Michela Manzotti

Review Article: Pulmonary Sarcomatoid Carcinomas: A Practical Overview

Pulmonary sarcomatoid carcinomas (PSCs) are currently defined as poorly differentiated non-small-cell carcinomas containing a component with sarcoma or sarcoma-like (spindle and/or giant cell) features. They consist of 5 major histological variants, namely pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma, and pulmonary blastoma. The segregation of PSCs into a distinct clinicopathologic entity seems justified on the basis of morphologic, behavioral, and genotypic/phenotypic attributes. As a group, PSCs generally run an aggressive clinical course and may cause major difficulties in the differential diagnosis with other primary and secondary malignancies of the lung. At present, PSCs are believed to represent a family of carcinomas “in transition,” in which diverse pathways of clonal evolution account for histological differences of a common ancestor lesion. The sarcomatous or sarcomatoid component of these tumors is thought to derive from carcinoma cells during the progression of carcinogenesis through the activation of an epithelial—mesenchymal transition program leading to sarcomatous transformation or metaplasia (conversion paradigm). Conceivably, targeting the epithelial—mesenchymal transition program could become a valid therapeutic strategy for these life-threatening tumors, whose sensitivity to current medical manipulation is disappointing.

Activity of epidermal growth factor receptor-tyrosine kinase inhibitors in patients with non-small cell lung cancer harboring rare epidermal growth factor receptor mutations.

Introduction: Mutations of the epidermal growth factor receptor (EGFR) have been proven to predict activity of the EGFR-tyrosine kinase inhibitors (EGFR-TKI), gefitinib and erlotinib. Although the “common” EGFR mutations, such as the L858R point mutation in exon 21 and the in-frame deletional mutation in exon 19, have been definitively associated with response to EGFR-TKIs, the correlation with response to treatment for many other rarer mutations is still unclear. In this study, we report the results of treating patients with advanced non-small cell lung cancer harboring rare EGFR mutations treated with EGFR-TKIs. Methods: The frequency of rare mutations has been investigated in 681 cases of non-small cell lung cancer screened between 2006 and 2010. Mutations in exons 18 and 20, uncommon mutations in exons 19 and 21, and/or the presence of different mutations in a single tumor (complex mutations) were considered rare. Results: EGFR mutations were detected in 99 tumors (14.5%). Eighteen cases carried rare mutations, and 10 of these patients were treated with erlotinib or gefitinib. The clinical outcome was described case by case with references to the literature. Of note, we found two EGFR mutations never identified before and one of unknown response to EGFR-TKIs. Conclusions: Gefitinib and erlotinib have different antitumor activity according to the type of the EGFR mutation borne. Report of cases harboring rare mutations can support the decision-making process in this subset of patients.

Reverse transcription-polymerase chain reaction assay for multiple mRNA markers in the detection of breast cancer metastases in sentinel lymph nodes.

The identification of specific tumor mRNA markers by reverse transcription‐polymerase chain reaction might be a valuable diagnostic adjunct for the detection of breast cancer metastases in axillary sentinel lymph nodes (SLNs). In this study we have compared the diagnostic accuracy of an extensive histopathologic examination of 146 SLNs from 123 breast carcinoma patients with that of the evaluation of 5 mRNA markers. When analyzed individually, none of the different markers attained a sensitivity higher than 77.8%, and the general concordance with the histopathologic findings ranged from 78.8 to 83.6%. In a multiple‐marker assay, taking into account the expression of at least 1 of the 5 tumor markers, the sensitivity of the test rose to 95.6%, with a specificity of 66.3% and a general concordance with the histopathologic status of 75.3%. Finally, when at least 2 of 3 markers (maspin, cytokeratin 19 and mammaglobin 1) were expressed, the concordance with either SLN or axillary lymph node status was highest (88.4% and 84.6%, respectively). The high prevalence of positive reverse transcription‐polymerase chain reaction assays in histologically uninvolved SLNs, however, may hamper extensive application of these techniques in the clinical setting.

