Feng Zhou

Pilomatrix-like High-grade Endometrial Carcinoma

Pilomatrix-like high-grade endometrial carcinoma (PiMHEC) is a rare and aggressive variant of endometrial carcinoma often misdiagnosed due to overlapping features with other high-grade malignancies. This study characterizes its clinicopathologic, immunophenotypic, and molecular features to establish key diagnostic criteria and propose a standardized terminology. Ten tumors were analyzed using histopathologic examination, immunohistochemistry, and next-generation sequencing. All but 1 tumor exhibited both low-grade endometrioid and high-grade basaloid components, the latter characterized by either geographic or comedo-type necrosis and shadow cells. Although shadow cells are a hallmark feature, they may be focal or absent, necessitating careful evaluation. High-grade areas consistently showed ER and PR negativity with diffuse nuclear β-catenin staining, correlating with CTNNB1 exon 3 mutations in all tumors. Identical CTNNB1 mutations in spatially distinct tumor components suggest a clonal progression from a low-grade precursor. Additional mutations in ARID1A, PTEN, and PIK3CA were identified. Clinically, PiMHEC exhibited aggressive behavior, with 7 patients experiencing recurrence and 1 succumbing to the disease within 9 months. Metastatic sites included the lungs, liver, lymph nodes, and abdominal wall. PD-L1 expression in 4 tumors suggests potential responsiveness to immune checkpoint inhibitors, whereas low-level HER2 expression (1+ to 2+) in 5 tumors raises the possibility of HER2-targeted therapies. Folate receptor alpha was not expressed in any tumor. In conclusion, PiMHEC is a distinct and highly aggressive endometrial carcinoma with unique histopathologic and molecular features that differentiate it from high-grade endometrioid and other high-grade endometrial cancers including squamous cell carcinoma in rare situations. Its key diagnostic features include high-grade basaloid tumor cells associated with shadow cells, tumor necrosis, and diffuse nuclear β-catenin staining. To improve diagnostic accuracy and reduce ambiguity, we propose adopting “pilomatrix-like high-grade endometrial carcinoma” as a standardized term.

High-grade endometrioid carcinomas with pilomatrix-like features lacking CTNNB1 Mutations: Clinicopathologic characteristics and novel molecular events

Pilomatrix-like high-grade endometrioid carcinoma (PiMHEC) represents a recently described, aggressive variant of endometrial carcinoma. Prior reports have linked PiMHEC with CTNNB1 exon 3 mutations and abnormal nuclear β-catenin expression. We aimed to expand the understanding a potential subclassification of PiMHEC by analyzing three new cases that lack CTNNB1 mutations and β-catenin nuclear accumulation. Three cases of high-grade endometrioid carcinomas with pilomatrix-like features were identified and their clinical presentations and pathologic features reviewed. Immunohistochemistry (IHC) and targeted next-generation sequencing (NGS) were performed. All tumors demonstrated two components: a high-grade basaloid component with solid sheets of atypical basaloid cells, geographic necrosis, and focal "ghost" cells, and an associated low-grade FIGO grade 1 endometrioid carcinoma component. Notably, none of the three cases showed nuclear β-catenin expression by IHC, and all lacked CTNNB1 exon 3 mutations. Despite this, the tumors fulfilled the morphologic criteria for PiMHEC described in prior studies and displayed aggressive clinical behavior. All the patients presented with advanced-stage disease (stages IIC-IVB), and two patients had a recurrence within 12 months. NGS revealed no CTNNB1 mutations in any case, but identified alternative likely oncogenic alterations: one tumor harbored an FGFR4 p. T259A mutation, two tumors had pathogenic TSC2 mutations, one had a KRAS p.G12D mutation, and two showed MYC amplification, among other genetic changes. High-grade endometrioid carcinomas with pilomatrix-like features lacking CTNNB1 mutations may represent a potential subclassification of PiMHEC, which exhibit aggressive behavior. CTNNB1-wildtype cases appear to rely on alternative oncogenic drivers, indicating that CTNNB1 mutation maybe not an absolute requirement for the PiMHEC phenotype.

