The Search for the Optimal cut-off Value of p53-Immunohistochemistry to Predict Prognosis of Invasive Bladder Cancer: A Multi-Center, Multi-Laboratory Analysis

Introduction: Mutations in the TP53 gene are indicative of worse outcome in bladder cancer and are usually assessed by immunohistochemistry. To define p53-overexpression, a threshold of >10% is most commonly used (cut-off1). Recently, a novel cut-off (aberrant = 0% or ≥50%) (cut-off2) showed better correlation to clinical outcome. In this study, we evaluate the association between p53-immunohistochemistry cut-offs, clinico-pathological variables and disease-specific survival (DSS). Methods: Seven-hundred-fifty chemotherapy-naïve patients who underwent radical cystectomy were included (92% muscle-invasive bladder cancer. In addition to cut-off1 and cut-off2, a third cut-off (cut-off3) was determined based on the highest Youden-index value. Cut-off values were associated with clinico-pathological variables and FGFR3 mutation status. The Kaplan-Meier method was used to estimate DSS. Results: Aberrant p53-expression was found in 489 (65%) (cut-off1) and 466 (62%) (cut-off2) tumors. Cut-off3 was determined at 25% and aberrant p53-expression in 410 cases (55%) (cutoff3). p53-expression levels were significantly associated with higher pT-stage (cut-off1/2/3: P = 0.047, P = 0.006 and P = 0.0002, respectively), higher grade (all, P < 0.0001), and FGFR3 wild-type (cut-off1: P = 0.02, cut-offs2&3: P = 0.001). Median follow-up was 5.3 years (interquartile range, 4.0-6.0 years). p53-expression was not associated with DSS for any of the three cut-offs (cut-off1/2/3: P-log-rank = 0.566, 0.77 and 0.50, respectively). If we only considered locally advanced bladder cancer, results on DSS remained non-significant. Conclusion: This multi-center, multi-laboratory study showed that, regardless of the cut-off used, p53-immunohistochemistry did not enable selection of patients with worse outcome. Our results suggest that p53-immunohistochemistry alone is not suitable to guide clinical decision making after radical cystectomy.

Cytologic features of gynecologic germ cell tumors and carcinomas exhibiting germ cell tumor differentiation

BACKGROUND

In this study, the authors sought to describe the cytologic features of primary gynecologic germ cell tumors and carcinomas exhibiting germ cell differentiation because little information currently exists.

METHODS

An institutional database search was performed to identify histologically confirmed gynecologic germ cell tumors and carcinomas with germ cell tumor differentiation. Available cytologic material was reviewed by three observers, and morphologic features were recorded in addition to patient age at original diagnosis, primary tumor site, site(s) from which the examined cytologic material was obtained, and the type of examined cytologic preparations.

RESULTS

In total, 15 cytologic specimens from 12 women (aged 19-82 years) were identified and included touch preparations of core biopsies from various sites (n = 6), fine-needle biopsies (n = 2), pelvic washings (n = 1), ascitic fluids (n = 4), pelvic cyst fluid (n = 1), and endometrial aspirate (n = 1). Of the 12 patients, seven had primary gynecologic germ cell tumors, four had gynecologic (ovarian and endometrial) tumors exhibiting somatic yolk sac tumor-like differentiation, and the remaining patient had an intestinal-type adenocarcinoma arising within an ovarian teratoma. There was morphologic overlap among many of the cases, although cytoplasmic vacuolation/granular cytoplasm was seen in 75% of primary yolk sac tumors or carcinomas with yolk sac tumor differentiation, and dense/squamoid cytoplasm was seen in 100% of teratomatous elements that were sampled.

CONCLUSIONS

Germ cell tumors and somatic neoplasms exhibiting germ cell tumor differentiation occurring in adult women share some cytologic features and may be difficult to distinguish from one another, although some tumor types showed characteristic cytomorphologic findings.

Wetting of a Stepped Platinum (211) Surface

Steps stabilize water adsorption on metal surfaces, providing favorable binding sites for water during wetting or ice nucleation, but there is limited understanding of the local water arrangements formed on such surfaces. Here we describe the structural evolution of water on the stepped Pt(211) surface using thermal desorption, low-energy electron diffraction, and scanning tunneling microscopy to probe the water structure. At low coverage water forms linear structures comprising zigzag chains along the steps that are decorated by H-bonded rings every one or two units along the terrace. Simple 2-coordinate H-bonded chains are not observed, indicating the Pt step binds too weakly to compensate entirely for a low water H-bond coordination number. As the coverage increases, water chains assemble into a disordered (2 × 1) structure, likely made up of the same narrow water chains along the steps with little or no H-bonding between adjacent structures. The chain structure disappears as water adsorption saturates the surface to form an incommensurate, disordered network of water rings of different size. Although the steps on Pt(211) clearly stabilize water adsorption and direct growth, the surface does not support the simple 1D chains previously proposed or an ordered 2D network such as seen on other surfaces. We discuss reasons for this and the factors that determine the behavior of the first water layer on stepped metal surfaces.

Cytohistologic immunohistochemical correlation of epithelial tubo-ovarian neoplasms: Can cell blocks substitute for tissue?

BACKGROUND

Cytologic specimens often represent the initial diagnostic material for tubo-ovarian neoplasms resulting from therapeutic paracentesis for patients presenting with high-volume ascites. However, subtyping and immunohistochemical (IHC) characterization, which have implications in preoperative management and downstream ancillary testing, are not routinely performed in many institutions. This study aims to perform cytohistologic correlation of commonly used IHC stains to establish their reliability in peritoneal fluids/washing specimens.

METHODS

A retrospective search of the laboratory information systems was performed to identify peritoneal fluid/washing specimens involved by borderline or malignant epithelial tubo-ovarian neoplasms and concurrent/subsequent surgical resection specimens. Cell blocks and tissue were stained for PAX8, WT-1, p53, p16, Napsin-A, estrogen receptor, and progesterone receptor, and staining between cytological and surgical specimens was compared.

