Real-world EGFR testing practices for non-small-cell lung cancer by thoracic pathology laboratories across Europe

BACKGROUND

Testing for epidermal growth factor receptor (EGFR) mutations is an essential recommendation in guidelines for metastatic non-squamous non-small-cell lung cancer, and is considered mandatory in European countries. However, in practice, challenges are often faced when carrying out routine biomarker testing, including access to testing, inadequate tissue samples and long turnaround times (TATs).

MATERIALS AND METHODS

To evaluate the real-world EGFR testing practices of European pathology laboratories, an online survey was set up and validated by the Pulmonary Pathology Working Group of the European Society of Pathology and distributed to 64 expert testing laboratories. The retrospective survey focussed on laboratory organisation and daily EGFR testing practice of pathologists and molecular biologists between 2018 and 2021.

RESULTS

TATs varied greatly both between and within countries. These discrepancies may be partly due to reflex testing practices, as 20.8% of laboratories carried out EGFR testing only at the request of the clinician. Many laboratories across Europe still favour single-test sequencing as a primary method of EGFR mutation identification; 32.7% indicated that they only used targeted techniques and 45.1% used single-gene testing followed by next-generation sequencing (NGS), depending on the case. Reported testing rates were consistent over time with no significant decrease in the number of EGFR tests carried out in 2020, despite the increased pressure faced by testing facilities during the COVID-19 pandemic. ISO 15189 accreditation was reported by 42.0% of molecular biology laboratories for single-test sequencing, and by 42.3% for NGS. 92.5% of laboratories indicated they regularly participate in an external quality assessment scheme.

CONCLUSIONS

These results highlight the strong heterogeneity of EGFR testing that still occurs within thoracic pathology and molecular biology laboratories across Europe. Even among expert testing facilities there is variability in testing capabilities, TAT, reflex testing practice and laboratory accreditation, stressing the need to harmonise reimbursement technologies and decision-making algorithms in Europe.

Integrative molecular analysis of combined small-cell lung carcinomas identifies major subtypes with different therapeutic opportunities

BACKGROUND

Combined small-cell lung cancer (C-SCLC) is composed of SCLC admixed with a non-small-cell cancer component. They currently receive the same treatment as SCLC. The recent evidence that SCLC may belong to either of two lineages, neuroendocrine (NE) or non-NE, with different vulnerability to specific cell death pathways such as ferroptosis, opens new therapeutic opportunities also for C-SCLC.

MATERIALS AND METHODS

Thirteen C-SCLCs, including five with adenocarcinoma (CoADC), five with large-cell neuroendocrine carcinoma (CoLCNEC) and three with squamous cell carcinoma (CoSQC) components, were assessed for alterations in 409 genes and transcriptomic profiling of 20 815 genes.

RESULTS

All 13 cases harbored TP53 (12 cases) and/or RB1 (7 cases) inactivation, which was accompanied by mutated KRAS in 4 and PTEN in 3 cases. Potentially targetable alterations included two KRAS G12C, two PIK3CA and one EGFR mutations. Comparison of C-SCLC transcriptomes with those of 57 pure histology lung cancers (17 ADCs, 20 SQCs, 11 LCNECs, 9 SCLCs) showed that CoLCNEC and CoADC constituted a standalone group of NE tumors, while CoSQC transcriptional setup was overlapping that of pure SQC. Using transcriptional signatures of NE versus non-NE SCLC as classifier, CoLCNEC was clearly NE while CoSQC was strongly non-NE and CoADC exhibited a heterogeneous phenotype. Similarly, using ferroptosis sensitivity/resistance markers, CoSQC was classified as sensitive (as expected for non-NE), CoLCNEC as resistant (as expected for NE) and CoADC showed a heterogeneous pattern.

CONCLUSIONS

These data support routine molecular profiling of C-SCLC to search for targetable driver alterations and to precisely classify them according to therapeutically relevant subgroups (e.g. NE versus non-NE).

Monoclonal/polyclonal PAX-8, PTH and GATA3 immunohistochemistry in parathyroid lesions

BACKGROUND

Parathyroid gland (PG) is an endocrine organ which may display different immunohistochemical stainings with chief cells and oxyphilic cells in normal as well as hyperplasic/tumoral lesions.

PURPOSE

In this study, we aimed to identify the demographic properties and diagnostic value of the GATA3 antibody, which is a transcription factor in addition to PTH, and of PAX-8 (monoclonal and polyclonal) antibody.

METHODS

We have analyzed in detail the cellular components and staining intensities of 46 adenomas all of which contained parathyroid rims, 12 hyperplasia and 5 adjacent non-neoplastic thyroidectomy materials (63 patients, 114 tissues).

RESULTS

While no staining was identified in the thyroid tissue, cytoplasmic PTH immunoreactivity was observed in all (100%) normal parathyroid tissues, rim of PGs and hyperplasia, and in 43/46 cases (93.4%) of adenomas. Adenoma and hyperplasia were less stained than normal PG (p < 0.05). We detected GATA3 staining in all cases except for the thyroid (100%). Weak positivity (1+) was most apparent in adenoma cases (p < 0.05). Monoclonal PAX-8 immunoreactivity was not identified in any normal parathyroid tissue and rim of PG but positive immunoreactivity was detected in 83.3% of hyperplasia cases (10/12), 84.8% of adenoma (39/46) and 100% of thyroid tissues (5/5) (p < 0.05). However, polyclonal PAX-8 immunoreactivity was detected in one normal parathyroid tissue (1/5) and seven (7/46) rim of PGs. In cases of hyperplasia and adenoma, positive immunoreactivity was 75% (9/12) and 74% (34/46), respectively.

CONCLUSION

In conclusion, we have observed that PTH and GATA3 constitute a much more reliable and sensitive marker for parathyroid and are stained less in adenomas. While monoclonal PAX-8 (MRQ-50) never stains normal parathyroid and rim of PGs, it may help in the differential diagnosis of proliferated parathyroid lesions as a considerably sensitive and relatively specific marker by staining hyperplasic parathyroid, adenomas and the thyroid.

