Polish Journal of Pathology

Endometrial adenocarcinoma with gastrointestinal differentiation – a newly described entity, with morphologic diversity

Gastrointestinal type of endometrial carcinoma is a newly described entity for which clearly defined diagnostic criteria have only recently been published. Among morphologic criteria, gastrointestinal mucinous adenocarcinoma of endometrium must not show a typical endometrioid component. We present a case with morphologic diversity, with areas showing gastric and intestinal differentiation as well as an endometrioid-like component. However, the endometrioid-like component not only did not show classic squamous metaplasia, but was also MUC6-positive, while the positivity for ER/PR was only focal. The recognition of gastric/gastrointestinal differentiation in endometrial carcinomas is best accomplished using both morphology and immunohistochemistry rather than either alone.

High mitotic index has no prognostic significance in mixed tumor of the vagina

Mixed tumor of the vagina is a benign neoplasm usually developing in the posterior and distal vaginal wall, close to the hymen, with almost all reported cases exhibiting no or little cellular pleomorphism and rare mitotic activity. The present paper presents a case of a 30 year-old pregnant patient also known to have human immunodeficiency virus (HIV) infection in which a mixed tumor of the vagina was identified and completely surgically removed. Microscopic examination revealed a predominant spindle cell component characterized by high mitotic activity and mild cellular pleomorphism admixed with a minor epithelial component mainly represented by glandular structures lacking atypia and mitoses. Close follow-up showed that the high mitotic index has no prognostic significance in mixed tumor of the vagina, as our patient is well at 3 years after the initial diagnosis.

Interlaboratory agreement in assessment of gynaecological cytology in Cervical Cancer Screening Programme in Poland – a pilot evaluation

In our pilot study we have aimed to assess interlaboratory variability of cytological diagnoses in selected laboratories participating in the Polish Cervical Cancer Screening Programme (CCSP) to establish grounds for certification system for cytodiagnosticians and to monitor the quality of services. Set of 50 selected Pap smears, previously reassessed by an expert on the grounds of clinical, colposcopic and histological data was blinded and sent to 15 laboratories in Poland with request for evaluation according to routine practice according to the Bethesda 2001 system. Concordance with expert diagnoses reached a median of 82% (range: 66% to 92%), with median unweighted κ coefficient at κ = 0.67 (range 0.40 to 0.86) depending on laboratory. This indicates substantial agreement among laboratories, however with essential differences in proper evaluation in some outlying laboratories. Agreement was highest in samples with high-grade, lower for low-grade abnormalities. Slides with ASC-US and ASC-H expert diagnoses were most troubling for cytodiagnosticians. Sets of highly selected cytological slides with expert diagnoses may serve as a tool in the process of comprehensive periodic recertification of cytodiagnosticians in the screening programme. A benchmark level of agreement with expert diagnoses should be established to guide corrective actions for cytodiagnosticians with lowest agreement.

Why are Polish women diagnosed with invasive cervical cancer after negative cytology in the organized screening programme – a pilot reevaluation of negative Pap smears preceding diagnoses of interval cancers

We have aimed to study reasons for reporting false-negative cytology results preceding diagnosis of interval cervical cancers (CC) in Poland. Data on all Pap smears collected in the organised screening in 2010-2015 were retrieved from the electronic database and linked with Polish National Cancer Registry (PNCR) data. False-negative results were defined as those sampled and assessed normal up to 3.5 years before diagnosis of invasive CC. False-negative slides were then seeded among twice as many randomly selected slides from the same lab and reviewed independently by three expert cytomorphologists. New diagnosis was established when experts agreed on a result. Of 48 selected false-negative slides, 1 case was diagnosed as a low-grade abnormality, 22 cases as a high-grade abnormalities, 3 cases as unsatisfactory for evaluation and 5 as no intraepithelial lesion of malignancy (NILM) by all three experts. There was no agreement in 17 cases. Percentages of agreement between experts was 64.6. Interobserver agreement rate was moderate with Fleiss' κ values. Our pilot study indicates evaluation errors as the main reason of false-negative cytology preceding interval CC in the organized screening programme in Poland. True lack of abnormal cells on the slide is the next reason.

