Tumours of kidney and urinary tract – update on WHO classification, IHC

and molecular morphology STEWART FLEMING

UNIVERSITY OF DUNDEE

• MAJOR PARADIGM SHIFT IN EARLY 1990S IN UNDERSTANDING RENAL CANCER

A CLASSIFICATION …BASED ON UNDERSTANDING THE GENETIC ABNORMALITIES INVOLVED WILL BE ROBUST IN TERMS OF BIOLOGY, CLINICAL BEHAVIOUR AND RESPONSE TO THERAPY

Molecular differential pathology of renal cell tumours G. KOVACS

TUMOUR HISTOLOGY MATTERS BECAUSE IT REVEALS THE UNDERLYING GENETICS

WHO v4 • Clear cell renal cell carcinoma VHL and 3p-

– Multilocular clear cell renal cell neoplasm of low malignant potential • Papillary renal cell carcinoma c-met and chr 7+; Fumarate hydratase • Chromophobe renal cell carcinoma Multiple chromosome loss

– Hybrid oncocytic chromophobe tumour Folliculin • Carcinoma of the collecting ducts of Bellini • Renal medullary carcinoma INI1 and sickle cell • MiT family translocation renal cell carcinoma

– Xp11 translocation renal cell carcinoma – t(6;11) renal cell carcinoma

• Carcinoma associated with neuroblastoma • Mucinous tubular and spindle cell carcinoma Multiple chromosomal losses • Tubulocystic renal cell carcinoma Fumarate hydratase • Acquired cystic disease associated renal cell carcinoma • Clear cell papillary (tubulopapillary) renal cell carcinoma • Hereditary leiomyomatosis associated renal cell carcinoma Fumarate hydratase • SDH deficient RCC SDHB • RCC with monosomy 8 Monosomy * TCEB1 • ALK associated RCC ALK translocation or amplification • Renal cell carcinoma, unclassified

HISTOPATHOLOGY 3p LOSS

VHL MUTATION

Y N Y N

CLEAR CELL 25 8 18 25

PAPILLARY 1 7 0 8

ONCOCYTOMA 2 3 0 5

CHROMOPHOBE 0 3 0 3

FOSTER ET AL 1994 Somatic mutations of the von Hippel - Lindau disease tumour suppressor gene in non-familial clear cell renal carcinoma

GENETIC ALTERATION IN RCC CORRELATES STRONGLY WITH MORPHOLOGY

3p FISH

HYPOXIA SENSING AND RCC

PROLINE HYDROXYLASE

OXOGLUTARATE

O RCC

MUTATED IN CLEAR CELL RCC

HYPOXIA INDUCIBLE PROTEINS MARK CLEAR CELL RCC

CARBONIC ANHYDRASE 9

TUMOUR HISTOLOGY MATTERS BECAUSE IT REVEALS THE UNDERLYING GENETICS

WHO v4 • Clear cell renal cell carcinoma VHL and 3p-

– Multilocular clear cell renal cell neoplasm of low malignant potential • Papillary renal cell carcinoma c-met and chr 7+; Fumarate hydratase • Chromophobe renal cell carcinoma Multiple chromosome loss

– Hybrid oncocytic chromophobe tumour Folliculin • Carcinoma of the collecting ducts of Bellini • Renal medullary carcinoma INI1 and sickle cell • MiT family translocation renal cell carcinoma

– Xp11 translocation renal cell carcinoma – t(6;11) renal cell carcinoma

• Carcinoma associated with neuroblastoma • Mucinous tubular and spindle cell carcinoma Multiple chromosomal losses • Tubulocystic renal cell carcinoma Fumarate hydratase • Acquired cystic disease associated renal cell carcinoma • Clear cell papillary (tubulopapillary) renal cell carcinoma • Hereditary leiomyomatosis associated renal cell carcinoma Fumarate hydratase • SDH deficient RCC SDHB • RCC with monosomy 8 Monosomy * TCEB1 • ALK associated RCC ALK translocation or amplification • Renal cell carcinoma, unclassified

0

10

20

30

40

50

60

70

80

90

100

CUMULATIVE FREQUENCY BY DIAGNOSIS OF RCC TYPES

RARE TYPES <2% 200-300 CASES PER ANNUM UK

COLLECTING DUCT CARCINOMA

1. Medullary involvement 2. Predominant tubular morphology 3. Desmoplastic stromal reaction 4. Cytologically high grade 5. Infiltrative growth pattern 6. Absence of other renal cell carcinoma subtypes or urothelial carcinoma • OCT ¾ neg, p63 neg • High MW CK pos

