1
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Guerini C, Furlan D, Ferrario G, Grillo F, Libera L, Arpa G, Klersy C, Lenti MV, Riboni R, Solcia E, Fassan M, Mastracci L, Ardizzone S, Moens A, De Hertogh G, Ferrante M, Graham RP, Sessa F, Paulli M, Di Sabatino A, Vanoli A. IDH1-mutated Crohn's disease-associated small bowel adenocarcinomas: Distinctive pathological features and association with MGMT methylation and serrated-type dysplasia. Histopathology 2024; 84:515-524. [PMID: 37988281 DOI: 10.1111/his.15095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/04/2023] [Accepted: 10/28/2023] [Indexed: 11/23/2023]
Abstract
AIMS Patients with Crohn's disease (CrD) have an elevated risk for the development of small bowel adenocarcinomas (SBAs). Actionable isocitrate dehydrogenase 1 (IDH1) mutations have been reported to be more frequent in CrD-SBAs than in sporadic SBAs. The present study aimed to investigate the clinicopathological and immunophenotypical features, as well as methylation profiles, of IDH1-mutated CrD-SBAs. METHODS AND RESULTS An international multicentre series of surgically resected CrD-SBAs was tested for IDH1 mutation. Clinicopathological features, immunophenotypical marker expression and O6-methylguanine-DNA methyltransferase (MGMT) and long interspersed nuclear element-1 (LINE-1) methylation were compared between IDH1-mutated and IDH1 wild-type CrD-SBAs. Ten (20%) of the 49 CrD-SBAs examined harboured an IDH1 mutation and all the mutated cancers harboured the R132C variant. Compared to IDH1 wild-type cases, IDH1-mutated CrD-SBAs showed significantly lower rates of cytokeratin 7 expression (P = 0.005) and higher rates of p53 overexpression (P = 0.012) and MGMT methylation (P = 0.012). All three dysplastic growths associated with IDH1-mutated SBAs harboured the same IDH1 variant (R132C) of the corresponding invasive cancer, and all were of non-conventional subtype (two serrated dysplastic lesions and one goblet cell-deficient dysplasia). In particular, non-conventional serrated dysplasia was significantly associated with IDH1-mutated CrD-SBAs (P = 0.029). No significant cancer-specific survival difference between IDH1-mutated CrD-SBA patients and IDH1 wild-type CrD-SBA patients was found (hazard ratio = 0.55, 95% confidence interval = 0.16-1.89; P = 0.313). CONCLUSIONS IDH1-mutated CrD-SBAs, which represent approximately one-fifth of total cases, are characterised by distinctive immunophenotypical features and methylation profiles, with potential therapeutic implications. Moreover, IDH1-mutated non-conventional, serrated dysplasia is likely to represent a precursor lesion to such CrD-SBAs.
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Affiliation(s)
- Camilla Guerini
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
- Unit of Anatomic Pathology, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Daniela Furlan
- Pathology Unit, Department of Medicine and Technological Innovation, University of Insubria, Varese, Italy
| | - Giuseppina Ferrario
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
- Unit of Anatomic Pathology, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Federica Grillo
- Pathology Unit, Department of Surgical and Diagnostic Sciences, University of Genoa, Genoa, Italy
- Ospedale Policlinico San Martino University Hospital, Genoa, Italy
| | - Laura Libera
- Pathology Unit, Department of Medicine and Technological Innovation, University of Insubria, Varese, Italy
| | - Giovanni Arpa
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
| | - Catherine Klersy
- Clinical Epidemiology and Biometry, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Marco V Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Roberta Riboni
- Unit of Anatomic Pathology, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Enrico Solcia
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
| | - Matteo Fassan
- Surgical Pathology and Cytopathology Unit, Department of Medicine, DIMED, University of Padua, Padua, Italy
- Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | - Luca Mastracci
- Pathology Unit, Department of Surgical and Diagnostic Sciences, University of Genoa, Genoa, Italy
- Ospedale Policlinico San Martino University Hospital, Genoa, Italy
| | - Sandro Ardizzone
- Gastroenterology Unit, Luigi Sacco University Hospital, Milan, Italy
| | - Annick Moens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Gert De Hertogh
- Department of Pathology, KU Leuven University Hospitals, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fausto Sessa
- Pathology Unit, Department of Medicine and Technological Innovation, University of Insubria, Varese, Italy
| | - Marco Paulli
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
- Unit of Anatomic Pathology, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Alessandro Vanoli
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia, Italy
- Unit of Anatomic Pathology, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
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2
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Bhatt H, Mathis KL. Small Bowel Carcinoma in the Setting of Inflammatory Bowel Disease. Clin Colon Rectal Surg 2024; 37:46-52. [PMID: 38188070 PMCID: PMC10769580 DOI: 10.1055/s-0043-1762929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Small bowel carcinomas are rare in the general population, but the incidence is increasing. Patients with inflammatory bowel diseases (IBDs) are at significantly higher risk of small bowel adenocarcinomas than their non-IBD counterparts, with Crohn's patients having at least a 12-fold increased risk and ulcerative colitis patients with a more controversial and modest 2-fold increased risk compared with the general population. IBD patients with small bowel carcinomas present with nonspecific symptoms that overlap with typical IBD symptoms, and this results in difficulty making a preoperative diagnosis. Cross-sectional imaging is rarely diagnostic, and most cancers are found incidentally at the time of surgery performed for an IBD indication. As such, most small bowel carcinomas are found at advanced stages and carry a poor prognosis. Oncologic surgical resection is the treatment of choice for patients with locoregional disease with little evidence available to guide adjuvant therapy. Patients with metastatic disease are treated with systemic chemotherapy, and surgery is reserved for palliation in this population. Prognosis is poor with few long-term survivors reported.
