非小细胞肺癌病理学检查原则NCCN指南2017V3

PRINCIPLES OF PATHOLOGIC REVIEW 病理学检查原则

NSCLC NCCN Guidelines 2017V3
非小细胞肺癌NCCN指南2017V3

Pathologic Evaluation 山东省肿瘤医院呼吸肿瘤内科张品良
病理评估

* The purpose of pathologic evaluation is to classify the histologic type of lung cancer and to determine all staging parameters as recommended by the AJCC, including tumor size, the extent of invasion (pleural and bronchial), adequacy of surgical margins, and presence or absence of lymph node metastasis. Further, determination of the specific molecular abnormalities of the tumor is critical for predicting sensitivity or resistance to an increasing number of drugable targets, primarily tyrosine kinase inhibitors (TKIs) (see Molecular Diagnostic Studies in Lung Cancer in this section).
*病理评估的目的是分类肺癌的组织学类型并确定AJCC推荐的所有分期数据，包括肿瘤大小、浸润范围（胸膜、支气管）、手术切缘是否适当以及有无淋巴结转移。此外，测定肿瘤特定的分子异常是预测越来越多的可用靶向药物敏感性或抵抗性的关键，主要是酪氨酸激酶抑制剂（TKIs）（见本节中的肺癌分子诊断研究）。

* The WHO tumor classification system has historically provided the foundation for the classification of lung tumors, including histologic types, clinical features, staging considerations, and the molecular, genetic, and epidemiologic aspects of lung cancer.
*历史上WHO肿瘤分类系统为肺肿瘤的分类提供了基础，包括组织学类型、临床特征、分期需要考虑的事项以及肺癌的分子、遗传和流行病学方面的研究。

* The pathology diagnostic report should include the histologic classification in resection specimens or small biopsies as described by the WHO for carcinomas of the lung. Use of bronchioloalveolar carcinoma (BAC) terminology is strongly discouraged.
*切除或小活检标本的病理诊断报告应包括WHO对肺恶性肿瘤描述的组织学分类。强烈反对使用细支气管肺泡癌（BAC）术语。

* The generic term “non-small cell lung cancer (NSCLC)” should be avoided as a single diagnostic term. In small biopsies of poorly differentiated carcinomas where immunohistochemistry (IHC) is used, the following terms are acceptable: “NSCLC favor adenocarcinoma” or “NSCLC favor squamous cell carcinoma.” Mutational testing (eg, epidermal growth factor receptor [EGFR]) is strongly recommended in all NSCLC favor adenocarcinomas.
*术语“非小细胞肺癌（NSCLC）”应避免作为一个单独的诊断术语。应避免作为一个单独的诊断术语。使用免疫组化（IHC）的低分化癌小活检中，下列术语是可以接受的：“非小细胞肺癌倾向于腺癌”或“非小细胞肺癌倾向于鳞状细胞癌。”在所有倾向于腺癌的非小细胞肺癌中强烈建议突变检测（如，表皮生长因子受体[EGFR] ）。

* Formalin-fixed paraffin-embedded tumor is acceptable for most molecular analyses.
*对于大多数的分子分析，福尔马林固定石蜡包埋的肿瘤是可以接受的。

* Limited use of IHC studies in small tissue samples is strongly recommended in samples that cannot be reliably classified on the basis of routine histology alone, thereby preserving critical tumor tissue for molecular studies, particularly in patients with advanced-stage disease.
*在单独基于常规组织学不能可靠分类的标本中，强烈建议在小组织标本中限制使用免疫组化检查，从而保留关键的肿瘤组织用于分子研究，尤其是在晚期疾病患者中。

A limited panel of one squamous cell carcinoma marker (eg, p63, p40) and one adenocarcinoma marker (eg, TTF-1, napsin A) should suffice for most diagnostic problems.
对于大多数诊断问题，一个鳞状细胞癌标记 （如p63、p40） 和一个腺癌标记 （如TTF-1、新天冬氨酸蛋白酶A）的有限组合应该足够。

