Ultrastructural Pathology Society, Seattle, March, 2016 Small Round Cell Tumors in Soft Tissue and Bone ACCME/Disclosure Dr. Fisher has nothing to disclose Cyril Fisher MA MD DSc FRCPath Professor of Tumor Pathology Royal Marsden Hospital and Institute of Cancer Research University of London UK Adult Small Round Cell Tumors Ewing Sarcoma Ewing sarcoma Ewing sarcoma-like tumors Desmoplastic small round cell tumor Mesenchymal chondrosarcoma Small cell osteosarcoma Poorly differentiated synovial sarcoma Small cell MPNST Myoepithelial tumor Clear cell sarcoma like tumor of GI tract NE carcinoma, lymphoma, melanoma Endometrial stromal sarcoma Seminoma Any age mostly young adults Bone or soft tissue Thorax, paravertebral Abdomen Lung/chest wall Skin Aggressive 1
Ewing Sarcoma Ewing Sarcoma Ewing Sarcoma Small round cell Atypical large cell Adamantinoma-like Clear cell Sclerosing CD99 CD99 + CK ± S100 pr ± CD56 ± CK FLI1 ± ERG ± NKX2.2 + Folpe 2005; Llombart-Bosch 2009 NKX2.2 Ewing Sarcoma: Ultrastructure NK2 homeobox 2, at 20p11.22 (target of EWSR1-FLI1) Ewing sarcoma >90% Olfactory neuroblastoma 80-100% Small cell carcinoma 25-30% Mesenchymal chondrosarcoma 33-75% PD synovial sarcoma 13% Desmoplastic SRCT 0% Merkel cell carcinoma 0% *1 of CIC-DUX4 sarcoma, DSRCT, neuroblastoma, myoepithelial ca Yoshida 2012;* Hung 2016 2
Ewing Sarcoma Ewing Sarcoma and ES-like Tumors Primitive cells Scanty cytoplasm Few organelles Rare tonofilaments junctions neural processes Glycogen t(11;22)(q24;q12) t(21;22)(q22;q12) t(2;22)(q35;q12) t(7;22)(p22;q12) t(17;22)(q12;q12) inv(22)t(1;22)(q12;q12) t(2;22)(q31;q12) t(20;22)(q13;q12) t(4;22)(q31;q12) t(16;21)(p11;q22) t(2;16)(q35;p11) t(4;19)(q35;q13) inv(x)(p11.4p11.22) t(x;19)(q13;q13) EWSR1-FLI1 85% EWSR1-ERG 10% EWSR1-FEV EWSR1-ETV1 EWSR1-E1AF EWSR1-ZSG EWSR1-SP3 EWSR1-NFATC2 EWSR1-SMARCA5 FUS-ERG FUS-FEV CIC-DUX4 BCOR-CCNB3 CIC-FOXO4 Ewing Sarcoma with FUS-ERG fusion S100 pr Ewing Sarcoma with FUS-ERG fusion SOX10 F 27 subcutaneous lesion thigh circumscribed 2 cm diameter encapsulated CD99 ERG CD99 S100 pr ERG SOX10 NKX.2.2 FUS-ERG 3
Promiscuous Fusions EWSR1-CREB1 angiomatoid FH, clear cell sarcoma, CCSLTGIT, PPMS EWSR1-ATF1 angiomatoid FH, clear cell sarcoma, CCSLTGIT myoepithelial tumor, angiosarcoma, salivary HCCC, CCOC ETV6-NTRK3 infantile fibrosarcoma, inflammatory myofibroblastic tumor, mesoblastic nephroma, AML, secretory ca breast, mammary analogue secretory carcinoma of salivary glands, GIST ASPSCR1-TFE3 alveolar soft part sa, juvenile renal cell carcinoma TMP3-ALK inflammatory myofibroblastic tumor, anaplastic large cell lymphoma YWHAE-NUTM22A/B endometrial stromal sarcoma, clear cell sarcoma of kidney FUS-ERG Ewing sarcoma, AML BRD4-NUT Ewing-like sarcoma, thymic & other carcinomas Ewing Sarcoma and ES-like Tumors t(11;22)(q24;q12) t(21;22)(q22;q12) t(2;22)(q35;q12) t(7;22)(p22;q12) t(17;22)(q12;q12) inv(22)t(1;22)(q12;q12) t(2;22)(q31;q12) t(20;22)(q13;q12) t(4;22)(q31;q12) t(16;21)(p11;q22) t(2;16)(q35;p11) t(4;19)(q35;q13) inv(x)(p11.4p11.22) t(x;19)(q13;q13) EWSR1-FLI1 