Placental Tissue Destruction and Insufficiency From COVID-19 Causes Stillbirth and Neonatal Death From Hypoxic-Ischemic Injury.

CONTEXT.­: Perinatal death is an increasingly important problem as the coronavirus disease 2019 (COVID-19) pandemic continues, but the mechanism of death has been unclear. OBJECTIVE.­: To evaluate the role of the placenta in causing stillbirth and neonatal death following maternal infection with COVID-19 and confirmed placental positivity for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). DESIGN.­: Case-based retrospective clinicopathologic analysis by a multinational group of 44 perinatal specialists from 12 countries of placental and autopsy pathology findings from 64 stillborns and 4 neonatal deaths having placentas testing positive for SARS-CoV-2 following delivery to mothers with COVID-19. RESULTS.­: Of the 3 findings constituting SARS-CoV-2 placentitis, all 68 placentas had increased fibrin deposition and villous trophoblast necrosis and 66 had chronic histiocytic intervillositis. Sixty-three placentas had massive perivillous fibrin deposition. Severe destructive placental disease from SARS-CoV-2 placentitis averaged 77.7% tissue involvement. Other findings included multiple intervillous thrombi (37%; 25 of 68) and chronic villitis (32%; 22 of 68). The majority (19; 63%) of the 30 autopsies revealed no significant fetal abnormalities except for intrauterine hypoxia and asphyxia. Among all 68 cases, SARS-CoV-2 was detected from a body specimen in 16 of 28 cases tested, most frequently from nasopharyngeal swabs. Four autopsied stillborns had SARS-CoV-2 identified in internal organs. CONCLUSIONS.­: The pathology abnormalities composing SARS-CoV-2 placentitis cause widespread and severe placental destruction resulting in placental malperfusion and insufficiency. In these cases, intrauterine and perinatal death likely results directly from placental insufficiency and fetal hypoxic-ischemic injury. There was no evidence that SARS-CoV-2 involvement of the fetus had a role in causing these deaths.

Perfusion fraction derived from IVIM analysis of diffusion-weighted MRI in the assessment of placental vascular malperfusion antenatally.

INTRODUCTION: Specific placental pathologies that may impact fetal development, such as vascular malperfusion, are diagnosed postpartum. We aimed to evaluate if placental perfusion fraction (f) derived from intravoxel incoherent motion (IVIM) analysis of diffusion-weighted magnetic resonance imaging (DWI) can be used to identify specific types of placental vascular malperfusion antenatally. METHOD: 93 women who underwent placental DWI with multiple b-values at 23.9-41.3 week's gestation and postpartum histological examination were identified in the local placental MRI research database. Based on the placental examination, 44 were defined as normal controls and 49 cases had placental vascular malperfusion. Vascular malperfusion was subdivided into fetal vascular malperfusion (n = 13), maternal vascular malperfusion (n = 30) or both (n = 6). For each placenta, regions of interest were drawn on three placental slices and their mean f was estimated using intravoxel incoherence motion analysis. RESULTS: In normal placentas mean f was 26.0 ± 4.6% (mean ± SD) and no linear correlation between f and gestational age was found, r = -0.05, p = 0.72. Placentas with fetal vascular malperfusion showed a significantly lower f (22.7 ± 4.4%) compared to normal controls, p = 0.03. In cases of maternal vascular malperfusion (25.2 ± 6.4%), no significant difference in f was revealed, p = 0.55. CONCLUSIONS: These results indicate that placental DWI-derived f may identify fetal vascular malperfusion in vivo. This study confirms a previous pilot study and provides initial evidence that fetal and maternal vascular malperfusion have different MRI signatures. Future studies are needed to further explore the clinical significance of this interesting finding.

Placental MRI: Longitudinal relaxation time (T1) in appropriate and small for gestational age pregnancies.

