Atypical Well differentiated Hepatocellular Neoplasms Cruising through the maze of criteria, terminology and risk assessment

Transcription

1 2016 Hans Popper Companion Meeting Atypical Well differentiated Hepatocellular Neoplasms Cruising through the maze of criteria, terminology and risk assessment Disclosure Dr. Kakar has nothing to Disclose Sanjay Kakar, MD University of California, San Francisco Hepatocellular adenoma Well differentiated hepatocellular neoplasms Atypical Hepatocellular carcinoma Features that define atypical category Suitable terminology Recommendations Atypical features Clinical Male gender (any age) Age (>50 years) Glycogen storage diseases, androgen use Morphologic Focal cytologic atypia (<5%) Focal reticulin loss (<5%) Nuclear β catenin, diffuse GS HSP70, glypican 3 Molecular β catenin mutation TERT promoter mutations Cytogenetic changes: gains of 1,8 1

2 American Revolution French Revolution Hepatocellular adenoma A story of two revolutions HCA: The American Revolution oral contraceptives and HCA Journal reviews Journal of the American Medical Association New England Journal of Medicine Radiology Rejected with ridicule Janet Baum, MD Dept of Radiology, Harvard Univ Reuben, Hepatology,2004 2

3 Lancet. 1973;2: Possible association between benign hepatomas and oral contraceptives. Baum JK, Bookstein JJ, Holtz F, Klein EW. Hepatocellular adenoma The French Revolution 2006 Abstract 7 case reports of women with benign hepatic adenoma suggest that, since all of the women were taking oral contraceptives (OCs), there may be an association between ingestion of exogenous hormones and development of benign hepatoma of the liver. The cases were rapidly diagnosed by using hepatic arteriography; prompt, precise diagnosis is emphasized because, though the tumors are benign, they may cause serious, if not fatal, hemorrhage if left unchecked. Case 1 was a 26 year old woman who had taken Enovid for 2 years, who presented with acute abdomen and impending shock. Coliotomy was performed, in which a left lobe hepatic tumor was found; she underwent left hepatectomy and cholecystectomy and no evidence of recurrence was found 1 year later. Case 2 had been taking Oracon for a unknown time. Case 3, on OCs for 6 years, had a pedunculated mobile tumor removed. Case 4, 25 years old, had been taking Ovral for 6 months before diagnosis and excision of a right lobe liver tumor. Case 5, 5 years on combined OCs, required surgical intervention for a hypervascular mass. Case 6, taking a total of 8 years of OC therapy, was operated on for an hepatic mass which was a white to yellow hemorrhagic mass. Case 7, taking Enovid for 7 years, yielded a surgical specimen that was hemorrhagic, partly necrotic, and yellowtan, about 10 cm in diameter. HCA classification: WHO 2010 Wnt signaling pathway Gonzalez, Hepatol, 2006 HNF1αinactivated β catenin activated Inflammatory Women ~90% ~ 60% ~90% Steatosis Common Minority Minority Cytological Rare Common 5 10% abnormalities Association Rare 40% Uncommon with HCC Inflammation Uncommon Minority Common Sinusoidal dil Rare Rare Common Zucman Rossi, Hepatology, 2006 WHO blue book,

4 Hepatocellular neoplasm with exon 3 β catenin mutation Nuclear translocation of β catenin Normal liver: perivenular glutamine synthetase (GS) β catenin activation: diffuse GS β catenin activated hepatocellular neoplasms β catenin activated hepatocellular neoplasms Association with HCC Frequent cytologic atypia Frequent loss of reticulin Cytogenetic changes like HCC HCA Atypical HCC HNF1α Inflammatory Unclassified β catenin mutation Zucman Rossi, Hepatol 2006 Bioulac Sage, Hepatol 2007 Evason/Kakar, Hum Pathol2013 4

