International Journal of Gynecological Pathology 34:136–142, Lippincott Williams & Wilkins, Baltimore r 2015 International Society of Gynecological Pathologists
Case Report
NUT Midline Carcinoma Presenting With Bilateral Ovarian Metastases: A Case Report Ema Dragoescu, M.D., Christopher French, M.D., Anthony Cassano, M.D., Sherman Baker, Jr, M.D., and Weldon Chafe, M.D.
Summary: Nuclear protein of the testis (NUT) midline carcinoma (NMC) is an uncommon, relatively recently characterized carcinoma, which is defined by NUT gene rearrangements. We are reporting a case of NMC in a 38-year-old female who presented with pleural effusion and bilateral ovarian masses. We also discuss some of the difficulties encountered by the practicing pathologist in reaching the diagnosis and the role of ancillary studies. Immunohistochemical staining using a commercially available monoclonal antibody showing nuclear expression of the NUT protein is diagnostic of NMC. Dual-color split-apart fluorescence in situ hybridization (FISH) or reverse transcription polymerase chain reaction (RT-PCR) can be used to characterize the fusion gene, whether BRD4-NUT or BRD3-NUT, or NUT-variant. Key Words: Ovary— NUT—Midline carcinoma.
is diagnostic of NMC. Characterization of the fusion gene, whether BRD4-NUT or BRD3-NUT, or the NUT-variant, is established by fluorescence in situ hybridization (FISH) or reverse transcription polymerase chain reaction (RT-PCR) (1,4).
NUT midline carcinoma (NMC) is an uncommon, relatively recently characterized carcinoma, which is defined by NUT gene rearrangements (1–3). We are reporting here a case of NMC with an unusual clinical presentation and discuss some of the difficulties encountered by the practicing pathologist in reaching the diagnosis. Immunohistochemical staining using a commercially available monoclonal antibody showing nuclear expression of the NUT protein
CASE REPORT Clinical Presentation A 38-yr-old white G0 female presented to the Emergency Department at our institution for a small pneumothorax and possible right-sided rib fractures from a mountain biking accident 5 wk prior. The patient had been in her usual state of health before the accident. She initially felt sore after the accident, then 5 wk later developed more right-sided chest pain. The patient saw her primary care physician who obtained a plain x-ray and then referred her to the emergency room. In the Emergency Department, the patient underwent computed tomography (CT) of the chest, abdomen, and pelvis with oral and intravenous contrast. The chest CT showed a large, complex right-sided pleural fluid
From the Department of Pathology (E.D.); Department of Surgery, Division of Cardiothoracic Surgery (A.C.); Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care (S.B.); Department of Obstetrics and Gynecology, Division of Gynecologic Oncology (W.C.), VCU Health System, Richmond, Virginia; and Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (C.F.). C.F. is a consultant for Glaxo-Smith Kline and is currently receiving grants from NIH, Samuel Waxman Cancer Research Foundation, and St. Baldricks’ Cancer Research Foundation. S.B. has received payment for lectures including service on speakers bureau from Lilly. All other authors declare no conflict of interest. Address correspondence and reprint requests to Ema A. Dragoescu, MD, Department of Pathology, VCU Health System, 1200 East Marshall Street, P.O. Box 980662, Richmond, VA 23298-0662. E-mail: [email protected].
DOI: 10.1097/PGP.0000000000000129
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FIG. 1. (A) Chest computed tomography with intravenous contrast showing right-sided pleural effusion and atelectasis of the right lower lobe. (B) Pleural biopsy showing tumor cells in solid sheets separated by fibrous stroma (hematoxylin and eosin). (C) Higher magnification showing uniform tumor cells with moderate amount of amphophilic cytoplasm and centrally located nuclei with smooth nuclear contours, pale chromatin, and prominent nucleoli (hematoxylin and eosin). (D) Focal squamous differentiation noted within the pleural biopsy (hematoxylin and eosin).
