Prognostic significance of cell proliferation in mucoepidermoid carcinomas of the salivary gland: clinicopathological study using MIB 1 antibody in paraffin sections

Mucoepidermoid carcinomas of salivary gland origin have an uncertain clinical course not directly predictable by histomorphology. The MIB 1 antibody, which detects Ki-67 antigen in formalin-fixed, paraffin-embedded tissues, was used to study cell proliferation in these tumors. An MIB 1 index was developed to express the percentage of MIB 1-positive proliferating cells, and the results were compared with histomorphological tumor grade and clinical outcome. All patients with MIB 1 indices lower than 10% in their primary tumors had a favorable clinical outcome. Most patients with MIB 1 indices higher than 10% developed a recurrent or metastasizing disease. All patients who died of their tumor or who had persistent tumor had MIB 1 indices higher than 10%. Thus, the MIB 1 index defines two virtually nonoverlapping forms of the disease, an indolent one and an aggressive one. Cell proliferation in mucoepidermoid carcinomas, assessed with the MIB 1 antibody, thus represents a significant prognostic factor for improving the accuracy of conventional histological grading.

Salivary gland cancer: ESMO-European Reference Network on Rare Adult Solid Cancers (EURACAN) Clinical Practice Guideline for diagnosis, treatment and follow-up

•This ESMO–EURACAN Clinical Practice Guideline provides key recommendations for managing salivary gland cancer. •The guideline covers clinical and pathological diagnosis, staging and risk assessment, treatment and follow-up. •Treatment algorithms for parotid, submandibular, sublingual and minor salivary gland cancer are provided. •The author group encompasses a multidisciplinary group of experts from different institutions and countries in Europe. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

Cell proliferation correlates with prognosis in acinic cell carcinomas of salivary gland origin. Immunohistochemical study of 30 cases using the MIB 1 antibody in formalin-fixed paraffin sections

Immunohistochemical staining with the MIB 1 antibody was used to assess cell proliferation in 30 cases of acinic cell carcinoma of salivary glands. Until now, no prognostic factors have been available for these rare tumours. The MIB 1 monoclonal antibody recognizes the Ki-67 antigen in formalin-fixed, paraffin-embedded tissues. A MIB 1 index was developed as a means of expressing the percentage of MIB 1-positive tumour cell nuclei, and the tumours were scored without prior information of clinical behaviour. The staining results were then compared with the clinical outcome of the patients. All eight patients who developed tumour recurrences had MIB 1 indices higher than 5 per cent. Tumour recurrences could be predicted even in cases of bland morphology and low mitotic rate. Three patients died of their recurrent tumours, and had MIB 1 indices of 56.2, 12.7, 7.8 per cent in their primary tumours. Five of seven patients with MIB 1 indices higher than 10 per cent had unfavourable outcomes. None of the 17 patients with MIB 1 indices lower than 5 per cent developed recurrences during follow-up periods up to 30 years. The present results indicate that MIB 1 staining appears to be a significant prognostic factor in acinic cell carcinomas of salivary gland origin.

Salivary acinic cell carcinoma: reappraisal and update

Epidemiologic and clinicopathologic features, therapeutic strategies, and prognosis for acinic cell carcinoma of the major and minor salivary glands are critically reviewed. We explore histopathologic, histochemical, electron microscopic and immunohistochemical aspects and discuss histologic grading, histogenesis, animal models, and genetic events. In the context of possible diagnostic difficulties, the relationship to mammary analog secretory carcinoma is probed and a classification is suggested. Areas of controversy or uncertainty, which may benefit from further investigations, are also highlighted.

Clinicopathologic and molecular characterization of mammary analogue secretory carcinoma of salivary gland origin

BACKGROUND

Mammary analogue secretory carcinoma (MASC) is a newly recognized salivary gland tumor that harbors a characteristic balanced chromosomal translocation t (12; 15) (p13; q25) resulting in an ETV6-NTRK3 fusion gene.

METHODS

Retrospective study of 111 salivary gland carcinomas revealed 37 cases with secretory features and growth patterns resembling secretory carcinoma of breast. These 37 cases were originally diagnosed as acinic cell carcinoma, adenocarcinoma not otherwise specified and cystadenocarcinoma. Positive immunostaining for S-100 protein and mammaglobin, followed by detection of ETV6 gene rearrangement by FISH and/or ETV6-NTRK3 fusion transcript by RT-PCR were used to identify MASCs.

