Massively parallel sequencing analysis of 68 gastric-type cervical adenocarcinomas reveals mutations in cell cycle-related genes and potentially targetable mutations.

Gastric-type cervical adenocarcinoma (GCA) is an aggressive type of endocervical adenocarcinoma characterized by mucinous morphology, gastric-type mucin, lack of association with human papillomavirus (HPV) and resistance to chemo/radiotherapy. We characterized the landscape of genetic alterations in a large cohort of GCAs, and compared it with that of usual-type HPV-associated endocervical adenocarcinomas (UEAs), pancreatic adenocarcinomas (PAs) and intestinal-type gastric adenocarcinomas (IGAs). GCAs (n = 68) were subjected to massively parallel sequencing targeting 410-468 cancer-related genes. Somatic mutations and copy number alterations (CNAs) were determined using validated bioinformatics methods. Mutational data for UEAs (n = 21), PAs (n = 178), and IGAs (n = 148) from The Cancer Genome Atlas (TCGA) were obtained from cBioPortal. GCAs most frequently harbored somatic mutations in TP53 (41%), CDKN2A (18%), KRAS (18%), and STK11 (10%). Potentially targetable mutations were identified in ERBB3 (10%), ERBB2 (8%), and BRAF (4%). GCAs displayed low levels of CNAs with no recurrent amplifications or homozygous deletions. In contrast to UEAs, GCAs harbored more frequent mutations affecting cell cycle-related genes including TP53 (41% vs 5%, p < 0.01) and CDKN2A (18% vs 0%, p = 0.01), and fewer PIK3CA mutations (7% vs 33%, p = 0.01). TP53 mutations were less prevalent in GCAs compared to PAs (41% vs 56%, p < 0.05) and IGAs (41% vs 57%, p < 0.05). GCAs showed a higher frequency of STK11 mutations than PAs (10% vs 2%, p < 0.05) and IGAs (10% vs 1%, p < 0.05). GCAs harbored more frequent mutations in ERBB2 and ERBB3 (9% vs 1%, and 10% vs 0.5%, both p < 0.01) compared to PAs, and in CDKN2A (18% vs 1%, p < 0.05) and KRAS (18% vs 6%, p < 0.05) compared to IGAs. GCAs harbor recurrent somatic mutations in cell cycle-related genes and in potentially targetable genes, including ERBB2/3. Mutations in genes such as STK11 may be used as supportive evidence to help distinguish GCAs from other adenocarcinomas with similar morphology in metastatic sites.

Choriocarcinoma in Women: Analysis of a Case Series With Genotyping.

Choriocarcinoma is an uncommon malignant neoplasm, which can be either gestational or nongestational in origin. Distinction of these subtypes has prognostic and therapeutic implications. Twenty-two tumors were genotyped using polymerase chain reaction amplification of 15 short tandem repeat loci and the amelogenin locus (XY determination). DNA patterns from tumor and maternal tissue, as well as villous tissue from any available prior or concurrent gestation, were compared, to determine gestational versus nongestational nature (containing vs. lacking a paternal chromosome complement, respectively) and the relationship between the tumor and any prior or concurrent gestation. Nineteen tumors were gestational. Of these, 14 were purely androgenetic/homozygous XX: 6 uterine tumors with a concurrent or prior genetically related complete hydatidiform mole (CHM), 4 uterine tumors without an accompanying villous component, 1 uterine cornual tumor separate from a genetically distinct second trimester intrauterine placenta, 1 ectopic ovarian tumor separate from a genetically distinct third trimester intrauterine placenta, and 2 ectopic fallopian tube tumors. Five gestational tumors were biparental: 3 (2 XX, 1 XY) intraplacental choriocarcinomas genetically related to the placenta and 2 uterine tumors without accompanying placental tissue after term deliveries (1 XX 4 weeks postpartum and 1 XYY with allelic imbalances 1 year postpartum; prior placentas not available for analysis). Three tumors were nongestational: all XX with allelic imbalances; 2 ovarian, 1 pelvic. Gestational choriocarcinoma can be androgenetic or biparental. Most are androgenetic/homozygous XX, often associated with a genetically related concurrent or prior CHM, and thus of molar-associated type. These findings support that homozygous XX CHMs are associated with some risk of significant gestational trophoblastic disease. Intraplacental choriocarcinomas are biparental and genetically related to the placenta. Biparental choriocarcinoma detected in a postpartum uterine sample is consistent with undetected intraplacental choriocarcinoma. Eutopic or ectopic androgenetic choriocarcinoma separate from a concurrent intrauterine placenta is not derived from intraplacental tumor and is consistent with either a form of dispermic twin gestation (molar-type choriocarcinoma and coexistent nonmolar fetus) or origin from an antecedent molar pregnancy. While fallopian tube tumors are usually gestational, tumors in other sites (ovary, pelvis) can be nongestational and should not be assumed to be metastatic from a regressed or occult intrauterine or intraplacental gestational tumor.

