The Immunohistochemical Profile of Mammary Tissue in Women With Macromastia and Its Potential Clinical Implications.

Macromastia is an excessive, rapid, or slow growth of breast tissue in 1 or both breasts. While macromastia represents a benign lesion, it may cause breast, shoulder, back, and neck pain, poor posture, infections, and loss of nipple sensation. The pathogenesis of macromastia or hypertrophy of mammary tissue remains poorly understood. The purpose of this study is to investigate the immunohistochemical expression of several hormone receptors that may potentially influence the growth of breast tissue in women with macromastia. Immunohistochemical studies performed on representative sections of breast tissue from 63 patients diagnosed with macromastia included estrogen receptor, progesterone receptor, androgen receptor (AR), prolactin receptor, growth hormone receptor, and vascular endothelial growth factor. The expression of each stain was evaluated separately in the glandular epithelium and adipose tissue and calculated as an H-score. We observed that AR expression in breast glandular and adipose tissue in women with macromastia was significantly lower than benign, nonhypertrophic breast tissue of a control group. Although the analyses were controlled for the age, the fact the mean age and hormonal status differed between the patients and the controls could have affected the results. Additional large studies will be required to further verify this finding and increase the knowledge about the etiology of this condition and then guide pharmacological treatment of juvenile and/or idiopathic gigantomastia.

Implementation of Digital Image Analysis in Assessment of Ki67 Index in Breast Cancer.

The clinical utility of the proliferation marker Ki67 in breast cancer treatment and prognosis is an active area of research. Studies have suggested that differences in pre-analytic and analytic factors contribute to low analytical validity of the assay, with scoring methods accounting for a large proportion of this variability. Use of standard scoring methods is limited, in part due to the time intensive nature of such reporting protocols. Therefore, use of digital image analysis tools may help to both standardize reporting and improve workflow. In this study, digital image analysis was utilized to quantify Ki67 indices in 280 breast biopsy and resection specimens during routine clinical practice. The supervised Ki67 indices were then assessed for agreement with a manual count of 500 tumor cells. Agreement was excellent, with an intraclass correlation coefficient of 0.96 for the pathologist-supervised analysis. This study illustrates an example of a rapid, accurate workflow for implementation of digital image analysis in Ki67 scoring in breast cancer.

Utility of TRPS1 immunohistochemistry in confirming breast carcinoma: Emphasis on staining in triple-negative breast cancers and gynecologic tumors.

OBJECTIVES: Our aim was to explore the performance of TRPS1 as an immunohistochemical diagnostic marker; find the optimal conditions for its use in breast carcinomas, especially triple-negative breast cancers (TNBCs); and compare its results in carcinomas of a select few organ sites, with an emphasis on gynecologic tumors. METHODS: Tissue microarrays from breast carcinomas (n = 197), endometrial adenocarcinomas (n = 69), ovarian tumors (n = 250), vulvar squamous cell carcinomas (n = 97), pancreatic ductal adenocarcinomas (n = 20), and gastric adenocarcinomas (n = 12) were stained with TRPS1 using 2 different conditions (protocol 1: high pH; protocol 2: low pH). Breast carcinomas consisted of hormone receptor (HR)-positive/ERBB2 (formerly HER2 or HER2/neu)-negative (n = 53) samples, HR-positive/ERBB2-positive (n = 6) samples, and TNBCs (n = 138). RESULTS: Comparing TRPS1 results in breast carcinomas vs tumors from other organ sites, the sensitivity of TRPS1 was 91% and 87%, respectively, while the specificity was 66% and 74% for protocol 1 and 2, respectively. For TNBCs vs gynecologic tumors, the sensitivity of TRPS1 was 89% and 85%, respectively, while the specificity was 65% and 73%, respectively. CONCLUSIONS: TRPS1 stains approximately 90% of breast carcinomas but also up to 71% of endometrial carcinomas, albeit with a weaker median expression. Our data show that although TRPS1 is a highly sensitive marker for TNBCs, it is not as highly specific as previously reported.

