differential diagnosis of paediatric small round and blue cell … · 2016. 6. 29. · embryonal...
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Differential Diagnosis of Paediatric Small Round and Blue Cell Tumors – An Update
Ivo Leuschner Kiel Paediatric Tumor Registry
Dept. of Paediatric Pathology
University Hospital Schleswig-Holstein
Campus Kiel UK SH
WHO - Classification of Soft Tissue Tumors (2013)
Tumor of the Paediatric Age Group Kiel Paediatric Tumor Registry
1995 (n) 1995 % 2011 (n)
Embryonal Tumors 4.060 15,2 8.676
Neuroblastoma 1.333 6,7 4.880
Nephroblastoma (1995 ‚with Variants‘) 1.282 6,4 3.337
Clear Cell Sarcoma of the Kidney 156
Malignant Rhabdoid Tumor of the Kidney 97
Hepatoblastoma 153 0,8 459
Sarcoma 1.755 14,0 8.482
Rhabdomyosarcoma 1.045 5,2 2.990
Ewing-Sarcoma-Family 830 4,2 1.233
Osteosarcoma 171 0,9
MPNST 177 0,9 513
Germ Cell Tumors 995 5,0 3.251
Vaskular Tumors 898 4,5 1.551
Langerhanszell Histiozytosis 529 2,7 1.114
Brain Tumors 453 2,3
Carcinoma 381 1,9 823
Mal. Lymphoma 2.667 13,4
others (mainly benigne Lesions) 8.206 43,8
total 19.944 44.638
Molecular Genetic Changes in Soft Tissue Tumors (1)
Tumor Entity chromosomal Aberration Molecular genetic change
myxoid/round cell Liposarcoma t(12;16)(q13;p11) t(12;22)(q13;q12)
FUS-DDIT3 (CHOP) EWSR1-DDIT3
inflammatory myofibroblastic Tumor (IMT) t(1;2)(q21;p23) t(2;2)(p23;q35) t(2,4)(p23;q21) t(2;11)(p23;p15)
TMP3-ALK RANBP2-ALK SEC31A-ALK CARS-ALK
infantile Fibrosarcoma t(12;15)(p13;q25) ETV6-NTRK3
'low-grade' fibromyxoid Sarcoma t(7;16)(q33-34;p11) t(11;16)(p11;p11)
FUS-BREB3l2 FUS-CREB3L1
Dermatofibrosarcoma protuberans Ring chromosome t(17;22)(q21;q13)
COL1A1-PDGFB
alveolar Rhabdomyosarcoma t(1;13)(p36;q14) t(2;13)(q36;q14) t(X;2)(q13;q36) t(2;2)(q35;p23) t(8;13;9)(p11.2;q14;9q32)
PAX7-FOXO1A (FKHR) PAX3-FOXO1A (FKHR) PAX3-FOXO4 (AFX) PAX3-NCOA1 FGFR1-FOXO1A (FKHR)
angiomatoid fibrous Histiocytoma t(2;22)(q33;q12) t(12;16)(q13;p11) t(12;22)(q13;q12)
EWSR1-CREB1 FUS-ATF1 EWSR1-ATF1
Synovial sarcoma t(X;18)(p11;q11) t(X;20)(p11;q13)
SS18-SSX1 (oder SSX2 or SSX4) SS18L1-SSX1
Clear cell sarcoma of Soft Tissues t(11;22)(q33;q12) t(12;22)(q13;q12)
EWSR1-CREB1 EWSR1-ATF1
Molecular Genetic Changes in Soft Tissue Tumors (2)
Tumor Entity chromosomal Aberration Molecular genetic chnage
DSRCT t(11;22)(q13;q12) EWSR1-WT1
extrask. myxoid Chondrosarcoma t(9;22)(q22;q12) t(9;17)(q22;q11) t(9;15)(q22;q21) t(3;9)(q12;q23)
EWRS1-NR4A3 TAF15-NR4A3 TCF12-NR4A3 TGF-NR4A3
Alveolar Soft Part Sarcoma t(X;17)(p11;q25) ASPSCR1-TFE3
Ewing-Sarcoma-Family t(11;22)(q24;p12) t(21;22)q22.2;q24) t(7;22)(p22;q12) t(17;22)(q12;q12) t(2;22)(q33;q12) t(2;16)(q35;p11) t(16;21)(p11;q24)
EWSR1-FLI1 EWSR1-ERG EWSR1-ETV1 EWSR1-ETV4(E1AF) EWSR1-FEV FUS-FEV FUS-ERG
aggressive Fibromatosis of Desmoid type Mutation CTNNB1-Gen (beta-catenin)
Lipoblastoma t(8;8)(q12;q24.1) tT(8;7)(q12;q22) t(8;14)(q12;q24) t(8;2)(q12;q31) T(8;8)(q12;q12.1)
PLAG1-HAS2 PLAG1-COLIA2 PLAG1-RAD5ILI PLAG1-COL3AI PLAG1-RAB2A
Myxoma, intramusculär Mutation GNAS1-Gen
Ewing-Tumor-Family
Typical ‚small, round and blue cell‘ Tumor
Ewing-Sarcoma
Front page Time Magazine 1931
James Ewing, 1866 – 1943 Pathologist, Cornell University, New York Co-Founder of Sloan Kettering Cancer Centre
PAS
Retikulin Fasern
CD99
Ewing-Tumor- Family
HE, x400 CD 99 (MIC2)
PAS Recticulin fibers
