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Combined adenocarcinoma–atypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two components
SHORT CASE
Combined adenocarcinoma eatypical carcinoid of the lung. Targeted NextGeneration Sequencing (NGS) suggests a monoclonal origin of the two components
Abstract Combined neoplasms of the lung are defined by the WHO classification as an admixture of a small or large cell neuroendocrine carcinoma and a non-neuroendocrine component. However, rare cases of carcinoids combined with a non-neuroendocrine component have been described. These tumor types are not included as a specific entity in the WHO classification of pulmonary neoplasms and their pathogenesis is still unknown. We describe the clinico-pathologic and molecular features of a mixed (combined) lung neoplasm composed of adenocarcinoma and atypical carcinoid. The NGS analysis of the two different tumor components shows a similar molecular profile suggesting their monoclonal origin from a transformed stem/progenitor tumor cell which acquires a divergent differentiation during its development and progression. We also suggest the use of the recently proposed term of mixed neuroendocrine/nonneuroendocrine neoplasm (MiNEN) to define mixed (combined) neoplasms of the lung, because it seems to better cover the wide spectrum of different possible combinations of neuroendocrine and nonneuroendocrine components.
Stefano La Rosa Michele Simbolo Francesca Franzi Silvia Uccella
Keywords adenocarcinoma; carcinoid; combined neoplasm; lung; mixed neoplasm; monoclonality
Andrea Imperatori Elisa Nardecchia Nicola Rotolo Lorenzo Dominioni
Introduction
Aldo Scarpa
The coexistence of neuroendocrine and non-neuroendocrine components in the same epithelial neoplasm is a well known phenomenon. The wide application of immunohistochemistry has increased the possibility of identifying these mixed neoplasms, and their recognition in diagnostic practice is not as rare as in the past. During the last years different terms have been used for defining mixed neoplasms and this has created some confusion among clinicians and pathologists. In the digestive systems these tumors have been defined mixed adenoneuroendocrine carcinomas (MANECs) but this definition has several weak points.1 We have recently proposed to use the more general term of mixed neuroendocrine/nonneuroendocrine neoplasm (MiNEN) to unify the concept of these neoplasms which show similar morphological, clinicopathological and pathogenetic features, although they may originate in different organs.2 The term MiNEN has been recently adopted by the WHO to classify mixed neoplasms of the pancreas.3 In the lung the WHO classification defines mixed neoplasms with the term “combined”. In particular, combined small cell carcinoma and combined large cell neuroendocrine carcinoma are considered as subtypes of the respective pure forms, and are defined as an admixture of neuroendocrine and non-neuroendocrine components.4 Although the combination of a poorly differentiated neuroendocrine carcinoma (small or large cell subtype) with a non-neuroendocrine carcinoma (squamous or adenocarcinoma) is more frequent, rare cases of carcinoids combined with a non-neuroendocrine component have been described. However, the latter tumor types are not included as a specific entity in the WHO classification of pulmonary neoplasms and their pathogenesis is still unknown. We present a rare case of mixed (combined) lung neoplasm composed of an atypical carcinoid and an adenocarcinoma including a molecular analysis of the two different tumor components.
Fausto Sessa
Stefano La Rosa MD Senior Consultant Pathologist, Invited Professor of Pathology, Service of Clinical Pathology, Lausanne University Hospital, Institute of Pathology, Lausanne, Switzerland. Conflicts of interest: none. Michele Simbolo PhD Biologist, Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy. Conflicts of interest: none. Francesca Franzi MD PhD Consultant Pathologist, Department of Pathology, Ospedale di Circolo, Varese, Italy. Conflicts of interest: none. Silvia Uccella MD PhD Associate Professor of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none. Andrea Imperatori MD Associate Professor of Thoracic Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none. Elisa Nardecchia MD Consultant Thoracic Surgeon, Unit of Thoracic Surgery, Ospedale di Circolo, Varese, Italy. Conflicts of interest: none. Nicola Rotolo MD Associate Professor of Thoracic Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none. Lorenzo Dominioni MD Professor of Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none. Aldo Scarpa MD PhD Professor of Pathology, ARC-Net Center for Applied Research on Cancer and Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy. Conflicts of interest: none. Fausto Sessa MD Professor of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none.
