Non-endometrioid carcinomas of the uterine corpus: a review of their pathology with emphasis on recent advances and problematic aspects

DNA ploidy may be a prognostic marker in stage I and II serous adenocarcinoma of the endometrium

In patients with serous adenocarcinoma (SAC) of the endometrium, we evaluated the prognostic importance of clinicopathological parameters, DNA ploidy, and immunoexpression of p53, estrogen receptor (ER), progesterone receptor (PR), and Ki-67. In a series of 73 stage I and II SAC, DNA ploidy analysis was performed on hysterectomy specimens using DNA image cytometry. Immunohistochemical analysis of p53, ER, PR, and Ki-67 expression was additionally performed. In the review of the histological slides by three gynecologic pathologists, the presence of a serous component was not agreed upon in 17 (23 %) cases. The remaining 56 cases, consisting of pure SAC or SAC mixed with endometrioid adenocarcinoma, were further analyzed. Tumor recurrence was observed in 14 patients, and 28 patients died during the follow-up period. Patients with diploid (n = 19), aneuploid (n = 29), and tetraploid (n = 8) tumor had 5-year recurrence rates of 10, 38, and 53 %, respectively (p = 0.09). A DNA ploidy parameter, 5c exceeding rate, was found to be a prognostic marker for recurrence (p = 0.03), progression-free survival (p < 0.01), and overall survival (p = 0.02). Immunoexpression of p53, ER, PR, and Ki-67 did not have prognostic value, and the same was true for FIGO stage, lymphovascular invasion, the extent of myometrial invasion, and lymphadenectomy. The histological diagnosis of SAC may be difficult in some cases. Established clinicopathological parameters do not seem to be strong prognosticators in stage I and II disease. A DNA ploidy parameter, 5c exceeding rate, may be a prognostic marker in this patient group and should be further validated in larger series.

Cooperation between p53 and the telomere-protecting shelterin component Pot1a in endometrial carcinogenesis

Type II endometrial cancer (EMCA) represents only 10% of all EMCAs, but accounts for 40% of EMCA-related mortality. Previous studies of human tumors have shown an association between Type II tumors and damaged telomeres. We hypothesized that the lack of murine Type II EMCA models is due to the extremely long telomeres in laboratory mouse strains. We previously showed that telomerase-null mice with critically short telomeres developed endometrial lesions histologically resembling endometrial intraepithelial carcinoma (EIC), the accepted precursor for Type II EMCA. However, these mice did not develop invasive endometrial adenocarcinoma, and instead succumbed prematurely to multi-organ failure. Here, we modeled critical telomere attrition by conditionally inactivating Pot1a, a component of the shelterin complex that stabilizes telomeres, within endometrial epithelium. Inactivation of Pot1a by itself did not stimulate endometrial carcinogenesis, and did not result in detectable DNA damage or apoptosis in endometrium. However, simultaneous inactivation of Pot1a and p53 resulted in EIC-like lesions by 9 months indistinguishable from those seen in late generation telomerase-null mice. These lesions progressed to invasive endometrial adenocarcinomas as early as 9 months of age with metastatic disease in 100% of the animals by 15 months. These tumors were poorly differentiated endometrial adenocarcinomas with prominent nuclear atypia, resembling human Type II cancers. Furthermore, these tumors were aneuploid with double-stranded DNA breaks and end-to-end telomere fusions and most were tetraploid or near-tetraploid. These studies lend further support to the hypothesis that telomeric instability has a critical role in Type II endometrial carcinogenesis and provides an intriguing in-vivo correlate to recent studies implicating telomere-dependent tetraploidization as an important mechanism in carcinogenesis.

Efficacy of systematic pelvic lymphadenectomy in patients with non-endometrioid endometrial cancers: a retrospective, multicenter study in Korea

AIM

Non-endometrioid endometrial cancer is a clinically and pathologically distinct subtype of endometrial cancer. The aim of this study was to determine whether systematic pelvic lymphadenectomy improves overall survival compared to no lymphadenectomy in non-endometrioid endometrial cancer.

MATERIAL AND METHODS

The authors retrospectively reviewed the medical records and pathological findings of 112 patients who underwent surgical staging for non-endometrioid endometrial cancer from 2000 to 2006 in Korea.

RESULTS

Systematic pelvic lymphadenectomy was performed in 71 patients. Pelvic lymph node metastases were identified in 31% and 14.6% patients who underwent systematic pelvic lymphadenectomy and no lymphadenectomy, respectively. After adjusting for risk factors, there was no significant difference in overall survival (odds ratio = 0.69; 95% confidence interval, 0.29-1.67) between patients who did or did not undergo systematic pelvic lymphadenectomy. On multivariate analysis, patients with lymph node metastasis had higher risk of death (odds ratio = 3.11; 95% confidence interval, 0.97-10.00) than the patients with no lymph node metastasis.

CONCLUSION

Although systematic pelvic lymphadenectomy did not affect overall survival in patients with the non-endometrioid subtype, it has the potential benefit of providing prognostic information and acting as a guide for further adjuvant treatment.

