Prognostic significance of cytokeratin 19 expression in pancreatic neuroendocrine tumor: A meta-analysis

Expression profiles of cadherin 17 and claudin 18.2 in comparison with peptide hormonal expression in pancreatic neuroendocrine tumours: Implications for targeted immunotherapy

Cadherin 17 (CDH17) and claudin 18.2 (CLDN18.2) are highly selective markers of intestinal and gastric lineages and are expressed in adenocarcinomas of various organs. They have also been identified as potential targets for immunotherapy. Expression of CDH17 and CLDN18.2 has been observed in a subset of pancreatic neuroendocrine tumours (PanNETs). This study investigates the immunohistochemical expression of CDH17 and CLDN18 in PanNETs in comparison with hormonal expression profiles to provide baseline data for determining candidate indications for targeted therapy with CDH17 and CLDN18.2 in PanNETs, including insulinomas (n = 22), glucagonomas (n = 13), gastrinomas (n = 3), serotoninomas (n = 2) and PanNETs not otherwise specified (NOS) (n = 17). In the normal pancreas, CDH17 was expressed in the lateral membrane of ducts and some islet cells, whereas CLDN18 was occasionally expressed in the intercalated ducts and centroacinar cells. In PanNETs, CDH17 and CLDN18 was detected by membranous staining. CDH17 expression was observed in 10 to 17 (58.8 %) PanNETs NOS, 3 of 13 (23.1 %) glucagonomas, 1 of 3 (33.3 %,) gastrinomas, 1 of 2 (50 %) serotoninomas, and none of the insulinomas. According to predefined criteria, 7 of 17 (41.2 %) PanNETs NOS, 1 of 3 (33.3 %) gastrinomas, and 1 of 2 (50 %) serotoninomas were classified as CDH17-positive. There were no significant differences in clinicopathological features between CDH17-positive and CDH17-negative PanNETs, except for a higher tumour grade in the former (p<0.05). For CLDN18, expression was noted in 2 out of 3 (66.7 %) gastrinomas, one with focal staining and the other with diffuse staining. One of three (33.3 %) gastrinomas was classified as CLDN18-positive using predefined criteria. These findings suggest that a particular subset of PanNETs, including PanNET NOS, gastrinoma, and serotoninoma, may be potential candidates for CDH17-targeted immunotherapy. Additionally, gastrinoma may be a potential candidate for immunotherapy targeting CLDN18.2.

Total pancreatoduodenectomy for multiple pancreatic cysts in von Hippel-Lindau disease presenting as obstructive jaundice: A case report

INTRODUCTION

Von Hippel-Lindau (VHL) disease can be known as a rare autosomal dominant syndrome that affects some organ systems and is characterized by the growth of both benign and malignant tumors. Diagnosis and management of VHL were needed to have better outcomes.

CASE PRESENTATION

A 39-year-old male with a history of VHL disease and positive family history presented with jaundice and pruritus. He had a history of craniotomy thrice. Laboratory workup revealed elevated total bilirubin level with conjugated bilirubin predominant. The contrast-enhanced MRI showed dilatation of biliary tree with suspicion of partial obstruction by multiple cysts in the pancreas, with ±0.5-5 cm in diameter. A PET/CT scan showed multiple lesions corresponding to VHL disease. The patient underwent total pancreatoduodenectomy. The histopathology finding was multicystic pancreatic hamartoma with neuroendocrine cell hyperplasia.

CLINICAL DISCUSSION

Multiple pancreatic cysts without prior pancreatic inflammatory episodes should suggest VHL disease and prompt a genetic test, according to clinical presentation. As soon as the diagnosis is made, all potential family members must be screened, and those who are affected must receive genetic counseling and strict follow-up care to treat the disease's potentially fatal CNS and visceral manifestations. Total pancreatoduodenectomy was performed according to jaundice, risk of pancreas malignancy, and the existence of endocrine pancreatic insufficiency.

CONCLUSION

Total pancreatoduodenectomy could be performed to relieve the symptom severity and avoid the possibility of malignant changes in VHL.

Predictive value of the preoperative prognostic nutritional index for postoperative progression in patients with pancreatic neuroendocrine neoplasms

Objective

The preoperative nutritional status of cancer patients is closely related to prognosis. The prognostic nutritional index (PNI) has been shown to predict the prognosis of a variety of tumors, but its study in pancreatic neuroendocrine neoplasms (pNENs) is lacking. The aim of the present study is to investigate the predictive value of the preoperative PNI for postoperative progression in patients with pNENs.

