Human Pathology (2014) xx, xxx–xxx
www.elsevier.com/locate/humpath
Original contribution
GATA3 expression in sarcomatoid urothelial carcinoma of the bladder☆ Nazneen Fatima MD a , Adeboye O. Osunkoya MD a,b,c,⁎ a
Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322 Department of Urology, Emory University School of Medicine, Atlanta, GA 30322 c Emory Winship Cancer Institute, Atlanta, GA 30322 b
Received 11 February 2014; revised 21 March 2014; accepted 26 March 2014
Keywords: GATA3; Urothelial carcinoma; Sarcomatoid differentiation; Cystectomy; Cystoprostatectomy
Summary The current available data on GATA-binding protein 3 (GATA3) expression in sarcomatoid urothelial carcinoma are limited, especially in the non–tissue microarray–based setting. In this study, we analyzed the expression of GATA3 in sarcomatoid urothelial carcinoma of the bladder in cystectomy/ cystoprostatectomy specimens. A search was made through our surgical pathology and consultation files for cystectomy/cystoprostatectomy specimens with a diagnosis of sarcomatoid urothelial carcinoma. Only cases with available tissue blocks were selected. Immunohistochemical staining for GATA3 was performed, and staining in adjacent/overlying conventional urothelial carcinoma and/or benign urothelium was also documented. Twenty-two cases were obtained. Of 22 cases, 16 (73%) of sarcomatoid urothelial carcinoma were positive for GATA3. In the 7 (27%) of 22 cases that were negative for GATA3, it was observed that these cases were predominantly composed either of pleomorphic undifferentiated sarcomatoid areas or foci composed of extensive heterologous elements (chondroid, osteoid, or rhabdoid). GATA3 staining was positive in the adjacent/overlying conventional urothelial carcinoma and/or benign urothelium in all cases. This is one of the largest studies to date analyzing the expression of GATA3 in sarcomatoid urothelial carcinoma in cystectomy/cystoprostatectomy specimens. GATA3 is expressed in most cases of sarcomatoid urothelial carcinoma. Negative expression may, however, be observed in cases composed predominantly of pleomorphic undifferentiated sarcomatoid areas or extensive heterologous elements. We recommend including GATA3 in the panel of immunohistochemical stains for sarcomatoid carcinomas of unknown origin, especially if a bladder primary is being considered in the differential diagnosis. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Urothelial carcinoma of the bladder with sarcomatoid differentiation is a rare biphasic neoplasm that contains both ☆ Disclosures: The authors have no conflict of interest or funding to disclose. ⁎ Corresponding author. Department of Pathology, Emory University School of Medicine, Room H174, 1364 Clifton Road, NE, Atlanta, GA 30322, USA. E-mail address: [email protected] (A. O. Osunkoya).
http://dx.doi.org/10.1016/j.humpath.2014.03.015 0046-8177/© 2014 Elsevier Inc. All rights reserved.
epithelial and mesenchymal components. Different names have been previously used for these biphasic tumors; however, in 2004, the World Health Organization classification of urothelial neoplasms clarified the nomenclature by using the term sarcomatoid carcinoma [1,2]. Sarcomatoid carcinoma was considered the preferred name for all biphasic malignant neoplasms of the genitourinary tract with evidence of both epithelial and mesenchymal differentiation [1]. Urothelial carcinoma with sarcomatoid differentiation of the bladder occurs more frequently in elderly male patients and in some cases has been reported to be associated with a previous history
2
N. Fatima, A. O. Osunkoya
of chemotherapy or radiation therapy [2,3]. Other commonly reported risk factors include previous urothelial carcinoma, tobacco smoking, recurrent cystitis, diabetes, neurogenic bladder, and bladder diverticulum [4]. The pathogenesis of urothelial carcinoma with sarcomatoid differentiation of the urinary bladder is controversial. Different theories exist based on clonality to explain the origin of these morphologically diverse and biphasic tumors. Studies primarily based on morphologic analysis, propose a collision tumor theory of 2 simultaneously occurring independent monoclonal tumors [5,6]. However, other studies suggest a common clonal origin with divergent differentiation into carcinomatous and sarcomatoid components [7]. The diagnosis is easily made on hematoxylin and eosin (H&E) in most cases, especially if there is clear demonstration of a transition from the epithelial component to the sarcomatoid or spindle cell component. However, difficulty arises in cases in which the sarcomatoid component predominates, with lack of evidence of epithelial differentiation (conventional invasive urothelial carcinoma or urothelial carcinoma in situ). In such cases, the differential diagnosis of urothelial carcinoma with sarcomatoid differentiation is broad, and the entities that must be considered include but are not limited to inflammatory myofibroblastic tumor, leiomyosarcoma, rhabdomyosarcoma, angiosarcoma, malignant fibrous histiocytoma, and spindle cell malignant melanoma. In addition, other entities that should be excluded include urothelial carcinoma with pseudosarcomatous stroma and urothelial carcinoma with osseous or cartilaginous metaplasia. Identifying the primary origin of a metastatic sarcomatoid carcinoma of unknown origin may be very challenging. Immunohistochemistry may be a useful adjunct in this setting. GATA-binding protein 3 (GATA3) has been reported to be a novel marker for urothelial carcinoma [8-11]. However, the current available data of GATA3 expression in urothelial carcinoma with sarcomatoid differentiation are somewhat limited, especially in the non–tissue microarray (TMA)–based setting. In this study, we analyzed the expression of GATA3 in urothelial carcinoma with sarcomatoid differentiation of the bladder in cystectomy/cystoprostatectomy specimens.
