Diagnostische Pathologie van de long in vogelvlucht · 2019. 10. 10. · • bestraling van de long...

Pathology UNIVERSITY MEDICAL CENTER GRONINGEN

Diagnostische Pathologie van de long in vogelvlucht

Wim TimensDept. Pathology and Medical Biology, University Medical Center Groningen

“Week van de Pathologie" 27 – 30 maart 2017, Ede

(potentiële) belangenverstrengeling Zie hieronder

Voor bijeenkomst mogelijk relevante relaties met

bedrijvenBedrijfsnamen

• Adviesraad (niet persoonlijk, vergoeding naar

afdeling)

• Lezing / cursus (niet persoonlijk, vergoeding naar

afdeling)

• Merck Sharp & Dohme, Pfizer,

Roche/Ventana.

• Boehringer Ingelheim, Bristol-Myers

Squibb, Glaxo Smith Kline, Biotest, Chiesi,

Lilly Oncology, Merck Sharp & Dohme,

Novartis, Pfizer, Roche/Ventana

Disclosure belangen spreker


Pathologie van de long

• Interstitiële longziekten

• Longkanker

• Infecties


Interstitiële longziektenHistopathologische reactiepatronen bij diffuse alveolair-interstitiële longafwijkingen:

“The alphabet soup”


Alveolair-interstitiele longafwijkingen

• diffusieweg voor gaswisseling langer

• long stijver, minder compliant

• ventilatie-perfusie wanverhoudingen


Transbronchiaal biopt:

Beperkte diagnostische mogelijkheden:

• Longtransplantatie

• Sarcoidose e.a. granulomateuze afwijkingen

• Infecties

• Pulmonale Langerhanscel histiocytose

• Eosinofiele pneumonie

• Lymfangioleiomyomatose

• (sommige) maligniteiten

• Churg-Strauss syndroom/vasculitis

http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjB5_i2lu3SAhVFF8AKHcP3AHMQjRwIBw&url=http://www.ramsayhealth.co.uk/treatments/transbronchial-biopsy&bvm=bv.150475504,d.ZGg&psig=AFQjCNE2w7psSWfhtK0W0-T8G2OYwa4nig&ust=1490377245351062http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjB5_i2lu3SAhVFF8AKHcP3AHMQjRwIBw&url=http://www.ramsayhealth.co.uk/treatments/transbronchial-biopsy&bvm=bv.150475504,d.ZGg&psig=AFQjCNE2w7psSWfhtK0W0-T8G2OYwa4nig&ust=1490377245351062


Open long / VATS biopsie:

Welke?…antwoorden mag je verwachten:

• Identificatie van potentieel behandelbare afwijkingen:

– Infectie

– Alveolaire proteinose

– Extrinsieke allergische alveolitis (hypersensitiviteits pneumonitis)

• Identificatie van eerste manifestatie van systeemziekte:

– Immuundeficientie

– Auto-immuunziekte

• Classificatie van (idiopathische) interstitiele pneumonieën

• Vaatpathologie van de long (pulmonale hypertensie, pulmonale veneuze occlusie)

• Belangrijke prognostische informatie


Interpretatie longbiopten

• Belangrijkste plaats van afwijkingen:

– luchtruimte

– interstitieel

– gemengd

• Uitbreiding van het proces:

– diffuus

– wisselend in ernst

• indien wisselend bepaling van patroon.

– willekeurig

– specifiek:

• bronchiolair

• lymfbanen volgend

• arterieel


Cryptogene organiserende pneumonie

(Bronchiolitis obliterans organiserende pneumonie)


Interstitiële pneumonie

• Bekende oorzaken:

– Infectieus of postinfectieus

– Omgevingsfactoren (inhalants)

– Geneesmiddelen

• Idiopathisch

– Neoplastisch

– Lymfoproliferatief

– Metabool

Acute interstitiele pneumonie (AIP)

Usual interstitiele pneumonie (UIP)

Desquamatieve interstitiele pneumonie (DIP) / Respiratoire bronchiolitis interstitiele pneumonie

(RBILD)

Niet-specifieke interstitiele pneumonie (NSIP)


Overige vormen idiopathische interstitiele

pneumonie

(doch vaak etiologie wel bekend)

• Reuscel interstitiele pneumonie

(meestal pneumoconiose, geassoc. met zware metalen)

• Granulomateuze interstitiele pneumonie.

