NOVARTIS EXHIBIT 2018
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`World Health Organization Classification of Tumours
`
`.,
`
`OMS
`
`WHO
`
`i .'F' i
`\t 1~ fl
`
`~~
`
`International Agency for Research on Cancer (IARC)
`
`~athology and Genetics of
`Tumours of Endocrine Organs
`
`Edited by
`
`Ronald A. Delellis
`
`Ricardo V. Lloyd
`
`Philipp U. Heitz
`
`Charis Eng
`
`(ARC Press
`
`Lyon , 2004
`
`
`
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`.. ' --t·
`
`I
`
`World Health Organization Classification of Tumours
`
`Serfes Editors Paur Kleihues, M.D.
`Leslie H. Sobin. M.D.
`
`Pathology and Genetics of Tumours of Endocrine Organs
`
`Editors Ronald A. Del ellis. M.D.
`Ricardo V. Lloyd. M.D.
`Philipp U. Heitz, M.D.
`Charis Eng, M. D .. Ph.D.
`
`Coordinating Editors Wojc1ech Biernat. M.D.
`Janice Sych, Ph.D.
`
`/
`./
`
`LC Contro l Number Edltorial Assistants
`
`i\ \\\\\\\\\\\\\\\\\ \\\ \\\\\ i, \\
`
`;~)(.4hl 7
`
`Isabelle Forcier
`Voich1ta Meyronein
`Agnes Meneghel
`
`Layout
`
`Vanessa Meister
`Marlen Grassinger
`Sibylle Soring
`
`Illustrations
`
`Thomas Odin
`
`Printed by
`
`Team Rush
`69603 Villeurbanne, France
`
`Publisher
`
`IA RC Press
`International Agency for
`Research on Cancer (IARC)
`69008 Lyon. France
`
`
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`This volume was produced in collaboration with the
`
`International Academy of Pathology (IAP)
`
`The WHO Classification of Tumours of Endocrine Organs
`presented in this book reflects the views of a Working Group that
`convened for an Editorial and Consensus Conference in Lyon, France,
`April 23-26, 2003
`
`Members of the Working Group are indicated
`in the List of Contributors on page 263
`
`
`
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`Published by IARC Press. International Agency for Resear ch on Cancer,
`150 cours Alben Thomas. F-69008 Lyon. Frar,ce
`
`© International Agency for Research on Cancer , 2004
`
`Publications of the World Health Organization enioy copyright protection in
`accordance with the provisions of Protocol 2 of the Universal Copyright Convention.
`All rights reserved.
`
`The lnterna11onal Agenc11 for Research on Cancer welcomes
`requests for permission to reproduce or translate its publications. in part or in lull
`Requests for permission lo reproduce figures or charts from tt,is publication should be directed 10
`the respective contributor (see section Source of Charts and Photographs).
`
`The designations used and the presentation ol the material in this pubhcalion do not imply the
`e~press1on ol any opinion whatsoever on the part of the Secretariat of the
`World Health Organization concerning lhe legal status of any country, territory, c,ry,
`or area or of its authorities, or concern ing the delimitation of ,ts frontiers or boundaries.
`
`The mention of specific companies or of cerialn manufacturers' products does not imply
`that they are endorsed or recommended by the World Health Organization in preference 10 others
`of a similar nature that are not mentioned. Errors and omissions excepted ,
`the names of proprietary products are distinguished by lnitial capital letters
`
`The authors alone are responslble for the views expressed 1n this publlcation
`
`Enquiries should be addressed to the
`Communications Unit, lnternaoonal Agency for Research on Cancer . 69008 Lyon . France.
`which will provide the latest information on any changes made to the text and plans for new editions.
`
`Format for bibliographic citations:
`Delellis RA . Lloyd R.V. , Heitz P.U., Eng C. (Eds.): World Health Organization
`Ctasslfication of Tumours. Pathology and Genetics of Tumours of Endocrine Organs.
`IARC Press: Lyon 2004
`
`IARC Library Cataloguing In Publication Data
`
`Pathology and genetics of ,tumours of endocrine organs /
`editors RA Delellis ... [et al.]
`
`(World Health Organization classification of tumours : 8)
`
`1. Pituitary gland neoplasms - genetics 2 Pituitary gland neoplasms - pathology
`3. Thyroid neoplasms - genetics 4. Thyroid neoplasms. - pathology
`5. Endocrine pancreas neoplasms - genetics 6 Endocrine pancreas neoplasms - pathology
`7. Adrenal neoplasms - geneHcs 8. Adrenal neoplasms - pathology
`L Delellis Ronald A. II . Series
`
`ISBN 92 832 24 16 7 {NLM Classifica,tion . WJ 160)
`
`
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`\.,..~
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`,,. .... ,;
`CHAPTER 4
`
`TUmours of the Endocrine Pancreas
`
`Tumours of the endocrine pancreas are much less frequent
`than those of the exocrine pancreas and usually have a much
`better prognosis. Hormones secreted by endocrine neoplasms
`include insulin, glucagon; somatostatin, gastrin, vasoactive
`intestinal polypeptide (VIP), pancreatic polypeptide (PP), sero(cid:173)
`tonin , ACTH; and calcitonin . Depending on the peptide hor(cid:173)
`,_ :-." mones produced, they may,cause>distinct clinical syndromes,
`including life-threatening hypoglycaemia, gastric and/or duo-;.