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Affiliation(s)
- Himani Bhatt
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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3
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Kerisnon@Krishnan T, Mohtarrudin N, Wan Yaacob WA, Hussin H. Grades of Poorly Differentiated Clusters are Associated with Lymph Node and the Tumour, Node and Metastasis Stages in Colorectal Carcinoma. Malays J Med Sci 2023; 30:70-78. [PMID: 38239248 PMCID: PMC10793141 DOI: 10.21315/mjms2023.30.6.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/10/2023] [Indexed: 01/22/2024] Open
Abstract
Background Colorectal carcinoma (CRC) is the third most common cancer globally. In Malaysia, CRC is most prevalent among males and the second most common cancer among females. The CRC arises mainly from the adenocarcinoma sequence. Poorly differentiated clusters (PDCs) and tumour budding (TB) are believed to represent sequential steps in tumour growth. Therefore, this study analysed the association between PDC grades with clinicopathological and demographic characteristics of CRC. Methods A total of 47 CRC cases previously diagnosed by histopathological examination were reviewed for the presence of PDCs and graded accordingly. The association between PDC grades with clinicopathological and demographic characteristics was statistically analysed. Results Out of the 47 cases with PDCs, most of them were of grade 3 (G3) (n = 27, 57.4%), followed by grade 2 (G2) (n = 13, 27.7%) and grade 1 (G1) (n = 7, 14.9%). Higher PDC grades (G2 and G3) were mainly observed in higher tumour stage (T); T3 (n = 26, 83.9%), T4 (n = 12, 92.3%), N1 (n = 20, 86.9%), N2 (n = 15, 100%). In addition, there was a significant association between PDC grades with the nodal stage (N) (P = 0.013) and the tumour, node and metastasis (TNM) stages (P = 0.012). Conclusion The PDC grades are useful for assessing the disease prognosis in CRC. A statistically significant association between PDC grades with N and TNM stages suggested that PDC grades are potential predictive parameters for invasive and metastatic risks in CRC.
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Affiliation(s)
- Thanamogan Kerisnon@Krishnan
- Department of Pathology, Hospital Raja Permaisuri Bainun, Perak,
Malaysia
- Department of Pathology, Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia, Selangor, Malaysia
| | - Norhafizah Mohtarrudin
- Department of Pathology, Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia, Selangor, Malaysia
| | | | - Huzlinda Hussin
- Department of Pathology, Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia, Selangor, Malaysia
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4
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Vanoli A, Guerini C, Arpa G, Klersy C, Grillo F, Casadei Gardini A, De Hertogh G, Ferrante M, Moens A, Furlan D, Sessa F, Quaquarini E, Lenti MV, Neri G, Macciomei MC, Fassan M, Cascinu S, Paulli M, Graham RP, Di Sabatino A. Mismatch repair deficiency as prognostic factor for stage III small bowel adenocarcinoma: A multicentric international study. Dig Liver Dis 2023; 55:1261-1269. [PMID: 37236851 DOI: 10.1016/j.dld.2023.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Small bowel adenocarcinoma (SBA) is a rare cancer with an aggressive behavior. No study has specifically addressed the putative prognostic role of mismatch repair status in stage III SBAs. AIMS We aimed to investigate whether mismatch repair deficiency is associated with cancer-specific survival in a Western cohort of patients with stage III SBAs. METHODS In this retrospective multicentric international cohort study, we enrolled 70 patients who underwent surgically resection for stage III SBAs and we analyzed the frequency of mismatch repair deficiency, tested by immunohistochemistry for mismatch repair proteins and by polymerase chain reaction for microsatellite instability, and its association with cancer-specific survival and other clinic-pathologic factors. RESULTS We found sixteen (23%) patients with mismatch repair deficient adenocarcinoma, without discordance between immunohistochemical and polymerase chain reaction for microsatellite instability analyses. Mismatch repair deficiency proved to be associated with a better outcome both at univariable analysis (hazard ratio: 0.28, 95% confidence interval: 0.08-0.91, p: 0.035) and in bivariable models adjusted for patient age or gender, tumor site, pT4 stage, tumor budding, and perineural invasion. CONCLUSION This study highlights the importance of testing mismatch repair status to improve prognostic stratification in stage III SBAs.
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Affiliation(s)
- Alessandro Vanoli
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia 27100, Italy; Unit of Anatomic Pathology, Fondazione IRCCS San Matteo Hospital, Pavia 27100, Italy
| | - Camilla Guerini
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia 27100, Italy
| | - Giovanni Arpa
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia 27100, Italy
| | - Catherine Klersy
- Clinical Epidemiology and Biometry, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia 27100, Italy
| | - Federica Grillo
- Pathology Unit, Department of Surgical and Diagnostic Sciences, University of Genoa and Ospedale Policlinico San Martino University Hospital, Genoa 16132, Italy
| | - Andrea Casadei Gardini
- Department of Oncology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute Hospital, Milan 20132, Italy
| | - Gert De Hertogh
- Department of Pathology, KU Leuven University Hospitals, Leuven 3000, Belgium
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven 3000, Belgium
| | - Annick Moens
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Leuven 3000, Belgium
| | - Daniela Furlan
- Pathology Unit, Department of Medicine and Surgery, University of Insubria, Varese 21100, Italy
| | - Fausto Sessa
- Pathology Unit, Department of Medicine and Surgery, University of Insubria, Varese 21100, Italy
| | - Erica Quaquarini
- Medical Oncology Unit, ICS Maugeri-IRCCS SpA SB, Pavia 27100, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, University of Pavia, San Matteo Hospital Foundation, Pavia 27100, Italy
| | - Giuseppe Neri
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia 27100, Italy
| | | | - Matteo Fassan
- Surgical Pathology and Cytopathology Unit, Department of Medicine, DIMED, University of Padua, Padua 35122, Italy; Veneto Institute of Oncology, IOV-IRCCS, Padua 35128, Italy
| | - Stefano Cascinu
- Department of Oncology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute Hospital, Milan 20132, Italy
| | - Marco Paulli
- Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Pavia 27100, Italy; Unit of Anatomic Pathology, Fondazione IRCCS San Matteo Hospital, Pavia 27100, Italy
| | | | - Antonio Di Sabatino
- Department of Internal Medicine, University of Pavia, San Matteo Hospital Foundation, Pavia 27100, Italy.
