Lutfi ALIA Aguayo & Miller Disease

AGUAYO – MILLER DISEASE MORPHOLOGICAL AND IMMUNOHISTOCHEMICAL FEATURES

Lutfi ALIA (MD) Siena – Italy

SPECTRUM OF PULMONARY NEUROENDOCRINE LESIONS AND NEOPLASMS CLASSIFICATIONS OF LUNG TUMORS: 1999 (WHO – IASCL) , 2004 (Travis & WHO - IARC), 2005, 2011 (IASCL-ATS/ERS) Denver 2015 (WHO)

PRE-NEOPLASTIC LESIONS (1999) - Dysplasia - Carcinoma in situ - Angiomatous Squamous Dysplasia - Atypic Adenomatous Hyperplasia - Idiopathic Hyperplasia of Neuroendocrine Cells - Tumorlets

NE tumors rappresent 12 - 20 % of all lung tumors

I. NEUROENDOCRINE CELL HYPERPLASIA AND TUMORLETS (2004 & 2015) a. Neuroendocrine Cell Hyperplasia 1. NE cell hyperplasia associated with fibrosis and/or inflammation.

2. NE cell Hyperplasia, adjacent to carcinoid tumors.

3. Diffuse Idiopatic NE Cell Hyperplasia with or without airway fibrosis/obstruction. b. Tumorlets

II. COMMON NEOPLASMS WITH NEUROENDOCRINE MORPHOLOGY a. Typical Carcinoid b. Atypical Carcinoid c. Large Cell Neuroendocrine Carcinoma (LCNEC) [Combined SCLC] d. Small Cell Neuroendocrine Carcinoma (SCLC) [Combined SCLC]

FIRST RISK FACTOR:

III. NON – SMALL CELL CARCINOMA WITH NEUROENDOCRINE DIFFERENTATION a. Squamous Cell Carcinoma b. Adenocarcinoma c. Large Cell Carcinoma with Neuroendocrine features not seen by light microscopy but delected by immunohistochemestry of ultrastructure.

IV. OTHER TUMORS WITH NEUROENDOCRINE PROPERTIES A. Pulmonary blastoma.

B. Primitive neuroectodermal tumour.

C. Desmoplastic round cell tumour.

D. Carcinomas with rhabdoid phenotype.

E. Paraganglioma.

- SCC - AC - ACBA - Small CC - LCNEC

smoker

non smoker

98, 0 % 81, 6 % 70, 6 % 98, 9 % 93, 3 %

2, 0 % 18, 4 % 29, 4 % 1, 1 % 6, 7 %

Travis W. Lung tumors with neuroendocrine differentiation: Chest 2004 Travis W. : The 2015 World Health Organization Classification of Lung Tumors. J. Thorac Oncol. 2015;10: 1243–1260) Rossi G et al: Europ. SS Respir. Journal. 2016 American Cancer Society: Cancer Facts and Figures 2018. Atlanta, Ga: American Cancer Society, 2018.

DIFFUSE IDIOPATIC PULMONARY NE CELL HYPERPLASIA IS A FREQUENT LESION, THAT ASSOCIATED SEVERAL DISEASES.

SMOKERS

CARCINOIDS of the LUNG

BPCO (COPD) TUMORLETS

I.L. FIBROSIS

DIPNECH

NE - LUNG TUMORS

HYPER-S PNEUMONITIS

NON NE-Ca of LUNG

METASTATIC TUMORS

NE tumors arise from Kulschitsky cells (Feyrter cells), in the epithelium of pulmonary airways: 1 – 2 cells dispersedly every 2, 5 cm a long epithelium, or place as cell cluster, so called Neuroendocrine body.

Aguayo S. Miller Y: New Engl. J. Med 1992 Alia L. Bazat Patologjike te semundjeve. Pneumonite inetrsticiale. Vol. 1, ISSUU. Siena 2014 Carr L.L, Chung J.H. et all. Chest 2015 Sauer R et all: Journ. Med. Case Rep. 2017 American Cancer Society: Cancer Facts and Figures 2018. Atlanta, Ga: American Cancer Society, 2018.

Travis W.D, et al. ATS/ERS international multidisciplinary consensus classification of idiopathic interstitial pneumonias. General principles and recommendations. Am J Respir Crit Care Med 2002;165

According to the WHO, the definition of DIPNECH is purely histological.

The criteria for the morphologic diagnosis of DIPNECH, is the presence of multifocal of 5 or more PNEcells, in last 3 separate small airways, and associated with 3 or more tumorlets.

Aguayo M.S. Miller Y. et all: New Engl. J. Med. 1992.

