Immunohistochemical localizations of CA 125, carcinoembryonic antigen, and CA 19-9 in normal and neoplastic glandular cells of the uterine cervix

Uterine Glandular Carcinoma

This study correlated the histologic and immunohistochemical features of cervical and endometrial glandular carcinomas (adenosquamous carcinoma [ADENSQ] and ade nocarcinoma [AC] ) with clinical outcome. A series of 87 uterine glandular carcinomas (53 cervical, 33 endometrial, and 1 arising in both cervix and endometrium) were histologically classified into mullerian subtypes: 28 ADENSQ, 19 serous AC, 19 mu cinous AC, 15 endometrioid AC, and 6 clear cell AC. Utilizing both nuclear and archi tectural features, 66 glandular carcinomas were high histologic grade (3) and 21 were low histologic grade (1 or 2). Immunohistochemical studies performed on 83 of the cases showed: 33 + for monoclonal carcinoembryonic antigen (CEA-M); 38 + for polyclonal CEA (CEA-P); 26 + for placental alkaline phosphatase; 18 + for CA 125; 29 + for CA 19-9; 24 + for vimentin; 60 + for cytokeratin CAM 5.2; and 81 + for cytokeratin AE 1 : 3. The following significant correlations were identified. ADENSQ histology was associated with CEA-M staining (P < .025), and mucinous histology was associated with CA 19-9 staining (P < .025). Cervical primary site was associated with ADENSQ histology (P < .001) and staining with CEA-M (P < .025) and CEA-P (P < .05). Endometrial primary site was associated with endometrioid histology (P < .001). Forty-five patients had recurrent disease, 30 patients were disease-free for more than 1 year, and 12 patients had insufficient follow-up evaluation. Recurrent disease was associated with stage III or IV tumors (P < .001), grade 3 histology (P < .001), serous differentiation (P < .001), invasion to at least the middle third of the myometrium (P < .001) and large size of residual tumor at hysterectomy (mean 3.9 cm versus 1.3 cm, P < .005). Disease-free survival was associated with endometrioid differentiation (P < .05), strong CEA-M staining (P < .001), CEA-P staining (P < .025), and CA 19-9 staining (P < .05). Considering only stage 1 and 2 patients, grade 3 histology ( P < .025), deep myometrial invasion (P < .01), and size (P < .05) were still associated with recurrence and strong CEA-M staining (P < .025) was still associ ated with disease-free survival. However, strong CEA-M staining, deep myometrial invasion, and size of tumor after hysterectomy were all associated with histologic grade. Considering just histologic grade 3 carcinomas in stage 1 and 2 patients, absence of strong CEA-M staining, deep myometrial invasion, and size of tumor was no longer associated with recurrent disease. Histologic grade was the only independent predictor of prognosis in stage I and II patients. Int J Surg Pathol 1 (1): 13-24, 1993

Adenocarcinoma and Adenosquamous Carcinoma of the Uterine Cervix

A series of 53 carcinomas of the uterine cervix with a component of glandular differen tiation were identified and included 29 pure adenocarcinomas and 24 adenosquamous carcinomas. Cervical adenosquamous carcinomas were defined as glandular carcino mas mixed with a squamous carcinoma component. Cervical pure adenocarcinomas were classified into various Mullerian subtypes analogous to other portions of the female genital tract yielding 14 mucinous/endocervical, 11 serous, 2 clear cell, and 2 endometrioid adenocarcinomas. A panel of immunostains including monoclonal carcinoembryonic antigen (CEA-M), polyclonal carcinoembryonic antigen (CEA-P), CA 125, CA 19-9, placental alkaline phosphatase, and vimentin showed no association with histologic differentiation except for mucinous/endocervical subtype (7 of 11 CEA- M or CEA-P positive and 7 of 11 CA 19-9 positive). Recurrent disease in adenocarci noma and adenosquamous carcinoma was associated with stage III or IV disease at presentation (P < .001), serous histology (P < .05), absence of strong CEA-M staining (P < .025), absence of strong CEA-P staining (P < 05), and presence of vimentin staining (P < .05). No association was found between survival and other histologic subtypes of adenocarcinoma (mucinous/endocervical, endometrioid, or clear cell), ad enosquamous carcinoma, histologic grade, lymphatic invasion, age, or immunohisto chemical staining for CA 125, CA 19-9, or placental alkaline phosphatase. When only stage I and II disease was considered, there was no correlation between histology or immunohistochemistry and outcome. Int J Surg Pathol 1(3):181-190, 1994

The spectrum of cervical glandular neoplasia and issues in differential diagnosis

CONTEXT

Premalignant and malignant glandular lesions of the cervix are known to often cause diagnostic problems with a variety of benign (more common) as well as other malignant mimics, the latter setting often being represented by secondary involvement by endometrioid endometrial carcinoma especially in small samplings.

