The Silva pattern-based classification for HPV-associated endocervical adenocarcinoma: A single institution concordance study of trainees and gynecologic pathologists.

The Silva pattern-based classification of HPV-associated endocervical adenocarcinoma has become an integral part of the histologic assessment of these tumors. Unfortunately, the Silva system reproducibility has had mixed results in past studies, and clinical practice still favors the FIGO stage assessment in directing therapeutic interventions for patients. In our study, we aimed to assess our institution's concordance including not only gynecologic pathologists, but also pathology trainees through a series of 69 cases. The grouped total kappa concordance from all participants was 0.439 (Moderate), with an overall trainee kappa of 0.417 (moderate) and an overall pathologist kappa of 0.460 (moderate). Perfect concordance among all 10 study participants was seen in 8/69 cases (11.6 %), corresponding to 5/22 Pattern A cases (22.7 %), 0/16 Pattern B cases (0 %), and 3/31 Pattern C cases (9.7 %), with similar findings between trainees and pathologists when compared within their own cohorts. Recurrence was identified in 2 Pattern A cases, indicating a potential issue with limited excisional specimens which may not fully appreciate the true biologic aggressiveness of the lesions.

Histological and molecular analysis of cellular leiomyoma with sclerosis: linked to HMGA2 overexpression.

HMGA2 overexpression is found in 10-15% of leiomyomas (LM). HMGA2 overexpression is common in variants of hydropic, intravenous and lipo-LM. Cellular or highly cellular LM (CLM) is a LM variant with a less well-defined molecular nature. In this study, we identified and examined 52 hypercellular LM with sclerotic collagen, herein defined as cellular leiomyoma with sclerosis (CLM-S). CLM-S shows large tumour size (average 12.2 cm) and characteristic histology of tumour cells, arranged in cellular fascicles, sheets and trabeculae with abundant dense, pink sclerotic extracellular matrix in bands and nodules and increased vascularity. Tumour cells are uniform with small, round-oval nuclei and scant, pale-eosinophilic to vacuolated cytoplasm reminiscent of pericytes. The differential diagnosis of CLM-S includes conventional CLM, endometrial stromal tumours and perivascular epithelioid cell tumour. Immunohistochemical profile [HMGA2, fumarate hydratase, smooth muscle markers, Melan A and HMB-45] and molecular alterations [by HMGA2 mRNA reverse transcription-polymerase chain reaction (RT-PCR), HMGA2 fluorescence in-situ hybridisation and MED12 sequencing] were analysed in comparison to matched myometrium and CLM controls. Remarkably, 96% (50 of 52) of CLM-S demonstrated diffuse positive immunoreactivity for HMGA2 and up to an 80-fold increase in HMGA2 mRNA, determined by RT-PCR. FISH analysis with break-part probes at intron 3 and the 5' UTR detected HMGA2 rearrangements in 47% (18 of 38) of CLM-S. All CLM-S retained expression of fumarate hydratase. No MED12 mutations were found in any CLM-S. Our findings show that CLM-S has unique and characteristic histomorphology probably driven by HMGA2 overexpression.

Correlation of manual semi-quantitative and automated quantitative Ki-67 proliferative index with OncotypeDXTM recurrence score in invasive breast carcinoma.

