Evaluating expression of the Human epidermal growth factor receptor 2 (Her2) by visual examination of immunohistochemistry (IHC) on invasive breast cancer (BCa) is a key part of the diagnostic assessment of BCa due to its recognised importance as a predictive and prognostic marker in clinical practice. However, visual scoring of Her2 is subjective and consequently prone to inter-observer variability. Given the prognostic and therapeutic implications of Her2 scoring, a more objective method is required. In this paper, we report on a recent automated Her2 scoring contest, held in conjunction with the annual PathSoc meeting held in Nottingham in June 2016, aimed at systematically comparing and advancing the state-of-the-art Artificial Intelligence (AI) based automated methods for Her2 scoring.
The contest dataset comprised of digitised whole slide images (WSI) of sections from 86 cases of invasive breast carcinoma stained with both Haematoxylin & Eosin (H&E) and IHC for Her2. The contesting algorithms automatically predicted scores of the IHC slides for an unseen subset of the dataset and the predicted scores were compared with the “ground truth” (a consensus score from at least two experts). We also report on a simple Man vs Machine contest for the scoring of Her2 and show that the automated methods could beat the pathology experts on this contest dataset.
This paper presents a benchmark for comparing the performance of automated algorithms for scoring of Her2. It also demonstrates the enormous potential of automated algorithms in assisting the pathologist with objective IHC scoring.
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Cancer cells must alter their metabolism in order to satisfy the demands of necessary energy and cellular building blocks. These metabolic alterations are mediated by many oncogenic changes that affect cellular signalling pathways, which result in sustained cell growth and proliferation. Recently, metabolomics, has received great attention in the field of cancer research and as the essential metabolic pathways that drive tumour growth and progression are determined, the possibilities of new targets for therapeutic intervention are opened. More specifically, as breast cancer is a heterogeneous disease there is growing evidence that differences in metabolic changes exist between molecular subtypes.
In this review, the most recent findings in breast cancer cell metabolism are discussed, with particular emphasis on glutamine and its transporters which is considered one of the key amino acids fuelling cancer growth. Furthermore, the metabolic differences between the molecular subtypes of breast cancer are examined, highlighting the clinical utility for breast cancer diagnosis and treatment.
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Intravascular lymphoma (IVL) is a rare entity. Most cases are a variant of extranodal diffuse large B-cell lymphoma, and fewer than 10% of the published cases are of T-cell origin. Only intravascular B-cell lymphoma is recognized as a distinct entity in the most recent WHO classification of lymphoproliferative disorders. We describe a case of cutaneous NK/T IVL, with a cytotoxic immunophenotype and EBV positivity. However, our case was immunohistochemically negative not only for TCR-βF1 and TCR-γ (TCR-silent), but also for CD56, making it the first triple-negative NK/T IVL case to be described. We urge the recognition of this NK/T-cell lineage intravascular lymphoma due to its particular immunophenotypic profile and its unvarying relationship with EBV. Its occurrence should not be considered a coincidence, but rather a key aspect of the pathogenic background of this haematological neoplasm.
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The current WHO classification categorises high grade neuroendocrine (NE) carcinomas of the prostate into small cell and large cell types. A distinct form of carcinoma demonstrating synchronous dual exocrine and NE differentiation, termed amphicrine carcinoma, has been described at various other sites, primarily within the gastrointestinal tract. In this study, we describe the clinicopathologic features of a series of metastatic prostatic carcinomas with amphicrine features.
Five cases of high grade prostatic carcinoma (PCa) demonstrating an amphicrine immunohistochemical phenotype were prospectively collected.
Serum prostate specific antigen (PSA) level at diagnosis ranged from 38-992ng/ml (median 200ng/ml). All 5 patients had metastatic disease; 4 at initial presentation. Microscopically, the tumours demonstrated a solid/nested growth pattern composed of cells with amphophilic cytoplasm, vesicular nuclei and macronucleoli. Morphologic features of small cell or large cell NE carcinoma were absent. Compared with conventional high grade PCa, the tumour cells displayed greater nuclear pleomorphism, brisk mitotic activity and a high Ki67 proliferation index (median 50%). All cases demonstrated immunohistochemical positivity for PSA, androgen receptor (AR) and prostatic specific acid phosphatase (PSAP) combined with diffuse or confluent/non-focal positivity for chromogranin-A and synaptophysin. Two hormone-naive cases showed a clinical response to androgen deprivation therapy.
This series highlights a previously undefined, clinically aggressive variant of PCa exhibiting dual exocrine and NE differentiation, for which we are proposing the term PCa with amphicrine features. Increased recognition of these tumours may lead to a better understanding of their biology and ultimately improve their clinical management.
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Well differentiated and dedifferentiated liposarcomas (WD/DDLPS) are underlined by 12q13-q14 amplifications encompassing MDM2, considered as the core oncogene driving their pathogenesis through TP53 inactivation1, 2. Their progression involves the inactivation of the RB1 pathway through CDKN2A-CCND1-CDK4 alterations3. According to the French sarcoma database RRePS, 1% of cases suspicious for WD/DDLPS fail to prove MDM2 amplification, therefore suggesting that alternative oncogenic pathways might replace MDM2 amplification.
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A recent paper1 reported microscopic nodules of sex-cord stromal proliferations mimicking adult granulosa cell and sex-cord tumour with annular tubules in extraovarian locations. However, Sertoli cell tumour patterns were not described in them. We add two cases of multiple, microscopic foci of differentiated Sertoli cell proliferation in the fallopian tube, one of which coexisted and merged with areas of fimbrial ectopic ovarian-like stroma.
Both cases were incidental findings in the fallopian tubes from 42 and 35 year-old patients, operated respectively for uterine leiomyoma and ovarian grade 1 endometrioid carcinoma. Both were recent cases with short follow-up.
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Tubo-ovarian high-grade serous carcinoma (HGSC) is the most common female adnexal malignancy and by far the most lethal. There is now compelling evidence that most of these neoplasms arise from the distal fallopian tube from a precursor referred to as serous tubal intraepithelial carcinoma (STIC) (1-5). Most cases present at advanced stage (FIGO stages III-IV) and the overall prognosis is poor (6). While most cases respond well initially to chemotherapy, early recurrence (within a few years) is common and most patients will eventually succumb to their disease (6)
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The biological importance of tumour-associated stroma is increasingly apparent, yet clinical utility remains ill-defined. In stage-II / Dukes B colorectal cancer (CRC), clinical biomarkers are urgently required to direct therapeutic options. We report here prognostic/predictive analyses, and molecular associations, of stromal morphometric quantification in the Quick and Simple and Reliable (QUASAR) trial of CRC
Relative proportions of tumour epithelium (PoT) or stroma (PoS) were morphometrically quantified using digitised haematoxylin and eosin sections derived from 1,800 patients enrolled in QUASAR which randomised 3,239 (91% stage II) CRC patients between adjuvant fluorouracil/folinic acid (FUFA) chemotherapy and observation. The prognostic/predictive value of PoT/PoS measures were determined by stratified log-rank analyses
High tumour stroma (≥50%) was associated with increased recurrence risk: 31.3% (143/457) recurrence for ≥50% versus 21.9% (294/1,343) if <50% [Rate ratio (RR)=1.62; 95%CI 1.30-2.02, p<0.0001)]. For stromal proportions of ≥65%, 40% (46/115) of patients had recurrent disease within 10 years. The adverse prognostic effect of high stroma was independent of established prognostic variables, and maintained in stage II / Dukes B patients (RR=1.62; 95%CI=1.26-2.08; p=0.0002). KRAS mutation in the presence of high stroma augmented recurrence risk (RR=2.93; 95%CI=1.87-4.59; p=0.0005). Stromal morphometry did not predict response to FUFA chemotherapy
Simple digital morphometry applied to a single representative H&E section identifies CRC patients with over 50% higher risk of disease recurrence. This technique can reliably partition patients into sub-populations with differential risks of tumour recurrence in a simple and cost-effective manner. Further prospective validation is warranted.
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to test the validity of diagnostics incorporating digital image analysis (DIA) for human epidermal growth factor 2 (HER2) immunohistochemistry (IHC) in gastro-oesophageal adenocarcinomas, as an alternative to current standard diagnostics using manual scoring.
we included 319 consecutive gastro-oesophageal adenocarcinomas (232 biopsies and 87 surgical specimens). DIA was applied to determine HER2 IHC classification, using both standard breast cancer (BC) and modified gastro-oesophageal cancer (GEC) cutoffs. Consensus manual scores were established by four independent observers. Chromogenic in situ hybridization (CISH) was performed on all 2+ cases by manual scoring, DIA or both. HER2 status was considered positive in 3+ and CISH positive 2+ cases. Overall agreement between DIA and consensus manual scores was 76.5% (weighted κ=0.66, BC cutoffs) and 85.6% (weighted κ=0.80, GEC cutoffs). Agreement was similar for biopsies and surgical specimens. All disagreement occurred in the manual IHC equivocal cases. DIA resulted in a reduction of 2+ cases: 75.8% with BC cutoffs and 46.5% with GEC cutoffs. HER2 status was positive in 48 cases (15%) with standard diagnostics and DIA using GEC cutoffs, and 46 cases (14.4%) using BC cutoffs (all with CISH in 2+ cases). Considering standard diagnostics as a reference, DIA showed 93.8% sensitivity and 99.6% specificity (BC cutoffs) or 97.9% sensitivity and 99.6% specificity (GEC cutoffs).
DIA is a reliable and feasible alternative to manual HER2 IHC scoring in gastro-oesophageal adenocarcinoma, both in biopsies and surgical specimens, leading to a reduction of 2+ cases for which subsequent ISH testing is required.
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In near future, an immunoscore based on the quantification of lymphocytic populations can be expected as fundamental supplement of colorectal cancer (CRC) classification. This study explored, whether latent viral infection has an influence on prognostic relevant host immunity in CRC.
CD8+ lymphocytic infiltration in three tumour compartments of 121 CRC was compared with clinical data and occurrence of latent infection with HSV1, HSV2, CMV, EBV, HPV16, and HPV18 in the tumour tissue, which was determined by PCR. Intraepithelial CD8+ lymphocytic infiltration (IECD8+) showed a trend towards correlation with clinical stage (p = 0.073), significant differences between CRC with metastases and without metastases (p = 0.001), and a significant correlation with overall survival (OS, p = 0.001). Each of these three clinical parameters showed a significant link to IECD8+ in the virus DNA-negative (p-values: 0.001 – 0.036), but no significant differences in the virus DNA-positive subgroup, which is consistent with a moderating effect of virus DNA on these associations. A significant correlation of CD8+ infiltration in the invasive margin (IMCD8+) with OS (p = 0.016) was also moderated by virus DNA.
Our data hint at a possible influence of latent viral infection on the association between clinical outcome and CD8+ lymphocytic infiltration in CRC tissue. After confirmation of these results by large cohort studies, a potential interaction between microbial pathogens and host immunity in CRC and its impact on prognostic immunoscores and/or new therapeutic strategies should be further investigated.
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The vermiform appendix is the primary site of several distinctive benign and malignant neoplasms. Some can produce the clinical syndrome of pseudomyxoma peritonei (PMP). A consensus on their terminology was reached by an international panel of pathologists and clinicians working under the auspices of the Peritoneal Surface Oncology Group International (PSOGI) and this review discusses the application of the PSOGI classification to routine reporting. We discuss diagnosis and differential diagnosis together with implications for patient management, covering low-grade appendiceal mucinous neoplasms, high-grade appendiceal mucinous neoplasms, serrated polyps, adenomas, and adenocarcinomas. We do not cover goblet cell tumours or neuroendocrine neoplasms in this article.
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Malignant pleural mesothelioma (MPM) is the most common primary pleural tumor and an aggressive neoplasm that arises from mesothelium of the pleura. The prognosis is poor with the overall median survival of 9-11 months1. For the diagnosis of MPM, differentiating MPM from pleural metastatic tumors is important.
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Invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) are predominant and well-documented types of invasive breast cancers (IBC). However, clinical outcomes of other types of IBC (i.e., uncommon IBC), which collectively account for about 20% of all IBC cases, are largely unknown.
We identified all IBC cases diagnosed in 2004-2006 (n=159,293) and 2010-2011 (n=118,822) from the Surveillance, Epidemiology and End Results (SEER) database. Uncommon IBC included mixed IDC and ILC (MDLC), IDC mixed with other types of carcinoma (IDC-MO), ILC mixed with other types of carcinoma (ILC-MO), and other-type of breast cancers (OC). We estimated overall survivals (OS) and cancer-specific survivals in multivariate regression models.
Compared with IDC, MDLC was associated with a better OS (adjusted hazard ratio [aHR]=0.92, P<0.001 at approximately 10-year follow-up; aHR=0.88, P=0.01 at approximately 4-year follow-up) while OC had a worse OS (aHR=1.06, P=0.005 at approximately 10-year follow-up; aHR=1.23, P<0.001 at approximately 4-year follow-up). Other uncommon IBCs had an OS similar to IDC. Heterogeneity in survivals was observed in some subtypes of OC, with better OS in MDLC and tubular carcinoma. Radiotherapy extended OS for all types of IBC in older women (50+ years). For younger women (<50 years), radiotherapy improved OS in women with IDC, but not ILC or uncommon IBC. Radiotherapy did not change cancer-specific survival of any IBC in younger women.
Uncommon IBCs have distinct patterns in prognosis and survival. Effectiveness of radiotherapy in women with uncommon IBC may differ by age. The underlying mechanisms warrant further studies.
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Because the term ‘naevoid melanoma’ has variable clinical and pathologic interpretations, we aimed to clarify the features of melanomas referred to as naevoid.
A review was undertaken of 102 melanomas diagnosed histopathologically as naevoid melanomas and ascertained by European Organisation for Research and Treatment of Cancer Melanoma Group Subcommittee pathologists from their records. We found these could be classified morphologically into 3 groups. Thirteen melanomas were overlying genuine naevi and were therefore excluded. Of the 89 melanomas considered to be naevoid, 11 presented clinically as exophytic papillomatous nodules with little junctional component and composed of small atypical cells showing numerous mitoses and no change with depth; we termed these “papillomatous naevoid” melanomas. The other 78 were flat or only slightly raised and had a superficial spreading melanoma (SSM)-like component with maturation to a small cell, but still atypical, dermal component; we termed these “maturing naevoid” melanomas. We showed that papillomatous and maturing naevoid melanomas also have differing immunochemical profiles. Preliminary clinical follow-up suggested different outcomes for these two naevoid melanoma types.
Melanomas that have been classified as naevoid melanomas comprise two types with distinct clinical, histopathologic and immunohistochemical features that may also be prognostically significant.
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Telomerase reverse transcriptase (TERT) is a ribonucleoprotein involved in maintaining the length of telomeres. In the absence of TERT expression, differentiated cells can only divide a finite number of times before undergoing cellular senescence – often referred to as the Hayflick limit. Mutations within the promoter region of TERT that create consensus binding sequences for ETS family transcription factors are a common mechanism by which neoplastic cells increase TERT expression and overcome this limit [1]. TERT promoter mutations are common in many cancer types including 60-80% of urothelial carcinomas (UC) [2,3]. Given the high frequency of these mutations in UC and absence of these mutations in non-neoplastic/benign mimics of UC [4], TERT promoter mutations may serve as potential biomarker for monitoring patients with a history of malignancy.
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Low grade follicular lymphoma (FL1/2) has an annual risk of transformation of approximately 3% which is associated with aberrations in CDKN2A/B, TP53 and MYC. Like in DLBCL high MYC expression in transformed FL (tFL) might predict a MYC breakpoint. We quantified MYC expression by immunohistochemistry and digital analysis in 41 paired biopsies from 20 patients with FL1/2 with subsequent transformation and in 4 isolated biopsies of tFL. As controls 28 biopsies of FL1/2 without transformation (median follow up 105 months) and 9 FL3A/B were analyzed. In the 20 FL1/2-tFL pairs MYC expression was significantly higher in tFL than in the initial FL1/2 biopsies (median 54% vs 6%; 7% in FL3A, 35% in FL3B). MYC-breaks (MYC-R+) were detected in 8/21 (38%) of by FISH analyzed tFL with a median MYC score of 86%. In 2 of the analyzed tFL cases the translocation was already detected in antecedent FL1/2. MYC-partners were Immunoglobulin (IG) loci in 3/8 cases (1x IGL, 1x IGH, 1x IGK) and non-IG in 5/8 cases (2x PAX5, 1x BCL6, 2x unknown). Of the 8 MYC-R+ cases 6 were BCL2+/MYC+ double-hit, one a BCL2+/BCL6+/MYC+ triple-hit and one MYC+ single-hit. All 3 IG-MYC positive cases showed MYC expression >85% while the 5 cases with a non-IG MYC partner had a wider range of expression (median 68%, range 13-86%). Among the 13 MYC-R negative tFL two groups with an almost dichotomous MYC expression could be observed (3 cases showed ≥90% MYC expression) suggesting alternative mechanisms of MYC activation.
