Histological subtypes and survival of malignant mesothelioma patients..

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1 Histological subtypes and survival of malignant mesothelioma patients.. Pr Francoise Galateau-Sallé 1,2, 3 N. Le Stang 1,2, P. Astoul 2,3, P. Brochard 2,3, P. Rolland 2,3, JC. Pairon 2,3, G. Launoy 1, E. Imbernon 3 A. Gilg soit Ilg 3, M.Goldberg 2,3 ERI 3 INSERM 1 MESONAT Register 2 PNSM 3

2 Background Survival DMM is a very heterogeneous disease considered to be rapidly fatal with a median survival of less than one year from diagnosis. The worldwide incidence of MM parallels the exploitation and the use of asbestos after a long latency (30 to 40 years-mean latency 40 yrs). The lack of obvious early symptoms means that MM remains undetectable until clinical symptoms manifest and as a result is diagnosed late in disease progression. Although the prognostic is extremely poor in general, individual patients might live for an unexpectedly long time.

3 Background It is notorious that MM is refractory to most of the different treatment modalities available. Nowadays, the search for clinician guidelines in clinical decision is important with the emergence of newer therapies. The use of prognostic factors is hampered by the fact that a good clinical outcome is difficult to predict.

4 Variables are: Age Sex PS Background Prognostic factors for survival Presence of chest pain, dyspnea Duration of symptoms Asbestos exposure Staging of disease [IMIG staging] Histological type Immunohistochemical markers Molecular markers Genomic profile

5 Background Prognostic factors important for survival A list of previous studies on survival of MM patients stated that sex, age, stage, asbestos exposure and treatment were important prognostic factors: Chahinian et al, Ann Intern Med 1982, 96: Ribak & Selikoff Br J ind Med, 1988;45:182 Spirtas et al, Int J Cancer 1988;41: histologically confirmed MM patients ( women and asbestos exposure) Tammilehto Lung Cancer Lung Cancer 1992; 8: Simmon et al, Br J Cancer 1994;69: Br J Cancer 1994;69: But conflicting results were published and were related to single institution trials with small numbers of patients, variable eligibility criteria and statistical methodology used.

6 More recently : Background Factors predictive of survival Curran et al, J Clin Oncol 1998; 16: showed the importance of histologic subtype as a prognostic factor and identified five prognostic factors important for survival of patients PS, WBC count, certainty of the histological diagnosis, gender and histology Edwards et al, Thorax 2000;55: validate the prognostic factors EORTC and CALGB Herndon et al, Chest 1998;113: Univariate: Male sex, older age, weight loss>5kg, poor PS, Low Haem (<14g/l), leucocytosis (>8.3x10), Thrombocytosis (>400x10) Multivariate: Male sex, poor PS, Low Haem, Leucocytosis, non epithelial subtype Baas, Lung Cancer 2007;57: S24-S29 Lung Cancer 2007;57: S24-S29 showed that the discovery of new treatment modalities such as pemetrexed in combination with cisplatin were associated with extremely promising results and stressed the emergency to define poor and good prognosis group.

7 MESONAT registry French population ~60 millions Register all mesothelioma cases from France MESOPATH Repository [ cases & collection of paraffin embedded blocks] College of pathologists -certification of MM cases with a standardized procedure Frozen tissue bank Biological ressources center CRB Inserm n 8 Pilot centre for exposure and aetiology Clinical ascertainment center Coordination center PNSM- NIH INVs Recognition of MM as a compensable occupational disease Multidisciplinary approach

8 MESONAT REGISTRY Design of the study To evaluate the prognostic role of age, sex, time of diagnosis, and asbestos exposure variables The prognostic role of histological subtypes The possible role of Ipox and genomics as a diagnostic, prognostic and predictive tool for outcome and management of MM. In a large population of patients from the Mesonat registry/pnsm

9 Material of the study 2045 cases were retrieved from the files of the MESONAT Registry through repeated inquiries among various sources have been validated according to the standardized procedure of certification of the Mesopath group including H&E and Ipox analysis ( 2 positive /2 negative markers). (Goldberg M, et al,. The French National Mesothelioma Surveillance Program. Occup Environ Med 2006, Feb 2006). Cases were classified as definitively meso or other tumors of mesothelial origin Occupational histories were evaluated by a group of asbestos epidemiological experts using a standardized questionnaire directly with the subject during a faceto-face interview.