RESULTS

A total of 56 case pairs were included, with the following final diagnoses on histological examination: 37 high-grade serous carcinomas, eight clear cell carcinomas, one endometrioid adenocarcinoma, two low-grade serous carcinomas, and eight serous borderline tumors. There was perfect cytohistologic correlation for PAX8 (Lin's concordance correlation coefficient [LINCCC] = 1.00) and WT-1 (LINCCC = 1.00), substantial/good correlation for p53 (LINCCC = 0.96), p16 (LINCCC = 0.93), napsin-A (LINCCC = 0.91) and ER (LINCCC = 0.77), and moderate correlation for PR (LINCCC = 0.54).

CONCLUSIONS

Immunohistochemical correlation between peritoneal fluid and surgical resection specimens for tubo-ovarian neoplasms is high. Common subtypes of tubo-ovarian carcinomas can be reliably distinguished on fluids using IHC.

Management of patients with early-stage ovarian clear cell carcinoma: risk stratification and fertility conservation

OBJECTIVE

We sought to describe clinicopathologic and treatment factors associated with oncologic outcomes in patients with early-stage ovarian clear cell carcinoma undergoing complete staging and in a sub-set of these patients undergoing fertility-conserving surgery.

METHODS

We retrospectively identified patients with ovarian clear cell carcinoma initially treated at our institution from January 1, 1996 to March 31, 2020. Survival was estimated using Kaplan-Meier curves and compared by log-rank test. Survival-associated variables were identified by Cox proportional hazards regression.

RESULTS

Of 182 patients, mismatch repair and p53 protein expression were assessed by immunohistochemistry on 82 and 66 samples, respectively. There were no significant differences in progression-free survival or overall survival between mismatch repair-deficient (n=6, including 4 patients with Lynch syndrome; 7.3%) and mismatch repair-proficient patients, whereas aberrant p53 expression (n=3; 4.5%) was associated with worse progression-free (p<0.001) and overall survival (p=0.01). Patients with stage IA/IC1 disease had a 95% 5-year overall survival rate (95% CI 88% to 98%); patients with stage IC2/IC3 disease had a similar 5-year overall survival rate (76%; 95% CI 54% to 88%) to that of patients with stage IIA/IIB disease (82%; 95% CI 54% to 94%). There was no difference in 5-year overall survival in patients with stage IA/IC1 undergoing chemotherapy versus observation (94% vs 100%). Nine patients underwent fertility-sparing surgery and none experienced recurrence. Of five patients who pursued fertility, all had successful pregnancies.

CONCLUSIONS

In patients with completely staged ovarian clear cell carcinoma, those with stage IA/IC1 disease have an excellent prognosis, regardless of chemotherapy. Aberrant p53 expression may portend worse outcomes. Additional investigation is warranted on the safety of fertility conservation in patients with stage IA/IC1 disease.

Clinical, Morphologic, and Molecular Features Associated With Ovarian Metastases From Pattern A Endocervical Adenocarcinomas

Ovarian metastases from endocervical adenocarcinomas (EAs) are rare but well-described. Silva Pattern A tumors have been reported to pose essentially no risk of lymph node metastases or recurrence. We describe a cohort of patients with Silva Pattern A EAs with ovarian metastases, as well as involvement of other sites. Eight pattern A EAs with ovarian metastases (4 synchronous, 4 metachronous) were identified from our institution's pathologic archives (2008-2021). Clinicopathologic and molecular features for each case were recorded. All patients were treated by hysterectomy; in each case, the entire tumor was submitted for histologic evaluation. The synchronous metastases were all clinically suspected to be ovarian primary tumors; EAs with metachronous ovarian involvement were confined to the uterus at initial diagnosis, with ovarian metastasis occurring 5 to 171 months after hysterectomy. Morphologically, all tumors were predominantly gland-forming, 5/8 (63%) displayed prominent mucinous differentiation, and 5/8 (63%) involved the corpus. All EAs were either noninvasive (exophytic/papillary/more complex than adenocarcinoma in situ) or showed nondestructive cervical stromal invasion to a depth of 5 mm or less. In the 5 tumors tested by next-generation sequencing, ARID1A, GNAS, and KRAS mutations were detected in 2 (40%), 3 (60%), and 4 (80%) cases, respectively. All 6 patients with follow-up (range, 32 to 181 mo; median, 99.5 mo) had at least 1 recurrence. All but one are without evident disease at last clinical assessment. In an otherwise typical Silva Pattern A EA, corpus involvement, mucinous differentiation, and certain gene mutations may be associated with risk for synchronous or metachronous ovarian metastases.

Gene of the month: STK11

STK11 encodes for the protein liver kinase B1, a serine/threonine kinase which is involved in a number of physiological processes including regulation of cellular metabolism, cell polarity and the DNA damage response. It acts as a tumour suppressor via multiple mechanisms, most classically through AMP-activated protein kinase-mediated inhibition of the mammalian target of rapamycin signalling pathway. Germline loss-of-function mutations in STK11 give rise to Peutz-Jeghers syndrome, which is associated with hamartomatous polyps of the gastrointestinal tract, mucocutaneous pigmentation and a substantially increased lifetime risk of many cancers. In the sporadic setting, STK11 mutations are commonly seen in a subset of adenocarcinomas of the lung in addition to a number of other tumours occurring at various sites. Mutations in STK11 have been associated with worse prognoses across a range of malignancies and may be a predictor of poor response to immunotherapy in a subset of lung cancers, though further studies are needed before the presence of STK11 mutations can be implemented as a routine clinical biomarker.

New imaging modalities to distinguish rare uterine mesenchymal cancers from benign uterine lesions

PURPOSE OF REVIEW

Uterine sarcomas are rare and are often challenging to differentiate on imaging from benign mimics, such as leiomyoma. As functional MRI techniques have improved and new adjuncts, such as machine learning and texture analysis, are now being investigated, it is helpful to be aware of the current literature on imaging features that may sometimes allow for preoperative distinction.

