What I Learned from 3 Cases and 3 Antibodies

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1 What I Learned from 3 Cases and 3 Antibodies Melinda Sanders, M.D Vanderbilt University Medical Center Professor of Pathology Consultant in Breast Pathology Disclosure of Relevant Financial Relationships USCAP requires that all faculty in a position to influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest. Dr. Melinda Sanders declares he/she has no conflict(s) of interest to disclose. Case #1 History Left Breast Biopsy 61 yo female with stage 4 appendiceal adenocarcinoma 2.1 cm left breast mass and an enlarged axillary lymph node found during staging work up Core needle biopsy performed Left Breast Biopsy Left breast biopsy 1

2 Appendiceal adenocarcinoma Breast biopsy GATA3 Biopsy #1 Immunohistochemistry CDX 2 SOX10 Repeat Needle Core Biopsy of Breast Negative expression GATA3, ER, PR, CK7, CK20, CDX 2 Diagnosis: Poorly differentiated malignant neoplasm and skeletal muscle, cytologically different from abdominal mutinous adenocarcinoma (CDX 2 + ) Note: Does not exclude a breast primary 2

3 CK AE1/3 S100 Biopsy #2 Immunohistochemistry GATA3 CK 7 CK 8/18 SOX10 MITF MelanA HMB 45 Diagnosis Malignant Melanoma Wire localized partial mastectomy 17 mm Malignant Melanoma SNL 1/1 lymph node 2.5 mm metastasis LN dissection 0/19 lymph nodes Case #1 Melanoma AE 1/3 + patchy weak mod CK7 Breast ER GATA3 CK 8/18 S100 + SOX10 + Melanoma MITF + MelanA + HMB45 + GI CDX2 HER2 ND Melanoma is most common non hematopoietic malig to met to breast, may rare occur as primary Think about melanoma when ER /PR tumor, nested morphology, especially if TILs Aberrant CK expression = major pitfall, especially in melanoma metastases. If GATA3 negative, perform panel of MM markers Keratin Expression in Melanoma Keratin expression typically helps support a diagnosis of carcinoma and rules out sarcoma, lymphoma, and melanoma Expression not infrequent most common AE 1/3, CK8, CK18, MNF 116 Aberrant keratin expression more common in metastatic than primary 4 10% primary melanomas 40 70% metastatic melanoma Implies a correlation between keratin expression and a more aggressive tumor phenotype. Safadi et al.,oral and Maxillofacial Pathol 2016;121: Plaza et al., App Immunohistochem Mol Morphol 2007;15: Percentage of Primary vs. Metastatic Melanoma Cases with Keratin Expression MNF 116 CK18 CK7 CK18 MNF 116 CK8 CK7 S 100 is Highly Sensitive but not Specific for MM Normally found in cells derived for neural crest including melanocytes and myoepithelial cells Most sensitive melanoma marker (>95%), not very specific Approximately 50% of BC may express S100 DDx for cytokeratin + /S100 + tumor inc. melanoma and BC Additional markers mandatory to distinguish Primary Melanoma Metastatic Melanoma Safadi et al., Oral and Maxillofacial Pathol 2016;121: Dwarakanath Hum Pathol 1987;18: Stroup Hum Pathol 1988;19:

4 Case #2 History 31 yo female h/o left shoulder melanoma ; Negative left axillary sentinel nodes Presented 7 mo later with left axillary mass Core needle biopsy performed Left Axillary Lymph Node Biopsy Left Axillary Mass Immunohistochemistry CK 7 CAM5.2 GATA3 CK AE 1/3 Diagnosis Melan A SOX10 S100 HMB45 Metastastic carcinoma, most consistent with breast cancer AR, likely ruling out adnexal carcinoma 4

5 Melanoma Left Shoulder Immunohistochemistry Left Shoulder Mass CK7 AE 1/3 GATA3 AR HMB 45 S100 MelanA SOX10 Case #2, Diagnosis #2 Left Shoulder Malignant melanoma with intratumoral focus of carcinoma consistent with metastasis from breast cancer BC vs Melanoma Immunohistochemistry Case #1 Case #2 Melanoma BC Melanoma AE 1/3 + patchy weak mod + diffuse weak CK7 + diffuse strong Breast ER ND GATA3 + diffuse strong CK 8/18 ND ND S SOX Melanoma MITF + ND ND MelanA + + HMB GI CDX2 ND ND HER2 ND ND 5