PD-L1 Expression in Human Placentas and Gestational Trophoblastic Diseases.

One of the major immune checkpoints responsible for immune evasion in cancer cells is the interaction between programmed cell death-1 (PD-1) and its ligand (PD-L1). As human trophoblastic cells display many of the features of malignant cells such as the ability to invade normal tissue including blood vessels and are apparently not eradicated by the host immune system, we undertook the present study to determine whether PD-L1 was upregulated in different types of trophoblastic cells during normal pregnancy and in gestational trophoblastic diseases. Immunohistochemistry using an anti-PD-L1-specific antibody demonstrated that in early and term normal placentas, PD-L1 was highly expressed in syncytiotrophoblast and to a much lower extent in intermediate trophoblastic cells located in the chorion laeve and implantation site. PD-L1 immunoreactivity was undetectable in cytotrophoblastic cells. This staining pattern in normal placenta was recapitulated in various types of gestational trophoblastic disease. PD-L1 was highly expressed by syncytiotrophoblast in complete moles and choriocarcinomas. The intermediate trophoblastic neoplasms, placental site trophoblastic tumors, and epithelioid trophoblastic tumors showed variable PD-L1 immunoreactivity but at a lower intensity than in the neoplastic syncytiotrophoblast in choriocarcinoma. In addition, we observed PD-1-positive lymphocytes located within the implantation site and in trophoblastic tumors. In summary, this study describes a novel mechanism for trophoblastic cells to create a tolerogenic feto-maternal interface by upregulating PD-L1 in syncytiotrophoblast and in intermediate trophoblast. Trophoblastic tumors may also use PD-L1 expression to evade the host immune response thereby promoting their survival.

Morphological and Immunohistochemical Reevaluation of Tumors Initially Diagnosed as Ovarian Endometrioid Carcinoma With Emphasis on High-grade Tumors.

Ovarian endometrioid carcinomas (OEC) of low grade have characteristic morphologic features, but high-grade tumors can mimic high-grade serous and undifferentiated carcinomas. We reviewed tumors initially diagnosed as OEC to determine whether a combination of pathologic and immunohistochemical features can improve histologic subclassification. Tumors initially diagnosed as OEC were reviewed using World Health Organization criteria. We also noted the presence of associated confirmatory endometrioid features (CEFs): (i) squamous metaplasia; (ii) endometriosis; (iii) adenofibromatous background; and (iv) borderline endometrioid or mixed Mullerian component. A tissue microarray was constructed from 27 representative tumors with CEF and 14 without CEF, and sections were stained for WT-1, p16, and p53. Of 109 tumors initially diagnosed as OEC, 76 (70%) tumors were classified as OEC. The median patient age was 55 years, and 75% of patients were younger than 60 years. Ninety-two percent presented with disease confined to the pelvis, and 87% of tumors were unilateral. The median tumor size was 11.8 cm. Only 3% of tumors were high grade (grade 3of 3). Eighty percent of cases had at least 1 CEF, and 59% had at least 2 CEFs. Eleven percent overexpressed p16, 0% overexpressed p53, and 3% expressed WT-1. Only 10% of patients died of disease at last follow-up. Thirty-three (33) tumors, or 30% of tumors originally classified as endometrioid, were reclassified as serous carcinoma (OSC). The median patient age was 54.5 years, and 59% of patients were younger than 60 years of age. Only 27% had disease confined to the pelvis at presentation, 52% of tumors were unilateral, and the median tumor size was 8 cm. Associated squamous differentiation, endometrioid adenofibroma, and endometrioid or mixed Mullerian borderline tumor (CEFs) were not present in any case, but 6% of patients had endometriosis. Approximately one half of the reclassified OSC demonstrated SET-pattern morphology (combinations of glandular, cribriform, solid, and transitional cell-like architecture) and were immunophenotypically indistinguishable from OSCs with papillary architecture. Sixty percent of OSC overexpressed p16, 50% overexpressed p53, and 82% expressed WT-1. At last follow-up, 52% had died of disease. Compared with OSC, OEC patients more frequently presented below 60 years of age (P=0.046), had low-stage tumors (P<0.001), were more frequently unilateral (P<0.001), more frequently had synchronous endometrial endometrioid carcinomas (P<0.001); and had no evidence of disease at last follow-up (P<0.001). Their tumors were of lower grade (P<0.001), had more CEFs (P<0.001), and less frequently overexpressed p16 and p53 (P=0.003 and P<0.001, respectively) and less frequently expressed WT-1 (P<0.001). This analysis emphasizes the diagnostic value of CEFs, the presence of a low-grade gland-forming endometrioid component, and WT-1 negativity, as valid, clinically relevant criteria for a diagnosis of OEC. Glandular and/or cribriform architecture alone may be seen in both OECs and OSCs and are therefore not informative of diagnosis. Further study is needed to elaborate the characteristics of the exceedingly rare high-grade OEC.