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5
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Bak MTJ, Albéniz E, East JE, Coelho-Prabhu N, Suzuki N, Saito Y, Matsumoto T, Banerjee R, Kaminski MF, Kiesslich R, Coron E, de Vries AC, van der Woude CJ, Bisschops R, Hart AL, Itzkowitz SH, Pioche M, Moons LMG, Oldenburg B. Endoscopic management of patients with high-risk colorectal colitis-associated neoplasia: a Delphi study. Gastrointest Endosc 2023; 97:767-779.e6. [PMID: 36509111 DOI: 10.1016/j.gie.2022.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/23/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Current guidelines recommend endoscopic resection of visible and endoscopically resectable colorectal colitis-associated neoplasia (CAN) in patients with inflammatory bowel disease (IBD). However, patients with high-risk CAN (HR-CAN) are often not amenable to conventional resection techniques, and a consensus approach for the endoscopic management of these lesions is presently lacking. This Delphi study aims to reach consensus among experts on the endoscopic management of these lesions. METHODS A 3-round modified Delphi process was conducted to reach consensus among worldwide IBD and/or endoscopy experts (n = 18) from 3 continents. Consensus was considered if ≥75% agreed or disagreed. Quality of evidence was assessed by the criteria of the Cochrane Collaboration group. RESULTS Consensus was reached on all statements (n = 14). Experts agreed on a definition for CAN and HR-CAN. Consensus was reached on the examination of the colon with enhanced endoscopic imaging before resection, the endoscopic resectability of an HR-CAN lesion, and endoscopic assessment and standard report of CAN lesions. In addition, experts agreed on type of resections of HR-CAN (< 20 mm, >20 mm, with or without good lifting), endoscopic success (technical success and outcomes), histologic assessment, and follow-up in HR-CAN. CONCLUSIONS This is the first step in developing international consensus-based recommendations for endoscopic management of CAN and HR-CAN. Although the quality of available evidence was considered low, consensus was reached on several aspects of the management of CAN and HR-CAN. The present work and proposed standardization might benefit future studies.
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Affiliation(s)
- Michiel T J Bak
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Eduardo Albéniz
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra Navarrabiomed, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - James E East
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, and Oxford NIHR Biomedical Research Centre, Oxford, UK; Division of Gastroenterology and Hepatology, Mayo Clinic Healthcare, London, UK
| | | | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, London, UK
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Iwate, Japan
| | - Rupa Banerjee
- Inflammatory Bowel Disease Center, Asian Institute of Gastroenterology, Hyderabad, India
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Ralf Kiesslich
- Department of Internal Medicine and Gastroenterology, Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Emmanuel Coron
- Department of Gastroenterology and Hepatology, University Hospital of Geneva, Geneva, Switzerland
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Belgium
| | - Ailsa L Hart
- Department of Gastroenterology, St Mark's Hospital and Academic Institute, London, UK
| | - Steven H Itzkowitz
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
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6
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Vanoli A, Guerini C, Grillo F, Klersy C, Fassan M, Arpa G, Neri G, Luinetti O, Lenti MV, Ulivi P, Tedaldi G, Furlan D, Quaquarini E, Ardizzone S, Sampietro G, Biancone L, Monteleone G, Solcia E, Sessa F, Paulli M, Adsay NV, Di Sabatino A. Poorly Cohesive Carcinoma of the Nonampullary Small Intestine: A Distinct Histologic Subtype With Prognostic Significance. Am J Surg Pathol 2022; 46:498-508. [PMID: 34628432 DOI: 10.1097/pas.0000000000001821] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Poorly cohesive carcinomas (PCCs) are neoplasms characterized by a dyshesive cell invasion pattern featuring single-cell or cord-like stromal infiltration. Although they have been extensively studied in the stomach and other digestive system organs, limited data regarding nonampullary small bowel poorly cohesive carcinomas (SB-PCCs) are hitherto available. The aims of our study were to analyze the clinicopathologic and immunophenotypical features of SB-PCCs (PCC pattern accounting for >50% of the neoplasm) and to compare them with small bowel adenocarcinomas (SBAs), not otherwise specified (SBAs-NOS) and with cancers with a histologically distinct PCC component accounting for 10% to 50% of the neoplasm (mixed-poorly-cohesive-glandular-SBAs). Fifteen SB-PCCs were identified and compared with 95 SBAs-NOS and 27 mixed-poorly-cohesive-glandular-SBAs. Most SB-PCCs (67%) were composed of <10% of signet-ring cells, and all but 1 SB-PCCs exhibited loss of membranous expression of E-cadherin. Compared with SBAs-NOS, SB-PCCs showed a significantly younger patient age at diagnosis, and a stronger association with Crohn disease, and both SB-PCCs and mixed-poorly-cohesive-glandular-SBAs featured a higher rate of lymphovascular and perineural invasion and a lower percentage of mismatch repair-deficient cases. Importantly, the cancer-specific survival of SB-PCC (hazard ratio: 3.81; 95% confidence interval: 1.90-7.64; P<0.001) and mixed-poorly-cohesive-glandular-SBA (4.12; 2.20-7.71; P<0.001) patients was significantly worse compared with SBAs-NOS cases. This study provides objective evidence to the World Health Organization (WHO) 2019 introduction of SB-PCC as a distinctive subtype of nonampullary SBA, by virtue of its unique clinical and histologic features, and suggests that both SB-PCCs and mixed-poorly-cohesive-glandular-SBAs should be separated from SBAs-NOS.
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Affiliation(s)
- Alessandro Vanoli
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia
- Anatomic Pathology, Fondazione IRCCS San Matteo Hospital
| | - Camilla Guerini
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia
| | - Federica Grillo
- Pathology Unit, Department of Surgical and Diagnostic Sciences (DISC), University of Genoa and Ospedale Policlinico San Martino IRCCS, Genoa
| | - Catherine Klersy
- Clinical Epidemiology & Biometry Unit, Fondazione IRCCS San Matteo Hospital
| | - Matteo Fassan
- Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua
- Veneto Institute of Oncology, IOV-IRCCS, Padua
| | - Giovanni Arpa
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia
| | - Giuseppe Neri
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia
| | | | - Marco V Lenti
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital
| | - Paola Ulivi
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola
| | - Gianluca Tedaldi
- Biosciences Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori," Meldola
| | - Daniela Furlan
- Pathology Unit, Department of Medicine and Surgery, University of Insubria, Varese
| | | | - Sandro Ardizzone
- Gatroenterology Unit, ASST Fatebenefratelli-Sacco, L. Sacco University Hospital
- Department of Biochemical and Clinical Sciences, University of Milan, Milan
| | | | - Livia Biancone
- Gatroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata," Rome, Italy
| | - Giovanni Monteleone
- Gatroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata," Rome, Italy
| | - Enrico Solcia
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia
| | - Fausto Sessa
- Pathology Unit, Department of Medicine and Surgery, University of Insubria, Varese
| | - Marco Paulli
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia
- Anatomic Pathology, Fondazione IRCCS San Matteo Hospital
| | - Nazmi V Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Antonio Di Sabatino
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital
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7
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Arpa G, Fassan M, Guerini C, Quaquarini E, Grillo F, Angerilli V, Guzzardo V, Lonardi S, Bergamo F, Lenti MV, Pedrazzoli P, Paulli M, Di Sabatino A, Vanoli A. Claudin-18 expression in small bowel adenocarcinoma: a clinico-pathologic study. Virchows Arch 2022; 481:853-863. [PMID: 35925388 PMCID: PMC9734203 DOI: 10.1007/s00428-022-03393-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 01/22/2023]
Abstract
Non-ampullary small bowel adenocarcinoma is a rare neoplasm with an ominous prognosis, whose incidence is higher in some chronic immuno-inflammatory conditions, such as coeliac and Crohn's disease. Recently, claudin 18.2, a transmembrane protein normally expressed in gastric mucosa, has been recognized as a novel pan-cancer therapeutic target, and several clinical trials with claudin-18-directed drugs have shown promising results on various gastrointestinal malignancies. This is the first study focusing on claudin-18 expression in small bowel adenocarcinomas. The immunohistochemical expression of claudin-18 (clone 43-14A) was assessed in 81 small bowel adenocarcinomas of diverse aetiologies and correlated with several clinico-pathologic features and patient survival. We found that 28% of adenocarcinomas were immunoreactive for claudin-18, with cutoff values of ≥1% at any intensity, while 6% of cancers showed immunoexpression of ≥75% with 2+/3+ score. Moreover, claudin-18 (≥1%) was positively associated with cytokeratin 7 (CK7) and MUC5AC expression, showing CK7+/MUC5AC+ carcinomas the highest rate of positive cases, whereas a negative correlation was found between claudin-18 and CDX2 expression. In addition, some cancer-adjacent dysplastic growths and foci of gastric-type metaplasia in Crohn's disease-associated cases showed claudin-18 immunoreactivity. Survival analysis showed a non-significant trend towards a worse cancer-specific survival for claudin-18-positive cases. A fraction of small bowel adenocarcinomas, mainly sporadic or Crohn's disease-associated, and often exhibiting a non-intestinal immunoprofile, expressed claudin-18, suggesting that claudin-18-directed targeted therapy is worth investigating in such cancers.