10 Material of the study Cases were selected from January 1998 to October 25 th, Clinical features were identified according to a standardized questionnaire Overall survival was calculated from the date of initial biopsy based on the Kaplan and Meyer method.

11 Results 1514 cases have been validated according to the standardized procedure of certification of the Mesopath group: 1207 M (80%) 307 F (20%) Median age at the initial diagnosis 71 years (Min-Max: yrs) Asbestos exposure 920 cases/ 1092 (84%) Unknown asbestos exposure (28%) 220 cases (14.5%) were classified according to the WHO classification IARC Lyon 2004: 145 subtypes features (deciduoid/clear cells etc /osteocartilageneous etc 54 rare variants (desmoplastic/lymphohistiocytoid/ pleomorphic ) 21 other mesothelial tumors ( Well Differentiated Papillary Mesothelioma, adenomatoid tumor).

12 Results Clinical features Clinical symptoms for pleural MM (from 49% of the cases) were: Pain 24% ( n= 181) Fatigue 16% (=119) Loss of weight 12% (n=87) Dyspnea 20% ( n=148) Unilateral pleural effusion 77% (n=571) Diffuse pleural thickening or multiples nodules 59% ( n=442) Localized mass 6% (n= 43) Pneumothorax 3% (n= 19) Hyalin fibrous plaques 15% (n=113)

13 Results Histological subtypes and rare variants % of cases according to histological subtypes, WHO classification, 2004 DMM histological subtypes. Epithelioid 78% (n=1168 ) Biphasic 12% (n=180) Sarcomatoid 7% (n=111) Desmoplastic 2% (n=34) Biphasi c 12% Sarcom atoid 7% Desmo plastic 2% Adeno matoid <1% WDPM 1% Other tumor of mesothelial origin WDPM 1% (n=15) Adenomatoid tumor<1% (n=6) Epitheli oid 78%

14 Results overall survival Median survival: 11 months 2 years survival: 15% CI 95% = [12% ; 18%] Spirtas et al, 1988, Int J Cancer 41: Overall survival was 7 months

15 Results overall survival by gender Median survival 2 years survival Male: 11 months 16% CI 95% = [13% ; 19%] Female: 10 months 13% CI 95% = [7% ; 19%]

16 Results overall survival by asbestos exposure Median survival 2 years survival Exposure: 11 months 17% CI 95% = [14% ; 20%] No exposure: 11 months 28% CI 95% = [24% ; 32%]

17 Results overall survival by age distribution Median survival 2 years survival <50 yrs 16 months 24% CI 95% = [8% ; 40%] 50!age!69 12 months 19% CI 95% = [14% ; 23%] "70 yrs 9 months 12% CI 95% = [9% ; 15%]

18 Results overall survival by histological subtype Median survival 2 years survival Epithelioid: 12 months 18% CI 95% = [14% ; 21%] Biphasic: 8 months 7% CI 95% = [2% ; 12%] Sarcomatoid: 5 months 9% CI 95% = [2% ; 16%] Desmoplastic: 5 months 4% CI 95% = [0% ; 12%]

19 Desmoplastic type of MM Mangano et al, Am J Clin Pathol, 1998;110:191-9 Churg et al, Am J Surg Pathol, 2000; 24: Cagle and Churg, Arch Pathol Lab Med, 2005, 129: Datas were updated october 25, 2007; A Series of 34 cases Male n=33 (97%): Female n=1 (3%) Median age 70 years [40-92 years] Asbestos exposure 29 /31 (94%) Clinical features Pain 63 % (n=15) Fatigue 21 % ( n=5) Weight loss 21 % (n=5) Dyspnea 25% ( n=6) Unilateral pleural effusion 79% (n=19) Diffuse pleural thickening 71% (n=17) Hyalin fibrous plaques 25% (n=6) Pneumothorax 4% (n=1)