Does the Loss of ARID1A (BAF-250a) Expression in Endometrial Clear Cell Carcinomas Have Any Clinicopathologic Significance? A Pilot Assessment

SWI/SNF chromatin-modification complexes use the energy of ATP hydrolysis to remodel nucleosomes and to affect transcription and several cellular processes. Accordingly, their loss of function has been associated with malignant transformation. ARID1A (the expression of whose product, BAF250a, a key complex component, is lost when mutated) has recently been identified as a tumor suppressor gene that is mutated in 46-57% of ovarian clear cell carcinoma (CCC). The purposes of this study are to assess the frequency of loss of BAF250a expression in endometrial CCC and whether this loss has any discernable clinicopathologic implications. 34 endometrial carcinomas with a CCC component (including 22 pure CCC, 8 mixed carcinomas with a 10% CCC component, and 4 carcinosarcomas with a CCC epithelial component), were evaluated by immunohistochemistry using a monoclonal antibody directed against the human BAF250a protein. 5 (22.7%) of the 22 pure CCC were entirely BAF250a negative, whereas the remainder showed diffuse immunoreactivity. None of 4 carcinosarcomas and only 1 (12.5%) of the 8 mixed carcinomas were BAF250a negative. There was no discernable relationship between BAF250a immunoreactivity status and tumor architectural patterns (solid, papillary or tubulocystic areas) or cell type (flat, hobnail or polygonal). Of the 22 patients with pure CCC, 14, 2, 3, and 3 were International Federation of Gynecology and Obstetrics stages 1, II, III and IV respectively. Interestingly, all 5 BAF250a negative cases were late stage [stages III or IV] as compared with 1 of 17 BAF250a positive cases (p=0.0002). Thus, 83% (5/6) of all late stage cases were BAF250a [-], as compared with 0 (0%) of the 16 early stage (I or II) cases (p=.0002). BAF250a negative and positive cases did not show any statistically significant difference regarding patient age and frequency of lymphovascular invasion or myometrial invasion. As may be anticipated from the concentration of late stage cases in the BAF250a negative group, patient outcomes were worsened in that group on univariate analysis. In conclusion, we found in this pilot assessment that 22.7% of endometrial CCC displays complete loss of BAF250a expression. There was a disproportionate concentration of BAF250a negative cases in the late stage group, with the attendant possibility of an associated worsened prognosis for those CCC patients whose tumors are BAF250a negative. These preliminary findings suggest the need for larger analyses to evaluate the prognostic significance, if any, of the loss of BAF250a expression in this rare histotype of endometrial cancer.

Endometrial carcinomas: a review emphasizing overlapping and distinctive morphological and immunohistochemical features

This review focuses on the most common diagnostic pitfalls and helpful morphologic and immunohistochemical markers in the differential diagnosis between the different subtypes of endometrial carcinomas, including: (1) endometrioid versus serous glandular carcinoma, (2) papillary endometrioid (not otherwise specified, villoglandular and nonvillous variants) versus serous carcinoma, (3) endometrioid carcinoma with spindle cells, hyalinization, and heterologous components versus malignant mixed müllerian tumor, (4) high-grade endometrioid versus serous carcinoma, (5) high-grade endometrioid carcinoma versus dedifferentiated or undifferentiated carcinoma, (6) endometrioid carcinoma with clear cells versus clear cell carcinoma, (7) clear cell versus serous carcinoma, (8) undifferentiated versus neuroendocrine carcinoma, (9) carcinoma of mixed cell types versus carcinoma with ambiguous features or variant morphology, (10) Lynch syndrome-related endometrial carcinomas, (11) high-grade or undifferentiated carcinoma versus nonepithelial uterine tumors. As carcinomas in the endometrium are not always primary, this review also discusses the differential diagnosis between endometrial carcinomas and other gynecological malignancies such as endocervical (glandular) and ovarian/peritoneal serous carcinoma, as well as with extra-gynecologic metastases (mainly breast and colon).

Uterine Papillary Serous, Clear Cell, and Poorly Differentiated Endometrioid Carcinomas: A Comparative Study

Introduction:

Uterine papillary serous and clear cell carcinomas (UPSCs/CCs) show a different spreading from that of poorly differentiated endometrioid carcinomas (PDECs) and are usually thought to be prognostically more aggressive than PDECs. On the contrary, it has been recently claimed that UPSC/CC and PDEC have a similar prognosis. In this retrospective study on 2 institutional databases, the surgical-pathological data and survival have been compared in patients with UPSC/CC and PDEC.

Methods:

A total of 139 surgically staged consecutive patients, 63 with UPSC/CC (37 UPSC; 26 CC) and 76 with PDEC clinically limited to the uterine corpus, have been compared for nuclear ploidy, myometrial invasion, (occult) cervical extension, peritoneal, and lymph node metastasis. Prognostic factors have been correlated through multivariate analysis with survival (disease-specific [DSS] and disease-free [DFS]).

Results:

Peritoneal metastases and aneuploidy were found to be the only parameters significantly different in the 2 groups: peritoneal metastases 28.6% in UPSC/CC (extrapelvic 19%) and 7.9% in PDEC (extrapelvic 2.6%) (P= 0.001), aneuploidy 48.6% in UPSC/CC and 30.6% in PDEC (P= 0.05). Five-year DSS was 57.9% versus 75.2% (P= 0.02), and DFS was 52.3% versus 71.4% (P= 0.04) for UPSC/CC and PDEC, respectively. All but cervical and lymph node involvement were significant predictors of survival. After multivariate analysis, histotype (DSS: hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.02-3.86;P= 0.04; DFS: HR, 1.94; 95% CI, 1.04-3.63;P= 0.04), stage (DSS: HR, 2.26; 95% CI, 1.10-4.65;P= 0.03; DFS: HR, 2.21; 95% CI, 1.12-4.38;P= 0.02), and myometrial invasion (DSS: HR, 2.86; 95% CI, 1.22-6.69;P= 0.01; DFS: HR, 3.96; 95% CI, 1.63-9.62;P= 0.002) were independent risk factors for survival.