OBJECTIVE

To highlight key histologic features and immunohistochemical markers that may be helpful in the distinction of in situ endocervical carcinoma from benign glandular proliferations, and those that separate different subtypes of invasive endocervical carcinoma, as well as invasive carcinoma from other carcinomas secondarily involving the cervix and nonneoplastic proliferations of the cervix.

CONCLUSIONS

Clinical and morphologic features as well as immunohistochemistry results should be used in conjunction in the differential diagnosis of glandular proliferations of the cervix, as correct interpretation has major clinical consequences for the patient in most instances (especially benign versus malignant). Immunohistochemical markers should be used as part of a panel of antibodies, as exceptions may occur to the usual pattern of staining, and if used singly, they may mislead the pathologist to establish a wrong diagnosis.

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.

Microglandular adenocarcinoma of the uterus mimicking microglandular cervical hyperplasia

We present a rare case of microglandular carcinoma of the uterus occurring in 76-year-old woman. The tumor tissue in the curettage specimen showed strong similarity with microglandular hyperplasia of the cervix. Microglandular aggregates of glands with only mild nuclear atypia but without any structures of conventional endometrioid carcinoma were seen. Therefore, a microglandular hyperplasia of the cervix was seriously considered. The following features were helpful in the differential diagnosis: numerous neutrophils and "dirty" amount within glandular lumens; very scarce (but nevertheless present) mitoses; isolated single glands with more endometrioid than endocervical appearance; and strong expression of vimentin, which is unusual for microglandular hyperplasia of the cervix. In the resectate, a conventional well-differentiated endometrioid adenocarcinoma with microinvasion of the myometrium (under 1 mm of depth) was found. Microglandular differentiation has been, however, present in plaque-like proliferation replacing the endometrium and on the surface of conventional adenocarcinoma. Eleven months after the hysterectomy, the patient has no signs of recurrence or metastasis. Our case shows the difficulties in the diagnosis of this lesion and confirms a low aggressiveness that was observed in all 10 cases described to date.

Mucinous endometrial adenocarcinoma simulating microglandular hyperplasia of the cervix

A case of endometrial adenocarcinoma simulating microglandular hyperplasia (MGH) of the cervix is presented. A postmenopausal 53-year-old woman, with no previous history of taking exogenous hormones, presented with vaginal bleeding. An endometrial biopsy exhibited a tumor composed predominantly of a microglandular proliferation of tightly packed glands with mild to moderate atypia and mitotic figures. The majority of the tumor cells contained intracytoplasmic mucin. There were numerous neutrophils within the microglandular lumens and in the stroma. The tumor was focally positive for carcinoembryonic antigen and vimentin. The MGH-like proliferation, focally, had a transition to a conventional mucinous adenocarcinoma. Hysterectomy specimens showed a residual mucinous endometrial adenocarcinoma with no myometrial invasion, the uterine cervix was unremarkable. Four years following her hysterectomy the patient was well, with no evidence of disease. Pathologists need to be cautious about MGH-like changes in the endometrial biopsy of postmenopausal women and be aware of this type of endometrial cancer as it may be misdiagnosed.

Distribution of epithelial-specific antigen in uterine cervix with endocervical glandular dysplasia

The natural history of cervical adenocarcinoma is largely unknown, and whether endocervical glandular dysplasia is a precursor lesion to malignant tumor formation is a controversial issue. The aim of this study was to clarify the relationship of endocervical glandular dysplasia to the uterine endocervical adenocarcinoma. Thirty-one cases of glandular abnormalities of the uterine cervix were identified histologically from January 1984 to April 1992. These included 11 cases of endocervical glandular dysplasia, 5 cases of adenocarcinoma in situ, 4 cases of microinvasive adenocarcinoma, and 11 cases of invasive adenocarcinoma. The immunohistochemical localization of epithelial-specific antigen (ESA) was examined in these cases of endocervical glandular dysplasia and related lesions, and was compared to 10 normal endocervical specimens. ESA immunoreactivities were usually present in the basolateral membrane of endocervical cells in the normal endocervix. However, the expressions of ESA were increasing from the basolateral membrane to the diffuse cytoplasmic membrane, along with the malignant transformation of the endocervical cells, in 6 of 11 cases with glandular dysplasia, in 9 of 9 cases with in situ and microinvasive adenocarcinomas, and in 11 of 11 cases with invasive adenocarcinomas. This finding indicates that ESA is a useful marker for endocervical glandular dysplasia and related lesions with malignant transformation, and suggests that endocervical glandular dysplasia may be a precursor lesion to uterine cervical adenocarcinomas.