6 Primary Clinical Use Breast carcinoma (92% primary, 96% met) Urothelial carcinoma (91% primary) GATA3 Expression Other Carcinomas SCC variety of sites 80% Adnexal carcinomas 70% Salivary gland carcinomas >99% Choriocarcinoma and trophoblastic tumors >99% Mesothelioma 58% Chromophobe carcinoma 51% Pancreatic ductal carcinoma 10 37% Other adenocarcinomas < 10% lung stomach endometrium ovary thyroid Metastatic melanoma 0/74 GATA3 in the Breast Transcription factor with role in differentiation of mammary luminal epithelial cells In BC cell lines and mouse models 1) reduces tumor initiating capacity of luminal progenitor cells & 2) impedes EMT by interaction with BRCA1 In ER+ cell lines, required for estradiol stimulation of cell cycle prog In ER-/BRCA1 mutant cell lines, BRCA1 unable to associate with GATA3 leading to a drug-resistant and mesenchymal phenotype GATA3 somatic mutations identified most commonly in ER+ but also ER- Asch Kendrick Hum Path 2016;48:37 47 Miettinen Am J Surg Pathol 2014;38:13 22 Yang Mod Pathol 2010;23: Asch Kendrick Hum Path 2016;48:37 47 Kouros Mehr Curr Open Cell Bio 2008;20:164 Tkocz Oncogene 2012;31: GATA3 Expression in Breast Cancer Primary BC ER % NST (ductal) % Lobular % ER+/HER2+ 100% ER-/HER % TNBC 2.6%-83%(70-80%) Apocrine 83-91% Metaplastic 17-56% MBC All 73-95% ER+ >99% HER2+ >99% TNBC 56% (44-70%) Useful internal positive controls B9 luminal cells and lymphocytes Recommendations for GATA3 use Breast Primary Highly sensitive for ER+, routinely unnecessary Greatest utility, ER HG tumor, esp if lacking an in situ component, positivity strongly supports breast primary, further strengthened by other markersdiffuse strong CK7+, SOX10+ More sensitive and specific than mammoglobin and GCDFP 15 for dx BC esp in TNBC Rules out melanoma (at present) Metastasis Strongly supportive of breast origin in patient with known history of ER+ or ER BC Suggests mammary origin in CK7+/CK20 carcinoma of unk primary, req other markers to r/o other CK7+ adeno, TTF 1 and napsin lung, PAX8 renal & gyn, CDX2 GI GATA3+/CK7 broader ddx SCC Asch Kendrick Hum Path 2016;48:37 47 Miettinen Am J Surg Pathol 2014;38:13 22 Liu Am J Clin Patol 2014;141: Cimino Mathews Hum Pathol 2013;44: Voduc Cancer Epi Bio Prev 2008;17: Ciocca Hum Pathos 2009;40: Yang Mod Pathol 2010;23: Asch Kendrick Hum Path 2016;48:37 47 Miettinen Am J Surg Pathol 2014;38:13 22 Krings Hum Pathol 2014;45: Case #3 History and Presentation 74 year old female presented to her PCP with an inverted nipple PMH Right elbow melanoma Mammogram Photo Album Right breast, 12 o'clock 1.7 cm x 6.4 cm asymmetric density 2 cm from the nipple. by Sanders, Melinda Ultrasound 1.5 cm x 1.3 cm x 1.7 cm hypoechoic mass with posterior shadowing A right axillary ultrasound also revealed multiple morphologically abnormal lymph nodes. Ultrasound guided core needle biopsy performed. Breast Core Needle Biopsy 6

7 Hormone Receptor Immunohistochemistry HER2 FISH ER (3+, 100%) PR (2+, 85%) Not Amplified HER2/Cep17 ratio 1.0 Average HER2 copy # 1.9 Wire-Localized Partial Mastectomy 7