Regional differences in gallbladder cancer pathogenesis: insights from a comparison of cell cycle-regulatory, PI3K, and pro-angiogenic protein expression.

BACKGROUND: The variable incidence of gallbladder cancer (GBCA) suggests regional pathogenetic differences. This study compares cell cycle-regulatory, angiogenesis-related, and PI3K pathway protein expression in GBCAs from three continents. METHODS: Immunohistochemical expression of several proteins was assessed, correlated with clinicopathologic variables, and compared among centers from Chile (Fundación Arturo López Pérez [FALP]), Japan (Yokohama City University [YCU]), and the United States (Memorial Sloan-Kettering Cancer Center [MSKCC]). Hierarchical clustering was used to partition the data based on protein-expression and treatment center. RESULTS: Tissue from 117 patients (MSKCC = 76; FALP = 22; YCU = 19) was analyzed. Mdm2 overexpression was seen only at MSKCC (p < 0.0001). Absence of p21 (p = 0.03) and VEGFR2 (p = 0.018) were more common and p27 expression was less frequent (p = 0.047) in tumors from YCU. Ki-67 labeling index in YCU tumors (median = 10) was two-thirds lower than at other centers. On hierarchical clustering analysis, all YCU patients (p = 0.017) and those with early tumors (p = 0.017) clustered separately from MSKCC. Median disease-specific survival after curative intent (R0) resection was 27 months and was similar among centers (p = 0.9). Median disease-specific survival of patients with early tumors was 28.4 months and was higher at YCU (not reached, p = 0.06). CONCLUSIONS: Cell cycle-regulatory protein expression patterns of YCU tumors differed from those treated at FALP and MSKCC. The differential clustering of protein expression and survival in patients with early tumors suggest regional differences in pathogenesis and disease biology.

Comparing human pancreatic cell secretomes by in vitro aptamer selection identifies cyclophilin B as a candidate pancreatic cancer biomarker.

Most cases of pancreatic cancer are not diagnosed until they are no longer curable with surgery. Therefore, it is critical to develop a sensitive, preferably noninvasive, method for detecting the disease at an earlier stage. In order to identify biomarkers for pancreatic cancer, we devised an in vitro positive/negative selection strategy to identify RNA ligands (aptamers) that could detect structural differences between the secretomes of pancreatic cancer and non-cancerous cells. Using this molecular recognition approach, we identified an aptamer (M9-5) that differentially bound conditioned media from cancerous and non-cancerous human pancreatic cell lines. This aptamer further discriminated between the sera of pancreatic cancer patients and healthy volunteers with high sensitivity and specificity. We utilized biochemical purification methods and mass-spectrometric analysis to identify the M9-5 target as cyclophilin B (CypB). This molecular recognition-based strategy simultaneously identified CypB as a serum biomarker and generated a new reagent to recognize it in body fluids. Moreover, this approach should be generalizable to other diseases and complementary to traditional approaches that focus on differences in expression level between samples. Finally, we suggest that the aptamer we identified has the potential to serve as a tool for the early detection of pancreatic cancer.

A nomogram to predict postresection 5-year overall survival for patients with uterine leiomyosarcoma.

BACKGROUND: The clinical course of patients with uterine leiomyosarcoma (LMS) is difficult to predict with the currently available categorical staging systems of the American Joint Committee on Cancer (AJCC) and the International Federation of Gynecology and Obstetrics (FIGO). The objective of the current study was to develop and validate a novel, clinically relevant, individualized prognostic model for patients with uterine LMS. METHODS: Patients with uterine LMS who presented at the authors' institution from 1982 to 2008 were analyzed. The nomogram model was chosen based on the clinical evidence and statistical significance of the predictors, including age at diagnosis, tumor size, histologic grade, uterine cervix involvement, extrauterine spread, distant metastases, and mitotic index. Five-year overall survival (OS) was the predicted endpoint. The concordance probability (CP) was used as a predictive accuracy measure and compared with the CP of current staging systems. The model was internally validated using 200 bootstrap samples to correct for over fitting. RESULTS: One hundred eighty-five of 270 patients were eligible for the nomogram analysis. The median follow-up was 5.4 years, and the median OS was 3.75 years (95% confidence interval, 3-6 years). The CP of the newly developed nomogram was 0.67 (95% confidence interval, 0.63-0.72). This was superior to predictions based on AJCC and FIGO staging. The bootstrap-validated CP was 0.65 with good calibration accuracy. CONCLUSIONS: The authors developed and internally validated a uterine LMS-specific nomogram to predict 5-year OS. This novel, individualized prognostic model outperforms traditionally used categorical staging systems and may be useful for patient counseling and for better selection of patients for adjuvant therapy trials.

