Immunohistochemistry for histone H3G34W and H3K36M is highly specific for giant cell tumor of bone and chondroblastoma, respectively, in FNA and core needle biopsy.

BACKGROUND: Diagnosing giant cell-rich bone tumors can be challenging on limited biopsies. H3 histone family member 3A (H3F3A) (G34W/V/R/L) mutations are present in the majority of giant cell tumors (GCTs) of bone and H3 histone family member 3B (H3F3B) (K36M) mutations are present in nearly all chondroblastomas, but are absent in histologic mimics. Mutation-specific immunohistochemistry (IHC) is highly specific for GCT and chondroblastoma in surgical excisions. The objective of the current study was to validate H3G34W and H3K36M IHC in the diagnosis of giant cell-rich bone tumors on fine-needle aspiration and core needle biopsy specimens. METHODS: IHC was performed using monoclonal antibodies against histone H3.3 G34W and K36M in GCTs of bone (26 cases, including 2 malignant cases), GCT of Paget disease (1 case), chondroblastoma (8 cases), aneurysmal bone cyst (7 cases), and osteosarcoma (13 cases) with available fine-needle aspiration and/or core needle biopsy specimens from 2 institutions. H3F3A and H3F3B Sanger sequencing was performed on all 4 H3G34W IHC-negative GCTs. RESULTS: IHC for H3G34W was positive in 22 of 26 GCTs (85%) and negative in all histologic mimics. IHC for H3K36M was positive in all 8 chondroblastomas and negative in all histologic mimics. IHC results were concordant between biopsy and surgical specimens in 152 of 158 samples (96%). Sequencing identified alternate H3F3A G34L and G34V mutations in 1 IHC-negative GCT each, but no mutation was found in the remaining 2 cases. CONCLUSIONS: H3G34W and H3K36M IHC is highly specific for GCT and chondroblastoma, respectively, among giant cell-rich bone tumors, and is useful for confirming the diagnosis in limited biopsies. The presence of alternate H3F3A mutations accounts for the H3G34W IHC negativity in a subset of GCT of bone cases. Cancer Cytopathol 2018. © 2018 American Cancer Society.

Immune Surveillance Plays a Role in Locally Aggressive Giant Cell Lesions of Bone.

BACKGROUND: Giant cell lesions are locally aggressive intraosseous neoplasms with capacity to metastasize. The role of immune surveillance in the pathophysiology of giant cell lesions is poorly understood, and understanding what role the immune system plays in giant cell lesions may lead to the development of more effective treatment. The aim of this study was to explore the role of immune surveillance in giant cell lesions by examining the expression of the HLA class I and class II antigens and tumor infiltrating lymphocytes. In addition, we examined the role of the immune modulating surface antigen B7-H3, which belongs to the B7 superfamily, a group of molecules that modulates T-cell responses. QUESTIONS/PURPOSES: (1) Is an immune response elicited by giant cell lesions? (2) Do clinically relevant human leukocyte antigen (HLA) defects exist in giant cell lesions? (3) Is B7-H3 a clinically relevant immune modulator? METHODS: The study sample was derived from the population of patients presenting to the Massachusetts General Hospital for evaluation and management of giant cell lesions from 1993 to 2008. We included patients with histologically confirmed giant cell lesions with a minimum followup of 6 months. Patients with systemic diseases (n = 4 [3%]), syndromes associated with giant cell lesions (n = 4 [3%]), and those without sufficient followup (n = 26 [19%]), inadequate records (n = 7 [5%]), or inadequate tissue available (n = 2 [1%]) were excluded. Tissue microarray, containing 288 tissue cores for 93 patients, was carefully constructed. This contained tissue from 45 patients with maxillofacial lesions, 38 with aggressive and seven with nonaggressive lesions, and 48 patients with axial and appendicular lesions, 30 with aggressive lesions and 18 with nonaggressive lesions. The population mean age was 28 ± 12 years and the duration of followup was 4 ± 3 years. The tissue microarray was immunohistochemically stained with monoclonal antibodies specific for HLA classes I and II and B7-H3 antigens and analyzed for tumor infiltrating lymphocytes. Antigen expression was examined in multinucleated giant cells and mononuclear stromal cells. The results were correlated with local invasion and tumor aggressiveness, which is based on accepted staging criteria. RESULTS: Tumor infiltrating lymphocytes were detected in all the tumors. The mean number of CD8+ T cell infiltration was lower in aggressive tumors (median, 4.8; interquartile range [IQR], 0.4-13.4), when compared with nonaggressive tumors (median, 15.8; IQR, 4.3-46.3; p = 0.007). HLA class I antigens were highly expressed by multinucleated giant cells in all tumors, but were lightly expressed on mononuclear stromal cells in 53% (45 of 84) to 73% (56 of 77) of tumors. HLA class I antigen low expression in mononuclear stromal cells was associated with tumor aggressiveness (odds ratio [OR], 4.3; p = 0.005). Low HLA class I expression combined with low CD8+ T cell infiltration was most highly associated with tumor aggressiveness (OR, 7.81; p = 0.011). B7-H3 antigen was expressed in 36.9% mononuclear stroma cells and also was associated with local tumor invasion (OR, 1.36; p < 0.001). Similarly, giant cell lesions with high B7-H3 expression and low CD8+ tumor infiltrating lymphocytes were associated with increased tumor aggressiveness (OR, 8.89; p = 0.0491). CONCLUSIONS: Locally aggressive giant cell lesions are associated with low HLA class 1 antigen expression, low CD8+T cell infiltration, and high expression of the immune modulator B7-H3. CLINICAL RELEVANCE: Failure of immune surveillance implies that there may be an opportunity to target aspects of the immune surveillance machinery to treat giant cell lesions.

