Improvement of vascular invasion scoring in stage I testicular non-seminomas

to predict relapse during surveillance after orchiectomy

João Lobo

Hans Stoop, Ad Gillis, Leendert HJ Looijenga, J. Wolter Oosterhuis

No conflicts of interest8th September 2019

Lobo et al. Hum Pathol 2018TGC

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Lobo et al. Int J Mol Sci 2019TGC

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ges “Germ cell tumors are at the crossroads between

developmental biology and cancer"

1% male cancer

Decreasing mortality

Most curable solid neoplasms

Same cytogenetic background (i12p) and low mutational burden

Most common cancer in Caucasian men 15—44yo

Rising incidence

15-20% disseminated disease recurs (poor prognosis)

Cisplatin resistance

Iatrogeny (young patients)

Better disease biomarkers urgently neededW

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sin

g o

n T

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1% male cancer

Decreasing mortality

Most curable solid neoplasms

Same cytogenetic background (i12p) and low mutational burden

Most common cancer in Caucasian men 15—44yo

Rising incidence

15-20% disseminated disease recurs (poor prognosis)

Cisplatin resistance

Iatrogeny (young patients)

Better disease biomarkers needed

Wh

y fo

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ng

on

TG

CTs

?

Costa and Lobo et al. Epigenomics 2017

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Prognostic marker

Metastases, recurrence

TNM (pT2, stage IA)

Patient stratification

Inter-observer agreement in reporting

Not ideal

Most common disagreement upon centralized review

Subjectivity, artifacts, criteria…

Immunohistochemistry and type of vessel

No formal recommendation (ISUP)

Lack of data

Aim

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nd

Met

ho

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log

y

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• Inter-observer agreement in VI scoring on H&E

2

• Additional value of adding IHC for vascular markers

3

• Additional value of characterizing the type of vessel invaded

“Clean” cohort

Strict inclusion criteria

H&E + IHC panel (D2-40, CD31, FVIII)

Scoring by 3 independent

observers

✓ Consecutively diagnosed NS patients✓ Stage I✓ Only surveillance after orchiectomy

✓ 2 FFPE samples✓ >1cm2 tumor✓ Tumor-parenchyma interface

✓ Dedicated to TGCT pathology

✓ D2-40: lymph vessels✓ CD31, FVIII: blood vessels

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nVariables

Patient cohort

(n=52)Age [years (median, IQR)] 31 (24-35)Laterality (n, %)

Right 21/52 (40.4)Left 31/52 (59.6)

Pre-operative serum tumor markers

(n, %)Within normal range 20/52 (38.5)Elevated 32/52 (61.5)

Histologic subtypes (n, %)Pure embryonal carcinoma 5/52 (9.6)Pure postpubertal-type teratoma 2/52 (3.8)Mixed tumor, without seminoma 21/52 (40.4)Mixed tumor, with seminoma 24/52 (46.2)

Multifocality (n, %)Absent 50/52 (96.2)Present 2/52 (3.8)

Largest tumor size [cm (median, IQR)] 3.5 (2.5-5.4)Rete testis invasion (n, %)

Absent 30/42 (71.4)Present, stromal 9/42 (21.4)Only pagetoid spread of GCNIS 3/42 (7.1)

Vascular invasion (n, %)Absent 25/50 (50.0)Present 25/50 (50.0)

VariablesPatient cohort

(n=52)Relapse (n, %)

No 21/52 (40.4)Yes 31/52 (59.6)

Type of relapse (n, %)Early 28/31 (90.3)Late 3/31 (9.7)

Site of relapse (n, %)Only serum markers 6/31 (19.4)Serum markers + PAoLN 14/31 (45.2)Only PAoLN 4/31 (12.9)Only Lung 2/31 (6.5)Serum markers + Lung + PAoLN 4/31 (12.9)Serum markers + Liver + Lung + PAoLN 1/31 (3.2)

Treatment performed for relapses (n, %)Only chemotherapy 26/31 (83.9)Chemotherapy + RPLND 5/31 (16.1)

Vital status at last follow-up (n, %)A-NED 50/52 (96.2)D-NED 1/52 (1.9)DFD 1/52 (1.9)

Pro

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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)

Inte

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Testicular germ cell tumor-dedicated pathologists’ assessment of vascular invasion

Agreement

Cohen’s Kappa = 0.54 (p<0.001)

Pathologist 3

Absent Present

Pathologist 1

Absent 23 4

Present 8 17

Agreement

Cohen’s Kappa = 0.50 (p<0.001)

Pathologist 2

Absent Present

Pathologist 1

Absent 22 5

Present 8 17

Agreement

Cohen’s Kappa = 0.49 (p<0.001)

Pathologist 2

Absent Present

Pathologist 3

Absent 24 7

Present 6 15

Agreement among TGCT-dedicated pathologists was moderate, as

reported(κ 0.49-0.54)

Per

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Vascular invasion

scoring

Sensitivity

(%)

Specificity

(%)

PPV

(%)

NPV

(%)

Accuracy

(%)

H&E (consensus) 61.3 85.7 86.4 60.0 71.2

Immunohistochemistry

(D2-40 + FVIII +

CD31)

71.0 71.4 78.6 62.5 71.2

IHC resulted in increase in sensitivity and decrease in

specificity

IHC upgraded 8 cases of “absent VI on H&E” → 3 of them developed

relapseIHC downgraded 2 cases of

“present VI on H&E” → both did not develop relapse

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H&E

D2-40

CD31

FVIII

H&E

D2-40

CD31

FVIII

Typ

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Vascular invasion scoring No relapse (n) Relapse (n)

IHC showing LVI only 3 12

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?

Co

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usi

on

s

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• Inter-observer agreement in VI scoring on H&E

2

• Additional value of adding IHC for vascular markers

3

• Additional value of characterizing the type of vessel invaded

Moderate among TGCT-dedicatedpathologists, but can be improved

Increase in sensitivity for predictingdisease relapse

Identification of high-risk patients

(both LVI and BVI)

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Indication for routine IHC use?

Endpoint: relapse-free survival

Large, prospective studies, with IHC

FUTURE

Supervising team:Rui Henrique

Carmen JerónimoLeendert Looijenga

Department of PathologyÂngelo Rodrigues

Paula LopesMariana Cantante

Rita Guimarães

Cancer Biology & Epigenetics GroupVera Gonçalves

Daniela Barros SilvaSandra Nunes

Ethics approval: CES IPO 1/2018

IPO Porto

The Netherlands

Project Funding: POCI-01-0145-FEDER-29043Doctoral Grant: SFRH/BD/132751/2017

Urology ClinicJorge Oliveira

Joaquina MaurícioIsaac Braga

Department of EpidemiologyLuís Antunes

PMC Utrecht (Group Looijenga)Ad Gillis

Annette van den BergRachita Lahri

Dennis Timmerman

Erasmus MC Rotterdam & LEPO

Wolter OosterhuisLambert Dorssers

Hans StoopWillem Boellaard

Thank you for your attention!