dilution, retrieval solution and pH, and detection system were optimized before the study was undertaken. Antigen retrieval was in citrate buffer (pH 6.0), using an electric pressure cooker for 5 minutes at 120°C (15 psi), with cooling for 10 minutes before immunostaining. Slides were loaded on the Dako automated system, exposed to 3% hydrogen peroxide for 5 minutes, GATA3 antibody for 30 minutes, labeled polymer HRP for 30 minutes, 3,3′-diaminobenzidine as chromogen for 5 minutes, and Dako automation hematoxylin as counterstain for 5 minutes. These incubations were performed at room temperature; between incubations, sections were washed with tris-buffered saline. Tween 20 was included in this buffer. A known positive control of urothelial carcinoma was used with each run. Negative controls had primary antibody replaced by buffer. Immunohistochemical staining was performed on selected blocks with sarcomatoid urothelial carcinoma, and staining in adjacent/overlying conventional urothelial carcinoma and/or benign urothelium was also documented, with nuclear staining for GATA3 in at least 10% of the cells considered a positive result. This study was completed following the guidelines of and with approval from our institutional review board.
2. Materials and methods
Urothelial carcinoma with sarcomatoid differentiation is a biphasic malignant neoplasm, with morphologic and/or immunohistochemical evidence of epithelial and mesenchymal differentiation. Different hypotheses exist regarding the pathogenesis of urothelial carcinoma with sarcomatoid differentiation. Studies primarily based on morphologic analysis, propose a collision tumor theory of 2 simultaneously occurring independent monoclonal tumors [2,6,7]. However, other studies suggest a common clonal origin with divergent differentiation into sarcomatoid and carcinomatous components [2,7]. Some authors have analyzed X chromosome inactivation and loss of heterozygosity in cases of sarcomatoid carcinomas and reported a concordant pattern of nonrandom X chromosome inactivation, supporting the hypothesis that
A search was made through our surgical pathology and consultation files of the senior author for cystectomy/ cystoprostatectomy specimens with a diagnosis of sarcomatoid urothelial carcinoma from 2005 to 2013. Only cases with available tissue blocks were selected. All the selected cases were originally formalin fixed and paraffin embedded. Fivemicrometer sections from each case was deparaffinized and dehydrated. Immunostaining used standard heat-induced epitope retrieval, the Dako Envision Detection System (Dako, Carpinteria, CA), and the Dako Autostainer (Dako). Antiserum to monoclonal GATA3 was used (L50-823, 1:50 dilution; Biocare Medical, Concord, CA). The primary antibody
3. Results Twenty-two cases were selected. Of 22 cases, 16 (73%) of sarcomatoid urothelial carcinoma were positive for GATA3 (Fig. 1A-H). In the 7 (27%) of 22 cases that were completely negative for GATA3, it was observed that these cases were predominantly composed either of pleomorphic undifferentiated sarcomatoid areas (Fig. 2A and B) or foci composed of extensive heterologous elements (chondroid, osteoid, or rhabdoid). GATA3 staining was positive in the adjacent/ overlying conventional urothelial carcinoma and/or benign urothelium in all cases (Fig. 1B and D).
