Ronald Ghossein, M.D.

Transcription

1 None.

2 THE CONTRIBUTION OF MOLECULAR PATHOLOGY TO THE CLASSIFICATION OF THYROID TUMORS Ronald Ghossein, M.D. Attending Director of Head and Neck Pathology Department of Pathology Memorial Sloan-Kettering Cancer Center New York, NY USA European Congress of Pathology 2017

3 The Lamentation of Pierre Masson No classification is more difficult to establish than that of thyroid [carcinomas]. Their pleomorphism is almost the rule; very few are adapted to a precise classification Masson P.Human Tumors:Histology, diagnosis and technique, 2 nd Ed, p

4 SOME IMPORTANT LIMITATIONS OF THE CURRENT HISTOLOGIC CLASSIFICATION Encapsulated follicular variant of papillary carcinoma: controversial at the diagnostic and prognostic level. The position of Hurthle cell carcinoma vis a vis follicular carcinoma The concept of minimally invasive Follicular/Hurthle cell ca still poorly defined, vague. The definition of poorly diff carcinoma still controversial

5 IMPORTANT LIMITATIONS OF THE CURRENT CLASSIFICATION NEGATIVE IMPACT ON MANAGEMENT AND RESEARCH (MOLECULAR) IMPROVEMENT BADLY NEEDED

6 IMPACT OF MOLECULAR PATHOLOGY ON NOVEL ENTITIES AND CLASSIFICATION OF THYROID CARCINOMA Reclassification of follicular variant of papillary thyroid carcinoma. Hurthle cell carcinoma. Possible future impact. -Papillary carcinoma in general

7 FOLLICULAR VARIANT OF PAPILLARY CARCINOMA A PROBLEMATIC AND CONTROVERSIAL ENTITY.

8 Papillary Carcinoma Follicular variant (Modern definition) Subset of papillary carcinoma entirely or almost completely composed of follicles lined by cells having the nuclear features of papillary carcinoma.

9 NUCLEAR FEATURES ARE EVERYTHING Clear nuclei, grooves, pseudoinclusions NUCLEAR FEATURES ALONE DIAGNOSTIC OF PAPILLARY CARCINOMA FOLLICULAR VARIANT EVEN IN THE TOTAL ABSENCE OF INVASION

10 Spectrum of nuclear changes in follicular lesions Follicular adenoma Follicular variant

11 INTEROBSERVER VARIABILITY (Lloyd et al. Am J Surg Path) 87 cases from Mayo clinic were reviewed by 8 pathologists with > 10 years experience in endocrine pathology. Cases diagnosed as follicular variant ranged from 57.5 to 100% ONLY 50.6% were diagnosed as follicular variant by ALL pathologists. Of 21 patients with follicular variant and metastatic disease, a BENIGN diagnosis was made in 3 cases.

12 INTRAOBSERVER AGREEMENT EXPERT: AMONG EXPERTS Agreement Follicular variant Dx: 1 4/7 (57%) 2 6/7 (86%) 3 11/12 (92%) 4 1/6 (17%) 5 14/14 (100%) 6 1/2 (50%) ElSheikh T et al. Am J Clin Pathol 130:736, 2008

13 FOLLICULAR VARIANT OF PAPILLARY CARCINOMA A CONTROVERSIAL ENTITY AS TO ITS BEHAVIOR

14 Problematic, most common Papillary Carcinoma Follicular Variant SUBVARIANTS Original description, 1977 Encapsulated Infiltrative Multinodular

15 DO ALL THESE FOLLICULAR VARIANT SUBTYPES BELONG TO THE PAPILLARY THYROID CARCINOMA CLASS OF TUMORS?

16 Mitogen-activated protein kinase (MAPK) pathway is activated in thyroid carcinoma

17 Mitogen-activated protein kinase (MAPK) pathway is activated in thyroid carcinoma

18 1) Correlate with histiotype 2) little overlap Foll adenoma/ca Papillary carcinoma Papillary carcinoma

19 Foll Variant Follicular Adenoma/ Ca Classical Pap RET/PTC 3% 0% 28% RAS 40% 24-50% 0% BRAF 3% 0% 53% Nikiforov group 2003

20 Follicular Variant of PTC: Genome Wide Appraisal of a Controversial Entity V.B. Wreesman, R. Ghossein, M. Hezel, D. Banerjee, A.R. Shaha, RM Tuttle, JP Shah, PH. Rao, and B. Singh Gene Chromosomes and Cancer, 40: 355, 2004