20 Desmoplastic type of MM histopathological features Histopathological features have been initially described by Mangano et al, Am J Clin Pathol 1998;110: No zonation ( cellularity away from effusion) Storiform pattern present Abrupt and haphazard transition in cellularity Bland necrosis Capillaries haphazardly distributed and inconspicuous Ipox: CK positive cells invading adipose tissue

21 Desmoplastic type of MM overall survival Median survival 2 years survival Median survival : 5 months 4% CI 95% = [0% ; 12%]

22 Lymphohistiocytoid variant of MM In 1988, LM was first described by Henderson et al. They showed that of 394 definite mesothelioma entered in the Australian Mesothelioma Surveillance Program Panel, three patients were presenting a striking resemblance with a Lymphoma. In 2000, Khalidi et al, described three additional cases They described pleural- based mass and a diffuse proliferation of large, atypical, spindle histiocytoid cells admixed with lymphocytes, plasma cells...

23 Lymphohistiocytoid variant of MM F. Galateau-Salle et al, a series of 22 cases Am J Surg Pathol,, 2007; 31:711-6 Datas were updated october 25, 2007; A Series of 20 cases Male n= 14 (70%): Female n=6 (30%) Median age 70 years [52-84 years] Asbestos exposure 14 /19 (74%) Clinical features Pain 56 % (n=9) Fatigue 44 % ( n=7) Weight loss 19 % (n=3) Dyspnea 25% ( n=4) Unilateral lymphocytic pleural effusion 75% (n=12) Diffuse pleural thickening or multiples nodules 75% (n=12) Localized mass 31% ( n=5)

24 Lymphohistiocytoid MM histological features Proliferation of large, spindle, histiocytoid, or ovoid discohesive cells intermingled with lymphoplasmacytic infiltrate Some Sternberg-like cells Calretinin positivity > 20%

25 Lymphohistiocytoid unusual variants of MM overall survival Median survival 2 years survival Epithelioid: 12 months 18% CI 95% = [14% ; 21%] Lymphohistiocytoid: 11 months 28 % CI 95% = [6% ; 50%] Sarcomatoid: 5 months 9% CI 95% = [2% ; 16%]

26 Lymphohistiocytoid unusual variants of MM overall survival Median survival 2 years survival Epithelioid: 12 months 18% CI 95% = [14% ; 21%] Lymphohistiocytoid: 11 months 28 % CI 95% = [6% ; 50%] Sarcomatoid: 5 months 9% CI 95% = [2% ; 16%]

27 Pleomorphic variant of MM Datas were updated october 25, 2007; A Series of 42 cases Male n=35 (83%): Female n=7 (17%) Median age 68 years [50-85 years] Asbestos exposure 28 /36 (78%) Clinical features Pain 42 % (n=11) Fatigue 54 % ( n=14) Weight loss 15 % (n=4) Dyspnea 27% ( n=7) Unilateral pleural effusion 77% (n=20) Diffuse pleural thickening or multiples nodules 54 % (n=14) Localized mass 16% ( n=3) Hyalin fibrous plaques 4% (n=1).

28 Pleomorphic variant of histological features MM Pleomorphic mesothelioma 3 9 calretinin 20 Proliferation of large and giant cells with pleomorphic nuclei % 73% 37% TTF-1 Calrétinin CK 5/6 TTF-1

29 Pleomorphic variant of MM overall survival Median survival 2 years survival: Epithelioid: 12 months 18% CI 95% = [14% ; 21%] Pleomorphic: 7 months 3% CI 95% = [0% ; 10%] Sarcomatoid: 5 months 9% CI 95% = [2% ; 16%]