Phenotypic and molecular differences between giant-cell tumour of soft tissue and its bone counterpart.

AIMS: Giant-cell tumour (GCT) of soft tissue (GCT-ST) is a primary soft tissue neoplasm that is histologically similar to GCT of bone (GCT-B). Recently, it has been reported that >90% of GCT-Bs have a driver mutation in the H3F3A gene. As the relationship between GCT-ST and GCT-B is unclear, the aim of this study was to compare a series of GCT-STs and GCT-Bs with regard to the presence of H3F3A mutations and several immunophenotypic markers. METHODS AND RESULTS: Eight GCT-STs were retrieved from our institutional archives. Fifteen GCT-Bs served as controls. Direct sequencing for H3F3A mutations in coding regions between codons 1 and 42, including the hotspot codons (28, 35, and 37), was performed on DNA extracted from formalin-fixed paraffin-embedded tissue. Tumours were studied immunohistochemically for the expression of CD14, CD33, RANKL, RANK, p63, and the osteoblastic markers SATB2 and RUNX2. None of the seven GCT-STs that could be analysed showed H3F3A mutations, whereas 14 GCT-Bs (93.3%) were mutated. All eight GCT-STs were positive for RANK and RUNX2, whereas RANKL and SATB2 were detected in only two cases (25%). CD14 was detected only in mononuclear elements, whereas multinucleated giant cells and a proportion of the mononuclear population expressed CD33. Few mononuclear cells of GCT-STs expressed p63. In comparison, GCT-Bs showed higher expression of p63 (14 of 15 cases with >50% of positive mononuclear cells), RANKL, and SATB2, whereas CD14, CD33, RANK and RUNX2 were similarly expressed. CONCLUSIONS: Although GCT-ST and GCT-B are similar in histological appearance, our results indicate that they are immunophenotypically and genetically distinct.

RANKL, denosumab, and giant cell tumor of bone.

PURPOSE OF REVIEW: Giant cell tumor (GCT) of bone is a benign, osteolytic neoplasm of bone. The receptor activator of NF-KB ligand (RANKL) pathway has recently been shown to play a key role in the pathogenesis of GCT. RECENT FINDINGS: Treatment for refractory, recurrent, or metastatic GCT remains challenging. The recent development of a monoclonal antibody to RANKL, denosumab, offers promise in the management of these patients. A recent phase 2 study suggested denosumab offers disease and symptom control for patients with advanced or refractory disease. In this population, denosumab appears to be well tolerated. There are key questions which remain to be addressed, including patient selection, optimal scheduling, use as an adjuvant, and application to other giant cell-rich disorders. SUMMARY: Denosumab offers a new treatment option for a subset of patients with previously untreatable GCT. The role of denosumab in curative treatment is the subject of ongoing studies.

T cells stimulate catabolic gene expression by the stromal cells from giant cell tumor of bone.

