Papers by David Kindelberger
Advances in Anatomic Pathology, 2006
Prophylactic salpingo-oophorectomies from women with BRCA mutations (BRCA+) have identified the t... more Prophylactic salpingo-oophorectomies from women with BRCA mutations (BRCA+) have identified the tube as a frequent site of early pelvic serous carcinoma (tubal intraepithelial carcinoma [TIC]). These observations have implications for both the early recognition of pelvic serous carcinoma in susceptible women and determining the ultimate site of origin for pelvic serous carcinomas. Moreover, the unique pathology of TIC has shifted attention from the more exuberant proliferations mentioned in prior studies to a spectrum of neoplastic atypias that can be morphologically subtle. This review addresses a multitude of epithelial changes; benign, malignant, and an intriguing third group, which we term "p53 signatures," is found in benign, nonciliated epithelium and stain intensely positive for p53. Understanding all 3 is important for the proper management of women undergoing prophylactic salpingo-oophorectomy and possibly formulating an integrated model for the pathogenesis of serous carcinoma in the reproductive tract. A protocol for sectioning and extensively examining the fimbriated end (SEE-FIM), and its rationale, is described.
Journal of Clinical Oncology, Sep 1, 2008
A diagnosis of primary peritoneal serous carcinoma (PPSC) requires exclusion of a source in other... more A diagnosis of primary peritoneal serous carcinoma (PPSC) requires exclusion of a source in other reproductive organs. Serous tubal intraepithelial carcinoma (STIC; stage 0) has been described in asymptomatic women with BRCA mutations and linked to a serous cancer precursor in the fimbria. This study examined the frequency of STIC in PPSC and its clinical outcome in BRCA-positive women. Presence or absence of STIC was recorded in consecutive cases meeting the 2001 WHO criteria for PPSC, including 26 patients with nonuniform sampling of the fallopian tubes (group 1) and 19 patients with complete tubal examination (group 2; sectioning and extensively examining the fimbriated end, or SEE-FIM protocol). In selected cases, STIC or its putative precursor and the peritoneal tumor were analyzed for p53 mutations (exons 1 to 11). Outcome of STIC was ascertained by literature review. Thirteen (50%) of 26 PPSCs in group 1 involved the endosalpinx, with nine STICs (35%). Fifteen (79%) of 19 cases in group 2 contained endosalpingeal involvement, with nine STICs (47%). STIC was typically fimbrial and unifocal, with variable invasion of the tubal wall. In five of five cases, the peritoneal and tubal lesion shared an identical p53 mutation. Of 10 reported STICs in BRCApositive women, all patients were without disease on follow-up. The fimbria is the source of nearly one half of PPSCs, suggesting serous malignancy originates in the tubal mucosa but grows preferentially at a remote peritoneal site. The generally low risk of recurrence in stage 0 (STIC) disease further underscores STIC as a possible target for early serous cancer detection and prevention.
The classification of lymphoma and leukemia is successfully done by using normal cell types as a ... more The classification of lymphoma and leukemia is successfully done by using normal cell types as a reference point which is one of the many reasons that better therapies are available for their treatment. In case of breast cancer, clinically it is classified as Estrogen Receptor positive, Human Epidermal Growth Factor Receptor 2 (Her2) positive and triple negative breast cancer while in the research settings, it has been classified by mRNA expression profiling but these classification systems are still evolving. Our laboratory attempted to classify breast cancer by examining the expression of different keratin isoforms and Hormone Receptors (HR) studied through immunostaining in 36 normal breast samples and later in 1731 breast tumors from the Nurses' Health Study (NHS) cohort with a patient follow up extending beyond 25 years. Among the various receptors tested, three of these receptors: Androgen Receptor, Estrogen Receptor and Vitamin D Receptor were capable of identifying four major subgroups being designated as HR0-3, depending on the number of hormone receptors present. More importantly, radically different survival outcomes were observed between these HR sub-groups through Kaplan Meier curve analysis; which highlights their usefulness as vital biological markers as wells as targets for breast cancer treatment. Furthermore, the characterization of these HR was carried out in 20 different breast cancer cell lines and the combination of different receptor modulators alone or in combination was attempted with better anti-proliferative effects being observed in the combinatorial group than either treatment alone. Thus, our new classification not only re-classifies breast cancer but also gives insight on how patients could be treated through targeting hormone receptors. Citation Format: Ankita Thakkar, Sandro Santagata, Ayse Ergonul, Bin Wang, Terri Woo, Rong Hu, J. Chuck Harrell, George McNamara, Matthew Schwede, Aedin C. Culhane, David Kindelberger, Scott Rodig, Andrea Richardson, Stuart J. Schnitt, Rulla M. Tamimi, Tan A. Ince. Taxonomy of breast cancer based on normal cell phenotype and ontology. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr B067.
