histological grades of · endpoints: development of recurrences/ metastases and...
TRANSCRIPT
Histological grades of
malignancy and prognosis
in canine mammary tumors.
Veterinary Faculty
Complutense University of Madrid,
Spain
Laura Peña, Alicia Álvarez,
María López de la Banda, Natividad Martínez,
Mª Dolores Pérez-Alenza.
Histological Malignancy Grading in
canine mammary tumors.
Histological diversity of canine mammary tumors
(CMT) makes difficult their diagnosis.
A grading system has been proposed to better
accurate the tumor information provided from the
pathologist to the clinician.
Histological Malignancy Grading
for human breast cancer
Method for human breast cancer: Elston and Ellis’
/Bloom and Richardson’s/ Nottingham method(Elston and Ellis, 1991)
Tubule formation
Nuclear pleomorphism
Mitotic counts
Directed principally at invasive
(simple) adenocarcinomas.
Elston and Ellis’ Histological
Malignancy Grading in canine
mammary tumors (CMT)
Used in several studies on CMT (Peña et al., 1998; Nieto et al., 2000.; Reis et al., 2003;
Matos et al., 2006; Millanta et al., 2006; Gama et al., 2008; Alves et al., 2008; De Oliveira et al., 2009; Gama et al., 2010; Santos et al., 2010)
Prognostic value in CMT? :
- 1998, 2000: Grade related to survival in univariate but
not in multivariate analyses. (Peña et al., 1998; Nieto et al., 2000.)
- 2005: Grade related to survival in univariate analyses.
NO MULTIVARIATE study. (Karayannopoulou et al., 2005)
Prognostic factors should be evaluated using prospective
multivariate analyses, in order to know whether or not a
factor could predict prognosis independently.
How to evaluate myoepithelial areas ?
Histological Malignancy Grading of CMT:
The need of a canine adapted system
CMT are less aggresive than human breast cancers
(only few metastatize). (Withrow, 2001; Clemente et al., 2010 ).
Histological Malignancy Grading of CMT:
The need of a canine adapted system
CMT are less aggresive than human breast cancers
(only few metastatize).
The existence of complex and mixed malignant
tumors. It is essential to use uniform criteria in assessing
these areas.
Histological Malignancy Grading of CMT:
The need of a canine adapted system
CMT are less aggresive than human breast cancers
(only few metastatize). (Withrow., Clemente et al., 2010 ).
The existence of complex and mixed malignant
tumors. It is essential to use uniform criteria in assessing
these areas.
Specific criteria of malignancy in canine mammary
tumors (Goldschmidt et al., 2011): Nuclear pleomorphism- even in benign
tumors- is frequent.
Histological Malignancy Grading of CMT:
The need of a canine adapted system
CMT are less aggresive than human breast cancers
(only few metastatize). (Withrow., Clemente et al., 2010 ).
The existence of complex and mixed malignant
tumors. It is essential to use uniform criteria in assessing
these areas.
Specific criteria of malignancy in canine mammary
tumors (Goldschmidt et al., 2011): Nuclear pleomorphism- even in benign
tumors- is frequent.
Histological Malignancy Grading of
CMT by a canine adapted system
In 2000- start to use a modification of the Elston and
Ellis’ method for CMT.
Related to prognosis? According to clinicians (VTH
Madrid) yes => a prognostic study including the grading
system was needed.
Histological Malignancy Grading of
CMT by a canine adapted system
Grading system partially published and compared with a
previous system by Misdorp. (Clemente et al. 2010; Goldschmidt, Peña et al., Vet.
Pathol. 48:117-131, 2011).
Histological Malignancy Grading of
CMT by a canine adapted system
Grading system partially published and compared with a
previous system by Misdorp. (Clemente et al. 2010; Goldschmidt, Peña et al., Vet.
Pathol. 48:117-131, 2011).
Retrospective study: Better associated to lymph node
metastases at time of diagnosis than Misdorp’s. (Rasotto et al., Vet
Pathol 0nline published on June 13, 2011).
To study the prognostic value of
histological grade in canine mammary
cancer in a prospective clinical study
with two-years follow-up
AIM
Materials and Methods
Prospective study.
Female dogs with malignant CMT (no sarcomas) presented at
Complutense University Veterinary Teaching Hospital (Madrid), clinically
evaluated and surgically treated through 2008. Clinical stages: I, II
(local), III (local advanced), IV (regional). No distant metastasis (V). No
chemotherapy.
Follow-up: 28-38 months. Clinical evaluations every 4-6 months.
Endpoints: Development of recurrences/ metastases and neoplasia-
associated death.
Only animals with complete data were included (n=66).
Recruitment of animals, criteria of inclusion,
and clinical procedures
Recommended Guidelines for the conduct and evaluation
of prognostic studies in Veterinary Oncology. Vet. Pathol .