collection associated with multifocal, variable-sized, enhancing implants along the dependent and nondependent parietal pleural surfaces and diaphragm. The pleural fluid collection extended from the apex through the posterior recess and into the oblique fissure. There was atelectasis of the entire right lower lobe associated with partial collapse of the right middle lobe and posterior segment of the right upper lobe (Fig. 1A). Areas of altered perfusion and devitalized lung were appreciated in the right lower lobe. In addition to the right-sided pleural fluid collection, a dominant pericarinal and subcarinal mediastinal mass was identified. This mass, measuring 4.4 cm (cranial to caudal) 2.8 cm (anterior to posterior) 2.6 cm (transverse), was inseparable from the subcarinal esophagus. The mass was associated with effacement of the right mainstem bronchus, enveloping the origin of the right middle and lower lobe bronchi and deforming the dorsal surface of the left atrium and right superior pulmonary vein. Also present was an additional right infrahilar mass measuring 2.7 cm in greatest dimension and intimately associated with the bronchial and segmental arterial divisions of the right middle and lower lobes. No
pneumothorax or displaced rib fractures were identified. The etiology of the complex right pleural fluid collection associated with the parietal pleural implants was favored to be malignant. The abdomen and pelvis CT was remarkable for bilateral solid and cystic adnexal masses (Fig. 2A). The left-sided adnexal mass measured 6.5 4.5 cm and had an attached second mass situated more midline that measured 5.0 4.0 cm. The right-sided adnexal mass measured 2.7 2.7 cm. Ascitic fluid was present extending around the liver and the right paracolic gutter. There was minimal peritoneal thickening in the pelvis but no obvious peritoneal carcinomatosis. In addition, the uterine cervix appeared enlarged and slightly inhomogenous. The patient’s past medical and surgical history was unremarkable. Family history was remarkable for patient’s mother diagnosed with ovarian cancer at age 62. The patient had quit smoking 14 yr ago, after having smoked for 10 yr. Serum tumor markers were within normal limits [CEA = 2.2 ng/mL (normal: 0–3), b-HCGo5 mIU/mL (normal: 0–5), a-fetoprotein = 7.2 ng/mL (normal: Int J Gynecol Pathol Vol. 34, No. 2, March 2015
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FIG. 2. (A) Abdomen and pelvis computed tomography with intravenous contrast showing solid and cystic bilateral adnexal masses. (B) Gross photomicrograph of the left ovary replaced by multiple, solid nodules with a white, gritty appearance (the bar equals 2.0 cm). (C) Representative area from the adnexal masses showing angiolymphatic space invasion (hematoxylin and eosin). (D) Focal squamous differentiation present in the adnexal masses as well (hematoxylin and eosin).
0–8), CA19-9 = 17 U/mL (normal: 0–35)], with the exception of CA-125, which was mildly elevated at 88 U/mL (normal: 0–30).
Treatment The patient was admitted to our institution and the next day underwent right video-assisted thoracoscopic surgery with pleural biopsy. The operative findings were 2 L of bloody effusion, which was drained, and multiple tumor implants studding the parietal and visceral pleura and diaphragmatic surfaces. Right pleural biopsy was submitted for intraoperative consultation, which revealed metastatic poorly differentiated carcinoma with squamous differentiation. Talc pleurodesis was performed. Given the presence of bilateral adnexal masses with significant tumor burden and patient’s family history of ovarian cancer in her mother, an exploratory laparotomy was performed 6 d later after the videoassisted thoracoscopic surgery. The purpose of the abdominal exploration was to determine whether the ovarian masses were the primary site that had produced the pleural metastases, or whether they Int J Gynecol Pathol Vol. 34, No. 2, March 2015
were involved as well by metastatic disease from an unknown primary source. Upon entering the peritoneal cavity approximately 200 mL of bloody ascitic fluid was encountered, aspirated, and submitted for cytologic examination. The ovaries were enlarged, left more than right, with a nodular, solid appearance. Left salpingo-oophorectomy was performed. The specimen was submitted to pathology for intraoperative consultation, which revealed a poorly differentiated carcinoma with squamous differentiation. Morphologically, the tumor was similar to the pleural biopsy, and metastasis was favored. As the right ovary had a similar appearance to the left ovary, although smaller in size, right salpingo-oophorectomy was performed. There was no evidence of disease elsewhere in the abdomen; specifically, there were no peritoneal implants or omental cake. At the same time, endometrial biopsy and endocervical curettage were performed to evaluate for the possibility of a primary site within the gynecologic tract. Postoperative course after these 2 surgeries was uneventful; the patient recovered well with no complications and was discharged home in stable condition 9 d after hospital admission. Home medications
NUT MIDLINE CARCINOMA included Enoxaparin 40 mg subcutaneous daily and Percocet 5/325 mg 1–2 oral tables every 6 hr for pain.