Adenocarcinoma Classification
腺癌的分类

* Adenocarcinoma in situ (AIS; formerly BAC): ≤3 cm nodule, lepidic growth, mucinous, non-mucinous, or mixed mucinous/non-mucinous types.
*原位腺癌（AIS；原名细支气管肺泡癌）：结节≤3cm、贴壁生长、粘液性、非黏液性或黏液/非黏液混合性。

* Minimally invasive adenocarcinoma (MIA): ≤3 cm nodule with ≤5 mm of invasion, lepidic growth, mucinous, non-mucinous, or mixed mucinous/non-mucinous types.
*微浸润腺癌（MIA）：结节≤3cm、浸润≤5mm、贴壁生长、粘液性、非黏液性或黏液/非黏液混合性。

* Invasive adenocarcinoma, predominant growth pattern: lepidic >5 mm of invasion, acinar, papillary, micropapillary, or solid with mucin.
＊浸润腺癌，主要的生长模式：贴壁浸润>5mm、腺泡状、乳头状、微乳头状或伴有黏液的实体瘤。

* Invasive adenocarcinoma variants: mucinous adenocarcinoma, colloid, fetal, and enteric morphologies.
*浸润腺癌：黏液腺癌、胶冻、胚胎及肠道形态。

Immunohistochemical Staining
免疫组化染色

* Judicious use of IHC is strongly recommended to preserve tissue for molecular testing. IHC should be utilized only after consideration of all data including routine H&E histology, clinical findings, imaging studies, and patient’s history.
*强烈建议明智、合理使用IHC以保留组织用于分子检测。只有在评估所有的资料包括常规H&E组织学、临床表现、影像学检查及患者的病史之后才应该考虑使用IHC。

* Although the concordance is generally good between the histologic subtype and the immunophenotype seen in small biopsies compared with surgical resection specimens, caution is advised in attempting to subtype small biopsies with limited material or cases with an ambiguous immunophenotype.
*与手术切除的标本相比，小活检标本的组织学亚型和免疫表型之间尽管观察到的一致性总体而言是好的，但是，试图对材料有限的小活检或免疫表型模棱两可的患者进行亚型诊断时建议应慎重。

* IHC should be used to differentiate primary pulmonary adenocarcinoma from the following: squamous cell carcinoma, large cell carcinoma, metastatic carcinoma, and malignant mesothelioma; to determine whether neuroendocrine differentiation is present.
*应使用IHC以鉴别原发性肺腺癌与下列疾病：鳞状细胞癌、大细胞癌、转移癌以及恶性间皮瘤；以确定是否存在神经内分泌分化。

* Primary pulmonary adenocarcinoma
*原发性肺腺癌

▶ In patients for whom the primary origin of the carcinoma is uncertain, an appropriate panel of immunohistochemical stains is recommended to exclude metastatic carcinoma to the lung.
▶在肿瘤原发部位尚不明确的患者中，建议适当的免疫组化染色组合以排除肺转移性癌。

▶ TTF-1 is a homeodomain-containing nuclear transcription protein of the Nkx2 gene family that is expressed in epithelial cells of the embryonal and mature lung and thyroid. TTF-1 immunoreactivity is seen in primary pulmonary adenocarcinoma in the majority (70%–100%) of non-mucinous adenocarcinoma subtypes. Metastatic adenocarcinoma to the lung is virtually always negative for TTF-1 except in metastatic thyroid malignancies, in which case thyroglobulin is also positive.
▶甲状腺转录因子1（TTF-1）是Nkx2基因家族的一种含同源结构域的核转录蛋白，在肺和甲状腺胚胎以及成熟的上皮细胞中表达。在原发性肺腺癌中见到甲状腺转录因子1（TTF-1）免疫反应活性大多数（70%–100%）为非黏液腺癌亚型。肺的转移性腺癌中，TTF-1几乎均阴性，除了转移性甲状腺恶性肿瘤外，在转移性甲状腺癌病例中，甲状腺球蛋白也阳性。