The transactivating isoforms of p63 are overexpressed in high-grade follicular lymphomas independent of the occurrence of p63 gene amplification

p63 is a p53‐related gene mapping to 3q28 that codes for multiple mRNA transcripts with (TA‐p63) or without (ΔN‐p63) transactivating effects on genes that promote cell differentiation and apoptosis. We analysed p63 alterations by immunohistochemistry, quantitative real‐time RT‐PCR and FISH in a series of 45 follicular lymphomas (FL). None of the tumours showed immunoreactivity for the p40 antibody, which recognizes only the truncated isoforms of p63, or ΔN‐p63 mRNA expression. Immunoreactivity for the 4A4 antibody, which recognizes both the transactivating and the truncated p63 isoforms, was found in 5 ± 5.5%, 6.85 ± 4.88% and 33.2 ± 22.31% of grade I, II and III FL cells, respectively (p < 0.0001). Quantitative RT‐PCR analysis showed that all cases but one had TA‐p63 mRNA levels higher than non‐neoplastic lymphocytes, and that TA‐p63 mRNA expression correlated significantly (r = 0.9194, p < 0.0001) with the prevalence of p63 immunoreactivity. FISH extra signals for the p63 gene were found in seven (23.3%) of the 30 cases analysed (0/6 grade I, 2/15 grade II and 5/9 grade III; p = 0.01937). Further hybridizations showed a pattern highly suggestive of chromosome 3 polysomy in six cases. One of these cases also bore extra copies of the p63 and bcl‐6 genes. Co‐localization of p63 and IgH signals was found in one case. No association between the prevalence of p63 immunoreactivity and extra p63 gene signals was detectable when the cases were dichotomized according to a p63 immunoreactivity threshold of 10%. Our data suggest that TA‐p63 is overexpressed in high‐grade FL, possibly independent of the occurrence of gene abnormalities, and that it may be involved in the highly complex mechanism of regulation of apoptosis of FL cells. Copyright

Pathologic and molecular features of screening low-dose computed tomography (LDCT)-detected lung cancer : A baseline and 2-year repeat study

Detailed studies on the pathologic and molecular features of low-dose computed tomography (LDCT)-detected carcinomas and comparison with unscreened tumors are still lacking. We evaluated the histopathologic features of 89 LDCT-detected lung cancers resected between 2004 and 2006. These tumors occurred within a cohort of 5202 volunteers undergoing annual LDCT, aged > or =50 years, and with a minimum 20 pack-year index. In adenocarcinomas, central scar diameter, invasion foci size and K-ras mutations were also assessed. The results were compared with those of 89 consecutive lung carcinomas matched for confounding factors (sex, smoking habit), selected from group of 363 consecutive clinically worked-up lung cancer, surgically resected in the same period and at the same Institution. The tumors were diagnosed in 63 males and 26 females (range 50-79 years), 55 of which diagnosed at the baseline (1.05%) and 34 (including 10 repeat cancers) operated after work-up during the second year (0.72%). LDCT-detected tumors showed high resectability rate (89%), earlier stage (63%) and prevalence of adenocarcinoma nodules (72%), most often of the mixed subtype, in comparison with unscreened tumors. A similar prevalence of K-ras mutations was found in both screened and unscreened adenocarcinomas. Repeat cancers were found in 10 screened patients, and were predominantly stage I adenocarcinomas of mixed subtype exhibiting smaller dimension but greater central scar diameter and stromal invasion size in comparison with the other second-year, slower-growing adenocarcinomas. Multiple tumor nodules were identified in 10 patients exclusively at the baseline, were mostly mixed adenocarcinomas and differed in their K-ras mutation profile. Screening-detected lung cancers shared most of the histologic features of fully malignant tumors, in addition to a similar prevalence of K-ras mutations, despite their earlier detection and less advanced clinical stage. Repeat cancers are potentially aggressive tumors. K-ras mutation analysis supports the impression that multifocal tumors at baseline are separate synchronous primaries.