Prognostic value of the histochemical expression of helix pomatia agglutinin in advanced colorectal cancer. A univariate and multivariate analysis

PURPOSE

The expression of helix pomatia agglutinin in advanced colorectal cancer was evaluated in order to determine whether helix pomatia agglutinin could serve as an effective prognostic indicator.

METHODS

Using the histochemical procedure, the expression of helix pomatia agglutinin was studied in 117 patients with primary colorectal cancer. Sixty of 117 patients who died of either recurrence or metastasis within two years (Group 1) after resection were compared with the other 57 patients who survived for five years or longer (Group 2).

RESULTS

The helix pomatia agglutinin-positive expression was seen in 34 cases of Group 1 and in only 15 cases of Group 2 (P < 0.01). Lymph node metastasis, lymphatic invasion, venous invasion, mucin production, and helix pomatia agglutinin expression all had a significant correlation with the prognosis in the univariate analysis; however, only lymph node metastasis, venous invasion, and helix pomatia agglutinin expression were prognostic factors with a significant difference in the multivariate analysis.

CONCLUSIONS

Histochemical expression of helix pomatia agglutinin will indeed aid in accurately predicting the prognosis of patients with advanced colorectal cancer.

Epidermal growth factor enhances secretion of the ovarian tumor-associated cancer antigen CA125 from the human amnion WISH cell line

OBJECTIVE

We studied the relation between epidermal growth factor (EGF)/epidermal growth factor receptor (EGFR) and CA125 production in WISH cells.

METHODS

We investigated quantitatively and immunohistochemically EGF-stimulated CA125 release from WISH cells and the effect of EGF on CA125 phosphorylation.

RESULTS

Immunohistochemical staining demonstrated that CA125 and EGFR expression on the plasma membrane of the WISH cells was closely correlated with cell density. The WISH cell monolayers (day 4) stained for CA125 in both the cytoplasm and plasma membrane. By day 8, cells began to form clumps in the surrounding monolayer that were positive for membrane-associated CA125 and EGFR, while the monolayer was almost negative for both molecules. Four-day and 8-day cells exposed to EGF demonstrated a loss of both CA125 and EGFR staining. Epidermal growth factor increased the secreted CA125 levels by 50% in day-4 cells but had no effect on day-8 cells. CA125 from WISH cells was phosphorylated, and EGF further enhanced this phosphorylation.

Unusual endocervical lesions with endocrine cells

Four cases of unusual lesions of endocervix are presented. They were all incidental findings, showing no obvious infiltrative and metastatic properties to attest their malignant nature. Two lesions were entirely confined to the endocervical mucosa. The main characteristics of these proliferative processes thus were an abnormal architecture with branched or small glands, a hypermucinous benign-appearing epithelium of endocervical type, and stromal smooth-muscle. In contrast with normal endocervical mucosa, all lesions contained prominent and variegated endocrine cells. These 4 cases were quite comparable to 3 other observations previously reported. This homogeneous group of endocervical lesions does not correspond to a well-defined type of endocervical neoplasia. It shares morphological analogies with adenoma malignum. The relationship with adenoma malignum as well as with some other gynaecological neoplasms is discussed. The recognition of these small-sized and highly differentiated lesions is largely facilitated by the use of the Grimelius reaction to detect argyrophilic cells.

