Immunohistochemical and putative morphological markers related to lynch syndrome in ovarian endometrioid adenocarcinoma

AMAÇ: Over kanserlerinin %5-15'i aileseldir. Ailesel over kanserlerinin yaklaşık %10- 15'i Lynch Sendromu ile ilişkilidir. Lynch Sendromu ile ilişkili over kanserlerinde en sık histolojik alt tür endometrioid adenokarsinomdur (EAK). Lynch Sendromu açısından daha ileri genetik araştırma yapılması gerekebilecek endometrial kanserli olguları saptamada klinik kriterlere ek olarak, tümör morfolojisi (tümörü infiltre eden lenfositler-TIL, peritümöral lenfositler-PTL, vb), "mismatch" tamir sistemi (MMR) protein immunhistokimyası ve MSI testleri de yararlıdır. Bu çalışmadaki amaç; primer over kanserlerinde, bugüne kadar araştırılmamış olan, MMR defektlerinin varsayılan morfolojik belirleyicilerinin insidansı ve bunların MMR durumu ile ilişkisini ortaya koymak ve böyle bir ilişkinin, over kanserli hastalar arasında Lynch Sendromu açısından daha ileri araştırma yapılması gereken aday olguları belirlemek ve prognozu öngörmek açısından değerli olup olmadığını araştırmaktır. Bu amaçla; overin primer EAK'lu olgularında, MMR proteinleri olan MLH-1, MSH-2, MSH-6 ve PMS-2'nin immunekspresyon profilleri ile morfolojik belirleyiciler ve MMR protein durumunun birbiri ile ilişkisi ve klinik anlamları araştırılmıştır. YÖNTEM: Çalışmamız 1985-2009 yılları arasında California, San Francisco Üniversitesi (UCSF) Tıp Fakültesi Hastanesi'nde primer cerrahi tedavi uygulanan 71 adet primer over EAK'lu olguyu içermektedir. Olgulara ait tüm kesitler, tümör sınıflaması, histolojik alt tür, derece ve evrenin doğrulanması açısından iki patolog tarafından tekrar gözden geçirilmiştir. Primer over tümörlerinde ve varsa olgulara ait eşlik eden uterus tümörlerinde, anormal MMR protein durumunu öngörebileceği bildirilen morfolojik belirleyiciler (TIL, PTL ve tümörün dediferansiye komponent içermesi) değerlendirilmiştir. MMR protein ekspresyonunun immunhistokimyasal değerlendirmesi Doku Mikroarray (TMA) yöntemi uygulanarak yapılmıştır. Antikor olarak MLH-1, MSH-2, MSH-6 ve PMS-2 kullanılmıştır. Her olgu için, herhangi sayıda tümör hücre nükleusunda boyanma olması, o belirleyici için pozitif sonuç olarak kabul edilmiştir. Dört MMR protein antikorunun dördünde de pozitif sonuç elde edilen olgular, normal/intakt MMR durumuna sahip olarak değerlendirilmiştir. BULGULAR: Yetmiş bir adet saf over EAK'u olgusunun 29 tanesinde eşlik eden eş zamanlı uterus EAK'u vardır. Over EAK'lu olguların %13'ünde TIL, %3'ünde PTL varlığı saptanmış olup, dediferansiye komponent hiçbir olguda izlenmemiştir. Over EAK'lu olguların yaklaşık %10'unda (7/71) MMR protein defekti saptanmıştır. MMR protein defekti varlığı ile klinik gidiş arasında ilişki saptanmamıştır. Elli yaş altı ile 50 ve üstü yaştaki hastalar karşılaştırıldığında, TIL ya da PTL insidansı ve MMR protein defekti insidansı açısından istatistiksel fark saptanmamıştır. Over EAK'lu olgularda, MSI ile ilişkili olduğu varsayılan morfolojik belirleyiciler (TIL, PTL vb) ile MMR protein defektleri arasında korelasyon olmadığı saptanmıştır. SONUÇ: Çalışmamızda, overin EAK'larının bir kısmında anormal MMR proteini varlığı gösterilmiş olmakla birlikte, MMR protein durumu ile ilişkisi gösterilebilen herhangi bir morfolojik belirleyici bulunmamıştır. Bu nedenle, uterus kanserli olgularda, Lynch Sendromu için çeşitli morfolojik belirleyicileri kriter olarak kullanan tarama algoritmaları, over kanserli olgular için uygun olmayabilir. Over kanserli olgularda Lynch Sendromu açısından risk miktarını tanımlamak için yeni geliştirilecek stratejilerde, hasta yaşı ya da tümör morfolojisi gibi kriterlerden çok, klinik bilgiler ve MMR/MSI için yapılacak biyobelirleyici tetkik sonuçlarının yer alması gerektiği sonucu ortaya çıkmaktadır. AIM: Hereditary gynecologic cancer accounts for 5% to 15% of ovarian cancers. 10- 15% of hereditary ovarian cancer is associated with Lynch syndrome. The most frequent histologic subtype of Lynch syndrome-associated ovarian cancer is endometrioid adenocarcinoma. In addition to clinical criteria, tumor morphology (including tumor infiltrating lymphocytes-TIL, peritumoral lymphocytes-PTL), MMR protein immunohistochemistry, and MSI testing are also useful screening tools for identifying women with endometrial cancer who may benefit from further genetic evaluation and definitive germline testing for Lynch syndrome. The aim in this study is to define the incidence of putative morphologic markers of MMR defects and their association with MMR status in primary ovarian cancer, which has not been studied before and to research whether such an association is valuable in identifying ovarian cancer patients who may be candidates for further Lynch syndrome genetic evaluation and in predicting prognosis or not. For this purpose, we studied the immunoexpression profile of MMR proteins MLH-1, MSH-2, MSH-6 and PMS-2 in these tumors and the association between morphologic markers and MMR protein status. METHODS: The study included 71 patients with primary ovarian endometrioid adenocarcinoma who underwent primary surgical management at California San Francisco Universtity Hospital between 1985 and 2009. All slides for each case were reviewed by 2 gynecologic pathologists to confirm the tumor classification, histologic subtype, grade and stage. Morphologic markers (presence of TIL, PTL and dedifferentiated component) that have been reported in uterine tumors as potential predictors of abnormal MMR protein status were evaluated in the primary ovarian tumors and, when present, in the concurrent uterine tumors. Immunohistochemical evaluation of MMR protein expression was performed on tissue microarrays (TMA). The antibodies used were MLH-1, MSH-2, MSH-6 and PMS-2. A positive result was recorded if any tumor cell nucleus expressed the marker for each case. Cases in which all four MMR protein antibodies yielded a positive result were considered to have normal/intact MMR status. RESULTS: Among 71 patients, 29 had an ovarian pure endometrioid adenocarcinoma with a concurrent uterine endometrioid adenocarcinoma. Among the ovarian tumors, TIL were present in 13% of the cases, PTL were present in 3% of the cases. Dedifferentiated component was not detected among all cases. MMR protein defects are detected in 10% (7/71) of all cases with ovarian endometrioid adenocarcinoma. There was no association between the presence of MMR protein defects and behaviour. Comparing patients aged 50 years or older to those younger than 50 years, there was no statistical difference in the incidence of TIL or PTL and the incidence of MMR protein defects. No correlation was found between morphology markers and MMR status in the ovarian tumors. CONCLUSION: In our study, although abnormal MMR was present in a subset of ovarian endometrioid adenocarcinoma, there were no morphologic features identified that were associated with MMR status. Therefore, current Lynch syndrome screening algorithms that utilize morphologic markers in uterine cancer patients may not be applicable in ovarian cancer patients. Strategies to identify ovarian cancer patients at risk for Lynch syndrome will require investigation into clinical and biomarker screening criteria for MMR/MSI testing other than patient age and routinely-assessed tumor morphology

