Dedifferentiation in gastrointestinal stromal tumor to an anaplastic KIT-negative phenotype: a diagnostic pitfall: morphologic and molecular characterization of 8 cases occurring either de novo or after imatinib therapy

Abstract

Most gastrointestinal stromal tumors (GISTs) can be recognized by their monotonous cytologic features and overexpression of KIT oncoprotein. Altered morphology and loss of CD117 reactivity has been described previously after chronic imatinib treatment; however, this phenomenon has not been reported in imatinib-naive tumors. Eight patients with abrupt transition from a classic CD117-positive spindle cell GIST to an anaplastic CD117-negative tumor were investigated for underlying molecular mechanisms of tumor progression. Pathologic and molecular analysis was performed on each of the 2 components. Genomic DNA polymerase chain reaction for KIT, PDGFRA, BRAF, and KRAS hot spot mutations and fluorescence in situ hybridization for detecting KIT gene copy number alterations were performed. TP53 mutational analysis was performed in 5 cases. There were 7 men and 1 woman, with an age range of 23 to 65 years. Five of the primary tumors were located in the stomach, and 1 case each originated in the small bowel, colon, and rectum. In 3 patients, the dedifferentiated component occurred in the setting of imatinib resistance, whereas the remaining 5 occurred de novo. The dedifferentiated component had an anaplastic appearance, including 1 angiosarcomatous phenotype, with high mitotic activity and necrosis, and showed complete loss of CD117 (8/8) and CD34 (5/8) expression and de novo expression of either cytokeratin (4/8) or desmin (1/8). There was no difference in the KIT genotype between the 2 components. However, 2 imatinib-resistant tumors showed coexistence of KIT exon 11 and exon 13 mutations. Fluorescence in situ hybridization showed loss of 1 KIT gene in 3 cases and low-level amplification of KIT in 2 other cases in the CD117-negative component, compared with the CD117-positive area. TP53 mutation was identified in 1/5 cases tested, being present in both components. In summary, dedifferentiation in GIST may occur either de novo or after chronic imatinib exposure and can represent a diagnostic pitfall. This phenomenon is not related to additional KIT mutations, but might be secondary to genetic instability, either represented by loss of heterozygosity or low level of KIT amplification.

Figure 1

Dedifferentiated GIST (case #1) showing a conventional, spindle cell component (A, 100×), which is strongly positive for CD117 and CD34 (B,C, 100×, upper left corner), in abrupt transition to a pleomorphic, anaplastic area (D, 200×), which is negative for CD117, CD34 (B, C, lower right corner; J), while also showing aberrant expression of cytokeratin AE:AE3 (E, 200×) and desmin (F, 200×). The CD117-positive component (G, 100×) shows two KIT signals by FISH (H) as well as two SNPs in intron 17 (I, ABI seq, arrows). In contrast the KIT-negative dedifferentiated component (J, 200×) shows loss of one KIT signal by FISH, with two reference green CEP4 (K), reflected also by the loss of heterozygosity on the ABI sequence of intron 17 (L).

Figure 2

Dedifferentiated GIST (case #2) showing the conventional component (A, 100×) is strongly positive for CD117 (B, 100×), but shows no increased Ki67 labeling (C, 100×) or p53 overexpression (D, 100×). In contrast the CD117-negative anaplastic component (E, F, 200×) shows a high proliferation index (G, 200×) and overexpression of P53 (H, 200×). FISH analysis showed the normal pattern of two red (KIT) and two green (CEP4) signals in the KIT-positive component (I), while a heterogeneous pattern was noted in the KIT-negative component, with either tetraploid cells that have undergone further rounds of replication without centromere separation (4 green (CEP) signals, each green being surrounded by ~4 red (KIT) signals) (J) or occasional cells with numerous, amplified red (KIT) signals (K).

Figure 3

In one of debulking procedure for imatinib-resistant disease (A), in addition to the classic spindle cell GIST component (B, 100×) which was strongly positive for CD117 (C, 100×), there were areas composed of complex, anastomotic vascular spaces, lined by highly atypical cells (D, 200×), which lost CD117 expression (E, 200×) and instead were strongly positive for CD31, in keeping with an angiosarcoma component (case#7).