Rare primary non-neuroendocrine tumours of the sella

About 1% of primary tumour of the sellar region can be diagnostically challenging. The spectrum of these lesions includes lesions that have been codified in 4th edition of the WHO classification of tumours of the pituitary gland published in 2017 such as posterior lobe and neuronal and paraneuronal tumours as well as lesions that have not been included such as the sellar atypical teratoid rhabdoid tumour, salivary gland-like tumours and primary sellar melanocytic tumours. This review aims to provide the diagnostic criteria for these rare lesions and an overview of their essential clinical and neuroimaging features.     

Sustentacular cells in pulmonary neuroendocrine tumours

AIMS: To determine the prevalence of sustentacular cells across the range of pulmonary neuroendocrine tumours: typical and atypical carcinoid tumours and large cell and small cell neuroendocrine carcinomas. METHODS AND RESULTS: Sustentacular cells were sought in 80 pulmonary neuroendocrine tumours by immunolabelling for S100 protein, nerve growth factor receptor and glial fibrillary acidic protein. Intratumoural macrophages and Langerhans cells were identified with the KP 1 (CD68) and CD1A antibodies. S100-positive sustentacular cells were present in 25 of 30 typical carcinoids, 200 of 25 atypical tumours, six of 10 large cell carcinomas and six of 15 small cell lesions. They were most numerous in the typical carcinoids but very few in the small cell carcinomas, their prevalance being clearly related to grade of differentiation and, in particular, to the degree of architectural organization. CONCLUSIONS: Sustentacular cells are often found in pulmonary neuroendocrine tumours, especially better-differentiated lesions with a well-developed architecture. their prevalence clearly reflecting the degree of structural organization. Whether their prevalence is a useful prognostic indicator within a particular group of such tumours, such as the atypical carcinoids or the large cell carcinomas, as appears to be the case with paragangliomas, is unclear.     

Thymic neuroendocrine tumours

Thymic epithelial tumours include the subcategory of thymic neuroendocrine neoplasms, which comprise a spectrum of entities that mirrors their counterparts in the lung, i.e. typical carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma and small cell carcinoma. These tumours are classified according to the current WHO classification for lung tumours, and their relevant histomorphological and immunohistochemical criteria will be discussed in this brief review. Thymic neuroendocrine neoplasms do, however, also have clinical and molecular characteristics which set them apart from their pulmonary relatives, and recent research has provided valuable insights into possible molecularly-informed classification systems, which broadly align with classical categories, but also show some discrepancies. The most salient recent studies in that respect will also be discussed, as will the avenues for locally ablative therapy and possibilities for systemic treatment.     

Morphometrical differences between pseudo-epitheliomatous hyperplasia in granular cell tumours and squamous cell carcinomas

AIM: Granular cell tumour (GCT) is a benign tumour which occasionally induces pseudo-epitheliomatous hyperplasia (PEH) of the covering epithelium, mimicking squamous cell carcinoma (SCC) invasion. PEH cells do not show marked atypia, but the presence of pseudoinvasive patterns remains a diagnostic problem since several misdiagnosed cases have been reported. This study investigated objective morphometric criteria to distinguish GCT-PEH from SCC. METHODS AND RESULTS: The complexity of the epithelial connective tissue interface (ECTI) in 57 profiles from nine SCC and 12 GCT-PEH cases was analysed using fractal geometry. Epithelial and non-epithelial cells were segmented using a space partition procedure and analysed morphometrically. GCT ECTI profiles were significantly more complex than those of SCC. The complexity of ECTI quantified by global and local fractal dimensions allowed up to 86% correct discrimination between GCT-PEH and SCC. The cell-wise discrimination between the two entities using cellular morphology was 76% but when the two approaches were combined, the correct discrimination was 96%. CONCLUSIONS: The architectural features of GCT-PEH and SCC show differences which, when quantified, could be used to differentiate the two diagnostic classes. Characterization of these differences may help to elucidate some of the mechanisms of tumour infiltration and metastasis.     

Current concepts in the classification of thoracic neuroendocrine tumours

Bronchopulmonary neuroendocrine tumours (NETs) share features with extrathoracic NETs and comprise a spectrum of neuroendocrine neoplasms, most of which are also mirrored by counterparts in the thymus. Accurate classification remains difficult on morphological criteria alone, as overlapping and transitional phenotypes occur and reproducibility of classification is marred by ambiguity, heterogeneity and sampling error, and artefacts, especially in cytology and small biopsy specimens. While there have been significant advances in the immunohistochemical and molecular characterization and phenotyping of thoracic NETs in recent years, and this holds great promise for the development of therapeutically relevant categories, this has not yet led to a shift in pathology practice. In this review, the current World Health Organization (WHO) classification of thoracic NETs will be discussed, areas of diagnostic difficulty highlighted, an overview of recent evidence for clinically relevant immunohistochemical and molecular phenotypes provided, and their potential for introduction into routine practice discussed.     

