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Klinisch belang van chromosomale translocatie detectie in sarcomen

Judith V.M.G. Bovée, M.D., Ph.D.Department of Pathology

Leiden University Medical Center

WMDP 27-02-09

Classification of bone and soft tissue tumors

• Bone and soft tissue tumours are difficult for pathologists:

• Relatively rare

• >40 entities

• Considerable morphological overlap

• Entities differ widely in treatment and outcome

• Increasing knowledge on genetic background

of tumours

• 2002 WHO classification on bone and soft

tissue tumours

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Diagnosis of soft tissue tumours

• Classifying soft tissue tumours:

• H&E

• Immunohistochemistry

• Molecular diagnostics

• 15-20% of mesenchymal tumours carry translocations

• Only in specific tumour types:

• Ewing sarcoma, myxoid liposarcoma, synoviosarcoma up to 100%

• Absent in osteosarcoma, chondrosarcoma, leiomyosarcoma

Cornerstone of diagnosis

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Translocations in sarcomas

RNA binding DNA binding

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Relevance of translocations in sarcomas

1. Clues about the pathogenesis

2. Classification of sarcomas

3. Usefull in differential diagnosis

4. Detection minimal residual disease?

5. Prediction of outcome?

6. Identify targets for treatment

WMDP 27-02-09

•• Conventional Conventional cytogeneticscytogenetics (fresh tissue)(fresh tissue)

•• RTRT--PCRPCR (frozen tissue, paraffin)(frozen tissue, paraffin)

•• FISHFISH (paraffin material, not (paraffin material, not

decalcified!)decalcified!)

•• ((immunohistochemistryimmunohistochemistry))

Techniques for translocation detection

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Conventional karyotyping

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RT-PCR

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2211 11 der11 der22 22

normal t(11;22)

FISH analysis

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EWSR1EWSR1

FLI1FLI1ERGERGETV1ETV1E1AFE1AFFEVFEVWT1WT1NR4A3NR4A3ATF1ATF1CREB1CREB1GADD153GADD153

Ewing sarcoma / Ewing sarcoma / PNETPNETDesmoplasticDesmoplastic small small round cell round cell tumourtumourExtraskeletalExtraskeletal myxoidmyxoidchondrosarcomachondrosarcomaClear cell sarcomaClear cell sarcomaAngiomatoidAngiomatoid FHFH

MyxoidMyxoid liposarcomaliposarcoma

EWSR1 translocation

Clear cell sarcomaClear cell sarcoma

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•• Ewing sarcoma / PNETEwing sarcoma / PNET

•• RhabdomyosarcomaRhabdomyosarcoma

•• NeuroblastomaNeuroblastoma

•• Non Hodgkin Non Hodgkin LymfomaLymfoma / leukemia/ leukemia

•• Small cell Small cell osteosarcomaosteosarcoma

•• MesenchymalMesenchymal chondrosarcomachondrosarcoma

•• Poorly differentiated Poorly differentiated monofasicmonofasic synoviosarcomasynoviosarcoma

CD99-CD45+

desmin+, MYF4+

osteoid (ALP)cartilage

Small blue round cell tumours; differential diagnosis

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HEHE

CD99CD99

kerker

HEHE

CD99CD99

kerker

25%17%S100

67%8%keratin

66%99%CD99

Synovio(poorly diff)

Ewing

Ewing versus poorly diff synovio: immunohistochemistry

t(11;22)EWSR1 break

t(X;18)SYT break

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Ewing sarcoma

De Alava et al. 2000 J De Alava et al. 2000 J ClinClin OncolOncol 18:20418:204--213213

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De Alava et al. 2000 J Clin Oncol 18:204-213

t(11;22)(q24;q12)

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Ewing sarcoma / PNET

•• White, young persons (80% < 20 White, young persons (80% < 20 jaarjaar))•• Male > femaleMale > female•• In bone and soft tissueIn bone and soft tissue•• Resection, with chemotherapy (Resection, with chemotherapy (inclincl prepre--operative), operative),

radiotherapyradiotherapy•• 5 years survival 50%5 years survival 50%

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•• t(11;22)(q24;q12)t(11;22)(q24;q12) EWSEWS--FLI1FLI1 85%85%

