Download Nuclear protein in testis midline carcinoma of larynx

CASE REPORT
Jonathan Irish, MD, FRCSC, Section Editor
Nuclear protein in testis midline carcinoma of larynx: An underdiagnosed entity
Ajay Kundra, MD,1 Mirela Andrei, MD,1 William Westra, MD,2 Rashid Chaudhry, MD,3 Harry Moussouris, MD,4 Arash Gohari, MD,5 Jen C. Wang, MD1*
1
Division of Hematology and Oncology, Brookdale University Hospital and Medical Center, Brooklyn, New York, 2Division of Pathology, Oncology, and Otolaryngology/Head and
Neck Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, 3Division of Otolaryngology/Head and Neck Surgery, Brookdale University Hospital and Medical Center, Brooklyn, New York, 4Division of Pathology, Brookdale University Hospital and Medical Center, Brooklyn, New York, 5Division of Radiology, Brookdale University Hospital and
Medical Center, Brooklyn, New York.
Accepted 30 December 2015
Published online 29 March 2016 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.24418
ABSTRACT: Background. Nuclear protein in testis (NUT) carcinomas are
very rare and have a very poor survival rate. The most common sites of
involvement include the nasal cavity, sinus, and mediastinum. Laryngeal
NUT midline carcinoma is extremely rare, with only 2 cases reported thus
far. Here, we are describing another case of NUT laryngeal carcinoma.
Methods and Results. The patient was a light smoker and nondrinker
who presented with upper respiratory tract obstruction. Imaging and laryngoscopic evaluation revealed a large intraluminal laryngeal mass.
Biopsy demonstrated poorly differentiated carcinoma with intact mucosa
and only focal coexpression of CK5/6 and p40. NUT protein immune-
stain positivity conclusively established the diagnosis of NUT midline
carcinoma.
Conclusion. Absence of well-known risk factors, pathologic finding of
lack of mucosal involvement and lack of squamous differentiation with
poorly differentiated carcinoma, should prompt clinicians to consider this
C 2016 Wiley Periodicals, Inc. Head
rare entity as a possible diagnosis. V
Neck 38: E2471–E2474, 2016
INTRODUCTION
of the soft tissue in the neck showed a large supraglottic
laryngeal mass of 3.7 3 2.8 3 2.6 cm with near complete
occlusion of the supraglottic laryngeal airway and distended hypopharyngeal airway. The mass extended into
the paralaryngeal fat, the inner margin of the thyroid, and
hyoid cartilages. There was no gross extra laryngeal
spread or radiologic evidence of lymph node enlargement
(Figures 1A and 1B). A CT scan of the chest, abdomen,
and pelvis did not reveal any distant pathology. Because
of severely compromised upper airway, the patient underwent emergent insertion of a tracheostomy tube along
with tumor debulking and biopsy. A large, ill-defined,
fungating mass was observed on laryngoscopic evaluation, mostly arising from right supraglottis and extending
to piriformis. There was no evidence of true vocal cord
involvement, but it was difficult to check for mobility.
Fiber-optic bronchoscopy did not show mucosal lesions
distal to the mass. A cervical esophagoscopy was negative
for upper esophageal pathology as well. The tissue biopsy
on hematoxylin-eosin stain showed a high-grade malignant neoplasm with a diffuse infiltrative pattern and
prominent associated tumor necrosis. On light microscopy, the mucosa was intact, the neoplastic cells appeared
small to medium sized, and very rare large cells with
moderate-high nuclear cytoplasmic ratio. The chromatin
was open with prominent single nucleoli and soft nuclear
outlines with delicate nuclear membranes in the more viable portions of the sampling (Figures 2A and 2B). As the
tumor did not show microscopic evidence of any specific
Nuclear protein in testis (NUT) carcinomas arising from
midline structures are very rare but particularly aggressive
neoplasms with a very poor survival. The most common
sites of involvement include the nasal cavity, sinus, and
mediastinum. Laryngeal NUT midline carcinoma is
extremely rare with only 2 cases reported thus far. Hence,
we are describing another case of a 39-year-old man with
NUT laryngeal carcinoma to supplement existing literature. Although this rare disease has been published since
2000, it seems to be an unrecognized and, hence, underdiagnosed entity. Given the significantly adverse clinical
course, it is important to recognize NUT midline carcinoma and to identify it as a distinct entity from undifferentiated squamous cell carcinoma of the larynx.
CASE REPORT
A 39-year-old man presented with 2-week history of
hemoptysis and hoarseness. His medical history was unremarkable. He was a former light smoker with no history
of alcohol intake. Symptoms started a few months before
presentation when he noticed progressive unintentional
weight loss of about 50 pounds, followed by right-sided
ear pain, shortness of breath, and dysphagia. A CT scan
*Corresponding author: J. C. Wang, Division of Hematology and Oncology,
Brookdale University Hospital and Medical Center, Brooklyn, NY 11212.