85% EWSR1-ERG 10% EWSR1-FEV EWSR1-ETV1 EWSR1-E1AF EWSR1-ZSG EWSR1-SP3 EWSR1-NFATC2 EWSR1-SMARCA5 FUS-ERG FUS-FEV CIC-DUX4 BCOR-CCNB3 CIC-FOXO4 Tumors with CIC-DUX4 fusion CIC-DUX4 t(4;19)(q35;q13.1) t(10;19)(q26.3;q13.1) Adult or pediatric Trunk, extremities Mild pleomorphism, nucleoli Highly aggressive CD99+ (67% diffuse) CK S100pr MUC4 desmin WT1 Calretinin FLI1± ERG c-myc Graham 2012; Italiano 2012; Choi 2013; Machado 2013; Specht 2014; Yoshida 2015 ; Smith 2015 Original images courtesy Dr EA Montgomery 4
CIC-DUX4 vs Ewing sarcoma Tumors with BCOR-CCNB3 Fusion CIC-DUX ES Nuclear pleomorphism +/- - Nucleoli +/- - Myxoid change + - CD99 +/-focal uniform WT1, calretinin + + NKX2.2 - + t(x;x)(p11;p11) M, 7-13 years, trunk, extremities Bone or soft tissue 5 year survival 75%, 10 year 56% Also BCOR-MAML3, BCOR-ZC3H7B Graham 2012; Italiano 2012; Choi 2013; Machado 2013; Smith 2014; Specht 2014; Yoshida 2015 Pierron 2012; Cohen-Gogo, 2014; Puls 2014; Peters 2015 BCOR-CCNB3 E/S Mesenchymal Chondrosarcoma CD99 CCNB3 CD99+ (60%) bcl-2 (90%) CCNB3 CD117 (60%) CD99 Original images courtesy Drs F Puls and V Sumathi 5
Mesenchymal Chondrosarcoma Small Cell Osteosarcoma Ultrastructure no external lamina surface processes RER glycogen Translocation t(8;8)(q21;q13.3) HEY1-NCOA2 <1% of osteosarcoma Peak 3 rd -4 th decade Behavior like conventional OS, but limited experience 12.5 % 37 25 12.5 12.5 Image courtesy of Dr R Tirabosco Small Cell Osteosarcoma SATB2 Special AT-rich sequence binding protein 2 2q33 Ultrastructure CD99 - fibroblastic EWSR1 - EWSR1-CREB3L1 RER no external FUS lamina - glycogen CIC-DUX - pre-osteoid SATB2+ Small cell osteosarcoma 100% Undifferentiated pleo. sarcoma (bone) 50% Fibrosarcoma (bone) 45% Mes chondrosarcoma 23% Ewing sarcoma 10% DLBC lymphoma 17% Original images courtesy Dr R Tirabosco Debelenko 2011; Righi 2015, Davis 2015 Righi 2015; Davis 2015 6
Synovial Sarcoma % 100 Synovial Sarcoma 80 CK EMA 60 40 20 0 CK EMA bcl2 CD99 S100 CD34 Des SMA calret b-cat CD56 % 100 80 60 40 Synovial Sarcoma TLE1 Transducin-like enhancer of Split 9q21.32 Groucho/TLE family transcription inhibitors Derived from profiling studies Santa Cruz Biotechnology M101 1:20 Cell Marque Clone 1F5 1:200 20 0 CK EMA bcl2 CD99 S100 CD34 Des SMA calret b-cat CD56 TLE1 7
TLE1 Synovial Sarcoma Synovial sarcoma 90-100% Sometimes positive in MPNST fibrosarcoma solitary fibrous tumor mesothelioma sarcoma NOS Useful when negative Monophasic SS MPNST Poorly Differentiated SS External lamina fragmented Cell processes Junctions Kosemehmetoglu 2009; Jagdis 2009; Knosel 2009; Foo 2011 Fisher 1987 Synovial Sarcoma 8
Synovial Sarcoma Malignant Peripheral Nerve Sheath Tumor SS18 (18q11.2) SSX (Xp11.21-23) types 1, 2, 4 (of 5) SS18/SSX fusion genes 60% SSX1 40% SSX2 <1% SSX4 Fusion protein competes with wild type SS18 - loss of BAF47 > SOX2 activation > proliferation Ladanyi 2002; Guillou 2004; Baird 2005; Storlazzi 2007; Amary 2007; Nakayama 2007; Kadoch 2013 MPNST: Small cell % 100 Malignant Peripheral Nerve Sheath Tumor 80 SOX10 S100 pr 60 40 20 0 S100 CD34 bcl2 GFAP PGP Des SMA CK EMA cat calret nestin TLE1 SOX10 9