Pathology Case Reviews, Sep 1, 2005
Fine needle aspiration (FNA) cytology is a powerful tool for the evaluation of adrenal masses. Th... more Fine needle aspiration (FNA) cytology is a powerful tool for the evaluation of adrenal masses. The method is safe and offers high sensitivity, specificity, and diagnostic accuracy, particularly in cases of metastatic disease to the adrenals. Once it has been determined that the mass lesion is metastatic, the clinical history, lesion cytomorphology, and—if needed—immunocytochemistry and other ancillary techniques can be used to identify the primary sites, even when clinically and radiographically occult. Continued improvements in image-guided FNA methods will enhance this useful technique for the initial evaluation of suspected metastatic disease involving the adrenals.
Molecular and Cellular Biology, Jun 1, 1995
Clb2 is the major B-type mitotic cyclin required for entry into mitosis in the budding yeast Sacc... more Clb2 is the major B-type mitotic cyclin required for entry into mitosis in the budding yeast Saccharomyces cerevisiae. We showed that accumulation of CLB2 transcripts in G 2 cells is controlled at the transcriptional level and identified a 55-bp upstream activating sequence (UAS) containing an Mcm1 binding site as being necessary and sufficient for cell cycle regulation. Sequences within the cell cycle-regulated UAS were shown to bind Mcm1 in vitro, and mutations which abolished Mcm1-dependent DNA binding activity eliminated cell cycle-regulated transcription in vivo. A second protein with no autonomous DNA binding activity was also recruited into Mcm1-UAS complexes, generating a ternary complex. A point mutation in the CLB2 UAS which blocked ternary complex formation, but still allowed Mcm1 to bind, resulted in loss of cell cycle regulation in vivo, suggesting that the ternary complex factor is also important in control of CLB2 transcription. We discuss the possibility that the CLB2 gene is coregulated with other genes known to be regulated with the same periodicity and suggest that Mcm1 and the ternary complex factor may coordinately regulate several other G 2 -regulated transcripts.
International Journal of Gynecological Pathology, 2008
The fimbria is the most common site of early serous cancer (tubal intraepithelial carcinoma or ST... more The fimbria is the most common site of early serous cancer (tubal intraepithelial carcinoma or STIC) in women with BRCA mutations (BRCA+). A candidate serous cancer precursorVthe p53 signatureVhas been found in nonneoplastic secretory cells of the fimbria, suggesting serous carcinogenesis in the tube (SCAT). This study surveyed fallopian tubes from 3 populations to characterize the morphological and immunohistochemical correlates of SCAT. The SCAT sequence was defined by strong nuclear p53 staining and DNA damage (F-H2AX+) in secretory cells and subdivided morphologically by (1) degree of nuclear stratification, (2) proliferative index, and (3) degree of disorganized growth. Fallopian tubes from women without a current ovarian cancer, women with BRCA mutations, and women with a coexisting pelvic serous cancer were completely examined. p53 signatures exhibited cuboidal to pseudostratified, polarized p53+ epithelial segments with variable nuclear enlargement and a MiB1 index of 0% to 30%. Tubal intraepithelial carcinomas contained from single (uncommon) to multilayered, poorly polarized, uninterrupted neoplastic cell populations that completely displaced the normal mucosa; MiB1 index exceeded 45% and was usually more than 70%. An uncommon third category, p53-positive foci with features intermediate between p53 signatures and STICs, exhibited preserved epithelial polarity, pseudostratification, incomplete replacement of the adjacent normal ciliated cells, and a MiB1 index between 40% and 75%. Transitions from 1 category to another were documented. Combined with recent reports associating STICs with pelvic serous cancer, this continuum of epithelial change validates the SCAT sequence and the fimbrial secretory cell as the site of origin for many serous carcinomas.