Conclusions:

Uterine papillary serous and clear cell carcinomas spread to abdominal peritoneum more frequently than PDEC; multivariate analysis confirms UPSC/CC as an independent, unfavorable predictor of outcome.

High-Grade Endometrial Carcinomas

High-grade endometrial carcinomas are a heterogeneous group of clinically aggressive tumors. They include FIGO grade 3 endometrioid carcinoma, serous carcinoma, clear cell carcinoma, undifferentiated carcinoma, and malignant mixed Müllerian tumor (MMMT). Epidemiologic, genetic, biologic prognostic and morphologic differences between these entities are striking in prototypic cases, yet substantial overlap exists and diagnostic criteria and therapeutic approaches that account for the group's diversity are currently insufficient. FIGO grade 3 endometrioid carcinoma demonstrates solid, trabecular or nested growth and may resemble poorly differentiated squamous cell carcinoma. Endometrioid glandular differentiation is usually focally present. Serous carcinoma usually displays papillary architecture but glandular and solid patterns may predominate. Tumor cells typically display diffuse and severe atypia. Clear cell carcinoma should be diagnosed by recognizing characteristic papillary or tubulocystic architecture with cuboidal tumor cells showing atypical but uniform nuclei. Cells with clear cytoplasm are frequently but not always present. On the other hand, clear cells may be encountered in endometrioid and serous carcinomas. Immunohistochemical stains for p53, p16, ER, PR, mib-1, hepatocyte nuclear factor 1β and pan-cytokeratin can be helpful in classifying these high-grade carcinomas. They should be used in concert with thorough morphologic examination, as part of a rational panel of markers and only in specific circumstances. Although these tumors may appear clinically and even morphologically similar, demographic and epidemiologic features as well as patterns of spread and treatment modalities differ.

Intake of fruits and vegetables, and risk of endometrial cancer in the NIH-AARP Diet and Health Study

BACKGROUND

Fruits and vegetables contain a wide variety of phytochemicals which may have anti-carcinogenic effects. Although the results of case-control studies have suggested a possible protective effect of fruit and vegetable intake on the risk of endometrial carcinoma, few cohort studies have examined this association.

MATERIALS AND METHODS

We used data from the NIH-AARP Diet and Health Study to assess the association of fruit and vegetable consumption, as well as intake of specific botanical groupings of fruits and vegetables, with endometrial cancer risk among 112,088 women who completed a food-frequency questionnaire at baseline, in 1995-1996. During 8 years of follow-up 1142 incident cases of endometrial cancer were ascertained. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI).

RESULTS

After adjustment for covariates, HRs for the highest compared to the lowest quintile of total fruit and total vegetable intake were 1.30 (95% CI 1.04-1.61, P for trend 0.05) and 1.09 (95% CI 0.90-1.33, P for trend 0.55), respectively. No inverse associations were observed for intake of any of 13 botanical groupings of fruits and vegetables.

CONCLUSIONS

Results from this large prospective study do not support a protective role of a high intake of fruits or vegetables on the risk of endometrial cancer in older women.

Endometrial giant cell carcinoma: a case series and review of the spectrum of endometrial neoplasms containing giant cells

Poorly differentiated endometrial carcinomas of specific type include the rarely reported endometrial carcinoma with a malignant giant cell component [endometrial giant cell carcinoma (GCC)]. Since the initial description in 1991, there has only been 1 subsequent case report of this entity. We report another 5 cases. The patients ranged in age from 53 to 83 years, presenting with vaginal bleeding, anemia, or a pelvic mass. Four of the 5 tumors contained areas of endometrial adenocarcinoma of usual type, with a variable giant cell component. The conventional cell types present included 1 case with clear cell carcinoma (30% of tumor volume), 2 with high-grade endometrioid carcinoma (50% and 70% of tumor volume, respectively) and 1 with serous histology (10% of tumor volume). One was composed exclusively of giant cell carcinoma. The giant cell component in all cases consisted of poorly cohesive nests of bizarre multinucleated giant cells with mononuclear tumor cells. A striking peritumoral and intratumoral inflammatory cell infiltrate composed of lymphocytes, plasma cells and focal eosinophils, and neutrophils was present and emperipolesis was noted in 4 of the 5 cases. The giant cells showed focal staining for epithelial markers (AE1/AE3 and CAM 5.2). Three of the patients presented with stage 1A disease, 1 with stage 1B disease, and 1 tumor was advanced, presenting as stage IIIC2. One patient in whom the tumor was exclusively of the giant cell type, developed lung metastasis 4 years after diagnosis and 1 patient is disease free after 14 years. The remaining 3 patients showed no evidence of disease with 15 to 32 months of follow-up. As histotype supplemented by staging information is critical in selection of treatment modalities and in prognostication in uterine malignancies, accurate classification is mandated. Here, we present a series of endometrial carcinomas containing a component of GCC and discuss the spectrum of giant cell-containing uterine neoplasms. At this time, however, the cumulative data on endometrial GCC are limited and the prognostic significance of the presence and the extent of a giant cell component in endometrial carcinoma remains uncertain.

