Annals of Diagnostic Pathology

Immunohistochemical staining of podoplanin is helpful in determining the microinvasion of cervical squamous cell carcinoma

Cervical squamous cell carcinoma develops through a series of stages, including low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), microinvasive squamous cell carcinoma (MISCC), and invasive squamous cell carcinoma (ISCC). The difference between HSIL and MISCC is the appearance of microinvasion, which determines the treatment for patients. However, sometimes it is difficult to differentiate HSIL from MISCC in morphology, and no effective markers are available to help determine microinvasion. Here, we evaluated the expression patterns of podoplanin in cervical tissues by immunohistochemistry staining. Results showed that podoplanin was specifically expressed in a continuous or discontinuous linear pattern within the basal layer of cells from normal cervical squamous epithelium (NS) (100%, 96/96) and HSIL (81%, 57/70). However, its expression was completely absent in microinvasive lesions (0%, 72/72), and the location of podoplanin expression loss was consistent with that of microinvasive lesions. Thus, for HSIL with positive podoplanin expression, the sudden loss of podoplanin represents the occurrence of early invasion. Furthermore, podoplanin was expressed in 3.4% (4/118) of ISCC, and its expression was not correlated with the age of the patient, tumor size, differentiation, FIGO stage, depth of invasion, lymph node, or distant metastasis. The prognosis of patients with positive podoplanin was slightly better than those without it (p > 0.05). Therefore, we found that podoplanin, as a new specific marker for the basal layer cells of cervical squamous epithelium, could assist the diagnosis of microinvasion in cervical squamous cell carcinoma. The specific staining pattern of podoplanin provides the possibility of clinical application in the future.

Comparison of liquid-based cytology and cell blocks prepared from cell remnants for diagnosis of cervical pathology

Cervical cancer is a global public health problem with high mortality. Advances in screening programs for cervical cancer are considered key to eliminate cervical cancer. We aimed to examine the contribution of cell block analysis to the detection of epithelial cell abnormalities in cervical smear samples. A total of 559 patients with suspected cervical pathology were examined, and their samples were analyzed by both liquid-based cytology (LBC) and cell blocks. The biopsy results of 149 out of the 559 patients were obtained. Of the 50 patients who were identified as HSIL by biopsy, only 12 were diagnosed as HSIL by the LBC method, 22 as LSIL, 12 as ASCUS, and 4 as ASC-H (p < 0.001). With the cell block analysis, results for these patients were: 20 HSIL, 17 LSIL, 7 NILM, 4 'unsatisfactory', and 2 ASC cases (p < 0.001). LBC detected only 1 of the 10 patients with biopsy-diagnosed tumors, while 7 of these were defined as HSIL, 1 as ASCUS and 1 as AGC. The results of cell block analysis in patients with biopsy-diagnosed tumors were as follows: 7 HSIL, 1 tumor, 1 ASC and 1 LSIL. Cell block analysis might be superior to LBC in terms of diagnostic accuracy in cervical pathologies, particularly in the detection of HSIL. However, both methods were similarly poor in diagnosing tumors. Cell blocks may improve diagnostic accuracy and can be a complementary method to LBC, while having the advantage of revealing histological architecture.

Correlation of folate receptor alpha expression with clinicopathological parameters and outcome in triple negative breast cancer

Folate receptor alpha (FRα) is a membrane-bound protein with a high affinity for folate, which is necessary for the biosynthesis of amino acids and nucleotide bases. It has been shown to be a potential prognostic and therapeutic target, primarily in lung and ovarian cancer, as well as in breast cancer. The aim of this study was to examine FRα expression in a cohort of patients with triple negative breast cancer (TNBC), in correlation with clinicopathological parameters and prognostic factors. By using polyclonal FRα antibody on archival paraffin blocks immunohistochemistry was performed. To evaluate the expression of FRα, H-score was used, which marks both the proportion of stained cells and the intensity of staining. Statistical analysis correlating FRα expression with clinicopathologic parameters and clinical outcome were performed. FRα was expressed in most of the patients (85%). Significant correlation of expression and histologic grade (Mann Whitney U test, P = 0,03) and type of tumor (P = 0,02), was found. It was noticed that with higher Ki-67 proliferation index values, H-score has lower values (r = -0,284, P = 0,006). Multivariant regression analysis (Cox regression, Stepwise method) showed H-score as a significant predictor for the risk of disease recurrence (OR = 1,005, P = 0,04). No correlation between FRα expression and overall survival (OS) and disease-free survival (DFS) was found. In conclusion, FRα is highly expressed in TNBC, and, given the correlation with clinicopathological parameters, subpopulation of patients could be identified that could be potential targets for new therapeutic perspectives in the treatment of this breast cancer subtype.

Diagnostic and prognostic inferences of Tricho-rhino-phalangeal Syndrome 1 (TRPS1) protein immunohistochemical expression in primary epithelial ovarian cancers

Vitamin D receptor and cellular retinol-binding protein-1 immunohistochemical expression in normal, hyperplastic and neoplastic endometrium: Possible diagnostic and therapeutic implications

We conducted this study to assess the effect of VDR and CRBP-1 immunohistochemical expression on the endometrium and to explore their role in endometrial cancer carcinogenesis. This study comprised two hundred paraffin-embedded endometrial tissue samples diagnosed as 42 and 63 proliferative and secretory endometrium respectively, 45 endometrial hyperplasias with atypia and 50 endometrial carcinomas (25 low-grade and 25 high-grade endometrial carcinomas). The immunohistochemical method was done to determine the expression of VDR and CRBP-1. VDR was strongly expressed in 8 (17.8%) cases with endometrial hyperplasia, 15 (60%) cases with low-grade endometrial carcinoma, and 22 (88%) cases with high-grade endometrial carcinoma. While CRPB1 overexpression was noted in cases with proliferative endometrium, secretory endometrium and endometrial hyperplasia with atypia, 37 (88.1%), 56 (88.9%) and 3 (6.7%) cases respectively and all malignant cases showed negative expression. Increased VDR expression and reduced CRBP-1 expression are associated with malignant features of the endometrium with a significant statistical difference of immunoreactivity between groups of normal endometrium, hyperplastic changes & carcinoma. Our data suggested that increased VDR expression is partly associated with endometrial cancers through a premalignant phase. Also, increased VDR and reduced CRBP-1 expression are associated with the progression of endometrial carcinoma with higher grades.

Clinicopathological features of 50 mismatch repair (MMR)-deficient endometrial carcinomas, tested by immunohistochemistry: A single institutional feasibility study, India

There are few comprehensive studies from Asia on clinicopathologic features of mismatch repair (MMR)-deficient endometrial carcinomas, including rarely from our country. One hundred and four cases of endometrial carcinomas were tested for four MMR proteins by immunohistochemistry. Among 50 MMR-deficient (MMRd) tumors(48%), age-range was 27-68 years(median = 53) and tumor size(n = 34) varied from 1.2-10 cm(average = 4.6). Lower uterine segment(LUS) was involved in 21/31 cases(67.7%). Histopathologically, all cases were endometrioid adenocarcinomas(EMACs), of FIGO grade 2(low-grade)(18 cases) and 3(high-grade)(32 cases), displaying de-differentiated, undifferentiated and lymphoepithelioma(LE)-like patterns, in 24 cases(48%). Tumor infiltration ≥ half of myometrium was seen in 30/44 cases (68.1%); lymphovascular emboli in 19/43 cases(44.1%); and lymph node metastasis in 7/22(31.8%) cases. Uncommonly, clear cell component(n = 2) and focal neuroendocrine differentiation (n = 2) were observed. Immunohistochemically, tumor cells showed paired loss of MLH1 and PMS2 in 33(66%) and MSH2 and MSH6 in 14(28%) cases, along with loss of MSH2 and PMS2, in two and a single case, respectively. Nine patients(18%) were treated for another cancer and 9/33(27.2%) disclosed familial history of cancer. MSH2 was the most frequently lost MMR protein in those cases. Additionally, tumor cells displayed ER positivity in 41/50 cases(82%), PR in 38/41cases(92.6%) and wild-type p53 staining in 24/28 cases(85.7%). Tumor with LE-pattern showed PDLI immunoexpression. Certain clinicopathologic features suggestive for MMRd associated ECs, such as relatively large-sized tumors, involving LUS; especially high-grade, infiltrative EMACs, with undifferentiated/de-differentiated, and LE-like patterns; showing deep muscle invasion, frequent PR immunoexpression and invariably, wild-type p53 immunostaining can be useful in screening cases of Lynch syndrome. This constitutes the first report on these tumors from our country.