Outcome and diagnostic reproducibility of the thyroid cytology "indeterminate categories" SIAPEC/SIE 2014 in a consecutive series of 302 cases

PURPOSE

The clinical impact of the SIAPEC/SIE 2014 classification for thyroid cytology has been addressed in few studies that evaluated the malignancy rate and the relative prevalence of each category. No study analyzed its intra-observer and inter-observer reproducibility, so far.

METHODS

We retrospectively collected all "indeterminate" lesions diagnosed before (2011-2014) and after (2015-2018) the application of the SIAPEC/SIE 2014 classification at our Institution. Their relative malignancy risks were calculated based on available histological diagnoses. Cytological and clinical features of TIR3A were compared with the surgical outcome. Finally, a large set of samples was re-evaluated in blind of the original cytological and histological diagnoses by two pathologists, independently.

RESULTS

The prevalence of "indeterminate" diagnoses increased in years 2015-2018 (302/1482, 21% with 14% of TIR3A and 7% TIR3B categories) compared to years 2011-2014 (261/1680, 16%). Surgery was performed in 27% TIR3A and in 97% TIR3B cases. Malignancy rates were 40% for TIR3B and 17% for TIR3A, but were greatly influenced by the adoption of the WHO 2017 re-classification of encapsulated follicular-patterned lesions (decreasing to 28% and 6%, respectively). No criteria except for tumor size were associated to malignancy in TIR3A category. Intra-observer agreement of the experienced pathologist was 122/141 (86%), whereas inter-observer agreement between the expert and in-training pathologist was 95/141 (67%).

CONCLUSIONS

In this real-life experience, the sub-classification of TIR3A and TIR3B slightly increased the overall prevalence of "indeterminate" diagnoses. Malignancy rates were higher than estimated for both TIR3A and TIR3B categories. Agreement among observers highly depended on pathologist's training.

The IGF2 methylation score for adrenocortical cancer: an ENSAT validation study

Adrenocortical carcinoma (ACC) is diagnosed using the histopathological Weiss score (WS), but remains clinically elusive unless it has metastasized or grows locally invasive. Previously, we proposed the objective IGF2 methylation score as diagnostic tool for ACC. This multicenter European cohort study validates these findings. Patient and tumor characteristics were obtained from adrenocortical tumor patients. DNA was isolated from frozen specimens, where after DMR2, CTCF3, and H19 were pyrosequenced. The predictive value of the methylation score for malignancy, defined by the WS or metastasis development, was assessed using receiver operating characteristic curves and logistic and Cox regression analyses. Seventy-six ACC patients and 118 patients with adrenocortical adenomas were included from seven centers. The methylation score and tumor size were independently associated with the pathological ACC diagnosis (OR 3.756 95% CI 2.224-6.343; OR 1.467 95% CI 1.202-1.792, respectively; Hosmer-Lemeshow test P = 0.903), with an area under the curve (AUC) of 0.957 (95% CI 0.930-0.984). The methylation score alone resulted in an AUC of 0.910 (95% CI 0.866-0.952). Cox regression analysis revealed that the methylation score, WS and tumor size predicted development of metastases in univariate analysis. In multivariate analysis, only the WS predicted development of metastasis (OR 1.682 95% CI 1.285-2.202; P < 0.001). In conclusion, we validated the high diagnostic accuracy of the IGF2 methylation score for diagnosing ACC in a multicenter European cohort study. Considering the known limitations of the WS, the objective IGF2 methylation score could potentially provide extra guidance on decisions on postoperative strategies in adrenocortical tumor patients.

Integrative and comparative genomic analyses identify clinically relevant pulmonary carcinoid groups and unveil the supra-carcinoids

The worldwide incidence of pulmonary carcinoids is increasing, but little is known about their molecular characteristics. Through machine learning and multi-omics factor analysis, we compare and contrast the genomic profiles of 116 pulmonary carcinoids (including 35 atypical), 75 large-cell neuroendocrine carcinomas (LCNEC), and 66 small-cell lung cancers. Here we report that the integrative analyses on 257 lung neuroendocrine neoplasms stratify atypical carcinoids into two prognostic groups with a 10-year overall survival of 88% and 27%, respectively. We identify therapeutically relevant molecular groups of pulmonary carcinoids, suggesting DLL3 and the immune system as candidate therapeutic targets; we confirm the value of OTP expression levels for the prognosis and diagnosis of these diseases, and we unveil the group of supra-carcinoids. This group comprises samples with carcinoid-like morphology yet the molecular and clinical features of the deadly LCNEC, further supporting the previously proposed molecular link between the low- and high-grade lung neuroendocrine neoplasms.

Adrenal gland tumors in dairy cattle from Northern Italy: morphological and phenotypical characterization in comparison with human pathology

Bovine adrenal gland tumours are considered relatively common, although scarce data are available about their real incidence, pathological characterization, classification criteria and immunohistochemical profile. This study describes the morphological and immunophenotypical characteristics of 35 dairy cattle adrenal gland tumors from Northern Italy and compare them with human pathology. Macroscopical, histological, histochemical and immunohistochemical investigations were performed. Microscopically proliferative lesions were classified as focal hyperplasia (8/35), primary cortical tumors (15/35) , primary medullary tumors (12/35). The cortical tumors showed a highly heterogeneous spectrum of morphological aspects not matching the two major diagnostic categories of adenoma and carcinoma in either cattle or humans. The medullary tumors (7 neuroblastomas and 5 pheochromocytomas) showed morphological and immunophenotypical features largely overlapping with human counterparts. Although limited by the small number of neoplasms and the lack of evidence of metastases precluding a clear distinction between benign and malignant lesions, this study represents the first attempt to compare the bovine and the human pathology. The present data support the concept that adrenal tumors in cattle have distinctive features that deserve a species- specific classification.