4. Discussion
F1
F2
GATA3 expression in sarcomatoid urothelial carcinoma
3
Fig. 1 A, Urothelial carcinoma with sarcomatoid differentiation (note overlying benign urothelium, upper left corner). B, Positive GATA3 expression in urothelial carcinoma with sarcomatoid differentiation (note positive expression also in overlying benign urothelium, upper left corner). C, Urothelial carcinoma with sarcomatoid differentiation with overlying/adjacent benign urothelium. D, Positive GATA3 expression in urothelial carcinoma with sarcomatoid differentiation (note positive expression also in overlying/adjacent benign urothelium) E, Urothelial carcinoma with sarcomatoid differentiation. F, Positive GATA3 expression in urothelial carcinoma with sarcomatoid differentiation. G, Urothelial carcinoma with sarcomatoid differentiation. H, Positive GATA3 expression in urothelial carcinoma with sarcomatoid differentiation (note positive expression is limited to the left side of the image, although the H&E morphology of the right side is identical). H&E, original magnification ×100 (A and B, E-H), ×200 (C and D).
both sarcomatoid and carcinomatous components of these tumors are of a monoclonal origin [2,7]. Additional evidence of a common clonal origin for both the phenotypically
distinct components of these tumors was confirmed in a study of 17 cases of sarcomatoid carcinomas of the bladder, which showed identical mutation patterns and nuclear p53
4
N. Fatima, A. O. Osunkoya
Fig. 2 A, Urothelial carcinoma with sarcomatoid differentiation composed predominantly of pleomorphic undifferentiated sarcomatoid areas. B, Negative GATA3 expression in urothelial carcinoma with sarcomatoid differentiation composed predominantly of pleomorphic undifferentiated sarcomatoid areas. H&E, original magnification ×200 (A and B).
immunohistochemical staining characteristics in both components [2,12]. Furthermore, in a study analyzing chromosomal aberrations in 3 cases of sarcomatoid carcinoma of the bladder by comparative genomic hybridization, Torenbeek et al [13] found 20% to 50% homology in chromosomal aberrations, between the carcinomatous and sarcomatoid components of each tumor, strengthening the theory of monoclonal origin of this biphasic tumor [2]. Heterologous differentiation can be seen in the form of rhabdomyosarcoma, chondrosarcoma, liposarcoma, and osteosarcoma [14]. The malignant epithelial component is typically urothelial carcinoma in situ or invasive urothelial carcinoma, but adenocarcinoma, squamous cell carcinoma, and small cell carcinoma have also been reported [4,14]. Foci of sarcomatoid dedifferentiation have been identified in conventional as well as other variants of urothelial carcinoma, including plasmacytoid and villoglandular variants [15-17]. The immunohistochemical analysis of carcinomatous and sarcomatoid components are known to variably express epithelial antigens including pancytokeratin and epithelial membrane antigen. Ikegami et al [18] examined the expression of cell adhesion molecules in 12 cases and reported that the carcinomatous components were positive for E-cadherin (8 of 12 cases), CD44s (8 of 12 cases), and CD44v6 (6 of 12 cases). The sarcomatoid components were also positive but to a lesser extent: E-cadherin (5 of 12 cases), CD44s (4 of 12 cases), and CD44v6 (3 of 12 cases). Occasionally, the sarcomatoid component predominates, and in some cases, there may be no apparent evidence of epithelial differentiation on H&E, making the distinction of a sarcomatoid urothelial carcinoma from other spindle cell lesions difficult. Identifying the primary origin of a metastatic sarcomatoid carcinoma of unknown origin may also be very challenging. In both the former and latter situations, immunohistochemistry can be a useful adjunct. GATA3 is a member of the GATA family of 6 zinc finger transcription factors. This 50 kd nuclear protein regulates the development and maintenance of multiple tissues including hematopoietic cells, skin, kidney, mammary gland, and the central nervous system [8]. GATA3 is reported to be a sensitive and specific
