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TUMOR BUDDING IN PRE‐OPERATIVE BIOPSIES AND RESECTIONS
Alessandro Lugli, MD
Institute of Pathology and Translational Research Unit (TRU)
University of Bern
Bern, Switzerland
Disclosure of Relevant Financial Relationships
The USCAP requires that anyone in a position to influence or control the content of all CME activities disclose any relevant relationship(s) which they or their spouse/partner have, or have had within the past 12 months with a commercial interest(s) [or the products or services of a commercial interest] that relate to the content of this educational activity and create a conflict of interest. Complete disclosure information is maintained in the USCAP office and has been reviewed by the CME Advisory Committee. Dr. Alessandro Lugli declares he has no conflict(s) of interest to disclose.
CONTENT
DEFINITION AND CHARACTERISTICS OF TUMOR BUDDING
CLINICAL IMPLICATIONS OF TUMOR BUDDING
PRACTICAL ASPECTS OF TUMOR BUDDING
SUMMARY & OPEN POINTS
TUMOR BUDDING
At a glance
Definition
Single tumor cells or clusters of up to 5 tumor cells at the invasive margin
Jass et al, JCP 2003
Characteristics
Part of the tumor microenvironment (EMT like cells ?) Transformation to a motile and invasive phenotype
Low proliferation
Marker of tumor progression
TUMOR BUDDING
A motile and invasive phenotype
Protein level
Molecular level
Increased expression
MMP2 (c), MMP‐9 (c)
CathB (c), CXCL12 (m/c)
b‐Catenin (n)
Beta‐III‐Tubulin (c)
hMena (c), cyclin D1 (n)
Laminin5y2 (c), p16 (n)
ABCG5 (c), CD133 (c)
Deregulation of the wnt signalling
pathway
Decreased expression
Ki67 (n)
E‐Cadherin (c)
Activated p16INK4a
Less frequent in MSI‐H CRC
MSS/MSI, KRAS and BRAF mutational status (Zhao et al, Poster Session III # 62)
m: membraneous
c: cytoplasmic
n: nuclear
Zlobec et al, Oncotarget 2010
Jass et al, JCP 2003
Zlobec et al, Histopathology 2012 TUMOR BUDDING
Low proliferation
Dawson et al, Histopathology 2014
TUMOR BUDDING
A marker of tumor progression
Tumor budding is associated with:
Selected references:
Okuyama et al, J Surg Oncol 2003
Lymphovascular invasion
(L and V stage)
Ueno et al, Gastroenterology 2004
Nakamura et al, Dis Colon Rectum 2008
Wang et al, Am J Surg Pathol 2009
Lymph node metastasis (N stage)
Karamitopoulou et al, Mod Pathol 2013
Hase et al, Dis Colon Rectum 1993
Tateishi et al, Mod Pathol 2010
Distant metastasis (M stage)
Choi et al, Int J Colorect Dis 2007
CONTENT
DEFINITION AND CHARACTERISTICS OF TUMOR BUDDING
CLINICAL IMPLICATIONS OF TUMOR BUDDING
PRACTICAL ASPECTS OF TUMOR BUDDING
SUMMARY & OPEN POINTS
TUMOR BUDDING
Potential clinical scenarios
Malignant polyps
Tumor budding as a predictor of lymph node metastases
Clinical implication: resection
Stage II CRC
Tumor budding as a factor of tumor progression
Clinical implication: adjuvant therapy
Pre‐operative biopsies of colon and rectal cancer
Tumor budding as a factor of tumor progression and predictor of regression grade and (non‐) response to neo‐adjuvant therapy
Clinical implication: neo‐adjuvant therapy
TUMOR BUDDING
Malignant polyps
Risk factors for an adverse outcome in early invasive colorectal carcinoma
Absence of
‐ Unfavourable tumor grade
‐ Vascular invasion
‐ Tumor budding
‐ Extensive submucosal invasion
Watch‐and‐ see
policy