Adjuvant mitotane therapy is beneficial in non-metastatic adrenocortical carcinoma at high risk of recurrence

Objective Many patients with adrenocortical carcinoma (ACC) suffer from tumor recurrence despite radical surgery. Evidence on the post-operative use of mitotane is controversial and no predictors of response are available. We aimed to assess whether adjuvant mitotane treatment may prolong survival in patients with non-metastatic ACC following complete resection and whether ACC patients at high risk of recurrence may benefit from treatment. Design and methods We retrospectively reviewed data from 152 non-metastatic ACC patients followed at the San Luigi Gonzaga Hospital: 100 patients were treated with adjuvant mitotane and 52 patients were left untreated following surgery. We assessed a number of potential predictive factors of recurrence and death. Mitotane effect was explored stratifying patients by staging (stage I-II vs stage III), hormone secretion (yes vs no) and Ki67 index. Results The non-treated group had a higher risk of recurrence (HR: 2.79, 95%CI: 1.58-4.91; P < 0.001) than mitotane-treated group, while overall survival was not significantly different between groups. Hormone secretion, elevated Weiss score and elevated Ki67 index confer a higher risk of both recurrence and death and stage III ACC of death. Adjuvant mitotane treatment reduced significantly the risk of death in patients with elevated Ki67 index (P = 0.005) and in patients with stage III ACC (P = 0.02). Conclusions Adjuvant mitotane may prolong recurrence-free survival in radically resected ACC patients with acceptable toxicity and may also prolong overall survival in a subgroup of ACC patients at high risk of recurrence.

Increased production of 27-hydroxycholesterol in human colorectal cancer advanced stage: Possible contribution to cancer cell survival and infiltration

So far, the investigation in cancer cell lines of the modulation of cancer growth and progression by oxysterols, in particular 27-hydroxycholesterol (27HC), has yielded controversial results. The primary aim of this study was the quantitative evaluation of possible changes in 27HC levels during the different steps of colorectal cancer (CRC) progression in humans. A consistent increase in this oxysterol in CRC mass compared to the tumor-adjacent tissue was indeed observed, but only in advanced stages of progression (TNM stage III), a phase in which cancer has spread to nearby sites. To investigate possible pro-tumor properties of 27HC, its effects were studied in vitro in differentiated CaCo-2 cells. Relatively high concentrations of this oxysterol markedly increased the release of pro-inflammatory interleukins 6 and 8, monocyte chemoattractant protein-1, vascular endothelial growth factor, as well as matrix metalloproteinases 2 and 9. The up-regulation of all these molecules, which are potentially able to favor cancer progression, appeared to be dependent upon a net stimulation of Akt signaling exerted by supra-physiological amounts of 27HC.

Efficacy and safety of everolimus treatment in a hemodialysis patient with metastatic atypical bronchial carcinoid: case report and literature review

Background

Everolimus was recently approved for the treatment of neuroendocrine tumors. However, its efficacy and tolerability in hemodialysis patients with end-stage renal disease is not established.

Case presentation

We describe the case of a 47-year-old man with end-stage renal disease who received everolimus plus Lanreotide for 9 months for the management of metastatic atypical bronchial carcinoid.

Conclusions

Everolimus is a treatment option for hemodialysis patients with metastatic atypical bronchial carcinoid. Based on our case report and review of literature, Everolimus does not require any dose reductions and is overall well tolerated in hemodialysis patients.

Prostatic Duct Carcinoma with Combined Prostatic Duct Adenocarcinoma and Urothelial Carcinoma Features

We report a unique case of prostatic duct carcinoma (PDC) featuring both prostatic duct adenocarcinoma (PDA) and high-grade urothelial carcinoma (HG-UC). An 84-year-old man presenting with hematuria showed at ultrasonography and cystoscopy a papillary neoplasia located near to the verumontanum. Histopathologic examination of specimens from transurethral resection revealed a tumor originating from large prostatic ducts showing 2 different components: PDA with endometrioid features (main pattern) and HG-UC (minor part). Immunohistochemically, the areas of PDA were positive for prostatic acid phosphatase (PAP), prostatic specific antigen (PSA), and androgen receptors (AR), while negative for estrogen (ER) and progesterone receptors (PGR). Prognostic factors evaluation pointed out a low proliferation index (10%) and focal expression of p53 (6%); c-erb-B2 was not overexpressed. The HG-UC areas were negative for all previous markers, while positive for thromobomodulin. The proliferation index was high (60%), and p53 was diffusely expressed (55%). The incidence and significance of PDC with combined features is discussed with reference to literature data.

Prognostic factors in stage III-IV adrenocortical carcinomas (ACC): an European Network for the Study of Adrenal Tumor (ENSAT) study

BACKGROUND

The clinical course of advanced adrenocortical carcinoma (ACC) is heterogeneous. Our study aimed primarily to refine and make headway in the prognostic stratification of advanced ACC.

PATIENTS AND METHODS

Patients with advanced ENSAT ACC (stage III or stage IV) at diagnosis registered between 2000 and 2009 in the ENSAT database were enrolled. The primary end point was overall survival (OS). Parameters of potential prognostic relevance were selected. Univariate and multivariate analyses were carried out: model 1 'before surgery'; model 2 'post-surgery'.

RESULTS

Four hundred and forty-four patients with advanced ENSAT ACC (stage III: 210; stage IV: 234) were analyzed. After a median follow-up of 55.2 months, the median OS was 24 months. A modified ENSAT (mENSAT) classification was validated: stage III (invasion of surrounding tissues/organs or the vena renalis/cava) and stage IVa, IVb, IVc (2, 3 or >3 metastatic organs, including N, respectively). Two- or 5-year OS was 73%, 46%, 26% and 15% or 50%, 15%, 14% and 2% for stages III, IVa, IVb and IVc, respectively. In the multivariate analysis, mENSAT stages (stages IVa, IVb, or IVc, respectively) were significantly correlated with OS (P < 0.0001), as well as additional parameters: age ≥ 50 years (P < 0.0001), tumor- or hormone-related symptoms (P = 0.01 and 0.03, respectively) in model 1 but also the R status (P = 0.001) and Grade (Weiss >6 and/or Ki67 ≥ 20%, P = 0.06) in model 2.

CONCLUSION

The mENSAT classification and GRAS parameters (Grade, R status, Age and Symptoms) were found to best stratify the prognosis of patients with advanced ACC.