5 β catenin activation β catenin mutation present 70% HCC: nuclear β catenin 20% adenomas/atypical: nuclear β catenin Diffuse GS staining Some studies: ~100% correlation β catenin: membranous GS: diffuse β catenin mutated No nuclear β catenin Diffuse GS Hale/Kakar, USCAP 2015 Bioulac Sage, Hepatol 2007 Interpretation of GS staining Spectrum of histologic patterns Examine evidence for presumed high correlation of diffuse GS staining with β catenin mutation Definition of diffuse GS staining: Positive cytoplasmic overexpression, homogeneous or heterogeneous, but on >50% of tumor e Patchy: Less than 50% Zucman Rossi, Oncol, 2007 Bioulac Sage, Hepatology,

6 GS in adenoma: 'Patchy' staining Perivascular and patchy Expanded perivascular Diffuse homogeneous GS ~100% Diffuse heterogeneous GS >50% Peripheral accentuation Diffuse heterogeneous GS, >50% Patchy GS, <50% Diffuse GS >50% <50% or >50% 6

7 Interpretation of GS staining Adenomas/atypical neoplasms Spectrum of histologic patterns Examine evidence for presumed high correlation of diffuse GS staining with β catenin mutation Study Zucman Rossi, Hepatol 2006 Hale/Kakar, USCAP 2015 (Mod Pathol, under review) Diffuse GS staining β catenin mutation >90% 33% HCA 75% Atypical Hepatocellular carcinoma Study Audard, JPathol 2007 Zucman Rossi, Hepatol 2006 Austinat, Mol Cancer 2008 Cieply, Hepatol 2007 Hale/Kakar, USCAP 2015 Correlation: Diffuse GS and β catenin mutation 90% >90% 29% 28% 21% Reasons for discrepancy Type of β catenin mutation Limitations of the assay Other Wnt signaling pathway mutations Other mechanisms 7

8 Diffuse GS staining Mutations in other exons β catenin abnormality Exon 3: deletions Exon 3: point mutation T41A, S33C, S45P GS staining Diffuse homogeneous GS Most mutations: no definite GS pattern Codon 45: heterogeneous GS 223 hepatocellular adenomas Mutations in exon 7 and 8: 10% Increased but not diffuse GS No nuclear β catenin No atypical features Zucman Rossi, Oncogene 2007, Bioulac Sage, Hepatol 2007 Hale/Kakar, USCAP 2015 Pilati, Cancer Cell 2014 Mutations in other Wnt genes Gonzalez, Hepatol, 2006 AXIN1 mutation: 10 15% of HCC Diffuse GS: AXIN1 mutation Diffuse GS: other explanations Hypoxia, cholestasis, fibrosis Alterations in blood flow FNH, hemangiomas Tumors: Adenomas, HCC Zucman Rossi, Oncogene 2007 Paxian, Anesthesiology 2003 Ueberham, J Hepatol 2004 Berry, Virchow Arch,

9 β catenin abnormality Exon 3: deletions Exon 3 point mutation T41A, S33C, S45P Exon 7, 8 mutation Other Wnt signaling pathway mutations Other Diffuse GS staining GS staining Diffuse homogeneous GS Most mutations: no definite GS pattern Patchy (not diffuse) GS Axin 1 Hypoxia, cholestasis, alterations of blood flow Interpretation of GS staining Staining pattern Diffuse homogeneous Diffuse heterogeneous >50% tumor cells Patchy, <50% tumor Expanded perivascular Peripheral Focal weak Staining pattern Staining in close to 50% of tumor cells Interpretation Associated with β catenin activation in majority of cases Associated with β catenin activation in a subset of cases β catenin activationuncommon Interpretation Indeterminate for β catenin activation Atypical features Combined immunostaining HSP70, GS and GPC 3: HCA vs. HCC Clinical Male gender (any age) Age (>50 years) Glycogen storage diseases, androgen use Morphologic Focal cytologic atypia (<5%) Focal reticulin loss (<5%) Nuclear β catenin, diffuse GS HSP70, glypican 3 Molecular β catenin mutation TERT promoter mutations Cytogenetic changes: gains of 1,8 Study Lagana et al, Appl Immunohistochem Mol Morph, 2012 Nguyen/Kakar, Mod Pathol, 2015 Results HSP70 <50% sensitivity 100% specific HSP70: 10% of atypical tumors 60% HCC 9