ARID1A, BRG1, and INI1 deficiency in undifferentiated and dedifferentiated endometrial carcinoma: a clinicopathologic, immunohistochemical, and next-generation sequencing analysis of a case series from a single institution.

Undifferentiated/dedifferentiated endometrial carcinomas (UDEC and DDEC) are rare, aggressive uterine neoplasms, with no specific line of differentiation. A significant proportion of these cases feature mutations of SWI/SNF chromatin remodeling complex members, including ARID1A, SMARCA4, and SMARCB1 genes. To study these entities more comprehensively, we identified 10 UDECs and 10 DDECs from our pathology archives, obtained clinicopathologic findings and follow-up data, and performed immunohistochemical studies for ARID1A, BRG1 (SMARCA4), and INI1 (SMARCB1) proteins. In addition, we successfully conducted targeted next-generation sequencing for 23 samples, including 7 UDECs, and 7 undifferentiated and 9 well/moderately-differentiated components of DDECs. Cases consisted of 18 hysterectomies and 2 curettage/biopsy specimens. Patient age ranged from 47 to 77 years (median, 59 years), with a median tumor size of 8.0 cm (range, 2.5-13.0 cm). All cases demonstrated lymphovascular invasion and the majority (13/20) were FIGO stage III-IV. By immunohistochemistry, ARID1A loss was observed in 15 cases, BRG1 loss in 4, and all cases had intact INI1 expression. A trend for enrichment of the undifferentiated component of DDECs for ARID1A loss was seen, although not statistically significant. Sequencing revealed frequent pathogenic mutations in PTEN, PIK3CA, ARID1A, CTNNB1, and RNF43, a recurrent MAX pathogenic mutation, and MYC and 12p copy number gains. In DDECs, the undifferentiated component featured a higher tumor mutational burden compared to the well/moderately-differentiated component; however, the mutational landscape largely overlapped. Overall, our study provides deep insights into the mutational landscape of UDEC/DDEC, SWI/SNF chromatin remodeling complex member status, and their potential relationships with tumor features.

The Utility of SOX10 Immunohistochemical Staining in Breast Pathology.

OBJECTIVES: SOX10 expression helps identify melanocytic lesions. Over time, novel uses have been identified, such as expression in triple-negative breast cancer (TNBC). We evaluated the usefulness of SOX10 in breast pathology-specifically, identification and subtyping of TNBC and distinction from gynecologic carcinomas, use as a myoepithelial marker, and in the distinction of usual ductal hyperplasia (UDH) from atypical ductal hyperplasia (ADH). METHODS: Several breast and gynecologic carcinoma tissue microarrays containing a total of 492 cases were stained with SOX10. Whole sections of 34 ADH, 50 UDH, and 29 ductal carcinoma in situ (DCIS) samples were also stained with SOX10. RESULTS: SOX10 expression was identified in 67% of consecutive TNBC cases. Expression was mostly seen in nonapocrine, androgen receptor (AR)-negative TNBCs. All gynecologic carcinomas (n = 157) were negative. All UDH cases showed mosaic SOX10 expression, while all ADH cases lacked expression. All estrogen receptor (ER)-positive DCIS (n = 19) specimens were negative for SOX10, while 2 of 10 ER-negative DCIS specimens were positive for SOX10. The latter 2 cases showed SOX10-positive invasive carcinomas. CONCLUSIONS: SOX10 identifies nonluminal AR-type TNBC and is useful in distinguishing TNBC from gynecologic carcinomas. SOX10 can distinguish UDH from ADH. SOX10 is not useful in distinguishing ADH from DCIS.

The Potential Prognostic and Therapeutic Implications of Prolactin Receptor and Growth Hormone-releasing Hormone Receptor Expression in Uterine Leiomyosarcomas.