Grading the neuroendocrine tumors of the lung: an evidence-based proposal

Lung neuroendocrine tumors are catalogued in four categories by the World Health Organization (WHO 2004) classification. Its reproducibility and prognostic efficacy was disputed. The WHO 2010 classification of digestive neuroendocrine neoplasms is based on Ki67 proliferation assessment and proved prognostically effective. This study aims at comparing these two classifications and at defining a prognostic grading system for lung neuroendocrine tumors. The study included 399 patients who underwent surgery and with at least 1 year follow-up between 1989 and 2011. Data on 21 variables were collected, and performance of grading systems and their components was compared by Cox regression and multivariable analyses. All statistical tests were two-sided. At Cox analysis, WHO 2004 stratified patients into three major groups with statistically significant survival difference (typical carcinoid vs atypical carcinoid (AC), P=0.021; AC vs large-cell/small-cell lung neuroendocrine carcinomas, P<0.001). Optimal discrimination in three groups was observed by Ki67% (Ki67% cutoffs: G1 <4, G2 4-<25, G3 ≥25; G1 vs G2, P=0.021; and G2 vs G3, P≤0.001), mitotic count (G1 ≤2, G2 >2-47, G3 >47; G1 vs G2, P≤0.001; and G2 vs G3, P≤0.001), and presence of necrosis (G1 absent, G2 <10% of sample, G3 >10% of sample; G1 vs G2, P≤0.001; and G2 vs G3, P≤0.001) at uni and multivariable analyses. The combination of these three variables resulted in a simple and effective grading system. A three-tiers grading system based on Ki67 index, mitotic count, and necrosis with cutoffs specifically generated for lung neuroendocrine tumors is prognostically effective and accurate.

Mitotane levels predict the outcome of patients with adrenocortical carcinoma treated adjuvantly following radical resection

CONTEXT

Mitotane plasma concentrations ≥ 14 mg/l have been shown to predict tumor response and better survival in patients with advanced adrenocortical carcinoma (ACC). A correlation between mitotane concentrations and patient outcome has not been demonstrated in an adjuvant setting.

OBJECTIVE

To compare recurrence-free survival (RFS) in patients who reached and maintained mitotane concentrations ≥ 1 4 mg/l vs patients who did not.

DESIGN AND SETTING

Retrospective analysis at six referral European centers.

PATIENTS

Patients with ACC who were radically resected between 1995 and 2009 and were treated adjuvantly with mitotane targeting concentrations of 14-20 mg/l.

MAIN OUTCOME MEASURES

RFS (primary) and overall survival (secondary).

RESULTS

Of the 122 patients included, 63 patients (52%) reached and maintained during a median follow-up of 36 months the target mitotane concentrations (group 1) and 59 patients (48%) did not (group 2). ACC recurrence was observed in 22 patients of group 1 (35%) and 36 patients in group 2 (61%). In multivariable analysis, the maintenance of target mitotane concentrations was associated with a significantly prolonged RFS (hazard ratio (HR) of recurrence: 0.418, 0.22-0.79; P=0.007), while the risk of death was not significantly altered (HR: 0.59, 0.26-1.34; P=0.20). Grades 3-4 toxicity was observed in 11 patients (9%) and was managed with temporary mitotane discontinuation. None of the patients discontinued mitotane definitively for toxicity.

CONCLUSIONS

Mitotane concentrations ≥ 14 mg/l predict response to adjuvant treatment being associated with a prolonged RFS. A monitored adjuvant mitotane treatment may benefit patients after radical removal of ACC.

Hyalinizing trabecular tumor of the thyroid: a case report

Hyalinizing trabecular tumor (HTT) of the thyroid is a rare neoplasm that was first described by Carney in 1987. It is a tumor of follicular derivation with peculiar nuclear, architectural, histochemical, and immunohistochemical features. We report a case of HTT in a 69-year-old woman with a mutinodular goiter. Since the clinical and ultrasonographic features were nonspecific, fine needle aspiration biopsy (FNAB) of the left lobe-dominant node was performed that resulted in an indeterminate cytologic diagnosis (category THY-3). The patient underwent total thyroidectomy, with a histologic diagnosis of HTT. We discuss the clinical and diagnostic approach, including the role of FNAB, and the pathologic features of HTT with special reference to the possible differential diagnosis. Total thyroidectomy or hemithyroidectomy represent adequate treatments, while radioiodine ablation is not standard. Although rare cases of malignant HTT have been documented, this tumor should be considered a benign neoplasm or, at most, a neoplasm of extremely low malignant potential. As a consequence, once this diagnosis is rendered, clinical management should be conservative, which may include a precautionary annual follow-up in order to exclude the very rare possibility of recurrence, as exceptionally reported.

Somatostatin receptor tissue distribution in lung neuroendocrine tumours: a clinicopathologic and immunohistochemical study of 218 'clinically aggressive' cases

BACKGROUND

The management of pulmonary neuroendocrine tumours (NETs), with special reference to clinically aggressive carcinoids and large-cell neuroendocrine carcinomas (LCNECs), is poorly standardised and data about somatostatin receptor (SSTR) expression or therapeutic guidelines for somatostatin analogue administration are still debated.

MATERIALS AND METHODS

A series of 218 lung NETs [24 metastatic typical carcinoids (TCs), 73 atypical carcinoids (ACs), 60 LCNECs and 61 surgically resected small-cell lung carcinomas] were investigated for SSTR types 2A and 3 tissue distribution using immunohistochemistry, in correlation with clinicopathologic parameters, outcome, scintigraphy and treatment.

RESULTS

SSTRs were heterogeneously distributed with a significant progressive decrease from low- to high-grade forms. SSTR type 2A was strikingly overexpressed in metastatic TCs as compared with ACs and clinically benign TCs. SSTR tissue immunolocalization correlated with octreotide scintigraphy in 20 of 28 cases.

CONCLUSION

The immunohistochemical determination of SSTRs, with special reference to low-grade/intermediate-grade tumours, may assist the clinical approach with somatostatin analogue-based diagnostic and therapeutic procedures in clinically aggressive pulmonary NETs.

