M. Papotti, M. VolanteUniversità di Torino
M. Papotti, M. VolanteUniversità di Torino
Tumori neuroendocrini
Il ruolo dell’anatomia patologica
Corso AME
Milano, 25 maggio 2007
Caro Mauro,….Riguardo alla tua relazione, considerato il titolo, avremmo piacere che tu affrontassi nel tempo che hai a disposizione 20 min la classificazione del neuroendocrino, i limiti della citologia in rapporto alle scelte terapeutiche, il discorso dei recettori e della loro utilità in pratica clinica.considera che sarà un corso AME (…) con un taglio decisamente pratico e questo anche per quanto riguarda l'anatomia patologica.
Invito del dr R. Cozzi
•Medullary thyroid carcinoma
•Pheochromocytoma/Paraganglioma
•Parathyroid adenoma/carcinoma
•Pituitary adenoma/carcinoma
Different diagnostic criteria and classification
for
neuroendocrine tumor classification
MENU
neuroendocrine tumor classification
MENU - History, Definition & Glossary
- Pathological classification
pure NE tumors
mixed NE/exocrine tumors
- Further characterisation
- History, Definition & Glossary
- Pathological classification
pure NE tumors
mixed NE/exocrine tumors
- Further characterisation
History
1907 “carcinoid” term Oberndorfer
1930 carcinoid syndrome Cassidy
1940/50 “helle zellen” Feyrter
1952 serotonin discovery Erspamer & Asero
1963 fore-, mid-, hind-gut carcinoids Williams &
Sandler
1965/70 APUD concept Pearse
1980 diffuse NE system WHO
1994 “neuroendocrine tumor” replaces carcinoid Capella et al
2000 classification of endocrine tumors WHO Solcia et al
History
1907 “carcinoid” term Oberndorfer
1930 carcinoid syndrome Cassidy
1940/50 “helle zellen” Feyrter
1952 serotonin discovery Erspamer & Asero
1963 fore-, mid-, hind-gut carcinoids Williams &
Sandler
1965/70 APUD concept Pearse
1980 diffuse NE system WHO
1994 “neuroendocrine tumor” replaces carcinoid Capella et al
2000 classification of endocrine tumors WHO Solcia et al
History
1907 “Karzinoid” term Siegfried Oberndorfer
History
1907 “Karzinoid” term Siegfried Oberndorfer
6 ileal tumors, slowly growing, no metastases
NE TUMORSNE TUMORS
• carcinoid, malignant carcinoid• apudoma• islet cell tumor• adenoma / microadenoma vs carcinoma• Kultchisky cell tumor / carcinoma• endocrine carcinoma• endocrine neoplasm• hormone…-oma (insulinoma, gastrinoma,..)
• pancreatic (A/B/D/PP)-cell tumor
• carcinoid, malignant carcinoid• apudoma• islet cell tumor• adenoma / microadenoma vs carcinoma• Kultchisky cell tumor / carcinoma• endocrine carcinoma• endocrine neoplasm• hormone…-oma (insulinoma, gastrinoma,..)
• pancreatic (A/B/D/PP)-cell tumor
Glossary & SynonymsGlossary & Synonyms
Neuroendocrine tumor classification
MENU
Neuroendocrine tumor classification
MENU - History, Definition & Glossary
- Pathological classification
pure NE tumors
mixed NE/exocrine tumors
- Further characterisation
- History, Definition & Glossary
- Pathological classification
pure NE tumors
mixed NE/exocrine tumors
- Further characterisation
WHICH CLASSIFICATION CRITERION ????
Clinical
Morphological
Hormonal
Ki67
Gene expression
THE BENIGNTHE MALIGNANTTHE CLINICALLY AGGRESSIVE
Incidence,
Localisation,
Endocrine function,
Symptoms,
Treatment,
Behavior,
Survival
ClinicalMorphological
Hormonal
Ki67
Gene expression
• Single or multiple
• Well demarcated or invasive
• Size 0.5-15 cm.
• Cystic appearance
• Lymph node mets
• Distant mets
• Single or multiple
• Well demarcated or invasive
• Size 0.5-15 cm.
