Intestinal type adenocarcinoma of the endometrium with signet ring cells, a rare aggressive variant

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Intestinal type mucinous adenocarcinoma is a rare variant of mucinous carcinoma of the endometrium.

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Intestinal differentiation in the endometrium can manifest with a wide spectrum of morphologies including signet-ring cells.

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E-cadherin expression is downregulation in the signet-ring cell component in all three cases.

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Cases described provides further evidence of the aggressive nature of intestinal type mucinous adenocarcinoma.

Objective

Intestinal type mucinous adenocarcinoma (iMACE) is a rare and unusual variant of mucinous carcinoma of the endometrium that can show focal features of poorly differentiated adenocarcinomas of gastric, pancreatic or intestinal origin by producing signet ring cells. To date, only two reported cases of signet ring cells as a morphological feature of iMACE have been reported. Alterations in E-cadherin expression have been linked to increased metastatic potential, tumor dedifferentiation, and deep myometrial invasion in endometrial carcinomas. The presence or absence of E-cadherin in iMACE with signet-ring cells has not been studied. Thus, we sought to analyze E-cadherin expression in this aggressive variant of endometrial carcinoma.

Cases

Diagnosis of iMACE with signet ring cells was rendered with the aid of immunohistochemical staining and histological analysis. Average age of diagnosis was 72 with the presenting complaint of postmenopausal bleeding in all three women. Focal loss or weakly positive E-cadherin expression was seen in areas of signet-rings cell morphology in all three cases.

Conclusion

This case report adds to the body of literature that demonstrates the aggressive nature of intestinal differentiation in the endometrium. In addition, this report suggests that the presence of signet-rings cells and loss of E-cadherin expression may render a poorer prognosis as seen in other parts of the body.

Unexpected endometrial malakoplakia in a 74-year-old-female: A case report

Introduction/Objective

Malakoplakia is a chronic inflammatory disease, usually associated with bacterial infection. The urinary system is the most commonly involved site. Involvement of the female genital tract is extremely rare. Histopathologically, the disease is manifested by solid sheets of histiocytes with abundant granular eosionophilic cytoplasm, and intra- and extracellular basophilic bodies. It should be differentiated from other types of granulomatous inflammation and from signet ring cell carcinoma. Treatment consists of antibiotics, but surgery is sometimes necessary.

Methods/Case Report

A 74-year-old woman experienced postmenopausal bleeding for several years. A previous endometrial biopsy showed a mucinous glandular proliferation of uncertain etiology. She also had coronary heart disease, hypertension, diabetes mellitus and hyperlipidemia. A prior urinalysis showed abundant bacteria, and she had been hospitalized recently for urinary tract infection (UTI). She underwent laparoscopic total hysterectomy. Grossly, the endometrium was mostly uniform, 0.1 cm in thickness, with one 0.4-cm polyp. Microscopically, the endometrium showed simple hyperplasia without atypia, benign endometrial polyp, and multifocal malakoplakia, manifested by sheets of histiocytes with granular eosinophilic cytoplasm, many of them containing variably-sized basophilic spherules imparting to them a targetoid, or bull’s eye, appearance. Multiple endometrial plasma cells were also seen.

Results (if a Case Study enter NA)

NA

Conclusion

Very few cases of endometrial malakoplakia have been reported in the medical literature. Here we present unexpected malakoplakia coexisting with endometrial simple hyperplasia without atypia. Reports from the electron microscopy literature suggest that the basophilic spherules, named Michaelis-Gutmann inclusion bodies, are electron-dense granules that result from coalescence of phagolysosomes, reflecting failed digestion of bacteria. In our patient, longstanding chronic endometritis, confirmed by the presence of endometrial plasma cells, possibly coexisting with chronic UTI, culminated in malakoplakia, which clinically and pathologically mimicked endometrial hyperplasia or even carcinoma, given her old age, chronic bleeding, and the mucinous epithelium in the endometrial biopsy. The finding of endometrial malakoplakia should remind us of the bacterial etiology of chronic endometritis and the need for timely treatment of urogenital infections with antibiotics.