Methylation of O 6-methylguanine-DNA methyltransferase (MGMT) promoter gene in triple-negative breast cancer patients

Triple-negative breast cancers are characterized by the triple-negative (ER/PgR/Her2 negative) phenotype, are frequently associated with BRCA gene mutation, and are not candidate to currently available endocrine and HER2-targeted treatments. MGMT is involved in direct DNA repair exerted by cleavage of mutagenic alkyl adducts within DNA, and its epigenetic silencing confers susceptibility to DNA-damaging alkylating agents in glioblastomas and melanomas. MGMT methylation status has not been extensively investigated in breast cancer patients. The goal of our study was to evaluate the MGMT methylation status in TNBC patients, for most of which BRCA1 and BRCA2 mutational status was known. We evaluated MGMT methylation status by methylation-specific PCR (MSP) in formalin-fixed and paraffin-embedded tumor specimens from 92 TNBC patients. By using the GelDoc system (Biorad) software, the cases were further classified as follows: 0 (absence of methylated signal), 1 (prevalence of unmethylated signal, U/M ratio >1), 2 (prevalence of methylated signal, U/M ratio <1), and 3 (absence of unmethylated signal). MSP products were obtained in 89 (96.7%) of the cases. Overall, 15 (16.9%) cases were classified as 0, 33 (37.1%) cases as 1, 39 (43.8%) cases as 2, and 2 (2.2%) cases as 3. The 48 cases classified as 0 and 1 were considered as MGMT unmethylated, and the 41 cases classified as 2 and 3 as MGMT methylated. The prevalence of MGMT methylation in patients with BRCA1 mutated, wild-type, and unknown was 30.2% (13/43), 63.6% (14/22), and 58.3% (14/24), respectively. MGMT methylation was unrelated to the main clinical pathological characteristics, with the exception of a weak association with advanced age. In conclusion, our data suggest that in TNBC with wild-type BRCA1, the direct DNA repair system may be frequently (63.6%) silenced by MGMT methylation. The evaluation of the MGMT status could offer a new adjunct in predicting tumor response to alkylating drugs in TNBC patients.

Expression of gemcitabine-and cisplatin-related genes in non-small-cell lung cancer

The aim of this study was to investigate the influence of histology and site of analysis (primary tumor versus lymph node) on the expression of genes involved in gemcitabine and cisplatin activity in non-small-cell lung cancer (NSCLC). Excision repair cross-complementing-1 (ERCC1), human equilibrative nucleoside transporter-1 (hENT1), deoxycytidine kinase (dCK), 5′-nucleotidase (5′-NT), cytidine deaminase (CDA) and ribonucleotide-reductase regulatory subunits (RRM1 and RRM2) were analyzed by quantitative-reverse transcription-PCR in 88 microdissected samples from 69 chemonaive patients. The results showed different patterns of expression for all studied genes, suggesting a possible stratification of the patients. No difference was observed between primary tumor and lymph node metastasis, as well as in adenocarcinoma and squamous-cell carcinoma specimens, while we found a correlation between the CDA-A79C polymorphism and gene expression levels. These data suggest a similar genetic susceptibility to gemcitabine–cisplatin regimens for squamous cell and adenocarcinoma and support the use of both lymph node and primary tumor for the expression profiling of NSCLC.

