Lung Cancer Cytology in the Molecular Era Lecture 19 - PDF

Lung cancer in the molecular era Dr Chris van Vliet Consultant Anatomical Pathologist Lead pathologist Oncology FISH section PathWest QEII Medical Centre [email protected] PATH3309 ...

Lung cancer in the molecular era Dr Chris van Vliet Consultant Anatomical Pathologist Lead pathologist Oncology FISH section PathWest QEII Medical Centre [email protected] PATH3309  Lung cancer in Australia Lung cancer is the leading cause of cancer death in Australia Lung cancer is the 5th most commonly diagnosed cancer in both males & females Incidence rate of lung cancer has fallen in males but risen in females (overall slight decrease) Prognosis poor – 5 year relative survival 17% Australian Institute of Health and Welfare 2021. Cancer in Australia 2021. Cancer series no. 133. Cat. no. CAN 144. Canberra: AIHW.  Risk factors for lung cancer TOBACCO SMOKING Occupational & environmental carcinogens (asbestos, silica, radon, heavy metals, polycyclic aromatic carbons, diesel exhaust) Radiation exposure Chronic inflammation e.g. Tuberculosis Pulmonary fibrosis Family history (relative diagnosed at a young age, multiple family members) Specific inherited conditions e.g. Li Fraumeni syndrome, alpha-1 antitrypsin deficiency.  Sampling techniques for diagnosis of lung cancer Transbronchial FNA (+/- EBUS) Percutaneous transthoracic FNA/core biopsy Bronchial washings & brushings Pleural fluid aspiration Endobronchial biopsy Sputum collection  Transbronchial FNA – Endobronchial ultrasound (EBUS) guided Haas A. Am J Resp Crit Med 2010  Transbronchial FNA – Endobronchial ultrasound (EBUS) guided Percutaneous transthoracic FNA/core biopsy – CT guided FNA squash smear preparation Cell block preparation  Ancillary studies on neoplastic cytology/biopsy specimens Histochemical stains (e.g. mucin stains) Immunohistochemistry (IHC) Sanger and next-generation sequencing (NGS) Polymerase chain reaction (PCR) based techniques Fluorescence in-situ hybridisation (FISH) (Electron microscopy) Flow cytometry  Major categories of lung cancer Small cell carcinoma (14%) - Usually non-resectable - Chemoradiotherapy Adenocarcinoma (38%) Squamous cell carcinoma (20%) “Non-small cell lung carcinoma (NSCLC)” Large cell carcinoma Resect if possible Look for “druggable” Adenosquamous carcinoma targets, otherwise chemoradiotherapy Sarcomatoid carcinoma  Small cell carcinoma Highly aggressive malignant epithelial tumour with neuroendocrine differentiation Strongly associated with smoking Males > Females Central >> peripheral Ectopic hormone production common Widespread metastases & virtually always fatal Treated with chemoradiation  Small cell carcinoma c’tinued Small cells with scant cytoplasm, finely granular chromatin & absent/inconspicuous nucleoli Nuclear molding, necrosis, mitoses++ Immunohistochemistry: CD56+, synaptophysin+, chromogranin+/-, TTF-1+ Electron microscopy: Neuroendocrine granules in 2/3 Small cell carcinoma – perihilar lung mass Small cell carcinoma (Papanicolaou stain) Small cell carcinoma (H&E) Image courtesy of Dr Yale Rosen www.flickr.com  Major categories of lung cancer Small cell carcinoma (14%) Adenocarcinoma (38%) Squamous cell carcinoma (20%) “Non-small cell lung Large cell carcinoma carcinoma (NSCLC)” Adenosquamous carcinoma Sarcomatoid carcinoma  Adenocarcinoma Invasive malignant epithelial tumour with glandular differentiation or mucin production Males = Females Most cases are in smokers, but commonest type of lung cancer in non-smokers Increasing incidence relative to SqCCa Peripheral > central Extrathoracic metastases (adrenal, bone, brain) common Adenocarcinoma – peripheral lung mass Adenocarcinoma – acinar growth pattern (H&E stain)  Adenocarcinoma in-situ Neoplastic glandular proliferation ≤3cm with pure lepidic growth along alveolar walls No stromal, vascular or pleural invasion Most cases non-mucinous, rarely mucinous CT chest: ground glass nodule 100% 5-year disease free survival if completely resected CT chest: Ground glass nodule Image courtesy of Dr Usman Bashir Radiopaedia.org Adenocarcinoma in-situ, non-mucinous (H&E stain) Oncogenic drivers of lung adenocarcinoma KRAS G12C Boollell V et al. Cancers (Basel) 2015;7(3):1815-1846.  