Immunohistochemistry: CD99 (MIC2): 90%+
Ewing-Sarcoma-Variants
• Typical Ewing‘s sarcoma
• Adamantinoma-like Ewing Family tumor (EFT)
• Typical primitive neurectodermal tumor
• Spindle cell sarcoma-like EFT
• Sclerosing EFT
• Large cell EFT (atypical Ewing‘s sarcoma)
Folpe et al., 2005
Adamantinoma-like Ewing Family tumor (EFT)
Folpe et al., 2005
Spindle cell sarcoma-like EFT
Arnold et al., 2014
Large cell EFT (atypical Ewing‘s sarcoma)
Llombart-Bosch et al., et al., 2014
Chromosomal rearrangement Fusion gene Frequency
t(11;22)(q24;q12) FLI1-EWSR1 85
t(21;22)(q22;q12) ERG-EWSR1 5 - 15
t(7;22)(p22;q12) ETV1-EWSR1 <1
t(17;22)(q21;q12) ETV4-EWSR1 <1
t(17;22)(q12;q12 E1AF-EWSR1 <1
t(2;22)(q33;q12 FEV-EWSR1 <1
t(20;22)(q13;q12) NFATC2-EWSR1 <1
t(6;22)(p21;q12) POU5FI-EWSR1 <1
t(4;22)(q31;q12 SMARCA5-EWSR1 <1
inv(22)(q22q22) ZSG-EWSR1 <1
t(1;22)(p36.1;q12) ZNF278-EWSR1 <1
t(2;22)(q31;q12) SP3-EWSR1 <1
inv(22) in t(1;22)(p36.1;q12) PATZ-EWSR1 <1
t(16;21)(p11;q22) ERG-FUS <1
t(2;16)(q35;p11) FEV-FUS <1
t(4;19)(q35;q13) CIC-DUX4 <1
Inv(X)(p11) BCOR-CCNB3 <1
Genetic changes in Ewing-Sarcoma and ‚Ewing-like‘-Sarcoma
EWSR1 break-apart probe
Chromosomal rearrangement Fusion gene Frequency
t(11;22)(q24;q12) FLI1-EWSR1 85
t(21;22)(q22;q12) ERG-EWSR1 5 - 15
t(7;22)(p22;q12) ETV1-EWSR1 <1
t(17;22)(q21;q12) ETV4-EWSR1 <1
t(17;22)(q12;q12 E1AF-EWSR1 <1
t(2;22)(q33;q12 FEV-EWSR1 <1
t(20;22)(q13;q12) NFATC2-EWSR1 <1
t(6;22)(p21;q12) POU5FI-EWSR1 <1
t(4;22)(q31;q12 SMARCA5-EWSR1 <1
inv(22)(q22q22) ZSG-EWSR1 <1
t(1;22)(p36.1;q12) ZNF278-EWSR1 <1
t(2;22)(q31;q12) SP3-EWSR1 <1
inv(22) in t(1;22)(p36.1;q12) PATZ-EWSR1 <1
t(16;21)(p11;q22) ERG-FUS <1
t(2;16)(q35;p11) FEV-FUS <1
t(4;19)(q35;q13) CIC-DUX4 <1
Inv(X)(p11) BCOR-CCNB3 <1
Genetic changes in Ewing-Sarcoma and ‚Ewing-like‘-Sarcoma
Small round blue cell tumor with CIC-DUX4-translocation
Antonescu, 2013
CD99
Small round blue cell tumor with BCOR-CCNB3-translocation
Pierrone et al., 2012
Pathologists need a ‚thick skin‘ …
International Classification of Rhabdomyosarcoma (1995)
Favorable Prognosis Botryoid embryonal Rhabdomyosarcoma Spindle cell type of embryonal Rhabdomyosarcoma Intermediate Prognosis ‚Classical‘ embryonal Rhabdomyosarcoma (incl. pleomorphic embryonal RMS) Unfavorable Prognosis Alveolar Rhabdomyosarcoma
Newton et al., 1995
WHO Classification of Tumors of Soft Tissue and Bone (2013)
Embryonal rhabdomyosarcoma (ICD-O 8910/3)
(incl. botryoid variant) Alveolar rhabdomyosarcoma (ICD-O 8920/3)
Pleomorphic rhabdomyosarcoma (ICD-O 8901/3)
Spindle cell/sclerosing rhabdomyosarcoma (ICD-0 8912/3)
Alveolar Rhabdomyosarcoma
– about 20-30% of all Rhabdomyosarcoma
– Incidence equally distributed in children and adolescents
– Main sites: Extremities, Trunk
– high rate of Lymph node metastases
Embryonal Rhabdomyosarcoma ‚classical‘ type
Myogenin Expression in Rhabdomyosarcoma
• Embryonal RMS: low to moderate (up to 50% of tumor cells)
• Alveolar RMS: high (usually > 75% of tumor cells)
Myogenin expression in an alveolar RMS
Alveolar RMS Embryonal RMS
AP2 EGFR
P-cadherin Fibrillin
Diagnosis of alveolar RMS
• Based on:
– Cytology of cells: (usually) monomorphous small round blue cell tumor
– Reticulin fiber content: (Mostly) no fibers in tumor cell nests
– Immunohistochemistry:
• Myogenin: more than 75% of cells
