Deoxyribonucleic acid content of presumed precursors of endometrial carcinoma

PET/MRI and PET/CT Radiomics in Primary Cervical Cancer: A Pilot Study on the Correlation of Pelvic PET, MRI, and CT Derived Image Features

PURPOSE

To evaluate the correlation of radiomic features in pelvic [2-deoxy-2-18F]fluoro-D-glucose positron emission tomography/magnetic resonance imaging and computed tomography ([¹⁸F]FDG PET/MRI and [¹⁸F]FDG PET/CT) in patients with primary cervical cancer (CCa).

PROCEDURES

Nineteen patients with histologically confirmed primary squamous cell carcinoma of the cervix underwent same-day [¹⁸F]FDG PET/MRI and PET/CT. Two nuclear medicine physicians performed a consensus reading in random order. Free-hand regions of interest covering the primary cervical tumors were drawn on PET, contrast-enhanced pelvic CT, and pelvic MR (T2 weighted and ADC) images. Several basic imaging features, standard uptake values (SUV_mean, SUV_max, and SUV_peak), total lesion glycolysis (TLG), metabolic tumor volume (MTV), and more advanced texture analysis features were calculated. Pearson's correlation test was used to assess the correlation between each pair of features. Features were compared between local and metastatic tumors, and their role in predicting metastasis was evaluated by receiver operating characteristic curves.

RESULTS

For a total of 101 extracted features, 1104/5050 pairs of features showed a significant correlation (ρ ≥ 0.70, p < 0.05). There was a strong correlation between 190/484 PET pairs of features from PET/MRI and PET/CT, 91/418 pairs of CT and PET from PET/CT, 79/418 pairs of T2 and PET from PET/MRI, and 50/418 pairs of ADC and PET from PET/MRI. Significant difference was seen between eight features in local and metastatic tumors including MTV, TLG, and entropy on PET from PET/CT; MTV and TLG on PET from PET/MRI; compactness and entropy on T2; and entropy on ADC images.

CONCLUSIONS

We demonstrated strong correlation of many extracted radiomic features between PET/MRI and PET/CT. Eight radiomic features calculated on PET/CT and PET/MRI were significantly different between local and metastatic CCa. This study paves the way for future studies to evaluate the diagnostic and predictive potential of radiomics that could guide clinicians toward personalized patients care.

Optimal management of endometrial hyperplasia

The optimal management of endometrial hyperplasia is the subject of considerable debate. In this chapter the development of our current classification of endometrial hyperplasias is outlined in some detail in order to give an understanding of the complexity of the problem of determining the malignant potential of the hyperplasia which is the central issue in determining optimal treatment. While hysterectomy is still the definitive treatment for older women with hyperplasia, conservative therapy is perfectly acceptable in a defined group of younger women who are closely monitored.

Treatment of endometrial hyperplasias with gonadotropin-releasing hormone agonists: pathological, clinical, morphometric, and DNA-cytometric data

On the basis of the recently reported observation that gonadotropin-releasing hormone agonists (GnRH-a) can affect endometrial cell proliferation, both indirectly, through the hormonal axis, and directly, by acting on the GnRH-a receptors, we investigated how far GnRH-a can be used as a new treatment mode for endometrial hyperplasias. Forty-two women, aged 28-60 years, with histologically confirmed simple (n = 30) or complex (n = 12, 2 with atypias) hyperplasia of the endometrium were involved in the study. According to the protocol they were treated for 6 months with GnRH-a (leuprolide acetate or triptorelin), and each patient underwent uterine curettage in the third and the sixth month of treatment, and 6 and at least 12 months after cessation of the treatment, for histological examination and morphometric and DNA-cytometric evaluation of the endometrium (mean pathological follow-up, 19.2 months; mean clinical follow-up, 30.7 months). During treatment, most of the women first revealed endometrial atrophy, and, after cessation of the treatment, again an atrophic or mainly functional endometrium; in 7 women, all with initial diagnosis of simple hyperplasia, the endometrial hyperplasia reappeared, which led in all 7 cases to hysterectomy. The mean values of almost all morphometric and DNA-cytometric parameters during and after treatment showed statistically significant changes in relation to pretreatment values, indicating a decrease in the proliferative activity of the endometrial cells; the GnRH-a antiproliferative effect was still active for a long time after cessation of the therapy. Our results, based for the first time not only on histological but also on serial nuclear morphometric and DNA-cytometric examinations of the endometrial cells and on the longest follow-up time, support the view that in cases of endometrial hyperplasia, especially of complex type, the use of GnRH agonists, which decrease the proliferative tendency of endometrial cells, could represent an alternative conservative therapeutic approach, which, however, requires close monitoring of the endometrium.

