Immunohistochemical and functional biomarkers of value in female genital tract lesions

Expression Patterns of Cytokeratins (CK7, CK20, CK19, CK AE1/AE3) in Atypical Endometrial Hyperplasia Coexisting with Endometrial Cancer

Few studies have evaluated cytokeratin's (CK) staining patterns in atypical endometrial hyperplasia (AEH) coexisting with early-stage endometrial cancer (EC). We aimed to assess the staining patterns of selected CKs (CK7, CK19, CK20, CK AE1/AE3) in 74 patients with coexisting AEH and EC by independently analyzing both morphological variables. Specimens were collected from women with AEH and EC who underwent surgical interventions between 2012 and 2019 at the Department of Obstetrics and Gynecology of Vilnius University Hospital "Santaros Klinikos" in Vilnius, Lithuania. Immunostaining was also qualitatively classified as being heterogeneous or intense. The results revealed heterogeneous CK7 expression in all AEH cases and intense staining in 95.95% cases of AEH. The heterogeneous expression of CK7 was detected in all EC specimens. Intense CK7 expression was observed in 95.09% cases of EC G1 and in all G2 ECs. Heterogenous CK19 expression was present in all AEH specimens with intense staining in 92.42% of cases. Heterogeneous CK19 expression was observed in all EC samples with intense expression in 86.27% cases of EC G1 and 100% cases of EC G2. Interestingly, a significant relationship was found when comparing the heterogeneous expression of CK19 between AEH and well-differentiated EC. A significant difference was reported in the intense expression of CK AE1/AE3 (p = 0.031; p = 0.029) between AEH and G2 ECs and in the intense expression of CK AE1/AE3 between G1 and G2 ECs. CK20 staining was not a characteristic feature for AEH and early-stage EC. CK staining is present either in AEH or in early-stage endometrioid-subtype EC in different manners. Heterogeneous CK19 expression was significantly more common in AEH than in EC. CK20 expression was not associated with either AEH nor early-stage EC. An intense expression of CK AE1/AE3 was mainly present in moderately differentiated ECs, whereas the intense reactivity of AE1/AE3 showed a significant difference in well to moderately differentiated uterine tumors. The clinical implication of CK staining may aid in the more accurate diagnosis of AEH and early-stage EC as well as detect micrometastases leading to better oncological outcomes.

Inter‑component immunohistochemical assessment of proliferative markers in uterine carcinosarcoma

In the scientific literature, a selected number of reports have investigated the impact of proliferative activity on the development and progression of uterine carcinosarcomas (UC). The aim of the present retrospective study was to compare the immunohistochemical proliferation markers [Ki67, proliferating cell nuclear antigen (PCNA), minichromosome maintenance complex component 3 (MCM3), and topoisomerase IIα (topoIIα)] assessment in both components of UC. A total of 30 paraffin-embedded slides of UCs, obtained from patients who underwent surgery between January 1, 2006, and December 31, 2020, were analyzed. Medical records and clinicopathological data of patients were reviewed. Formalin-fixed, paraffin-embedded tissue sections were immunostained with monoclonal antibodies against Ki67, PCNA, MCM3 and topoIIα. Ki67-positive nuclear immunoreactivity was reported in 20 (67%) and 16 (53%) UC carcinomatous and sarcomatous components, respectively. In the epithelial component, Ki67 positive staining was related to the International Federation of Gynecology and Obstetrics (FIGO) stage (P=0.025), and histological grade (G1 vs. G2/G3, P=0.031). Nuclear PCNA reactivity was observed in 18 (60%) and 16 (53%) carcinomatous and sarcomatous components, respectively. Notably, all four cases with omental metastases were PCNA-positive, and a relationship between staining pattern and the existence of metastases was of significant value (P=0.018). MCM3-positive nuclear staining was found nearly twice as high in the carcinomatous (n=19; 63%), compared with the sarcomatous (n=11; 37%) component, respectively, and MCM3 expression in the epithelial component was related to clinical stage (P=0.030), and the existence of omental metastasis (P=0.012). In addition, out of the 30 UCs, 17 (57%) and 13 (43%) showed topoIIα positivity in the carcinomatous and sarcomatous UC components, respectively. A significant relationship between protein immunoreactivity and FIGO stage (P=0.049), and omental metastasis (P=0.026) was revealed to exist. However, no significant differences between expression of proliferation markers and clinicopathological features in the sarcomatous UC component were identified. Finally, a significant correlation between each protein immunohistochemical staining was demonstrated, particularly in the sarcomatous UC component. Collectively, a combined analysis of Ki67, PCNA, MCM3, and topoIIα may provide more detailed information of cell-cycle alterations determining the heterogeneity of uterine carcinosarcomas.

