Squamous intraepithelial neoplasia in an ovarian cyst, cervical intraepithelial neoplasia, and human papillomavirus

Oncogenic Human Papillomavirus involvement in epithelial ovarian carcinoma among women in Morocco

Epithelial Ovarian cancer (EOC) although rare is the most lethal gynecological cancer in women worldwide. Despite its high prevalence few studies have been performed to evaluate the prevalence and determinants of HPV infection worldwide. The aim of the present study was to investigate the presence of HPV-DNA in Moroccan patients with EOC using PCR among women in Casablanca, and to examine the prevalence of some HPV genotypes in Moroccan population. We performed a study of HPV detection on Fresh biopsies of 70 epithelial ovarian cancer patients. PCR was realized using the MY09/11 and GP5+/6+ primers. Genotyping of HPV was performed by PCR typespecific for HPV 6, 11, 16, 18, 31, and 33.Data was statistically analyzed using SPSS software. Hence, the mean age was 48.9 years (range,21-76 years). Serous adeno carcinoma (75.71%) and stage III of the disease represent the majority of cases. eight patients were HPV positive (11.42%).Results of HPV genotyping revealed predominance of two genotypes: HPV 16 (87.5%) and HPV 31(12.5).No co-infection identified. Approximately 75% of positive cases had a serous cystadeno carcinoma and more than 62,5% had FIGO advanced stage (III or IV).Our study showed that high-risk HPV infection could play a major role among patients with EOC in Morocco.

Ovarian borderline mucinous tumor with squamous overgrowth: An unusual finding with review of literature

Borderline mucinous tumor (BMT) is often associated with other entities such as dermoid cyst, Brenner tumor, and endometriosis. Squamous areas are often associated which may be a part of BMT or its associated conditions. Here, we describe squamous overgrowth in a case of intestinal type of mucinous borderline tumor in a 29-year-old uniparous female and discuss the diagnostic difficulties.

Detection of human papillomavirus in squamous cell carcinoma arising from dermoid cysts

OBJECTIVE

Primary squamous cell carcinoma (SCC) of the ovary in humans is rare. Most cases represent a malignant transformation of ovarian teratoma, Brenner tumor, or endometriosis. The etiology of this cancer remains largely unknown. Human papillomavirus (HPV) infection is a critical factor that induces tumor formation, particularly cervical cancer. Therefore, this study aimed to evaluate the association of HPV with malignant transformation of mature cystic teratoma (MCT) into SCC of the ovary.

MATERIALS AND METHODS

The samples included four formalin-fixed paraffin-embedded SCC-MCT tissues and their adjacent tissues from the cervix to the ovaries, 12 cases of benign teratoma ovarian tissues (dermoid tissues), and 11 cases of benign nonteratoma ovarian tissues (nondermoid tissues). The two squamous carcinoma tissues of the cervix were used as control samples. HPV was detected by immunohistochemistry (IHC) with anti-HPV capsid or E6 (HPV type 16/18) antibodies and in situ hybridization (ISH) with three sets of genotyping probes, HPV types 6/11, 16/18, and 31/33.

RESULTS

IHC revealed HPV infection associated with the four cases of SCC-MCT and the two cases of control cervical cancer samples. Importantly, HPV was also detected in adjacent reproductive tissues of the SCC-MCT cases, which suggested that the viral particles might spread in an ascending route through the fallopian tubes, endometrium, endocervix, and cervix to the ovaries. ISH revealed HPV type 16/18 in all SCC-MCT cases and HPV type 31/33 in two, with no HPV type 6/11 in any SCC-MCT cases. However, compared with the SCC-MCT cases, the lower detection rates of HPV in dermoid cysts and nondermoid tissues suggested that HPV might not be associated with normal ovarian tissues or benign ovarian teratomas.

CONCLUSION

Our data suggest that high-risk HPV infection might be a causal factor that induces malignant transformation of MCT into SCC of the ovary, although further investigation is still required.

