Impact of immunostaining of pulmonary and mediastinal cytology Harman Sekhon MD, PhD Director of Cytopathology Head of Ottawa-site Ontario Tumour Bank June 20, 2014
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OBJECTIVES To understand the limitations of cytomorphological features in achieving the specific diagnosis To know the role of ancillary studies in cytological diagnoses of lung and mediastinal neoplasms To understand the implications of delivering information of specific cellular differentiation in lung cancer oncology practice
Lung Tumours Central (1) Squamous cell Carcinoma (70%- 75%) Small cell Carcinoma (90%-95%) Adenocarcinoma (5%-10%) Typical carcinoid Peripheral (2) Adenocarcinoma (80%) Squamous cell carcinoma (25%- 30%) Atypical carcinoid SCLC (5%-10%) Metastatic (Mostly), multiple 1 Pleural (3) Adenocarcinoma (rare) Mesothelioma 3 2
TRENDING CYTOLOGY Molecular era: Shift in oncology practice and expectations Diagnostic pathway: less invasive, cost effective, reliable, optimal Cytomorphological features: Reliability for specific cellular differentiation Ancillary studies: Knowledge and interpretation skills Cytology Radiology Correlation: Understanding and integration Ground glass, spiculated, circumscribed Solid, cavitary, consolidation Solitary, multiple, location Specific diagnoses: Translations and implications
CYTOLOGY: IMPLICATIONS Standard chemotherapy ADC more responsive to Gemcitabine + Docetaxel Non-ADC more responsive to Cisplatin + Docetaxel Targeted chemotherapies VEGF inhibitor (i.e Bevacizumab): Contraindicated in SQCC - EGFR mutation (i.e. Erlotinib, Gefitinib): Adenocarcinoma (race, age, gender, smoking status) - ALK gene-rearrangement (i.e. Crizotinib): Adenocarcinoma - ROS gene-rearrangement (i.e. Crizotinib): Adenocarcinoma Predictor and prognostic markers Type of adenocarcinomas have higher frequency of gene aberrations (mucinous and signet ring for ALK gene) Patient management: Response and outcome Patient quality of life: Therapy administration and toxicity
CYTOLOGY: EVOLUTION Sekhon et al. Thorac Surg Clin. 2013;23:163-78
CYTOLOGICAL AND SMALL BIOPSY DIAGNOSIS Adenocarcinoma: features suggestive of lepidic growth pattern (note: invasive component cannot be excluded) 2004 WHO AND 2011 ADENOCARCINOMA CLASSIFICATION Non-mucinous AIS(<3 cm), MIS(<3 cm with <0.5 cm invasion) and lepidic predominant (>3 cm) Mucinous adenocarcinoma (Describe pattern if identifiable) Mucinous AIS, MISand predominant pattern (lepidic, acinar, papillary, micropapillary, solid) Adenocarcinoma: features suggestive of identifiable growth pattern Adenocarcinoma with fetal pattern Adenocarcinoma with colloid pattern Adenocarcinoma (pattern) with signet ring or clear cell features Non-small carcinoma, favour adenocarcinoma (immunophenotypically consistent with adenocarcinoma) Squamous cell carcinoma (morphologically squamous cell differentiation present) Non-small carcinoma, favour squamous cell carcinoma (immunophenotypically consistent with squamous cell carcinoma) Predominant growth pattern (acinar, papillary, micropapillary and solid) Fetal Adenocarcinoma 8Mucinous or colloid adenocarcinoma Signet ring or clear cell adenocarcinoma Mostly solid pattern Squamous cell carcinoma (papillary, clear cell, small cell, basiloid variants) Squamous cell carcinoma
CYTOLOGICAL AND SMALL Bx DIAGNOSIS Small cell carcinoma Non-small cell carcinoma, not otherwise specified (NOS) (no clear immunohistochemical profile to favour adenocarcinoma or squamous cell carcinoma) Non-small cell carcinoma with neuroendocrine morphology (positive NE stains) Non-small cell carcinoma with neuroendocrine morphology (negative NE stains) Note: LCNEC suspected but immunohistochemical stains (IHC) failed to demonstrate NE differentiation 1. Non-small cell carcinoma with squamous and adenocarcinoma morphology 2. Non-small cell carcinoma, NOS (IHC demonstrates squamous cell and adenocarcinoma differentiation) Comment: It could represent adenosquamous carcinoma 2004 WHO AND 2011 ADENOCARCINOMA CLASSIFICATION Small cell carcinoma Large cell carcinoma Large cell neuroendocrine carcinoma (LCNEC) Large cell carcinoma with NE morphology (LCNEC) Adenosquamous carcinoma Poorly differentiated non-small cell carcinoma with spindle and/or giant cell carcinoma (mention if squamous cell or adenocarcinoma differentiation present) Sarcomatoid carcinoma Travis W et al. J Thorac Oncol. 2011;6:244-85
CYTOLOGY: TISSUE ISSUE EBUS (lymph nodes for staging, central tumours, mediastinal tumours) EUS (lymph nodes not accessible with EBUS) Image-guided FNA (lung, pleural, chest wall, mediastinal tumours) Bronchial brush and wash Broncho-alveolar lavage Effusions Adequate specimen is the key!!!!
