Vestibular Sclerosis: Is This a New, Distinct Clinicopathological Entity?

OBJECTIVES: The aims of this case series were to present a series of patients with clinical and histopathological findings consistent with a recently described condition vestibular sclerosis (VS) and to contribute to the current discussion of whether VS is a subset of lichen sclerosus (LS) or a distinct entity. MATERIALS AND METHODS: This case series of 6 women for a 12-month period was initiated from an ongoing collaboration between a gynecological dermatologist and an anatomical pathologist specializing in gynecological dermatopathology. RESULTS: We describe 6 women with white, hyperkeratotic patches and plaques confined to the vulvar vestibule with stromal sclerosis and an absence of inflammation on histology. All our patients were either perimenopausal or postmenopausal. The condition was either asymptomatic or characterized by mild to moderate dyspareunia. No patient had LS elsewhere on the vulva. There was no response to estrogen or topical corticosteroid therapy in symptomatic patients. CONCLUSIONS: Vestibular sclerosis may be a new distinct clinicopathologial entity, which is in the differential diagnosis of white plaques and patches in the vulvar vestibule. The characteristic siting in the anterior vestibule only, in the presence of an otherwise normal vulva and absence of inflammation on histology, is a reason to separate this condition from LS.

Looking beyond human papillomavirus (HPV) genotype 16 and 18: Defining HPV genotype distribution in cervical cancers in Australia prior to vaccination.

Australia has implemented a high-coverage HPV vaccination program but has not, to date, established the distribution of HPV types that occur in cervical cancers in Australia. This information is important for determining the potential for cervical cancer prevention with both current and broader spectrum HPV vaccines. We analysed 847 cervical cancers diagnosed 2005 to 2015 in tertiary centres in the three most populous Australian states with resolution of specimens containing multiple HPV types using laser-capture microdissection. Archived FFPE tissue was reviewed by specialist pathologists, sandwich sectioned, and initially whole-tissue sections genotyped for HPV. Samples were first genotyped using SPF10-LiPA25 (version 1). Negative samples were screened with DNA ELISA kit HPV SPF10, followed by genotyping with SPF+ LiPA if ELISA positive. If still negative, samples were tested on a qPCR assay targeting the E6 region of HPV16, 18, 45 and 33. Of the 847 cancers (65.1% squamous, 28.7% adenocarcinoma, 4.3% adenosquamous, 2.0% other), 92.9% had HPV detected. Of the HPV-positive cancers, 607 of 787 (77.1%) contained HPV16 or 18, 125 of 787 (15.9%) contained HPV31/33/45/52 or 58, and 55 (7.0%) another HPV type. There was a strong correlation between HPV type and age, with younger women most likely to have HPV16/18 detected and least likely HPV negative. Our findings indicate that cervical cancers diagnosed in Australia more frequently contain HPV16/18 than in international series. This could be due to cervical screening in Australia increasing the proportion of adenocarcinomas, in which types 18 and 16 more strongly predominate, due to prevention of squamous cancers.

A vesicular variant of pseudoverrucous papules and nodules in the genital area of an incontinent 4-year-old.

Irritant contact dermatitis is a common cause of chronic vulvitis in patients wearing diapers and incontinence garments. In most cases the diagnosis is obvious; however, atypical presentations may mimic more serious dermatoses. We present a 4-year-old girl who presented at birth with cloacal atresia corrected surgically and resulting in chronic incontinence requiring full-time diapers. She presented with crops of herpetiform vesicles and bullae on a base that ranged from normal skin to severe erythema and oedema. A histological examination revealed a well-demarcated lesion showing a thickened epidermis with hyperkeratosis and parakeratosis, acanthosis and an abrupt transition to pallor of the upper half. Focal full thickness epidermis necrosis and small areas of spongiosis, acantholysis and apoptotic keratinocytes were seen. Immunofluorescence was negative. The lesions improved with the treatment of secondary infection and minimal topical therapy with an emollient only. This case represents an unusual vesicular variant of pseudoverrucous papules and nodules, which has been reported only once previously.

Unusual locations of primary subepithelial squamous cell carcinomas of the vulva.

OBJECTIVE: This study aimed to report 2 cases of squamous cell carcinoma (SCC) of the vulva, arising from unusual subepithelial locations. MATERIALS AND METHODS: The first case was of an 85-year-old woman with a 65-year history of a mass in the left labium majus. The second case was of a 54-year-old woman who presented with a 1-week history of a painful left inguinal mass. She had previously sought medical attention for a 2-year history of a left-sided painless vestibular mass. RESULTS: In the first case, a simple excision showed a purely dermal SCC with no attachment to the epidermis. After the diagnosis of SCC, a wide, deep local excision of the left side of the vulva and left inguinofemoral lymph node dissection were performed. Pathological findings showed no residual tumor in the vulva, and the lymph nodes were clear. Based on the long history of a mass at the same site, the pathogenesis of the SCC was considered to be malignant degeneration of a previously benign epidermal cyst.In the second case, SCC was diagnosed on fine-needle aspirations of the vulvar and groin masses. The patient was treated with primary chemoradiation. Subsequently, wide, deep local excision of the left side of the vulva and left inguinofemoral lymph node dissection were performed. No residual tumor was found in the vulva, although atrophic Bartholin gland tissue was found at the site of the SCC. One 5-mm inguinofemoral lymph node metastasis was found in the groin node dissection. In the absence of any evidence of another pathogenesis, it was believed that the SCC had arisen from an unusually anterior located Bartholin gland. CONCLUSIONS: Subepithelial SCC should be considered in the differential diagnosis of unusually located vulvar masses.