Methods

The medical records of 181 patients with pNENs, who underwent surgery, were retrospectively analyzed. A time-dependent receiver operating characteristic (ROC) curve was plotted to determine the optimal cut-off value of the preoperative PNI. Correlations between the preoperative PNI and clinicopathological parameters were analyzed using multiple linear regression. A Kaplan-Meier curve was applied to assess the progression-free survival (PFS) rate, which was tested using a log rank. Univariate and multivariate Cox proportional risk regression models were used to analyze the predictive value of the preoperative PNI on prognosis.

Results

The optimal cut-off value of the preoperative PNI was 48.275. The patients were divided into a high PNI group (PNI > 48.275, n = 92) and a low PNI group (PNI ≤ 48.275, n = 89). The proportion of patients with tumor progression after surgery was significantly higher in the low PNI group compared with that in the high PNI group (P = 0.004). The Kaplan-Meier curve showed that the PFS rate after surgery was significantly lower in the low PNI group compared with that in the high PNI group (P = 0.026). The preoperative PNI was an independent predictor of PFS (HR: 2.727, 95% CI: 1.174∼6.333, P = 0.020).

Conclusion

The preoperative PNI has a predictive value for postoperative progression in patients with pNENs.

Immunohistochemistry as predictive and prognostic markers for gastrointestinal malignancies

Biomarkers play a key role in the comprehensive pathologic evaluation of gastrointestinal malignancies. These biomarkers can be predictive, indicating whether a tumor is likely to respond to a particular therapy, or prognostic, providing information about the likely course and outcome of a disease. This review article will discuss available immunohistochemical stains for assessing these markers, including staining rationale, scoring criteria, associated systemic therapies, and pictorial examples. PD-L1, HER2, and mismatch repair status can be evaluated via immunohistochemistry for esophageal, gastric, and colorectal carcinomas. Biomarkers currently play a more limited role in evaluation of pancreatic and small bowel malignancies. Immunohistochemistry can also be used to evaluate biomarker status in gastrointestinal stromal tumors, gastrointestinal malignancies with NTRK gene fusions, and undifferentiated carcinomas with switch-sucrose non-fermentable complex abnormalities.

A Keratin 7 and E-Cadherin Signature Is Highly Predictive of Tubo-Ovarian High-Grade Serous Carcinoma Prognosis

During tubo-ovarian high-grade serous carcinoma (HGSC) progression, tumoral cells undergo phenotypic changes in their epithelial marker profiles, which are essential for dissemination processes. Here, we set out to determine whether standard epithelial markers can predict HGSC patient prognosis. Levels of E-CADH, KRT7, KRT18, KRT19 were quantified in 18 HGSC cell lines by Western blot and in a Discovery cohort tissue microarray (TMA) (n = 101 patients) using immunofluorescence. E-CADH and KRT7 levels were subsequently analyzed in the TMA of the Canadian Ovarian Experimental Unified Resource cohort (COEUR, n = 1158 patients) and in public datasets. Epithelial marker expression was highly variable in HGSC cell lines and tissues. In the Discovery cohort, high levels of KRT7 and KRT19 were associated with an unfavorable prognosis, whereas high E-CADH expression indicated a better outcome. Expression of KRT7 and E-CADH gave a robust combination to predict overall survival (OS, p = 0.004) and progression free survival (PFS, p = 5.5 × 10⁻⁴) by Kaplan–Meier analysis. In the COEUR cohort, the E-CADH-KRT7 signature was a strong independent prognostic biomarker (OS, HR = 1.6, p = 2.9 × 10⁻⁴; PFS, HR = 1.3, p = 0.008) and predicted a poor patient response to chemotherapy (p = 1.3 × 10⁻⁴). Our results identify a combination of two epithelial markers as highly significant indicators of HGSC patient prognosis and treatment response.