DISEASE SPECIFIC MORTALITY CCRCC CDC

WRIGHT ET AL

*p < 0.001

• Lymph node metastases are common and early (42%)

• Blood borne metastases M1 at presentation 45%

• 40% of CDC have urinary collecting system invasion

TUBULOCYSTIC CARCINOMA

• FORMERLY LOW GRADE CDC

• STRONG MALE PREDOMINANCE

• >75% KIDNEY CONFINED

• 10-15% PROGRESS WITH METASTASES AND DEATH POSSIBLE

TUBULOCYSTIC CARCINOMA OF KIDNEY

WELL

CIRCUMSCRIBED

TUBULAR OR

MICROCYSTIC

SINGLE LAYERED

CUBOIDAL EPITHELIUM

MILD NUCLEAR

PLEOMORPHISM

CHROMOPHOBE V ONCOCYTOMA

MORPHOLOGY

PERINUCLEAR HALO

BINUCLEATE CELLS

RAISINOID NUCLEI

MITOSES

CHROMOPHOBE V ONCOCYTOMA IMMUNOPHENOTYPE

ANTIBODY CHROMOPHOBE ONCOCYTOMA

DIFFUSE CK7 65% RARE

FOCAL CK7 35% 79%

CD117 MOST MOST

RCC 45% <5%

CD82 78% RARE

AMACR 36% >90%

PAX 2 6% >90%

CK 7 CHROMOPHOBE CARCINOMA V ONCOCYTOMA

CK7 CHROMOPHOBE ONCOCYTOMA

CHROMOPHOBE V ONCOCYTOMA

FLOW CYTOMETRY

ONCOCYTOMA DIPLOID

CHROMOPHOBE HYPODIPLOID

CHROMOSOMAL LOSSES

FISH

MOLECULAR VIRTUAL KARYOTYPING

CHROMOPHOBE V ONCOCYTOMA

CHROMOPHOBE

MULTIPLE

CHROMOSOMAL

LOSSES

ONCOCYTOMA

DIPLOID WITH

OCCASIONAL 1-

CHROMOSOME 2 PROBE BRUNELLI ET AL 2006

CHROMOPHOBE V ONCOCYTOMA

MORPHOLOGY

IMMUNOCYTOCHEMISTRY

FISH

CENTROMERIC PROBES 2,6,7,9,10,13,17

COMPARED TO CONTROL (CH 9)

>33% SINGLE COPY – LOSS

>11% ADDITIONAL COPIES - GAIN

ESRD ASSOCIATED RCC

• 30 YEAR HISTORY OF RCC IN ESRD

• PREVIOUSLY CONSIDERED TO BE MOSTLY PAPILLARY

• NOW AT LEAST TWO NEW TYPES OF RCC RECOGNISED IN THIS CLINICOPATHOLOGICAL CONTEXT – ACKD ASSOCIATED RCC

– CLEAR CELL PAPILLARY RCC IN ESRD

• 60% OF RCC IN ESRD

OXALATE AND ACKD RCC

SULE et al 2005

•OFTEN ENCAPSULATED

•OFTEN ARISING FROM CYST

•SOLID TUBULO-ACINAR MORE

OFTEN THAN PAPILLARY

ARCHITECTURE

•FINE LUMINAL SPACES

•CALCIFICATION & PSAMMOMA

BODIES

•LARGE CELL WITH EOSINOPHILIC

CYTOPLASM

•ONLY OCCASIONALLY CLEAR

CELL

IHC AND ACKD RCC

• There are conflicting data on CD57 expression.