The value of Ki67 for the diagnosis of LSIL and the problems of p16 in the diagnosis of HSIL

p16 and Ki67 are immunohistochemical markers related to cervical squamous intraepithelial lesions. p16 has been widely used to assist in the diagnosis of high-grade squamous intraepithelial lesions. However, a conclusion about the role of Ki67 in the diagnosis of squamous intraepithelial lesions has not been established. The aim of this study was to analyze the role of p16 and Ki67 immunohistochemical staining in assisting cervical squamous intraepithelial lesions. This study performed immunohistochemical staining for p16 and Ki67 on 1024 cervical biopsy specimens at our hospital to compare the differences between p16 and Ki67 in different cervical lesions using the chi-squared test and Fisher's exact test. This study also evaluated the value of Ki67 for the diagnosis of low-grade squamous intraepithelial lesions (LSILs) using the receiver operating characteristic curve. The results indicated that Ki67 had high specificity and sensitivity in distinguishing LSIL from normal cervix. p16 was diffusely and strongly positive in some LSILs, and some problems were encountered in the interpretation of p16 staining. Therefore, we believe that Ki67 can be used as an immunohistochemical marker to help in the diagnosis of LSIL, to distinguish lesions that are difficult to morphologically determine and to avoid misdiagnosis. The practical application of p16 staining is still problematic. It may be necessary to find other auxiliary means to distinguish this small proportion of cervical lesions.

Role of immunohistochemistry in gynec oncopathology including specific diagnostic scenarios with associated treatment implications

Over the years, immunohistochemistry has emerged as a powerful tool for a more precise diagnosis of certain tumors in gynecologic oncopathology and resolving certain diagnostic dilemmas with significant treatment implications. Certain specific immunohistochemical (IHC) markers have been useful in the more correct identification of rare tumors, characterized by specific molecular signatures. Immunohistochemistry has also been useful in the identification of underlying genetic events, characterizing various tumors, as well as precancerous lesions. This review will focus upon the judicious application of various IHC antibody markers in gynec oncopathology, including authors' experience during "sign-outs" and especially during interaction with other oncology colleagues within the institutional disease management group. The updated references were retrieved from PubMed.

Review of immunohistochemical typing of endometrial carcinoma at the Lagos University Teaching Hospital

BACKGROUND

Categorization of endometrial carcinomas as type I and II provides useful insights into their different risk factors, pathogenesis and biologic behaviours.

AIM

To determine the immunohistochemical classifications of endometrial carcinomas in Nigerian women.

DESIGN

A retrospective review of histopathologic slides of cases of endometrial carcinomas seen at the Lagos University Teaching Hospital (LUTH) over a 5-year period. The slides were reviewed, and the diagnoses made according to the WHO nomenclature. The classification of endometrial carcinomas into Type I and II was made by immunohistochemistry using antibodies to ER, PR, p53 and Ki-67.

RESULTS

Eight cases of endometrial adenocarcinoma were reported accounting for 53.3% of all endometrial malignancies. Of these, only 1 case showed the classic type I immunophenotype while type II staining pattern was seen in 4 cases. The remaining 3 cases had equivocal immunophenotypes: one was p53+ but showed ER+, PR+ and high Ki-67 index; the second was p53-, ER+, PR+ but had a high Ki-67 expression; while the last was p53-, but ER-, PR- and had high Ki-67 expression.

CONCLUSION

Endometrial carcinomas in Nigerian women are more likely to be type II carcinomas. A reasonable proportion of the cases were equivocal thus requiring further categorization with molecular studies.

