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Histopathological Patterns of Ovarian Tumours and HER2 Expression in Epithelial Ovarian Carcinoma

Histopathological Patterns of Ovarian Tumours and HER2 Expression in Epithelial Ovarian Carcinoma

*Barua M,1  Hossain MI,2  Bini UH,3 Nasreen S,4 Ahamad MU,5 Bhattecharjee P,6 RahmanM Z7

 

 

  1. * Mitasree Barua, Lecturer, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh. mitakmc12@gmail.com
  2. Mohammad Ismail Hossain, Lecturer, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh
  3. Umme Habiba Bini, Assistant Professor, Department of Pathology, Pabna Medical College, Pabna, Bangladesh.
  4. Sayeeda Nasreen, Assistant Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
  5. M. Sahab Uddin Ahamad, Associate Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
  6. Pradip Bhattacharjee, Associate Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
  7. Md. Zillur Rahman, Professor & Head, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.

 *For correspondence

 Abstract

Background: Ovarian tumours are a heterogenous group of neoplasm of epithelial, stromal and germ cell origin. The management of which depends on the histological type of the tumour. Neoadjuvant chemotherapy is limited by toxicity and resistance. Hence targeted therapy is now being proposed to overcome these hurdle.

Objectives: To find out the histopathological patterns of ovarian tumours and to evaluate HER2 overexpression in epithelial ovarian carcinoma.

Methods: This study was carried out in the Department of Pathology, Chittagong Medical College, Chattogram, received from Department of Gynaecology and Obstetrics, Chittagong Medical College Hospital, Chattogram during the period from January 2016 to December 2016. A total of 92 cases of ovarian tumours were selected consecutively. The age range was 12-80 years. Histopathological sections were stained with Hematoxylin and Eosin stain and epithelial ovarian carcinoma were subjected to HER2/neu immunohistochemical stain. Histopathological patterns of ovarian neoplasm, histopathological subtyping and grading of epithelial ovarian tumours and the expression of HER2/neu among epithelial ovarian carcinomas on immunohistochemistry was analyzed.

Results: Out of total 92 cases, histopathological diagnosis showed 65 (70.7%) were benign tumours and 27 (29.3%) were malignant tumours. Histologically, surface epithelial tumours were the most common (74%) followed by germ cell tumours (21.7%) and sex cord stromal tumours (4.3%). Age incidence of benign tumour was age group of 21-40 yrs and malignant 41-60 years. One in 23 epithelial ovarian carcinoma cases (4.3%) exhibits HER2 overexpression. Only one HER2 positive case was mucinous cystadenocarcinoma grade II.

Conclusion: Surface epithelial tumours were most common followed by germ cell tumours. Serous cystadenocarcinoma were most common epithelial ovarian carcinoma.

 

[Journal of Histopathology and Cytopathology, 2020 Jan; 4 (1):23-32]

 Keywords: Ovarian tumour, Epithelial Carcinoma, HER2/neu.

 

Introduction

Ovarian tumours account for 3% of all cancers in females, being the second most common cancer of the female genital tract, next only to uterine cancer.1 Ovarian cancer, traditionally known as the silent killer, is a dreaded disease because of its vague, nonspecific symptoms and late presentation. Worldwide, it is the seventh most common cause of cancer and eighth most common cause of cancer-related death among women.2 It is be a disease of developed and industrialized countries where parity of women is low. As the standard of living increases and resources for a medical infrastructure improve in Bangladesh, there will be an increased need to address less common but highly lethal cancers such as ovarian cancer. Globocan predicts a change in the reported incidence of ovarian cancer from 2912 in year 2012 to 3132 in year 2015.3

Risk factors for ovarian cancer are not well defined. However, there is general agreement on two: nulliparity and family history. Women 40 to 59 years of age who have taken oral contraceptives or undergone tubal ligation have a reduced risk of developing ovarian cancer.4 Two treatment options, available for ovarian cancers in advanced stage, are either a primary surgical cytoreduction/debulking or chemotherapy in an attempt to downstage the tumor followed by surgery. Though platinum-based therapy has produced an impressive result, chemoresistance and toxicity are creating hurdles. To overcome this, monoclonal antibodies targeting HER2/neu, a transmembrane protein homologous to epidermal growth factor receptor, has been introduced recently that might bring a new era of management.5

HER2/neu protein expression is commonly measured using immunohistochemistry (IHC).6 Overexpression of HER2/neu is seen in 20–30% patients with ovarian cancer. Some of these differences are likely to be attributable to the diagnostic technique used to measure HER2 expression. HER2/neu overexpression in epithelial ovarian carcinomas has not been studied as extensively as it has been studied in case of breast carcinomas, especially in Bangladesh scenario.

The aim of my study was to determine histopathological patterns of ovarian tumor and to evaluate the frequency of the expression of HER2 among epithelial ovarian carcinomas.

 Methods

It was a cross-sectional descriptive study carried out in the Department of Pathology of Chittagong Medical College, Chattogram, Bangladesh. Study period was for one year from 1st January, 2016 to 31st December, 2016. All female patients clinically diagnosed as ovarian neoplasm received at the Department of Pathology of Chittagong Medical College, Chattogram referred from Department of Gynaecology and Obstetrics, Chittagong Medical College Hospital (CMCH) during the specified time duration. Finally, 92 consecutive patients were selected according to time frame.

 Inclusion criteria

Patient with clinically diagnosed as ovarian tumours who underwent intervention like diagnostic laparoscopy or laparotomy; at least for biopsy in Chittagong Medical College Hospital, Chattogram.  Patient with histopathologically diagnosed ovarian tumour in the Department of Pathology, Chittagong Medical College.

 Exclusion criteria

Previously diagnosed case of ovarian tumour who already has got treatment. Patient unwilling to give written consent.

Protocol was ethically reviewed and approved by the Ethical review Committee of Chittagong Medical College, Chattogram. All the patients included in the study were informed and explained about the nature of study. Informed written consent was taken from all the subjects after full explanation of nature, purpose and potential risks of all the procedures.

A brief clinical history was taken from each patient with particular reference to the age, occupation, marital history, parity, menstrual history, family history, history of breast feeding, use of contraceptives etc. Clinical history, questionnaire, thorough physical examination, and relevant investigations were recorded in details in all cases.Routine histopathology with H & E stain and Immunohistochemistry for ovarian carcinoma were done.

H&E stained slides were examined under light microscope to get a definitive diagnosis of the ovarian tumour and its type. Histological classification was based on the 2003 World Health Organization classification of ovarian tumours. The Shimizu-Silverberg three-grade histological grading system was used in epithelial ovarian carcinoma (EOC).

The most representative tumor tissue was chosen from each epithelial ovarian carcinoma case and 4 μm sections were taken to poly-L-lysine coated slides for immunohistochemical staining. For immunohistochemistry, epitope retrieval was done with a polymer-based detection system (Envision; Dako) using a Herceptin kit (HercepTest; Dako) according to the manufacturer’s instructions.Antigen retrieval for HER2 using Hercep Test was performed by immersing and incubating the slides in 10 mmol/L citrate buffer in calibrated water bath (95- 99°C) for 40 minutes. After decanting the epitope-retrieval solution, the sections was rinsed in the wash buffer and later, soaked in the buffer for 5 to 20 minutes before staining. Then the slides were rinsed, placed in 200 μL peroxidase-blocking reagent for 5 minutes, rinsed, placed in 200 μL primary anti-HER2 protein (or negative control reagent) for 30 minutes, rinsed twice, and finally immersed in 200 μL substrate chromogen solution (3,3´-diaminobenzidinetetrahydrochloride, DAB) for 10 minutes. The slides were counter stained with hematoxylin and finally were cover slipped.