RESULTS

In the cohort of 37 salivary carcinomas with secretory features we have identified 10 cases of MASC. All 10 MASCs were positive for mammaglobin, S-100 protein and SOX10, while staining for DOG1 and p63 protein were mostly absent. In 7/10 cases, both FISH and RT-PCR were positive while three remaining cases showed break of ETV6 gene by FISH analysis and the RT-PCR was negative. Clinical follow-up data were obtained in 6 out of 10 patients with MASC. In 3 patients cervical lymph node metastases developed, one patient with high grade transformed MASC died with multiple distant bone metastases, and local recurrence was observed in three patients.

CONCLUSION

Our clinicopathological data are in keeping with previous studies; in most cases, MASC is a low-grade malignancy with overall favorable prognosis. In rare cases, however, MASC with high-grade transformation may behave aggressively, and these patients could benefit from targeted biological treatment using tyrosine kinase inhibitors.

Sinonasal tubulopapillary low-grade adenocarcinoma. Histopathological, immunohistochemical and ultrastructural features of poorly recognised entity

We present the clinicopathological, histological and immunohistochemical findings of six cases of primary tubulopapillary low-grade adenocarcinoma of the sinonasal tract with ultrastructural examination in one case. Due to its unique features, we believe that primary tubulopapillary low-grade adenocarcinoma of the sinonasal tract represents a tumour entity different from any tumours generally recognised in the sinonasal region. Our cases had an equal sex incidence, with an age range of 44-76 years. The tumour has a tendency to recur, but none of our six patients developed metastases. We feel that it is important to separate this tumour entity from other types of sinonasal adenocarcinomas that exhibit a papillary growth pattern, as they frequently pursue a much more aggressive clinical course than the tumours in this study.

Analysis of collagen isotypes in crystalloid structures of salivary gland tumors

Extracellular collagenous crystalloids (CCs) have been reported in salivary gland tumors. To study the occurrence and characteristics of these structures we reviewed 230 pleomorphic adenomas and myoepitheliomas of both major and minor salivary glands. Twelve of these cases contained crystalloids composed of radially arranged collagen fibers. However, no CCs were found in 124 malignant salivary gland tumors of different types. We show that CCs contain types I and III collagen but not type II, IV, or VI collagen. Moreover, cells surrounding CCs expressed the basement membrane molecules laminin and type IV collagen. These cells also showed other immunohistochemical features typical of myoepithelial cells.

Basement membrane proteins in salivary gland tumours. Distribution of type IV collagen and laminin

Immunohistochemical localization of type IV collagen and laminin in normal salivary glands and in salivary gland tumours of various types was studied using rabbit antisera. In normal salivary glands, type IV collagen and laminin were co-localized in basement membranes surrounding acini, ducts, fat cells and peripheral nerves. In salivary gland tumours, three main patterns of co-expression of these basement membrane proteins were distinguished. Linear basement membrane-like staining was detected in duct-cell-derived benign salivary gland tumours and in acinic cell carcinomas. In invasive lesions, however, these basement membrane proteins were distributed in an irregular, interrupted manner, and in many cases they were completely absent. Both benign and malignant salivary gland tumours which have a prominent myoepithelial cell component display a particular deposition of basement membrane molecules adjacent to the modified myoepithelial cells, and at the margins of extracellular matrix deposits within these tumours.

Human papillomavirus and Epstein-Barr virus in nasopharyngeal carcinoma in a non-endemic eastern european population

Nasopharyngeal carcinoma (NPC) is a rare malignancy in the Czech Republic and Slovakia, with the standardized incidence rate of < 1:100000 person-years. Viral status of NPC in these non-endemic Eastern European regions is currently unknown. In a retrospective study, we evaluated the presence of EBV and HPV in 62 NPC cases. EBV status was determined by the use of in situ hybridization (ISH) for EBV encoded small RNA 1 (EBER1). HPV status was examined with p16 immunohistochemistry, DNA ISH and DNA polymerase chain reaction. Sixty-one studied cases showed non-keratinizing morphology and one was keratinizing squamous cell carcinoma. Only one NPC with non-keratinizing morphology was scored as p16-positive (nuclear and cytoplasmic staining ≥ 70% of tumor cells). This case was positive for high-risk HPV by ISH and the DNA PCR confirmed the presence of HPV18 type. At the same time, this case was found negative for EBV. Remaining sixty-one cases that were scored as p16-negative were all found HPV-negative by ISH and the DNA PCR. EBV was detected in 85.5% (53/62) of cases and 9 cases were EBV-negative, including the case of keratinizing NPC. In contrast with previous reports on the prevalence of EBV-positivity in Caucasian patients with NPC, the majority of patients coming from this non-endemic region show EBV-positivity; therefore, they may be candidates for novel EBV-targeting therapies. Conversely, HPV-positive NPC is very rare and HPV does not seem to play a significant role in the etiopathogenesis of NPC in these Eastern European populations.