The management of uterine leiomyosarcomas (uLMS) remains challenging. The rate of recurrence and metastasis is high, with 5-yr survival reaching only 40% to 50% in patients with tumor confined to the uterus (FIGO stage I or II). Prolactin receptor (PRLR) and growth hormone-releasing hormone receptor (GHRHR) have been implicated in the carcinogenesis of malignant tumors of the breast, endometrium, ovary, liver, and prostate. GHRHR antagonists inhibit in vitro growth of many human tumors and the expression of PRLR is associated with resistance to chemotherapy. The immunohistochemical expression of PRLR and GHRH in 24 primary and 2 recurrent uLMS was evaluated. Representative sections were stained with PRLR and GHRHR antibodies and immunoreactivity was calculated using H -score. The results were correlated with clinicopathologic data using Kaplan-Meier survival and multivariable Cox proportion hazard regression analyses. All tumors were positive for both markers with predominantly moderate to strong expression of PRLR (89%) and GHRHR (82%). Patients with tumors showing moderate to strong expression of PRLR were significantly less likely to achieve disease-free survival ( P =0.004) and significantly more likely to have a poor overall survival ( P =0.049). No significant difference in mean PRLR expression was found between tumors with higher mitotic counts (>20/10 hpf) and lower mitotic counts (20 or less/10 hpf). Furthermore, in 2 patients where the primary and recurrent tumors were tested, there was stronger expression of PRLR in the recurrence compared with the primary. This correlation was not found with GHRHR. Both PRLR and GHRHR may play a role in carcinogenesis in uLMS, as they do in other malignant neoplasms. To our knowledge, this study is the first evaluating the expression of these receptors in uLMS. Moderate or high expression of PRLR may serve as a prognostic marker associated with recurrences and increased mortality in uLMS patients.

Immunohistochemical Markers With Potential Diagnostic, Prognostic, and Therapeutic Significance in Uterine Carcinosarcoma: A Clinicopathologic Study of 43 Cases.

Uterine carcinosarcomas (UCS) are rare and highly aggressive tumors. Although it is currently accepted that the majority of UCS are metaplastic carcinomas, their aggressive behavior is unparalleled to that of any other high-grade endometrial neoplasms. Therefore, the search for the distinct immunohistochemical and molecular features that could help in the development of new treatment strategies continues. We evaluated the expression of PDL-1, growth hormone releasing hormone receptor, p53, WT1, PAX-8, estrogen receptor, HNF-1, and mismatch repair proteins in 43 UCS. Tumors were selected from the archives of the Magee-Womens Hospital University of Pittsburgh Medical Center Department of Pathology. Seventeen were stage I, 4 were stage II, 15 were stage III, and 7 were stage IV. The median age was 67 yr and median overall survival was 3.2 yr. Immunostaining for PAX8, HNF-1, and estrogen receptor showed statistically significant difference between epithelial and stromal components. Expression of p53 was significantly associated with clinical high stage, but other markers did not correlate with stage or survival. Immunostaining for programmed death ligand-1 was strongly positive in 30 UCS (70%), including 24 cases with tumor cell positivity, 12 cases with tumor cell and tumor-infiltrating immune cell positivity, and 6 cases with tumor-infiltrating immune cell positivity only. Of 27 tumors tested for mismatch repair expression, 12 (44%) showed loss of expression, 7 of which were PDL-1 positive. Growth hormone releasing hormone receptor was positive in 38 tumors (88%) and predominantly expressed in the epithelial component. The range of positivity for programmed death ligand-1 and growth hormone releasing hormone receptor suggests a possible potential adjuvant treatment that may be considered for UCS.

Highly heterogeneous genomic landscape of uterine leiomyomas by whole exome sequencing and genome-wide arrays.