SOX10 SRY-related HMG Box 10 (22q13.1) Melanocytes, Schwann cells, myoepithelial cells, mast cells Schwannoma MPNST BPNST Schwannoma, neurofibroma, granular cell tumor MPNST 49% (SS 3%) more sensitive than S100 protein Clear cell sarcoma of soft tissue Myoepithelial tumors Salivary gland tumors Ultrastructure external lamina interdigitating processes pseudomesaxons Luse bodies Nonaka 2008; Ordonez 2013; Miettinen 2015 Malignant Peripheral Nerve Sheath Tumor 17p, 17q abnormalities NF1 (17q11.2) inactivation sporadic and in NF1 neurofibromin Ras inactivation TP53 (17p13) mutations CDKN2A (9p21) (p16 INK4A) mutations, deletion Malignant Peripheral Nerve Sheath Tumor Am J Surg Pathol. 2015 rabbit monoclonal antibody, clone C36B11 (1:200 dilution; Cell Signaling Technology, Danvers, MA). 69% of all MPNST show complete or partial loss 0% of epithelioid MPNST showed loss EGFR (7p12) Overexpression Loss of H3K27me3 expression (1q42) (sporadic and postradiation) Carroll 2012; Prieto-Grenada 2015 10
Myoepithelial Tumors of ST/Bone Malignant Myoepithelial Tumors M > F, 0-83 years (38) Limbs, HN, trunk, lung Subcutaneous > deep Circumscribed 42% myoepithelioma 25% mixed tumors 32% ca or malignant mixed tumors Stout 1959; Kilpatrick 1997; Fernandez-Figueras 1998; Michal 1999; Kutzner 2001; Mentzel 2003; Hornick 2003; Flucke 2011; Agaram 2014; Puls 2014; Huang 2015 % 100 90 80 70 60 50 40 30 20 10 Myoepithelial Tumors of ST/Bone/Lung 0 AE1/3 EMA S100 GFAP SMA Calpo Des p63 INI1 SOX10 Aggregated Data INI1 EMA Myoepithelial Tumors of ST/Bone/Lung t(6;22)(p21;q12) EWSR1-POU5F1 (4/6 malignant) t(1;22)(q23;q12) EWSR1-PBX1 (3/7 mal) t(19:22(q13;q12) EWSR1-ZNF444 (2/2 mal) t(12;22)(q13;q12) EWSR1-ATF1 (0/1 mal) t(9;22)(q33;q12) EWSR1-PBX3 (0/3 mal) t(6;16)(p21;p11) FUS-POU5F1 (0/1 mal) t(1;22))(p34;q12) EWSR1-KLF17 (0/1 mal)* t(1;16)(p34;p11) FUS-KLF17 (1/5 mal) Brandal 2008; Brandal 2009; Antonescu 2010; Flucke 2012; Agaram 2014; Puls 2014; Huang 2015; Leduc 2016 *kidney 2015 11
Myoepithelial Tumors of ST/Bone/Lung Morphology variable IHC variable EMA, S100 protein Genetics variable EWSR1, FUS Many partners Gold standard EM CCS-like Tumor of GI Tract CCS-like Tumor of GI Tract About 40 cases M>F, median 41 years Ileum > jejunum > stomach Metastasis to lymph node, liver Poor 2 year survival Large size, necrosis are adverse In bowel wall Solid sheets Discohesion Mitoses, necrosis O-L giant cells Aggressive Alpers 1985; Donner 1998; Fukuda 2000; Pauwels 2002; Zambrano 2003; Friedrichs 2005; Venkataraman 2005; Huang 2006;; Antonescu 2006; Comin 2007; Joo 2009; Lagmay 2009; Terazawa 2009; Balkaransingh 2011; Shenjere 2012; Stockman 2012; Yang 2012; Thway 2014; Yegen 2015 12