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Affiliation(s)
- Giovanni Arpa
- grid.8982.b0000 0004 1762 5736Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Via Carlo Forlanini 16-27100, Pavia, Italy ,grid.419425.f0000 0004 1760 3027Anatomic Pathology Unit, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Matteo Fassan
- grid.5608.b0000 0004 1757 3470Department of Medicine, DIMED, University of Padua, Padua, Italy ,grid.419546.b0000 0004 1808 1697Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | - Camilla Guerini
- grid.8982.b0000 0004 1762 5736Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Via Carlo Forlanini 16-27100, Pavia, Italy ,grid.419425.f0000 0004 1760 3027Anatomic Pathology Unit, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Erica Quaquarini
- Medical Oncology Unit, ICS Maugeri-IRCCS SpA SB, 27100 Pavia, Italy
| | - Federica Grillo
- grid.5606.50000 0001 2151 3065Pathology Unit, Department of Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy ,grid.410345.70000 0004 1756 7871IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Valentina Angerilli
- grid.5608.b0000 0004 1757 3470Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Vincenza Guzzardo
- grid.5608.b0000 0004 1757 3470Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Sara Lonardi
- grid.419546.b0000 0004 1808 1697Department of Oncology, Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | - Francesca Bergamo
- grid.419546.b0000 0004 1808 1697Department of Oncology, Veneto Institute of Oncology, IOV-IRCCS, Padua, Italy
| | - Marco Vincenzo Lenti
- grid.8982.b0000 0004 1762 5736First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Paolo Pedrazzoli
- grid.8982.b0000 0004 1762 5736First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy ,grid.419425.f0000 0004 1760 3027Oncology Unit, IRCCS San Matteo Hospital, Pavia, Italy
| | - Marco Paulli
- grid.8982.b0000 0004 1762 5736Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Via Carlo Forlanini 16-27100, Pavia, Italy ,grid.419425.f0000 0004 1760 3027Anatomic Pathology Unit, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Antonio Di Sabatino
- grid.8982.b0000 0004 1762 5736First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Alessandro Vanoli
- grid.8982.b0000 0004 1762 5736Department of Molecular Medicine, Unit of Anatomic Pathology, University of Pavia, Via Carlo Forlanini 16-27100, Pavia, Italy ,grid.419425.f0000 0004 1760 3027Anatomic Pathology Unit, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
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Jun SY, Lee EJ, Hong SM, Jung ES, Chung JY. Tumor Microenvironmental Prognostic Risk in Primary Operable Small Intestinal Adenocarcinoma. Am J Surg Pathol 2021; 45:917-929. [PMID: 33443865 DOI: 10.1097/pas.0000000000001668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The tumor microenvironment (TME) has become an important area of investigation with respect to improving prognosis in malignancies. Here we evaluated TME prognostic risk in small intestinal adenocarcinomas based on histologic assessment of tumor budding at the peritumoral-invasive front (pTB) and stromal tumor-infiltrating lymphocytes (sTILs). pTB and sTILs were analyzed in 230 surgically resected small intestinal adenocarcinomas, as recommended by the International Tumor Budding Consensus Conference (ITBCC) and the International TILs Working Group (ITWG). On the basis of high levels of pTB count (≥10) and sTIL density (≥20%), we combined pTB and sTIL to produce a collective TME-based prognostic risk index: low-risk (pTBLow/sTILHigh; n=39, 17.0%), intermediate-risk (pTBLow/sTILLow or pTBHigh/sTILHigh; n=99, 43.0%), and high-risk groups (pTBHigh/sTILLow; n=92, 40.0%). TME risk index provided better prognostic stratification than the individual pTB and sTIL (14.9 vs. 6.7 vs. 10.3). Tumors with higher TME prognostic risk were associated with an infiltrative growth pattern and nonintestinal immunophenotype (both P=0.001), pancreatic invasion (P=0.010), lymphovascular (P<0.001) or perineural invasion (P=0.006), higher T-category (P<0.001), N-category (P=0.004), and stage grouping (P=0.002), and KRAS mutation (P=0.008). In multivariate analysis, higher TME prognostic risk index (P<0.001), distal tumor location and nonintestinal immunophenotype (both P=0.001), higher N-category (P<0.001), and microsatellite stable (P=0.015) were worse-independent prognosticators. TME prognostic risk index consistently stratified patient survival regardless of tumor location (P<0.001 in proximal; P=0.002 in distal), stages (P<0.001 in lower stages I to II; P=0.028 in stage III), and DNA mismatch repair gene status (P<0.001 in microsatellite stable; P=0.001 in microsatellite instability). TME risk index is a powerful prognostic predictor for risk stratification of patients with small intestinal adenocarcinoma.