 Results

In this study the age range of 92 ovarian tumours was 12-80 years, were divided into seven age groups and it was observed that maximum number of benign lesions 19 (20.6%) were in age groups 21-30 years. Maximum number of malignant tumours were found 9 (9.8%) in age group 41-50 years. Among 92 ovarian lesions, 68 (74%) were surface epithelial tumour, 20 (21.7%) were germ cell tumour, 4 (4.3%) were sex cord stromal tumours .

Discussion 

Current study was carried out in Departmant of pathology, Chittagong Medical College to see the histopathological patterns of ovarian tumours and HER2 expression in epithelial ovarian carcinoma (EOC).Total number of the patients in this study was 92. The age range was 12-80 years. The mean age was 34.64 years. Patients were divided into seven groups consisting of each decade as a single group and maximum number patients 23 (25%) were in 21 – 30 years group, followed by 21 (22.8%) were in 41-50 years age group. Study done in Nepal by Vaidya et al.(2014) showed highest number of patients (58%) were in 21-40 years age group which is similar to present study.7 In this study in 21-40 years age group total number of patients were 42 (45.65%). Study done in India by Bhagyalakshmi et al (2014)) patients age ranged from 11-70 years, majority of benign cases and malignant cases were between 21 to 40 years and 41 to 60 years respectively.8 Agrawal et al. (2015) also showed age ranged from 12 to 80 years with most common benign and malignant lesions cases were 21 to 40 years and 41 to 60 years respectively which was consistent with this study.9

In this study, among 92 cases, 72 (78.3%) were married and 20 (21.7%) cases were unmarried women. This is probably due to more married women presented to the outpatient department than unmarried ones. Among 72 married women 08 (11.1%) were nulliparous, 03(4.2%) were primiparous and 64 (84.7%) were multiparous.Study done in Dhaka by Dhar et al (2015) showed 8% were unmarried and 92% were married, of whom 12% were nulliparous and 80% was parous.10

Regarding socio-economic status 68 (73.9%) cases were from average socioeconomic condition, 23 (25%) were from poor and only 1 (1.1%) cases from high socioeconomic family. Among the malignant cases maximum 13 (48.1%) cases were from average socioeconomic condition. This is similar to the finding of  Dhar et al (2015).10This may be due to the fact that patients attended at a government hospital and most of the people of average and poor socioeconomic conditions usually come here to get treatment.

In this study, it was seen that, 19 (20.7%) had history of hormonal contraceptive use and 49 (53.3%) had no history. Among 27 malignant cases 3 (11.1%) had history of contraceptive use. Ness et al (2011) had reported that oral contraceptives reduce the risk of developing ovarian cancer.11

In this study 75 (81.5%) patients presented with lower abdominal pain 74 (80.4%) with lower abdominal mass. Study done by Jaffar et al (2013) showed, abdominal pain was in 90% cases, abdominal mass was present in 24% of the patients with benign tumours and in 66% with malignant tumours.12

In the present study, among 65 benign lesions 20 (21.7%) cases had increased level of CA-125 and among 27 malignant lesions 3(3.3%) cases were found within normal level.Miralles et al. (2003) suggested that variety of malignancies and benign conditions courses with increased CA-125 level and it is observed that CA-125 is very important as tumour marker for malignancy.13

In the present study, out of 65 benign tumours 62(95.3%) were unilateral and 3(4.6%) were bilateral. Out of 27 malignant tumours 5(18.51%) were bilateral and 22(81.48%) were unilateral. Modepalli et al (2016) reported 93.8% of the neoplasms were unilateral and remaining 6.2% of the lesions were bilateral.14 Benign tumours were more unilateral than malignant tumours. In this present study, out of 92 cases, maximum number of lesions were 48 (52.2%) in the right side of abdomen which is similar to the study done by Modepalli et al (2016).14

Among 92 cases 43 (46.7%) were solid and cystic lesion, 41 (44.6%) were cystic lesions and 8 (8.7%) were solid. Similar study done by Agrawal et al (2017) showed 83.3% benign tumours were cystic whereas 65.3% malignant tumours were solid and cystic.9 Benign tumors were more often cystic in consistency in this study and malignant tumors were solid consistency which was comparable to the study of Kanthikar et al. (2014).15

In this study of the 92 cases of ovarian tumours, 67 (70.7%) were benign and 27 (29.3%) were malignant. Similar studies in India carried out by GG swamy et al. (2010) showed 86 (71.6%) benign tumours, 30 (25.1%) malignant and 4 (3.3%) borderline tumors.16 In Nepal R Jha et al reported 83.9% benign, 16.1% malignant and 2.8% borderilne ovarian tumour.17 In  Pakistan a similar study by Ahmed et al showed 59.18% benign and 40.81% malignant tumour. In this study there was no borderline malignancy which were similar to the study done by Yasmine et al. (2008).18

Among the histologic types, in the present study, surface epithelial tumours were most common 68 (74%), germ cell tumour was 20 (21.7%), and sex cord stromal tumour was 4 (4.3%).Similar observation made by Pilli et al.(2002) showed 70.9% surface epithelial tumours, 21.2% germ cell tumours and 6.7% sex cord stromal tumours.19

In this present study Among 92 cases the most common benign surface epithelial tumour was mucinous cystadenoma 26 (28.3%) followed by serous cyst adenoma 18 (19.6%) and benign brenner tumour 1(1.1%). The most common benign germ cell tumour was mature cystic teratoma 18 (19.6%).In this study benign sexcord stromal tumour was fibroma 2(2.2%). Studies done by Bhagyalakshmi et al (2014)8 and Mondol et al (2011)20 showed serous cystadenoma was the most common benign tumour. Study done by Ahmed et al (2000) however found the most common benign tumour to be benign cystic teratoma.21

The commonest malignant tumour was serous cyst adenocarcinoma 13 (14.1%), followed by mucinous cystadenocarcinoma 8 (8.7%), malignant brenner tumour 1 (1.1%) and clear cell carcinoma 1 (1.1%). Similar results were shown in studies by Mondol et al (2011) and Yogambal et al (2014).22

In this present study 23 cases of epithelial ovarian carcinoma (EOC) were evaluated for HER2/neu protein expression using immunohistochemistry.The positive expression rate of HER2/neu in this study was 1(4.3%).This is comparable to the rate of  HER2/neu positivity in EOC reported in the literature,which ranges from 7-50%Verri et al (2005),23 Berchuck et al (1990),24 Mayr et al (2006).25 The variation in HER2/neu protein expression rate in different studies may be early stage and 17% of patients with advanced stage disease in the study by Kacinsky et al (1992). However, multiple factor may be involved in producing a wide range of positivity, such as sample size, the detection technique and type of monoclonal antibody used, staining intensity and the tissue where analysis is performed. Studies with populations smaller than 100 patients reported a frequency of 1.8-76%,(Serrano-Olvera et al., 2006).26

In this study among 8 mucinous cystadenocarcinoma, HER2 expression was positive in 1 (12.5%) case and was in Grade-II. In the study done by Missaoui et al (2014),27 HER2 expression was described in 14.3% of mucinous carcinoma. Study in Nijeria done by Ajani et al.(2015) 28 observed that a higher proportion of serous carcinoma (as opposed to mucinous carcinoma) was HER2/neu positive. Sarkar et al (2015)2 also showed that HER2 expression was more intense for high grade serous carcinoma.

In this study HER2 expression is relatively common in mucinous epithelial carcinoma of the ovary and trastuzumab therapy would be an option for patients with mucinous carcinoma when the tumour has HER2 overexpression.