Invasive Keratinizing Squamous Cell Carcinoma of the Endometrium as Extension of Invasive Cervical Squamous Cell Carcinoma

Squamous cell carcinoma of the endometrium, either primary or as an extension of a cervical carcinoma, is extremely rare. We report a case of invasive keratinizing squamous cell carcinoma of the cervix, in which there was replacement of the entire endometrial cavity by an intraepithelial and invasive cervical squamous cell carcinoma with production of a large column of keratin that bridged the endometrial cavity. Int J Surg Pathol 4(3):00-00, 1997

Pure primary ovarian squamous cell carcinoma: A case report and review of the literature

Pure primary ovarian squamous cell carcinoma (SCC) is a rare lesion that usually arises from the malignant transformation of an existing ovarian dermoid cyst. The de novo occurrence of an ovarian SCC in the absence of a prior ovarian dermoid cyst, Brenner tumor or endometriosis is extremely rare. At present, no effective therapy exists for treating pure primary ovarian SCC. The present case study describes a patient that presented with progressive coughing, who was diagnosed with an International Federation of Gynecology and Obstetrics stage IV pure primary ovarian SCC with lung metastases. The patient received postoperative chemotherapy, however, the patient succumbed to the disease. The current study also presents a review of the literature.

Ovarian squamous cell carcinoma which metastasized 8 years after cervical conization for early microinvasive cervical cancer: a case report

Squamous cell cervical carcinoma that metastasized to the ovary is common in patients with bulky tumors or locally advanced disease; however, ovarian squamous cell carcinoma that metastasized after cervical conization surgery for early microinvasive uterine cervical carcinoma is very rare. We present a case of ovarian squamous cell carcinoma that metastasized 8 years after cervical conization surgery for early microinvasive cervical carcinoma. She had no sign of recurrence in the uterine cervix. We detected human papillomavirus type 16 DNA in both cervical tissue and ovarian tissue, suggesting that ovarian squamous cell carcinoma is derived from microinvasive cervical cancer. Although there are very few cases of early microinvasive squamous cell carcinoma that metastasized to the ovary with delayed recurrence, we should pay attention strictly not only to the cervical condition but also to the ovarian condition on regular post-operative follow-up.

Metastatic Neoplasms Involving the Ovary

In this review, ovarian metastatic carcinomas from various sites, as well as other neoplasms secondarily involving the ovary, are discussed. As well as describing the morphology, the value of immunohistochemistry in distinguishing between primary and metastatic neoplasms in the ovary is discussed. While immunohistochemistry has a valuable role to play and is paramount in some cases, the results should be interpreted with caution and with regard to the clinical picture and gross and microscopic pathologic findings.

Squamous cell carcinoma of the ovary arising from a mucinous cystic tumor of endocervical (müllerian) type

Primary squamous cell carcinoma of the ovary is extremely rare. We studied a 58-year-old woman in whom a keratinizing squamous cell carcinoma of the ovary had arisen from a mucinous cystic tumor of endocervical (müllerian) type. The tumor was interpreted initially as a transitional cell carcinoma of the ovary with marked squamous differentiation, but there was no evidence of either transitional cell carcinoma or malignant Brenner tumor. Furthermore, features of dermoid cyst (mature cystic teratoma), endometriosis, or adenosquamous carcinoma were not seen. The mucinous columnar epithelial component was largely benign and only focally proliferative or borderline. As found typically in endocervical (müllerian) mucinous tumors, numerous polymorphonuclear leukocytes were seen in the stroma and the neoplastic mucinous epithelium.

Endocervical adenocarcinomas with ovarian metastases: analysis of 29 cases with emphasis on minimally invasive cervical tumors and the ability of the metastases to simulate primary ovarian neoplasms