`denal ulcers, or dehydration due to diarrhoea.
`.
`Most pancreatic neuroendocrine tumours can be surgically
`resected and this leads to a rapid regression of clinical symp(cid:173)
`toms. Poorly differentiated neoplasms may be metastatic at the
`time of clinical presenfation, and this is associated with a poor
`prognosis.
`Genetic susceptibility may play an important role. Up to 20% of
`gastrinomas are associated with the inherited MEN-1 syn(cid:173)
`drome. _
`
`~ -
`
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`
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`WHO histological classification of tumours of the
`endocrine pancreas
`
`Well-differentiated endocrine tumour
`Functioning
`Insulin-producing (insulinoma)
`Glucagon-producing (glucagonoma)
`Somatostatin-producing (somatostatinoma)
`Gastrin-producing (gastrinoma)
`VIP-producing (VIPoma)
`Others
`
`Non-functioning
`Microadenoma (<0.5 cm)
`Others
`
`8150/1 1
`
`8151/1
`8152/1
`8156/1
`8153/1
`8155/1
`
`8150/0
`
`Well-differentiated endocrine carcinoma
`Functioning
`Insulin-producing (insulinoma)
`Glucagon-producing (glucagonoma)
`Somatostatin-producing (somatostatinoma)
`Gastrin-producing (gastrinoma)
`VIP-producing (VIPoma)
`Serotonin producing with carcinoid syndrome
`ACTH producing with Cushing syndrome
`
`Non-functioning
`
`Poorly-differentiated endocrine carcinoma •
`small cell carcinoma
`
`Mixed exocrine - endocrine carcinoma
`
`8150/3
`
`8151/3
`8152/3
`8156/3
`8153/3
`8155/3
`8241/3
`8150/3
`
`8150/3
`
`8041/3
`
`8154/3
`
`1 Morphology code of the International Classification of Diseases for Oncology (ICD-0) {664} and the Systematized Nomenclature of Medicine lhttp://snomed.org).
`Behaviour is coded /0 for benign tumours, /3 for malignant tumours, and /1 for borderline or uncertain behaviour.
`
`176
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`Pancreatic endocrine tumours:
`'.ntroduction
`
`;~rminology
`this chapter the term "pancreatic
`·1
`:1docrine
`tumour"
`replaces earlier
`0rms. e.g. pancreatic neuroendocrine
`,,mour. islet cell tumour. and APUDoma.
`
`epidemiology
`tumours are
`ancreatic endocrine
`. ,-,common and represent 1-2% of all
`ancreatic neoplasms. The
`tumours
`how no significant gender predilection
`,nd occur at all ages. with a peak inci(cid:173)
`:ence between 30-60 years. Clinically
`:nrecognised or asymptomatic, and usu(cid:173)
`;!ly small tumours (diameter less than 1
`,m) have been found in 0.4-1.5% of uns(cid:173)
`•lected autopsies 1779, 1086, 1154.1356,
`187 4, 2097}.
`incidence of
`fhe
`reported overall
`·umours of the endocrine pancreas has
`ncreased during recent years. This is
`~)robably due to the application of more
`;ensitive diagnostic approaches such as
`,maging techniques, reliable laboratory
`:ests and careful "morphofunctional"
`rnalysis by immunohistochemical and
`molecular biological techniques {2097f
`
`Endocrine function
`Pancreatic endocrine tumours are sepa(cid:173)
`<'ated based on their clinical manifesta(cid:173)
`tion, into functioning and non-functioning.
`
`Functioning tumours are associated with
`clinical syndromes caused by inappro(cid:173)
`priate secretion of hormones. Within this
`group are insulinomas, glucagonomas.
`somatostatinomas. gastrinomas. VIP(cid:173)
`omas. and other less common tumours.
`The clinical syndromes are described
`under the headings of the various func(cid:173)
`tioning tumours .
`
`Non-functioning tumours (or inactive.
`clinically silent. nonsyndromic) are not
`associated with a distinct hormonal syn(cid:173)
`drome but may still show elevated hor(cid:173)
`mone levels in the blood or immunoreac(cid:173)
`tivity in tissue sections. For this reason.