• Lymfoide interstitiele pneumonie

(meestal geassoc. met immuundeficienties)


Desquamatieve interstitiële

pneumonieDesquamatieve interstitiele pneumonie (DIP)


Desquamatieve

interstitiële pneumonieDesquamatieve

interstitiele

pneumonie (DIP)


Niet-specifieke interstitiële pneumonieNiet-specifieke interstitiële pneumonie (NSIP)


Niet-specifieke

interstitiële

pneumonie

Niet-specifieke

interstitiële

pneumonie

(NSIP)


Niet-specifieke interstitiële

pneumonie,

Fibroserende vorm

F-NSIP


Waar moet je aan denken bij NSIP-patroon?

• Collageen ziekten

• Geneesmiddelen reacties

• Hypersensitiviteitspneumonie (extrinsieke allergische alveolitis)

• Pneumoconiose

• Chronisch pulmonale veneuze hypertensie (mitraalstenose)

• Allogene beenmergtransplantatie

• Idiopathisch


Acute interstitiële

pneumonie

Diffuse alveolaire schade (“DAD”)Acute interstitiële pneumonie (AIP)


Acute interstitiële

pneumonie

diffuse fibroblasten

proliferatie en sporadische

lymfocyten

Diffuse alveolaire

schade (“DAD”)Acute interstitiële

pneumonie (AIP)


Oorzaken van diffuse alveolaire schade

• inhalatie van toxische gassen of dampen

• inhalatie van anorganische stoffen (pneumoconiosen)

• sommige cytostatica (busulfan, bleomycine)

• bestraling van de long (bestralingspneumonitis)

• sepsis, shock, diffuse intravasale stolling

• beademing met hoge concentraties O2

• aspiratie van de maaginhoud

• narcotica-abusus (hereoïne, methadon)

• ernstige infecties, vooral bij immuundeficiënties

Pathology UNIVERSITY MEDICAL CENTER GRONINGENSlide courtesy of KO Leslie, MD.

Stadium heterogeniteit in UIPUsual interstitial pneumonie (UIP)


Usual interstitial pneumonia: fibroblast focus

Usual interstitial pneumonie (UIP):

“Fibroblast focus”


Interstitiële longziektenMultidisciplinaire aanpak!

Histopathologische diagnose moet tesamen met radiologie, klinische informatie en beloop

worden overwogen

• Histopathologisch onderzoek:

• in veel gevallen gouden standaard; kan belangrijke bijdrage leveren in aanvulling op klinische gegevens

en beeldvormende diagnostiek, relevant voor verdere behandeling en therapie.

• Informatie m.b.t. klinisch beloop en radiologische bevindingen essentieel voor optimale diagnose

• Belang van beeldvormende diagnostiek:

• naast diagnostische bijdrage ook als uitgangspunt voor:

• biopsie van anatomische locatie, representatief voor de afwijking

• locatie alwaar actieve of vroege fase van het ziekteproces

• Tijdstip biopsie is belangrijk:

• indien indicatie dan vroeg in het ziekteproces

• geïndividualiseerde multidisciplinaire besluitvorming


Longkanker


What was the past:

• Clinical Relevance:

– SCLC vs NSCLC

– Neuroendocrine tumors

• NSCLC:

– Adenocarcinoma

– Squamous cell carcinoma

– Large cell carcinoma• Large cell neuroendocrine carcinoma


How defined then:

WHO: definition: morphology by histochemistry (only)

• Squamous cell carcinoma:

– Intercellular bridges

– keratinization

• Adenocarcinoma:

– Glandular morphology

– Mucus production (PAS, Alcian Blue)

• Large cell carcinoma: all NSCLC that do not have above criteria


Reactive atypia courtesy Dr. Doug Flieder, Cornell University, New York


Atypical Adenomatous hyperplasia

courtesy Dr. Doug Flieder, Cornell University, New York


Bronchiolization of alveolar septa



Adenocarcinoma in situ



Papillary adenocarcinoma



Targeted therapy: new demands


Targeted therapy: new demands

Phenotyping more relevant, because restriction to phenotype:

• Side effects of new drugs

• Driver mutations with therapeutic effects

• Mutations with adverse effects

• But also: easy and accurate identification of patients without

likelihood of relevant mutations

• Expensive diagnostics and therapy:

the right drug in the right patient

http://davidjrodger.files.wordpress.com/2011/12/photography-c2a6-the-end-of-business-old-man-with-a-double-barrel-shotgun-by-danielle-tunstall.jpghttp://davidjrodger.files.wordpress.com/2011/12/photography-c2a6-the-end-of-business-old-man-with-a-double-barrel-shotgun-by-danielle-tunstall.jpg


How to identify our targetable patient?


Relevance of lung cancer histotyping

• p53 mutations: frequent in all lung carcinomas

• HER2/neu expression infrequent in AC; rare in SCC

• K-RAS mutations: found in AC, rare in SCC

• EGFR-(tyrosine kinase) inhibitors: Erlotinib and Gefinitib:

do not work in SCC: > 80% SCC are EGFR positive (but in general no relevant EGFR-TK driver

mutations)

• Pemetrexed (anti-folate agent): little effect in SCC

• VEGF-inhibitors (Bevacuzimab): serious side effects in SCC (hemorrhage)

• EML4-ALK translocations (Crizoitinib): associated with signet ring adenocarcinoma

• ……………….

• ……………….


Diagnostic pathology in lung cancer:What are the challenges?

• Include appropriate molecular pathology

• Include other companion diagnostics (Immunotherapy)

• Fast

• Accurate

• What is possible with cytology (EUS/EBUS) and small biopsies

• Limited costs


Vraag 1: kan een diagnose grootcelligcarcinoom van de long worden gesteld

op cytologie

1. Nee, nooit

2. Ja, indien gesteund door immunocytologie

3. Ja, indien gesteund door moleculaire diagnostiek

4. Nee, daarvoor heb je een biopt nodig


What was/is to improve:

• Large cell carcinoma (NSCLC) is a wastebag (and therefore mixed bag!) category:

should be reduced

• “Classic” (so mostly: well-differentiated) squamous cell carcinoma and

adenocarcinoma are not so frequent:

– On morphology often over-interpretation in poorly to moderately differentiated SCC and

AC: too often wrong

Much more relevant role for immunohistochemistry

Criteria phenotyping should be re(de)fined


J Thor Oncology

2011: 244-285 (41

pages!)


Rossi et al. Int. J Surg Path 2009


p63p63


p63


TTF1

Pathology UNIVERSITY MEDICAL CENTER GRONINGENRekhtman, Biannual meeting Pulmonary Pathology Soc. New York, 2011


Tumour heterogeneityis it a problem?

• Variabele differentiation within one type NSCLC

• Mixed tumours

• Mosaic of mutations: do they exist?

• Small samples (biopsies / cytology):

– Selection bias / representativity

– Risk false negatives

– Risk selective detection in case of mosaic


Present day diagnostic pathology:

• Phenotyping is not only giving main classifying

diagnosis, but:

• Describe all components and differentiation

• Selecting for MolDiag, not only “percentage” but also

right part of the tumor!

Extraction of tumour cells

(if necessary, separate tumour cells from non-tumour cells)

Preservation = formalin fixation and

embedding using paraffin

How do we test for a mutation?

Sectioning = confirmation of tumour content

and tissue quality

DNA extraction and purification

Mutation analysis (e.g. sequencing)

Tumour sample collection = histological specimen

http://www.clker.com/clipart-11526.htmlhttp://www.clker.com/clipart-11526.html


Vraag 2: welk antwoord is beste m.b.t moleculaire diagnostiek

1. Levert beter resultaat bij coloncarcinoom dan bij longcarcinoom, omdat

daar meestal resectiemateriaal ter beschikking is

2. Kan op cytologie als er maar genoeg celmateriaal ter beschikking is

3. NGS op weefsel zal op termijn vervangen kunnen worden door “liquid

biopsy”

4. Moleculaire pathologie geeft meer waarschijnlijkheid op een zinvolle

diagnose dan huidige whole genome sequencing


Present day diagnostic pathology:

(and in fact also for clinician….)