Inhibin-alpha, -betaA and -betaB subunits in uterine non-endometrioid carcinomas: prognostic significance and clinical implications

Inhibins, dimeric peptide hormones composed of an alpha-subunit and one of two possible beta-subunits (betaA or betaB), exhibit substantial roles in human reproduction and in endocrine-responsive tumours. However, the prognostic significance and clinical implications of the inhibin-alpha, -betaA and -betaB subunits in uterine non-endometrioid cancers are still quite unclear. A series of 41 uterine non-endometrioid carcinomas were immunohistochemically analysed with monoclonal antibodies against inhibin-subunits. The staining reactions were correlated with several clinicopathological characteristics and clinical outcome. The inhibin-alpha subunit showed a significant association with age although the loss of this subunit did not affect the survival of patients with non-endometrioid carcinomas and did not constitute an independent prognostic parameter. The inhibin-betaA expression was not associated with any of the analysed clinicopathological parameters and did not affect patients' survival. In contrast, a low betaB-subunit demonstrated a significant better cause-specific survival. Moreover, inhibin-betaB did constitute an independent prognostic parameter in uterine non-endometrioid cancer patients. In contrast to inhibin-alpha and -betaA subunits, the inhibin-betaB subunit seems to have a substantial role in the carcinogenesis and pathology of uterine non-endometrioid carcinomas and might be used as a marker to identify high-risk patients and may aid in the selection of patients for a more aggressive adjuvant therapy.

Minor serous and clear cell components adversely affect prognosis in ''mixed-type'' endometrial carcinomas: a clinicopathologic study of 36 stage-I cases

Most endometrial carcinomas contain only 1 Müllerian cell type although the presence of 2 or more cell types within 1 tumor, for example a predominantly low-grade endometrioid carcinoma with a minor component (arbitrarily defined as 30% or less) of high-grade serous and/or clear cell carcinoma, is not uncommon. The current study attempts to evaluate whether the presence of minor serous or clear cell components exerts an adverse effect on the prognosis in stage-I endometrial carcinomas of ''mixed-type.'' The study cases include 22 cases of stage-I endometrioid carcinoma with a minor component of serous carcinoma and 14 cases of endometrioid carcinoma with a minor component of clear cell carcinoma. Minor components were arbitrarily defined as representing anywhere between 5% and 30% of the total tumor. The study cases were compared with 56 cases of histologically pure age-matched and stage-matched endometrioid carcinomas, 6 pure serous carcinomas, and 13 pure clear cell carcinomas. All study and control cases were fully staged. Treatment history and outcome status were obtained and follow-up ranged from 56 to 140 months. Our study suggests that the presence of minor components of serous and clear cell carcinoma, defined as between 5% and 30%, within a mixed-type endometrial carcinoma appears to adversely influence the long-term survival of stage-I tumors, although a larger study is needed to corroborate our findings.

Minimal deviation mucinous adenocarcinoma ('adenoma malignum') of the uterine corpus

Primary mucinous adenocarcinomas of the uterine corpus are typically low grade and frequently associated with endometrial hyperplasia and/or ordinary endometrioid adenocarcinoma, but may appear as a heterogeneous group of neoplasms. A case is described of a 56-year-old postmenopausal woman who presented with mucinous vaginal discharge. Imaging demonstrated thickened myometrium due to adenomyosis. Serum CA19-9 levels were elevated to 486 U/mL. Microscopic examination of hysterectomy specimens indicated highly differentiated mucinous adenocarcinoma diffusely infiltrating the portion of adenomyosis of the corpus. In some areas endometrial glands of adenomyosis were replaced by benign-looking mucinous metaplasia. The uterine cervix showed no abnormalities. HIK1083 and MUC6 immunohistochemistry indicated a gastric phenotype of the tumor, as seen in cases of prototypical minimal deviation adenocarcinoma (MDA) of the cervix. In summary, mucinous endometrial adenocarcinoma rarely shows features similar to MDA of the cervix. This case provokes a discussion on diagnostic and management strategy, and histogenesis of mucinous neoplasm of the endometrium.

The significance of neuroendocrine expression in undifferentiated carcinoma of the endometrium

Carcinomas with neuroendocrine (NE) differentiation have been associated with poor outcome in different organs. The purpose of this study was to evaluate the presence and significance of NE expression in a series of 46 undifferentiated endometrial carcinomas diagnosed between 1988 and 2005. NE expression was studied by immunohistochemistry including synaptophysin, chromogranin, and/or CD56. The patients' age ranged from 30 to 84 years (mean 55). Staging information was available for 45 cases and according to the International Federation of Gynecology and Obstetrics system they were distributed as follows: stage I (9 cases), stage II (2 cases), stage III (9 cases), and stage IV (25 cases). NE expression was present in 19/46 (41%) cases; however, it was diffuse in only 9% of the tumors. The median survival for patients without NE expression was 7 months (95% confidence interval 4-10 mo) and for patients with NE expression was 12 months (95% confidence interval 6-27 mo). The survival curves do not differ significantly (P=0.49). NE expression is common in undifferentiated carcinoma of the endometrium, as it was found in 41% of our cases. In most cases, NE expression is only focally present (< or =10% of the cells). There is no difference in overall survival in patients with or without NE expression.

