SMALL ROUND CELL TUMORS

Moderators: Dr. V.VIJAYA SREEDHAR ( Professor & HOD) Dr. PADMAVATHI ( Associate Professor) Dr.SRILAKSHMI (Assistant Professor) Dr. Suresh PG Dr.B.S.chathanya PG

Topics
Introduction
Definition

List of these tumors

Individual tumors Diagnostic approach to round cell tumors.

Introduction
The term small round cells are used to describe the lesions in which dominant population consists of relatively small cells with basophilic nuclei and little or no cytoplasm.
These round cells tumors have several histological pattern, immunohistochemical & electronmicroscopic features that can help in differential diagnosis.

Cell sizes
Conventional cell size compared to 1) lymphocyte or 2) intermediate squamous cell 3) histiocyte nucleus Small cell =2-2 and half times . Intermediate cell = 3-6 times. Large cell = 6-10 times .

Definition
Small round blue cell tumor is the name given to a group of highly malignant neoplasms that occur mostly in the pediatric age group. Although this term could also apply to some adult neoplasms, notably small cell carcinoma of the lung, the term has become widely associated with childhood cancer.

The name is derived from the primitive, highly cellular nature of these lesions, which typically present a vast sea of dark-blue nuclei on hematoxylin-based stains.

List of these tumors

Neuroblastoma Rhabdomyosarcoma Lymphoma Ewing sarcoma/primitive neuroectodermal tumor.

Desmoplastic small cell tumor

Melanotic neuroectodermal tumor Mesenchymal chondrosarcoma Rhabdoid tumor Germ cell tumors

List of these tumors..

Organ-specific blastomas
Wilms tumor (nephroblastoma) Hepatoblastoma Sialoblastoma

Pancreatoblastoma
Pleuropulmonary blastoma Medulloblastoma

Retinoblastoma

Ewing's sarcoma family tumors

The term Ewing family of tumors (EFT) comprises both ES and PNET. Ewing sarcoma (ES) and primitive neuroectodermal tumor (PNET) are rare sarcomas of bone and soft tissue, which may involve any location. Although ES and PNET were originally regarded as distinct entities, it is now known that they are ends along the histologic spectrum of a single neoplasm, sharing in more than 90% of cases a balanced translocation (11;22) (q24;q12)

Ewing's sarcoma /PNET

Definition A group of primitive sarcomas composed of small cells with uniform, round, hyperchromatic nuclei that demonstrate differing degrees of neuroectodermal differentiation. Ewing sarcoma is the name applied when the tumors are devoid of neural differentiation by conventional means.

PNET is applied when some degree of neuroendocrine differentiation can be demonstrated

Ewing's sarcoma /PNET

Sex, Race, and Age Distribution Male predominance (male/female ratio, 1.4:1)

Extremely uncommon in black individuals of African ancestry

Peak incidence is in the second decade of life; only 20% of patients are younger than 8 years or older than 20 years Location Usually affects the metadiaphyseal regions of long bones in children.

In adolescents and young adults, it may be seen in the axial bones.

Ewing's sarcoma /PNET

Ewing's sarcoma /PNET

Clinical features As with any malignant bone tumor, a history of pain, often beginning as pain noticed on exertion, is usually present, and it may cause loss of normal function. Approximately 10% of patients present with pathologic fracture. Radiological features Tumor is often radiolucent and ill-defined.

Cortical saucerization

Onion skin periosteal reaction

Hair on end or sun burst periosteal reaction

Ewing's sarcoma /PNET

Gross Findings Grayish yellow and soft

Areas of spontaneous necrosis may resemble chyle or pus.