Baseline thymidylate synthase expression according to histological subtypes of non-small cell lung cancer

7521

Background: In non-small cell lung cancer (NSCLC) baseline thymidilate synthase (TS) levels are higher in squamous cell carcinoma (SCC) compared to adenocarcinoma (AC) and randomized clinical trials have shown a selective benefit for patients with non-squamous histology treated with pemetrexed, a TS-inhibiting agent. TS expression in undifferentiated large cell carcinoma (LCC) is unknown. Methods: TS expression at both mRNA (using tissue microdissection and qRT-PCR) and protein (through immunohistochemistry, IHC) levels was tested in 34 surgically resected LCC (stage I=20,II=6,IIIa=8) and compared with TS expression in surgical cases of SCC (n= 31) and AC (n=40). In addition other comparisons were made: a) TS protein expression with Ki-67 index; b) TS mRNA and E2F1 transcription factor mRNA; c) in all histotypes TS protein level with desmocollin-3 (DSC-3) immunostaining, a marker of squamous cell differentiation. TS expression level was assessed in a group of patients (n=22) with cytological diagnosis of NSCLC-NOS (not otherwise specified) and compared with TS data in tissue specimens obtained through subsequent bronchial biopsy or surgical resection. Results: Significantly higher median TS levels in LCC compared to AC (p<0.001 for both mRNA and protein values) and SCC compared to AC (p=0.002 mRNA, p<0.001 protein) were detected. A strong correlation between TS mRNA and protein levels were found (p<0.001) in SCC and AC, but not in LCC. TS and both Ki-67 and E2F1 were significantly correlated in AC and SCC (p=0.003 and p=0.05, respectively), but in LCC no correlation was found. In LCC, significantly higher TS levels were observed in DSC3-positive compared to DSC3-negative tumors (p=0.02). A significant correlation between TS IHC scores in matched cytological and corresponding tissue specimens was observed (p<0.001). Conclusions: This study demonstrates and confirms the: a) differential expression of TS among the NSCLC histotypes; b) lack of DSC-3 immunoreactivity in LCC is associated with lower TS expression; c) assessment of TS by IHC in cytological specimens correlates with the corresponding tissue TS expression.

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Arcanobacterium haemolyticum: two case reports

Two uncommon presentations of Arcanobacterium Haemolyticum infection (sinusitis and pharyngitis) are described, emphasizing the poor response to commonly used antibiotics and the possibility of serious local and systemic complications. The difficulties still encountered in the clinical diagnosis are underlined, since this organism could easily pass unrecognized in bacteriological cultures.

Somatostatin, cortistatin and their receptors in tumours

Somatostatin (SS) and its synthetic analogs have a role in the treatment of neuroendocrine tumours both in terms of symptoms control and antiproliferative activities. These effects are mediated by five SS receptors, widely expressed in both human neuroendocrine and non-neuroendocrine tumours, which were demonstrated to be diagnostically and therapeutically valuable targets. Cortistatin (CST), a brain cortex peptide, partially homologous to SS and having similar functions is also expressed in peripheral tissues and tumours. CST binds all SS receptors, and, differently from SS, also the ghrelin receptor GHSR1a and the CST specific receptor MrgX2. The expression profile of CST is mostly restricted to neuroendocrine tumours (gastrointestinal, pancreas, lung, parathyroid, thyroid, adrenal). In these tumours, CST probably acts via the SS or ghrelin receptor, the MrgX2 receptor being absent. Thus, in comparison to SS analogs, CST synthetic analogs may represent additional diagnostic/therapeutic tools in those tumours expressing the receptors for SS, for ghrelin or for both peptides.

DNA copy number status is a powerful predictor of poor survival in endocrine pancreatic tumor patients

The clinical behavior of endocrine pancreatic tumors (EPTs) is difficult to predict in the absence of metastases or invasion to adjacent organs. Several markers have been indicated as potential predictors of metastatic disease, such as tumor size > or =2 cm, Ki67 proliferative index > or =2%, cytokeratin (CK) 19 status, and recently in insulinomas, chromosomal instability (CIN). The goal of this study was to evaluate the value of these markers, and in particular of the CIN, to predict tumor recurrence or progression and tumor-specific death, using a series of 47 insulinomas and 24 non-insulinoma EPTs. From these EPT cases, a genomic profile has been generated and follow-up data have been obtained. The proliferative index has been determined in 68 tumors and a CK19 expression pattern in 50 tumors. Results are statistically analyzed using Kaplan-Meier plots and the log-rank statistic. General CIN, as well as specific chromosomal alterations such as 3p and 6q loss and 12q gain, turned out to be the most powerful indicators for poor tumor-free survival (P< or =0.0004) and tumor-specific death (P< or =0.0113) in insulinomas. The CIN, chromosome 7q gain, and a proliferative index > or =2% were reliable in predicting a poor tumor-free survival in non-insulinoma EPTs (P< or =0.0181, whereas CK19 expression was the most optimal predictor of tumor-specific death in these tumors. In conclusion, DNA copy number status is the most sensitive and efficient marker of adverse clinical outcome in insulinomas and of potential interest in non-insulinoma EPTs. As a consequence, this marker should be considered as a prognosticator to improve clinical diagnosis, most practically as a simple multi-target test.

Clinical impact of ERCC1 and TOPOIIα gene expression in small-cell lung cancer patients treated with platinum/etoposide