BACKGROUND: Ki-67 immunohistochemistry (IHC) staining is a widely used cancer proliferation assay; however, its limitations could be improved with automated scoring. The OncotypeDXTM Recurrence Score (ORS), which primarily evaluates cancer proliferation genes, is a prognostic indicator for breast cancer chemotherapy response; however, it is more expensive and slower than Ki-67. OBJECTIVE: To compare manual Ki-67 (mKi-67) with automated Ki-67 (aKi-67) algorithm results based on manually selected Ki-67 "hot spots" in breast cancer, and correlate both with ORS. METHODS: 105 invasive breast carcinoma cases from 100 patients at our institution (2011-2013) with available ORS were evaluated. Concordance was assessed via Cohen's Kappa (κ). RESULTS: 57/105 cases showed agreement between mKi-67 and aKi-67 (κ 0.31, 95% CI 0.18-0.45), with 41 cases overestimated by aKi-67. Concordance was higher when estimated on the same image (κ 0.53, 95% CI 0.37-0.69). Concordance between mKi-67 score and ORS was fair (κ 0.27, 95% CI 0.11-0.42), and concordance between aKi-67 and ORS was poor (κ 0.10, 95% CI -0.03-0.23). CONCLUSIONS: These results highlight the limits of Ki-67 algorithms that use manual "hot spot" selection. Due to suboptimal concordance, Ki-67 is likely most useful as a complement to, rather than a surrogate for ORS, regardless of scoring method.

Successful management of stage IV epithelioid trophoblastic tumor using multimodality treatment: A case report.

Epithelioid trophoblastic tumor (ETT) is a rare variant of gestational trophoblastic neoplasia (GTN) that develops from chorionic-type intermediate trophoblast, is more resistant to chemotherapy than choriocarcinoma, and presents with metastatic disease in 25-35% of cases. We report a case of a 32-year-old who presented one week postpartum with severe abdominal pain and was found to have profound anemia and an elevated hCG level. CT scans and MRI revealed bleeding from hepatic masses, multiple hemorrhagic pulmonary nodules, a 7 cm uterine mass, and brain metastases. She underwent emergent hepatic embolization, was started on induction chemotherapy with weekly low-dose etoposide and cisplatin followed by a transition to etoposide, high-dose methotrexate, actinomycin D, etoposide, and cisplatin (HD EMA-EP), received stereotactic brain radiotherapy, and subsequently underwent minimally-invasive hysterectomy. She remains disease free over one year after the completion of treatment. An aggressive multimodal treatment approach employing etoposide/cisplatin-based chemotherapy as well as surgical procedures to control hemorrhage or excise resistant disease, and radiotherapy for brain metastases can result in successful treatment of stage IV ETT.

Cytomorphologic analysis of clear cell papillary renal cell carcinoma: Distinguishing diagnostic features.

BACKGROUND: Clear cell papillary renal cell carcinoma (CCPRCC) shares histomorphologic and immunophenotypic features with clear cell RCC (CCRCC) and papillary RCC (PRCC). METHODS: We compared the cytomorphology, immunoprofile, and clinical management of CCPRCC (n = 18), CCRCC (n = 20), and PRCC (n = 18). RESULTS: Useful cytomorphologic features for comparing CCPRCC with CCRCC include 3-dimensional clusters (72% vs 0%), papillae (50% vs 0%) and sheets (22% vs 70%), vasculature (papillary vs traversing), naked nuclei (17% vs 100%), prominent nucleoli (0% vs 65%), and amount of cytoplasm (small vs large). Useful cytomorphologic features for comparing CCPRCC with PRCC include sheets (22% vs 61%), naked nuclei (17% vs 67%), nuclear grooves (5% vs 67%) and inclusions (17% vs 67%), and pigmented cytoplasm (17% vs 83%). At on-site evaluation, 16 of 18 (86%) CCPRCC specimens were deemed adequate, with suspicion for CCPRCC in 5 of 16 (31%) cases. Core histology of CCPRCC showed low-grade malignant cells in nests (67%), tubules (100%), and papillae (72%), frequently in myxohyaline stroma (67%). Immunostains demonstrated expression of cytokeratin 7 (CK7; 100%), carbonic anhydrase IX (CA IX; 100%, cup-like), CD10 (53%, reverse cup-like), and α-methylacyl-CoA racemase (AMACR; 35%). Among 18 CCPRCC patients, 9 (50%) underwent nephrectomy, 5 (28%) underwent cryo-ablation, and 4 (22%) were under surveillance with serial imaging. CONCLUSION: Certain morphologic features represent diagnostic criteria of CCPRCC in cytology specimens and help distinguish CCPRCC from CCRCC and PRCC. Immunostaining patterns with CK7, CA IX, CD10, and AMACR can confirm the diagnosis. Delineating CCPRCC from more biologically aggressive RCC types in cytology specimens enhances presurgical and clinical management of patients given CCPRCC's low-grade, indolent behavior.