Cystic hypersecretory carcinoma: rare and poorly recognized variant of intraductal carcinoma of the breast. Report of five cases

AIMS

To report five cases of a rare variant of intraductal carcinoma of the breast, so-called cystic hypersecretory carcinoma. The clinical and pathological characteristics of the lesion are described, along with a review of the literature.

METHODS AND RESULTS

The patients were females aged between 53 and 78 years (average 66.8 years). The size of the lesions ranged between 70 and 80 mm in largest dimension. In two cases, the development of high-grade invasive ductal carcinoma was observed; in one additional case there was recurrence of high-grade in-situ carcinoma after 3 years. This emphasizes the importance of correct diagnosis of this potentially aggressive lesion. Strong over-expression of HER-2/neu protein was observed in three cases, including the two with an invasive component. Protein p53 was variably positive in all cases. Steroid receptor immunohistochemistry yielded variable results with only one case being positive for both oestrogen and progesterone receptors. Interestingly, in most cases (4/5) staining for androgen receptors was observed.

CONCLUSIONS

Cystic hypersecretory ductal carcinoma of the breast is a rare distinctive variant of ductal carcinoma in situ. It has the potential for invasive growth and the development of metastases.

Significance of transcriptionally-active high-risk human papillomavirus in sinonasal squamous cell carcinoma: Case series and a meta-analysis

Sinonasal cancers represent a highly heterogeneous group of head and neck cancers, for which etiological and prognostic significance of high-risk human papillomavirus (HPV) infections has not yet been conclusively established. We investigated the presence of transcriptionally-active high-risk HPV in a series of 34 sinonasal squamous cell cancer (SNSCC) cases and evaluated the effect of transcriptionally-active HPV on the overall survival. In addition, we performed a meta-analysis of previously published studies, including this study, to summarize the prevalence of HPV positivity across histological subtypes of SNSCC. The presence of transcriptionally-active HPV was detected by HPV mRNA using the polymerase chain reaction (PCR) or in situ hybridization (ISH). p16 expression was evaluated as a surrogate marker for transcriptionally-active HPV infection by immunohistochemistry (IHC), the presence of high-risk HPV DNA was tested by PCR and the HPV genotypes were determined by sequencing of PCR amplicons. Transcriptionally-active HPV infections were found in ~25% of the SNSCC cases. The role of HPV infection in keratinizing SNSCC may be higher than previously reported (~32% in our study vs. ~0-6.3% in all other studies). Patients with transcriptionally-active HPV-positive SNSCCs were more likely to be diagnosed at earlier stages (p<0.05) and displayed better mean overall survival, although the difference between HPV-positive and HPV-negative groups was not statistically significant. In contrast to other non-oropharyngeal squamous cell carcinomas (non-OPSCCs) of the head and neck, in SNSCCs, p16/IHC and p16/IHC+HPV DNA displayed high specificity as surrogate markers of transcriptionally-active HPV infections. However, p16/IHC may have significantly lower sensitivity as a surrogate marker of transcriptionally-active HPV in SNSCCs compared to OPSCCs. Furthermore, in our group of SNSCCs, all cases positive for high-risk HPV DNA by PCR were also transcriptionally-active (causative) infections with positive HPV mRNA by ISH. Our results imply a possible different role of HPV-mediated carcinogenesis of squamous cell epithelium in oropharyngeal and sinonasal sites with the latter displaying a lower proportion of causative HPV infections; nevertheless, most cases positive for high-risk HPV DNA, p16/IHC or combination thereof were also found positive for transcriptionally-active HPV. The prognostic significance of HPV status in SNSCCs remains inconclusive and future studies should investigate the presence of transcriptionally-active HPV by direct HPV testing.

