Faculty Bibliography

The accurate diagnosis of mesothelioma is critical for the appropriate clinical management of this cancer. Many issues complicate making the diagnosis of mesothelioma including the presence of reactive mesothelial cells in benign pleural effusions, the heterogeneity of mesothelioma histopathology, the relatively high incidence of other epithelial malignancies that metastasize to the pleura, and primary sarcomas that arise within the pleura. Given the rapidly evolving field of molecular profiling and the need for translational correlates in mesothelioma clinical trials, the National Cancer Institute-International Association for the Study of Lung Cancer-Mesothelioma Applied Research Foundation Clinical Trials Planning Meeting was convened in March 2017 to develop a consensus on standard pathology guidelines for future NCI-sponsored clinical trials in mesothelioma. This consensus statement covers recommendations for specimen handling, pathologic classification and diagnosis, biobanking and tissue correlative studies.

Background: PD-L1 immunohistochemistry (IHC) is now performed for advanced non-small cell lung cancer (NSCLC) patients to examine their eligibility for pembrolizumab treatment, as well as in Europe for durvalumab therapy after chemoradiation for stage III NSCLC patients. Four PD-L1 clinical trial validated assays (commercial assays) have been FDA/EMA approved or are in vitro diagnostic tests in multiple countries, but high running costs have limited their use; thus, many laboratories utilize laboratory-developed tests (LDTs). Overall, the PD-L1 testing seems to be diversely implemented across different countries as well as across different laboratories.
Method(s): The Immune biomarker working group of the IASLC international pathology panel conducted an international online survey for pathologists on PD-L1 IHC testing for NSCLC patients from 2/1/2019 to 5/31/2019. The goal of the survey was to assess the current prevalence and practice of the PD-L1 testing and to identify issues to improve the practice globally. The survey included more than 20 questions on pre-analytical, analytical and post-analytical aspects of the PDL1 IHC testing, including the availability/type of PD-L1 IHC assay(s) as well as the attendance at a training course(s) and participation in a quality assurance program(s).
Result(s): 344 pathologists from 310 institutions in 64 countries participated in the survey. Of those, 38% were from Europe (France 13%), 23% from North America (US 17%) and 17% from Asia. 53% practice thoracic pathology and 36%, cytopathology. 11 pathologists from 10 countries do not perform PD-L1 IHC and 7.6% send out to outside facility. Cell blocks are used by 75% of the participants and cytology smear by 9.9% along with biopsies and surgical specimens. Pre-analytical conditions are not recorded in 45% of the institutions. Clone 22C3 is the most frequently used (61.5%) (59% with the commercial assay; 41% with LDT) followed by clone SP263 (45%) (71% with the commercial assay; 29% with LDT). Overall, one or several LDTs are used by 57% of the participants. A half of the participants reported turnaround time as 2 days or less, while 13% reported it as 5 days or more. Importantly, 20% of the participants reported no quality assessment, 15%, no formal training session for PD-L1interpretation and 14%, no standardized reporting system.
Conclusion(s): There is marked heterogeneity in PD-L1 testing practice across individual laboratories. In addition, the significant minority reported a lack of quality assurance, formal training and/or standardized reporting system that need to be established to improve the PD-L1 testing practice globally. Keywords: global survey, NSCLC, PD-L1 immunohistochemistry
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Background: Tumor grading has been a traditional component of the pathologic evaluation and in many organ systems, tumor grading offers guideline to therapy and patient management. The latter has not been applied to NSCLC. However, considering the new advances in therapy modalities for NSCLC and advances in adenocarcinoma classification, it is now clear that there are different types of adenocarcinomas and these tumors should not be treated the same way. The 2015 WHO classification of pulmonary adenocarcinoma based on the predominant histological pattern has consistently been found to correlate with prognosis. There is broad agreement that the five histological patterns (lepidic, acinar, papillary, solid and micropapillary) are important prognostic indicators. Recent studies have proposed the inclusion of a number of additional pathologic features (the role of secondary patterns, non-traditional pattern such as cribriform and complex glandular patterns, nuclear grade, mitotic counts, presence of spread through alveolar space (STAS), and necrosis.) that also have prognostic value. The addition of these histological features to the predominant pattern could offer greater refinement of a grading scheme. Supplementing the classification of lung adenocarcinomas with an objective grading system will help define prognostic groups that could benefit from the changing landscape of emerging management and treatment options. Contrary to adenocarcinoma, there has been little advancements in the histological prognostic indicators in squamous cell carcinoma of the lung. Isolated reports have suggested that the presence of tumor budding into the stroma is the sole indicator of poor prognosis. Keratinization, which has been traditionally used to grade these tumors, does not appear to have prognostic value. However, a systematic evaluation of prognostic markers in these tumors have not been carried out. A summary of the current efforts in squamous cell carcinoma will be discussed. The IASLC pathology panel has proposed a systematic study to evaluate a set of histological criteria that have been described as prognostic indicators in adenocarcinoma aimed at establishing an objective grading system of invasive lung adenocarcinoma.