21 Comparative Genomic Hybridization (CGH) MSKCC Series Classical Papillary thyroid carcinoma :25 Follicular variant of papillary :17 (14 encapsulated) Follicular adenoma : 11 Follicular carcinoma :3 1st study to assess CGH by types of Papillary Carcinoma

22 Classical Pap A X Y % of alterations 1/25 (4%) p= B. Follicular variant papillary /17 (59%) X Y Follicular adenoma/c arcinoma C /14 (36%) X Y

23 Expression arrays of follicular variant different than classical and tall cell papillary carcinoma Tall cells: Red Classical: Yellow Follicular variant: Blue Follicular variant Giordano TJ. Oncogene :

24 Genomic of papillary carcinoma subtypes The Cancer Genome Atlas 2014 (TCGA) Papillary carcinoma cases genotyped: 496 Mutation analysis Copy number analysis Methylation analysis mrna seq microrna seq Cell :159,

25 BRAF V600E and RAS Mutations are Associated with Different PTC Variants BRAF V600E classical and tall cell variants RAS Mutations Follicular Variant

26 The Cancer Genome Atlas Somatic copy number alteration Present Absent P value Classical (n=123) 20 (18%) 103 (82%) 0.01 Follicular variant (n=61) 20 (33%) 41 (67%) Tall cell (n=22) 1 (4.5%) 21 (95.5%)

27 mrna seq subtype 1 The Cancer Genome Atlas mrna clusters in papillary ca correlate with histo subtype mrna seq subtype 2 mrna seq subtype 3 mrna seq subtype 4 Follicular variant Classical Tall

28 The Cancer Genome Atlas Methylated genes clusters in papillary ca correlate with histo subtype Methylation subtype 1 Methylation subtype 2 Methylation subtype 3 Follicular variant Classical Tall

29 mir seq subtype 1 The Cancer Genome Atlas microrna clusters in papillary ca correlate with histo subtype mir seq subtype 2 mir seq subtype 3 Follicular variant Classical Tall

30 Molecular Findings Molecular profile of Follicular Variant much closer to Follicular Adenoma and Carcinoma than to Classical papillary Carcinoma.

31 Follicular variant of papillary thyroid carcinomas: a clinicopathologic study of a problematic entity. Jeffrey Liu MD, Bhuvanesh Singh MD, PhD Giovanni Tallini MD, Diane L. Carlson MD, Nora Katabi MD, Ashok Shaha MD, R. Michael Tuttle MD, Ronald A. Ghossein MD. Cancer. 2006, 107:

32 MSKCC STUDY Detailed microscopic review of all cases between labeled: - Follicular variant papillary carcinoma - Follicular adenoma - Follicular carcinoma

33 MSKCC STUDY INCLUSION CRITERIA Follicular variant of papillary carcinoma as defined by AFIP fascicle. >= 1 CM No more than 2 additional foci of microcarcinomas

34 ENCAPSULATED FOLLICULAR VARIANT

35 INFILTRATIVE FOLLICULAR VARIANT

36 Infiltrative follicular variant

37 78 cases fulfilling MSKCC study criteria ENCAPSULATED follicular variant: 61 - Without invasion: 43 - Invasive: 18 Diffuse/infiltrative: 17 * Total: 78 * Incidence similar to Rosai 1977 paper.

38 Follicular Variant MSKCC Study All cases Encapsulated Infiltrative p Marked fibrosis: 18% 88% < LN met: 5% 65% < Extra-thyroid 5% 65% < extension:

39 ENCAPSULATED FOLLICULAR VARIANT WITHOUT INVASION TREATED BY LOBECTOMY ALONE 31 treated by LOBECTOMY and no RAI No Recurrence and No lymph node metastasis. Median FU: 11.1 years Median size: 2.3 cm Median age: 43.4

40 Other studies on encapsulated follicular variant PTC non-invasive show almost no recurrence Reference Invasion (No of pts) Nodal met (No pts) Baloch, Livolsi(2000) - non-invasive, n=1 (? entirely examined)) 0 Follow up (yrs) NA Outcome (No of pts) Bone met (n=1) Piana (2010) Non-invasive (n=45) NA NA 0/45 Barletta (2013) Non-invasive (n=43) 0 median: 9.5 1*/43 (2%) Rosario (2013) Non-invasive (n=57) 0 Median: 5.8 0/57 (No RAI) * Tumor bed recurrence, positive margin

41 Encapsulated follicular variant metastatic to rib without nodal metastasis T Vascular invasion A B C DD Rib met

42 Molecular genotyping of Follicular variant according to its subtypes (Memorial Hospital). 28 encapsulated 19 infiltrative M.Rivera, J. Ricarte-Filho, J. Fagin, R. Ghossein. Mod Pathol 2010; 23:1191.

