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PHH3 immunostaining: a novel prognostic biomarker in pancreatic neuroendocrine tumors
Vol. 217, No. 3S, September 2013
PHH3 immunostaining: a novel prognostic biomarker in pancreatic neuroendocrine tumors Matteo Ligorio, MD, Jan Paul Briet, MD, Eduardo Alfaro, MD, Francesco Sabbatino, MD, Jennifer Wargo, MD, Deshpande Vikram, MD, Carlos Fernandez-del Castillo, MD, FACS, Stephanie Goff, MD, Keith D Lillemoe, MD, FACS, Cristina R Ferrone, MD, FACS Massachusetts General Hospital, Boston, MA INTRODUCTION: Histopathologicalgrade (HG) is an independent prognostic factor in pancreatic neuroendocrine tumors (PNETs). Counting mitotic figures on hemotoxylin and eosin (H&E) stained slides is cumbersome. Phospho-Histone H3 (PHH3) has been evaluated as a mitosis-specific marker in melanoma. The aim of this study is to determine whether PHH3 immunostaining is a feasible and more accurate method to evaluate mitotic figures in patients with PNETs. METHODS: Sequential slides from seventy-four PNETs were stained with H&Eand PHH3 specific immunostaining. Two MGH pancreatic-dedicated pathologists independently counted mitotic figures. Patients were classified according to the WHO staging. Kaplan-Meier curves, log-rank test and ROC curves were used to evaluate recurrence, overall patient survival and the sensitivity and specificity. RESULTS: PHH3 immunostaining was feasible in all seventy-four slides. The mean number of mitotic figures was 5.1 and 4.1 for PHH3 and H&E, respectively. ROC curves demonstrate a more accurate classification (sensitivity and specificity) for patients classified by PHH3 compared to H&E with an area under the curve of 0.899 vs 0.771, respectively. Kaplan-Meier curves demonstrated a high statistical significance (P<0.001) using PHH3 immunostaining for both overall patient survival and recurrence. CONCLUSIONS: PHH3 immunostaining is able to more accurately identify mitotic figures than H&E. This allows for improved staging of patients with PNETs. Gene expression in neuroendocrine tumor liver metastases accurately distinguishes between pancreas and small bowel primary tumors Scott K Sherman, MD*, Jennifer C Carr, MD, Donghong Wang, MS, M Sue O’Dorisio, MD, PhD, Thomas M O’Dorisio, MD, James R Howe, MD, FACS University of Iowa, Iowa City, IA INTRODUCTION: Although percutaneous liver biopsy can diagnose metastatic neuroendocrine tumors (NETs), even with advanced CT-imaging, up to 20% of tumors have an unknown primary site prior to surgery. We therefore sought to distinguish pancreatic and small bowel neuroendocrine tumors based on gene expression in metastatic tissue. METHODS: Neuroendocrine tumor tissues were collected at surgery under an IRB-approved protocol, and RNA was extracted. Quantitative PCR measured expression of 13 genes, normalized to internal controls (dCT method). Nodal metastases without associated liver metastases (n¼20) were used to develop a logistic
Surgical Forum Abstracts
S129
regression model, which was validated on remaining metastases (n¼90). Welch t-test compared mean gene expression. RESULTS: In 110 metastases from 99 patients, two genes showed significantly different expression in metastases from different primary tissue types. Comparing pancreas to small bowel metastases, BRS3 dCT was lower (mean 5.31 vs 10.56, p<0.0001) and OPRK1 dCT was higher (mean 8.12 vs 2.90, p<0.0001). Nodal and liver metastases had similar gene expression, allowing development of a model to distinguish primary sites using a subset of nodal metastases with validation on the full data set. This model correctly identified the primary site in 104/110 metastases (94.5% accuracy). Liver metastases were correctly distinguished in 44/48 samples (91.7%), with positive predictive values of 91.2% for small bowel and 92.9% for pancreas-primary liver metastases.
