Race-specific molecular alterations correlate with differential outcomes for black and white endometrioid endometrial cancer patients.

BACKGROUND: The objective of this study was to identify molecular alterations associated with disease outcomes for white and black patients with endometrioid endometrial cancer (EEC). METHODS: EEC samples from black (n = 17) and white patients (n = 13) were analyzed by proteomics (liquid chromatography-tandem mass spectrometry) and transcriptomics (RNA-seq). Coordinate alterations were validated with RNA-seq data from black (n = 49) and white patients (n = 216). Concordantly altered candidates were further tested for associations with race-specific progression-free survival (PFS) in black (n = 64) or white patients (n = 267) via univariate and multivariate Cox regression modeling and log-rank testing. RESULTS: Discovery analyses revealed significantly altered candidate proteins and transcripts between black and white patients, suggesting modulation of tumor cell viability in black patients and cell death signaling in black and white patients. Eighty-nine candidates were validated as altered between these patient cohorts, and a subset significantly correlated with differential PFS. White-specific PFS candidates included serpin family A member 4 (SERPINA4; hazard ratio [HR], 0.89; Wald P value = .02), integrin subunit α3 (ITGA3; HR, 0.76; P = .03), and Bet1 Golgi vesicular membrane trafficking protein like (BET1L; HR, 0.48; P = .04). Black-specific PFS candidates included family with sequence similarity 228 member B (FAM228B; HR, 0.13; P = .001) and HEAT repeat containing 6 (HEATR6; HR, 4.94; P = .047). Several candidates were also associated with overall survival (SERPINA4 and ITGA3) as well as PFS independent of disease stage, grade and myometrial invasion (SERPINA4, BET1L and FAM228B). CONCLUSIONS: This study has identified and validated molecular alterations in tumors from black and white EEC patients, including candidates significantly associated with altered disease outcomes within these patient cohorts. Cancer 2017;123:4004-12. © 2017 American Cancer Society.

Nestin suppression attenuates invasive potential of endometrial cancer cells by downregulating TGF-ß signaling pathway.

Nestin, an intermediate filament protein and a stem cell marker is expressed in several tumors. Until recently, little was known about the expression levels and the role of Nestin in endometrial cancer. Compared to the immortalized endometrial epithelial cell line EM-E6/E7-TERT, endometrial cancer cell lines express high to moderate levels of Nestin. Furthermore, endometrial tumors and tumor cell lines have a cancer stem-like cell subpopulation expressing CD133. Among the cancer lines, AN3CA and KLE cells exhibited both a significantly higher number of CD133+ cells and expressed Nestin at higher levels than Ishikawa cells. Knockdown of Nestin in AN3CA and KLE increased cells in G0/G1 phase of the cell cycle, whereas overexpression in Ishikawa decreased cells in G0/G1 phase and increased cells in S-phase. Nestin knockdown cells showed increased p21, p27, and PNCA levels and decreased expression of cyclin-D1 and D3. In contrast, Nestin overexpression revealed an inverse expression pattern of cell cycle regulatory proteins. Nestin knockdown inhibited cancer cell growth and invasive potential by downregulating TGF-ß signaling components, MMP-2, MMP-9, vimentin, SNAIL, SLUG, Twist, N-cadherin, and upregulating the epithelial cell marker E-cadherin whereas the opposite was observed with Nestin overexpressing Ishikawa cells. Nestin knockdown also inhibited, while overexpression promoted invadopodia formation and pFAK expression. Knockdown of Nestin significantly reduced tumor volume in vivo. Finally, progesterone inhibited Nestin expression in endometrial cancer cells. These results suggest that Nestin can be a therapeutic target for cancer treatment.

Nestin: A biomarker of aggressive uterine cancers.

OBJECTIVE: Evidence of potential prognostic and predictive value for nestin was investigated in well-annotated uterine cancers (UCs). METHODS: Nestin expression and previously-published biomarkers were evaluated by immunohistochemistry (IHC) in UC tissue microarrays. Biomarkers were categorized as low vs. high, and nestin was cut at 10% positive staining. Relationship between nestin and clinicopathologic factors, biomarkers and outcome were evaluated using exact/log-rank testing or logistic/Cox modeling. RESULTS: There were 323 eligible cases, 34% had advanced stage disease, 37% had type II disease, and 5% were carcinosarcomas. High nestin, observed in 19% of cases, was more common in advanced vs. early stage disease, type II cancers or uterine carcinosarcoma vs. type I cancers, grade 3 disease, positive lymphovascular space invasion (LVSI) and tumors >6cm (p<0.05). Nestin was inversely correlated with ER, PR and TFF3, and correlated with p53 and IMP3. Women with high vs. low nestin had worse progression-free survival (PFS) and cancer-specific survival overall, and worse PFS in the subset who received no adjuvant therapy or radiation, or had early stage, type I disease or tumors with both low and high ER, PR, TFF3, PTEN, p53 or IMP3. The relationship between nestin and PFS was independent of stage, LVSI and risk categorization but not type of UC. CONCLUSIONS: High nestin was more common in UCs with aggressive features and poor outcome. Nestin may represent a predictive biomarker for treatment selection for patients previously considered to be lower risk and a candidate for no or radiation-based adjuvant therapy, and compliment ER/PR testing.