Rearrangement of chromosome 1 is a frequent finding in endometrial carcinoma. An in situ hybridization study in nine endometrial carcinomas

Nine endometrial carcinomas were examined for numerical aberrations of the chromosomes 1,7, and X by fluorescence in situ hybridization using highly repetitive chromosome-specific probes. In addition, a combination of a centromeric and a telomeric chromosome 1 probe was applied to detect structural chromosome 1 aberrations. Chromosome aberrations were found in six tumors. In four of these, an imbalance between 1q12 and 1p36 was detected, indicating the presence of an extra 1p- chromosome. In regard to the chromosomes 7 and X, monosomies and trisomies were found. Intratumoral genetic heterogeneity in endometrial carcinomas was detectable by FISH and flow cytometry. In conclusion, our findings confirm that chromosome 1 is frequently involved in structural chromosome changes, indicating chromosome 1 to be of importance in the evolution of endometrial carcinoma.

Endometrial adenocarcinoma

Adenocarcinoma of the endometrium is the most common gynecologic malignancy in the United States, accounting for some 36,000 cases of invasive cancer each year. Hyperplastic lesions of the endometrium follow a continuum, with the risk of progression to carcinoma being related to the severity of the disorder. Risk factors associated with the development of adenocarcinoma include hyperplasia, obesity, menstrual abnormalities, diabetes, hypertension, prior pelvic irradiation, sequential oral contraceptive use, diet, and exogenous estrogen use. There is also some evidence of genetic predisposition, and some data indicating the possibility of specific genetic abnormalities and activation of oncogenes as factors determining the etiology of the disease. At this time there is no accepted screening test for endometrial carcinoma, though the role of immunochemistry techniques for screening and follow-up has just begun to be realized. Dilatation and curettage along with hysteroscopy remain the major means of diagnosis. A variety of prognostic variables including tumor cell type, histologic grade, depth of myometrial invasion, status of peritoneal cytology, presence of disease in preformed vascular spaces, presence of adnexal metastases, and presence of cervical involvement have been defined. Although the treatment plan for each patient must be individualized, the mainstay of treatment remains total abdominal hysterectomy with bilateral salpingo-oophorectomy. Metastatic and recurrent disease is usually treated with hormonal therapy and systemic chemotherapy. Radiation therapy like surgery in recurrent disease is only applicable for the treatment of local recurrences.

The study of endocrine tumors by flow and image cytometry

Both DNA flow and image cytometry are methods that can be used for the quantitative determination of cellular DNA content. Objective, quantitative analysis of cellular morphology can also be obtained using image cytometry. Data thus generated have been shown to be of diagnostic and prognostic use in the study of many solid tumors and would be of particular value in the evaluation of endocrine tumors that show a poor correlation between their histology and biological behavior. The main application of these techniques to endocrine tumors has been in the analysis of thyroid nodules, although a limited number of studies of parathyroid, pituitary, adrenal, and pancreatic neuroendocrine tumors and tumors of the dispersed neuroendocrine system have been reported. Review of these studies shows that in the endocrine organs DNA and morphometric measurements have a very limited role in the diagnosis of individual cases, but are important as prognostic variables. The high incidence of abnormal DNA content in histologically benign lesions of the endocrine glands has important biological implications. Further investigation of this phenomenon may help to elucidate the process of endocrine tumorigenesis.

Nucleolar organizer regions in the normal, hyperplastic and carcinomatous epithelium of endometrium

A silver colloid technique to identify nucleolar organizer region associated protein (AGNORs) has been applied to paraffin sections in a total of 43 endometrial hyperplasias (24 adenomatous and 19 adenocystic) 26 endometrial carcinomas and 22 normal endometria (11 of proliferative and 11 of secretory phase). A morphometric analysis of highly magnified photographic images of AGNORs in light microscopic preparations was performed. Malignant tumor cells showed significantly higher AGNOR numbers, maximum diameter and mean area compared with normal and hyperplastic endometrium, with the exception of adenocystic hyperplasia whose Dmax and mean area were significantly larger. Regarding the distribution pattern of AGNOR dots in the cases studied, it was found that normal and hyperplastic endometrium had a mainly clustered distribution while endometrial adenocarcinomas revealed a scattered one. The significant differences observed in the number of AGNORs, their size and mean area between benign and malignant endometrial epithelia suggest that the AGNOR staining technique is of diagnostic importance in distinguishing between these two groups.