Differential roles of telomere attrition in type I and II endometrial carcinogenesis

Endometrial cancer has been generally categorized into two broad groups of tumors, type I (TI) and type II (TII), with distinct epidemiological/clinical features and genetic alterations. Because telomere attrition appears to trigger genomic instability in certain cancers, we explored the role of telomere dysfunction in endometrial cancer by analyzing telomeres and other markers of telomere status in both tumor types. We describe a new method, telomere chromogenic in situ hybridization, which permitted us to detect cells with short telomeres relative to control (stromal) cells within the same tissue section. Using this method, we found that both types of tumor cells had short telomeres. However, only TII tumors were significantly associated with critical telomere shortening in adjacent, morphologically normal epithelium, suggesting that telomere shortening contributes to the initiation of TII but not TI tumors. To explore this hypothesis, we analyzed mice with critically short telomeres and documented distinctive endometrial lesions that histologically resembled the in situ precursor of TII serous carcinomas; these lesions have not been observed previously in TI mouse models of endometrial cancer. Based on this and previous studies, we propose a model in which telomere attrition contributes to the initiation of TII and progression of TI endometrial cancers.

Clinical aspects of uterine papillary serous carcinoma

PURPOSE OF REVIEW

We review the demographic and clinicopathologic characteristics, and prognosis of women diagnosed with uterine papillary serous carcinoma, with a focus on clinical management.

RECENT FINDINGS

Pathologic evaluation of postmenopausal bleeding is preferred for patients who fit the profile of a high-risk endometrial cancer such as uterine papillary serous carcinoma. Women diagnosed with endometrial cancer who fit this profile and all women with uterine papillary serous carcinoma should undergo comprehensive surgical staging and aggressive cytoreduction of extrauterine disease. Adjuvant therapy remains controversial. Several recent investigations reported on the potential benefit of adjuvant chemotherapy, with many recommending additional loco-regional radiation.

SUMMARY

Despite the lack of randomized trials on uterine papillary serous carcinoma, several recent reports have provided insight into the diagnosis, surgical management, and adjuvant treatment of this high-risk endometrial cancer.

Endometrial Glandular Dysplasia (EmGD): morphologically and biologically distinctive putative precursor lesions of Type II endometrial cancers

In this article, the authors briefly review the historical evolution of the various putative precursor lesions for Type II endometrial cancers, with an emphasis on the newly defined "Endometrial Glandular Dysplasia (EmGD)". The evidentiary basis for delineating serous EmGD as the most probable precursor lesions to endometrial serous carcinoma is reviewed in detail. An argument is advanced for the discontinuation of the term serous "endometrial intraepithelial carcinoma (EIC)" as a descriptor for a supposedly intraepithelial, precancerous lesion. Preliminary evidence is also presented that suggests that there is a morphologically recognizable "clear cell EmGD" that probably represents a precancerous lesion to endometrial clear cell carcinomas.

Endometrioid carcinoma of the endometrium with choriocarcinomatous differentiation: a case report and review of the literature

OBJECTIVE

An endometrioid adenocarcinoma (EAC) with true trophoblastic differentiation is a rare event with a highly aggressive clinical course.

CASE

We report an endometrioid adenocarcinoma of the endometrium in which there was a morphologically conventional-appearing EAC component admixed with multinucleated giant cells and large pleomorphic tumor cells that resembled a choriocarcinoma without an elevated serum level of human chorionic gonadotropin (hCG) in a 42-year-old unmarried woman with a history of abnormal uterine bleeding. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection were performed. Histopathologic study of the specimen showed endometrioid adenocarcinoma extended to the deep myometrium with a focus of hemorrhagic and necrotic tumor composed of multinucleated giant cells, large pleomorphic tumor cells, suggesting choriocarcinomatous differentiation (CD). Immunohistochemical studies demonstrated intense reactivity of tumor cells for human chorionic gonadotropin (hCG) confirming the diagnosis. A complete clinical workup ruled out metastatic spread to the brain, lungs, skeleton, or abdomen. The patient was alive with no evidence of disease 6 months later.

CONCLUSION

Although endometrioid adenocarcinoma with choriocarcinomatous differentiation is known to behave in a more aggressive course, this disease may have a good prognosis with a clinically indolent course when it is small, and without elevated serum hCG levels.

Primary Endometrioid Adenocarcinoma of the Vagina

Vaginal adenocarcinoma is the second most common primary cancer of the vagina, yet there has been very little study of most subtypes other than clear cell carcinoma. We reviewed 18 cases of primary vaginal endometrioid adenocarcinoma, in our experience the second most common subtype. The patients ranged from 45 to 81 years of age (mean 60). Most presented with vaginal bleeding, and had had a prior hysterectomy. Five had a history of unopposed estrogen therapy but none had a history of intrauterine diethylstilbestrol exposure. The tumors were at the vaginal apex in 10 cases, in the posterior wall in 3, the lateral wall in 3, and the anterior wall in 1. On microscopic examination, each of the tumors had a pure or predominant component of typical endometrioid adenocarcinoma. There was squamous metaplasia in 4 cases, mucinous metaplasia in 4, and prominent nonvillous papillae in 2. The tumors were grade 1 of 3 in 4 cases, grade 2 in 13, and grade 3 in 1. Eleven cases were FIGO stage I, 5 stage II, and 2 stage IV. Vaginal endometriosis was identified in 14 cases, and is important in indicating a primary vaginal tumor, rather than secondary spread from the endometrium. Other subtypes of adenocarcinoma (such as serous when the tumor has a papillary pattern) and atypical forms of endometriosis, including polypoid endometriosis, are the most common other differential diagnostic considerations. The prognosis seems to be good in low-stage patients, with 11 patients alive and well and 2 alive with recurrent disease.

