3/22/2017. Disclosure of Relevant Financial Relationships. Disclosure of Relevant Financial Relationships

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1 Ki67 in Pituitary Tumors: What Information Could We Obtain? Robert Y. Osamura, MD International University of Health and Welfare Ki67 in Pituitary Tumors: What Information Could We Obtain? Robert Y. Osamura, MD International University of Health and Welfare Disclosure of Relevant Financial Relationships USCAP requires that all planners (Education Committee) 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. Disclosure of Relevant Financial Relationships Dr. Robert Y. Osamura, MD has nothing to disclose. Lighted-up San Antonio Church March 3, 2017 WHO 2017 Pituitary adenomas Approximately 15% of all intracranial neoplasms Most pituitary tumors are adenomas and are benign and non-invasive. But invasive adenomas are also frequent. Pituitary carcinomas are rare, accounting for only % of all pituitary endocrine tumors. Definition Pituitary adenoma is a neoplastic proliferation of anterior pituitary producing cells The tumors are frequently benign, but can be aggressive and invasive into adjacent structures. How much does Ki67 contribute to predict aggressive and invasive pituitary adenomas? 1

2 Huge and invasive pituitary adenoma 1.Measurement of Ki67 in pituitary adenomas 2.WHO classification 2004 Typical and atypical adenomas 3.Ki67 index and behavior of pituitary adenomas Ki67 and Knosp Grading 4.New WHO Classification Pituitary carcinoma and Ki67 6.Summary How to measure Ki67 index? Three-four high power fields(x400) were captured by Olympus Digital Camera On the printed images, Ki67-positive nuclei were counted on nuclei of the tumor cells (MGH) Antibody against Ki67 MIB1(DAKO Agilent) Typical and Atypical Pituitary Adenoma Typical and atypical pituitary adenomas(who 2004) 2. How much do Ki67 indices contribute to predict aggressive pituitary adenomas 3. Adenoma subtypes and aggressive nature 4. Pituitary carcinoma and Ki67 Ki67 >3% P53 positive 2

3 Tumors of the pituitary(who 2004) Pituitary adenomas Growth hormone producing adenoma Prolactin producing adenoma Thyrotropin producing adenoma ACTH producing adenoma Gonadotropin producing adenoma Null cell adenoma Plurihormonal adenoma Pituitary carcinoma WHO 2004 Atypical adenoma J Neurosurg Sep 24. Atypical pituitary adenomas: incidence, clinical characteristics, and implications. Zada G, Woodmansee WW, Ramkissoon S, Amadio J, Nose V, Laws ER Conclusions: Atypical tumors were identified in 15% of resected pituitary adenomas, and they tended to be aggressive, invasive macroadenomas. More longitudinal follow-up is required to determine whether surgical outcomes, potential for recurrence, or metastasis of atypical adenomas vary significantly from their typical counterparts. Atypical pituitary adenomas(who 2004) Cases Ki67 >3% Ki67 >3% and p53 positive (19%) 11 (17%) 5 4 (16%) 3 (6%) (9%) Total 染色数 numbers of cases ki 67 Ki67 3% 以上 > 3% Atypical adenomas Ki67 >3% P53 + ki 67 3% 以上かつ p53+ Total 245 cases Types of tumors and Ki67 index Cases % Ki67 <3% 82.4% 82.4% of all pituitary adenomas show Ki67 index less than 3% NF TSH ACTH PRL GH % 12.2% % 4.5% 2.4% 0.4% 0.4% Ki67 indices Atypical adenomas: low in incidence and not necessarily aggressive Interpretation of p53 IHC is subjective 3