Martins C. M. – J. B. Pneumologia 2009.

Miller A and Glawin M. Amer. Jorn. Respiratory. 2012 M. C. Aubery: Chest 2007, Davis S: Thorax 2007.

Kuruva M et all: Clin Nucl. Med. 2016.

AGUAYO & MILLER DISEASE

SAMUEL AGUAYO AND YORK MILLER – 1992 (Aguayo M.S. Miller Y. et all: New Engl. Journ. Med. 1992. n. 376 , 1285 – 1290)

Reported six patients with airways disease, in whom a pulmonary biopsy after lobectomie, revealed an ensamble of lesions:  Nodular proliferation of PNECs submucosal and intraluminal in bronchiolis; linear ductal and alveolar proliferation of PNECs.  Obstructive bronchiolitis, interstitial fibrosis and chronic inflamation.  Tumorlets.  Typical Carcinoids The patients can be symptomatic (cough and dyspnea), as well asymptomatic in the case with DIPNECH associated with tumorlets and carcinoid.

Mosaicism with noduls and reticular pattern on high resolution Computed Tomography.

Gorstein A, Groos D.J et all,; Cancer 2012 Rossi G, et all: Europ. Respir. Journ. Jun 2015

MATERIAL AND METHODE OF THE STUDY

2010 – 2017 were diagnosticated 51 cases with DIPNECH (Department of Pathology – University of Siena) 10 cases (19, 6 %) non NE lung carcinomas, associated with focal hyperplasia of NE cells.

12 cases (23, 4 %) NEPCH associated with fibrosis, chronic inflammation, bronchectasia.

9 cases (17, 6 %) NEP cell hyperplasia and tumorlets 20 cases (39, 2 %) diagnosed Aguayo - Miller Disease.  8 cases are women and 12 cases are male.  18 patients are SMOKERS (90 %)  Mean age 64 years (range 40 – 86 year)

THE AIM: We reviewed our experience to determine the range of histopathological and immunohistochemical features in the Aguayo – Miller disease.



HISTOPATOLOGY Eosine & haematoxyline Light microscopy is sufficient to diagnose the Diffuse Idiopathic Hyperplasia of Neuroendocrine Cells



IMUNOHISTOCHEMISTRY Neuroendocrine Markers with antibodis: Chromogranin A Sinaptophysin Bombesine CD56 Neuron Specific Enolase Polyclonal (NSE) Expression of Growth Factors: EGF, FGF, VEGF Apopoptic markers: Bax (pro – apopoptic) bcl-2 (anti – apopoptic) Fraction of growth: MIB-1: Monoclonal antibody for the antigen Ki–67 Expression of citokeratins: Antibodies anti CK7, anti CK20

1. DIFFUSE IDIOPATIC NEUROENDOCRINE CELLS HYPERPLASIA

MICROSCOPICALLY H & E staining: in lung surgical specimens of our 20 cases with TC, we have revealed:

 Noduar proliferation of PNEC, as well as submucosal and endoluminal in terminal bronchioles, respiratory bronchiols, and lineare proliferation in alveolar ducts and alvoles.  Peribronchiolar fibrosis with little active interstitial inflammation, and emphyseme panacinare.  Multiple Tumorlets.  Typical Carcinoids.

IMUNOHISTOCHEMISTRY

NEP- cells are positive with antibodies anti Chromogranin A

CHROMOGRANIN A

Parathyroid Secretory Protein 1 Gene CHGA 14q31,3 – 31, 2 Endogen PH Convertase: vasostatina, pancreastatina, parastatina etc.

Schnabel PA, Junker K (2015) Pulmonary neuroendocrine tumors in the new 2015 WHO classification: Start of beaking new grounds? Pathologe 36:283-292

NEP- cells are positive with antibodies anti Synaptophysine

SYNAPTOPHYSINE Gene SYP Chromosme X Xp11,23 – 11,22

2. OBSTRUCTIVE BRONCHIOLITIS, INTERSTITIAL FIBROSIS AND CHRONIC INFLAMATION.

Intraluminal Nodular Proliferation of NE Cells

Submucosal, peribronchial and interstitial fibrosis

The residual airway lumen is replaced by nodular and circumferential arrangement of NE cells and circumscribed by inflammation, interstitial fibrosis, body of Masson, peribronchiolar and interstitial lymphocyte accumulation.

Martins Coletta M. – J. B. Pneumologia. 2009 Miller A and Glawin M. Amer. Jorn. Respiratory. 2012

3. TUMORLETS

• •

Are millimetre-sized nodular proliferation of NE cells (1 – 5 mm diameter), that are embedded in a dense fibroelastic stroma.