Acta Cytologica, 2011
Objective: Serous neoplasms of the female pelvis share a müllerian phenotype. Unlike low-grade se... more Objective: Serous neoplasms of the female pelvis share a müllerian phenotype. Unlike low-grade serous neoplasms (LGSNs), high-grade serous carcinomas (HGSCs) commonly display p53 mutations. The current study correlates p53 immunoreactivity in peritoneal washings with the cytologic interpretation and histology of the corresponding serous neoplasm. Study Design: Peritoneal washings from consecutive cases of pelvic serous neoplasms were identified (n = 45, 31 HGSCs and 14 LGSNs), with a control population selected from benign resections. Immunoreactivity for p53 was scored as a percentage of positive epithelioid cells by blinded manual cell count. Results: Washings from LGSNs and HGSCs were cytomorphologically positive with similar frequency (57 vs. 77%, respectively, p = 0.15, Fisher’s exact test). Immunoreactivity for p53 was not predictive of morphologic positivity. The percentage of p53-positive cells was higher in HGSCs (47 ± 42%), compared to LGSNs (9 ± 9%) and negative controls (2 ± 2%, n = 10). The difference in p53 immunoreactivity was statistically significant (p < 0.00009, ANOVA). Conclusions: The proportion of p53 immunoreactive cells was higher in cases of HGSCs, reflecting the importance of p53 mutations in high-grade serous tumorigenesis. The presence of p53 staining is not diagnostic for neoplastic cells; however, peritoneal washings are potential specimens in the investigation of serous neoplasia.
International Journal of Gynecological Pathology, Jul 1, 2009
Most serous adenocarcinomas involving both the endometrium and ovary are presumed to arise in the... more Most serous adenocarcinomas involving both the endometrium and ovary are presumed to arise in the endometrium. Recently, serous tubal intraepithelial carcinoma (STIC) has been implicated in the pathogenesis of pelvic serous carcinoma. This study explored the potential relationship between STIC and uterine serous carcinoma. Twenty-two consecutive cases of serous carcinoma involving the endometrium were studied. In each case, fallopian tubes were submitted in toto according to the protocol for sectioning and extensive examination of the fimbriated end. Extent of the endometrial tumor and presence/absence of STIC were documented. Immunostaining for p53 and Wilms tumor-1 was performed on all cases with STIC. p53 mutation analysis was performed in a subset of matched STICs and endometrial tumors. Eleven cases showed concurrent endometrial and adnexal involvement, including 6 with endosalpingeal involvement; STIC was confirmed in 5. In all 5, the concurrent endometrial tumor was either noninvasive, or exhibited only superficial (o5%) myometrial invasion. In 2 cases, identical p53 mutations were shared by both tubal and endometrial lesions. This study shows that noninvasive, genetically related serous carcinomas may coexist in both tube and endometrium. As management of serous neoplasms is predicated on site of origin, we propose that the sectioning and extensively examining the fimbria protocol be applied to all endometrial serous carcinomas and that tumors with concurrent STIC be classified as a distinct subset of pelvic serous carcinomas pending a clearer understanding of tumor origin.