Discordance of PD-L1 expression in primary and metastatic ovarian high-grade serous carcinoma and its correlation with CD8 + tumor-infiltrating lymphocytes and patient prognosis

Differential expression of programmed death-1 ligand (PD-L1) and its clinical significance in primary and metastatic ovarian high-grade serous carcinoma (HGSC) have not been defined. Thus, we investigated the PD-L1 expression of paired ovarian primary and omental metastatic HGSC and its correlation with CD8 + tumor-infiltrating lymphocyte (TILs) and patient survival. A total of 212 cases of ovarian HGSCs with matched primary ovarian and metastatic omental tumors accessioned between 2003 and 2018 were selected for further analysis. Using immunohistochemistry, we evaluated the density of CD8 + TILs and expression of PD-L1 on whole tissue sections. Applying tumor proportion score (TPS, cutoff 1%) and combined positive score (CPS, cutoff 1), the prevalence of PD-L1 expression was similar but with significant discordance in ovarian and omental tumor. Using TPS, patients with PD-L1-positive tumors demonstrated significantly worse recurrence free survival (RFS) and overall survival (OS) than patients with PD-L1-negative tumors. Using CPS, patients with PD-L1-positive ovarian tumors demonstrated significantly worse OS while no significant difference in RFS was found. Patients with PD-L1-positive omental tumors demonstrated significantly worse RFS and OS. Patients with omental PD-L1-positive tumors (TPS) were associated with poorer RFS and OS, while patients with ovarian PD-L1-positive tumors (TPS) were associated with OS not RFS, in COX multivariant analysis. Nonetheless, ovarian and omental high CD8 TILs density was not associated with worse OS in univariant and COX multivariant analysis. PD-L1 expression in ovarian and omental tumor associated with an increased CD8 + TILs density. PD-L1 expression by TPS was better correlated with survival than by CPS, and PD-L1 expression in omental tumors was a stronger prognostic indicator than that in ovarian tumors.

Endocervical Adenocarcinoma With Micropapillary Component, a Distinct Histological Subtype Associated With Aggressive Behavior and Poor Prognosis: A Clinicopathologic Study of 10 Patients

Objective. Endocervical adenocarcinoma (ECA) with a micropapillary component is considered to be associated with aggressive behavior and poor prognosis. So far, only limited studies investigated this histological subtype of ECA in the literature. In this study, we present a clinicopathological analysis of 10 such tumors. Methods. We retrieved ten ECAs with a micropapillary component between January 2014 and July 2023 and analyzed their clinicopathologic features. Results. At diagnosis, nine tumors (90%) were of advanced clinical stage (FIGO stage ≥ IIA), nine tumors (90%) exhibited deep stromal invasion (≥2/3 of the cervix), and three tumors (30%) showed parametrial involvement. Lymphovascular invasion was evident in all tumors (100%), and lymph node metastasis was found in eight tumors (80%). Among the 10 patients, six were alive without disease (60%), one had a recurrent/later metastatic tumor (10%), and three died from the disease (30%). Furthermore, eight tumors were positive for PD-L1 expression (80%), while only one tumor showed HER2 overexpression (10%), and one tumor exhibited p53 mutant-type staining (10%). Conclusion. Endocervical adenocarcinomas with micropapillary components are associated with aggressive clinical behavior and a poor prognosis, which can be found in various conventional histological types of ECAs regardless of the HPV status. The high prevalence of PD-L1 expression suggests that patients with micropapillary ECAs may be good candidates for PD-L1 inhibitor treatment.

Gastric Type Endocervical Adenocarcinoma With Concurrent High-Grade Squamous Intraepithelial Lesion: A Clinicopathologic Study of Three Patients