`the
`term "nonsyndromic" pancreatic
`endocrine tumour may more accurately
`describe this group, but is not widely
`used 120941. Therefore, tumours with the
`majority of cells expressing (and often
`secreting) pancreatic polypeptide (PP),
`or neurotensin are included in the group
`of non-functioning tumours (as are many
`"D-cell tumours" or "somatostatin pro(cid:173)
`ducing tumours"), because they do not
`cause a distinct hormonal syndrome.
`Non-functioning tumours only become
`clinically apparent due to their large size,
`to invasion of adjacent organs. or the
`occurrence of metastases. Rarely they
`may present as acute pancreatitis.
`
`lnsulinoma•
`
`Glui::agonomaa Somatostatlnomas Gastrinomas
`
`Tumours
`producing ectopic
`hormones
`Fig. 4.01 Frequency of various types of pancreatic endocrine tumours, based on a series of 638 cases.
`
`Vlpomas
`
`Nortfum:tionlng
`tumours
`
`Ph.U. Heitz
`P. Komminoth
`A. Perren
`D.S. Klimstra
`Y. Dayal
`
`C. Bordi
`J. Lechago
`BA Centeno
`G. Kloppel
`
`Increasingly. they are incidentally detect(cid:173)
`ed on imaging tests.
`Tumours with a diameter of less than 0.5
`cm, the minimum size required for gross
`detection, are defined as microadeno(cid:173)
`mas and are, as a rule. non-functioning.
`
`Macroscopy
`The majority of the tumours are well
`demarcated and solitary, showing a
`white-yellow or pink-brown colour. The
`consistency is variable. Rarely, they are
`cystic { 1301 I.
`Their diameter ranges usually around 1-5
`cm. Among the functioning tumours.
`insulinomas are usually smaller (less
`than 2 cm in diameter) than glucagono(cid:173)
`mas, somatostatinomas, gastrinomas or
`VIPomas, but the size of the tumours is
`not related to the severity of the hormon(cid:173)
`ally induced symptoms.
`Non-functioning tumours are generally
`larger than 2 cm in diameter (often 5 cm
`or more). They are probably detected rel(cid:173)
`atively late because they do not induce a
`clinical syndrome due to inappropriate
`hormone secretion.
`Tumours with a diameter of more than 2
`cm have an increased risk of malignant
`behaviour and those over 3 cm are usu(cid:173)
`ally malignant.
`
`Cytopathology
`Fine needle aspiration biopsy (FNAB) is
`a useful method for investigating pancre(cid:173)
`atic endocrine tumours and their metas(cid:173)
`tases. Guidance techniques
`include
`computed tomography (CT), transab(cid:173)
`dominal ultrasonography (TUS) and,
`more recently, endoscopic ultrasonogra(cid:173)
`phy (EUS). The cytomorphological fea(cid:173)
`tures of pancreatic endocrine tumours
`are the same for functioning and non(cid:173)
`functioning tumours [25, 161,401,20721.
`Smears are usually uniformly cellular and
`composed of a relatively monotonous
`population of
`cells predominantly
`arranged singly, but also in loose clus(cid:173)
`ters or pseudorosettes. The round to
`ovoid,
`smoothly contoured nuclei
`demonstrate a salt-and-pepper chro(cid:173)
`is
`matin pattern. The
`cytoplasm
`
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`and an elevated mitotic index (>10 p,·
`10 HPF).
`
`Markers of neuroendocrine
`differentiation
`Pancreatic endocrine tumours can cleE::
`ly be identified by using antibodies
`markers common to all or most neuroer
`docrine cells, i.e. synaptophysin, an intf·
`gral membrane glycoprotein of synapH
`vesicles, or protein gene product (PGF
`9.5, a cytoplasmic protein. Neuron sp·
`cific enolase (NSE) is widely reported
`these tumours, but the resu','
`stain
`should be interpreted with caution in li9 1:'
`of the low specificity of this marker. Tn
`presence of
`immunoreactive chrorr ..
`granins, which are glycoprotein comp··.
`nents of the matrix of neuroendocrir<,
`secretory granules. indicates the prE ·
`ence of secretory granules, i.e. sorr,,
`degree of differentiation of the tumr,,
`cells 11874,2097) In less well granulat1.
`examples, chromogranin staining is ge·
`erally less intense and extensive, des pi:
`diffuse strong staining for synaptophy,:i: ·
`Pancreatic endocrine tumours also cm:
`lain cytokeratins 8, 18 and 19 and m::/
`often contain neurofilaments as well.
`
`Hormonal markers
`The use of these markers is helpful
`characterizing tumour cell types
`specific
`hormonal
`produci
`their
`However,
`functioning
`tumours
`defined on the basis of clinical sympto1
`due to inappropriate hormone secret,·
`immunohistochemical fi1·
`rather than
`ings.