Presence of tumor cells in the vagina during surgical treatment could be the source of vaginal recurrence in patients with endometrial carcinoma — A pilot prospective study

The commonest site of recurrence in endometrial cancer (EC) is the vagina, with a rate of 16%. The aim of this study was to determine if vaginal recurrences in EC patients could develop due to contamination of the vagina with glandular tumor cells dropping off on polypoid, large size EC or tumors involving the endocervix, through manipulation of the uterus during surgery. This pilot prospective study included 10 consecutive patients with EC, surgically treated with hysterectomy and additional lymphadenectomy according to stage. In every case, 2 proximal vaginal smears were collected before and during the hysterectomy procedure. All smears underwent Papanicolaou staining and the presence of atypical glandular cells in the smears was correlated with clinico-pathological parameters. Residual tumor was identified on the surgical specimen in the 10 cases; the tumor characteristics were large size (median 6 cm), polypoid type (80%), infiltrating the cervix (70%), and infiltrating more than half of the myometrium (60%). The smears obtained from the vagina showed that five cases (50%) presented tumor cells of glandular type in all smears (before and during the surgery), while in 3 cases (30%) the smears were negative for tumor cells preoperatively, but positive in the perioperative smears. Our results suggest that the vagina is most often contaminated preoperatively due to bleeding; however, the vaginal wound may also be contaminated perioperatively. We propose a change in the surgical procedure, which is easy to perform and inexpensive compared to postsurgical vaginal radiotherapy.

Diagnostic value of dystrophin immunostaining for histopathologic diagnosis of uterine smooth muscle tumors

Uterine smooth muscle tumors are a heterogeneous group of mesenchymal neoplasms with diagnostic challenges and overlapping histopathologic features. Recently, the molecular or immunohistochemical evaluation of dystrophin in the diagnosis of mesenchymal tumors with muscle differentiation has gained attention. In this retrospective study, the immunohistochemical expression of dystrophin was examined in 105 cases of uterine smooth muscle neoplasms, including 71 cases of leiomyoma (LM) and its variants, 6 cases of smooth muscle tumor of uncertain malignant potential (STUMP), and 28 cases of leiomyosarcoma (LMS). After thorough analysis, dystrophin expression was positive in 83.3 % of STUMP cases and 96.7 % of leiomyoma cases. In contrast, only 8 cases of LMS (28.6 %) expressed dystrophin. A significant difference in dystrophin expression was noted between STUMP and LMS, as well as LMS and LM and its variants. The median H-score in LM was significantly higher than in leiomyoma variants, STUMP, and LMS. In conclusion, dystrophin expression may be useful in distinguishing uterine LM, LM variants, and STUMP from LMS.

Do urinary bladder smooth muscle neoplasms show morphologic and immunophenotypic features of their uterine fumarate hydratase-deficient counterparts?

While the morphologic and immunophenotypic features of smooth muscle neoplasms of the uterus and skin have been well-described in relationship to fumarate hydratase (FH) deficiency (FHD), a potential association of urinary bladder smooth muscle tumors with FH tumor predisposition syndrome (FHTPS) has not been previously investigated. Given an index urinary bladder leiomyoma which showed some of the purported morphologic features seen in uterine FHD leiomyomas, we performed a multi-institutional search for bladder smooth muscle tumors to further evaluate a putative FHTPS association. Cases were re-reviewed for the presence of the following well-described FHD-associated cytomorphologic features: macronucleoli ("cherry red") surrounded by halo, isolated nuclear pleomorphism ("symplastic" nuclei), cytoplasmic eosinophilic globules, staghorn vasculature, alveolar-pattern edema, and chain-like distribution of smooth muscle fibers. Tumors with available material underwent whole-slide staining for FH and 2SC immunohistochemistry. A total of 40 bladder smooth muscle tumors (35 leiomyomas, 5 leiomyosarcomas) were collected from patients (33 females, 17 males) of ages 30-86 years (mean=56.3 years). Among leiomyomas, cytoplasmic eosinophilic globules were seen most frequently (31%), followed by CMV-like macronucleoli (17%), staghorn-type vasculature (11%), "symplastic" nuclei (9%), and alveolar-pattern edema (6%). Among the leiomyosarcomas, cytoplasmic eosinophilic globules or CMV-like macronucleoli were infrequently seen (20%), while staghorn-type vasculature was seen in 60% and "symplastic" nuclei were seen in all (100%) tumors. No cases exhibited chain-like muscle fibers. Of the stained tumors, all (100%) showed retained FH expression and negative 2SC immunoreactivity. Three female patients with bladder leiomyomas had a prior history of uterine leiomyomas all lacking FHD histology. Although a subset of bladder smooth muscle tumors show overlapping morphologic features with uterine FHD leiomyomas, they do not appear to harbor FHD or an association with FHTPS, although the findings warrant confirmation in future studies, perhaps inclusion of FH and/or 2SC immunohistochemistry.

Sarcomatoid squamous cell carcinoma of the cervix: A case series and literature review

Primary cervical sarcomatoid squamous cell carcinoma (SSCC), a rare biphasic malignancy with 29 documented cases, is characterized by co-existing malignant squamous epithelium and sarcomatoid spindle cells. Immunohistochemical co-expression of epithelial (PCK) and mesenchymal (vimentin) markers remains diagnostic. We analyzed 8 institutional cases (2006-2024) alongside literature reports. Patients (median age 46, range 28-72) predominantly presented with vaginal bleeding (7/8 cases), while one exhibited abdominal pain with discharge. HPV16 was detected in 2 cases. All tumors showed variable immunoreactivity for PCK, vimentin, p16, and ≥ 1 squamous marker (p63/p40/CK5/6). Treatment included chemotherapy (6/8) and radiotherapy (3/8). Follow-up (median 57.4 months, n = 7) revealed aggressive behavior: two stage IIIC patients developed supraclavicular/visceral metastases (alive with disease at 10-31 months), one stage IIIA patient died at 24 months, while others remained disease-free. Combined analysis with 29 published cases confirms SSCC's dual histologic presentation (biphasic/monophasic) and consistent epithelial-mesenchymal marker co-expression. These findings underscore SSCC's clinicopathologic heterogeneity and metastatic potential despite multimodal therapy.

Revisiting the necessity for routine appendectomies in mucinous neoplasms of the ovary: An evaluation of 460 mucinous ovarian tumors

Appendectomies are not uncommonly performed following an intraoperative diagnosis of a mucinous ovarian neoplasm, although the evidentiary basis for the practice is relatively limited. The current study is a contemporary re-examination of the issue, based on an analysis of a large single institutional cohort. We assessed whether there are any composite of factors that may be associated with the finding of significant disease in the appendix in this setting following intraoperative consultation (IOC) diagnosis of a mucinous neoplasm on an ovary-based mass. Records for 460 consecutive patients whose ovarian tumors were classified as "mucinous" on IOC (n = 246) and/or permanents (n = 214) were reviewed. The distribution of IOC diagnoses on the 246 tumors were as follows: cystadenoma (114), borderline (55), carcinoma (21), mucinous neoplasm or tumor without definitive classification (53), and probable metastases (3). Appendectomies were performed on 82 (33%) of the 246 cases. In 30 (36%) of these 82 cases, the appendix was grossly normal, the ovarian tumor was unilateral, and there was no intraabdominal/peritoneal disease. Microscopic examination of the appendices in these 30 cases showed no mucinous neoplasms therein, but one case had a grossly inapparent, 4 mm well-differentiated carcinoid. In contrast, among the remaining 52 cases (i.e. those with at least one of the "key abnormal features": intra-abddominal/peritoneal disease and/or appendiceal gross abnormality and/or ovarian tumor bilaterality), 12 neoplasms (23%) were microscopically identified in the appendix (4 adenocarcinomas; 7 LAMN; 1 carcinoid) [p = 0.0256]. Of these 12, a grossly abnormal appendix, intraabdominal/peritoneal disease, and ovarian tumor bilaterality was the sole key abnormal feature in 10, 8 and 4 cases respectively, meaning that requiring that any one feature be present to justify the appendectomy would have missed 17%, 33% and 67% of cases respectively. Only 33% (3/12) cases had all 3 features. Our findings support the emerging body of work that indicates that appendectomies should not be routinely performed during the primary surgery for suspected or confirmed mucinous tumors that involve the ovary, unless there is a specific indication. In our cohort, all identified mucinous appendiceal neoplasms were associated with at least one key abnormal feature (gross abnormalities of the appendix, intraabdominal/peritoneal disease, ovarian tumor bilaterality), which suggests that only in patients that meet these criteria would appendectomies most likely be beneficial.

Role of SIX1, EYA2, and E-cadherin in ovarian carcinoma. Evidence on epithelial-mesenchymal transition from an immunohistochemical study

This study aims to investigate the expression of SIX1, EYA2, and E-cadherin in ovarian cancer (OC). It was conducted on 97 cases of surface epithelial tumors (SEOTs). Immunohistochemistry (IHC) staining for the three markers was applied to archival paraffin-embedded sections. Results of semi-quantitative scoring were statistically compared, correlated with clinic-pathologic parameters, response to therapy and with patient survival. RESULTS: There was a significant association of SIX1 expression in the intratumoral stroma (ITS) with malignant cases (P < 0.0001). There was a significant direct correlation between tumour cell expression of SIX1 and EYA2 (P = 0.03) and an inverse correlation between SIX1 and E-cadherin (P = 0.03). Additionally, there were direct correlations between SIX1 expression and larger tumour size (P = 0.05), high mitosis (P < 0.0001), and advanced FIGO stage (P = 0.06), and between EYA2 expression and LN metastasis (P = 0.02), and low apoptotic index (P = 0.007). Only SIX1 expression in ITS affected the patient survival by univariate analysis (P = 0.004). CONCLUSIONS: SIX1/EYA2 complex may have a poor prognostic role in OC. SIX1 expression in ITS may be used as a predictive marker of stromal invasion in ovarian borderline tumors and could affect patients' survival in OC. SIX1, EYA2, and E-cadherin may constitute a pathway that could be targeted to stop the progression of SEOTs.