Serial changes of serum CA125 levels during menstrual cycles

Serial changes of serum CA125 levels during 32 menstrual cycles were examined in 32 healthy young women (19-21 years of age) charting basal body temperature (BBT) and measuring serum estradiol and progesterone levels. Analysis of BBT charts and serum progesterone levels revealed that the 32 menstrual cycles could be classified into either an ovulatory cycle with a sustained BBT temperature increase for at least 10 days (type I: 9 cycles), an ovulatory cycle with a sustained BBT temperature increase for less than 10 days (type II: 17 cycles), or anovulation (type III: 6 cycles). All 32 cycles exhibited basal CA125 levels of less than 35 u/ml throughout the cycle, except during the period of menstruation. At menstruation, 7 of the 9 cycles of type I showed a marked, transient elevation of CA125 levels from previous basal levels (a mean net increase). On the other hand, 12 of 17 cycles of type II showed only a slight elevation of CA125 levels during the period of menstruation. None of the 6 cycles of type III showed any apparent increase in CA125 levels during the period of menstruation. The mean net increase of CA125 levels during the period of menstruation in the cycles of type I was significantly higher than that of the cycles of type II (p less than 0.05) and type III (p less than 0.05). These results imply that a transient elevation of serum CA125 levels during the period of menstruation occurs in cycles with ovulation, and the levels of elevation seem to be closely associated with the duration of the sustained BBT temperature increase.

Secondary müllerian system and endometriosis

The pathogenesis of endometriosis is controversial. The two principal histogenetic theories are (1) metastases of endometrial tissues to an ectopic location (metastatic theory) and (2) metaplastic development of endometrial tissue at the ectopic site (metaplastic theory). Studies on the development of the coelomic cavity and the müllerian duct, as well as expression of CA 125 during the fetal period and in the adult, strongly suggest that coelomic epithelium-related tissues and müllerian-derived epithelia of the adult have a shared embryologic ancestry. Many manifestations of müllerian-directed metaplasia suggest that tissues derived from the coelomic epithelium and its accompanying mesenchymal cells, referred to as the "secondary müllerian system," have the potentiality to differentiate into müllerian-directed epithelium and stroma. This metaplastic potentiality of the secondary müllerian system constitutes a basic concept in the pathogenesis of endometriosis.

Endocervical carcinoma

The past two decades have seen an increase in the incidence of endocervical carcinoma. Numerous studies have increased understanding of these tumors; hormonal therapy, human papilloma virus, and other cofactors have been implicated in the etiology of endocervical carcinoma. Early diagnosis is difficult: precursor lesions to adenocarcinoma in situ are still poorly defined and understood, and there may be a rapid transit time from in situ to invasive carcinoma. The definition of microinvasive adenocarcinoma is not uniformly agreed upon, and at this time the recommendation is not to use the term. Histologic typing and grading of adenocarcinoma may be useful in the prediction of prognosis for patients. Therapy is based upon stage of disease, the most beneficial results being obtained from either radical surgery or combination surgery and radiation therapy.

Elevated CA125 serum levels in a patient with tuberculous peritonitis

We report a case of tuberculous peritonitis in a 59-year-old post-menopausal woman. Her serum CA125 level was raised and fell in response to antituberculous therapy.

Immunohistochemical localization of CA130 in fetal tissues, and in normal and neoplastic tissues of the female genital tract

A murine monoclonal antibody, 130-22, produced against a human lung adenocarcinoma cell line (PC-9) has been suggested as recognizing an antigenic determinant (CA130) which is different from an epitope recognized by OC125 on CA125 glycoprotein molecules. The immunohistochemical reactivity with the 130-22 antibody (anti-CA130) was examined in human fetal tissues, and normal and neoplastic tissues of female genital tracts, and compared to those using OC125. Among the fetal tissues, the amnion and the cells of coelomic epithelium and mullerian-derived epithelia reacted with anti-CA130. In normal adult tissues, cervical and endometrial gland cells, tubal epithelial cells, and ovarian surface cells reacted with anti-CA130. In addition, predecidual cells in the late secretory endometrium and decidual cells during gestation were positive. Among the neoplastic tissues, tubal and endometrial adenocarcinomas and epithelial ovarian tumors were positive for anti-CA130. There were no differences in the respective specimens between the immunohistochemical localization of anti-CA130 and of OC125. Therefore, anti-CA130 is considered to be useful in the immunohistochemical detection of CA125 glycoprotein molecules as well as OC125.