marker for the diagnosis of breast and urothelial carcinomas and is proposed to be routinely included in the initial screening panel if either a breast or urothelial primary tumor is suspected [9,10]. The positive staining in urothelial carcinoma is reported as typically nonfocal and moderate or strong in intensity [11]. However, the current available data of GATA3 expression in urothelial carcinoma with sarcomatoid differentiation are limited, especially in the non-TMA–based setting. Chang et al [19], in a TMA-based study, showed that GATA3 is a relatively specific marker for urothelial carcinoma with sarcomatoid differentiation but lacks sensitivity. In their study, they evaluated PAX8 and GATA3 expression in TMAs constructed from 45 cases of sarcomatoid renal cell carcinoma and 45 cases of urothelial carcinoma with sarcomatoid differentiation of the lower urinary tract, with an additional 11 cases of urothelial carcinoma with sarcomatoid differentiation of the upper tract. PAX8 and GATA3 were also evaluated in TMAs from 161 sarcomas from other sites, including atypical epithelioid angiomyolipomas of the kidney, inflammatory myofibroblastic tumors of the bladder, and bladder and renal leiomyosarcomas [19]. In their study, urothelial carcinoma with sarcomatoid differentiation of the bladder, GATA3 and PAX8, were positive in 14 (31%) of 45 cases and 2 (4%) of 45 cases, respectively [19]. The current study is one of the largest studies to date analyzing the expression of GATA3 in sarcomatoid urothelial carcinoma in cystectomy/cystoprostatectomy specimens. Of 22 cases, 16 (73%) of sarcomatoid urothelial carcinoma were positive for GATA3. In the 7 (27%) of 22 cases that were negative for GATA3, it was observed that these cases were predominantly composed either of pleomorphic undifferentiated sarcomatoid areas or foci composed of extensive heterologous elements (chondroid, osteoid, or rhabdoid). GATA3 staining was positive in the adjacent/overlying conventional urothelial carcinoma and/or benign urothelium in all cases. It should be noted that in a number of cases (Fig. 1G and H), GATA3 was not positive in the entire sarcomatoid component (just as seen in some cases of conventional urothelial carcinoma in general practice), which would be a limitation of TMA-based studies. In conclusion, we recommend including GATA3 in the panel of
GATA3 expression in sarcomatoid urothelial carcinoma immunohistochemical stains for sarcomatoid tumors involving the bladder or adjacent organs and also in cases of sarcomatoid carcinomas of unknown origin, especially if a bladder primary is being considered in the differential diagnosis.
References [1] Eble JN, Epstein JI, Sauter G, et al, editors. Tumours of the Urinary and Male Reproductive System, WHO Classification of Tumours: Pathology and Genetics. Lyon, France: IARC Press; 2004. [2] Cheng L, Zhang S, Alexander R, et al. Sarcomatoid carcinoma of the urinary bladder: the final common pathway of urothelial carcinoma dedifferentiation. Am J Surg Pathol 2011;35:e34-46. [3] Black PC, Brown GA, Dinney CP. The impact of variant histology on the outcome of bladder cancer treated with curative intent. Urol Oncol 2009;27:3-7. [4] Torenbeek R, Blomjous CE, de Bruin PC, et al. Sarcomatoid carcinoma of the urinary bladder: clinicopathologic analysis of 18 cases with immunohistochemical and electron microscopic findings. Am J Surg Pathol 1994;18:241-9. [5] Holtz F, Fox JE, Abell MR. Carcinosarcoma of the urinary bladder. Cancer 1972;29:294-304. [6] Perret L, Chaubert P, Hessler D, et al. Primary heterologous carcinosarcoma (metaplastic carcinoma) of the urinary bladder: a clinicopathologic, immunohistochemical, and ultrastructural analysis of eight cases and a review of the literature. Cancer 1998;82:1535-49. [7] Sung MT, Wang M, MacLennan GT, et al. Histogenesis of sarcomatoid urothelial carcinoma of the urinary bladder: evidence for a common clonal origin with divergent differentiation. J Pathol 2007;211:420-30. [8] Higgins JP, Kaygusuz G, Wang L, et al. Placental S100 (S100P) and GATA3: markers for transitional epithelium and urothelial carcinoma discovered by complementary DNA microarray. Am J Surg Pathol 2007;31:673-80.