Non-random adenomatoid tumours of the female genital system: A comparative clinicopathologic analysis of 14 cases

The aim of this study was to evaluate adenomatoid tumours (AT) clinicopathologically in the female genital tract and compare the histomorphological features of ATs according to their uterine or tuba-ovarian location. Cases of AT were excised and collected from female genital tracts between the years of 2010-2017. Cases were evaluated depending on their clinical findings, localisation and pathological properties. There were 14 cases of AT. Ten cases were uterine, and 4 cases were adnexal tumours. The diagnostic ratio of uterine ATs was 64.3%, and of tuba-ovarian ATs was 21.4% (P > 0.05). The size of the largest tumour was 6 cm. Two of the uterine and one of the ovarian cases had a macrocyst; 2 uterine and one ovarian case had a microcyst; and 6 uterine had a combined microcystic/trabecular pattern. Uterine cases showed a higher number of smooth muscle component, signet-ring cells and infiltrative nature compared with other cases (P < 0.05). All uterine cases were infiltrative. Most of ATs of the female genital system were small in size and incidentally diagnosed in our cases but rarely detected as an adnexal mass forming lesion which mimics a malignancy. A comparative clinicopathologic analysis of these cases should be considered with the histomorphological and immunohistochemical features for an accurate differential diagnosis.

Are polyploid giant cancer cells in high grade serous carcinoma of the ovary blastomere-like cancer stem cells?

Polyploid giant cancer cells, either multinucleated or mononucleated, in high grade serous carcinoma of the ovary have been previously recognized. Different theories including degenerative changes or an important step in the development of high grade serous carcinoma have been proposed. Here we investigate possible explanations for the presence of polyploid giant cancer cells in high grade serous carcinoma. We reviewed 33 cases of ovarian high grade serous carcinoma (12 stage I, 7 stage II, and 14 stage III). We counted the number of polyploid giant cancer cells in 20 consecutive 10× fields. In 11 cases where polyploid giant cancer cells were easily found, immunohistochemistry for Ki67, p53, and OCT 3/4 was performed. Patients with polyploid giant cancer cells were older than those without. Polyploid giant cancer cells were more frequent in stage I lesions (75%) than in stages II or III (57% in both) and less frequent in metastases compared with primary ovarian tumors. Mitotic figures were present in regular sized cells but were absent in polyploid giant cancer cells. OCT3/4 was negative in all cases assessed. In 8 cases, more than 70% of the mononuclear cells were positive for Ki-67, similar to the percentage of Ki-67 positive cells in polyploid giant cancer cells. p53 had a perfect correlation in regular sized cancer cells and in polyploid giant cancer cells. Polyploid giant cancer cells are neither degenerative cells nor traditional cancer stem cells but most probably represent an intermediate step between stem cells and mature tumor cells formed by endoreplication.

The expression and prognostic role of IMPDH2 in ovarian cancer

Inosine 5'-monophosphate dehydrogenase type II (IMPDH2), as an oncogene, is reported to be involved in tumor formation and progression. However, the role of IMPDH2 in ovarian cancer remains unclear. Present study is aimed to investigate the expression and clinical significance of IMPDH2 in ovarian cancer. The mRNA and protein levels of IMPDH2 were measured in 126 ovarian cancer and matched adjacent normal tissues by quantificational real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry (IHC), respectively. Then, the association of IMPDH2 with clinicalpathological characters and prognosis was further evaluated. Significant higher mRNA levels of IMPDH2 were observed in ovarian cancer compared with those in normal tissues (P < 0.001). IHC results shown the high-expression rate of IMPDH2 in ovarian cancer was 56.3%, which was obviously higher compared with that in normal tissues (23.8%, P < 0.0001). Moreover, IMPDH2 high-expression significantly correlated with tumor types and Federation International of Gynecology and Obstetrigue (FIGO) stages in ovarian cancer (P < 0.05). IMPDH2 overexpression predicted poorer prognosis and could serve as an independent prognostic factor. IMPDH2 is highly expressed in ovarian cancer and correlates with prognosis, which may serve as a potential prognostic biomarker.

Diagnostic value of p16 and Ki-67 expression in cervical glandular intraepithelial disease: A review

Cervical adenocarcinoma has been increasing in frequency, particularly among young women. Its diagnosis still presents many challenges. In addition to the difficulty in accessing the lesion, the lack of well-established criterias for cytological and histological diagnosis, and colposcopic images that are often not very clear, there are many benign situations that mimic glandular diseases. Immunohistochemistry has been used to aid this diagnosis. The purpose of this review is to evaluate the data available in the literature related to the use of p16 and Ki-67 as an auxiliary tool in the diagnosis of glandular disease. Original articles were searched in the PUBMED/MEDLINE, EMBASE, SCOPUS and BVS using different combinations of keywords and descriptors. Of the 83 initial articles, 10 were selected. The criterias used for immunohistochemical interpretation showed many differences. The studies compared benign pathologies to malignant pathologies and some used panels with different immunomarkers while others used only p16. P16 showed an intense staining pattern in malignant pathologies, despite some studies have shown a negative pattern in adenocarcinoma. This can be explained by the histological subtype, not always related to HPV. Some studies have shown immunopositivity for p16 in normal tissues, tubal metaplasia and cervical endometriosis, but the staining pattern was never intense, as in malignant tissues. Ki-67 showed a more intense staining in AIS and adenocarcinoma tissues and was also present in normal tissues, mainly in tubal metaplasia and cervical endometriosis. Biomarkers have proved to be important tools in aiding the diagnosis of glandular lesions, either alone or in panels. Standardization in the interpretation of immunochemistry is required.

Juvenile granulosa cell tumor of the ovary: A comprehensive clinicopathologic analysis of 15 cases

Juvenile granulosa cell tumor(JGCT) is an uncommon ovarian sex-cord stromal tumor, with diverse clinical, radiological and histopathologic features. The present study describes the clinicopathological and histomorphological spectrum of JGCTs, and highlights the key differentiating features from its mimics. A retrospective analysis of all cases reported as JGCTs during 2011-19 (8 years) was performed with detailed evaluation of clinical, histopathologic data and follow-up details. Of a total 115 GCTs reported during the study period, 15(13%) were reported as JGCTs. The mean age at presentation was 17 years. Abdominal pain and distension were the most common clinical presentations. Five patients were pre-menarchal with 3 exhibiting precocious puberty. Majority of tumors were unilateral(left>right), solid-cystic, ranging in size from 4 to 20 cm. Microscopically, macrofollicular architecture was most frequent (n = 12;80%). The tumor cells depicted variable nuclear pleomorphism, small distinct nucleoli and moderate-abundant pale eosinophilic-clear/vacuolated cytoplasm. Mitotic activity ranged from 1 to 10/10HPFs. Uncommon histopathologic features included microcystic and tubulo-cystic architecture, myxoid degeneration, bizarre tumor giant cells, hob-nailing of the tumor cells, intracytoplasmic hyaline globules, multifocal calcification and thick hyalinized blood vessels. Majority(n = 12;80%) presented in stage I. Surgical treatment included unilateral salpingo-oophorectomy without any adjuvant chemotherapy, bilateral salpingo-oophorectomy (BSO) and total abdominal hysterectomy with BSO with adjuvant BEP chemotherapy (Bleomycin, etoposide, cisplatin). JGCT is a rare ovarian tumor affecting young women and children with diverse histopathologic features. Despite an aggressive histopathology, these tumors have a good outcome, when diagnosed at an early stage.

Benign stratified intraepithelial mucinous proliferation of the uterine cervix: Significance of a previously unreported potential mimic of SMILE

Stratified mucin-producing intraepithelial lesion (SMILE) is a histologic subtype of HPV-associated endocervical adenocarcinoma in situ. We have observed benign endocervical changes resembling SMILE. We aim to characterize this pattern and explore its potential association with dysplasia. We retrospectively retrieved all 296 consecutive cases accessioned as endocervical biopsies. Some included multiple specimens, totaling 483 biopsies and 219 endocervical curettages (ECC), n = 702. We included cases showing endocervical epithelial stratification often with pencillate (triangular-shaped) nuclei. We rejected cases in which layering represented tangential sectioning, metaplasia, microglandular hyperplasia, gastric type epithelial changes, and dysplasia. We found benign stratified intraepithelial mucinous proliferation in 51 patients, either with a multilayered (n = 27) or a two-layered appearance (n = 24). Overall, multilayered proliferation occurred in 6 % (29/483) of biopsies and in 0.9 % of ECCs (2/219). Two-layering was identified in 4 % of all biopsies (20/482) and was not seen in ECCs. Histologic findings included stratification, intracytoplasmic mucin, paler cytoplasm, low nuclear-to-cytoplasmic ratio, often pencillate nuclei, rare mitoses, and no apoptotic bodies. P16 immunohistochemistry (n = 12) was negative, suggesting absence of underlying high-risk HPV infection. HSIL was concomitant in 29.6 % (8/27) of patients with multilayered proliferation. Concurrent SMILE was not observed. We also reviewed 13 SMILE cases. Concurrent multilayered benign proliferation was identified in 54 % (7/13) of cases. We describe benign stratified intraepithelial mucinous proliferation of the cervix, which morphologically may overlap with SMILE. Its presence in most SMILE cases suggests a potential relationship. The multilayered form represents a diagnostic pitfall when mitotically active. Because of the often-coexistent HSIL, we propose that its presence should prompt scrutiny to rule out any associated dysplasia.