OBJECTIVE: The antenatal detection of small for gestational age (SGA) pregnancies is a challenge, which may be improved by placental MRI. The longitudinal relaxation time (T1) is a tissue constant related to tissue morphology and tissue oxygenation, thereby placental T1 may be related to placental function. The aim of this study is to investigate placental T1 in appropriate for gestational age (AGA) and SGA pregnancies. METHODS: A total of 132 singleton pregnancies were retrieved from our MRI research database. MRI and ultrasound estimated fetal weight (EFW) was performed at gestational week 20.6-41.7 in a 1.5 T system. SGA was defined as BW ≤ -15% of the expected for gestational age (≤10th centile). A subgroup of SGA pregnancies underwent postnatal placental histological examination (PHE) and abnormal PHE was defined as vascular malperfusion. The placental T1 values were converted into Z-scores adjusted for gestational age at MRI. The predictive performance of placental T1 and EFW was compared by receiver operating curves (ROC). RESULTS: In AGA pregnancies, placental T1 showed a negative linear correlation with gestational age (r = -0.36, p = 0.004) Placental T1 was significantly reduced in SGA pregnancies (mean Z-score = -0.34) when compared to AGA pregnancies, p = 0.03. Among SGA pregnancies placental T1 was not reduced in cases with abnormal PHE, p = 0.84. The predictive performance of EFW (AUC = 0.84, 95% CI, 0.77-0.91) was significantly stronger than placental T1 (AUC = 0.62, 95% CI, 0.52-0.72) (p = 0.002). DISCUSSION: A low placental T1 relaxation time is associated with SGA at birth. However, the predictive performance of placental T1 is not as strong as EFW.

T2* weighted placental MRI in relation to placental histology and birth weight.

INTRODUCTION: Placental dysfunction may be found among normal birth weight (BW) pregnancies, as indicated by abnormal histological findings in postnatal placental examination in some of these pregnancies. T2* weighted placental MRI provides non-invasive information on placental oxygenation and thereby placental function. The aim of this study was to investigate the correlation between placental T2*, BW and placental histology. METHODS: A total of 63 pregnant women underwent T2* weighted placental MRI at 15-40 week's gestation and a standardized placental histological examination (PHE). Abnormal PHE was defined by vascular malperfusion according to the Amsterdam workshop consensus. The correlation between PHE, BW z-score and T2* z-score was analyzed by logistic regression. RESULTS: Abnormal PHE was revealed in 28 pregnancies. Multiple logistic regression revealed a significant correlation between abnormal PHE and T2* z-score (OR = 0.34, p = 0.008), whereas BW z-score did not add significantly to the correlation of placental histology (OR = 0.52, p = 0.115). In BW z-score≥0, PHE was normal in 100% of pregnancies. In BW z-score ≤ -2, PHE was abnormal in 89% of pregnancies. In intermediate BW (z-score between -2 and 0), PPE was abnormal in 35% of pregnancies. In this intermediate group, placental T2* z-score was reduced (-1.52 ± 1.22 (mean SD)) when compared to normal PHE pregnancies (-0.28 ± 1.17), p = 0.006. DISCUSSION: This study demonstrates a correlation between abnormal placental histology and low placental T2* value regardless of fetal size. This indicates that T2* provides information of placental function in vivo even when fetal size is normal. This finding highlights that fetal size alone is not a valid marker of placental dysfunction.

An integrated multi-omics analysis identifies prognostic molecular subtypes of non-muscle-invasive bladder cancer.

The molecular landscape in non-muscle-invasive bladder cancer (NMIBC) is characterized by large biological heterogeneity with variable clinical outcomes. Here, we perform an integrative multi-omics analysis of patients diagnosed with NMIBC (n = 834). Transcriptomic analysis identifies four classes (1, 2a, 2b and 3) reflecting tumor biology and disease aggressiveness. Both transcriptome-based subtyping and the level of chromosomal instability provide independent prognostic value beyond established prognostic clinicopathological parameters. High chromosomal instability, p53-pathway disruption and APOBEC-related mutations are significantly associated with transcriptomic class 2a and poor outcome. RNA-derived immune cell infiltration is associated with chromosomally unstable tumors and enriched in class 2b. Spatial proteomics analysis confirms the higher infiltration of class 2b tumors and demonstrates an association between higher immune cell infiltration and lower recurrence rates. Finally, the independent prognostic value of the transcriptomic classes is documented in 1228 validation samples using a single sample classification tool. The classifier provides a framework for biomarker discovery and for optimizing treatment and surveillance in next-generation clinical trials.

Whole-exome sequencing identifies a GREB1L variant in a three-generation family with Müllerian and renal agenesis: a novel candidate gene in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. A case report.