`In the majority of functioning tumours. 1!
`hormone causing the syndrome can
`detected by
`immunohistochemisi
`However, staining intensity or the num! ·
`of positive cells is not related to
`severity of symptoms. This is in part
`to the impairment of the genetic
`posttranslational regulation of hormo
`synthesis and secretion. There is a
`degree of heterogeneity among the
`the contenl
`vidual tumour cells in
`immunoreactive peptide hormones
`corresponding mRNA.
`In add ii'•
`immunoreactive hormones with redu··
`biological activity or with a greatly sf,,
`ened or prolonged hall·life in tr1e ser•
`may be produced. Highly functirn :
`tumrnJrs may paradoxically lack 1mmu: ·
`histochemically detectable hormo1 ..
`presumably due to their rapid secret
`in suer, cases. mRf\jA detection u ·
`
`Fig. 4.02 Growth patterns of pancreatic endocrine tumours. A Solid growth pattern. B Trabecular growth
`pattern. C Gland formation. The cells lining the lumina are cytologically identical to those of the remainder
`of the tumour. D Gyriform growth pattern: Nested architecture and peripheral palisading of nuclei. E Clear
`lipid-rich cells.H&E. F Solid growth pattern and focal oncocytic metaplasia.
`
`amphophilic and varies in quantity and
`density. Some cells may be stripped of
`their cytoplasm whereas others may
`have abundant cytoplasm and a plasma(cid:173)
`cytoid appearance.
`
`Histopathology
`Most pancreatic endocrine tumours are
`well differentiated showing various histo(cid:173)
`logical patterns, characterised by a solid,
`trabecular, glandular, gyriform, tubuloaci(cid:173)
`nar or pseudorosette arrangement of their
`cells. The cells are relatively uniform.
`show finely granular eosinophilic cyto(cid:173)
`plasm and a centrally located round to
`oval nucleus that may display a distinct
`nucleolus. Occasionally, clear cells, vac(cid:173)
`oncocytes
`uolated
`lipid-rich
`cells,
`or"rhabdoid" features 11717 l may be
`observed. The amount of stroma snd
`degree of fibrosis vary. These patterns
`differ considerably from one tumour to
`ancther and may vary witi,in the same
`
`tumour. However, in most instances these
`features are sufficiently distinctive to per(cid:173)
`mit recognition of the endocrine nature of
`a given tumour.
`In general, the histological pattern of a
`tumour does not allow a conclusion as to
`its functional state or type of the hormone
`produced. There are two exceptions to
`this rule: amyloid deposits are indicative
`of insulinomas, and glandular structures
`containing psammoma bodies are com(cid:173)
`monly observed in somatostatin produc(cid:173)
`ing tumours of the periampullary duode(cid:173)
`num.
`Poorly differentiated endocrine carcino(cid:173)
`mas are uncommon. These highly
`aggressive neoplasms are hardly recog(cid:173)
`nizable as endocrine tumours at first
`sight and require immunohistochemical
`examination to reveal
`their neuroen(cid:173)
`docrine phenotype. They show rather
`pieomorphic cells. usually in a solid
`arrange1r1ent. witi1 hyperchron1atic nuclei
`
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`n1ques may be useful. On the other hand,
`an 1mmunoreactlve hormone may not be
`secreted due to an impaired secretory
`pathway. Thus, 1mmunoreac t1ve hor(cid:173)
`,nones very often can be localized lo
`Geils o f non- functioning tumours.
`Upon caretul investigation it has become
`•Jbv1ous that many tumours are composed
`ul more than one phaenotype (mult1hor(cid:173)
`mona1 tumours) . As a rule t1owever, only
`•Jne cell type correlates wi th an associat(cid:173)
`ed syndrome of endocrine hyperfunction.
`fhe c lassification of the tumours must
`tllerefore be "morphofunct1onal", i.e. not
`,Jnly based on cell typing. It must primari (cid:173)
`'Y take in to consideration the c linical signs
`.rnd symptoms, and determination of cir(cid:173)
`c ulating hormone concen trations. Meta(cid:173)
`stases may produce hormones other than
`those found in the primary (20971
`
`Staging and prognosis
`No staging system . such as the UICC
`TNM system , has been applied to pan(cid:173)
`creatic endocrine tumours.
`fhe most reliable evidence of malignant
`beha viour 1n pancreatic endocrine
`tumours ,s metastasis to the regional
`lymph nodes or the liver or gross infi ltration
`of adjacent organs. Many of the smaller
`examples, including most insulinomas,
`probably have malignant potential. but
`Interruption of their natural history by sur(cid:173)
`J1cal resection prevents the e, pression of
`such potential. A proposal has been made
`to separate pancreatic endocrine tumours
`into prognostic groups based on mitotic
`rate and necrosis \8991.