Reliability of negative cone specimens of the cervix: A review

Cervical conization specimens with a negative result for high-grade lesion are not infrequent in clinical practice and there are no protocols to address this issue. The purpose of this manuscript is to analyze factors that affect the reliability on these situations and provide recommendations to guide the gynecologists on their practice. We searched original articles on Pubmed/Medline database that analyzed negative cones using different combinations of descriptors. There were no restrictions regarding the language or the year of publication. Nineteen articles were selected and a total of 7310 cones analyzed. The negative excision rate ranged from 10 to 35%. Among the reasons to explain absence of lesion, the most frequent were errors in colposcopy, spontaneous lesion regression, complete removal of small lesions during biopsy, errors in the pre-conization material, false-negative results, and excisional error. Pathological specimen review and application of immunohistochemical biomarkers p16 and Ki-67 seemed to improve accuracy and help in challenging differential diagnosis. Recurrence was detected in up to 30%, as seen in positive cones with compromised margins. Importantly, testing for HPV demonstrated benefits in reducing the number of negative cones. Several factors could contribute to a negative result in a conization. Our main recommendations include: interval of 4-6 weeks between biopsy and conization, repeat the colposcopy during the excision, consider short-term reevaluation for small colposcopy lesions, perform deep sectioning levels in the paraffin block, use of immunohistochemical markers, HPV testing, and strict surveillance during follow-up as performed for positive cases with compromised margins.

From the archives of MD Anderson Cancer Center: EBV-positive fibrin-associated large B-cell lymphoma in an ovarian leiomyoma with cystic degeneration: A case report and discussion of differential diagnosis

Fibrin-associated large B-cell lymphoma (FA-LBCL) is a rare type of lymphoma usually associated with Epstein-Barr virus (EBV) infection. We report a case incidentally detected in a right ovarian mass of a 53-year-old woman. The patient presented with bloating and weight gain over 8 months. Imaging studies showed a 20.7 cm, complex right adnexal mass. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Macroscopic examination revealed a 25 x 18.5 x 9.5 cm predominantly cystic right ovarian mass with focal solid areas. Microscopically, most of the mass was a leiomyoma with hyaline necrosis and extensive cystic degeneration. In areas, the cyst showed focally necrotic, fibrinous material associated with small aggregates of round and atypical lymphoid cells with prominent karyorrhexis and mitotic activity These large cells were confined within the cystic spaces. Immunohistochemical analysis showed that the atypical cells were positive for CD20, CD30, CD79a and MUM1/IRF4, and were negative for CD3, CD10 and BCL6, supporting B-cell lineage. In situ hybridization for Epstein-Barr virus-encoded RNA (EBER ISH) was also positive in the atypical cells supporting the diagnosis of EBV-positive fibrin-associated large B-cell lymphoma. The patient subsequently received four cycles of chemotherapy using rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP). Computed tomography (CT) scan of the neck, chest, abdomen and pelvis 5 months after the last chemotherapy cycle showed no evidence of disease. After a follow-up of 17 months, the patient is alive with no evidence of disease. This report is being used to discuss the salient features of this rare entity and its differential diagnosis.

Appendix-like morphology in primary ovarian mucinous tumors lacking a concurrent mature teratoma: A series of 4 cases illustrating the utility of STR analysis

Recently in this journal, Ramalingam et al described the clinicopathological features of mucinous ovarian tumors arising in association with mature cystic teratomas (MT). Of particular interest to us are the appendix-like histological features including prominent subepithelial stromal clefts and pseudomyxoma ovarii described by Ramalingam et al and others. In our own practice, we have encountered a handful of mucinous ovarian tumors with the above-noted histological features for which no MT and no appendiceal tumor could be found, leaving the tumors' origin in question. Here we share our experience using short tandem repeat (STR) analysis in order to address this very scenario using 4 illustrative cases. Using STR analysis, we show that the above-noted histological features may indeed suggest a teratomatous origin even in the absence of a histologically apparent MT. We also show that these same histological features may be seen in bona fide primary ovarian mucinous tumors that have a purely somatic origin.

Metastatic tumors to the pancreas: An institutional experience

Immunohistochemistry combined with Alcian Blue-Periodic Acid Schiff (AB-PAS) staining in the differentiation of ovarian seromucinous borderline tumors and mucinous borderline tumors

This study aimed to evaluate the clinicopathological features of ovarian seromucinous borderline tumors (SMBTs) and mucinous borderline tumors (MBTs) and to establish a diagnostic approach using immunohistochemistry (IHC) and Alcian Blue-Periodic Acid Schiff (AB-PAS) histochemical staining. A retrospective analysis of 73 MBT and 34 SMBT cases was conducted at a single institution. Clinical, pathological, IHC (CK7, CK20, ER, PAX8), and histochemical (AB-PAS) features were compared. Both of SMBTs and MBTs frequently occurred in patients under 40 years. Patients with SMBTs were older, their tumors were of significantly smaller tumor size, and were more likely to be bilateral and associated with endometriosis than MBTs. Recurrence rates were 9.1 % (SMBTs) and 1.9 % (MBTs). 85.3 % of SMBTs exhibited CK7 cytoplasmic positive (+++) as compared with 46.6 % of MBTs. All SMBTs were CK20-negative and 68.5 % of MBTs showed CK20 cytoplasmic positivity. 100 % of SMBTs showed ER nuclear positivity, whereas all MBTs were ER-negative. PAX8 were consistently expressed (++/+++) in 97.1 % of SMBTs but 11 % in MBTs, respectively. AB-PAS staining distinguished SMBTs (acidic mucin: blue) from MBTs (neutral mucin: magenta; goblet cells: blue). Overall, our study affirms that SMBTs and MBTs exhibit distinct clinicopathological profiles. A combined IHC panel (CK7, CK20, ER, PAX8) with AB-PAS staining enhances diagnostic accuracy, potentially guiding clinical management.

Mucinous neoplasms associated with mature cystic teratomas: A clinicopathologic study of 50 cases: Are we ready for nomenclature change?

Mucinous neoplasms associated with ovarian teratomas (MOvNTs) are uncommon with only a few large series published thus far. Their clinicopathologic features are evaluated in this multi-institutional study. Fifty MOvNTs were retrieved from the files of four institutions over 16-years (yr). Patient age, CEA and CA-125 levels, laterality, tumor size, type of mucinous tumor (according to gynecologic pathology criteria and proposed appendiceal nomenclature when applicable), immunohistochemistry (IHC), FIGO stage, presence of pseudomyxoma ovarii and peritonei, treatment, follow-up in months (mos), and outcome were recorded. Patients ranged in age from 17 years to 74 years (mean 43, median, 42). Increased CA-125 levels correlated with mucinous carcinoma and mucinous borderline tumor (p=0.0270), and CEA correlated with mucinous carcinoma (p=0.0256). Mucinous neoplasms were either cystadenomas (16), borderline tumors (20) or carcinomas (14). Forty-one were Mullerian/surface epithelial type and 9 were appendiceal-like. Using appendiceal nomenclature: Seven were low grade mucinous appendiceal neoplasms and 2 high grade appendiceal neoplasms. IHC: 39 % were CK20/CDX2/SATB2 positive and 61 % were CK7 > CK20 (+), and SATB2-. Almost all patients presented with FIGO stage I disease; except one each with FIGO II and IIIC disease. All patients had surgical resection, and 10 patients had adjuvant therapy. Recurrences occurred in 4 patients (range: 10-84 mos). At last follow-up (median 60 mos): 33 patients had no evidence of disease, 3 died of disease, 1 was alive with disease, 2 died of other causes, and 11 were lost to follow-up. MOvNTs are usually Mullerian/surface epithelial type and FIGO stage I. As the only patients with adverse outcome were those who had a diagnosis of mucinous carcinoma or microinvasive carcinoma, whether of appendiceal-like or Mullerian/surface epithelial type, using established gynecologic, rather than GI criteria for classifying all types of MOvNTs is recommended.

The frequency and prognostic role of P53 and P16 immunoexpression in primary ovarian mucinous tumors

Primary ovarian mucinous tumors are uncommon. Factors leading to invasive progression and metastatic disease have not been fully delineated yet. The aim of this study is to determine the rates of p53 and p16 immunoexpressions in primary ovarian mucinous tumors, to investigate their relationship with clinicopathologic factors and their impact on prognosis and survival. Seventy-eight primary ovarian mucinous tumors (30 mucinous cystadenomas, 30 mucinous borderline tumors (MBOT), 18 mucinous carcinomas (MOC)) were evaluated immunohistochemically with p53 and p16 staining. The demographic, clinicopathological data, and postoperative follow-up findings of the patients were analyzed. Mutation-type p53 staining was present in 1/30 (3.3 %) cystadenoma, 10/30 (33.3 %) MBOT and 9/18 (50 %) MOC (p = 0.001). p16 overexpression was detected in 3/30 (10.0 %) MBOT and 5/18 (27.8 %) MOC, but not in any cystadenoma (p = 0.04). The frequency of mutation-type p53 staining in MBOTs with microinvasion was higher (71.4 %) than in those without (28.6 %, p = 0.026). The frequencies of p16 or p53 mutations were similar in MBOTs with and without intraepithelial carcinoma, or mural nodule (p > 0.05). In MOCs with ovarian surface involvement, mutation-type p53 staining was detected in 66.7 % (6/9) and p16 overexpression in 55.6 % (5/9) of the cases. A significant difference was found between MOCs with or without ovarian surface involvement regarding the frequency of p16 overexpression (p = 0.029). Any relationship was not detected between survival and p53 and p16 expression in MOCs (p > 0.05). p53 and p16 mutation rates were higher in MOCs compared to mucinous cystadenomas and MBOTs and suggest a relevant role in the development of primary ovarian mucinous carcinoma, however further studies are needed in this regard.