Pathology Reporting in Neuroendocrine Neoplasms of the Digestive System: Everything You Always Wanted to Know but Were Too Afraid to Ask

During the 5th NIKE (Neuroendocrine tumors Innovation in Knowledge and Education) meeting, held in Naples, Italy, in May 2019, discussions centered on the understanding of pathology reports of gastroenetropancreactic neuroendocrine neoplasms. In particular, the main problem concerned the difficulty that clinicians experience in extrapolating relevant information from neuroendocrine tumor pathology reports. During the meeting, participants were asked to identify and rate issues which they have encountered, for which the input of an expert pathologist would have been appreciated. This article is a collection of the most rated questions and relative answers, focusing on three main topics: 1) morphology and classification; 2) Ki67 and grading; 3) immunohistochemistry. Patient management should be based on multidisciplinary decisions, taking into account clinical and pathology-related features with clear comprehension between all health care professionals. Indeed, pathologists require clinical details and laboratory findings when relevant, while clinicians require concise and standardized reports. In keeping with this last statement, the minimum requirements in pathology datasets are provided in this paper and should be a baseline for all neuroendocrine tumor professionals.

Tumor microtubes connect pancreatic cancer cells in an Arp2/3 complex-dependent manner

Actin-based tubular connections between cells have been observed in many cell types. Termed "tunneling nanotubes (TNTs)," "membrane nanotubes," "tumor microtubes (TMTs)," or "cytonemes," these protrusions interconnect cells in dynamic networks. Structural features in these protrusions vary between cellular systems, including tubule diameter and the presence of microtubules. We find tubular protrusions, which we classify as TMTs, in a pancreatic cancer cell line, Dartmouth-Hitchcock Pancreatic Cancer (DHPC)-018. TMTs are present in DHPC-018-derived tumors in mice, as well as in a mouse model of pancreatic cancer and a subset of primary human tumors. DHPC-018 TMTs have heterogeneous diameter (0.39-5.85 µm, median 1.92 µm) and contain actin filaments, microtubules, and cytokeratin 19-based intermediate filaments. TMTs do not allow intercellular transfer of cytoplasmic GFP. Actin filaments are cortical within the protrusion, as opposed to TNTs, in which filaments run down the center. TMTs are dynamic in length, but are long lived (median >60 min). Inhibition of actin polymerization, but not microtubules, results in TMT loss. Extracellular calcium is necessary for TMT maintenance. A second class of tubular protrusion, which we term cell-substrate protrusion, has similar width range and cytoskeletal features but makes contact with the substratum as opposed to another cell. Similar to previous work on TNTs, we find two assembly mechanisms for TMTs, which we term "pull-away" and "search-and-capture." Inhibition of Arp2/3 complex inhibits TMT assembly by both mechanisms. This work demonstrates that the actin architecture of TMTs in pancreatic cancer cells is fundamentally different from that of TNTs and demonstrates the role of Arp2/3 complex in TMT assembly.

Clinicopathological and Prognostic Characteristics in Extra-Axial Chordomas: An Integrative Analysis of 86 Cases and Comparison With Axial Chordomas

BACKGROUND

Currently, clinical characteristics and prognostic factors of extra-axial chordoma (EAC) remain poorly understood.

OBJECTIVE

To characterize clinicopathological characteristics in a large EAC cohort and investigate their correlation with survival. We also attempted to compare these outcomes with axial chordoma (AC).

METHODS

Medline and Embase searches (from inception to February 28, 2018) were conducted to identify eligible studies as per predefined criteria. The local database at our center was also retrospectively reviewed to include additional patients.

RESULTS

Forty-three studies from the literature and 86 patients from our local institute were identified, resulting in a total of 86 EAC patients and 75 AC patients for analysis. Overall, EAC had similar characteristics to AC, except for having higher CAM5.2 expression, common lobular growth pattern, and better prognosis. Whereas wide surgical resection was consistently associated with favorable survival in both EAC and AC cohorts on univariate analyses, most parameters showed differential prognostic implications between the 2 groups. Significant prognostic factors for local recurrence-free survival on multivariate analysis included type of surgery in both cohorts and tumor Brachyury expression and adjuvant radiotherapy in AC cohort. Multivariate analysis of overall survival demonstrated that type of surgery, tumor Brachyury expression, and duration of symptoms were significant predictors in the AC cohort, whereas none of the analyzed parameters were predictive of overall survival for the EAC group.

CONCLUSION

These data suggest potentially distinct biological behaviors between EAC and AC and may provide useful information to better understand the prognostic characteristics and improve the outcome prediction of EAC patients.