The aetiology of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, characterized by uterovaginal agenesis in 46,XX women, remains poorly understood. Since familial occurrences are rare, genetic findings reported so far only apply to a minority of mainly sporadic cases and most studies have not included other family members enabling segregation analysis. Herein, we report on the investigation of a unique three-generation family of two female cousins with MRKH syndrome and unilateral renal agenesis (RA) and two deceased male relatives with RA. We performed whole-exome sequencing (WES) in eight family members leading to the identification of a novel pathogenic (CADD = 33) c.705G>T missense variant in GREB1L, a gene recently identified as a novel cause of RA. Previous reports include several cases of female fetuses with bilateral RA and uterus agenesis, which support GREB1L as an important gene in both kidney and female genital tract development. The pedigree is compatible with autosomal dominant inheritance with incomplete penetrance following a parent-origin-specific manner, which could be due to imprinting. To our knowledge, this is the first investigation of a larger MRKH syndrome pedigree using WES, and we suggest GREB1L as a novel and promising candidate gene in the aetiology of MRKH syndrome.

Molecular Markers Increase Precision of the European Association of Urology Non-Muscle-Invasive Bladder Cancer Progression Risk Groups.

Purpose: The European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC) recommend risk stratification based on clinicopathologic parameters. Our aim was to investigate the added value of biomarkers to improve risk stratification of NMIBC.Experimental Design: We prospectively included 1,239 patients in follow-up for NMIBC in six European countries. Fresh-frozen tumor samples were analyzed for GATA2, TBX2, TBX3, and ZIC4 methylation and FGFR3, TERT, PIK3CA, and RAS mutation status. Cox regression analyses identified markers that were significantly associated with progression to muscle-invasive disease. The progression incidence rate (PIR = rate of progression per 100 patient-years) was calculated for subgroups.Results: In our cohort, 276 patients had a low, 273 an intermediate, and 555 a high risk of tumor progression based on the EAU NMIBC guideline. Fifty-seven patients (4.6%) progressed to muscle-invasive disease. The limited number of progressors in this large cohort compared with older studies is likely due to improved treatment in the past two decades. Overall, wild-type FGFR3 and methylation of GATA2 and TBX3 were significantly associated with progression (HR = 0.34, 2.53, and 2.64, respectively). The PIR for EAU high-risk patients was 4.25. On the basis of FGFR3 mutation status and methylation of GATA2, this cohort could be reclassified into a good class (PIR = 0.86, 26.2% of patients), a moderate class (PIR = 4.32, 49.7%), and a poor class (PIR = 7.66, 24.0%).Conclusions: We conclude that the addition of selected biomarkers to the EAU risk stratification increases its accuracy and identifies a subset of NMIBC patients with a very high risk of progression. Clin Cancer Res; 24(7); 1586-93. ©2018 AACR.

Prognostic Impact of a 12-gene Progression Score in Non-muscle-invasive Bladder Cancer: A Prospective Multicentre Validation Study.

BACKGROUND: Progression of non-muscle-invasive bladder cancer (NMIBC) to muscle-invasive bladder cancer (MIBC) is life-threatening and cannot be accurately predicted using clinical and pathological risk factors. Biomarkers for stratifying patients to treatment and surveillance are greatly needed. OBJECTIVE: To validate a previously developed 12-gene progression score to predict progression to MIBC in a large, multicentre, prospective study. DESIGN, SETTING, AND PARTICIPANTS: We enrolled 1224 patients in ten European centres between 2008 and 2012. A total of 750 patients (851 tumours) fulfilled the inclusion and sample quality criteria for testing. Patients were followed for an average of 28 mo (range 0-76). A 12-gene real-time qualitative polymerase chain reaction assay was performed for all tumours and progression scores were calculated using a predefined formula and cut-off values. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We measured progression to MIBC using Cox regression analysis and log-rank tests for comparing survival distributions. RESULTS AND LIMITATIONS: The progression score was significantly (p<0.001) associated with age, stage, grade, carcinoma in situ, bacillus Calmette-Guérin treatment, European Organisation for Research and Treatment of Cancer risk score, and disease progression. Univariate Cox regression analysis showed that patients molecularly classified as high risk experienced more frequent disease progression (hazard ratio 5.08, 95% confidence interval 2.2-11.6; p<0.001). Multivariable Cox regression models showed that the progression score added independent prognostic information beyond clinical and histopathological risk factors (p<0.001), with an increase in concordance statistic from 0.82 to 0.86. The progression score showed high correlation (R2=0.85) between paired fresh-frozen and formalin-fixed paraffin-embedded tumour specimens, supporting translation potential in the standard clinical setting. A limitation was the relatively low progression rate (5%, 37/750 patients). CONCLUSIONS: The 12-gene progression score had independent prognostic power beyond clinical and histopathological risk factors, and may help in stratifying NMIBC patients to optimise treatment and follow-up regimens. PATIENT SUMMARY: Clinical use of a 12-gene molecular test for disease aggressiveness may help in stratifying patients with non-muscle-invasive bladder cancer to optimal treatment regimens.