Adenocarcinoma of the uterine cervix. Prognostic significance of pretreatment serum CA 125, squamous cell carcinoma antigen, and carcinoembryonic antigen levels in relation to clinical and histopathologic tumor characteristics

The prognostic value of the pretreatment serum CA 125, squamous cell carcinoma antigen (SCC), and carcinoembryonic antigen (CEA) levels in relation to tumor type, vascular invasion by tumor cells, and lymph node metastases was investigated in 77 patients with cervical adenocarcinoma. In Stage IB (International Federation of Gynecology and Obstetrics [FIGO]), the five-year actuarial survival of patients with pretreatment serum CA 125 levels greater than 16 U/ml was 52.4% versus 95.6% when normal serum CA 125 levels were determined (P less than 0.01). Pretreatment serum SCC or CEA levels had no substantial prognostic value. In Stage IB (FIGO), 42% of the patients with elevated serum CA 125 levels had lymph node metastases versus 4% when normal levels were found (P = 0.012). The presence of vascular invasion (P = 0.01) or lymph node metastases (P = 0.001) was associated with an increased risk for recurrent disease. Adenosquamous tumors showed a higher incidence of vascular invasion (P = 0.05) and a higher incidence of elevated serum CA 125 levels (P = 0.03). Particularly in Stage II, adenosquamous tumors were found to have a poorer prognosis than adenocarcinomas (P = 0.0566). We conclude that in cervical adenocarcinoma serum CA 125 is an important prognostic factor and an implicit indicator of tumor virulence.

Mucin leakage into the cervical stroma may increase lymph node metastasis in mucin-producing cervical adenocarcinomas

The relationships between the histologic feature of mucin leakage into the cervical stroma, lymph node metastasis, and the levels of serum carcinoembryonic antigen (CEA), CA 19-9, and CA 125 were analyzed in 35 cases of cervical adenocarcinoma. Histologically, mucin leakage was identified in 14 (40%) cases as amorphorous materials dissecting the connective tissues and permeating the lymphatic channels, associated with or without cancer cells. The cases with mucin leakage showed a significantly higher incidence of lymph node involvement than those without mucin leakage (71.4% versus 23.8%; P less than 0.01). In addition, when the mucin leakage was immunohistochemically positive for CEA or CA 19-9, elevated serum levels of these antigens were frequently observed. These results suggest that the mucin leakage into the cervical stroma represents not only stromal invasion, but also a means that frequently conducts cancer cells into the lymphatic channels. Clinically, this is reflected in an elevation of serum CEA or CA 19-9 levels in cervical adenocarcinoma patients.

CA 125 in the epithelium closely related to the embryonic ectoderm: the periderm and the amnion

The amnion is believed to be derived from either cytotrophoblastic cells or embryonic ectoderm. However, it produces and secretes CA 125, which is considered a differentiation antigen of fetal coelomic epithelium derived from the mesoderm of germ cells. To verify this, the immunohistochemical localization of CA 125 in human fetal tissues (between 7 and 23 weeks of gestation) derived from the ectoderm, endoderm, or mesoderm, and in the fetal membranes and placenta was studied. Among the mesoderm-derived tissues, only the fetal coelomic epithelium-related tissues were positive for anti-CA 125 from 15 weeks of gestation. The endoderm-derived tissues did not react with anti-CA 125. However, among the ectoderm-derived tissues, only the periderm reacted with anti-CA 125 from 7 weeks until it sloughed from the stratum intermedium by 23 weeks of gestation. Among the fetal membranes and placenta, only the amnion reacted with anti-CA 125 from 9 weeks to term. These findings indicate that the amnion and the periderm, both of which constitute the epithelia covering the amniotic cavity, in addition to the fetal coelomic epithelium-related tissues, produce CA 125.

Immunohistochemical localization and tissue levels of tumor-associated glycoproteins CA 125 and CA 19-9 in the decidua and fetal membranes at various gestational ages

To investigate the sources and biologic significance of CA 125 and CA 19-9 in amniotic fluid, immunohistochemical and biochemical localization of these tumor-associated glycoproteins in the decidua and fetal membranes was studied. Immunohistochemically, CA 125 and CA 19-9 were localized in the cytoplasm of decidua cells and amnion epithelial cells but not in the chorion and placental tissue. Biochemically, the 12,000 X g supernatant fractions of decidua and amnion tissues contained relatively large amounts of CA 125 and CA 19-9, 73% to 96% of which was present in the cytosolic fractions of these tissues. The CA 125 levels in the amniotic fluid decreased, whereas those of CA 19-9 increased with gestation, which correlated well with the respective levels in amnion tissues. These findings suggest that amnion cells produce and secrete these glycoproteins into the amniotic cavity. However, it is possible that the decidua also secretes CA 125 into the amniotic cavity through the chorion and amnion such as in the case of prolactin.