DIAGNOSTIC HISTOPATHOLOGY --:-
1
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: La Rosa S, et al., Combined adenocarcinomaeatypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two..., Diagnostic Histopathology (2018), https://doi.org/10.1016/j.mpdhp.2018.02.002
SHORT CASE
On gross examination a sub-pleural, whitish, 1 cm nodule was identified. Histological assessment identified a well circumscribed lesion composed of two different morphological components which were separated in some areas and intermingled in others. The first component, representing about 60% of the tumor burden, showed a glandular architecture corresponding to an acinar lung adenocarcinoma (Figure 2a). The second component was characterized by an organoid proliferation of polygonal shaped uniform tumor cells with abundant eosinophilic cytoplasm and nuclei with finely granular chromatin and inconspicuous nucleoli, consistent with a carcinoid (Figure 2b). In this latter component, 3 mitoses 2 mm2 were identified, while necrosis was absent. Immunohistochemical analysis showed immunoreactivity for synaptophysin, chromogranin A (Figure 2c), TTF1, calcitonin, and CEA in the organoid component, while the glandular component was only positive for TTF1 and negative for the other markers. Ki67 proliferative index in the organoid (neuroendocrine) component was 8% (Figure 2d). No immunohistochemical expression of somatostatin receptor 2A was demonstrated. Metastatic disease, consisting of the carcinoid component only, was identified in the 4R lymph node, in one of 7 peri-bronchial lymph nodes, and in one of 3 intralobar lymph nodes isolated from the lobectomy specimen. The final diagnosis was: combined lung neoplasm composed of acinar adenocarcinoma and atypical carcinoid (pT2a, pN2, R0). In addition to morphological and immunohistochemical investigations, a molecular analysis using Ion Torrent NGS platform and six multigene panels was performed in microdissected exocrine and neuroendocrine components of the primary neoplasm and in the 4R lymph node metastasis to investigate the mutational status of 107 selected genes: ABL1, AKT1, AKT3, ALK, APC, ARID1A, ARID1B, ARID2, ATM, ATRX, BCOR, BRAF, CDH1, CDH10, CDKN1B, CDKN2A, CHD7, CHEK2, CSF1R, CSMD3, CTNNB1, CUL3, DAXX, DDR2, DEPDC5, DST, DYNC1I1, EGFR, ERBB2, ERBB4, EZH2, FBN3, FBXW7, FGFR1, FGFR2, FGFR3, FLT3, GNA11, GNAQ, GNAS, H3F3A, HNF1A, HRAS, HSPG2, IBTK, IDH1, IDH2, INK4C, JAK2, JAK3, KDM6A, KDR, KEAP1, KIT, KMT2D, KRAS, MACF1, MAGEC1, MEN1, MET, MLH1, MPL, MUTYH, NCOA1, NF1, NFE2L2, NOTCH1, NOTCH3, NPAP1, NPM1, NRAS, PALB2, PAPPA2, PBRM1, PCLO, PDGFRA, PIK3CA, PRO-TERT, PTEN, PTPN11, PTPRZ1, RAI1, RASA1, RB1, RET, SBDS, SCAF1, SDHB, SDHD, SETD2, SIN3A, SMAD4, SMARCA2, SMARCA4, SMARCB1, SMO, SRC, STAT3, STK11, TERT, TIE1, TP53, TRIOBP, TSC1, TSC2, VHL, YY1. DNA from each component of the primary tumor and of the metastasis was qualified for NGS application as reported elsewhere5 and an adequate library for deep sequencing was obtained for each panel used. The adenocarcinomatous and carcinoid components of the primary neoplasm and the neuroendocrine metastasis in the lymph node shared the same missense mutations in KRAS (Gly13Asp), PAPPA2 (Arg901Leu) and NF1 (Val2106Phe) genes. An additional somatic mutation was detected in the NF1 gene (Val813GlyfsTer6) in the carcinoid component in both primary and metastatic sites, while an additional missense mutation in SMARCA4 gene (Pro171Leu) was only identified in the adenocarcinoma component (Figure 3). After surgery, the patient underwent thyroid examination, which did not reveal any lesion, and the post-surgical calcitonin serum level was normal. These findings ruled out the possibility
Case report A 59-year-old woman with unremarkable past medical history presented with right chest pain, unsuccessfully treated with analgesics for about 4 months, without dyspnea, hemoptysis or pneumonia. She was a former smoker. Chest X-rays revealed a pulmonary opacity of the right upper lobe (Figure 1a) confirmed by computed tomography (CT) scan which showed a 13 mm nodule with irregular margins and pleural indentation (Figure 1b), associated with an enlarged right paratracheal lymph node (station 4R) (Figure 1c). Positron emission tomography demonstrated abnormal uptake in the right pulmonary lesion and in the lower paratracheal (4R station) lymph node. Laboratory tests, tumor markers and bronchoscopy were unremarkable. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the 4R lymph node was performed and the diagnosis of metastatic lung carcinoid was made. Right postero-lateral thoracotomy was performed, and upper lobectomy with mediastinal lymph node dissection was carried out.