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Affiliation(s)
| | - Eui-Jin Lee
- Clinical Research Center, Incheon St. Mary's Hospital
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun Sun Jung
- Department of Pathology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea
| | - Joon-Yong Chung
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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9
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Arpa G, Vanoli A, Grillo F, Fiocca R, Klersy C, Furlan D, Sessa F, Ardizzone S, Sampietro G, Macciomei MC, Nesi G, Tonelli F, Capella C, Latella G, Ciardi A, Caronna R, Lenti MV, Ciccocioppo R, Barresi V, Malvi D, D'Errico A, Rizzello F, Poggioli G, Mescoli C, Rugge M, Luinetti O, Paulli M, Di Sabatino A, Solcia E. Prognostic relevance and putative histogenetic role of cytokeratin 7 and MUC5AC expression in Crohn's disease-associated small bowel carcinoma. Virchows Arch 2021; 479:667-678. [PMID: 33963925 PMCID: PMC8516779 DOI: 10.1007/s00428-021-03109-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/28/2021] [Accepted: 04/21/2021] [Indexed: 01/27/2023]
Abstract
Most Crohn’s disease-associated small bowel carcinomas (CrD-SBCs) are diagnosed in advanced stage and have poor prognosis. To improve diagnosis and therapy, a better knowledge of tumour precancerous lesions, histotypes and prognostic factors is needed. We investigated histologically and immunohistochemically 52 CrD-SBCs and 51 small bowel carcinomas unrelated to inflammatory disease, together with their tumour-associated mucosa, looking for Crohn-selective changes. Histologic patterns and phenotypic markers potentially predictive of CrD-SBC histogenesis and prognosis were analysed. Cytokeratin 7 or MUC5AC-positive metaplastic changes were found in about half of investigated CrD-SBCs, significantly more frequently than in CrD-unrelated SBCs. They correlated with metaplastic changes of their associated mucosa, while being absent in normal ileal mucosa. Histologic patterns suggestive for progression of some cytokeratin 7 and/or MUC5AC-positive metaplastic lesions into cancer of the same phenotype were also observed. Patient survival analyses showed that tumour cytokeratin 7 or MUC5AC expression and non-cohesive histotype were adverse prognostic factors at univariable analysis, while cytokeratin 7 and non-cohesive histotype were also found to predict worse survival in stage- and age-inclusive multivariable analyses. Besides conventional dysplasia, hyperplasia-like non-conventional lesions were observed in CrD-SBC-associated mucosa, with patterns suggestive for a histogenetic link with adjacent cancer. In conclusion the cytokeratin 7 and/or MUC5AC-positive metaplastic foci and the non-conventional growths may have a role in cancer histogenesis, while tumour cytokeratin 7 and non-cohesive histotype may also predict poor patient survival. Present findings are worth being considered in future prospective histogenetic and clinical studies.
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Affiliation(s)
- Giovanni Arpa
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Via Carlo Forlanini 16 -, 27100, Pavia, Italy
| | - Alessandro Vanoli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Via Carlo Forlanini 16 -, 27100, Pavia, Italy.
| | - Federica Grillo
- Pathology Unit, Department of Surgical and Diagnostic Sciences, University Hospital and Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Roberto Fiocca
- Pathology Unit, Department of Surgical and Diagnostic Sciences, University Hospital and Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Catherine Klersy
- Service of Clinical Epidemiology & Biometry, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Daniela Furlan
- Anatomic Pathology Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fausto Sessa
- Anatomic Pathology Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | | | | | - Gabriella Nesi
- Division of Pathological Anatomy, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Francesco Tonelli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Carlo Capella
- Anatomic Pathology Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Giovanni Latella
- Gastroenterology Unit, Department of Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Ciardi
- Department of Radiological, Oncological, Pathological Sciences, Umberto I Hospital, La Sapienza University, Rome, Italy
| | - Roberto Caronna
- Surgical Sciences, Umberto I Hospital, La Sapienza University, Rome, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, Pavia, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona, Verona, Italy
| | - Valeria Barresi
- Section of Anatomical Pathology, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Deborah Malvi
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Institute of Oncology and Transplant Pathology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonietta D'Errico
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Institute of Oncology and Transplant Pathology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Fernando Rizzello
- Intestinal Chronic Bowel Disease Unit, Department of Medical and Surgical Sciences, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola - Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Claudia Mescoli
- Pathology Unit, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Massimo Rugge
- Pathology Unit, Department of Medicine DIMED, University of Padua, Padova, Italy
| | - Ombretta Luinetti
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Via Carlo Forlanini 16 -, 27100, Pavia, Italy
| | - Marco Paulli
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Via Carlo Forlanini 16 -, 27100, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, Pavia, Italy
| | - Enrico Solcia
- Unit of Anatomic Pathology, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Via Carlo Forlanini 16 -, 27100, Pavia, Italy
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10
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Vanoli A, Grillo F, Guerini C, Neri G, Arpa G, Klersy C, Nesi G, Giuffrida P, Sampietro G, Ardizzone S, Fociani P, Fiocca R, Latella G, Sessa F, D'Errico A, Malvi D, Mescoli C, Rugge M, Ferrero S, Poggioli G, Rizzello F, Macciomei MC, Santini D, Volta U, De Giorgio R, Caio G, Calabrò A, Ciacci C, D'Armiento M, Rizzo A, Solina G, Martino M, Tonelli F, Villanacci V, Cannizzaro R, Canzonieri V, Florena AM, Biancone L, Monteleone G, Caronna R, Ciardi A, Elli L, Caprioli F, Vecchi M, D'Incà R, Zingone F, D'Odorico A, Lenti MV, Oreggia B, Reggiani Bonetti L, Giannone AG, Orlandi A, Barresi V, Ciccocioppo R, Amodeo G, Biletta E, Luinetti O, Pedrazzoli P, Pietrabissa A, Corazza GR, Solcia E, Paulli M, Di Sabatino A. Prognostic Role of Mismatch Repair Status, Histotype and High-Risk Pathologic Features in Stage II Small Bowel Adenocarcinomas. Ann Surg Oncol 2021; 28:1167-1177. [PMID: 32761330 PMCID: PMC7801310 DOI: 10.1245/s10434-020-08926-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/04/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Small bowel adenocarcinoma is a relatively rare cancer, often diagnosed in an advanced stage. In localized and resectable disease, surgery alone or in combination with adjuvant chemotherapy is the mainstay of treatment. In the recently published National Comprehensive Cancer Network Clinical Practice guidelines, criteria for selecting patients with stage II small bowel adenocarcinoma to receive adjuvant chemotherapy are provided, and they are mainly extrapolated from studies on colorectal cancer. PATIENTS AND METHODS In the present study, we aimed to verify whether mismatch repair deficiency phenotype, high-risk pathologic features (including T4, positive resection margins and a low number of lymph nodes harvested), as well as tumor histologic subtype, were associated with cancer-specific survival in 66 stage II non-ampullary small bowel adenocarcinoma patients, collected through the Small Bowel Cancer Italian Consortium. A central histopathology review was performed. Mismatch repair deficiency was tested by immunohistochemistry for MLH1, MSH2, MSH6 and PMS2, and confirmed by polymerase chain reaction for microsatellite instability. RESULTS We identified mismatch repair deficiency, glandular/medullary histologic subtype, and celiac disease as significant predictors of favorable cancer-specific survival using univariable analysis with retained significance in bivariable models adjusted for pT stage. Among the high-risk features, only T4 showed a significant association with an increased risk of death; however, its prognostic value was not independent of mismatch repair status. CONCLUSIONS Mismatch repair protein expression, histologic subtype, association with celiac disease, and, in the mismatch repair proficient subset only, T stage, may help identify patients who may benefit from adjuvant chemotherapy.