Most endocervical adenocarcinomas ( approximately 90%) are high-risk human papillomavirus (HPV)-related neoplasms, with the remainder being unrelated to HPV; both types infrequently metastasize to the ovaries. Clinicopathologic features of 29 cases of synchronous and metachronous endocervical and ovarian tumors (26 HPV-related, 3 unrelated to HPV) were analyzed. In 18 cases, the cervical tumors were clearly invasive; these included 5 clinically evident tumors diagnosed before the ovarian metastases (immediately preoperatively to 7 y), 11 clinically unsuspected tumors diagnosed concurrently in specimens obtained for evaluation of ovarian/pelvic masses, 1 case with concurrent clinically evident cervical and ovarian masses, and 1 clinically occult tumor diagnosed subsequent to the ovarian metastasis. In 11 cases, the cervical tumors were more limited; these included 5 tumors comprised predominantly of adenocarcinoma in situ with small foci of superficial invasion ("microinvasive carcinomas") diagnosed before the ovarian metastases (3 mo to 7 y) and 6 tumors comprised of extensive adenocarcinoma in situ lacking unequivocally recognizable stromal invasion diagnosed before (9 mo to 7 y, n=4), concurrently with (n=1), or subsequent to (n=1) the ovarian metastases. Fifteen cervical tumors involved lower uterine segment corpus endometrium or endomyometrium, including 4 tumors that were minimally invasive or not recognizably invasive in the cervix. The ovarian tumors ranged in size from 2.1 to 30.0 cm (mean/median=12.7/13.5); they were unilateral in 19 cases (65.5%) and 12 of these were unilateral and 10 cm or greater. In 26 cases, including the 19 unilateral tumors, the ovarian tumors exhibited "borderlinelike," confluent glandular, cribriform, and/or villoglandular patterns simulating primary ovarian atypical proliferative (borderline) tumors or well-differentiated carcinomas; these patterns were pure in 24 and admixed with minor infiltrative foci in 2. The ovarian tumors had features typical of metastases (bilateral and infiltrative) in only 3 cases. In all HPV-related cases the paired endocervical and ovarian tumors contained identical HPV types, establishing the ovarian tumors as metastases. Endocervical adenocarcinomas, including microinvasive forms and some not recognizably invasive, have the potential to metastasize to the ovaries; extension into the lower uterine segment/corpus endometrium may be a risk factor, with retrograde uterine/transtubal spread as a possible mechanism.

p16 expression in primary ovarian mucinous and endometrioid tumors and metastatic adenocarcinomas in the ovary: utility for identification of metastatic HPV-related endocervical adenocarcinomas

Distinction of primary ovarian epithelial tumors from metastatic adenocarcinomas is challenging for tumors exhibiting mucinous, endometrioid, or mixed endometrioid/mucinous differentiation. Metastatic carcinomas with these types of differentiation can be derived from several sites, including the gastrointestinal tract and the uterus. Most endocervical adenocarcinomas exhibit mucinous and/or endometrioid differentiation; they infrequently metastasize to the ovaries but may simulate primary ovarian tumors [both atypical proliferative (borderline) and carcinoma]. Most are high-risk human papillomavirus (HPV)-related and demonstrate diffuse p16 over-expression due to complex molecular mechanisms by which high-risk HPV transforming proteins interact with cell cycle regulatory proteins. The performance of this expression pattern for identifying metastatic endocervical adenocarcinomas in the ovaries among primary ovarian tumors and other metastatic adenocarcinomas having mucinous and/or endometrioid/endometrioidlike differentiation has not been evaluated. Immunohistochemical expression of p16 was assessed in 195 tumors, including 98 primary ovarian tumors (51 mucinous, 47 endometrioid, and 4 mixed mucinous-endometrioid tumors), 93 metastatic adenocarcinomas of known primary sites (colorectum: 34, endocervix: 19, pancreaticobiliary tract: 17, appendix: 7, stomach: 5), 11 metastatic adenocarcinomas of unknown origin (7 established as noncervical), and 4 adenocarcinomas of uncertain (primary ovarian vs. metastatic) origin. The HPV status of the endocervical adenocarcinomas was determined by in situ hybridization and polymerase chain reaction (when in situ hybridization was negative). Expression was assessed based on the percentage of moderately to strongly positive cells, estimated to the nearest 10%. Mean and median expression values for HPV-positive endocervical adenocarcinomas (99%, 100%; range 90% to 100%) were substantially higher than those for primary ovarian mucinous (5%, 0%; range 0% to 70%) and endometrioid (20%, 10%; range 0% to 100%) tumors, HPV-unrelated endocervical adenocarcinomas (0%, 0%; range 0% to 60%), metastatic adenocarcinomas of unknown origin (11%, 0%; range 0% to 30%), and adenocarcinomas of uncertain (primary ovarian vs. metastatic) origin (40%, 35%; range 0% to 90%); only the 15 HPV-positive endocervical adenocarcinomas and 6 other tumors had values of 80% or greater. Diffuse (>75% positive tumor cells) moderate to strong p16 expression is a sensitive (100%) and specific (97%) marker for identifying HPV-related endocervical adenocarcinomas metastatic to the ovary among the primary ovarian tumors and metastatic adenocarcinomas from other sites that are in the differential diagnosis of ovarian tumors having mucinous and/or endometrioid/endometrioidlike differentiation. p16 is useful as part of a panel of immunohistochemical markers for distinguishing primary ovarian tumors from metastases and, when diffusely positive, can suggest the cervix as a potential primary site for metastatic adenocarcinomas of unknown origin.