30 Other tumor of mesothelial origin Well differentiated papillary mesothelioma Clinical features (10cases) Pain 0 % (n=0) Fatigue 20% % ( n=2) Weight loss 0 % (n=0) Dyspnea 30 % ( n=3) Unilateral pleural effusion 100 % (n=10) Multiples micronodules or focal thickening 40 % (n=4) Localized mass 0% (n=0) Hyalin fibrous plaques

31 Other tumor of mesothelial origin Well differentiated papillary mesothelioma New concept of superficial mesothelial proliferation Datas were not updated october 25, 2007; A Series of 15 cases Male n=10 (67 %): Female n=5 (33%) Median age 74 years [43-80 years] Asbestos exposure 11 /13 (85 %) Clinical features (10cases) Pain 0 % (n=0) Fatigue 20% % ( n=2) Weight loss 0 % (n=0) Dyspnea 30 % ( n=3) Unilateral pleural effusion 100 % (n=10) Multiples micronodules or focal thickening 40 % (n=4) Localized mass 0% (n=0) Hyalin fibrous plaques Histologically Superficial mesothelial proliferation of papillae with stout cores Without invasion in the adipose tissue or lung

32

33 Results overall survival of WDPM Median survival:63 months 2 years survival: 66% CI 95% = [38% ; 94%]

34 Different pathways in mesothelial carcinogenesis? WDPM Superficial mesothelial proliferation Invasive proliferation AMH Non invasive MM

35 Peritoneal malignant mesothelioma 3119 cases 155 cases have been validated definitively meso according to the standardized procedure of certification of the Mesopath group during the period : M (76%) F (24%) Median age at the initial diagnosis 70 years (Min-Max: yrs) Asbestos exposure 1349 cases/ 1775 (76%) Unknown asbestos exposure (43%) Peritoneal 5% Pleural location 94% Pericardial 0.3% Testis vaginalis < 0.2%

36 Peritoneal malignant mesothelioma overall survival Median survival 2 years survival Peritoneum 10 mois 33% CI 95% = [15% ; 51%] Pleura 11 mois 18% CI 95% = [16% ; 21%]

37 Peritoneal malignant mesothelioma overall survival by gender Median survival 2 years survival Male: 10 mois 19% CI 95% = [0% ; 38%] Female: - 59% CI 95% = [39% ; 79%]

38 Peritoneal malignant mesothelioma overall survival by age for female Median survival 2 years survival <50 yrs - 57% CI 95% = [23% ; 91%] 50!age!69 yrs 9 mois 36% CI 95% = [12% ; 60%] "70 yrs 5 mois 26% CI 95% = [2% ; 50%]

39 Plateform presentation USCAP meeting San Diego, 2007 Malignant pleural mesothelioma presenting as recurrent or spontaneous pneumothorax: a series of 35 cases cases validated according to the procedure of certification of the Mesopath group. (Goldberg M, et al,. The French National Mesothelioma Surveillance Program. Occup Environ Med 2006, Feb (H&E + Ipox ; 2 positive /2 negative markers). Cases were selected from January 1999 to December A series of 35/2463 MM cases (1.4%) presenting with spontaneous or recurrent pneumothoraces were selected. 2 PNO were excluded due to iatrogenic procedure. For these 35 cases, the diagnosis was not suspected at surgery and was made by histological examination.

40 Methods MM were classified according to the WHO classification Epithelioid, biphasic, sarcomatoid and desmoplastic. Occupational histories were evaluated by a group of asbestos epidemiological experts using a standardized questionnaire directly with the subject during a face-to-face interview. Smoking history in PNO MPM was evaluated according to: Number pack/years Current smoker/former smoker/passive smoker/non smoker.