Histopathology of endometrial hyperplasia and endometrial carcinoma: an update

Endometrial cancer (EC) is the most common malignancy of the female genital tract in the western world. Conceptually, a dualistic model of endometrial carcinogenesis exists for sporadic EC, based on molecular findings with a good correlation to the morphologic phenotype and clinical behavior. Type 1 endometrial carcinoma represents an estrogen-related tumor, which usually arises in the setting of endometrial hyperplasia, has endometrioid histology with low grade, and tends to be biologically indolent. Grade 3 endometrioid cancers, which constitute a minority of EC, also behave aggressively. The type 2 cancers are not estrogen-driven and have a higher grade, various histologies, particularly serous carcinomas and clear-cell carcinomas, and a poorer prognosis. The diagnostic criteria of endometrial hyperplasia, endometrial in situ carcinoma, and of the different histologic types of EC, according to the most recent World Health Organization classification, are given in detail. In addition, the risk of progression of endometrial hyperplasia into endometrioid type EC and their treatment modalities are discussed. Endometrial pathologies in patients with breast cancer, receiving tamoxifen, and women affected by hereditary nonpolyposis colorectal cancer syndrome are described, including their pathogenetic aspects. Finally, a short practical description for the handling of surgical specimens from fractional curetting and hysterctomies is given.

Precursors of Endometrial Clear Cell Carcinoma

The recognition of morphologically identifiable lesions which may confer an increased risk for subsequent development of an invasive malignancy offers an opportunity to investigate and better understand the molecular-genetic etiopathogenesis of the well-developed tumor, and potentially, to administer a therapeutic intervention before its development. In contrast to uterine endometrioid and serous carcinomas, very little is known about the potential precursor lesions of endometrial clear cell carcinoma (ECCC). In our routine practice, we have noted the presence of a spectrum of atypical glandular changes in the endometria adjacent to ECCC or endometrial carcinomas with a clear cell component, which on the basis of current criteria, would not qualify for any specific designation. We hypothesize that these lesions represent the earliest morphologically recognizable precursor lesions of ECCC and systematically characterize their clinicopathologic features herein. Thirty archived cases of pure ECCC (n=14) or mixed endometrial carcinomas with a >10% clear cell component (n=16) were retrieved and the "normal" endometria adjacent to the malignancies were evaluated in detail. Thirty-eight benign uteri and 30 uteri with classic endometrial endometrioid carcinoma (EEC) served as controls. All cases were reviewed in a blinded fashion. Putative precursor lesions (PPL) were searched for and identified microscopically. The lesions were typically isolated glands or surface epithelium (within an otherwise normal endometrial region) that displayed cytoplasmic clarity and/or eosinophilia with varying degrees of nuclear atypia. Twenty-seven (90%) of the 30 cases had at least 1 PPL. In contrast, PPL were identified neither in the benign uteri nor in endometrioid carcinoma control groups (P<0.001). A total of 67 foci of PPL were identified in the 27 cases with an average of 2.5 foci per case. The immunohistochemical expression of p53, mib-1, estrogen receptor (ERs), and progesterone receptor in the benign endometria, ECCC, and the PPL were evaluated on all 27 cases. The mean p53 scores for the benign endometria, PPL, and ECCC were 0, 4.5, and 6.2, respectively. Parallel values for mib-1 were 15%, 45%, and 63%. ER/progesterone receptor indices for benign endometria, PPL, and carcinoma were 90/80, 21.52/4.61, and 11/4, respectively. The PPL described herein have a morphologic and immunophenotypic profile which seems to be distinct from both the benign endometria in which they reside and the adjacent areas of ECCC. The high frequency of association of these lesions with ECCC, their frequent occurrence as isolated lesions within otherwise "benign-appearing" endometria, and their continuous spectrum of nuclear atypia from minimum (grade 1, cytologic atypia falls short of ECCC cells) to maximum (grade 3, cytologically identical to ECCC cells), argues in favor of our hypothesis that these may represent precursor lesions of ECCC. Further studies are required to conclusively define the nature of these lesions. However, such studies can only be performed if diagnostic surgical pathologists recognize, highlight, and segregate these lesions for further analysis.

p16, p14, p53, cyclin D1, and steroid hormone receptor expression and human papillomaviruses analysis in primary squamous cell carcinoma of the endometrium