Leukaemia-related protein 16 is highly expressed in oestrogen-dependent endometrial carcinoma and potentially promotes Ishikawa human endometrial cancer cells growth – a histopathological study

Leukaemia-related protein 16 (LRP16) has been found to be highly expressed in various tumours and to be related to poor prognosis. However, the role of LRP16 in endometrial carcinoma remains to be explored. We aimed to investigate the prognosis and role of LRP16 in endometrial carcinoma. Overall, 160 endometrial carcinoma (EC) tissues and 60 benign samples were collected. The expression of LRP16 protein in EC tissues was significantly increased compared with that in normal endometrial tissues, and high LRP16 expression was related to poor patient prognosis. Reduced LRP16 expression markedly inhibited cancer cell growth. The proliferation rates in the prophylactic bilateral salpingectomy (PBS) group and the shNon group were 0.727 ±0.015 and 0.743 ±0.009, respectively, while the proliferation rate in the shLRP16 group was only 0.373 ±0.012. The migration experiment showed that the number of cells passing through the basement membrane in the shLRP16 group was 34.2 ±5.1, which was significantly different to the shNon (161.6 ±7.8) and PBS groups (138.0 ±7.2). The results of the invasion experiment showed that the number of cells was 39.2 ±6.2 in the shLRP16 group, 146.7 ±8.2 in the shNon group, and 141.2 ±8.1 in the PBS group ( p < 0.05). Leukaemia-related protein 16 is highly expressed in oestrogen-dependent EC and may promote cancer cell growth.

Immunohistochemical expression of PARP-1 in triple-negative endometrial cancer – a comparison of different score systems

Endometrial cancer is the most common malignant neoplasm of the female reproductive system. The number of diagnosed cases is increasing every year. In recent years, the triple-negative phenomenon (TNP) has been identified as one of the determinants of shorter survival in endometrial cancer patients. The aim of the study was to compare the PARP-1 protein expression in triple-negative (TNEC) and non-triple-negative (NTNEC) endometrial cancer patients and determine the relationship between the PARP-1 protein expression in endometrial cancer cells and patient's overall survival depending on the adopted scale (H-SCORE < 75, H-SCORE < 50, Allred scale). The study involved 265 patients with histopathologically confirmed endometrial cancer. The patients were divided into 2 groups: patients with TNEC and patients with NTNEC. The study was conducted using a tissue microarray technique. Expression of PARP-1 protein was determined by immunohistochemistry. Protein expression evaluation was performed using virtual microscopy and the Image Scope computer image analysis system. The following conclusions were reached: total and individual levels of nuclear or cytoplasmic PARP-1 expression varied with the presence or absence of TNP, and PARP-1 nuclear expression at the 2+ level had a significant effect on the increased risk of death (according to H-SCORE < 75).

Primary extrauterine cystic low-grade endometrioid stromal sarcoma mimicking stromal endometriosis. A case report emphasizing the differential diagnosis and its potential local aggressive behavior

Genital and pelvic endometriosis is a frequently encountered lesion and its importance rely on associated symptoms and its propensity for malignant transformation. In the present paper we comment on the importance of correctly diagnose the malignant transformation of an endometriotic lesion into a cystic low-grade endometrial stromal sarcoma, which is a very rare event. Moreover, we discuss the ability of a low-grade endometrial stromal sarcoma to locally recurr and the differential diagnosis with stromal endometriosis, a lesion that is very rare, almost always microscopic and solid.

Retrospective analysis of negative cytology results correlated with a positive high-risk in the human papillomavirus result and subsequent results of patients over a period of three years

This research paper evaluates the efficacy of co-testing in precluding cervical cancer, with a particular focus on distinguishable outcomes of the human papillomavirus (HPV) vs. cytology tests. A retrospective review of 5948 patients, who tested positive for high-risk HPV but showed negative cytologic findings, revealed that 15.006% tested positive in subsequent screenings. A comparative analysis of various commercial HPV tests highlighted the precision of mRNA-based HPV testing by Aptima (Hologic) in reducing the likelihood of false-negative cytology. The paper challenges the conviction that a negative cytology alone suffices advocating for a condensed testing interval in instances of positive HPV outcomes, thereby facilitating earlier intervention and optimal preventive care. These findings unveil an exigency for reconsidering preventive strategies based on test outcomes.