RECENT FINDINGS

MRI, with both conventional and functional imaging, is the modality of choice for evaluating uterine mesenchymal tumors, especially in differentiating uterine leiomyosarcoma from leiomyoma through validated diagnostic algorithms. MRI is sometimes helpful in differentiating high-grade stromal sarcoma from low-grade stromal sarcoma or differentiating endometrial stromal sarcoma from endometrial carcinoma. However, imaging remains nonspecific for evaluating rarer neoplasms, such as uterine tumor resembling ovarian sex cord tumor or perivascular epithelioid cell tumor, primarily because of the small number and power of relevant studies.

SUMMARY

Through advances in MRI techniques and novel investigational imaging adjuncts, such as machine learning and texture analysis, imaging differentiation of malignant from benign uterine mesenchymal tumors has improved and could help reduce morbidity relating to misdiagnosis or diagnostic delays.

Gene of the month: FH

Fumarate hydratase (FH), encoded by the FH gene, is an enzyme which catalyses the conversion of fumarate to L-malate as part of the tricarboxylic acid cycle. Biallelic germline mutations in FH result in fumaric aciduria, a metabolic disorder resulting in severe neurological and developmental abnormalities. Heterozygous germline mutations in FH result in hereditary leiomyomatosis and renal cell carcinoma, a cancer predisposition syndrome. FH deficiency has multiple oncogenic mechanisms including through promotion of aerobic glycolysis, induction of pseudohypoxia, post-translational protein modification and impairment of DNA damage repair by homologous recombination. FH-deficient neoplasms can present with characteristic morphological features that raise suspicion for FH alterations and also frequently demonstrate loss of FH immunoreactivity and intracellular accumulation of 2-succinocysteine, also detected by immunohistochemistry.

Social facilitation for conservation planning: understanding fairy tern behavior and site selection in response to conspecific audio-visual cues

Simulated social facilitation techniques (e.g. decoys and call playbacks) are commonly used to attract seabirds to restored and artificially created nesting habitats. However, a lack of social stimuli and conspecific cueing at these habitats may limit the use of these sites, at least in the short term. Therefore, testing the effectiveness of simulated audio-visual cues for attracting gregarious birds is important for conservation planning. In this study, we (1) assessed whether call playback and decoys were associated with an increased likelihood of Australian fairy terns Sternula nereis nereis visiting potentially suitable nesting habitats; (2) tested their behavioral response to different cues; and (3) documented whether social facilitation had the potential to encourage colony establishment. A full cross-over study design consisting of all possible pairings of decoy and call playback treatments (control [no attractants], decoys, call playback, both decoys and playback), allocated as part of a random block design, was undertaken at 2 sites. Linear modeling suggested that call playback was important in explaining the time spent aerial prospecting as well as the maximum number of fairy terns aerial prospecting, although this only appeared to be the case for 1 of the 2 sites. Decoys, on the other hand, did not appear to have any effect on time spent aerial prospecting. The results from this study suggest that audio cues have the potential to encourage site selection by increasing social stimuli, but attractants may be required over several breeding seasons before colonies are established.

Three-antibody classifier for muscle invasive urothelial carcinoma and its correlation with p53 expression

AIMS

To assess the utility of a three-antibody immunohistochemistry panel to classify muscle invasive bladder cancers (MIBCs) in correlation with morphological features and p53 status.

METHODS

A retrospective review of 243 chemotherapy naïve MIBC cystectomy specimens was performed to assess morphological features. A tissue microarray was sequentially stained with CK5/6, GATA-3 and p16. Subgroups were assigned as basal-like (CK5/6+, GATA3-) and luminal (CK5/6-, GATA3+), with the latter subdivided into genomically unstable (GU, p16+) and urothelial like (Uro, p16-) subgroups. p53 staining was assessed as abnormal/wild type. Cases from the The Cancer Genome Atlas (TCGA) portal were assessed as external validation.

RESULTS

We identified 78.8% luminal, 21.2% basal cases within our cohort and 63.4% luminal, 36.6% basal in the TCGA dataset. Divergent differentiation (p<0.001) was significantly associated with basal-subtype cases in both cohorts. Within the luminal subgroup (n=186), 81 cases were classified as GU and 105 as Uro. Abnormal p53 staining was noted in 48.0% of basal, 80.2% GU and 38.1% Uro cases. Further, basal-subtype tumours significantly correlated with disease-specific death compared with Uro cases in multivariate survival analysis.

CONCLUSIONS

This retrospective study demonstrates the potential utility of a three-antibody immunohistochemistry panel to differentiate luminal and basal MIBC.

Case report: Sentinel lymph node mapping of endometrial carcinoma occurring in uterine didelphys

•

In a bleeding postmenopausal woman with didelphys uterus, endometrial biopsy should be taken from both uterine cavities.

•

Sentinel lymph node mapping has not been previously described in the setting of endometrial cancer and uterine didelphys.

•

Routine sentinel lymph node mapping was successfully performed in a patient with endometrial cancer and uterine didelphys.

Pathology of Hereditary Breast and Ovarian Cancer

Hereditary breast and ovarian cancer (HBOC) syndrome is most commonly characterized by deleterious germline mutations in BRCA1 and BRCA2. HBOC patients are prone to the development of malignant neoplasms in multiple organs including the breast, ovary, and fallopian tube. From a pathological perspective, a number of morphological features have been described in BRCA-associated breast and tubo-ovarian cancers. For example, breast cancers diagnosed in BRCA1-mutation carriers are frequently of a high Nottingham grade and display medullary morphology and a triple-negative and/or a basal-like immunophenotype. In contrast, breast cancers in BRCA2-mutation carriers are similar to sporadic luminal-type tumors that are positive for hormone receptors and lack expression of human epidermal growth factor receptor 2. Cancers arising in the fallopian tube and ovary are almost exclusively of a high-grade serous histotype with frequent Solid, pseudo-Endometrioid, and Transitional cell carcinoma-like morphology (“SET features”), marked nuclear atypia, high mitotic index, abundant tumor infiltrating lymphocytes, and necrosis. In addition, pushing or infiltrative micropapillary patterns of invasion have been described in BRCA-associated metastases of tubo-ovarian high-grade serous carcinomas. Besides BRCA1 and BRCA2 mutations, alterations in a number of other homologous recombination genes with moderate penetrance, including PALB2, RAD51C, RAD51D, BRIP1, and others, have also been described in HBOC patients with varying frequency; however, distinct morphological characteristics of these tumors have not been well characterized to date. In this review, the above pathological features are discussed in detail and a focus is placed on how accurate pathologic interpretation plays an important role in allowing HBOC patients to receive the best possible management.