5 [9] Chou J, Provot S, Werb Z. GATA3 in development and cancer differentiation: cells GATA have it! J Cell Physiol 2010;222:42-9. [10] Zheng R, Blobel GA. GATA transcription factors and cancer. Genes Cancer 2010;1:1178-88. [11] Chang A, Amin A, Gabrielson E, et al. Utility of GATA3 immunohistochemistry in differentiating urothelial carcinoma from prostate adenocarcinoma and squamous cell carcinomas of the uterine cervix, anus, and lung. Am J Surg Pathol 2012;36:1472-6. [12] Armstrong AB, Wang M, Eble JN, et al. TP53 mutational analysis supports monoclonal origin of biphasic sarcomatoid urothelial carcinoma (carcinosarcoma) of the urinary bladder. Mod Pathol 2009;22:113-8. [13] Torenbeek R, Hermsen MA, Meijer GA, et al. Analysis by comparative genomic hybridization of epithelial and spindle cell components in sarcomatoid carcinoma and carcinosarcoma: histogenetic aspects. J Pathol 1999;189:338-43. [14] Lopez-Beltran A, Sauter G, Gasser T, et al. Infiltrating urothelial carcinoma. In: Eble JN, Sauter G, Epstein JI, Sesterhenn IA, editors. World Health Organization Classification of Tumours. , Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. Lyon: IARC Press; 2004. p. 93-109. [15] Lim M, Adsay NV, Grignon D, Osunkoya AO. Urothelial carcinoma with villoglandular differentiation: a study of 14 cases. Mod Pathol 2009;22:1280-6. [16] Nigwekar P, Tamboli P, Amin MB, Osunkoya AO, Ben-Dor D, Amin MB. Plasmacytoid urothelial carcinoma: detailed analysis of morphology with clinicopathologic correlation in 17 cases. Am J Surg Pathol 2009;33:417-24. [17] Oliva IV, Smith SL, Chen Z, Osunkoya AO. Urothelial carcinoma of the bladder with transmural and direct prostatic stromal invasion: does extent of stromal invasion significantly impact patient outcome? HUM PATHOL 2011;42:51-6. [18] Ikegami H, Iwasaki H, Ohjimi Y, Takeuchi T, Ariyoshi A, Kikuchi M. Sarcomatoid carcinoma of the urinary bladder: a clinicopathologic and immunohistochemical analysis of 14 patients. HUM PATHOL 2000;31:332-40. [19] Chang A, Brimo F, Montgomery EA, Epstein JI. Use of PAX8 and GATA3 in diagnosing sarcomatoid renal cell carcinoma and sarcomatoid urothelial carcinoma. HUM PATHOL 2013;44:1563-8.
www.elsevier.com/locate/humpath
Original contribution
GATA3 expression in sarcomatoid urothelial carcinoma of the bladder☆ Nazneen Fatima MD a , Adeboye O. Osunkoya MD a,b,c,⁎ a
Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322 Department of Urology, Emory University School of Medicine, Atlanta, GA 30322 c Emory Winship Cancer Institute, Atlanta, GA 30322 b
Received 11 February 2014; revised 21 March 2014; accepted 26 March 2014
Keywords: GATA3; Urothelial carcinoma; Sarcomatoid differentiation; Cystectomy; Cystoprostatectomy
Summary The current available data on GATA-binding protein 3 (GATA3) expression in sarcomatoid urothelial carcinoma are limited, especially in the non–tissue microarray–based setting. In this study, we analyzed the expression of GATA3 in sarcomatoid urothelial carcinoma of the bladder in cystectomy/ cystoprostatectomy specimens. A search was made through our surgical pathology and consultation files for cystectomy/cystoprostatectomy specimens with a diagnosis of sarcomatoid urothelial carcinoma. Only cases with available tissue blocks were selected. Immunohistochemical staining for GATA3 was performed, and staining in adjacent/overlying conventional urothelial carcinoma and/or benign urothelium was also documented. Twenty-two cases were obtained. Of 22 cases, 16 (73%) of sarcomatoid urothelial carcinoma were positive for GATA3. In the 7 (27%) of 22 cases that were negative for GATA3, it was observed that these cases were predominantly composed either of pleomorphic undifferentiated sarcomatoid areas or foci composed of extensive heterologous elements (chondroid, osteoid, or rhabdoid). GATA3 staining was positive in the adjacent/overlying conventional urothelial carcinoma and/or benign urothelium in all cases. This is one of the largest studies to date analyzing the expression of GATA3 in sarcomatoid urothelial carcinoma in cystectomy/cystoprostatectomy specimens. GATA3 is expressed in most cases of sarcomatoid urothelial carcinoma. Negative expression may, however, be observed in cases composed predominantly of pleomorphic undifferentiated sarcomatoid areas or extensive heterologous elements. We recommend including GATA3 in the panel of immunohistochemical stains for sarcomatoid carcinomas of unknown origin, especially if a bladder primary is being considered in the differential diagnosis. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Urothelial carcinoma of the bladder with sarcomatoid differentiation is a rare biphasic neoplasm that contains both ☆ Disclosures: The authors have no conflict of interest or funding to disclose. ⁎ Corresponding author. Department of Pathology, Emory University School of Medicine, Room H174, 1364 Clifton Road, NE, Atlanta, GA 30322, USA. E-mail address: [email protected] (A. O. Osunkoya).