43 MOLECULAR GENOTYPING OF FOLLICULAR VARIANT ACCORDING TO ITS SUBTYPES (paraffin tissue) Multiplexed Sequenom mass spectrometry-based mutation assay for 111 mutations. 16 different genes:braf, RET, NRAS, HRAS, KRAS, PIK3CA, MAP2K1, AKT1, MET, IKBKB, PIK3R5, PRKCZ, RHEB, RPS6AK3, RPS6KB1, FRAP1 RT PCR screening for RET/PTC and PAX8-PPAR gamma

44 Follicular Variant Molecular genotyping study BRAF Encapsulated (n=28) Infiltrative (n=19) p V600E: 0 5 (26%) RAS 10 (36%) 2 (10%) 0.09 RET/PTC 0 2 (10%) NS PAX8-PPARg 1 (4%) 0 NS

45 Follicular variant of papillary carcinoma Encapsulated Non-invasive cases have an extremely low recurrence rate. Metastatic nodal pattern : - Encapsulated follicular variant close to follicular carcinoma - Infiltrative /diffuse close to classical papillary Molecular profile: - Encapsulated follicular variant similar to follicular adenoma/ carcinoma. - Infiltrative follicular variant close to classical papillary.

46 Relationship between papillary carcinoma (PTC), follicular variant of papillary carcinoma (FVPTC), follicular adenoma/carcinoma(fa/ftc) PTC Classical PTC Infiltrative/diffuse FVPTC FVPTC Old concept FVPTC FA/FTC Encapsulated FVPTC New concept

47 Reclassification of the encapsulated follicular variant as a close entity to the Follicular adenoma/carcinoma group Countless number of patients with non-invasive follicular variant will be spared unnecessary therapy with its attached morbidity, financial costs and the psychological impact of a clinical cancer diagnosis.

48 OBSTACLES FROM Endocrinologists who think RAI is water. Surgeons who overtreat microcarcinomas Expert pathologists who fail to communicate the extremely indolent nature of the non-invasive encapsulated follicular variant.

49 After 30 long years of overcalling and overtreating.

50 Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: A Paradigm Shift to Reduce Overtreatment of Indolent Tumors Yuri E. Nikiforov, MD, PhD 1 ; Raja R. Seethala, MD 1 ; Giovanni Tallini, MD 2 ; Zubair W. Baloch, MD, PhD 3 ; Fulvio Basolo, MD 4 ; Lester D. R. Thompson, MD 5 ; Justine A. Barletta, MD 6 ; Bruce M. Wenig, MD 7 ; Abir Al Ghuzlan, MD 8 ; Kennichi Kakudo, MD, PhD 9 ; Thomas J. Giordano, MD, PhD 10 ; Venancio A. Alves, MD, PhD 12,13 ; Elham Khanafshar, MD, MS 14 ; Sylvia L. Asa, MD, PhD 15 ; Adel K. El-Naggar, MD 16 ; William E. Gooding, MS 17 ; Steven P. Hodak, MD 18 ; Ricardo V. Lloyd, MD, PhD 19 ; Guy Maytal, MD 20 ; Ozgur Mete, MD 15 ; Marina N. Nikiforova, MD 1 ; Vania Nosé, MD, PhD 21,22 ; Mauro Papotti, MD 23 ; David N. Poller, MB, ChB, MD, FRCPath 24 ; Peter M. Sadow, MD, PhD 21,22 ; Arthur S. Tischler, MD 25 ; R. Michael Tuttle, MD 26 ; Kathryn B. Wall 27 ; Virginia A. LiVolsi, MD 3 ; Gregory W. Randolph, MD 28 ; Ronald A. Ghossein, MD 29 JAMA Oncol. April 2016

51 Conference Recommended New Terminology: Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) *Adequate sampling of entire tumor capsule is required to establish this diagnosis

52 IMPACT OF NIFT-P - 45,000 patients worldwide. (10,000 in US). - side effects of completion thyroidectomy (recurrent nerve, hypopth, thyroid hormone replacement). - side effect of RAI. - Health care cost (5,000-8,000 US $/RAI Tx) - Psychological and financial burden.