Realize (and report?) which limitations are relevant for which technique:

• Mutation analysis: percentage of nucleated cells (not volume% !!) in a certain area of

the tissue or cell block: morphology doesn’t help anymore to recognize the tumor

DNA between the normal DNA

• ISH: number of recognizable tumor cells is relevant: cut-off points for counting are

validated on minimum number of “countable” tumor cells: morphology (and IHC?)

help if many normal (often inflammatory) cells present


Metastases:

• Intrinsic to tumor heterogeneity

• In general prognosis determined by metastatic disease:

• Metastases can acquire organ-specific mutations

Should metastases more often be biopsied (and re-phenotyped!) for molecular diagnosis?


Sequist et al. : Genotypic and Histological

Evolution of Lung Cancers Acquiring

Resistance to EGFR Inhibitors

Sci Transl Med 2011: 3 (75): 75ra26

Is this really evolution or could

extended sampling have

shown both components early

on…?


Other targets: Immunotherapy…


Immune checkpoint blockade

Drake, C. G. et al. (2013) Nat. Rev. Clin. Oncol.

Mechanisms by Which Cancers Evade Immune Destruction

Excluded infiltrate

CD8

Immunologic ignorance

CD8

…unable to act

PD-L1

T cells present but..

CD8

68

Early Data Suggest that Anti-PDL1/PD1 is Active Across a

Wide Range of Tumor Types

Bladder cancerColorectal cancer

Renal cancer

Melanoma

Liver cancer

Lung cancer

Gastric

Breast cancer

Glioblastoma

Pancreatic

Head & neck cancer

Ovarian

Hodgkin lymphoma

69

Non-sq.=non-squamous; sq.=squamous

1. Weber et al. Lancet 2015; 2. Robert et al. Lancet 2015; 3. Larkin et al. N Engl J Med 2015; 4. Borghaei et al. N Engl J Med 2015

5. Brahmer et al. N Engl J Med 2015; 6. Antonia et al. ASCO 2015; 7. Motzer et al. J Clin Oncol 2015; 8. Le et al. ASCO GI 2016

9. Kefford et al. ASCO 2014; 10. Garon et al. N Engl J Med 2015; 11. Plimack et al. ASCO 2015; 12. Vansteenkiste et al. ECC 2015

13. Rosenberg et al. Lancet 2016; 14. McDermott et al. J Clin Oncol 2015; 15. Rizvi et al. ASCO 2015; 16. Segal et al. ASCO 2015

17. Gulley et al. ASCO 2015; 18. Apolo et al. ASCO GU 2016; 19. Dirix et al. SABCS 2015; 20. Chung et al. ASCO GI 2016

Response Rate by PD-L1 Status

0

20

40

60

80ITT

PD-L1+

PD-L1-

Nivolumab Pembrolizumab Durvalumab AvelumabAtezolizumab

OR

R (

%)

70

Hegde, et al. Clin Cancer Res 2016

The Tumor Immunity Continuum

Pre-existing immunity Excluded infiltrate Immunologically ignorant

Inflamed Non-inflamed

Convert to inflamed phenotype with combinations

CD8 T cells/IFNPD-L1

TILs

Mutational Load

Reactive stroma

Angiogenesis

Respond favorably to

checkpoint inhibition

MDSCs

Proliferating

Tumors/ Low

MHC Class I

71

Immune cells

(ICs)

Tumor cells

(TCs)

Tumor and immune cells

(TCs and ICs)

PD-L1 Staining Can Be Observed In Tumor Cells, Immune Cells

or Both

72


Vraag 3: Bij diagnostiek t.b.v. immunotherapie:

1. Moet altijd een PD-L1 kleuring worden verricht

2. Zijn alle beschikbare assays geschikt om dit te doen

3. Moet dit op histologie worden verricht

4. Kan het beste de “mutational load” worden bepaald


Agent Nivolumab Pembrolizumab Durvalumab Atezolizumab

Antibody Dako 28-8 VentanaSP263

Dako 22C3 VentanaSP263

VentanaSP142

Cut-off(s)Tested (NSCLC)