Tissue type
Small bowel (all) Liver mets Nodal mets Pancreas (all) Liver mets Nodal mets Total
Prediction model result, n Correct Incorrect Total, n Percent correct
77 31 46 27 13 14 104
2 1 1 4 3 1 6
79 32 47 31 16 15 110
97.5 96.9 97.9 87.1 81.3 93.3 94.5
CONCLUSIONS: Expression of BRS3 and OPRK1 in liver or lymph node metastases can accurately distinguish pancreas and small bowel neuroendocrine tumor primary sites, suggesting that liver biopsy could allow primary-site determination prior to or instead of surgery in this population. The utility of measuring ionized calcium levels in identifying recurrent disease in patients following curative parathyroidectomy for primary hyperparathyroidism Azadeh A Carr, MD, Tina W F Yen, MD, MS, FACS, Kara Doffek, BS, Douglas B Evans, MD, FACS, Tracy S Wang, MD, MPH, FACS Medical College of Wisconsin, Milwaukee, WI INTRODUCTION: Ionized calcium (iCa) levels have been shown to be a useful adjunct in the diagnosis of primary hyperparathyroidism (HPT). This study investigated the utility of measuring iCa levels after curative parathyroidectomy for predicting recurrent HPT. METHODS: This is a retrospective review of a prospectively collected, single-institution parathyroid database between 12/993/12. Sporadic HPT patients with >1 postoperative iCa level and >6 months of follow-up were included. Recurrent HPT was defined as an elevated total serum calcium (tCa[>10.2]) with a concurrent PTH level >40 six months after parathyroidectomy. RESULTS: The study cohort included 388 patients; median age was 59 years (range, 20e87). Of these 388 patients, 71 (53%)
PHH3 immunostaining: a novel prognostic biomarker in pancreatic neuroendocrine tumors Matteo Ligorio, MD, Jan Paul Briet, MD, Eduardo Alfaro, MD, Francesco Sabbatino, MD, Jennifer Wargo, MD, Deshpande Vikram, MD, Carlos Fernandez-del Castillo, MD, FACS, Stephanie Goff, MD, Keith D Lillemoe, MD, FACS, Cristina R Ferrone, MD, FACS Massachusetts General Hospital, Boston, MA INTRODUCTION: Histopathologicalgrade (HG) is an independent prognostic factor in pancreatic neuroendocrine tumors (PNETs). Counting mitotic figures on hemotoxylin and eosin (H&E) stained slides is cumbersome. Phospho-Histone H3 (PHH3) has been evaluated as a mitosis-specific marker in melanoma. The aim of this study is to determine whether PHH3 immunostaining is a feasible and more accurate method to evaluate mitotic figures in patients with PNETs. METHODS: Sequential slides from seventy-four PNETs were stained with H&Eand PHH3 specific immunostaining. Two MGH pancreatic-dedicated pathologists independently counted mitotic figures. Patients were classified according to the WHO staging. Kaplan-Meier curves, log-rank test and ROC curves were used to evaluate recurrence, overall patient survival and the sensitivity and specificity. RESULTS: PHH3 immunostaining was feasible in all seventy-four slides. The mean number of mitotic figures was 5.1 and 4.1 for PHH3 and H&E, respectively. ROC curves demonstrate a more accurate classification (sensitivity and specificity) for patients classified by PHH3 compared to H&E with an area under the curve of 0.899 vs 0.771, respectively. Kaplan-Meier curves demonstrated a high statistical significance (P<0.001) using PHH3 immunostaining for both overall patient survival and recurrence. CONCLUSIONS: PHH3 immunostaining is able to more accurately identify mitotic figures than H&E. This allows for improved staging of patients with PNETs. Gene expression in neuroendocrine tumor liver metastases accurately distinguishes between pancreas and small bowel primary tumors Scott K Sherman, MD*, Jennifer C Carr, MD, Donghong Wang, MS, M Sue O’Dorisio, MD, PhD, Thomas M O’Dorisio, MD, James R Howe, MD, FACS University of Iowa, Iowa City, IA INTRODUCTION: Although percutaneous liver biopsy can diagnose metastatic neuroendocrine tumors (NETs), even with advanced CT-imaging, up to 20% of tumors have an unknown primary site prior to surgery. We therefore sought to distinguish pancreatic and small bowel neuroendocrine tumors based on gene expression in metastatic tissue. METHODS: Neuroendocrine tumor tissues were collected at surgery under an IRB-approved protocol, and RNA was extracted. Quantitative PCR measured expression of 13 genes, normalized to internal controls (dCT method). Nodal metastases without associated liver metastases (n¼20) were used to develop a logistic
Surgical Forum Abstracts
S129
regression model, which was validated on remaining metastases (n¼90). Welch t-test compared mean gene expression. RESULTS: In 110 metastases from 99 patients, two genes showed significantly different expression in metastases from different primary tissue types. Comparing pancreas to small bowel metastases, BRS3 dCT was lower (mean 5.31 vs 10.56, p<0.0001) and OPRK1 dCT was higher (mean 8.12 vs 2.90, p<0.0001). Nodal and liver metastases had similar gene expression, allowing development of a model to distinguish primary sites using a subset of nodal metastases with validation on the full data set. This model correctly identified the primary site in 104/110 metastases (94.5% accuracy). Liver metastases were correctly distinguished in 44/48 samples (91.7%), with positive predictive values of 91.2% for small bowel and 92.9% for pancreas-primary liver metastases.
Tissue type
Small bowel (all) Liver mets Nodal mets Pancreas (all) Liver mets Nodal mets Total
Prediction model result, n Correct Incorrect Total, n Percent correct
77 31 46 27 13 14 104
2 1 1 4 3 1 6
79 32 47 31 16 15 110
97.5 96.9 97.9 87.1 81.3 93.3 94.5
CONCLUSIONS: Expression of BRS3 and OPRK1 in liver or lymph node metastases can accurately distinguish pancreas and small bowel neuroendocrine tumor primary sites, suggesting that liver biopsy could allow primary-site determination prior to or instead of surgery in this population. The utility of measuring ionized calcium levels in identifying recurrent disease in patients following curative parathyroidectomy for primary hyperparathyroidism Azadeh A Carr, MD, Tina W F Yen, MD, MS, FACS, Kara Doffek, BS, Douglas B Evans, MD, FACS, Tracy S Wang, MD, MPH, FACS Medical College of Wisconsin, Milwaukee, WI INTRODUCTION: Ionized calcium (iCa) levels have been shown to be a useful adjunct in the diagnosis of primary hyperparathyroidism (HPT). This study investigated the utility of measuring iCa levels after curative parathyroidectomy for predicting recurrent HPT. METHODS: This is a retrospective review of a prospectively collected, single-institution parathyroid database between 12/993/12. Sporadic HPT patients with >1 postoperative iCa level and >6 months of follow-up were included. Recurrent HPT was defined as an elevated total serum calcium (tCa[>10.2]) with a concurrent PTH level >40 six months after parathyroidectomy. RESULTS: The study cohort included 388 patients; median age was 59 years (range, 20e87). Of these 388 patients, 71 (53%)