http://dx.doi.org/10.1016/j.humpath.2014.03.015 0046-8177/© 2014 Elsevier Inc. All rights reserved.
epithelial and mesenchymal components. Different names have been previously used for these biphasic tumors; however, in 2004, the World Health Organization classification of urothelial neoplasms clarified the nomenclature by using the term sarcomatoid carcinoma [1,2]. Sarcomatoid carcinoma was considered the preferred name for all biphasic malignant neoplasms of the genitourinary tract with evidence of both epithelial and mesenchymal differentiation [1]. Urothelial carcinoma with sarcomatoid differentiation of the bladder occurs more frequently in elderly male patients and in some cases has been reported to be associated with a previous history
2
N. Fatima, A. O. Osunkoya
of chemotherapy or radiation therapy [2,3]. Other commonly reported risk factors include previous urothelial carcinoma, tobacco smoking, recurrent cystitis, diabetes, neurogenic bladder, and bladder diverticulum [4]. The pathogenesis of urothelial carcinoma with sarcomatoid differentiation of the urinary bladder is controversial. Different theories exist based on clonality to explain the origin of these morphologically diverse and biphasic tumors. Studies primarily based on morphologic analysis, propose a collision tumor theory of 2 simultaneously occurring independent monoclonal tumors [5,6]. However, other studies suggest a common clonal origin with divergent differentiation into carcinomatous and sarcomatoid components [7]. The diagnosis is easily made on hematoxylin and eosin (H&E) in most cases, especially if there is clear demonstration of a transition from the epithelial component to the sarcomatoid or spindle cell component. However, difficulty arises in cases in which the sarcomatoid component predominates, with lack of evidence of epithelial differentiation (conventional invasive urothelial carcinoma or urothelial carcinoma in situ). In such cases, the differential diagnosis of urothelial carcinoma with sarcomatoid differentiation is broad, and the entities that must be considered include but are not limited to inflammatory myofibroblastic tumor, leiomyosarcoma, rhabdomyosarcoma, angiosarcoma, malignant fibrous histiocytoma, and spindle cell malignant melanoma. In addition, other entities that should be excluded include urothelial carcinoma with pseudosarcomatous stroma and urothelial carcinoma with osseous or cartilaginous metaplasia. Identifying the primary origin of a metastatic sarcomatoid carcinoma of unknown origin may be very challenging. Immunohistochemistry may be a useful adjunct in this setting. GATA-binding protein 3 (GATA3) has been reported to be a novel marker for urothelial carcinoma [8-11]. However, the current available data of GATA3 expression in urothelial carcinoma with sarcomatoid differentiation are somewhat limited, especially in the non–tissue microarray (TMA)–based setting. In this study, we analyzed the expression of GATA3 in urothelial carcinoma with sarcomatoid differentiation of the bladder in cystectomy/cystoprostatectomy specimens.
dilution, retrieval solution and pH, and detection system were optimized before the study was undertaken. Antigen retrieval was in citrate buffer (pH 6.0), using an electric pressure cooker for 5 minutes at 120°C (15 psi), with cooling for 10 minutes before immunostaining. Slides were loaded on the Dako automated system, exposed to 3% hydrogen peroxide for 5 minutes, GATA3 antibody for 30 minutes, labeled polymer HRP for 30 minutes, 3,3′-diaminobenzidine as chromogen for 5 minutes, and Dako automation hematoxylin as counterstain for 5 minutes. These incubations were performed at room temperature; between incubations, sections were washed with tris-buffered saline. Tween 20 was included in this buffer. A known positive control of urothelial carcinoma was used with each run. Negative controls had primary antibody replaced by buffer. Immunohistochemical staining was performed on selected blocks with sarcomatoid urothelial carcinoma, and staining in adjacent/overlying conventional urothelial carcinoma and/or benign urothelium was also documented, with nuclear staining for GATA3 in at least 10% of the cells considered a positive result. This study was completed following the guidelines of and with approval from our institutional review board.