Follow-up The patient was scheduled to receive chemotherapy, and, to obtain a baseline of the extent of the disease, CT of the chest, abdomen, and pelvis with oral and intravenous contrast was performed 16 d after hospital discharge. These studies revealed progression of the mediastinal disease and interval development of a single pulmonary nodule (0.4 cm) and metastases to the liver (2 new hypodense lesions measuring 0.8 and 0.9 cm) and right adrenal gland (new mass measuring 1.5 cm). A nonocclusive pulmonary embolus in the pulmonary artery branch of the right lower lobe was noted as well. The next day, the patient experienced acute onset of central vision loss with a central brown scotoma in the left eye and she came immediately to the emergency room. The patient was admitted and started on therapeutic doses of Lovenox 60 mg every 12 hr; she was hemodynamically stable and had no oxygen requirements. Ophthalmologic examination revealed retinal elevation in the left eye (possible retinal detachment or infiltrative process). Magnetic resonance imaging of the head with intravenous contrast revealed multiple subcentimeter metastatic foci throughout the right cerebral hemisphere and a single 0.2 cm metastatic focus in the left parietal lobe. These lesions had no mass effect on adjacent structures; in addition, no midline shift or uncal herniation was present. There were no definitive masses identified within the orbital globes bilaterally and no abnormal enhancement along the course of the optic nerves and optic chiasm. A positron emission tomography with CT scan from vertex to toes revealed, in addition to the known areas of disease identified by the prior imaging studies, hypermetabolic activity in the right supraclavicular lymph node, right axillary lymph node, and diffuse bone metastatic disease. There were numerous areas of tumor involvement (within the spine, sternum, pelvis, bilateral femurs, right scapula, right humerus, right tibia, right calcaneous, and right talus), with a standardized uptake value ranging from 4.1 to 14.6. The patient was discharged home the following day, receiving an outpatient whole-brain external beam radiotherapy, 3 Gray (Gy) per fraction for a cumulative dose of 30 Gy. This was followed by systemic chemotherapy with Romidepsin. During the second chemotherapy cycle the patient experienced
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increased cough with foul smelling yellow sputum production, dyspnea on exertion, shortness of breath, and an increase in body temperature to 100.11F. Chest CT revealed complete occlusion of the right bronchus intermedius with complete collapse of the right middle and lower lobes. In addition, groundglass and tree-in-bud opacities in the right upper lobe and left lower lobe were present. The patient was admitted to the hospital and started on Vancomycin and Zosyn. A short course of palliative radiation therapy to the right chest, 4 Gy per fraction for a cumulative dose of 20 Gy, was started. However, dyspnea did not improve, and the patient was transferred to palliative care service where she expired, 2 mo and 19 d from diagnosis.
Pleural Biopsy Pathologic Findings The right pleural biopsy consisted of multiple fragments of pink-tan soft tissue, the largest fragment measuring 0.9 0.4 0.2 cm. The histologic examination revealed a poorly differentiated carcinoma with squamous features. Tumor cells were arranged in solid sheets and nests separated by a fibrous stroma (Fig. 1B). Tumor cells were morphologically uniform, with minimal variation in size and shape. They had a moderate amount of amphophilic cytoplasm and a large, round, centrally located nucleus. Tumor cell nuclei had a smooth contour, pale nuclear chromatin, and a very prominent, round-oval, cherry-red nucleolus (Fig. 1C). Mitotic figures, apoptotic bodies, and focal tumor necrosis were found. Very focally, tumor cells had more ample, waxy, orangeophilic cytoplasm with sharp borders. Within these areas, individual cell keratinization was noted (Fig. 1D). These last 2 features were indicative of squamous differentiation in this otherwise poorly differentiated malignant neoplasm. Immunohistochemical staining analyses performed on the pleural biopsy showed that tumor cells were positive for p63 and CK5/6 and negative for all the other antibodies (CDX2, CK20, vimentin, thrombomodulin, uroplakin, WT-1, HPV, B72.3, and estrogen receptor). CK7 and p16 showed focal staining in 50% of nuclei are positive, and is thus consistent with NUT rearrangement and diagnostic of NMC (4). NUT rearrangements can also be detected through various techniques (traditional cytogenetics karyotyping, FISH, or RT-PCR) (1). However, the value of FISH or RTPCR is to identify the partner gene to NUT, which may be essential to providing a rationale for treatment with targeted inhibitors (below). Int J Gynecol Pathol Vol. 34, No. 2, March 2015
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E. DRAGOESCU ET AL.