Immunohistochemistry as an adjunct for challenging histological patterns of borderline Brenner tumors: An illustrative study of 4 cases

Borderline Brenner tumors (BBT) have a range of morphology that shows considerable overlap with that of malignant Brenner tumors (MBT). In particular, two histological patterns of BBT can be particularly challenging: 1) BBT with intraepithelial carcinoma (BBT-IEC) and 2) BBT with a small nested pattern (BBT-SNP). BBT-IEC is characterized by a tumor with the low-power non-infiltrative silhouette of a conventional BBT, but with increased cytological atypia and mitotic activity similar to that of MBT. Conversely, BBT-SNP is characterized by a complex proliferation of small tumor nests that closely resemble the infiltrative growth pattern of MBT, but without the obligate cytologic atypia and mitotic activity of MBT. We suggest that the combination of p16, p53 and Ki-67 may be helpful in distinguishing these 2 patterns of BBT from both conventional BBT and from MBT. While both conventional BBT and BBT-IEC show a null pattern of p16 expression, our case of BBT-IEC showed aberrant p53 overexpression, albeit with a maturation pattern similar to that described for TP53 mutant mucinous ovarian carcinoma and differentiated vulvar intraepithelial neoplasia (dVIN). Similarly, while BBT-SNP shows an infiltrative-like growth pattern similar to that of MBT, our case also showed a wild-type pattern of p53 expression and a Ki-67 proliferative index similar to areas with conventional BBT histology. In conclusion, in our small case series, we show that the use of immunohistochemistry for p53 and Ki-67 may help to distinguish challenging patterns of BBT from MBT. Further studies are needed to validate this finding in a larger case cohort.

Evaluation of the recently established Dutch nationwide Archipelago of Ovarian Cancer Research biobank

Fundamental and translational research in ovarian cancer aims to enhance understanding of disease mechanisms and improve treatment and survival outcomes. To support this, we established the Dutch multicenter, interdisciplinary Archipelago of Ovarian Cancer Research (AOCR) infrastructure, which includes a nationwide biobank. In this study, we share our experiences in establishing the infrastructure, offer guidance for similar initiatives, and evaluate the AOCR patient cohort. Key challenges included obtaining Data Protection Impact Assessment (DPIA) clearance, drafting the consortium agreement, and securing ethical approval from all hospitals. Over three years, 1093 patients were enrolled across 17 hospitals, resulting in the collection of 1339 tissue samples and 2280 blood samples. Of the 523 patients with currently available clinical and pathological data, 74 % (n = 387) had primary ovarian cancer. Among these patients, 73.4 % was diagnosed with high-grade serous ovarian carcinoma, and 80.9 % presented with advanced-stage disease. Surgery was performed on 93 % of patients with primary ovarian cancer, and chemotherapy was administered to 90.4 % of these patients. In conclusion, the AOCR biobank has established a robust foundation for future fundamental and translational ovarian cancer research. This manuscript provides valuable insights and guidance for developing future research infrastructures and biobanks, and contains detailed information about the AOCR patient cohort to date.

Development of a digital algorithm for assessing tumor-stroma ratio, tumor budding and tumor infiltrating lymphocytes in vulvar squamous cell carcinomas

Tumor-stroma ratio (TSR), tumor budding (TB), and tumor-infiltrating lymphocytes (TILs) are prognostic markers in some cancers but with unknown significance in vulvar squamous cell carcinoma (VSCC). This pilot study primarily aimed to develop a digital method for evaluating TSR, TB and TILs in VSCC and secondarily to investigate variation in these factors by p16 status. An independent training set stained with CD3/cytokeratin and CD8/cytokeratin was used to develop a deep learning-based Application Protocol Package (APP) segmenting tissue into background, epithelium, or stroma. TSR was defined as percentage of tumor epithelium relative to total tumor area, and tumor buds were defined as clusters of 1-4 tumor cells. A second APP quantified CD3+ and CD8+ lymphocytes in the intraepithelial and stromal compartments, respectively. The digital algorithms were applied to the study cohort of 41 VSCC cases, achieving satisfactory performance without manual corrections. TSR ranged between 33 and 91% with median of 64%, and median number of buds was 4 (range: 0-48) buds/mm

A prediction model based on clinical and histological features for predicting recurrence in patients with stage I-II endometrial cancer after surgical treatment

The study aimed to develop a prediction model combining clinical and histological features to predict recurrence in patients with stage I-II endometrial cancer (EC) after surgical treatment. A total of 746 stage I-II EC patients who had received primary surgical treatment at Taizhou People's Hospital between 2014 and 2018 were included and randomly divided as a Training cohort (n = 520) and a Validation cohort (n = 226) at a 7:3 ratio. Clinical features including age, body mass index, comorbidities, lymphadenectomy, and adjuvant treatment, and histological features including histologic type, myometrial invasion, cervical stromal invasion, and expression levels of Ki67, estrogen receptor (ER), progesterone receptor (PR), whey acidic protein 4-disulphide core domain 2 (WFDC2), and p53 were used to develop a prediction model for EC recurrence in the Training cohort using a multivariable Cox regression model. Model discrimination and calibration were further evaluated in the Validation cohort. EC recurrence was observed in 60 (11.54%) patients in the Training cohort with a median length of follow-up of 39 months. Age, adjuvant treatment, histologic type, cervical stromal invasion, and expression levels of Ki67, ER, PR, and WFDC2 were factors significantly associated with EC recurrence based on univariable Cox regression analysis. After a model selection by AIC in a stepwise algorithm, the final model incorporated the above predictors showed a C-index of 0.85 and fair calibration in the Training cohort. In the Validation cohort, the model still showed good discrimination power (C-index 0.80) but moderate calibration. The developed prediction model combining clinical and histological features can help to predict the EC recurrence in patients with stage I-II EC after surgical treatment.

Cytological features of oral malignant lymphoma in scraping liquid-based cytology: Cases of plasmablastic lymphoma and anaplastic lymphoma kinase-positive anaplastic large cell lymphoma

The main purpose of cytological examination in the oral region is to screen for squamous cell carcinoma or intraepithelial neoplasms; thus, the background tends to be considered a deterrent for microscopy. From this perspective, liquid-based cytology (LBC) is favorable for preparing clear samples with few backgrounds. However, background hemocytes are sometimes of critical importance in the diagnosis. We report two cases of oral malignant lymphoma, plasmablastic lymphoma, and anaplastic large cell lymphoma in which careful observation of the background in scraping LBC sample contributed to the early diagnosis. Atypical lymphoid cells were observed only in a very small part of the LBC samples from the presented patients; however, cytological findings, such as large lymphoid cells with outstanding nucleoli, large mitotic cells, or intermediate-to-large lymphoid cells with pleomorphic nuclei were sufficient for obtaining a cytological diagnosis of malignant lymphoma. Although the number and cell size of leukocytes in LBC with Papanicolaou staining were significantly different from those in air-dried conventional smears with Romanovsky staining, which are commonly preferred for the discrimination of hemocytes, the corresponding cytological features could be observed. Therefore, attention should be paid to the background as well as squamous epithelium to prepare for such unexpected cases. The LBC examination with Papanicolaou staining alone can suggest the possibility of malignant lymphoma.

Gross mucinous multinodular appearance aids in the identification of ovarian metastases in low-grade appendiceal mucinous neoplasms during intraoperative consultation

Ovarian metastases of low-grade appendiceal mucinous neoplasms (LAMNs) show grossly abundant nodular mucous cells, with a gross mucinous multinodular appearance and a histological resemblance to primary ovarian mucinous tumors (POMTs). This study aimed to elucidate the utility of gross features including the gross mucinous multinodular appearance and available clinical information at the time of intraoperative consultation, in distinguishing the ovarian metastases of LAMNs from POMTs or the ovarian metastases of colorectal cancer (CRC). In total, 776 patients with primary ovarian tumor and 68 patients with ovarian metastases underwent intraoperative consultation during 1998-2018. Of the total cases, 4 ovarian metastases of LAMNs, 19 ovarian metastases of CRC, and 50 POMTs (36 borderline tumors and 14 carcinomas) were identified. The gross features including the gross mucinous multinodular appearance were analyzed based on the gross photographs obtained before formalin fixation and the available clinical information collected during intraoperative consultation. The analysis indicated that the ovarian metastases of LAMNs significantly presented with gross mucinous multinodular appearance (4/4 vs. 0/50, P < 0.0001), extraovarian disease (4/4 vs. 2/50, P < 0.0001), ovarian surface involvement (3/4 vs. 2/50, P = 0.0016), and abnormal appendix (4/4 vs. 0/50, P < 0.0001) as compared to POMT. Moreover, the gross mucinous multinodular appearance was a distinguishable feature between the ovarian metastases of LAMNs and ovarian metastases of CRC (4/4 vs. 0/19, P = 0.0001). Based on these results, we proposed an algorithm to diagnose ovarian tumors using the gross mucinous multinodular appearance. Thus, recognizing unique gross features including the gross mucinous multinodular appearance would be useful for both pathologists and surgeons to accurately diagnose ovarian metastases of LAMNs during intraoperative consultation.