4 P53 gene mutation in pituitary adenomas and carcinomas Tanizaki Y, Jin L, Scheithauer BW, Kovacs, K, Roncarol,F Lloyd, RV P53 gene mutation in pituitary carcinomas Endocr Pathol (2007) 18(4): Exon 5,6,7,8 A case of 60% overexpression:codon 248 Common hot spot Another case with 90% overexpression:codon 135 All adenomas negative for mutations Levy A, Hall L, Yeudall WA, Lightman, SL P53 gene mutations in pituitary adenomas:rare event Clin Endocrinol (1994) 41(6): No mutations were identified in 29 cases Exon 4,5,6,7,8 (MGH) Ki67 1.3% threshold for post-surgical tumor progression Atypical pituitary adenomas(who 2004) 1. Rare in incidence 5%-15% 2. Not necessarily correlated with prognosis Atypical adenoma is not recommended(who 2017) 1. Ki67 index should be analyzed. 2. p53 is good indicator of malignancy PA vs APA Ki67(MIB-1) LI >4% Cases of Knosp Grade 4 CK Max M/F Age Diagnosis GH PRL ACTH FSH LH TSH SU ki-67 P53 CAM5 Fb diameter.2 1 M 44 ACTH Knosp Grad 4 invasion 2 F 55 ACTH Not measurable 3 M 66 ACTH > + 4 M 71 ACTH F 31 GH F 32 GH M 28 GH > 1> - 8 F 33 GH > F 44 NF M 82 NF > 11 M 61 NF > 12 F 64 NF a few > 13 F 56 NF a few - a few F 69 NF - - a few > 15 M 37 NF F 42 NF F 72 NF F 74 NF > 19 M 63 NF M 68 NF F NF > F 77 NF % M 20 NF a few a few Ki67 indices vary from <1% to 23% Ki67 >3% 5/20 25% 4

5 Pituitary adenomas with Ki67 >3% M/ 年 GH PR AC FS TS LH H H S U ki-67 P53 AIP Knosp Max Diameter (mm) 診断 F 齢 L TH Clinical history 1 F 42 GH 4+ ± % 3% 2 20 Total removal Endocrine therapy No recurrence 2 F 18 PRL % 2.70% 2 20 Total removal Endocrine therapy No recurrence 3 F 23 PRL % 1% Total removal Endocrine therapy No recurrence 4 F 24 PRL % 0 8 Total removal Endocrine therapy No recurrence 5 F 17 PRL % 3% Total removal Endocrine therapy No recurrence 6 F 16 PRL % 1> Residual tumor Control with Cabergoline0..25mg/w 7 F 43 PRL % 1% Ki67 >3% 5/15 cases (33%) Knosp 3,4 8 F 37 PRL % 9 F 26 PRL % 1> 1 13 Total removal Endocrine therapy No recurrence 10 M 71 ACTH % 1% 4 29 Residual tumor Lost follow-up 1 year post-operatively Apoplexy 11 F Pit % 8% Total removal Endocrine therapy No recurrence Invation to maxillary sinus 1996 年 surgery Recurrence and ocular 12 M 65 NF % movment disturbance Residual tumor+ Cavernous sinus invation growth Ciber 13 F NF % 1> 4 38 knife 14 F 77 NF % 1% 4 40 Second surgery enlargement of cavernous sinus invasion Ocular nerve paralysis Ciber knife a 15 M 20 NF few a + few 23.0% 80% Onset with ocular nerve palsy invasive Post operative radiation How much does Ki67 contribute to predict aggressive and invasive pituitary adenomas? Contribution of Ki67 indices alone is limited, but together with images(mri), we may predict aggressive nature of the adenomas, such as residual tumor, recurrence. Trouillas J et al. Acta Neuropathol 2013 Pituitary adenomas often associated with aggressive behavior Morphology as biomarkers Sparcely granulated somatotroph adenoma Densely granulated lactotroph adenoma Acidophil stem cell adenoma Thyrotroph adenoma Sparcely granulated corticotroph adenoma Crooke s cell adenoma Silent subtype III adenoma(plurihormonal Pit-1 positive adeoma) Mete O and Asa SL Clinicopathological correlations in Pituitary adenomas. Brain Pathol 22(2012) Subtypes of pituitary adenomas tend to show more aggressive behavior(who 2017) Sparcely granulated somatotroph adenoma Lactotroph macroadenoma in men Crooke cell corticotroph adenoma Silent corticotroph adenoma Plurihormonal PIT-1 positive adenoma (previous Silent subtype III adenoma) Subtypes of pituitary adenomas tend to show more aggressive behavior(who 2017) Sparcely granulated somatotroph adenoma Lactotroph macroadenoma in men Crooke cell corticotroph adenoma Silent corticotroph adenoma plurihormonal PIT-1 positive adenoma (previous Silent subtype III adenoma) Mete O and Asa SL Clinicopathological correlations in Pituitary adenomas. Brain Pathol 22(2012)