The importance of small samples 7̴ 0% of pts with non-small cell lung carcinoma (NSCLC) present with unresectable disease A small biopsy/cytology sample may be all you get! Historically “NSCLC not otherwise specified” was good enough for treatment purposes Refining a diagnosis is now critical for patient management Careful tissue management for diagnosis, IHC & molecular studies Travis WD. Histology Matters: Personalized therapy for patients with nonsmall cell lung cancer. Johns Hopkins Advanced Studies in Medicine July 3, 2011  Subtyping of NSCLC Subtyping of NSCLC combining morphology & ancillary studies is feasible and accurate Periodic acid-Schiff + diastase (PASD) for mucin Immunohistochemistry: – TTF-1: primary lung adenoca – p40 and CK5/6: squamous markers (Don’t forget about metastatic disease and lymphoma) Rekhtman N et al. J Thorac Oncol 2011;6:451-458. Bubendorf L et al. Eur Respir J 2017;26:170007.  Case #1. 65 yo female, East Asian, right upper lobe lung mass, non-smoker, previous breast ca. CT chest EBUS FNA 4R lymph node (H&E)  TTF1 Cell block Mammaglobin ER EGFR Sanger bi-directional Sequencing Exon 19: Deletion mutation c.2235_2249del15; p.Glu746_Ala750del Forward reaction Reverse reaction Exon 19: Deletion (GGAATTAAGAGAAGC)  EGFR-mutated lung adenocarcinoma 10-20% Western and 30-50% of East Asian pts, particularly women & never smokers Adenocarcinomas with lepidic growth pattern Mutations in exon 19 and 21 most common Real-time PCR, Sanger sequencing, next- generation sequencing Predicts response to EGFR tyrosine kinase inhibitors Yousem SA. Mod Pathol 2012; 25:S11-S17. Cheng L et al. Mod Pathol 2012; 25:347-369. Cooper WA et al. Pathology 2011; 43:103-115. Shim HS et al. Arch Pathol Lab Med 2011;135:1329–1334 Epidermal Growth Factor Receptor (EGFR) signalling pathway Gazdar AF et al. N Engl J Med 2009; 361:1018-1020. EGFR mutation in lung adenocarcinoma PATH3309 Imielinski M et al. Cell 2012;150:1107-1120. Case #2. 33 yo female, dysphagia & cough, non-smoker. CT chest EBUS FNA 4R lymph node (H&E stain)  Cell block TTF1 p63 ALK D5F3 clone Vysis ALK FISH break apart FISH probe ALK-rearranged lung adenocarcinoma Uncommon, ~4% of all NSCLC Almost always mutually exclusive with other driver mutations Younger pts, light or never smokers Adenocarcinoma with solid-signet ring or mucinous cribriform pattern Detection by IHC, FISH and NGS (but FISH is the “gold standard”) Soda M et al. Nature 2007; 448:561-566. Shaw AT et al. J Clin Oncol 2013; 31:1105-1111. Yoshida A et al. Am J Surg Pathol 2011;35:1226–1234 Thunnissen E et al. Virchows Arch 2012; 461:245-57. Yoshida A et al. Am J Surg Pathol 2011;35:1226–1234.  ALK fusion oncogenes and downstream signaling pathways Alice T. Shaw, and Benjamin Solomon. Clin Cancer Res 2011;17:2081-2086 ©2011 by American Association for Cancer Research ALK-rearranged lung adenocarcinoma PATH3309  Crizotinib therapy for ALK+ lung cancer Pre-treatment After 2 cycles of crizotinib Kwak EL et al. N Engl J Med 2010;363:1693-1703. Copyright © 2010 Massachusetts Medical Society.  Squamous cell carcinoma Invasive malignant epithelial tumour showing keratinisation and/or intercellular bridges Males > Females >90% occur in smokers Central > peripheral, often antedated by squamous dysplasia/carcinoma in-situ Prone to necrosis and cavitation Locally aggressive, less frequent distant metastases than other types Squamous cell carcinoma involving bronchus. Image courtesy of Dr Yale Rosen www.flickr.com Squamous cell carcinoma (Papanicolaou stain) Keratinising squamous cell carcinoma (H&E stain) Case #3. 66 yo male, left upper lobe lung mass, ex heavy smoker EBUS FNA of enlarged 4L & 7 lymph nodes EBUS FNA 7 lymph node (Papanicolaou stain) Cell block CK5/6 Metastatic squamous cell carcinoma p40 TTF-1 Programmed cell death ligand-1 (PD-L1) immunohistochemistry ≥ 50% membrane staining of tumour cells (Dako 22C3 clone) Eligibility for pembrolizumab therapy  Pembrolizumab (Keytruda) in NSCLC (2015) Identify patients with an enhanced likelihood to respond to pembrolizumab At least 50% staining was associated with - higher (p