Objective: We investigate gastric-type endocervical adenocarcinoma (ECA), a prominent HPV-independent adenocarcinoma, and its coexistence with high-grade squamous intraepithelial lesion (HSIL) through the examination of three such tumors. Methods: In this study, we conducted an in-depth review of three patients with gastric-type ECA, each associated with high-risk HPV infection as detected on Pap smears. We detailed the clinical and pathological features of each patient and utilized RNAscope for high-risk HPV testing to ascertain HPV status in both gastric-type ECA and HSIL components. Immunohistochemistry with p16, p53, and other biomarkers was also applied. Results: The gastric-type ECA component, characterized by well-differentiated glands with abundant, clear to eosinophilic cytoplasm, distinct cellular borders, and pale nuclei with conspicuous nucleoli, tested negative for both p16 and high-risk HPV, unlike the concurrent HSIL components which were positive. Additionally, two tumors showed aberrant p53 protein expression in the gastric-type ECA areas, and elevated carbohydrate antigen19-9 levels were noted in two patients. Treatment consisted of total abdominal hysterectomy and bilateral salpingo-oophorectomy, supplemented by chemotherapy and/or radiation, with disease-free intervals of 24, 12, and 40 months post-treatment, respectively. Conclusion: This study highlights the critical need for meticulous diagnostic protocols that combine morphological examination, immunohistochemistry, and HPV RNA in situ hybridization. The rarity of gastric-type ECA coexisting with HPV infection underscores the necessity for continuous research and vigilant monitoring in the field of gynecological oncology.

Letter to “Correlation of immediate prevalence of cervical squamous cell precancers and cancers with HPV genotype and age in women with LSIL cytology”

Primary ovarian serous carcinomas with extensive squamous differentiation: a case report and literature review

Abstract Background Primary ovarian serous carcinomas (OSC) with extensive squamous differentiation is a rare, and histological diagnostic criteria and biological behavior have not been fully established. We present an extremely rare case of primary OSC of the ovary with squamous differentiation. Case presentation A 58-year-old (gravidity 3, parity 2) female was admitted complaining of abdominal distention for 6 months. No apparent tumor in the cervix was found by a physical examination. Serum levels of cancer antigen 125 (CA125) was elevated (2723.0 IU/L). Macroscopically, a 7 cm tumor of the left uterine adnexa, a 5 cm tumor of the right adnexa, and a 3 cm tumor of the omentum were found. Histological and immunochemical tests confirmed a diagnosis of OSC with squamous differentiation. Debulking surgery with tumor resection was performed. The patient was subsequently received postoperative chemotherapy. Conclusions In summary, OSC with extensive squamous differentiation is a rare, and the inter- and intratumor heterogeneity may be the reason for this phenomenon. Histological diagnostic criteria and biological behavior have not been fully established because of the limited data.

Programmed death‐ligand 1 expression in human papillomavirus‐independent cervical adenocarcinoma and its prognostic significance

AimsIn the 2020 World Health Organization classification of female genital tumours, endocervical adenocarcinomas (ECAs) are subclassified into human papillomavirus (HPV)‐associated (HPVA) and HPV‐independent (HPVI) groups on the basis of their distinct aetiologies and clinical behaviours. The aim of this study was to investigate programmed death‐ligand 1 (PD‐L1) expression and its prognostic value in HPVI ECA and HPVA ECA, and compare these between the two entities.Methods and resultsA total of 93 ECAs accessioned between 2013 and 2020 were selected for further analysis, including 48 usual‐type HPVA ECAs and 45 HPVI ECAs. Then, we evaluated PD‐L1 expression in whole tissue sections of these cases by using the tumour proportion score (TPS) and the combined positive score (CPS). Heterogeneous PD‐L1 expression was observed in both HPVI ECAs and usual‐type HPVA ECAs. However, no significant difference in PD‐L1 expression was seen among different histological types of ECA when either the CPS or the TPS was used. Gastric‐type ECA (GEA) was associated with higher clinical stage (P = 0.001), worse progression‐free survival (PFS) (P = 0.008) and worse overall survival (OS) (P = 0.02) than usual‐type HPVA ECA and non‐GEA HPVI ECA. When the TPS was used, PD‐L1‐positive GEA was associated with significantly worse PFS (P = 0.03) and OS (P = 0.015) than PD‐L1‐negative GEA.ConclusionsOur data show frequent PD‐L1 expression in HPVI ECAs, supporting the potential role of the programmed cell death protein 1/PD‐L1 pathway as a therapeutic target for these tumours. Our data also support PD‐L1 as a negative prognostic marker associated with a potentially unfavourable outcome for GEAs.