Yolk sac tumor of the endometrium in a post-menopausal woman: Case report and review of the literature

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Seven of eighteen postmenopausal female endometrial YST cases were pure YST.

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IHC supports somatic tumor cell retro-differentiation yielding extra-gonadal YST.

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Studying genetic alterations in endometrial YST may elucidate its histiogenesis.

Image Descriptors for Weakly Annotated Histopathological Breast Cancer Data

Introduction

Cancerous Tissue Recognition (CTR) methodologies are continuously integrating advancements at the forefront of machine learning and computer vision, providing a variety of inference schemes for histopathological data. Histopathological data, in most cases, come in the form of high-resolution images, and thus methodologies operating at the patch level are more computationally attractive. Such methodologies capitalize on pixel level annotations (tissue delineations) from expert pathologists, which are then used to derive labels at the patch level. In this work, we envision a digital connected health system that augments the capabilities of the clinicians by providing powerful feature descriptors that may describe malignant regions.

Material and Methods

We start with a patch level descriptor, termed Covariance-Kernel Descriptor (CKD), capable of compactly describing tissue architectures associated with carcinomas. To leverage the recognition capability of the CKDs to larger slide regions, we resort to a multiple instance learning framework. In that direction, we derive the Weakly Annotated Image Descriptor (WAID) as the parameters of classifier decision boundaries in a Multiple Instance Learning framework. The WAID is computed on bags of patches corresponding to larger image regions for which binary labels (malignant vs. benign) are provided, thus obviating the necessity for tissue delineations.

Results

The CKD was seen to outperform all the considered descriptors, reaching classification accuracy (ACC) of 92.83%. and area under the curve (AUC) of 0.98. The CKD captures higher order correlations between features and was shown to achieve superior performance against a large collection of computer vision features on a private breast cancer dataset. The WAID outperform all other descriptors on the Breast Cancer Histopathological database (BreakHis) where correctly classified malignant (CCM) instances reached 91.27 and 92.00% at the patient and image level, respectively, without resorting to a deep learning scheme achieves state-of-the-art performance.

Discussion

Our proposed derivation of the CKD and WAID can help medical experts accomplish their work accurately and faster than the current state-of-the-art.

Synovial Metaplasia of the Endometrium

Introduction/Objective

Synovial-like metaplasia is well known to accompany breast implants, but it can also rarely be found in the endometrium, associated with intrauterine devices. We present two cases of endometrial synovial-like metaplasia.

Methods

The hysterectomy specimens were diagnosed at Northwell Health and reviewed at the departmental Consensus Conference. Immunostains for cytokeratin AE1/AE3 were performed on the endometrium. The histopathologic findings were correlated with the clinical information.

Results

Both patients had had intrauterine devices placed for birth control. One, a 47-year-old female with a family history of Lynch syndrome and newly diagnosed with a corresponding mutation, underwent prophylactic hysterectomy. The second patient, a 50-year-old female with a history of uterine prolapse, was experiencing stress urinary incontinence, for which she underwent supracervical hysterectomy. Both patients had intrauterine devices in place at the time of hysterectomy.

Both uteri showed endometrial synovial-like metaplasia. It was associated with a complete absence of the endometrial surface epithelium. The synovial-like cells were eosinophilic, plump and elongated, were palisaded perpendicular to the endometrial surface and were negative for cytokeratin AE1/AE3, which immunostain also confirmed the absence of the endometrial surface epithelium and the presence of some residual deeper endometrial glands.

Conclusion

Endometrial synovial-like metaplasia is a rare entity described in patients with intrauterine devices. The mesodermal-derived endometrium is apparently able, when exposed to a semi-mobile foreign body, to develop a way to minimize friction by mimicking synovium, similar to the connective tissue facing breast implants. Such surface must be better at withstanding chronic friction than the regular endometrial epithelial surface, leading to this unusual and fascinating change. Since the resulting surface mimics synovium perfectly, both morphologically and immunohistochemically, and serves a very similar mechanical purpose, we propose to call this phenomenon, wherever it is found, “synovial metaplasia” instead of the current term “synovial-like metaplasia.”