Reassessment of p53 immunohistochemistry thresholds in invasive high grade bladder cancer shows a better correlation with TP53 and FGFR3 mutations

FGFR3 mutations are frequently mutually exclusive of TP53 mutations in invasive high grade urothelial carcinoma (HGUC) and p53 immunohistochemistry is often used as a surrogate for TP53 mutations. A 10 % staining cut off has been used in HGUC for designation as p53 positive or negative however, a novel contemporary method we have previously proposed (0% or >50 % - abnormal vs. 1-49 % - wild type) has shown significant correlation with oncologic outcome as well. We aimed to compare how a ≥10 % vs. 0 % and ≥ 50 % cut off p53 assessment method correlates with TP53 and FGFR3 mutation status. Tissue microarrays created from three retrospective cohorts (two cystectomy cohorts (cohort A, n = 206 and cohort B, n = 91; one T1 transurethral resection cohort (cohort C, n = 47)) were stained with p53 and scored by two blinded reviewers using both p53 scoring schemes. 50 cases from cohort A were assessed for TP53 and FGFR3 mutation status using next generation sequencing and FGFR3 mutation status was separately assessed in cohorts B and C using SNaPshot methodology. 202 (58.7 %) and 142 (41.3 %) cases showed abnormal and wild type p53 staining, respectively. Using the 10 % cut off, 254 cases were positive (73.8 %) and 90 cases were negative (26.2 %). 27 (14.4 %) and 15 (30 %) assessed cases demonstrated FGFR3 and TP53 mutations, respectively; 19/27 FGFR3 mutated showed a wild type pattern of p53 expression while 15/15 TP53 mutated tumours showed an abnormal pattern of p53 expression. There was a significant correlation between the contemporary p53 scoring scheme and TP53 and FGFR3 mutations (p < 0.0001 and p = 0.002, respectively). Improved sensitivity, specificity, positive predictive value, and negative predictive value for TP53 mutation was also seen compared to the 10 % cut off; specifically, the sensitivity and negative predictive value were 100 %. These findings might be of clinical relevance in the era of precision medicine.

Gene fusions characterize a subset of uterine cellular leiomyomas

Uterine leiomyomas are the most common benign tumor of the female genital tract. Previous studies have shown that conventional leiomyomas often harbor-specific alterations including rearrangements involving HMGA2. Cellular leiomyomas are a variant of uterine leiomyoma that are less well-studied from a genomic point of view. Morphologically and immunohistochemically, cellular leiomyomas may be confused with low-grade endometrial stromal neoplasms, a group of tumors which frequently harbor a number of recurrent gene fusions. Ancillary molecular testing may be used to investigate tumors where low-grade endometrial stromal neoplasms enter into the differential diagnosis. At our institution, we identified a uterine cellular leiomyoma harboring a HMGA2-TRAF3IP2 fusion. After a retrospective review 11 additional tumors were identified. All included cases were reviewed and evaluated for immunohistochemical expression of smooth muscle actin, desmin, h-caldesmon, CD10, estrogen receptor, and progesterone receptor. RNA sequencing using the TruSight RNA Fusion Panel was performed on formalin-fixed paraffin-embedded tissue samples. In addition to the index case, two other cases harbored fusions: HMGA2-NAA11 and TPCN2-YAP1, of which the latter is novel and was confirmed with reverse transcriptase-polymerase chain reaction. In conclusion, a subset of cellular leiomyomas harbor rearrangements involving HMGA2, suggesting molecular kinship with conventional uterine leiomyomas. In addition, the prevalence of the novel TPCN2-YAP1 gene fusion in cellular leiomyomas requires further study. The fusions reported here, when identified, may be useful when the diagnosis of cellular leiomyoma is in question.

Immune gene expression profiles in high-grade urothelial carcinoma of the bladder: a NanoString study

AIMS

The advent of immune checkpoint inhibitor therapy has proven beneficial in a subset of high-grade urothelial carcinomas (HGUC) of the bladder. Although treatment selection is currently largely determined by programmed death-ligand 1 (PD-L1) status, multiple factors in the immune system may modulate the host immune response to HGUC and immunotherapy. In this pilot study, we used a transcriptomic approach to identify the immune milieu associated with PD-L1 expression to enhance our understanding of the HGUC immune evasion network.

METHODS

The immune transcriptome of 40 HGUC cystectomy cases was profiled using the NanoString nCounter Human V.1.1 PanCancer Panel. All cases were assessed for associated PD-L1 status (SP263) using whole tissue sections. PD-L1 status was determined as high or low using 25% tumour and/or immune cell staining.

RESULTS

The most significantly differentially expressed gene was PD-L1 messenger RNA (CD274), which strongly correlated with protein expression (r=0.720, p<0.001). The sensitivity, specificity, positive and negative predictive values of CD274 for PD-L1 expression were 85%, 96%, 92% and 93%, respectively. The PD-L1 associated gene signature also included complement components C1QA and CD46 and NOD2 (innate immune system), proinflammatory cytokines CXCL14, CXCL16, CCL3, CCL3L1 and OSM along with the immune response mediator SMAD3, among others. Pathway analysis determined enrichment of these genes in interleukin-10 production, lymphocyte chemotaxis and aberrant IFNγ, NF-κB and ERK signalling networks.

CONCLUSIONS

We report key genes and pathways in the immune transcriptome and their association with PD-L1 status, which may be involved in immune evasion of HGUC and warrants further investigation.

