Alpha-fetoprotein producing uterine corpus carcinoma: A hepatoid adenocarcinoma of the endometrium

Disseminated Primary Uterine Hepatoid Adenocarcinoma with α-Fetoprotein Production Demonstrated on 18F-FDG PET/CT

We present the 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) findings in a 57-year-old woman with post-menopausal bleeding diagnosed with hepatoid adenocarcinoma (HAC) with a primary tumour in the uterine corpus and a highly elevated level of serum-α-fetoprotein (S-AFP) at presentation. HAC is a variant of adenocarcinoma with hepatic differentiation representing a heterogeneous group of neoplasms that morphologically and immunphenotypically resemble hepatocellular carcinoma (HCC) but are of extrahepatic origin. Microscopically, they are usually poorly differentiated adenocarcinomas proliferating in solid sheets or in a trabecular or cord-like arrangement. Primary uterine HAC is exceedingly rare with a general poor prognosis, and data is sparse and limited to case reports, making the clinical management challenging. Various primary anatomical sites have been reported in the literature, with the stomach being the most common primary site. 18F-FDG PET/CT plays an important role in staging and follow-up in many gynecological malignancies including uterine corpus cancer. To the best of our knowledge, this is the first report describing a primary uterine hepatoid adenocarcinoma with metastases to bone, vagina and lymph nodes on 18F-FDG PET/CT. By utilizing the ability of PET to detect early metabolic changes prior to visible structural changes on conventional imaging, this case illustrates a potential role of 18FDG-PET/CT in the staging of primary endometrial HAC by depicting distant metastasis that is not readily identifiable on CT alone.

α-Fetoprotein-Producing Endometrial Carcinoma Is Associated With Fetal Gut-Like and/or Hepatoid Morphology, Lymphovascular Infiltration, TP53 Abnormalities, and Poor Prognosis: Five Cases and Literature Review

The clinicopathological, immunohistochemical, and molecular characteristics of α-fetoprotein (AFP)-producing endometrial carcinoma (AFP+ EC) are poorly understood. From 284 cases of endometrial carcinoma in our pathology archive, we identified five cases (1.8%) of AFP+ EC with fetal gut–like (4/5) and/or hepatoid (2/5) morphology. All cases exhibited lymphovascular infiltration. In addition, 24 cases of endometrial carcinoma with elevated serum AFP levels were retrieved from the literature. The patient age ranged from 44 to 86 years (median: 63). Of 26 cases whose FIGO (International Federation of Gynecology and Obstetrics) stage and follow-up information was available (mean follow-up 24 months), 15 were stage I or II and 11 were stage III or IV. Even in stage I or II disease, death or relapse occurred in more than half of the patients (8/15). Detailed analysis of our five cases revealed that, on immunohistochemistry, AFP+ EC was positive for SALL4 (4/5), AFP (3/5), and HNF1β (4/5) in >50% of neoplastic cells and negative for estrogen and progesterone receptors (5/5), PAX8 (4/5), and napsin A (5/5). Four cases exhibited aberrant p53 immunohistochemistry and were confirmed to harbor TP53 mutations by direct sequencing. No mutation was found in POLE, CTNNB1, or KRAS. In conclusion, AFP+ EC merits recognition as a distinct subtype of endometrial carcinoma, which occurs in 1.8% of endometrial carcinoma cases, are associated with TP53 abnormalities, exhibit lymphovascular infiltration, and can show distant metastasis even when treated in early stage.

Extra-Hepatic Hepatoid Carcinomas in Female Reproductive System: Three Case-Reports with a Literature Review

PURPOSE

Hepatoid carcinoma of the ovary (HCO) and hepatoid carcinoma of the uterus (HCU) are rare malignancies that can be difficult to distinguish from other diseases such as hepatocellular carcinoma. In extremely rare cases, patients are negative for α-fetoprotein (AFP) by immunohistochemistry. Here we report 3 cases of HC of the female reproductive system, including 1 that was negative for AFP.