HMGA2-mediated tumorigenesis through angiogenesis in leiomyoma.

OBJECTIVE: To study the role of HMGA2 in promoting angiogenesis in uterine leiomyoma (LM). DESIGN: This study involved evaluation of vessel density and angiogenic factors in leiomyomas with HMGA2 overexpression; examining angiogenic factor expression and AKT signaling in myometrial (MM) and leiomyoma cells by introducing HMGA2 overexpression in vitro; and exploring vessel formation induced by HMGA2 overexpression both in vitro and in vivo. SETTING: University research laboratory. PATIENTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The main outcome measures include vessel density in leiomyomas with HMGA2 (HMGA2-LM) or MED12 (MED12-LM) alteration; angiogenic factor expression in primary leiomyoma and in vitro cell line model; and vessel formation in leiomyoma cells with HMGA2 overexpression in vitro and in vivo. RESULTS: Angiogenic factors and receptors were significantly upregulated at mRNA and protein levels in HMGA2-LM. Specifically, HMGA2-LM exhibited increased expression of VEGFA, EGF, bFGF, TGFα, VEGFR1, and VEGFR2 compared to MED12-LM and myometrium. Overexpression of HMGA2 in MM and LM cell lines resulted in increased secretion of angiogenesis-associated factors. Secreted factors promoted human umbilical vein endothelial cell (HUVEC) migration, tube formation, and wound healing. HMGA2 overexpression upregulated IGF2BP2 and pAKT, and silencing the IGF2BP2 gene reduced pAKT levels and reduced HUVEC migration. Myometrial cells with stable HMGA2 overexpression exhibited increased colony formation and cell growth in vitro and formed xenografts with increased blood vessels. CONCLUSIONS: HMGA2-LM have a high vasculature density, which likely contributes to tumor growth and disease burden of this leiomyoma subtype. HMGA2 plays an important role in angiogenesis and the involvement of IGF2BP2-mediated pAKT activity in angiogenesis, which provides a potential novel target for therapy for this subtype of LM.

Upregulated MELK Leads to Doxorubicin Chemoresistance and M2 Macrophage Polarization via the miR-34a/JAK2/STAT3 Pathway in Uterine Leiomyosarcoma.

Uterine leiomyosarcoma (ULMS) is the most lethal gynecologic malignancy with few therapeutic options. Chemoresistance prevails as a major hurdle in treating this malignancy, yet the mechanism of chemoresistance remains largely unclear. In this study, we certified MELK as a poor prognostic marker through bioinformatic analysis of the GEO database. Cellular experiments in vitro revealed that MELK played an essential role in ULMS cells' chemoresistance and that a high expression of MELK could lead to doxorubicin resistance. mRNA profiling uncovered the pathways that MELK was involved in which led to doxorubicin resistance. MELK was found to affect ULMS cells' chemoresistance through an anti-apoptotic mechanism via the JAK2/STAT3 pathway. miRNA profiling also revealed that upregulated MELK could induce the decrease of miRNA-34a (regulated by JAK2/STAT3 pathway). We detected that MELK overexpression could induce M2 macrophage polarization via the miR-34a/JAK2/STAT3 pathway, contributing to doxorubicin chemoresistance in the tumor microenvironment. OTSSP167, a MELK inhibitor, may increase ULMS sensitivity to doxorubicin. Our investigation could propose novel targets for early diagnosis and precision therapy in ULMS patients.

Hydropic leiomyoma: a distinct variant of leiomyoma closely related to HMGA2 overexpression.