Proteomics of the human endometrial glandular epithelium and stroma from the proliferative and secretory phases of the menstrual cycle.

Despite its importance in reproductive biology and women's health, a detailed molecular-level understanding of the human endometrium is lacking. Indeed, no comprehensive studies have been undertaken to elucidate the important protein expression differences between the endometrial glandular epithelium and surrounding stroma during the proliferative and midsecretory phases of the menstrual cycle. We utilized laser microdissection to harvest epithelial cells and stromal compartments from proliferative and secretory premenopausal endometrial tissue and performed a global, quantitative mass spectrometry-based proteomics analysis. This analysis identified 1224 total proteins from epithelial cells, among which 318 were differentially abundant between the proliferative and secretory phases (q < 0.05), and 1005 proteins from the stromal compartments, 19 of which were differentially abundant between the phases (q < 0.05). Several proteins were chosen for validation by immunohistochemistry in an independent set of uterine tissues, including carboxypeptidase M, tenascin C, neprilysin, and ectonucleotide pyrophosphatase/phosphodiesterase family member 3 (ENPP3). ENPP3, which was elevated in epithelial glandular cells in the secretory phase, was confirmed to be elevated in midsecretory-phase baboon uterine lavage samples and also observed to have an N-linked glycosylated form that was not observed in the proliferative phase. This study provides a detailed view into the global proteomic alterations of the epithelial cells and stromal compartments of the cycling premenopausal endometrium. These proteomic alterations during endometrial remodeling provide a basis for numerous follow-up investigations on the function of these differentially regulated proteins and their role in reproductive biology and endometrial pathologies.

The association between specialty match and third-year clerkship performance.

PURPOSE: The United States is experiencing an accelerating physician shortage, especially within primary care. Medical educators are actively seeking ways to predict student specialty match and workforce requirements. Previous studies investigating specialty match have focused on factors known at the time of matriculation. This study examined whether third-year clerkship performance could be used to predict specialty match later in medical school. METHOD: The authors evaluated the clerkship performance of 802 students graduating from the Uniformed Services University between 2007 and 2011. They examined the relationship of students' clerkship grades and National Board of Medical Examiners' clinical subject examination scores to specialty match. In addition, the authors combined student performance in family medicine, internal medicine, and pediatrics to create composite variables and assessed their associations with the match. RESULTS: Among 802 students, 339 (42.4%) students matched to primary care specialties. There was a positive association between higher family medicine (Odds ratio [OR] 1.65, 95% confidence interval [CI] 1.05, 2.59), general surgery (OR 1.91, 95% CI 1.22, 2.99), internal medicine (OR 2.17, 95% CI 1.35, 3.49), and pediatrics (OR 2.59, 95% CI 1.52, 4.43) clerkship grades and students matching into family medicine, general surgery, internal medicine, and pediatrics, respectively. Only family medicine showed a weak correlation between higher National Board of Medical Examiners' scores and specialty match. CONCLUSIONS: Higher clerkship performance in four of six Uniformed Services University third-year clerkships is associated with matching into the corresponding specialty. Clerkship performance provides a potential tool for educators in counseling students and predicting future specialty match.

Laparoscopic hysterectomy using various energy sources in swine: a histopathologic assessment.

OBJECTIVE: Analyze energy-induced damage to the swine vagina during laparoscopic hysterectomy. STUDY DESIGN: Laparoscopic colpotomy was performed in swine using ultrasonic, monopolar, and bipolar energy. Specimens (n = 22) from 13 swine were stained with hematoxylin and eosin and Masson's trichrome for energy-related damage. The distal scalpel-cut margin was used as reference. Energy induced damage was assessed by gynecologic and veterinary pathologists blinded to energy source. RESULTS: Injury was most apparent on Masson's trichrome, demonstrating clear injury demarcation, allowing consistent, quantitative damage measurements. Mean injury was 0 ± 0 µM (scalpel, n = 22), 782 ± 359 µM (ultrasonic, n = 7), 2016 ± 1423 µM (monopolar, n = 8), and 3011 ± 1239 µM (bipolar, n = 7). Using scalpel as the reference, all were significant (P < .001). CONCLUSION: All energy sources demonstrated tissue damage, with ultrasonic showing the least and bipolar the greatest. Further study of tissue damage relative to cuff closure at laparoscopic hysterectomy is warranted.