Erlotinib-Induced Breast Cancer Regression

Objective: To report a case of erlotinib-induced breast cancer regression. Case Summary: A 38-year-old woman developed bilateral locoregional malignant cutaneous lymphangitis following a right subcutaneous mastectomy and 3 months of adjuvant chemotherapy. After several systemic chemotherapy regimens, the lymphangitis worsened rapidly, with progressive skin ulceration. Morphine and dexamethasone were given, with suboptimal pain control. A chemotherapy regimen of gemcitabine and vinorelbine was started. After 2 full-dose administrations, while lymphangitis continued to worsen, erlotinib 150 mg/day was added to the regimen. After 10 weeks of treatment, pain subsided and analgesics were discontinued. Physical examination revealed a partial regression of malignant cutaneous lymphangitis and pulmonary metastases, with resolution of ulceration. Discussion: There has been increased interest in epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors in the treatment of breast cancer. Gefitinib has shown a low level of efficacy, while preliminary clinical data on erlotinib were not conclusive and suggested lack of clinical activity. Molecular analysis of the tumor in our patient revealed a profile predictive of response to EGFR selective inhibitors in some patients with lung cancer. Conclusions: The addition of erlotinib to our patients chemotherapy regimen resulted in antitumor activity in breast cancer in which an activated EGFR pathway was demonstrated. This finding is consistent with available preclinical and clinical data on EGFR tyrosine kinase inhibitors across tumor types and supports the efforts to optimize EGFR selective inhibitors in treating breast cancer and other malignancies.

Angioimmunoblastic T‐cell lymphoma with hyperplastic germinal centres and a high content of EBV‐infected large B‐cells carrying IgH chain gene monoclonal rearrangement

Sir: In June 2001, a 52-year-old man was admitted to a general hospital because of generalized lymphadenopathy associated with fever, sweats, hepato-splenomegaly and a skin rash on the arms. A lymph node biopsy led to the diagnosis of nodal marginal zone B-cell NHL (MZL) with a high content of large cells. He therefore started in July 2002 on systemic combined treatment and maintained a clinical and radiological complete remission until November 2002, when he presented with bilateral cervical lymphadenopathy. He was then referred to our institution, where he had a cervical lymph node biopsy that led to the diagnosis of angioimmunoblastic T-cell non Hodgkin’s lymphoma (AITL), also confirmed after review of the original slides. The patient underwent an intensified chemotherapy program (R-CHOP, ESHAP), obtaining a complete remission (December 2003). Histologically, the typical picture of AITL is a partial effacement of the lymph node architecture and a diffuse infiltrate of polymorphous small to medium-sized lymphocytes with minimal cytological atypia, in a background of reactive lymphocytes, eosinophils, plasma cells, hyperplastic follicular dendritic cells and high endothelial venules. Although one of the most important criteria for the diagnosis of AITL is the lack of germinal centres, the possible occurrence of truly hyperplastic follicles has been described. Moreover, it has been emphasized that 20% of AITL may show a high content of EBV-infected large B-cells. AITL shows TCR monoclonal rearrangement, but approximately 10% of the cases also harbour a monoclonal rearrangement of IgH, possibly related to the presence of expanded EBV-positive clones. In the present case, the lymph node interfollicular zone was expanded by a polymorphous infiltrate consisting of small to medium-sized lymphocytes, eosinophilic granulocytes and plasma cells, intermingled with larger cells isolated or in small aggregates, especially around hyperplastic branching vessels with prominent endothelium. Atypical cells with clear

Molecular features and clinical outcome of lung malignancies in very young people.

INTRODUCTION We describe the clinical features, outcome and incidence of druggable targets of lung cancers in patients ≤ 40 years old. MATERIALS & METHODS Young patients were compared with two other groups (41-64 and ≥ 65 years). Neuroendocrine tumors, adenocarcinoma and non-adenocarcinoma/unspecified non-small-cell lung cancer were analyzed separately. Molecular characteristics of adenocarcinoma were evaluated in a subset of young patients. RESULTS Of 2847 patients with lung cancer, 100 were ≤ 40 years old. The young group contained more women, never-smokers and patients presenting with advanced disease. The commonest tumor in young patients was adenocarcinoma. In total, 19 of 34 young patients with adenocarcinoma had tumors with specific molecular alterations. CONCLUSION Lung cancers in young patients have distinctive features but outcomes similar to those in older patients.