Pathogenetically, endometrioid adenocarcinomas of the endometrium are associated with hyperestrogenism and serous papillary carcinomas with alterations of p53. The etiology of primary endometrial squamous cell carcinoma (ESCC), however, is speculative. The purpose of this study was to evaluate the role of p14, p16, p53, cyclin D1, steroid hormone receptors, and human papillomaviruses (HPV) infection in the pathogenesis of primary endometrial squamous cell carcinoma. The expression of p16, p14, p53, cyclin D1, and steroid hormone receptors (estrogen, progesterone, and androgen) was examined immunohistochemically in 8 primary ESCCs. HPV analysis was performed using general primers and HPV typing. The median age of the patients was 62.1 years. Four cases showed positive nuclear and cytoplasmic p16 staining in an insular pattern, and 1 case nuclear positivity for p53 and estrogen receptors, respectively. Four of 8 cases were positive for progesterone receptor analysis and cyclin D1. All cases were negative for p14 and androgen receptor staining. All but one case were negative for HPV analysis. Five patients were alive with and without evidence of disease after a mean follow-up of 6.1 years. The results of this study suggest that alterations of the p16 pathway may play an etiologic role in at least a proportion of the ESCC, but without any association to HPV infection. Factors known to play a pathogenetic role in types 1 and 2 of endometrial carcinomas are not associated with primary ESCC. However, prognostically, ESCCs are more related to type 1 cancers.

Uterine papillary serous and clear cell carcinomas predict for poorer survival compared to grade 3 endometrioid corpus cancers

To compare the survival of women with uterine papillary serous carcinoma (UPSC) and clear cell carcinoma (CC) to those with grade 3 endometrioid uterine carcinoma (G3EC). Demographic, pathologic, treatment, and survival information were obtained from the Surveillance, Epidemiology, and End Results Program from 1988 to 2001. Data were analysed using Kaplan–Meier and Cox proportional hazards regression methods. Of 4180 women, 1473 had UPSC, 391 had CC, and 2316 had G3EC cancers. Uterine papillary serous carcinoma and CC patients were older (median age: 70 years and 68 vs 66 years, respectively; P<0.0001) and more likely to be black compared to G3EC (15 and 12% vs 7%; P<0.0001). A higher proportion of UPSC and CC patients had stage III–IV disease compared to G3EC patients (52 and 36% vs 29%; P<0.0001). Uterine papillary serous carcinoma, CC and G3EC patients represent 10, 3, and 15% of endometrial cancers but account for 39, 8, and 27% of cancer deaths, respectively. The 5-year disease-specific survivals for women with UPSC, CC and G3EC were 55, 68, and 77%, respectively (P<0.0001). The survival differences between UPSC, CC and G3EC persist after controlling for stage I–II (74, 82, and 86%; P<0.0001) and stage III–IV disease (33, 40, and 54; P<0.0001). On multivariate analysis, more favourable histology (G3EC), younger age, and earlier stage were independent predictors of improved survival. Women with UPSC and CC of the uterus have a significantly poorer prognosis compared to those with G3EC. These findings should be considered in the counselling, treating and designing of future trials for these high-risk patients.

Association of low-grade endometrioid carcinoma of the uterus and ovary with undifferentiated carcinoma: a new type of dedifferentiated carcinoma?

Low-grade endometrioid carcinomas, either of the endometrium or the ovaries, usually have an excellent prognosis. The association of this type of tumor with undifferentiated carcinoma is rare. In this study, we present the clinicopathologic features of 25 such cases. The age of the patients ranged from 30 to 82 years (median, 51 years). At presentation, the patients had either vaginal bleeding or pelvic pain. The endometrioid carcinoma involved the endometrium in 14 cases, the endometrium and 1 or both ovaries in 9 cases, and the ovaries in 2 cases. Undifferentiated carcinoma associated with low-grade endometrioid carcinoma was found at presentation in 19 grade 1 or 2 endometrioid carcinomas: 15 in the endometrium and 5 in the ovary. In one of these cases, undifferentiated carcinoma was found in the endometrium and the ovary. Undifferentiated carcinoma was found after resection of low-grade endometrioid carcinoma in six cases, involving the retroperitoneum, pelvis, vagina, or liver. The undifferentiated carcinoma was composed exclusively of diffuse sheets and solid nests of epithelial cells in l0 cases. Epithelial cells with isolated foci of keratinization were seen in nine cases and rhabdoid cells in a myxoid background in six cases. Twenty-four patients were treated with total abdominal hysterectomy and with bilateral salpingo-oophorectomy. Twenty-two patients received additional therapy as follows: chemotherapy (), radiotherapy (), and tamoxifen (). Follow-up showed that 15 patients died of disease in 1 to 60 months (median, 6 months), and 5 patients are alive with progressive disease with a follow-up between 6 and 8 months; 1 patient is alive with no evidence of disease at 104 months. In four cases, the diagnosis was made recently, with short follow-ups of 3 and 4 months. Foci of undifferentiated carcinoma may be confused with solid endometrioid adenocarcinoma erroneously leading to the diagnosis of a grade 3 or a significantly less aggressive grade 2 endometrioid carcinoma. The recognition of undifferentiated carcinoma in an otherwise low-grade endometrioid adenocarcinoma is extremely important because it indicates aggressive behavior. In asynchronous cases, being aware of this association can explain the absence of a second primary.