HPV induced ovarian squamous cell carcinoma: case report and review of the literature

BACKGROUND

Ovarian squamous cell carcinoma is usually derived from a teratoma, a Brenner tumour or endometriosis. Association with an HPV infection is rare.

CASE

A fourth case of ovarian squamous cell cancer associated with HR-HPV is presented. Debulking for stage IIIc ovarian squamous cell cancer was performed and she received adjuvant combination chemotherapy. She developed bone metastases and received radiotherapy. The Progression of these metastases and the newly developed metastases did not respond to an oral tyrosine kinase inhibitor (gefitinib).

CONCLUSION

The development of bone metastases in association with an ovarian squamous cell carcinoma is a rare finding, and it did not respond to treatment with a tyrosine kinase. A review of literature is presented.

Analysis of ovarian tumors for the presence of human papillomavirus DNA

AIM

The role of human papillomavirus (HPV) infection in ovarian tumorigenesis is uncertain. The objective of this study was to screen a collection of ovarian tumors for the presence of high-risk oncogenic HPV types 16, 18 and 33.

METHODS

Twenty benign and malignant ovarian tumors were obtained from women undergoing pelvic surgery at a regional comprehensive cancer institution in North America. DNA was isolated from the snap-frozen tumors, and commercial polymerase chain reaction (PCR) detection sets were used to analyze the tumor DNA samples for the presence of DNA from HPV types 16, 18 and 33.

RESULTS

The DNA from HPV types 16, 18 and 33 was not detected in any of the ovarian tumors.

CONCLUSIONS

Our findings do not support an association between infection with HPV types 16, 18 and 33 and ovarian neoplasia in this patient population.

Metastatic neoplasms involving the ovary: a review with an emphasis on morphological and immunohistochemical features

The ovary is a common site of metastatic tumour. In many cases of ovarian metastasis there is a known history of malignancy but in other cases the ovarian tumour is the first manifestation of disease. In this review metastatic colorectal, appendiceal, gastric, breast, pancreatic and biliary tract, hepatocellular, renal, transitional and cervical carcinomas and metastatic malignant melanoma involving the ovary are discussed, as is the issue of synchronous ovarian and endometrial carcinomas. Peritoneal tumours, including primary peritoneal carcinoma, mesothelioma and intra-abdominal desmoplastic small round cell tumour, involving the ovary are also discussed, together with a variety of other rare, metastatic ovarian neoplasms. Many metastatic adenocarcinomas involving the ovary, especially those exhibiting mucinous differentiation, closely mimic primary ovarian adenocarcinomas with morphologically bland areas simulating benign and borderline cystadenoma. This is referred to as a maturation phenomenon. In recent years immunohistochemistry, especially but not exclusively differential cytokeratin (CK7 and CK20) staining, has been widely used as an aid to distinguish between a primary and secondary ovarian adenocarcinoma. While immunohistochemistry undoubtedly has a valuable role to play and is paramount in diagnosis in some cases, the results must be interepreted with caution, especially in mucinous tumours, and within the relevant clinical context. We feel the significance of differential cytokeratin staining is not always understood by histopathologists and this can result in erroneous interpretation. We critically discuss the value of immunohistochemistry and associated pitfalls with each tumour type described.