Correlation of mismatch repair protein deficiency, PD-L1 and CD8 expression in high-grade urothelial carcinoma of the bladder

Mismatch repair-deficient (d-MMR) tumours have been reported to show susceptibility to immune checkpoint inhibitors targeting programmed death-1/PD ligand-1 (PD-1/PD-L1). In this study, we sought to correlate the association of d-MMR, PD-L1 and CD8 expression in muscle invasive, high-grade urothelial carcinoma (HGUC) of bladder. A tissue microarray (TMA) was constructed from 201 cases and sequentially stained with PD-L1, CD8, MSH2, MSH6, MLH1 and PMS2. PD-L1 was assessed in tumour and immune cells. CD8 was assessed in a hotspot fashion with results averaged across cores. Loss of nuclear MMR expression on TMA sections was further assessed using corresponding whole tissue sections. d-MMR was identified in four cases (2%). The mean CD8 count was significantly higher in d-MMR tumours (10 vs 35, p=0.007) as was the proportion of PD-L1 positivity (75% vs 20%, p=0.031). d-MMR is uncommon in HGUC of bladder but shows strong correlation with cytotoxic T lymphocyte infiltration and PD-L1 tissue expression.

Evaluation of cancer testis antigen (CT10, PRAME) and MHC I expression in high-grade urothelial carcinoma of the bladder

Immunotherapeutic strategies are increasingly used in the treatment of a number of malignancies including high grade urothelial carcinoma (HGUC) of the bladder. Because of this, detailed and accurate assessment of the tumour immune microenvironment is paramount. In this study, we aimed to correlate the composition of the tumour immune microenvironment with oncologic outcome and the expression of two cancer testis antigens (CTAs), CT10 and PRAME, potential cancer vaccine targets, as well as major histocompatibility complex I (MHC I), a molecule associated with tumour immune escape and resistance to immunotherapy.

Triplicate tissue microarrays (TMAs) were constructed using 207 cases of HGUC of the bladder. Oncologic outcome data was gathered for each case. Consecutive sections from the TMA blocks were stained with CD3, CD4, CD8, FOXP3, PD1, PD-L1, CT10, PRAME, and MHC I. 21% and 15% of cases expressed CT10 and PRAME, respectively. 88% of cases showed absent or decreased MHC I expression. CT10-expressing tumours showed a significantly worse disease specific survival (p = 0.007, hazard ratio 2.245, confidence interval 1.223–4.122). CT10, PRAME, and MHC I expression significantly correlated with other some immune parameters. CT10 and PRAME are expressed in a subset of HGUC and CTA and MHC I expression correlate with a number of important immune parameters. Together, these findings highlight the potential for exploring novel immune therapeutic strategies in HGUC. Additional studies evaluating the clinical relevance of these findings are warranted.

Immunohistochemical expression of HIK1083 and MUC6 in endometrial carcinomas

AIMS

Gastric-type endocervical adenocarcinoma (EA) is characterised by aggressive behaviour and pathogenesis independent of human papillomavirus infection. Because of its morphology and frequent mutation-pattern expression of p53, gastric-type EA may be confused with several types of endometrial carcinoma, particularly in biopsy and curettage specimens. HIK1083 and MUC6 are immunohistochemical markers used to support a diagnosis of gastric-type EA; however, the rates of expression of these markers in endometrial tumours are largely unknown. We therefore aimed to assess the expression of HIK1083 and MUC6 in a cohort of different types of endometrial carcinoma.

METHODS AND RESULTS

Ninety-one endometrial carcinomas (56 endometrioid, 16 clear cell, and 19 serous) from 91 patients treated with hysterectomy were included. A representative tumour block from each case was used for immunohistochemical staining with HIK1083 and MUC6. The percentage of stained cells (0-100%) and average staining intensity (weak, moderate, and strong) were recorded for both markers. None of 91 cases expressed HIK1083. In contrast, 66% (60/91) of cases showed at least focal expression of MUC6; importantly, 54 of 60 (90%) positive cases showed moderate or strong staining. Five of 60 (8%) cases showed MUC6 staining in ≥50% of tumour cells. Endometrioid tumours (49/56, 88%) were more likely to express MUC6 than cases of clear cell (1/16, 6%) or serous (10/19, 53%) carcinoma.

DISCUSSION

Endometrial carcinoma often expresses MUC6. In contrast, HIK1083 is consistently negative, and thus, when positive, is a more reliable marker for distinguishing gastric-type EA from some of its endometrial mimics.

International Endocervical Adenocarcinoma Criteria and Classification (IECC): correlation with adverse clinicopathological features and patient outcome

AIMS

The International Endocervical Adenocarcinoma Criteria and Classification (IECC) was recently proposed as an improved method for categorising endocervical adenocarcinoma (EA) into human papillomavirus (HPV)-associated adenocarcinomas (HPVAs) and non-HPV-associated adenocarcinomas (NHPVAs). Such categorisation correlates with patient age and tumour size; however, its association with patient outcome remains to be established.

METHODS

Institutional cases of EA with histological material available were selected. Three gynaecological pathologists independently classified all tumours according to the IECC with consensus review used when necessary. Clinicopathologic variables were recorded for each case.

RESULTS

Of a total of 87 EAs, 71 (82%) were classified as HPVA and 16 (18%) as NHPVA. Among HPVA, most were usual type (51/71, 72%) followed by mucinous not otherwise specified (10/71, 14%) and invasive stratified mucin-producing carcinoma (ISMC, 8/71, 11%). Most NHPVAs were of gastric type (12/16, 71%) followed by clear cell and mesonephric (two each, 12%). Compared with HPVAs, NHPVAs were significantly associated with older age (p<0.001), larger horizontal extent (p=0.013), greater depth of invasion (p=0.003), lymphovascular space invasion (p<0.001), advanced stage (p<0.001) and invasive pattern C (p<0.001). On univariate analysis, worse disease-free survival (DFS) and disease-specific survival (DSS) correlated with NHPVA group. Among the HPVA subtypes, ISMC showed worse DFS and DSS compared with other HPVA types.

CONCLUSIONS

The simple morphological approach of the IECC appears to be prognostically valuable. NHPVA (in particular gastric type) and ISMC (a recently recognised subset of HPVA) have an adverse outcome and their recognition following the IECC is important. We provide further evidence to replace the current WHO classification with the IECC.