Overall Survival and Adjuvant Therapy in Women with Ovarian Carcinosarcoma: A Single-Institution Experience

BACKGROUND

Carcinosarcoma of the ovary (CSO) is a rare and aggressive variant of ovarian cancer. Due to the rare nature of the disease there is insufficient evidence to make recommendations regarding standard management and overall prognosis.

METHODS

An Institutional Review Board-approved study identified all our patients with CSO between January 2011 and May 2018. Demographic and outcome measures were abstracted from the medical records and tumor board files. Cox proportional hazard models, log rank tests, and comparisons of means were used to calculate significance (p < 0.05).

RESULTS

27 women with CSO were identified. The median age at diagnosis was 65 years (range 48-91). Five women (18%) presented with early stage disease (Stage I or II) and 22 patients (82%) presented with late stage III or IV disease. Twenty patients (74%) received intravenous platinum-based combination chemotherapy. Seven patients did not receive chemotherapy during their treatment course. The median overall survival was 23 months (range 2-68 months). Overall survival was not significantly worsened by the stage of disease at diagnosis. There was no difference in survival based on the age at diagnosis, tobacco status or ethnicity (p > 0.05).

CONCLUSION

This is one of the largest single institution experiences with CSO. The majority of our patients presented with advanced stage disease and received adjuvant platinum-based chemotherapy after cytoreductive surgery. The median overall survival of 23 months was not affected by the stage of the disease. The optimal management of this rare disease needs further study with collaborative, prospective multi-institutional trials.

Targeting TAZ-Driven Human Breast Cancer by Inhibiting a SKP2-p27 Signaling Axis

Deregulated expression of the transcriptional coactivator with PDZ-binding motif (WWTR1/TAZ) is a common feature of basal-like breast cancer (BLBC). Yet, how oncogenic TAZ regulates cell-cycle progression and proliferation in breast cancer remains poorly understood, and whether TAZ is required for tumor maintenance has not been established. Here, using an integrative oncogenomic approach, TAZ-dependent cellular programs essential for tumor growth and progression were identified. Significantly, TAZ-driven tumor cells required sustained TAZ expression, given that its withdrawal impaired both genesis and maintenance of solid tumors. Moreover, temporal inhibition of TAZ diminished the metastatic burden in established macroscopic pulmonary metastases. Mechanistic investigation revealed that TAZ controls distinct gene profiles that determine cancer cell fate through cell-cycle networks, including a specific, causal role for S-phase kinase-associated protein 2 (SKP2) in mediating the neoplastic state. Together, this study elucidates the molecular events that underpin the role of TAZ in BLBC and link to SKP2, a convergent communication node for multiple cancer signaling pathways, as a key downstream effector molecule. IMPLICATIONS: Understanding the molecular role of TAZ and its link to SKP2, a signaling convergent point and key regulator in BLBC, represents an important step toward the identification of novel therapeutic targets for TAZ-dependent breast cancer.

The Hippo Signaling Transducer TAZ Regulates Mammary Gland Morphogenesis and Carcinogen-induced Mammary Tumorigenesis

Hippo signaling pathway is an evolutionarily conserved pathway that controls organ size by regulating cell proliferation, apoptosis and stem cell self-renewal. TAZ (transcriptional coactivator with the PDZ-binding motif) is a key downstream effector of the mammalian Hippo pathway. Here, using a transgenic mouse model with mammary-gland-specific expression of constitutively active TAZ, we found that TAZ induction in mammary epithelial cells was associated with an increase in mammary glandular size, which probably resulted from adipocyte hypertrophy. Consistent with its known oncogenic potential, we observed tumor formation in TAZ transgenic mice after administration of the carcinogen 7,12-dimethylbenzanthracene (DMBA) and demonstrated that tumorigenesis was reliant on the presence of TAZ. Our findings establish a previously unknown roles of TAZ in regulating both mammary gland morphogenesis as well as carcinogen-induced mammary tumor formation.

Clinical features and outcomes of uterine and ovarian carcinosarcoma

BACKGROUND

The objective of this study was to compare the clinical presentation and outcomes of women with ovarian and uterine carcinosarcoma (CS).

METHODS

We performed a retrospective review of patients treated for uterine or ovarian CS from 1952 to 2003. Fisher's Exact Test was used to compare patient characteristics. Survival curves were estimated using the Kaplan-Meier method and compared using the log rank test.