Ewing's sarcoma /PNET

MICROSCOPY Ewing sarcomas present a relatively monotonous pattern of sheets of small blue cells with round to oval, hyperchromatic nuclei, modest amounts of cytoplasm, and inconspicuous cellular boundaries. HISTOLOGICAL THREE TYPES 1) TYPICAL EWINGS 2)ATYPICAL EWINGS 3) PNET

Ewing's sarcoma /PNET

Ewing's sarcoma /PNET

Ewing's sarcoma /PNET

Ewing's sarcoma /PNET

Immunohistochemical Findings CD99 stains the cells in a characteristic membranous distribution. FLI-1 is a sensitive but not specific marker for Ewing sarcoma. Neuron-specific enolase, synaptophysin, and neuron triplet Filament protein are expressed in tumors with neural differentiation.

Tumor cells are negative with CD45 (leukocyte common antigen).

Ewing's sarcoma /PNET

Genetics and Molecular Findings A characteristic reciprocal translocation between chromosomes 11 and 22 is found in about 85% of cases. A second variant of reciprocal translocation between chromosomes 21 and 22 is found in 10% to 15% of cases. The remaining tumors have shown translocations of chromosomes 7 and 22, 17 and 22, 2 and 22, and inversions of chromosome 22; the resulting chimeric proteins function as abnormal transcription factors

DIFFERENTIAL DIAGNOSIS
In young age patients the main DD for Ewings sarcoma

Neuroblastoma VS PNET (Both have rosettes)

See for catecholamine secretion

CD99 positivity with FLI1 postivity

Rhabdomyosarcoma MyoD and Desmin positivity

Wilms tumor
Location WT1 postivity .

NEUROBLASTOMA
Definition

A neuroblastoma is a neuroblastic tumor arising from primitive sympathetic ganglia and containing variably differentiated neural elements and variable amounts of Schwann cells.
Epidemiology Neuroblastomas are relatively common lesions in children and constitute the single most common intraabdominal malignancy and nonhematopoietic, non- CNS pediatric cancer.

NEUROBLASTOMA

NEUROBLASTOMA
Terminology and Synonyms Neuroblastomas comprise the most primitive end of the spectrum and contain no Schwann cell elements or fully differentiated ganglion cells. Ganglioneuroblastomas contain variable amounts of fully mature ganglionic neurons in addition to Schwann cell elements. Neuroblastoma and the Ewing sarcoma family of tumors share several pathologic features, such as rosettes and primitive histology, and are sometimes referred together as the primitive neuroectodermal tumor family.

NEUROBLASTOMA
Clinical features
Neuroblastoma is the most common solid tumor of children <1 year of age.
It typically presents as an abdominal mass, although it can also arise in sympathetic ganglia of the neck, thorax, and pelvis . The adrenal gland is the most common site of origin, and neuroblastoma - can be considered a tumor of the sympathetic nervous system, with production of catecholamines.

NEUROBLASTOMA
The ratio of the precursor molecule, HVA, to its product, VMA, correlates with the degree of tumor differentiation and survival. Other hormonal substances produced by neuroblastoma, such as vasoactive intestinal polypeptide, can cause a paraneoplastic syndrome with watery diarrhea and hypokalemia.
Other paraneoplastic syndromes can result from immune phenomena. In the opsoclonus myoclonus syndrome, antibodies produced against the tumor cause cerebellar ataxia and rapid eye movements. Horner syndrome, Ondines curse, and a host of other unusual clinical symptoms can also occur.

NEUROBLASTOMA
Neuroblastoma only rarely metastasizes to the lung. Conversely, aggressive PNETs typically exhibit pulmonary metastases. Both tumors can show bone marrow metastases, but this phenomenon is more typical of neuroblastoma. Radiologic Features
Stippled calcification by X-ray or CT, in patient

younger than 5 years with midline or adrenal mass .

Ganglioneuroma can also show calcification on radiograph or CT scan.

NEUROBLASTOMA
Gross
Neuroblastoma may present as a large (>10 cm) mass and is lobulated, encapsulated, soft, tangray, hemorrhagic, sometimes cystic, and often calcified. Intra-adrenal lesions may show a thin rim of residual adrenal gland flattened against the capsule of the neuroblastoma. Ganglioneuroblastoma and ganglioneuroma tumors are more firm and tanwhite. Ganglioneuroblastomas often contain nodules of grossly different appearance and consistency.