The study also has some limitations. This study was severely constrained by the limited duration that led to have small population size and this study was done in patient who underwent surgery and samples were collected from Chittagong Medical College and Hospital only. In spite of these reason the present study showed more or less acceptable findings with consideration of the observations by others.

 Conclusion

Ovarian cancer presents a tremendous clinical challenge to gynecologists, medical oncologists and radiotherapists. It is a silent menace and is not associated with significant symptoms. Surface Epithelial Tumours were the commonest group followed by Germ Cell Tumours. Most common Germ cell tumours were mature cystic teratoma occured in much younger women. Malignant ovarian neoplasms were more common in patients above 40 years. Sex Cord Stromal Tumours were also common with Fibroma and Granulosa cell tumour. Unilateral involvement of ovarian neoplasms was more common than bilateral and involvement of right ovary was more than the left. Mucinous cystadenoma was the commonest benign ovarian neoplasm while the commonest malignant tumour was serous cystadenocarcinoma. Mucinous epithelial carcinoma have expressed HER2.

 References

  1. Lora EH, & Edyta PC. The Female Genital Tract. 8 ed. Philadelphia; Saunders; 2010.1040p.
  2. SarkarM, JhaT, Das TK, SauV et al. Spectrum of Epithelial ovarian tumors with HER2/new expression by the carcinomas among patients admitted in a tertiary care hospital in Eastern India.J Med Sci Public Health. 2015; 4(10):1388-1392.
  3. Pervin S, Islam F, Hall T, & Goodman A. The management of ovarian cancer in Bangladesh: A report of a long-term survivor.Austin Journal of obstetrics and Gynecology. 2015;2(4):1047.
  4. Ness RB, Dodge RC, Edwards RP, et al. Contraception Methods, beyond Oral Contraceptives and Tubal. Ann Epidemiology. 2001;21(3):188–196.
  5. Ray-Coquard I, Gaustalla JP, Allouache D, Combe M, et al. HER2 Overexpression / amplification and trastuzumab treatment in advanced ovarian cancer: a GINECO Phase II study. Clin Ovarian Cancer. 2008;1(1):54-59.
  6. Wolff AC, Hammond ME, Schwartz JN. et al. American Society of Clinical Oncology/College of American Pathologists guideline recommendations for human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol. 2007;25:118–45.
  7. Vaidya S, Sharma P, KC S,Vaidya SA . Spectrum of ovarian tumour in a referral hospital in Nepal. Journal of Pathology Nepal. 2014; l4: 539-543.
  8. BhagyalakshmiA, SreelekhaA, Sridevi S, Chandralekha J, Parvathi G,Venkatalaksmi A Prospective study of histopathological patterns of ovarian tumours in a tertiary care centre. International Journal of Research in Medical Sciences. 2014;2(2):448-456.
  9. Agrawal P, Kulkarni DG, Chakrabarti PR, Chourasia S, Dixit M, Gupta K. Clinicipathological Spectrum of Ovarian Tumors: A 5 Year Experience in a Tertiary Health Care Center. Journal of Basic and Clinical Reproductive Science. 2015;4(2), 90-96.
  10. Dhar SR, Begum S, Zabin F, Akter S. Socio-demographic Characteristics of Ovarian Tumor Patients attended at a tertiary care hospital in Dhaka city. Journal of Current and Advance Medical Research. 2015;2(2):39-41.
  11. Ness RB, Dodge RC, Edwards RP, et al. Contraception Methods, beyond Oral Contraceptives and Tubal. Ann Epidemiology. 2001;21(3):188–196.
  12. Jaffer Y, Ehsan N, Ambreen. Clinical presentation of ovarian tumors. Journal of Surgery Pakistan (International). 2013;18(2):82-86.
  13. Miralles C, Orea M, España P, Provencio M, Sánchez,A, Cantos B,etal.Cancer Antigen 125 Associated With Multiple Benign and Malignant Pathologies. Annals of Surgical Oncology. 2003;10(2):150–154 DOI: 10.1245/ASO.2003.05.015
  14. Modepalli N and VenugopalSB. Clinicopathological Study of Surface Epithelial Tumours of the Ovary. An Institutional Study,Journal of Clinical and Diagnostic Research. 2016;10(10):01-04.
  15. Kanthikar SN,Dravid NV, DeorePN ,Nikumbh DB, Suryawanshi KH. et al.Clinico-Histopathological Analysis of Neoplastic and Non-Neoplastic Lesions of the Ovary: A 3-Year Prospective Study in Dhule, North Maharashtra, India,Journal of Clinical and Diagnostic Research. 2014;8(8):04-07.
  16. Swamy GG, SatyanarayanaN.Clinicopathological analysis of ovarian tumor – a study on five year samples. Nepal Med Coll J. 2010;12(4):221-3.
  17. Jha R & Karki S. Histological pattern of ovarian tumors and their age distribution.Nepal Med Coll J. 2008;10(2):81-85.
  18. Yasmin S, Yasmin A, Asif M. Clinicohistological pattern of ovarian tumors in Peshawar region. J Ayub Med Coll Abbottabad. 2008;20:11–13.
  19. Pilli GS, Suneeta KP, Dhaded AV, Yenni VV. Ovarian tumours: A study of 282 cases. J Indian Med Assoc. 2002; 100:423-424.
  20. Mondal SK, Bandopadhyay R, Nag DR, Roychowdhury S, Mondal PK, Sinha SK, Histological pattern, bilaterality and clinical evaluation of 957 ovarian neoplasms. A 10 year study in a tertiary hospital of Eastern India. J Can Res Ther.2011; 7:433-437.
  21. Ahmad Z, Kayani N, Hasan SH & Muzaffar S. Histopathological Pattern of Ovarian NeoplasmJ Pak Med Assoc. 2000;50(12):416-419.
  22. Yogambal M, Arunlatha P, Chandramouleeswari K, PalaniappanV.Ovarian tumors- incidence and distribution in a tertiary referral center in south India. IOSR-JDMS 2014;13(2):74-80.
  23. Verri E, Guglielmini P, Puntoni M, Perdelli L, Papadia A, Lorenzi P, et al. HER2/neuoncoprotein overexpression in epithelial ovarian cancer: evaluation of its prevalence and prognostic significance. Oncology. 2005;68:154–61.
  24. Berchuck A,Kamel A,Whitaker R, Kerns B, Olt G, Kinney R, et al. Over-expression of HER-2/neu is associated with poor survival in advanced epithelial ovarian cancer.Cancer Res.1990;50:4087–91.
  25. Mayr D, Kanitz V, Amann G, et al. HER-2/neu gene amplification in ovarian tumours: a comprehensive immunohistochemical and FISH analysis on tissue microarrays. Histopathology. 2006;48:149–56.
  26. Serrano-OlveraA,Dueñas-González A, Gallardo-Rincón D, Candelaria M, Garza J. et al . Prognostic, predictive and therapeutic implications of HER2 in invasive epithelial ovarian cancer. Cancer treatment reviews. 2006;32(3):180-90.
  27. Missaoui N, Ben AS, Ayachi M, Hmissa S,  Yaacoubi M et al. (2014). HER2 Expression in Ovarian Mucinous Carcinomas in Tunisia. Asian Pacific journal of cancer prevention: APJCP. 2014; 15(19): 8121-5.
  28. Ajania MA, Salamia A, Awoludeb OA,Oluwasolaa AO, and Akang EU, etal. The expression status of human epidermal growth factor receptor 2 in epithelial ovarian cancer in Ibadan, Nigeria South Afr J Gynaecol Oncol. 2016; 8(1):1–13.
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Correlation of Lymphovascular Density with Histological Prognostic Parameters in Gastric Carcinoma