OBJECTIVE: To determine the genomic signatures of human uterine leiomyomas and prevalence of MED12 mutations in human uterine leiomyosarcomas. DESIGN: Retrospective cohort study. SETTING: Not applicable. PATIENT(S): This study included a set of 16 fresh frozen leiomyoma and corresponding unaffected myometrium specimens as well as 153 leiomyosarcomas collected from women diagnosed with uterine leiomyomas or leiomyosarcomas who underwent clinically indicated abdominal hysterectomy. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Whole exome sequencing and high-resolution X-chromosome and whole genome single nucleotide polymorphism microarray analyses were performed on leiomyoma samples negative for the known MED12 mutations and compared with their corresponding myometrium. Leiomyosarcoma specimens were examined for exon 2 MED12 mutations to evaluate the frequency of MED12 mutated leiomyosarcomas. RESULT(S): Our results indicate remarkable genomic heterogeneity of leiomyoma lesions. MED12-negative leiomyomas contain copy number alterations involving the Mediator complex subunits such as MED8, MED18, CDK8, and long intergenic nonprotein coding RNA340 (CASC15), which may affect the Mediator architecture and/or its transcriptional activity. We also identified mutations in a number of genes that were implicated in leiomyomagenesis such as COL4A6, DCN, and AHR, as well as novel genes: NRG1, ADAM18, HUWE1, FBXW4, FBXL13, and CAPRIN1. CONCLUSION(S): Mutations in genes implicated in cell-to-cell interactions and remodeling of the extracellular matrix and genomic aberrations involving genes coding for the Mediator complex subunits were identified in uterine leiomyomas. Additionally, we discovered that ∼4.6% of leiomyosarcomas harbored MED12 exon 2 mutations, but the relevance of this association with molecular pathogenesis of leiomyosarcoma remains unknown.

Immunohistochemistry and HPV in situ hybridization in pathologic distinction between endocervical and endometrial adenocarcinoma: a comparative tissue microarray study of 76 tumors.

OBJECTIVES: It is clinically important to determine whether adenocarcinoma present in a biopsy or curettage is of endometrial or endocervical origin. When tumors are difficult to distinguish based on routine histologic sections, immunohistochemistry and human papillomavirus (HPV) in situ hybridization may be used. MATERIALS AND METHODS: We compare immunohistochemical profile and HPV expression in 76 tumors, including various types of endocervical adenocarcinoma and the most common endometrioid type of endometrial adenocarcinoma using tumor tissue microarray. Immunostaining for p16, mammaglobin, vimentin, monoclonal carcinoembryonic antigen, estrogen receptor, progesterone receptor, and PAX-8 as well as HPV in situ hybridization was performed in 37 endocervical adenocarcinomas and 39 endometrioid-type endometrial adenocarcinomas. The staining patterns were analyzed with Bayesian network model. RESULTS: The markers with the highest discriminatory values were p16, HPV, vimentin, estrogen receptor, and monoclonal carcinoembryonic antigen. The various histologic types of endocervical adenocarcinoma showed similar immunohistochemical profile, and most were positive for p16 (86%) and HPV (65%). Most (90%) of the endometrial adenocarcinomas were positive for vimentin and estrogen receptor, all were negative for HPV, and 97% were negative for carcinoembryonic antigen. CONCLUSIONS: Immunohistochemical testing with multiple markers and HPV testing aids in diagnostic evaluation of adenocarcinomas of endocervix and endometrium and is recommended in tumors of uncertain origin.

Interobserver agreement among pathologists for semiquantitative hormone receptor scoring in breast carcinoma.

The American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines recommend reporting of hormone receptor test results in a semiquantitative manner. This study used 74 resected estrogen receptor (ER)-positive invasive breast cancers to determine reproducibility of semiquantitative scoring of hormone receptors using the H-score method. Four pathologists independently scored each slide. Agreement among observers was analyzed via Fleiss κ statistics on ER and progesterone receptor (PR) categorical scores. Intraclass correlation coefficient (ICC) was used to estimate the interobserver agreement for ER and PR H-scores on a continuous scale (0-300). There was 100% agreement for categorical ER results (κ = 1) and 97% agreement (κ = 0.823, P < .001) for categorical PR results. For quantitative H-scores, ICC agreement was 0.85 (95% confidence interval [CI] = 0.79-0.90) for ER and 0.87 (95% CI = 0.82-0.92) for PR. Because the H-score provides a continuous measure of tumor hormone receptor content, we suggest universal adoption of this method.