Correlation of immediate prevalence of cervical precancers and cancers with HPV genotype and age in women with atypical glandular cells cytology: A retrospective analysis of 369 cases

AbstractBackgroundThis study aims to assess the immediate risk of cervical precancers and cancers in women with atypical glandular cells (AGC) cytology, based on high‐risk human papillomavirus (hrHPV) genotypes and age.MethodsA retrospective analysis was conducted on 369 cases of AGC with immediate follow‐up biopsy results, including 299 AGC‐not otherwise specified (NOS) and 70 AGC‐favor neoplastic (FN).ResultsAmong the 369 AGC cases, 127 tested positive for hrHPV (34.4%). The predominant high‐risk type was other 11 genotypes (44.1%), followed by 16+ (29.1%), 18/45+ (26.0%), and 16 and 18/45 double‐positive (0.79%). Precancers and cancers were detected in 30.4% (112 of 369) and 9.8% (36 of 369) of cases, respectively. The HPV‐18/45+ group had notably higher adenocarcinoma in situ and adenocarcinoma (AIS+) prevalence compared to other 11 genotype groups (p < .0001 and p = .001, respectively). The HPV‐16+ group showed significantly higher high‐grade cervical squamous epithelial lesion and squamous cell carcinoma prevalence than other 11 genotype groups (p < .0001 and p = .017, respectively). Using 40‐year cutoff, older women had significantly higher prevalence of abnormal glandular lesion+ lesions (17.6% vs. 7.6%, p = .005) and adenocarcinoma (AC) (12.4% vs. 2.5%, p = .001). Using 50‐year cutoff, older women had higher prevalence of squamous cell carcinoma (SCC) (3.3% vs. 0.4%, p = .042) and AC (15.2% vs. 5.8%, p = .005). Subgroup analysis revealed that AGC‐FN women showed more severe cervical pathology than AGC‐NOS women (p < .001).ConclusionsAGC women have a significantly increased risk of cervical precancerous lesions and cancer. HPV genotyping and patient age factors need to be taken into consideration in the clinical management process of AGC patients.

Expression of B7‐H3 and TIM‐3 in gastric‐type endocervical adenocarcinoma: prevalence, association with PD‐L1 expression, and prognostic significance

AbstractGastric‐type endocervical adenocarcinoma (GEA) is the second most common subtype of endocervical adenocarcinoma and has a poor prognosis. Anti‐programmed death‐1 and anti‐programmed death‐ligand 1 (PD‐L1) inhibitors have emerged as a major treatment option for GEA; however, data on the expression of other immune checkpoints in GEA are limited. We analyzed the expression of T‐cell immunoglobulin and mucin‐domain containing‐3 (TIM‐3) and B7 homolog 3 protein (B7‐H3) in 58 GEA and investigated their prognostic significance as well as association with PD‐L1 expression and other known prognostic factors. Applying the tumor proportion score (TPS) with a cutoff of 1%, B7‐H3 and TIM‐3 were present in 48.3% and 17.2% of cases, respectively. Applying the combined positive score (CPS) with a cutoff of 1, TIM‐3 expression was present in 70.7% of cases. Moreover, the expression of three checkpoints (B7‐H3, TIM‐3, and PD‐L1) was incompletely overlapping. Patients with B7‐H3 positive tumors (by TPS) or TIM‐3 positive tumors (by TPS) had significantly worse recurrence‐free survival (RFS) and overall survival (OS) (log‐rank). Using CPS, patients with TIM‐3 positive tumors showed significantly worse RFS (log‐rank). Similarly, B7‐H3 positivity (by TPS) and TIM‐3 positivity (by TPS) were associated with worse RFS and OS in univariate analysis. TIM‐3 positivity (by CPS) was associated with worse RFS in univariate analysis and the final Cox multivariate analysis. In conclusion, our results show that (1) B7‐H3 and TIM‐3 are frequently expressed in GEA and their expression overlaps incompletely with PD‐L1; and (2) both B7‐H3 and TIM‐3 are independent negative prognostic markers in GEA.