• Cystic appearance
• Lymph node mets
• Distant mets
1 cm
Gastric micro-carcinoids
insulinoma
Macro
Clinical
MorphologicalHormonal
Ki67 Gene expression
Tumor architectureMicro
Gross features and structure are not enough for the purpose of identifying homogeneous groups with clinical relevance
Gross features and structure are not enough for the purpose of identifying homogeneous groups with clinical relevance
Clinical
MorphologicalHormonal
Ki67 Gene expression
THE BENIGN
THE MALIGNA
NT
THE CLINICAL
LY AGGRESS
IVE
19941994
20002000
CLASSIFICATION PROBLEMSCLASSIFICATION PROBLEMS
2000 WHO CLASSIFICATION2000 WHO CLASSIFICATION
• Introduces terms tumor/carcinoma (vs carcinoid) ….LUNG EXCLUDED
• Replaces neuroendocrine with endocrine
• Incorporates hormonally active tumors
(morpho-functional approach)
• Recognizes mixed exo-endocrine tumors
• Incorporates information on tumor grade
• Introduces criteria of malignancy (angioinvasion, Ki67 pancreas, only)
• Introduces terms tumor/carcinoma (vs carcinoid) ….LUNG EXCLUDED
• Replaces neuroendocrine with endocrine
• Incorporates hormonally active tumors
(morpho-functional approach)
• Recognizes mixed exo-endocrine tumors
• Incorporates information on tumor grade
• Introduces criteria of malignancy (angioinvasion, Ki67 pancreas, only)
Microscopic features of malignancy
• Depth of Depth of invasioninvasion
• Size of tumorSize of tumor• AngioinvasionAngioinvasion• High grade High grade
cellular atypiacellular atypia
GI NETS
3 TIE SYSTEM for GI NETs
• Invasion of surrounding tissues
• Size of tumor (>6 cm is suspected)
• High grade cellular atypia
• Focal or diffuse necrosis• High mitotic index• Blood or lymph vessel &
nerve invasion• Ki67 > 2%
• Invasion of surrounding tissues
• Size of tumor (>6 cm is suspected)
• High grade cellular atypia
• Focal or diffuse necrosis• High mitotic index• Blood or lymph vessel &
nerve invasion• Ki67 > 2%
Microscopic features of malignancy
Microscopic features of malignancy
PANCREATIC NETs
3 TIE SYSTEM for pancreatic NETs
Does this system fit with the clinical practice?
Is it easily applicable?
Problem of other non-carcinoid NETs (eg malignant pheochromocytoma, MTC, parathyroid carcinoma, Merkel cell carcinoma, etc…)
E. Bajetta, L. Catena, G. Procopio, E. Bichisao, L. Ferrari, S. Della Torre, S. De Dosso, S. Iacobelli, R. Buzzoni, L. Mariani and J. Rosai Is the new WHO classification of neuroendocrine tumours useful for selecting an appropriate treatment? Ann Oncol 2005 16:1374
Does this system fit with the clinical practice?
Is it easily applicable? • Benign vs uncertain behaviour in well differentiated pancreatic NETs
• Appendiceal NETs (small & invasive?)
• Mixed endocrine – exocrine tumors
• Use morphology or Ki67 first?