Gross and microscopic changes of liver neoplasms and background hepatic structures following neoadjuvant therapy

Liver transplantation is a surgical option with curative intent used in the management of some cases of hepatocellular carcinoma and cholangiocarcinoma (hilar, rarely intrahepatic). A number of different therapeutic modalities including ablative techniques, arterially directed therapies, radiation and chemotherapy are used in the neoadjuvant setting prior to liver transplantation with the goals of preventing tumour progression, decreasing post-transplant recurrence and possibly downstaging patients with tumour burden beyond what is acceptable by current transplant criteria. Pathologists evaluating hepatic explants must be aware of these neoadjuvant therapies and the alterations induced by them in both tumourous and non-tumourous tissue. In this review, we discuss common neoadjuvant therapies used in in this setting, as well as the gross and microscopic changes induced by these presurgical treatments within hepatic neoplasms as well as the background hepatic parenchyma and nearby structures. Select secondary tumours involving the liver which are pretreated will also be discussed. Finally, proper reporting of these changes will be mentioned.

Cervical Adenocarcinomas: A Heterogeneous Group of Tumors With Variable Etiologies and Clinical Outcomes

Context.—

Cervical adenocarcinomas are a heterogeneous group of tumors with varying morphologies, etiologies, molecular drivers, and prognoses, comprising approximately 25% of all cervical cancers. Unlike cervical squamous cell carcinoma, adenocarcinomas are not uniformly caused by high-risk human papillomavirus (HPV) infection and, therefore, would not necessarily be prevented by the HPV vaccine.

Objective.—

To provide a review of endocervical adenocarcinoma subtypes and, when appropriate, discuss precursor lesions, etiologies, molecular genetics, and ancillary studies within the context of clinical care. Some historical perspectives will also be provided.

Data Sources.—

Data sources included published peer-reviewed literature and personal experiences of the senior author.

Conclusions.—

Endocervical adenocarcinomas are a histologically diverse group of tumors with various causes and molecular drivers, not all related to HPV infection. Distinguishing them has important implications for treatment and prognosis as well as strategies for prevention.

International Endocervical Adenocarcinoma Criteria and Classification: Validation and Interobserver Reproducibility

The current World Health Organization (WHO) classification for endocervical adenocarcinoma (EA) is based on descriptive morphologic characteristics; however, it does not fully reflect our current knowledge of the diverse pathogenesis of cervical glandular neoplasia. A novel classification system, the International Endocervical Adenocarcinoma Criteria and Classification (IECC), which incorporates etiology and biological behavior into the morphologic scheme, has been recently proposed. We aimed to validate the IECC by assessing its interobserver reproducibility in comparison to the WHO system. A cohort of 75 EAs was reviewed independently by 7 gynecologic pathologists and categorized following IECC and WHO criteria based on hematoxylin and eosin material alone and after immunohistochemistry results for p16, PR, p53, Napsin-A, vimentin, CDX2, and GATA3 were provided. Human papillomavirus (HPV) in situ hybridization and polymerase chain reaction results were compared with consensus diagnoses. IECC was superior to WHO in terms of interobserver agreement with κ=0.46 versus 0.3, respectively, on hematoxylin and eosin review and κ=0.51 versus 0.33, respectively, with immunohistochemistry. Under the IECC, 73 (97%) of EAs had majority agreement (≥4 reviewers in agreement) whereas 42 (56%) had perfect agreement (7/7 reviewers in agreement). Conversely, WHO showed majority agreement in 56 (75%) and perfect agreement in only 7 (10%) EAs. Reproducibility was poor in HPV-related WHO types (usual κ=0.36, mucinous not otherwise specified κ=0.13, intestinal κ=0.31, villoglandular κ=0.21) and good in major HPV-unrelated categories (gastric type κ=0.63, clear cell κ=0.81, mesonephric κ=0.5). Classification as per the IECC had excellent correlation with HPV status (by RNA in situ hybridization or polymerase chain reaction). We have shown that the IECC has superior interobserver agreement compared with the WHO classification system, and that distinction between HPV-related and HPV-unrelated EA can be made with good reproducibility and excellent prediction of HPV status. WHO morphologic variants of HPV-related EA are poorly reproducible. Conversely, agreement is high among important high-risk HPV-unrelated subtypes. Thus, our results further support replacing the current WHO classification with the IECC.

The reactivity of water and OH on Pt-Ni(111) films

Bimetallic Pt catalysts are of interest as water redox catalysts in low temperature fuel cells. Here we compare water and hydroxyl adsorption on Pt-Ni(111) films and a PtNi(111) alloy surface with the behaviour on the pure metals. Whereas water adsorbs and desorbs intact from close packed Pt and Ni, it dissociates on PtNi surfaces to form adsorbed hydroxyl and hydrogen. Reactivity to water increases in the order Pt(111) < monolayer Pt-Ni(111) < multilayer (2-6 ML) Pt-Ni(111) ∼ PtNi(111) surface alloy and does not scale directly with the Pt strain. Hydroxyl can also be formed by reaction with pre-adsorbed O and is less stable than on pure Pt, decomposing to water and O in a broad peak near 180 K, 20 K lower than on Pt(111). The reduced stability of OH on Pt-Ni(111) films is common to all the PtNi surfaces and consistent with bimetallic PtNi surfaces showing less blocking by OH during the oxygen reduction reaction.