Reproducibility of endocervical curettage diagnoses.

OBJECTIVE: To estimate overall interobserver variability of histopathology diagnoses on endocervical curettage (ECC) specimens. METHODS: Five study pathologists, blinded to the original diagnosis, reviewed archived ECC specimens initially interpreted as normal, low-grade dysplasia, and high-grade dysplasia. We assessed interobserver agreement and agreement between pathologists using the κ statistic and analyzed the effect of reducing diagnostic choices to two categories (one method using "normal and dysplasia" and another method using "normal and low-grade" and "high-grade or worse"). RESULTS: A total of 90 specimens were reviewed. The overall observer agreement was moderate (κ = 0.52). For specific diagnoses, cases interpreted as normal or high-grade dysplasia demonstrated greater agreement than those interpreted as low-grade dysplasia. Individual pathologists' comparison κ values ranged from 0.31 to 0.80. Changing diagnostic options to a two-tiered system resulted in significant improvement in κ values for only 1 of 36 pathologist comparisons. Using the gynecologist pathologist consensus interpretation, study pathologists downgraded 44% of cases originally interpreted as high-grade. CONCLUSION: Interobserver agreement in the interpretation of ECC specimens is at best moderate, even between those with additional experience and training in gynecologic pathology. Furthermore, reducing diagnostic options to two categories did not improve agreement. It is concerning that important clinical decisions may be made based on an ECC diagnosis that is moderately or poorly reproducible. LEVEL OF EVIDENCE: II.

Anatomical and histological examination of the porcine vagina and supportive structures: in search of an ideal model for pelvic floor disorder evaluation and management.

OBJECTIVE: : The objective of the study was to examine the anatomy and histology of the swine vagina and adjacent supportive structures in comparison to human tissues to determine the potential utility of this model for pelvic floor disorder evaluation and management. METHODS: : This is a descriptive study of the gross anatomy and histology of the swine vagina, uterosacral ligament, cardinal ligament, and rectovaginal space. Tissue was collected from 6 different sites in each of the 6 animals, processed, and stained with hematoxylin-eosin, Masson trichrome, and van Gieson and evaluated by both gynecologic and veterinary pathologists. RESULTS: : Porcine tissues were similar to the human vagina and supporting structures. The origin, insertion, and course of the uterosacral and cardinal ligaments appeared similar to those in humans. Histologically, both the porcine and human vagina and rectum consist of a mucosal, muscular, and adventitial layers. The swine vaginal smooth muscle is arranged in an inner circular and outer longitudinal manner. Collagen, elastin, and smooth muscle were identified in 5 sites. Collagen was highest in the cardinal compared with the uterosacral ligament (P = 0.03), whereas elastin was highest in the uterosacral ligament. The vaginal epithelium measured approximately 40 µm at the vaginal cuff and 50 to 200 µm at anterior and posterior vagina. The swine vagina appeared thinner and contained less elastin. The rectovaginal region contained a smooth muscle layer leading to a thin adventitial layer. CONCLUSIONS: : The swine vagina and adjacent supportive structures appear to be grossly and histologically similar to human vaginal anatomy, and these similarities could lead to further investigation of the porcine model in the study of pelvic support and support disorders.

Diffuse laminar endocervical glandular hyperplasia: a case report.

BACKGROUND: Diffuse laminar endocervical glandular hyperplasia is extremely rare with only 14 cases reported in the literature. Diffuse laminar endocervical glandular hyperplasia is a benign lesion that is easily confused with malignancy. CASE REPORT: We present a 22-year-old woman referred to our gynecologic oncology service with a 2.0 x 4.0-cm exophytic cervical mass. Colposcopic-directed cervical biopsies were diagnosed as adenocarcinoma, suggestive of minimal deviation adenocarcinoma. Computed tomographic scans of the abdomen and the pelvis failed to reveal any metastatic foci. A radical abdominal hysterectomy with pelvic and para-aortic lymph node sampling was performed without complications. Final pathology revealed diffuse laminar endocervical glandular hyperplasia. CONCLUSIONS: Diffuse laminar endocervical glandular hyperplasia is an uncommon histological type of pseudoneoplastic glandular lesions that may be found in the cervix, and this entity should be considered in the differential diagnosis of a potentially malignant endocervical glandular lesion.