Correlation of Lymphovascular Density with Histological Prognostic Parameters in Gastric Carcinoma

*Hassan MI,1 Kabir AN,2 Poly FH,3 Ray S,4 Munmun UK,5 Mehjabin M6

 

  1. * Mohammed Imran Hassan, Assistant Professor (CC), Department of Pathology, National Institute of Diseases of Chest and Hospital, Mohakhali, Dhaka. imran.vua@gmail.com
  2. AKM Nurul Kabir, Associate Professor, Department of Pathology, BangabandhuSheikh Mujib Medical University, Shahbag,Dhaka.
  3. Ferdousi Hossain Poly, Medical Officer, OSD, DGHS, Attached- Department of Pediatric Neurology, National Institute of Neurosciences and Hospital, Dhaka.
  4. Subrata Ray, Assistant Professor, Department of Pathology, Jashore Medical College.
  5. Umme Kulsum Munmun, Lecturer, Department of Pathology, Dhaka Medical College, Dhaka.
  6. Monika Mehjabin, Lecturer, Department of Pathology, Shahid Suhrawardy Medical College, Dhaka.

*For correspondence

 Abstract

Background: Carcinoma of the stomach is a major cause of cancer mortality worldwide. Gastric cancer is actually a curable disease if it is detected at an appropriate stage and treated adequately. It rarely disseminates widely before it has involved the lymph nodes and, therefore, there is an opportunity to cure the disease prior to dissemination. Tumor-induced lymphangiogenesis plays a crucial role in metastasis and tumor progression. However, the significance of lymph vessel density has been controversial in gastric cancer. Specific lymphatic markers are now available making possible analysis of lymphatic in cancer. The aim of this study was to investigate the relation of lymph vessel density with histological prognostic factors in gastric cancer as potential indicator.
Objectives: To estimate of the lymph vessel density using Podoplanin immunostain in gastric cancer and then to correlate lymph vessel density with histological prognostic factors.
Methods: Sections from Paraffin blocks of gastric adenocarcinoma with routine stain were assessed to detect prognostic factors and then assessed with immunostain Podoplanin to count lymph vessel density. The mean number of lymph vessels in five hot spots was calculated in both intratumoral and peritumoral areas. Finally correlation was seen between histological prognostic factors and lymph vessel density in gastric carcinoma.
Results: A positive significant correlation was found between lymph node metastasis with lymph vessel density in both intratumoral and peritumoral area. Similarly, a positive significant correlation was found between tumor stage with lymph vessel density in both intratumoral and peritumoral area.

 [Journal of Histopathology and Cytopathology, 2020 Jan; 4 (1):12-22]

 Keywords: Podoplanin, Lymphovascular density, Gastric carcinoma

 Introduction

Carcinoma of the stomach is a major cause of cancer mortality worldwide. The prognosis of gastric carcinoma is poor with cure rates little better than 5–10%, although better results are obtained in Japan where the disease is common. Gastric cancer is actually a curable disease provided that it is detected at an appropriate stage and treated adequately. It rarely disseminates widely before it has involved the lymph nodes and, therefore, there is an opportunity to cure the disease prior to dissemination.1

Worldwide gastric cancer ranks fourth in frequency and second in cancer mortality rate; with a 5-year survival rate not exceeding 30% in Western countries.2 Gastric cancer incidence varies markedly with geography. In Japan, Chile, Costa Rica, and Eastern Europe the incidence is up to 20-fold higher than in North America, northern Europe, Africa, and Southeast Asia.1 The incidence of gastric carcinoma in Bangladesh is 5.2 per 100,000.3

 

Gastric cancer is a multi-factorial disease. Epidemiological studies point to a role for Helicobacter pylori, although its importance is disputed. Helicobacter pylori seem to be principally associated with carcinoma of the body of the stomach and the distal stomach rather than the proximal stomach. As Helicobacter is associated with gastritis, gastric atrophy and intestinal metaplasia, the association with malignancy is perhaps not surprising. Patients with pernicious anemia, gastric atrophy, duodenogastric reflux and reflux gastritis, intestinal metaplasia and cigarette smoking are at increased risk, as are those with gastric polyps. Diet appears to be important factor. The ingestion of substances such as spirits may induce gastritis and, in the long term, cancer. Excessive salt intake, deficiency of antioxidants and exposure to N-nitroso compounds are also implicated.1

The most useful classification of gastric cancer is the Lauren classification.4 In this system, there are principally two forms of gastric cancer: intestinal gastric cancer and diffuse gastric cancer. In intestinal gastric cancer, the tumor resembles carcinomas found elsewhere in the tubular gastrointestinal tract and forms polypoid tumors or ulcers. It probably arises in areas of intestinal metaplasia. In contrast, diffuse gastric cancer infiltrates deeply into the stomach without forming obvious mass lesions but spreading widely in the gastric wall.1

These tumors have several prognostic and predictive factors. The depth of invasion and the nodal and distant metastasis at the time of diagnosis remain the most important prognostic indicators for gastric carcinoma. Currently tumor size, nuclear grade and patient’s age are well known prognostic factors for patients with operable gastric cancer. These prognostic factors are widely used to determine whether to apply neo-adjuvant therapy in patient with gastric cancer.  In advanced cases, gastric carcinoma may first be detected as metastases to the supraclavicular sentinel lymph nodes, also called Virchow’s node. Gastric carcinoma can also metastasize to the periumbilical region to form a subcutaneous nodule, termed as Sister Mary Joseph nodule. Local invasion into the duodenum, pancreas, and retroperitoneum is also characteristic. In such cases efforts are usually focused on chemotherapy or radiation therapy and palliative care. However, surgical resection remains the preferred treatment for gastric carcinoma.5

Lymphangiogenesis is a critical process for tumor growth, invasion and metastasis.  That is why measurement of lymph vessel density may be clinically important in gastric cancer specimens. The induction of lymphangiogenesis by a tumor is controlled process, influenced by lymphangiogenic factors, which involve a complex interaction between tumor and endothelial cells.6 The pathologic approach to assess lymphangiogenesis involves microscopic estimation of lymph vessel density by using endothelial markers in immunohistochemistry.

On previous studies detection of lymphangiogenesis was limited due to lack of specific lymphatic endothelial markers. The recent discovery of anti-Podoplanin antibody has a major impact on lymphatic studies. Podoplanin has become a valuable marker for detecting lymph vessels and for identifying lymph vessel invasion in tumor.7

Podoplanin is a specific marker of the lymphatic endothelium and is not expressed in blood vessels. It is expressed by both developing and mature lymphatic endothelial cells and seems to be a more specific marker of lymphatic endothelial cells.  By electron microscopy and immunoelectron microscopy, it was demonstrated that Podoplanin is mainly expressed on the luminal surface of lymphatic endothelial cells.  Peritumoral (PT) lymphatic vessels are larger and more irregular than the intratumoral (IT) lymphatic’s, with a significantly lower density. Intratumoral lymphatic vessels are found in a large variety of tumors and are usually small, flattened and irregular. It was suggested that Podoplanin has potential role in invasion and metastasis of tumor. This hypothesis is mainly based on the observation that high expression of Podoplanin is consistently correlated with the presence of metastases. It was reported that Podoplanin expressing cells were found at the invasion.8 The use of an anti-Podoplanin-based therapeutic strategy could be suggested in the treatment of lymphatic metastases based on three considerations: (i) Podoplanin is a well-known marker of lymphatic endothelial cells; (ii) its expression seems to be associated with bad prognosis and high risk for lymph node metastases; (iii) it is involved in tumor invasion. In conclusion, Podoplanin is a sensitive marker of lymphatic endothelial cells and is very useful in evaluating lymphatic micro vessel density. Immunohistochemical detection of Podoplanin is helpful in the diagnosis of lymphovascular invasion.8 Some studies have suggested that lymph vessel density is associated with an increased risk of lymph node metastasis;9 however, this conclusion is not supported by all of the published studies.10

 

 

 

 

 

 

 

 

 

 

 

The study was conducted a) to investigate morphological prognostic factors of gastric adenocarcinoma, b) to estimate lymph vessel density by using immunostain Podoplanin and c) to correlate lymph vessel density with prognostic factors.