NEUROBLASTOMA

Microscopic features
Neuroblasts are small, dark cells with high nuclear-to-cytoplasmic ratio and stippled chromatin. Neuroblastoma usually has high mitotic activity and karyorrhexis, and is often hemorrhagic.

Ganglion cells maturing from neuroblasts are defined as having an enlarged, eccentrically located nucleus with a prominent nucleolus and synchronously abundant amphophilic cytoplasm that is twice or more the diameter of the nucleus.

Microscopic features
stroma refers to Schwann cell elements and not neurofibrillary material. The mitosiskaryorrhexis index (MKI) is a semiquantitative value derived from counting the number of mitoses and fragmented karyorrhectic nuclei in a 40X objective, high-power field. MKI (mitosis/karyorrhexis index):

low = <100/5000 cells;

intermediate = 100200/5000 cells; high = >200/5000 cells.

Microscopic features

Homer Wright rosettes are composed of lightly eosinophilic, neurofibrillary cores surrounded by wreaths of round, hyperchromatic nuclei with coarsely granular chromatin and inconspicuous nucleoli.

NEUROBLASTOMA
Immunohistochemical Findings
Synaptophysin, chromogranin, neurofilament, NSE, and protein gene product 9.5 may be positive in neuroblastoma. CD99 is generally negative.

CD44 expression may be a prognostic factor.

Genetics

Neuroblastomas are typified by three cytogenetic abnormalities:

deletions of chromosome 1--- 1p including 1p36.2 and 1p36.3 double minute chromosomes, homogeneous staining regions.

Differential diagnosis

Other small blue cell tumors, primitive neuroectodermal tumor, rhabdomyosarcoma, lymphoma, desmoplastic small round cell tumor

RHABDOMYOSARCOMA
Rhabdomyosarcomas are an important category because they represent the largest subgroup of sarcomas in children. Types of Rhabdomyosarcoma

Embryonal
Alveolar Pleomorphic

Adult sclerosing Rhabdomyosarcoma

EMBRYONAL RHABDOMYOSARCOMA
Definition

A primitive soft tissue sarcoma, showing a variable degree of embryonic skeletal muscle differentiation.
Incidence and Location The most frequent sarcoma of childhood and the most frequent type of rhabdomyosarcoma, occurring in 3 per 1 million children younger than 15 years The head and neck region and genitourinary system are most frequently involved.

EMBRYONAL RHABDOMYOSARCOMA
Clinical Features

Variable and aspecific, depending on site of involvement, and ranging from painful/less mass, obstruction, or bleeding.
Gross Findings Poorly circumscribed masses

Spindle cell variant: firm and fibrous

Botryoid variant: grape-like polypoid

MICROSCOPY
1) CONVENTIONAL 2) BOTRYOID VARIANT 3) SPINDLE CELL VARIANT 4) ANAPLASTIC VARIANT

EMBRYONAL RHABDOMYOSARCOMA
GENETICS Structural and numeric changes are quite frequent, including extra copies of chromosomes 2, 8, and 13. Allelic loss in chromosomal region 11p15. Immunohistochemical Features Staining for desmin, or myogenin/MyoD1 should be present.

EMBRYONAL RHABDOMYOSARCOMA
Prognosis The botryoid and paratesticular spindle cell variants have a good prognosis (> 90% overall survival rate), the conventional and nonparatesticular spindle cell variants an intermediate prognosis anaplastic variant a poor prognosis ( 45%)

 Definition

ALVEOLAR RHABDOMYOSARCOMA

A high-grade round cell sarcoma with an alveolar or solid growth pattern with variable rhabdomyoblastic differentiation. Incidence and Location Rare (20% to 25% of all childhood rhabdomyosarcomas) Deep soft tissues of the extremities most frequently involved. Sex, Race, and Age Distribution Children and young adults between 2 and 25 years of age are mainly affected No sex or race predominance

ALVEOLAR RHABDOMYOSARCOMA
Clinical Features

Rapidly growing mass, with secondary signs/symptoms depending on the location.