Prophylactic Burch colposuspension at the time of abdominal sacrocolpopexy: a survey of current practice patterns.

INTRODUCTION: The purpose of this study was to determine the utilization of the prophylactic Burch procedure with abdominal sacrocolpopexy since the publication of the Colpopexy and Urinary Reduction Efforts (CARE) trial. METHODS: Using an Internet survey, 1,134 members of the American Urogynecological Society (AUGS) were contacted in May 2008 and questioned regarding their practice patterns to prevent de novo stress incontinence after sacrocolpopexy. RESULTS: Two hundred sixty-six responses were obtained for a 23% response rate. Of the 235 respondents actively performing sacrocolpopexies, 133 (57%) would not perform a prophylactic Burch colposuspension at the time of sacrocolpopexy in a woman without symptoms of stress urinary incontinence. Respondents were more likely to perform a prophylactic Burch if it had been more than 6 years since they completed residency or fellowship training. CONCLUSIONS: Prophylactic Burch colposuspension at the time of abdominal sacrocolpopexy has not been uniformly implemented into clinical practice by AUGS members since the publication of the CARE Trial.

The use of reflex high-risk human papillomavirus testing for atypical squamous cells of undetermined significance interpretations on vaginal specimens.

BACKGROUND: The use of reflex high-risk human papillomavirus (hrHPV) testing as a triage method for cervical specimens with an interpretation of atypical squamous cells of undetermined significance (ASC-US) is well established. To the authors' knowledge, very little has been reported regarding the utility of this approach in vaginal specimens in women with a prior hysterectomy. The current study evaluated the results of hrHPV testing in women with vaginal specimens interpreted as ASC-US in the authors' laboratory. METHODS: Follow-up information, including results of hrHPV testing, was sought for all vaginal smears reported as ASC-US from the authors' cytology laboratory during the calendar years 2005 and 2006. RESULTS: For the 2 years reviewed, 254 ASC-US vaginal specimens were available for assessment. Reflex hrHPV testing was requested on 236 (92.9%), with sufficient residual material available in 193 specimens. hrHPV was detected in 44 (22.8%). Follow-up results were available for 136 specimens, with a squamous intraepithelial lesion (SIL, all but 1 of which was low grade) found to be present in 21 (15.4%). SIL was identified in significantly more women in whom hrHPV was detected compared with those in whom hrHPV was not detected (41.9% vs 4.2%; P < .001 by the Fisher exact test). CONCLUSIONS: Rates of detection of squamous abnormalities in women with ASC-US on vaginal preparations in whom hrHPV was detected were found to be higher than in those without hrHPV. These findings suggest that clinical follow-up is needed for women in whom hrHPV is detected. hrHPV testing may be clinically useful as a method of triage for women with ASC-US vaginal smears.

Symptomatic stress urinary incontinence not demonstrated clinically: survey of practice patterns.

The aim of this study was to survey obstetrician/gynecologists and urologists regarding management of women undergoing hysterectomy with complaints of stress urinary incontinence (SUI) not demonstrated clinically. A survey was distributed electronically to military healthcare system OB/GYN and urologist physicians. Overall descriptive data and responses analyzed according to respondent demographics and the presence or absence of pelvic organ prolapse are reported. Two-hundred forty-two responses were obtained (44% response rate). Without prolapse, only 32% would perform an anti-incontinence procedure, more often by urologists than OB/GYN physicians. With prolapse, more respondents would perform an anti-incontinence procedure (32% increasing to 59%, p < 0.001). A mid-urethral sling was the most common procedure that was offered. Trainee versus attending status and teaching versus non-teaching responsibilities did not affect responses. There is no consensus among military obstetricians/gynecologists and urologists regarding management of women otherwise undergoing pelvic surgery with subjective SUI. The presence of prolapse influences this decision.

To ECC or not to ECC: the question remains.

The usefulness of endocervical curettage (ECC) in evaluating women who have abnormal cervical cytology and histopathology has been debated for years; data regarding performance of ECC in the diagnostic evaluations of squamous and glandular lesions are mixed. There are no well-done randomized trials or systematic reviews regarding the usefulness of ECC. The yield on ECC increases in the setting of unsatisfactory colposcopy; in this situation, there seems less controversy regarding performance of an ECC. Reproducibility of ECC-rendered diagnosis is a concern. Data are needed to further define the role of ECC in evaluating women who have cervical disease.