FNA Requisition and ROSE Two extra passes submitted in formalin for cell block after establishing rapid on site adequacy (ROSE)
LUNG CYTOLOGY: FNA Sekhon et al. Thorac Surg Clin. 2013;23:163-78
ADC and SQCC Smear CB
Squamous cell carcinoma Smear CB CK5/6 P40
Adenocarcinoma Smear CB TTF-1 Surfactant-A
NSCLC: Cytology +/- IHC IHC is not 100% sensitive and specific Ancillary studies!!! SQCC: p40/p63+, CK5/6+, CK7+/-, TTF-1- ADC: p40/p63-, CK5/6-, CK7+, TTF-1+/- Diagnosis of SQCC and ADC (2000-4 and 2005-10) (R. Ocque et al., Am J Clin Pathol. 2011; 136:81-7) Cytomorphology alone: 75.1% vs 40.7% Increase in IHC use: 11% to 89% vs 14.1% to 85.9% Increase in diagnostic accuracy: ADC: 56% -> 83.2 SQCC : 77% -> 74%
?: Case 1 Case 2
Dual IHC: Case 1 Adenocarcinoma TTF-1 + Napsin P63 + CK5/6 TTF-1 + Napsin
Dual IHC: Case 2 Squamous cell Carcinoma P63 + CK5/6 TTF-1 + Napsin P63 + CK5/6
Utility of IHC in NSCLC Immunostains Adenocarcinoma Squamous cell carcinoma TTF-1 78-89% 6% Napsin-A 84% 21% Surfactant-A 54% 2% P40/p63 0% / 23-32% 96%/ 97% CK5/6 12-18% 93% Dual stains help conserve tissue for molecular tests
CYTOLOGY: IHC Panel (Canadian consensus recommendations, 2011) H&E TTF-1 p63/p40 CK5 ADC SQCC Mucin stains: Only 30% ADC contain mucin vacuoles
CYTOLOGY: NSCLC IHC Diffuse TTF-1 staining more specific for adenocarcinoma Minimal overlap between TTF-1 and p63+ck5/6 (Rekhtman et al., Mod Pathol. 2011; 24:1348-59) Small number of adenocarcinomas are positive for p63, CK5/6 and 34BE12 34BE12 is not a good marker for squamous cell as P63- P63+ P63++ TTF-1++ ADC (84% any) ADC ADC TTF-1+ ADC ADC (6%) SQCC (3%) TTF-1- ADC (10%) INDET (1% + CK5/6 SQCC) SQCC (96%) (Rekhtman et al., Mod Pathol. 2011; 24:1348-59)
Case 3 65 yrs old gentleman, smoker (44 pack yrs) 7.1 x 5.9 cm mass in the left upper lobe, previously 5.8 x 5.3 cm; 1.7 x 2.0 cm mass in the left lower lobe Multiple granulomas are seen bilaterally Multiple enlarged lymph nodes Right hilar: 2.9 x 2.8 cm 6 cm mass in stomach assumed as GIST, YTD PH: Melanoma resected 10 yrs ago 2 MIs, stenting, cardiomegaly, CHF
Case 3: FNA Ddx: Sarcomatoid SQCC, melanoma, sarcoma
Sarcomatoid carcinoma CK7 Vim TTF-1 p40
Adeno-squamous
FNA LUNG MASS: ALK At least 50 countable tumour cells are required for FISH
IHC: SPECIFIC DIAGNOSIS 25% of NSCLC are poorly differentiated 70% of NSCLC cases are non-resectable Any mediastinal lymph node positive (N2, levels 1-9) Greater than 4 cm (ECOG score, chemo) Multiple tumours Clinical stage T3a and above: Invasion into chest wall, mediastinum and invasion into the other structures Distant metastasis Molecular testing? All cases except pure squamous cell carcinoma, pure small cell carcinoma, pure neuroendocrine carcinomas (including carcinoids) All cases where adenocarcinoma component cannot be excluded including in squamous or small cell with appropriate clinical criteria
Case 4: NEUROENDOCRINE TUMOURS 55 year man, non-smoker Presented with a non-resolving productive cough for three months Abnormal chest X-ray followed by CT showed left lung, central mass (4.2 x 4.0 cm), circumscribed, partially occluding the main bronchus Consolidation of upper lobe Fine needle aspirate performed