•• t(21;22)(q22;q12)t(21;22)(q22;q12) EWSEWS--ERGERG 10%10%

•• t(7;22)(q22;q12)t(7;22)(q22;q12) EWSEWS--ETV1ETV1

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100%66%CD99

64%25%S100

28%94%Bcl2

15%67%keratine

17%78%EMA

MPNSTSynovialsarcoma

Synoviosarcoma vs. MPNST; immunohistochemistry

t(X;18)SYT break

No specificchanges

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Synovial sarcoma

•• All ages, peak 10All ages, peak 10--35 yrs35 yrs

•• Soft tissue: 60% in lower extremity (Soft tissue: 60% in lower extremity (espesp thigh)thigh)

•• High High gradegrade sarcomasarcoma

•• 5 year survival 50%5 year survival 50%

•• 10 year survival 2010 year survival 20--30%30%

•• MorphologyMorphology

•• BiphasicBiphasic: : spindlespindle and and epithelialepithelial cellcell component component

•• MonophasicMonophasic: : onlyonly spindlespindle ((oror epithelialepithelial) ) cellscells

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Mod Pathol 2000; 13:1253-1263

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•• Association fusion type and morphology:Association fusion type and morphology:

•• MonophasicMonophasic: mostly SYT: mostly SYT--SSX2SSX2

•• Biphasic: mostly SYTBiphasic: mostly SYT--SSX1SSX1

•• SYTSYT--SSX1 associated with early relapseSSX1 associated with early relapse

Ladanyi et al. 2002 Cancer Res

SYT-SSX fusion; prognostic value?

Canter et al. 2008 Clin Cancer Res

• Other groups: no association fusion type and prognosis (n=141 and n=91)

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•• t(16;17)(q22;p13)t(16;17)(q22;p13) CDH11CDH11--USP6USP6•• t(1;17)(p34.1t(1;17)(p34.1––34.3;p13)34.3;p13) TRAP150TRAP150--USP6USP6•• t(3;17)(q21;p13)t(3;17)(q21;p13) ZNF9ZNF9--USP6USP6•• t(9;17)(q22;p13)t(9;17)(q22;p13) OMDOMD--USP6USP6•• t(17;17)(q12;p13)t(17;17)(q12;p13) COL1A1COL1A1--USP6USP6

→→oncogeniconcogenic activationactivation USP6 geneUSP6 gene

Aneurysmal Bone Cyst

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Clear cell sarcoma vs. melanoma

++HMB45

--keratin

++vimentin

++S100

melanomaClear cell sarcoma

t(12;22)t(12;22)EWSR1 breakEWSR1 break

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Clear cell sarcoma vs. melanoma

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•• ““A soft tissue sarcoma of young adults with A soft tissue sarcoma of young adults with melanocyticmelanocytic

differentiation, typically involving tendons and differentiation, typically involving tendons and aponeurosesaponeuroses””

•• Equal maleEqual male--female distribution, 5female distribution, 5--85 years (median 30 yrs.) 85 years (median 30 yrs.)

•• extremitiesextremities

•• Deep locationDeep location

•• Variable outcome, prognosis usually bad, recurrence Variable outcome, prognosis usually bad, recurrence

sometimes after 10 yearssometimes after 10 years

Clear cell sarcoma

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Clear cell sarcoma; genetics

• Clear cell sarcoma

• t(12;22)(q13;q12) ATF1-EWSR1

• t(2;22)(q32;q12) EWSR1-CREB1

• Angiomatoid fibrous histiocytoma

• t(2;22)(q32;q12) EWSR1-CREB1

• t(12;22)(q13;q12) EWSR1-ATF1

• t(12;16)(q13;p11) FUS-ATF1

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Dermatofibrosarcoma protuberans

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Dermatofibrosarcoma Protuberans (DFSP)

• Poorly recognized by clinicians

• Adults 20-50 years, male predominance

• Duration prior to diagnosis > 5 year; long clinical course

• Location: Trunk, head & neck, proximal extremity

• Regarded a superficial low-grade sarcoma

• Significant risk of local recurrence (

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Glivec (STI571)

NucleusSig

nal T

rans

duct

ion

Pat

hway

s A

ctiv

ated

Pre-glivec Glivec

Blocks ATPbinding

Signal TransductionPathways Inhibited

CellmembraneATP binds to

kinase portion of receptor

PDGFRBcr-ablKIT

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Conclusion

Detection of translocations in sarcomas is relevant for:

1. Clues about the pathogenesis

2. Classification of sarcomas

3. Usefull in differential diagnosis

4. Detection minimal residual disease?

5. Prediction of outcome?

6. Identify targets for treatment