Nucleolar organiser regions in endometrial hyperplasia and neoplasia

Nucleolar organiser regions (NORs) were counted in the nuclei of both epithelial and stromal cells in cases of endometrial hyperplasia and carcinoma. The scores for each case were expressed as a ratio. No significant difference was found between the ratios for cystic hyperplasia and hyperplasia with architectural atypia, confirming the view that these are morphological variants of the same benign hyperplastic process. The ratios for hyperplasia with cytological atypia and adenocarcinoma differed significantly from the benign hyperplasias. This adds support to the view that hyperplasia with cytological atypia should be considered a neoplastic condition.

DNA content as a prognostic index in gestational trophoblastic neoplasia

Hydatidiform mole will progress to malignant gestational trophoblastic neoplasia (GTN) in some cases. Aneuploidy and high proliferative activity are associated with malignant tumors. Molar pregnancy tissue was considered a precursor to malignant GTN, and was studied retrospectively using paraffin-embedded tissue to determine whether aneuploidy or proliferative rates measured on molar tissue could predict a malignant course. Tissues from 51 complete hydatidiform moles were analyzed for nuclear DNA content by flow cytometric techniques. A chart review identified the clinical course after evacuation of the mole. A satisfactory DNA histogram was generated in 40 cases. Of the 40 patients, 22 (55%) had spontaneous resolution, and 18 patients (45%) required treatment for persistent GTN. The molar tissue was found to be euploid in 27 cases and aneuploid in 13 cases. Eight of the twenty-seven euploid cases (30%) required treatment after evacuation, whereas 10 of the 13 aneuploid cases (77%) required treatment after molar evacuation. Proliferative index (PI) was compared with treatment requirements. Average PI was 0.11 +/- 0.10 for the treatment group and 0.08 +/- 0.06 for the spontaneous resolution group. The correlation of clinical course with ploidy was significant (P less than 0.01). The association with proliferative index was not (P greater than 0.05). Aneuploidy, therefore, identifies a high-risk group of molar pregnancies, and may represent those that have undergone one stage of malignant transformation.

Flow cytometric deoxyribonucleic acid index: a prognostic factor in endometrial carcinoma

In a prospective study, flow cytometric deoxyribonucleic acid analyses were performed on cell samples from benign and malignant tumors of the endometrium and benign endometrium. No ploidy aberrations were found in normal endometrium. Of 52 cases with adenocarcinomas, 38 (73%) were diploid and 14 (27%) aneuploid. Both the frequency and the degree of aneuploidy were correlated to histologic tumor grade but not to other prognostic variables such as International Federation of Gynecologists and Obstetricians stage, depth of myometrial invasion, or patient age. Patients with aneuploid tumors had a higher recurrence rate and shorter disease-free intervals as compared to those with diploid tumors. Similarly, death rates were higher and the median survival was shorter in the aneuploid group. Flow cytometric ploidy determination may therefore serve as an important prognostic parameter.

Flow cytometric analysis of adrenal cortical tumor DNA. Relationship between cellular DNA and histopathologic classification

Nuclear DNA contents of 22 paraffin-embedded adrenal cortical tumors (16 adenomas and 6 carcinomas) were determined by flow cytometric analysis. While all of the sixteen adenomas had a diploid pattern, 83.3% (5/6) of the carcinomas were aneuploid. Three of the six patients with carcinomas (50%) developed metastases and died of their disease; all had aneuploid tumors. The three living patients with carcinoma included two children, with aneuploid tumors, and one adult, with a diploid tumor. Large tumor size correlated with aneuploidy. This study indicated that flow cytometric analysis of nuclear DNA content complements conventional histopathologic methods in the diagnosis of malignancy in adrenal cortical tumors. It may also prove to be a valuable tool in predicting the prognosis of patients with adrenal cortical carcinomas.