Unusual ovarian stromal tumor with radiation changes mimicking carcinoma.

Radiation-related changes including fibrosis, nuclear enlargement, hyperchromasia and cytoplasmic vacuolization may alter the appearance of normal ovarian tissue and ovarian tumors. We describe radiation-related changes in ovarian stromal neoplasm with mixed features of sclerosing stromal tumor and fibrothecoma. The right ovarian mass was discovered in a 38 year-old woman with past history of invasive squamous cell carcinoma of the cervix treated with cone biopsy and brachytherapy. The low power architecture of cellular pseudolobules and small sheets of tumor cells with scattered hyaline plaques was consisted with the pattern of combined sclerosing stromal tumor and fibrothecoma. However, the presence of severe cytologic atypia, as well as clear cell and signet ring differentiation and arrangements of tumor cells in single files and nests, raised a possibility of primary or metastatic carcinoma. The tumor cells were positive for calretinin, vimentin, inhibin, and WT1 and negative for AE1/3, cytokeratin 7 and 20, CD99, estrogen and progesterone receptors, mammaglobin, chromogranin, and S100 protein. Based on the results of immunostains and a subsequently provided history of radiation, a diagnosis of sex cord stromal tumor with mixed fibrothecoma and sclerosing stromal differentiation was made. Radiation-related atypia and fibrosis in sex cord stromal tumor may create a pattern mimicking carcinoma and therefore, in the presence of unusual histology, the use of immunohistochemistry is recommended.

Immunohistochemical profile of steroid cell tumor of the ovary: a study of 14 cases and a review of the literature.

Fourteen steroid cell tumors (SCTs) of the ovary were studied by immunohistochemistry including inhibin, calretinin, CD99, Melan A, androgen receptor, and AE1/3. Twelve tumors were primary and 2 were recurrent. The primary tumors included 5 stromal luteomas (SL), 5 SCTs, not otherwise specified, and 2 Leydig cell tumors, 1 of the hilar type and 1 of the nonhilar type. All tumors were classified according to the predominant cell type. Six tumors were eosinophilic cell type, 3 clear-cell type, and 5 were mixed eosinophilic-clear-cell type. Inhibin, calretinin, and CD99 were positive in all 14 tumors. Twelve of 14 tumors (86%) were positive for Melan A and 9 of 14 (64%) for androgen receptor. AE 1/3 immunopositivity was found in 5 of 14 tumors (36%). Immunohistochemistry helps in the distinction between SCTs of the ovary and other primary or metastatic ovarian neoplasms with eosinophilic and clear-cell histology. In addition, immunohistochemistry can confirm the presence of recurrent SCT, if no sufficient clinical history is provided. As some SCTs can be positive for epithelial markers and histologically similar epithelial tumors can be positive for sex cord stromal markers, the use of multiple immunohistochemical stains is recommended.

Analysis of allelic loss as an adjuvant tool in evaluation of malignancy in uterine smooth muscle tumors.