2526

Background: Platinum/etoposide is a commonly used regimen both in limited (LS) and extensive stage (ES) small-cell lung cancer (SCLC). The study was aimed at testing retrospectively the predictive role of mRNA quantification of genes correlated to platinum/etoposide therapy: ERCC1, RRM1 and TOPOIIa. Methods: Total RNA was extracted from microdissected sections of 103 formalin-fixed, paraffin embedded bronchial biopsies. Relative quantification for ERCC1, RRM1 and TOPOIIa and an internal reference gene (β- Actin) was performed by Real-Time PCR using intron-spanning primers. ERCC1 expression was also evaluated by immunohistochemistry using a semi-quantitative score. Results: Eighty-five samples (83%) were successfully amplified. Overall median survival (MS) was 9.9 months, 45 patients had LS (MS=13.1 months) and 40 had ES (MS=7.1 months). Fifty-six (65%) had an objective (complete or partial) response to treatment. Immunohistochemical staining of ERCC1 evidenced a positivity in 2 out of 85 patients with no correlation with clinico-pathological factors. By contrast, a gene expression level was detectable in all samples and a significant correlation between ERCC1 and RRM1 levels (Rs=0.34, p=0.0011) was found. By segregating patients according to response to treatment, it was found that lower TOPOIIa expression was associated to a better response in LS patients (p=0.025) and, more interestingly, those who had a complete response had low TOPOIIa levels than both partial and non-responsive patients (p=0.015). By adopting cut-offs according to median values, univariate analysis of survival by Kaplan-Meier method showed that LS patients with low ERCC1 had a significantly longer survival (MS 14.9 vs. 9.9 months, p=0.012), while RRM1 and TOPOIIa levels showed no influence on outcome. In multivariate analysis, ERCC1 was an independent prognostic factor for survival of LS patients, together with PS and response to therapy. No significant role was found for ERCC1, RRM1 and TOPOIIa in patients with ES. Conclusions: ERCC1 and TOPOIIa represent reliable candidate markers in predicting clinical outcome and response to treatment in LS SCLC patients, who may benefit from a better individualized therapy.

[Table: see text]

Peptide receptors in neuroendocrine tumors of the lung as potential tools for radionuclide diagnosis and therapy

Neuroendocrine tumors of the lung are carcinomas characterized by different impact on the patients' prognosis, ranging from relatively indolent, low- to intermediate-grade neoplasms with longer life expectation (i.e., typical and atypical carcinoids) to very aggressive and poorly differentiated neoplasms with dismal prognosis (i.e., large cell neuroendocrine carcinoma and small cell lung cancer). The standard treatment of typical or atypical carcinoids is the complete surgical resection, whereas the role of radio-chemotherapy in a multimodality treatment or for palliation remains controversial. Conversely, high-grade neuroendocrine carcinomas are in primis treated by aggressive combination chemotherapy, deserving surgical resection for uncommon low-stage tumors. Since evidence has been accumulated that neuroendocrine tumors of the lung are supplied with a wide array of peptide receptors detectable on cell membranes by immunohistochemical methods, innovative strategies for diagnosis and radiometabolic therapy have been devised to target these molecules for the correct clinical management of the patients. In this paper, the structural and functional aspects and the clinical applications of the detection of several peptide receptors in pulmonary neuroendocrine tumors will be reviewed, including somatostatin receptors, vasoactive intestinal peptide/pituitary adenylate cyclase activating peptide family receptors, cholecystokinin /gastrin receptors, bombesin/gastrin releasing peptide receptors, neurotensin receptors, substance P receptors, neuroepeptide Y receptors, calcitonin/calcitonin gene-related peptide receptors, atrial natriuretic peptide receptors, glucagon-like-peptide-1 receptors, oxytocin receptors and endothelin receptors. Only a detailed knowledge of the peptide receptor distribution in these tumor types, especially in uncommon neoplasms such as atypical carcinoids and large cell neuroendocrine carcinomas, is pivotal for planning the most adequate interventions for the patients' diagnosis and therapy.

ERCC1 and RRM1 gene expressions but not EGFR are predictive of shorter survival in advanced non-small-cell lung cancer treated with cisplatin and gemcitabine

BACKGROUND

Pivotal studies indicate a role of excision repair cross-complementation 1 (ERCC1) gene and ribonucleotide reductase M1 (RRM1) gene in conferring a differential sensitivity to cytotoxic chemotherapy and epidermal growth factor receptor (EGFR) gene has been recently extensively investigated in non-small-cell lung cancer (NSCLC).

DESIGN

Formalin-fixed, paraffin-embedded bronchoscopic/fine needle aspiration biopsies obtained from 70 patients with advanced NSCLC were retrospectively collected to investigate the expression level of ERCC1, RRM1 and EGFR by real-time PCR. Sufficient amounts of messenger RNA (mRNA) were successfully extracted from 61 (87%) specimens, reverse transcribed and amplified with intron-spanning primers. Forty-one patients had stage IV disease and 43 received cisplatin/gemcitabine chemotherapy.

RESULTS

A strong correlation between ERCC1 and RRM1 mRNA levels (r(s) = 0.624, P < 0.0001) was found. Median survival time in patients with low ERCC1 was significantly longer (17.3 versus 10.9, P = 0.0032 log-rank test) as well as in patients with low RRM1 (13.9 versus 10.9, P = 0.0390 log-rank test). Concomitant low expression levels of ERCC1 and RRM1 (n = 33) were predictive of a better outcome (14.9 versus 10.0, P = 0.0345 log-rank test). Among cisplatin-treated patients, a low ERCC1 level was highly predictive of a longer survival (23.0 versus 12.4, P = 0.0001 log-rank test). No correlation between gene expression levels and histology was reported. No significant correlation between EGFR expression level and survival was found. At multivariate analysis, performance status, response to chemotherapy, presence of weight loss and ERCC1 were independent prognostic factors for survival.

CONCLUSIONS

This retrospective study further validates ERCC1 and RRM1 genes as reliable candidates for customized chemotherapy and shows a higher impact on the survival of NSCLC patients treated with cisplatin/gemcitabine for ERCC1. Prospective pharmacogenomic studies represent a research priority in early and advanced NSCLC.

Absence of gene mutations in a case of concomitant presence of carcinoid of the ampulla of vater pheochromocytoma and Von Recklinghausen disease

The rare association between Von Recklin-ghausen's disease (VRD) and tumours other than in central nervous system is well recognized. However, the concomitance of VRD, a carcinoid of the ampulla of Vater, and a pheochromocytoma has been described very rarely in literature. Furthermore, the possible role of the genes usually involved in multiple endocrine neoplasia (MEN) syndromes, in this association, is unclear. We report the case of a patient affected by VRD and extra-adrenal pheochromocytoma, operated on in the past for a carcinoid of the ampulla of Vater. To determine if genes involved in MEN syndromes might play a role in this particular triad, we investigated the presence of somatic or germline mutations in the RET proto-oncogene and menin gene by non isotopic polymerase chain reaction single stranded conformation polymorphism (PCR-SSCP) and heteroduplex gel electro-phoresis. The results demonstrated that no somatic or germline mutations in the MEN-1 and MEN-2 genes were involved in the pathogenesis of these tumours.