2. Materials and methods
Urothelial carcinoma with sarcomatoid differentiation is a biphasic malignant neoplasm, with morphologic and/or immunohistochemical evidence of epithelial and mesenchymal differentiation. Different hypotheses exist regarding the pathogenesis of urothelial carcinoma with sarcomatoid differentiation. Studies primarily based on morphologic analysis, propose a collision tumor theory of 2 simultaneously occurring independent monoclonal tumors [2,6,7]. However, other studies suggest a common clonal origin with divergent differentiation into sarcomatoid and carcinomatous components [2,7]. Some authors have analyzed X chromosome inactivation and loss of heterozygosity in cases of sarcomatoid carcinomas and reported a concordant pattern of nonrandom X chromosome inactivation, supporting the hypothesis that
A search was made through our surgical pathology and consultation files of the senior author for cystectomy/ cystoprostatectomy specimens with a diagnosis of sarcomatoid urothelial carcinoma from 2005 to 2013. Only cases with available tissue blocks were selected. All the selected cases were originally formalin fixed and paraffin embedded. Fivemicrometer sections from each case was deparaffinized and dehydrated. Immunostaining used standard heat-induced epitope retrieval, the Dako Envision Detection System (Dako, Carpinteria, CA), and the Dako Autostainer (Dako). Antiserum to monoclonal GATA3 was used (L50-823, 1:50 dilution; Biocare Medical, Concord, CA). The primary antibody
3. Results Twenty-two cases were selected. Of 22 cases, 16 (73%) of sarcomatoid urothelial carcinoma were positive for GATA3 (Fig. 1A-H). In the 7 (27%) of 22 cases that were completely negative for GATA3, it was observed that these cases were predominantly composed either of pleomorphic undifferentiated sarcomatoid areas (Fig. 2A and B) or foci composed of extensive heterologous elements (chondroid, osteoid, or rhabdoid). GATA3 staining was positive in the adjacent/ overlying conventional urothelial carcinoma and/or benign urothelium in all cases (Fig. 1B and D).
4. Discussion
F1
F2
GATA3 expression in sarcomatoid urothelial carcinoma
3
Fig. 1 A, Urothelial carcinoma with sarcomatoid differentiation (note overlying benign urothelium, upper left corner). B, Positive GATA3 expression in urothelial carcinoma with sarcomatoid differentiation (note positive expression also in overlying benign urothelium, upper left corner). C, Urothelial carcinoma with sarcomatoid differentiation with overlying/adjacent benign urothelium. D, Positive GATA3 expression in urothelial carcinoma with sarcomatoid differentiation (note positive expression also in overlying/adjacent benign urothelium) E, Urothelial carcinoma with sarcomatoid differentiation. F, Positive GATA3 expression in urothelial carcinoma with sarcomatoid differentiation. G, Urothelial carcinoma with sarcomatoid differentiation. H, Positive GATA3 expression in urothelial carcinoma with sarcomatoid differentiation (note positive expression is limited to the left side of the image, although the H&E morphology of the right side is identical). H&E, original magnification ×100 (A and B, E-H), ×200 (C and D).
both sarcomatoid and carcinomatous components of these tumors are of a monoclonal origin [2,7]. Additional evidence of a common clonal origin for both the phenotypically
distinct components of these tumors was confirmed in a study of 17 cases of sarcomatoid carcinomas of the bladder, which showed identical mutation patterns and nuclear p53
4
N. Fatima, A. O. Osunkoya
Fig. 2 A, Urothelial carcinoma with sarcomatoid differentiation composed predominantly of pleomorphic undifferentiated sarcomatoid areas. B, Negative GATA3 expression in urothelial carcinoma with sarcomatoid differentiation composed predominantly of pleomorphic undifferentiated sarcomatoid areas. H&E, original magnification ×200 (A and B).
