|Year : 2008 | Volume
| Issue : 6 | Page : 68-73
|Lung cancer specimen guidelines for handling and reporting
King Abdulaziz Medical City for National Guard, Riyadh, Saudi Arabia
Consultant of Anatomic Pathology, Pathology and Laboratory Medicine, King Abdulaziz Medical City, P.O. Box 22490, Riyadh 11426
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The proper handling of a lung specimen by a competent pathologist is the most important step to reach an accurate diagnosis and to generate a comprehensive pathology report that will characterize patient management and prognosis.
Keywords: Lung cancer, pathology, specimen, staging
|How to cite this article:|
Bamefleh H. Lung cancer specimen guidelines for handling and reporting. Ann Thorac Med 2008;3, Suppl S2:68-73
Guidelines for reporting and handling most of the solid organ malignancies are under continuous review and update by many study groups and centers. It is important for every anatomic pathology department to establish a definite protocol for each organ or to adopt internationally recognized guidelines and to come to an agreement with a multidisciplinary team composed of a surgeon, a radiologist, a medical oncologist and a radiation oncologist before applying these guidelines to their oncology specimens.
Regular updating of these guidelines with the most recent staging system and molecular markers that are useful for targeted therapy is crucial for up-to-date patient care and management.
In this manuscript, the proper handling and reporting of a diagnostic and therapeutic malignant lung specimen will be summarized referring to the current International System for staging lung cancer 1997. 
| Receiving and Specimen Examination|| |
Two types of lung specimens are sent to the laboratory: diagnostic and therapeutic  [Table 1]. The therapeutic specimens should be oriented by the surgeon using a code for specimen orientation as agreed by the pulmonary pathologist.
Access to specimen radiology for selected cases should be available, if relevant to the diagnosis, and the specimen should be examined grossed and dissected according to the guidelines. ,, Representative sections from the tumor can be frozen and stored for research purpose only if it is in surplus of the requirement for proper diagnosis and after patient consent and ethical approval.
Frozen section can be performed in some cases to confirm adequacy of diagnostic specimens and to assess clearance of resection margins. [Table 2] includes a checklist for examination and blocking of the surgical specimen. 
| Microscopic Examination|| |
Histologic typing is of considerable clinical importance as different tumor types clearly differ in their clinical behavior and response to treatment. The small size of some diagnostic specimens, especially bronchoscopic biopsy, imposes a problem in the accurate histologic typing. The World Health Organization (WHO) histologic classification of tumors of the lung 2001 is the most widely accepted [Table 3].  It is based solely on light microscopy, but special stains, immunohistochemistry and electron microscopy are needed for definitive histologic typing of some primary tumor and for differentiating between primary vs. secondary. Furthermore, it is needed for accurate typing of some metastatic tumors.
| Immunohistochemistry|| |
The panels commonly and routinely used for the diagnosis of primary and metastatic carcinoma are listed in [Table 4]. For more detailed study on all types including rare primary lung and rare metastatic tumor, refer to specific references and sites. 
| Primary Adenocarcinoma|| |
Positive markers: TTF-1, CK7, CEA, B72.3, surfactant apoprotein A and B, Ber-EP4, MOC 31 and Napsin A, which is a new marker.
Negative markers: CD20, WT-1, D2 - 40, calretinin and cytokeratin 5/6 (CD20 is positive in mucinous carcinoma and mucinous bronchioloalveolar carcinoma, two primary lung adenocarcinoma types that are usually negative for TTF-1).
Napsin A is more sensitive for pulmonary adenocarcinoma than TTF-1 90% compared with 75%.
| Squamous Cell Carcinoma (SCC) of Primary Lung Origin|| |
Helpful markers are listed in the [Table 4] 
| Bronchioloalveolar Carcinoma|| |
- Nonmucinous type positive for CK7 and TTF-1.
- Mucinous type positive for CK20 and TTF-1.
- Mixed type positive for CK7, CK20 and TTF-1. This immunoprofile is the same as enteric type of primary pulmonary adenocarcinoma.
| Neuroendocrine Tumors|| |
Small cell carcinoma and large cell neuroendocrine carcinoma are both positive for CD56, CK8, TTF-1, CK7, synaptophysin and chromogranin and negative for CK5. ,
| Large Cell Carcinoma|| |
Positive for TTF-1, CK7 and ES1 and negative for CK5.
| Mesothelioma|| |
Positive markers: WT-1, D2-40, cateretinin, CK5/6, vimentin and thrombomodulin. These help to differentiate it from adenocarcinoma along with the following negative markers.
Negative markers: CEA, B72.3, BER-EP4 and MOC31.
| Metastatic Carcinoma|| |
- Metastatic gastric carcinoma: 70% are positive for CK 7 and 20% are positive for CK20 and also CEA and EMA. Positivity for MUC1, MUC2 and MUC5AC varies according to location and type.
- Metastatic colonic: CK20 and CDX-2.
- Metastatic prostatic adenocarcinoma is positive for PSA, PAP and racimas.
- Metastatic breast carcinoma is positive for ER, GCDFP-15, mamoglobin and CK7.
- Metastatic melanoma, HMB-45, S100, MART-1 and Melan A.
- Metastatic renal cell Ca is positive for CK 8 and 18EMA, CEA, vimentin, CD 10 and RCC.
- Metastatic merkel cell Ca is positive for TTF-1 and CK20.
| Small Cell Lung Carcinoma (SCLC) vs Carcinoid|| |
SCLC usually has >10 mitosis/10 high-power field (hpf), with positive Ki-67 (MIB-1) >50%.
