Diagnosis and Classification of Neuroendocrine Lung Tumors Jeffrey L. Myers, M.D. A. James French Professor Director, Anatomic Pathology & MLabs University of Michigan, Ann Arbor, MI myerjeff@umich.edu Lost In Processing Neuroendocrine Lung Neoplasms As a result of this presentation, attendees who were fully engaged will be able to, apply criteria for separating low grade from high grade neuroendocrine tumors, and articulate the clinical, biological, histologic, immunohistochemical, and molecular overlap between them. Neuroendocrine Lung Neoplasms Classification WHO* Typical carcinoid Atypical carcinoid Small cell carcinoma Large cell neuroendocrine carcinoma Other Well differentiated/ low grade Moderately differentiated/ intermediate grade Poorly differentiated/ high grade Neuroendocrine carcinoma *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004.
Neuroendocrine Lung Neoplasms Classification WHO* Typical carcinoid Atypical carcinoid Small cell carcinoma Large cell neuroendocrine carcinoma Other Well differentiated/ low grade Moderately differentiated/ intermediate grade Poorly differentiated/ high grade Neuroendocrine carcinoma *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004. TYPICAL CARCINOID TUMOR ~ 75% central ~ 25% peripheral TYPICAL CARCINOID TUMOR Definition* neuroendocrine growth pattern organoid, trabecular, insular, palisading, ribbon, rosette-like *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004.
organoid, trabecular, insular, palisading, ribbon, rosette-like organoid, trabecular, insular, palisading, ribbon, rosette-like organoid, trabecular, insular, palisading, ribbon, rosette-like
uniform cytology ± atypia TYPICAL CARCINOID TUMOR Definition* neuroendocrine growth pattern uniform cytology ± atypia < 2 mits/2 mm 2 no necrosis *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004. Neuroendocrine Lung Neoplasms Classification WHO* Typical carcinoid Atypical carcinoid Small cell carcinoma Large cell neuroendocrine carcinoma Other Well differentiated/ low grade Moderately differentiated/ intermediate grade Poorly differentiated/ high grade Neuroendocrine carcinoma *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004.
ATYPICAL CARCINOID TUMOR Definition* neuroendocrine growth pattern uniform cytology ± atypia 2-10 mits/2 mm 2, and/or necrosis *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004. TYPICAL VS. ATYPICAL CARCINOID TUMOR Ha et al. Lung Cancer 2013; 80: 146 Histology Typical (40) Atypical (23) p value rosettes 0 6 (26%).001 parenchymal invasion* 5 (13%) 9 (39%).01 vascular invasion 0 3 (13%).04 lymphatic invasion 2 (5%) 6 (26%).04 abundant basophilic cytoplasm 10 (25%) 0.01 * invasion to the adjacent lung parenchyma with an infiltrative border
TYPICAL VS. ATYPICAL CARCINOID TUMOR Ha et al. Lung Cancer 2013; 80: 146 invasion to the adjacent lung parenchyma with an infiltrative border moderate marked * ATYPICAL CARCINOID TUMOR Comparison with Typical Carcinoid from Garcia-Yuste et al. Eur J CV Surg 2007 (n = 661 surgical patients) Survival 5 years 10 years typical carcinoid 89-99% 82-93% atypical carcinoid 61-78% 35-67% ATYPICAL CARCINOID TUMOR Definition* 97 (91.5%) of 106 cases had neuroendocrine 2 mits/2 mm 2 growth pattern Beasley et al Hum Pathol 2000; 31: 1255 uniform cytology ± atypia 2-10 mits/2 mm 2 *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004.
TYPICAL VS. ATYPICAL CARCINOID TUMOR Ha et al. Lung Cancer 2013; 80: 146 Mitoses ATYPICAL CARCINOID TUMOR Definition* 71 (67%) of 106 cases had neuroendocrine necrosis growth pattern Beasley et al Hum Pathol 2000; 31: 1255 uniform cytology ± atypia 2-10 mits/2 mm 2 ± necrosis *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004. Neuroendocrine Lung Neoplasms Classification WHO* Typical carcinoid Atypical carcinoid Small cell carcinoma Large cell neuroendocrine carcinoma Other Well differentiated/ low grade Moderately differentiated/ intermediate grade Poorly differentiated/ high grade Neuroendocrine carcinoma *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004.