Laryngeal carcinoma and laryngo-pharyngeal reflux disease

A correlation between laryngo-pharyngeal reflux and laryngeal carcinoma is currently debated. Chronic inflammation is a mutagen factor confirmed in the cancerogenesis of various tumours. Aim of the present study was to evaluate, in an objective and consecutive way, with 24h multi-electrode pH-metry the presence of proximal and distal oesophageal reflux in patients presenting pre-cancerosis or squamous cell laryngeal and/or pharyngeal carcinomas. From our data, a strict correlation emerged between laryngo-pharyngeal reflux and neoplasias of the upper airways, documented through multi-electrode pH-metry. Data emerging from this study would seem to support the theory that the protracted exposure (> 20 years) to biliary reflux would represent a statistically significant added risk factor in the precancerous lesions and squamous pharyngo-laryngeal carcinoma as it occurs at oesophageal level. Moreover, a significant statistical association (p < 0.0001) emerged between laryngeal carcinoma and previous gastro-resection (odds ratio 3.8).

Accumulation of p27(kip1) is associated with cyclin D3 overexpression in the oxyphilic (Hurthle cell) variant of follicular thyroid carcinoma

BACKGROUND

The down regulation of protein p27(kip1) (p27) in most cases of thyroid cancer has relevant diagnostic and prognostic implications. However, the oxyphilic (Hurthle cell) variant of follicular thyroid carcinoma expresses more p27 than benign oxyphilic lesions do.

AIM

To evaluate the mechanism underlying this difference in expression of p27.

METHODS

Because high levels of cyclin D3 lead to p27 accumulation in cell lines and clinical samples of thyroid cancer, the immunocytochemical pattern of cyclin D3 in oxyphilic (n = 47) and non-oxyphilic (n = 70) thyroid neoplasms was investigated.

RESULTS

In the whole study sample, there was a significant correlation between p27 and cyclin D3 expression (Spearman's r: 0.64; p<0.001). The expression of cyclin D3 and p27 was significantly higher in the oxyphilic variant of follicular carcinomas than in non-oxyphilic carcinomas (p<0.001). In the former, cyclin D3 overexpression and p27 accumulation were observed in a median of 75% and 55% of cells, respectively. In co-immunoprecipitation experiments, the level of p27-bound cyclin D3 was much higher in oxyphilic neoplasias than in normal thyroids and other thyroid tumours.

CONCLUSION

These results show that increased p27 expression in the oxyphilic (Hurthle cell) variant of follicular thyroid carcinoma results from cyclin D3 overexpression.

Matrix metalloproteinase type 2 (MMP2) is selective expressed in adrenocortical carcinoma but not in adrenal adenoma: An immunohistochemical study

14534

Background: Adrenocortical carcinoma (ACC) is a very rare disease which account for no more than 0.2% of all malignancies, and its differential diagnosis from adrenocortical adenomas (ACA) is based on the application of different scoring systems, which, however, lack a sensitivity and specificity of 100%. Little is known on the mechanisms leading to the malignant phenotype in adrenocortical tumors; among alternative mechanisms, metalloproteinases (MMPs) have been demonstrated in solid tumors, including endocrine ones, to be implicated in malignant progression and metastatization. Our aim was to investigate metalloproteinase 2 (MMP2) expression in adrenocortical tumors. Methods: A series of 33 ACC and 23 ACA was retrospectively collected from a large series of adrenocortical lesions, and the diagnosis was reviewed independently by three investigators (MV, EB, MP) according to the Weiss histological criteria. MMP2 was determined by immunohistochemistry and the results scored by semi-quantitative analysis, based on the intensity of the staining and the percentage of tumor cells positive. Immunohistochemical results were compared to clinico-pathological parameters, such as sex, age, hormonal secretion, and outcome. Results: MMP2 expression was detected in 1/23 ACA (4%), and in 25/33 ACC (76%) (X-square test p < 0.001). MMP2 immunohistochemical pattern in ACC was focal to moderate to strong in 10, 12 and 3 cases, respectively. In addition, moderate to strong MMP2 expression, as compared to low or negative immunostaining, correlated with shorter disease-free survival (p = 0.012) and poor outcome (p = 0.07). No correlation were found comparing MMP2 expression and other clinico-pathological parameters. Conclusions: As reported in a variety of solid tumors, our data indicates a possible role of MMP2 in the malignant evolution of adrenocortical tumors, and its immunohistochemical localization may be a potential useful tool in the differential diagnosis of benign versus malignant adrenocortical lesions. In addition, a strong immunohistochemical MMP2 expression seems to be related to a poor prognosis in ACC.

No significant financial relationships to disclose.

ERCC1 and RRM1 but not EGFR gene expression is predictive of shorter survival in advanced non-small cell lung cancer (NSCLC)

10030

Background: Pivotal studies indicate a role of excision repair cross-complementation 1 (ERCC1) and ribonucleotide reductase M1 (RRM1) in conferring a differential sensitivity to cytotoxic chemotherapy and epidermal growth factor receptor (EGFR) has been recently deeply investigated in NSCLC. Methods: We retrospectively collected 70 formalin-fixed paraffin-embedded (FFPE) bronchoscopic/fine needle aspiration biopsies of NSCLC to investigate the expression levels of ERCC1, RRM1 and EGFR by Real-Time PCR (Lord R et al. Clin Cancer Research 2002, 8:2286–91). Results were correlated with survival using the Kaplan-Meier method. Results: Sixty-one (87%) specimens were successfully amplified. Median age was 62 years (range 26–75), male/ female ratio 44/17, stage III/IV 20/41; 43 patients received cisplatin-based chemotherapy; overall median survival (MS) was 13.3 months over a median follow-up time of 45 months. ERCC1 expression level ranged from 0.70 to 15.12, RRM1 0.60–17.82. By adopting cut-off values according to median expression levels, we found a strong correlation between ERCC1 and RRM1 mRNA levels (r=0.410; p<0.001). MS in patients with low ERCC1 was significantly longer (16.9 vs 11.3 months, p<0.006) as well as in patients with low RRM1 (13.9 vs 10.9 months, p<0.03). Concomitant high expression levels of ERCC1 and RRM1 (n=26) are predictive of a worse outcome (13.9 vs 10.9 months, p<0.05). Among patients treated with cisplatin-based regimens, low ERCC1 levels were also predictive of a significantly longer MS (23.0 vs 11.6 months, p<0.002). A lower median ERCC1 level (3.2 vs 4.7) and a correlation with a better outcome were also observed in females vs males. No correlation between gene expression levels and histology was reported. No significant correlation between EGFR expression levels (range 0.5–85.8) and survival was found, even when different cut-off values were tested. Conclusions: This retrospective study further validates ERCC1 and RRM1 as good candidates genes to customize chemotherapy. Prospective studies based on the selection of patients according to genes expression levels are a research priority in early and advanced stages of NSCLC.