How to Set Up a Molecular Pathology Lab: A Guide for Pathologists

In today's pathology practice, pathologists combine molecular tests with conventional histopathological methods. Pathology laboratories should therefore be designed and operated in accordance with the requirements of molecular testing procedures. While the specifics of the requirements may vary depending on the spectrum of the tests that will be performed, there are several basic criteria that need to be fulfilled for standardization. Adequate space, appropriate equipment and qualified personnel are required to establish a molecular pathology laboratory. One of the most important points that should be taken into consideration while designing a molecular pathology laboratory is to create a plan to prevent contamination. As molecular diagnosis has a major role in treatment decisions, the management of the molecular pathology laboratory is of utmost importance. In this review, the criteria required to establish an optimal molecular pathology laboratory will be reviewed

Reconsideration of Clinicopathologic Prognostic Factors in Pancreatic Neuroendocrine Tumors for Better Determination of Adverse Prognosis

The question of how successful we are in predicting pancreatic neuroendocrine tumors (panNET) with poor prognosis has not been fully answered yet. The aim of this study was to investigate the effects of clinicopathological features on prognosis and to determine their validity in prediction of prognosis and whether a better prognostic classification can be made. Fifty-six patients who underwent pancreatic resection for pancreatic neuroendocrine tumor were included. The associations between clinicopathological parameters and prognosis were evaluated statistically. Efficiencies of different thresholds for tumor size, mitotic count, and Ki67 proliferation index for prognosis prediction were compared. Vascular invasion was statistically associated with high tumor grade, advanced pT stage, and mortality rate. The presence of non-functional tumor, lymphatic invasion, and > 10 cm tumor size were significantly related to shorter overall survival. Advanced pT stage (pT3-4), > 5 cm tumor size, and high tumor grade (grades 2-3) were significantly associated with shorter disease-free survival. The mortality rate showed the strongest statistical significance with mitotic count when grouped as 1: 10 mitosis/ 2 mm(2). The 10% threshold value for Ki67 index was more successful in predicting adverse prognosis. Among the morphologic variants, the ductulo-insular variant was the most promising to have positive prognostic value in our series, although no statistical significance was detected. In conclusion, threshold values of 5 cm and 10 cm for tumor size, 10% for Ki67 proliferation index, and 10/2 mm(2) for mitotic count and vascular and lymphatic invasion assessed separately are potential prognostic candidates for better stratification of panNETs