eletron mirosopy showed that lysosomal strutures were sparsely present in annibalisti ells as ompared to the interiorized ell. Cell annibalism is different from the phenomen of phagoytosis. In phagoytosis, there are usually abundant lysosomes in the outer ell and this leads to destrution of the interiorized ell. In the present study a total of seventy ases of breast arinomas, inluding 68 females and two males, were studied. The mean age of the ases studied was 52 years. Oiler Kjellgren [20] studied 253 ases of palpable breast masses with a bloody disharge and mean age of 48 years. Many studies on breast ytology have been done so far and many ytologists have enountered this phenomenon of annibalism. They gave due importane to it and mentioned it in their studies. Oiler Kjellgren [20] observed 13 ases of invasive dutal arinoma showing ative ell annibalism along with other features of ytologial atypia. Similarly, Uei et al [12] have reported ytophagoytosis in 47% ases presenting with small lusters and in 65% ases with large lusters. This is omparable with our study. In our study we got % (48 out of 70 ases) of breast arinoma positive for ell annibalism during initial sreening. Ng & Hong [21] demonstrated ell in ell appearane in all 5 ases of metaplasti arinoma, of whih 4 were diagnosed as well differentiated squamous ell arinoma and 1 invasive dutal arinoma NOS. In the present study ell annibalism was observed in 68.57% ases (48 out of 70) ases of in ltrating dutal arinoma of breast, 44.4% of grade I, 71.4% of grade II and 100% of grade III arinomas aording to Robinson's grading system. Comparative study of malignany grade and annibalism index, showed that grade I arinomas had a mean of 1.62/1000 tumour ells, grade II (Fig.1) with a mean of 2.50/ 1000 tumour ells and grade III (Fig.2) with a mean of 4.90/ 65

6 1000 tumour ells. These ndings are well in onordane with study done by W.T. Abodief et al (2006) [14]. They studied 50 ases of dutal arinoma breast. They observed ell annibalism/1000 tumour ells grade I showing a mean of 1.07/1000 tumour ells, grade II showing a mean of 2.67/1000 tumour ells and grade III showing a mean of 4.89 /1000 tumour ells. In our study sample size is bigger and the results are slightly higher in ase of grade I ases and omparable in grade II and grade III ases. The relationship between ell annibalism and distant metastasis should be explored in further studies, as it may prove to be a riterion of malignany [22]. In the present study, there had been a good orrelation between tumour grade and annibalism index in the ases of arinoma breast. The phenomenon of annibalism thus, predits both the anaplasti grade and invasiveness, although its value as an independent prognosti marker has yet to be established. Hene, a onlusion an be drawn that a orrelation between ell annibalism and aggressive tumour behaviour do exists. But still a further extensive study regarding ell annibalism in relation to tumour behaviour is required. 1. Wang S, He MF, Wang M-y,Yu X-m et al. Rapid uptake of granzyme B leads to emperitosos: an apoptoti ellin-ell death of immune killer ells inside tumor ells. Cell Death and Disease 2013; 4, e Overholtzer M, Brugge JS. The ell biology of ell-in ell strutures. Nat Rev Mol Cell Biol 2008; 9: Chen YH, Wang S, He MF, Wang Y, Zhao H, Zhu HY et al. Prevalene of heterotypi tumor/immune ell- in ell struture in vitro and in vivo leading to formation of aneuploidy. PLoS One 2013; 8:e Fais S. Cannibalism: a way to feed on metastati tumors. Caner Lett 2007; 258: Lugini L, Matarrese P, Tinari A, Lozupone F, Federii C, Iessi E et al. Cannibalism of live lymphoytes by human metastati but not primary melanoma ells. Caner Res 2006; 66: Lugini L,Lozupone F, Matarrese P, Funaro C,Luiani F, Malorni W et al. Potent phagoyti ativity disriminates metastati and primary human malignant melanomas: a key role of ezrin. Lab Inveat 2003; 83: Bauhitz MA. The bird's eye ell: annibalism or abnormal division of tumour ells. Ata Cytol 1981; 25:92. Referenes 8. Breier F, Feldmann R, Fellenz C, Neuhold N, Gshnait F. Primary invasive signet-ring ell melanoma. J Cutan Pathol 1999; 10: Brouwer M, de Ley L, Feltkamp CA, Elema J, Jongsma A P. S e r u m d e p e n d e n t a n n i b a l i s m a n d autodestrution in ultures of human small ell arinoma of the lung. Caner Res 1984; 44: De Siome PA, East R, Powell RD, Jr. Phagoyti tumor ell ativity in oat ell arinoma of the lung. Hum Pathol 1980; 11: Craig ID, Desrosiers P, Lefooe MS. Giant ell arinoma of the lung. A ytologi study. Ata Cytol 1983; 27: Uei Y, Wantanabe Y, Hirota T, Yamamoto H, Wantanabe H. Cytologi diagnosis of breast arinoma with nipple disharge: speial signi ane of the spherial ell luster. Ata Cytol 1980; 24: Hong IS The exfoliative ytology of endometrial stromal saroma in peritoneal uid. Ata Cytol 25: Abodief WT, Dey P, Al-Hattab O. Cell annibalism in dutal arinoma of breast (orrespondene). Cytopathology 2006, 17,

7 15. Caruso RA, Muda AO, Bersiga A, Rigoli L, Interferrera C. Morphologial evidene of neutrophil-tumor ell phagoytosis( annibalism) in human gastri adenoarinomas. Ultrastrut Pathol. 2002; 26: Chandrasoma P. Polymorphs phagoytosis by aner ells in an endometrial adenoaanthoma. Caner 1980; 45: Matarrese P, Ciarlo L, Tinari A, Piaentini M, Malori W. Hetero-annibalism as an exaerbation of selfannibalism: a possible fruitful survival strategy for aner ells. Curr Pharm Des 2008; 14: Robinson I A, Mkee G, Niholsan A. Prognosti value of ytologial grading of ne needle aspirates from breast arinoma. Lanet 1994; 343: Yue-qin Yang and Ji heng Li. Progress of researh in Cell-in Cell Phenomena. Anat Re 2012; 295: Oiler Kjellgren. The ytologi diagnosis of aner of the breast. Ata Cytol 1964; 8: Ng W K, Hong JH. Signi ane of squamous ells in FNAC of the breast. A review of ases in seven year period. Ata Cytol 2003; 47(1): Meléndez-Lazo A, Cazzini P, Camus M, Doria-Torra G, Maro Valle AJ, Solano-Gallego L, Pastor J. Cell annibalism by malignant neoplasti ells: three ases in dogs and a literature review. Vet Clin Pathol 2015; 44(2): *Author for Correspondene: Dr. Alok Mohan, 749/6 Jagriti Vihar Meerut , Uttar Pradesh, India dr.alokmohansinha@gmail.om Cell: