Fascin expression in undifferentiated and dedifferentiated endometrial carcinoma

Dedifferentiated Endometrial Carcinoma: A Rare Aggressive Neoplasm-Clinical, Morphological and Immunohistochemical Features

Dedifferentiated endometrioid adenocarcinoma is characterised by the coexistence of an undifferentiated carcinoma and a low-grade endometrioid adenocarcinoma. The low-grade component in this subtype of endometrial carcinoma is Grade 1 or 2 according to the Federation of Gynaecology and Obstetrics (FIGO) grading system. The coexistence of low-grade endometrial carcinoma and solid undifferentiated carcinoma can cause diagnostic problems on histological examination. In fact, this combination can often be mistaken for a more common Grade 2 or Grade 3 endometrial carcinoma. Therefore, this subtype of uterine carcinoma can often go under-recognised. An accurate diagnosis of dedifferentiated endometrial carcinoma is mandatory because of its poorer prognosis compared to Grade 3 endometrial carcinoma, with a solid undifferentiated component that can amount to as much as 20% of the entire tumour. The aim of this review is to provide clinical, immunohistochemical, and molecular data to aid with making an accurate histological diagnosis and to establish whether there are any findings which could have an impact on the prognosis or therapeutic implications of this rare and aggressive uterine neoplasm.

Fascin in Gynecological Cancers: An Update of the Literature

Simple Summary

Fascin, an actin-binding protein, is upregulated in different types of human cancers. It is reportedly responsible for increasing the invasive and metastatic ability of cancer cells by reducing cell–cell adhesions. This review provides a brief overview of fascin and its interactions with other genes and oncoviruses to induce the onset and progression of cancer.

Abstract

Fascin is an actin-binding protein that is encoded by the FSCN1 gene (located on chromosome 7). It triggers membrane projections and stimulates cell motility in cancer cells. Fascin overexpression has been described in different types of human cancers in which its expression correlated with tumor growth, migration, invasion, and metastasis. Moreover, overexpression of fascin was found in oncovirus-infected cells, such as human papillomaviruses (HPVs) and Epstein-Barr virus (EBV), disrupting the cell–cell adhesion and enhancing cancer progression. Based on these findings, several studies reported fascin as a potential biomarker and a therapeutic target in various cancers. This review provides a brief overview of the FSCN1 role in various cancers with emphasis on gynecological malignancies. We also discuss fascin interactions with other genes and oncoviruses through which it might induce cancer development and progression.

Undifferentiated and dedifferentiated neoplasms of the female genital tract

Undifferentiated neoplasms in the female gynecologic tract comprise two main groups-undifferentiated carcinoma, most common in the endometrium and ovary, and undifferentiated uterine sarcoma, although tumors with an undifferentiated appearance may occur in all gynecologic organs. Their differential diagnosis is broad and generous sampling, careful morphological evaluation, judicious use of immunohistochemistry, and in many cases, molecular testing is often essential in the diagnostic work-up. As some of these neoplasms fail to respond to conventional chemotherapy regimens and/or radiation therapy, targeted therapy may be valuable in treating these highly aggressive tumors, thus the importance of precise diagnosis. In this review we discuss the clinicopathological features of undifferentiated carcinoma, dedifferentiated carcinoma, and undifferentiated uterine sarcoma, followed by a comprehensive analysis of morphological mimickers. Finally, we briefly review ovarian and lower genital tract tumors with an undifferentiated histological appearance.

SWI/SNF-deficient malignancies of the female genital tract

Mutations and other molecular events involving subunits of the SWI/SNF chromatin remodelling complex are common in a wide variety of malignancies, including those arising at various sites in the female genital tract. Endometrioid and clear cell carcinomas in the uterine corpus and ovary not uncommonly contain mutations in ARID1A and these also occur in other endometriosis-associated ovarian neoplasms such as seromucinous tumours. In these organs, mutations in SMARCA4, SMARCB1, ARID1A and ARID1B (with subsequent loss of corresponding protein expression as a reliable surrogate) are relatively common in undifferentiated carcinomas, including the undifferentiated component of dedifferentiated carcinoma. SMARCA4 mutations are extremely common (almost ubiquitous) in small cell carcinoma of the ovary of hypercalcaemic type (SCCOHT), occurring in about 98% of these neoplasms, often in association with epigenetic SMARCA2 loss. SMARCB1-deficient vulval neoplasms include epithelioid sarcoma and myoepithelial carcinoma, as well as related malignancies which defy easy classification. Recently the spectrum of SWI/SNF deficient female genital malignancies has been expanded to include SMARCA4-deficient undifferentiated uterine sarcoma and mural nodules of anaplastic carcinoma in ovarian mucinous neoplasms.

Cytologic features of undifferentiated and dedifferentiated carcinomas of the endometrium

BACKGROUND

Undifferentiated carcinoma (UC) is a rare, aggressive subtype of endometrial carcinoma. Dedifferentiated carcinomas (DCs) are UCs associated with a component of well differentiated endometrioid carcinoma. The authors sought to describe the morphologic features of UCs and DCs in cytologic specimens.

METHODS

Cytologic specimens from 23 women (aged 46-86 years; median age, 59 years) were reviewed, including cervicovaginal specimens (n = 7), peritoneal washings (n = 5), touch preparations of core biopsies from various sites (n = 5), fine-needle biopsies of lymph nodes (n = 3), ascitic fluid (n = 1), pleural fluid (n = 1), and intrauterine fluid (n = 1).

RESULTS

There were 10 UCs (43%) and 13 DCs (57%). Tumor cells were arranged as single cells (9 UCs, 90%; 12 DCs, 92%) and 3-dimensional groups (8 UCs, 80%; 11 DCs, 85%). Most cases showed high nuclear-to-cytoplasmic ratios. Nuclear molding was observed in 3 UCs (30%) and in 5 DCs (38%). Nuclear chromatin was often coarsely granular 6 UCs, 60%; 9 DCs, 69%). Nucleoli were inconspicuous in some cases (6 UCs, 60%; 8 DCs, 62%) but were appreciable in others. Necrosis was observed in 5 UCs (50%) and in 5 DCs (38%). Most cases exhibited clean backgrounds, and a few showed acute inflammation. Comparison of the cytologic features of UCs and DCs did not reveal any statistically significant differences.

CONCLUSIONS

UCs and DCs have a spectrum of cytomorphologic appearances that are not pathognomonic, but the presence of some of these (relatively uniform population of predominantly singly dispersed cells with high nuclear-to-cytoplasmic ratios and variably conspicuous nucleoli) should prompt consideration of UC and DC in the differential diagnosis.

Novel anti-invasive properties of a Fascin1 inhibitor on colorectal cancer cells

Tumor invasion and metastasis involve processes in which actin cytoskeleton rearrangement induced by Fascin1 plays a crucial role. Indeed, Fascin1 has been found overexpressed in tumors with worse prognosis. Migrastatin and its analogues target Fascin1 and inhibit its activity. However, there is need for novel and smaller Fascin1 inhibitors. The aim of this study was to assess the effect of compound G2 in colorectal cancer cell lines and compare it to migrastatin in in vitro and in vivo assays. Molecular modeling, actin-bundling, cell viability, inmunofluorescence, migration, and invasion assays were carried out in order to test anti-migratory and anti-invasive properties of compound G2. In addition, the in vivo effect of compound G2 was evaluated in a zebrafish model of invasion. HCT-116 cells exhibited the highest Fascin1 expression from eight tested colorectal cancer cell lines. Compound G2 showed important inhibitory effects on actin bundling, filopodia formation, migration, and invasion in different cell lines. Moreover, compound G2 treatment resulted in significant reduction of invasion of DLD-1 overexpressing Fascin1 and HCT-116 in zebrafish larvae xenografts; this effect being less evident in Fascin1 known-down HCT-116 cells. This study proves, for the first time, the in vitro and in vivo anti-tumoral activity of compound G2 on colorectal cancer cells and guides to design improved compound G2-based Fascin1 inhibitors. KEY MESSAGES: • Fascin is crucial for tumor invasion and metastasis and is overexpressed in bad prognostic tumors. • Several adverse tumors overexpress Fascin1 and lack targeted therapy. • Anti-fascin G2 is for the first time evaluated in colorectal carcinoma and compared with migrastatin. • Filopodia formation, migration activity, and invasion in vitro and in vivo assays were performed. • G2 blocks actin structures, migration, and invasion of colorectal cancer cells as fascin-dependent.

Markers of Cancer Cell Invasion: Are They Good Enough?

Invasion, or directed migration of tumor cells into adjacent tissues, is one of the hallmarks of cancer and the first step towards metastasis. Penetrating to adjacent tissues, tumor cells form the so-called invasive front/edge. The cellular plasticity afforded by different kinds of phenotypic transitions (epithelial-mesenchymal, collective-amoeboid, mesenchymal-amoeboid, and vice versa) significantly contributes to the diversity of cancer cell invasion patterns and mechanisms. Nevertheless, despite the advances in the understanding of invasion, it is problematic to identify tumor cells with the motile phenotype in cancer tissue specimens due to the absence of reliable and acceptable molecular markers. In this review, we summarize the current information about molecules such as extracellular matrix components, factors of epithelial-mesenchymal transition, proteases, cell adhesion, and actin cytoskeleton proteins involved in cell migration and invasion that could be used as invasive markers and discuss their advantages and limitations. Based on the reviewed data, we conclude that future studies focused on the identification of specific invasive markers should use new models one of which may be the intratumor morphological heterogeneity in breast cancer reflecting different patterns of cancer cell invasion.

High-grade Endometrial Carcinomas: Morphologic and Immunohistochemical Features, Diagnostic Challenges and Recommendations

This review of challenging diagnostic issues concerning high-grade endometrial carcinomas is derived from the authors' review of the literature followed by discussions at the Endometrial Cancer Workshop sponsored by the International Society of Gynecological Pathologists in 2016. Recommendations presented are evidence-based, insofar as this is possible, given that the levels of evidence are weak or moderate due to small sample sizes and nonuniform diagnostic criteria used in many studies. High-grade endometrioid carcinomas include FIGO grade 3 endometrioid carcinomas, serous carcinomas, clear cell carcinomas, undifferentiated carcinomas, and carcinosarcomas. FIGO grade 3 endometrioid carcinoma is diagnosed when an endometrioid carcinoma exhibits >50% solid architecture (excluding squamous areas), or when an architecturally FIGO grade 2 endometrioid carcinoma exhibits marked cytologic atypia, provided that a glandular variant of serous carcinoma has been excluded. The most useful immunohistochemical studies to make the distinction between these 2 histotypes are p53, p16, DNA mismatch repair proteins, PTEN, and ARID1A. Endometrial clear cell carcinomas must display prototypical architectural and cytologic features for diagnosis. Immunohistochemical stains, including, Napsin A and p504s can be used as ancillary diagnostic tools; p53 expression is aberrant in a minority of clear cell carcinomas. Of note, clear cells are found in all types of high-grade endometrial carcinomas, leading to a tendency to overdiagnose clear cell carcinoma. Undifferentiated carcinoma (which when associated with a component of low-grade endometrioid carcinoma is termed "dedifferentiated carcinoma") is composed of sheets of monotonous, typically dyscohesive cells, which can have a rhabdoid appearance; they often exhibit limited expression of cytokeratins and epithelial membrane antigen, are usually negative for PAX8 and hormone receptors, lack membranous e-cadherin and commonly demonstrate loss of expression of DNA mismatch repair proteins and SWI-SNF chromatin remodeling proteins. Carcinosarcomas must show unequivocal morphologic evidence of malignant epithelial and mesenchymal differentiation.

Analyses on K-ras mutations and fascin expression in patients with cardia cancer

Mutations of K-rat sarcoma (K-ras) in patients with cardia cancer and their effects on the expression of fascin were investigated. A total of 90 cardia cancer patients treated in Jining First People's Hospital from March 2014 to March 2017 were randomly selected. Genomic deoxyribonucleic acid (DNA) was extracted from paraffin-embedded cardia cancer specimens. Pyrosequencing was applied to detect sequences of K-ras gene in all patients and to analyze the mutations of K-ras gene. Then, genotyping of mutations at each mutation site was carried out using quantitative polymerase chain reaction (qPCR). The expression level of fascin in patients was measured via immunohistochemistry and qPCR. The results revealed that among 90 patients with cardia cancer, 21 patients had K-ras mutations (23.3%), including 20 cases of exon 12 mutation and 1 case of exon 13 mutation. Risk factor analyses revealed that alcohol abuse was a high risk factor for mutations (p<0.05). There was no significant difference in the mutation probability between heterozygotes and homozygotes for four mutations at codon 12 (p>0.05). The heterozygote at codon 13 had a higher mutation probability than homozygote (p<0.05). Immunohistochemistry suggested that the number of positive cells in the mutant group was larger than that in the non-mutant group (p<0.05). The results of qPCR showed that the expression level of fascin gene in the mutant group was 2.3 times higher than that in the non-mutant group (p<0.05). In conclusion, the probability of codon 12 mutation in K-ras gene is increased in patients with cardia cancer, and fascin is highly expressed in mutant patients, which is positively correlated with the mutations in K-ras gene.

Two Cases of Dedifferentiated Endometrioid Carcinoma: Case Presentation and Brief Review of the Literature

Endometrioid carcinoma is the most common histological type of uterine endometrial cancer and particularly dedifferentiated endometrioid carcinomas (DEC) are less commonly observed. Silva et al. reported the biological features of UC based on the undifferentiated component of DEC, although the component represented only 20% of undifferentiated carcinoma. In this study, we report two cases of DEC with different presentation. Case 2 presented with the invasion to the bladder, rectum, and LN metastases. In contrast, the tumor in case 1 advanced into the endometrial cavity, similar to an endometrial polyp, without myometrial invasion. Hence, the diagnosis was established early. While we strive to improve the diagnosis of DEC, it is also crucial to better assess the prognosis and the appropriate treatment for the patients with established diagnosis of DEC.

Dedifferentiated endometrioid adenocarcinoma; clinicopathologic and immunohistochemical features of five cases

Objective:

Dedifferentiated endometrioid adenocarcinoma is a recently defined uterine tumor composed of low-grade endometrioid adenocarcinoma and undifferentiated carcinoma. Herein, we present clinicopathologic, morphologic, and immunohistochemical features of 5 cases of dedifferentiated endometrioid adenocarcinoma.

Material and Methods:

All cases which were diagnosed as mixed endometrial adenocarcinoma (endometrioid+undifferentiated carcinoma) or dedifferentiated endometrioid adenocarcinoma between January 2008 and December 2014 were retrieved from the archives of our institution’s pathology department.

Results:

The median age of the patients was 58 years. Polypoid growth pattern was seen in 3 patients and 2 were diagnosed at advanced stage. All patients received either external radiotherapy, brachytherapy, chemotherapy or an appropriate combination according to the stage. Only one patient died of the disease. Microscopically, there was a sharp demarcation between the two tumor components. The undifferentiated carcinoma component was composed of diffuse sheets of monomorphic cells lacking any differentiation. Focal pleomorphism and rhabdoid features were also noted. The undifferentiated carcinoma component was variably positive for PAX-8, cytokeratin, EMA, estrogen receptor, and neuroendocrine markers.

Conclusion:

Misdiagnosis of undifferentiated carcinoma in dedifferentiated endometrioid adenocarcinoma as grade 3 endometrioid adenocarcinoma is not uncommon. The recognition of morphologic and immunohistochemical features of this newly described entity is crucial because it alters treatment and prognosis.

High expression of SALL4 and fascin, and loss of E-cadherin expression in undifferentiated/dedifferentiated carcinomas of the endometrium: An immunohistochemical and clinicopathologic study

Undifferentiated/dedifferentiated endometrial carcinomas (UCE/DCEs) of the endometrium are rare tumors with poor prognosis. There are few clinicopathologic studies with detailed immunohistochemical analysis regarding UCE/DCEs.We evaluated the diagnostic value of a selected tumor stem-cell marker and epithelial-mesenchymal transition (EMT) markers, in addition to previously studied markers in identifying UCE/DCEs from other types of high-grade endometrial carcinomas.Eleven cases of UCE/DCEs with complete clinical follow-up that were diagnosed between 2006 and 2015 were included in the study. For immunohistochemical comparison, 11 clinically matched cases for each type of other high-grade endometrial carcinomas (high-grade endometrioid (F3-EC), serous [SC], and clear cell carcinoma [CCC]) were used as a control group. An immunohistochemical analysis including fascin, SALL4, E-cadherin, and β-catenin, in addition to epithelial and neuroendocrine markers was performed in each case.The majority of UCE/DCEs displayed diffuse expression of fascin (81.9%) and loss of E-cadherin expression (54.5%). SALL4 expression was detected in 36.3% of the UCE/DCE cases. SALL4 expression was significantly more frequent in UCE/DCEs than all other high-grade carcinomas (P < 0.001). Loss of E-cadherin and fascin expression was significantly more frequent in UCE/DCEs than high-grade endometrioid and clear cell adenocarcinomas (P = 0.012, 0.014 and P = 0.01, 0.003, respectively).We suggest that loss of E-cadherin expression together with fascin and SALL4 immunopositivity in addition to morphologic features have an impact in differential diagnosis of UCE/DCEs from other high-grade endometrial carcinomas.

Tumor progression, metastasis, and modulators of epithelial-mesenchymal transition in endometrioid endometrial carcinoma: an update

Endometrioid endometrial carcinoma (EEC), also known as type 1 endometrial cancer (EC), accounts for over 70-80% of all cases that are usually associated with estrogen stimulation and often develops in a background of atypical endometrial hyperplasia. The increased incidence of EC is mainly confined to this type of cancer. Most EEC patients present at an early stage and generally have a favorable prognosis; however, up to 30% of EEC present as high risk tumors, which have invaded deep into the myometrium at diagnosis and progressively lead to local or extra pelvic metastasis. The poor survival of advanced EC is related to the lack of effective therapies, which can be attributed to poor understanding of the molecular mechanisms underlying the progression of disease toward invasion and metastasis. Multiple lines of evidence illustrate that epithelial-mesenchymal transition (EMT)-like events are central to tumor progression and malignant transformation, endowing the incipient cancer cell with invasive and metastatic properties. The aim of this review is to summarize the current knowledge on molecular events associated with EMT in progression, invasion, and metastasis of EEC. Further, the role of epigenetic modifications and microRNA regulation, tumor microenvironment, and microcystic elongated and fragmented glands like invasion pattern have been discussed. We believe this article may perhaps stimulate further research in this field that may aid in identifying high risk patients within this clinically challenging patient group and also lead to the recognition of novel targets for the prevention of metastasis - the most fatal consequence of endometrial carcinogenesis.