Figure 1 (a) Chest X-ray shows a centimetric pulmonary round opacity of the right upper lobe (arrow) confirmed by CT scan which reveals a 13 mm sized solid pulmonary nodule of the right upper lobe (b) with a right paratracheal lymph node enlargement (c, arrowhead).
DIAGNOSTIC HISTOPATHOLOGY --:-
2
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: La Rosa S, et al., Combined adenocarcinomaeatypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two..., Diagnostic Histopathology (2018), https://doi.org/10.1016/j.mpdhp.2018.02.002
SHORT CASE
Figure 2 The neoplasm shows one component characterized by a glandular architecture corresponding to an acinar lung adenocarcinoma (a) and a second component characterized by an organoid proliferation of polygonal shaped uniform tumor cells with nuclei with finely granular chromatin and inconspicuous nucleoli (b) strongly and diffusely immunoreactive for chromogranin A (c). The Ki67 proliferative index in this neuroendocrine component was 8% (d).
of an occult medullary carcinoma metastatic to the lung, suggested by the immunoreactivities for calcitonin and CEA. The post-operative course was uneventful and the patient was discharged in good conditions on postoperative day 8. After multidisciplinary discussion, the patient received four cycles of
adjuvant chemotherapy (Cisplatinum and Vinorelbine) but, unfortunately, she presented recurrent disease in 4R lymph node station after one year, and liver metastases after six more months. The patient is alive 26 months after operation, currently under treatment with Temozolomide.
Figure 3 Summary of gene mutations observed in the two components of the primary lung neoplasm and in the mediastinal lymph node metastasis.
DIAGNOSTIC HISTOPATHOLOGY --:-
3
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: La Rosa S, et al., Combined adenocarcinomaeatypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two..., Diagnostic Histopathology (2018), https://doi.org/10.1016/j.mpdhp.2018.02.002
SHORT CASE
Discussion
REFERENCES 1 Rindi G, Arnold R, Bosman FT, et al. Nomenclature and classification of neuroendocrine neoplasms of the digestive system. In: Bosman FT, Carneiro F, Hruban RH, Theise ND, eds. WHO classification of tumours of the digestive system. 4th edn. Lyon: IARC Press, 2010; 13e4. 2 La Rosa S, Sessa F, Uccella S. Mixed neuroendocrinenonneuroendocrine neoplasms (MiNENs): unifying the concept of a heterogeneous group of neoplasms. Endocr Pathol 2016; 27: 284e311. €ppel G, Couvelard A, Hruban RH, et al. Neoplasms of the 3 Klo neuroendocrine pancreas. Introduction. In: Lloyd RV, € ppel G, Rosai J, eds. WHO classification of Osamura RY, Klo tumours of endocrine organs. 4th edn. Lyon: IARC Press, 2017; 211e4. 4 Travis WD, Brambilla E, Burke AP, Marx A, Nicholson AG, eds. WHO classification of tumours of the lung, pleura, thymus and heart. 4th edn. Lyon: IARC Press 2015, 2015. 5 Simbolo M, Gottardi M, Corbo V, et al. DNA qualification workflow for next generation sequencing of histopathological samples. PLoS One 2013; 8: e62692. 6 Li DH, Wang C, Chen HJ, Huang H, Ding ZY. Clinical characteristics of the mixed form of neuroendocrine tumor in the lung: a retrospective study in 2501 lung cancer cases. Thorac Cancer 2015; 6: 25e30. 7 Sen F, Borczuk AC. Combined carcinoid tumor of the lung: a combination of carcinoid and adenocarcinoma. Lung Cancer 1998; 21: 53e8. 8 Owens CL, Fraire AE. Combined carcinoid tumor and squamous cell carcinoma of lung: expanding the spectrum of combined tumors of lung. Int J Surg Pathol 2011; 19: 273e5. 9 Okazaki M, Sano Y, Soga Y, et al. Combined atypical carcinoid tumour and squamous cell carcinoma of the lung. Intern Med 2015; 54: 1385e8. 10 Neal MH, Kosinski R, Cohen P, Orenstein JM. Atypical endocrine tumors of the lung: a histologic, ultrastructural, and clinical study of 19 cases. Hum Pathol 1986; 17: 1264e77. 11 Furlan D, Cerutti R, Genasetti A, et al. Microallelotyping defines the monoclonal or the polyclonal origin of mixed and collision endocrine-exocrine tumors of the gut. Lab Invest 2003; 83: 963e71. 