`Among tl1e functioning tumours , most
`1nsulinomas show benign behaviour. In
`contrast. the other types of functioning
`tumours fall either into the categories of
`v11ell-d itterentiated tumours with uncertain
`behaviour (approx . 10-15%) or. more fre -
`
`,; ~
`I
`
`$
`
`\
`
`.~
`
`1
`
`/
`•f
`~
`
`4.
`•'
`
`... -y
`..
`,..
`., ~
`.~.~~.,~, -~ .,
`.
`:"' ..
`" ' ~ "
`'
`-·_ •1·; \
`,
`-. l t
`,.
`;. _•r .•
`.l.
`Fig. 4.03 Fine needle aspiration IFNAI ol a pancre (cid:173)
`atic endocrine wmour. Arnphophihc cytoplasm,
`uniform nuclei and linely granular chromatin.
`imparting a salt-and-pepper appearance.
`
`,
`~ ..
`
`.(rt._ ~
`. ,.
`
`·~
`
`'t
`,.
`
`-.;
`
`Tabfe 4.01
`lmmunophaenotyping of pancreatic endocrine
`tumours.
`
`Table 4.02
`Cmeria for the clinicopathological classificat1011 of
`pancreatic endocrine tumours.
`
`General neuroendocrine markers
`Synaptuphysin
`Protein Gene Product (PGP) 9.5
`C056
`MAPt8
`
`Markers of lhe matrix of secretory granules
`Chromogranins
`
`Hormone (cell type) - specific markers
`Insulin
`Glucagon
`Somatostatin
`Gastrin
`Vasoactive Intestinal Polypeptide (VIP)
`Pancreatic Polypeptide IPP)
`Serotonin
`ACTH
`Neurotensin
`Calcitonin
`
`Well-dilferentialed endocrine tumour
`
`1.1 'Benign' behaviour
`Confined to the pancreas, non-angioinvasive,
`no perlneural invasion, <2 cm in diameter,
`<2 initoses/10 HPF and <2% Ki-67 posilive cells
`
`1.2 Uncertain behaviour
`Confined to the pancreas and one or more of
`the following features: ?:2 cm in diameter, 2-10
`mitoses/10 HPF, >2% Ki-67 positive cells,
`angioinvasion, perineural invasion
`
`2 Well-differentiated endocrine carcinoma
`low grade malignant
`Gross local invasion and/or metastases
`
`J Poorly-differentiated endocrine carcinoma
`High grade malignant
`~ 10 mitoses / 10 HPF
`
`quently, of well-differentiated carcinomas
`(approx. 85,-90%).
`A small number of non-functioning
`tumours are well-diff erentiated tumours
`showing benign or uncer1ain behaviour;
`however. the vast majority (approx. 90·
`95%) are welf-ditterent1ated carcinomas.
`Poorly differentiated endocrine carcino(cid:173)
`mas are uncommon 120971
`
`Clinicopathological correlations
`There 1s an obvious need to establish a
`close correlation between morphologica l
`c lassificalion and
`tumour-associa ted
`syndromes. This is emphasized by the
`in predict ing the b iological
`d ifficulty
`behaviour of well-d ifferentiated endo(cid:173)
`crine tumours based on histological c ri(cid:173)
`lena alone. In addition, available follow(cid:173)
`up studies most often re fer to tumours
`
`diagnosed according to the assocrated
`cl ,nrcal syndrome due 10 inappropriate
`hormone secretion .
`To definitely establ ish the benign nature
`ol a tumour, a long clinical follow-up peri(cid:173)
`od Is needed , because metastases may
`develo years after removal of 1he prr(cid:173)
`mary lesion.
`With the exception of the poorly differen(cid:173)
`tiated endocrine carcinomas, the pro(cid:173)
`gression of the disease 1s olten remark(cid:173)
`ably slow. Survival for five to ten years
`after appearance of liver metastases is
`not uncommon. However. inappropriate
`secretion of hormones may cause life(cid:173)
`threatening hypog lycaemia, gastri c
`and/or duodenal ulcers. or important loss
`or fluid by watery diarrhoea .
`The final 'morpho-functional' classifica(cid:173)
`tion of an endocrine tumour of the pan·
`
`J'
`
`~
`B
`A
`.., .. .
`•
`~-
`Fig. 4.04 Gastrinorna. Endocrine differentiation is more universal than cell-specific hormone production.
`A Virtually all tumour cells contain synaptophysin. B The majority, but clearly lewer cells contain chromo(cid:173)
`granln A.
`
`17Q
`
`
`
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`
`. . .... . ~ -
`
`•
`
`. . - -:. ··- .
`
`- •
`
`- 4,· ! ;\' · -
`
`. ..