Correlation of immediate prevalence of cervical squamous cell precancers and cancers with HPV genotype and age in women with LSIL cytology: A retrospective analysis of 1617 cases

AbstractAimsTo evaluate the immediate risk of cervical squamous cell precancers and cancers in women with low‐grade squamous intraepithelial lesion (LSIL) cytology according to different high‐risk human papillomavirus (hrHPV) results and age stratification.MethodsThe study included 1617 women with LSIL cytology and underwent simultaneous Aptima HPV genotyping (E6/E7 mRNA test) followed by cervical biopsy.ResultsAmong 1317 hrHPV positive cases, other 11 types of hrHPV were the most frequent (68.8%), followed by HPV16 (11.1%), HPV18/45 (4.1%), and HPV16/HPV18/45 (0.5%). Compared to other groups, HPV18/45 positive group and other 11 types of hrHPV group showed significantly higher prevalence of intraepithelial neoplasia grade (CIN)1 (p < .0001), while HPV16 positive and HPV16/HPV18/45 dual positive groups showed significantly higher prevalence of CIN2/3 (p < .0001). In addition, hrHPV positive, 25–39 years‐old age group showed a significantly higher prevalence of CIN1 (p = .032) than the other age groups. Furthermore, CIN1 prevalence was significantly higher in patients under 40 or 50 years of age than in those over 40 or 50 years of age (p = .005 and p = .011, respectively). However, there was no significant difference among the different age groups in CIN2/3 prevalence in women with LSIL cytology.ConclusionIn southern Chinese women population, LSIL cytology carries very low immediate risk of high‐grade squamous intraepithelial lesions (HSIL) (CIN2/3) in general. However, HPV16 positive and HPV16/HPV18/45 dual positive indicated a higher immediate risk of high‐grade squamous intraepithelial lesions (HSIL) (CIN2/3). Age is not an immediate risk factor in this patient population for high‐grade squamous lesions or SCC. These results are similar to data from cytology laboratories in the United States and other international settings, therefore strongly support the usage of ASCCP guidelines in this patient population.

Correlation of immediate prevalence of cervical precancers and cancers with HPV genotype and age in women with ASC-US/hrHPV+: a retrospective analysis of 2292 cases

Aims To stratify the risk of cervical precancers (high-grade squamous intraepithelial lesion (HSIL) and adenocarcinoma in situ (AIS)) and cancers (squamous cell carcinoma (SCC) and adenocarcinoma) based on distinct high-risk human papillomavirus (hrHPV) genotypes as well as age groups among women with atypical squamous cells of undetermined significance (ASC-US) and hrHPV+results. Methods In total, 2292 cases of ASC-US/hrHPV+ with immediate follow-up biopsy results were included in the study for prevalence analysis. Results Overall, 12.2% women with ASC-US /hrHPV+ had HSIL+ while 0.22% had AIS+ lesions. The HPV-16+ group (31.6%) showed significantly higher prevalence of HSIL+ squamous lesions than other genotype groups (p<0.0001). The prevalence of SCC is significantly higher in HPV-16+ (1.8%) or HPV-18/45+ (1.1%) group than women in other genotype groups (0.1%) (p<0.0001). The HPV-18/45+ group (1.7%) showed significantly higher prevalence of AIS+ glandular lesions than other genotype groups (p=0.003). In addition, SCC prevalence was significantly higher in age over 50 group than that in age under 50 group (1.2% vs 0.2%, p=0.012). Conclusion Women with ASC-US/hrHPV+ are at significant risk of cervical precancers and cancers; notably, HPV-16+ group has a higher risk of HSIL squamous lesions and SCC while HPV-18/45+ group has a higher risk of AIS+ glandular lesions. In addition, the older patient group (>50 years) has a significantly higher risk of SCC. Therefore, HPV genotyping as well as patient age need to be considered in the clinical management of patient.

Effect of Compound Kushen Injection Combined With Pabolizumab in the Treatment of Cervical Adenocarcinoma

In the past few decades, the incidence of endocervical adenocarcinomas (ECAs) has been on the rise both in absolute numbers and overall proportion in cervical cancers. ECAs remain a significant public health problem despite advances in treatment options. Patients with ECA have a poorer survival rate than patients with squamous cell carcinoma (SCC), especially in patients with metastatic tumors. In the newly published 2020 World Health Organization (WHO) Classification of Female Genital Tumors, ECAs are subclassified into human papillomavirus-associated (HPVA) and human papillomavirus-independent (HPVI) groups. Meanwhile, PD-1/PD-L1 immunotherapy has been approved for the treatment of advanced cervical cancer, but there are still many deficiencies. Therefore, the investigators plan to use the new classification of female genital tumors and conduct a clinical trial to explore the safety and effectiveness of compound kushen injection combined with pabolizumab in the treatment of metastatic, recurrent, persistent cervical adenocarcinoma.