PATIENTS AND METHODS

Three women aged 48, 56, and 67 years were treated at Qilu Hospital of Shandong University for HCO or HCU. We describe these cases in detail, including clinical features, diagnosis, treatment, and outcome, and review similar cases reported in the literature.

RESULTS

All of our patients underwent surgery including hysterectomy and bilateral adnexectomy, and were treated with platinum-based chemotherapy. One patient died 3 months after the operation, and the other 2 are alive 22 and 63 months post surgery.

CONCLUSION

The first-choice treatment for HCO and HCU is staging surgery, which should be followed by platinum-based chemotherapy.

Endometrial tumors with yolk sac tumor-like morphologic patterns or immunophenotypes: an expanded appraisal

Uterine yolk sac tumors have gained increased recognition in recent years. The current study is a multi-faceted examination of yolk sac tumor-like phenotypes in endometrial tumors, based on an analysis of 3 groups of uterine tumors: Group 1: 9 endometrial tumors that had been classified as yolk sac tumor, or as having a yolk sac tumor component, were assessed with a 35-marker immunohistochemical panel, with the goal of defining their immunophenotypic spectrum; Group 2, comprised of 70 endometrial carcinomas of various histotypes, were analyzed for their expression of SALL4, Glypican-3, and AFP, to assess the specificity of these markers for yolk sac tumors relative to endometrial carcinomas; Group 3, comprised of 626 archived cases of endometrial carcinoma/carcinosarcoma, reviewed to define the frequency of yolk sac tumor-like morphology therein. Yolk sac tumor areas in the Group 1 cases were consistently immunoreactive for SALL4 and Glypican-3; variably positive for AFP (89%), Villin (89%), PLAP (78%), 34βE12 (67%), CAM 5.2 (62.5%), EMA (56%), CD117 (50%), p16 (50%), CDX2 (44%), p53 (44% aberrant), MOC31 (37.5%), CK7 (33%), GATA3 (33%), CK5 (25%), and PAX8 (11%); and were negative for CD30, Napsin A, OCT4, estrogen, androgen, and progesterone receptors. 29 (41%) of the 70 group-2 cases expressed at least one of the 3 markers, and 96% of the positive cases was a high-grade histotype. Glypican-3, SALL4, and AFP were positive in 30, 20, and 2.8% of group-2 cases respectively; however, co-expression of any 2, or all 3 markers was uncommon (<9 and 1.4% of cases respectively). Potential yolk sac tumor-like morphology was identified in 5 (0.8%) of 626 group-3 cases, and three were ultimately deemed to be true yolk sac tumor phenotypes based on their morphologic and immunophenotypic similarity to the group 1 cases. These findings highlight the broad immunophenotypic spectrum of uterine yolk sac tumors, the potential pitfalls associated with using immunophenotypes alone to define yolk sac tumor differentiation in endometrial carcinoma, and the utility and limitations of morphologic assessment to identify yolk sac tumors at this site.

Endometrial hepatoid adenocarcinoma: a rare cause of elevated serum α-fetoprotein

Hepatoid adenocarcinoma is a rare and unusual tumor in the female genital tract. Hepatoid adenocarcinoma resembles hepatocellular carcinoma morphologically but develops in extrahepatic organs, and usually demonstrates foci of adenocarcinoma of the primary organ. Tumor cells often stain positive for anti-α-fetoprotein antibody, and may be associated with elevated serum α-fetoprotein, which may be useful as a tumor marker to guide treatment. There is little reliable information to guide clinical management of these unusual tumors and prognosis is poor despite multi-modal treatment. This report describes the diagnosis and treatment of this tumor in a postmenopausal woman.