`
`I
`
`•
`
`.A. ~- if_}
`fl
`-
`'
`Fig. 4_06 A Pancreatic endocrine tumour. Vascular invasion, B Well diHerentiated eodocr1ne carcino,n.
`with massive vascular lnvasion.
`
`.......
`
`cytokera tin, but expresses vlmentin.
`alpha- 1-antitrypsin and corn, 8) 1t lacks
`immunohistochemicaf expression of pep(cid:173)
`tide hormones. 9) it occurs predominant(cid:173)
`in young women , and 10) most
`ly
`tumours show a benign b1ologicat behav(cid:173)
`iour 118741
`Further tumours Whlch may be conrused
`with pancreatic endocrine tumours are
`acinar cell carcinoma, pancreatobfas(cid:173)
`tomas I 1537}. poorly differentiated ductal
`adenocarc,noma , clear cell carcinoma ,
`e-pithelioid
`gastrointestinal
`stromal
`tumours ,
`pr1m1 t1ve neuroectodermal
`tumours (PNET) and pancreat1t metas(cid:173)
`tases (e .g .. renal cell carcinoma, small
`cell lung carcinoma. melanoma)
`Acinar cell carcinomas , which histologi(cid:173)
`cally may be very difficult to distinguish
`from endocrine tumours of the pancreas.
`usually produce trypsin (-ogen) and
`other pancreatic (pro-) enzymes _ The
`same is true for pancreatoblastomas .
`Both neoplasms may contain scattered
`endocrine cells. Truly mixed acinar(cid:173)
`endocrlne or ductal-endocrine carcino(cid:173)
`mas are very rare . In these tumours the
`endocrine cell
`component
`should
`account for at least one third of the entire
`cell population . Poorly differentiated duc(cid:173)
`tal adenocarcinornas as well as c lear cell
`carc,nomas reveal focal expression of
`
`rnucin (MUC1) and carcinoembryoni(
`antigen (CEA), Most epithelioid Qslstroin(cid:173)
`testina l stromal tumours (GIST) are char
`acterized by the expression of C-l', 11
`fo(cid:173)
`(CD 117) and absence of staining
`neuroendocrine markers. PNETs expres~
`a set of markers, including cogg_ Meta(cid:173)
`stases of c lear cell carcinomas of the kid(cid:173)
`ney lack neuroendocrine markers, but in
`addition
`to cytokeratins
`frequent! _
`express vimentln and CD10
`
`Cytopathology
`The key entity in the differential d1agnos1c
`1s acinar celf carcinoma. lt can be dist,n·
`ram pancreat ic endocr1n~
`gu1shed
`tumours by its arrangement 1n
`loose
`grapehke clusters. granular cytoplasn
`and prominent cherry
`red nucleo1
`I 1191 I, The neoplastic cells from a solid
`pseudopap1llary tumour. when detache(
`from the fibrovascular cores may be mi s
`taken lor those of a pancreatic endocrin1
`tumour. A search in the remainder o t th,
`smear for structures with the characteri,
`11c three-layered papillary architecture/ , .
`central capillary. a middle layer of my1
`oid stroma and an outer layer of neoplac
`tic cel ls) Will yreld the correct interpreta
`tion 17601 .
`Pancreatic endocrine tumours may b,
`mistaken lor lymphomas because the
`
`Table 4.03
`Adverse prognostic fac\ors ot_ well-drtferentiated pancrea1ic endocrine wmours-
`
`Metastasis
`Gross invasion
`Tu,nour diameter
`Angioinvasion
`Perineural invasion
`Mitoses
`Prolilerative index Ki-67 / MIB-1
`Necrosis
`Funct,omng tumours excepl insulinoma
`
`Reg ional lymph nodes, liver
`Adja cent organs
`2 cm or more
`Veins, lymphatic vessels
`lntrapancreatic nerves
`>2 per 10 HPF
`>2%
`
`creas should take into consideration ( 1)
`the clinical syndrome induced by or asso(cid:173)
`ciated with, a tumour, (2) determination oi
`the blood concentration of hormone(s) to
`identify the hormone(s) secreted by the
`tumour, (3) the s,ze (mass) of the tumour.
`(4) the histological differentiation and
`probable blologlcal behaviour of
`the
`tumour, (5) the phaenotype(s) of the vari(cid:173)
`ous tumour cells and, if necessary and
`feasible. (6) molecular genetic analysis of
`the tumour
`
`Differential diagnosis
`Histopatho/ogy
`Most pancreatic endocrine tumours are
`recognizable withoui much difficulty_ The
`use of immunohistochem1cal markers of
`the neuroendocnne phenotype and of
`hormonal content most often can estab(cid:173)
`lish the diagnosis unequivocally.