 Methods

It was a cross sectional observational study carried out from March, 2016 to July, 2018at the Department of Pathology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. The study population was paraffin blocks of gastric adenocarcinoma from pathological laboratory in the same Institute with consecutive convenience sampling. Inclusion Criteria was paraffin blocks of gastric samples diagnosed as gastric adenocarcinoma in pathology laboratory and Exclusion criteria were with history of treated gastric carcinoma cases like neo adjuvant therapy, blocks containing autolyzed tissue, extensive necrosis, hemorrhage and desmoplasia, blocks having no tissue or damaged blocks and blocks containing other cancers like lymphoma, carcinoid tumor, malignant GIST etc. The sample size was 53. Monoclonal Anti-Human Podoplanin antibody, clone D2-40, Ready to use (code- IR072) was used for detecting lymph vessel. In this study, sections of normal vermiform appendix were taken as positive control (as recommended by Dako). Podoplanin antigen expression was detected by immunohistochemistry in the submitted blocks (paraffin blocks with maximum tumor bulk were chosen) and were performed using DAKO Cytomation at immunohistochemistry laboratory, department Pathology, BSMMU.

Histopathological categorization of tumor and grading of all the cases were done. Lymphovascular invasion was recorded. Each lymph node was histologically examined to determine metastasis. Numbers of lymph vessels were counted by Weidner’s method in peritumoral (PT) and intratumoral (IT) areas.11

 Micro vessel Quantification

Determination of lymph vessel density (LVD) were performed according to Weidner et al.11Brown staining of cytoplasmic membrane of endothelial cells of lymph vessels were considered as positive reaction. Lymph vessel density was calculated according to Weidner’s method by Olympus microscope model BH51. The immunostained sections were scanned by light microscopy at low magnification (10x) and the areas of tissue with the greatest numbers of distinctly highlighted lymph vessels (“hot spots”) were selected. So, “hot spot” is an area with the most dense lymph vessels growth. Five hot spots were selected in intratumoral (IT) and peritumoral (PT) areas. When the hot spots were defined, lymph vessel count were performed by counting the individual stained lymph vessel (at power 20x) representing a field size of 0.74mm2 (i.e. – 20x objective lens, 10x ocular lens; equivalent to 0.7386 mm2 per 200x field).11 The mean number of lymph vessels in each case were determined and considered as the lymph vessel density.7So, at first five hot spots were chosen in intratumoral (IT) and peritumoral (PT) area. In each hot spot, lymph vessel count was performed at power x20. Finally lymph vessel density was calculated as the mean of the total number of lymph vessels in these five hot spots. Lymph vessel density (LVD) assessed in this manner may be not equivalent to LVD seen in multiple areas of multiple samples of the stomach; however, it is well accepted that these hot spots, not arbitrary areas, are representative of the entire tumor. Although there is some variability in the distribution of lymph vessels within the layers of the gastric wall, the five ‘hot spot’ areas were chosen to obtain an objective assessment and to avoid observer variation.7

Results

A total number of fifty three diagnosed cases of gastric adenocarcinoma were taken for this study. Forty six samples were partial/subtotal gastrectomy specimen and seven samples were total gastrectomy specimen. All fifty three samples contain epigastric lymph nodes ranging one to twenty five. Thirty seven cases had lymph node metastasis and the rest sixteen were free of tumor metastasis. Thirty seven cases were LVI positive in H&E routine stain and forty two cases were LVI positive with Podoplaninimmunostain.

In the group of 53 patients with gastric carcinoma, mean patients’ age was 49.87±11.38 years (range 20-70).33 patients ware male and 20 patients ware female with a male/female ratio of 1.6:1. According to Lauren’s classification, 30 cases ware diffuse type and 23 cases were intestinal type. Two third (60.4%) samples belonged to tumor size ≤ 5 cm. The mean tumor size was 5.61±1.92 cm, ranged from (3.0 – 11.0) cm. Lymph vessel density (LVD) was more frequent in cases having tumor size > 5 cm in diameter.

The histological grade was assessed according to WHO grading system. 33(62.3%) samples belonged to grade-III (poorly differentiation), followed by grade-II (moderate differentiation) (24.5%) and grade-I (well differentiation)(13.2%). Lymph vessel density (LVD) was most frequent in grade- II group.

Cases were grouped according to depth of invasion (tumor stage) as T1, T2, T3 and T4. 41.5% samples belonged to subserosal invasion (T3). T3 was followed by T2(32.1%), T4 (20.8%) and T1(5.7%). Lymph vessel density(LVD) was most frequent in T3 group.

Numbers of lymph node ranged from 1-25. Cases were grouped according to the numbers of lymph node metastasis as N0, N1, N2 and N3. 30.2% samples had no lymph node metastasis (nodal stage N0). 28.3% samples belonged to nodal stage N1, followed by nodal stage N2 (20.8%) and N3 (20.8%). Nodal stages were increasing with increase of Lymph vessel density (LVD).

Lymph vessels in intratumoral (IT) area ranged from 1-12 and peritumoral (PT) area ranged 2-11. Mean LVD in IT area was 5.93 ±2.79 cm and mean LVD in PT area was 5.50±2.38 cm.

A positive correlation was found between Lymph vessel density(LVD) and tumor stage in intratumoral (IT) area (Figure 7).

The value of Pearson’s correlation coefficient was 0.377 and it was significant (p=0.005). Therefore, there was linear association between tumor stage and lymph vessel density (LDV) in intratumoral (IT) area with Podoplanin stain.

A positive correlation was found between Lymph vessel density(LVD) and tumor stage in peritumoral (PT) area (Figure 8).  The value of Pearson’s correlation coefficient was 0.334 and it was significant (p=0.014). Therefore, there was linear association between tumor stage and lymph vessel density (LVD) in peritumoral (PT) area with Podoplanin stain.

A positive correlation was found between Lymph vessel density (LVD) and Lymph node metastases inintratumoral (IT) area (Figure 9).

The value of Pearson’s correlation coefficient was 0.855 and it was significant (p=0.000). Therefore, there was linear association between lymph node metastasis and lymph vessel density (LVD) in intratumoral (IT) area with Podoplanin stain.

A positive correlation was found between Lymph vessel density (LVD) and Lymph node metastases in peritumoral (PT) area (Figure 10).

The value of Pearson’s correlation coefficient was 0.791 and it was significant (p=0.000). Therefore, there was linear association between lymph node metastasis and lymph vessel density (LVD) in peritumoral (PT) area with Podoplanin stain.

A positive correlation was found between LVD in IT and PT.

The value of Pearson’s correlation coefficient was 0.937 and it was significant (p=0.000). Therefore, there was linear association between LVD in intratumoral (IT) and peritumoral (PT) area with Podoplanin stain.