53 IMPACT OF NIFT-P - Initial patient reactions (Relief): Hi Rony, I wanted to let you know that one of my clients came in this week and told me that she found out last week that the cancer she thought she had had was not cancer - it was a benign thyroid tumor. She was crying tears of relief when she told me. She is a relatively young woman (late 30s) with two small children. Letter from psychotherapist

54 IMPACT OF NIFT-P Initial patient reactions (Anger): - I was denied life insurance and prevented from donating blood because of that thing Physician-Scientist

55 To kill an error is as a good service as, and sometimes even better than, the establishing of a new truth or fact. Charles Darwin

56 IS HURTHLE CELL CARCINOMA A VARIANT OF FOLLICULAR CARCINOMA

57 FOLLICULAR and HURTHLE CELL CARCINOMA. Diagnosis of follicular carcinoma depends on capsular and vascular invasion. Criteria for capsular and lymphovascular invasion controversial. WHO 2004: Hurthle cell tumors variants of follicular carcinoma.

58 Defective Oxidative Phosphorylation in Thyroid Oncocytic Carcinoma Is Associated with Pathogenic Mitochondrial DNA Mutations Affecting Complexes I and III Bonora E, Porcelli AM, Gasparre G, Biondi A, Ghelli A, Carelli V, Baracca A, Tallini G, Martinuzzi A, Lenaz G, Rugolo M, Romeo G Cancer Research 66: , 2006 Disruptive mitochondrial DNA mutations in complex I subunits are markers of oncocytic phenotype in thyroid tumors Gasparre G, Porcelli AM, Bonora E, Pennisi LF, Toller M, Iommarini L, Ghelli A, Moretti M, Betts CM, Martinelli GN, Rinaldi Ceroni A, Curcio F, Carelli V, Rugolo M, Tallini G, Romeo G Proceedings of the National Academy of Sciences USA 104: , Mutations in mitochondrial DNA coding for oxidative phosporylation complex cause the biochemical, metabolic and phenotypic (i.e. accumulation of mitochondria) alterations of oncocytic tumors of thyroid -while these are absent in follicular carcinomas Complex I (NADH coenzyme Q reductase)

59 Molecular characterization of Hurthle cell carcinoma (MSKCC) Ian Ganly, Julio Ricarte Filho, Stephanie Eng, Rony Ghossein, Luc G.T. Morris, Yupu Liang, Nicholas Socci, Kasthuri Kannan, Qianxing Mo, James Fagin, Timothy A. Chan. J Clin Endocrinol Metab 98: E962 E972, 2013

60 Genetic alterations of Hurthle cell carcinomas vs other thyroid ca Genetic alterations in Hurthle cell tumors compared to other thyroid cancers Gene Prevalence stratified by thyroid histology PTC FTC PDTC ATA HCC RET point mutation 0% RET rearrangements Sporadic 20% 0% Radiation induced 50-80% BRAF mutations 30-70% 0% 0-15% 10-35% 0% RAS mutations 10% 45% 20-35% 50-60% 16% PIK3CA point mutation or amplification 10-30% 25-45% 0% PPARG rearrangement 25-60% 0% PTC-papillary thyroid cancer FTC-follicular thyroid cancer PDTC-poorly differentiated thyroid cancer ATC-anaplastic thyroid cancer

61 Summary of chromosomal regions of gain and loss in HCC compared with PTC and FTC

62 Tumor type and recurrence free survival in encapsulated PTC, follicular carcinomas and Hurthle cell carcinoma (N=267) Median follow up: 6 years Hurthle cell carcinoma Xu B et al. Hum Pathol. 2015

63 RAI (+) DM AT Rx-WBS RAI(+) Distant Mets BY HISTOLOGY (Tala, Tuttle, et al) All patients Confirmed Histology

64 Is Hurthle cell carcinoma a subtype of follicular carcinoma? Follicular carcinoma seems very different from Hurthle cell carcinoma at molecular level, and in regard to RAI avidity and recurrence rates

65 WHO 2017 Hurthle cell carcinoma NOT a variant of follicular carcinoma

66 FUTURE POTENTIAL IMPACT ON PTC BRAF RAS SCORE Thyroid differentiation score (TDS)

67 Gene Expression and Differentiation Thyroid Differentiation Score (TDS) A panel of 16 thyroid metabolism and function, e.g. TPO, TSHR, thyroglobulin, and PAX8. BRAF V600E RAS Score (BRS) 71-gene signature derived from comparing the RNA sequencing data BRAF V600E and RAS-driven tumors.

68 Clinical implications: RAI refractory PTCs are enriched in BRAF-mutants. BRAF V600E downregulates gene involved in iodine metabolism. BRAF V600E -like PTC Less Differentiated (Low TDS Score) Classical & TCV High MACIS High Risk RAS-like PTC Highly differentiated (High TDS Score) FVPTC Low MACIS Low risk

69 BRS Mutation/fusion TDS, Histology Protein mirna mrna DNA methylation RAS-like PTC : a relatively homogenous group - Low risk of recurrence; younger patient - FVPTC, Highly differentiated - Distinct mrna expression with low expression of immune response gen - High expression of mir-182-5p and mir-183 5p

70 BRS Mutation/fusion TDS, Histology Protein mirna mrna DNA methylation BRAF V600E -like PTC : a heterogenous group - 2 subgroups based on DNA methylation to 5 based on mirna data. - A tall-cell like subgroup on mrna and mrna clustering: - Strongest BRAF like phenotype and least differentiated - More advanced stage and higher risk.