The prevalence of pancreatic acinar differentiation in gastric adenocarcinoma: report of a case and immunohistochemical study of 111 additional cases.

Although pancreatic acinar metaplasia in the gastric mucosa is well recognized in chronic gastritis, gastric carcinoma with acinar differentiation is very rare. We encountered a case of gastric adenocarcinoma with prominent histologic and immunohistochemical features of pancreatic acinar differentiation in the absence of identifiable heterotopic pancreatic tissue. Distinct glandular and diffuse patterns of adenocarcinoma were also present, and there was focal mucin production. The tumor strongly expressed pancreatic exocrine enzymes trypsin and chymotrypsin, and focal neuroendocrine staining was also present. To investigate the prevalence of acinar differentiation in histologically typical gastric cancers, we performed immunohistochemical staining for trypsin and chymotrypsin on a tissue microarray containing 111 conventional gastric adenocarcinomas (60 intestinal, 28 mixed, 22 diffuse type, and 1 undifferentiated). No obvious morphologic evidence of acinar differentiation was identified in any of the 111 cases. Although some cases showed equivocal staining for at least 1 pancreatic exocrine enzyme on the initial tissue microarray sections, repeat immunohistochemical staining on representative whole-tissue sections failed to reproduce positive staining. Thus, acinar differentiation is rare in gastric adenocarcinomas, other than in histologically unusual cases such as the one we report, and in others from the literature, which are reviewed.

"Low-grade leiomyosarcoma" and late-recurring smooth muscle tumors of the uterus: a heterogenous collection of frequently misdiagnosed tumors associated with an overall favorable prognosis relative to conventional uterine leiomyosarcomas.

In most instances, uterine smooth muscle tumors (USMTs) are readily diagnosed as either benign or malignant. Rare patients whose smooth muscle tumors fail to meet leiomyosarcoma (LMS) diagnostic criteria will experience recurrence, and occasional cases of LMS patients experience a protracted clinical disease course. The aim of this study was to investigate whether "low-grade uterine LMS" can be defined as a clinicopathological entity and to learn which histologic features of USMTs correlate with indolent prognosis. We searched institutional databases for cases diagnosed between 1982 and 2008 that had been coded as low-grade LMS and/or cases coded as LMS that were associated with recurrences after 5 years of diagnosis. There were 185 cases with available clinical follow-up data (mean follow-up for survivors was 5.4 y); 57% of patients were dead of disease (DOD), 16% of patients were alive with disease (AWD), and 24% had no evidence of disease (NED). All available slides were reviewed by 2 pathologists (E.V. and R.S.) using Stanford USMT criteria to identify cases of bona fide LMS. Cases were not excluded if they failed to meet these criteria. Nine percent (16 of 185) of tumors had been coded as low-grade LMS. On review of cases with available slides (n=16), only 4 cases (25%) met Stanford USMT criteria for LMS, and 1 additional case was a myxoid LMS. Three cases were reclassified as endometrial stromal sarcomas with smooth muscle differentiation, and 7 cases (44%) failed to meet criteria for sarcoma [ie, they were atypical smooth muscle neoplasms (ASMNs)]. Six of 16 (38%) patients were NED with a mean follow-up of 76 months; 4 of 16 (25%) patients were AWD with a mean follow-up of 102.5 months; 4 of 16 (25%) patients were DOD with a mean follow-up of 79.2 months; and 2 of 16 (12.5%) patients died of unknown causes at 104 and 120 months. Despite being coded as having low-grade LMS in the database, none of the ASMN patients died of disease. Twelve percent of all cases (n=22) were associated with late recurrences. Of the 9 cases with available slides, 5 were bona fide LMSs, and 4 were ASMNs (coded as low-grade LMS in the database and included as part of the low-grade LMS portion of this study). Five of 9 (56%) patients were NED with a mean follow-up of 214 months; 2 (22%) are AWD with a follow-up of 107 and 201 months; and 2 patients were DOD with a follow-up of 108 and 143 months. Bona fide LMS recurrences in this group were earlier (mean, 6.2 y) and frequently fatal (2 of 5), whereas those patients with recurrent ASMN experienced disease progression later (mean, 12 y), and none died of disease. Whether "low-grade" uterine LMSs indeed exist is a matter still open for debate; however, when Stanford criteria are strictly applied, all tumors classified as LMSs should be regarded as intrinsically "high grade."