6 Table 1 Morphofunctional Classification of Pituitary Adenomas WHO 2017 Adenoma Types Immunophenotypes Transcription Factors and other co Factors <1% <1% <1% <1% 1.9% Somatrotroph Adenoma Densely granulated adenoma Sparsely granulated adenoma GH ± PRL ± α subunit Pit 1 LMW CK : perinuclear or diffuse GH ± PRL LMW CK : fibrous bodies Mammosomatotroph adenoma GH + PRL (in same cell) ± α subunit Pit 1, ERɑ Mixed Somatotroph Lactotroph adenoma GH + PRL (in different cells) ± α subunit Pit 1, ERɑ Pit 1 Lactotroph Adenoma Sparsely granulated adenoma PRL Pit 1, ERɑ Densely granulated adenoma PRL Pit 1, ERɑ Acidophilic stem cell adenoma PRL, GH (focal and inconstant) LMW CK : fibrous bodies (inconstant) Thyrotroph Adenoma βtsh, α subunit Pit 1, GATA2 Corticotroph Adenoma Densely granulated adenoma ACTH, LMW CK : diffuse pattern Tpit Sparsely granulated adenoma ACTH, LMW CK : diffuse pattern Tpit Crooke s cell adenoma ACTH, LMW CK : ring like pattern Tpit Gonadotroph adenoma Sparsely granulated βfsh, βlh, α subunit (various combinations) SF 1, GATA2, ERɑ (variable) Null cell adenoma None None Age αsu+ ACTH a few ACTH Silent corticotroph adenoma Plurihormonal adenomas Plurihormonal Pit 1 positive adenoma GH, PRL, βtsh ± α subunit (previously termed Silent subtype 3 adenoma) Pit 1 Adenomas with unusual immunohistochemical Various combinations combinations other transcription factors variable Double adenomas Distinct adenomas Usually PRL and ACTH adenomas Pit 1 and Tpit, respectively most common subtype; LMW CK: low-molecular weight cytokeratin Table 2 Additional parameters that may be added to the morphofunctional types WHO 2017 Tumor size Microadenoma, Macroadenoma, Giant adenoma Tumor clinically presentation Clinically functioning, clinically non functioning, silent Invasiveness on MRI (Knosp s grade) Invasive, non invasive (grades : 1, 2, 3, 4) Metastasis or spinal spread Carcinoma Additional immunohistochemistry Chromogranin A Keratin (Low molecular weight): CK 7/8 (CAM 5.2), CK18 Proliferative markers: Ki 67, p53 (in limited cases) Transcription factors and co factors: Pit 1, SF 1, ERɑ, Tpit, GATA2, Neuro D1 Predictive therapeutic factors: SSTR2/5, MGMT, MSH6 Biomarkers of aggressiveness Fibrous bodies Sparsely granulated Somatotroph adenoma Crooke cell Corticotroph adenoma Pituitary carcinomas Ki67 index Invasion, spread and metastases Functioning or non-functioning Ki67 >20% 4/11 36% Ki67 >10% 8/11 73% 6

7 3/22/2017 Ki67 higher than 20-30% would indicate carcinoma in situ or premetastatic intrasellar pituitary carcinoma 20M Aggressive pituitary adenoma Knosp Grade 4 Ki67 23% p53 80% Pituitary adenoma with aggressive nature 20M Aggressive pituitary adenoma Knosp Grade 4 Ki67 23% p53 80% Post-operative Residual tumor PRL αsu GCC GTC Ex8 A276V P53 Point mutation Ki67 p５３ 7

8 20M Aggressive pituitary adenoma Knosp Grade 4 Ki67 23% p53 80% P53 mutation and residual tumor Pituitary carcinoma in situ(premetastatic)? Needs follow-up and aggressive treatment? Radiation Octreotide Pasireotide Temozolomide(TMZ) Other Chemotherapies Summary 1. Majority(more than 80%) of pituitary adenomas show Ki67 index lower than 3%. 2. Ki67 index does not always correlate with invasion or aggressive behavior 3. Higher Ki67 index may be associated with aggressive behavior 4. WHO classification(who 2017) does not recommend atypical adenoma (WHO 2004) 5. Morphologic changes, sparsely granulated somatotroph adenoma, Crooke s adenoma, correlate aggressive behavior. 6. Some biomarkers may be helpful to predict prognosis 7. Pituitary carcinomas in general demonstrate higher Ki67 index, but some cases revealed low Ki67 index. 1. Typical and atypical adenomas(who 2004) 2. How much does Ki67 indices contribute to predict aggressive pituitary adenomas 3. Adenoma subtypes and aggressive nature 4. Pituitary carcinoma and Ki67 High-risk pituitary adenomas Rapid growth Radiological invasion High Ki67 proliferative index Clinically aggressive pituitary adenoma WHO 2017 Thank you very much for your kind attention 8