E-mail: [email protected]
KEY WORDS: nuclear protein in testis (NUT) midline carcinoma,
laryngeal carcinoma
HEAD & NECK—DOI 10.1002/HED
AUGUST 2016
E2471
KUNDRA ET AL.
FIGURE 1. CT scan of the soft tissue of the neck of a 39-year-old man with large supraglottic laryngeal mass. (A) Sagittal CT image showed a large
laryngeal mass. (B) Axial CT image showed near complete occlusion of the supraglottic laryngeal airway.
differentiation, the differential diagnosis was very broad
and included carcinoma, lymphoma, mucosal melanoma,
primitive sarcoma, and primitive neuroectodermal tumor.
An extensive immunohistochemical (IHC) panel confirmed epithelial differentiation (focal staining for CK5/6,
p40, CAM 5.2, and AE-1/AE-3) and failed to demonstrate
any evidence of lymphoid (negative staining for CD10,
CD20, CD43, CD3, CD23, BCL-2, BCL-6, and MUM-1),
melanocytic (negative staining for S100, MELAN-1,
MART-1, and HMB-45), mesenchymal (negative staining
for actin, desmin, and myogenin), neuroectodermal (negative staining for FLI-1), or neuroendocrine (negative
staining for chromogranin and synaptophysin) differentiation. Oncovirus analysis was negative (p16-negative by
IHC; and Epstein–Barr virus negative, and high-risk
human papillomavirus negative by in situ hybridization).
The cell proliferation marker study (K1-67) showed 100%
positive nuclear staining. Then, the tissue was evaluated
for nuclear reactivity for NUT protein using a monoclonal
antibody at Johns Hopkins laboratory. Final result showed
positive staining with a diffuse and strong nuclear reactivity, consistent with diagnosis of NUT laryngeal carcinoma
(Figures 3A and 3B). The sensitivity and specificity of
NUT antibody are excellent; hence, there was no need for
further confirmatory tests, such as cytogenetics, fluorescent in situ hybridization, or reverse transcriptase polymerase chain reaction.
DISCUSSION
NUT midline carcinoma belongs to a subset of squamous cell carcinoma with a predisposition for upper aerodigestive tract and, less commonly, infradiaphragmatic or
nonmidline structures involvement.1 Common locations
include the nasal cavity, sinuses, and mediastinum/thymus.2 NUT midline carcinomas that arise in the larynx
are extremely rare, only 2 cases reported thus far; in a
78-year-old woman and 13-year-old girl.3,4 The most
comprehensive review was reported by Bauer et al5 establishing a clinical database using retrospective data of 63
published and unpublished cases. Clinicopathologic features and demographics were available for all patients,
with survival analysis done for 54 cases. Primaries
involved the thorax (n 5 31), head and neck (n 5 19),
and other sites (n 5 4). Of the 63 tumors, a little over
half of the cases have been reported in patients <18 years
of age. In meta-analysis of 32 cases reported by
FIGURE 2. (A) Hematoxylin-eosin stain section magnification 320 of a high-grade laryngeal nuclear protein in testis (NUT) carcinoma; mucosa
appeared intact. (B) Magnification 340 of small to medium-sized cells with round nuclear contour and clear cytoplasm.
E2472
HEAD & NECK—DOI 10.1002/HED
AUGUST 2016
NUCLEAR
PROTEIN IN TESTIS MIDLINE CARCINOMA OF LARYNX
FIGURE 3. Immunohistochemistry of high-grade laryngeal nuclear protein in testis (NUT) carcinoma. On 320 magnification, the tumor demonstrates a solid growth pattern with no mucosal involvement (A). Diffuse, speckled, nuclear staining using NUT-specific monoclonal antibody at
340 magnification, consistent with a diagnosis of NUT midline carcinoma (B).