Gross Findings Fleshy mass with variable fibrous/hemorrhagic areas

ALVEOLAR RHABDOMYOSARCOMA
All alveolar rhabdomyosarcomas show round cell features, reminiscent of lymphoma, but with variable rhabdomyoblastic differentiation.
The conventional type of alveolar rhabdomyosarcoma is characterized by fibrovascular septa that separate the tumor into nests.

ALVEOLAR RHABDOMYOSARCOMA
The tumor cells are relatively large, the largest ones (15 to 30 m) often showing rhabdomyoblastic differentiation with eccentric eosinophilic cytoplasm, with or without cross striations.
Multinucleated giant (wreath) cells are often present as well and are of help in the (differential) diagnosis.

ALVEOLAR RHABDOMYOSARCOMA

ALVEOLAR RHABDOMYOSARCOMA
Genetics t(2;13)(q35;q14) or t(1;13)(p36;q14) as variant translocation Juxtaposition of the PAX3 (chromosome 2) or PAX7 (chromosome 1) with the FKHR on chromosome 13 Immunohistochemical Features Staining for desmin should be present or myogenin/MyoD1 should be present Myogenin expression more diffuse than in embryonal type of rhabdomyosarcoma.

ALVEOLAR RHABDOMYOSARCOMA
Prognosis and Treatment

No efficient therapy is available

Prognosis dependent on stage but always more aggressive than embryonal rhabdomyosarcoma

LYMHOMA OF BONE
Approximately one-third of lymphomas originate in tissues other than lymph nodes. These tissues have native population of lymphoid cells, such as lung, gastrointestinal tract, and bone.

Lymphomas of these extranodal sites are regarded as primary extranodal lymphomas.

LYMHOMA OF BONE

Approximately 5% of extranodal lymphomas are primary in bone. It accounts for 7% of all malignant bone tumors.

LYMHOMA OF BONE
Clinical Features Primary lymphoma of bone occurs at any age. However, 50% of patients are older than 40 years. Rarely, children may experience development of primary lymphoma of bone. In a child, a variant of this neoplasm may be the precursor B-cell (lymphoblastic) lymphoma. The femur and pelvis are the most common bones to be involved.

LYMHOMA OF BONE
Radiologic Features Lymphoma of bone is usually a poorly defined, permeative lytic lesion Occasionally, a lesion may have extensive osteosclerosis, a feature that often leads lymphoma of bone to be misdiagnosed as Paget disease Occasionally, the permeative pattern of bone destruction is subtle and difficult to appreciate on plain radiographs. MRI may show a strikingly strong signal on T2weighted images.

MICROSCOPY

IHC
Ewing sarcomas will be positive with CD99 and negative with CD45.

However, precursor B-cell lymphoblastic lymphomas can also be positive with CD99, and negative with CD45and CD20. Therefore, it may be easy to misdiagnose a lymphoblastic lymphoma as a Ewing sarcoma.
Additional markers such as Tdt, CD43, and CD79a that are expressed by lymphoblastic lymphoma but not Ewing Sarcoma In adults, primary lymphoma of bone may be confused with multiple myeloma.

LYMHOMA OF BONE
Immunostains can also be helpful because myeloma cells show strong cytoplasmic immunoglobulin light-chain stain restriction, whereas they are weakly positive or negative for CD45 and CD20. In contrast, most B-cell lymphomas show the converse staining pattern, with strong positivity for CD45 and CD20, and little reactivity for CD138 and immunoglobulin light chains. Metastatic carcinoma must also be included in the differential diagnosis in adults. Some lymphomas are anaplastic and may be confused with metastatic epithelial neoplasms. Therefore, cytokeratin stains should be performed to rule out metastatic carcinoma.

PROGNOSIS
This disease is best treated with radiation and chemotherapy. Lymphomas of bone without visceral or nodal disease have a good prognosis with this therapy. In patients with lymphoma confined to the bone, reported 5-year survival rates range from 60% to 90%.