Prognostic potential of PRMT5 and DSG2 proteins in pre-malignant cervical lesions

Precancerous cervical lesions are metaplastic alterations of epithelial cells of the cervix, eventually developing into cervical cancer. Despite primary and secondary prevention, the burden of cervical cancer remains high globally. Protein arginine methyltransferases (PRMT) represent post-translational modifications that interact with multiple signalling pathways, playing a role in epithelial-mesenchymal transition. In complex with desmoglein-2 (DSG2), a cell adhesion protein, both participate in the progression of dysplastic changes with potential malignant development. The presented study was performed on archival paraffin-embedded blocks from adult women. The studied samples were categorised into low-grade and high-grade intraepithelial lesions. Immunohistochemical analysis was used to observe subcellular localisation, immunoreaction intensity, and percentage of PRMT5- and DSG2-expressing cells, followed by statistical analysis. Preliminary results identified statistically significant differences between the expression and subcellular localisation of proteins in question in low-grade and high-grade squamous intraepithelial lesions. The primary goal of the presented study is to perceive the involvement of PRMT5 and DSG2 in the initiation and progression of cervical lesions. Our observations indicate the potential of the assessed proteins as prognostic markers. However, further studies of PRMT5 and DSG2 are required to provide greater insight into cervical carcinogenesis.

Microscopic extraovarian sex cord proliferation: report of a case with bilateral Fallopian tube involvement and a comprehensive molecular analysis

We report a case of a 58-year-old female with microscopic extraovarian sex cord proliferations affecting both Fallopian tubes. Molecular analysis showed likely pathogenic germline missense mutations of the KDM5A and KMT2D genes. However, mutations of other genes, including FOXL2 and STK11, were not detected. Our case represents the 12th case of extraovarian sex cord proliferation reported in the literature to date. This is the first time that a molecular genetic analysis of the lesion has been performed, and it showed a wild-type FOXL2 gene, which represents another argument supporting the estimated benign nature of these rare lesions.

Serous borderline tumor with distant mediastinal metastasis? An Exceptional presentation of ovarian tumor

Borderline ovarian tumor is a non-invasive lesion with an excellent prognosis. Here we report a case of 48-year-old woman with distinctive clinical presentation of metastasis of ovarian adenocarcinoma, which was an microinvasive component of a serous borderline tumor. On initial diagnosis patient did not present any clinical manifestation of ovarian tumor. Histological examination of resected ovary showed typical features of the serous borderline tumor with one very diminutive focus of invasive serous adenocarcinoma 4mm in diameter. This exceptional case shows that borderline tumors of ovary with any features of invasion could present an aggressive course with distant metastases.

Prognostic and clinicopathological implications of expression of Beclin-1 and hypoxia-inducible factor 1α in serous ovarian carcinoma: an immunohistochemical study

Serous ovarian carcinoma (SOC) is an ovarian cancer with a high fatality rate. Therefore, a lot of researchers have tried to identify novel prognostic biomarkers which might improve the patient prognosis. The aims of the study were to detect the tissue protein expression of Beclin-1 in addition to HIF-1α in SOC patients, to evaluate the relationship between their expression, the clinicopathological parameters, patients' prognosis, and the relation to chemotherapy resistance in SOC. We evaluated the expression of Beclin-1 in addition to HIF-1α in 60 patients with SOC using immunohistochemistry, followed all patients for about 36 months, analyzed associations between both markers' expression, clinicopathological data, and patients' prognosis. Beclin-1 expression was related to low grade (p = 0.002), early SOC stage, absence of peritoneal spread (p = 0.006), and absence of lymph nodes, and distant metastases (p = 0.004 and < 0.001 respectively), while HIF-1α expression was associated with higher grade and stage (p = 0.007), and presence of nodal and distant metastases (p < 0.001 and = 0.012 respectively). High Beclin-1 expression and low HIF-1α expression were positively associated with good response to chemotherapy (p = 0.047 and p = 0.022 respectively), a lower recurrence rate after successful therapy (p = 0.006 and < 0.001 respectively), and increased three-year recurrence-free and overall survival rates (p < 0.001). In SOC patients; Beclin-1 is a good prognostic marker, while HIF-1α is a poor prognostic marker.