Nakamura et al,6 approximately one-third involved the
mediastinum/thymus (n 5 12), 5 involved the nasal cavity or paranasal sinuses, 1 case each involved the epiglottis, nasopharynx/hypopharynx, or other infrequent sites
(orbit/supraorbit, parotid/submandibular glands, tonsil,
lung, hepatic/pancreatic, or bladder). Almost half of the
cases (n 5 15) occurred in patients <18 years of age and
5 patients were older than 35 years. The case with laryngeal involvement included a 13-year-old girl with a rapidly growing epiglottic mass leading to superior vena
cava syndrome and rapidly fatal course within 9 months
of diagnosis. The tumor displayed features of poorly differentiated carcinoma and showed cytogenetic evidence
of chromosomal 15;19 translocation. The patient was
treated with 3 cycles of docetaxel, cisplatin, 5fluorouracil, and leucovorin with partial response, followed by radiation and left modified radical neck dissection. Shortly after the neck dissection, the patient
presented with a rapidly progressing deep left posterior
neck metastasis unresponsive to subsequent palliative
chemotherapy. The other reported case of right supraglottic laryngeal NUT carcinoma has been that of a 78-yearold woman in whom original cytologic diagnosis was
suggestive of poorly differentiated neoplasms consistent
with metastatic disease. The diagnosis of laryngeal NUT
carcinoma was confirmed by fluorescent in situ hybridization. The patient was treated with chemoradiotherapy, laryngectomy, and neck dissection. Despite aggressive
treatment, the patient died in 8 months.3 Clinical symptoms depend on the site of presentation but invariably
included pain and swelling of the surrounding structures
because of mass effect. Other reported signs and symptoms were site specific, such as hoarseness and wheezing
with upper airway involvement, and shortness of breath
with mediastinal involvement. In general, imaging tests
are nonspecific and may mimic other diseases, such as
lymphoma, sarcoma, and metastatic tumors. On contrastenhanced multidetector CT, NUT midline carcinoma
appears as a low attenuation mass with heterogeneous
enhancement associated with necrotic lymph nodes.7,8
Fluorodeoxyglucose-positron emission tomography imaging usually reveals hypermetabolic activity well correlated
with multidetector CT findings.9 The rarity of this tumor
type, a general lack of awareness among pathologist, its
nonspecific morphologic features, and the way these features overlap with a large and diverse group of other
poorly differentiated neoplasm, all contribute to the difficulty in establishing a diagnosis of NUT midline carcinoma. This difficulty may be intensified when a NUT
midline carcinoma is encountered in an unexpected site in
an older patient. There are few histologic clues that may
aid in the recognition of this tumor and guide further
diagnostic evaluation. First, for a high-grade carcinoma,
NUT midline carcinomas are comprised of remarkably
uniform small round cells with minimal variation in size
and shape. Second, sheets of these uniformly small round
cells are sometimes punctuated by abrupt foci of
keratinization.
There is poor response of NUT midline carcinomas to
chemotherapeutic drugs designed to treat carcinomas.5
There is an exception of 1 patient with NUT midline carcinoma treated with Ewing sarcoma regimen resulting in
cure.10 There has been an increasing trend toward using
Ewing sarcoma protocol for NUT midline carcinomas.
This has also led to an increased interest in proper diagnosis of NUT midline carcinomas.11
A genetic abnormality involving fusion of the NUT
gene and 1 member of the BET family constitutes the
genetic hallmark of NUT midline carcinomas. In 80% of
cases, the gene fusion occurs between NUT and BRD4,
and in the remaining tumors, BRD3 or NUT-variant
fusion. The NUT-BRD4 fusion transcript encodes an
oncoprotein that arrests normal cellular differentiation and
maintains tumor growth.12 NUT IHC has greatly simplified the diagnosis by demonstration of nuclear reactivity
for NUT protein by using a monoclonal antibody. Haack
et al13 demonstrated that immunohistochemical staining
with C52 antibody correlated with rearrangement of the
NUT and provided a highly sensitive and specific assay
for diagnosing NUT midline carcinoma. Because NUT
HEAD & NECK—DOI 10.1002/HED
AUGUST 2016
E2473
KUNDRA ET AL.
midline carcinomas are uncommon yet highly aggressive,
a high index of suspicion is required for timely diagnosis
and prompt initiation of therapy.
Based on the largest clinical database analysis reported
by Bauer et al,5 different intensive chemotherapy regimens
have been used, including those used to treat patients with
germ cell tumors, squamous cell carcinoma of the head
and neck, non-small cell lung carcinoma, and sarcoma.
Most patients received combination chemotherapy consisting of platinum-based therapy, anthracyclines, or nonplatinum alkylating agents. Because of the rarity of this
malignancy and nonspecific multiagent chemotherapy
used, an analysis that identifies a specific chemotherapeutic
regimen that results in improved outcome was not possible.
However, it was noted that the extent of surgical resection
and initial radiotherapy was associated with a slight extension of survival. Overall, prognosis is extremely poor with
median overall survival of 6.7 months with no significant
differences between younger or older patients. Thoracic
involvement and metastatic spread were associated with
lower progression-free survival and overall survival.
