A 70-year old Man with Pleural Effusion

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1 Mesothelioma Diagnosis: Pitfalls and Latest Updates S Klebe and DW Henderson

2

3 Recommendations Indisputable malignant cells on cytomorphological criteria which demonstrate a mesothelial phenotype, which should be verified by ancillary techniques Cytomorphological features which are not unequivocally malignant, but ancillary techniques confirm malignancy and a mesothelial phenotype

4 A 70-year old Man with Pleural Effusion DQ stain DQ stain

5 A 70-year old Man with Pleural Effusion Cell block Limited IHC was performed CK7 +ve TTF1-ve No other markers at that time Adenocarcinoma

6 Appearances can be deceiving PAP IHC for calretinin

7 Whilst we talk IHC. all recent publications recommend that IHC for suspected mesothelioma is performed- applies to cytology and surgicals At least 2 mesothelial and 2 carcinoma markers WHAT MARKERS?????? Most of us use TTF-1????

8 TTF-1 Member of homeodomain TFs: morphogenesis of thyroid, lung, forebrain In human fetal lung at 11 wks' gestation. Adult: alveolar epithelium 70-90% adenocarcinomas lung express TTF-1, also in small cell carcinomas Ordonez: 0/55 MMs Henderson: 4/45 MMs (9%) Strong nuclear labelling for TTF-1 is evidence against a dx of MM Most IHC panels include TTF-1

9 Sarcomatoid Mesothelioma TTF-1 antibody 8G7G3/1 Napsin

10 Same Case- Confirmed Mesothelioma TTF-1 Clone SP141, Outside Lab TTF-1 clone SP141, FMC

11 Another Case.Desmoplastic Mesothelioma Dako TTF-1, 8G7G3/1, FMC TTF-1, SP141, FMC

12 Squamous Metaplasia in Bronchial Epithelium- Should be TTF-1 -ve H&E TTF-1, SP141, FMC

13 A Brain Metastasis in a Male with a Lung Lesion H&E TTF-1, SP141 FMC

14 ..actually, Prostate Metastasis TTF-1, 8G731, FMC PSA

15 Our Data

16 Some Inconsistencies with TTF-1 Clones Reported NordiQC (quality control) 2014 in concordance with previous NordiQC assessments for TTF1, mab clone SPT24 was a very robust and sensitive marker SP141 also very sensitive Once again no laboratories using the mab clone 8G7G3/1 achieved optimal mark had significant lower sensitivity resulting in an alarming overall pass rate of only 13% Ordóñez NG. Appl Immunohistochem Mol Morphol. 2012;20(5) Value of thyroid transcription factor-1 immunostaining in tumor diagnosis: a review and update. increased sensitivity at the expense of specificity with SPT24 (Novocastra) clone

17

18 Data from GEO sets: Some Mesotheliomas DO show mrna Expression of TTF-1, at Low Levels

19 Increased Labelling is Real - but what Does this Mean for Diagnosis? low levels of TTF-1 in tumour tissue, previously below detection limit labelling appears to be real? biologically significant May cause misdiagnosis if pathologists are not aware of the differences in sensitivities with this antibody

20 And Another IHC marker BAP1 BRCA1-Associated Protein 1 Tumour suppressor gene located on chromosome 3p21.1 Mutation may be sporadic or germline Tumours described with germline mutations: Uveal melanomas Other melanocytic tumours including cutaneous melanoma Other tumours Mesothelioma Lung adenocarcinoma Meningioma Neuroendocrine carcinoma Paraganglioma Cholangiocarcinoma RCC

21 Improved Survival in Mesothelioma when BAP1 is lost Arzt et al Path & Oncol Research Jan 2014 Farzin et al Pathology 47(4): , June 2015

22 We looked at this, too.. Subject Characteristics Median Age (range) 75 (35-94) Gender - Male 66 - Female 21 Histologic Subtype - Epithelioid 63 - Sarcomatoid 12 - Biphasic 12

23 No Association With Survival in our Cohort if ALL Cases are considered p=0.360 n=27 n=46

24 Epithelioid Cases- Cytology Samples n=20 p=0.029 n=14

25 BAP 1 Labelling in Cytology Samples

26

27 IHC for BAP 1 suitable for Screening May be not: for Germline Mutation.? Patient with uveal melanoma, cholangiocarcinoma, (peritoneal) mesothelioma Family history of RCC and mesothelioma (x2)

28 IHC for BAP1 Mesothelioma Cholangiocarcinoma

29 Germline Sequencing

30 A new mutation Resulting in non-functional protein (but still labelling/translocating to nucleus)? How common are these? IHC for BAP 1 may be useful for screening patients for germline mutations--- but proceed with caution

31 Serum Markers to Establish Malignancy: how about Hyaluronic Acid

32 Usefulness of Hyaluronic Acid in Diagnosis of Malignancy * * * * * p<0.05 * p<0.05 n=30 n=60 n=30 n=30 n=30

33 Summary Cytology-Only diagnosis is not that easy IHC is essential for diagnosis- but know your clone! BAP 1 shows definite promise as prognostic and possibly diagnostic marker- but more work needed Oldie but Goodie Hyaluronic Acid stands the test of time but lacks specificity

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