DNA and nuclear protein measurement in isolated nuclei of human endometrium

Feulgen-DNA and nuclear light green-protein measurements have been performed in isolated nuclei of normal (nonmalignant) and malignant human endometrial homogenates. The DNA content of the G0/G1 fraction of malignant endometrium showed much overlap with that of normal endometrium, or was slightly increased. Two of the 18 carcinomas were clearly aneuploid. No correlation was found between the histological grade and the DNA content. The tumors of clinical stage II and higher all had a higher DNA content than that of normal endometrium. The percentage of cells present in the proliferative fraction was higher in proliferative endometrium than in secretory and post-menopausal atrophic endometrium. For malignant endometrium, percentages were found comparable to that of normal endometrium or higher. No correlation was found with the histological grade. Tumors of stage II and higher had intermediate values compared to those of carcinomas below stage II. The nuclear protein/DNA ratio of malignant endometrium completely overlapped that of normal endometrium. However, for post-menopausal women, most values of the carcinomas exceeded that of normal, atrophic, endometrium. Within the tumor population, no correlation was found with the histological grade. Higher values were found with tumors of clinical stage II and higher.

Cytodynamics of endometrial hyperplasia and neoplasia, Part II: in vitro DNA histoautoradiography

The cytokinetics of normal, hyperplastic, and neoplastic human endometrium were evaluated by in-vitro double labeling with low- and high-dose radiothymidine. Relative to cyclic, proliferative endometrium, the mean S-phase duration was shorter in anovulatory, persistent proliferative endometrium, cystic glandular hyperplasia, and adenomatous hyperplasia without atypia, similar in adenomatous hyperplasia with severe atypia (AAH), and significantly prolonged in carcinoma in situ and invasive carcinoma. The S-phase patterns suggest a pathogenetic relationship between hyperplasias of increasing atypia as well as between hyperplasia and carcinoma, with carcinoma in situ as a transitional state between AAH and invasive carcinoma.

The endometrial hyperplasias and their relationship to endometrial neoplasia

The various forms of endometrial hyperplasia are classified and a description given of their pathology and of their inter-relationships. The nosological status of endometrial adenocarcinoma in situ and the histological differentiation between hyperplasia with severe cellular atypia and endometrial adenocarcinoma are discussed. The aetiology and pathogenesis of the various endometrial hyperplasias are considered and grounds are given for the belief that glandular hyperplasia with cellular atypia is a form of intraendometrial neoplasia. A new terminology, based on the biological nature of the various endometrial abnormalities, is proposed and a plea is made for the introduction of the term 'intraendometrial neoplasia' to encompass all forms of endometrial glandular hyperplasia with cellular atypia and intraendometrial adenocarcinoma.

Cytophotometric determinations of DNA, histone, arginine, lysine, and their concentrations in eu- and heterochromatin of the cell nucleus of dysplasias, carcinoma in situ, and carcinoma of the human cervix uteri

In the cell nuclei of dysplasias, carcinoma in situ, and carcinoma the amount of DNA, histone, arginine, lysine, and their condensed areas were determined by cytophotometry. Moreover their concentrations in the euchromatic and heterochromatic areas of the nuclei were measured. Statistical analysis showed that the quantitative relations between parameters did not change during carcinogenesis. The significantly increased amount of lysine underlines the role of the lysine-rich histones in producing denser coiling of the chromatin fibril in heterochromatin.

DNA-flow-cytometric measurements on the normal, atrophic, hyperplastic and neoplastic human endometrium

DNA distribution patterns and the fractions of the cell cycle phases were determined by means of flow-through cytometry in 87 samples of normal, atrophic, hyperplastic and carcinomatous human endometrium. The S-phase fractions vary during the normal menstrual cycle between 1 and 3% and reach a periovulatory maximum between 4.4 and 4.7%. Atrophic endometrium and regressive glandular cystic hyperplasia have little DNA synthesis (1.01% and 1.68% S-phase fractions respectively). Proliferating glandular cystic hyperplasia reveals 3.38% S-phase fraction, whereas adenomatous hyperplasia has an increased number of DNA-synthesizing cells (4.81%). The well-differentiated endometrial carcinoma shows no cytophotometrically detectable differences in comparison to adenomatous hyperplasia. All endometrial samples except for poorly differentiated endometrial carcinoma showed a diploid to tetraploid DNA distribution pattern. The poorly differentiated endometrial carcinoma displays two different types: one rapidly growing diploid-tetraploid tumor with 8.0 to 9.6% S-phase fractions, and another type with stemline deviations, polyploid nuclei and less pronounced synthetic activity.