The factors that promote the localized bone resorption by giant cell tumor of bone (GCT) are not fully understood. We investigated whether T cells could contribute to bone resorption by stimulating expression of genes for parathyroid hormone-related protein (PTHrP), matrix metalloproteinase (MMP)-13, and the receptor activator of nuclear-factor κB ligand (RANKL). Two cell lines, Jurkat clone E6-1 and D1.1, were co-cultured with isolated GCT stromal cells. Real-time PCR analyses demonstrated a significant increase of all three genes following 48h incubation, and PTHrP and MMP-13 gene expression was also increased at 24h. Further, we examined the expression of CD40 ligand (CD40L), a protein expressed by activated T cells, and its receptor, CD40, in GCT. Immunohistochemistry results revealed expression of the CD40 receptor in both the stromal cells and giant cells of the tumor. RNA collected from whole GCT tissues showed expression of CD40LG, which was absent in cultured stromal cells, and suggests that CD40L is expressed within GCT. Stimulation of GCT stromal cells with CD40L significantly increased expression of the PTHrP and MMP-13 genes. Moreover, we show that inhibition of PTHrP with neutralizing antibodies significantly decreased MMP13 expression by the stromal cells compared to IgG-matched controls, whereas stimulation with PTHrP (1-34) increased MMP-13 gene expression. These results suggest that T cells may potentiate the catabolic effect of GCT.

The immunophenotype of osteoclasts and macrophage polykaryons.

AIM: Osteoclasts are multinucleated cells which are specialised to carry out lacunar bone resorption. Osteoclasts form part of the mononuclear phagocyte system, and immunophenotypic criteria for distinction from macrophage polykaryons include expression of CD51 (vitronectin receptor) and absence of HLA-DR and CD14. METHODS: The expression of CD14, CD163, HLA-DR and CD51 in formalin-fixed paraffin-embedded sections of normal bone and neoplastic and non-neoplastic lesions of bone and soft tissue known to contain osteoclasts and macrophage polykaryons respectively was assessed immunohistochemically; the immunophenotype of osteoclast-like giant cells in a wide range of giant cell-containing bone lesions was similarly assessed. RESULTS: Both osteoclasts and macrophage polykaryons were found to express CD51. Macrophage polykaryons, but not osteoclasts, expressed CD14 and HLA-DR. CD51+/CD14-/HLA-DR-/CD163- giant cells were noted in all giant-cell lesions of bone, including giant cell tumour of bone, aneurysmal bone cyst, non-ossifying fibroma, chondroblastoma, telangiectatic osteosarcoma, chondromyxoid fibroma, Langerhans cell histiocytosis and brown tumour. CONCLUSION: Our findings indicate that CD51 expression alone is not sufficient for immunocytochemical identification of osteoclasts, which do not express the macrophage-associated antigens CD14 and HLA-DR. Giant cells in most giant cell-rich lesions of bone have an osteoclast phenotype, suggesting that they are formed from mononuclear phagocyte osteoclast precursors.

Morphological and immunophenotypic features of primary and metastatic giant cell tumour of bone.

Giant cell tumour of bone (GCTB) is a primary tumour of bone that may rarely, in the absence of malignant cytological features, produce metastatic lesions, most commonly in the lungs. Whether these lung nodules represent true neoplastic secondaries or implants derived from the primary tumour is not certain. In this study, we have analysed the morphological and immunophenotypic features of 19 conventional GCTBs and corresponding lung nodules for expression of macrophage, osteoclast, proliferation and tumour-associated markers. A striking morphological feature of all GCTBs that produced lung secondaries was the presence of large areas of haemorrhage and thrombus formation; mononuclear and multinucleated cells of GCTB were frequently found within these areas of haemorrhage and thrombus. A similar pattern of CD14, CD33, HLA-DR and CD51 expression was seen in macrophages and giant cells in primary and secondary tumours. Smooth muscle actin expression was frequently noted in primary GCTBs that recurred and metastasised. No difference was seen in the expression of p53, p63, Ki-67, cyclin D1 or Bcl-2 in primary and secondary tumours. Our findings suggest that most lung nodules associated with primary conventional GCTBs are implants derived from tumour emboli formed in areas of haemorrhage and thrombus formation within the primary tumour.

CD34 staining density predicts giant cell tumor clinical behavior.

PURPOSE: To evaluate the staining density of CD34, a glycoprotein expressed in hematopoetic precursor and capillary endothelial cells, as a molecular marker for predicting clinical behavior of giant cell tumors. MATERIALS AND METHODS: This was a retrospective study of patients with giant cell lesions of the jaws treated over a 15-year period. The primary predictor variable was mean CD34 staining density. The outcome measure was giant cell tumor clinical behavior (aggressive vs nonaggressive). Bivariate analyses were computed to evaluate the association between the predictors and outcome. A receiver-operator characteristic (ROC) curve was used to establish the threshold for a positive diagnostic test. A logistic regression model was used to evaluate the association between the clinical behavior and a positive test. A value of P

Cytokine receptor profile of arthroplasty macrophages, foreign body giant cells and mature osteoclasts.