Ancillary Studies For the purpose of this case report, it is useful to review the salient genetic alterations that characterize NMC, in order to understand the role of the confirmatory ancillary diagnostic tests needed for a definitive diagnosis of NMC. Excellent detailed articles on this topic exist in the literature (1–3). As previously mentioned, NMC is defined by the presence of NUT gene rearrangements. The nuclear protein of the testis (NUT) gene is localized on chromosome 15q14 (1,2) and little is known about its normal function. It appears that this gene is restricted to mammals and in humans is normally expressed only in the adult testis and ciliary ganglion (18). The most common rearrangement is t(15;19)(q14;p13.1) forming BRD4-NUT fusion gene. However, in a third of cases, BRD3 or some other yet unidentified genes are involved in the rearrangement with the NUT (6); these are called NUT-variant fusion genes (2,6). These rearrangements can be detected by dual-color split-apart FISH using probes flanking the NUT locus or by RT-PCR using primers flanking the known NUT and BRD4 breakpoints. Even when the diagnosis of NMC is made with NUT immunohistochemistry, it is still recommended, when possible, to test for the partner gene fused to NUT, because this may be relevant for ongoing clinical trials using targeted bromodomain inhibitors that specifically target BRD3 and BRD4 proteins (ClinicalTrials.gov identifiers: NCT01587703 and NCT01987362) (19,20). Therefore, the diagnostic algorithm suggested is to perform immunohistochemistry using NUT monoclonal antibody, followed by FISH using a dual-colored split-apart probe for NUT gene locus. Considering the essential role of ancillary studies and these described diagnostic challenges, it is incumbent upon the pathologist considering NMC in the differential diagnosis to seek appropriate ancillary studies and expert consultation. A very useful resource for pathologists and oncologists, as well as patients and their families, is the international NMC registry accessible at http://www.NMCRegistry.org (1). Acknowledgment: The authors thank Mr Alex Burke from the Writing Center, University College at Virginia
Int J Gynecol Pathol Vol. 34, No. 2, March 2015
Commonwealth University, Richmond, Virginia, for critical review of the manuscript and useful suggestions.
REFERENCES 1. French CA. Pathogenesis of NUT midline carcinoma. Annu Rev Pathol 2012;7:247–65. 2. French CA. Demystified molecular pathology of NUT midline carcinomas. J Clin Pathol 2010;63:492–6. 3. French CA. NUT midline carcinoma. Cancer Genet Cytogenet 2010;203:16–20. 4. Haack H, Johnson LA, Fry CJ, et al. Diagnosis of NUT midline carcinoma using a NUT-specific monoclonal antibody. Am J Surg Pathol 2009;33:984–91. 5. Bauer DE, Mitchell CM, Strait KM, et al. Clinicopathologic features and long-term outcomes of NUT midline carcinoma. Clin Cancer Res 2012;18:5773–9. 6. Stelow EB. A review of NUT midline carcinoma. Head Neck Pathol 2011;5:31–5. 7. den Bakker MA, Beverloo BH, van den Heuvel-Eibrink MM, et al. NUT midline carcinoma of the parotid gland with mesenchymal differentiation. Am J Surg Pathol 2009;33:1253–8. 8. Shehata BM, Steelman CK, Abramowsky CR, et al. NUT midline carcinoma in a newborn with multiorgan disseminated tumor and a 2-year-old with a pancreatic/hepatic primary. Pediatr Dev Pathol 2010;13:481–5. 9. Teo M, Crotty P, O’Sullivan M, et al. NUT midline carcinoma in a young woman. J Clin Oncol 2011;29:e336–9. 10. Bott-Kothari T, Aron BS, Bejarano P. Malignant thymoma with metastases to the gastrointestinal tract and ovary: a case report and literature review. Am J Clin Oncol 2000;23:140–2. 11. Briese V, Rohde E. Ovarian metastasis of a thymoma. Zentralbl Gynakol 1984;106:473–6. 12. Yoshida A, Shigematsu T, Mori H, et al. Non-invasive thymoma with widespread blood-borne metastasis. Virchows Arch A Pathol Anat Histol 1981;390:121–6. 13. Petrini P, French CA, Rajan A, et al. NUT rearrangement is uncommon in human thymic epithelial tumors. J Thorac Oncol 2012;7:744–50. 14. Irving JA, Young RH. Lung carcinoma metastatic to the ovary: a clinicopathologic study of 32 cases emphasizing their morphologic spectrum and problems in differential diagnosis. Am J Surg Pathol 2005;29:997–1006. 15. Polsani A, Braithwaite KA, Alazraki AL, et al. NUT midline carcinoma: an imaging case series and review of literature. Pediatr Radiol 2012;42:205–10. 16. Rosenbaum DG, Teruya-Feldstein J, Price AP, et al. Radiologic features of NUT midline carcinoma in an adolescent. Pediatr Radiol 2012;42:249–52. 17. Zhu B, Laskin W, Chen Y, et al. NUT midline carcinoma: a neoplasm with diagnostic challenges in cytology. Cytopathology 2011;22:414–7. 18. French CA, Miyoshi I, Kubonishi I, et al. BRD4-NUT fusion oncogene: a novel mechanism in aggressive carcinoma. Cancer Res 2003;63:304–7. 19. Filippakopoulos P, Qi J, Picaud S, et al. Selective inhibition of BET bromodomains. Nature 2010;468:1067–73. 20. French CA. The importance of diagnosing NUT midline carcinoma. Head Neck Pathol 2013;7:11–6.