Definition of precursors in gynecologic cancer

Epithelial lesions of the vulva with patterns of dysplasia or carcinoma in situ may be associated with underlying invasive squamous cell carcinoma or the presence of dysplasia or carcinoma elsewhere on the vulva. These lesions may regress spontaneously, particularly when they appear as multiple papules in young patients. Two major classifications of precancerous lesions of the cervix are in current usage: 1) mild to severe dysplasia and carcinoma in situ; 2) cervical intraepithelial neoplasia, grades I to III. Both of them imply a more complete understanding of the nature of these changes than exists at the present time. Precancerous lesions of the cervix, vagina, vulva, and/or perineum are often associated synchronously or asynchronously. Although there are numerous designations for precancerous lesions of the endometrium, relatively little precise information exists about their significance. In managing women with these lesions, the gynecologist should communicate with the pathologist about the meaning of his diagnostic term, inquiring how far along the road toward invasive carcinoma the precancerous process is judged to be.

The DNA content and nuclear size in normal, dysplastic and carcinomatous laryngeal epithelium. A spectrophotometric study

The aim of the present study was to obtain a more objective evaluation of nuclear hyperchromasia and polymorphism in laryngeal epithelium. The method is based on a photometric assay of nuclear size and DNA content in Feulgen stained slides. The DNA content of hyperchromatic nuclei should exceed the mean for nuclei of normal epithelium by more than twice the standard deviation. In comparison with lymphocytes (2N) the DNA content in hyperchromatic nuclei corresponds to 3.3 N. The mean DNA contents of normal, dysplastic and carcinomatous laryngeal nuclei were 69, 71 and 118 A.U. The mean nuclear area for normal, dysplastic and carcinomatous epithelial cells were 48, 41 and 73 micrometer2. The higher the degree of atypia displayed by the cells the greater was the variability of the DNA content and the nuclear size. The investigation shows that the method may provide a more objective basis for evaluating hyperchromasia and polymorphism.

Precancerous lesions of the endometrium

The existence of precancerous lesions of the endometrium is well established, but differences in terminology and difficulties in the interpretation of published studies have complicated quantitation of the malignant potential of the descibed subtypes. Clinical investigations, cellular studies, chromosome and DNA analyses, and animal experiments suggest that the malignant potential of cystic hyperplasia is low in contrast to that of the more complex types of hyperplasia. The significance of atypical secretory hyperplasia, squamous metaplasia, and endometrial polyps in the evolution of endometrial cancer has not been investigated adequately. Artifactual crowding of glands due to fragmentation and benign processes such as the epithelial regeneration in late menstrual endometrium and the Arias-Stella reaction should not be confused with precancerous changes. A classification of precancerous lesions is presented and the need for adoption of a uniform terminology for future investigations and communication with gynecologists is emphasized.

The nuclear DNA content of lobular neoplasia of the mammary gland

Twelve cases of lobular neoplasia and three cases of invasive lobular carcinoma of the breast were examined by Feulgen microspectrophotometry. Two different ranges of nuclear DNA values were observed. Eight cases of lobular neoplasia fell within the diploid range and the four remaining cases within the diploid to tetraploid range, while the three cases of invasive lobular carcinoma showed a DNA distribution between the diploid and tetraploid range. Cytophotometrically, lobular neoplasia with diploid DNA values can be considered to represent a precancerous condition, whereas lobular neoplasia with diploid to tetraploid values are regarded as a more advanced stage of an non infiltrating carcinoma still confined to the performed spaces.

The ultrastructural morphology of gynecologic neoplasms

Our knowledge of the morphology and pathogenesis of malignant neoplasms of the female genital tract has traditionally depended heavily on their light microscopic characteristics. The introduction of transmission, and most recently, scanning electron microscopy, into the field of gynecologic pathology has resulted in a considerable improvement in the diagnosis of genital cancers that are difficult to classify and has provided valuable information for a better understanding of their subcellular dynamics and pathogenetic development. This paper describes and illustrates the ultrastructural alterations that are considered specific for the most common malignant and potentially malignant neoplasms of the genital system in this context. The value of electron microscopy in the morphologic study of genital cancers warrants its increased use in routine diagnostic pathology, as well as further evaluation of it in basic research in this challenging area of investigation.

A chromosome study of seven near-diploid carcinomas of the corpus uteri

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