12 La Rosa S, Furlan D, Franzi F, et al. Mixed exocrineneuroendocrine carcinoma of the nasal cavity: clinico-pathologic and molecular study of a case and review of the literature. Head Neck Pathol 2013; 7: 76e84. 13 Volante M, Monica V, Birocco N, et al. Expression analysis of genes involved in DNA repair or synthesis in mixed neuroendocrine/nonneuroendocrine carcinomas. Neuroendocrinology 2015; 101: 151e60. 14 Scardoni M, Vittoria E, Volante M, et al. Mixed adenoneuroendocrine carcinomas of the gastrointestinal tract: targeted next-generation sequencing suggests a monoclonal origin of the two components. Neuroendocrinology 2014; 100: 310e6. 15 Jesinghaus M, Konukiewitz B, Keller G, et al. Colorectal mixed adenoneuroendocrine carcinomas and neuroendocrine carcinomas are genetically closely related to colorectal adenocarcinomas. Mod Pathol 2017; 30: 610e9.
The WHO defines lung neoplasms composed of both a neuroendocrine and non-neuroendocrine component as combined neoplasms. However, this category is only specified for those cases in which the neuroendocrine component is represented by a poorly differentiated neuroendocrine carcinoma of either small or large cell subtype.4 Nevertheless, rare cases of carcinoids, both typical and atypical, associated with a squamous cell carcinoma or an adenocarcinoma have been described in the literature.6e9 Moreover, Neal and co-workers, analyzing a series of 19 atypical carcinoids, demonstrated a glandular differentiation in 12 of 19 cases,10 thus suggesting that the spectrum of pulmonary mixed neoplasms composed of a neuroendocrine and non-neuroendocrine component is wider than that considered in the WHO classification4 and also includes mixed typical and atypical carcinoids. For this reason, the recently proposed term MiNEN seems more appropriate also to classify pulmonary mixed (combined) neoplasms.2 In the last 10 years several attempts have been made to elucidate the pathogenesis and the molecular profile of MiNENs. With few exceptions, available molecular data, obtained analyzing MiNENs of different organs, point towards a common origin of the neuroendocrine and non-neuroendocrine component supporting the concept of a single (monoclonal) neoplastic proliferation with different phenotypic features and progression of a non-neuroendocrine neoplasm (squamous cell carcinoma or adenocarcinoma) towards a more malignant neuroendocrine phenotype.11e15 This model of tumor progression is supported by growing evidence in MiNENs with a poorly differentiated neuroendocrine component.12e15 By contrast, very few molecular data are available regarding MiNENs with a well differentiated neuroendocrine component.
Conclusion The present study is the first demonstration of close molecular alterations in the different components of a pulmonary MiNEN composed of atypical carcinoid and adenocarcinoma. Our findings suggest a monoclonal origin of the two components from a common transformed stem/progenitor tumor cell, which acquires divergent differentiation during neoplastic development and progression, witnessed by additional mutations, unique for each component.A
Practice points C
C
C
The term mixed neuroendocrine/non-neuroendocrine neoplasm (MiNEN) seems appropriate to encompass the wide spectrum of mixed (combined) lung neoplasms which includes the combination of either poorly differentiated neuroendocrine carcinoma (small or large cell subtype) or carcinoid (typical or atypical) with non-endocrine tumor types. The term MiNEN may be used in the pathology report, always accompanied by a detailed morphological description of the two neoplastic components, to provide the clinician with the prognostic information useful for choosing the most appropriate therapy. The two components of the MiNEN (adenocarcinoma and atypical carcinoid) described in the present paper show a similar molecular profile suggesting a monoclonal origin from the same stem/progenitor tumor cell.