Evaluation of MTAP immunohistochemistry loss of expression in ovarian serous borderline tumors as a potential marker for prognosis and progression

Serous borderline tumors (SBT) are the most common subtype of ovarian borderline tumors with excellent clinical course. However, they can recur or progress to low-grade serous carcinoma (LGSC) in a small proportion of the cases. Beside BRAF and KRAS mutations, copy number alterations (CNA), particularly loss of chromosome 9p21 locus which results in deletion of genes CDKN2A and MTAP, have been suggested to be involved in disease progression. MTAP immunohistochemistry recently has been introduced for mesothelioma as a reliable surrogate marker for the homozygous deletion of chromosome 9p21 locus. Therefore, in the current study, we aimed to evaluate the MTAP loss of expression in serous borderline tumors and low-grade serous carcinomas to identify if it can be used as a marker for prognosis and progression. Eighty-four total cases of ovarian serous lesions, including 21 cases of serous cystadenomas, 21 cases of serous borderline tumors, 12 cases of low-grade serous carcinomas and 30 cases of high-grade serous carcinomas were selected. MTAP immunohistochemistry was performed on the representative blocks and cytoplasmic staining was used for interpretation. The cases were labeled as positive (retained) if MTAP showed cytoplasmic granular staining and negative (loss of expression) if negative cytoplasmic staining was observed in the presence of positive internal control. Ten of 21 cases of serous borderline tumors showed loss of MTAP expression (48%). Among those, 7 cases were bilateral, 2 cases had micropapillary features, one case had supraclavicular and cervical lymph node involvement by serous borderline tumor and 2 cases had progression to low-grade serous carcinoma, including one of micropapillary tumors. Also 8 out of 12 cases of LGSCs showed MTAP loss of expression (66%). Only 4 of 30 cases of high-grade serous carcinomas (13%) and none of the serous cystadenoma cases showed loss of expression of MTAP. To our knowledge, this is the first description of MTAP immunohistochemistry in serous borderline tumors and low-grade serous carcinomas. Our study was limited due to small sample size. However, it showed an association between MTAP loss of expression and adverse clinical behavior in ovarian serous borderline tumors. This supports the role for further investigations in larger series to evaluate the role of MTAP stain as a prognostic marker in these neoplasms.

Role of podoplanin, E-cadherin, Ki-67 in the dissemination of tumor cells in ovarian surface epithelial carcinoma-An immunohistochemical study

To understand the biological behaviour, ovarian carcinoma should be approached as a complex tissue composed of tumor cells, ECM proteins, endothelial cells, fibroblasts, inflammatory cells and lymphatics. We aimed to investigate the role of proliferation index of the tumor cells, cell adheshion molecules and lymphangiogenesis in the dissemination of tumor in ovarian surface epithelial carcinomas using suitable antibodies. Fifty-nine cases of ovarian carcinoma were assessed immunohistochemically to quantify the intratumoral and peritumoral LVD, podoplanin expression in stroma, E-cadherin expression and proliferation index of the tumor cells. Descriptive statistics were done stratifying the cases into early stage(FIGO-I) and advanced stage (FIGO-II,III,IV).Receiver operating curve was applied to determine the cut off of intratumoral LVD, peritumoral LVD, Ki-67 to discriminate early stage and advanced stage disease and the cut offs were validated by generating regression model. Intratumoral LVD (p = 0.001), peritumoral LVD (p = 0.000), high Ki-67 (p = 0.000), podoplanin expressing cancer associated fibroblasts (p = 0.002) and macrophages expressing podoplanin (p = 0.003) were significantly associated with advanced stage disease. Intratumoral LVD, peritumoral LVD and Ki67 at cut offs of 3.5, 9.5 and 30 % emerged as discriminators of early stage disease from advanced stage disease by ROC curve analysis. Peritumoral LVD > 9.5 had the highest odds of advanced disease (OR-33.948, CI-4.631-38.622). OSECs with intratumoral LVD > 3.5, peritumoral LVD > 9.5 and Ki-67 > 30 % should be considered for aggressive chemotherapy and frequent follow-up. Peritumoral LVD and podoplanin expression in components of tumor stroma have a determinant role in tumor dissemination in OSEC.

Mucinous cystadenoma of the liver with pathological-radiological correlation

The paper presents a pathological-radiological correlation of the manifestation of mucosal cystadenoma with ovarian stroma of the liver with examination and correlation with the new stroma nomenclature and differential diagnostic dilemmas of radiologists and pathologists.

The value of ‘raspberry bodies’ in intraoperative cytologic evaluation of adnexal masses for the diagnosis of clear cell carcinoma of the ovary: A cytological-pathological correlation

We report a case of a 48-year-old female who presented to the emergency department with pelvic/abdominal pain and a recent history of irregular periods. Pelvic ultrasound and computed tomography (CT) scan of the abdomen/pelvis revealed a 7.3 cm adnexal mass with suspicious features. During the intraoperative evaluation, a frozen section slide and a cytological smear were prepared. The cytological preparation was moderately cellular, showing cohesive groups of atypical cells with anisonucleosis, high nuclear to cytoplasmic ratio, and oval nuclei with prominent nucleoli. The tumor cells surrounded extracellular, magenta hyaline globules, forming raspberry bodies. Raspberry bodies are comprised of basement membrane deposits and are a unique finding in ovarian clear cell carcinoma. Raspberry bodies were also found in the frozen section slide, but, in comparison to the cytological preparation, were rare, difficult to identify, and resembled necrotic debris. The intraoperative diagnosis of a clear cell carcinoma is important because the surgical management will be more aggressive, as optimal tumor debulking is shown to have better overall survival. In this manuscript, we detail the intraoperative evaluation of an ovarian mass, the utility of cytological preparation and importance of identifying raspberry bodies in the evaluation of ovarian masses, and surgical management of clear cell carcinoma.

Predictors of Human papillomavirus (HPV) persistence after treatment of high grade cervical lesions; does cervical cytology have any prognostic value in primary HPV screening?

This study aimed to determine the factors associated with Human Papillomavirus (HPV) persistence in women undergoing cervical excision for pre-invasive lesions, after they have been referred from a primary HPV screening program. A retrospective study design involving patients who were treated at a Cervical Disease Screening and Treatment Unit, in a university hospital setting. After initial treatment, cervical HPV infection status was analyzed at the sixth month, first year and then subsequently after the second year. Totally, 395 patients who were diagnosed with pre-invasive cervical lesions and who subsequently undergone cervical excision were identified. In the first-year visit after cervical excision, HPV 18 was cleared in almost all (95.8%) cases, followed by HPV 16 (69.9%) and other hrHPV types (65.6%). Available data documented that 88.6% of women reached clearance after the two-year follow-up. Univariate analysis revealed a significantly higher proportion of HPV clearance among women who were younger (p = 0.019), premenopausal (p = 0.002), and who had been found to have a negative cytology result on their initial Pap test (p = 0.018). However, only cervical cytology result remained as the independent predictor of HPV persistence on a multivariate logistic regression (OR 0.43; 95% CI 0.21-0.87; p = 0.019). A low risk of HPV persistence was found among every HPV genotype in women undergoing cervical excision for pre-invasive cervical lesions. Initial cervical cytology result was the only independent predictor of HPV clearance during surveillance, which indicates the prognostic value of Pap test in primary HPV screening.

A broad-based approach to differentiate CIN from its mimics: The utility of in situ hybridization and immunohistochemistry

The hematoxylin and eosin slides of 100 consecutive cases diagnosed as CIN 1-2 were combined with 25 CIN 1 and 25 negative for CIN as documented by in situ HPV testing. The 150 cases were then reviewed blinded and scored as "CIN" or "negative for CIN". Each of the 50 controls was correctly scored. Of the 100 cases, 62 were diagnosed as CIN and the other 38 were scored as negative for CIN on re-review. Each of the CIN cases was positive for HPV as proven by the in situ detection of either HPV DNA or the L1 capsid protein. The 38 cases diagnosed as negative for CIN and 38 of the CIN cases were tested for HPV DNA by in situ hybridization and for a panel of biomarkers that included p16, Ki67, importin-β, exportin-5, and Mcl1 plus the L1 HPV capsid protein. Each of the 38 CIN cases was positive for HPV as well as each biomarker that localized towards the basal aspect of the lesion. Two of the 38 negative for CIN cases were positive for HPV DNA/L1 capsid protein and each of the biomarkers. The other 36 cases were negative for HPV DNA/L1 protein and each of the biomarkers showed baseline expression. Thus, 36% of the diagnoses of CIN 1-2 were incorrect and this could have been prevented with either in situ detection of the viral DNA/capsid protein or the immunohistochemistry detection of a panel of biomarkers that included p16, Ki67, importin-β, exportin-5, and Mcl1.