• The new TNM system for foregut NETs
• Extra GEP: pulmonary NETs especially intermediate grades
BENIGN vs UNCERTAIN BEHAVIORBenign
UncertainExtrapancreatic growth no noAngioinvasion no yesSize >=2 cm no yesMitoses >2 /10HPF no yesKi67 >2% no yes
BENIGN vs UNCERTAIN BEHAVIORBenign
UncertainExtrapancreatic growth no noAngioinvasion no yesSize >=2 cm no yesMitoses >2 /10HPF no yesKi67 >2% no yes
Resembles WD NET (benign), but in general: size >3 cm, mitoses >2, Ki67 >5%but above all: unequivocal signs of malignancy must be present
Resembles WD NET (benign), but in general: size >3 cm, mitoses >2, Ki67 >5%but above all: unequivocal signs of malignancy must be present
LYMPHNODE LIVERLOCAL LOCAL INVASIONINVASION
FOREGUT NET CLASSIFICATIONFOREGUT NET CLASSIFICATION
Recent proposal of a staging system for fore-gut NETs and improvement of grading system using mitoses + Ki67
Recent proposal of a staging system for fore-gut NETs and improvement of grading system using mitoses + Ki67
Difficulties in Difficulties in identifying the identifying the intermediate intermediate
entities entities
Difficulties in Difficulties in identifying the identifying the intermediate intermediate
entities entities
TC SCLC
LCNECAC
SPECTRUM OF PULMONARY NETS
Indolent clinical behaviorIndolent clinical behavior Aggressive clinical behaviorAggressive clinical behaviorIndolent clinical behaviorIndolent clinical behavior
Aggressive clinical behaviorAggressive clinical behavior
TCTC AC AC SCLC SCLCTCTC AC AC SCLC SCLC
Significantly Significantly different survivaldifferent survival
Significantly Significantly different survivaldifferent survival
Arrigoni et al 1972Arrigoni et al 1972Arrigoni et al 1972Arrigoni et al 1972
SPECTRUM OF PULMONARY NETS
<2 mitoses 3-10 mitoses >10 mitoses small cells<2 mitoses 3-10 mitoses >10 mitoses small cellsno necrosis or necrosis (necrosis) (necrosis)no necrosis or necrosis (necrosis) (necrosis)<2 mitoses 3-10 mitoses >10 mitoses small cells<2 mitoses 3-10 mitoses >10 mitoses small cellsno necrosis or necrosis (necrosis) (necrosis)no necrosis or necrosis (necrosis) (necrosis)
TCTC ACAC LCNECLCNEC SCLC SCLCTCTC ACAC LCNECLCNEC SCLC SCLC
Significantly Significantly different survival different survival p<0.0001p<0.0001
Significantly Significantly different survival different survival p<0.0001p<0.0001
Significantly Significantly different survival different survival p<0.0001p<0.0001
Significantly Significantly different survival different survival p<0.0001p<0.0001 NO significantly NO significantly
different survivaldifferent survival NO significantly NO significantly different survivaldifferent survival
Travis et al
Am J Surg Pathol 22,934,1998
SPECTRUM OF PULMONARY NETS
TCTC ACAC LCNECLCNEC SCLC SCLCTCTC ACAC LCNECLCNEC SCLC SCLC
TCTC ACAC LCNEC LCNECTCTC ACAC LCNEC LCNEC
SCLCSCLC SCLCSCLC
NO significantly NO significantly different survivaldifferent survival NO significantly NO significantly different survivaldifferent survival
Asamura et al JCO 24:70,2006
SPECTRUM OF PULMONARY NETS
Biological behaviourBiological behaviour
Degree of differentiationDegree of differentiation
LUNGLUNG
GEPGEP
TYPICAL CARCINOID
ATYPICAL CARCINOID
SMALL CELL/LARGE CELL
NE CARCINOMA
WELL DIFF. NE TUMOR
benign/borderline
WELL DIFF. NE
CARCINOMA
POORLY DIFF. NE CARCINOMA
(small/large cell)
WELL DIFF.WELL DIFF.
HIGH GRADEHIGH GRADE
POORLY DIFF.POORLY DIFF.
LOW GRADELOW GRADE
MEEC
Neuroendocrine tumor classification
MENU
Neuroendocrine tumor classification
MENU - History, Definition & Glossary
- Pathological classification
pure NE tumors
mixed NE/exocrine tumors
- Further characterisation
- History, Definition & Glossary
- Pathological classification
pure NE tumors
mixed NE/exocrine tumors
- Further characterisation
2000 WHO CLASSIFICATION
CATEGORIES RECOGNIZED1 well differentiated endocrine
tumor2 well differentiated endocrine
carcinoma3 poorly differentiated endocrine
carcinoma• 4 mixed exocrine-endocrine tumor
• (5 tumor-like lesions)
CATEGORIES RECOGNIZED1 well differentiated endocrine
tumor2 well differentiated endocrine
carcinoma3 poorly differentiated endocrine
carcinoma• 4 mixed exocrine-endocrine tumor
• (5 tumor-like lesions)
CGA
Exocrine
Endocrine
NE differentiation in colon cancer
CGA mucin
1995
pure non-NE
ca.focal
NE
non-NE ca.