DIAGNOSTIC HISTOPATHOLOGY --:-
4
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: La Rosa S, et al., Combined adenocarcinomaeatypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two..., Diagnostic Histopathology (2018), https://doi.org/10.1016/j.mpdhp.2018.02.002
Combined adenocarcinoma eatypical carcinoid of the lung. Targeted NextGeneration Sequencing (NGS) suggests a monoclonal origin of the two components
Abstract Combined neoplasms of the lung are defined by the WHO classification as an admixture of a small or large cell neuroendocrine carcinoma and a non-neuroendocrine component. However, rare cases of carcinoids combined with a non-neuroendocrine component have been described. These tumor types are not included as a specific entity in the WHO classification of pulmonary neoplasms and their pathogenesis is still unknown. We describe the clinico-pathologic and molecular features of a mixed (combined) lung neoplasm composed of adenocarcinoma and atypical carcinoid. The NGS analysis of the two different tumor components shows a similar molecular profile suggesting their monoclonal origin from a transformed stem/progenitor tumor cell which acquires a divergent differentiation during its development and progression. We also suggest the use of the recently proposed term of mixed neuroendocrine/nonneuroendocrine neoplasm (MiNEN) to define mixed (combined) neoplasms of the lung, because it seems to better cover the wide spectrum of different possible combinations of neuroendocrine and nonneuroendocrine components.
Stefano La Rosa Michele Simbolo Francesca Franzi Silvia Uccella
Keywords adenocarcinoma; carcinoid; combined neoplasm; lung; mixed neoplasm; monoclonality
Andrea Imperatori Elisa Nardecchia Nicola Rotolo Lorenzo Dominioni
Introduction
Aldo Scarpa
The coexistence of neuroendocrine and non-neuroendocrine components in the same epithelial neoplasm is a well known phenomenon. The wide application of immunohistochemistry has increased the possibility of identifying these mixed neoplasms, and their recognition in diagnostic practice is not as rare as in the past. During the last years different terms have been used for defining mixed neoplasms and this has created some confusion among clinicians and pathologists. In the digestive systems these tumors have been defined mixed adenoneuroendocrine carcinomas (MANECs) but this definition has several weak points.1 We have recently proposed to use the more general term of mixed neuroendocrine/nonneuroendocrine neoplasm (MiNEN) to unify the concept of these neoplasms which show similar morphological, clinicopathological and pathogenetic features, although they may originate in different organs.2 The term MiNEN has been recently adopted by the WHO to classify mixed neoplasms of the pancreas.3 In the lung the WHO classification defines mixed neoplasms with the term “combined”. In particular, combined small cell carcinoma and combined large cell neuroendocrine carcinoma are considered as subtypes of the respective pure forms, and are defined as an admixture of neuroendocrine and non-neuroendocrine components.4 Although the combination of a poorly differentiated neuroendocrine carcinoma (small or large cell subtype) with a non-neuroendocrine carcinoma (squamous or adenocarcinoma) is more frequent, rare cases of carcinoids combined with a non-neuroendocrine component have been described. However, the latter tumor types are not included as a specific entity in the WHO classification of pulmonary neoplasms and their pathogenesis is still unknown. We present a rare case of mixed (combined) lung neoplasm composed of an atypical carcinoid and an adenocarcinoma including a molecular analysis of the two different tumor components.
Fausto Sessa
Stefano La Rosa MD Senior Consultant Pathologist, Invited Professor of Pathology, Service of Clinical Pathology, Lausanne University Hospital, Institute of Pathology, Lausanne, Switzerland. Conflicts of interest: none. Michele Simbolo PhD Biologist, Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy. Conflicts of interest: none. Francesca Franzi MD PhD Consultant Pathologist, Department of Pathology, Ospedale di Circolo, Varese, Italy. Conflicts of interest: none. Silvia Uccella MD PhD Associate Professor of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none. Andrea Imperatori MD Associate Professor of Thoracic Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none. Elisa Nardecchia MD Consultant Thoracic Surgeon, Unit of Thoracic Surgery, Ospedale di Circolo, Varese, Italy. Conflicts of interest: none. Nicola Rotolo MD Associate Professor of Thoracic Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none. Lorenzo Dominioni MD Professor of Surgery, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none. Aldo Scarpa MD PhD Professor of Pathology, ARC-Net Center for Applied Research on Cancer and Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy. Conflicts of interest: none. Fausto Sessa MD Professor of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy. Conflicts of interest: none.