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Accumulation of copper and copper binding protein in periportal hepatocytes is generally considered to be an indicator of chronic cholestasis and a sign of chronic biliary pathology, particularly at an early stage when bilirubinostasis is lacking (1). Rhodanine and Orcein or Victoria blue staining methods detect copper and copper binding protein respectively. Cytokeratin 7 expression by periportal hepatocytes or hepatocyte-like cells (intermediate hepatobiliary cells) (2) is also considered an early marker of chronic cholestasis (1). It is referred to as “periportal Ker7” in the rest of this letter.
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The assessment of BRAF p.V600E mutational status has already become an essential part of the diagnostic routine in colorectal cancer (CRC). Indeed, on one side, the BRAF mutational status is regarded as being a key molecular marker to definitely decide the most proper therapeutic options in a selected cohort of patients. On the other, it is used to exclude a suspicious of Lynch Syndrome in case of MLH1 absence in deficient mismatch repair (dMMR) tumors [1].
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Despite efforts to standardize histopathology practice through the development of guidelines, the interpretation of morphology is still hampered by subjectivity. We here describe Pathology Imagebase, a novel mechanism for establishing an international standard for the interpretation of pathology specimens.
The International Society of Urological Pathology (ISUP) established a reference image database through the input of experts in the field. Three panels were formed, one each for prostate, urinary bladder and renal pathology, consisting of 24 international experts. Each of the panel members uploaded microphotographs of cases into a non-public database. The remaining 23 experts were asked to vote from a multiple-choice menu. Prior to and while voting panel members were unable to access the results of voting by the other experts. When a consensus level of at least 2/3 or 16 votes was reached, cases were automatically transferred to the main database. Consensus was reached in a total of 287 cases across five projects on the grading of prostate, bladder and renal cancer and classification of renal tumours and flat lesions of the bladder. The full database is available to all ISUP members at www.isupweb.org. Non-members may access a selected number of cases.
It is anticipated that the database will assist pathologists in calibrating their grading and will also promote consistency in the diagnosis of difficult cases.
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We occasionally encounter patients with idiopathic pulmonary fibrosis (IPF) who have similar imaging patterns to pleuroparenchymal fibroelastosis (PPFE) in the upper lung fields but are not diagnosed as PPFE clinically. The clinicopathological features and intrapulmonary distribution of elastic fibers and collagen fibers in these patients have not been fully elucidated.
We retrospectively reviewed the medical records of patients with a clinical diagnosis of IPF and selected the consecutive patients who received autopsy or pneumonectomy for lung transplantation. Patients with histologically confirmed PPFE were also reviewed for a comparison. We quantified the collagen fibers and elastic fibers in each lobe as a percentage of the nonaerated lung area (collagen fiber score and elastic fiber score, respectively) in histological specimens using a whole-slide image analysis, and compared these scores between IPF and PPFE patients.
In a total of 55 patients (IPF, 48; PPFE, 7), there were no significant differences in the collagen fiber scores between IPF and PPFE patients. The elastic fiber scores in the upper lobe in PPFE patients were significantly higher than those in IPF patients (23.5 versus 10.3, p = 0.005). Of note, however: in 12 of 48 patients with IPF, the elastic fiber scores of the upper lobes were above the first quartile of those in the PPFE patients.
IPF shows intense elastosis in the upper lobes occasionally, and such cases are histologically indistinguishable from PPFE. There seem to be histological borderline cases between PPFE and IPF.
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In 2012, the International Society of Urological Pathology (ISUP) introduced a novel grading system for clear cell and papillary renal cell carcinoma (RCC) based upon increasing nucleolar prominence in grades 1 to 3, with the presence of extreme nuclear pleomorphism and/or tumour giant cells and/or sarcomatoid and/or rhabdoid differentiation as criteria for grade 4. This system is now incorporated in the latest World Health Organization renal tumour classification, being designated WHO/ISUP grading.
This study was undertaken to compare WHO/ISUP and Fuhrman grading and to validate WHO/ISUP grading as a prognostic parameter in a series of clear cell RCC. Analysis of 681 cases of clear cell RCC showed that 144 tumours could not be assigned a Fuhrman grade on the basis of ambiguous grading features.
The application of WHO/ISUP grading resulted in a general down-grading of cases when compared with Fuhrman grading. In a sub-group of 376 cases, for which outcome data were available, 9.3% were WHO/ISUP grade 1, 50.0% were grade 2, 24.2% grade 3 and 16.5% grade 4, while the distribution of Fuhrman grades was 0.4% grade 1, 48.7% grade 2, 29.4% grade 3 and 21.5% grade 4. There were no recurrence/metastases amongst patients with WHO/ISUP grade 1 tumours and there was a significant difference in outcome for WHO/ISUP grades 2, 3 and 4. For Fuhrman grading the cancer-free survival was not significantly different for grade 2 and grade 3 tumours. On multivariate analysis WHO/ISUP grade and pT staging category were found to retain prognostic significance.
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Esophageal adenocarcinoma (EAC) tumorigenesis has been primarily linked to loss-of-function mutations in tumor suppressor genes. Knowledge of specific oncogenes that drive tumor progression, and their relationship to outcomes, is limited. High Mobility Group AT-Hook 2 (HMGA2) has been reported to be amplified in a subset of EACs, but the clinicopathologic and prognostic implications of HMGA2 expression in EAC is unknown.
We performed HMGA2 immunohistochemistry and fluorescence in-situ hybridization (FISH) in EAC to determine its clinicopathologic and prognostic significance. Ninety-one primary EAC resections without neoadjuvant treatment were identified and immunohistochemistry for HMGA2 was performed. The presence or absence of nuclear staining was evaluated and correlated with predetermined clinicopathologic parameters and patient outcomes. A selected subset of tumors was subjected to FISH to identify alterations at the HMGA2 locus. HMGA2 expression was present in 25/91 (27.4%) tumors. HMGA2 expressing cells were present in solid, poorly differentiated areas of the tumors at the invasive front, or as single infiltrating cells. FISH showed that 3-4 copies of HMGA2 are frequently present in EAC irrespective of HMGA2 protein expression and that high level HMGA2 amplification is a rare event. HMGA2 expression was associated with numerous adverse clinicopathologic parameters including higher T- and N-stage, the presence of lymphovascular invasion, and with a worse recurrence free and overall survival.
Our data suggests that HMGA2 is primarily regulated in EAC through non-chromosomal level alterations that lead to increased HMGA2 expression. HMGA2 positive EAC correlates with adverse pathologic features and worse patient outcomes.
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to evaluate whether a comprehensive histological evaluation of reticulin fibrosis, collagen deposition and osteosclerosis in bone marrow trephine biopsies (BMBs) of primary myelofibrosis (PMF) patients may have prognostic implications.
reticulin fibrosis, collagen deposition and osteosclerosis were graded from 0 to 3 in a series of 122 base-line BMBs. Then, we assigned to each case a comprehensive score (RCO score, ranging from 0 to 9) that allowed us to distinguish two groups of patients, with low-grade (RCO score 0-4) and high-grade (RCO score 5-9) stromal changes.
of 122 patients, 88 displayed a low-grade and 34 a high-grade RCO score. The latter was more frequently associated with anemia, thrombocytopenia, peripheral blood blasts and increased lactate dehydrogenase levels. RCO score resulted strictly correlated with overall mortality (p=0.013) and International Prognostic Scoring System (IPSS) risk categories, and was able to discriminate the overall survival of both low- and high-grade patients (Log-Rank test: p<0.001). Moreover, it proved to be more accurate than the European Consensus on grading of bone marrow fibrosis (ECGMF grade) in identifying high-risk patients with poor prognosis.
Finally, a combined analysis of RCO scores and IPSS risk categories in an integrated clinical-pathological evaluation was able to increase the positive predictive value (PPV) for mortality in high-risk patients.
the comprehensive RCO score, obtained by histological evaluation of reticulin fibrosis, collagen deposition and osteosclerosis, resulted prognostically significant, more accurate than ECGMF grade in identifying high-risk patients, and improved PPV when applied in addition to IPSS.
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Fumarate hydratase (fumarase) is a ubiquitous enzyme that catalyzes the conversion of fumarate to S-malate in the tricarboxylic acid cycle and amino acid metabolism. A subset of leiomyomas and renal cell carcinomas (RCC) demonstrate loss of function of fumarase, which may occur through mutation or deletion of the FH gene on chromosome 1q42.3-q43 in a sporadic or germline fashion. Heterozygous germline loss of function results in hereditary leiomyomatosis and renal cell carcinoma syndrome (HLRCC). HLRCC is characterized by development of multiple pilar and uterine leiomyomas, and early development of aggressive RCCs.
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Mesonephric carcinoma, a rare malignant tumor thought to be derived from mesonephric remnants and/or hyperplasia, has recently been characterized by recurrent KRAS/NRAS mutations (1). The molecular features of mesonephric hyperplasia and whether it truly represents a precursor lesion to mesonephric carcinoma are unknown.
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Breast cancer is one of the most common cancer diseases in women with more than 1.67 million cases diagnosed worldwide each year. In breast cancer, the sentinel lymph node (SLN) pinpoints the first lymph node(s) into which the tumor spreads and it is usually located in the ipsilateral axilla. In patients with no clinical signs of metastatic disease in the axilla, a SLN biopsy (SLNB) is performed. Assessment of metastases in the SLNB is done in a conventional microscope by manually observing a metastasis and measuring its size and/or counting the number of tumor cells. This is done essentially to categorize the type of metastases as macrometastases, micrometastases or isolated tumor cells, which is used to determine which treatment the breast cancer patient will benefit mostly from. The aim of this study was to evaluate whether digital image analysis can be applied as a screening tool for SNLB assessment without compromising the diagnostic accuracy.
Consecutive SLNB from 135 patients with localized breast cancer receiving surgery in the period of February to August 2015 were collected and included in this study. Of the 135 patients, 35 were received at Dept. of Pathology, Rigshospitalet, Copenhagen University Hospital, 50 at Dept. of Pathology, Zealand University Hospital, and 50 at Dept. of Pathology, Odense University Hospital. Formalin-fixed and paraffin-embedded tissue sections were analyzed by immunohistochemistry (IHC) using the BenchMark ULTRA Ventana platform. Rigshospitalet used a mixture of cytokeratin CK7 and CK19, Zealand University Hospital used pancytokeratin AE1/AE3 and Odense used pancytokeratin CAM5.2 for detection of epithelial tumor cells. Slides were stained locally. SLNB sections were assessed in a conventional microscope according to national guidelines for SLNB in breast cancer patients. The IHC stained sections were scanned by a Hamamatsu NanoZoomer-XR digital whole slide scanner and the images were analyzed by Visiopharm's software using a custommade algorithm for SLNB in breast cancer. The algorithm was optimized to the cytokeratin antibodies and the local laboratory conditions, based on staining intensity and background staining.
Conventional microscopy was used as golden standard for assessment of positive tumor cells and compared with digital image analysis (DIA). The algorithm demonstrated a sensitivity of 100% (i.e. no false negative slides were observed), including 67.2%, 19.2% and 56.1% of the slides from the three pathology departments being negative, respectively. This means that on average, the workload could have been decreased by 58.2% by using the digital SLNB algorithm as a screening tool.
The SLNB algorithm demonstrated a sensitivity of 100% regardless of the antibody used for IHC and the staining protocol. No false negative slides were observed, which proves that the SLNB algorithm is an ideal screening tool for selecting those slides not necessary for a pathologist to see. Implementation of automated digital image analysis of SLNB in breast cancer would decrease the workload in this context for examining pathologists by almost 60%.
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Terminal deoxynucleotidyl transferase (TdT) is a DNA polymerase expressed in immature, normal and neoplastic, lymphoid or hematopoietic cells and in neuroendocrine carcinomas, like Merkel cell carcinoma and small cell carcinoma. It has not yet been described in cells of epithelial origin. After observing TdT immunoreactivity in normal sebaceous glands we analyzed its spectrum of expression in cases of sebaceous cell hyperplasia and sebaceous cell neoplasms.
Twelve cases of sebaceous gland hyperplasia (SGH), and three cases of other benign lesions, namely, sebaceoma, sebaceous adenoma and sebaceous nevus, along with four archived cases of sebaceous cell carcinomas (SC) were collected and stained with TdT antibody. In addition, tissue microarrays (TMAs) were constructed from eleven cases of basal cell carcinoma (BCC) and ten cases of squamous cell carcinoma (SCC), which offered nine evaluable cases each, and after carcinoma type confirmation with immunostaining for epithelial membrane antigen (EMA), TdT immunohistochemistry was performed. All cases of SGH and sebaceous cell neoplasms were positive for TdT. Staining intensity was variable, often weak to moderate in a significant proportion of cells, apart from one case of SC and the case of sebaceous nevus that were only focally positive. None of BCC and only one SCC showed immunoreactivity.
TdT protein can be found in epithelial origin cells and specifically sebaceous cells, both benign and malignant. It can be hypothesized that this expression is due to sebaceous cell nature to be lead into apoptosis via its holocrine secretion mode. Additional studies are needed to further elucidate its biological role.
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Glomus tumors are uncommon perivascular neoplasms.1 Derived from the glomus bodies of the dermis involved in thermoregulation, glomus tumors are found most frequently in areas of the body rich in such glomus bodies, including the subungual areas of the digits and the distal extremities in general. Although they are most common in the superficial tissues, glomus tumors may occur in visceral organs, including the liver, lung, pancreas, and gastrointestinal and genitourinary tracts.2 When glomus tumors do occur in the gastrointestinal tract, they are most often located in the stomach.3
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In the above-referenced commentary,1 Murali Varma raises two valid concerns regarding implications for communication from the message of our study2. First, introducing a term ”Atypical Intraductal Proliferation (AIP)” or “low-grade intraductal carcinoma (IDC-P)” for which there are no well-defined morphological cut-offs or criteria and, second, for the risk of overtreatment.
In this author's experience which is based on current2 and previous studies,3-6 AIPs represent significant lesions and must be distinguished from HGPIN. Morphologically, the vast majority of AIPs present with cribriform morphology which have been increasingly recognized as significant lesions.
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Human papillomavirus (HPV)-related carcinoma with adenoid cystic-like features is a newly described entity of the sinonasal tract. In this study, we evaluated histomorphology, immunophenotype, and molecular testing to identify potentially helpful features in distinguishing it from classical adenoid cystic carcinoma (AdCC).
We retrospectively collected 5 HPV-related carcinomas with adenoid cystic-like features and 14 AdCCs of the sinonasal tract. All histologic slides were retrieved for morphological evaluation. Comparing to AdCC, HPV-related carcinomas with adenoid cystic-like features were associated with squamous dysplasia of surface epithelium (80% vs 0%, P<0.01) and presence of solid growth pattern (100% vs 29%, P=0.01), but less densely hyalinized tumor stroma (20% vs 86%, P=0.02). Squamous differentiation in the invasive tumor was seen in 3 HPV-related carcinomas with adenoid cystic-like features, 2 of them showing abrupt keratinization and 1 with scattered non-keratinizing squamous nests. Diffuse p16 staining in ≧75% of tumor cells was noted in all HPV-related carcinomas with adenoid cystic-like features but only in 1 AdCC (100% vs 7%, P<0.01). High-risk HPV testing was positive in all HPV-related carcinomas with adenoid cystic-like features (4 associated with type 33 and 1 type 16) but not AdCCs. MYB rearrangement was tested in 4 HPV-related carcinomas with adenoid cystic-like features and all showed negative.
This study further clarified the histologic spectrum of this tumor type and reported the first HPV type 16-related case. Diffuse p16 staining followed by HPV molecular testing is useful in distinguishing HPV-related carcinomas with adenoid cystic features from classical AdCCs.
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The primary aim of this study is to characterize hepatocellular malignant neoplasm, NOS (HEMNOS), a new provisional entity describing a subset of paediatric hepatocellular tumours, which have histological features of neither typical hepatoblastoma (HB) nor hepatocellular carcinoma (HCC).