Discussion

Gastric carcinoma is the most common leading tumor of the world. Although great efforts have been made in the field of early diagnosis and adjuvant therapy, the incidence and overall mortality of gastric carcinoma continues to increase. Since gastric tumor cells commonly infiltrate into the lymphatic system, lymph node status is routinely used to identify a patient’s prognosis, tumor stage, and treatment modality. Inhibition of tumor cells to lymph node metastasis (LNM) is a promising way to prevent distant metastasis. However, the relationship between lymphangiogenesis, lymphovascular invasion and lymph node metastasis (LNM) remains ambiguous.

This cross sectional study was carried out with an aim to estimate the density of expression of Podoplanin in lymphangiogenic vessel in gastric adenocarcinoma and to see the correlation between the percentages of area covered by lymphangiogenic vessels with prognostic factors. The present study findings were discussed and compared with previously published relevant studies.

In this study, 62.3% sample had grade-III (poorly differentiation) followed by 24.5% grade-II (moderately differentiation) and 13.2 % grade-I (well differentiation). Significant relation was found between lymph vessel density-intratumoral (LVD-IT) area (p=0.013) and lymph vessel density-peritumoral (LVD-PT) area (p= 0.006) with different histological differentiation. In their study, Pak et al., 201512 found that 53.3 % sample had grade-III and significant relation (p= 0.021) between LVD-IT area with histological differentiation, which is comparable with the current study.

 

It was observed that 41.5 % of samples belonged to T3, followed by 32.1% T2, 20.8% T4  and 5.7% T1 and significant relation found between LVD-IT area (p=0.019) and LVD-PT area (p=0.041) with different tumor stage. Gresta, Rodrigues Jr and Cabral, 201413 found 63.5% cases were T3, followed by 19.2% T2, 13.4% T1 and 3.8% T4. Pak et al., 2015 found 39.3% samples were T3 followed by 16.6 % T2 and T4. They also found significant association between LVD-IT area (p=0.024) with different tumor stage. Raica et al., 20088 found significant correlation between LVD with tumor stage (p<0.002) and Nakamura et al., 20067 found significant positive correlation between LVD with tumor stage (p=0.0008). So, present study result is consistent with previous study.

According to number of lymph node metastasis (LNM), it was observed that 30.2% sample belonged to nodal stage 0 (N0), followed by 28.3% stage-I (N1), 20.8% stage II (N2) and stage III (N3). There was significant relation was found between LVD-IT area (p<0.001) and LVD-PT area (p<0.001) with nodal status. Yan et al., 200814 reported that LVD was obviously higher in the colorectal cancer sample with metastasis (12.08 ± 4.96) than in those without (8.26 ± 4.08) (p<0.001). Schoppmann et al., 200115 demonstrated that lymph vascular invasion (LVI), assessed by anti-Podoplanin immunostain, has been strongly associated with presence of lymph node metastasis. Pak et al. 201512 found LVD-IT area was a higher than LVD-PT area (12.29± 4.36 vs. 11.01±3.62), Nodal stage N0 cases were more frequent and significant relation between LVD-PT in area (p=0.040) with nodal status. Nakamura et al., 20067 found significant positive correlation between LVD with nodal metastasis (p= 0.0094). Raica et al., 20088 found significant correlation between LVD with nodal metastasis (p<0.031) which is comparable with current study.

In this study, there was a positive significant Pearson’s correlation (r= 0.855, p= 0.000) was found between lymph node (LN) metastasis with LVD in IT area. Similarly, there was a positive significant Pearson’s correlation (r= 0.791 p= 0.000) was found between LN metastasis with LVD in PT area. Pak et al., 201512 found in their study that LVD in PT area was significantly associated with LN metastasis (p=0.040). Nakamura et al., 20067 found significant correlation between LN metastasis with LVD (p= 0.0094). Raica et al., 20088 reported that there was significant positive correlation between both LVD in IT and PT areas with LN metastasis (P<0.031). So current study result is consistent with previous study.

In this current study, there was a positive significant Pearson’s correlation (r= 0.377, p= 0.005) was found between tumor stages with LVD in IT area. Similarly, there was a positive significant Pearson’s correlation (r= 0.334, p= 0.014) was found between tumor stage with LVD in PT area. Nakamura et al., 20067 found significant positive correlation between tumor stage with LVD (p= 0.0008). Raica et al., 20088 reported that there was significant positive correlation between both LVD-IT area and LVD-PT area with tumor stage (P<0.02).

In this current study, there was a positive significant Pearson’s correlation (r= 0.937, p= 0.000) was found between LVD-IT areas with LVD-PT areas. Pak et al., 201512 found significant correlation (p=0.028) between LVD-IT area with LVD-PT area.

Conclusion

Total fifty three cases of gastric adenocarcinoma were examined for lymphangiogenic vessels in peritumoral (PT) and intratumoral (IT) areas. Thirty seven cases had lymph node metastasis and the rest sixteen were free of tumor metastasis. Both peritumoral and intratumoral lymphangiogenic vessel count (density) stained by Podoplanin antibody correlated with lymph node metastasis and tumor stage. Lymphatic vessel count is more in the intratumoral area.  The specific lymphatic endothelial marker Podoplanin proved to be a valuable tool in highlighting lymph vessel density (LVD) and lymphovascular invasion, and therefore a predictor of lymph node metastasis.

Limitation 

The study population was selected from one institute in Dhaka city, so that the results may not be reflect the exact picture of the country.  The study period was short. Sample size was small. Podoplanin was only marker used to detect lymph vessels. Sometimes differentiation between blood vessels and lymph vessels were difficult in tissue sections. Differentiation between blood vessels and lymph vessels was also a limitation of this study.  Use of blood vessel immunostain like factor VIIIa, CD31, and CD 34 etc. could have overcome the limitation and overall no control was used.

 