10 GS Atypical features HSP70 Clinical Male gender (any age) Age (>50 years) Glycogen storage diseases, androgen use Morphologic Focal cytologic atypia (<5%) Focal reticulin loss (<5%) Nuclear β catenin, diffuse GS HSP70 positive Molecular β catenin mutation TERT promoter mutations Cytogenetic changes: gains of 1,8 Molecular studies Formalin fixed paraffin embedded tissue β catenin mutation analysis TERT promoter mutation Cytogenetic changes: Gains of 1, 7, 8 TERT promoter mutation Typical HCA HCA with borderline features HCA with HCC 0 17% 54% Hale/Kakar, USCAP 2015 Pilati, Cancer Cell 2014 Evason/Kakar, Hum Pathol 2013 Pilati, Cancer Cell

11 Atypical features CEP 1 CEP 8 Clinical Male gender (any age) Age (>50 years) Glycogen storage diseases, androgen use Morphologic Focal cytologic atypia (<5%) Focal reticulin loss (<5%) Nuclear β catenin, diffuse GS HSP70 positive Molecular β catenin mutation TERT promoter mutations Cytogenetic changes: gains of 1,8 FISH by JP Grenert, UCSF Terminology Human Pathology Letter to the Editor Atypical hepatocellular neoplasm Well differentiated hepatocellular neoplasm with atypical features Hepatocellular neoplasm with uncertain malignant potential (HUMP) Hepatocellular neoplasm with atypical characteristics (HONC) 11

12 Are you a HUMPer or a HONCer? 34/M, 4.5 cm liver mass HUMP: Hepatocellular neoplasm with uncertain malignant potential HONC: Hepatocellular neoplasm with atypical characteristics Clinical Male gender (any age) Age (>50 years) Glycogen storage diseases, androgen use Morphologic Focal cytologic atypia (<5%) Focal reticulin loss (<5%) Nuclear β catenin, diffuse GS HSP70 positive Other TERT promoter mutations Cytogenetic changes: gains of 1,7, 8 Minimal atypia Reticulin loss 12

13 Diffuse GS Nuclear β catenin Atypical features Clinical: male Morphologic Reticulin loss β catenin activation Atypical or HCC 40/F, 9 cm liver mass Most of the tumor: no atypia 8 mm atypical focus 13

14 Pseudoacinar, small cell change Reticulin stain Atypical features Cytoarchitetural abnormalities Abnormal reticulin pattern Atypical or HCC Recommendations Clinically atypical Diagnosis Biopsy Resection Well differentiated hepatocellular neoplasm Histologic features most c/w HCA High risk related to clinical setting Adenoma 14

15 Recommendations Recommendations Morphologically atypical Biopsy Resection Diagnosis Atypical hepatocellular neoplasm, or Hepatocellular neoplasm with uncertain malignant potential (HUMP) Depending on extent and degree of atypia: Adenoma Atypical Hepatocellular carcinoma HCC Cytoarchitectural abnormalities Multifocal reticulin loss Unclear situations Small (<5 cm) tumors Atypical clinical setting, no atypical morphologic features Borderline GS staining pattern Atypical neoplasm extending to margin 15

16 Applying Criteria for HUMP Reclassifies >50% of Hepatocellular Adenomas Larson/Guindi [Abstract 1668] 1 criterion: 59% 2 criteria: 24% HCC: criteria for diagnosis β catenin exon 3 sequencing from FFPE Two criteria (most cases) Cytoarchitectural abnormalities Small cell change/cytologic atypia Thick cell plates (at least focally) Prominent pseudoacinar architecture Multifocal reticulin loss (not necessary if sufficient cytoarchitectural atypia) HCC (n=60) β-catenin mutation (n=10) HCA/borderline (n=20) β-catenin mutation (n=5) Patchy GS (negative) Diffuse GS 2/13 (15%) 8/47 (17%) Patchy GS (negative) Diffuse GS 0/10 5/10 (50%) Hale/Kakar, USCAP

