Joint session molecular pathology and trainees Next...

Joint session molecular pathology and trainees

Next generation pathology

A challenging diagnosis in paediatric pathology

11 September 2019 - SS13 Slide seminar - Next generation pathology

Gullo IreneCentro Hospitalar Universitário São João, Porto, Portugal

Faculty of Medicine of the University of Porto, Portugal

Angela Rita SementaIstituto Giannina Gaslini, Genoa, Italy

Co-authors:

Katia Mazzocco, Francesca Buffelli, Angelica ZinIstituto Giannina Gaslini, Genoa, Italy

Institute of Paediatric Research (IRP), Fondazione Città della Speranza, Padova, Italy

I have no conflict of interest to declare

Case report

• Four year-old boy

• Past medical history: irrelevant

• Family history: irrelevant

• Presenting problem: localised swelling of the right hand

• Magnetic resonance imaging:

Case report






Axial STIR (Short Tau Inversion Recovery) MR images

Case report






Axial STIR (Short Tau Inversion Recovery) MR images

3.3cm 4.6cm24 days

Case report





• Magnetic resonance imaging

• An incisional biopsy was performed

Microscopy

Differential diagnoses

Entity Epidemiological/clinical features

Infantile fibrosarcomaFirst year of life; 30-80% are congenital

Distal extremities, trunk, head and neck

Synovial sarcomaAdolescents/young adults; also older patients/children

~25% arise in the distal extremities

RhabdomyosarcomaChildren and adults. Location varies depending on subtyping

(embryonal, alveolar, spindle cell, pleomorphic, …)

Extraskeletal Ewing sarcomaAdolescents/young adults

Deep soft tissues of the extremities, paraspinal area

Rare entities related to specific molecular alterations:

‣Primitive myxoid mesenchymal tumour of infancyInfancy or early childhood

Trunk, extremities and head and neck

‣ “Ewing-like sarcomas”:

- Sarcoma with CIC-related gene fusions

- Sarcoma with BCOR-related gene fusions

Adults (20-40 yy). Deep soft tissues of trunk and extremities

Children and adults. Bone/soft tissues of trunk and extremities

‣ Infantile NTRK-associated mesenchymal tumourEarly childhood

Distal extremities and trunk

Present case:

4 year-old boy, tumour in the right hand

Myxoid spindle- round- cell ST neoplasm

WHO classification of Tumours of Soft Tissue and Bone. 4th Edition . Fletcher C et al Eds. 2013. IARC.

Practical Soft Tissue Pathology: A Diagnostic Approach. Second Edition. Chapter 8. Hornick J Ed. 2019. Elsevier

Positive Negative

‣ Bcl2

‣ CD99

‣ INI1

Keratins

EMA

Myogenin (Myf4)

MyoD1

Desmin

SMA

CD34

S100

Immunohistochemical study

Bcl2

Present case


INI1

Positive Negative

‣ Bcl2

‣ CD99

‣ INI1

Keratins

EMA

Myogenin (Myf4)

MyoD1

Desmin

SMA

CD34

S100

Present case


CD99

Positive Negative

‣ Bcl2

‣ CD99

‣ INI1

Keratins

EMA

Myogenin (Myf4)

MyoD1

Desmin

SMA

CD34

S100

Present case


SMA

Positive Negative

‣ Bcl2

‣ CD99

‣ INI1

Keratins

EMA

Myogenin (Myf4)

MyoD1

Desmin

SMA

CD34

S100

Present case

Entity Immunophenotype

Infantile fibrosarcomaVimentin

SMA±

Synovial sarcomaCK/EMA± (patchy/focal)

CD99±

Rhabdomyosarcoma

Desmin+

Myogenin+

MyoD1+

Extraskeletal Ewing sarcomaCD99 (diffuse membranous)

CK (rare)


‣Primitive myxoid mesenchymal tumour of infancy Vimentin+




CD99±

CD99±

‣ Infantile NTRK-associated mesenchymal tumour

SMA±

CD34±

S100±



Differential diagnoses: immunophenotype

Positive Negative

‣ Bcl2

‣ CD99

‣ INI1

Keratins

EMA

Myogenin (Myf4)

MyoD1

Desmin

SMA

CD34

S100

Present case

Differential diagnoses: molecular alterations



EntityMolecular alterations

Surrogate IHC biomarkers

Infantile fibrosarcoma ETV6-NTRK3 /

Synovial sarcomaSS18-SSX1

SS18-SSX2TLE1+

Extraskeletal Ewing sarcoma

EWSR1-FLI1 (85%)

EWSR1-ERG (10%)

EWSR1 fusion with other genes

FUS-ERG/FEV

/


‣ Primitive myxoid mesenchymal tumour of infancy BCOR internal tandem duplications BCOR+




CIC-DUX4; CIC-FOXO4

BCOR-CCNB3

DUX4+

BCOR+, CCNB3+

‣ Infantile NTRK-associated mesenchymal tumour TMP3-NTRK1; LMNA-NTRK1 NTRK1+

Molecular study – FLUORESCENT IN SITU HYBRIDISATION

EWSR1 break-apart SS18 break-apart



EntityGene fusions / other molecular alterations

Present case(RT-PCR)

Infantile fibrosarcoma ETV6-NTRK3 Negative

Synovial sarcomaSS18-SSX1

SS18-SSX2Negative

Extraskeletal Ewing sarcoma

EWSR1-FLI1 (85%)