In the arthroplasty pseudomembrane surrounding a loose prosthesis there is a marked macrophage and foreign body giant cell (FBGC) response to implant-derived wear particles. These cells contribute to the osteolysis of loosening by releasing cytokines and growth factors which influence the formation and activity of osteoclasts. Using a panel of monoclonal antibodies directed against known cytokine/growth factor receptors, we have determined by immunohistochemistry whether arthroplasty macrophages, FB-GCs and osteoclasts express receptors for cytokines and growth factors that are known to modulate osteolysis. All these cell types reacted with antibodies directed against the following cytokine/growth factor receptors: gp130, IL-1R type 1, IL-2R, IL-4R, IL-6R, TNFR, M-CSFR, GM-CSFR and SCFR but not with antibodies directed against IL-3R and IL-8R. Arthroplasty macrophages, FBGCs and osteoclasts thus show a similar pattern of cytokine/growth factor receptor expression. This reflects the fact that arthroplasty macrophages are capable of osteoclast differentiation and that these cell types form part of the mononuclear phagocyte system. As regards the osteolysis of aseptic loosening, it also indicates that these cells are targets for numerous cytokines and growth factors which influence osteoclast formation and bone resorption.

Association of HLA-DRB1 alleles with giant cell tumour of bone.

AIM: To examine the possible influence of the MHC class II antigens alleles in the formation of the multinucleate aggressive giant cell tumour of bone. METHODS: HLA class II antigen alleles were investigated in eight white patients from north east England with confirmed diagnosis of giant cell tumour of bone. All had locally aggressive, immunophenotypically HLA-DR negative giant cell tumours. RESULTS: Five of the eight patients were found to be positive for HLA-DRB1*0801/3, the distribution of this allele in healthy white controls being quite low (2%). All but one of the patients possessing DRB1*080 also expressed DRB1*070. CONCLUSIONS: HLA-DRB1*080 is pre-dominant in patients with immunophenotypic HLA-DR negative giant cell tumour of bone; individuals with the genotype 070/080 are at particularly high risk of developing giant cell tumour of bone.

Gene expression of monocyte chemoattractant protein-1 in giant cell tumors of bone osteoclastoma: possible involvement in CD68+ macrophage-like cell migration.

Giant cell tumor of bone (GCT) is one of a few neoplasms in which the macrophage/osteoclast precursor cells and osteoclast-like giant cells infiltrate the tumor mass. Monocyte chemoattractant protein 1 (MCP-1) is a potent chemotactic factor specific for monocytes. In search of relevant cytokines that may enhance the recruitment of these reactive cells, we evaluated the localization and regulation of MCP-1 mRNA and protein in GCT by using Northern blot analysis, in situ hybridization and immunohistochemistry. We also determined whether conditioned medium obtained from GCT cultures can recruit human peripheral blood monocytes (CD68+) in an in vitro chemotactic assay. Using Northern blot analysis, we detected the specific gene transcript for MCP-1 in all GCT samples tested. In situ hybridization and immunohistochemistry revealed that both MCP-1 gene transcript and protein were consistently present in the cytoplasm of stromal-like tumor cells of GCT. Treatment of mononuclear cells from GCT at third passage with TGF-beta1 for 24 h increased the level of MCP-1 mRNA in a dose-dependent manner, with the maximum effect at 1 ng/ml. Conditioned media from GCT cultures promoted the chemotactic migration of CD68+ peripheral monocytes, an activity which was abolished by the addition of MCP-1 antibody to the conditioned medium. Thus, the results of this study suggest that recruitment of CD68+ macrophage-like cells may be due to the production MCP-1 by stromal-like tumor cells. These CD68+ cells may originate from peripheral blood and could have the capability of further differentiating into osteoclasts in the tumor.

Surgical treatment of bone tumors in conjunction with microwave-induced hyperthermia and adjuvant immunotherapy. A preliminary report.