SMALL CELL CARCINOMA General cigarette smoking ~ 15% of incident cases men women (~1-2:1) central >> peripheral SMALL CELL CARCINOMA General clinical stage (n=7,960 ) I 7% II 4% III 32% IV 57% clinical stage (n=4,532 ) limited 45% extensive 55% from Shepherd et al. J Thorac Oncol 2007 SMALL CELL CARCINOMA General clinical stage (n=4,532 ) limited 45% extensive 55% from Shepherd et al. J Thorac Oncol 2007 Survival (n = 7,960 ) cstage % of pts 1 year 5 years I 7% 41% 28% II 4% 73% 21% III 32% 54% 11% IV 57% 22% 1%
SMALL CELL CARCINOMA WHO Definition malignant epithelial tumor consisting of, small cells with scant cytoplasm, ill-defined cell borders usually less than the size of three small resting lymphocytes WHO size rule 3 x lymphocyte diameter SMALL CELL CARCINOMA WHO Definition small cells with scant cytoplasm, illdefined cell borders
SMALL CELL CARCINOMA WHO Definition small cells with scant cytoplasm, illdefined cell borders finely granular nuclear chromatin, and absent or inconspicuous nucleoli finely granular chromatin absent/inconspicuous nucleoli In 29 cases, a varying percentage of cells demonstrated nucleoli that were conspicuous but small. Nicholson et al. AJSP 2002
SMALL CELL CARCINOMA WHO Definition small cells with scant cytoplasm, illdefined cell borders finely granular nuclear chromatin, and absent or inconspicuous nucleoli cells are round, oval and spindleshaped; nuclear molding is prominent round, oval and spindle-shaped nuclear molding is prominent
nuclear spooning is prominent spooning high mitotic count (>10/2 mm 2 )
Regional Pathologists SMALL CELL CARCINOMA WHO Definition small cells with scant cytoplasm, illdefined cell borders finely granular nuclear chromatin, and absent or inconspicuous nucleoli cells are round, oval and spindleshaped; nuclear molding is prominent mitotic count is high (>10/2 mm 2 ) CLASSIFICATION OF LUNG TUMORS Rates of Diagnostic Agreement SqCC Adca LCC SCLC SCLC SqCC Adca LCC Mixed Other 0% 25% 50% 75% 100% Central Pathologist N = 668 (tissue ± cytology specimens) SCLC highest rates of agreement (92%, Κ = 0.82) Stang et al. Lung Cancer 2006; 52: 29-36 WHO IASLC WHO (1981) (1988) (1999-2004) oat cell small cell small cell intermediate cell SMALL CELL CARCINOMA Histologic Variants mixed small/large cell combined combined combined small cell small cell small cell
small cell & adenocarcinoma Neuroendocrine Lung Neoplasms Classification WHO* Typical carcinoid Atypical carcinoid Small cell carcinoma Large cell neuroendocrine carcinoma Other Well differentiated/ low grade Moderately differentiated/ intermediate grade Poorly differentiated/ high grade Neuroendocrine carcinoma *Travis et al (editors). WHO Classification of Tumours. Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, Lyon 2004. LARGE CELL CARCINOMA WHO 2004 poorly differentiated NSCLC that lacks cytologic and architectural features of SCLC and glandular or squamous differentiation
LARGE CELL CARCINOMA WHO 2004 poorly differentiated NSCLC that lacks cytologic and architectural features of SCLC and glandular or squamous differentiation 5 variants: large cell neuroendocrine basaloid carcinoma lymphoepithelioma-like carcinoma clear cell carcinoma large cell ca with rhabdoid phenotype LARGE CELL NEUROENDOCRINE CARCINOMA Definition neuroendocrine morphology
LARGE CELL NEUROENDOCRINE CARCINOMA Definition neuroendocrine morphology necrosis (extensive) >10 mitosis/2 mm 2 (10 hpf) cytologic features of NSCLC: large size, low N:C, nucleoli, coarse chromatin
LARGE CELL NEUROENDOCRINE CARCINOMA Definition neuroendocrine morphology necrosis (extensive) >10 mitosis/2 mm 2 (10 hpf) cytologic features of NSCLC: large size, low N:C, nucleoli, coarse chromatin immunohistochemical confirmation chromogranin LARGE CELL NEUROENDOCRINE CARCINOMA Comparison with Atypical Carcinoid Asamura et al. J Clin Oncol 2006; 24: 70-6 atypical carcinoid LCNEC NE morphology necrosis ± atypia mitotic rate 2-10/2 mm 2 >10/2 mm 2
LARGE CELL NEUROENDOCRINE CARCINOMA Comparison with Atypical Carcinoid atypical carcinoid LCNEC 10 mits/2 mm 2 LARGE CELL NEUROENDOCRINE CARCINOMA Comparison with Small Cell Carcinoma small cell ca LCNEC 3 x lymphocytes, nucleoli, cytoplasm Hypothesis: LCNEC & SCLC are different They look (and stain) differently. They behave differently. They are genetically distinct.