Carcinoid is positive for chromogranin and synaptophysin with less than 2 mitosis/10 hpf, but atypical carcinoid has mitosis of 2-10/10 hpf with obvious areas of necrosis, nuclear moulding and salt and pepper chromatin.
| Molecular Markers for Lung Carcinoma|| |
Epidermal growth factor receptor (EGFR)
The overall EGFR expression rate in non-SCLC is 51%. Expression is less frequent in adenocarcinoma (46.2%) than in squamous cell carcinoma (82.6%).
EGFR expression and amplification can be detected by immunohistochemistry and fluorescence in situ hybridization on formaline-fixed, paraffin-embedded tissue and are associated with a better response to EGFR inhibitors.
Certain EGFR mutations on exons 19-21 and gene amplification have also been implicated in a better prognosis. EGFR exon 18-21 mutation is shown to be highly predictive of EGFR inhibitors. Genomic DNA can be extracted from all tumors according to standard procedures.
Polymerase chain reaction amplification of exons 18, 19, 20 and 21 with subsequent sequencing of the polymerase chain reaction products can be performed following Lynch et al .'s protocol. ,,,
There are marked differences in the prevalence of exon 18-21 mutations between lung cancers from different ethnic groups. Although the frequency of these mutations in the USA and the European lung cancers consistently ranged between 1 and 10%, a much higher mutation frequency (25.9%) has been reported in Japanese lung cancer. AL. Kuraya et al ., in study of 47 patients with NSCLC from Saudi Arabia, found only one exon 18-21 mutation among 34 lung cancers that could be successfully sequenced, i.e. rare in Middle East patients. 
Other prognostic markers
The expression of DNA synthesis and repair genes RRM1 and ERCC1 shows prognostic value in lung cancer and has been studied in formaline-fixed, paraffin-embedded tissue using immunofluorescence and automated quantitation. Zeng et al . found that RRM1 and ERCC1 were both useful survival markers after surgical treatment of early-stage, non-SCLC.  However, it was found that in advanced lung cancer, these two markers serve as chemo resistance markers and indicate poor survival.
Reporting of lung cancer
After surgery, pathological staging provides a useful adjunct to the clinical assessment of tumor size and lymph node involvement. A protocol for reporting lung specimens resected in the treatment of lung cancer is found in [Table 5]. 
| Staging of Lung Cancer|| |
The current staging system widely used is the TNM [Table 6]. The effect of the stage is shown at the end of the table. If the tumor is more than 3 cm in size or extends to the pleura, then it will be T2 category. The performance of elastic stain is important to assess pleural invasion.
A new staging system to accurately stage lymph node involvement (N) is currently under way. So the current N descriptors will be revised for the next edition of the International Lung Cancer Staging System. The current N descriptors are N1, N2 and N3. The proposed descriptors and subdivisions are N1a, N1b, N2a, N2b and so forth. 
| The New Staging System (Seventh Edition)|| |
The current version of the TNM staging system is the sixth edition of the 'TNM Classification of Malignant Tumors.' Refinements of the T and M descriptors, as well as the tumor stage groupings, have been proposed and are expected for the seventh edition of the 'TNM Classification of Malignant Tumors.' Proposed changes include reclassification of malignant pleural effusions and satellite nodules. Other proposed changes include new size cutoffs and new subdivisions of the T1 (into T1a and T1b), T2 (into T2a and T2b) and M1 (into M1a and M1b) descriptors. ,
Changes in the proposed seventh edition of TNM classification of lung tumors:
Primary tumor (T):
- T1 lesions are divided based on size T1a (<2 cm) and T1b (>2 cm but less than 3 cm).
- T2 lesions are divided into T2a (<5 cm) and T2b (>5cm but <7 cm).
- T2 tumors >7 cm are reclassified as T3.
- T4 tumors with satellite nodules in the same lobe as the primary tumor are reclassified as T3.
Additional nodules in a different lobe of the same lung are reclassified as T4 rather than as M1.
Malignant pleural or pericardial effusions or pleural nodules are now classified as metastasis (M1a) rather than T4.
Regional nodes (N):
Subdivided into M1a (malignant pleural or pericardial effusion, pleural nodules, nodules in contralateral lung) and M1b (distant metastasis).
The new stage grouping:
- T2aN1M0 lesions are classified as IIA rather than as IIB.
- T2bN0M0 lesions are classified as IIA rather than as IB.
- T3 (>7 cm) N0M0 lesions are classified as IIB rather than as IB.
- T3 (>7 cm) N1M0 lesions are classified as IIIA rather than as IIB.
- T3N0M0 (nodules in the same lobe) lesions are classified as IIB rather than as IIIB.
- T3N1M0 or T3N2M0 (nodules in the same lobe) are classified as IIIA rather than as IIIB.
- T4M0 (ipsilateral lung nodules) lesions are classified as IIIA (if N0 or N1) and IIIB (if N2 or N3) rather than as stage IV.
- T4M0 (direct extension) lesions are classified as IIIA (if N0 or N1) rather than as IIIB.
Malignant pleural effusion (M1a) are classified as IV rather than as IIIB.
The new staging accordingly is:
- Stage 0: TisN0M0.
- Stage IA: T1a-1bN0M0.
- Stage IB: T2aN0M0 or T2bN0M0.
- Stage IIB: T2bN1M0 or T1a-3N2M0 or T4N0-1M0.
- Stage IIIB: T4N2M0 or T1a-4N3M0.
- Stage IV: any T and N M1a-1b.
| Conclusion|| |
The proper orientation, grossing, reporting and storage of diagnostic and therapeutic malignant lung specimens are crucial in obtaining an accurate diagnosis and providing up to date patient management.
Any anatomic pathologist handling the lung specimen should be kept up to date with the most recent guidelines for grossing and reporting of the lung specimen, including molecular markers that are used or will be used for future targeted therapy.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]