• AP2 and/or p-cadherin expression
Incidence of alveolar RMS
Variabel incidence between Treatment-Studies/Countries:
• Newton 1995 (IRS; USA): 32 %
• COG D9803 Study (USA): 41 %
(after re-review) 25-30 %
• RMS 79 (Italy) 25.9 %
• CWS-81, -86, -91, -96 (Germany): 14.9 %
Incidence of alveolar RMS
Variabel incidence between Treatment-Studies/Countries:
• Newton 1995 (IRS; USA): 32 %
• COG D9803 Study (USA): 41 %
(after re-review) 25-30 %
• RMS 79 (Italy) 25.9 %
• CWS-81, -86, -91, -96 (Germany): 14.9 %
Diagnosis with H&E only
Molecular genetics of alveolar Rhabdomyosarcoma
– t(2;13)(q35;p14) Translocation (ca. 75 %)
• FOXO1A-PAX3 (FOXO1A: previous FKHR gene)
– t(1;13)(p36;q14) Translocation (5 bis 22 %)
• FOXO1A-PAX7
– t(13;8)(q14;p12) Translocation (rare)
• FOXO1A-FGFR1
– t(2;2)(q35;p23) Translocation (rare)
• PAX3-NCOA1
– t(2;X)(q35;q13) Translocation (rare)
• PAX3-AFX
Krams, 2002; Sorensen, 2002; Williamson, 2010, Wachtel 2004, Barr 2002
Incidence of ‚Fusion-negative‘ alveolar RMS
• COG: IRS III and IV: 20 - 25 %
later Studies: 40 - 45 %
• CWS: 17 % (2011)
• Aktuell: ca. 5 – 6% (recent data)
Incidence of ‚Fusion-negative‘ alveolar RMS
• COG: IRS III and IV: 20 - 25 %
later Studies: 40 - 45 %
• CWS: 17 % (2011)
• Aktuell: ca. 5 – 6% (recent data)
1 case every 2 to 3 years in Germany!
Molecular genetics of alveolar Rhabdomyosarcoma
• Genetic testing is mandatory in all alveolar RMS
Williamson et al., 2010 Davicione et al., 2009
Spindle cell differentiation in alveolar RMS
– Rarely a focal spindle cell differentiation can occur in alveolar RMS
• Especially in recurrences
Myogenin expression
P-cadherin expression
… sometimes pathologists just disappear
'Small round blue'-Tumors with loss of INI1-Expression
Tumors with Loss of INI1 Expression
Tumor type Loss of INI1 Expression (%)
Malignant Rhabdoid tumor of Soft Tissue of the Kidney in the Brain (ATRT) in the Liver (‚small cell undifferentiated Hepatoblastoma‘)
98
Medulläry Renal Cell Carcinoma 100*
Epitheloid Sarcoma 90
Epitheloid MPNST 50
Myoepithelial Carcinoma 40 (Pediatric cases) 10 (Adult cases)
Extraskeletal myxoid Chondrosarcoma 17
from: Hollmann 2011 * Very small numbers studied yet
Typical morphology of a malignant Rhabdoid Tumour
Small cell differentiation in INI1-negative Tumours
• A small cell differentiation is within the spectrum of rhabdoid tumours
• A genetic change in the SMARCA4 gene is found in a small subset of tumors instead of INI1 loss resulting in a loss of BRG1 expression
• SMARCA4 gene changes are typically found in ‚small cell carcinoma of the ovary
From: Kreiger et al., 2009
SMARCB1-(INI1) Gene
• Protein is part of the chromatin-remodeling complex
• Activates the transcription of genes
Malignant Rhabdoid Tumor of Soft Tissues
• Mean Age: 52 months (in comparison: mean age 16 months in renal MRT)
• Sex distribution m:w = 1,5:1
• Sites:
• Almost all sites of the body
Reinhard et al., 2008
INI-Protein
INI1 stain in small round blue cell tumors in patients below 5 years of age
Spectrum of genetic changes in the SMARCB1/INI1 gene Genetic Testing: • FISH: Deletions in 22q • Sequencing: SMARCB1 for mutations • MLPA: SMARCB1 In addition peripheral blood cells: 20 to 30% of patients have genetic germ line changes in the SMARB1/INI1 gene
aus: Eaton et al., 2011
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