Role and significance of HER-2/neu as a biomarker in the premalignant and malignant lesions of uterine cervix

Cancer of uterine cervix is the most common cancer among Indian females. Surgery is the main modality of treatment along with radiation and chemotherapy depending upon clinical stage of the tumor and surgical findings. However, patients with advanced or recurrent disease have a poor survival despite the use of cisplatin-based combination chemotherapy. Hence, there is an increasing need for developing novel therapeutic target that can replace or be added to the current therapy for these patients. The present study was conducted to evaluate the presence of Her-2/neu expression. Two hundred cervical specimens were included in this study. These comprised cases with diagnosis of cervical intraepithelial neoplasia, squamous cell carcinoma, adenocarcinoma. HER-2/neu immunostaining was performed by using BioGenex monoclonal mouse anti-human HER-2/neu Receptor IgG1 antibody. Higher expression of HER-2/neu was noted in malignant lesions as compared to premalignant lesions. Intensity of staining also correlated with grade of malignant tumor, clinical stage and lymph node metastasis. The over-expression of HER-2/neu oncoprotein is found to be associated with poor prognosis, metastatic potential and aggressive biological behaviour.

Histomorphology and utility of CK17, p53 dual stain with CK 13 in the diagnosis of differentiated vulvar intraepithelial neoplasia

Differentiated vulvar intraepithelial neoplasia (dVIN) is a known precursor for HPV-independent vulvar squamous cell carcinoma (VSCC). Diagnosis of dVIN can be challenging, and immunohistochemistry (IHC) may be a useful aid in this setting. A mutated pattern of p53 staining is associated with dVIN. This retrospective study evaluated the histological features and immunohistochemical utility of p53/Cytokeratin 17 (CK17) dual staining and cytokeratin 13 (CK13) staining in dVINs. At our institution, the diagnosis of dVIN is primarily based on morphology, and p53 stain is not routinely performed, especially in cases with concurrent invasive carcinoma or in recurrences. Thirty-two cases of dVIN identified from the pathology archives included 21 cases with p53 mutations and 11 cases without p53 mutations. Fourteen cases were biopsies. The staining patterns of CK17 and CK13 were compared in p53-mutated and non-mutated dVINs. p53/CK17 dual stain was used, which helped assess aberrant CK17 staining patterns adjacent to the mutated p53 patterns. Of the p53-mutated dVINs, 18/21(85.7 %) cases showed full-thickness CK17 staining. Of the remaining 11 cases with p53 wild-type staining, 5 cases showed full-thickness CK17 staining (45 %). Of the p53-mutated dVIN cases, 8/21 (38.09 %) showed full-thickness CK13 staining. Only 2/21 (9.5 %) showed loss of CK13 staining, as seen in oral dysplasia. Amongst dVINs with wild-type p53 staining, 50 % showed full-thickness CK13 staining. None of the lichen sclerosus cases showed full-thickness staining for CK13. The utility of CK13 staining in dVIN has been studied in only one previous study. A Panel consisting of p53, CK13, and CK17 antibodies may aid in increasing the accuracy of dVIN diagnosis, especially when a full-thickness staining pattern of CK13 and CK17 is noted. Further investigation of dVINs with full-thickness CK13 staining in a larger cohort is needed to confirm the results.

Acantholytic squamous cell carcinomas of the cervix: A case series

Squamous cell carcinoma of the uterine cervix is considered the most common histologic variant of cervical cancer, with well-established treatment protocols and prognosis. An infrequent histologic variant of cervical squamous cell carcinoma is the acantholytic variant (ASCC), which is characterized by discohesive cells that result in a pseudoglandular and/or angiomatoid pattern of growth. This variant of squamous cell carcinoma has been regarded as having a poor prognosis at certain anatomic sites such as the head and neck and vulva. In the uterine cervix, the importance of this variant has not been yet established. A ten-year retrospective review of squamous cell carcinoma of the uterine cervix was performed to identify this variant and correlate it with clinical characteristics to better define its prognostic implications. During the study period 19 cases were identified containing from 10 to 80% acantholytic component. Mean age at diagnosis was 49 years. Clinical stages were 1A2 (1 case), Ib1 (16), and IIA1 (2). Median follow-up was 92 months. When compared with controls, ASCC were larger in size (1.4 vs 3.5 cm), had deeper involvement of the cervical stroma (21 vs 47%), had more lymph node metastasis (8 vs 26%), more frequent recurrences (4 vs 15%) and a shorter disease-free survival; however, no statistical differences were identified in overall survival. ASCC is an infrequent variant of cervical cancer which seems to have an impact on disease-free survival but no in overall survival.

Ovarian angiosarcoma: A systematic review of literature and survival analysis

Ovarian angiosarcoma (OA) is rare, with only sporadic cases reported in English literature. We performed a systematic review of cases published in the PubMed, Science Direct, and Google Scholar databases with the aim of describing the reported clinicopathological features of OA. Fifty-three articles that reported 60 patients were reviewed. Of the 60 patients, 7 (11.6 %) were diagnosed with secondary (metastatic) ovarian angiosarcoma and 53 (88.3 %) were diagnosed with primary ovarian angiosarcoma. The mean age at presentation for ovarian angiosarcoma was 38.3±17.8 years. The average tumor size for ovarian angiosarcoma was 11.9±6.1 cm. Abdominal distention was reported in 45/60 (75 %). Microscopic examination revealed necrosis in 28/60 (46.7 %), pleomorphism in 32/59 (54.2 %), mitotic figures in 44/60 (73.3 %), spindle-shaped cells in 27/36 (75 %), epithelioid-shaped cells in 20/36 (55.5 %), and mixed epithelioid and spindle-shaped cells in 12/36 (33.3 %) patients. On immunohistochemistry CD 31 was positive in 41/41 (100 %), CD 34 in 38/39 (97.4 %), and Factor VIII related antigen in 18/21 (85.7 %) patients. Metastasis was present in 43/60 (71.6 %) patients. Chemotherapy and surgery was performed in 36/52 (69.2 %). The median follow-up time for ovarian angiosarcoma was 7 months (IQR1-IQR3:2-13.5 months). 24 (48 %) of the 50 patients with available survival data were alive and 26/50 (52 %) were dead of disease. Survival analyses (KM curves) revealed that the presence of necrosis (log-rank test; p = 0.05) and absence of spindle-shaped cells (log rank test; p = 0.04) on histopathology were associated with worse outcomes, while treatment with combined chemotherapy and surgical excision was associated with better survival (P < 0.001) therefore, prompt diagnosis and early treatment with combined chemotherapy and surgical excision can prolong survival in OA.

Meta-analysis of SATB2 immunohistochemical expression in colorectal cancer versus primary ovarian mucinous neoplasms

Reliably distinguishing primary ovarian mucinous neoplasms (POMNs) from metastatic colorectal cancers (CRCs) is both challenging to the histopathologist and of great clinical importance. Special AT-rich sequence binding protein-2 (SATB2) has emerged as a useful diagnostic immunohistochemical marker of colorectal cancer. This meta-analysis compares SATB2 expression in POMNs and CRC. A systematic literature search for relevant studies was conducted. Meta-analysis of SATB2 positivity was undertaken using a random effects model. Seven studies including 711 CRCs and 528 POMNs were included. SATB2 positivity was seen in 81 % (95 % CI: 72-88 %) of CRCs and 4 % (95 % CI: 1-11 %) of POMNs. Variation was seen in immunohistochemical methods used for SATB2 detection and threshold for positivity. SATB2 staining remains high in CRC and low in POMNs, supporting its use in differentiating these two pathologies with vastly differing prognosis and treatment.

Lesions of anogenital mammary-like glands: Four cases including novel pathologic and immunohistochemical observations

Anogenital mammary-like glands, formerly described as ectopic breast tissue, are currently considered to be normal histologic components of the anogenital region. Anogenital mammary-like glands can give rise to many lesions identical to counterparts in the native female breast. We describe four cases of such lesions, including fibroadenoma, gynecomastia-like hyperplasia, and ectopic mammary-type tissue with a spectrum of usual ductal hyperplasia, apocrine metaplasia, adenosis, and pseudolactational change. All four cases occurred in young women (ages 29-38) who presented with vulvar or perianal masses. Similar to previously reported cases, these lesions shared histologic and immunohistochemical characteristics identical to native female breast lesions. Novel findings in our cases included (1) the first case of gynecomastia-like change to be reported in the perianal area of a female, (2) Immunohistochemical staining identifying a 3-layered epithelium characterized by a population of CK14 and CK5/6 positive and hormone receptor negative superficial luminal cells, and (3) diffuse, strong positivity for GATA3 in all cases. Our study adds to the literature on these rare lesions and highlights findings which may be useful in understanding the pathogenesis and improving the diagnosis of anogenital mammary-like gland lesions.