EWSR1-ERG (10%)

EWSR1 fusion with other genes

FUS-ERG/FEV

Negative


‣ Primitive myxoid mesenchymal tumour of infancy BCOR internal tandem duplications Negative




CIC-DUX4; CIC-FOXO4

BCOR-CCNB3

Negative

Positive

‣ Infantile NTRK-associated mesenchymal tumour TMP3-NTRK1; LMNA-NTRK1 Not available

Molecular study - REVERSE TRANSCRIPTASE POLYMERASE CHAIN REACTION

Diagnosis

BCOR-CCNB3 fusion-positive sarcoma

Diagnosis


Pierron G et al. Nat Genet 2012

Intra-chromosomal para-centric inversion on chromosome X resulting in

fusion between the BCOR (encoding the BCL6 co-repressor) and CCNB3

(encoding the testis-specific cyclin B3) genes

Diagnosis


Pierron G et al. Nat Genet 2012; Specht K et al. Am J Surg Pathol 2016.

The term “sarcomas with BCOR-related gene fusions” has been proposed:

‣ Other BCOR gene fusion partners (MAML3, ZC3H7B and KMT2D)

‣ Sarcomas displaying BCOR rearrangements with unknown partners

Intra-chromosomal para-centric inversion on chromosome X resulting in

fusion between the BCOR (encoding the BCL6 co-repressor) and CCNB3

(encoding the testis-specific cyclin B3) genes

Sarcomas with BCOR-related gene fusions

Transcriptomic profiling

Kao YC et al. Am J Surg Pathol 2017; Pierron G et al. Nat Genet 2012

Sarcomas with BCOR-related gene fusions

At a glance

- About one-hundred cases have been reported in the literature

- Affect mainly children and teenagers (2-19 years). Few cases (n=6) have been

described also in adults patients (31-44 years)

- Show striking male gender predominance (male-to-female ratio of 4.5:1)

- Evenly distributed between bone (60%) and soft tissue (40%) of trunk and

extremities. Visceral involvement (lung, kidney) is rare

- Less aggressive clinical course than Ewing sarcomas according to some reports

Puls F et al. BCOR-CCNB3 (Ewing-like) sarcoma: a clinicopathologic analysis of 10 cases, in comparison with conventional Ewing sarcoma. Am J Sure Pathol 2014;

Machado I et al. Ewing sarcoma and the new emerging Ewing-like sarcomas: (CIC and BCOR-rearranged sarcomas). A systematic review. Histol Histopathol 2016

Kao YC et al. Am J Surg Pathol 2017; Matsuyama A et al. Am J Surg Pathol 2017; Li WS et al. Histopathology 2016

TAKE-HOME MESSAGE

Sarcomas with BCOR-related gene fusions may

display morphologic heterogeneity and

immunophenotypic overlap with other entities


a. b. c. d. e.

TAKE-HOME MESSAGE

a. Synovial sarcoma ➔ Both are immunoreactive for TLE1

b. Primitive myxoid mesenchymal tumour of infancy ➔ Both are immunoreactive for BCOR

c. Ewing sarcoma ➔ CD99 staining pattern interpretation

d. Solitary fibrous tumour ➔ Diffuse nuclear positivity for STAT6

e. Vascular tumours ➔ Staining for vascular markers





a. b. c. d. e.

TAKE-HOME MESSAGE

a. Synovial sarcoma ➔ Both are immunoreactive for TLE1

b. Primitive myxoid mesenchymal tumour of infancy ➔ Both are immunoreactive for BCOR

c. Ewing sarcoma ➔ CD99 staining pattern interpretation

d. Solitary fibrous tumour ➔ Diffuse nuclear positivity for STAT6

e. Vascular tumours ➔ Staining for vascular markers

The identification of specific

molecular alterations (FISH, RT-

PCR, RNA seq, NGS) is essential to guarantee diagnostic accuracy




Gullo Irene, MD, PhDCentro Hospitalar Universitário São João, Porto, Portugal

Faculty of Medicine of the University of Porto, Portugal

[email protected]

A challenging diagnosis in paediatric pathology

Sarcoma with BCOR-CCNB3 gene rearrangement

11 September 2019 - SS13 Slide seminar - Next generation pathology

Thank you for your attention

mailto:[email protected]

Kao YC et al. Am J Surg Pathol 2016; Kao YC et al. Am J Surg Pathol 2017; Practical Soft Tissue Pathology: A Diagnostic Approach, Second Edition. Chapter 8. Hornick J

Ed. 2019. Elsevier; Matsuyama A et al. Am J Surg Pathol 2017

BCOR immunoreactivity CCNB3 immunoreactivity

Sensitivity 100% ~90%

Other tumours showing

immunoreactivity

PMMTI

CCS kidney

SS (>50%)

Rare: ES, ERMS

Rare: SFT, ES, ERMS, fibrous

sarcoma

Surrogate biomarkers for BCOR-CCNB3 translocation

% of positive cases

BCOR 100%

CCNB3 >90%

Bcl2 >90%

CD99 ~50% - patchy/focal and not membranous (cytoplasmic/dotted)

CD117 ~50%

CD56 >90%

Cyclin D1 >90%

TLE1 80-100%

CD34 0%

SMA 0%

Desmin 0%

S100 0%

CK 0%

EMA 0%

Immunophenotypic profile of BCOR-CCNB3 positive sarcoma

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