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Malignant Mesothelioma Audit

Malignant Mesothelioma Audit. April 2014 Dr J King Dr K Syred. Background. 90% mesotheliomas are linked to asbestos exposure May be eligible for compensation 3 yr survival rate 8% Subtype related to prognosis and different treatment options Epithelioid 1yr survival 52%

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Malignant Mesothelioma Audit

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  1. Malignant Mesothelioma Audit April 2014 Dr J King Dr K Syred

  2. Background • 90% mesotheliomas are linked to asbestos exposure • May be eligible for compensation • 3 yr survival rate 8% • Subtype related to prognosis and different treatment options • Epithelioid 1yr survival 52% • Sarcomatoid 1 yr survival 13%

  3. Diagnosis • Correlation of tissue diagnosis with clinical and radiology • IHC: • Panel 1: TTF-1, CEA, calretinin, CK5, D240, WT-1, MOC31 • Panel 2: MNF116, CD15, CK7, CK20

  4. Aim • Identify practice within our department • Typing • Assess what ihc has been performed • Determine any improvements in diagnosis • Report quality

  5. Objectives • Reviewed mesothelioma reports in the last 9 months (1/1/14 – 30/9/14) • Identify further work done • Possibly devise an improved panel of markers make diagnosis more efficient and cost saving

  6. Standards and criteria

  7. RCPath Guidelines • ‘6.4 Pathological • Histological type should be stated (epithelioid, biphasic, sarcomatoid (desmoplastic variant if present). Given the need for ancillary investigations to make the diagnosis, the immunohistochemistry panel used should be documented, this being at least two ‘mesothelium-associated’ markers and two ‘epithelium-associated’ markers for epithelioid and biphasic tumours (discussed in section 5). For sarcomatoid variants, due to the wide differential diagnosis, the full repertoire of antibodies used should be listed.’

  8. ‘Guidelines for the diagnosis and treatment of malignant pleural mesothelioma’ recommendation 6 states: • ‘For pleural mesothelioma-like tumours with an epithelial component, it is recommended that immunolabelling for both calretinin and TTF-1 is routinely carried out.’

  9. RCPath • ‘As with biopsies, cytological findings should be correlated with the clinical and imaging findings to establish whether the available cytological material is sufficient to render a specific diagnosis or a clinically relevant differential diagnosis. If a pleural cytology specimen is positive or suspicious for malignancy, and there is no other specimen, then material should undergo the same ancillary investigations as for biopsies in terms of the differential diagnosis, which ideally is via a cell pellet for histology as this allows preservation of residual material. Identification of an epithelial phenotype will allow a definitive diagnosis of metastatic carcinoma. Identification of a mesothelial phenotype will allow further management decisions in terms of a definitive diagnosis of mesothelioma or further sampling, dependent on the clinical scenario’

  10. Standards: • All diagnoses of mesothelioma should be typed. • Where immunohistochemistry is performed, there should be a panel including 2 mesothelial and 2 epithelial markers. • If an epithelioid subtype, caltretinin and TTF-1 should be performed • Immunohistochemistry should be performed on tissue rather than pleural fluid when available.

  11. Methods • Search on i-lab • M-90503 – mesothelioma, NOS • M-90513 – fibrous mesothelioma, NOS • M-90523 – epithelioid mesothelioma, NOS • M-90533 – biphasic mesothelioma, NOS • 1/1/14 – 30/9/14 • From the list each report looked up on i-lab • Data in-putted into spread sheet

  12. Data: • Lab no • What procedure was done to obtain a diagnosis • Any previous relevant investigations • Any immunohistochemistry performed on the procedure and if so what was ordered (the SPLI function was used to identify the immunohistochemical stains performed as not all of them were mentioned in the report. Where mentioned in the report, the result (positive or negative) was recorded). • It was noted if there was pleural fluid taken at the same time as any biopsy. • If there was mention of a pleural fluid on the biopsy form

  13. Inclusion criteria • Diagnosis of mesothelioma if pleural or peritoneal in during the time period stated above. • Previous results e.g. any previous pleural fluids sampled in previous years were also included in this audit.

  14. Exclusion Criteria • Outside cases for review at the MDT eg. from Truro. • Cases that are coded incorrectly. • LN biopsy for metastatic malignant mesothelioma • PM histology as not all of the PMs would have been picked

  15. Results • Total 31 biopsies performed • 3 excluded 1outside case 2 adenocarcinomas coded incorrectly • Remaining 28 • 26 pleural bx - 20 had cytology at the same time • 2 omentalbx • 27 had ihc • 1 did not as it was being performed on the fluid • 1 had ihc on both bx and fluid

  16. Results • Accompanying cytology • 8/20 (36%) malignant or suspicious of malignancy • 12/20 no malignant cells seen • 6 cytology forms mentioned bx taken • 7 cases bx only taken • 1 recurrent case with prev diagnosis 3 yrs ago • 1 had 2 previous pleural fluids – blood only and nmcs • 5 did not have any previous procedure • 2 cases diagnosed on pleural fluid alone

  17. Standard 1: subtype • 24/28 (86%) mesotheliomas diagnosed on tissue were subtyped.

  18. Standard 1: subtype • 13/29 cytology cases were suspicious/ malignant. • only 7 were classed as mesothelioma and only 2 were subtyped. 2/13 = 15%

  19. Which specimens had IHC?

  20. 39 different immuno-stains were ordered • Total of 286 ihc orders • Average = 8 per case • Mucin stains = 10

  21. Top mesothelial and epithelial markers

  22. Standard 2: where ihc performed, there should be 2 epithelial and 2 mesothelial markers • 30/35 (86%) had 2 epithelial and 2 meso markers • Remaining 5: • One had reactive panel • 4 had both an epithelial and mesothelial marker, some with 2 of one but not 2 of both

  23. Standard 3: if an epithelioid subtype, calretinin and TTF-1 should be performed • 23 of mesotheliomas typed as epithelioid • 15/23 (65%) had both calretinin and TTF-1 performed • One had reactive panel • The remaining did not have TTF-1 • 2 were omentalbx and may not need TTF-1

  24. Standard 4: ihc should be performed on tissue rather than pleural fluid when available • Ihc performed on 27 of the biopsies • 1 did not have ihc as it was requested on the cytology (commented on in the report) • Only 1 patient had ihc on both biopsy and cytology

  25. Conclusion: • Standard 1: 86% tissue and 15% cytology subtyped • Standard 2: 86% had 2 mesothelial and 2 epithelial markers • Standard 3: 65% epithelioidmesotheliomas had calretinin and TTF-1 • Standard 4: 1 had ihc on fluid rather than bx and 1 had ihc on both

  26. Recommendations: • New mesothelioma IHC panel • CK5 CEA • Calretinin BerEp4 • WT-1 Moc31 TTF-1 • Proforma to guide reporting biopsies and cytology • Subtype • List of ihc

  27. References: • http://www.hscic.gov.uk/media/15038/Mesothelioma-audit/pdf/EMBARGOEDTO120914_NLCA_Meso_Report_final.pdf • Standards and datasets for reporting cancers. The dataset for the histological reporting of mesothelioma. RCPath guidelines

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