Predictive value of endocervical curettage at cervical conization and provider practices in management of high-grade cervical dysplasia.

OBJECTIVE: To determine the utility of endocervical curettage (ECC) at cervical conization for predicting residual or recurrent dysplasia and to evaluate differences in management between general gynecologists and gynecologic oncologists. STUDY DESIGN: From February 1999 to November 2007, 192 patients with high-grade dysplasia on conization were retrospectively identified. Data were analyzed for 54 patients who underwent repeat conization or hysterectomy to evaluate predictors of disease. Data for all patients were analyzed based on provider. RESULTS: Among patients who underwent secondary procedures, 68.5% (37/54) had residual or recurrent disease. Eighty-six percent of patients with a positive ECC had residual or recurrent disease compared to 48% of patients with a negative ECC (OR 6.91, CI 1.595-30.00, p=0.01). Among all patients, 77% (148/192) were managed by a generalist, and 23% (44/192) by a gynecologic oncologist. Oncologists were significantly more likely to perform a hysterectomy (45.5% vs. 14.2%, OR 5.04, CI 2.38-10.69, p<0.0001). CONCLUSION: Endocervical curettage at the time of conization with high-grade dysplasia is a simple and reliable predictor of residual or recurrent disease and should be performed routinely. Gynecologic oncologists are more likely than general gynecologists to perform a hysterectomy in the management of high-grade dysplasia on conization.

Solitary synovial osteochondroma.

Solitary synovial osteochondroma (SSO) is a rare variant of extraskeletal osteochondroma. The aim of this study was to review 5 cases of SSO, including clinical, radiographic, and histopathologic features. Five cases of SSO were retrieved from our files. Histopathologic and radiographic findings were reviewed, and a clinicopathologic correlation was performed. Patients' ages ranged from 33 to 63 years. Knee mass was the most common presentation. All cases were well circumscribed and had multiple cartilaginous lobules surrounded by fibroadipose tissue. Microscopically, lobulated adult-type hyaline cartilage with central calcification was noted. Cytologic atypia was present in one case, but malignant features were absent. Two cases were suggestive of chondrosarcoma on imaging studies. Patients underwent surgery, which was curative in cases for which follow-up was available. In conclusion, SSO is a rare lesion that may mimic low-grade chondrosarcoma at times. Correct recognition of SSO depends on radiographic and clinicopathologic analysis.

Ovarian intestinal type mucinous borderline tumors: are we ready for a nomenclature change?

At a National Cancer Institute-sponsored workshop it was proposed that the borderline category of ovarian intestinal-type mucinous tumors (OInMTs) could be eliminated if the apparent benign behavior of these tumors could be confirmed. We reviewed 33 cases of borderline OInMT, with either optimal or adequate sampling and with at least 5 years of follow-up, to investigate their behavior. Optimal sampling and adequate sampling were defined as at least 1 section per centimeter of maximum tumor dimension and at least 1 section per 2 cm of maximum tumor dimension, respectively. The patients' age ranged from 16 to 89 years (mean 49 yr). Tumor size ranged from 8 to 39 cm (mean 20 cm). The sampling of the ovarian tumor was optimal in 28 cases and adequate in 5 cases. The patients were treated surgically as follows: cystectomy (1), unilateral oophorectomy or unilateral salpingo-oophorectomy with or without total abdominal hysterectomy (13), and bilateral salpingo-oophorectomy with or without total abdominal hysterectomy (19). Complete or partial staging was obtained in 26 patients. All of them had Federation of Gynecology and Obstetrics stage I disease. Thirty-one patients with a follow-up ranging from 5 to 18 years (mean 10 yr) had no recurrences. Two patients had recurrences 12 and 14 months after their initial surgery. The first patient underwent a left salpingo-oophorectomy and limited staging for a borderline OInMT adherent to the ileum and sigmoid. The tumor was incompletely removed and recurred in the pelvis 1 year later. It was again incompletely excised. Ten months later, the tumor re-recurred in the pelvis and could only be drained because of the patient's advanced age and her poor medical status. She died of other causes 5 years later. The second patient with recurrent tumor had undergone a cystectomy and full staging for a borderline OInMT. Fourteen months later, she developed a recurrence in the residual ovary. She underwent a right salpingo-oophorectomy and total abdominal hysterectomy and has been without evidence of disease for 11 years. In this study of 33 Federation of Gynecology and Obstetrics stage I borderline OInMTs that were optimally or adequately sampled to exclude intraepithelial carcinoma, microinvasion, or invasive carcinoma, there were only 2 cases with recurrence, secondary to incomplete excision or cystectomy, and no deaths from disease. However, borderline OInMTs are usually large and heterogeneous, and the standard sampling protocol for them is not evidence based. As indicated by one of our consultation cases, there remains the potential for a sampling artifact in which a focus of carcinoma is missed. Caution dictates retaining the current nomenclature to ensure the follow-up of patients affected by this disease until uncertainty regarding the extent of sampling needed to exclude the presence of carcinoma is resolved.