DESMOPLASTIC SMALL ROUND CELL TUMOR

Definition

A small round cell desmoplastic tumor is a primitive polyphenotypic neoplasm usually arising in the abdomen and characterized by small cell nests enmeshed in a dense fibrous stroma.
Incidence and Location
Rare 15 to 35 years of age Almost always occurs in mesothelial lined spaces, particularly the abdomen and pelvis, but may rarely occur in other locations

DSRT
Clinical Features DSRCT is far more common in men than in women (male/female ratio, 4:1). Most patients have a large intra-abdominal mass, with symptoms attributable to mass effect.

Cytogenetics
Similar to Ewing sarcoma and alveolar Rhabdomyosarcoma, desmoplastic small round cell tumor is cytogenetically defined by a reciprocal translocation: the t(11;22)(p13;q12).

This translocation creates a fusion gene that transcribes a chimeric protein containing portions of the WT1 protein and the EWS protein

DSRT

The fusion protein produced by the WT1/EWS gene is capable of inducing the expression of endogenous platelet-derived growth factor- A, which is a powerful mitogen and chemoattractant. Thus, by fusion with EWS, WT1 is converted from a tumor suppressor gene into an oncogene.

DSRT
Gross Findings Large, fibrous mass, often with necrosis and hemorrhage Microscopic Findings Nests of malignant round blue cells in a highly vascular, desmoplastic stroma. Occasional cases with pleomorphism and rhabdoid cells. Glandular and papillary structures may rarely be seen

DSRT
Immunohistochemical Findings Coexpression of desmin, cytokeratins, and vimentin, often in a dot-like pattern. Positivity with antibody to carboxyl-terminal WT1, reflecting Presence of EWS-WT1 fusion protein. Positive for CD99 in up to one-third of cases. Positive for epithelial markers such as EMA and Ber-Ep4; negative for mesothelial markers such as calretinin and CK5/6 Neuron-specific enolase positive; negative for chromogranin A and synaptophysin

PROGNOSIS

> 75% of patients dead of disease in < 5 years. progression-free survival may be increased with aggressive debulking, in patients whose tumors have responded to multiagent chemotherapy

MESENCHYMAL CHONDROSARCOMA
Definition High-grade biphasic sarcoma composed of undifferentiated small blue cells and islands of well-formed hyaline cartilage. Incidence and Location These tumors are rare, comprising less than 1% of soft tissue sarcomas. The most common location is within the soft tissues of the Craniospinal axis, including the paraspinal musculature; The meninges represent the most common extraskeletal site for this tumor

MESENCHYMAL CHONDROSARCOMA

Sex and Age Distribution Male and female individuals are affected equally Tumors occur at all ages; however, the majority occur in the second through the fourth decades of life

MESENCHYMAL CHONDROSARCOMA
Clinical Features Patients present with a soft tissue mass similar to other soft Tissue sarcomas. Because of their association with the craniospinal axis, focal Neurologic signs or symptoms, or both, may occur Radiologic Features Cartilaginous-type calcification is often present on plain Radiographs that otherwise show a nonspecific appearance.

MESENCHYMAL CHONDROSARCOMA
Gross Findings

MCs have a wide range in size from less than 5.0 to greater than 20.0 cm.
The tumors appear grossly well defined and have a tangray cut surface. Focal hemorrhage or necrosis is commonly present. Gritty areas representing the calcified cartilage are often present.

MICROSCOPY

MESENCHYMAL CHONDROSARCOMA

Immunohistochemistry
Vimentin labels the small blue cells and the chondrocytes.

CD99 is positive within the blue cell component, whereas S-100 labels the chondrocytes.