Mesonephric adenocarcinoma of the cervix: a case report with a three-year follow-up, lung metastases, and next-generation sequencing analysis

Background

Mesonephric adenocarcinoma (MNAC) is a rare tumor of the female genital tract, which originates from mesonephric duct remnants. Its diagnosis is pathologically challenging, because MNAC may exhibit a mixture of morphological patterns that complicates the differential diagnosis.

Case presentation

The patient in this case was a 48-year-old woman with a polypoid mass protruding into the endocervical canal. The patient underwent a total hysterectomy outside the institution. During biopsy, the mass showed a cerebroid aspect. Histological study revealed a tumor with a predominantly tubular and ductal growth pattern. The immunoprofile showed negative staining for calretinin, carcinoembryonic antigen (CEAm), estrogen receptors (ER), and progesterone receptors (PR), and positive staining for CD10, p16, and PAX2. The Ki-67 score was 46%. Using a next-generation sequencing assay, we documented genomic alterations in KRAS and CTNNB1, low tumor mutation burden (TMB), and an absence of microsatellite instability. In addition, gain of the long arm of chromosome 1 (1q) was also documented using chomogenic in situ hybridization (CISH). Three years later, the patient presented pulmonary nodules in the lingula and left basal lobe that were resected by thoracotomy. The histopathologic study of the pulmonary nodules confirmed the presence of metastases.

Conclusion

Carcinomas of mesonephric origin are among the rarest subtypes of cervical tumors. We report the first case of mesonephric adenocarcinoma of the cervix with lung metastases showing a CTNNB1 gene mutation.

An update on the use of immunohistochemistry and molecular pathology in the diagnosis of pre-invasive and malignant lesions in gynecological oncology

OBJECTIVE

One of the most common challenges in everyday clinical practice of gynecological oncology is to identify the type and the primary origin of a tumor. This is a crucial step in the management, treatment, prognosis, and survival of patients suffering from a gynecological malignancy. Immunohistochemistry has been widely adopted over the last three decades in pathology laboratories all over the world. Recent advances in our understanding of the differentiation of gynecological tumors based on immunohistochemical expression have resulted in use of immunohistochemistry as a major diagnostic tool in gynecology, for precise tumor classification. More recently, advances in molecular pathology, have taken this disease sub-classification further resulting in more effective personalised treatment regimens. The aim of this review is to provide clinicians with up to date information on the various immunohistochemical and molecular tests used in the diagnosis of gynecological malignancies of the female genital tract and an understanding of how to interpret them.

METHODS

We performed a review of the current literature including review articles, original research articles, and guidelines on various immunohistochemical markers and molecular techniques which are used for the differential diagnosis of gynecologic malignancies.

CONCLUSIONS

Immunohistochemistry is useful as an objective means for improved diagnostic reproducibility, accuracy, and precise classification in cases where the diagnosis with histochemical stains is inconclusive, providing a more reliable estimate of clinical outcomes. The diagnosis, in some cases, can be further refined by the use of molecular techniques leading to personalised medical treatments.

The Putative Role of TP53 Alterations and p53 Expression in Borderline Ovarian Tumors - Correlation with Clinicopathological Features and Prognosis: A Mini-Review

Borderline ovarian tumors (BOTs) represent an independent group among ovarian malignancies, being diagnosed at clinical stage earlier than invasive ovarian carcinomas (OCs) and characterized by a rather favorable outcome after careful surgical management. Data published worldwide showed a substantial discordance of p53 expression in BOTs. The purpose of this work was to present the current status of knowledge on the significance of TP53 gene and p53 protein product alterations in BOTs. In general, higher p53 expression patterns were reported for ovarian malignancies compared to BOTs. Serous, mucinous, and endometrioid BOTs differ substantially in relation to p53 immunostaining, but data concerning the relationship between the protein's immunoreactivity and other clinico-pathological variables are scarce. Finally, reports published to date support the view that TP53 alterations may not be commonly associated with the borderline phenotype of ovarian tumors but they probably occur during the development of invasive OCs. In light of these uncertainties, the impact of TP53 alterations and p53 expression on overall survival in women affected by BOTs requires further multi-institutional studies in large cohorts of patients.