Case Report
NUT Midline Carcinoma Presenting With Bilateral Ovarian Metastases: A Case Report Ema Dragoescu, M.D., Christopher French, M.D., Anthony Cassano, M.D., Sherman Baker, Jr, M.D., and Weldon Chafe, M.D.
Summary: Nuclear protein of the testis (NUT) midline carcinoma (NMC) is an uncommon, relatively recently characterized carcinoma, which is defined by NUT gene rearrangements. We are reporting a case of NMC in a 38-year-old female who presented with pleural effusion and bilateral ovarian masses. We also discuss some of the difficulties encountered by the practicing pathologist in reaching the diagnosis and the role of ancillary studies. Immunohistochemical staining using a commercially available monoclonal antibody showing nuclear expression of the NUT protein is diagnostic of NMC. Dual-color split-apart fluorescence in situ hybridization (FISH) or reverse transcription polymerase chain reaction (RT-PCR) can be used to characterize the fusion gene, whether BRD4-NUT or BRD3-NUT, or NUT-variant. Key Words: Ovary— NUT—Midline carcinoma.
is diagnostic of NMC. Characterization of the fusion gene, whether BRD4-NUT or BRD3-NUT, or the NUT-variant, is established by fluorescence in situ hybridization (FISH) or reverse transcription polymerase chain reaction (RT-PCR) (1,4).
NUT midline carcinoma (NMC) is an uncommon, relatively recently characterized carcinoma, which is defined by NUT gene rearrangements (1–3). We are reporting here a case of NMC with an unusual clinical presentation and discuss some of the difficulties encountered by the practicing pathologist in reaching the diagnosis. Immunohistochemical staining using a commercially available monoclonal antibody showing nuclear expression of the NUT protein
CASE REPORT Clinical Presentation A 38-yr-old white G0 female presented to the Emergency Department at our institution for a small pneumothorax and possible right-sided rib fractures from a mountain biking accident 5 wk prior. The patient had been in her usual state of health before the accident. She initially felt sore after the accident, then 5 wk later developed more right-sided chest pain. The patient saw her primary care physician who obtained a plain x-ray and then referred her to the emergency room. In the Emergency Department, the patient underwent computed tomography (CT) of the chest, abdomen, and pelvis with oral and intravenous contrast. The chest CT showed a large, complex right-sided pleural fluid
From the Department of Pathology (E.D.); Department of Surgery, Division of Cardiothoracic Surgery (A.C.); Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care (S.B.); Department of Obstetrics and Gynecology, Division of Gynecologic Oncology (W.C.), VCU Health System, Richmond, Virginia; and Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (C.F.). C.F. is a consultant for Glaxo-Smith Kline and is currently receiving grants from NIH, Samuel Waxman Cancer Research Foundation, and St. Baldricks’ Cancer Research Foundation. S.B. has received payment for lectures including service on speakers bureau from Lilly. All other authors declare no conflict of interest. Address correspondence and reprint requests to Ema A. Dragoescu, MD, Department of Pathology, VCU Health System, 1200 East Marshall Street, P.O. Box 980662, Richmond, VA 23298-0662. E-mail: [email protected].
DOI: 10.1097/PGP.0000000000000129
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NUT MIDLINE CARCINOMA
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FIG. 1. (A) Chest computed tomography with intravenous contrast showing right-sided pleural effusion and atelectasis of the right lower lobe. (B) Pleural biopsy showing tumor cells in solid sheets separated by fibrous stroma (hematoxylin and eosin). (C) Higher magnification showing uniform tumor cells with moderate amount of amphophilic cytoplasm and centrally located nuclei with smooth nuclear contours, pale chromatin, and prominent nucleoli (hematoxylin and eosin). (D) Focal squamous differentiation noted within the pleural biopsy (hematoxylin and eosin).