References

  1. Williams NS, Bulstrode CJ, O’connell PR. Bailey & Love’s short practice of surgery. Crc Press; 2008. pp.450-456.
  2. Carl-McGrath S, Ebert M, Röcken C. Gastric adenocarcinoma: epidemiology, pathology and pathogenesis. Cancer therapy. 2007; 5(2):877-94.
  3. Rahman R, Asombang AW, Ibdah JA. Characteristics of gastric cancer in Asia. World journal of gastroenterology: WJG. 2014;20(16):4483.
  4. Lauren P. The two histological main types of gastric carcinoma: diffuse and so called intestinal type carcinoma: an attempt at a histoclinical classification. Acta Pathologica Microbiologica Scandinavica. 1965; 64(1):31-49.
  5. Kumar V, Abbas AK, Fausto N, Aster JC. Robbins and Cotran pathologic basis of disease, professional edition e-book. elsevier health sciences. 2014 Aug 27. pp.760-777.
  6. Joo YE, Sohn YH, Joo SY, Lee WS, Min SW, Park CH, Rew JS, Choi SK, Park CS, Kim YJ, Kim SJ. The role of vascular endothelial growth factor (VEGF) and p53 status for angiogenesis in gastric cancer. The Korean journal of internal medicine. 2002; 17(4):211.
  7. Nakamura Y, Yasuoka H, Tsujimoto M, Kurozumi K, Nakahara M, Nakao K, Kakudo K. Importance of lymph vessels in gastric cancer: a prognostic indicator in general and a predictor for lymph node metastasis in early stage cancer. Journal of clinical pathology. 2006; 59(1):77-82.
  8. Raica M, Ribatti D, Mogoanta L, Cimpean AM, Ioanovici S. Podoplanin expression in advanced-stage gastric carcinoma and prognostic value of lymphatic micro vessel density. Neoplasma. 2008;55(5):455-60.
  9. El-Gohary YM, Metwally G, Saad RS, Robinson MJ, Mesko T, Poppiti RJ. Prognostic significance of intratumoral and peritumoral lymphatic density and blood vessel density in invasive breast carcinomas. American journal of clinical pathology. 2008;129(4):578-86.
  10. Zhao YC, Ni XJ, Li Y, Dai M, Yuan ZX, Zhu YY, Luo CY. Peritumorallymphangiogenesis induced by vascular endothelial growth factor C and D promotes lymph node metastasis in breast cancer patients. World journal of surgical oncology. 2012;10(1):165.
  11. Weidner N, Folkman J, Pozza F, Bevilacqua P, Allred EN, Moore DH, Meli S, Gasparini G. Tumor angiogenesis: a new significant and independent prognostic indicator in early-stage breast carcinoma. JNCI: Journal of the National Cancer Institute. 1992;84(24):1875-87.
  12. Pak KH, Jo A, Choi HJ, Choi Y, Kim H, Cheong JH. The different role of intratumoral and peritumoral lymphangiogenesis in gastric cancer progression and prognosis. BMC cancer. 2015; 15(1):498.
  13. Gresta LT, Júnior IA, Cabral MM. Micro vessel density quantification in gastric cancer: comparing methods for standard measures. J Cancer SciTher. 2014;6(10):401-5.
  14. Yan G, Zhou XY, Cai SJ, Zhang GH, Peng JJ, Du X. Lymphangiogenic and angiogenicmicrovessel density in human primary sporadic colorectal carcinoma. World Journal of Gastroenterology: WJG. 2008; 14(1):101.
  15. Schoppmann SF, Birner P, Studer P, Breiteneder-Geleff S. Lymphatic microvessel density and lymphovascular invasion assessed by anti-podoplanin immunostain in human breast cancer. Anticancer research. 2001; 21(4A):2351-5.
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Malignant Solid Childhood Tumors: Morphological Study in a Tertiary Hospital

Original Contribution

Malignant Solid Childhood Tumors: Morphological Study in a Tertiary Hospital

 *Rahman SS,1 Hossain MI,2 Nasreen S,3 Ahamad MU,4 Bhattecharjee P,5 Rahman Z,6 Khan MA7

 *Dr. Sharmin Sultana Rahman, Assistant Professor, Department of Pathology, Tairunnessa Memorial Medical College, Gazipur, Bangladesh. path@gmail.com

  1. Mohammad Ismail Hossain, Lecturer, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh. ismail.tushar@gmail.com.
  2. Sayeeda Nasreen, Assistant Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
  3. M. Shahabuddin Ahamad, Associate Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
  4. Pradip Bhattecharjee, Associate Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh, 4203.
  5. Zillur Rahman, Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh, 4203.
  6. Md. Morshed Alam Khan, Public Health Graduate. West Chester University of Pennsylvania, USA.

*For correspondence

Abstract

Background: Malignancy is the second most common childhood mortality in the developed world. The types of cancer that develop in children are often different  types that develop in adult with respect to incidence, type of tumor, underlying familial or genetic aberration and tendency to regress spontaneously or cytodifferentiation. In recent years, identification of specific genes, oncogenes, tumor markers and other biological and pathological factors have played an important role in staging and classifying risk categorization of specific tumors as low, intermediate and high-risk lesions.

Objectives: This study was done to evaluate the incidence and morphological patterns of solid malignant tumors in children.

Method: This hospital based cross-sectional descriptive study was conducted the Department of Pathology, Chattogram Medical College, Chattogram referred from Department of Pediatric Surgery, Chattogram Medical College Hospital, Chattogram. All the cases were subjected to examine histopathological slides with haematoxylin and eosin stain, and IHC done in malignant small round cell tumors and few tumors cases.
Results: An analysis of 43 cases of childhood solid malignant tumors, over a period of a year, was done. The study found that 28 out of 43cases of malignant tumors were seen in boys, whereas 15 casesin girls. The commonest tumor was lymphoma (11 cases) with non-hodgkin’s predominance (10 cases), followed by nephroblastoma (10 cases). In addition, the common age group was found 0-4 years (22 cases), with male predominance.
Conclusion: Histopathological diagnosis could be confirmed with IHC in cases B cell non-hodgkin lymphoma, infantile fibrosarcoma, malignant fibrous histocytoma, Ewing’s sarcoma / PNET. The frequency of tumors and their distribution was comparable to that report from other studies.

[Journal of Histopathology and Cytopathology, 2020 Jan; 4 (1):3-11]

 Keywords: Morphology, Malignant, Childhood, Solid tumour.

 

 Introduction

Malignancy is the 2nd most common cause of childhood mortality in the developing world 1st being malnutrition and infection. About 1/650 children develops malignancy before their 15thbirthday.1

In Bangladesh, there are no perfect cancer registries. Childhood cancers are expected to be high in Bangladesh because of the young population structure – about 30% (47.4 million) of the population is under 15 years old.2

Common childhood malignant tumor (almost 80%) arises from haemopoietic elements, lymphnodes, bones and soft tissues. The childhood cancer often the result of DNA changes in the cells that take places very early in life, sometimes even before birth. A few environmental factors, such as radiation exposure, have been linked with some types of childhood cancer. Some children inherit DNA mutation from parents that increases their risk of certain types of cancer. The reason for DNA changes that cause most childhood cancers are not known.3

Childhood malignancies differ biologically and histopathologically from those of adults with respect to incidence, type of tumor, underlying familial or genetic aberration and tendency to regress spontaneously or cytodifferentiate4. In recent years, identifications of specific gene, oncogenes, tumor markers and other biological and pathological factors have played an important role in staging and risk categorization of specific tumors. Hence there is a need for accurate histopathological reporting in conjugation with ancillary methods.5 Histological type is important for understanding etiology and progression of disease.

This study aims to provide a comprehensive recent overview on childhood cancers in the Department of Pathology, Chittagong Medical College, Chattogram which would contribute to the understanding of characteristics and provide a basis for the future strategies to deal with childhood cancer.

Method

It is a hospital based cross-sectional descriptive study carried out in the Department of Pathology, Chittagong Medical College, Chattogram over a one year period from 1st January 2017 to 31st December, 2017.

Children of 0-14 years old age diagnosed as malignant tumor, who had undergone operative treatment in the Department of Pediatric Surgery, were included in this study. Patients diagnosed as a case of malignant solid tumor was subjected to detail clinical history and thorough physical examination followed by relevant investigations.

All the specimens sent from Department of Pediatric Surgery were evaluated and stained by haematoxylin and eosin in all cases and immunohistochemistry (IHC) done in malignant small round cell tumors and (few tumors cases). All the necessary and relevant data regarding patients were recorded methodically in pre-designed data sheet.

 Statistical analysis

The data were collected from the filled data sheet and statistical analysis was done using the SPSS (Statistic Package for Social Science) Version-20 software package for windows.

 Result

Age incidence ranged from 0-14 years. Patients were divided into 3 age groups. The mean age was 6 years 9 months. 28 (65.1%) cases were seen in boys and 15 (34.9%) cases were seen in girls showing male preponderance. Male and female ratio: 1.87:1.

Lymphoma is the commonest malignant tumor and it constituted 25.3% of all tumors. 10 cases were Non-Hodgkin’s lymphoma and 01 case is Hodgkin lymphoma. Mean age is 8 years. Male is more prevalent than female with male female ratio 9:1, more frequently found in 0-4years age group. Immunohistochemistry CD20 and CD3 are done in selective cases. 6 cases of Non-Hodgkin’s lymphoma were B cell origin, CD20 positive and one case was T-cell origin which is CD3 positive. Hodgkin’s lymphoma was CD30 negative. 8 cases arose from lymph nodes and 2 cases were soft tissue origin. One of them was diagnosed as a case of malignant small round cell tumor.