DIAGNOSTIC HISTOPATHOLOGY --:-
1
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: La Rosa S, et al., Combined adenocarcinomaeatypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two..., Diagnostic Histopathology (2018), https://doi.org/10.1016/j.mpdhp.2018.02.002
SHORT CASE
On gross examination a sub-pleural, whitish, 1 cm nodule was identified. Histological assessment identified a well circumscribed lesion composed of two different morphological components which were separated in some areas and intermingled in others. The first component, representing about 60% of the tumor burden, showed a glandular architecture corresponding to an acinar lung adenocarcinoma (Figure 2a). The second component was characterized by an organoid proliferation of polygonal shaped uniform tumor cells with abundant eosinophilic cytoplasm and nuclei with finely granular chromatin and inconspicuous nucleoli, consistent with a carcinoid (Figure 2b). In this latter component, 3 mitoses 2 mm2 were identified, while necrosis was absent. Immunohistochemical analysis showed immunoreactivity for synaptophysin, chromogranin A (Figure 2c), TTF1, calcitonin, and CEA in the organoid component, while the glandular component was only positive for TTF1 and negative for the other markers. Ki67 proliferative index in the organoid (neuroendocrine) component was 8% (Figure 2d). No immunohistochemical expression of somatostatin receptor 2A was demonstrated. Metastatic disease, consisting of the carcinoid component only, was identified in the 4R lymph node, in one of 7 peri-bronchial lymph nodes, and in one of 3 intralobar lymph nodes isolated from the lobectomy specimen. The final diagnosis was: combined lung neoplasm composed of acinar adenocarcinoma and atypical carcinoid (pT2a, pN2, R0). In addition to morphological and immunohistochemical investigations, a molecular analysis using Ion Torrent NGS platform and six multigene panels was performed in microdissected exocrine and neuroendocrine components of the primary neoplasm and in the 4R lymph node metastasis to investigate the mutational status of 107 selected genes: ABL1, AKT1, AKT3, ALK, APC, ARID1A, ARID1B, ARID2, ATM, ATRX, BCOR, BRAF, CDH1, CDH10, CDKN1B, CDKN2A, CHD7, CHEK2, CSF1R, CSMD3, CTNNB1, CUL3, DAXX, DDR2, DEPDC5, DST, DYNC1I1, EGFR, ERBB2, ERBB4, EZH2, FBN3, FBXW7, FGFR1, FGFR2, FGFR3, FLT3, GNA11, GNAQ, GNAS, H3F3A, HNF1A, HRAS, HSPG2, IBTK, IDH1, IDH2, INK4C, JAK2, JAK3, KDM6A, KDR, KEAP1, KIT, KMT2D, KRAS, MACF1, MAGEC1, MEN1, MET, MLH1, MPL, MUTYH, NCOA1, NF1, NFE2L2, NOTCH1, NOTCH3, NPAP1, NPM1, NRAS, PALB2, PAPPA2, PBRM1, PCLO, PDGFRA, PIK3CA, PRO-TERT, PTEN, PTPN11, PTPRZ1, RAI1, RASA1, RB1, RET, SBDS, SCAF1, SDHB, SDHD, SETD2, SIN3A, SMAD4, SMARCA2, SMARCA4, SMARCB1, SMO, SRC, STAT3, STK11, TERT, TIE1, TP53, TRIOBP, TSC1, TSC2, VHL, YY1. DNA from each component of the primary tumor and of the metastasis was qualified for NGS application as reported elsewhere5 and an adequate library for deep sequencing was obtained for each panel used. The adenocarcinomatous and carcinoid components of the primary neoplasm and the neuroendocrine metastasis in the lymph node shared the same missense mutations in KRAS (Gly13Asp), PAPPA2 (Arg901Leu) and NF1 (Val2106Phe) genes. An additional somatic mutation was detected in the NF1 gene (Val813GlyfsTer6) in the carcinoid component in both primary and metastatic sites, while an additional missense mutation in SMARCA4 gene (Pro171Leu) was only identified in the adenocarcinoma component (Figure 3). After surgery, the patient underwent thyroid examination, which did not reveal any lesion, and the post-surgical calcitonin serum level was normal. These findings ruled out the possibility
Case report A 59-year-old woman with unremarkable past medical history presented with right chest pain, unsuccessfully treated with analgesics for about 4 months, without dyspnea, hemoptysis or pneumonia. She was a former smoker. Chest X-rays revealed a pulmonary opacity of the right upper lobe (Figure 1a) confirmed by computed tomography (CT) scan which showed a 13 mm nodule with irregular margins and pleural indentation (Figure 1b), associated with an enlarged right paratracheal lymph node (station 4R) (Figure 1c). Positron emission tomography demonstrated abnormal uptake in the right pulmonary lesion and in the lower paratracheal (4R station) lymph node. Laboratory tests, tumor markers and bronchoscopy were unremarkable. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the 4R lymph node was performed and the diagnosis of metastatic lung carcinoid was made. Right postero-lateral thoracotomy was performed, and upper lobectomy with mediastinal lymph node dissection was carried out.