Juvenile Granulosa Cell Tumour: Anaplastic Variant with Omental Deposits

Juvenile Granulosa Cell Tumour (JGCT) of ovary represents a small fraction of all primary ovarian malignancies. It is a subtype of granulosa cell tumour that is almost always found during the first three decades of life. Histologically, it differs from the typical adult type of granulosa cell tumour. It accounts for 5-15% of all granulosa cell tumours, majority being unilateral. Herein, we describe an unusual histopathological variant of JGCT with numerous large cystic spaces, anaplasia and focal syncytiotrophoblast like giant cells.

The role of immunohistochemistry in the evaluation of gynecologic pathology part 2: a comparative study between two academic institutes

Use of specific immunohistochemistry (IHC) marker, singly or in panels, differs and is influenced by practice setting, individual experience beside other factors. This is a part 2 study where we surveyed the application of IHC in gynecologic (gyn) pathology. Our specific aim in this part was to identify what specific stains are preferentially used. A retrospective chart review on all cases accessioned to the gyn pathology specialty sign out service during a 1-year period was performed at two academic pathology departments. Outside referral and consult as well as gyn cytology cases were excluded from the study. The most commonly ordered markers in diagnostic gyn pathology in descending order of frequency were as follows: P16, ki-67, p53, estrogen receptor (ER), progesterone receptor (PR), and CK7. P16 was used mainly in establishing the diagnosis/grading of squamous intraepithelial lesions (SIL) and differentiating serous from endometrioid carcinomas (ECs). P53 was used particularly in the diagnosis of serous carcinomas and establishing the diagnosis of differentiated vulvar intraepithelial neoplasia. Positive p16 was documented in all high-grade SIL, endocervical carcinomas, and serous carcinomas. In contrast, p16 was negative in all benign, low-grade SIL, and ECs. ER and PR were used in panels with p16, p53, vimentin, and carcinoembryonic antigen to assign tumors to specific site, in differentiating EC from serous carcinomas and in establishing the diagnosis of endocervical adenocarcinomas. Immunohistochemistry was used in 4.7% and 8.7% of gyn surgical path cases at two institutions. P16, ki-67, and p53 were the most commonly used markers especially in grading SIL. This study documents the most commonly used IHC biomarkers at two tertiary care academic centers for defining benchmarks for IHC use.

The Utility of Immunohistochemistry in the Differential Diagnosis of Gynecologic Disorders

Context

Immunohistochemistry has assumed an increasing role in the identification and characterization of gynecologic disorders including lesions with deceptively bland morphology, uncommon and underdiagnosed neoplasms, and neoplasms with specific genetic alterations associated with overexpression or loss of expression of specific proteins. The diagnostic accuracy has been significantly improved owing to the discovery and increasing experience with the tumor-associated biomarkers, and the increasing demand for precise tumor classification to assess suitability for the expanding therapeutic modalities including clinical trials.

Objective

To differentiate lesions of the gynecologic tract through the use of effective immunohistochemical panels.

Data Sources

Literature review and authors' personal practice experience.

Conclusions

The application of diagnostic and prognostic immunohistochemical panels has enabled pathologists to better guide therapeutic decisions and to better predict the clinical outcome. It is now well established that the use of ancillary testing, including immunohistochemistry, has a significant power in the identification, differentiation, and classification of reactive, premalignant, and malignant gynecologic disorders. This article discusses the utilities and pitfalls of the commonly used immunohistochemical markers in the context of overlapping morphologic features encountered in the uterus, ovaries, and fallopian tubes.

Metastatic ovarian carcinoma to the brain: an approach to identification and classification for neuropathologists

Brain metastasis is an uncommon but increasing manifestation of ovarian epithelial carcinoma and neuropathologists' collective experience with these tumors is limited. We present clinicopathological characteristics of 13 cases of brain metastases from ovarian epithelial carcinoma diagnosed at two academic institutions. The mean ages at diagnosis of the ovarian carcinoma and their subsequent brain metastases were 58.7 and 62.8 years, respectively. At the time of initial diagnosis of ovarian carcinoma the majority of patients had an advanced stage and none had brain metastases as their first manifestation of malignancy. Brain metastases tended to be multiple with ring-enhancing features on neuroimaging. Primary tumors and their brain metastases were all high-grade histologically and the histologic subtypes were: nine high-grade serous carcinoma (HGSC) cases, two clear cell carcinoma (CCC) cases and a single case each of carcinosarcoma and high-grade adenocarcinoma. A recommended histo- and immunopathological approach to these tumours are provided to aid neuropathologists in the recognition and classification of metastatic ovarian carcinoma to the brain.