Non-NE carcinomas
with NE differentiation
Breast (WHO2004)Lung (WHO2004)GI tract (WHO2003)Prostate (WHO2003)
BREAST and BREAST and COLORECTAL COLORECTAL CANCERSCANCERS
……..ANY BIOLOGICAL ..ANY BIOLOGICAL and/or CLINICAL and/or CLINICAL SIGNIFICANCE??SIGNIFICANCE??
STOMACH & STOMACH & PROSTATE PROSTATE CANCERSCANCERS
YES
NO
Y/N ? NSCLCNSCLC
>5% NE+ cells
Am J Surg Pathol August 2006LCNEC of the stomach
are significantly more aggressive than conventional ADC.
ADC-NED have also a worse prognosis than conventional ADC (borderline significance)
CGA increase during progression
Reduced survival of CGA+ cases
July 1996 Nov 1997 Oct 1999 May 2000
Rectal polyp, cancerised
Rectum resection
Local recurrence
Pelvic recurrence
Stable disease
Radical Surgery
ChTx 1 RT ChTx 2
April 2007
ADC stage B1
CgA CgA CgA
•ChTx 1: 5-FU + folic acid (6x)
•RT: 50 Grey
•ChTx 2: oxaliplatin + 5-FU + folic acid (12x)
CASE REPORT
FNAB
Oncologia
Prof Dogliotti dr Tampellini
pure NE tum.
pure non-NE
ca.focal
non-NE
focal NE
100%
100%
30% 0%
0%
mixed (collision)
NE tum. non-NE ca.
WDET - TC
WDEC - AC
PDEC – SCLC/LCNEC
Mixed NE/non-NE carcinomas
Non-NE carcinomas
with NE differentiation
Breast (WHO2004)Lung (WHO2004)GI tract (WHO2003)Prostate (WHO2003)
WHO 2000 Endocrine tumors
WHO 2000 Endocrine WHO 2004 lung
NE
non-NE30%
mixed (intermingled)
Biological behaviourBiological behaviour
Degree of differentiationDegree of differentiation
LUNGLUNG
GEPGEP
TYPICAL CARCINOID
ATYPICAL CARCINOID
SMALL CELL/LARGE CELL
NE CARCINOMA
WELL DIFF. NE TUMOR
benign/borderline
WELL DIFF. NE
CARCINOMA
POORLY DIFF. NE CARCINOMA
(small/large cell)
WELL DIFF.WELL DIFF.
HIGH GRADEHIGH GRADE
POORLY DIFF.POORLY DIFF.
LOW GRADELOW GRADE
Mixed Endo-
Exocrine Ca
LUNGLUNG
GEPGEP
TYPICAL CARCINOID
ATYPICAL CARCINOID
SMALL CELL/LARGE CELL
NE CARCINOMA
WELL DIFF. NE TUMOR
benign/borderline
WELL DIFF. NE
CARCINOMA
POORLY DIFF. NE CARCINOMA
(small/large cell)
HOW TO BREAK THE ARROW?
GEPGEP
LUNGLUNG
MEEC
Light microscopy + ……??
Neuroendocrine tumor classification
MENU
Neuroendocrine tumor classification
MENU - History, Definition & Glossary
- Pathological classification
pure NE tumors
mixed NE/exocrine tumors
- Further characterisation
- History, Definition & Glossary
- Pathological classification
pure NE tumors
mixed NE/exocrine tumors
- Further characterisation
Further characterisation
• hormonal
• Ki 67
• receptors
• molecular
Further characterisation
• hormonal
• Ki 67
• receptors
• molecular
THE BENIGNTHE MALIGNANTTHE CLINICALLY AGGRESSIVE
MARKERSMARKERSMARKERSMARKERS ChromograninsChromograninsSynaptophysinSynaptophysin
N-CAMN-CAMCytoker. 34Cytoker. 34E12E12
NSE, VMATNSE, VMATPGP9.5PGP9.5
NeurofilamentsNeurofilaments
ChromograninsChromograninsSynaptophysinSynaptophysin
N-CAMN-CAMCytoker. 34Cytoker. 34E12E12
NSE, VMATNSE, VMATPGP9.5PGP9.5
NeurofilamentsNeurofilaments
Hormones: Hormones: calcitonin, bombesin, insulin,
glucagon, somatostatin, gastrin, PP, VIP, ACTH,
serotonin, …NEW: NEW: ghrelin, cortistatin, obestatin, secretagogin secretagogin
[Virch Arch 449, 402, Oct 2006][Virch Arch 449, 402, Oct 2006]
Hormones: Hormones: calcitonin, bombesin, insulin,