Large Cell Neuroendocrine Carcinoma Definition neuroendocrine morphology necrosis (extensive) >10 mitosis/2 mm 2 (10 hpf) cytologic features of NSCLC: large size, low N:C, nucleoli, coarse chromatin LCNEC vs immunohistochemical confirmation SCLC Large Cell Neuroendocrine Carcinoma Definition Is cell size a reliable criterion for separating large cell neuroendocrine carcinoma from small cell carcinoma? Marchevsky et al. Am J Clin Pathol 2001; 116: 466. SCLC vs LCNEC Nuclear Size Overlap n = 12 LCNEC and 16 SCLC measured tumor cell (TC) and lymphocyte (L) nuclear areas histograms for each peak TC/L: A = 2 B = 3 C = 4 D = 5 E = 6 F no peak 100 50 0 e.g. type A (peak TC/L = 2) 1 2 3 4 5 6 7
8 7 6 5 small SCLC vs LCNEC Nuclear Size Overlap 5 (31%) of 16 SCLC had predominant population SCLC of cells 4-6 times larger LCNEC than lymphocytes 4 3 2 1 * * * large 0 TC/L = 2 (Type A) TC/L = 3 (Type B) TC/L = 4 (Type C) TC/L = 5 (Type D) TC/L = 6 (Type E) no peak (Type F) Marchevsky et al. Am J Clin Pathol 2001; 116: 466. SCLC vs LCNEC Role of Immunohistochemistry 100% 50% c-kit pos bcl-2 pos c-kit/bcl-2 pos c-kit/bcl-2 expression in SCLC & LCNEC 0% typical carcinoid (16) atypical carcinoid (6) small cell ca (7) LCNEC (14) LaPoint et al. Appl IHC Mol Morphol 2007; 15: 401-6 SCLC vs LCNEC Role of Immunohistochemistry 90% 60% 30% Diffuse (> 10%) 2-3+ intensity PAX-5 expression in SCLC & LCNEC 0% typical carcinoid (44) atypical carcinoid (7) small cell ca (26) LCNEC (3) Sica et al. Am J Clin Pathol 2008; 129: 556-62
SCLC vs LCNEC Role of Immunohistochemistry 100% POSITIVE EQUIVOCAL 80% NEGATIVE 60% 40% 20% 0% typical carcinoid (31) atypical carcinoid (15) small cell ca (54) LCNEC (4) CRMP5 expression in SCLC & LCNEC Meyronet et al. Am J Surg Pathol 2008; 32: 1699-708 SCLC vs LCNEC Role of Immunohistochemistry 100% 80% SCLC LCNEC p.0018 p.0422 p.0150 60% p.0022 p.0369 40% 20% 0% CRG SYN CD56 mash1 NeuroD TTF p63 p16 PTEN Hiroshima et al. Mod Pathol 2006; 19: 1358 SCLC vs LCNEC Role of Immunohistochemistry 100% 80% 60% FoxM1 p27kip1(high) p21waft1/cip1(+) 40% 20% 0% TC (19) AC (6) LCNEC (17) SCLC (18) Ha et al. Histopathology 2012; 60: 731-9
Large Cell Neuroendocrine Carcinoma Conclusion Neither cell size nor immunohistochemistry reliably separate large cell neuroendocrine carcinoma from small cell carcinoma. Large Cell Neuroendocrine Carcinoma Definition neuroendocrine morphology necrosis (extensive) LCNEC vs >10 mitosis/2 mm 2 other NSCLC (10 hpf) cytologic features of NSCLC: large size, low N:C, nucleoli, coarse chromatin immunohistochemical confirmation squamous cell carcinoma organoid?