Hydropic leiomyoma (HLM) is a variant of uterine leiomyoma with characteristic features of zonal distributions of edema, increased vascularity, and tumor cells arranged in nodules or cords. Diagnostic difficulty and patient management are further complicated by a lack of studies and unknown cause of the disease. To study this tumor's nature, 24 HLM cases were selected for analysis of cytohistologic features, immunohistochemical profile (HMGA2, FH, CD34, pAKT, p16, ER, SMA, and Ki-67), and molecular alterations of HMGA2 by fluorescence in situ hybridization and MED12 mutations. HLM showed large tumor size (average 14.4 cm) and unique histology, characterized by edematous areas of tumor cells with mostly round-oval nuclei, arranged in cords and/or with perinodular growth around vessels, and increased thick-walled vessels (average 17 vessels/10× medium-power field). Immunohistochemistry revealed that 76% (18/24) of HLMs had HMGA2 overexpression, 32% (6/19) of which harbored HMGA2 rearrangement detected by fluorescence in situ hybridization. Thick-walled vessels in HLM were composed of mostly HMGA2-positive tumor cells, and HLM with HMGA2 overexpression also showed CD34-positive tumor vessel-supporting pericytes. In contrast to usual-type leiomyoma with a high frequency of MED12 mutations, no MED12 mutations were found in any HLM. HLM showed increased pAKT activity, indicating a strong contribution of AKT pathway signaling in HLM promoting tumor growth. Our findings suggest that HLM is a distinct variant of uterine smooth muscle tumor likely driven by HMGA2 overexpression.

Management of patients with renal mass lesions based on renal biopsy cytology results.

The benefit of renal biopsy, especially in patients with a history of malignancy (HOM), has not been well-studied. We studied the clinical management of 339 renal masses after fine needle aspirate and/or core needle biopsy with touch preparation. Forty-one percent of patients had HOM, which did not increase the incidence of renal malignancy. The main reasons for renal biopsy were HOM and small renal masses (≤3 cm). The most common renal masses were clear cell renal cell carcinoma (32%). Thirty percent of renal masses metastasized. The overall accuracy of renal biopsy for subclassification was 76%. Nephrectomy was selected to manage 41% of renal masses, most for primary renal carcinoma. Chemoradiation was selected to treat 15% of patients, especially those with lymphoma (93%), metastatic malignancy (93%), and urothelial carcinoma (69%). Ablation was used to treat 6% of patients. Active surveillance was selected for 34% of patients, predominantly those with benign condition. Our results showed that renal biopsy was an easy and less aggressive tool for obtaining adequate diagnostic materials to render reliable and accurate diagnoses. Initial renal biopsy prevented unnecessary nephrectomy in patients with diagnoses of metastatic malignancy, lymphoma, and most benign tumors/lesions (for most but not all cases). Renal biopsy avoided chemoradiation against prior HOM in patients with diagnosis of benign tumors/lesions (22% of all patients) and primary renal carcinoma (38%). Therefore, renal biopsy significantly impacts the management of patients with renal mass, and any questionable renal mass should be biopsied before further management.

Anti-angiogenesis effect of Neferine via regulating autophagy and polarization of tumor-associated macrophages in high-grade serous ovarian carcinoma.

High-grade serous ovarian carcinoma (HGSOC) is one of the most lethal gynecologic malignancies. Currently, anti-angiogenesis therapy is the most promising strategy for the successful treatment of HGSOC. In this study, we found Neferine could inhibit the angiogenesis of ovarian cancer cells both in vitro and in vivo. Further analysis revealed that its suppressive effect on human umbilical vein endothelial cell (HUVEC) proliferation correlated with promoting cell cycle arrest and autophagy. The cell cycle genes were dose-dependently reduced and the level of LC3II/LC3I (microtubule associated protein 1 light chain 3) was increased. Using a specific marker for macrophages (CD206 and Mrc1), we indicated that Neferine could inhibit M2-macrophage in vivo. Finally, CD206 was stained in 150 HGSOC samples and its high expression predicted inferior overall survival. Our current study is the first to demonstrate the anti-angiogenesis mechanism of Neferine by inducing autophagy via mTOR/p70S6K pathway inhibition and suppressing M2-macrophage polarization. Our findings suggest that Neferine is an attractive reagent with great potential in HGSOC therapy, especially in standard-therapy resistant cases.