The clinicopathological features of 11 patients with HEMNOS were analyzed retrospectively. The median age and serum alpha-fetoprotein level at diagnosis was 7 years and 182,000 ng/mL respectively. Ten patients presented with PRETEXT stage III/IV multifocal tumours, eight with major vascular involvement, three with lung metastases, and three with extrahepatic extension. The original pathology diagnoses were: HB in seven patients, HCC in two and HEMNOS in two. Our pathology review of pre-chemotherapy specimens showed that six tumours had equivocal/overlapping histological features of HB and HCC, four had predominant HB histology along with focal HCC-like histology, and one had HB histology. Seven of nine post-chemotherapy resection specimens showed predominant HCC-like histology. Beta-catenin, glypican 3 and spalt-like transcription factor 4 immunostaining showed that all the tumours had a mixed HB/HCC immunophenotype. Telomerase reverse-transcriptase immunostaining showed nuclear staining in nine of the eleven tumours. All patients received chemotherapy and achieved gross total primary tumor resection. Nine of the eleven patients were treated with established HB chemotherapy regimens. After a median follow-up of 6.1 years (range, 1.2 to 11.8 years), all patients were in remission.
HEMNOS is a subtype of HB with focal HCC-like histology, a high-risk clinical profile but favorable outcome following chemotherapy and complete tumor resection.
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Gender dysphoria is a diagnosis wherein an individual identifies as the opposite gender. Management of patients seeking female-to-male (FTM) transition includes hormonal therapy and surgical intervention, including mastectomy. We aim to characterize the immunohistologic findings in resection specimens from FTM patients.
We reviewed 68 cases (67 patients, 1 with re-excision) of FTM breast tissue resection by collecting clinical data, reviewing breast imaging and pathology reports (gross fibrous density, specimen weight and number of cassettes submitted), and reviewing pathology slides (number of tissue pieces submitted, number of terminal duct lobule units [TDLUs], and presence of histologic findings).
Significant histologic findings were present in 51/68 (75.0%) cases and included one case (1.5%) of flat epithelial atypia. Fibrocystic changes were the most common finding (27/68, 39.7%), followed by gynecomastoid change, fibrotic stage, (22/68, 32.4%) and fibroadenomatoid change (11/68, 16.2%). Fibrocystic change was associated with increased TDLUs and gynecomastoid change was associated with lower body mass index and decreased TDLUs. Gynecomastoid change showed a moderate proportion of luminal epithelial cells with strong intensity staining via estrogen receptor, progesterone receptor and androgen receptor immunohistochemistry and a 3-layered epithelium via cytokeratin 5/6 immunohistochemistry.
We identified gynecomastoid change at a significantly higher rate than previously reported in female patients. We support the continued gross and histologic evaluation of FTM specimens in light of identification of atypia in one case.
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Shah et al describe a prostatic intraductal proliferation morphologically intermediate between high-grade PIN (HGPIN) and intraductal carcinoma (IDCP) for which they use the term “atypical intraductal proliferation (AIP).1 They compared the clinicopathological and immunohistochemical characteristics (ERG and PTEN expression) of AIP and IDCP in consecutive prostate biopsies and concluded based on this and previous findings2 that AIP represents lower-grade morphological spectrum of IDCP associated with an intermediate risk of associated prostate cancer compared to HGPIN and IDCP. Finally, they propose expanding the morphological spectrum of IDCP to include AIP within the category of “low-grade IDCP” (LG-IDCP).adenocarcinoma could represent a morphological continuum with rather arbitrary cut-offs.
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Uterine tumour resembling ovarian sex cord tumour (UTROSCT) is an uncommon mesenchymal neoplasm of uncertain histogenesis. While it is considered a neoplasm of uncertain but low malignant potential, there is limited evidence for this since there are no large studies with follow-up. We aimed to determine the clinical behaviour of this uncommon neoplasm and investigate clinicopathological parameters which predict behaviour.
From a series of 34 cases of UTROSCT, mainly from consultation practice, we obtained follow-up information which was obtained by contacting referring pathologists and clinicians. The follow-up periods ranged from 6-135 months (mean 39 months). Eight of 34 patients (23.5%) developed extrauterine metastasis to a variety of sites, including pelvic and abdominal peritoneum, ovary, lymph nodes, bone, liver and lung and three patients (8.8%) died of tumour. Those neoplasms which exhibited malignant behaviour on average occurred in older patients and were larger and more likely to exhibit necrosis, lymphovascular invasion, cervical involvement, significant nuclear atypia and significant mitotic activity. However, only the presence of necrosis and significant mitotic activity was statistically significant
While our figure of 23.5% of cases exhibiting malignant behaviour may reflect some bias related to consultation practice, our results show that these neoplasms not uncommonly have an aggressive clinical course with extrauterine metastasis. Given the overlap in pathological parameters between clinically benign and malignant neoplasms, UTROSCTs are all best regarded as potentially malignant.
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Mucinous tubular and spindle cell carcinoma (MTSC) of the kidney is a distinct entity characterized by bland tightly packed elongated tubules and spindle cells with low nucleolar grade in a basophilic mucinous stroma. Several case studies have reported MTSC with high grade features and have brought into question whether they represented MTSC or a variant of papillary renal cell carcinoma.
We searched our pathology database and identified seven cases: six MTSC with high International Society of Urological Pathology (ISUP) nucleolar grade, and one MTSC with overall low nucleolar grade but extensive necrosis. DNA samples were extracted from paraffin blocks and analyzed using a SNP array platform.
Six out of seven patients were female, with ages between 46 to 82 years. Tumour sizes range from 3 to 7.5 cm. One case showed involvement of renal sinus fat and a second case showed involvement of the perinephric fat. All cases shared common chromosomal abnormalities observed with the more typical MTSC, with monosomy of chromosomes 1,4,6,8,9,13,14,15 and 22. Trisomy of chromosomes 7, 17 and loss of Y chromosome were not observed in any of the cases. None of the patients showed evidence of recurrence or metastasis.
The molecular analysis performed in this study support that MTSC of the kidney can have high nucleolar grade or extensive necrosis, and that they are not papillary renal cell carcinoma. We support modifying the definition of MTSC to include those with higher nucleolar grade.
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Surgical excision of all benign vascular lesions of the breast identified by core needle biopsy has been recommended in the past to rule out a more serious lesion. In this study we investigated the clinical, radiologic, and pathologic findings in patients diagnosed with a benign vascular lesion at our institution to assess whether excision may be spared for lesions without atypia.
We searched the electronic medical record for patients with a vascular lesion of the breast diagnosed between 2000 and 2015. The study population consisted of 84 patients, 83 females and 1 male. The index diagnoses included 76 benign vascular lesions, 5 vascular lesions with cytologic atypia, and 3 angiosarcomas. A radiologist reviewed all pre and post-biopsy imaging studies; all cases had concordant radiologic and pathologic findings. Based on radiologic and histologic correlation, the vascular lesion accounted for the radiologic target in 40 (48%) cases and was deemed an incidental finding in 44 (52%). 7 of 32 (22%) targeted and 10 of 44 (23%) incidental benign vascular lesions underwent surgical excision; there were no upgrades at excision. No recurrences or clinical events were observed in patients with a targeted or incidental benign vascular lesion with a median followup of 39 months and 40.6 months, respectively.
Our data suggest that benign vascular lesions diagnosed on core biopsy with concordant radiologic and pathologic findings do not warrant surgical excision.
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Gastrointestinal stromal tumors (GISTs) may arise anywhere in the gastrointestinal tract, but are rare in the esophagus. We describe the clinical, pathologic, and molecular characteristics of 27 primary esophageal GISTs, the largest series to date.
DNA was extracted and exons 9, 11, 13 and 17 of KIT, exons 12, 14 and 18 of PDGFRA and exon 15 of BRAF were amplified and sequenced. Esophageal GISTs occurred in 14 men and 13 women between 22 and 80 years of age (mean, 56 years). All 27 cases were immunohistochemically positive for KIT, and 92% and 47% co-expressed CD34 or smooth muscle actin, respectively. Fifteen (71% of analyzed cases) harbored KIT exon 11 mutations and one case each had a mutation in KIT exon 13 (K642E) or BRAF exon 15 (V600E). Long-term follow-up data (median, 96.5 months) were obtained for 20 cases; 2 patients had metastases at presentation and 7 had developed local recurrence and/or metastasis after surgery. A large tumor size (≥ 10 cm), high mitotic rate (> 5/5 mm2), presence of a deletion mutation in KIT exon 11 involving codons 557-558 and a positive microscopic margin were associated with recurrence and metastasis. The KIT mutations identified in esophageal GISTs are similar to those observed in gastric GISTs.
Complete surgical resection with clear margins is recommended, if technically feasible, and genotyping can help to improve diagnosis and further patient management in esophageal GIST.
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Neuroblastoma shows considerable histologic overlap with other small round blue cell tumors. PHOX2B, a transcription factor essential for autonomic nervous system development, has been reported as an immunohistochemical marker for neuroblastoma. The purpose of this study was to validate the specificity and diagnostic utility of PHOX2B for peripheral neuroblastic tumors.
We evaluated 240 cases (133 in whole-tissue sections; 107 in tissue microarrays), including 76 peripheral neuroblastic tumors [median age 2 years; including 4 adults] and 164 other tumors: 44 Wilms tumors; 20 Ewing sarcomas; 10 each CIC-rearranged round cell sarcomas, poorly differentiated synovial sarcomas, lymphoblastic lymphomas, alveolar rhabdomyosarcomas, embryonal rhabdomyosarcomas, mesenchymal chondrosarcomas, Merkel cell carcinomas, olfactory neuroblastomas, and melanomas; 5 each NUT midline carcinomas and desmoplastic small round cell tumors. Immunohistochemistry for PHOX2B was performed using a rabbit monoclonal antibody. PHOX2B positivity was defined as the presence of nuclear immunoreactivity in ≥5% of cells. PHOX2B was positive in 70 (92%) peripheral neuroblastic tumors, including 68 of 72 (94%) pediatric and 2 of 4 (50%) adult cases. Furthermore, PHOX2B was consistently negative in all non-peripheral neuroblastic tumors, with staining absent in 160 cases and limited in 4 cases.
PHOX2B is a highly sensitive and specific immunohistochemical marker for peripheral neuroblastic tumors including neuroblastoma. PHOX2B reliably distinguishes neuroblastoma from histologic mimics such as Wilms tumor, Ewing sarcoma, and CIC-rearranged round cell sarcoma. PHOX2B negativity in 2 of 4 adult neuroblastoma cases raises the possibility that some adult neuroblastomas are of a different lineage than pediatric cases.
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Sir: We thank Wang et al for their interest and pertinent comments about our article “Incidence, clinicopathologic features, and fusion transcript landscape of translocation renal cell carcinomas”. We totally agree that the TFE3 break-apart FISH assay is sometimes difficult to interpret and may give rise to false-negatives. The authors question the FISH features observed in the newly described GRIPAP1-TFE3 fusion transcript.
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MYC overexpression is a common feature of diffuse large B-cell lymphoma (DLBCL) and is associated with poor prognosis in patients with this neoplasm. The underlying mechanisms of MYC dysregulation, however, have not been fully understood.
We immunohistochemically evaluated the correlation between BCR-PI3K pathway activity and MYC protein level in 108 cases of de novo DLBCL, twenty five of which featured loss of B-cell receptor (BCR-negative), and investigated the effects of BCR-PI3K signaling on MYC protein level and phosphorylation in DLBCL cell lines.
The expression level of pSYK and pAKT correlated with MYC protein in BCR-positive DLBCL. MYC protein expression was significantly lower in BCR-negative tumor tissues compared to BCR-positive ones. Upon BCR stimulation, the BCR-positive cell lines demonstrated active BCR-PI3K signaling and decreased MYC phosphorylation at T58 site (pT58-MYC), leading to increased overall level of MYC. Conversely, inhibition of BCR-PI3K signaling increased MYC phosphorylation and thus resulting in a decreased level of total MYC proteins. No effects were observed in the BCR-negative cell lines.
Overexpression of MYC in DLBCL can be driven by BCR-PI3K signaling pathway via dephosphorylation at T58, and BCR inhibitors may exert their functions via down-regulating of MYC protein.
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Mantle cell lymphoma (MCL) is characterized by distinctive histologic and molecular features. Aberrant expression of BCL6 and CD10 has occasionally been reported, but the biological features of such cases are largely unknown. This study aimed to define the epidemiologic, histologic and cytogenetic characteristics of BCL6 and CD10-positive MCLs, also investigating possible biological features.
165 cases of cyclin D1 and t(11;14)(q13;q34) positive MCLs were studied for CD10 and BCL6 immunohistochemical expression which was documented in 26/165 (15.8%) cases (BCL6 17/165; CD10 11/165; BCL6 and CD10 co-expression 2/165). CD10-positivity was significantly more frequent in females (63.3%; p<0.01). Either expression significantly correlated with higher mean proliferation index and higher prevalence of MUM1 positivity (p<0.05). Fluorescence in situ hybridization (FISH) for BCL6 (3q27) gene derangements was performed on the BCL6 and CD10-positive cases and 98 matched controls: amplifications were more frequently documented in BCL6-positive than BCL6-negative cases (50.0% versus 19.4% of cases) (p<0.05). The mutational status of the variable immunoglobulin heavy chain genes (IGVH) was investigated by Sanger sequencing: 5 of the 6 successfully tested cases (83.3%) showed no somatic hyper-mutations.
Aberrant CD10 and BCL6 expression defines a subset of MCLs with higher mean Ki67 index and higher prevalence of MUM1 expression. BCL6 protein positivity correlates with cytogenetic aberrations involving the BCL6 gene. Though successfully examined in few cases, the high prevalence of un-mutated IGVH genes points at a pre-germinal cell origin also for these phenotypically aberrant cases.
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Pediatric follicular thyroid carcinomas are uncommon and their clinicopathological features and molecular profiles are still unknown. In this present study, we aimed to investigate the clinicopathological aspects of a large series of follicular thyroid carcinomas (FTCs) in pediatric patients and to analyse the point mutations in codons 12, 13 and 61 of NRAS, HRAS and KRAS genes and the rearrangements of PAX8-PPARG.
A total of 41 pediatric FTCs less than 21 years of age were enrolled in the present study. We used direct sequencing and RT-PCR to detect RAS mutations and PAX8-PPARG fusions, respectively.
The pediatric FTCs were 6:1 in female to male ratio, with a mean tumor size of 52.7 mm. Distant metastasis was found in one case at time of presentation. During a median follow-up time of 69 months, two cases had lung metastasis and all patients were alive. Histologically, all cases were minimally invasive FTCs and varied in growth patterns: microfollicular (39%), follicular (14.6%), solid/trabecular (6%), oncocytic (4.9%) and mixed patterns (26.8%). The mean Ki67 index was 5.7% and it was not statistically different among the growth patterns. NRAS mutations were found in five cases (12.2%) and significantly associated with small tumor size (p = 0.014). PAX8-PPARG fusion was not detected in our series.
Pediatric FTCs are indolent in clinical course in spite of their large tumor size and have a distinct genetic background. RAS mutations and PAX8-PPARG fusions may not play major roles in the tumorigenesis of pediatric FTCs.
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Heat shock proteins (HSPs) are a group of molecules induced by a variety of environmental and pathophysiologic stresses, including cancer. HSPs are implicated in the regulation of apoptosis and immunity in neoplasm. Transcription factor heat shock factor1 (HSF1) acts as the master regulator to control HSP expression, and therefore is involved in tumorigenesis. The purpose of this study was to evaluate the expression and clinicopathologic relevance of HSPs and HSF1 in clear cell renal cell carcinoma (ccRCC).
The expression of HSP27, HSP60, HSP70, HSP90 and HSF1 was assessed in 428 cases of ccRCC using immunohistochemistry. High expression of HSP60 and HSP70 was positively correlated with grade and stage. High expression of HSF1 was positively correlated with stage. Univariate and multivariate analyses demonstrated that 216 patients (52%) with tumour expressing 3 or 4 markers in a panel of HSP60, HSP70, HSP90, and HSF1 had a significantly heightened risk for cancer-specific mortality than tumours expressing <3 markers (P<0.0001; concordance index, 0.81).
Immunohistochemical examination of HSPs and HSF1 provides useful prognostic information that may contribute to the design of therapeutic strategies for patients with ccRCC.