glucagon, somatostatin, gastrin, PP, VIP, ACTH,
serotonin, …NEW: NEW: ghrelin, cortistatin, obestatin, secretagogin secretagogin
[Virch Arch 449, 402, Oct 2006][Virch Arch 449, 402, Oct 2006]CGA
SSTR2
Further characterisation• Ki 67 proliferation index
Further characterisation• Ki 67 proliferation index
LOWLOW HIGHHIGH
KI-67:KI-67:DIAGNOSTIC USEDIAGNOSTIC USE
2000
TTP
P = 0.043
Brizzi et al, 2007 (submitted)Brizzi et al, 2007 (submitted)
KI-67: KI-67: PROGNOSTIC PROGNOSTIC USEUSE
Prognostic value if groups are homogeneous (eg all WDCA or PDCA). Otherwise possible bias due to tumor differentiation
0 10 20 30 40 50 60 70 80 90 100 110
Months
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Cu
mu
lative Pro
po
rtion
Su
rviving
Ki67<5% Ki67>5%
P = 0.017
KI-67 in WD NE KI-67 in WD NE carcinomacarcinoma
OS OS
10 to 15% cut-o
ff
10 to 15% cut-o
ff
levels according to
levels according to
therapy modaliti
es
therapy modaliti
es
KI-67: USE for Tx STRATEGYKI-67: USE for Tx STRATEGY
SEQUENTIAL STEPS in the DIAGNOSTIC PROCESS of the PATHOLOGIST
1 Use morphology (histopathology + markers) to enter each NET case into homogeneous groups (eg WHO classification criteria)
2 Within each group, analyse known (eg Ki67) or new prognostic markers
3 Analyse molecules useful for targeted therapy, if requested
SOMATOSTATIN RECEPTORS (SSTR) SOMATOSTATIN RECEPTORS (SSTR) The pathologist has to search for SSTR presence in a tumor (YES/NO) and, if YES, provide information on SSTR subtype
The pathologist has to search for SSTR presence in a tumor (YES/NO) and, if YES, provide information on SSTR subtype
PROBLEM 1: What to search for?PROBLEM 1: What to search for?
selective SRIF analogs for single SSTR subtypes
vs
universal analog for all SSTR subtypes
selective SRIF analogs for single SSTR subtypes
vs
universal analog for all SSTR subtypes
PROBLEM 2: How to identify SSTRs?PROBLEM 2: How to identify SSTRs?
•Accessible to all laboratoriesAccessible to all laboratories•Low costLow cost•Commercial antibodies Commercial antibodies [??][??]•Applicable on archival tissues Applicable on archival tissues •Applicable on biopsies and FNAsApplicable on biopsies and FNAs•Identifies SSTR type (1-5) Identifies SSTR type (1-5) [??][??]•Need to standardize interpretationNeed to standardize interpretation
•Accessible to all laboratoriesAccessible to all laboratories•Low costLow cost•Commercial antibodies Commercial antibodies [??][??]•Applicable on archival tissues Applicable on archival tissues •Applicable on biopsies and FNAsApplicable on biopsies and FNAs•Identifies SSTR type (1-5) Identifies SSTR type (1-5) [??][??]•Need to standardize interpretationNeed to standardize interpretation
HowHow to identify SSTRs? to identify SSTRs?HowHow to identify SSTRs? to identify SSTRs?
3 Immunohistochemistry3 Immunohistochemistry3 Immunohistochemistry3 Immunohistochemistry
1 Autoradiography 1 Autoradiography
2 RT-PCR / ISH2 RT-PCR / ISH
1 Autoradiography 1 Autoradiography
2 RT-PCR / ISH2 RT-PCR / ISH
sst2
predominant membrane staining for SSTR2predominant membrane staining for SSTR2
Which SSTR antibodies for IHC ??
Which SSTR antibodies for IHC ??