▶ Napsin A - an aspartic proteinase expressed in normal type II pneumocytes and in proximal and distal renal tubules - appears to be expressed in >80% of lung adenocarcinomas and may be a useful adjunct to TTF-1.
▶新天冬氨酸蛋白酶A（Napsin A）——在正常肺泡Ⅱ型上皮细胞和近端与远端肾小管中表达的一种天门冬氨酸蛋白酶——似乎在80%以上的肺腺癌中表达，因此作为TTF-1的辅助可能是有用的。

▶ The panel of TTF-1 (or alternatively napsin A) and p63 (or alternatively p40) may be useful in reining the diagnosis to either adenocarcinoma or squamous cell carcinoma in small biopsy specimens previously classified as NSCLC NOS.
▶在既往分类为非小细胞肺癌非特指的小活检标本中，在“驾驭”腺癌或鳞状细胞癌诊断时，TTF-1（或Napsin A）和p63（或p40）组合可能是有用的。

* Neuroendocrine differentiation
*神经内分泌分化

▶ CD56, chromogranin, and synaptophysin are used to identify neuroendocrine tumors.
▶CD56、嗜铬素以及突触素用于鉴别神经内分泌肿瘤。

* Malignant mesothelioma versus pulmonary adenocarcinoma
＊恶性间皮瘤与肺腺癌

▶ The distinction between pulmonary adenocarcinoma and malignant mesothelioma (epithelial type) can be made by correlation of the histology with the clinical impression, imaging studies, and a limited panel of immunomarkers if needed.
▶肺腺癌与恶性间皮瘤（上皮型）的鉴别可以根据组织学与临床印象、影像检查的相互关系以及有限的免疫标记组合（如果需要的话）做出诊断。

♢ Immunostains relatively sensitive and specific for mesothelioma include WT-1, calretinin, D2-40, HMBE-1, and cytokeratin 5/6 (negative in adenocarcinoma).
♢对于间皮瘤相对敏感且特异的免疫标记包括Wilm's肿瘤基因（WT-1）、钙结合蛋白、D2-40、HMBE-1和细胞角蛋白5/6（在腺癌中阴性）。

♢ Antibodies immunoreactive in adenocarcinoma include CEA, B72.3, Ber-EP4, MOC31, CD15, claudin-4, and TTF-1 (negative in mesothelioma).
♢在腺癌中免疫活性抗体包括CEA、B72.3、Ber-EP4、MOC31、CD15、紧密连接蛋白-4和TTF-1（在间皮瘤中阴性）。

Molecular Diagnostic Studies in Lung Cancer
肺癌的分子诊断研究

* EGFR and KRAS
* EGFR和KRAS

▶ EGFR is normally found on the surface of epithelial cells and is often overexpressed in a variety of human malignancies. Presence of EGFR-activating mutations represents a critical biological determinant for proper therapy selection in patients with lung cancer.
▶EGFR通常在上皮细胞中发现，往往在多种人类恶性肿瘤中过表达。表皮生长因子受体活化突变的存在是肺癌患者合理选择治疗的一个关键的生物学决定因素。

▶ There is a significant association between EGFR mutations—especially exon 19 deletion and exon 21 (L858R, L861), exon 18 (G719X, G719), and exon 20 (S768I) mutations—and sensitivity to EGFR TKIs.
▶EGFR突变——尤其是外显子19缺失和外显子21（L858R，L861）、外显子18（G719X，G719）和外显子20（S768I）突变——之间显著相关并且对EGFR-TKI敏感。

▶ The exon 20 insertion mutation may predict resistance to clinically achievable levels of TKIs.
▶外显子20插入突变可预测对酪氨酸激酶抑制剂临床可达到的耐药程度。

▶ Overlapping EGFR and KRAS mutations occur in<1% of patients with lung cancer.
▶不到1%的肺癌患者存在EGFR和KRAS基因叠加突变。