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Affiliation(s)
- Alessandro Vanoli
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy.
| | - Federica Grillo
- Pathology Unit, Department of Surgical and Diagnostic Sciences, University of Genoa and Ospedale Policlinico San Martino University Hospital, Genoa, Italy
| | - Camilla Guerini
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Giuseppe Neri
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Giovanni Arpa
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Catherine Klersy
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Gabriella Nesi
- Division of Pathological Anatomy, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Paolo Giuffrida
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Gianluca Sampietro
- Unit of General Surgery, ASST Rhodense, Rho Hospital, University of Milan, Milan, Italy
| | - Sandro Ardizzone
- Gastroenterology Unit, Luigi Sacco University Hospital, Milan, Italy
| | - Paolo Fociani
- Anatomic Pathology Unit, ASST Ovest Milanese, Milan, Italy
| | - Roberto Fiocca
- Pathology Unit, Department of Surgical and Diagnostic Sciences, University of Genoa and Ospedale Policlinico San Martino University Hospital, Genoa, Italy
| | - Giovanni Latella
- Gastroenterology Unit, Department of Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Fausto Sessa
- Pathology Unit, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonietta D'Errico
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Institute of Oncology and Transplant Pathology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Deborah Malvi
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Institute of Oncology and Transplant Pathology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudia Mescoli
- Pathology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Massimo Rugge
- Pathology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Stefano Ferrero
- Division of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Fernando Rizzello
- Intestinal Chronic Bowel Disease Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | | | - Donatella Santini
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Institute of Oncology and Transplant Pathology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto De Giorgio
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Giacomo Caio
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Antonio Calabrò
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Carolina Ciacci
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Maria D'Armiento
- Public Health Department, Federico II University of Naples, Naples, Italy
| | - Aroldo Rizzo
- Unit of Pathology, Cervello Hospital, Palermo, Italy
| | - Gaspare Solina
- Units of General Surgery, Cervello Hospital, Palermo, Italy
| | - Michele Martino
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Francesco Tonelli
- Surgery and Translational Medicine, University of Florence, Florence, Italy
| | | | - Renato Cannizzaro
- Department of Gastroenterology, Centro di Riferimento Oncologico (CRO) di Aviano IRCCS, Aviano, Italy
| | - Vincenzo Canzonieri
- Pathology Unit, Centro di Riferimento Oncologico (CRO) di Aviano IRCCS, Aviano, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Ada Maria Florena
- Pathologic Anatomy Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Livia Biancone
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | | | - Roberto Caronna
- Department of Surgical Sciences, La Sapienza University, Rome, Italy
| | - Antonio Ciardi
- Department of Radiological, Oncological, Pathological Sciences, Umberto I Hospital, La Sapienza University, Rome, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Renata D'Incà
- Gastroenterology Section, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Fabiana Zingone
- Gastroenterology Section, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Anna D'Odorico
- Gastroenterology Section, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Barbara Oreggia
- General Surgery Unit, Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Reggiani Bonetti
- Section of Pathology, Department of Diagnostic Medicine and Public Health, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonino Giulio Giannone
- Pathologic Anatomy Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Augusto Orlandi
- Department of Biopathology and Image Diagnostics, University of Tor Vergata, Rome, Italy
| | - Valeria Barresi
- Section of Anatomical Pathology, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona, Verona, Italy
| | - Giuseppe Amodeo
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona, Verona, Italy
| | | | - Ombretta Luinetti
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Paolo Pedrazzoli
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
- Oncology Unit, IRCCS San Matteo Hospital, Pavia, Italy
| | - Andrea Pietrabissa
- Department of Surgery, General Surgery II, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Enrico Solcia
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Marco Paulli
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, Pavia, Italy
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11
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Neri G, Arpa G, Guerini C, Grillo F, Lenti MV, Giuffrida P, Furlan D, Sessa F, Quaquarini E, Viglio A, Ubezio C, Pasini A, Ferrero S, Sampietro G, Ardizzone S, Latella G, Mescoli C, Rugge M, Zingone F, Barresi V, Ciccocioppo R, Pedrazzoli P, Corazza GR, Luinetti O, Solcia E, Paulli M, Di Sabatino A, Vanoli A. Small Bowel Adenocarcinomas Featuring Special AT-Rich Sequence-Binding Protein 2 (SATB2) Expression and a Colorectal Cancer-Like Immunophenotype: A Potential Diagnostic Pitfall. Cancers (Basel) 2020; 12:cancers12113441. [PMID: 33228145 PMCID: PMC7699330 DOI: 10.3390/cancers12113441] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/26/2020] [Accepted: 11/17/2020] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Since small bowel adenocarcinoma may mimic a colorectal primary neoplasm histologically, it is pivotal to find biomarkers to discriminate these two biologically distinct neoplasms. The aim of our study was to evaluate the expression of special AT-rich sequence-binding protein 2 (SATB2), expressed in the vast majority of colorectal