`An 1mportan1 dlfferenual d iagnostic prob(cid:173)
`lem is to distinguish solid-pseudopap1l(cid:173)
`lary neoplasms from endocrine tumours
`of the pancreas . Solid-pseudopapillary
`neoplasms morph ologically resemble
`endocrine tumours . and furthermore.
`produce CD56 , NSE and sometimes
`synaptophysin , as has been demonstrat(cid:173)
`ed by immunohistochemistry. Arguments
`in tavour of the diagnosis of a sohd(cid:173)
`pseudopapillary neoplasm of the pan(cid:173)
`c reas are the !allowing: 1) it does not pro(cid:173)
`duce a hormonal syndrome but only local
`symptoms . 2) it 1s usually large , with a
`diameter often over 5 cm, 3) it con1ains
`clusters of cells with a clear foamy cyto(cid:173)
`plasm, 4) ii often shows aggregates of
`PAS-positive hyaline globules 1n and
`between the tumour cells. 5) it contains
`broad . hya linized septa including small
`blood vessels, 6) ii displays haemor(cid:173)
`rhages , necrotic foci and occasionally
`cholesterol crystals. 7) ii lacks expres(cid:173)
`sion of chromog ranin and usually also
`
`180
`
`
`
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`

`
`fable 4.04
`·:,enetic alterations detected by loss of heterozygosity analysis (LOH), comparative genomic hybridization (CGH) and mutation analysis.
`
`Locus
`
`1p36-
`lq32-
`3p23-
`3p25-26-
`6q22-
`9p-
`9q+
`10q23-
`1lp14-
`11q13
`11 q22-23
`12µ12+
`15q-
`17p13-
`17µ+
`18q21-
`22ql2.1
`Xq-
`y.
`
`LOH
`
`10/29 (34%)
`8/29 (28%)
`23/31 (74%)
`31/73 (42%)
`43/69 (62%)
`12/37 (32%)
`
`8/16 (50%)
`
`75/111 (67%)
`20/37 (54%)
`
`15/40 (38%)
`
`23/68 (34%)
`9/12 (75%)
`11/23 (48%)
`5/14 (36%)
`
`Gene
`
`Mutation
`
`CGH {2105,2107.2154,2490}
`
`Reference
`
`VHl
`
`1/75 (1%)
`
`CDKN2A/pl6
`
`1/44 (2%)
`
`PTEN
`
`MENT
`SDHD
`K-Ras
`SMAD3
`TP53
`
`DPC4
`
`1/31 (3%)
`
`33/155 (21 %)
`0/20 (0%)
`1/39 (3%)
`0/18 (0%)
`1/40 (3%)
`
`0/41 (0%)
`
`21/102 (21 %)
`16/102 (16%)
`19/102 (19%)
`19/102 (19%)
`29/102 (28%)
`0/102 (0%)
`29/102 (28%)
`14/102 (14%)
`28/102 (27%)
`31/102 (30%)
`31/102 (30%)
`23/102 (23%)
`6/102 (6%)
`2/102 (2%)
`32/102 (31 %)
`6/102 (6%)
`4/102 (4%)
`14/46 (30%)
`14/56 (25%)
`
`{541}
`(1830}
`{120}
`{382,879, 1530, 1830}
`{121,1830}
`{1531,2008}
`
`{1723}
`
`{441,750,879,880, 1530,2018,2350,2495}
`{1721,1830}
`{1531}
`(2025}
`{1531, 1830}
`
`{879, 1531,1722}
`{2385}
`{1512)
`{1512}
`
`ire dyscohesive and may lack much
`;ytoplasm {161). However, an absence
`,f lymphoglandular bodies in the back(cid:173)
`Jround and the formation of loosely
`;ohesive epithelial
`structures will
`.ixclude the diagnosis of lymphoma.
`?ossibly more likely to occur is the misdi(cid:173)
`,gnosis of a pancreatic endocrine
`•umour as a plasmacytoma, since pan(cid:173)
`;reatic endocrine tumours may have a
`;ery plasmacytoid appearance {505).
`,.=eatures that will help to avoid this error
`,re the presence of a salt-and-pepper
`· ;hromatin pattern in the nuclei rather
`than the clock-face chromatin pattern
`0.een in a plasmacytoma, greater vari-
`1bility in nuclear size and shape, and an
`1bsence of a paranuclear halo in the
`1)ancreatic endocrine tumour.
`
`Molecular genetic analysis
`'J\/hereas the molecular basis of familial
`pancreatic endocrine tumours associat(cid:173)
`ed with multiple endocrine neoplasia
`:ype 1 (MEN 1) and von Hippel-Lindau
`:. VH L) syndrome has
`recently been
`•::stablished {351, 1241}, little is known
`,bout the oncogenesis and the molecu-·
`iar basis of progression of sporadic
`:umours.