▶ KRAS mutations are associated with intrinsic EGFR TKI resistance, and KRAS gene sequencing could be useful for the selection of patients as candidates for EGFR TKI therapy. KRAS testing may identify patients who may not benefit from further molecular diagnostic testing.
▶KRAS突变与EGFR TKI原发耐药相关，因此，KRAS基因测序对于选择EGFR TKI治疗的候选患者可能是有用的。KRAS检测可识别出不会获益于进一步分子诊断检测的患者。

▶ The prevalence of EGFR mutations in adenocarcinomas is 10% of Western and up to 50% of Asian patients, with higher EGFR mutation frequency in non-smokers, women, and non-mucinous cancers. KRAS mutations are most common in non-Asians, smokers, and in mucinous adenocarcinoma. The most common EGFR mutations result in an arginine for leucine substitution at amino acid 858 in exon 21 (L858R) and in frame deletions at exon 19. Mutations are more common in non-mucinous lung adenocarcinoma with lepidic pattern (former BAC pattern) and in lung adenocarcinoma with papillary (and or micropapillary) pattern.
▶腺癌EGFR突变的发生率西方患者是10%，而亚洲患者高达50%，在非吸烟者、女性以及非黏液癌中EGFR突变率更高。在非亚洲人、吸烟者和粘液腺癌中KRAS突变最常见。最常见的EGFR突变引起外显子21（L858R）第858个氨基酸的亮氨酸取代了精氨酸和外显子19帧缺失。突变在贴壁生长模式（原细支气管肺泡癌）的非黏液性肺腺癌和乳头状（和或微乳头状）肺腺癌中更常见。

▶ Primary resistance to EGFR TKI therapy is associated with KRAS mutation. Acquired resistance is associated with second-site mutations within the EGFR kinase domain (such as T790M), amplification of alternative kinases (such as MET), histologic transformation from NSCLC to SCLC, and epithelial to mesenchymal transition (EMT).
▶KRAS突变与对EGFR TKI治疗原发性耐药有关。获得性耐药与EGFR激酶域内的第二个位点突变（如T790M）、另一个激酶扩增（如MET）、非小细胞肺癌组织转化为小细胞肺癌以及上皮间质转化（EMT）有关。

* ALK

▶ Anaplastic lymphoma kinase (ALK) gene rearrangements represent the fusion between ALK and various partner genes, including echinoderm microtubule-associated protein-like 4 (EML4). ALK fusions have been identified in a subset of patients with NSCLC and represent a unique subset of NSCLC patients for whom ALK inhibitors may represent a very effective therapeutic strategy. Crizotinib, ceritinib, and alectinib are oral ALK inhibitors that are approved by the FDA for patients with metastatic NSCLC who have the ALK gene rearrangement (ie, ALK positive).
▶间变性淋巴瘤激酶（ALK）基因重排是ALK和各伙伴基因之间的融合，包括棘皮动物微管结合蛋白4（EML4）。ALK融合已在非小细胞肺癌患者的一个亚组中识别出来，代表一个独特的非小细胞肺癌患者亚组，ALK抑制剂对其可能是一种非常有效的治疗策略。克唑替尼、色瑞替尼和阿雷替尼是口服的ALK抑制剂，FDA已批准用于治疗有ALK基因重排（即ALK阳性）的转移性非小细胞肺癌患者。

▶ ALK NSCLC occurs most commonly in a unique subgroup of NSCLC patients who share many of the clinical features of NSCLC patients likely to harbor EGFR mutations. However, for the most part, ALK rearrangements and EGFR mutations are mutually exclusive.
▶ALK非小细胞肺癌最常出现在一个独特的非小细胞肺癌患者亚组中，同时具有许多临床特征的非小细胞肺癌患者可能存在EGFR突变。然而，大多数情况下，ALK重排和EGFR突变是互相排斥的。