Immunohistochemical evaluation of forkhead box A1 and EphA5 markers in serous ovarian carcinomas, and their impact on the clinical outcome of patients

Ovarian cancer is the most lethal gynaecological neoplasm in females. In ovarian cancer, forkhead box A1 (FOXA1) aids transcription of YAP-associated protein mediated by the cyclic adenosine monophosphate response element-binding protein. As a result, cellular proliferation and migration increased. The roles of erythropoietin-producing human hepatocellular carcinoma cell (Eph) receptors and ephrin ligands in cell adhesion, migration, cell proliferation regulation in various cancers, and angiogenesis are well characterized. This study included formalin-fixed, paraffin-embedded tissue specimens from 41 patients with ovarian serous cystadenocarcinoma, including both low- and high-grade tumours. For each case, a paraffin block with tumour tissue was chosen for an immunohistochemical procedure using primary antibodies against EphA5 and FOXA1. By the end of 2017, patients finished their chemotherapy and were followed for the next 3 years. Positive FOXA1 and EphA5 results were presented in 68.3% and 39% of patients, respectively. A statistically significant correlation was detected between FOXA1 expression and each of CA-125 level, tumour stage, tumour grade, and the presence of lymph node metastasis. In our work, the overall survival was positively correlated with EphA5 expression and inversely correlated to FOXA1 immunoreactivity. The estimated disease-free survival (DFS) and EphA5 immunoreactivity had a significant positive association, whereas DFS and FOXA1 protein expression had a significant inverse link. FOXA1 and EphA5 expression play a role in ovarian cancer progression and prognosis prediction.

Diagnostically misleading aberrant terminal deoxynucleotidyl transferase expression in germ cell tumors

Terminal deoxynucleotidyl transferase (TdT) is a unique type of DNA polymerase predominantly expressed in precursor lymphoid cells and acute lymphoblastic leukemia. It participates in the junctional diversity of T-cell receptors and immunoglobulins. Recently, aberrant TdT expression was found in seminomas. Here, we evaluated the expression of TdT in our cohort of germ cell tumors (GCTs) with two anti-TdT antibody clones. We included 173 cases of testicular GCTs, 5 ovarian dysgerminomas, and one gonadoblastoma in the study. Tissue microarrays containing representative tumor samples were constructed and subsequently stained with anti-TdT monoclonal rabbit antibody EP266 (Dako) and TdT rabbit polyclonal antibody (Cell Marque). Expression was assessed with the H-score. No specific nuclear reaction was observed for the polyclonal anti-TdT antibody. The H-score values varied between the histological subtypes for the EP266 antibody. Positive nuclear staining was consistently seen in germ cell neoplasia in situ , seminoma, dysgerminoma, and embryonal carcinoma. Pure tumors had higher TdT H-scores than the mixed ones. Teratomas, yolk sac tumors, and choriocarcinomas were almost uniformly negative. Our study confirms that aberrant expression of TdT by testicular and ovarian GCTs exemplifies a potential diagnostic pitfall in histopathological diagnostics.

Expression of fascin in association with p16 and Ki-67 in cervical lesions: immunohistochemical study

Annual gynecological examination with cervical cancer screening and HPV vaccination ensures the appropriate prevention of the onset and progression of cervical cancer. Currently, efforts are being made to find new diagnostic and prognostic biomarkers. Fascin, an actin-bundling protein, promotes cellular migration. Its overexpression has been observed in many types of squamous carcinomas and was usually correlated with a worse prognosis and metastasis. However, the data on fascin expression in cervical lesions are limited. This study focuses on the quantitative evaluation of fascin expression, the immunoreaction intensity and subcellular localization of fascin expression in low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL) and squamous cell carcinomas (SCC). Fascin expression was also correlated with the routinely used diagnostic markers p16 and Ki-67. Biopsy specimens (n = 67) of LSIL, HSIL and SCC were taken from adult women in the age range 20-86 years. Fascin expression was detected by immunohistochemical analysis and quantified using morphometric software. Analysis of variance confirmed statistically significant differences in the percentage of fascin-positive cells between the LSIL, HSIL and SCC groups. Finally, the results showed a significant positive correlation between fascin expression and p16 and Ki-67 expression.