carcinomas, and other gastrointestinal phenotypic markers, such as cytokeratin 7, cytokeratin 20 and caudal type homeobox 2 (CDX2), in 100 small bowel adenocarcinomas. We identified 20 SATB2-positive small bowel adenocarcinomas, including nine sporadic cancers, seven celiac disease-associated cancers and four Crohn’s disease-associated small bowel adenocarcinomas. Six small bowel adenocarcinomas, including two cases associated with celiac disease and four sporadic, displayed a full colorectal carcinoma-like immunoprofile. Unlike SATB2, cytokeratin patterns stratified small bowel adenocarcinoma patient prognosis. The small bowel should be considered as one of the possible sites of origin in cancers of unknown primary, even when the neoplasm shows a colorectal carcinoma-like immunoprofile. Abstract Special AT-rich sequence-binding protein 2 (SATB2) is a transcription factor expressed by colonic cryptic epithelium and epithelial neoplasms of the lower gastrointestinal (GI) tract, as well as by small bowel adenocarcinomas (SBAs), though at a lower rate. Nevertheless, up to now, only small SBA series, often including a very limited number of Crohn’s disease-associated SBAs (CrD-SBAs) and celiac disease-associated SBAs (CD-SBA), have been investigated for SATB2 expression. We evaluated the expression of SATB2 and other GI phenotypic markers (cytokeratin (CK) 7 and CK20, caudal type homeobox 2 (CDX2) and alpha-methylacyl-CoA racemase (AMACR)), as well as mismatch repair (MMR) proteins, in 100 SBAs, encompassing 34 CrD-SBAs, 28 CD-SBAs and 38 sporadic cases (Spo-SBAs). Any mutual association and correlation with other clinico-pathologic features, including patient prognosis, were searched. Twenty (20%) SATB2-positive SBAs (4 CrD-SBAs, 7 CD-SBAs and 9 Spo-SBAs) were identified. The prevalence of SATB2 positivity was lower in CrD-SBA (12%) in comparison with both CD-SBAs (25%) and Spo-SBAs (24%). Interestingly, six SBAs (two CD-SBAs and four Spo-SBAs) displayed a full colorectal carcinoma (CRC)-like immunoprofile (CK7−/CK20+/CDX2+/AMACR+/SATB2+); none of them was a CrD-SBA. No association between SATB2 expression and MMR status was observed. Although SATB2-positive SBA patients showed a more favorable outcome in comparison with SATB2-negative ones, the difference did not reach statistical significance. When cancers were stratified according to CK7/CK20 expression patterns, we found that CK7−/CK20- SBAs were enriched with MMR-deficient cases (71%) and patients with CK7−/CK20− or CK7−/CK20+ SBAs had a significantly better survival rate compared to those with CK7+/CK20− or CK7+/CK20+ cancers (p = 0.002). To conclude, we identified a small (6%) subset of SBAs featuring a full CRC-like immunoprofile, representing a potential diagnostic pitfall in attempts to identify the site of origin of neoplasms of unknown primary site. In contrast with data on colorectal carcinoma, SATB2 expression is not associated with MMR status in SBAs. CK patterns influence patient survival, as CK7−/CK20− cancers show better prognosis, a behavior possibly due to the high rate of MMR-deficient SBAs within this subgroup.
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Affiliation(s)
- Giuseppe Neri
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Lombardy, Italy; (G.N.); (G.A.); (C.G.); (A.V.); (O.L.); (E.S.); (M.P.)
| | - Giovanni Arpa
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Lombardy, Italy; (G.N.); (G.A.); (C.G.); (A.V.); (O.L.); (E.S.); (M.P.)
| | - Camilla Guerini
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Lombardy, Italy; (G.N.); (G.A.); (C.G.); (A.V.); (O.L.); (E.S.); (M.P.)
| | - Federica Grillo
- Pathology Unit, Department of Surgical and Diagnostic Sciences, University of Genoa and Ospedale Policlinico San Martino University Hospital, 16132 Genoa, Liguria, Italy;
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, 27100 Pavia, Lombardy, Italy; (M.V.L.); (P.G.); (C.U.); (A.P.); (P.P.); (G.R.C.); (A.D.S.)
| | - Paolo Giuffrida
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, 27100 Pavia, Lombardy, Italy; (M.V.L.); (P.G.); (C.U.); (A.P.); (P.P.); (G.R.C.); (A.D.S.)
| | - Daniela Furlan
- Pathology Unit, Department of Medicine and Surgery, University of Insubria, 21100 Varese, Lombardy, Italy; (D.F.); (F.S.)
| | - Fausto Sessa
- Pathology Unit, Department of Medicine and Surgery, University of Insubria, 21100 Varese, Lombardy, Italy; (D.F.); (F.S.)
| | - Erica Quaquarini
- Medical Oncology Unit, IRCCS ICS Maugeri and Experimental Medicine School, University of Pavia, 27100 Pavia, Lombardy, Italy;
| | - Alessandra Viglio
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Lombardy, Italy; (G.N.); (G.A.); (C.G.); (A.V.); (O.L.); (E.S.); (M.P.)
| | - Cristina Ubezio
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, 27100 Pavia, Lombardy, Italy; (M.V.L.); (P.G.); (C.U.); (A.P.); (P.P.); (G.R.C.); (A.D.S.)
| | - Alessandra Pasini
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, 27100 Pavia, Lombardy, Italy; (M.V.L.); (P.G.); (C.U.); (A.P.); (P.P.); (G.R.C.); (A.D.S.)
| | - Stefano Ferrero
- Division of Pathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Lombardy, Italy;
| | | | - Sandro Ardizzone
- Gastroenterology Unit, Luigi Sacco University Hospital, 20157 Milan, Lombardy, Italy;
| | - Giovanni Latella
- Gastroenterology Unit, Department of Life and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Abruzzo, Italy;
| | - Claudia Mescoli
- Pathology Unit, Department of Medicine DIMED, University of Padua, 35121 Padova, Veneto, Italy; (C.M.); (M.R.)
| | - Massimo Rugge
- Pathology Unit, Department of Medicine DIMED, University of Padua, 35121 Padova, Veneto, Italy; (C.M.); (M.R.)
- Veneto Tumor Registry, 35121 Padova, Veneto, Italy
| | - Fabiana Zingone
- Gastroenterology Section, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Veneto, Italy;
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Anatomical Pathology, University and Hospital Trust of Verona, 37126 Verona, Veneto, Italy;
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, AOUI Policlinico G.B. Rossi, University of Verona, 37134 Verona, Veneto, Italy;
| | - Paolo Pedrazzoli
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, 27100 Pavia, Lombardy, Italy; (M.V.L.); (P.G.); (C.U.); (A.P.); (P.P.); (G.R.C.); (A.D.S.)