• Usually CK7, CD10 and RCC positive

CD57 IHC

CLEAR CELL PAPILLARY RCC

• ACKD OR NON-CYSTIC ESRD

• TUBULO-PAPILLARY ARCHITECTURE

• MAY BE CYSTIC

• CLEAR CELL CYTOLOGY

• SUBNUCLEAR CLEAR CYTOPLASM

– MIMICKING SECRETORY ENDOMETRIUM

Aydin et al Am J Surg

Path 2010

CLEAR CELL PAPILLARY RCC

• NO VHL MUTATION NOR 3P LOSS

• NO TRISOMIES OF 7 AND 17

• POSITIVE CK7, HIF1a, CaIX

• NEGATIVE CD10, AMACR, TFE3

MiT FAMILY TRANSLOCATION RENAL CELL CARCINOMA

• YOUNGER PATIENTS

• MIXED CLEAR CELL

AND PAPILLARY

• VOLUMINOUS

CYTOPLASM

• PSAMMOMA BODIES

• TFE3, rarely B or C in

nucleus

• FISH

TFE 3 IHC

INHERITED RCC

• VHL

• FAMILIAL PAPILLARY RCC

• BIRT HOGG DUBE SYNDROME

• TUBEROUS SCLEROSIS

• HLRCC

• SDHB

• NON-SYNDROMIC FAMILIAL RCC

DIAGNOSIS – MUTATION – FAMILY MEMBERS - SCREENING

1973

HEREDITARY LEIOMYOMATOSIS AND RENAL CELL CARCINOMA (HLRCC)-ASSOCIATED

RENAL CELL CARCINOMA AND FUMARATE HYDRATASE MUTATION

• FIRST REPORT TYPE 2 PAPILLARY

• SECOND REPORT LOW GRADE CDC (TUBULOCYSTIC)

• SUBSEQUENT REPORTS ARCHITECTURE MAY BE TUBULAR, PAPILLARY, TUBULOCYSTIC OR MIXED

• USUALLY SOLITARY TUMOUR

• NUCLEOLAR MORPHOLOGY

• AGGRESSIVE BEHAVIOUR

• MUTATION MUST BE DEMONSTRATED

TOMLINSON ET AL 2002 ALAM ET AL 2003

2010 FAMILY HISTORY SUMMARY

Malignant phaeochromocytoma aged 24

EC

Renal tumour histologyunknown

ADRENAL

PHAEOCHROMOCYTOMA

RCC RCC

?VHL NO VHL MUTATIONS

?

SUCCINATE DEHYDROGENASE DEFICIENT RCC 2010

MUTATION IN THE SDHB GENE ARE FOUND IN THE FAMILY MEMBERS WITH THE CANCERS BUT NOT THOSE WITHOUT

SUCCINATE DEHYDROGENASE DEFICIENT RCC

Gill et al 2014

SDHB IHC

Isaacs J et al

2-OXOGLUTARATE AND FUMARATE/SUCCINATE COMPETE FOR THE BINDING SITE ON THE PROLINE HYDROXYLASE

HIF PROLINE HYDROXYLATION

UBIQUITIN DEPENDENT DEGRADATION

NORMOXIA NORMAL pVHL

VHL MUTATION

HIF PROLINE HYDROXYLATION

DEGRADATION FAILURE

MUTANT VHL

O2

O2

O2 FAILED HIF PROLINE HYDROXYLATION HIF

ACCUMULATION

NORMOXIA

O2 HIF PROLINE HYDROXYLATION

NORMOXIA

O2

NORMAL pVHL HIF PROLINE

HYDROXYLATION

NORMOXIA

O2

NORMAL pVHL HIF PROLINE

HYDROXYLATION

NORMOXIA

O2 UBIQUITIN DEPENDENT HIF DEGRADATION

NORMAL pVHL HIF PROLINE

HYDROXYLATION

NORMOXIA

O2

VHL MUTATION

O2 HIF PROLINE HYDROXYLATION

VHL MUTATION

O2 HIF PROLINE HYDROXYLATION

VHL MUTATION

O2 MUTANT VHL HIF PROLINE

HYDROXYLATION

VHL MUTATION

O2

VHL MUTATION

O2 HIF PROLINE HYDROXYLATION

VHL MUTATION

O2 HIF PROLINE HYDROXYLATION

VHL MUTATION

O2 O2

VHL MUTATION

O2 HIF PROLINE HYDROXYLATION

VHL MUTATION

O2 MUTANT VHL HIF PROLINE

HYDROXYLATION

VHL MUTATION

O2 MUTANT VHL HIF PROLINE

HYDROXYLATION

VHL MUTATION

O2 MUTANT VHL HIF PROLINE

HYDROXYLATION

VHL MUTATION

O2 DEGRADATION FAILURE

MUTANT VHL HIF PROLINE HYDROXYLATION

VHL MUTATION

O2

O2 O2 O2 FAILED HIF PROLINE HYDROXYLATION

O2 FAILED HIF PROLINE HYDROXYLATION

O2 HIF ACCUMULATION

‘PSEUDOHYPOXIA’

FUMARATE OR SUCCINATE ACCUMULATION

CONCLUSIONS

• MOLECULAR ALTERATIONS REMAIN AS THE BASIS FOR THE CLASSIFICATION OF RENAL CANCER

• ACCURATE AND COMPLETE CATEGORISATION OF INDIVIDUAL TUMOURS IS BASED ON SOUND MORPHOLOGY SUPPORTED BY IHC AND MOLECULAR GENETICS