Double-Equivocal HER2 Invasive Breast Carcinomas: Institutional Experience and Review of Literature.

CONTEXT.­: HER2 status is a prognostic factor and therapeutic target in invasive breast carcinomas. Reflex testing using an alternate method is recommended on equivocal cases via immunohistochemistry or fluorescence in situ hybridization (FISH). Therapeutic dilemmas arise when both tests are equivocal. The standard chromosome 17 centromere reference probe (CEP17) is in close proximity to the HER2 locus and may be coamplified, leading to equivocal results. Alternate chromosome 17 reference probes may aid in establishing the true HER2 status. OBJECTIVE.­: To describe our institutional experience using D17S122 probe for reflex FISH testing on double-equivocal invasive breast carcinomas and review the literature on alternate reference probes. DATA SOURCES.­: Twenty-two patients with double-equivocal invasive breast carcinomas, defined as HER2 immunohistochemistry score 2+ and FISH equivocal per the 2013 guidelines, were reviewed. Reflex FISH was performed with alternate probe D17S122 and the HER2 status classified for 11 cases by using a revised HER2: D17S122 ratio. Seven of 11 cases (63.6%) were ultimately classified as HER2 positive, while 4 cases (36.4%) remained equivocal. The 7 positive cases showed a HER2: D17S122 greater than 2.0. CONCLUSIONS.­: Alternate probe D17S122 reclassified more than half of our cases as HER2 positive. Alternate probes may establish true HER2 status and direct proper management, as evidenced by our experience and the literature. Additional investigation is needed to determine which alternate probe(s) is(are) best for reflex testing. Finally, the American Society of Clinical Oncology/College of American Pathologists guidelines may need to be updated to reflect more specific recommendations for the utilization of appropriate probes in double-equivocal HER2 cases.

Malignant Ectomesenchymoma: Series Analysis of a Histologically and Genetically Heterogeneous Tumor.

AIMS: Malignant ectomesenchymoma is a rare pediatric neoplasm with dual mesenchymal and neuroectodermal elements. Mesenchymal component is usually rhabdomyosarcoma, particularly embryonal subtype, whereas neuroectodermal derivatives are frequently a neuroblastic tumor. Ectomesenchymoma manifests in various sites given the wide migration of neural crest cells during development, though the pelvis/perineum is most often involved. Moreover, no unique unifying molecular abnormality has been determined. METHODS: We conducted a retrospective study to analyze the spectrum of ectomesenchymal tumors encountered in our pediatric population. Six patients were identified and data pertaining to patients' demographic, tumor size and site, histologic components with immunophenotypic profile, molecular alterations, treatment, and outcome were collected. RESULTS: Mesenchymal elements, represented by rhabdomyosarcoma in all instances, were the dominant component in the majority of cases (5/6). Embryonal and alveolar morphology had similar distribution (3/6) and all patients with alveolar subtype harbored the characteristic translocations of this entity. The neuroectodermal component was most often a neuroblastic-like neoplasm (4/6); however, 2/6 cases demonstrated primitive neuroectodermal tumor-like morphology. No unifying alterations were found on molecular studies. CONCLUSIONS: Our analysis extends the histologic and molecular spectrum of these tumors and highlights their heterogeneity. The percentage of cases with alveolar rhabdomyosarcoma or primitive neuroectodermal-like tumor components suggests that these types of elements might be underreported. This study is also the first to demonstrate FOXO1 gene rearrangements in malignant ectomesenchymoma with alveolar rhabdomyosarcoma subtype.