collection associated with multifocal, variable-sized, enhancing implants along the dependent and nondependent parietal pleural surfaces and diaphragm. The pleural fluid collection extended from the apex through the posterior recess and into the oblique fissure. There was atelectasis of the entire right lower lobe associated with partial collapse of the right middle lobe and posterior segment of the right upper lobe (Fig. 1A). Areas of altered perfusion and devitalized lung were appreciated in the right lower lobe. In addition to the right-sided pleural fluid collection, a dominant pericarinal and subcarinal mediastinal mass was identified. This mass, measuring 4.4 cm (cranial to caudal) 2.8 cm (anterior to posterior) 2.6 cm (transverse), was inseparable from the subcarinal esophagus. The mass was associated with effacement of the right mainstem bronchus, enveloping the origin of the right middle and lower lobe bronchi and deforming the dorsal surface of the left atrium and right superior pulmonary vein. Also present was an additional right infrahilar mass measuring 2.7 cm in greatest dimension and intimately associated with the bronchial and segmental arterial divisions of the right middle and lower lobes. No
pneumothorax or displaced rib fractures were identified. The etiology of the complex right pleural fluid collection associated with the parietal pleural implants was favored to be malignant. The abdomen and pelvis CT was remarkable for bilateral solid and cystic adnexal masses (Fig. 2A). The left-sided adnexal mass measured 6.5 4.5 cm and had an attached second mass situated more midline that measured 5.0 4.0 cm. The right-sided adnexal mass measured 2.7 2.7 cm. Ascitic fluid was present extending around the liver and the right paracolic gutter. There was minimal peritoneal thickening in the pelvis but no obvious peritoneal carcinomatosis. In addition, the uterine cervix appeared enlarged and slightly inhomogenous. The patient’s past medical and surgical history was unremarkable. Family history was remarkable for patient’s mother diagnosed with ovarian cancer at age 62. The patient had quit smoking 14 yr ago, after having smoked for 10 yr. Serum tumor markers were within normal limits [CEA = 2.2 ng/mL (normal: 0–3), b-HCGo5 mIU/mL (normal: 0–5), a-fetoprotein = 7.2 ng/mL (normal: Int J Gynecol Pathol Vol. 34, No. 2, March 2015
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E. DRAGOESCU ET AL.
FIG. 2. (A) Abdomen and pelvis computed tomography with intravenous contrast showing solid and cystic bilateral adnexal masses. (B) Gross photomicrograph of the left ovary replaced by multiple, solid nodules with a white, gritty appearance (the bar equals 2.0 cm). (C) Representative area from the adnexal masses showing angiolymphatic space invasion (hematoxylin and eosin). (D) Focal squamous differentiation present in the adnexal masses as well (hematoxylin and eosin).
0–8), CA19-9 = 17 U/mL (normal: 0–35)], with the exception of CA-125, which was mildly elevated at 88 U/mL (normal: 0–30).
Treatment The patient was admitted to our institution and the next day underwent right video-assisted thoracoscopic surgery with pleural biopsy. The operative findings were 2 L of bloody effusion, which was drained, and multiple tumor implants studding the parietal and visceral pleura and diaphragmatic surfaces. Right pleural biopsy was submitted for intraoperative consultation, which revealed metastatic poorly differentiated carcinoma with squamous differentiation. Talc pleurodesis was performed. Given the presence of bilateral adnexal masses with significant tumor burden and patient’s family history of ovarian cancer in her mother, an exploratory laparotomy was performed 6 d later after the videoassisted thoracoscopic surgery. The purpose of the abdominal exploration was to determine whether the ovarian masses were the primary site that had produced the pleural metastases, or whether they Int J Gynecol Pathol Vol. 34, No. 2, March 2015
were involved as well by metastatic disease from an unknown primary source. Upon entering the peritoneal cavity approximately 200 mL of bloody ascitic fluid was encountered, aspirated, and submitted for cytologic examination. The ovaries were enlarged, left more than right, with a nodular, solid appearance. Left salpingo-oophorectomy was performed. The specimen was submitted to pathology for intraoperative consultation, which revealed a poorly differentiated carcinoma with squamous differentiation. Morphologically, the tumor was similar to the pleural biopsy, and metastasis was favored. As the right ovary had a similar appearance to the left ovary, although smaller in size, right salpingo-oophorectomy was performed. There was no evidence of disease elsewhere in the abdomen; specifically, there were no peritoneal implants or omental cake. At the same time, endometrial biopsy and endocervical curettage were performed to evaluate for the possibility of a primary site within the gynecologic tract. Postoperative course after these 2 surgeries was uneventful; the patient recovered well with no complications and was discharged home in stable condition 9 d after hospital admission. Home medications
NUT MIDLINE CARCINOMA included Enoxaparin 40 mg subcutaneous daily and Percocet 5/325 mg 1–2 oral tables every 6 hr for pain.