Prognostic and diagnostic significance of DNA methylation patterns in high grade serous ovarian cancer.

OBJECTIVE: Altered DNA methylation patterns hold promise as cancer biomarkers. In this study we selected a panel of genes which are commonly methylated in a variety of cancers to evaluate their potential application as biomarkers for prognosis and diagnosis in high grade serous ovarian carcinoma (HGSOC); the most common and lethal subtype of ovarian cancer. METHODS: The methylation patterns of 10 genes (BRCA1, EN1, DLEC1, HOXA9, RASSF1A, GATA4, GATA5, HSULF1, CDH1, SFN) were examined and compared in a cohort of 80 primary HGSOC and 12 benign ovarian surface epithelium (OSE) samples using methylation-specific headloop suppression PCR. RESULTS: The genes were variably methylated in primary HGSOC, with HOXA9 methylation observed in 95% of cases. Most genes were rarely methylated in benign OSE, with the exception of SFN which was methylated in all HGSOC and benign OSE samples examined. Methylation of DLEC1 was associated with disease recurrence, independent of tumor stage and suboptimal surgical debulking (HR 3.5 (95% CI:1.10-11.07), p=0.033). A combination of the methylation status of HOXA9 and EN1 could discriminate HGSOC from benign OSE with a sensitivity of 98.8% and a specificity of 91.7%, which increased to 100% sensitivity with no loss of specificity when pre-operative CA125 levels were also incorporated. CONCLUSIONS: This study provides further evidence to support the feasibility of detecting altered DNA methylation patterns as a potential diagnostic and prognostic approach for HGSOC.

MAL2 and tumor protein D52 (TPD52) are frequently overexpressed in ovarian carcinoma, but differentially associated with histological subtype and patient outcome.

BACKGROUND: The four-transmembrane MAL2 protein is frequently overexpressed in breast carcinoma, and MAL2 overexpression is associated with gain of the corresponding locus at chromosome 8q24.12. Independent expression microarray studies predict MAL2 overexpression in ovarian carcinoma, but these had remained unconfirmed. MAL2 binds tumor protein D52 (TPD52), which is frequently overexpressed in ovarian carcinoma, but the clinical significance of MAL2 and TPD52 overexpression was unknown. METHODS: Immunohistochemical analyses of MAL2 and TPD52 expression were performed using tissue microarray sections including benign, borderline and malignant epithelial ovarian tumours. Inmmunohistochemical staining intensity and distribution was assessed both visually and digitally. RESULTS: MAL2 and TPD52 were significantly overexpressed in high-grade serous carcinomas compared with serous borderline tumours. MAL2 expression was highest in serous carcinomas relative to other histological subtypes, whereas TPD52 expression was highest in clear cell carcinomas. MAL2 expression was not related to patient survival, however high-level TPD52 staining was significantly associated with improved overall survival in patients with stage III serous ovarian carcinoma (log-rank test, p < 0.001; n = 124) and was an independent predictor of survival in the overall carcinoma cohort (hazard ratio (HR), 0.498; 95% confidence interval (CI), 0.34-0.728; p < 0.001; n = 221), and in serous carcinomas (HR, 0.440; 95% CI, 0.294-0.658; p < 0.001; n = 182). CONCLUSIONS: MAL2 is frequently overexpressed in ovarian carcinoma, and TPD52 overexpression is a favourable independent prognostic marker of potential value in the management of ovarian carcinoma patients.

Low meprin alpha expression differentiates primary ovarian mucinous carcinoma from gastrointestinal cancers that commonly metastasise to the ovaries.

BACKGROUND: Currently, no specific immunohistochemical markers are available to differentiate primary mucinous epithelial ovarian cancer (MOC) from adenocarcinomas originating at other sites that have metastasised to the ovary, which may have an impact on patient management and prognosis. AIM: To investigate the expression of two intestinal markers, galectin 4 and meprin alpha, in mucinous carcinomas of the ovary and gastrointestinal tract. METHODS: Using immunohistochemical analysis, the expression of galectin 4 and meprin alpha was investigated in 10 MOCs and in 38 mucinous adenocarcinomas of colon, pancreas, stomach and appendix, the most common sites of origin of ovarian metastases. RESULTS: Total cytoplasmic galectin 4 expression was relatively consistent between the different carcinomas. Membranous meprin alpha expression was significantly lower in MOCs compared with gastrointestinal carcinomas. Moreover, meprin alpha expression showed greater discrimination between the ovarian and gastrointestinal carcinomas than the cytokeratins CK7 and CK20, the current standard immunohistochemical markers used to determine the tissue origin of mucinous carcinomas involving the ovaries. CONCLUSIONS: Meprin alpha is a useful additional marker in differentiating primary from secondary mucinous adenocarcinomas of the ovary.