8 surgery surgery surgery ER Immunohistochemistry Breast CK7 CK8/18 GATA3 MelanA S100 MITF SOX10 Synaptophysin Diagnosis Invasive mammary carcinoma, no special type with neuroendocrine differentiation WHO 2012 : well-differentiated [carcinoid-like] neuroendocrine carcinoma 24 mm Metastatic tumor involving 11 of 24 lymph nodes, largest focus measuring 35 mm with extracapsular extension. 8

9 Axillary Lymph node with Metastatic Breast Cancer Axillary lymph node CK 8/18 CK 7 ER GATA3 MelanA S100 SOX10 MITF Axillary Lymph Node Axillary Lymph node with Metastatic Melanoma CK8/18 CK7 ER GATA3 MelanA S100 SOX10 MITF Axillary Lymph Node Axillary Lymph Node with Metastatic BC and Melanoma GATA3 CK8/18 MelanA Sox10 9

10 Diagnosis Invasive mammary carcinoma, no special type with neuroendocrine differentiation Metastatic mammary carcinoma involving 11 of 24 lymph nodes, largest focus measuring 35 mm with extracapsular extension. Metastatic melanoma involving 2 of 24 lymph nodes, 1.2 mm 0.5 mm. BC vs Melanoma Immunohistochemistry Case #1 Case #2 Case #3 Melanoma BC Melanoma BC Melanoma AE 1/3 + patchy weak mod + diffuse weak + CK7 + diffuse strong Breast ER ND + GATA3 + diffuse strong + CK 8/18 ND ND + S SOX Focal LN+ + Melanoma MITF + ND ND + MelanA + + Focal LN+ + HMB ND + GI CDX2 ND ND ND ND HER2 ND ND ND SOX10 Expression in Breast Cancer Transcription factor mediates differentiation of neural crest derived cells Most common clinical use IHC, support diagnosis of malignant melanoma Expressed by mammary myopepithelial cells and approximately 40% of breast cancers Most commonly expressed in TNBC Cimino-Mathews Human Pathol 2013;44: Mollaaghababa Oncogene 2003;22: Dravis et al. Cell Reports 2015;12: Nonaka Am J Surg Pathol 2008;32: Immunohistochemical labeling of Sox10 in breast carcinoma Tumor type n Intensity of Sox10 staining Total positive Luminal A (0%) Luminal B (14%) Her (7%) Basal like (69%)* TNBC,NOS (77%)* Metaplastic (46%)* Table 2 Cimino Mathews Hum Pathol 2013; 44: *P < % (35/40) Nuclear Sox10 labeling defined as 0, 1+ (1% 25%), 2+ (25% 50%), 3+ (50% 75%), 4+ (>75%) Subtypes determined by surrogate panel of IHC: LumA = >75% ER+/HER2 LumB = ER+/HER2+, Basal TNBC = ER /PR /HER2 / CK5/6 +/or EGFR+ TNBC, NOS = ER /PR /HER2 /CK5 6 /EGFR 10

11 Summary- What I learned from 3 cases and more than 3 antibodies: Melanoma - 2nd most common non-hematopoietic neoplasm to metastasize to the breast, and although rare, primary melanomas of the breast occur MM must be in ddx for woman presenting with an ER-/PR- breast or axillary mass, esp if unusual morph, nested and TILs Evidence of CK expression in a breast/axillary mass does not R/O MM Aberrant CK expression (esp. CK7/8/18, AE1/3, CAM5.2, MNF-116) in melanoma, especially metastatic, should prompt use of a battery of melanoma markers- MITF, HMB-45, MART-1 before excluding MM Summary- What I learned from 3 cases and more than 3 antibodies: Approx 10% BC CK7, further highlighting the unreliability of CKs in this distinction GATA3 most sensitive marker for BC in both in breast and metastases, ER+ and ER, most helpful in identification of CK7 TNBC GATA3 + excludes melanoma Important pitfall, SOX 10 expressed in 92% of melanomas also expressed in 40% breast cancers, most common in TNBC (>60%), inc. metaplastic carcinomas S100 most sensitive marker for MM (>95%), however, up to 50% of BC may express S100, thus ddx for S100+/SOX10+ neoplasm must inc. BC requiring additional w/u When evaluating metastatic biopsy, do not underestimate value of obtaining block of primary for comparison IHC testing Consider molecular testing in unresolvable cases THANK YOU 11

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