41 Demographic features Repartition of age at the first collection Gender repartition 50% 40% 30% 43% 38% 48% 37% PNO MPM 69% 31% 20% 17% 10% 0% 1% 0% 25 to 39 yrs 9% 40 to 54 yrs MPM without PNO 55 to 69 yrs 70 to 84 yrs PNO MPM 4% 3% 85 to 99 yrs MPM without PNO 77% 23% 0% 20% 40% 60% 80% 100% Male Female MPM without PNO (2426) PNO MPM (35) Comparison tests Median age (yrs) [Range] 70 [27-97] 67 [40-87] P=0.26 Gender (%) Sex ratio (M/F) 3 2 P=0.26

42 Exposition factors Overall population Asbestos exposure known Yes (% known) No (% known) MPM without PNO 2426 N= (75%) 325 (25%) PNO MPM N= (70%) 10 (30%) Smoking history known Current smoker (% known) Former smoker (% known) Non smoker (% known) N= (22%) 8 (36%) 5 (22%) [10 to 42 PY] [20 to 55 PY]

43 Clinicopathologic features Overall population Pneumothorax Spontaneous Recurrent Right/left/bilateral With concomitant pleural effusion Hemorrhagic Exsudative Lymphocytic Hyalin fibrous plaques present PNO MPM (74%) 9 (26%) 10/12/2 25 (71%) 9 (26%) 4 (11%) 3 (9%) 7 (20%)

44 Histological features Overall population MPM without PNO 2426 PNO MPM 35 Comparison test WHO Classification Epithelioid type Biphasic type Sarcomatoid PNO MPM (35) type Desmoplastic type MPM w ithout PNO (2426) (77%) 32 (91%) 289 (12%) 1 (3%) 91% 189 (8%) 1 (3%) 73 (3%) 1 (3%) 77% 12% 8% 3% 3% P=0.24 3% Epithelioid Biphasic 3% Sarcomatoid Desmoplastic 0% 20% 40% 60% 80% 100%

45 Histological features They were epithelioid type in 32 cases, biphasic, desmoplastic and sarcomatoid in one each. Invasion of lung parenchyma was present in all. Major trabecular component parallel to the surface (29), or tubulopapillary (4), macro/microcystic (2) were noted. Necrosis was present in (2). Fistulae between distal alveoli and pleural cavity were present in two cases. Reactive eosinophilic pleuritis was present in 3 cases.

46 Trabecular pattern n=29/35

47 Alveolar invasion Invasion of parietal fat KL-1

48 Pathogenic mechanisms

49 Overall survival Population collected in first between Jan and Dec % 75% 50% PNO MPM 25% 0% Logrank test: p<0.001 MPM without PNO Patients at risk Months since first collection PNO MPM MPM without PNO Plateform presentation USCAP meeting San Diego, 2007

50 Conclusion Mesothelioma presenting as spontaneous PNO is a rare event and may be misdiagnosed Hillerdall G PNO/DMPM 1/ % Br J Dis Chest 1983, 77: 321 Mesonat PNO/DMPM 35/ % Spontaneous or recurrent pneumothorax in a patient over 40 years with a history of asbestos exposure should raise the suspicion of MPM. The mechanisms most frequently discussed is the invasion of the visceral pleura and distal lung by the mesothelial cells resulting in a bronchiolo-pleural fistula.

51 Immunohistochemical markers affecting prognosis p27 p53 MIB-1 Cyclooxygenase-2 Epidermal growhth factor receptor (EGFR) Platelet derived growth factor (PDGF) Vascular endothelial growth factor (VEGF)

52 Immunohistochemical markers affecting prognosis p53 87 DMM cases were retrieved from the files of the PNSM with follow up [Period time ]. Additionnally 23 WDPM were collected from the files of the Mesopath group with follow up- Period of time Mutation DMM n = 42 absence of mutation WDPM n = 23 absence of mutation p53 expression (>25% nuclear staining) DMM n= 84 84% WDPM n=23 0% Is there a correlation between the expression of p53 and histological subtype in DMM. Is there a correlation between the expression of p53 and AE in DMM. p= 0.51 ns p= 0.15 ns Epidermal growhth factor receptor (EGFR) Platelet derived growth factor (PDGF)