Unlike most solid tumors that are classified according
to the tissue of origin, NUT midline carcinomas are
defined genetically. NUT midline carcinomas are characterized by specific reciprocal chromosomal translocation,
t(15;19), which differentiates them from other poorly differentiated carcinomas. The most common and studied
fusion genes are NUT and BRD4. The NUT gene is
located on the long arm of chromosome 15q14 that encodes NUT protein, normally expressed only in testis tissue.14 The normal function of NUT protein is not well
characterized. However, it is hypothesized that it is
involved in chromatin compaction during spermatogenesis, interfering with the balance of histone acetylation/
deacetylation.15 As shown by French,16 NUT remains
bound to chromatin upon fusion to BRD4 or BRD3 and
activates a histone acetyl-transferase, p300, that is essential to the oncogenic function of BRD4-NUT. The presence of a consistent chromosomal rearrangement may
provide a specific target for biological therapeutic agents.
Indeed, preliminary studies using histone deacetylase
inhibitors and BET inhibitors have shown promising
results both in vitro and in vivo, and clinical trials using
these agents are forthcoming.16,17 Clearly, the recognition
of NUT midline carcinoma is very important from both a
prognostic and therapeutic perspective.
In conclusion, we present a rare case of laryngeal NUT
midline carcinoma occurring in a 39-year-old man. In
E2474
HEAD & NECK—DOI 10.1002/HED
AUGUST 2016
essence, this entity should be considered in the differential
diagnosis in patients with clinical presentation of rapidly
growing midline tumors. Lack of typical histologic and
IHC hallmarks of squamous differentiation should prompt
clinicians to consider this rare entity as a possible diagnosis. In general, these tumors have variable responses to initial combination treatment modalities. Eventually, however,
they have a rapidly progressive and fatal course. The
ongoing developments will hopefully improve the outcome
of patients with this challenging disease.
REFERENCES
1. Mills AF, Lanfranchi M, Wein RO, et al. NUT midline carcinoma: a case
report with a novel translocation and review of the literature. Head Neck
Pathol 2014;8:182–186.
2. Stelow EB. A review of NUT midline carcinoma. Head Neck Pathol 2011;
5:31–35.
3. Bellizzi AM, Bruzzi C, French CA, Stelow EB. The cytologic features of
NUT midline carcinoma. Cancer 2009;117:508–515.
4. Vargas SO, French CA, Faul PN, et al. Upper respiratory tract carcinoma
with chromosomal translocation 15;19: evidence for a distinct disease
entity of young patients with rapidly fatal course. Cancer 2001;92:1195–
1203.
5. Bauer DE, Mitchell CM, Strait KM, et al. Clinicopathologic features and
long-term outcomes of NUT midline carcinoma. Clin Cancer Res 2012;18:
5773–5779.
6. Nakamura H, Tsuta K, Tsuda H, et al. NUT midline carcinoma of the mediastinum showing two types of poorly differentiated tumor cells: a case
report and a literature review. Pathol Res Pract 2015;211:92–98.
7. Nelson BA, Lee EY, French CA, Bauer DE, Vargas SO. BRD4-NUT carcinoma of the mediastinum in a pediatric patient: multidetector computed
tomography imaging findings. J Thorac Imaging 2010;25:W93–W96.
8. Polsani A, Braithwaite KA, Alazraki AL, Abramowsky C, Shehata BM.
NUT midline carcinoma: an imaging case series and review of literature.
Pediatr Radiol 2012;42:205–210.
9. Niederkohr RD, Cameron MJ, French CA. FDG PET/CT imaging of NUT
midline carcinoma. Clin Nucl Med 2011;36:e124–e126.
10. Mertens F, Wiebe T, Adlercreutz C, Mandahl N, French CA. Successful
treatment of a child with t(15;19)-positive tumor. Pediatr Blood Cancer
2007;49:1015–1017.
11. Wartchow EP, Moore TS, French CA, Mierau GW. Ultrastructural features
of NUT midline carcinoma. Ultrastruct Pathol 2012;36:280–284.
12. French CA, Ramirez CL, Kolmakova J, et al. BRD-NUT oncoproteins: a
family of closely related nuclear proteins that block epithelial differentiation and maintain the growth of carcinoma cells. Oncogene 2008;27:2237–
2242.
13. 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:
984–991.
14. French CA, Miyoshi I, Kubonishi I, Grier HE, Perez–Atayde AR, Fletcher
JA. BRD4-NUT fusion oncogene: a novel mechanism in aggressive carcinoma. Cancer Res 2003;63:304–307.
15. Dey A, Ellenberg J, Farina A, et al. A bromodomain protein, MCAP, associates with mitotic chromosomes and affects G(2)-to-M transition. Mol
Cell Biol 2000;20:6537–6549.
16. French CA. Pathogenesis of NUT midline carcinoma. Annu Rev Pathol
2012;7:247–265.
17. Schwartz BE, Hofer MD, Lemieux ME, et al. Differentiation of NUT midline carcinoma by epigenomic reprogramming. Cancer Res 2011;71:2686–
2696.