CCS-like Tumor of GI Tract CCS-like Tumor of GI Tract GI tract Soft tissue S100 pr 100% 100% HMB45 Uniform clear 0 cells in nests 97% Melan-A 0 72% Sheets of relatively small cells MiTF 0 80% CK Pseudoglandular/pseudopapillary 0 10% EMA Spindled, plasmacytoid, 0 36% rhabdoid Osteoclast-like (CD56, Clear SYN, secretory giant NF, NB84, vesicles cells SOX10) Dense-core granules Occasional gap junctions No melanogenesis Stockman 2012 CCS-like Tumor of GI Tract GI tract Soft tissue S100 pr 100% 100% HMB45 Uniform clear 0 cells in nests 97% Melan-A 0 72% Sheets of relatively small cells MiTF 0 80% CK Pseudoglandular/pseudopapillary 0 10% EMA Spindled, plasmacytoid, 0 36% rhabdoid Osteoclast-like t(2;22)(q33;q12) (CD56, SYN, giant NF, EWSR1-CREB1 NB84, cells SOX10) t(12;22)(q13;q12) EWSR1-ATF1 Tumors with EWSR1-ATF1 or EWSR1-CREB1 fusions Angiomatoid fibrous histiocytoma Clear cell sarcoma of soft tissue Clear cell sarcoma-like tumor of GIT Primary pulmonary myxoid sarcoma Myoepithelial tumor of soft tissue Angiosarcoma of salivary gland Hyalinizing clear cell salivary carcinoma Clear cell odontogenic carcinoma Thway 2012; Gru 2013; Bilodeau 2013 13
Endometrial Stromal Sarcoma Case 19 Seminoma CD10 ER PgR SMA CK H-caldesmon - Ultrastructure Fibroblastic RER, Golgi, few desmosomes, cilia JAZF1-SUZ12 Middle aged males Midline in abdomen Primary or metastatic Lymphocytes/granulomas Raised serum HCG Seminoma CD117 CK CD117 OCT3/4 SALL4 podoplanin OCT3/4 PLAP CK Ultrastructure HCG smooth nuclei rope-like nucleoli,, glycogen, few junctions annulate lamellae Small Round Cell Tumors Alveolar rhabdomyosarcoma desmin, myogenin Desmoplastic round cell tumor WT1, EMA, CK, desmin, NSE, NF, CD56 Ewing sarcoma CD99, FLI1, ERG, CK, desmin CIC-DUX4 tumors CD99, ERG, MUC4, PD synovial sarcoma TLE1, EMA, CK, CD99, CD56, bcl-2 Mesenchymal chondrosarcoma CD99 Small cell neuroendocrine carcinoma TTF1, CK, CD56, CG 14
Small Round Cell Tumors Alveolar rhabdomyosarcoma desmin, myogenin FOXO1 (+PCR) Desmoplastic round cell tumor WT1, EMA, CK, desmin, NSE, CD56 EWSR1 (+PCR) Ewing sarcoma CD99, FLI1, ERG, CK, desmin EWSR1 (+PCR) CIC-DUX4 tumors CD99, ERG, MUC4, CIC-DUX4 PD synovial sarcoma TLE1, EMA, CK, CD99, CD56, bcl-2 SS18 Mesenchymal chondrosarcoma CD99 HEY-NCOA2 Small cell neuroendocrine carcinoma TTF1, CK, CD56, CG Small Round Cell Tumors Ultrastructure Ewing sarcoma sparse organelles, glycogen, microtubules, tonofilaments DSRCT rare microtubules, DCG, glycogen, IF whorls Poorly differentiated synovial sarcoma processes, junctions, fragmented external lamina MPNST processes, external lamina, Luse bodies Mesenchymal chondrosarcoma surface villi, scalloping, glycogen E/s osteosarcoma fibroblastic, RER, glycogen, pre-osteoid Adjunctive Techniques in ST Pathology 1970 1980 1990 2000 2010 Personalisation Next Generation Sequencing Prognosis Classification Diagnosis Electron Microscopy Gene Expression Profiling Molecular Diagnosis FISH, PCR, CGH Immunohistochemistry THE END Light Microscopy 15