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72 THE END

73 FUTURE POTENTIAL IMPACT ON POORLY DIFFERENTIATED THYROID CARCINOMAS

74 le Type er stasis site val rvation al tissue r purity otype th classification Number 3 6 of mutations 4 in genes 1 Sample Type Age Gender Met site Survival Tumor purity Phenotype Growth PDTC defin. le Type er le Type stasis site val er stasis rvation site val tissue rvationr purity otype al tissue th r purity otype classification th classification BRAF NRAS HRAS KRAS NF1 TSHR STK11 EIF1AX PIK3CA PTEN RET/PTC PAX8- PPARɣ ALK TERT NUT-BRD4 TP53 ATM RB1 NF2 MEN1 PI3K/AKT SWI/SNF HMTS MMR Genetic alteration missense truncating Poorly-differentiated thyroid cancers (PDTC) M1 Fusion 45% 14% inframe fusion CCDC6-RET NCOA4-RET STRN-ALK EML4-ALK CCDC149-ALK PIK3CA Sample Type Age Gender Met site Survival Tumor purity Phenotype % of tumors mutated Anaplastic (ATC) BRAF 81% (33% of BRAF PD, 45% ATC) and 92% RAS of (21% PD, * 18% ATC) main drivers PDTC MSKCC RAS Turin proposal definition high mitotic rate vs. solid growth * plus BRAF and RAS and dictate necrosis distinct tropisms high for grade metastasis features in * PDTCs irrespective of (mitosis and Total PDTC = 84 BRAF wt BRAF + p Total PDTC = 84 RAS wt RAS + growth (56) pattern (28) value necrosis) * (60) (24) * Tumor size 4 40% 70% >4 60% 30% 0.01 Pathology staging T1/T2 11% 15% T3/T4 89% 85% Nx/N0 61% 37% N1a/N1b 39% 63% M0 38% 79% Mx 17% 7% * M1 22% TERT promoter67% E542K/E545K (helical) H1047R (kinase) E81K K111E C228T (-124) C250T (-146) Sample type primary metastasis recurrence Age p value Tumor size % 19% >4 37% 81% Pathology staging T1/T2 16% 5% T3/T4 84% 95% Nx/N0 37% 86% N1a/N1b 63% 14% <0.001 M0 62% 25% Mx 16% Gender male female Met-site no met lung bone lung+bone other NA Survival alive deceased NA Tumor purity <50% 50-70% >70% NA Hiltzik D, et al. Cancer 2006 Volante M, et al. Am J Surg Pathol 2007 Phenotype papillary follicular tall-cell variant Hurthle mixed/other NA Growth solid papillary mixed/other NA PDTC definition Turin proposal MSKCC NA CC TT Pathway altered

75 If robust targeted therapy available RAS driven PDTC and BRAFV600E driven PD carcinomas will be new entities

76 Poorly Differentiated Thyroid Carcinomas Tumors of follicular cell origin showing histologic and prognostic features intermediate between Well Differentiated Thyroid Carcinomas and Anaplastic Carcinoma.

77 Poorly Differentiated Carcinoma Turin proposal Solid/nested/insular growth pattern, and Absence of nuclear features of PTC, and At least one of the following features: Convoluted nuclei Mitotic index of 3/10 HPFs Tumor necrosis Volante et al., Am J Surg Pathol 31:

78 Poorly differentiated thyroid carcinomas defined on the basis of mitosis ( 5/10 HPF) and/or necrosis (MSKCC) necrosis Fulfill also Turin Hiltzik, D. Carlson, M. Tuttle, S. Chuai, N. Ishill, J. Shah, A. Shaha, B. Singh, R. Ghossein. Cancer (March) 2006.

79 TURIN PROPOSAL PTC No necrosis ANA PD Necrosis

80 Overall survival Poorly differentiated thyroid ca defined on the basis of mitosis and necrosis 5 year survival: 60% Predictors of survival within PDC Tumor > 4cm p=0.02 Absence of a capsule p=0.001 Extra-thyroid extension p=0.001 Margins p=0.001 Factor with no influence on survival Growth pattern (solid vs foll/pap) p=1