The American Journal of Surgical Pathology, Mar 1, 2009
Pelvic serous cancer is a diverse disease, and the assignment of primary site-ovarian, tubal, or ... more Pelvic serous cancer is a diverse disease, and the assignment of primary site-ovarian, tubal, or peritoneal-is often problematic. Recent studies indicate that a proportion of these tumors arise from the distal fallopian tube, originating as serous tubal intraepithelial carcinoma (STIC). This study examined the relationship of 2 parameters for assigning origin-endosalpingeal involvement and dominant ovarian mass-in the context of STIC. Endometrioid carcinomas served as a reference. Eighty-seven consecutive pelvic serous cancers in which the tubes and ovaries were completely examined (SEE-FIM protocol) were analyzed. The presence of a dominant ovarian mass (DOM+), involvement of the fimbrial mucosa (FIM+), and STIC were correlated. In addition, tumor categories were compared with respect to PAX8, p73, p53, and p16 immunohistochemistry. Of the 27 DOM+ cases, 13 (48%) were FIM+ and a STIC was present in 3 (11%). Of the 60 DOM( À ) cases, 48 (78%) were FIM+ and 28 (45%) harbored a STIC. In 92% of all cases, tumor distribution was extensive with bilateral ovarian and extraovarian peritoneal involvement. All tumor categories were immunophenotypically similar. In contrast, DOM+, FIM+, and STIC were found in 81%, 19%, and 0% of ovarian endometrioid carcinomas. In conclusion, there is a significant inverse relationship between DOM+ and STIC (P = 0.001), indicating both parameters are of value in grouping pelvic serous carcinomas more likely to be ovarian [DOM+/FIM( À )] versus fimbrial [DOM( À )/STIC], and ovarian or peritoneal surface (DOM À /FIM À ) in origin. Nevertheless, the shared immunophenotype suggests a common cell of origin for all categories, irrespective of site.
Clinical Medicine & Research, Mar 1, 2007
Ovarian epithelial cancer is diagnosed in approximately 25,000 women yearly in the United States,... more Ovarian epithelial cancer is diagnosed in approximately 25,000 women yearly in the United States, accounting for approximately 12,500 deaths. Of these tumors, serous cancer is the most lethal, due to its capacity to spread beyond the reproductive tract and involve the peritoneal surfaces or distant organs. Conventional classification systems designate tumor origins principally on the location of the largest tumor. However, despite the fact that the largest tumors typically involve the ovaries, demonstrations of a precise starting point for these tumors, including precursor lesions, have been inconsistent. In recent years, a major effort to prevent serous cancer in genetically susceptible women with mutations in BRCA1 or BRCA2 has spawned the practice of prophylactic salpingo-oophorectomy. This practice has surprisingly revealed that many early cancers in these women arise in the fallopian tube, and further studies have pinpointed the distal (fimbrial) portion as the most common site of origin. Emerging studies that carefully examine the fallopian tubes suggest a high frequency of early cancer in the fimbria in unselected women with ovarian and peritoneal serous carcinoma, raising the distinct possibility that a significant proportion of these tumors have a fimbrial origin.The evidence for these discoveries and their relevance to serous cancer classification, early detection and prevention are addressed in this review. A model for pelvic serous cancer is proposed that takes into account five distinct variables which ultimately impact on origin and tumor distribution: (1) location of target epithelium, (2) genotoxic stress, (3) type of epithelium, (4) mitigating genetic factors, and (5) tumor spread pattern. Ultimately, this model illustrates the importance of identifying cancer precursors, inasmuch as these entities are useful as both surrogate endpoints for their respective malignancies in epidemiologic studies and natural targets for cancer prevention.