Uterine smooth muscle tumors of uncertain malignant potential (STUMPs) are difficult both from the diagnostic and patient management standpoint because they cannot be classified as benign or malignant by conventional histologic criteria. This study's aim was to determine the diagnostic utility of allelic imbalance (AI) analysis in uterine smooth muscle tumors. Using microdissection and genotyping, we tested 5 leiomyomas, 6 STUMPs, and 10 leiomyosarcomas with follow-up for AI across a panel of seven tumor suppressor genes (p16, p21, p53, VHL, XRCC3, RB, and NM-23). None of the 6 patients with STUMP experienced recurrent disease, whereas 8 of the 10 patients diagnosed with leiomyosarcoma died of disease at follow-up. The mean frequency of allelic loss (FAL) for leiomyomas (18%) was not significantly different from that of STUMPs (21%) (P = 1), whereas leiomyosarcomas displayed a significantly higher FAL (52%) than both leiomyomas (P = 0.001) and STUMPs (P = 0.002). Loss of NM-23, a reported tumor metastasis suppressor gene, was found only in leiomyosarcomas (5 of 9, or 56%), and 4 of 5 (80%) of these were the only cases that demonstrated distant metastases (P = 0.04). Additionally, an FAL of >50% correlated with both NM-23 loss (P = 0.008) and distant metastatic disease (P = 0.04). In conclusion, leiomyomas and STUMPs displayed similar mean FALs and all were clinically benign, whereas uterine leiomyosarcomas had significantly higher frequencies of allelic loss than both leiomyomas and STUMPs. Molecular profiling may thus provide a valuable tool in assessment of malignancy in uterine smooth muscle tumors. Additionally, NM-23 is a promising candidate gene for determination of metastatic potential in these tumors.

Microdissection-based mutational genotyping of serous borderline tumors of the ovary.

Mutational changes in a number of genetic foci were studied in 12 serous borderline tumors (SBTs) of the ovary including 2 with a micropapillary pattern. The analysis was focused on chromosomal regions that have not been previously studied in these tumors. The findings were correlated with the morphology and the FIGO stage of the tumors. Six of the tumors were stage I, one was stage II, and five were stage III. Loss of heterozygosity analysis in each tumor was performed with a panel of 12 polymorphic markers on chromosomes 1p, 5q, 9p, 9q, 10q, and 17p. The ovarian tumors displayed allelic losses most frequently on 1p (83.3%), 9q (70%), and 17p (41.7%). In the extraovarian implants, allelic losses on 1p, 9q, and 17p were present in 66.7%, 75%, and 66.7% of cases respectively. In five of six cases, allelic losses were 88% concordant between multiple tumor sites. Only one case of stage III tumor displayed a discordant pattern of allelic loss at different tumor sites. Cumulative allelic losses did not show a statistically significant difference in stage I vs. higher stage disease. The pattern and cumulative allelic loss in the two cases with micropapillary architecture was similar to that of the other tumors. We report a high frequency of allelic loss on 1p and 9q that has not been previously reported in SBTs. Morphologically heterogenous areas including benign-appearing, typical borderline, and micropapillary areas had a similar pattern of allelic loss. Although the majority of SBTs seem to be monoclonal, a minor subset may be multiclonal in origin.

Immunohistochemical profile of cystosarcoma phyllodes of the breast: a study of 23 cases.

Cystosarcoma phyllodes (CP) of the breast is a rare biphasic tumor composed of benign epithelium and a spindle cell stroma. Biologic behavior of CP cannot be predicted with certainty on the basis of morphologic criteria only. We studied immunohistochemical expression of basic fibroblastic growth factor (bFGF), urokinase, Ki67, p53 protein, and microvessel density in stromal and epithelial components of 14 low-grade CP (LCP) and 9 high-grade CP (HCP). bFGF was more often positive in LCP than in HCP. The stroma was positive for bFGF in 86% of LCP and 67% of HCP, and the epithelium was positive in 64% of LCP and 14% of HCP. Urokinase was positive in stromal cells of 86% of LCP and 93% of HCP. The epithelial positivity for urokinase in both groups resembled closely that of the stroma. p53 protein was more often positive in stromal cells of HCP (67%) than in LCP (50%). Ki67 was positive in the stroma of 43% of LCP and 89% of HCP and in the epithelium of 14% of LCP and 33% of HCP. There was no significant difference in microvessel density (MVD) in low- and high-grade lesions. Our study demonstrates that stromal Ki67 and p53 immunohistochemical positivity are more often associated with high-grade tumors. The positive immunostaining for bFGF, urokinase, Ki67, and p53 in stroma and epithelium of the majority of CP supports the existence of epithelial-stromal interactions and recognizes epithelium as an integral part of this tumor.