Double neuroendocrine ductal carcinomas in situ coexisting with a background of diffuse idiopathic neuroendocrine cell hyperplasia of breast: a case report and hypothesis of neuroendocrine tumor development

This article reports the case of a 72-year-old woman with two nodules of neuroendocrine (NE) ductal carcinoma in situ coexistent with a background of NE cell hyperplasia. Both tumors, 15 and 3 mm in size, were incidentally revealed on computed tomography without any apparent clinical symptoms. The tumors showed similar histological features, and more than 50% of the tumor cells patchily expressed NE markers, such as chromogranin A, synaptophysin, CD56, and somatostatin receptor type 2. The surrounding nontumor ductal cells also showed spotty or linear positivity for NE markers in contrast to the cells of normal atrophic breasts, which rarely present with NE cells. Moreover, focal mucin production was also observed in the peripheral ducts. It is hypothesized that idiopathic breast NE cell hyperplasia with multiple small nests of NE cells may extend to form a true mass of NE neoplasms.     

Immunocytochemical localization of neuron specific enolase in small cell carcinomas and carcinoid tumours of the lung

Carcinoid tumours and small cell carcinomas of the lung share many characteristics with normal neuroendocrine cells. While carcinoid tumours contain many dense-cored neurosecretory granules and are frequently argyrophil, small cell carcinomas are poorly granulated and rarely argyrophil, which casts doubt on their neuroendocrine nature. Immunostaining of the enzyme neuron specific enolase (NSE) was recently used to demonstrate the neuroendocrine components of the lung including nerves and neuroendocrine cells. We therefore used NSE immunostaining to investigate neuroendocrine differentiation in 79 lung tumours, including 18 bronchial carcinoids and 31 small cell carcinomas, and compared these results with those obtained with silver stains. Thirteen of the 18 carcinoids were reactive to silver, all other types being negative. NSE-immunoreactivity occurred in 16 carcinoids and 18 small cell carcinomas. None of the squamous cell carcinomas, large cell anaplastic carcinomas and adenocarcinomas examined showed NSE-immunoreactivity. Radioimmunoassay of extractable NSE from 10 fresh lung tumours correlated well with the immunostaining results, demonstrating large amounts in two small cell carcinomas (334 and 517 ng/mg protein) and three carcinoids (152, 908, and 1143 ng/mg protein). Values were much lower for four squamous cell carcinomas (31-44 ng/mg protein) and one large cell anaplastic carcinoma (30 ng/mg protein) and were accounted for by the presence of NSE-positive nerves and neuroendocrine cells in the surrounding lung. NSE immunostaining is a useful marker of neuroendocrine differentiation in lung tumours and should prove particularly valuable in the diagnosis of small cell anaplastic tumours and their metastases.     

Expression of TGF-alpha in neuroendocrine tumours of the distal colon and rectum

AIM: Transforming growth factor alpha (TGF-alpha) has been localized in neuroendocrine L-cells of the colon and rectum in previous studies. We examined whether neuroendocrine tumours with L-cell differentiation express TGF-alpha. EXPERIMENTAL DESIGN: Immunohistochemistry was performed for proglucagon- and pro-pancreatic polypeptide derivatives, as well as for TGF-alpha, and epidermal growth factor receptor (EGFR) using paraffin sections from 16 neuroendocrine tumours of the colon and rectum. Also, in situ hybridization for TGF-alpha and proglucagon was carried out. MAIN RESULTS: A strong expression of TGF-alpha at the protein level can be shown for neuroendocrine tumours of the hindgut. In one third of our cases we found a strong hybridization signal and in two thirds a moderate signal for TGF-alpha. The immunohistological phenotype concerning gut hormones is highly heterogeneous. Glucagon-like peptide 2 (GLP2) in our series was the most sensitive immunohistological hormone marker. MAJOR CONCLUSIONS: The immunophenotype of colorectal neuroendocrine tumours regarding hormone markers is heterogeneous. The expression of TGF-alpha corresponds to the immunohistological profile of normal L-cells. TGF-alpha, especially in the neuroendocrine L-cells, most probably acts as a multifunctional trophic factor responsible for cellular integrity and survival, and not as an oncogenic growth factor.     