NE cells of tumorlets, like NE cells of carcinoids, contain neuroscretory granules and have the same immunohistochemical findings, expressing diffuse immunoreactivity for Chromogranin A, Synaptophysine and have overexpression of CD56

NE cells are postive with antibodies anti Chromogranin A.

CD56 positivity Marker of neuroendocrin differentiention overexpression in the Tumorlets.

Tumorlets

IMUNOHISTOCHEMISTRY OF THE TUMORLETS

The little nodule are organoid nests of NE cells prolferating within a dense fibroelastosis stroma.

Bombesine +++ in the tumorlets and in the in epithelial area.

(Neuropeptidic Growth Factor for human fibroblasts).

4. CARCINOIDS

CARCINOIDS REPRESENTS 10 % OF TUMOURS ARISE FROM NEUROENDOCRINE CELLS. Intest-Small Appendicitis

20 %

Colon

Bronchi

20 %

Stomach Panc_Liver Others

24 %

30 %

INCIDENCE:

LOCALISATION:

1, 3 – 2, 5 cases in 100 000 inhab.

20 – 40 new cases in 1 miljon inhab.

UK 1500 cases diagnosed each year.

5 % occurs in the patients with MEN – Type 1.

Carcinoid in Aguayo – Miller disease are sincrone and multicentric

1% 2%

LOW GRADE

70 – 75 % in the major bronchi 25 – 30 % located in the periphery of the lungs (segmental bronchi or beyond) 61 % in the right lung (middle lobe)

3% INTERMEDIATE GRADE

CARCINOIDS TYPICAL Rossi G. et all: Europ. Resp. Journ. 2016 American Cancer Society: Cancer Facts and Figures 2018. Atlanta, Ga: American Cancer Society, 2018

HIGH GRADE

CARCINOMAS ATYPICAL

LCNEC - SCLC

HISTOPATHOLOGY OF CARCINOIDS

NE cells present s variety of histological patterns can seen in both CT and AC -

Round and oval cells Spindle cell Clear cells Palisading

-

Trabecular Glandular Follicular Rosette like Papillary pattern Solid pattern Oncocytic pattern

TC is a circumscribed but not encapsulated

Organoid nests with fibrovascular stroma.

Solid pattern. Nucleus with finely granular chromatin (“salt and pepper�).

Oncocytic pattern

The cytologic appearence of the NE cells is basically the same: a round to oval shaped cell, with a moderate amount of eosinophilic citoplasm and nucleus with finely granular chromatin.

Travis W.D: 1991 Lihara K: 2005 Rossi G: 2016

ARRIGONI (1972) and TRAVIS (2004): 5 criteria

- Histopathology.

- Immunohistochemical demonstration of at least one specific neuroendocrine marker.

TYPICAL CARCINOID 0. 5 – 2. 0 cm < 2 mitotic figures per 2 mm 2 (10 HPF)

ATYPICAL CARCINOID > 2. 5 cm 3 - 10 mitotic figures per 2 mm 2 (10 HPF)

Without necrosis

With necrosis

Ki – 67

Ki – 67

<5%

Neuroendocrine marker – overexpression

> 20 %

Neuroendocrine marker – overexpression

IMUNOHISTOCHEMISTRY OF CARCINOIDS

CHROMOGRANI A +++

CD 56 +++

MIB-1 (Monoclonal antibody for the antigen Ki–67) Fraction of Growth < 5 % TC

MIB-1 (Monoclonal antibody for the antigen Ki–67) Fraction of Growth > 35 % AC

5 – 20 % metastases 5 year survival 100 %

> 50 % metastases 10 year survival 87 %

5 year survival 59 %

10 year survival 35 %

The microvascular component: distribution of antibody agianst alfa-SMA in the sinuisoidal capillars.

Perivascular stroma has undergo changes such as fibroelastosis and β-fibrillar deposits.

Pro-apopotic Bax +++

CONCLUSIONS DIPNECH is a primary process, also precursor of Tumorlets and for typical and atypical Carcinoids 20 cases with DIPNECH (39. 2 %) are diagnosed Aguayo - Miller Disease.

In all our cases we have revealed:  DIPNECH involved terminal bronchioles, respiratory bronchiols with nodular proliferation and linear proliferation in the alveolar ducts and alveols.  Obstructive bronchiolitis, interstitial fibrosis with little active interstitial inflammation and panacinar emphysema.  Multiple Tumorlets.  Mutiple typical Carcinoids.

The tumorlets represent a tiny peripheral carcinoid that differs mainly in size from the larger lesions identified as carcinoid tumours.