Case 4: FNA LUL MASS
Case 4: FNA LUL, IHC- TYPICAL CARCINOID AE1/AE3 TTF-1 Synaptophysin Ki-67
Pneumonectomy: ATYPICAL CARCINOID
Case 5: Station 7 Lymph node: FNA 51 yrs woman, 48 pack yrs smoker Ill-defined central mass with bronchial thickening 21 kg weight loss over 3 months, fatigued, lethargic Multiple mediastinal lymph nodes enlarged, FNA performed
Case 5: Station 7 Lymph node: FNA
Case 5: Station 7 Lymph node: IHC AE1/AE3 Ki-67 Dx: Small cell carcinoma
Case 6: Combined Small cell and ADC
Case 6: Combined Small cell and ADC CB Syn CD56 TTF-1
IHC: NEUROENDOCRINE TUMOURS Antibodies TC AC SCLC LCNEC NSCLC Synaptophysin + + + + Focal <20% CD56 + + + + Focal <20% Chromo + + +/- + - TTF-1 +/- +/- + +/- AD+/SQ- PANCK + + Dot-like + + Ki-67 0-5% (~2%) 5-20% (~10%) >25% (~70%) >25% (~40%) Variable Modified from Rekhtman N. Arch Pathol Lab Med.2010;134:1628 1638)
Case 7 58 year old man, smoker, AA, DA Cough for 1 month slowly resolved with antibiotics CT finding: Incidental, 2.3 x 2.2 cm cirumscribed, left upper lobe mass followed for three months with small increase in size No symptoms CT-Guided FNA performed
Case 7: LUNG MASS
INTRAPULMONARY B2 THYMOMA PAN-CK CD99 CD1a TdT
MEDIASTINAL MASS: TYPE A THYMOMA Thymoma and carcinoma Thyroid carcinoma Teratoma and other germ cell tumours T-cell lymphoma Tumour metastasis PAN-CK TdT
Case 8 58 yrs female, non-smoker 1.2 cm right middle lobe lesion, circumscribed, paracentral 4R lymph node enlarged 1.5 cm History: Colon Carcinoma 2012, Breast Ca 1999 EBUS of 4R
Case 8: FNA: EBUS 4R Lymph node TTF-1
Case 8: Metastatic Breast Ca Mammaglobin GATA3 ER PR
LUL MASS: Clear cell renal carcinoma Sekhon et al. Thorac Surg Clin. 2013;23:163-78
RUL MASS: UCC metastasis CK7 CK20 GATA-3 p63
Common metastasis: IHC Profile IHC Lung Colon Breast Thyroid UCC CK7 + - + + + CK20 - + - - +/- TTF-1 + - - + - CDX2 - + - - - ER - - + - - Mammaglobin - - + - - GATA-3 - - + - + PAX8 - - - + + Thyroglobulin - - - + -
Test Case: Question 67 yrs old gentleman, current smoker, laryngeal squamous cell carcinoma 5 years ago, presented with a paracentral, circumscribed, 5.5 cm mass with N2 nodes positive for metastasis. FNA was done and immunostains performed showed the following profile: CK5 p40 CK7 TTF-1
Question: 1. Treatment with Bevacizumab is contra-indicated in this patient 2. ALK stain to determine ALK gene-rearrangement and EGFR mutation analysis should be performed for treatment with Gefitinib or Crizotinib 3. This neuroendocrine carcinoma and the patient would need radiation therapy and surgery 4. This is metastasis from the laryngeal carcinoma
Question: Answer 1. Treatment with Bevacizumab is contra-indicated in this patient 2. ALK stain to determine ALK gene-rearrangement and EGFR mutation analysis should be performed for treatment with Gefitinib or Crizotinib 3. This neuroendocrine carcinoma and the patient would need radiation therapy and surgery 4. This is metastasis from the laryngeal carcinoma