1%, 5% or 10% (TC)

≥ 25% TC

TC ≥ 50% (and 1% any stroma)

≥ 25% TC TC 1%, 5%, 50%IC 1%, 5%, 10%

Analytically validated assays used in clinical studies


PD-L1 IHC variation

Different PD-L1 clones on consecutive sectionsof one tumor

Scheel et al. Modern Pathol 2016


Variable expression of PD-L1 within one tumor / within onepatient

Cree et al, Histopathology 2016

Pardoll. Nat Rev Cancer 2012

Regulation of T Cell Activation:

Balancing Activating and Inhibitory Signals

Inhibitory interactions

APC/tumor APC/tumor

CTLA-4

PD-1

PD-L1

B7.1

BTLA

LAG-3

HVEM

MHC

B7.1

PD-L2

B7.2

Activating interactions

CD137

CD28

OX40

GITR

CD27

CD70

CD137L

GITRL

OX40L

B7.1

TCR

B7.2

MHC

T cell

77

Chen & Mellman, Immunity 2013

Topalian et al. Nature Rev Cancer 2016

Multifactorial biomarkers


Kerr et a; Histopathology 1998, Johnson et al. Lung Cancer 2000

Kerr, USCAP 2015


Eur Respir J 2015; 46: 1762–

1772


Conclusions:

• PD-L1 testing evaluation is encouraging with respect to better and simpler, reliable routine application in pathology

• Since PD-L1 alone is not the optimal biomarker for PD-1 therapies, considerable effort is and should be spent in examining (combination with) others such as tumor-infiltrating immune cells, mutational load, gene signatures

• In the future, it is likely that it will be an optimal combination of biomarkers to be used to determine, with a sufficient degree of certainty, whether a particular patient will benefit from anti-PD-1/PD-L1 therapy and future immune checkpoint blocking drugs to come


Dank voor uw aandacht


Pitfalls of using PDL1 immunohistochemistry as a biomarker test for anti-PD1–PDL1 therapy

• Focal programmed cell death 1 ligand 1 (PDL1) expression in some tumoursmay be missed in small biopsy specimens, such as needle biopsies

• PDL1 expression among multiple tumour lesions from individual patients can vary over time and by anatomical site

• PDL1 expression in tumour biopsies collected months or years earlier might not accurately reflect PDL1 status at the time of treatment initiation; therapies given after biopsy but before administration of programmed cell death protein 1 (PD1) pathway blockade (radiation therapy, chemotherapy or kinase inhibitors) may alter PDL1 expression

• PDL1 epitopes detected by some antibodies are potentially unstable with prolonged specimen fixation or inadequate tissue handling before fixation (see NCI guidelines for tissue handling)

• Antibodies used for PDL1 detection have different affinities and specificities

• PDL1 protein expression can be membranous and/or cytoplasmic; however, only membranous PDL1 is functionally relevant, by contacting PD1+ T cells

• PDL1 can be expressed by multiple cell types within the tumourmicroenvironment, which poses challenges for scoring and interpretation




Multifactorial biomarkers

Figure 4. Percentage of PD-L1 expression in adenocarcinomas and mutational status of significantly associated genes. The combination of TP53 mutation, KRAS mutation and

STK11 wildtype is associated with the highest percentage of PD-L1 expression in adenocarcinoma tumor cells. Conversely, STK11 mutations in the absence of TP53 and

KRAS mutations are associated with the lowest percentage.

Scheel et al.

Oncoimmunology 2016


Rizvi et al, Science 2015


• In two independent cohorts treated with pembroluzimab(n=14 vs 18), higher nonsynonymous mutation burden in tumors was associated with: – improved objective response,

– durable clinical benefit, and

– progression-free survival

• Efficacy also correlated with:– molecular smoking signature,

– higher neoantigen burden, and

– Higher DNA repair pathway mutations;

– -> each factor was also associated with mutation burden.

Rizvi et al, Science 2015

Diagnostische Pathologie van de long in vogelvlucht · 2019. 10. 10. · • bestraling van de long...

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Transcript of Diagnostische Pathologie van de long in vogelvlucht · 2019. 10. 10. · • bestraling van de long...