Mitosis-specific marker phospho-histone H3 in the assessment of mitotic index in uterine smooth muscle tumors: a pilot study.

SUMMARY: The assessment of an accurate mitotic index (MI) is one of the major parameters in the proper classification of uterine smooth muscle tumors. This assessment can be hampered by the presence of increased number of apoptotic bodies or piknotic nuclei, which frequently mimic mitoses. Phospho-histone H3 (PHH3) is a recently described immunomarker specific for cells undergoing mitoses. In this study, we evaluated the MI of 2 subsets of uterine smooth muscle tumors--6 leiomyosarcomas (LMS) and 6 smooth muscle tumors of undetermined malignant potential (STUMP)--using PHH3-labeled sections and hematoxylin and eosin (H&E)-stained slides. In the STUMP group, the MI on H&E ranged from 0 to 9 mitoses/10 high-power fields (HPFs) (mean, 3.2), and in the LMS group, it ranged from 0 to 37 mitoses/10 HPFs (mean, 19). PHH3 showed 0 to 16 mitoses/10 HPFs (mean, 3.8) in the STUMP group and 0 to 61 mitoses/10 HPFs (mean, 26) in the LMS group. In 7 cases, the MI difference (MID) between H&E-stained and PHH3-stained slides varied from 0 to 3 mitoses (mean, 1.6). In only one LMS, the PHH3 MI was lower than on H&E-stained slides (MID 7). The MI on H&E-stained and PHH3-stained slides were comparable in 7 cases, 5 of which were STUMPs. In 4 other cases, 3 of which were LMS, the PHH3 MI was significantly higher than the one obtained on H&E. The higher MI obtained with PHH3-labeled sections in some cases is most likely due to the recognition of true mitoses by the antibody, which were initially misinterpreted as apoptotic bodies and/or piknotic nuclei on H&E and not included in the formal count, and the fact that the phosphorilation of histone H3 starts just before the prophase and at this stage mitoses cannot be identified by H&E.

Supernumerary nipple presenting as a vulvar mass in an adolescent: case report and literature review.

BACKGROUND: Ectopic breast tissues can be found along the embryonic mammary ridges and can occur in the vulva. While ectopic breast tissue is not uncommon, functional breast with overlying nipple located within the vulva is exceedingly rare. CASE: A 17-year-old with undiagnosed hypothyroidism presents with vulvar mass draining milky white fluid. A small lesion with appearance similar to a skin tag is noted and milky fluid expressed. Biopsy and excision of this mass confirmed the presence of a functional supernumerary nipple. SUMMARY AND CONCLUSIONS: This appears to be the first reported case of a supernumerary nipple with symptomatic lactation in a non-pregnant adolescent. Supernumerary nipple should be considered in the differential diagnosis of a vulvar mass. Ectopic breast tissue in the vulva can undergo malignant transformation, therefore excision of this tissue is generally recommended.

Frequent activating mutations of PIK3CA in ovarian clear cell carcinoma.

Ovarian clear cell carcinoma (CCC) is one of the most malignant types of ovarian carcinomas, particularly at advanced stages. Unlike the more common type of ovarian cancer, high-grade serous carcinoma, ovarian CCC is often resistant to platinum-based chemotherapy, and therefore an effective treatment for this tumor type at advanced stages is urgently needed. In this study, we analyzed 97 ovarian CCCs for sequence mutations in KRAS, BRAF, PIK3CA, TP53, PTEN, and CTNNB1 as these mutations frequently occur in other major types of ovarian carcinomas. The samples included 18 CCCs for which affinity-purified tumor cells from fresh specimens were available, 69 microdissected tumors from paraffin tissues, and 10 tumor cell lines. Sequence mutations of PIK3CA, TP53, KRAS, PTEN, CTNNB1, and BRAF occurred in 33%, 15%, 7%, 5%, 3%, and 1% of CCC cases, respectively. Sequence analysis of PIK3CA in 28 affinity-purified CCCs and CCC cell lines showed a mutation frequency of 46%. Samples with PIK3CA mutations showed intense phosphorylated AKT immunoreactivity. These findings demonstrate that ovarian CCCs have a high frequency of activating PIK3CA mutations. We therefore suggest that the use of PIK3CA-targeting drugs may offer a more effective therapeutic approach compared with current chemotherapeutic agents for patients with advanced-stage and recurrent CCC.