British Journal of Cancer, May 1, 2010
BACKGROUND: Circulating tumour cells (CTCs) offer a non-invasive approach to obtain and character... more BACKGROUND: Circulating tumour cells (CTCs) offer a non-invasive approach to obtain and characterise metastatic tumour cells, but their usefulness has been limited by low CTC yields from conventional isolation methods. METHODS: To improve CTC yields and facilitate their molecular characterisation we compared the Food and Drug Administrationapproved CellSearch Epithelial Kit (CEK) to a simplified CTC capture method, CellSearch Profile Kit (CPK), on paired blood samples from patients with metastatic breast (n ¼ 75) and lung (n ¼ 71) cancer. Molecular markers including Human Epidermal growth factor Receptor 2 (HER2) were evaluated on CTCs by fluorescence in situ hybridisation (FISH) and compared to patients' primary and metastatic cancer. RESULTS: The median cell count from patients with breast cancer using the CPK was 117 vs 4 for CEK (Po0.0001). Lung cancer samples were similar; CPK: 145 cells vs CEK:4 cells (Po0.0001). Recovered CTCs were relatively pure (60 -70%) and were evaluable by FISH and immunofluorescence. A total of 10 of 30 (33%) breast cancer patients with HER2-negative primary and metastatic tissue had HER2-amplified CTCs. CONCLUSION: The CPK method provides a high yield of relatively pure CTCs, facilitating their molecular characterisation. Circulating tumour cells obtained using CPK technology demonstrate that significant discordance exists between HER2 amplification of a patient's CTCs and that of the primary and metastatic tumour.
Cancer Epidemiology and Prevention Biomarkers, Dec 1, 2006
The tubal fimbria is a common site of origin for early tubal serous carcinomas in women with fami... more The tubal fimbria is a common site of origin for early tubal serous carcinomas in women with familial BRCA1 or 2 mutations (BRCA+). Moreover, these early tubal carcinomas commonly co-exist with tumors otherwise classified as ovarian or peritoneal serous cancers. Somatic ...
Background: CTC offer a potential non-invasive approach to obtain and characterize metastatic tum... more Background: CTC offer a potential non-invasive approach to obtain and characterize metastatic tumor cells from solid cancers. However, conventional methods for isolating CTC, which use Epcam specific immunomagnetic beads, have been limited by low CTC yields and contaminating leukocytes. We sought to optimize and characterize CTC isolation using the CPK(Veridex LLC) and compare it to conventional methods using the CEK and automated CellTracks counting system, the FDA approved standard. We hypothesized that the CPK, which avoids the potential CTC loss and destruction associated with the multiple washes and labeling steps included in the CEK, would offer improved cell recovery.Methods: We collected two peripheral blood samples from patients (Pts) with metastatic breast cancer (n = 75) and processed them in parallel. Following automated enumeration of the samples with the CEK method, the cells were washed, fixed, and processed as cytospin slides followed by H&E and FISH. Uncounted samples processed with the CPK method were similarly washed, fixed, and processed as cytospin slides, followed by either H&E, IHC (AE1/AE3), IF (HER2, pHER2, EGFR, pEGFR) or FISH using probes against CEP7, EGFR, HER2, and MET.Results: The median cell count from pts with breast cancer using the CPK method was 120 per 7.5 mL of blood (range 4-4967) compared to 4 (range 0-57) using the CEK method (p < 0.0001; t-test). The purity of these cells was high: 59.7 % of cells isolated by CPK (range: 20.9-95.0) were identified as tumor cells by cytokeratin staining while 6.4% (range: 0-21.8) were identified as WBCs by CD45 staining. The remaining 32.3% (range: 4.8-68.0) of cells stained with DAPI only and could not be classified as either tumor cells or lymphocytes, and appeared to have lost their membrane during the isolation. We confirmed the purity of the CTC by HER2 FISH. Among pts whose primary cancer was HER2+ (n=70), 72.4% (range: 44-100%) of CTC had an HER2 gene copy number > 4. From samples isolated from healthy controls (n = 40) and processed using the CPK method the mean total number of cells was 5 per 7.5 mL of blood (range 0-20). These cells were positive for CD45 with only 2 copies of HER2 by FISH. The CPK had low intrapatient variability (CV 9.6%) and samples were stable for at least 72hr. Recovered CTC were well suited for evaluation by IF for phospho antibodies (e.g. pHER2, pAkt), TUNEL (apoptosis), and Ki67 (proliferation). Studies using BC cell lines demonstrated that viable cells could be recovered and propagated with an input as few as 50 cells consistently yielding viable cultures.Conclusion: The CPK technique's relatively high yield, purity, and sample stability make it well suited for use in obtaining CTC's for molecular characterization, including FISH and IF. Assays for mutation detection are currently being evaluated. This technology potentially has a large number of applications in investigating the biology of metastatic cancer as well as in drug development where it can be used to identify predictive biomarkers, mechanisms of resistance, and facilitate pharmacodynamic studies. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3003.