Detection of human papillomavirus-16 in ovarian malignancy

Human papillomavirus is the causal factor for cervical cancer. However, the role of HPV infection in ovarian cancer is unclear. This study aimed to determine the presence of human papillomavirus-16 (HPV-16) in ovarian cancer tissues. Archived human ovarian cancer tissues (N=54 cases, 50 are epithelial cancer, four are nonepithelial cancer) embedded in paraffin blocks were used. Controls are 30 nonmalignant ovarian tissue blocks. In situ hybridisation (ISH) and immunohistochemistry (IHC) were used to detect the presence of HPV-16 and p53 expression. In all, 52 or 36% of the epithelial ovarian tumours detected by ISH or IHC, respectively, were HPV-16 E6 positive. In contrast, only 6.7% of normal ovarian tissues were HPV-16 positive proved by ISH. Human papillomavirus-16 infection was significantly higher in cancer tissues compared to controls with an odds ratio of 16.7 (95% confidence interval [CI]=3.2-71.4, P<0.01). No significant correlation between HPV-16 infection and histological types of cancer was found (P>0.05). p53 gene expression was detected in 42% epithelial ovarian cancers. No correlation between p53 expression and HPV-16 infection was found. The results showed the presence of HPV-16 E6 in ovarian carcinoma, suggesting that HPV infection might play a role in ovarian carcinogenesis.

HPV16 and HPV18 in genital tumors: Significantly different levels of viral integration and correlation to tumor invasiveness

The integration of the high-risk HPV16 and HPV18 types into the cell genome is considered an important step in malignant transformation. The relationship between the physical status of the virus and clinical/pathological parameters was studied by type-specific and multiplex PCR for E6, E2, and E1 sequences in 86 genital tumors from different sites, consisting of 69 invasive carcinomas (including 5 microinvasive carcinomas), 9 carcinomas in situ, 6 severe dysplasias, and 2 moderate dysplasias. Forty tumors contained HPV16 (46.6%), 7 HPV18 (8.1%), and 39 both viruses (45.3%). HPV16 DNA was found either as pure integrant (35.4%), or pure episome (36.7%), or a mixture of both (27.8%). Conversely, all 46 lesions containing HPV18 showed pure integrated forms. The physical status of both types was not related to the tumor site, the tumor/node/metastasis stage, or the histological differentiation grade of the invasive carcinomas. HPV16 integration was significantly associated with invasiveness. Interestingly, in double infections when HPV16 coexisted with HPV18, its genome was found more frequently in episomal form than in single infections where, conversely, it was mostly integrated (P < 0.0001), suggesting a sort of competition for cell integration sites. The complete HPV18 integration, even in pre-neoplastic lesions, indicates a different behavior in genital transformation compared with HPV16 and may reflect a major aggressiveness of this viral type. In conclusion, virus typing in conjunction with the evaluation of the integration status may provide a better prognostic evaluation together with an improved diagnosis.

Failure to demonstrate human papillomavirus DNA in epithelial ovarian cancer by general primer PCR

One of the recent controversies with substantial clinical interest is the role of HPV in pathogenesis of ovarian cancer. The available highly conflicting data are based on analysis of 175 ovarian carcinomas so far. As an attempt to further elucidate this issue, the first systematic study of HPV detection in ovarian cancer was carried out using a highly sensitive general primer PCR (confirmed by hybridization for low- and high-risk HPV types separately) in a series of 98 histologically and clinically well-characterized epithelial ovarian malignancies. Despite the high (fg) sensitivity and a wide HPV type coverage of the technique used, all 98 ovarian carcinomas failed to demonstrate any signs of HPV DNA whatsoever. The preexisting 12 reports comprising a total of 175 ovarian tumors analyzed for HPV were summarized, giving highly discrepant results (i.e., detection rates from 0 to 100%) with the overall HPV DNA detection rate of 25.7%. The reasons for these discrepant findings are most probably technical. Our data are consistent with those of the majority of the most recent reports failing to disclose HPV DNA in ovarian neoplasia. The present completely negative results make the authors inclined to conclude that HPV is highly unlikely to play any causal role in the pathogenesis of epithelial ovarian neoplasia.

Synchronous ovarian and cervical squamous intraepithelial neoplasia: an analysis of HPV status

In contrast to the strong association between human papillomavirus (HPV) and cervical intraepithelial neoplasia (CIN), the relationship between HPV and squamous epithelial lesions of the ovary is less clear. We report a case of synchronous ovarian and cervical squamous intraepithelial neoplasia. To investigate the possible association between HPV and squamous intraepithelial neoplasia/carcinoma in situ (CIS) of the ovary, DNA was extracted from paraffin-embedded tissues including normal cervix, CIN, CIS from both ovaries, and an area of ovarian endometriosis. All samples were positive for HPV 16 E6 except for one of the two samples from the normal cervical squamous epithelium. These results support the hypothesis that HPV may be involved in the development of ovarian squamous intraepithelial neoplasia.