Figure 1 (a) Chest X-ray shows a centimetric pulmonary round opacity of the right upper lobe (arrow) confirmed by CT scan which reveals a 13 mm sized solid pulmonary nodule of the right upper lobe (b) with a right paratracheal lymph node enlargement (c, arrowhead).
DIAGNOSTIC HISTOPATHOLOGY --:-
2
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: La Rosa S, et al., Combined adenocarcinomaeatypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two..., Diagnostic Histopathology (2018), https://doi.org/10.1016/j.mpdhp.2018.02.002
SHORT CASE
Figure 2 The neoplasm shows one component characterized by a glandular architecture corresponding to an acinar lung adenocarcinoma (a) and a second component characterized by an organoid proliferation of polygonal shaped uniform tumor cells with nuclei with finely granular chromatin and inconspicuous nucleoli (b) strongly and diffusely immunoreactive for chromogranin A (c). The Ki67 proliferative index in this neuroendocrine component was 8% (d).
of an occult medullary carcinoma metastatic to the lung, suggested by the immunoreactivities for calcitonin and CEA. The post-operative course was uneventful and the patient was discharged in good conditions on postoperative day 8. After multidisciplinary discussion, the patient received four cycles of
adjuvant chemotherapy (Cisplatinum and Vinorelbine) but, unfortunately, she presented recurrent disease in 4R lymph node station after one year, and liver metastases after six more months. The patient is alive 26 months after operation, currently under treatment with Temozolomide.
Figure 3 Summary of gene mutations observed in the two components of the primary lung neoplasm and in the mediastinal lymph node metastasis.
DIAGNOSTIC HISTOPATHOLOGY --:-
3
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: La Rosa S, et al., Combined adenocarcinomaeatypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two..., Diagnostic Histopathology (2018), https://doi.org/10.1016/j.mpdhp.2018.02.002
SHORT CASE
Discussion
REFERENCES 1 Rindi G, Arnold R, Bosman FT, et al. Nomenclature and classification of neuroendocrine neoplasms of the digestive system. In: Bosman FT, Carneiro F, Hruban RH, Theise ND, eds. WHO classification of tumours of the digestive system. 4th edn. Lyon: IARC Press, 2010; 13e4. 2 La Rosa S, Sessa F, Uccella S. Mixed neuroendocrinenonneuroendocrine neoplasms (MiNENs): unifying the concept of a heterogeneous group of neoplasms. Endocr Pathol 2016; 27: 284e311. €ppel G, Couvelard A, Hruban RH, et al. Neoplasms of the 3 Klo neuroendocrine pancreas. Introduction. In: Lloyd RV, € ppel G, Rosai J, eds. WHO classification of Osamura RY, Klo tumours of endocrine organs. 4th edn. Lyon: IARC Press, 2017; 211e4. 4 Travis WD, Brambilla E, Burke AP, Marx A, Nicholson AG, eds. WHO classification of tumours of the lung, pleura, thymus and heart. 4th edn. Lyon: IARC Press 2015, 2015. 5 Simbolo M, Gottardi M, Corbo V, et al. DNA qualification workflow for next generation sequencing of histopathological samples. PLoS One 2013; 8: e62692. 6 Li DH, Wang C, Chen HJ, Huang H, Ding ZY. Clinical characteristics of the mixed form of neuroendocrine tumor in the lung: a retrospective study in 2501 lung cancer cases. Thorac Cancer 2015; 6: 25e30. 7 Sen F, Borczuk AC. Combined carcinoid tumor of the lung: a combination of carcinoid and adenocarcinoma. Lung Cancer 1998; 21: 53e8. 8 Owens CL, Fraire AE. Combined carcinoid tumor and squamous cell carcinoma of lung: expanding the spectrum of combined tumors of lung. Int J Surg Pathol 2011; 19: 273e5. 9 Okazaki M, Sano Y, Soga Y, et al. Combined atypical carcinoid tumour and squamous cell carcinoma of the lung. Intern Med 2015; 54: 1385e8. 10 Neal MH, Kosinski R, Cohen P, Orenstein JM. Atypical endocrine tumors of the lung: a histologic, ultrastructural, and clinical study of 19 cases. Hum Pathol 1986; 17: 1264e77. 11 Furlan D, Cerutti R, Genasetti A, et al. Microallelotyping defines the monoclonal or the polyclonal origin of mixed and collision endocrine-exocrine tumors of the gut. Lab Invest 2003; 83: 963e71. 12 La Rosa S, Furlan D, Franzi F, et al. Mixed exocrineneuroendocrine carcinoma of the nasal cavity: clinico-pathologic and molecular study of a case and review of the literature. Head Neck Pathol 2013; 7: 76e84. 