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The identification of hepatocellular adenoma (HCA) with mutation in exon 3 of the CTNNB1 gene encoding for b-catenin is clinically relevant due to higher risk of malignant transformation. Inflammatory HCA (IHCA) can exhibit b-catenin activation (b-IHCA). We report 2 cases with multiple IHCA in which focal b-catenin activation has been found in one of the IHCA. In both cases, the diagnosis of IHCA was confirmed on the resected nodules by routine stains, immunohistochemical detection of C-reactive protein (CRP), and molecular biology on frozen material. An additional molecular analysis was performed on formalin fixed paraffin embedded (FFPE) material that showed focal glutamine synthetase (GS) staining, the surrogate marker of b-catenin activation. In case one, it was a 1.8 cm area within the 7.5 cm IHCA, and in case two, a small 0.3 cm area within a 1.8 cm resected IHCA located close to a larger IHCA, negative for GS. In both cases, nuclear beta-catenin expression and decreased reticulin network were observed in the GS expressing foci, together with cholestasis and diffuse CD34 expression in case one. Molecular analysis by pyrosequencing on FFPE material using the GS stained slides as reference to select areas with/without positive staining revealed a CTNNB1 exon 3 mutation restricted to the areas exhibiting both positive GS and CRP expression, whereas wild-type CTNNB1 was found in areas showing only CRP staining. These 2 cases illustrate focal b-catenin activation that can occur within IHCAs. Additional data are needed to tell if b-catenin mutation is a secondary event in IHCA.
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Uterine leiomyosarcomas frequently show p16 immunoexpression. However, p16 may also be expressed in some benign leiomyoma variants such as leiomyomas with bizarre nuclei and cellular leiomyomas, limiting its utility as a biomarker to distinguish between benign and malignant neoplasms. We investigated p16 expression in leiomyomas with infarct-type necrosis, tumours which may sometimes be misinterpreted as smooth muscle tumors of uncertain malignant potential or even leiomyosarcoma on conventional light microscopy.
p16 immunostaining was performed on 35 leiomyomas with infarct-type necrosis and the staining pattern was analyzed. Staining was classified as absent, scattered/isolated, <33%, 33-66% or >66% positive cells, and was assessed in the areas immediately surrounding and far from the infarct.
The median age of patients was 44 years. Seventeen had hormonal/non-hormonal drugs and 3 were pregnant. The median tumour size was 7.25 cm. The mean mitotic count was 0.9/10 high-power-fields. Only one tumour had multifocal mild nuclear atypia. Positive p16 was noted in 34 of 35 (97.2%) tumours. It was typically patchy and was concentrated in areas immediately surrounding the necrosis. Far from the necrosis, p16 positivity was predominantly seen in scattered/isolated cells. One tumour without any worrisome microscopic features showed diffuse p16 positivity throughout. Median follow-up was 55 months and none of the patients experienced any recurrence.
p16 expression in benign uterine smooth muscle tumours with infarct-type necrosis is common. The staining is particularly concentrated adjacent to areas of necrosis. It is important to be aware of this potential pitfall when interpreting p16 expression.
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The large nested variant of urothelial carcinoma (LNUC) has been added to the WHO 2016 classification. Scant data exist, little is known about its clinical behaviour.
Cases fulfilling the morphological criteria of LNUC were collected. Pure and mixed cases (i.e. with other patterns of invasive UC) were studied. Immunohistochemical staining with CK7, p63, GATA-3, CK20, p53 and Ki-67 was performed.
Included were 26 cystectomies (RC) and 10 resections (TURB) belonging to 36 patients with an average age of 66.7 years. Fourteen (39%) were pure LNUCs, and 22 (61%) displayed mixed features. 70% of the TURBs had pT2 tumors while 58% of RCs had extravesical disease (≥pT3 and/or ≥pN1), with the rate of advanced disease being higher in mixed (69%) in comparison to pure cases (40%). Similarly 38% of mixed cases had nodal metastases in comparison to 20% of pure cases.
Overall, 8 patients (24%) died of disease at a mean interval time of 21.7 months, 7 patients (21%) showed recurrence or metastases. disease progression was significantly higher in mixed cases (55% and 31% in mixed and pure cases, respectively). Positive staining was: CK7=87.5%, CK20=72%, GATA-3=91%, P63=100%, p53=56%, Ki-67=mean of 16%.
Despite the bland cytologic appearance and deceptive pattern of invasion of the LNUC, our study validates its fully malignant potential with metastatic spread and tumor related deaths. Distinguishing mixed from pure LNUCs seems to be of value. LNUCs show comparable immunophenotype to both conventional urothelial carcinoma and the nested variant of urothelial carcinoma.
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Adenoid cystic carcinoma (AdCC) is one of the most common salivary gland malignancies and the long-term prognosis is poor. In this study, we examined alterations of AdCC-associated genes, MYB, MYBL1, MYBL2, and NFIB, and their target molecules including MYC. The results were correlated to clinicopathological profile of the patients.
Using paraffin tumor sections from 33 cases of salivary gland AdCC, we performed a detailed fluorescence in situ hybridization (FISH) analysis for gene splits and fusions of MYB, MYBL1, MYBL2, and NFIB. We found that 29/33 (88%) AdCC cases showed gene splits in either MYB, MYBL1, or NFIB. None of the cases showed an MYBL2 gene alteration. AdCCs were genetically divided into six gene groups, MYB-NFIB (n=16), MYB-X (n=4), MYBL1-NFIB (n=2), MYBL1-X (n=1), NFIB-X (n=6), and gene-split-negative (n=4). AdCC patients showing the MYB or MYBL1 gene splits were associated with microscopically positive surgical margins (p=0.0148) and overexpression of MYC (p=0.0164). MYC expression was detected in both ductal and myoepithelial tumor cells, and MYC overexpression was associated with shorter disease-free survival of the patients (p=0.0268).
The present study suggests that 1) nearly 90% of AdCCs may have gene alterations of either MYB, MYBL1, or NFIB, suggesting diagnostic utility of the FISH assay, 2) MYB or MYBL1 gene splits may be associated with local aggressiveness of the tumors and overexpression of MYC, which is one of the oncogenic MYB/MYBL1 targets, and 3) MYC overexpression may be a risk factor for disease-free survival in AdCC.
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Atypical intraductal proliferation (AIP) of the prostate is histologically worse than high-grade prostate intraepithelial neoplasia, but lacks the diagnostic criteria of intraductal carcinoma (IDC-P). The study aims to compare clinicopathological and molecular characteristics (ERG overexpression and PTEN loss) of AIP and IDC-P in core needle biopsies.
Total 106 (84 (5.6%) of 1480 consecutive and 22 retrospectively collected) cases met the criteria: AIP only (2.4%), IDC-P only (1.3%), and IDC-P coexisting with AIP (2%). Invasive adenocarcinoma (PCa) was present in 96% and 97% cases of AIP and IDC-P respectively. The mean number of glands/focus and the largest gland diameter for AIP and IDC-P were 7.6 (range, 2-27) and 11.7 (range, 1-51) and 0.59 MM (range, 0.2-1.1) and 0.75 MM (range, 0.2-1.8) respectively. For AIP, loose cribriform architecture was the most common (93%) morphology. IDC-P associated PCa had more aggressive pathology including highest combined Gleason score (GS), high-grade GS ≥ 4+3, largest % involvement of core by PCa and % positive cores than AIP associated PCa (p<0.05). Within AIP group, ERG and PTEN status was similar to adjacent PCa in 97% and 88% of cases respectively. Within IDC-P group, ERG and PTEN status was similar among IDC-P, AIP and PCa in 96% and 91% of cases respectively. PTEN loss was frequently heterogeneous in PCa and localized adjacent to AIP or IDC-P
AIP represents lower-grade morphological spectrum of IDC-P associated with an intermediate risk PCa. Patients with only AIP need immediate repeat biopsy to rule out clinically significant PCa.
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Treatment of patients with tubo-ovarian high-grade serous carcinoma (HGSC) is increasingly based on diagnosis on small biopsy samples and the first surgical specimen is often post-chemotherapy. p53 and WT1 are important diagnostic markers for HGSC. The effect of neo-adjuvant chemotherapy on p53 and WT1 expression has not been widely studied. We aimed to compare p53 and WT1 expression in paired pre- and post-chemotherapy samples of HGSC.
Immunohistochemistry (IHC) was carried out for p53 and WT1 on paired omental HGSC samples pre- and post-chemotherapy. p53 IHC was recorded as normal (wild-type) or abnormal (mutation-type), further classified as overexpression, complete absence or cytoplasmic, and for WT1 as positive or negative. A subset of cases was further assessed for the extent of nuclear immunoreactivity of WT1 using the H-score.
57 paired samples were stained with p53. 56/57 (98%) cases showed mutation-type p53 staining. Pre- and post-chemotherapy IHC results were concordant in 55/57 (96%) cases. For WT1, pre- and post-chemotherapy IHC results were concordant in 56/58 (97%) of cases. In 23 paired WT1 cases the mean post-treatment H-score decreased from 227 (range 20-298, SD 64) to 151 (range 0-288, SD 78) (p=0.0008).
Immunohistochemical expression of p53 (abnormal/mutation-type pattern) and WT1 in HGSC is almost universal and largely concordant before and after chemotherapy. This finding underscores the reliability of these diagnostic markers in small samples and in surgical samples following neo-adjuvant chemotherapy with very few exceptions. A novel finding was the significant diminution in intensity of WT1 staining following chemotherapy.
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to determine the relative utility of in situ testing for hepatitis E virus (HEV) RNA and paraffin section PCR to diagnose HEV infection in paraffin-embedded clinical liver biopsies, and to correlate with clinico-pathological characteristics.
We evaluated in situ and quantitative PCR (qPCR)-based approaches to identifying HEV in clinical liver biopsies from infected patients from multiple centers, correlating with clinical setting (immunocompetent, allograft or immunosuppressed native liver) and histologic findings.
36 biopsies from 29 patients had histologic data, of which 27 and 23 biopsies had satisfactory material for in situ RNA testing and tissue qPCR respectively. Both approaches specifically identified HEV infection, but tissue qPCR was significantly more sensitive than in situ testing (P=0.035). In immunocompetent but not immunosuppressed patients the tissue qPCR yield correlated with the severity of lobular hepatitis (rho=0.94, P<0.001). qPCR viral yield was comparably high in allografts and immunosuppressed native livers and significantly greater than with native liver infection. Immunosuppressed patients showed reduced severity of hepatitis and cholestatic changes, compared with immunocompetent patients. Indeed, HEV-infected liver allografts could show minimal hepatitis for many months. In individual cases each technique was useful when serum was not available to retrospectively identify chronic infection (in biopsies taken 4-31 months before diagnosis), to identify persistent/residual infection when contemporary serum PCR was negative and to identify cleared infection.
qPCR is better than in situ RNA testing to identify HEV infection in paraffin-embedded liver biopsies and has diagnostic utility in selected settings.
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Low grade serous neoplasms of the testis are rare neoplasms that demonstrate striking morphological similarities with the better-understood ovarian neoplasms. The cell of origin, relation to serous ovarian tumour and the pathogenesis of these neoplasms are not fully established.
As low grade serous ovarian neoplasms are known to harbour mutations in the MAP-kinase pathway, we investigated the involvement of BRAF and KRAS mutations in low grade testicular serous tumour by way of mutational analysis of 7 cases. Mutational analysis was performed by melting curve analysis followed by bidirectional sequencing. Our findings showed BRAF and/or KRAS mutation in 3 of the 7 cases, similar to the proportions reported in low grade ovarian serous neoplasms. Out of these three cases, one showed co-mutation of BRAF and KRAS.
This supports the role of aberrant signalling of the MAP-kinase pathway in the pathogenesis of low grade serous testicular neoplasms and provides a genetic link between low grade testicular and ovarian serous tumours.
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The association between lung cancer and idiopathic pulmonary fibrosis (IPF) is well known, but the significance of this association is poorly understood. Bronchiolar honeycomb cysts have been proposed as possible precursors for the development of carcinoma, but limited evidence in support of this hypothesis is available. The aim of this study was to investigate this hypothesis analysing a series of carcinomas arising in IPF by immunohistochemistry.
Thirty-three lung carcinomas arising in patients with IPF were analysed with a panel of immunohistochemical markers. The antibodies included those against pneumocyte markers [thyroid transcription factor 1 (TTF1), napsin-A, and surfactant protein A], the goblet cell marker mucin 5AC, markers of basal/squamous cell differentiation [cytokeratin (CK) 5/6 and ΔN-p63], and markers related to enteric differentiation (CDX2, mucin 2, CK20, and villin). A series of 100 consecutive lung adenocarcinomas arising in smokers without IPF were investigated as controls. All carcinomas arising in IPF patients were peripherally located on imaging analysis. The diagnoses were: eight squamous cell carcinomas, 20 adenocarcinomas, three small-cell carcinomas (including one composite small-cell carcinoma and adenocarcinoma), and two large-cell carcinomas. Among adenocarcinomas, a ‘pneumocyte’ profile (TTF1/napsin-A/SPA1-triple-positive) was observed in seven of 20 (35% versus 84% in non-IPF controls, P = 0.0001). The remaining 13 adenocarcinomas (65%) showed rare histotypes: four invasive mucinous adenocarcinomas (20% in IPF patients versus 1% in non-IPF controls, P = 0.002), seven tumours (35%) that were characterized by variable expression of markers of enteric differentiation, and two tumours (10%) that showed a peculiar basaloid component.
The immunohistochemical characterization of carcinomas arising in IPF patients shows striking divergence from that in non-IPF smokers. The prevalence of rare entities showing bronchiole-related markers is in line with the hypothesis that these tumours arise from transformed small airways in honeycomb lung areas where abnormal bronchiolar proliferation takes place.
Myxomas are benign soft tissue tumours resembling primitive mesenchyme. They rarely involve ocular structures, and have been recognized in the conjunctiva, eyelids, cornea, and orbit. The aim of this study was to investigate the clinicopathological features of seven patients with primary conjunctival myxoma seen at Dr Luis Sánchez Bulnes Hospital, an ophthalmological referral centre in Mexico City.
We reviewed the clinical, histochemical and immunohistochemical studies of patients with documented myxoma of the conjunctiva diagnosed in our hospital. Seven conjunctival myxomas were retrieved from 5923 conjunctival biopsies (0.1%). The mean age of patients was 40 years, with a range of 27–51 years. Females were more frequently affected, and none of our patients had systemic disease. The left eye was involved in five cases, and most of the lesions were located in the bulbar conjunctiva. Histopathological examination revealed a benign tumour composed of spindle-shaped and stellate-shaped cells immersed within an abundant mucinous matrix with sparse vessels and reticulin fibres. Immunohistochemistry demonstrated positivity for vimentin and negativity for smooth muscle actin, SOX10 and GLUT1 in myxoma cells of all cases. S100 was found to be positive in four cases, and muscle-specific-actin in three cases.
Conjunctival myxomas are uncommon tumours. For accurate diagnosis, histopathological examination is mandatory. The treatment of choice is surgical removal, and the prognosis is excellent.
To compare the oncogenic mutation status among mucinous cystic neoplasms (MCNs) of different histological grades and between liver and pancreatic MCNs.
KRAS, GNAS, RNF43 and PIK3CA were sequenced in 25 surgical cases of hepatopancreatic MCN. Molecular features were correlated with clinicopathological and immunohistochemical findings. KRAS mutations were identified in five cases (20%), whereas GNAS, RNF43 and PIK3CA were wild-type in all cases. KRAS mutations were uncommon in cases of low-grade dysplasia (1/20, 5%), whereas KRAS was mutated in all cases of higher grades, except for one liver MCN with intermediate-grade dysplasia (4/5, 80%; P = 0.002). This genetic alteration was slightly more frequent in the pancreas than in the liver [4/17 (24%) versus 1/8 (13%), P = not significant]. KRAS-mutated MCNs more commonly had a multilocular cystic appearance (P = 0.040) and expression of mucin (MUC) 1 (P = 0.040), MUC2 (P = 0.016) and MUC5AC (P = 0.015) than KRAS-wild-type tumours. In cases of KRAS-mutated MCNs with intermediate-grade or high-grade dysplasia, identical mutations were also detected in areas of adjacent low-grade dysplasia.
KRAS mutations appear to be major driver genetic alterations in both liver and pancreatic MCNs. As identical KRAS mutations were present in low-grade and higher-grade areas in individual cases, KRAS mutations occurring in low-grade MCNs may lead to tumour progression. Thus, preoperative KRAS testing may contribute to estimations of malignant potential. The lower incidence of KRAS mutations in liver MCNs may also explain why the risk of malignant transformation in liver MCNs is lower than that in pancreatic MCNs.