48: 7-18, 2011
Materials and Methods
Performed in 2008 using a modification of the WHO’s
classification for CMT (vet. Pathol, Jan, 2011) (Goldschmidt, Peña
et al., Vet. Pathol. 48:117-131, 2011).
Histopathology
Histologic grading of CMT
Materials and Methods
Tubular formation (1 to 3 points):
– 1= formation of tubules in >75% – 2= formation of tubules in 10-75% (moderate formation of tubular arrangements admixed with areas of
solid growth) – 3= formation of tubules in (<10%) (minimal or no tubule formation) In complex or mixed tumors, tubular formation is evaluated only in epithelial areas In malignant myoepithelioma tubular formation is 2.
Nuclear pleomorphism (1 to 3 points):
– 1= uniform or regular small nucleus, and occasional nucleoli – 2= moderate degree of variation in nuclear size and shape, hypercromatic nucleus, presence of nucleoli
and some of them can be prominent – 3= marked variation in nuclear size, hypercromatic nucleus, often with one or more prominent nucleoli
In complex or mixed tumors, nuclear pleomorphism is evaluated in all the malignant components.
Mitotic rate (1 to 3 points): – 1= 0 to 9 mitotic figures/10 HPF; – 2= 10 to 19 mitotic figures/10 HPF; – 3= 20 or more mitotic figures/10 HPF.
The fields are selected at the periphery or the most mitotically active parts of the sample (not only epithelial
cells).
Modification of Elston and Ellis’ numeric method (1991)
- Grade I= 3-5 points, well differentiated;
- Grade II= 6-7 points, moderately differentiated;
- Grade III= 8-9 points, poorly differentiated.
Histologic grading of CMT
Materials and Methods
Tubular formation
Nuclear pleomorphism
Mitotic count
GRADE
Statistical study
Materials and Methods
Epidemiological variables: Age at diagnosis, spayed status, breed,
weight, regularity of estrus, and previous hormonal treatments.
Clinical variables: Number of neoplasms/animal, location, size in cm,
size (categorical), adherence to skin, adherence to underlying tissues, tumor
ulceration, clinical stage, lymph node status confirmed by cytology). Type of
surgery.
IBM SPSS Statistics 19
Statistical study Materials and Methods
Histological variables:
- Histological diagnosis
- Histol. Diagn. 3 cat
(HD3)
1
- In situ carcinoma.
- Simple carcinoma
- Carcinoma arising
- Complex carcinoma
- Mixed type carcinoma
- Ductal carcinoma
- Adenosquamous carcinoma
2
- Solid carcinoma
- Comedocarcinoma.
- Carcinoma and mal. myoepithelioma
- Anaplastic carcinoma
3
Other types
- Grade: I (n=29), II (n= 20), III (n=17).
- Lymph node metastases (surgical specimen, n=40, H&E)
HD3
Statistical study
Materials and Methods
Follow-up variables:
• Disease-free Survival (DFS)(months). DFS: Time from surgery to the development of recurrences and/or metastases)
• Overall Survival (OS)(months).
OS: Time from surgery to death by neoplasia or end of the follow-up.
Significant level p<0.05
• Recurrences/metastases (rec/met)(no/yes).
Recurrence: developing of a subsequent CMC at the original tumor location.
• Death by tumor (no/yes).
Results and Discussion
Rec/Met
A) Univariate analyses: Rec/Met, Cancer death
Age (9-11 years) (p=0.01)
Spayed status (p= 0.02)
Clinical stage (p=0.001)
Histological type (p=0.005) and HD3
(p<0.001)
Lymph node metastases (histologically
confirmed) (p=0.003)
Grade (p<0.001)
Cancer death (p<0.001)
Results and Discussion
0
10
20
30
40
50
60
70
80
90
100
Grade I Grade II Grade III
Rec/Met NO
Rec/Met YES
Rec/Met Grade /
(p<0.001)
%
Cancer death
A) Univariate analyses: Rec/Met, Cancer death
Age (9-11 years) (p=0.009)
Breed (large) (p= 0.04)
Clinical stage (regional) (p<0.001)
Histological type (p=0.01) and HD3
(p<0.001)
Lymph node metastases (histologically
confirmed) (p=0.001)
Grade (p<0.001)
Results and Discussion
Results and Discussion
Cancer death Grade /
(p<0.001)
%
0
10
20
30
40
50
60
70
80
90
100
Grade I Grade II Grade III
Cancer death NO
Cancer death YES
DFS OS
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS OS
Age 9-11 y. ↓DFS
(p=0.007)
9-11 y. ↓OS
(p=0.005)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS OS