Neural proximity, vascular remodeling, and perineural immune exclusion across the cervical neoplasia spectrum – a whole-slide, nerve-anchored spatial analysis of 135 cases

Cervical carcinogenesis unfolds within a complex tissue ecosystem. While epithelial biomarkers and HPV status inform risk, the contribution of local neural circuits and their relationship to angiogenesis and cytotoxic immunity remains insufficiently defined in cervical intraepithelial neoplasia (CIN). In a balanced, archival cohort (n = 135; 27 per group: normal, CIN1, CIN2, CIN3, squamous cell carcinoma - SCC), whole-slide images were analyzed using a pre-specified QuPath pipeline with fixed thresholds and area normalization. We created composite indices: a neuro-epithelial coupling index (NECI) integrating nerve density, caliber, PGP9.5 signal, and inverse nerve-basement membrane (BM) distance; a vascular remodeling index (VRI) integrating CD31/CD34 microvessel density, vascular endothelial growth factor, vessel caliber, and peribasement vessels. Cytotoxic access was captured by CD8 density within 0-50 µm of nerves (NACD50) NECI and VRI increased monotonically with grade (group medians, normal  SCC: NECI -1.29, -0.64, 0.00, 1.33, 3.54; VRI -1.35, -0.58, 0.00, 1.14, 2.06). Neurovascular progression index values differ between grades (-1.32, -0.64, 0.00, 1.24, 2.66). The minimum nerve-BM distance shortened stepwise. In contrast, nerve-adjacent CD8 access declined with grade: NACD50 fell (≈ 5, 8, 4, 2, 1 cells/mm²) and nerve-avoidance ratio decreased (≈ 0.9, 0.8, 0.6, 0.4, 0.3), indicating progressive perineural CD8 exclusion. Across the full histologic spectrum, neuro-epithelial proximity and vascular remodeling intensify, whereas cytotoxic access to the perineural niche declines. These nerve-anchored, spatially explicit metrics add a neural dimension to cervical carcinogenesis and nominate the 0-50 µm perineural zone as a quantifiable compartment for risk stratification and interventional trials. External validation and calibrated modeling are warranted.

Towards standardized categorization of serous effusions: application of the International System for Reporting Serous Fluid Cytopathology diagnostic framework with a special emphasis on borderline ovarian tumors

Borderline ovarian tumors (BOT) in effusion cytology are rare, and to date only limited literature has existed. The current study used the International System for Reporting Fluid Cytopathology (ISRSFC) criteria to reclassify 321 effusion cytology cases from 302 patients, analyzed diagnostic performance among different positive groups and evaluated the risk of malignancy (ROM). A total of 14 BOTs were included, majority of them were mucinous borderline and these tumors were reclassified into atypia of uncertain significance (AUS) and suspicious for malignancy (SFM) intermediate categories. According to ISRSFC criteria, effusion cases were categorized into five different groups: non-diagnostic (ND), negative for malignancy, AUS, SFM and malignant. The corresponding overall ROMs were 23.3%, 19.4%, 44%, 87.8% and 100%. Morphologically, mucinous BOTs in effusions presented mostly as acellular mucin, while serous BOTs exhibited mesothelial cells with few atypical cells showing mild to moderate nuclear atypia. These findings highlight the diagnostic difficulty of BOTs in effusion cytology and the need to apply ISRSFC criteria especially for AUS and SFM grey zone categories for standard reporting and clinical guidance.

Expression and clinical significance of KDM5A, KDM5B, and FOXO1 in endometrial cancer

There is growing evidence that the KDM5 family of histone demethylases plays a causal role in human cancer. However, few studies have been reported on the KDM5 family in endometrial carcinoma (EC). Moreover, it was found that there was some correlation between the KDM5 family and FOXO1 in EC. The current study was performed to explore the expressions of KDM5A, KDM5B, and FOXO1 in endometrioid adenocarcinoma detected by immunohistochemistry; paracancer endometrium, simple hyperplastic endometrium, and normal endometrium were used as control groups to explore the possible diagnostic value of KDM5A and KDM5B expression in endometrioid adenocarcinoma, with the aim of evaluating the potential of this marker in predicting the prognosis of endometrioid adenocarcinoma.