Ueno et al, Gastroenterology 2004
Systematic review including 17 studies: tumor budding and nodal involvement
‐ Sensitivity: 74.7%; Specificity: 63.4%
‐ PPV: 21.3%; NPV: 95%
Bosch et al, Endoscopy 2013
TUMOR BUDDING
Malignant polyps
Tumor budding in malignant polyps predicts pN+ status:
‐ In 22 of 24 studies
‐ Between 2002 and 2013
‐ High grade budding frequency: 11.8% ‐ 50.5%
Koelzer et al, Future Medicine Colorectal Cancer 2014
Tumor budding in stage I CRC predicts OS and DFS:
‐ In 8 of 10 studies
‐ Between 2005 and 2013
‐ In 5 of 10 studies independent prognostic factor
van Wyk et al, Cancer Treatment Reviews 2015
TUMOR BUDDING
Stage II CRC
Selected studies on stage II CRC and tumor budding as a marker of progression:
Colon Cancer
Rectal Cancer
Tanaka et al, Dis Colon Rectum 2003 (n=138)
Okuyama et al, J Surg Oncol 2003 (n=83)
Nakamura et al, Dis Colon Rectum 2008 (n=200)
Masaki et al, J Surg Oncol 2005 (n=72)
Wang et al, Am J Surg Pathol 2009 (n=128)
Betge et al, Ann Surg Oncol 2012 (n=120)
Canney et al, Histopathology 2012 (n=205)
Horcic et al, Hum Pathol 2013 (n=105)
TUMOR BUDDING
Pre‐operative biopsies
Intratumoral budding (ITB) can be applied in pre‐operative biopsies
Lugli et al, Human Pathology 2011
ITB in pre‐operative biopsies is associated with nodal and distant metastases
Giger et al, Mod Pathol 2012; Zlobec et al, BJC 2014
ITB is associated with higher T stage, higher N stage, lymphovascular invasion, response to neo‐adjuvant therapy and poor survival in pre‐operative rectal
cancer biopsies
Rogers et al, Mod Pathol 2014
Mitrovic et al, Modern Pathology 2012
TUMOR BUDDING
Classifications and guidelines
WHO Classification of Tumours of the Digestive System 2010
Bosman, Carneiro, Hruban, Theise
Prognostic factors not included in the TNM staging of carcinoma of the colon and rectum: infiltrative
pattern of invasion / budding
UICC Prognostic Factors in Cancer 2006
Gospodarowicz, O’Sullivan, Sobin
Tumor budding: additional prognostic factor
AJCC Cancer Staging Manual 2010
Tumor budding: not included
CAP Protocol for the Examination of Specimens From Patients With Primary Carcinoma of the
Colon and Rectum 2013
Tumor budding: not included
Royal College of Pathologists 2014
Tumor budding: mentioned, but not implemented
Uptodate 2014
Tumor budding: category IIB factor: shown to be promising in multiple studies; data insufficient for inclusion in category I or IIA.
TUMOR BUDDING
Examples for other tumor types
Breast cancer (ductal)
‐ N=160
‐ Independent prognostic factor
Liang et al, Pathol Res Pract 2013
Lung cancer
‐ N=485
‐ Independent prognostic factor
Kadota et al, J Torac Oncol 2014
Oesophageal and gastro‐oesophageal junction
cancers
‐ N=356
‐ Independent prognostic factor
Brown et al, Histopathology 2010
Pancreatic cancer (PDAC)
‐ N=117
‐ Independent prognostic factor
Karamitopoulou et al, Eur J Cancer 2013
Head and neck squamous cell
carcinoma
‐ Systematic review (N=5 studies)
‐ Marker of tumor progression and
prognosis
Almangush et al, Histopathology 2014
CONTENT
DEFINITION AND CHARACTERISTICS OF TUMOR BUDDING
CLINICAL IMPLICATIONS OF TUMOR BUDDING
PRACTICAL ASPECTS OF TUMOR BUDDING
SUMMARY & OPEN POINTS
TUMOR BUDDING
Points to discuss
H&E versus immunohistochemistry
Scoring systems in the literature
Which scoring systems for resections and biopsies ?