Age 9-11 y. ↓DFS
(p=0.007)
9-11 y. ↓OS
(p=0.005)
Spayed ↓DFS (p= 0.026)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS OS
Age 9-11 y. ↓DFS
(p=0.007)
9-11 y. ↓OS
(p=0.005)
Spayed ↓DFS (p= 0.026)
Breed large breed, ↓OS
(p=0.027)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS OS
Age 9-11 y. ↓DFS
(p=0.007)
9-11 y. ↓OS
(p=0.005)
Spayed ↓DFS (p= 0.026)
Breed large breed, ↓OS
(p=0.027)
Clinical stage local/regional
(p<0.001)
local/regional
(p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS OS
Age 9-11 y. ↓DFS
(p=0.007)
9-11 y. ↓OS
(p=0.005)
Spayed ↓DFS (p= 0.026)
Breed large breed, ↓OS
(p=0.027)
Clinical stage local/regional
(p<0.001)
local/regional
(p<0.001)
Tumor size >3cm, ↓OS
(p=0.028)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS OS
Age 9-11 y. ↓DFS
(p=0.007)
9-11 y. ↓OS
(p=0.005)
Spayed ↓DFS (p= 0.026)
Breed large breed, ↓OS
(p=0.027)
Clinical stage local/regional
(p<0.001)
local/regional
(p<0.001)
Tumor size >3cm, ↓OS
(p=0.028)
HD3 groups1/2 (p<0.001) groups1/2 (p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS OS
Age 9-11 y. ↓DFS
(p=0.007)
9-11 y. ↓OS
(p=0.005)
Spayed ↓DFS (p= 0.026)
Breed large breed, ↓OS
(p=0.027)
Clinical stage local/regional
(p<0.001)
local/regional
(p<0.001)
Tumor size >3cm, ↓OS
(p=0.028)
HD3 groups1/2 (p<0.001) groups1/2 (p<0.001)
Lymph node met.
(H&E)
(p<0.001) (p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS OS
Age 9-11 y. ↓DFS
(p=0.007)
9-11 y. ↓OS
(p=0.005)
Spayed ↓DFS (p= 0.026)
Breed large breed, ↓OS
(p=0.027)
Clinical stage local/regional
(p<0.001)
local/regional
(p<0.001)
Tumor size >3cm, ↓OS
(p=0.028)
HD3 groups1/2 (p<0.001) groups1/2 (p<0.001)
Lymph node met.
(H&E)
(p<0.001) (p<0.001)
Grade (p<0.001) (p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS
(p=0.007)
(p= 0.026)
(p<0.001)
(p<0.001)
(p<0.001)
(p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS
(p=0.007)
(p= 0.026)
(p<0.001)
(p<0.001)
(p<0.001)
(p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
DFS
(p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
OS
(p=0.005) (p=0.027)
(p<0.001)
(p=0.028) (p<0.001) (p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
OS
(p=0.005) (p=0.027)
(p<0.001)
(p=0.028) (p<0.001) (p<0.001)
B) Survival Study
Kaplan-Meier survival curves
Results and Discussion
OS
(p<0.001)
C) Survival study. Multivariate
analyses (Cox Regression)
Results and Discussion
To evaluate the influence of sets of variables on dependent follow-up
variables and find the independent predictive variables.
Step Selected variables
DFS 1 Clinical stage p<0.001
2 Grade p=0.01
Clinical stage
3 Grade
Spayed status p=0.06
Clinical Stage
C) Survival study. Multivariate
analyses (Cox Regression)
Results and Discussion
Step Selected variables
OS 1 Clinical stage p< 0.001
2 Grade p= 0.018
Clinical stage
3 Grade
Clinical stage
Ulceration p= 0.07
4 Grade
Ulceration
“Chuky”, Shitzu, intact female, 12 y.
Local stage, complex carcinoma, grade I.
Picture during follow-up visit two years
after surgery.
OS= 28 months
Besides the histological type, the grade gives accurate
information to clinician about the histological malignancy.
Easy to apply for clinicians.
Limitations:
- Sarcomas
- Carcinosarcomas (mesenchymal component)
Further studies including low frequent histological
types (Group 3, i.e.carcinosarcomas).
Grading of CMT
Conclusions
The histological grading system of canine
mammary tumors has prognostic value in
prospective univariate and multivariate
analyses (independent prognostic factor).
Conclusions
Grading of CMT
Clinicians after reading a mammary gland
histopathological report…..
… such as: “Diagnosis: tubular/solid
complex carcinoma with foci of
adenosquamous transformation in
benign tumor (mixed type)”
Clinicians after reading a mammary gland histopathological
report…..INCLUDING A GRADE
… such as: tubular/solid complex carcinoma with
foci of adenosquamous transformation in benign
tumor (mixed type), GRADE I.
“The pathologist”
¡Muchas
gracias!
Thank you
very much!
Tack så
mycket!