KIT overexpression is frequently observed in adenoid cystic carcinomas (AdCCs), chromophobe renal cell carcinomas (ChRCCs), and gastrointestinal stromal tumours (GISTs). Persistent KIT activation has been reported to be mediated by protein kinase C (PKC)-δ in a subset of colon cancers with wild-type KIT overexpression, and by PKC-θ in GISTs with mutant KIT overexpression. To elucidate the clinical implications of PKC-δ and PKC-θ expression in KIT-expressing tumours, we investigated the expression of KIT, PKC-δ and PKC-θ in AdCCs and ChRCCs in comparison with GISTs.
KIT expression, PKC-δ expression and PKC-θ expression were analysed in whole sections from 41 AdCCs, 40 ChRCCs and 56 GISTs by immunohistochemistry. Membranous expression of KIT was found in 34 AdCCs and all ChRCCs, whereas cytoplasmic expression of KIT was found in 46 GISTs. In AdCCs, PKC-δ expression was associated with histological grade (P = 0.049), lymphovascular invasion (P = 0.004), perineural invasion (P = 0.002), and KIT positivity (P = 0.002). PKC-δ positivity was associated with shorter relapse-free survival (RFS) (P = 0.017) and a tendency for there to be shorter overall survival (OS) (P = 0.090) in patients with AdCCs. No clinicopathological associations were observed between PKC-δ and KIT expression in ChRCCs. In GISTs, PKC-θ expression was associated with higher mitotic count (P = 0.011) and high grade according to the modified National Institutes of Health criteria (P < 0.001). PKC-θ positivity was associated with shorter RFS (P = 0.016) and a tendency for there to be shorter OS (P = 0.051) in patients with GISTs.
PKC-δ expression is associated with KIT expression and the prognosis of patients with AdCCs, suggesting that PKC-δ may be a potential therapeutic target for AdCCs.
The aim of this study was to evaluate the mutation status of epidermal growth factor receptor (EGFR) in gastrointestinal stromal tumours (GISTs) and its association with various clinicopathological variables, as well as to discuss further the effects of EGFR mutations on tumour formation and progression.
A well-characterized cohort of 323 GISTs, obtained between 2010 and 2015 from the surgical pathology files of at the Department of Pathology of the Nanjing Jinling Hospital, was screened for mutations in exons 19 and 21 of the EGFR gene. Patient clinical data and clinicopathological features were collected if available in the medical records. Among the 323 primary GISTs, we identified three cases (0.93%) of EGFR mutations; these mutations never occurred together with KIT, PDGFRα, KRAS or BRAF mutations. In two cases, tumour cells exhibited spindle cell morphology and, in one case, epithelioid cell morphology. Additionally, the morphology and immunophenotype of these three cases did not show significant differences compared to common GISTs. The clinical results in summary were that two cases of EGFR-mutated GISTs occurred in females and in the stomach. The mean age of EGFR-mutated cases was 54.33 years, and the follow-up data indicated that these tumours were low risk and exhibited low recurrence.
We first established that GISTs carrying EGFR mutation are relatively benign tumours. Although EGFR mutations were rarely present in GIST, EGFR seems to play a significant role in the development and progression of GIST.
To evaluate the relationships between immunohistochemical markers related to cellular senescence, cell proliferation and histological grade of epithelial dysplasia (OD) of the oral cavity. In addition, the predictive value of these markers for progression of OD was assessed.
Retrospective immunohistochemical analyses were performed on 86 formalin-fixed paraffin-embedded specimens of OD and oral squamous cell carcinoma (OSCC) for Ki67, phosphorylated histone H2AX (γH2AX), p53, p16, trimethyl-histone H3 (Lys9) (H3K9me3) and cyclin D1 (CycD1). Three separate areas representing the highest severity of OD on each slide were annotated digitally by two independent pathologists. Mean automated histoscores of the selected markers were generated and compared to that of age-matched healthy controls (n = 24). Follow-up data of OD were retrieved and anonymized by a clinical team member and linked using unique participant identifiers. The median follow-up was 10.9 years (interquartile range: 10.1–11.5). Ki67 (P < 0.0001), γH2AX (P = 0.03) and p53 (P = 0.04) were increased significantly with higher histological grade of OD. γH2AX (P = 0.03), but not histological grade of OD (P = 0.73), was associated prospectively with disease progression. Using the median histoscore for γH2AX (median histoscore = 17) as a cut-off, histoscore ≥17 was associated with an increased risk of disease progression [hazard ratio (HR) = 3.15, 95% confidence interval (CI): 1.41–7.39, P = 0.0064].
Although proliferation marker Ki67, DNA damage/checkpoint markers γH2AX and p53 were increased in higher grade of OD, only γH2AX was predictive of disease progression. These observations may reflect the role of DNA replicative stress in the transformation from OD to OSCC. Larger studies should evaluate whether γH2AX can be used as a predictive marker of OD.
Distinction between primary cutaneous follicular lymphoma (PCFL) and primary cutaneous marginal zone lymphoma (PCMZL) is challenging, as clear-cut immunophenotypical and cytogenetic criteria to segregate both entities are lacking.
To characterize PCFL and PCMZL more clearly and to define criteria helpful for the differential diagnosis, we compared expression of immunohistochemical markers [LIM-only transcription factor 2 (LMO2), human germinal centre-associated lymphoma (HGAL), stathmin 1 (STMN1), activation-induced cytidine deaminase (AID), myeloid cell nuclear differentiation antigen (MNDA)] and the presence of cytogenetic abnormalities described previously in nodal follicular lymphoma [B cell lymphoma 2 (BCL2) and BCL6 breaks, 1p36 chromosomal region deletion (del 1p36)] in a series of 48 cutaneous follicular and marginal zone lymphomas [cutaneous follicular lymphoma (CFL) and cutaneous marginal zone lymphoma (CMZL)]. Immunostaining for STMN1, LMO2, HGAL and AID allowed the distinction between CFL and CMZL, and STMN1 was the most sensitive marker (100% CFL, 0% CMZL). LMO2, HGAL and AID were positive in 93.2%, 82.1% and 86.2% CFL (all CMZL-negative). MNDA was expressed in both entities without significant difference (10.3% CFL, 30.8% CMZL, P = 0.18). BCL2, BCL6 breaks and the del 1p36 were present in 16.7%, 10.7% and 18.5% CFL and no CMZL. Finally, three and 29 CFL were reclassified as secondary cutaneous follicular lymphomas (SCFL) and PCFL without significant differences concerning phenotypical and cytogenetic features. BCL2, BCL6 breaks and the del 1p36 were present in 11.1%, 8% and 16.7% PCFL and did not impact the prognosis.
LMO2, HGAL, STMN1 and AID, but not MNDA, are discriminant for the recognition between CFL and CMZL. BCL2, BCL6 rearrangements and the del 1p36 have a role in the pathogenesis of PCFL, the latest being the most common alteration.
The clinical significance of mucinous prostatic adenocarcinoma (PCa) remains uncertain.
From 6440 cases of PCa treated by radical prostatectomy from 2009 to 2014, mucinous components of 5–100% were found in 143 (2.2%) cases.
The mean age was 61.4 years, mean pre-operative serum prostate-specific antigen (PSA) was 7.8 ng/ml and clinical stage category was cT1 in 81% and cT2 in 19% of cases. Cases were graded using the 2014 International Society of Urological Pathology recommendation of grading underlying architecture, and Gleason scores (GS) were 3 + 4 in 13.3%, 4 + 3 in 54.5%, 4 + 4 in 2.1%, 3 + 4 or 4 + 3 with tertiary 5 in 11.9% and 9–10 in 18.2%. The mucinous component invariably had a high-grade component. Extraprostatic extension was found in 46.8% of cases. In 21.6%, tumour volume was ≥3 cm³ and 9.7% had surgical margin positivity. Seminal vesicle involvement was found in 6.9%. In 73 cases the mucinous component was >25%, and when cases were divided on the basis of the area of mucin present (≤25 versus >25%) there was no significant difference between clinical or pathological features. Similar findings were achieved when cases were compared with grade-matched non-mucinous carcinoma controls. The 5-year biochemical recurrence rates for mucinous versus non-mucinous cancer were 12.5 versus 17% (P = 0.15).
PCa with mucinous components is often high grade; however, the prognosis appears to be similar to non-mucinous cancers of similar GS.
Accurate histological diagnosis and classification of germ cell tumours (GCTs) is key to informing successful therapeutic and surveillance strategy. The modern therapeutic approach for yolk sac tumour (YST) is highly curative. Because YST takes on a large morphological spectrum, it can be confused for other GCT subtypes as well as somatic carcinomas, particularly when YST presents in an extragonadal or a metastatic setting. Currently available immunohistochemical markers are limited by suboptimal sensitivity and specificity. We reported recently that ZBTB16 is a sensitive and specific marker for testicular YST. ZBTB16 is absent in other GCTs and in most common somatic carcinomas, including those of gastrointestinal, pancreatobillary, respiratory, genitourinary and gynaecological tracts. The purpose of this study is to investigate the diagnostic utility of ZBTB16 in the settings of metastatic and extragonadal YST.
We studied 32 archived metastatic and four extragonadal primary YSTs as well as 51 somatic malignancies for their immunohistochemical expression of ZBTB16. For comparison, α-fetoprotein (AFP) and glypican-3 were also studied in parallel. Our results demonstrated an overall sensitivity of 91.6% for ZBTB16 in detecting metastatic and extragonadal YSTs. The non-YST elements (teratoma and embryonal carcinoma) in 15 YST-containing metastatic mixed GCTs were non-reactive. With the exception of occasional myoepithelial cells of salivary gland carcinoma, all the 51 somatic malignancies were negative for ZBTB16.
ZBTB16 is a sensitive and specific marker for YST and is diagnostically superior to AFP and glypican-3 in metastatic and extragonadal settings.
HER2 is currently the only biomarker used to select eligible patients with advanced gastric cancer (GC) for targeted therapy. The aims of this study were to verify the value of dual-block HER2 assessment and to explore whether increasing the block number is more beneficial by carrying out a randomized prospective cohort study in which dual-block and all-block HER2 assessment were compared in resected specimens of GC.
Five hundred and forty-nine resected GC specimens were randomly enrolled into two cohorts: a dual-block group (n = 274) with two primary tumour blocks tested, and an all-block group (n = 275) with all primary tumour blocks tested. Immunohistochemical staining of HER2 was performed. For HER2-equivocal (2+) cases, fluorescence in-situ hybridization (FISH) was performed. As compared with single-block assessment, dual-block assessment increased the HER2 immunohistochemistry (IHC)-positive (3+) rate. The rate with dual-block assessment (11.3%) was significantly higher than that with block 1 assessment (8.8%) (P = 0.016) and block 2 assessment (9.1%) (P = 0.031). Similarly, all-block assessment demonstrated a higher HER2 3+ rate (12.4%) than single-block assessment (block 1, 6.5%; block 2, 6.2%; block 3, 7.2%; block 4, 8.7%) (P < 0.05). HER2 3+ rates of all-block and dual-block assessments showed no significant difference (P = 0.703). After IHC and FISH results had been combined, the HER2-positive rate with all-block assessment (13.5%) was slightly higher than that with dual-block assessment (12.0%), although the difference was not statistically significant (P = 0.62).
Dual-block immunohistochemical assessment is an effective, practical and economic approach that is suitable for the preliminary screening of HER2. We recommend that dual-block HER2 assessment be routinely performed on resected specimens of GC. All-block assessment can be a supplement to dual-block assessment if necessary.
Extra-uterine high-grade serous carcinoma (HGSC) accounts for most of the morbidity and mortality associated with ovarian carcinoma, and is one of the leading causes of cancer death in women. Until recently our understanding of HGSC was very limited compared to other common cancers, and it has only been during the last 15 years that we have learned how to diagnose this ovarian carcinoma histotype accurately. Since then, however, there has been rapid progress, with identification of a precursor lesion in the fallopian tube, development of prevention strategies for both those with inherited susceptibility (hereditary breast and ovarian cancer syndrome) and without the syndrome, and elucidation of the molecular events important in oncogenesis. This molecular understanding has led to new treatment strategies for HGSC, with the promise of more to come in the near future. In this review we focus on these recent changes, including diagnostic criteria/differential diagnosis, primary site assignment, precursor lesions and the molecular pathology of HGSC.
]]>Paired-like homeobox 2b (PHOX2B) is a transcription factor with expression outside of the central nervous system restricted to neurons and chromaffin cells of the autonomic nervous system. Germline mutations cause congenital central hypoventilation syndrome and predispose to neuroblastoma and Hirschsprung disease. Among paediatric small round cell tumours, PHOX2B is neuroblastoma-specific. Two studies of adult autonomic nervous system tumours (n = 62) produced conflicting results (all tumours stained in one; expression restricted to 40% of paragangliomas in the other). We examined PHOX2B expression in a large cohort of phaeochromocytomas and paragangliomas, as well as well-differentiated neuroendocrine tumours (WDNETs) and poorly differentiated neuroendocrine carcinomas (PDNECs).
Tissue microarrays (TMAs) were constructed from 609 tumours: 111 phaeochromocytomas, 146 paragangliomas, 250 WDNETs, and 102 PDNECs. PHOX2B immunohistochemistry was scored for extent (%) and intensity (0–3+), and an H-score (extent × intensity) was calculated. PHOX2B expression was seen in 32% of phaeochromocytomas and in 47% of paragangliomas. Mean/median H-scores for these tumours were in the 30–55 range (i.e. weak to moderate staining). No WDNETs and only 7% of PDNECs stained, the latter often strongly. In a representative cohort of corresponding whole sections (n = 55), the results in WDNETs and PDNECs were unchanged, whereas half of the phaeochromocytomas/paragangliomas that were negative on TMAs became focally, weakly positive.
We found frequent, weak to moderate PHOX2B expression in phaeochromocytomas/paragangliomas and no expression in WDNETs, which could be diagnostically useful in the distinction of these tumours. Expression in a minority of PDNECs probably reflects the transcription factor lineage infidelity that is characteristic of this tumour class.
Traditional serrated adenoma (TSA) is a rare but distinct type of colorectal polyp. Our previous study showed that PTPRK–RSPO3 fusions are frequent and characteristic genetic alterations in TSAs. This study aimed to characterize comprehensively the prevalence and variability of RSPO fusions in colorectal TSAs.
We examined RSPO expression and explored novel RSPO fusions in 129 TSAs, including 66 lesions analysed previously for WNT pathway gene mutations. Quantitative polymerase chain reaction (qPCR) analyses identified three and 43 TSAs overexpressing RSPO2 and RSPO3, respectively, whereas the expression of RSPO1 and RSPO4 was marginal or undetectable in all cases. RSPO overexpression was always mutually exclusive with other WNT pathway gene mutations. Known PTPRK–RSPO3 fusions were detected in 37 TSAs, all but one of which overexpressed RSPO3. In addition, rapid amplification of cDNA ends revealed three novel RSPO fusion transcripts, an NRIP1–RSPO2 fusion and two PTPRK–RSPO3 fusion isoforms, in six TSAs. Overall, 43 TSAs had RSPO fusions (33%), whereas four TSAs (3%) overexpressed RSPO in the absence of RSPO fusions. TSAs with RSPO fusions showed several clinicopathological features, including distal localization (P = 0.0063), larger size (P = 0.0055), prominent ectopic crypt foci (P = 8.4 × 10−4), association of a high-grade component (P = 1.1 × 10−4), and the presence of KRAS mutations (P = 4.5 × 10−5).
The present study identified RSPO fusion transcripts, including three novel transcripts, in one-third of colorectal TSAs and showed that PTPRK–RSPO3 fusions were the predominant cause of RSPO overexpression in colorectal TSA.
Two-thirds of early pregnancy failures present with reduced trophoblast invasion, and SLIT2/ROBO1 signalling is considered to play an important role in trophoblast function during pregnancy. We investigated SLIT2/ROBO1 signalling associated with missed and threatened miscarriage during early gestation.
Human placenta samples were collected from women with missed miscarriage (n = 25), threatened miscarriage (n = 22) and termination of pregnancy controls (n = 32). Corresponding decreases in beta human chorionic gonadotrophin (β-hCG) levels and shallow trophoblast invasion were observed in patients with missed and threatened miscarriage, immunohistological staining revealed abnormal Slit2 and Robo1, as well as E-cadherin and activating protein-2 alpha (AP-2α) expression in villi and extravillous trophoblasts, and the expression of these proteins were confirmed in villi and decidua of miscarriage material by Western blotting. Using HTR8/SVneo cells, blocking SLIT2/ROBO1 signalling promoted cell migration, proliferation and suppressed differentiation. Moreover, blocking SLIT2/ROBO1 signalling in HTR8/SVneo cells altered trophoblast differentiation-related and angiogenesis-related gene mRNA expression, which also occurred in the tissues of missed and threatened miscarriage.
