Im Improvement of of va vasc scula lar in inva vasion sc scor - PowerPoint PPT Presentation

Im Improvement of of va vasc scula lar in inva vasion sc scor oring in in stag age I I tes estic icular no non-semin inomas to o pre redic ict rela relapse du durin ing sur surveil illa lance aft fter er or orchiectomy João oão Lob Lobo Hans ns Stoo oop, Ad Ad Gi Gillis, Le Leend nder ert HJ Looi Looije jeng nga, J. J. Wol olter er Oost Oosterh rhui uis 8 th September 2019 No conflicts of interest

TGCTs: heterogeneity & challenges Lobo et al. Hum Pathol 2018

TGCTs: heterogeneity & challenges “Germ cell tumors are at the crossroads between developmental biology and cancer" Lobo et al. Int J Mol Sci 2019

Why focusing on TGCTs? Most common cancer in Caucasian men 15 — 44yo 1% male cancer Rising incidence Decreasing mortality 15-20% disseminated disease recurs (poor prognosis) Most curable solid neoplasms Cisplatin resistance Same cytogenetic background (i12p) and low mutational burden Iatrogeny (young patients) Better disease biomarkers urgently needed

Why focusing on TGCTs? Most common cancer in Caucasian men 15 — 44yo 1% male cancer Rising incidence Decreasing mortality 15-20% disseminated disease recurs (poor prognosis) Most curable solid neoplasms Cisplatin resistance Same cytogenetic background (i12p) and low mutational burden Iatrogeny (young patients) Better disease biomarkers needed Costa and Lobo et al. Epigenomics 2017

Vascular invasion as a biomarker Inter-observer agreement in Immunohistochemistry and Prognostic marker reporting type of vessel Metastases, recurrence Not ideal No formal recommendation (ISUP) Most common disagreement upon TNM (pT2, stage IA) Lack of data centralized review Patient stratification Subjectivity, artifacts, criteria…

✓ Consecutively diagnosed NS patients ✓ Stage I ✓ Only surveillance after orchiectomy • Inter-observer Aims and Methodology agreement in VI “Clean” 1 cohort ✓ 2 FFPE samples scoring on H&E ✓ >1cm 2 tumor ✓ Tumor-parenchyma interface Strict inclusion • Additional value of criteria ✓ D2-40: lymph vessels adding IHC for ✓ CD31, FVIII: blood vessels 2 vascular markers H&E + IHC panel (D2-40, CD31, FVIII) • Additional value of characterizing the Scoring by 3 3 independent type of vessel invaded observers ✓ Dedicated to TGCT pathology

Patient cohort Variables (n=52) Patient cohort Age [years (median, IQR)] 31 (24-35) Variables Laterality (n, %) (n=52) Cohort characterization Right 21/52 (40.4) Relapse (n, %) Left 31/52 (59.6) No 21/52 (40.4) Pre-operative serum tumor markers Yes 31/52 (59.6) Type of relapse (n, %) (n, %) Within normal range 20/52 (38.5) Early 28/31 (90.3) Elevated 32/52 (61.5) Late 3/31 (9.7) Site of relapse (n, %) Histologic subtypes (n, %) Pure embryonal carcinoma 5/52 (9.6) Only serum markers 6/31 (19.4) Serum markers + PAoLN 14/31 (45.2) Pure postpubertal-type teratoma 2/52 (3.8) Mixed tumor, without seminoma 21/52 (40.4) Only PAoLN 4/31 (12.9) Only Lung 2/31 (6.5) Mixed tumor, with seminoma 24/52 (46.2) Multifocality (n, %) Serum markers + Lung + PAoLN 4/31 (12.9) Absent 50/52 (96.2) Serum markers + Liver + Lung + PAoLN 1/31 (3.2) Treatment performed for relapses (n, %) Present 2/52 (3.8) Largest tumor size [cm (median, IQR)] 3.5 (2.5-5.4) Only chemotherapy 26/31 (83.9) Chemotherapy + RPLND 5/31 (16.1) Rete testis invasion (n, %) Absent 30/42 (71.4) Vital status at last follow-up (n, %) Present, stromal 9/42 (21.4) A-NED 50/52 (96.2) D-NED 1/52 (1.9) Only pagetoid spread of GCNIS 3/42 (7.1) Vascular invasion (n, %) DFD 1/52 (1.9) Absent 25/50 (50.0) Present 25/50 (50.0)

Prognostic value On multivariable analysis (age, tumor size, serum tumor markers, rete testis invasion) VI showed an independent impact in predicting disease relapse (HR 3.163, 95% CI 1.31-7.63)

Inter-observer agreement Testicular germ cell tumor- dedicated pathologists’ assessment of vascular invasion Pathologist 3 Agreement Cohen’s Kappa = 0.54 (p<0.001) Absent Present Absent 23 4 Agreement among TGCT-dedicated Pathologist 1 Present 8 17 pathologists was moderate, as Pathologist 2 reported Agreement Cohen’s Kappa = 0.50 (p<0.001) ( κ 0.49-0.54) Absent Present Absent 22 5 Pathologist 1 Present 8 17 Pathologist 2 Agreement Cohen’s Kappa = 0.49 (p<0.001) Absent Present Absent 24 7 Pathologist 3 Present 6 15

Performance in predicting relapse IHC resulted in increase in sensitivity and decrease in specificity Vascular invasion Sensitivity Specificity PPV NPV Accuracy scoring (%) (%) (%) (%) (%) H&E (consensus) 61.3 85.7 86.4 60.0 71.2 Immunohistochemistry (D2-40 + FVIII + 71.0 71.4 78.6 62.5 71.2 CD31) IHC upgraded 8 cases of “absent VI on H&E” → 3 of them developed relapse IHC downgraded 2 cases of “present VI on H&E” → both did not develop relapse

Vascular invasion: challenges Missed cases on H&E assessment D2-40 CD31 FVIII H&E Vascular invasion mimickers D2-40 CD31 FVIII H&E

No relapse (n) Relapse (n) Vascular invasion scoring IHC showing LVI only 3 12 Type of vessel IHC showing BVI only 3 2 IHC showing LVI + BVI 0 8 “Double vascular invasion patients” : 100% accuracy in predicting disease relapse Active selection for adjuvant treatment instead of surveillance?

• Inter-observer Moderate among TGCT-dedicated agreement in VI pathologists, but can be improved 1 scoring on H&E Conclusions • Additional value of Increase in sensitivity for predicting adding IHC for disease relapse 2 vascular markers • Additional value of Identification of high-risk patients characterizing the (both LVI and BVI) 3 type of vessel invaded

FUTURE Large, prospective studies, with IHC Conclusions Endpoint: relapse-free survival Indication for routine IHC use?

Ethics approval: CES IPO 1/2018 Doctoral Grant: SFRH/BD/132751/2017 Project Funding: POCI-01-0145-FEDER-29043 IPO Porto The Netherlands Department of Pathology Urology Clinic Ângelo Rodrigues Jorge Oliveira PMC Utrecht (Group Looijenga) Paula Lopes Joaquina Maurício Ad Gillis Mariana Cantante Isaac Braga Annette van den Berg Rita Guimarães Rachita Lahri Department of Epidemiology Dennis Timmerman Luís Antunes Cancer Biology & Epigenetics Group Vera Gonçalves Supervising team: Daniela Barros Silva Erasmus MC Rotterdam & LEPO Rui Henrique Sandra Nunes Wolter Oosterhuis Carmen Jerónimo Lambert Dorssers Leendert Looijenga Hans Stoop Willem Boellaard

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