17 Category Atypical features Clinical Age (>50 years), male gender Morphologic Atypical features (insufficient for HCC, <5%) Small cell change, cytologic atypia Pseudoacinar, focally thick plates Focal reticulin loss Immunohistochemical Molecular β catenin activation Nuclear β catenin Diffuse glutamine synthetase Heat shock protein (HSP) 70 Glypican 3 Diffuse sinusoidal CD34 β catenin mutation TERT mutation Cytogenetic changes (gains 1, 7, 8) Total: 35 cases catenin activated: 2 tumors Both were classified as HCC based on morphology and reticulin stain No recurrence/metastasis HCA subtypes: US and Europe HCC in adenoma Subtype Bioulac Sage, Hepatol, 2007 (n=93) Genrich/Kakar Hum Path 2014 (n=28) Thung, EASL 2013 (n=61) Bioulac Sage, AJSP 2012 (n=137) HNF1α 33% 29% 33% 22% Inflammatory 40% 32% 44% 53% β catenin, not IHCA 17% 0 2% 2% IHCA with 2% 3% 2% 11% β catenin Unclassified 8% 36% 16% 13% Adenoma Stoot, HPB, 2010 studies from Size >5 cm <5 cm Presence of HCC 68/1635= 4% >95% ~4% Shafizadeh/Ferrell/Kakar, Hum Pathol

18 Study Correlation of β catenin mutation and diffuse GS staining Bioulac Sage, 2007 HCC HCA not done 93% Audard, % not done Austinat, % not done Hale, % 50% 18

19 HCC arising in HCA: 11 cases β catenin activation in HCA portion: 6 cases Focal atypical features: all 6 cases Gains of 1, 8, Myc: 3 of 5 cases HCC in adenoma HCC arising in true adenoma Whole tumor is HCC: Adenoma like area: very WD HCC Recognizable HCC: higher grade portion Total: 35 cases catenin activated: 2 tumors Both were classified as HCC based on morphology and reticulin stain No recurrence/metastasis 19

20 Category Atypical features Clinical Age (>50 years), male gender Morphologic Focal atypical features (insufficient for HCC, <5%) Small cell change, cytologic atypia Pseudoacinar, focally thick plates Focal reticulin loss Immunohistochemical Molecular β catenin activation Nuclear β catenin Diffuse glutamine synthetase Heat shock protein (HSP) 70 Glypican 3 Diffuse sinusoidal CD34 β catenin mutation TERT mutation Cytogenetic changes (gains 1, 7, 8) Diffuse GS in a localized area Diffuse GS only in peliotic area Mutation in exon 45 of β catenin Berry, Virchow Arch, 2014 Staining pattern Diffuse homogeneous: Strongly associated with β catenin activation GS interpretation Diffuse heterogeneous Modest association with β catenin activation Other patterns (patchy, Perivascular, peripheral enhancement): β catenin activation uncommon 20

21 Some areas with diffuse GS; others weak patchy GS HCA: immunohistochemistry HNF 1α inactivated Liver fatty acid binding protein (LFABP) LFABP negative β catenin activated β catenin Glutamine synthetase (GS) Nuclear β catenin Diffuse GS Inflammatory Creactive protein (CRP) Serum amyloid associated protein (SAA) CRP+ SAA+ Unclassified No defining features 21

22 GS: normal FNH: map like HCA: genetic classification Category HNF 1α inactivation β catenin activation IL 6pathway activated Mutation negative Gene(s) involved TCF1 gene that encodes hepatocyte nuclear factor CTTNB1 exon 3 mutation (encodes β catenin) IL6RT gene (encodes gp130), FRK, STAT3, GNAS No characteristic mutation Zucman Rossi, Hepatology, 2006 WHO blue book, 2010 Diffuse GS staining Patchy GS staining 22