SLIT2/ROBO1 signalling may regulate trophoblast differentiation and invasion causing restricting β-hCG production, shallow trophoblast invasion and inhibiting placental angiogenesis in missed and threatened miscarriage during the first trimester.
HER2 testing of invasive breast cancer by in-situ hybridization guides therapy decisions. Probing HER2 and centromere of chromosome 17 (cen17) simultaneously is supposed to reveal both a potential HER2 gene amplification and polysomy 17. However, a considerable number of breast cancer patients with quasi polysomy 17 are considered ‘equivocal’, which is diagnostically meaningless. Moreover, patients with equivocal/false polysomic tumours are prevented from a potentially beneficial anti-HER2 treatment. Here we evaluated the RAI1, D17S122 and TP53 hybridization markers to indicate true polysomy reliably and to reclassify equivocal samples accurately as HER2-positive.
Samples with (n = 82) and without (n = 52) increased cen17 copy numbers and 78 evidently HER2-amplified specimens were analysed using dual and triple marker hybridization probes. Selected putative polysomic samples were subjected to array-based comparative genomic hybridization (aCGH). We found that 37.8% samples with putative polysomy 17 did not show any gain in RAI1, D17S122 or TP53. Accordingly, aCGH revealed evidence for the presence of HER2/cen17 co-amplification rather than for true polysomy in those cases. Reflex testing using alternate 17p markers reclassified up to 56.3% equivocal cases as HER2-positive and the combined assessment of a 17p and 17q locus allows the differentiation of true versus false polysomy.
An increased cen17 copy number does not necessarily reflect polysomy, and reflex testing facilitates the reclassification of ‘equivocals’. Nevertheless, the prognostic and predictive value of a HER2/cen17 co-amplification versus HER2 gene amplification alone must still be evaluated prospectively.
Approximately 60–70% of high-grade round-cell sarcomas that lack the Ewing sarcoma breakpoint region 1 (EWSR1) rearrangement harbour a rearrangement of the CIC gene, most commonly CIC–DUX4. Recent studies have established that CIC-rearranged sarcomas constitute a distinct group characterized by recognizable histology and immunoprofiles, such as positivity for ETV4 and WT1 and negativity for NKX2.2. Although these sarcomas are diagnosed increasingly in practice by fluorescence in-situ hybridization (FISH) with CIC break-apart probes, the optimal modality to diagnose these sarcomas has not been determined. In this study, we describe four round-cell sarcomas that showed false-negative results by CIC break-apart FISH assays.
These sarcomas showed characteristic histology of CIC-rearranged sarcomas, and all were immunohistochemically positive for ETV4 and WT1 and negative for NKX2.2. Although FISH showed non-atypical negative signals for CIC rearrangement, high-throughput RNA sequencing identified CIC–DUX4 and its fusion breakpoint in all cases. Their clinical and histological findings, as well as fusion points determined by RNA sequencing, did not differ significantly from those of nine FISH-positive CIC–DUX4 sarcoma cases. We estimated that the FISH false-negative rate for CIC-rearranged sarcomas was 14%. Although neither histology nor immunoprofiles (e.g. ETV4 and WT1) are entirely sensitive or specific for CIC-rearranged sarcomas, the observation that these four cases were identified successfully by such phenotypes suggested their practical utility.
CIC break-apart FISH assays missed a significant minority of CIC–DUX4 sarcomas, and full awareness of typical morphology and judicious immunohistochemical work-ups, including analyses of ETV4 and WT1, should complement diagnostic assessment.
Breast myxoid fibroadenomas (MFAs) are characterized by a distinctive hypocellular myxoid stroma, and occur sporadically or in the context of Carney complex, an inheritable condition caused by PRKAR1A-inactivating germline mutations. Conventional fibroadenomas (FAs) are underpinned by recurrent MED12 mutations in the stromal components of the lesions. The aim of this study was to investigate the genomic landscape of MFAs and compare it with that of conventional FAs.
Eleven MFAs from patients without clinical and/or genetic evidence of Carney complex were retrieved. DNA samples of tumour and matching normal tissue were subjected to massively parallel sequencing using the Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets (MSK-IMPACT) assay, an assay targeting 410 cancer genes. Genetic alterations detected by MSK-IMPACT were tested in samples in which the stromal and epithelial components were separately laser capture-microdissected. Sequencing revealed no germline PRKAR1A mutations and non-synonymous mutations in six MFAs. Interestingly, in three of the MFAs in which the stromal and epithelial components were separately microdissected, the mutations were found to be restricted to the epithelial rather than the stromal component. The sole exception was a lesion harbouring a somatic truncating PRKAR1A mutation. Upon histological re-review, this case was reclassified as a breast myxoma, consistent with the spectrum of tumous observed in Carney complex patients. In this case, the PRKAR1A somatic mutation was restricted to the stromal component.
MFAs lack MED12 mutations, and their stromal components seem not to harbour mutations in the 410 cancer genes tested. Whole-exome and/or whole-genome analyses of MFAs are required to elucidate their genetic drivers.
Accurate classification of salivary gland neoplasms may be challenging, owing to morphological overlap, particularly in small biopsies. Recurrent translocations involving the high-mobility group AT-hook 2 (HMGA2) gene are present in a subset of pleomorphic adenomas (PAs) and carcinoma ex-pleomorphic adenomas (CA ex-PAs). The aim of this study was to evaluate immunohistochemical HMGA2 expression in 225 salivary gland tumours, including 56 PAs, 37 CA ex-PAs, and 132 potential histological mimics, to determine its diagnostic utility.
HMGA2 expression was identified in 19 PAs (33.9%) and nine CA ex-PAs (24.3%). Expression was strong and diffuse throughout all PAs, and in four of nine positive CA ex-PAs. In five CA ex-PAs, HMGA2 showed weak-to-strong multifocal staining within the carcinomatous component, and strong diffuse HMGA2 expression in the residual PA. Among histological mimics, six de-novo salivary duct carcinomas (28.5%), three epithelial–myoepithelial carcinomas (33.3%) and one case each of myoepithelioma and basal cell adenoma expressed HMGA2. Fluorescence in-situ hybridization for HMGA2 rearrangement performed on a subset of tumours that showed diffuse HMGA2 expression in PAs and CA ex-PAs was frequently associated with rearrangement of the HMGA2 locus, whereas cases of de-novo salivary duct carcinoma, or CA ex-PA with limited or no HMGA2 expression, had an intact HMGA2 locus.
HMGA2 expression is a highly specific (96.2%), but low-sensitivity (29.8%), marker for PA and CA ex-PA when compared with histological mimics, and is frequently associated with rearrangement of the HMGA2 locus.
PD-1/PD-L1 checkpoint immunotherapy has been proposed recently as a promising treatment in relapsed/refractory disease, used eventually in combination with traditional chemotherapy in different cancer settings. To date, no data are available concerning PD-L1 expression in ampulla of Vater carcinoma and its pre-invasive lesions.
We assessed the immunohistochemical expression of PD-L1 in a series of 26 ampullary adenocarcinomas, 50 ampullary dysplastic lesions and 10 normal duodenal mucosa samples. Moreover, in all cases DNA mismatch repair proteins status was investigated. PD-L1 was expressed in seven of 26 (26.9%) invasive carcinomas and three of 50 (6.0%) dysplastic samples. Most of the PD-L1-positive tumours (seven of 10) were intestinal-type and poorly differentiated (G3). The number of PD-L1-positive stromal lymphoid cells was significantly higher in dysplastic and invasive lesions than in the normal samples (P = 0.011). Nineteen dysplastic lesions and eight invasive carcinomas did not show any evident epithelial or stromal PD-L1 expression. Four of the carcinomas were mismatch repair-deficient and two of these were PD-L1-positive. Furthermore, mismatch repair-deficient lesions showed a significantly higher average of PD-L1-positive stromal lymphoid cells than those of neoplastic PD-L1-negative samples (62.8 versus 21.6; P < 0.001).
The present results suggest a role of the PD-1/PD-L1 axis in ampullary adenocarcinomas, and therefore this may also prompt consideration of checkpoint immunotherapy as a novel promising treatment for these tumours.
Giant-cell tumour (GCT) of soft tissue (GCT-ST) is a primary soft tissue neoplasm that is histologically similar to GCT of bone (GCT-B). Recently, it has been reported that >90% of GCT-Bs have a driver mutation in the H3F3A gene. As the relationship between GCT-ST and GCT-B is unclear, the aim of this study was to compare a series of GCT-STs and GCT-Bs with regard to the presence of H3F3A mutations and several immunophenotypic markers.
Eight GCT-STs were retrieved from our institutional archives. Fifteen GCT-Bs served as controls. Direct sequencing for H3F3A mutations in coding regions between codons 1 and 42, including the hotspot codons (28, 35, and 37), was performed on DNA extracted from formalin-fixed paraffin-embedded tissue. Tumours were studied immunohistochemically for the expression of CD14, CD33, RANKL, RANK, p63, and the osteoblastic markers SATB2 and RUNX2. None of the seven GCT-STs that could be analysed showed H3F3A mutations, whereas 14 GCT-Bs (93.3%) were mutated. All eight GCT-STs were positive for RANK and RUNX2, whereas RANKL and SATB2 were detected in only two cases (25%). CD14 was detected only in mononuclear elements, whereas multinucleated giant cells and a proportion of the mononuclear population expressed CD33. Few mononuclear cells of GCT-STs expressed p63. In comparison, GCT-Bs showed higher expression of p63 (14 of 15 cases with >50% of positive mononuclear cells), RANKL, and SATB2, whereas CD14, CD33, RANK and RUNX2 were similarly expressed.
Although GCT-ST and GCT-B are similar in histological appearance, our results indicate that they are immunophenotypically and genetically distinct.
Pathological stage pT1 bladder cancers constitute a clinically heterogeneous group. However, current staging guidelines for superficially invasive cancers do not acknowledge the variability in type and extent of lamina propria invasion in papillary urothelial carcinomas (PUCs), and historically proposed substaging systems showed either high interobserver variation or limited value in predicting patient outcomes. The aim of this study was to reappraise pT1 PUC substaging, with the objective of identifying a novel scheme that is reproducible and prognostically meaningful.
pT1 PUCs diagnosed during 1999–2015 were retrospectively reviewed and characterized as focal invasion confined to the papillary stalk, focal invasion of the tumour base, or extensive invasion of the tumour base. Cases with concurrent flat carcinoma in situ, angiolymphatic invasion, absent muscularis propria or clinically advanced disease were excluded. We calculated cumulative incidence rates of recurrence, progression and death by tumour subtype, and evaluated differential risks by using log-rank tests and Kaplan–Meier curves stratified by type and extent of invasion. Among 62 patients satisfying the inclusion criteria, 22 of 29 patients with base-extensive invasion progressed, whereas four of 13 with base-focal and none of 20 with stalk-only invasion progressed. There was strong evidence that base-extensive patients had a higher risk of progression and death resulting from bladder cancer than base-focal or stalk-only patients (P < 0.0001). However, tumour subtype was not significantly associated with risk of recurrence (P = 0.21).
We propose an innovative substaging approach for reporting the site and extent of lamina propria invasion in patients with pT1 PUC, allowing patient stratification for risk of progression.
To investigate the expression of the programmed cell death 1 (PD-1) receptor–programmed cell death ligand 1 (PD-L1) pathway and the clinicopathological characteristics in extrahepatic cholangiocarcinoma (eCCA).
Tissue samples from patients with eCCA [n = 69; perihilar cholangiocarcinoma (CCA), 40; and distal CCA, 29] who underwent surgical resection in the period from 2007 to 2015 were evaluated for PD-1, PD-L1, CD3 and CD163 expression, and correlations with clinicopathological characteristics, including survival data, were determined. PD-L1 was found on both tumour cells of eCCA (8/69, 11.6%) and tumour-associated macrophages (21/69, 30.4%). Significant correlations of PD-L1 expression on cancer cells with venous invasion (P = 0.031) and poor differentiation of the tumour (P = 0.048) were observed. In 19 of 69 (27.5%) samples, tumour-infiltrating lymphocytes (TILs) expressed PD-1, whereas infiltration with CD3-positive and CD163-positive cells was found in 63 of 69 (91.3%) and 68 of 69 (98.6%) cases, respectively. The presence of fewer than five CD3-positive cells per high-power field was significantly correlated with poorer differentiation (P = 0.015) and venous invasion (P < 0.001) of CCA. PD-L1 expression was not correlated with patient survival, but PD-L1 expression on tumour cells combined with low infiltration of CD3-positive TILs was associated with an unfavourable outcome (P = 0.027).
Only a small number of eCCA patients are PD-L1-positive, which might be important for future application of PD-1/PD-L1-targeted immune-modulating therapy in these patients. A small subgroup of eCCAs with PD-L1 expression and low lymphocytic infiltration showed more invasive growth and worse overall survival.
The clinical outcome of patients with locally advanced rectal cancer who undergo neoadjuvant chemoradiotherapy (CRT) is influenced by the tumour response to treatment, which is reflected by tumour regression grade and post-treatment (y) TNM stage. Little is known about the prognostic value of pretreatment histopathological features of the tumour that may be useful to discriminate potential non-responders and to design tailored therapeutic strategies. In this study, we aimed to investigate the prognostic role of poorly differentiated clusters (PDCs) of neoplastic cells in pretreatment biopsies of patients with rectal cancer treated with neoadjuvant CRT.
Grading based on PDC counting was retrospectively applied to 204 pretreatment endoscopic biopsies of rectal carcinomas from patients treated with neoadjuvant CRT and surgery. Interobserver agreement in the assessment of PDC grade was good. High PDC grade was significantly associated with high yT stage (P = 0.044), yM+ status (P = 0.0004), and unchanged TNM stage or TNM upstaging (P = 0.032). In addition, high PDC grade was a significant and independent prognostic factor for cancer-specific survival.
PDC grade may be assessed in preoperative biopsies of rectal cancer with good reproducibility. High PDC grade in a pretreatment tumour is significantly associated with a poor response to therapy. Hence, we suggest that PDC grading might be used as a significant predictive and prognostic factor in patients with locally advanced rectal cancer who are treated with neoadjuvant CRT, and to identify high-risk patients who need surgery and adjuvant chemotherapy.
Somatic mutations in genes encoding chromatin remodellers have been reported recently in several cancer types, including approximately half of cholangiocarcinomas. One of the most commonly mutated chromatin remodellers in cholangiocarcinoma is the Polybromo-1 (PBRM1) gene located on chromosome 3p21, which encodes a subunit of the SWI/SNF complex. The aim of this study was to determine the timing of PBRM1 mutations in biliary carcinogenesis.
In order to accomplish this goal, we used immunohistochemistry to assess PBRM1 protein expression in a series of precursor lesions and invasive biliary carcinomas. Previous studies have correlated loss of protein expression on immunohistochemistry with inactivating mutations in this tumour suppressor gene. We found that PBRM1 loss occurred in approximately 26% of invasive cancers, but PBRM1 expression was retained in all biliary intra-epithelial neoplasia (BilIN) specimens, including 25 intrahepatic BilINs and 19 gallbladder BilINs.
These findings indicate that PBRM1 mutation (and resultant loss of expression) is a late event during biliary carcinogenesis. In addition, we confirm a lack of prognostic significance of PBRM1 status in invasive intrahepatic cholangiocarcinoma. This study provides important insights into the basic mechanisms of chromatin remodelling genes in carcinogenesis.
Secretory breast carcinoma is a rare, low-grade, translocation-associated invasive carcinoma with unique morphology and excellent prognosis. Three patterns (microcystic, tubular, solid) have often been described in secretory carcinoma. Herein, we reported one case of secretory breast carcinoma with an uncommon papillary-predominant growth pattern.
The patient was a 53-year-old female with a mass located in outer upper quadrant of her right breast. The patient had one positive axillary lymph node. Morphologically, tumour cells were arranged in a papillary growth pattern with sclerosis in most areas; glandular and microcystic patterns were observed only in focal areas at the periphery. The presence of intracellular and extracellular secretory material was observed. Tumour cells were mild-to-moderately atypical with granular eosinophilic to foamy cytoplasm. Tumour cells were triple-negative [negative for oestrogen receptor (ER), progestogen receptor (PR) and human epidermal growth factor receptor 2 (HER2)] with a basal-like phenotype, and strongly positive for S-100 protein. P63 and calponin staining showed the absence of myoepithelial cells around tumour cells. Fluorescence in-situ hybridization (FISH) analysis showed ETS variant 6 (ETV6) gene rearrangement.