Cystic and adenofibromatous clear cell carcinomas of the ovary: distinctive tumors that differ in their pathogenesis and behavior: a clinicopathologic analysis of 122 cases.

Ovarian clear cell carcinomas (CCC) typically present as large adnexal, stage I tumors and are generally considered highly malignant. They are frequently associated with endometriosis and, less often with clear cell adenofibromas. We hypothesized that CCCs are a heterogeneous group of tumors, some arising from a cyst and others from an adenofibroma. To test this hypothesis, 122 cases of CCC were retrieved from the surgical pathology files of National Taiwan University Hospital (74), The Johns Hopkins Hospital (23), and Serei Mikatahara General Hospital (23) (1985 to 2006). Cases were divided into 3 subgroups: (1) cystic, (2) adenofibromatous, and (3) indeterminate. Various features were analyzed including: age, race, laterality, tumor size, architectural pattern (papillary, tubulo-cystic, solid, mixed patterns), grade, mitotic index, association with endometriosis including atypical endometriosis/intraepithelial carcinoma, stage and survival. Nearly 70% of all the patients were diagnosed as stage I. The 2-year and 5-year survival (all stages) was 78% and 68%, respectively. Striking clinicopathologic differences were observed between cystic and adenofibromatous CCCs. Cystic CCC was more frequently diagnosed as stage I compared with adenofibromatous CCC (75% vs. 44%). Conversely, adenofibromatous CCCs were diagnosed more often in advanced stages (stages II-IV) compared with cystic CCCs (56% vs. 18%). Both the cystic and adenofibromatous CCC forms were associated with endometriosis and atypical endometriosis/intraepithelial carcinoma, but the frequency was much higher in the cystic group. Specifically, endometriosis was found in 91% of cystic CCCs and atypical endometriosis/intraepithelial carcinoma in 62% of these cases, whereas endometriosis was found in 44% of adenofibromatous CCCs and atypical endometriosis/intraepithelial carcinoma in 11% of cases. A predominantly papillary pattern was seen in 47% of cystic CCCs, whereas none of the adenofibromatous carcinomas displayed a predominantly papillary pattern. A more favorable outcome was observed for cystic CCCs compared with adenofibromatous CCCs (all stages) which was accounted for by the high proportion of stage I tumors. The 2-year and 5-year survival for the cystic CCCs was 82% and 77% and for the adenofibromatous CCCs (all stages), 62% and 37%, respectively. In summary, subdividing ovarian CCCs into cystic and adenofibromatous CCC reveals differences in a number of clinicopathologic features including their association with endometriosis, histologic patterns, stage distribution, and clinical behavior. Because there were a relatively small number of adenofibromatous CCCs in this series, additional cases must be studied to confirm these findings.

Myometrial myxoidosis: a report of 2 cases of a distinctive type of secondary myometrial hypertrophy in patients with lupus erythematosus.

Myxoid mesenchymal lesions of the uterus are generally restricted to tumors, but non-neoplastic myxoid mesenchymal lesions of the uterus have not received much attention in the literature. We analyzed the clinicopathologic features of 2 patients with lupus erythematosus (ages 43 and 52 yr, respectively) in whom myometrial myxoidosis produced a markedly enlarged uterus with myometrial thickening ("secondary myometrial hypertrophy"). Both patients underwent a hysterectomy for presumed leiomyomas, and intraoperatively an enlarged uterus was noted. On gross examination, the uteri measured 13.5 x 13.5 x 11.5 cm and 14.5 x 11.5 x 9.5 cm, respectively. The significantly thickened myometrium was due to marked expansion of the interstitial compartment of the myometrium, in which non-neoplastic smooth muscle fascicles were widely separated by abundant extracellular mucin producing a striking myxoid appearance ("myxoidosis"). These histologic findings are akin to the pattern of dermal mucin deposition seen in lupus erythematosus. The lesion in each case diffusely involved the entire myometrium. Histochemical stains were performed and showed the following results: mucicarmine-diffusely but weakly positive; periodic acid-schiff (PAS)-negative; colloidal iron-diffuse positive; alcian blue, pH 2.5 (without hyaluronidase digestion)-diffuse positive, and alcian blue, pH 2.5 (with hyaluronidase digestion)-negative. These histochemical findings are consistent with hyaluronic acid. Follow-up in 1 case was not available. In the other case, the patient presented to clinical attention 5 weeks after surgery because of ascites, which after an extensive clinical evaluation was interpreted as being of unknown etiology. To the best of our knowledge, this rare and unusual non-neoplastic myometrial lesion has not been previously described. Pathologists should be aware of its existence because of the distinctive appearance and as it may prompt consideration of various myxoid neoplasms of the uterus in the differential diagnosis. Patients with myometrial myxoidosis should be evaluated for lupus erythematosus.