p16 INK4a and Ki67 expression in normal, dysplastic and neoplastic uterine cervical epithelium and human papillomavirus (HPV) infection

Cellular cycle proteins like the p16(INK4a) and the Ki67 proliferation nuclear antigen have been used as oncogenicity cellular markers. The E6 and E7 oncoproteins interact with tumor suppressor genes p53 and pRb, culminating with the p16(INK4a) overexpression. The objective of this study was to evaluate the presence of HPV-DNA in 174 cervical biopsies and correlate the different histological grades with the p16(INK4a) and Ki67 immunohistochemical expression (IHC). A cross-sectional study that enrolled a total of 174 women who underwent uterine cervical biopsies between February 2003 and December 2006, in southern Brazil, was performed. Cervical smear samples were analyzed for the presence of HPV-DNA through polymerase chain reaction (PCR), and biopsy samples were examined for p16(INK4A) and Ki67 expression through IHC techniques. The presence of HPV-DNA was observed in 89% of the tested patients, among which 52% were positive for high-risk (HR) viral types [16, 18 and 31]. Regarding p16(INK4a), an expression of 69% was observed, being expressed in 100% of the high-grade squamous lesions (HSIL) and HR-HPV-DNA positives. Ki67 expression was associated with the lesion grade, being more expressive in the most severe lesions (p<0.001). p16(INK4A) and Ki67 markers coexpression was present in 86% of the samples (p<0.001), being 100% among those positive to HR-HPV-DNA with HSIL (p<0.001). The results suggest an association between the presence of HR-HPV infection and the p16(INK4a) and Ki67 expression and which is even stronger among women with HSIL.

Histologic and immunohistochemical analyses of endometrial carcinomas: experiences from endometrial biopsies in 358 consultation cases

CONTEXT

Uterine serous carcinoma is biologically more aggressive than the endometrioid carcinoma. Because uterine serous carcinoma has a high propensity for lymphovascular invasion and intraperitoneal and extra-abdominal spread, accurate diagnosis of this tumor type in endometrial biopsies/curettings is critical for appropriate clinical management.

OBJECTIVE

To share our experience in the evaluation of endometrial biopsy specimens in type I and type II endometrial adenocarcinoma.

DESIGN

We retrospectively reviewed 358 biopsies containing endometrial carcinoma during a recent 3 year period of our consultation records. In cases in which our interpretation differed from the submitting diagnosis, a panel of immunostains was performed. The performance characteristics of each antibody in our panel was calculated in this group of challenging cases.

RESULTS

Among the endometrial carcinomas we examined, a diagnosis of type I carcinoma accounted for 91% of cases (327 of 358) and type II carcinoma for 9% of cases (31 of 358); 41 cases (11.5%) were ambiguous or discordant (differing from submitted diagnoses and reviewed) based on histology alone. All 41 ambiguous and discordant cases were further evaluated with a battery of immunohistochemical markers. Of the 41 cases, 36 (88%) were ultimately classified (10 cases [24%] were endometrioid carcinoma; 18 cases [44%] were uterine serous carcinoma; 8 cases [20%] resulted in various other outcomes) and 5 cases (12%) remained indeterminate.

CONCLUSIONS

Making the distinction between type I and II endometrial carcinoma remains a common problem in general practice. Although no one biomarker provides excellent statistical performance, a panel of immunohistochemical markers is often useful in difficult cases.

Granulosa Cell Tumor of the Broad Ligament

This is a report of a paratubal adult granulosa cell tumor (GCT) located within the right broad ligament in a 62-year-old woman. These are rare tumors with only 8 cases reported so far. Because of an overlap of topographic, morphologic, and immunohistochemical features, it is not always possible to differentiate between the broad ligament GCT and female adnexal tumor of probable Wolffian origin (FATWO). Although nuclear grooving is not an exclusive feature of GCT and can be seen in a variety of other neoplasms, in the context of the differential diagnosis between broad ligament GCT and FATWO, the presence of this feature may be very useful in establishing the diagnosis of broad ligament GCT.