53 Immunohistochemical markers affecting prognosis p27 p27 ( kinase inhibitor protein- Kip) is a cyclin dependant kinase inhibitor which blocks the cell cycle by binding E/CdK2 complex which prevent progression of the cell cycle from the G1 to the S phase. p 27 loss decreases tumour suppressive activity Beer et al, Histopathology, 2001; 38: Bongiovanni et al, Cancer, 2001;92: Results: Low p27 expression is associated with shorter survival [4-6 months ] compared with high expression [10-11months] Cox-2 Cox 2 has been implicated in carcinogenesis through the down regulation of cell mediated immunity, promotion of angiogenesis, inhibition of apoptosis and the formation of carcinogenic metabolites Edwards et al, Clin Cancer Res 2002;8: Baldi et al, Thorax 2007; 59: Results: Low expression of p27 associated with High expression of Cox-2 correlated with poor prognosis.

54 Immunohistochemical markers affecting prognosis p53 pathways in mesothelioma p53 87 DMM cases were retrieved from the files of the PNSM with follow up [Period time ]. 23 WDPM were collected from the files of the Mesopath group with follow up- Period of time Mutation DMM n = 42 absence of mutation WDPM n = 23 absence of mutation p53 expression EM BM SM DM p53 expression (>25% nuclear staining) DMM n= 84 84% WDPM n=23 0% Is there a correlation between the expression of p53 and histological subtype in DMM? p= 0.15 ns Is there a correlation between the expression of p53 and AE in DMM? p= 0.51 ns 0 1 E E- 14 1

55 Is p53 expression could be a prognostic factor in DMM? test Khi2 DF Pr>Khi2 Log rank

56 Immunohistochemical marker affecting prognosis EGFR Edwards results n=74 patients EGFR overexpression 44% A better survival is observed with EGFR expression, epithelioïd type p<0.0001, PS p<0.000, Absence of chest pain p<0.001 Univariate EGFR expression is a good prognostic factor p=0.01 Multivariate analysis effect of EGFR expression is still independent good prognostic factor p< MESOPATH results n=100 patients Certification Mesopath Status of asbestos exposure EGFR overexpression in 88% Univariate analysis showed a better survival for young age p<0.05, epithelioid type p<0.01, no exposure p<0.05and EGFR expression p<0.01 Multivariate analysis; the effect on survival for EGFR was still significant (p<0.05) even after adjustment for histological type. Our study failed to detect mutation of EGFR ( 30 cases)

57 Genomic profile affecting prognosis Gordon et al J Nat Cancer Inst 2005;95: using oligonucleotide microarrays found fourgene expression ratio test predicted the treatment related patient outcome in MM independently from histological subtype Pass et al Clin Cancer Res; ; 2004:10: using U95 Affymetrix gene chip found that 27 gene classifier predicted prognosis with 95% accuracy Lopez Rios et al Cancer Res 2006;66: design a study for a critical evaluation o microarray based prognostic prediction. The power of microarray in the clinical prognostication has been overestimated

58 Conclusion Mesothelioma is a an heterogeneous disease with a dismal prognosis. In the past few years, there have been some advances in the management of patients with DMM and new molecular alterations have been reported providing broader insights into its biology and leading to the identification of possible new targets for therapy. The need for a better staging and more accurate histological classification leading to a strong selection of good and worst prognostic group will lead to improvement in the management of patients. Among these prognostic factors histopathological classification as a first step is crucial.

59 Nolwen Le Stang A. de Quillacq V. Abonnet S. Lecot F. Morlais J. Hoyez P. Rolland P. Brochard JC. Pairon P. Astoul A. Ilg soit Gilg M. Letourneux G. Launoy E. Imbernon M. Goldberg Goldberg National Health Institute of Surveillance [InVS] Acknowledgments I Abdalsamad H.Begueret E Brambilla F Capron MC Copin AY Delajartre A.Foulet-Rogé A de Mascarel L Garbe O Groussard R Loire JM Piquenot F Thivolet JM Vignaud

60 Ipox results