Differential expression of telomerase activity in neuroendocrine lung tumours: correlation with gene product immunophenotyping

Telomerase activity was examined by the telomeric repeat amplification protocol (TRAP) assay in 38 neuroendocrine (NE) lung tumours. A significantly (p = 0.001) different frequency of telomerase positivity was observed among different histological tumour types. Specifically, a positive TRAP signal was observed in 14 of 15 (93%) small cell lung cancers (SCLCs), 7 of 8 (87%) large-cell NE carcinomas (LCNECs), and only 1 of 15 (7%) typical carcinoid tumours. When telomerase activity was correlated with the gene product-based immunophenotypic profile of individual tumours, it was found that the absence of telomerase activity was associated with a lack of bcl-2, p53, and c-kit expression, and characterized by a low proliferation index consistent with the absence of cdk-4 expression and the presence of the cdk inhibitor Rb. Such a phenotype was appreciable in most of the carcinoid tumours. Conversely, telomerase-positive tumours generally showed an immunophenotype consistent with gene product alterations (including high expression of bcl-2, p53, and c-kit, and loss of Rb) and were characterized by a high proliferation index. These telomerase data support the previously reported evidence for two genetically unrelated groups of NE lung tumours (SCLC, and to some extent LCNEC, versus carcinoid tumours) that have distinct phenotypic profiles.     

Obestatin in human neuroendocrine tissues and tumours: expression and effect on tumour growth

The hormone obestatin, which is derived from the same precursor as ghrelin and whose receptor(s) is still unrecognized, possesses a variety of metabolic/modulatory functions mostly related to food intake suppression and reduction of gastrointestinal motility. The distribution of obestatin in normal and neoplastic human tissues is poorly understoood. We report that in fetal tissue samples, obestatin peptide was detected in the thyroid, pituitary, lung, pancreas and gastrointestinal tract, usually being co‐localized with chromogranin A. In adult tissues, obestatin protein expression was restricted to pituitary, lung, pancreas and gastrointestinal tract and was co‐localized strictly with ghrelin. By contrast, in endocrine tumours obestatin was expressed in a small fraction of thyroid, parathyroid, gastrointestinal and pancreatic neoplasms, in most cases with a focal immunoreactivity and co‐localized with ghrelin. Messenger RNA levels of the specific fragments of ghrelin and obestatin were comparable in both normal and tumour samples, confirming that post‐translational mechanisms rather than alternative splicing events lead to ghrelin/obestatin production. Finally, in TT and BON‐1 cell lines obestatin induced antiproliferative effects at pharmacological doses, opposite to those observed with ghrelin. In summary, our data demonstrate that obestatin is produced by the same endocrine cells that express ghrelin in normal tissues from fetal to adult life, whereas, as compared to ghrelin, in neoplastic conditions it is down‐regulated by post‐translational modulation and shows potential antiproliferative properties in vitro. Copyright © 2008 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.     

Gastrin releasing peptide in human neuroendocrine tumours

Neuroendocrine tumours of the lung and gut are known to possess bombesin-like immunoreactivity. The recent observation that gastrin releasing peptide (GRP), a 27 amino acid peptide isolated from the porcine intestine, may be the mammalian analogue of bombesin led us to look for this peptide in a variety of human neoplasms. Formalin-fixed tissues from 85 tumours were examined by the immunoperoxidase technique, using specific antisera to the GRP molecule (1-27) and the GRP fragment (1-16). Intense cytoplasmic GRP immunoreactivity was seen in thyroid medullary carcinomas (3/3), carcinoids of lung, pancreas, and intestine (22/36), and paragangliomas (2/3). Less frequent staining was present in pulmonary small cell (oat cell) carcinomas (1/8) and pituitary adenomas (1/6). Complete absence of immunoreactivity was observed in three phaeochromocytomas, five Merkel cell tumours, six neuroblastomas and 15 non-neuroendocrine tumours. Normal neuroendocrine cells of the thyroid (C-cells) and bronchial mucosa (Kulchitsky cells) exhibited GRP immunoreactivity; nerve fibres from all sites failed to demonstrate staining for GRP. In each positive case, the pattern of staining for GRP (1-27) and GRP (1-16) was identical, although the GRP (1-16) immunostaining was weaker. These findings indicate that bombesin immunoreactivity in human neuroendocrine cells and tumours is attributable to GRP-like molecules and that GRP is a useful marker of neuroendocrine differentiation in many tumours.     