Differential Diagnosis
Islands of cartilage, which allow distinction of MC from Ewing sarcoma/PNET. This differential may be extremely difficult on small biopsy samples. Molecular genetic examination for the translocation associated with Ewing sarcoma/PNET (t[11;22]) is extremely helpful in resolving this differential. Solitary fibrous tumor and synovial sarcoma are two tumors that may exhibit sheets of small, rather undifferentiated appearing cells often associated with a hemangiopericytoma- like vascular pattern. These tumors do not show islands of hyaline cartilage

MESENCHYMAL CHONDROSARCOMA
Prognosis and Treatment
MCs are high-grade, clinically aggressive tumors that are treated by a combination of surgery and systemic chemotherapy. Up to 50% of patients have died of disease at 5-year follow up.

Extra renal Rhabdoid tumor

Definition This tumor is a clinically aggressive lesion typically arising in infants and characterized by filamentous inclusions within primitive polyphenotypic cells. Genetically, a typical deletion of the INI1/SMARCB1 gene on chromosome 22q11 is found Although the eosinophilic rhabdoid cells, filled with whorled eosinophilic filaments, are morphologically highly distinctive, rhabdoid tumor is a problematic entity, because many other tumor types can have cells with rhabdoid cytoplasm.

Extra renal Rhabdoid tumor

Clinical Features One prominent feature of rhabdoid tumors of all sites is their predilection for occurring in infants and very young children. Rhabdoid tumors constitute a large percentage of infantile renal tumors.

Extrarenal rhabdoid tumors have been reported in a variety of sites.

Extra renal Rhabdoid tumor Gross

Grossly, the typical invasive, nonencapsulated appearance of rhabdoid tumors, accented by a soft, fleshy, focally necrotic cut surface.

Extra renal Rhabdoid tumor

MICROSCOPY
Microscopically, the rhabdoid cells have eccentric nuclei with prominent nucleoli and abundant cytoplasm with round, hyaline inclusions. Some lesions have less abundant cytoplasm, potentially simulating a hematopoietic neoplasm.

Extra renal Rhabdoid tumor

Diagnostic approach to small round cell tumors

A five step method for differential diagnosis 1)Divide the tissue properly so that fresh and frozen material is available for additional studies. 2)Examine histologic sections carefully for clues. 3)Carefully review the clinical data after first reviewing histologic sections. 4)Order immunostains based on histologic and clinical data. 5)Consider genetic tests.

Divide the tissue properly so that fresh and frozen material is available for additional studies
Electron microscopy may be useful in difficult cases and requires only minimal amounts of properly fixed tissue. Standard cytogenetics requires sterile, fresh tissue. If limited tissue is available, histology comes first, followed by frozen tissue for biology studies.

Examine histologic sections carefully for clues

Diffuse round cell pattern Ewing`s sarcoma Primitive neuroectodermal tumor Merkel cell carcinoma Embryonal rhabdmyosarcoma Small cell carcinoma

Lymphoma
Leukemic infiltrate

Patterns
Septate or lobulated round cell pattern
Small round cells are divided by fibrous/fibrovascular septate Ewing`s sarcoma Alveolar Rhabdomysarcoma

Alveolar/ Pseudoalveolar round cell pattern

Focal, poor cohesion of the round cell population resulting in pseudo alveolar appearance Alveolar Rhabdomyosarcoma Primitive neuroectodermal tumor

Pattern
Round cell pattern with Rosettes
A `rosette is like a flower, with the cells being arranged radially around a central area. Flexners( also called Flexner- Winterstein, true rosettes)-contain clearly delineated empty central lumen. e.g. Retinoblastoma. Homer Wright rosette-center has no lumen,but abundant fibrillary material e.g. Neuroblastoma Primitive neuroectodermal tumor( PNET)

Carefully review the clinical data after first reviewing histologic sections
Look into Age of presentation Site of presentation Radiological features Paraneoplastic syndromes Cathecholamine tests

Order immunostains based on histological and clinical data.

Consider genetic tests & others.

FISH RT-PCR Electron microscopy

Refernces

Small round cell tumours chapter 31 text book of modern soft tissue pathology Weidner , Cote, Suster, Weise. Internet

Thank you