The Mayak Worker Dosimetry System (MWDS-2013): A Bayesian Analysis to Quantify Pulmonary Binding of Plutonium in Lungs Using Historic Beagle Dog Data

The revised human respiratory tract model, published in Part 1 of the International Commission on Radiological Protection's (ICRP) report on Occupational Intakes of Radionuclides (OIR), includes a bound fraction, fb, to represent radionuclides that have become chemically bound in the lungs following dissolution of particulates in lung fluid. Bound radionuclides are not subject to particle transport clearance but can be absorbed to blood at a rate, sb. The occurrence of long-term binding of plutonium can greatly increase lung doses, particularly if it occurs in the bronchial and bronchiolar regions. However, there has been little evidence that currently supports the existence of a long-term bound state for plutonium. The present work describes the analysis of measurements of lung data obtained from a life span study of Beagle dogs that were exposed by inhalation to different concentrations of plutonium-239 (239Pu) nitrate aerosol at Pacific Northwest Laboratories, USA. The data have been analysed to assess whether a bound state was required to explain the data. A Bayesian approach was adopted for the analysis that accounts for uncertainties in model parameter values, including uncertainties in the rates of particle transport clearance. Furthermore, it performs the analysis using two different modelling hypotheses: a model based on the current ICRP human respiratory tract model and its treatment of alveolar particle transport clearance; and a model of particle transport clearance that is based on the updated model developed by ICRP to calculate dose coefficients for the OIR. The current model better represents clearance in dogs at early times (up to 1 year following intake) and the latter better represents retention at greater times (>5 years following intake). The results indicate that a long-term bound fraction of between 0.16 and 1.1%, with a mean value of between 0.24 and 0.8% (depending on the model) is required to explain the data.

Genomic abnormalities in invasive endocervical adenocarcinoma correlate with pattern of invasion: biologic and clinical implications

The pattern-based classification system for HPV-related endocervical adenocarcinoma, which classifies tumors based on the destructiveness of stromal invasion, is predictive of the risk of nodal metastases and adverse outcome. Previous studies have demonstrated clinically important molecular alterations in endocervical adenocarcinoma, including KRAS and PIK3CA mutations; however, correlation between the molecular landscape and pathological variables including pattern of invasion has not been thoroughly explored. In this study, 20 endocervical adenocarcinomas were classified using the pattern-based classification system and were subjected to targeted sequencing using the Ion AmpliSeq Cancer Hotspot Panel v2 (ThermoFisher Scientific, Waltham, MA, USA) that surveys hotspot regions of 50 oncogenes and tumor suppressor genes. Single-nucleotide polymorphisms were correlated with clinical and pathologic variables including pattern of invasion. Five (25%), six (30%), and nine (45%) cases were classified as patterns A, B, and C respectively. Lymph node metastases, advanced stage at presentation and mortality from disease were exclusively seen in destructively invasive tumors (patterns B or C). Prevalent mutations in the cohort involved PIK3CA (30%), KRAS (30%), MET (15%), and RB1 (10%). Most (94%) relevant genomic alterations were present in destructively invasive tumors with PIK3CA, KRAS, and RB1 mutations seen exclusively in pattern B or C subgroups. KRAS mutations correlated with advanced stage at presentation (FIGO stage II or higher). Our findings indicate that the pattern of stromal invasion correlates with genomic abnormalities detected by next-generation sequencing, suggesting that tumors without destructive growth (pattern A) are biologically distinct from those with destructive invasion (patterns B and C), and that pattern B endocervical adenocarcinoma is more closely related to its pattern C counterpart. The pattern-based classification may be used as a triage tool when considering molecular testing for prognostic or therapeutic purposes.

Tumour front inflammation and necrosis are independent prognostic predictors in high-grade urothelial carcinoma of the bladder

Aims

Inflammation and necrosis have been associated with prognosis in multiple epithelial malignancies. Our objective was to evaluate inflammation and necrosis in a cohort of patients with high-grade urothelial carcinomas of the bladder to determine their association with pathological parameters and their prognostic effect on relapse-free and disease-specific survival.

Methods

A retrospective cohort that underwent radical cystectomy for urothelial carcinomas (n=235) was evaluated for invasive front and central inflammation using the Klintrup-Makinen assessment method. Necrosis was scored using a four-point scale. The relationship of inflammation and necrosis with stage, nodal status, carcinoma in situ, tumour size, margin status and vascular space invasion and the impact on relapse-free and disease-specific survival were calculated using appropriate statistical tests.

Results

On multivariate analysis, invasive front inflammation (p=0.003) and necrosis (p=0.000) were independent predictors of relapse-free survival. Both invasive front inflammation (p=0.009) and necrosis (p=0.002) again were independent predictors of disease-specific survival. For pathological features, low invasive front inflammation was associated with lymphovascular space invasion (p=0.008), a positive soft tissue margin (p=0.028) and carcinoma in situ (p=0.042). Necrosis was statistically associated with tumours >3 cm in size (p=0.013) and carcinoma in situ (p<0.001).

Conclusions

Necrosis and invasive front inflammation are additional histological variables with independent prognostic relevance in high-grade urothelial carcinoma of the bladder.

Chiral segregation driven by a dynamical response of the adsorption footprint to the local adsorption environment: bitartrate on Cu(110)

Bitartrate, a strongly bound chiral modifier, is able to restructure its adsorption footprint on Cu(110) in response to local adsorbates.

Shifting from presumptive to test-based management of malaria - technical basis and implications for malaria control in Ghana

The presumptive approach was the World Health Organisation (WHO) recommended to the management of malaria for many years and this was incorporated into syndromic guidelines such as the Integrated Management of Childhood Illnesses (IMCI). In early 2010 however, WHO issued revised treatment guidelines that call for a shift from the presumptive to the test-based approach. Practically, this implies that in all suspected cases, the diagnosis of uncomplicated malaria should be confirmed using rapid test before treatment is initiated. This revision effectively brings to an end an era of clinical practice that span several years. Its implementation has important implications for the health systems in malaria-endemic countries. On the basis of research in Ghana and other countries, and evidence from program work, the Ghana National Malaria Control Program has issued revised national treatment guidelines that call for implementation of test-based management of malaria in all cases, and across all age groups. This article reviews the evidence and the technical basis for the shift to test-based management and examines the implications for malaria control in Ghana.

The role of lattice parameter in water adsorption and wetting of a solid surface

Reducing the lattice parameter of a Sn–metal surface alloy below the O–O separation of ice disrupts the flat wetting layer, causing the first layer to buckle and instead form ice clusters.