Journal of Clinical Oncology, May 20, 2010
5111 Background: Circulating tumor cells (CTC's) can be used for detection of cancer recurren... more 5111 Background: Circulating tumor cells (CTC's) can be used for detection of cancer recurrence and response to therapy. Epithelial ovarian cancer is diagnosed in an advanced stage in > 75% of patients, and despite high RR's of platinum- and taxane- based chemotherapy following diagnosis, most women will recur. The purpose of this study was to examine the utility of immunomagnetically-isolated CTC's, captured using the CellSearch System (Veridex) in predicting response to therapy in patients with known recurrent ovarian cancer. Methods: 50 consecutive patients with recurrent ovarian cancer (both platinum resistant and plat sensitive) were selected as part of an IRB-approved study at the Dana-Farber Cancer Institute. CTC's were isolated according to standard protocols for the Veridex CellSearch System. 7.5 mL of blood was collected in Cell Save Vacutainer tubes, samples were processed within 36 hrs of collection, and samples were immediately processed with the CellTracks Autoprep instrument using the Epith...
Journal of Clinical Investigation, Jan 27, 2014
Accurate classification is essential for understanding the pathophysiology of a disease and can i... more Accurate classification is essential for understanding the pathophysiology of a disease and can inform therapeutic choices. For hematopoietic malignancies, a classification scheme based on the phenotypic similarity between tumor cells and normal cells has been successfully used to define tumor subtypes; however, use of normal cell types as a reference by which to classify solid tumors has not been widely emulated, in part due to more limited understanding of epithelial cell differentiation compared with hematopoiesis. To provide a better definition of the subtypes of epithelial cells comprising the breast epithelium, we performed a systematic analysis of a large set of breast epithelial markers in more than 15,000 normal breast cells, which identified 11 differentiation states for normal luminal cells. We then applied information from this analysis to classify human breast tumors based on normal cell types into 4 major subtypes, HR0-HR3, which were differentiated by vitamin D, androgen, and estrogen hormone receptor (HR) expression. Examination of 3,157 human breast tumors revealed that these HR subtypes were distinct from the current classification scheme, which is based on estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2. Patient outcomes were best when tumors expressed all 3 hormone receptors (subtype HR3) and worst when they expressed none of the receptors (subtype HR0). Together, these data provide an ontological classification scheme associated with patient survival differences and provides actionable insights for treating breast tumors.
Molecular and Cellular Biology, 1995
Clb2 is the major B-type mitotic cyclin required for entry into mitosis in the budding yeast Sacc... more Clb2 is the major B-type mitotic cyclin required for entry into mitosis in the budding yeast Saccharomyces cerevisiae. We showed that accumulation of CLB2 transcripts in G2 cells is controlled at the transcriptional level and identified a 55-bp upstream activating sequence (UAS) containing an Mcm1 binding site as being necessary and sufficient for cell cycle regulation. Sequences within the cell cycle-regulated UAS were shown to bind Mcm1 in vitro, and mutation which abolished Mcm1-dependent DNA binding activity eliminated cell cycle-regulated transcription in vivo. A second protein with no autonomous DNA binding activity was also recruited into Mcm1-UAS complexes, generating a ternary complex. A point mutation in the CLB2 UAS which blocked ternary complex formation, but still allowed Mcm1 to bind, resulted in loss of cell cycle regulation in vivo, suggesting that the ternary complex factor is also important in control of CLB2 transcription. We discuss the possibility that the CLB2 ...
Molecular Cancer Therapeutics, Nov 1, 2020
Diagnostic Gynecologic and Obstetric Pathology, 2018
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Papers by David Kindelberger