Less extensive surgery compared to extensive surgery: survival seems similar in young women with adult ovarian granulosa cell tumor.

OBJECTIVE: To describe the outcome of adult granulosa cell tumor (AGCT) with respect to initial clinical findings, methods of surgery, and perioperative treatment. STUDY DESIGN: Retrospective follow-up study. SETTING: All hospitals in Jutland. SAMPLE: 163 women diagnosed with AGCT. METHODS: Follow-up by hospital data files, general practitioner, death certificate, and autopsy report. Revision of histopathology by a single pathologist. MAIN OUTCOME MEASURES: Survival and relapse by clinical data, stage, and type of surgery. RESULTS: The incidence of AGCT was 1.37 per year per 100,000 women (95% CI: 1.08, 1.68). The median follow-up time was 15 years and for the 79 surviving women 22 years. Stage I was found in 94% of cases. Relapse occurred in 24% of women in stage I and 100% of the other stages. Survival in stage I was 95%, 89% and 84% after 5, 10 and 20 years respectively. Increased survival of stage I in postmenopausal women was associated with surgery including hysterectomy and bilateral oophorectomy (p<0.001). In women younger than 40 years no difference in survival was found due to type of surgery. Endometrial carcinoma was found 138 times (95% CI: 48, 275) more prevalent than the expected rate. CONCLUSION: The survival of women was better in AGCT than in epithelial ovarian tumor. Age and type of surgery, besides stage, influenced survival. Total abdominal hysterectomy and bilateral salpingo-oophorectomy is the recommended treatment with advancing age. At younger age less extensive surgery was associated with similar survival compared to extensive surgery, but with advancing age conservative surgery increased the risk of relapse and death.

Ovarian granulosa cell tumor and increased risk of breast cancer.

Granulosa cell tumor of the ovary (GCT) is a rare neoplasm. The tumor often secretes estrogens and then presents at an earlier stage due to hormone-related symptoms. GCT women are at increased risk of endometrial carcinoma, but there is only limited information about GCTs and potential association to other hormone-related neoplasms such as breast cancer. We conducted a retrospective follow-up study on 163 women with GCT. Medical records and histological sections were reviewed and a search in the pathology registry performed. Eight [95% confidence interval (CI); 3.4-15.8] GCT women were diagnosed with a breast neoplasm; one with Paget's disease of the nipple and seven with breast carcinoma. Based on calculations using incidence rates on breast cancer among Danish women, we would have expected 2.5 cases of breast cancer. The odds ratio was 3.3 (95% CI, 1.6-6.6), suggesting an increased risk of breast cancer in GCT women.

Immunoglobulin levels and phagocytes in the cervical mucus plug at term of pregnancy.

BACKGROUND: To characterize the potential for adaptive immune protection in cervical mucus plugs with respect to immunoglobulin isotypes and effector cells (phagocytes). METHODS: Thirty-one cervical mucus plugs were collected from healthy women in labor at term. The cervical mucus plugs were allocated either to analysis of immunoglobulins by enzyme-linked immunosorbent assay (ELISA), gel chromatography and Western blotting (n = 20) or to microscopical, including immunocytochemical, analyses. The levels of immunoglobulin in the plugs were compared to the levels in 10 samples of ovulatory cervical mucus from nonpregnant women. RESULTS: In the cervical mucus plugs, levels of immunoglobulin G (IgG) [median 3270 microg/mL (100-14 500)] and IgA [540 (22-2820)], but not IgM [30.5 (1.0-160)], were significantly elevated compared to cervical mucus from nonpregnant women (p < 0.02 for IgG and IgA). The IgG : IgA ratio in the plugs was also elevated (p < 0.02). The proportion of secretory immunoglobulin A (SIgA) relative to total IgA in the plugs ranged from 16 to 65% (n = 5). IgA and IgG were largely intact. Microscopically, the vagina-proximal part of the cervical mucus plugs contained bacteria and was rich in cells, mainly phagocytes. Conversely, the uterine part contained few cells. CONCLUSION: The high immunoglobulin levels in combination with the presence of phagocytes suggest a potential for adaptive immune defense in the cervical mucus plug, which, together with innate immune factors, may act as an immunological gatekeeper protecting the fetomaternal unit against infection from the vagina.