Correlation SSTR-IHC with Octreotide scintigraphyCorrelation SSTR-IHC with Octreotide scintigraphy
Surgical samples (lung)88% (22/25 cases)
sst2sst2sst2sst2
bronchiabronchial biopsyl biopsy
bronchiabronchial biopsyl biopsy
Surgical Surgical specimespecime
nn
Surgical Surgical specimespecime
nn
Main goal of SSTR localisation: provide information correlated with clinical data
Main goal of SSTR localisation: provide information correlated with clinical data
Collaborative project on SSTR2A IHC Collaborative project on SSTR2A IHC in correlation with in correlation with in vivoin vivo data dataCollaborative project on SSTR2A IHC Collaborative project on SSTR2A IHC in correlation with in correlation with in vivoin vivo data data
107 cases of NET with variable degrees of 107 cases of NET with variable degrees of differentiation and different locations, all with differentiation and different locations, all with Octreoscan and/or information on clinical Octreoscan and/or information on clinical response to SS analogues (from Universities of response to SS analogues (from Universities of Turin, Varese and Naples)Turin, Varese and Naples)
Complete clinico-Complete clinico-pathological datapathological data
IHC for SSTR2A IHC for SSTR2A using 3 different using 3 different commercial commercial polyclonal Abs polyclonal Abs
Proposed IHC score for SSTR2 (based on staining pattern)
Proposed IHC score for SSTR2 (based on staining pattern)
Case 2187A/2187BCase 2187A/2187B
NE tumorNE tumor
2+2+
2+2+
3+3+
…2.5+?…2.5+?
1+ or +/-1+ or +/-
Score 0
(Negative)
SUBCELLULAR PATTERN
EXTENSION OF POSITIVE TUMOR CELL POPULATION
Score 1 Score 2 Score 3
Pure cytoplasmic
Membranous incomplete
Membranous circumferential
(Absent) 1-100% <50% >50%
CONCORDANCE WITH OCTREOSCAN DATA
50% 54% 87% 94%
Correlation SSTR2 IHC Correlation SSTR2 IHC with with in vivoin vivo data dataCorrelation SSTR2 IHC Correlation SSTR2 IHC with with in vivoin vivo data data
107 cases =107 cases =70 WD NET/CA70 WD NET/CA18 PD NE CA18 PD NE CA9 MTC9 MTC10 others10 others
Concordance IHC/Octreoscan:Concordance IHC/Octreoscan: 77%77% (82/107 (82/107
cases)cases)
Concordance IHC/SS analogue response:Concordance IHC/SS analogue response: 81%81% (21/26 cases)(21/26 cases)
IHC score:IHC score:0 totally negative0 totally negative1 cytoplasmic +1 cytoplasmic +2 focal membrane +2 focal membrane +3 diffuse membrane +3 diffuse membrane +
--
++
61 IHC+/OS+21 IHC-/OS-
(19/25 discrepant cases (19/25 discrepant cases being IHC-/Octreoscan+)being IHC-/Octreoscan+)
Thank you!!!
University of Turin at San Luigi Hospital, Orbassano
NSG NSG+MUC MUC
Pure NE cell Amphicrine cell
Pure non-NE cell (i.e.
mucinous)
sst3sst3sst3sst3 LCNEC
SqCa
sst in endothelia, necrosis and intra-tumoral lymphocytes
sst in endothelia, necrosis and intra-tumoral lymphocytes
SUMMARY OF OBSERVED STAINING PATTERNS IN sst IHC
sst2: predominant membrane (cytoplasmic possible, if weaker than
membrane )
sst3: cytoplasmic (with membrane increase)
sst5: membrane and cytoplasmic
sst2A IHC expression in 71 NE sst2A IHC expression in 71 NE tumors of the lungtumors of the lung
sst2A IHC expression in 71 NE sst2A IHC expression in 71 NE tumors of the lungtumors of the lung
Typical carcinoidTypical carcinoid (24)(24) score 0/1score 0/1 44 score 2/3score 2/3 2020 (83%)(83%)
Atypical carcinoidAtypical carcinoid (20)(20) score 0/1score 0/1 88score 2/3score 2/3 1212 (60%)(60%)
LCNECLCNEC (17)(17) score 0/1score 0/1 77score 2/3score 2/3 1010 (59%)(59%)
SCLCSCLC (10)(10) score 0/1score 0/1 44score 2/3score 2/3 66 (60%)(60%)