Follow-up The patient was scheduled to receive chemotherapy, and, to obtain a baseline of the extent of the disease, CT of the chest, abdomen, and pelvis with oral and intravenous contrast was performed 16 d after hospital discharge. These studies revealed progression of the mediastinal disease and interval development of a single pulmonary nodule (0.4 cm) and metastases to the liver (2 new hypodense lesions measuring 0.8 and 0.9 cm) and right adrenal gland (new mass measuring 1.5 cm). A nonocclusive pulmonary embolus in the pulmonary artery branch of the right lower lobe was noted as well. The next day, the patient experienced acute onset of central vision loss with a central brown scotoma in the left eye and she came immediately to the emergency room. The patient was admitted and started on therapeutic doses of Lovenox 60 mg every 12 hr; she was hemodynamically stable and had no oxygen requirements. Ophthalmologic examination revealed retinal elevation in the left eye (possible retinal detachment or infiltrative process). Magnetic resonance imaging of the head with intravenous contrast revealed multiple subcentimeter metastatic foci throughout the right cerebral hemisphere and a single 0.2 cm metastatic focus in the left parietal lobe. These lesions had no mass effect on adjacent structures; in addition, no midline shift or uncal herniation was present. There were no definitive masses identified within the orbital globes bilaterally and no abnormal enhancement along the course of the optic nerves and optic chiasm. A positron emission tomography with CT scan from vertex to toes revealed, in addition to the known areas of disease identified by the prior imaging studies, hypermetabolic activity in the right supraclavicular lymph node, right axillary lymph node, and diffuse bone metastatic disease. There were numerous areas of tumor involvement (within the spine, sternum, pelvis, bilateral femurs, right scapula, right humerus, right tibia, right calcaneous, and right talus), with a standardized uptake value ranging from 4.1 to 14.6. The patient was discharged home the following day, receiving an outpatient whole-brain external beam radiotherapy, 3 Gray (Gy) per fraction for a cumulative dose of 30 Gy. This was followed by systemic chemotherapy with Romidepsin. During the second chemotherapy cycle the patient experienced
139
increased cough with foul smelling yellow sputum production, dyspnea on exertion, shortness of breath, and an increase in body temperature to 100.11F. Chest CT revealed complete occlusion of the right bronchus intermedius with complete collapse of the right middle and lower lobes. In addition, groundglass and tree-in-bud opacities in the right upper lobe and left lower lobe were present. The patient was admitted to the hospital and started on Vancomycin and Zosyn. A short course of palliative radiation therapy to the right chest, 4 Gy per fraction for a cumulative dose of 20 Gy, was started. However, dyspnea did not improve, and the patient was transferred to palliative care service where she expired, 2 mo and 19 d from diagnosis.
Pleural Biopsy Pathologic Findings The right pleural biopsy consisted of multiple fragments of pink-tan soft tissue, the largest fragment measuring 0.9 0.4 0.2 cm. The histologic examination revealed a poorly differentiated carcinoma with squamous features. Tumor cells were arranged in solid sheets and nests separated by a fibrous stroma (Fig. 1B). Tumor cells were morphologically uniform, with minimal variation in size and shape. They had a moderate amount of amphophilic cytoplasm and a large, round, centrally located nucleus. Tumor cell nuclei had a smooth contour, pale nuclear chromatin, and a very prominent, round-oval, cherry-red nucleolus (Fig. 1C). Mitotic figures, apoptotic bodies, and focal tumor necrosis were found. Very focally, tumor cells had more ample, waxy, orangeophilic cytoplasm with sharp borders. Within these areas, individual cell keratinization was noted (Fig. 1D). These last 2 features were indicative of squamous differentiation in this otherwise poorly differentiated malignant neoplasm. Immunohistochemical staining analyses performed on the pleural biopsy showed that tumor cells were positive for p63 and CK5/6 and negative for all the other antibodies (CDX2, CK20, vimentin, thrombomodulin, uroplakin, WT-1, HPV, B72.3, and estrogen receptor). CK7 and p16 showed focal staining in 50% of nuclei are positive, and is thus consistent with NUT rearrangement and diagnostic of NMC (4). NUT rearrangements can also be detected through various techniques (traditional cytogenetics karyotyping, FISH, or RT-PCR) (1). However, the value of FISH or RTPCR is to identify the partner gene to NUT, which may be essential to providing a rationale for treatment with targeted inhibitors (below). Int J Gynecol Pathol Vol. 34, No. 2, March 2015