Mechanisms of neuroendocrine differentiation in pulmonary neuroendocrine cells and small cell carcinoma

We review the significance of a network of proneural basic helix-loop-helix (bHLH) factors. Immunohistochemically, pulmonary neuroendocrine cells (PNECs) are positive for Mash1, one of the activator bHLHs, and non-PNECs such as Clara cells are positive for Hes1, one of the repressor bHLHs. Since mice deficient for the Mash1 gene do not possess PNEC and mice deficient for the Hes1 gene have many PNECs, it is suggested that a network of bHLHs work in cell fate determination of lung epithelium. Moreover, the Notch pathway could play a role in cell differentiation mechanisms in the lung because this signaling pathway has been reported to work in various tissues. PNECs have been reported to modulate various nonneoplastic human lung diseases. We demonstrate that PNECs in usual interstitial pneumonia and hASH1 (human homolog of Mash1) are upregulated in diseased lung tissues. Moreover, studies of small cell carcinoma and non-small cell carcinoma suggest that neuroendocrine differentiation could be regulated by hASH1. In non-small cell carcinoma, Hes1 and Notch signaling may have roles in maintaining cell differentiation. Thus, a network of bHLHs and Notch signaling are important in cell differentiation of normal and pathologic lung epithelial cells.     

Immunocytochemical characterization of neuroendocrine tumours of the larynx

Twenty-two neuroendocrine tumours of the larynx were investigated using a panel of immunocytochemical markers. Three were small cell carcinomas, eight were large cell neuroendocrine carcinomas and 11 were paragangliomas. Twenty were positive for protein gene product 9.5, 19 for neuron-specific enolase, 15 for chromogranin A, nine for bombesin, eight for substance P, eight for neuropeptide Y, eight for metenkephalin, seven for somatostatin, five for calcitonin, eight for calcitonin gene-related peptide and one for vasoactive intestinal polypeptide. Bombesin immunoreactivity was largely restricted to the small cell carcinomas and large cell neuroendocrine carcinomas and neuropeptide Y, metenkephalin and substance P to the parangangliomas. This comprehensive immunocytochemical analysis of neuroendocrine tumours of the larynx demonstrates that these tumours represent special entities but have similar patterns of immunostaining to those of neuroendocrine tumours in other sites.     

Immunohistochemical markers of small cell carcinoma and related neuroendocrine tumours of the lung

A selected group of 263 pulmonary neuroendocrine tumours comprised 156 small cell carcinomas, five combined cell carcinomas, nine atypical carcinoid/small cell carcinomas, 32 atypical carcinoids, ten large cell/small cell carcinomas, and 51 carcinoid tumours. These were compared with a group of 109 non-small cell carcinomas, using four markers of neuroendocrine differentiation to determine differences in reactivity between the two groups and among the variants of neuroendocrine tumour. The antibodies used were neuron-specific enolase (NSE), protein gene product (PGP) 9.5, human bombesin, and the C-terminal flanking peptide of human bombesin (CTP). Most small cell carcinomas, carcinoid tumours, and atypical carcinoid variants showed immunoreactivity for both NSE and PGP 9.5 but a significant number of non-small cell carcinomas, mainly squamous cell carcinomas, were also positive (11 and 35 per cent, respectively). Bombesin was specific for neuroendocrine tumours, being demonstrable in 35 per cent carcinoids and 24 per cent small cell carcinomas, but staining was focal and often confined to scattered cells. Diffuse strongly positive immunoreactivity for CTP was seen in the majority of malignant neuroendocrine tumours, but only 12 per cent of carcinoid tumours were positive and non-small cell carcinomas were negative. CTP is therefore of potential value as a specific marker of malignant neuroendocrine tumours, particularly if the amount of biopsy material is limited and the tumour is an unusual variant, such as atypical carcinoid or large cell-small cell carcinoma.     

Epidermal growth factor receptors in lung tumours

Immunocytochemical analysis of epidermal growth factor (EGF) receptor expression was carried out on frozen sections of 109 primary lung tumours resected at the Brompton Hospital from February 1984 to May 1985. Tumours with detectable levels of this proto-oncogene protein were significantly more frequent among squamous cell carcinomas than among other types of lung tumour. No truncated EGF receptors were detected in the tumours using two monoclonal antibodies (Mabs) directed against different portions of the receptor (EGFR1 and F4). Mab F4 is the first antibody to the EGF receptor to show reactivity in paraffin sections. Southern blot analysis of a subset of the tumours detected amplification of the EGF receptor gene in squamous cell carcinomas but not in adenocarcinomas. The one carcinosarcoma examined had a re-arranged and amplified EGF receptor gene. Measurement of EGF receptor expression in lung tumours can be of diagnostic value and may prove to be useful in the development of antibody-directed therapy.