Immunohistochemical Markers of Value in the Diagnosis of Mesenchymal Lesions of the Female Genital Tract

Pure mesenchymal tumors may occur anywhere in the female genital tract, but they are most common in the uterine corpus, leiomyoma being by far the most prevalent. These tumors, and other uncommon mesenchymal lesions within the uterine corpus and elsewhere in the female genital tract, may result in several diagnostic problems. Morphology remains paramount and, in most cases, an unequivocal diagnosis can be made based on examination of the hematoxylin and eosin stained sections, combined with an appreciation of the clinical and gross pathologic features. In difficult cases, immunohistochemistry can significantly contribute to the final diagnosis. In this article, the immunohistochemistry of neoplastic and nonneoplastic mesenchymal lesions of the female genital tract is discussed site by site, concentrating on markers that are of value in diagnosis and in differential diagnosis. The immunophenotype of mixed epithelial and mesenchymal neoplasms and pure epithelial neoplasms with a component of spindle cells is discussed, where appropriate, because these can enter into the differential diagnosis of a pure mesenchymal lesion.

Diagnostic utility of p16INK4a: a reappraisal of its use in cervical biopsies

p16(INK4a), an indirect marker of cell cycle dysregulation, is commonly expressed in cervical dysplasias and carcinomas associated with high risk human papillomavirus (HR-HPV) infections. Although p16(INK4a) immunohistology is routinely used as a cost effective surrogate marker, many of the published articles are confusing and contradictory. The discrepancies can be ascribed to a multitude of factors operating at the molecular, technical and interpretative levels. In the first place, our simplistic model of viral mediated oncogenesis is speculative and fails to account for all the known biomolecular changes. Unresolved technical issues include the variables of tissue fixation, antibody dilution, antibody isotype and clone, and the sensitivity of the particular detection method. Within any controlled staining method, strong diffuse or 'block' immunoreactivity in squamous cells may be found in moderate/severe dysplasia (CIN 2/3) and invasive squamous carcinoma. In contrast, focal or multifocal reactivity in squamous cells may be artefactual, related to low risk or HR-HPV. p16(INK4a) is less reliable when dealing with glandular lesions since considerable overlap exists between reactive and dysplastic lesions. In addition not all glandular dysplasias/carcinomas are HR-HPV related, nor are all p16(INK4a) immunoreactive lesions associated with HR-HPV. We conclude that p16(INK4a) immunoperoxidase shows greater specificity than sensitivity for squamous lesions; in comparison, glandular dysplasias/carcinomas show reduced specificity and sensitivity. Like all cell cycle regulatory proteins, the future diagnostic role of p16(INK4a) is limited. The ideal diagnostic molecular test for cervical dysplasias will detect a HR-HPV related product after, but not before, cell transformation and will reliably predict those cases yet to experience disease progression.

[Natural history of precursor lesions of cervical cancer]

Precursor lesions of invasive cancer of uterine cervix begin at the squamocolumnar junction. On this zone in permanent transformation, human papillomavirus (HPV) gives condylomatous lesions, pure or associated with neoplasic transformation of the epithelium. For 50 years, various histological classifications have been proposed. First, four groups have been designed: light, moderate, severe dysplasia and in situ carcinoma. Secondly, Richart proposed the cervix intraepithelial neoplasia classification (CIN) with three grades (1 to 3) according to their severity. Progression from CIN 1 to CIN 3 and invasive carcinoma is admitted and is consistent with the concept of lesional continuum. However, because of the elevated rate of spontaneous regression of CIN 1, it is probably a lesion of very low potential aggressivity and its role as a precursor is uncertain. Now two groups of different evolutivity are currently considered: low grade and high grade lesions. The last one's, at the opposite of the first, are monoclonal, have major epithelial abnormalities with sometimes abnormal mitoses and are frequently aneuploid. Aggressivity depends on the persistence of HR HPV more than on progressive morphologic transformation. By integrating in-host genoma, it induces modifications on cellular cycle proteins. Revelation by immunohistochemistry brings help to diagnosis of high grade lesions when traditional morphology is ambiguous.