A randomized, comparative study of two regimens of β-artemether for the treatment of uncomplicated,Plasmodium falciparummalaria, in northern Ghana

In Ghana, wide-spread resistance to chloroquine has necessitated the drug's replacement as the first-line treatment for malaria, both to increase the likelihood of cure and to reduce transmission. To see if beta-artemether could be a suitable alternative to chloroquine, 223 adults (aged > or = 15 years) with uncomplicated, Plasmodium falciparum malaria were each given a total dose of 480 mg beta-artemether over 4 or 5 days. The patients were randomly allocated to receive an initial, loading dose of 80 or 160 mg, and were checked on days 1, 2, 3, 4 (or 5), 7 and 14, for fever clearance and any adverse events. Blood samples collected on days 0, 4 (or 5), 7 and 14 were smeared so that levels of parasitaemia could be evaluated. Haemoglobin concentrations on days 0 and 14 were also determined. In terms of the clinical cure 'rates' estimated in the intention-to-treat analysis (92.5% v. 97.4%) and the evaluability analysis (98.9% v. 100%), and of the frequency of parasitological cure by day 14 (97.0% v. 96.5%), the patients given an initial dose of 80 mg were similar to those given 160 mg as the loading dose. The regimen with the 160-mg loading dose appears as safe and as effective as the regimen with an initial dose of 80 mg. Since the regimen with the higher loading dose is shorter and involves fewer treatments than the other regimen, it would probably be associated with better compliance.

Infant illness spanning the antenatal to early neonatal continuum in rural northern Ghana: local perceptions, beliefs and practices

OBJECTIVE

To explore community understanding of perinatal illness in northern Ghana.

STUDY DESIGN

A cross-sectional descriptive study design.

RESULT

253 community members participated in in-depth interviews and focus group discussions, including women with newborn infants, grandmothers and health care providers. Four overarching themes emerged: (1) Local understanding of illness affects treatment practices. Respondents recognized danger signs of illness spanning antenatal to early neonatal periods. Understanding of causation often had a distinctly local flavor, and thus treatment sometimes differed from mainstream recommendations; (2) Mothers are frequently blamed for their infant's illness; (3) Healthcare decisions regarding infant care are often influenced by community members aside from the infant's mother and (4) Confidence in healthcare providers is issue-specific, and many households use a blended approach to meet their health needs.

CONCLUSION

Despite widespread recognition of danger signs and reported intentions to treat ill infants through the formal health care system, traditional approaches to perinatal illness remain common. Interventions need to be aligned with community perceptions if they are to succeed.

Urban-rural differences in the nature and prevalence of mental ill-health in adults with intellectual disabilities

BACKGROUND

In the general population there are statistically significant urban-rural differences in the rate of common mental disorders. In people with intellectual disability (ID) no study has attempted to address this issue.

AIMS

To compare the prevalence of mental illness, autism spectrum disorder (ASD) and behaviour disorder in people with ID living in urban areas with those living in rural areas.

METHODS

Cross-sectional study of 2713 individuals registered with an ID service. Participants were assigned to urban or rural groups using the Department for Environment Food and Rural Affairs rural/urban local authority classification for their district. The main outcome variable was a clinical diagnosis of mental illness, ASD and behaviour disorder. Differences between diagnoses of mental illness in urban and rural areas were evaluated using the chi-squared test for the difference in two independent proportions.

RESULTS

No differences were observed between gender, age and level of ID of service users based on their place of residence. But more people from an ethnic minority background were living in urban areas than rural areas. No differences were observed in the overall prevalence of mental illness by place of residence. However, the results showed that ASD was more common in people living in rural areas.

CONCLUSIONS

We found these results surprising and at odds with the majority of studies carried out in the general population and propose several reasons for the differences found. We believe that the results and further studies in this area will help inform health service provision for those with ID who live in different geographical areas.

Strain relief and disorder in commensurate water layers formed on Pd(111)

Water adsorbs and desorbs intact on Pd(111), forming a hydrogen-bonded wetting layer whose structure we examine by low energy electron diffraction (LEED) and He atom scattering (HAS). LEED shows that water forms commensurate (√3 × √3)R30° clusters that aggregate into a partially ordered, approximately (7 × 7) superstructure as the layer completes. HAS indicates that the water layer remains disordered on a local (approximately 10 Å) scale. Based on workfunction measurements and density functional theory simulations we propose that water forms small, flat domains of a commensurate (√3 × √3)R30° water network, separated by disordered domain boundaries containing largely H-down water. This arrangement allows the water layer to adapt its density and relieve the lateral strain associated with adsorbing water in the optimum flat atop adsorption site. We discuss different possibilities for the structure of these domain walls and compare this strain relief mechanism to the highly ordered, large unit cell structures formed on surfaces such as Pt(111).

Review of Antenatal-Linked Voluntary Counseling and HIV Testing in Sub-Saharan Africa: Lessons and Options for Ghana

SummaryVoluntary counselling and HIV testing has become an integral part of HIV prevention and care programs in many countries in sub-Saharan Africa. A number of interventions offer potential to reduce mother-to-child HIV transmission. These interventions, including antenatal and or intrapartum administration of antiretroviral drugs require the integration of voluntary counselling and HIV testing for pregnant women into antenatal care. Ghana's strategic framework for HIV control calls for the integration of voluntary counselling and HIV testing to antenatal care nationwide. It sets as target, the year 2005 when VCT would be widely available and accessible in the country. This paper reviews medline-indexed publications on antenatal-linked VCT programs of sub-Saharan Africa. Four critical themes were used in the medline search. These are acceptability, rates of return for test, disclosure of results vis-à-vis confidentiality and cost effectiveness. The growing consensuses on these issues are discussed in relations to the findings of a recent study conducted among 270 pregnant women in Navrongo in the Kassena-Nankana district of northern Ghana. Suggestions are made to guide the on-going pilot VCT and prevention of mother-to-child programs in Ghana. It is also suggested on the basis of the review and the findings of the Navrongo study that Ghana should explore options likely to promote universal access and overall acceptability. These include couple counselling, guarantee of confidentiality, free testing and continuum of care for mothers who are test positive.