Our study indicated that besides typical growth patterns (microcystic, solid and tubular), secretory carcinoma could also present with a papillary-predominant architecture. These cases should be differentiated from other breast tumours with a papillary pattern. It may have clinical significance to recognize this uncommon morphology variant of secretory carcinoma in routine practice.
Low-grade ovarian endometrioid carcinomas may be associated with high-grade components. Whether the latter are clonally related to and originate from the low-grade endometrioid carcinoma remains unclear. The aim of this study was to use massively parallel sequencing to characterize the genomic landscape and clonal relatedness of an ovarian endometrioid carcinoma containing low-grade and high-grade components.
DNA samples extracted from each tumour component (low-grade endometrioid, high-grade anaplastic and high-grade squamous) and matched normal tissue were subjected to targeted massively parallel sequencing with the 410-gene Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets (MSK-IMPACT) sequencing assay. Somatic single nucleotide variants, small insertions and deletions, and copy number alterations were detected with state-of-the-art bioinformatics algorithms, and validated with orthogonal methods. The endometrioid carcinoma and the associated high-grade components shared copy number alterations and four clonal mutations, including SMARCA4 mutations, which resulted in loss of BRG1 protein expression. Subclonal mutations and mutations restricted to single components were also identified, such as distinct TP53 mutations restricted to each histological component.
Histologically distinct components of ovarian endometrioid carcinomas may show intratumour genetic heterogeneity but be clonally related, harbouring a complex clonal composition. In the present case, SMARCA4 mutations were probably early events, whereas TP53 somatic mutations were acquired later in evolution.
Mammary-like adenocarcinoma (MLA) of the vulva is thought to be derived from vulvar mammary-like glands. The aim of this study was to characterize a series of MLAs by using an immunohistochemical algorithm that identifies the major molecular subtypes of breast cancer.
Seven cases of vulval MLA were stained for oestrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), Ki67, epidermal growth factor receptor (EGFR), cytokeratin (CK) 5, nestin, and inositol polyphosphate-4-phosphatase (INPP4b). Seventeen cases of vulval extramammary Paget disease (EMPD), seven with invasion, were studied for comparison. The median age of patients with MLA was 72 years. All tumours except one were early-stage tumours. On the basis of an immunohistochemical panel, three of seven tumours were classified as luminal B, two of seven as HER2-enriched, one of seven as luminal A, and one of seven as basal-like. ER was expressed in four of seven tumours, PR in three of seven, HER2 in three of seven, EGFR in two of seven, and CK5 in one of seven, and the Ki67 index was >15% in six of seven cases. Nestin and INPP4b were, respectively, negative and positive in all cases. Of the seven cases of invasive EMPD, two showed a luminal A profile, three a luminal B profile (two of three with HER2 amplification), one a HER2-enriched profile, and one a basal-like profile. Three of seven were HER2-amplified. Among the 10 cases of EMPD without invasion, seven showed a luminal A profile and three showed a luminal B profile (all HER2-amplified); no HER2-enriched or basal-like subtypes were identified.
Breast cancer subtyping can be applied to vulvar MLAs. All four intrinsic molecular subtypes are seen, with frequencies similar to those in breast carcinoma. Our results support the potential use of breast cancer molecular profiling algorithms to guide treatment for these cancers.
Formalin fixation can cause tumour shrinkage. The aim of this study was to prospectively evaluate the effect of overnight formalin fixation on tumour size and the effect of clinicopathological parameters on changes in tumour size in small-sized non-small-cell lung cancer (NSCLC).
Our study included 126 surgically resected NSCLC specimens submitted in a fresh state. We measured the largest cross-sectional tumour diameters in the fresh and formalin-fixed specimens. Tumour size significantly differed (mean, 0.66 mm; P < 0.001) and was positively correlated (r2 = 0.982; P < 0.001) between fresh and formalin-fixed specimens. The percentage difference after fixation was 4.06%. Formalin fixation caused tumour shrinkage in 46.8%, tumour enlargement in 4.8%, and a tumour stage shift in 3.17%. The risk of a > 10% change in tumour size after formalin fixation was increased in tumours with a lepidic pattern [odds ratio (OR): 6.268; P = 0.001], in subsolid tumours (OR: 4.068; P = 0.011), and in the presence of adenocarcinoma in situ (AIS)/minimally invasive adenocarcinoma (MIA) histology (OR: 6.545; P = 0.003). Pleural dimpling lowered the risk of tumour size change after fixation (OR: 0.162; P = 0.019). On multivariate analysis, a lepidic pattern (OR: 4.601; P = 0.010) and AIS/MIA histology (OR: 4.381; P = 0.026) were still significant risk factors. Longer ischaemic time was the single risk factor for tumour shrinkage in the invasive adenocarcinoma subgroup (OR: 5.357; P = 0.021).
NSCLC tumours shrank or enlarged by 4.06% after overnight formalin fixation. A lepidic pattern and AIS/MIA histology were independent risk factors for both significant tumour shrinkage and growth after fixation. Longer ischaemic time was the single risk factor for significant tumour shrinkage in invasive adenocarcinoma.
During recent years, immune checkpoint inhibition has proved to be effective in several solid malignancies. The aim of this study was to identify novel targets for immunotherapy in anaplastic thyroid cancer by analysis of the expression of tumour antigens for which therapeutic agents are available.
By immunohistochemistry we observed tumoral expression of CD70 in 49% of cases. Expression of its receptor, CD27, was present mainly in lymphocytes surrounding and infiltrating the tumour and observed only rarely in tumour cells. CD70 expression was associated with the presence of a precursor papillary thyroid carcinoma and the presence of BRAF V600E mutations in the anaplastic thyroid cancer lesion. Furthermore, the expression of CD70 seems stable during progression of the disease. Tumoral expression of programmed cell death ligand 1 (PD-L1) was found in 28.6% of the anaplastic thyroid cancer cases. Programmed cell death 1 (PD-1), the receptor of PD-L1, was not expressed on the tumour cells. No association between CD70 expression and PD-L1 expression could be demonstrated.
These data suggest that targeted immunotherapy for CD70/CD27 and PD-L1/PD-1 might be promising in anaplastic thyroid cancer. However, as a low amount of tumour-infiltrating lymphocytes was observed in most lesions, combined therapy with agents enhancing the invasion of lymphocytes in the tumour region needs to be considered.
To assess the distinct histopathological characteristics and their clinical significance between non-Hunner-type and Hunner-type interstitial cystitis (IC)/bladder pain syndrome (BPS).
We prospectively enrolled and classified IC/BPS patients, on the basis of cystoscopic findings, as having non-Hunner-type IC and Hunner-type IC. Specimens obtained from the posterior wall in non-Hunner-type IC cases during hydrodistension or from Hunner/non-Hunner lesions in Hunner-type IC cases during transurethral resection were evaluated. Stress urinary incontinence patients with microscopic haematuria were selected as controls. Biopsy specimens were obtained from 15 non-Hunner-type IC, 15 Hunner-type IC and 5 non-IC patients. Severe and moderate fibrosis was more frequently observed in non-Hunner-type IC than in Hunner-type IC and non-IC cases. However, severe and moderate inflammation was more frequently observed in Hunner-type IC than in non-Hunner-type IC cases. The remnant urothelium was significantly decreased in Hunner-type IC cases as compared with non-Hunner-type IC and non-IC cases (P < 0.05), and non-Hunner-type IC cases showed a higher number of mast cells than Hunner-type IC and non-IC cases (P = 0.035). Accordingly, several fibrosis-promoting genes were highly expressed in bladder tissues of non-Hunner-type IC, as compared with Hunner-type IC. Patients with severe fibrosis showed significantly higher urinary frequency and smaller bladder capacity than those with moderate and mild fibrosis (all P < 0.05).
Non-Hunner-type IC is characterized by severe fibrosis and increased mast cell infiltration, whereas Hunner-type IC is characterized by severe inflammation and urothelial denudation in the entire bladder. Fibrosis in the bladder of IC/BPS patients was correlated with increased urinary frequency and decreased bladder capacity.
Until the launch of the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society adenocarcinoma classification in 2011, there were no uniform histological grading criteria for pulmonary adenocarcinomas. The current classification highlights the prognostic importance of the various histological growth patterns observed in these morphologically heterogeneous neoplasias. In this study, we aimed to evaluate the classic histological parameters of malignancy in correlation with the growth patterns and patient outcomes in a series of 112 surgically operated stage I–IV lung adenocarcinomas.
Architectural growth pattern analysis was performed according to the current adenocarcinoma classification. Histological features including, for example, nuclear atypia, mitotic activity, tumour necrosis, and different patterns of invasion were assessed and correlated statistically with the architecture and the clinical data. A solid predominant histology was associated with increased levels of atypia (P = 0.027), mitotic activity (P < 0.001), necrosis (P < 0.001), and lymphovascular invasion (P = 0.001), and a non-predominant solid pattern was associated with intra-alveolar tumour spread (P = 0.004). The presence of a non-predominant lepidic tumour component showed inverse correlations with atypia (P = 0.002), mitotic rate (P = 0.009), and tumour necrosis (P < 0.001). Tumour size (P < 0.001), mitotic activity (P = 0.019), tumour necrosis (P = 0.002), lymphovascular invasion (P = 0.001) and visceral pleural involvement (P = 0.001) were all associated with reduced disease-specific survival.
The classic histological features of malignancy correlate with tumour architecture and patient outcome, confirming the prognostic value of the growth pattern analysis and questioning the need for a parallel grading system in pulmonary adenocarcinoma.
This study was designed to test programmed cell death 1 (PD-1) expression of T cells, the hallmark of T cell exhaustion, in different ‘immune-classes’ of colorectal carcinoma microenvironments as delineated by unsupervised hierarchical cluster analysis.
A tissue microarray was made with punches from the invasive margins of 40 microsatellite-unstable and 34 microsatellite-stable colorectal carcinomas. Immune cells were phenotyped by CD8, granzyme B, CD4, FoxP3, CD68, S-100, PD-1 and programmed cell death ligand 1 (PD-L1) immunohistochemistry; tumour area per tissue spot was quantified by cytokeratin (CK)18 immunohistochemistry. For each tissue spot, intra-epithelial immune cells were counted and densities of the various immune cells were calculated. Unsupervised hierarchical cluster analysis with these data yielded a group of ‘anergic/immune-naive’ microenvironments (47.3%), a group of ‘intermediates’ (27.0%) and a group of ‘immunoreactives’ (25.7%) in which PD-1 expressing T cells were prominent. Sixteen of 19 tissue spots representing immunoreactive microenvironments derived from microsatellite-unstable tumours and three were from microsatellite-stable tumours. Further phenotyping of intra-epithelial T cells by sequential immunohistochemistry showed frequent granzyme B/CD8 co-expression, whereas PD-1/CD8 co-expression was more variable. Using receiver operating curve (ROC) analysis, assignment to immune classes was seen to be feasible with good sensitivity and specificity by CD8 counts only.
A subset of colorectal carcinoma microenvironments is distinguished from the rest by an immune cell composition suggestive of active host anti-tumour immune defence, but this appears to be antagonized by a brisk undercurrent of T cell exhaustion. This observation may have implications for selecting colorectal carcinoma patients for immune checkpoint therapy.
GATA3 is a relatively new immunohistochemical marker which shows consistent nuclear expression in a variety of tumours, including breast and urothelial carcinoma. The staining pattern of GATA3 in adrenal lesions is not well established. We aim to describe the expression of GATA3 in adrenal tumours and determine if there is differential staining between pheochromocytoma and adrenal cortical carcinoma.
A retrospective search was performed to identify 74 adrenal lesions which were tested immunohistochemically for GATA3 expression. GATA3 was negative in 90% of adrenal cortical carcinoma. In contrast, pheochromocytomas were frequently positive (71%), including benign pheochromocytoma, pheochromocytoma with features concerning for malignancy, malignant (metastatic) pheochromocytoma and composite pheochromocytoma with ganglioneuroma. Metastatic lung adenocarcinoma in the adrenal gland had occasional (36%) expression, while metastatic clear cell renal cell carcinoma in the adrenal gland did not express GATA3.
As the most common pitfall in diagnosing adrenal cortical carcinoma is mistaking it for pheochromocytoma or vice versa, GATA3 may be useful in narrowing the differential diagnosis as a part of a panel of immunohistochemical markers. However, occasional GATA3 expression in the most common source of metastases within the adrenal gland, metastatic pulmonary adenocarcinoma, may confound the diagnosis due to the overlapping expression with pheochromocytoma and other carcinomas.
Eosinophilic inflammation in the gastrointestinal tract may occur as a primary eosinophilic disorder or as a secondary response with other causes. Primary eosinophilic gastrointestinal disorders (EGIDs) are Th2-mediated allergic diseases that overlap pathogenetically with atopic conditions involving other organs. The pathological diagnosis of primary EGIDs can be challenging, as the quantity of eosinophils considered to be ‘abnormal’ is difficult to define, and the diagnosis, by definition, requires exclusion of the far more common secondary causes. Our understanding of the basic biology and natural history of eosinophilic oesophagitis has advanced considerably over the last decade, whereas other EGIDs have proven more difficult to characterize; nonetheless, some recent advances have been made. This review summarizes current knowledge regarding the clinical presentation, diagnosis, natural history and treatment of EGIDs, including eosinophilic oesophagitis. We also draw attention to the numerous secondary causes of tissue eosinophilia in the gastrointestinal tract, and suggest a practical approach to the histological assessment, diagnosis and reporting of EGIDs.
]]>Extra-ampullary duodenal adenoma (EADA) is a rare condition with poorly described clinicopathological details. In this study, we aimed to characterize EADA clinicopathologically.
We performed a retrospective review of 44 serial cases of EADA. Each EADA was categorized as either gastric-type (n = 5) or intestinal-type (n = 39). All gastric-type adenomas were located in the first portion of the duodenum and exhibited a pedunculated shape. Gastric-type adenomas were classified into two subtypes: pyloric gland and foveolar. The former consisted of mucin 6 (MUC6)-positive glands covered with MUC5AC-positive cells, whereas nearly all the latter consisted of MUC5AC-positive cells. When EADAs were categorized into high and low grades, approximately 40% (16 of 44) were high-grade. The high-grade adenomas were significantly larger than the low-grade adenomas (19.4 ± 8.6 mm versus 11.8 ± 5.1 mm, P = 0.021), and all adenomas greater than 20 mm in largest diameter were categorized as high-grade adenomas. Among 16 individuals who underwent total colonoscopy before or after duodenal mucosal resection, nine had a colorectal neoplasm, and all nine duodenal lesions were of the intestinal phenotype.
We clarified the clinicopathological characteristics of gastric- and intestinal-type EADAs. EADAs greater than 20 mm at the largest diameter were consistently high-grade, and are thought to have the potential to progress to adenocarcinoma. These findings should be helpful for the clinical management of EADA.
Traditional serrated adenomas (TSAs) account for 5% of serrated polyps, and have a villiform architecture, eosinophilic cells with a brush border, and indented, flat-topped luminal serrations. However, some are composed of mucin-filled goblet cells (GCs): mucin-rich TSA (MrTSA). The aim of this study was to determine whether this variant has unique features as compared with classic TSA (cTSA).
One hundred and fifty-six TSAs were retrieved from the period 2010–2016. Patient demographics, site of polyps and 16 microscopic variables were evaluated. TSAs containing ≥50% GCs were classified as MrTSAs. Ectopic crypt foci (ECFs) were quantified as low (1–10) or high (>10), counted at ×200 magnification, and the average was taken for 10 fields. Twenty-four fulfilled the criteria for MrTSA. In males, MrTSAs (65%) were more prevalent than cTSAs (55%). There was no age difference, and both variants had a predilection for the left colon, although, in the right colon, MrTSAs were more frequent (39%) than cTSAs (10%) (P = 0.012). Adenomatous dysplasia was present in four of 24 MrTSAs (low grade, 3; high grade, 1). The most distinctive features of MrTSAs were: a variable growth pattern [endophytic (9%), mixed (30%), or villiform/exophytic (61%)], and a lower frequency of ECFs (P = 0.001) and more intraepithelial lymphocytes (P < 0.05) than in cTSAs. MrTSAs retain characteristic luminal serrations, at least focally. Inflamed MrTSAs can mimic inflammatory polyps and hamartomatous polyps (when there are >95% GCs).
MrTSA is characterized by >50% GCs, and fewer ECFs than cTSA, but with preservation of archetypal luminal serrations. Awareness of this variant will prevent misdiagnosis, given the association of TSA with the accelerated pathway to colorectal cancer.