Design(s): A multi-institutional study involving well-annotated multiple cohorts of stage 1 adenocarcinomas with at least five years of follow up were evaluated. Annotation included an estimate of the percentage for each histological pattern present for each case; nuclear grade, cytology grade; and mitotic counts with pattern hot-spot association, presence of STAS, and necrosis. A cohort of 284 cases was used as a training set. Univariate analysis was performed to identify significant associations of histological features with recurrence-free survival and overall survival. ROC curve analysis was used to select the best model based on combinations of several features and its association with disease recurrence or death of disease. The results were validate on independent cohorts of 212 cases.
Result(s): Review of the literature showed that there are many variation in the classification and definitions on non-traditional patterns. In our cohorts, cribriform and complex glandular patterns followed similar curve as traditional high grade patterns (solid and micropapillary), therefore these non-traditional pattern were defined as patterns of high grade in the model. Another are of variation is the percentage of high grade pattern that can influence outcome. Therefore, the cut-off for a high grade pattern associated with recurrence or death of disease was also established in the training cohort and correspond to 20%. Therefore, amounts smaller than 20% of high grade pattern did not influence outcome. In the training cohort (n=284) all parameters tested, predominant patterns, mitotic count, nuclear grade, cytological grade, and STAS (but not necrosis) were found to have significant prognostic value on a univariate analysis. A Baseline Model composed of Age + Gender + Race + Type of surgery + Pathological Stage; showed an AUC of 0.673. In an attempt to improve this curve, histological parameters were added to the model. The addition of only the predominant pattern to the baseline increases the AUC to 0.698. A model based on the combination of predominant pattern paired with the second predominant pattern was found to have the highest AUC (0.765), followed by a combination of predominant pattern plus worse pattern (AUC=0.74). Addition of other histological features (nuclear grade, mitotic count, STAS etc.) did not significantly improve the model. Similar results were found in the validation set (N=212). The combination of the two most predominant patterns showed an AUC = 0.763, followed by a combination of predominant + worse pattern with AUC = 0.766. Addition of other histological features did not show improvement of the model. There was no statistical difference between the models using the two most predominant patterns and the predominant plus worse. There was good reproducibility scores for the 2 models
Conclusion(s): Our results suggest that an objective grading system for pulmonary adenocarcinoma is possible. Considering that there is no significant differences between a model that accounts for the 2 most predominant pattern and another composed of the predominant plus worse pattern. The IASLC pathology panel proposes the later to be used, because pathologists traditionally grade tumors by the worse component. Therefore, histologic assessment of the predominant pattern and worse pattern, would represent the most parsimonious and prognostic grading system for stage I lung adenocarcinomas. The use of the model in two other independent cohorts of adenocarcinomas (stages 1-3), as well as a reproducibility study will be discussed. Keywords: tumor grading, adenocarcinoma, prognosis
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Introduction: Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive hereditary disorder characterized by oculocutaneous albinism and bleeding diathesis. Transplantation is often conducted to treat lung fibrosis, which is the most fatal complication of this disease. While the literature discusses the diagnosis of HPS based on genetic testing, radiology, and electron microscopic (EM) findings of platelet granules, there is a paucity of images in the literature illustrating the pulmonary histopathologic and EM features of HPS. Case Report: Here we present striking histopathologic and EM images from a case of pulmonary fibrosis due to HPS in a 48-year-old female. The patient presented with restrictive lung disease and bilateral decreased breath sounds with diffuse crackles. She was clinically diagnosed with HPS and underwent bilateral lung transplant. On histopathology, both pneumonectomy specimens showed diffuse interstitial fibrosing and cellular pneumonitis with end-stage remodeling and type II pneumocyte (PC-II) hyperplasia. The PC-IIs had abundant foamy cytoplasm and compressed scalloped nuclei. Alveolar macrophages contained fine brown granules positive for PAS-D stain. EM analysis revealed that the PC-IIs contained numerous lamellated myelin bodies (so-called giant lamellar body degeneration) suggestive of surfactant admixed with lipid and luminal microvilli. The pigmented alveolar macrophages also contained lamellated myelin bodies, as well as clusters of single membrane-bound structures with varying size and electron density admixed with vacuolar and granular debris suggestive of ceroid deposits.
Conclusion(s): Based on light microscopy, histochemical analysis, EM, and clinical presentation, it was concluded that our findings were consistent with pulmonary changes as seen in HPS