Among the renal tumors, only Wilm’s tumor (10 cases) was found, with classical triphasic tumors were more prominent feature. The mean age was 4 years 7 months. Male to female ratio was 1:1.

Among the germ cell tumors, 4 cases were noted as immature teratoma: 3 of them arose from sacro-coccygeal region and 1 from ovary; 2 cases were dysgerminoma and 2 cases were yolk sac tumor; 1 case was extra gonadal origin. Female predominance with male female ratio 1:2.5. Mean age was 5 years 7 months.

 

In this study, four cases were diagnosed as malignant small round cell tumor. For further evaluation, CD20, Myogenin, Desmin, Neuron-specific enulose (NSE), Synaptophysin markers were done. 2 cases were diagnosed as B cell Non-Hodgkin lymphoma, 1 case is desmoplastic malignant small round cell tumor and other was neuroblastoma.

 

Soft tissue sarcoma comprised 9.3% (4 cases). Mean age was 8 years 4 months, with male female ratio 3:1. 2 cases were histologically diagnosed as infantile fibrosarcoma and malignant fibrous histocytoma. Infantile fibrosarcoma was found, six months old, male baby, arising from abdomen. Malignant fibrous histocytoma was noted in male, 14 years old. Immunohistochemically both cases showed strong positive for vimentin. A case of desmoplastic small round cell tumor also found. Histologically diagnosed as a case of malignant small round cells arising from intra abdominal cavity and confirmed by desmin. 1 case was PNET/ Ewings sarcoma family. For further evaluation CD99 was recommended.

Colorectal adenocarcinoma accounts for 7% (3 cases) of pediatric malignant tumors in the present study and commonly seen in 10-14years age group. Mean age is 11 years 7 months.

Bone tumor constituted 7% (3 cases): 1 case was metastatic osteosarcoma on the left chest wall; 1 case was Ewing’s sarcoma/PNET family; another was chondrosarcoma. Male were predominant with male female ratio 2:1. Immunophenotyping CD99 and S100 were applied for confirming the diagnosis in respectively Ewing’s sarcoma and chondrosarcoma.

 

 

 

 

 

Discussion

Most of the childhood malignant tumors occur below the age of eight years, although wide age variability exists in children.6 In present study, 14 years was considered as the pediatric age with infancy as a separate age group. The peak occurrence of tumors was found in 0-4 year’s age.

 

 

The overall incidence of malignant tumors of childhood was more in male (M: F=1.53:1) patients. This observation has been made uniformly in literature by author. Male predominance is noted in all age groups and female predominance in germ cell tumor by Lee et al10 and Miler  et al,11 In present study, male predominant in all age group of tumor except germ cell tumors. Male and female ratio: 1.86:1.

 

The commonest tumor comprised of lymphoma (11cases, 25.3%). Similar results were reported by Sharma et al,13 and Baneerjee et al.14 NHL was more frequent than Hodgkin. Non-Hodgkin lymphoma represented 23.3% whereas Hodgkin 2.3%. Non-Hodgkin lymphoma commonly expressed in 0-4 years age group in this study. Patients presented with swelling, pain, fever, and loss of weight with the duration ranging from one month to year. IHC CD20 was applied in 6 cases and revealed B cell origin Non-Hodgkin lymphoma.

 

Wilm’s tumor is common renal tumour that is 100% as compared to the 78.4% by Louisa et al. This difference may be due to small sample size in present study. Male and female ratio is 1:1. Whereas in the study of Paul et al,6 11 infantile Wilm’s tumor found the male to female ratio was 2.3:1. Husain et al.2found that Wilm’s tumor was slightly more common in girls in whom it tends to present at an older age.

 

Malignant germ cell tumors in the ovaries of very young children are rare in condition1. Weinblatt and Ortega, 1982 noted dysgerminoma as the commonest tumor.16 In this study, 7 cases were malignant germ cell tumors. Among them 3 cases were gonadal origins. Rest of them arose from extragonadal site, and two cases of dysgerminoma in ovary were documented. It is more common in gonadal tumor in patient with gonadal dysgenesis.17 Tumors with syncytiotrophoblastic giant cells have the same prognosis as tumors in which they are absent.18 

 

In this study, two cases of yolk sac tumor was locates at testis and intra abdomen. Both of them had shown elevated level of AFP. One case of yolk sac tumor, in testicular origin, at the age of 8 years and other one of female patient with 45 days arising from intra abdomen.

 

Soft tissue sarcoma comprises 9.3% of pediatric malignancy. Two cases are histologically diagnosed as infantile fibrosarcoma and malignant fibrous histocytoma. Infantile fibrosarcoma is found, six months old, male baby, arising from abdomen. Malignant fibrous histocytoma is seen in male, 14 years old. Immunohistochemically both cases show strong positive for vimentin. A case of desmoplastic small round cell tumor is also found. Histologically it is diagnosed as a case of malignant small round cells arising from intra abdominal cavity and confirmed by desmin.

 

Bone tumor constitutes 7% of pediatric malignant tumors in this study: one case is metastatic osteosarcoma arising from the left chest wall; one case is Ewing’s sarcoma/PNET family; another is chondrosarcoma. Male are predomident, and male female ratio is 2:1. Immunophenotyping CD99 and S100 are applied for confirming the diagnosis in respectively Ewing’s sarcoma and chondrosarcoma.

In this study, colorectal adenocarcinoma account for 7% (3cases) of pediatric malignant tumor and commonly seen in 10- 14 years age group which is similar to the study of Tonbary et al. 2012.19 Among the three cases, tumor arises from appendix, descending colon and rectum, respectively.

In this study, four cases of malignant small round cell tumor are documented .Male to female ratio is 1:1. Out of four cases of small round cell tumor, three cases arose from intra abdominal mass and one case from axillary swelling. For further evaluation of immunohistochemistry of CD20, CD3, Myogenin, Desmin, Vimentin, Neuron-specific enulose (NSE), Chromogranin, Synaptophysin markers are done. Two cases were diagnosed as B cell Non- Hodgkin lymphoma as well as one case was diagnosed as desmoplastic malignant small round cell tumor and other was as neuroblastoma.

In this study, one case is noted as anaplastic astrocytoma; Pilocytic astrocytoma, the most common type of astrocytoma in children, is a low grade tumor that typically arises in the cerebellum. One case of invasive squamous cell carcinoma is documented in the study, arose from retro-molar mass, male, 10 years old patient. No predisposing factor was elicited.

 Because of unwanted technical fault like delayed cold ischemic time and fixative time, negative result of IHC was found.

 Conclusion

In this study, histopathological diagnosis could be confirmed with IHC in following cases: B cell non-hodgkin lymphoma, infantile fibrosarcoma, malignant fibrous histocytoma, Ewing’s sarcoma / PNET. The frequency of tumors and their distribution is comparable to that report from other studies. The early onset and the embryonal nature of the major pediatric tumors suggest a prenatal origin and role of genetic factors. Infection, exposure to drugs and chemicals during pregnancy are other contributory factors. Accurate incidence of data is important in the planning and evaluation of clinical trial. Documentation of cases, advanced diagnostic methods like IHC, cytogenetic studies and treatment modalities with close follow up is needed to achieve better statistical evaluation of the problem.

 Acknowledgement

We express our heartiest gratitude to the staffs of the Department of Pathology of Chittagong Medical College, Chattogram.

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