TUMOR BUDDING
H&E vs immunohistochemistry
The aim should be:
Optimal visualization
Reflection of the real tumor bud
count
Reproducibility
User friendly for daily diagnostics
Detection of tumor buds in lymphatic
and blood vessels
panCK/CD8
van Wyk et al, Cancer Treatment Reviews 2015
TUMOR BUDDING
Practical example
Elastin
panCK/D240
TUMOR BUDDING
Selected scoring systems
Hase method
None/mild vs moderate/severe
Predominant pattern at the invasive front
Wang method
Densest region at x40, counting 5 HPFs (x200)
Cut‐off: ≤9 buds (low grade)
Nakamura method
None
Mild (1/3 of the invasive front with tumor
buds)
Moderate (1/3‐2/3 of the invasive front with
tumor buds)
Marked (>2/3 of the invasive front with
tumor buds)
Rapid Wang method
≤9 buds: negative, ≥10 buds: positive
50% positive fields: high grade
Ueno method
Low power, densest tumor budding region
Positive: ≥5 buds in x20 visual field
(0.785mm2)
10 HPF method
Ten densest regions (0.49mm2)
≤100 buds: low grade; >100 buds: high grade
Continuous scale
1 HPF method
Densest region (0.49mm2)
≤6 buds: low grade; >6 buds: high grade
Continuous scale
TUMOR BUDDING IN RESECTIONS
1 HPF & 10 HPF method
Horcic et al, Hum Pathol 2011
TUMOR BUDDING IN RESECTIONS
Validation of the 10 HPF method
Karamitopoulou et al, Mod Pathol 2012
SWISS ASSOCIATION OF GASTROINTESTINAL PATHOLOGY (SAGIP) STUDY
Reproducibility of the 1HPF and 10HPF method
6 centers (4 academic centers, 1 community hospital and 1 private practice)
50 CRC cases (all stages)
Tumor buds criteria
‐ Single cells or clusters of up to 5 cells
‐ Clear panCK staining
‐ Nucleus present
‐ Pseudofragments and necrosis excluded
Koelzer et al, Poster Session III # 61
SWISS ASSOCIATION OF GASTROINTESTINAL PATHOLOGY (SAGIP) STUDY
Reproducibility of the 1HPF and 10HPF method
Koelzer et al, Poster Session III # 61
SWISS ASSOCIATION OF GASTROINTESTINAL PATHOLOGY (SAGIP) STUDY
Reproducibility of the 1HPF and 10HPF method
Koelzer et al, Poster Session III # 61
INTRATUMORAL BUDDING IN CRC
Peritumoral budding (PTB) = tumor buds at the invasive front of CRC
Intratumoral budding (ITB) = tumor buds within the CRC center
ITB (>6 buds pro HPF) is associated with:
Higher T stage
Higher N stage
Vascular invasion
PTB
Infiltrative margin
Poor survival
Lugli et al, Hum Pathol 2011
INTRATUMORAL BUDDING
1 HPF method in pre‐operative CRC biopsies
Zlobec et al, BJC 2014
TUMOR BUDDING
Application of the 1HPF & 10HPF method
Koelzer et al, Poster Session III # 61
TUMOR BUDDING
Possible workflow
Colon & rectal cancer specimens
Colon & rectal cancer
biopsies
Colon & rectal cancer
resections
1 HPF hot spot
1 HPF hot spot in malignant polyps
Cut‐off: 6 buds
Continuous scale
Cut‐off: 6 buds
or
Continuous scale
10 HPF in advanced CRC
Cut‐off: 100 buds
Continuous scale
CONTENT
DEFINITION AND CHARACTERISTICS OF TUMOR BUDDING
CLINICAL IMPLICATIONS OF TUMOR BUDDING
PRACTICAL ASPECTS OF TUMOR BUDDING
SUMMARY & OPEN POINTS
TUMOR BUDDING
Summary
Based on the literature tumor budding is a histomorphological biomarker of tumor
progression and an independent prognostic factor
The fields of action may include malignant polyps, stage II CRC and pre‐operative biopsies
The prognostic power of tumor budding seems to be independent of the applied
scoring system
Our own experience in Bern: ITB (1HPF) can be used in pre‐operative biopsies as
well as in malignant polyps whereas PTB (10HPF) can be applied in stage II CRC
TUMOR BUDDING
Open points
Three points need to be adressed for a standardized scoring system
‐ Consensus on the scoring system
‐ H&E vs immunohistochemistry
‐ Cut‐offs vs continuous probability scale
Validation on retrospective and prospective large multicentric cohorts
Shall tumor budding replace glandular formation for the definition of tumor grade (G) in the TNM classification ? MULTICENTRIC STUDY IN PREPARATION
ACKNOWLEDGMENTS
Interdisciplinary CRC Research Group, University and University Hospital Bern, Switzerland:
Translational Research Unit (TRU) & Clinical Pathology Division
Inti Zlobec, PhD
Lena Sokol, PhD
Viktor Kölzer, MD
Heather Dawson, MD
Gregor Rieger, MD
Oncology Department
Martin Berger, MD
Visceral Surgery and Medicine Department
Daniel Inderbitzin, MD
Beat Schnüriger, MD
Lukas Brügger, MD
Marion Hädrich, MD
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