trabecular? CK5/6 p63 TTF1 POS POS NEG squamous cell carcinoma, basaloid variant ribbons?
small cell? LCNEC? CD56 SYN Neuroendocrine Lung Tumors Diagnostic Reproducibility 120 n = 170 large bxs, resections, mets 9 assessors ( special interest in lung cancer ) 80 20 (12%) = unanimous 117 (69%) = consensus ( 5) 40 0 SCLC LCNEC Comb Carcinoid Other NSCLC Unsuitable den Bakker et al. Histopathol 2010; 56: 356
Neuroendocrine Lung Tumors Diagnostic Reproducibility SCLC & LCNEC accounted for the largest number of outliers compared to the consensus diagnosis den Bakker et al. Histopathol 2010; 56: 356 Hypothesis: LCNEC & SCLC are different They look (and stain) differently. They behave differently. LCNEC versus SCLC? Survival P =.9147 Asamura, 2006 J Clin Oncol 2006; 24: 70-6
Takei 2002 LCNEC versus SCLC? Survival in Stage I Disease P =.1851 Asamura 2006 Lung cancer-specific survival by histology for patients undergoing lobectomy or bilobectomy without radiation for pt1n0 tumors SEER database 2000 2007 LCNEC versus SCLC? Survival in Stage I Disease multivariate Cox analysis demonstrated no significant differences between SCLC and LCNELC... or between OLC and LCNELC. Varlotto et al. J Thorac Oncol 2012; 6: 1050 Fig 5. Kaplan-Meier curves for overall survival stratified according to chemotherapeutic protocols in the adjuvant setting and tumor stage LCNEC is more likely to respond to chemotherapeutic strategies targeting SCLC Rossi, G. et al. J Clin Oncol 2005; 23: 8774-8785 SCLC-based = platinum-etoposide
Hypothesis: LCNEC & SCLC are different They look (and stain) differently. They behave differently. They are genetically distinct. 2,803 differentially expressed genes Lancet 2004; 363 (9411): 775 unsupervised hierarchical clustering neuroendocrine tumors (38) typical (12) & atypical (1) carcinoids pure small cell ca (15) small cell & adca (2) pure LCNEC (6) LCNEC & adca (2) large cell carcinoma (13) well differentiated adenocarcinoma (12) normal (30) Lancet 2004; 363 (9411): 775 Most SCLC & LCNEC were comingled in 2 related but distinct groups HGNT1 HGNT2 HGNT3 4 pure SCLC 1 SCLC & adca 1 pure LCNEC 8 pure SCLC 4 pure LCNEC 2 pure SCLC 1 pure LCNEC 1 LCC
Lancet 2004; 363 (9411): 775 genetic profiles, but not histologic classification, separated patients with high grade NE tumors into prognostically distinct groups Hypothesis: LCNEC & SCLC are different They look (and stain) differently. They behave differently. They are genetically distinct. Large Cell Neuroendocrine Carcinoma Comparison with Small Cell Carcinoma small cell ca LCNEC 3 x lymphocytes, nucleoli, cytoplasm
Large Cell Neuroendocrine Carcinoma Practical Approach? LCNEC? any way to make this SCLC? finely dispersed chromatin? inconspicuous nucleoli? scant cytoplasm? is cell size the only issue? clinical context? central mass in smoker with mediastinal adenopathy? Large Cell Neuroendocrine Carcinoma Practical Approach? any way to make this SCLC? YES! SCLC Large Cell Neuroendocrine Carcinoma Practical Approach? any way to make this SCLC? NO compelling reason to acknowledge neuroendocrine differentiation? LCNEC already diagnosed IHC stains and it really, really looks neuroendocrine but atypical carcinoid been called SCLC but it isn t
Large Cell Neuroendocrine Carcinoma Practical Approach? LCNEC any way to make this SCLC? NO compelling reason to acknowledge neuroendocrine differentiation? YES! Large Cell Neuroendocrine Carcinoma Practical Approach? LCC, sq cell ca, adca any way to make this SCLC? NO NO compelling reason to acknowledge neuroendocrine differentiation? Neuroendocrine Lung Neoplasms As a result of this presentation, attendees who were fully engaged will be able to, apply criteria for separating low grade from high grade neuroendocrine tumors, and articulate the clinical, biological, histologic, immunohistochemical, and molecular overlap between them.