A clinicopathological review of 33 patients with vulvar melanoma identifies c-KIT as a prognostic marker.

Vulvar melanoma is the second most common vulvar cancer. Patients with vulvar melanoma usually present with the disease at a late stage and have a poor prognosis. The prognostic predictors reported in the literature are not unequivocal and the role of lichen sclerosus and c-KIT mutations in the aetiology of vulvar melanoma is unclear. Breslow staging currently seems to be the most adequate predictor of prognosis. We thus performed a clinicopathological and literature review to identify suitable predictors of prognosis and survival and investigated the expression of c-KIT (by immunohistochemistry) in patients with vulvar melanoma (n=33) from the Gynaecological Cancer Centres of the Royal Hospital for Women (Sydney, Australia) and John Hunter Hospital (Newcastle, Australia). Our series of 33 patients fitted the expected clinical profile of older women: delayed presentation, high stage, limited response to treatment and poor prognosis. We identified 3 patients (9.1%) with lichen sclerosus associated with melanoma in situ, although no lichen sclerosus was found in the areas of invasive melanoma. No patient had vulvar nevi. We identified a) Breslow's depth, b) an absence of any of the pathological risk factors, such as satellitosis, in-transit metastasis, lymphovascular space invasion (LVSI) and dermal mitosis, c) removal of inguino-femoral lymph nodes, d) lateral margin of >1 cm, and e) c-KIT expression as valuable prognostic predictors for disease-free survival. We conclude that c-KIT expression is, apart from Breslow's depth, another valuable predictor of prognosis and survival. Lichen sclerosus may be associated with vulvar melanoma.

Fatty infiltration of an aortic valve.

Adipose tissue is a normal constituent of the heart, but not a normal anatomic finding of cardiac valves. Fatty infiltration of the aortic valve is rare, with unknown significance on valve function. We report a case of fatty infiltration and replacement of the spongiosa layer in an incompetent aortic valve. The mechanism of fat infiltration is unknown, but may be explained by differentiation of preexisting valve interstitial cells secondary to valvular injury.

Integrative genome-wide expression and promoter DNA methylation profiling identifies a potential novel panel of ovarian cancer epigenetic biomarkers.

To identify epigenetic-based biomarkers for diagnosis of ovarian cancer we performed MeDIP-Chip in A2780 and CaOV3 ovarian cancer cell lines. Validation by Sequenom massARRAY methylation analysis confirmed a panel of six gene promoters (ARMCX1, ICAM4, LOC134466, PEG3, PYCARD & SGNE1) where hypermethylation discriminated 27 serous ovarian cancer clinical samples versus 12 normal ovarian surface epithelial cells (OSE) (ROC of 0.98). Notably, CpG sites across the transcription start site of a potential long-intergenic non-coding RNA (lincRNA) gene (LOC134466), was shown to be hypermethylated in 81% of serous EOC and could differentiate tumours from OSE (p<0.05). We propose that this potential biomarker panel holds great promise as a diagnostic test for high-grade (Type II) serous ovarian cancer.

Loss of secreted frizzled-related protein 4 correlates with an aggressive phenotype and predicts poor outcome in ovarian cancer patients.

BACKGROUND: Activation of the Wnt signaling pathway is implicated in aberrant cellular proliferation in various cancers. In 40% of endometrioid ovarian cancers, constitutive activation of the pathway is due to oncogenic mutations in ß-catenin or other inactivating mutations in key negative regulators. Secreted frizzled-related protein 4 (SFRP4) has been proposed to have inhibitory activity through binding and sequestering Wnt ligands. METHODOLOGY/PRINCIPAL FINDINGS: We performed RT-qPCR and Western-blotting in primary cultures and ovarian cell lines for SFRP4 and its key downstream regulators activated ß-catenin, ß-catenin and GSK3ß. SFRP4 was then examined by immunohistochemistry in a cohort of 721 patients and due to its proposed secretory function, in plasma, presenting the first ELISA for SFRP4. SFRP4 was most highly expressed in tubal epithelium and decreased with malignant transformation, both on RNA and on protein level, where it was even more profound in the membrane fraction (p<0.0001). SFRP4 was expressed on the protein level in all histotypes of ovarian cancer but was decreased from borderline tumors to cancers and with loss of cellular differentiation. Loss of membrane expression was an independent predictor of poor survival in ovarian cancer patients (p = 0.02 unadjusted; p = 0.089 adjusted), which increased the risk of a patient to die from this disease by the factor 1.8. CONCLUSIONS/SIGNIFICANCE: Our results support a role for SFRP4 as a tumor suppressor gene in ovarian cancers via inhibition of the Wnt signaling pathway. This has not only predictive implications but could also facilitate a therapeutic role using epigenetic targets.