Introduction: Desmoplastic mesothelioma (DMM), a rare histological subtype of malignant pleural mesothelioma (MPM), is lethal and has very poor prognosis. Metastasis is commonly reported in DMM compared to other histological subtypes. Here we report a case of DMM with good survival (>1 year) despite lymph node metastasis. Case Report: A 62-year-old female with a history of smoking and possible asbestos exposure presented with cough and wheeze in 2012. Computed tomography (CT) revealed left-sided pleural plaques and multiple groundglass pulmonary nodules. In 2017, repeat CT showed increased diffuse left nodular pleural thickening. Positron emission tomography revealed hypermetabolic, nodular pleural thickening in the hemithorax, compatible with neoplasia. Needle biopsy in January 2018 showed pleural tissue with haphazard, nodular growth of spindled mesothelial cells, suspicious for desmoplastic mesothelioma. Definitive diagnosis was not possible due to lack of fat invasion and absence of supportive evidence by immunohistochemical stains. The patient underwent pleurectomy in February 2018. On histopathology, the majority of the tumor showed a desmoplastic pattern, composed of malignant spindled cells arranged haphazardly in a dense hyalinized stroma with chronic inflammatory infiltrate. AE1/AE3, calretinin, and D2-40 immunohistochemical stains highlighted the infiltrating neoplastic cells, which were negative for WT-1. BAP-1 was retained. The pattern of immunoreactivity supported the diagnosis of DMM. The tumor also involved visceral pleura, pulmonary parenchyma, and pericardium. It invaded into fat and displayed lymphovascular invasion. A metastatic focus of DMM was present in a lymph node. The tumor was staged as pT3N1. On recent examination, the patient only had complaints of mild breathlessness and stable hydro-pneumothorax, without any other comorbidities.
Conclusion(s): Our finding is unusual, since among the mesothelioma subtypes, DMM has the shortest survival, usually not more than 6 months. We report an extremely rare case of DMM with survival of >1 year despite invasion of lung parenchyma and lymph node metastasis

Sarcomatoid carcinoma is rarely found in pleural or pericardial fluid, with very few cases published to date. Here, we describe a 59-year-old female who presented with cough persisting for 5 months. Chest CT scan revealed a 6.0 cm cavitary mass in the left lung base with bulky mediastinal and hilar lymphadenopathy. An additional 1.2 cm right adrenal mass was seen and was suspicious for metastatic disease. The patient developed dyspnea, tachycardia, pleuritic chest pain and generalized weakness and was admitted to the hospital. She was found to have pleural and pericardial effusions, which were drained and sent to cytology. The fluid revealed enlarged highly pleomorphic malignant cells, some displaying multinucleation with irregular nuclear borders, coarse chromatin and prominent nucleoli. Tumor cells were positive for CK7 and Vimentin and negative for MOC-31, Ber-EP4, B72.3, Sox10, Melan-A, TTF-1, Napsin-A and CK20. A concurrent surgical biopsy of the tumor mass displayed immunopositivity for AE1/AE3 and CAM5.2. The tumor was negative for p40, TTF-1, calretinin, D2-40 and STAT6. A diagnosis of sarcomatoid carcinoma with giant cells and spindle cells was rendered. Sarcomatoid carcinomas of the lung are very uncommon consisting of 1% of non-small-cell lung carcinomas and are even more unusual in cytology specimens. Despite its rarity, it is important to keep this entity in mind in the differential diagnosis of a fluid specimen with bizarre nuclear atypia and the above staining pattern.