- Oncology Unit, IRCCS San Matteo Hospital, 27100 Pavia, Lombardy, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, 27100 Pavia, Lombardy, Italy; (M.V.L.); (P.G.); (C.U.); (A.P.); (P.P.); (G.R.C.); (A.D.S.)
| | - Ombretta Luinetti
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Lombardy, Italy; (G.N.); (G.A.); (C.G.); (A.V.); (O.L.); (E.S.); (M.P.)
| | - Enrico Solcia
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Lombardy, Italy; (G.N.); (G.A.); (C.G.); (A.V.); (O.L.); (E.S.); (M.P.)
| | - Marco Paulli
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Lombardy, Italy; (G.N.); (G.A.); (C.G.); (A.V.); (O.L.); (E.S.); (M.P.)
| | - Antonio Di Sabatino
- Department of Internal Medicine, University of Pavia and Fondazione IRCCS San Matteo Hospital, 27100 Pavia, Lombardy, Italy; (M.V.L.); (P.G.); (C.U.); (A.P.); (P.P.); (G.R.C.); (A.D.S.)
| | - Alessandro Vanoli
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Lombardy, Italy; (G.N.); (G.A.); (C.G.); (A.V.); (O.L.); (E.S.); (M.P.)
- Correspondence: ; Tel.: +39-0382503612
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12
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Jun SY, Hong SM. Reply to Comment on "Jun, S.Y.; et al. Tumor Budding and Poorly Differentiated Clusters in Small Intestinal Adenocarcinoma" Cancers 2020, 12, 2199. Cancers (Basel) 2020; 12:E2987. [PMID: 33076410 PMCID: PMC7602524 DOI: 10.3390/cancers12102987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/13/2020] [Indexed: 11/16/2022] Open
Abstract
We thank Giuffrida et al [...].
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Affiliation(s)
- Sun-Young Jun
- Department of Pathology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 21431, Korea
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
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13
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Giuffrida P, Arpa G, Vanoli A, Di Sabatino A. Comment on Jun, S.Y.; et al. "Tumor Budding and Poorly Differentiated Clusters in Small Intestinal Adenocarcinoma" Cancers 2020, 12, 2199. Cancers (Basel) 2020; 12:cancers12102982. [PMID: 33076252 PMCID: PMC7602438 DOI: 10.3390/cancers12102982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
We read with interest the paper by Jun S [...].
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Affiliation(s)
- Paolo Giuffrida
- First Department of Internal Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Arpa
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (G.A.); (A.V.)
| | - Alessandro Vanoli
- Anatomic Pathology Unit, Department of Molecular Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (G.A.); (A.V.)
| | - Antonio Di Sabatino
- First Department of Internal Medicine, University of Pavia and Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- Correspondence: ; Tel.: +39-0382-502973
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14
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Shivji S, Conner JR, Barresi V, Kirsch R. Poorly differentiated clusters in colorectal cancer: a current review and implications for future practice. Histopathology 2020; 77:351-368. [PMID: 32358792 DOI: 10.1111/his.14128] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/16/2020] [Accepted: 04/26/2020] [Indexed: 12/13/2022]
Abstract
Poorly differentiated clusters (PDC), defined as small groups of ≥5 tumour cells without glandular differentiation, have gained recent attention as a promising prognostic factor in colorectal cancer (CRC). Numerous studies have shown PDC to be significantly associated with other adverse histopathological features and worse clinical outcomes. PDC may hold particular promise in stage II colon cancer, where risk stratification plays a critical role in patient selection for adjuvant chemotherapy. In addition, emerging evidence suggests that PDC can predict lymph node metastasis in endoscopically resected pT1 CRC, potentially helping the selection of patients for oncological resection. In 'head-to-head' comparisons, PDC grade has consistently outperformed conventional histological grading systems both in terms of risk stratification and reproducibility. With a number of large-scale studies now available, this review evaluates the evidence regarding the prognostic significance of PDC, considers its relationship with other emerging invasive front prognostic markers (such as tumour budding and stroma type), assesses its 'practice readiness', addressing issues such as interobserver reproducibility, scoring methodologies and special histological subtypes (e.g. micropapillary and mucinous carcinoma), and draws attention to ongoing challenges and areas in need of further study. Finally, emerging data on the role of PDC in non-colorectal cancers are briefly considered.
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Affiliation(s)
- Sameer Shivji
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - James R Conner
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Valeria Barresi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Richard Kirsch
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
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15
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PD-L1 in small bowel adenocarcinoma is associated with etiology and tumor-infiltrating lymphocytes, in addition to microsatellite instability. Mod Pathol 2020; 33:1398-1409. [PMID: 32066859 DOI: 10.1038/s41379-020-0497-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 12/13/2022]
Abstract
Small bowel adenocarcinomas (SBAs) are often associated with poor prognosis and have limited therapeutic options. Programmed cell death protein-1 (PD-1)/programmed cell death ligand 1 (PD-L1) pathway blockade is an effective treatment in many microsatellite instability-high (MSI-H) solid tumors. We aimed at investigating PD-L1 and PD-1 expression in non-hereditary, non-ampullary SBAs, associated with celiac disease (CeD), Crohn's disease (CrD), or sporadic, recruited through the Small Bowel Cancer Italian Consortium. We assessed PD-L1 and PD-1 by immunohistochemistry in a series of 121 surgically resected SBAs, including 34 CeD-SBAs, 49 CrD-SBAs, and 38 sporadic SBAs. PD-L1 and PD-1 expression was correlated with several clinico-pathological features, such as the etiology, microsatellite instability status, and tumor-infiltrating lymphocyte (TIL) density. The prevalence of PD-L1 positivity according to combined positive score (CPS) was 26% in the whole cohort of SBAs, with significantly (p = 0.001) higher percentage (35%) in both CeD-SBAs and CrD-SBAs in comparison with sporadic SBAs (5%). CPS ≥ 1 SBAs were significantly (p = 0.013) more frequent in MSI-H cases (41%) than in non-MSI-H ones (18%); however, 15 CPS ≥ 1 microsatellite stable SBAs were also identified. CPS ≥ 1 SBAs showed higher TIL and PD-1+ immune cell density, more frequently medullary histotype, as well as a better outcome in comparison with CPS < 1 cases. This study demonstrates an increased proportion of PD-L1+ cases in both CeD-SBAs and CrD-SBAs in comparison with sporadic SBAs. In addition, the identification of a subset of PD-L1+ microsatellite stable SBAs supports the need to ascertain additional biomarkers of response to immune checkpoint inhibitors along with MSI-H.
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