B7-1 drives TGF-β stimulated pancreatic carcinoma cell migration and expression of EMT target genes

B7-1 proteins are routinely expressed on the surface of antigen presenting cells (APC) and within the innate immune system. They function to establish a biologically optimal and dynamic balance between immune activation and inhibition or self-tolerance. Interactions between B7-1 and its receptors, which include CD28, CTLA4 and PD-L1, contribute to both stimulatory as well as inhibitory or homeostatic regulation. In the current study, we investigated whether the tumor-promoting actions of transforming growth factor beta (TGF-β) disrupted this equilibrium in pancreatic cancer to promote malignant progression and an enhanced means to evade immune detection. The data show that B7-1 is (i) upregulated following treatment of pancreatic carcinoma cells with TGF-β; (ii) induced by TGF-β via both Smad2/3-dependent and independent pathways; (iii) required for pancreatic tumor cell in vitro migration/invasion; and (iv) necessary for TGF-β regulated epithelial-mesenchymal transition (EMT) through induction of Snail family members. Results from the proposed studies provide valuable insights into mechanisms whereby TGF-β regulates both the innate immune response and intrinsic properties of pancreatic tumor growth.

Intermediate Filaments as Effectors of Cancer Development and Metastasis: A Focus on Keratins, Vimentin, and Nestin

Intermediate filament (IF) proteins make up the largest family of cytoskeletal proteins in metazoans, and are traditionally known for their roles in fostering structural integrity in cells and tissues. Remarkably, individual IF genes are tightly regulated in a fashion that reflects the type of tissue, its developmental and differentiation stages, and biological context. In cancer, IF proteins serve as diagnostic markers, as tumor cells partially retain their original signature expression of IF proteins. However, there are also characteristic alterations in IF gene expression and protein regulation. The use of high throughput analytics suggests that tumor-associated alterations in IF gene expression have prognostic value. Parallel research is also showing that IF proteins directly and significantly impact several key cellular properties, including proliferation, death, migration, and invasiveness, with a demonstrated impact on the development, progression, and characteristics of various tumors. In this review, we draw from recent studies focused on three IF proteins most associated with cancer (keratins, vimentin, and nestin) to highlight how several “hallmarks of cancer” described by Hanahan and Weinberg are impacted by IF proteins. The evidence already in hand establishes that IF proteins function beyond their classical roles as markers and serve as effectors of tumorigenesis.

BRAFV600E-induced KRT19 expression in thyroid cancer promotes lymph node metastasis via EMT

Keratin 19 (KRT19) is a type I cytokeratin that serves an important role in multiple types of cancer; however, little is known regarding its role in thyroid cancer. Therefore, the aim of the current study was to investigate the role of KRT19 in thyroid cancer. Using The Cancer Genome Atlas database, the expression and clinical significance of KRT19 in thyroid cancer tissues were investigated. The effect of KRT19 in thyroid cancer cell lines was also investigated in vitro. The results demonstrated that KRT19 expression was higher in thyroid cancer when compared with normal thyroid tissues, and was associated with lymph node metastasis, tumor stage and tumor-node-metastasis stage. Knockdown of KRT19 inhibited the proliferation and migration of thyroid cancer cell lines. In addition, increased KRT19 expression was observed only in tumors harboring the B-Raf Proto-Oncogene, Serine/Threonine Kinase (BRAF)^V600E mutation, and BRAF^V600E overexpression induced KRT19 expression. Furthermore, KRT19 exerted its phenotype via promoting epithelial-mesenchymal transition (EMT). In conclusion, the results of the current study suggest that BRAF^V600E-induced KRT19 expression may promote thyroid cancer metastasis via EMT.

Pancreatic Neuroendocrine Tumor in a Young Child With Tuberous Sclerosis Complex 1

Pancreatic neuroendocrine tumors (PNETs) occur in the context of tuberous sclerosis complex (TSC). To date, PNETs in association with TSC have been described almost exclusively in adults and in the context of TSC2. We present the evaluation of a PNET in a young child with TSC1. A 3-year, 6-month-old boy with TSC1 was found on surveillance to have a small pancreatic lesion measuring 0.4 cm on magnetic resonance imaging (MRI). The lesion showed interval enlargement to 1 cm on serial MRI studies during the ensuing 16 weeks. Endocrine laboratory tests did not reveal a functional tumor. The patient underwent enucleation of the pancreatic lesion. Microscopic examination defined a well-differentiated PNET, grade II/intermediate grade with a mitotic rate of two mitotic figures per 10 high-powered field and Ki-67 proliferation index of ∼15%. The tumor was positive for the TSC1 gene mutation. The patient was free of tumor recurrence at the 5-year follow-up examination, as determined by endocrine surveillance and annual MRI of the abdomen. In the reported data, PNET in patients with TSC has been primarily reported in association with TSC2. Our case demonstrates that patients with TSC1 can develop PNETs, even at an early age. The international TSC consensus group 2012 recommendation was to obtain MRI of the abdomen every 1 to 3 years for surveillance of renal angiomyolipomas and renal cystic disease. It might be beneficial to add a pancreatic protocol to the surveillance guidelines to evaluate for PNET.