`.2\ small number of published studies
`indicate that, in contrast to other human
`tumours, the activation of oncogenes is
`not a common event
`in pancreatic
`,,ndocrine tumours {903,980, 1346/. In
`particular, the common genetic muta-
`
`lions identified in pancreatic ductal ade(cid:173)
`nocarcinomas
`(e.g., TP53, K-RAS,
`COKN2Np16, OPC4) are not found in
`pancreatic endocrine tumours {931 /.
`Molecular and cytogenetic analyses
`have identified a number of chromoso(cid:173)
`mal alterations in pancreatic endocrine
`tumours.
`
`Chromosomal imbalances
`Comparative genomic hybridization
`(CGH) studies of 102 pancreatic
`endocrine tumours revealed that chro(cid:173)
`mosomal losses occur slightly more fre(cid:173)
`quently than gains, while amplifications
`are uncommon {2105,2107,2154,2490/.
`Furthermore, the total number of genom(cid:173)
`ic changes per tumour appears to be
`associated with both tumour volume and
`disease stage, indicating that genetic
`alterations accumulate during tumour
`progression (2105). Thus, large tumours
`or those with increased malignant poten(cid:173)
`tial, and especially metastases, harbour
`more genetic alterations than small and
`clinically benign neoplasms {2105,2490).
`These findings point toward a tumour
`suppressor pathway and genomic insta(cid:173)
`bility as important mechanisms associat(cid:173)
`ed with tumour progression.
`In the majority of tumour types chromo(cid:173)
`somal alterations are not randomly dis(cid:173)
`tributed but are particularly common in
`certain chromosomal regions, including
`4pq (17%), 5q (25%), 7pq (41%), 9q
`(28%), 12q (23%), 14q (32%), 17pq
`
`(31%) and 20q (27%) (gains) and 1p
`(21%), 3p (19%), 6q (28%), 10pq (14%),
`11q (30%), Y (31%) and X (31%) (loss(cid:173)
`es). Additional losses of 3p, 6pq, 10pq
`and gains of Sq, 12q, 18q and 20q are
`associated with malignant behaviour
`{2490).
`Losses of chromosome 1 and 11 q as well
`as gains of 9q appear to be early events
`in
`the development of pancreatic
`endocrine
`tumours, since
`they are
`already present in a substantial number
`of small (<2 cm) tumours {2490). The
`other aforementioned alterations appear
`to occur later, accumulating during pro(cid:173)
`gression and are frequently associated
`with malignant biological behaviour.
`Prevalent chromosomal aberrations com(cid:173)
`mon in metastases include gains of both
`chromosomes 4 and 7, and losses of 21 q
`/24901. implying that these chromosomal
`
`ao
`
`60
`
`-40
`
`Fig. 4.07 Pancreatic endocrine tumours, Summary
`of the results obtained by CGH. Gains of chromoso(cid:173)
`mal material are prominent on chromosomes 4, 5, 7,
`9, 14, 17 and 20, while losses are concentrated on
`chromosomes 1, 3, 6 and 11.
`
`181
`
`
`
`NOVARTIS EXHIBIT 2018
`Par v. Novartis, IPR 2016-01479
`Page 12 of 13
`
`

`
`Imbalances may contribute 10
`dissemination
`
`tumour
`
`A
`
`4
`
`6 FISH
`
`9
`
`11
`
`B ••• ~
`• . ,
`
`~
`
`9c-9q34
`
`9c-9q34
`
`6c-6q21
`
`3c-4p 16
`
`Fig. 4.08 Pancreatic endocrine tumour. Analysis by comparative genomic hybrid,zation(CGH) and fluore,.
`cence in-situ hybridization (FISH). Small lunclioning and non-func1ioning tumours of the pancreas: Gain r,1
`9q34 is an early event in insutinomas (green fluorescence in FISH; red : centromere of ct1romosome 9), The1,
`is a deletion of one copy of 6q21 fgreen fluorescence) m the presen ce of both ce ntromeres of chromoson11
`6 (red). A duplication of 4p16 as shown by FISH (green) is present as compared with the centromere 3 (re d
`From: E.J. Speel et al. {2107].
`
`GCT->TTI; Ala->Ph,
`
`1 1 t !C 10 1
`
`' 1 0 ·t.,AA '.;_ (
`
`...
`
`Fig. 4.09 Sporadic pancreatic neuroendocrine tumour. Loss of one chromosome 11 fred), including tt1•
`MEN ·1 locus (green) in the majority of tumour cells. PCR -SSCP shows a band shift in exon 2 (red arro1
`heads) which is caused by a ASOF missense mutation as shown by sequence analysis. From: B. Gartz et a
`1750].
`
`PCR-SSCP
`
`Exon 2; ASOF
`