Human papillomavirus and mixed epithelial tumors of the endometrium

Strong epidemiological evidence links human papilloma viruses (HPV) with the development of cervical intraepithelial neoplasia (CIN) and invasive cancers of the uterine cervix. The localization of HPV DNA sequences high up in the female genital tract (in benign and malignant lesions) is not that uncommon, but its precise significance is uncertain. In particular, the detection of HPV DNA sequences by polymerase chain reaction (PCR) needs careful interpretation, because the source of the amplicon may emanate from tumor cells, direct contamination from the cervix, or possibly from extratumoral sites in the endometrium. We have previously reported the identification of koilocyte-like changes in the squamous epithelium of some endometrial adenoacanthomas. Adenoacanthomas (adenocarcinoma with squamous metaplasia) are mixed epithelial tumors arising in the endometrium composed of malignant glandular areas admixed with benign metaplastic squamous epithelium. The rarer adenosquamous carcinoma containing both malignant glandular and squamous areas is also described. The origin of benign/malignant squamous epithelial islands in endometrial tumors has been the subject of speculation, with some investigators considering an origin from metaplastic glandular endometrial cells. In this study, we examined 10 normal endometrial samples, 20 adenocarcinomas, 41 adenocarcinomas with squamous metaplasia, and two adenosquamous carcinomas, (including control cervical material where possible) for the presence of HPV DNA sequences using nonisotopic in situ hybridization (NISH), type-specific HPV PCR, general primer PCR (to detect sequenced and unsequenced HPVs), and PCR in situ hybridization (PCR-ISH). We did not identify HPV DNA sequences in normal endometrial tissue. In adenocarcinomas (endometrioid type), HPV was only identified in 2 of 20 cases by PCR, both of which were HPV 11 positive. We were unsuccessful in identifying HPV in endometrial carcinomas by NISH or by PCR-ISH, raising the possibility of contamination from the cervix in the two positive cases. In adenoacanthomas, a low-risk HPV type (HPV 6) was found in 19 of 41 cases. NISH signals were intranuclear in location in squamous regions of adenoacanthomas. Additional positive nuclei were uncovered using PCR-ISH, which increases the sensitivity of standard NISH detection. HPV DNA sequences were located in some malignant endometrial glandular epithelial cells, but this accounted for a minority of samples. HPV DNA sequences were not detected in extraepithelial sites. Mixed infection by two different HPV types was identified in two cases. Most cases showed similar HPV types in cervical and endometrial lesions, although discordant cases were uncovered. In adenosquamous carcinomas, one case showed mixed infection with HPV 6 and 33 by PCR. The apparent segregation of low-risk HPV type (HPV 6) with benign squamous metaplastic epithelium in adenocarcinoma with squamous metaplasia, and high-risk type (HPV 33) with malignant squamous epithelium in adenosquamous carcinoma, raises important questions in relation to the role of HPVs in mixed epithelial tumors of the endometrium and their interplay in the pathogenesis of squamous metaplasia at extracervical sites.

Bilateral primary ovarian squamous cell carcinoma associated with human papilloma virus infection and vulvar and cervical intraepithelial neoplasia. A case report with review of the literature

Primary squamous cell carcinoma of the ovary is rare. Most cases represent malignant transformation of ovarian teratomas. Other cases are associated with preexisting Brenner tumor or ovarian endometriosis. We report a primary ovarian squamous cell carcinoma in a 40-year-old woman. The patient had recurrent high-grade intraepithelial neoplasia of the vulva (VIN) and recurrent high-grade cervical intraepithelial neoplasia (CIN). Human papilloma virus (HPV) DNA 16/18 was identified in an in situ and invasive carcinoma in the left ovary; CIN and VIN were identified with in situ hybridization with biotinylated DNA probes. Review of the literature revealed nine cases of primary ovarian squamous cell carcinoma not associated with a preexisting ovarian lesion. Three cases were not associated with CIN and occurred in women who ranged in age from 64 to 90 years and did not have carcinoma in situ component. Six cases were associated with CIN, had a carcinoma in situ, and occurred in younger women ranging from 33 to 54 of age. Our case belonged to the latter category. This report raises the possible causal relationship of HPV with primary ovarian squamous carcinoma in the group of middle-aged patients with CIN.