Survival and prognostic factors analysis of 151 intestinal and pancreatic neuroendocrine tumors: a single center experience

Background

Intestinal and pancreatic neuroendocrine tumors (IP-NETs) are rare tumors with heterogeneous outcomes. The aim of our study was to determine the clinical, therapeutic and pathological factors which impact the overall survival (OS) in IP-NETs.

Methods

All the patients diagnosed with IP-NETs at the Nantes University Hospital between October 1994 and October 2013 were retrospectively analysed. Patients with MEN-1 (Type 1 Multiple Endocrine Neoplasia) or Von Hippel-Lindau syndrome were excluded. Additionally, a prospective analysis of tumor grade (mitotic index and Ki67 index) was performed on tumor samples. OS was evaluated by Kaplan-Meier method and prognostic factors by log-rank test and Cox model.

Results

The study included 151 patients. Median age was 60 (range, 14-81). Primary tumor was pancreatic in 86 patients (56.95%) and intestinal in 65 patients (43.05%). Tumors were metastatic (synchronous or metachronous) in 72 patients (47.7%). The median OS was 157 months. For all IP-NETs, age >65 years (P<0.0001), Ki67 >5% (P=0.03), synchronous metastases (P=0.016), primary tumor size >25 mm (P=0.03) and emergency surgery (P=0.007) were independent poor prognostic factors.

Conclusions

In this large series of patients with IP-NET, age >65 years, Ki67 >5%, primary tumor size >25 mm, synchronous metastases and emergency surgery for acute complications have been identified as independent poor prognostic factors.

Diagnostic Value of TROP-2 and CK19 Expression in Papillary Thyroid Carcinoma in Both Surgical and Cytological Specimens

Papillary thyroid carcinoma (PTC) represents the most common primary malignant thyroid tumor and its diagnosis is dependent on the presence of classic nuclear features that are sometimes seen in some non-neoplastic and benign lesions. Several immunohistochemical markers are used individually or in combination to help in differentiation of PTC from mimickers. The aim of the current study was to assess the diagnostic value of TROP-2 and cytokeratin 19 (CK19) expression in differentiating PTC from other mimickers both singly and in combination. The current study was carried out on 77 surgical specimens (56 PTC and 21 non-neoplastic cases) and 12 cytological specimens (4 THY2, 6 THY4, and 2 THY5). TROP-2 was negative in 81% of non-neoplastic surgical specimens and in 100% of THY2 cytological specimens while it was positive in 71.4% of PTC surgical specimens and 100% of THY4/THY5 cytological specimens. Sensitivity and specificity of TROP-2 positive expression for diagnosis of PTC in surgical specimens reached 71% and 81%, respectively, while it reached 100% for both in cytological specimens. Cytokeratin 19 showed positive expression in 85.7% of non-neoplastic surgical specimens and in 92.9% of PTC surgical specimens. Cytokeratin 19 showed negative expression in 75% of Thy2 cases while it was positive in all studied Thy4 and Thy5 cases. Sensitivity and specificity of CK19 total estimated score for diagnosis of PTC in surgical specimens were 78.6% and 66.7%, respectively, while it reached 100% and 75% in cytological specimens. Positive TROP-2 and CK19 expression in PTC were associated with lymph node metastasis. TROP-2 is a specific rather than sensitive marker while CK19 is a sensitive rather than specific marker in differentiating PTC from other mimickers in surgical specimens. The diagnostic validity of both markers was superior in diagnosis of classic PTC compared with follicular variant PTC. TROP-2 is superior to CK19 in diagnosis of PTC in cytological specimens. Both TROP-2 and CK19 could be used preoperatively in adjunct to hematoxylin and eosin for more confident diagnosis of thyroid cytology and along with radiology as predictors of lymph node metastasis.