Application of immunohistochemistry to gynecologic pathology

CONTEXT

A large variety of tumors and lesions arise in the female genital tract. Although the majority of these can be correctly recognized on routine hematoxylin-eosin-stained slides, occasional cases present a diagnostic challenge. Immunohistochemical stains are extremely useful in resolving many of these problematic cases. As the knowledge in this area is constantly expanding, it is useful to have this updated information in a review form for easy access.

OBJECTIVE

To present our current knowledge of immunohistochemistry of the lesions of the female genital tract in a readily accessible form.

DATA SOURCES

The review is based on previously published articles on this topic.

CONCLUSIONS

Immunohistochemical stains help in reaching a conclusive diagnosis in a variety of problematic lesions seen in gynecologic pathology. As in any other system, immunohistochemical findings need to be interpreted in light of the clinical history and morphologic findings.

Immunohistochemical biomarkers of value in distinguishing primary ovarian carcinoma from gastric carcinoma: a systematic review with statistical meta-analysis

AIMS

To compare the relative risk of antigen expression being detected immunohistochemically in ovarian and gastric carcinoma aggregated from studies performed for diagnostic purposes, with the relative risks of their expression in all patients in the English literature.

METHODS AND RESULTS

Both types of series indicated that cytokeratin (CK) 7 expression was greater and that of CK20 and carcinoembryonic antigen less in ovarian than in gastric carcinoma (P < 0.05). Synthesis of all data available for MUC-2 suggested it was more commonly expressed in ovarian carcinoma, whereas the relative risk in papers that directly compared its expression suggested that it was more common in the gastric carcinoma (P = 0.2, NS). Aggregating all possible data suggested villin was more likely to be expressed in ovarian cancers, whereas studies in which its expression was compared directly in both tumours suggested the opposite. Although statistically significant, patient numbers were small.

CONCLUSION

Provided sufficient numbers of cases are studied, analysis of studies comparing antigen expression for diagnostic purposes in tumours from two body sites is likely to be supported in the wider literature. The design of such comparative studies is informed by aggregating data from single tumour studies.

Immunohistochemical Overexpression of p16 and p53 in Uterine Serous Carcinoma and Ovarian High-grade Serous Carcinoma

The immunohistochemical expression pattern of p16 in biopsy samples has been useful as part of a panel to distinguish adenocarcinomas arising from the endometrium from those arising from the endocervix. However, no information is available on the expression of p16 in uterine serous carcinoma (USC) or ovarian high-grade serous carcinoma that could be used for diagnostic purposes. Here, we retrospectively analyzed the immunohistochemical expression of p16 in 11 cases of USC (5 pure and 6 mixed with endometrioid adenocarcinoma) and 10 cases of ovarian high-grade serous carcinoma and compared p16 expression with that of p53 in the same samples. p16 was strongly expressed by 100% of tumor cells in all 11 uterine specimens and in 5 of the 10 ovarian specimens; of the other 5 ovarian specimens, 4 showed strong positivity in 20% to 80% of tumor cells, and 1 case showed only weak expression. Positivity for p53 was strong and diffuse (100% of tumor cells) in 5 uterine tumors and in 3 ovarian tumors. p53 expression in 6 of the uterine specimens and 7 of the ovarian specimens was present in fewer tumor cells, of weak intensity, or both. We also performed human papilloma virus (HPV) DNA in situ hybridization in 4 uterine pure serous carcinomas; all 4 were negative. The negative results were confirmed by reverse transcriptase in situ polymerase chain reaction. We conclude that p16, owing to its diffuse expression in USC, should not be interpreted as indicating cervical origin or HPV-induced carcinogenesis; however, p16 may be a better marker (albeit unspecific) than p53 for identifying USC. The overexpression of p16 in USC is unrelated to HPV. Further studies are necessary to determine whether p16 expression is useful in the differential diagnosis of ovarian high-grade serous carcinoma.

