IntroductionMulti-omic studies have identified three molecular separated pulmonary carcinoid (PC) subgroups (A1, A2, B) with distinctive mRNA expression profiles (e.g., orthopedia homeobox protein [OTP]/achaete-scute homolog [ASCL1]/hepatocyte nuclear factor 1 homeobox A [HNF1A]). We aimed to establish an immunohistochemical (IHC) biomarker panel that enables subgroup identification, and assessment of its potential clinical relevance. MethodsAll patients with resected pulmonary carcinoids (2003–2012) were identified from the Dutch Cancer/Pathology Registry, and tumors were revised. The IHC expression of OTP/ASCL1/HNF1A was scored in a blinded fashion in a mRNA-profiled (n = 5/subgroup) and national carcinoid cohort (n = 478). The expression of potential therapeutic targets (somatostatin receptor type 2a [SSTR2A]/delta-like canonical Notch ligand 3 [DLL3]) was assessed. Immunohistochemistry was assessed using H-scoring. ResultsOTP/ASCL1/HNF1A reported similar IHC and mRNA expression patterns in the matched primary samples. In the national cohort, IHC separated PCs into subgroups A1 (n = 224 [53%], OTPhigh/ASCL1high/HNF1Alow), A2 (n = 161 [38%], OTPhigh/ASCL1low/HNF1Ahigh), and B (n = 37 [9%], OTPlow/ASCL1low/HNF1Ahigh). In 12% of PCs, no distinct classification could be provided. Patients with A1 were enriched for older age (83% > 50 y), female individuals (83%), and peripheral location (55%) with low SSTR2A (median = 10) and high DLL3 (median = 52) expression. A2 included younger patients (34% < 40 y) and endobronchial/central (87%) tumors with high SSTR2A (median = 160), but low DLL3 (median 0) expression. Group B included more male individuals (59%) and recurrence was more frequent (19%) than in groups A1 (8%) and A2 (6%). Neuroendocrine cell hyperplasia was enriched in A1 (25%) compared with A2 (3%) and B (0%). ConclusionsAn OTP/ASCL1/HNF1A IHC panel enables the identification of molecular-defined pulmonary carcinoid subgroups with distinct clinical phenotypes and diverging therapeutic vulnerabilities that require further prospective evaluation.
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