Metastatic HPV-related cervical adenocarcinomas presenting with thromboembolic events (Trousseau Syndrome): clinicopathologic characteristics of 2 cases.

Two cases of systemic thromboembolism (Trousseau syndrome) associated with metastatic human papillomavirus (HPV)-related endocervical adenocarcinomas are reported. The first patient, age 36, presented with bilateral lower extremity deep vein thromboses, pulmonary embolism, and supraclavicular and cervical lymphadenopathy. Lymph node biopsy revealed metastatic mucinous adenocarcinoma with focal signet ring cell differentiation. Imaging studies demonstrated metastatic disease without a defined primary site. Acute renal and respiratory failure developed and the patient expired shortly after initiation of chemotherapy, 7 weeks after presentation. Autopsy examination revealed widespread metastatic adenocarcinoma with a 2 cm cervical adenocarcinoma. The second patient, age 43, presented with left internal jugular vein thrombosis, acute thrombophlebitis, and bilateral axillary lymphadenopathy. She developed progressive venous thrombosis despite anticoagulation. Imaging studies demonstrated widespread lymphadenopathy and an adnexal mass. Diagnostic laparoscopy with biopsies and left oophorectomy revealed metastatic mucinous adenocarcinoma with signet ring cell differentiation involving peritoneum, ovary, cervix, and bladder without a defined primary site. Progressive thromboembolic disease with acute renal failure and multiple cerebral infarcts developed and the patient expired shortly after initiation of chemotherapy, 2 months after presentation. No autopsy was performed. HPV DNA was detected by in situ hybridization in the lymph node metastasis in the first case and in the cervical and ovarian tumor specimens in the second case. High-risk HPV-related endocervical adenocarcinomas occasionally exhibit signet ring cell differentiation and can present with Trousseau syndrome. These features more commonly suggest metastatic adenocarcinoma of upper gastrointestinal tract origin but the presence of HPV DNA within the tumors establishes them as cervical in origin.

Sinonasal chondromyxoid fibroma.

Chondromyxoid fibroma (CMF) is a rare benign cartilaginous tumor that usually arises from the metaphysis of long bones. In rare cases, however, CMF presents in unusual locations, such as the facial bones and sinonasal tract. We present a case of a 60-year-old woman with a CMF of the nasal septum. The initial radiographic findings were suggestive of a vascular tumor or a malignancy, but microscopic examination revealed the typical pathologic features of CMF, and SOX9 immunostaining confirmed its cartilaginous origin. The tumor was successfully excised, and the patient was free of disease at 12-month follow-up. Recognizing CMF is important when it presents in unexpected locations, especially because of its histologic resemblance to chondrosarcoma. We believe that the use of SOX9 in our case assisted in the recognition of the chondroid nature of the lesion and facilitated the diagnosis of CMF.

Sclerosing mucoepidermoid carcinoma of the salivary glands.

Mucoepidermoid carcinoma (MEC) comprises approximately 30% of all salivary gland malignancies, making it the most common malignant tumor of the salivary glands. Multiple histologic variants with a wide range of differentiation have been described. Sclerosing MEC (SMEC) is a rare subtype that may be misdiagnosed as a benign reactive condition or low-grade non-SMEC malignancy. We report 4 cases of SMEC and evaluated them with Her-2/neu and MIB-1 to determine whether an association exists between the histologic grade and immunohistochemical findings. In 3 cases, histologic examination demonstrated relatively well-circumscribed, nonencapsulated tumors composed of extensive central sclerosis with keloid-like stroma and scattered epithelial islands of low-grade MEC. In the fourth case, the tumor showed similar sclerotic stroma; but the epithelial component was of intermediate grade. In all 4 cases, eosinophils and neutrophils were part of the inflammatory infiltrate; and the edges were surrounded by lymphoid tissue, with germinal center formation and residual epithelial islands. A Mayer mucicarmine stain revealed abundant intracytoplasmic mucin. We found MIB-1 labeling indices of 5% or less in cases 1, 2, and 3 and 12% in case 4, suggesting an association between MIB-1 index and tumor grade. The tumors were negative for Her-2/neu in all 4 cases. The latter seems to bear no relationship to tumor grade.