OBJECTIVE: To develop an alternative approach in conjunction with microwave-induced hyperthermia. PATIENTS AND METHODS: Thermotherapy with microwave intracorporeal irradiation was used to treat 73 patients with bone tumors. The series was composed of 58 patients with malignant tumors and 15 with benign tumors: most of tumors occurred about knee joints (53/73 = 72.6%). The surgical procedure included separating the tumor bearing segment from surrounding normal tissues with a safe margin, cooling the normal tissues including the neurovascular bundle and the intraarticular structures with a water circulation system, while heating the tumor with the antenna array of a microwave system and providing an adequate soft-tissue cover for the dead bone. Postoperatively, an immune therapy regimen was carried out regularly. The patients' immunologic functions were monitored by assay of the subpopulation of T cells, IL-2 and sIL-2 R (soluble IL-2 receptor). RESULTS: Follow-up varied from 3 to 38 months (mean 19 months). Excluding 3 patients with malignancy in the vertebrae treated for palliation, 70 were evaluated according to oncological and orthopedic criteria. Five patients had local recurrence and required amputation. The remaining 65 had excellent local control. In 6 of the 55 patients with malignancy of the extremities, lung metastasis occurred one to two years after surgery. The oncological results were similar to those obtained by other limb-saving procedures. Pathological fracture occurred at devitalized bone in 5 patients. In 72.5% of the patients (29 of 40 tumor-free cases followed more than one year), knee joints functioned well, being stable and painless with almost full range of motion. Single photon emission computered tomography (SPECT) for 16 patients revealed revascularization of the devitalized tumor bearing bone segment could accomplish in one year or more. The immune states were improved in various extends after thermotherapy plus immunotherapy in the majority of patients. CONCLUSION: These results show that the use of microwave hyperthermia and adjuvant immunotherapy in conjunction with the surgical treatment of bone tumors can be considered a definitive procedure, which is safe and well-tolerated. The oncological and orthopedic results are encouraging.

Lymphocyte in vitro response to human giant cell tumors.

Peripheral blood lymphocytes and tumor cells were obtained from 31 patients with giant cell tumors of bone and cocultured in vitro in a mixed lymphocyte tumor cell assay. The lymphocyte proliferative response was measured by incorporation of 3H thymidine. Also, the patients' lymphocytes were tested for proliferative reactivity to phytohemagglutinin and allogenic lymphocytes to evaluate nontumor immunologic competence. Mixed lymphocyte tumor cell assays showed higher lymphocyte stimulation in patients with Stage I as compared with Stages II and III giant cell tumors. The proliferative response was blocked partially when the patients' sera was used to supplement the cultures. Lymphocytes from patients with a recurring tumor showed lower responses, but the differences with primary tumors were not significant. This evidence suggests that there is an immune response to giant cell tumor antigens and that this response might be related to the aggressiveness of the tumor.

[Molecular weight determination and protein analysis of GCF-5 antigens of giant cell tumor of bone].

In order to understand the tumor antigen(s) of giant cell tumor of bone (GCT), monoclonal antibody GCF-5 developed in this laboratory was employed. GCF-5 reacted specifically against the tumor cell associated antigens of GCT. The membrane proteins of tumor cell were extracted by high concentration of SDS, followed by a series of treatment processes, including SDS-PAGE, western blotting and some staining methods, such as Periodic-Schiff for glycoprotein and oil red O for lipoprotein. The molecular weight and chemical characteristics of GCF-5 antigens were analysed. The preliminary results indicated that the main GCF-5 antigens were two glycoproteinis containing few saccharide chains, one of which was 13.5KD and the other 17.4KD.

Characterization of a subtype of primary osteoclastoma: extracellular calcium but not calcitonin inhibits aggressive HLA-DR-positive osteoclastoma possessing 'functional' calcitonin receptors.

We report here a case of primary osteoclastoma that despite possessing HLA-DR-positive status and 'functional' calcitonin receptors, exhibited aggressive in vitro and in vivo bone resorptive activity. In the osteoclast bone slice assay employing scanning electron microscopy, the giant cell-mediated bone resorption was uninhibited by salmon calcitonin (10 nM) and significantly inhibited by raised extracellular calcium (20 mM). In Fura-2AM based microspectrofluorimetric assays, the presence of the 'functional' calcitonin receptors was ascertained by a rise in intracellular calcium induced by calcitonin and high extracellular calcium. These findings provide evidence for a hitherto unrecognized subtype of giant cells that have HLA-DR-positive status, exhibit avid bone resorptive activity, but remain insensitive to calcitonin despite possessing calcitonin receptors.