The scirrhous variant of hepatocellular carcinoma (S-HCC) and fibrolamellar HCC (FL-HCC) are less common subtypes of HCC that are characterized by abundant fibrous stroma. Here, we aimed to investigate differences in the tumour microenvironment and the tumour epithelial cell characteristics of S-HCC and FL-HCC.
Whole tissue sections of 17 S-HCCs and 9 FL-HCCs were subjected to immunohistochemical stains for keratin 7 (K7), K19, EpCAM, CD56/NCAM, CD163, CD68, pSTAT3, FAP, CCN2 and Ki-67. FL-HCC patients were younger than S-HCC patients (P < 0.001), and chronic liver disease was seen in the background of 88.2% of S-HCC and in none of the FL-HCC. CD68 and CD163-positive tumour-infiltrating macrophages, and FAP-positive cancer-associated fibroblasts (CAFs) were more abundant in the stroma of S-HCCs compared to FL-HCCs (all P < 0.05). Tumour epithelial K19 expression was more frequent in S-HCCs compared to FL-HCCs (P = 0.023). Significant positive correlations were seen between pSTAT3 expression status in tumour epithelial cells and CAFs, the extent of stromal CAF and macrophage infiltration and K19 expression status. No significant differences were seen for K7, EpCAM, CD56/NCAM, CCN2 expression and Ki-67 labelling index between S-HCCs and FL-HCCs.
S-HCC and FL-HCC are subtypes of HCC with extensive fibrosis, and the nature of the fibrous stroma differs between them. While the stroma of FL-HCC is composed of dense lamellated collagenous bands with sparse cellular components, S-HCC demonstrates more abundant CAF and tumour-infiltrating macrophages and stemness-related marker expression, suggesting the presence of a complex tumour microenvironment that may influence the aggressive behaviour of S-HCCs.
β-Catenin signalling participates in the regulation of epithelial–mesenchymal transition (EMT)/cancer stem cell (CSC) properties. The aim of this study was to investigate the role of β-catenin in resistance to neoadjuvant chemoradiotherapy in patients with rectal cancer, especially pertaining to its association with EMT/CSC features.
A total of 109 cases of locally advanced rectal cancer, along with a colon cancer cell line, were investigated. Nuclear β-catenin accumulation in pretreatment-biopsied samples was inversely associated with the therapeutic efficacy of chemoradiotherapy in resected rectal cancer. In resected tumours, nuclear β-catenin was predominantly observed in EMT-like lesions with decreased E-cadherin and increased Snail expression, along with expression of CSC-related markers. The EMT-like lesions also showed significant decreases in both apoptosis and cell proliferation as compared with non-EMT lesions. In-vitro culture of a colon cancer cell line in STK2 was sufficient to induce EMT/CSC properties together with nuclear β-catenin accumulation, and showed inhibition of cell proliferation and resistance to doxorubicin treatment.
Nuclear β-catenin accumulation may contribute to chemoradioresistance in locally advanced rectal cancer, probably through its regulation of EMT/CSC properties. In addition, nuclear β-catenin in pretreatment-biopsied samples is useful in predicting the efficacy of chemoradiotherapy in patients with rectal cancer.
Vulvar squamous cell carcinoma (VSCC) can be subdivided by human papillomavirus (HPV) status into two clinicopathological entities. Studies on the prognostic significance of HPV in VSCC are discordant.
We performed a retrospective analysis of overall survival (OS), disease-specific survival (DSS) and progression-free survival (PFS) in 217 patients with VSCC. Cases were extracted from an era of more aggressive en-bloc radical dissections (1985–95) and more localized radical surgery through separate vulvar and groin excisions (1996–2005). p16 immunohistochemistry was used as a surrogate for HPV status. HPV status could be determined in 197 tumours, 118 HPV-independent and 79 HPV-associated tumours. Patients with HPV-associated tumours were younger (mean 58.8 versus 71.6 years for HPV-independent tumours, P < 0.0001) and more likely to have prior abnormal cervical cytology (41.1 versus 5.6% for HPV-independent tumours, P < 0.0001). In univariable analysis, patients with HPV-associated tumours had superior PFS [hazard ratio (HR): 0.37, 95% confidence interval (CI): 0.18–0.70], DSS (HR: 0.19, 95% CI: 0.08–0.41) and OS (HR: 0.35, 95% CI: 0.21–0.59). This was driven by worse outcomes (PFS, DSS and OS) for patients with HPV-independent tumours compared with HPV-associated tumours who underwent surgery after 1995. After adjusting for age and stage in multivariable analysis, patients with HPV-associated tumours showed superior PFS (HR: 0.25, 95% CI: 0.07–0.77) and DSS (HR: 0.21, 95% CI: 0.04–0.78).
VSCC can be stratified into two prognostically different diseases based on p16 immunostaining. HPV status was associated only with prognosis in the cohort that underwent surgery after 1995, suggesting that more conservative surgery may have led to worse outcomes for patients with HPV-independent tumours.
To evaluate the intraobserver and interobserver reproducibility of the HER2 in-situ hybridization (ISH) test in breast cancer by measuring the impact of counting different numbers of invasive cancer cells.
A cohort of 101 primary invasive breast cancer cases were evaluated for HER2 gene amplification by silver ISH, and the concordance among four observers with different levels of experience, counting different numbers of invasive cancer cells, was determined. The evaluation of the samples included scoring 20 nuclei, in three different areas. The cases were scored twice, with a washout interval of at least 2 weeks. We observed an increase in the intraobserver concordance rate between the first and second evaluations with an increase in cell count. A count of 60 invasive cells was needed to obtain a concordance rate near 95% and an agreement rate greater than 0.80 by all observers. The interobserver concordance rate of the HER2 test also increased with the increase in cell count, reaching at least a 90% concordance rate with a count of 60 invasive cells. The median variability of both the HER2/CEP17 ratio and the average HER2 copy number between different evaluations decreased with the increase in cell count, being statistically higher in HER2-positive cases.
The minimal cell number recommended in current guidelines should be raised to at least 40, and preferably 60, invasive cells. Moreover, cases with amplification levels close to the threshold should be subjected to a dual count from an experienced observer.
Tumour-infiltrating lymphocytes (TILs) are an important component of the immune response to cancer and have a prognostic value in breast cancer. Although several studies have investigated the role of T lymphocytes in breast cancer, the role of B lymphocytes (TIL-Bs) in ductal carcinoma in situ (DCIS) remains uncertain. This study aimed to assess the role of TIL-Bs in DCIS.
Eighty DCIS cases (36 pure DCIS and 44 mixed with invasive cancer) were stained immunohistochemically for B lineage markers CD19, CD20 and the plasma cell marker CD138. TIL-Bs density and localization were assessed, including relation to the in-situ and invasive components. An association with clinicopathological data and patient outcome was performed. Pure DCIS showed a higher number of TIL-Bs and lymphoid aggregates than DCIS associated with invasion. In pure DCIS, a higher number of peri- and paratumoral TIL-Bs was associated significantly with large tumour size (P = 0.016), hormone receptor (ER/PR) negative (P = 0.008) and HER2+ status (P = 0.010). In tumours with mixed DCIS and invasive components, cases with high-density B lymphocytes, irrespective of their location or topographic distribution, were associated significantly with variables of poor prognosis, including larger size, high grade, lymphovascular invasion, lymph node metastases, ER/PR-negative and HER2+ status. Outcome analysis showed that pure DCIS associated with higher numbers of B lymphocytes had shorter recurrence-free interval (P = 0.04); however, the association was not significant with the CD138+ plasma cell count (P = 0.07).
Assessment of TIL-B cells based on location and topographic distribution can provide prognostic information. Validation in a larger cohort is warranted.
The 2013 College of American Pathologists, the Association for Molecular Pathology and the International Association for the Study of Lung Cancer guideline for EGFR and ALK testing in lung carcinoma indicates that either the primary tumour or the metastasis is suitable for testing. The heterogeneity of gene mutations has been studied extensively, while similar reports on gene rearrangements are limited. The aim of this study was to determine if ALK status between primary tumour and matched metastasis differs.
Fifteen ALK fluorescence in-situ hybridization (FISH) rearranged and 19 non-ALK FISH rearranged adenocarcinomas were collected retrospectively based on availability of tissue from a matched metastatic site. Sixty-eight samples were tested by ALK FISH (Vysis ALK break-apart FISH kit) and ALK immunohistochemistry (IHC) (Ventana ALK D5F3 CDx assay). Overall agreement of FISH and IHC was 88%, with IHC showing 100% specificity and 71% sensitivity. Concordance between primary site and metastasis by ALK FISH was seen in 30 cases (88%), and in 32 cases (94%) by ALK IHC. Five discordant cases were found (15%). Three ALK FISH discordant cases had low percentage of ALK FISH-positive tumour cells (average 23%, range: 18–31%) and all were negative by ALK IHC. One IHC discordant case had a high percentage of ALK FISH-positive tumour cells (67%), and was ALK IHC-negative. One FISH discordant case showed ALK FISH- and ALK IHC-positive primary tumour, but ALK FISH- and ALK IHC-negative metastasis.
ALK FISH results show more frequent discordances between primary tumour and matched metastases than ALK IHC, due probably to technical challenges and sample quality. This observation indicates that the quality of sample and technical expertise of the laboratory should guide the decision about ALK testing in clinical practice.
Epigenetics refers to changes in cell characteristics that occur independently of modifications to the DNA sequence. Oral carcinogenesis is influenced by modifications in epigenetic mechanisms, including changes in histones, which are proteins that support chromatin remodelling for the dynamic regulation of gene expression and silencing. The dysregulation of histone acetylation can lead to the uncontrolled activity of different genes, thereby triggering events associated with malignant transformation. The aim of this study was to analyse the expression of acetyl-histone H3 at lys9 (H3K9ac) in oral leucoplakia (OL) and oral squamous cell carcinoma (OSCC) in addition to its association with cell proliferation, epithelial–mesenchymal transition (EMT) and clinical-pathological findings.
Samples of normal oral mucosa (NOM), OL and OSCC were submitted to immunohistochemical analysis using anti-H3K9ac, Ki67 and vimentin. Slides were submitted to quantitative analysis regarding the percentage of positive cells. OSCC presented less expression of H3K9ac in comparison to OL (P < 0.01), whereas Ki67 and vimentin levels increased from OL to OSCC (P < 0.001 and P = 0.03, respectively). OSCC patients with poor prognosis had less H3K9ac expression (P = 0.04). The Kaplan–Meier cumulative survival curves also revealed lower survival rates in patients with less H3K9ac expression (P < 0.01).
The present findings suggest that changes in H3K9ac occur during the process of oral carcinogenesis along with an increase in cell proliferation and EMT. The results demonstrate that H3K9ac may be a useful novel prognostic marker for OSCC.
The central nervous system (CNS) is a rare primary site of non-Hodgkin lymphoma. Although direct invasion of nasal natural killer (NK)/T cell tumours into CNS is reported occasionally, primary CNS NK/T cell lymphoma is extremely rare, and the clinicopathological features of primary CNS NK/T cell lymphoma remain largely unknown.
We identified four cases from our consultation files and analysed the clinicopathological features. Three were immunocompetent and one was immunosuppressed. There were three males and one female and their ages ranged from 21 to 77 years (median: 46 years). Radiotherapy was rendered for all patients, and methotrexate was administered to two patients. The overall survival was 4–29 months (median, 19 months) for the three immunocompetent patients. Neoplastic cells exhibited medium to large atypical nuclei. Angiocentric growth and necrosis were observed. The immunophenotype was typical of NK cell tumours: CD3ε, 100%; CD56, 67%; CD5, 50%; cytotoxic molecules, 100%; Epstein–Barr virus encoded small RNA (EBER), 100% and T cell receptor (TCR)-β or γ, 0%. No TCR–gene rearrangements were detected. Reviewing 10 additional cases from the literature and comparing with extranasal NK/T cell lymphoma of the more frequent origins (skin or gastrointestinal tract), primary CNS NK/T cell lymphoma was diagnosed at an earlier stage without B symptoms but exhibited aggressive clinical behaviours.
Although extremely rare, primary CNS NK/T cell lymphoma does occur and should always be included in the differential diagnosis and we should apply relevant markers routinely in conjunction with exploring the patient background. The accumulation of cases is indispensable to establish an effective treatment strategy for this rare and aggressive malignancy.
TP53 mutations are characteristic of the high-grade pathway in the dual pathway of urothelial carcinogenesis. These mutations have been correlated with aberrant accumulation of p53 protein; however the definition and significance of this vary in the literature. The aim of this study was to assess p53 immunostaining in a cohort of high-grade urothelial carcinomas by using standard published cut-offs and a novel binarized method that included assessment of the null phenotype. Each scoring method was correlated with oncological outcome.
A triplicate core tissue microarray was constructed from 207 cases of high-grade urothelial carcinoma treated by cystectomy, and was stained with p53. The percentage nuclear staining was recorded for each core and averaged for every case (206 cases were evaluable). Cases were categorized as positive/negative according to published cut-offs (10%, 40%) or by binarizing them as abnormal (null phenotype or >50% positivity) and wild type (1–49% positivity). Correlation with disease-specific survival was not significant according to standard definitions of p53 positivity. When a 40% cut-off was used, a correlation with relapse-free survival was significant on univariate analysis (P = 0.038) but not on multivariate analysis (P = 0.079). Abnormal p53 expression showed a near-significant trend for association with disease-specific survival (P = 0.052) and was a significant predictor for relapse-free survival on both univariate analysis (P = 0.047) and multivariate analysis (P = 0.035).
Prior to this study, the p53 null phenotype was not well described in urothelial carcinoma of the bladder. Abnormal p53 immunoexpression (null staining pattern or staining in >50% of cells) is prognostic in terms of oncological outcome.
Cancer/testis antigens (CTAs) are detected in cancer cells but not in healthy normal tissues, with the exception of gametogenic tissues. CTAs are highly immunogenic proteins, and thus represent ideal targets for cytotoxic T-lymphocyte-mediated specific immune therapy. The aim of this study was to screen CTA expression in various types of salivary gland carcinoma and to clarify clinicopathological significance of MAGE-A and NY-ESO-1 expression in adenoid cystic carcinomas (AdCCs) of the salivary gland, which is one of the most common salivary gland carcinomas, and usually has a fatal outcome.
We used immunohistochemistry to examine the expression of four CTAs (MAGE-A, NY-ESO-1, CT7, and GAGE7) in various types of salivary gland carcinoma (n = 95). When carcinoma cases were divided into low-grade and intermediate/high-grade types, NY-ESO-1 and CT7 were expressed more frequently in intermediate/high-grade carcinomas. We then focused on MAGE-A and NY-ESO-1 expression in a large cohort of adenoid cystic carcinomas (AdCCs) (n = 46). MAGE-A and NY-ESO-1 were frequently expressed in AdCC; specifically, MAGE-A was expressed in >60% of the AdCC cases. MAGE-A expression and tumour site (minor salivary gland) were identified as independent risk factors for locoregional tumour recurrence.
These findings suggest that CTAs may be expressed in a variety of salivary gland carcinomas, especially in those with higher histological grades. In addition, MAGE-A, which is frequently expressed in AdCC cases, may be a useful prognostic factor for poorer locoregional recurrence-free survival.
Pure erythroid leukaemia (PEL) is an extremely rare and aggressive subtype of acute myeloid leukaemia defined by the World Health Organization (WHO) as a neoplastic proliferation of immature cells committed exclusively to the erythroid lineage, comprising >80% of bone marrow cells and not meeting the criteria of other well-defined myeloid neoplasms. The aim of this study was to describe the clinicopathological features of acute leukaemias with a pure erythroid phenotype (ALPEP) irrespective of their WHO classification and to determine if ALPEP represents a distinct clinicopathological entity.
We identified seven cases of ALPEP, in which immature cells fulfilled WHO morphological and immunophenotypical criteria for PEL. All patients except one were male, with a median age of 60 years. Three cases represented de novo PEL, three were therapy-related myeloid neoplasms and one was a blast phase of a myeloproliferative neoplasm. Extensive tumour necrosis was present in five cases (71%). Five cases with available modal karyotypes all demonstrated a complex karyotype involving the TP53 gene locus, with three cases (60%) also showing a monosomy 5 or deletion 5q and additional material on chromosome 19q13. All patients died of their disease, with a mean overall survival of 189 and 64.7 days in cases without and with necrosis on the initial biopsy, respectively.
We describe previously unreported but relatively common findings of extensive tumour necrosis and recurring cytogenetic abnormalities in ALPEP. Our findings suggest strongly that ALPEP represents a distinct clinicopathological entity regardless of its WHO classification.