13 Volante M, Monica V, Birocco N, et al. Expression analysis of genes involved in DNA repair or synthesis in mixed neuroendocrine/nonneuroendocrine carcinomas. Neuroendocrinology 2015; 101: 151e60. 14 Scardoni M, Vittoria E, Volante M, et al. Mixed adenoneuroendocrine carcinomas of the gastrointestinal tract: targeted next-generation sequencing suggests a monoclonal origin of the two components. Neuroendocrinology 2014; 100: 310e6. 15 Jesinghaus M, Konukiewitz B, Keller G, et al. Colorectal mixed adenoneuroendocrine carcinomas and neuroendocrine carcinomas are genetically closely related to colorectal adenocarcinomas. Mod Pathol 2017; 30: 610e9.
The WHO defines lung neoplasms composed of both a neuroendocrine and non-neuroendocrine component as combined neoplasms. However, this category is only specified for those cases in which the neuroendocrine component is represented by a poorly differentiated neuroendocrine carcinoma of either small or large cell subtype.4 Nevertheless, rare cases of carcinoids, both typical and atypical, associated with a squamous cell carcinoma or an adenocarcinoma have been described in the literature.6e9 Moreover, Neal and co-workers, analyzing a series of 19 atypical carcinoids, demonstrated a glandular differentiation in 12 of 19 cases,10 thus suggesting that the spectrum of pulmonary mixed neoplasms composed of a neuroendocrine and non-neuroendocrine component is wider than that considered in the WHO classification4 and also includes mixed typical and atypical carcinoids. For this reason, the recently proposed term MiNEN seems more appropriate also to classify pulmonary mixed (combined) neoplasms.2 In the last 10 years several attempts have been made to elucidate the pathogenesis and the molecular profile of MiNENs. With few exceptions, available molecular data, obtained analyzing MiNENs of different organs, point towards a common origin of the neuroendocrine and non-neuroendocrine component supporting the concept of a single (monoclonal) neoplastic proliferation with different phenotypic features and progression of a non-neuroendocrine neoplasm (squamous cell carcinoma or adenocarcinoma) towards a more malignant neuroendocrine phenotype.11e15 This model of tumor progression is supported by growing evidence in MiNENs with a poorly differentiated neuroendocrine component.12e15 By contrast, very few molecular data are available regarding MiNENs with a well differentiated neuroendocrine component.
Conclusion The present study is the first demonstration of close molecular alterations in the different components of a pulmonary MiNEN composed of atypical carcinoid and adenocarcinoma. Our findings suggest a monoclonal origin of the two components from a common transformed stem/progenitor tumor cell, which acquires divergent differentiation during neoplastic development and progression, witnessed by additional mutations, unique for each component.A
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The term mixed neuroendocrine/non-neuroendocrine neoplasm (MiNEN) seems appropriate to encompass the wide spectrum of mixed (combined) lung neoplasms which includes the combination of either poorly differentiated neuroendocrine carcinoma (small or large cell subtype) or carcinoid (typical or atypical) with non-endocrine tumor types. The term MiNEN may be used in the pathology report, always accompanied by a detailed morphological description of the two neoplastic components, to provide the clinician with the prognostic information useful for choosing the most appropriate therapy. The two components of the MiNEN (adenocarcinoma and atypical carcinoid) described in the present paper show a similar molecular profile suggesting a monoclonal origin from the same stem/progenitor tumor cell.
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Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: La Rosa S, et al., Combined adenocarcinomaeatypical carcinoid of the lung. Targeted Next-Generation Sequencing (NGS) suggests a monoclonal origin of the two..., Diagnostic Histopathology (2018), https://doi.org/10.1016/j.mpdhp.2018.02.002