142
E. DRAGOESCU ET AL.
Ancillary Studies For the purpose of this case report, it is useful to review the salient genetic alterations that characterize NMC, in order to understand the role of the confirmatory ancillary diagnostic tests needed for a definitive diagnosis of NMC. Excellent detailed articles on this topic exist in the literature (1–3). As previously mentioned, NMC is defined by the presence of NUT gene rearrangements. The nuclear protein of the testis (NUT) gene is localized on chromosome 15q14 (1,2) and little is known about its normal function. It appears that this gene is restricted to mammals and in humans is normally expressed only in the adult testis and ciliary ganglion (18). The most common rearrangement is t(15;19)(q14;p13.1) forming BRD4-NUT fusion gene. However, in a third of cases, BRD3 or some other yet unidentified genes are involved in the rearrangement with the NUT (6); these are called NUT-variant fusion genes (2,6). These rearrangements can be detected by dual-color split-apart FISH using probes flanking the NUT locus or by RT-PCR using primers flanking the known NUT and BRD4 breakpoints. Even when the diagnosis of NMC is made with NUT immunohistochemistry, it is still recommended, when possible, to test for the partner gene fused to NUT, because this may be relevant for ongoing clinical trials using targeted bromodomain inhibitors that specifically target BRD3 and BRD4 proteins (ClinicalTrials.gov identifiers: NCT01587703 and NCT01987362) (19,20). Therefore, the diagnostic algorithm suggested is to perform immunohistochemistry using NUT monoclonal antibody, followed by FISH using a dual-colored split-apart probe for NUT gene locus. Considering the essential role of ancillary studies and these described diagnostic challenges, it is incumbent upon the pathologist considering NMC in the differential diagnosis to seek appropriate ancillary studies and expert consultation. A very useful resource for pathologists and oncologists, as well as patients and their families, is the international NMC registry accessible at http://www.NMCRegistry.org (1). Acknowledgment: The authors thank Mr Alex Burke from the Writing Center, University College at Virginia
Int J Gynecol Pathol Vol. 34, No. 2, March 2015
Commonwealth University, Richmond, Virginia, for critical review of the manuscript and useful suggestions.
REFERENCES 1. French CA. Pathogenesis of NUT midline carcinoma. Annu Rev Pathol 2012;7:247–65. 2. French CA. Demystified molecular pathology of NUT midline carcinomas. J Clin Pathol 2010;63:492–6. 3. French CA. NUT midline carcinoma. Cancer Genet Cytogenet 2010;203:16–20. 4. Haack H, Johnson LA, Fry CJ, et al. Diagnosis of NUT midline carcinoma using a NUT-specific monoclonal antibody. Am J Surg Pathol 2009;33:984–91. 5. Bauer DE, Mitchell CM, Strait KM, et al. Clinicopathologic features and long-term outcomes of NUT midline carcinoma. Clin Cancer Res 2012;18:5773–9. 6. Stelow EB. A review of NUT midline carcinoma. Head Neck Pathol 2011;5:31–5. 7. den Bakker MA, Beverloo BH, van den Heuvel-Eibrink MM, et al. NUT midline carcinoma of the parotid gland with mesenchymal differentiation. Am J Surg Pathol 2009;33:1253–8. 8. Shehata BM, Steelman CK, Abramowsky CR, et al. NUT midline carcinoma in a newborn with multiorgan disseminated tumor and a 2-year-old with a pancreatic/hepatic primary. Pediatr Dev Pathol 2010;13:481–5. 9. Teo M, Crotty P, O’Sullivan M, et al. NUT midline carcinoma in a young woman. J Clin Oncol 2011;29:e336–9. 10. Bott-Kothari T, Aron BS, Bejarano P. Malignant thymoma with metastases to the gastrointestinal tract and ovary: a case report and literature review. Am J Clin Oncol 2000;23:140–2. 11. Briese V, Rohde E. Ovarian metastasis of a thymoma. Zentralbl Gynakol 1984;106:473–6. 12. Yoshida A, Shigematsu T, Mori H, et al. Non-invasive thymoma with widespread blood-borne metastasis. Virchows Arch A Pathol Anat Histol 1981;390:121–6. 13. Petrini P, French CA, Rajan A, et al. NUT rearrangement is uncommon in human thymic epithelial tumors. J Thorac Oncol 2012;7:744–50. 14. Irving JA, Young RH. Lung carcinoma metastatic to the ovary: a clinicopathologic study of 32 cases emphasizing their morphologic spectrum and problems in differential diagnosis. Am J Surg Pathol 2005;29:997–1006. 15. Polsani A, Braithwaite KA, Alazraki AL, et al. NUT midline carcinoma: an imaging case series and review of literature. Pediatr Radiol 2012;42:205–10. 16. Rosenbaum DG, Teruya-Feldstein J, Price AP, et al. Radiologic features of NUT midline carcinoma in an adolescent. Pediatr Radiol 2012;42:249–52. 17. Zhu B, Laskin W, Chen Y, et al. NUT midline carcinoma: a neoplasm with diagnostic challenges in cytology. Cytopathology 2011;22:414–7. 18. French CA, Miyoshi I, Kubonishi I, et al. BRD4-NUT fusion oncogene: a novel mechanism in aggressive carcinoma. Cancer Res 2003;63:304–7. 19. Filippakopoulos P, Qi J, Picaud S, et al. Selective inhibition of BET bromodomains. Nature 2010;468:1067–73. 20. French CA. The importance of diagnosing NUT midline carcinoma. Head Neck Pathol 2013;7:11–6.