The significance of high-risk human papillomavirus detection in women aged > or = 50 years with atypical squamous cells of undetermined significance cytologic preparations.

BACKGROUND: The use of high-risk human papillomavirus (HRHPV) testing in the triage of women with a cytologic diagnosis of atypical squamous cells of undetermined significance (ASC-US) has gained widespread acceptance. To date, very little has been reported on the significance of the detection of HRHPV in elderly women. METHODS: Results of HRHPV testing performed on women aged > or =50 years were examined for a 20-month period. Reflex testing for HRHPV was performed on residual liquid-based cytology specimens from women who were diagnosed with ASC-US by using the Digene Hybrid Capture method. Follow-up information on women who had HRHPV detected was obtained from subsequent pathology reports (cytology and surgical). RESULTS: HRHPV testing was performed on 762 specimens from women aged > or =50 years; virus was detected in 105 specimens (13.8%), and follow-up was available in 63 of those women (60%). Follow-up results included negative tests in 32 women (50.8% of those with follow-up available), low-grade squamous intraepithelial lesion in 26 women (41.3%), and high-grade squamous intraepithelial lesion (HSIL) in 5 women (7.9%). No glandular neoplasia or invasive carcinoma was identified. Relative light units/cutoff (RLU/CO) values ranged from 1 RLU/CO to 1705 RLU/CO; no significant associations were identified between RLU/CO values and follow-up results. CONCLUSIONS: Although HRHPV was detected in a minority of samples, HSIL was present in 7.9% of those with HRHPV. This confirms that the presence of HRHPV in women aged > or =50 years with ASC-US specimens needs clinical follow-up. There were no significant differences in RLU/CO values between women with positive versus negative follow-up to allow for further discrimination for follow-up.

Simulation training improves resident performance in operative hysteroscopic resection techniques.

OBJECTIVE: The purpose of this study was to determine whether a simulated training scenario improved resident performance in operative hysteroscopic resection. STUDY DESIGN: An interventional cohort study evaluated the ability of a hysteroscopic simulation model to improve resident performance in hysteroscopy. Residents were evaluated on operative hysteroscopy before training and at 1 and 6 months after training. Two physician graders, who were blinded to training status, evaluated the residents' performances. Statistical analyses included the chi2 and the t test, as appropriate. RESULTS: Hysteroscopic simulation training was associated with a reduction in operative times (11.8 minutes vs 7.4 minutes; P < .001) and resection times (4.3 minutes vs 2.4 minutes; P < .007) 1 month after training. At 6 months, total operative times were greater compared with those measured at 1 month, but resection times differed minimally. The total number of questions regarding hysteroscopic knowledge that were answered correctly increased from 15 to 26 (P < .001). CONCLUSION: Training that used a simulation hysteroscopic model improved resident performance.

Establishing a mean postvoid residual volume in asymptomatic perimenopausal and postmenopausal women.

OBJECTIVE: To estimate mean postvoid residual (PVR) volumes among perimenopausal and postmenopausal women without significant lower urinary tract or pelvic organ prolapse symptoms. METHODS: Patients presenting for well-women encounters were offered study participation. Women with a history of urinary incontinence greater than twice per week, urinary retention, symptomatic pelvic organ prolapse, or neurologic disorders were excluded. Pelvic relaxation, if present, was characterized according to the pelvic organ prolapse quantification system. Within 10 minutes of spontaneously voiding, PVR volume was assessed with bladder ultrasonography. RESULTS: A total of 96 patients were enrolled; mean age was 60+/-11 years. The majority (80%) were postmenopausal; 30% had a previous hysterectomy. Most women (92%) had some degree of prolapse; the median stage was one, most commonly involving the anterior compartment (70%). The median PVR volume was 19 mL (range 0-145 mL); the mean PVR volume was 24+/-29 mL. Only 15% of patients had a PVR volume greater than 50 mL, and 95% had a PVR volume 100 mL or less. Only age 65 years or older was associated with a higher mean PVR volume; hormone therapy, vaginal atrophy, parity, and stage of asymptomatic prolapse did not affect PVR volumes. CONCLUSION: Most asymptomatic perimenopausal and postmenopausal women had a PVR volume less than 50 mL, which was unaffected by multiple factors that were thought to potentially affect bladder function. Establishing "normal" volumes in this population may aid in developing recommendations regarding appropriate bladder function and retention criteria for women who are symptomatic or those who have had pelvic floor surgery.