Basaloid squamous carcinoma with collagenous spherules and crystalloids

A case of basaloid squamous carcinoma with unusual spheruloid and crystalloid structures occurring in the left submandibular region of 45-year-old woman is described. The tumor displayed features typical of basaloid squamous carcinoma. In addition, there were numerous eosinophilic deposits of extracellular matrix, which reacted positively on periodic acid-Schiff staining. These deposits were arranged in lamellar concentric and radial patterns. Ultrastructurally, they were composed of extracellular matrix components rich in basement membrane substances. A few banded collagen fibers were found in some deposits. Basaloid squamous carcinoma is an aggressive variant of squamous cell carcinoma, with a predilection to the head and neck region, that needs to be distinguished from other tumors that may contain abundant deposits of basement membrane rich material, especially from adenoid cystic carcinoma.

Role of ancillary techniques in profiling unclassified laryngeal malignancies

Laryngeal biopsies, contrary to biopsies from many other sites of the body, very often contain minute amounts of tumour tissue that may consist of morphologically undifferentiated tumour only. In haematoxylin- and eosin-stained sections, there may be no indicative features of what specific tumour entity that is present. In the larynx, particularly small round cell neoplasms, primary or metastatic, often cause a diagnostic dilemma and where an incorrect diagnosis can induce substantial clinical consequences for the patient (e.g., primary neuroendocrine carcinomas vs metastatic variants, certain sarcomas). If sufficient/representative material has been obtained, the application of immunohistochemistry and/or molecular techniques should in virtually every case reveal the true nature of the malignancy. In cases with sparse amount of material, and therefore a limited number of sections to be cut, a careful and thoughtful stepwise approach is necessary to ascertain a reliable diagnosis, or at least guide the clinician to the most likely diagnoses. With today's advanced and widely available technology with an abundance of markers to discriminate different tumours, the use of the term "undifferentiated" should be largely unnecessary. In the exceptional, and indeed exceedingly rare cases, when a classification is not possible, even after repeat biopsy, we suggest that the laryngeal neoplasm is better termed "unclassified malignant neoplasm" rather than "undifferentiated malignant neoplasm".

The importance of prognostic factors in premenopausal women with breast cancer

BACKGROUND

Basic conventional prognostic factors for breast cancer include the age of the patient, tumor grade, regional lymph nodes status, and estrogen (ER) and progesterone (PR) receptor status. Positivity of the HER2 receptor (c-erbB-2) seems to be a new prognostic and predictive factor. Prognostic factors seem to be more important in the high-risk group of the premenopausal females. We evaluated individual prognostic factors (age, histology, TNM classification, ER, PR, CA 15-3, CEA, HER2) and their impact on disease-free survival (DFS) and overall survival (OS) during the 5-year follow-up period.

PATIENTS AND METHODS

Forty-two patients were monitored after standard oncology treatment for a period of at least 5 years. The statistical significance of the individual prognostic parameters was evaluated in relationship to the time to progression (DFS and OS).

RESULTS

The following were evaluated as statistically significant prognostic parameters for DFS: PR positivity (p = 0.0036), proliferative marker MIB1 (p = 0.0108), pre-operative level of CA 15-3 (p = 0.0425), ER negativity (p = 0.0507). The following were evaluated as statistically significant prognostic parameters for OS: PR positivity (p = 0.0003), MIB1 (p = 0.0005), ER (p = 0.0440), pre-operative level of CEA (p = 0.0495). Positivity of immunohistochemically performed test of c-erbB-2 was not statistically significant for DFS os OS (p = 0.6361 and 0.9323, respectively).

CONCLUSION

The statistically significant prognostic importance of the levels of tumor markers CA 15-3 and CEA for prognosis in breast cancer of premenopausal females was proven. So far, these factors have been underestimated. The prognostic parameters of ER, PR and MIB1 were statistically significant. While no prognostic importance was confirmed for c-erbB-2 positivity; this factor cannot be evaluated in premenopausal females separately from the other prognostic factors due to the predictive value in relation to the adjuvant therapy (patients with HER+, ER+, PR-).

Extracellular collagenous spherules in salivary gland tumors. Immunohistochemical analysis of laminin and various types of collagen

Collagenous spherulosis is a benign breast lesion involving lobular acini and ductules and containing eosinophilic spherules measuring up to 100 microns in diameter. We present an immunohistochemical analysis of similar collagen-rich spherules that are also found in salivary gland tumors. These collagenous spherules contain varying amounts of acidic mucins, elastin, basement membrane proteins including type IV collagen and laminin, and considerable amounts of interstitial collagen types I and III. Types II and VI collagen were not detected in collagenous spherules of salivary gland tumors. The cells surrounding these collagenous spherules expressed muscle actin, S100 protein, vimentin, and cytokeratins 8, 18, and 19, indicating that these cells have myoepithelial characteristics.