▶ The current standard method for detecting ALK NSCLC is fluorescence in situ hybridization (FISH). The appropriate antibody and detection method for ALK protein expression can be used for rapid prescreening of ALK-rearranged lung adenocarcinomas and selection of cases that will subsequently be confirmed by FISH testing.
▶检测ALK肺癌目前的标准方法是荧光原位杂交（FISH）。ALK蛋白表达相应的抗体检测方法可用于快速筛查ALK重排的肺腺癌病例，并随后将FISH检测证实的选择。

* ROS-1

▶ Although ROS1 is a distinct receptor tyrosine kinase, ROS1 has a high degree of homology with ALK (approximately 50% within the kinase domain and 75% within the ATP-binding site).
▶尽管ROS1是一个独特的受体酪氨酸激酶，但是ROS1与ALK具有高度的同源性（在激酶结构域中约50%，在ATP结合位点中约75%）。

▶ The majority of patients with ROS1-positive NSCLC respond to the first-generation ALK inhibitor crizotinib; however, certain other ALK inhibitors such as alectinib do not appear to have activity against ROS1-positive NSCLC.
▶ROS1阳性的非小细胞肺癌患者大多数对第一代ALK抑制剂克唑替尼应答；然而，某些其他ALK抑制剂如阿雷替尼对ROS1阳性的非小细胞肺癌似乎无效。

▶ ROS1 rearrangements occur in 1%–2% of patients with NSCLC. Similar to testing for ALK rearrangements, testing for ROS1 is also done using FISH.
▶1%–2%的非小细胞肺癌患者存在ROS1基因重排。与ALK重排检测相似，ROS1也用FISH检测。

* PD-L1

▶ Immune checkpoint inhibitors target programmed death receptor 1 (PD-1) or its ligand, programmed death ligand 1 (PD-L1).
▶免疫检查点抑制剂的靶点是程序性死亡受体1（PD-1）或其配体——程序性死亡配体1（PD-L1）。

▶ PD-1 is expressed by T-cells and regulates the activation of T-cells in peripheral tissues. PD-1 has two ligands, PD-L1 (also known as B7-H1 or CD274) and PD-L2 (B7-DC or CD273). These ligands are expressed on a wide range of immune effector cells, antigen-presenting cells, and tumor cells. PD-1 activation by ligand binding with PD-L1 on the tumor cells produces a number of intracellular effects that result in T-cell inactivity and reduced proliferation.
▶PD-1表达于T细胞，并调节外周组织中T细胞的活化。PD-1有两个配体，PD-L1（也称为B7-H1或CD274）和PD-L2（B7-DC或CD273）。这些配体表达于各种免疫效应细胞、抗原呈递细胞和肿瘤细胞。肿瘤细胞上的PD-L1配体与PD-1结合并激活，产生一系列的细胞间作用，引起T细胞失活并降低增殖。

▶ The therapeutic focus in NSCLC has been to interrupt the interaction of PD-1 and its ligand PD-L1 between tumor cells and immune effectors cells using monoclonal antibodies against PD-L1 or PD-1.
▶在非小细胞肺癌中治疗的重点是用抗PD-L1或PD-1的单克隆抗体阻断PD-1与肿瘤细胞和免疫效应细胞间其配体PD-L1的相互作用。

▶ Anti-PD-L1 IHC may be a biomarker used to select patients with NSCLC more likely to respond to immune checkpoint inhibitors, but the development of a variety of therapeutics, each with a different anti-PD-L1 IHC assay, has raised concerns among both pathologists and oncologists.
▶抗PD-L1免疫组化可能是一个用于选择更可能对免疫检查点抑制剂应答的非小细胞肺癌患者的生物标志物，但是开发的各种疗法，每一种都使用不同的抗PD-L1 IHC检测，加剧了病理学家和肿瘤学家的担忧。

▶ The definition of a positive PD-L1 test result varies depending on which biomarker assay is used. PD-L1 expression levels of ≥50% are a positive test result for first-line pembrolizumab therapy.
▶PD-L1检测结果阳性的定义取决于使用的生物标记法。对于一线派姆单抗治疗，PD-L1表达水平≥50%为阳性检测结果。