HER-2 overexpression in female genital tract clear cell carcinomas: Evaluation of different scoring guidelines, clinicopathological features and prognostic impact

Clear cell carcinoma (CCC) is a rare high-grade adenocarcinoma associated with poor response to platinum-based chemotherapy agents in the female genital tract. Human epidermal growth factor receptor 2 (HER2) overexpression is routinely used as a biomarker for targeted therapy in breast and gastric carcinomas, but its role in CCC remains unclear. In this study, HER2 overexpression was evaluated by immunohistochemistry (IHC) using College of American Pathologists (CAP) HER2 scoring guidelines for breast and endometrial serous carcinoma (ESC) on tissue microarray blocks. In equivocal and positive cases, fluorescence in situ hybridization (FISH) was performed. IHC score 3, and all amplified cases on FISH test were considered positive. Thirty-six cases of ovarian (OCCC), 36 endometrial (ECCC), and 2 cervical CCC were included. According to ESC and breast scoring guidelines, 20 % and 15.1 % of ECCC and 14.7 % and 6 % of OCCC were HER2 positive, respectively. Both cases of cervical CCC were negative. Scoring based on breast carcinoma guideline showed higher concordance (100 %) with gene amplification results, in comparison with ESC guideline (82.7 %). On multivariate survival analysis, HER2 positive ECCC and OCCC (based on ESC scoring methods) had significantly lower overall and disease-free survivals (OS, DFS) (P < 0.05). HER2 immunoscoring based on ESC guideline can yield a higher sensitivity with relevant clinical and prognostic features in OCCC and ECCC. HER2 can be considered a potential biomarker for targeted therapy and future clinical trials.

Accuracy and clinical value of intraoperative frozen section assessment in endometrial carcinoma

In this study, to evaluate the diagnostic accuracy and clinical reliability of intraoperative frozen sections (IFS) compared with paraffin-embedded sections (PS) in guiding surgical decision-making for endometrial carcinoma (EC) patients, we retrospectively analyzed the clinical data of 165 EC patients who underwent surgical resection with IFS evaluation. Diagnostic concordance between IFS and final PS pathology was assessed across six parameters: 1) tumor histological type, 2) tumor grade, 3) depth of myometrial invasion (MI), 4) cervical stromal involvement, 5) lymphovascular space invasion (LVSI) status, and 6) lymph node metastasis risk stratification. The data were statistically analyzed using Kappa coefficient and chi-square test. The IFS results concurred with the PS in 95.3 % for histological type (kappa 0.859, p = 0.125), 94.0 % for tumor grade (kappa 0.848, p = 0.039), 97.6 % for depth of MI (kappa 0.929, p = 0.046), 95.2 % for cervical involvement (kappa 0.481, p = 0.008), and 88.5 % for LVSI (kappa 0.155, p < 0.001). Risk assessment was accurately determined in 92.1 % of cases (kappa 0.796, p < 0.001). Final histopathology confirmed pelvic and paraaortic lymph node metastases in two patients whose metastatic risk had been underestimated based on the IFS risk stratification. High-intermediate/high-risk patients showed significantly higher lymph node involvement compared to low/intermediate-risk groups. IFS analysis demonstrates reliability and clinical utility in assessing disease extent and guiding surgical decisions regarding the need for complete staging procedures in EC patients.

Immunohistochemical markers of potential utility in identifying POLE-mutant endometrial carcinomas: An assessment of autocrine motility factor (AMF) and autocrine motility factor receptor (AMFR)

POLE status determination is necessary for the molecular classification of endometrial carcinomas (EC). However, this determination is only achievable by molecular techniques, which are not available in many practice settings. A previously published study reported elevated AMF/GPI and AMFR/gp78 levels in POLE-mutant EC. We examined the relationship between POLE status and AMF and AMFR expression. Our study included 55 molecularly classified EC, assessed for AMF and AMFR immunohistochemically. Staining intensity was scored 0 (negative), 1 (weak), 2 (medium), 3 (strong), extent was scored 0 (0 %), 1 (1-25 %), 2 (26-50 %), 3 (51-75 %), 4 (76-100 %), with those parameters summed for the final score for each case. The molecular subtypes POLE mutant, mismatch repair-deficient, no specific molecular profile, p53 abnormal had mean AMF scores of 5.909, 4.643, 5.000, 4.667, respectively. The POLE-mutant subtype had a significantly higher average AMF score than POLE wild-type (POLEwt) group (p = 0.003). Using POLE mutant status as an end-point, ROC analysis showed that an AMF immunohistochemical score of 6 and above had an 81.8 % sensitivity, 61.4 % specificity, AUC of 0.708 (95 % CI, 0.565-0.851). POLE-mutant subtype had higher prevalence of a score of 6 and above than the POLEwt group (9/11 vs 17/44 cases, p = 0.010). An AMF score 6 and above increased the likelihood of being POLE-mutant by a factor of 10.496 (95 % CI, 1.592-69.212). Similarly, the POLE-mutant subtype had higher prevalence of AMFR scores of 5 and above than the POLEwt group (p = 0.023). AMF may offer some promise in identifying POLE-mutant EC with relatively high sensitivity, but suboptimal specificity indicates that it cannot be applied alone in practice. Additional studies are required to determine whether AMF can be combined with other markers to more optimally identify POLE mutant EC.

Distinct histological and clinical features associated with pure uterine serous carcinoma: A single institution experience

To ascertain the clinicopathological features, survival, and prognostic factors of pure uterine serous carcinoma (pUSC) and compare its clinicopathological characteristics with those of serous-like grade-3 endometrioid endometrial carcinoma (G3-EEC). Consecutive patients with pUSC and p53 abnormal (p53abn) G3-EEC were retrospectively selected between 2014 and 2022. Histological and immunohistochemical features were reviewed, clinical information was collected, and survival analyses were performed. Eighty-five pUSC patients (mean age: 61.6 years) were included. Histologically, pUSC showed a predominantly glandular growth pattern (80.0 %) with high-grade nuclear atypia and obvious nucleoli and 53 cases showed admixtures of architectural patterns. The p53 aberrant expression rate was 98.8 %. 41.5 %, 53.7 %, and 67.5 % of cases were classified as negative for ER, PR, and WT1, respectively. Six (12.3 %) of 49 cases had a HER2 score of 3+ by immunohistochemistry (IHC). The overall survival and progression-free survival rates were 72.9 % and 63.5 %, respectively. Advanced stage, no adjuvant therapy, and lymph node metastasis were independent risk factors for poor survival in pUSC. Twenty-five p53abn G3-EEC patients were assessed. Women with p53abn G3-EEC were on average, younger than those with pUSC (53.4 vs. 61.6 years, P < 0.001). Papillary structures were observed more commonly in pUSC (16 % vs. 36.5 %, P = 0.042). Positive PR expression was significantly associated with p53abn G3-EEC (P = 0.009). Survival did not differ significantly between the subgroups in univariate and multivariate analyses. In this contemporary series, we affirm the suboptimal prognosis associated with pUSC, and that the survival associated with pUSC and p53abn G3-EEC are not significantly different. pUSC and p53abn G3-EEC have distinct morphological and immunohistochemical characteristics.

Extrauterine endometrial stromal sarcoma: A systematic review and outcome analysis

Endometrial stromal sarcoma (ESS) is the second most common uterine mesenchymal neoplasm. ESS can arise from extrauterine locations without any uterine involvement and is called extrauterine ESS (EESS). The epidemiological features of EESS are not well-known. Moreover, the factors affecting its outcome have not been systemically studied. The treatment of EESS closely follows that of uterine ESS, comprised of different combinations of surgical management, hormone therapy, chemotherapy, and radiation therapy. However, the effectiveness of different treatment protocols for EESS has not been studied. Here, we have performed a systematic review of all reported cases of EESS in the English literature. We further performed a meta-analysis of the outcome data and investigated how the patients' age, tumor site, tumor size, and management affect the overall and progression-free survival of the patients. We found that tumor site and mode of treatment significantly affected the overall survival and progression-free survival of the patients. Tumor size significantly affected overall survival but not progression-free survival, while the age at diagnosis did not affect patient outcome. As far as we know, ours is the first systematic study of this rare malignancy with an emphasis on outcome analysis.

Combined expression of HOXA11 and CD10 identifies endometriosis versus normal tissue and tumors

The gold standard for diagnosing endometriosis is by laparoscopic visual demonstration of ectopic endometrial lesions outside the uterus, preferably verified by biopsy and microscopical examination. Molecular markers to facilitate the microscopical diagnosis of endometriosis and for distinguishing endometriosis from other benign and malignant lesions are lacking. Our aim was to test and validate an immunohistochemical antibody panel for improved diagnostic accuracy of endometriosis. Both CD10 and HOXA11 have been implicated in regulation of endometrial homeostasis. Here we have analyzed the expression pattern of these two proteins using immunohistochemistry on human tissues in a tissue microarray format. CD10 and HOXA11 expression in endometriosis lesions were compared to expression patterns in a range of normal tissues and in primary- and metastatic lesions of endometrial-, cervical- and ovarian cancer. HOXA11 and CD10 were expressed in 98% and 91% of endometriosis lesions and the combined double-positive expression profile of both HOXA11 and CD10 was highly sensitive for ectopic endometrial tissue (90%). The specificity and sensitivity for this double-positive signature in endometriosis was significantly different from all investigated tissues, cancers and metastases except normal, eutopic endometrial- and cervical mucosa. The combination of HOXA11 and CD10 expression profiles provides a useful tool to identify ectopic endometrial tissue and for distinguishing endometriosis from various types of gynecological malignancies and metastases.