Background: Banking of human biospecimens linked to prospective, well-annotated clinical information is critical for advancing biomedical research. However, the establishment of an efficient biobank encompasses many issues including adherence to federal regulations, institutional policies and governance of the relationship between the biobank, investigators and funding agents. Here we report on the efforts of the Center for Biospecimen Research and Development (CBRD) at NYULH to establish a state-of-the-art biobank. Method(s): In 2015, we identified the need to establish a centralized infrastructure to facilitate research collaborations and support clinical trial studies. The four main considerations were: 1) creating a centralized mechanism to consent, collect and bank human biospecimens 2) Organizing, de-identifying, and annotating subjects' samples linked to their clinical data 3) Establishing multidisciplinary involvement of pathology departments 4) Enhancing quality control measures to achieve CAP and NYS DOH accreditation. To address these considerations, we created a Universal Consent (UC) form; developed a Laboratory Information Management System that assists in specimen organization and links subject samples to clinical data in their electronic medical record and fostered a partnership between the pathology department, individual researchers and the CBRD to develop best practices in biobanking. Result(s): Since June 2016, using the UC, 18,906 of 27,355 (70%) subjects agreed to use their specimens and data for research. 9,054 patients had specimens collected using the UC and additional specific consent if needed. We collected 4,178 unique samples (tissue, blood and fluids)-13,969 aliquots by the UC method and 7,713 samples from fresh and archival collections for specific research studies or clinical trials. The CBRD supported 93 research projects and 251 clinical trials. Conclusion(s): Establishment of the CBRD permitted the increase in absolute number of patients approached for research; enhancement of specimen quality and organization and introduction of the electronic crosslink to minimize the time and overhead needed for clinical data retrieval. Building on this success, we are upgrading our IT infrastructure to expand upon the data collected, digitalizing tissue slides to improve quality control and building an automated molecular genotyping database using existing NGS data to increase the number of trans-lational research projects

With an escalating number of predictive biomarkers emerging in non-small cell lung carcinoma (NSCLC), immunohistochemistry (IHC) is being used as a rapid and cost-effective tool for the screening and detection of many of these markers. In particular, robust IHC assays performed on formalin-fixed, paraffin-embedded (FFPE) tumor tissue are widely used as surrogate markers for ALK and ROS1 rearrangements and for detecting programmed death ligand 1 (PD-L1) expression in patients with advanced NSCLC; in addition, they have become essential for treatment decisions. Cytology samples represent the only source of tumor in a significant proportion of patients with inoperable NSCLC, and there is increasing demand for predictive biomarker testing on them. However, the wide variation in the types of cytology samples and their preparatory methods, the use of alcohol-based fixatives that interfere with immunochemistry results, the difficulty in procurement of cytology-specific controls, and the uncertainty regarding test validity have resulted in underutilization of cytology material for predictive immunocytochemistry (ICC), and most cytopathologists limit such testing to FFPE cell blocks (CBs). The purpose of this review is to: 1) analyze various preanalytical, analytical, and postanalytical factors influencing ICC results; 2) discuss measures for validation of ICC protocols; and 3) summarize published data on predictive ICC for ALK, ROS1, EGFR gene alterations and PD-L1 expression on lung cancer cytology. Based on our experience and from a review of the literature, we conclude that cytology specimens are in principal suitable for predictive ICC, but proper optimization and rigorous quality control for high-quality staining are essential, particularly for non-CB preparations.

Ancillary techniques play an essential role in pulmonary cytopathology. Immunoperoxidase and special stains are by far the most common ancillary techniques used in cytopathology; however, the role of molecular diagnosis is growing, especially in the fields of pulmonary oncology and infectious disease. In this article, we review the uses of ancillary techniques in lung tumor diagnosis, lung tumor classification, predictive marker determination, primary versus metastasis differential diagnosis, and infectious organism detection.

Objectives/UNASSIGNED:To evaluate whether non-small cell lung carcinoma (NSCLC) cytology specimens are reliable for programmed death-ligand 1 (PD-L1) immunohistochemical (IHC) testing. Methods/UNASSIGNED:Fifty-two cell blocks (CBs) with corresponding surgical pathology PD-L1 IHC testing were stained with a Dako PD-L1 pharmDX antibody (clone-22C3). Tumor cellularity was recorded as <100 or ≥100 cells. PD-L1 IHC was scored by percentage of tumor cells staining (<1%, ≥1%-49%, ≥50%) and compared between matched cases. Results/UNASSIGNED:Substantial agreement (κ = 0.63; 95% CI, 0.53-0.73) was reached between matched CB and surgical cases in CBs with ≥100 tumor cells compared to CBs with <100 tumor cells (slight agreement, κ = 0.19; 95% CI, 0.04-0.35). Overall, there was 67% agreement among paired cases (35/52 cases, κ = 0.51; 95% CI, 0.42-0.60). Conclusions/UNASSIGNED:CBs can be utilized for PD-L1 IHC testing, as illustrated by the 67% agreement between CB and surgical cases in our study. Disagreement is attributable to intratumoral heterogeneity and CB cellularity.