Undifferentiated carcinoma of the endometrium

Undifferentiated carcinoma arising in the endometrium is considered a rare neoplasm with only a few studies published thus far. This limited number of studies is most likely a reflection of the underrecognition of this tumor because of a lack of diagnostic criteria to separate it from endometrial endometrioid adenocarcinoma, FIGO grade 3. In this study, we present the clinicopathologic features of 16 cases of endometrial undifferentiated carcinoma. In addition, we review the clinicopathologic features of 33 cases of endometrial endometrioid adenocarcinoma, FIGO grade 3, and compare them with the undifferentiated cases. The age of the 16 patients with undifferentiated carcinoma of the endometrium ranged from 40 and 69 years (mean, 59 years). Stage was known in 13 patients. Six (46%) patients presented with early stage disease (4 stage I and 2 stage II). Seven (54%) patients presented with advanced stage disease (2 stage III and 5 stage IV). Staging information was not available for 3 patients. Undifferentiated carcinoma was characterized by a proliferation of medium-sized, monotonous, epithelial cells growing in solid sheets with no specific pattern. Glands were not identified. Keratin immunostaining was focally positive in 11 of 12 cases, and EMA was focally positive in all 12 cases. The age of the 33 patients with endometrial endometrioid carcinoma, FIGO grade 3, ranged from 40 to 90 years (mean, 68 years). Twenty-three (70%) patients presented with early stage disease (21 stage I and 2 stage II), and 10 (30%) patients presented with advanced stage disease (8 stage III and 2 stage IV). Focal glandular differentiation was seen in all cases. The solid component was different from the one seen in the undifferentiated carcinomas because well demarcated trabeculae, cords, or groups of cells were identified in all cases. The tumor cells in the solid areas resembled the cells in the glandular component of the tumor. Immunoperoxidase studies for keratin and EMA were positive in 23 of 23 cases. Twelve of the 16 (75%) patients with undifferentiated carcinoma died of disease; 10 (62.5%) of them within 5 years after diagnosis. In contrast, 13 of 33 (39.4%) patients with endometrial endometrioid carcinoma, FIGO grade 3, died of disease. Twelve (36.4%) died within 5 years after diagnosis. In summary, undifferentiated carcinoma of the endometrium appears to be more aggressive than endometrial endometrioid adenocarcinoma, FIGO grade 3. Its proper recognition is important for prognosis and potentially for therapy.

Eosinophilic cell change of the endometrium: a possible relationship to mucinous differentiation

Eosinophilic cell change is one of the most common endometrial metaplasias occurring in both non-neoplastic and neoplastic endometrium. Its phenotypic characteristics have not still been fully clarified. We examined expression of mucin core proteins in a total of 95 distinct histological areas of endometrial specimens comprising 39 benign nonhyperplastic endometria, 14 endometrial hyperplasias, and 42 endometrial carcinomas. Eosinophilic cell change was very common, seen in 27 endometrial areas (28%); mucinous metaplasia (28%) and ciliated (tubal) change (31%), were also frequently seen. Eosinophilic cell change was more frequently seen in endometrial hyperplasia and carcinoma than in benign nonhyperplastic endometrium. In endometrial carcinomas, eosinophilic cell change was frequently associated with mucinous metaplasia and the two types of metaplastic cells were occasionally intermingled in a single neoplastic gland. A total of 23 (85%) of 27 eosinophilic cell changes and 18 (72%) of 25 mucinous metaplasias showed MUC5AC expression. These frequencies of MUC5AC expression did not differ significantly among benign non-hyperplastic endometrium, endometrial hyperplasia and endometrial carcinoma. Totally, 15 (52%) of 29 ciliated (tubal) changes and two (100%) of two surface syncytial changes, which showed cytoplasmic eosinophilia at least focally, also expressed MUC5AC. Most of the endometrial changes characterized by cytoplasmic eosinophilia may be subtypes of immature mucinous metaplasia which express a mucin core protein but are not fully glycosylated.

Minimal uterine serous carcinoma: a clinicopathological study of 40 cases

The term 'minimal uterine serous carcinoma' has been proposed to include serous carcinomas with invasion limited to the endometrium (superficial serous carcinoma), and those without stromal invasion (intraepithelial serous carcinoma or endometrial intraepithelial carcinoma). Both lesions display similar cytological and immunohistochemical profiles of a typical invasive serous carcinoma with a high nuclear grade and an overexpression of mutant p53 protein. We studied the clinicopathologic features of 40 cases of minimal uterine serous carcinoma. All patients were postmenopausal and underwent hysterectomy and surgical staging procedures. There were nine cases of intraepithelial serous carcinoma and 31 cases of superficial serous carcinoma. Five intraepithelial serous carcinomas and 16 superficial serous carcinomas exclusively involved an endometrial polyp. A total of 18 minimal uterine serous carcinomas also involved, in addition to a polyp, the endometrium proper in the form of intraepithelial serous carcinoma (13 cases) and superficial serous carcinoma (five cases). Overall, minimal uterine serous carcinomas were found to involve an endometrial polyp in 88% of the cases (35/40) and were confined to the polyp in 53% (21/40). Extrauterine tumors were present in 45% of the cases (18/40). In all, 22 patients with tumor limited to their uteri demonstrated an overall survival of 94% (2-73 months of follow-up). Eight of 18 patients with extrauterine tumors died of their malignancy (1.5-62 months of follow-up). In conclusion, a significant majority of minimal uterine serous carcinomas involve an endometrial polyp. Complete surgical staging is important to predict the prognosis. When the lesion is confined to an endometrial polyp and/or the endometrium proper, the clinical outcome is excellent.