immunohistochemical staining characteristics in both components [2,12]. Furthermore, in a study analyzing chromosomal aberrations in 3 cases of sarcomatoid carcinoma of the bladder by comparative genomic hybridization, Torenbeek et al [13] found 20% to 50% homology in chromosomal aberrations, between the carcinomatous and sarcomatoid components of each tumor, strengthening the theory of monoclonal origin of this biphasic tumor [2]. Heterologous differentiation can be seen in the form of rhabdomyosarcoma, chondrosarcoma, liposarcoma, and osteosarcoma [14]. The malignant epithelial component is typically urothelial carcinoma in situ or invasive urothelial carcinoma, but adenocarcinoma, squamous cell carcinoma, and small cell carcinoma have also been reported [4,14]. Foci of sarcomatoid dedifferentiation have been identified in conventional as well as other variants of urothelial carcinoma, including plasmacytoid and villoglandular variants [15-17]. The immunohistochemical analysis of carcinomatous and sarcomatoid components are known to variably express epithelial antigens including pancytokeratin and epithelial membrane antigen. Ikegami et al [18] examined the expression of cell adhesion molecules in 12 cases and reported that the carcinomatous components were positive for E-cadherin (8 of 12 cases), CD44s (8 of 12 cases), and CD44v6 (6 of 12 cases). The sarcomatoid components were also positive but to a lesser extent: E-cadherin (5 of 12 cases), CD44s (4 of 12 cases), and CD44v6 (3 of 12 cases). Occasionally, the sarcomatoid component predominates, and in some cases, there may be no apparent evidence of epithelial differentiation on H&E, making the distinction of a sarcomatoid urothelial carcinoma from other spindle cell lesions difficult. Identifying the primary origin of a metastatic sarcomatoid carcinoma of unknown origin may also be very challenging. In both the former and latter situations, immunohistochemistry can be a useful adjunct. GATA3 is a member of the GATA family of 6 zinc finger transcription factors. This 50 kd nuclear protein regulates the development and maintenance of multiple tissues including hematopoietic cells, skin, kidney, mammary gland, and the central nervous system [8]. GATA3 is reported to be a sensitive and specific
marker for the diagnosis of breast and urothelial carcinomas and is proposed to be routinely included in the initial screening panel if either a breast or urothelial primary tumor is suspected [9,10]. The positive staining in urothelial carcinoma is reported as typically nonfocal and moderate or strong in intensity [11]. However, the current available data of GATA3 expression in urothelial carcinoma with sarcomatoid differentiation are limited, especially in the non-TMA–based setting. Chang et al [19], in a TMA-based study, showed that GATA3 is a relatively specific marker for urothelial carcinoma with sarcomatoid differentiation but lacks sensitivity. In their study, they evaluated PAX8 and GATA3 expression in TMAs constructed from 45 cases of sarcomatoid renal cell carcinoma and 45 cases of urothelial carcinoma with sarcomatoid differentiation of the lower urinary tract, with an additional 11 cases of urothelial carcinoma with sarcomatoid differentiation of the upper tract. PAX8 and GATA3 were also evaluated in TMAs from 161 sarcomas from other sites, including atypical epithelioid angiomyolipomas of the kidney, inflammatory myofibroblastic tumors of the bladder, and bladder and renal leiomyosarcomas [19]. In their study, urothelial carcinoma with sarcomatoid differentiation of the bladder, GATA3 and PAX8, were positive in 14 (31%) of 45 cases and 2 (4%) of 45 cases, respectively [19]. The current study is one of the largest studies to date analyzing the expression of GATA3 in sarcomatoid urothelial carcinoma in cystectomy/cystoprostatectomy specimens. Of 22 cases, 16 (73%) of sarcomatoid urothelial carcinoma were positive for GATA3. In the 7 (27%) of 22 cases that were negative for GATA3, it was observed that these cases were predominantly composed either of pleomorphic undifferentiated sarcomatoid areas or foci composed of extensive heterologous elements (chondroid, osteoid, or rhabdoid). GATA3 staining was positive in the adjacent/overlying conventional urothelial carcinoma and/or benign urothelium in all cases. It should be noted that in a number of cases (Fig. 1G and H), GATA3 was not positive in the entire sarcomatoid component (just as seen in some cases of conventional urothelial carcinoma in general practice), which would be a limitation of TMA-based studies. In conclusion, we recommend including GATA3 in the panel of
GATA3 expression in sarcomatoid urothelial carcinoma immunohistochemical stains for sarcomatoid tumors involving the bladder or adjacent organs and also in cases of sarcomatoid carcinomas of unknown origin, especially if a bladder primary is being considered in the differential diagnosis.
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