Prognosis of adenocarcinoma of the uterine cervix: p53 expression correlates with higher incidence of mortality

We investigated the significance of prognostic markers-estrogen receptor, progesterone receptor, p53, MIB-1 and bcl-2 - in adenocarcinoma of the uterine cervix. In 101 patients with primary cervical adenocarcinoma, treated from 1989 to 2000, we evaluated clinical parameters in relation to these prognostic markers. Mean age of patients was 45 years. Seventy eight percent of the patients were in FIGO stage I, 16% stage II, 7% stage III and IV. estrogen receptor, progesterone receptor, p53 and bcl-2 immunoreactivity was scored as 0 (up to 5% positive cells), 1+ (5-25% of cells positive), 2+ (26-50% of cells positive), 3+ (51-75% of cells positive) or 4+ (>76% of cells positive). MIB-1 was scored in 10 categories: 0-10, 11-20, 21-30, 31-40, 41-50, 51-60, 61-70, 71-80, 81-90, 91-100. The overall survival rate was 67%. Survival was not influenced by estrogen receptor, progesterone receptor, MIB-1, or bcl-2 strongly positive staining. Only p53 showed significant influence on survival, even when adjusted for stage or tumor grade. In conclusion, it does not seems useful to determine estrogen receptor, progesterone receptor, MIB-1 or bcl-2 in cervical adenocarcinomas as an indication of prognosis: survival is not influenced by presence or absence. However, if p53 staining is strongly positive survival is significantly worse than in tumors scored as negative or weak positive.

Ovarian mucinous tumour arising in mature cystic teratoma and associated with pseudomyxoma peritonei: report of two cases and comparison with ovarian involvement by low-grade appendiceal mucinous tumour

AIMS

It is currently accepted that primary ovarian tumours rarely, if ever, give rise to mucinous ascites/pseudomyxoma peritonei (PMP) which most commonly results from the intra-abdominal spread of an appendiceal mucinous neoplasm. However, primary ovarian mucinous tumours of appendiceal type arising within mature cystic teratomas appear to represent an exception to this rule. In this report two further examples of this rare tumour are described, and the immunohistological phenotype including expression of MUC proteins is compared with secondary ovarian involvement by low-grade appendiceal mucinous neoplasm.

METHODS

Two cases of ovarian mucinous tumour associated with mature cystic teratoma and PMP are described. The tumours were examined immunohistochemically for expression of cytokeratin (CK)7, CK20, carcinoembryonic antigen (CEA), CDX-2, MUC2, MUC5AC and MUC6. The results were compared with four cases of ovarian neoplasia secondary to primary appendiceal low-grade mucinous tumour.

RESULTS

The ovarian mucinous tumours associated with mature cystic teratomas were morphologically similar to those secondary to appendiceal neoplasia. They comprised irregularly distributed glands and cysts lined by tall, mucin-rich epithelial cells exhibiting focal villoglandular architecture and low grade cytological atypia. The immunophenotype of the teratoma-associated tumours and those secondary to appendiceal neoplasia was identical: there was strong and diffuse expression of CK20, CEA, CDX-2, MUC2 and MUC5AC with no reactivity for the other antisera tested.

CONCLUSIONS

PMP associated with primary ovarian neoplasia is rare, and probably restricted to mucinous tumours arising in mature cystic teratomas. The immunohistological findings in this study further support the view that such tumours exhibit a lower gastrointestinal and, more specifically, appendiceal phenotype. Careful examination and sampling of the ovaries may be required to demonstrate the teratomatous component of these tumours.

Squamous cell carcinoma with sarcomatoid features of the vulva: A case report and review of literature

BACKGROUND

A squamous cell carcinoma with sarcomatoid features of the vulva is an extremely rare malignancy of the female genital tract. This type of tumor is known to grow rapidly and associated with poorer clinical outcomes than those of squamous cell carcinoma of the vulva.

CASES

A 43-year-old woman presented to our institute with a 4-month history of an aggravated vulvar mass. A radical local excision, bilateral inguinal lymph node dissection and laparoscopic assisted vaginal hysterectomy were performed. The FIGO stage of the vulvar cancer was stage II (T(2)N(0)M(0)) and the pathologic finding was consistent with a poorly differentiated squamous cell carcinoma with extensive sarcomatoid features. No further treatment was given and there was no clinical evidence of recurrence during the 2 years of follow-up.

CONCLUSION

A squamous cell carcinoma with sarcomatoid features of the vulva is a tumor with aggressive biological behavior. To date, there have been only 15 cases of this disease reported in the literature. So, a collection and close study of these cases would be extremely useful in singling out and identifying the best treatment possible for this type of tumor.