[Table: see text]

Bone sialoprotein is predictive of bone metastases in resectable non-small cell lung cancer: A case-control study and prevalence data

7049

Background: Bone metastases (BM) in non small cell lung cancer (NSCLC) may be present at diagnosis or develop in the follow up, are associated with a worse prognosis, and currently there are no chemical or biological markers predicting their clinical onset. Methods: Thirty cases of resected NSCLC which subsequently develop BM (group A - mean follow up time 27.2 months) were matched for several clinico-pathological parameters (including age, sex, stage of the disease, histology, differentiation grade, adjuvant therapy) to 30 cases of resected NSCLC without any metastases (group B - mean follow up time 75.1 months) and 26 resected NSCLC with non-bone metastatic (group C - mean follow up 21.1 months). Primary tumor samples were investigated by immunohistochemistry for 10 markers previously recognized to be involved in bone resorption or metastatization process (cathepsin K, bone sialoprotein [BSP], VEGF, MMP-2, p53, RECK, TIMP-1, CD-117, Ki-67 and TRAcP). For statistical analysis the intensity of the staining was assessed by a semi-quantitative score (0, <10%, 10–50%, >50% +ve tumor cells). Differences among groups were estimated by X-square test, whereas the prognostic impact of clinico-pathological parameters and markers expression was evaluated by univariate and multivariate analyses. Results: Among the different markers investigated, BSP was strongly associated to bone dissemination (p < 0.001) and, independently, to poor outcome (p = 0.02 by Mantel-Cox test). None of the other markers was differentially expressed within the groups or demonstrated a prognostic impact, both in terms of overall survival and of time interval to metastases. Based on these findings, the prevalence of BSP in NSCLC was further estimated in a large series of 120 resected lung carcinomas (M:F ratio 3:1; mean age 67 years; adenocarcinomas 55%, squamous cell carcinoma 39%, others 6%; stages: I 54%, II 17%, III 29%). BSP prevalence reached 40%, without any statistically significant difference according to histotype or other clinico-pathological parameters. Conclusions: BSP protein expression in resected NSCLC strongly predicts bone dissemination, and may therefore be useful in selecting patients for treatments targeted to inhibit bone metastatic spread.

[Table: see text]

[Sporadic C-cell hyperplasia associated with multinodular goiter]

INTRODUCTION

C cell hyperplasia may arise in a familial setting, associated to MEN2 syndromes, or sporadic, associated to other thyroid diseases. Its prevalence in the sporadic form, as well as its biological significance, need to be determined to date. Sporadic C cell hyperplasia may be associated to elevated serum calcitonin levels, and routinary calcitonin screening tests on the search of early medullary carcinomas, have born to an increase of its diagnosis.

MATERIALS AND METHODS

We report herein the case of a 47-years old female, submitted to total thyroidectomy for nodular goiter, with slightly increased serum calcitonin levels and positive pentagastrin test. Familial history was negative for endocrinopathies.

CASE REPORT

Histological examination revealed in the setting of a multinodular goiter, the occurrence of C cell hyperplasia, demonstrated by means of calcitonin immunoistochemistry, in the absence of foci of medullary carcinoma. Morphological features (no atypia) were consistent with a sporadic physiologic form of C cell hyperplasia, as opposed to neoplastic C cell hyperplasia in the context of MEN2.

DISCUSSION

The prevalence of C cell hyperplasia is not well defined, and differently from the familial form, its progression to sporadic medullary carcinoma should still be proven. Therefore its observation in a sporadic form, as in the present case, do not modify the clinical and therapeutic approach in affected patients.

Sudden cochlear hearing loss as presenting symptom of arachnoid cyst of the posterior fossa

Arachnoid cysts account for almost 1% of neoformations located in the cerebellopontine angle. The aetiopathogenesis is unknown. Arachnoid cysts of the cranial posterior fossa may produce symptoms typical of a tumour such as headache, dizziness, tinnitus and progressive sensorineural hearing loss. Management of these lesions is still controversial; if the arachnoid cyst is symptomatic, surgical treatment is usually recommended. The case is described of an adult female with sudden unilateral cochlear hearing loss as presenting symptom of an arachnoid cyst in the cranial posterior fossa.

Tissue arrays as fiducial markers for section alignment in 3-D reconstruction technology

Combination of conventional histology and the three-dimensional spatial view of tissue structures offers new prospects for understanding and diagnosing nature and development of human diseases. The essential technical problem related to three-dimensional reconstruction in histopathology is represented by the correct alignment of serial sections. During the past years several methods have been proposed but failed to become popular because of their limits in terms of time consume and restricted applicability. We aimed to overcome this problem by applying the technology of Tissue Array, thus by positioning adequate fiducial markers from specific "donor" blocks into the "recipient" paraffin block of interest. Digitized pictures of serially cut sections were aligned according to the tissue markers embedded by Tissue Array, and then processed with specific softwares for three-dimensional reconstruction. Thirteen models, including fetal hearts, breast and thyroid carcinomas, were elaborated. We found the procedure to be easy, fast and reproducible. Moreover, by selectively embedding the fiducial markers according to specific angles, the Tissue Arrays can be exploited in order to establish the distance between sections. This original methodology of incorporating Tissue Arrays into paraffin blocks as fiducial markers for three-dimensional reconstruction has a potential impact on histology for research purposes and diagnostic applications.