RESULTS

We identified 87 patients with uterine CS and 18 with ovarian CS. There was no difference in age, body mass index, parity, menopausal status, family history of cancer, history of pelvic radiation, diabetes or hypertension between the two groups. 43% of women with uterine CS presented at stage I/II, compared to 28% of women with ovarian tumors (P = 0.0003). 82% of patients with ovarian tumors received adjuvant chemotherapy with or without radiation; 51% of the patients in the uterine CS group received adjuvant radiation therapy. The median length of follow-up was 13 months. There was no difference in the Kaplan-Meier estimates of overall survival between the two disease sites. The median survival for uterine CS patients was 16 months, compared to 11 months in the ovarian CS group; HR = 0.991 (95% CI = 0.534, 1.839).

CONCLUSIONS

We found no differences in patient demographics between the two groups. Despite differences in stage and initial treatment, there was no difference in survival between women with uterine and ovarian CS.

Endometrial and endocervical micro echogenic foci: sonographic appearance with clinical and histologic correlation

OBJECTIVE

The purpose of this research was to determine the clinical and histologic importance of small echogenic foci seen in the endometrium/endocervix on pelvic sonography.

METHODS

A retrospective study was performed on 62 women, aged 28 to 81 years, who had echogenic foci of the endometrium and endocervix. Patients' medical records were accessed to review pertinent obstetric and gynecologic information. Additionally, histopathologic slides from patients who underwent diagnostic procedures (endometrial biopsy or dilation and curettage) or hysterectomy were reviewed.

RESULTS

The clinical information for the 62 women included the following: mean age, 49 years; history of exogenous hormonal use, 84%; prior abortion (therapeutic or spontaneous), 57%; prior dilation and curettage, 56%; prior cesarean delivery, 28%; and sexually transmitted disease, 36%. The initial finding of echogenic foci was followed by ultrasound examinations in 18 patients for a mean interval of 16 months. Of the 18 patients, the foci remained unchanged in 13 women and disappeared or became less prominent in the other 5. Histopathologic results were available in 28 women, and microcalcifications were found in 15 of them. The etiology most common was microcalcification but also included crystals, debris from laminaria, and ossified tissues. Clinical follow-up in 62 patients showed that this condition was mostly benign (endometrioid carcinoma developed in 1 patient).

CONCLUSIONS

Histopathologic studies showed microcalcifications, which are the most common cause of echogenic foci. The foci were stable with time and seemed to be an incidental finding associated mostly with benign conditions. The etiologic factors for echogenic foci may be numerous.

Mutational analysis of K-ras segregates ovarian serous carcinomas into two types: invasive MPSC (low-grade tumor) and conventional serous carcinoma (high-grade tumor)

We previously proposed a dualistic model for ovarian serous carcinogenesis. One pathway involves the stepwise development of invasive micropapillary serous carcinoma (MPSC) from serous borderline tumor (atypical proliferative serous tumor) to noninvasive and then invasive MPSC. The carcinomas that develop in this fashion are characterized by low-grade nuclei and frequent K-ras mutations. They generally pursue an indolent course. In the other pathway conventional serous carcinoma (CSC) develops from the ovarian surface epithelium without what appears to be intermediate stages. These tumors display high-grade nuclei, wild-type K-ras, and are very aggressive. Some of these CSCs display micropapillary architecture and simulate invasive MPSCs. This raises the possibility that these CSCs develop from an invasive MPSC. To address this question we reviewed 31 moderately and poorly differentiated CSCs and identified 7 with morphological features of invasive MPSC. These seven tumors exhibited micropapillary architecture in at least 25% of the tumor but contained high-grade nuclei. The 31 tumors were assessed for K-ras mutations using digital polymerase chain reaction-based analysis. Despite their micropapillary architecture, all 7 CSCs with micropapillary features contained wild-type K-ras as did the other 24 pure CSCs. The results indicate that CSCs with micropapillary features are not derived from invasive MPSCs. The molecular findings also support the view that ovarian serous carcinomas should be graded as low- and high-grade tumors.