Establishment and biological characterization of a novel cell line derived from hepatoid adenocarcinoma originated at the ampulla of Vater

Hepatoid adenocarcinoma is a rare gastrointestinal tumor and mostly reported in the stomach. Effective chemotherapy has yet to be developed to improve poor prognosis. The present study was undertaken to establish a useful cell line derived from a hepatoid adenocarcinoma, possibly leading to a new therapeutic strategy. The new human cell line VAT-39 was established from a metastatic lymph node of a 69-year-old Japanese male patient with hepatoid adenocarcinoma of the ampulla of Vater. The primary tumor and metastatic lymph node were composed of hepatoid adenocarcinoma cells exhibiting immunohistochemical reactivity for alpha-fetoprotein (AFP) and glypican-3 (GPC3). In the metastatic lymph node, Periodic acid-Schiff (PAS) staining clarified diffuse deposition of glycogen in the cytoplasm, indicating analogous characteristics to the primary hepatoid adenocarcinoma. Moreover, VAT-39 cells produced high levels of AFP in the cultured medium, and reverse-transcriptase polymerase chain reaction (RT-PCR) verified increased expression of GPC3 mRNA in this cell line. Further, we evaluated the sensitivity to major chemotherapeutic drugs against the bile duct cancer. Neither 5-fluorouracil nor gemcitabine showed particular sensitivity to this cell line. The tumorigenicity of the cultured cells was confirmed in athymic nude mice and the histological features of the explanted tumor were similar to the VAT-39 cell line. The present VAT-39 is the first hepatoid adenocarcinoma cell line that originates from the ampulla of Vater and it will be applicable for basic biological studies searching for new strategies of molecular targeted chemotherapy to this disease.

α-fetoprotein produced by endometrioid adenocarcinoma of uterus

α-fetoprotein (AFP) producing adenocarcinoma of endometrium is a rare tumour. It is mostly high grade and has poor prognosis. Lung metastases are common. In this article, the authors present a case of a 57-year-old woman with AFP producing adenocarcinoma of endometrium and history of bilateral metachronous breast cancer, with lung, subcutaneous and brain metastases.

Carcinosarcoma of the uterine corpus with alpha-fetoprotein-producing hepatoid adenocarcinoma: a report of two cases

We report two cases of uterine carcinosarcoma associated with alpha-fetoprotein (AFP)-producing hepatoid adenocarcinoma. Samples were obtained from two women aged 63 and 82 years. Serum AFP levels of the two samples were 10,131 and 401 ng/ml, respectively. Histologically, in both cases the tumor cells were composed of hepatoid adenocarcinoma component and sarcoma component including rhabdomyosarcoma. Immunohistochemical analyses revealed that AFP was expressed in the cytoplasm of the carcinomatous component. After surgery, the patients received six courses of carboplatin/paclitaxel chemotherapy, and the serum levels of AFP decreased to normal range. The first patient is alive and well at the 2-year follow-up, while the second patient died of disease 1 year after initial operative treatment. This is, to our knowledge, the second report of carcinosarcoma of the uterine corpus with AFP-producing hepatoid adenocarcinoma, as proven by immunohistochemical analyses.

Primary hepatoid adenocarcinoma of the endometrium with a high alphafetoprotein level

Primary hepatoid adenocarcinoma of the endometrium is a rare tumour that is similar to hepatocellular carcinoma histologically. Here, a patient with primary hepatoid carcinoma of the endometrium with a high alphafetoprotein (AFP) level (90,508 ng/mL) is presented in a 75-year-old woman. The pelvic computed tomography and magnetic resonance imaging suggested a submucosal leiomyoma with degeneration or endometrial hyperplasia. However, the endometrial biopsy revealed a primary hepatoid carcinoma of the endometrium. The patient underwent a staging laparotomy including a total abdominal hysterectomy, bilateral salpingo-oophorectomy and lymph node sampling with pelvic cytology. The AFP level can be highly elevated in hepatoid carcinoma of the endometrium.

Clinicopathologic characteristics and treatment outcomes of hepatoid adenocarcinoma of the stomach, a rare but unique subtype of gastric cancer

BACKGROUND

Gastric hepatoid adenocarcinoma (HAC) is a special type of gastric cancer that morphologically mimics hepatocellular carcinoma. In this study, we performed an evaluation of clinicopathologic characteristics, treatment outcome, and prognosis in patients with gastric HAC.

METHODS

We consecutively enrolled patients with pathologically proven gastric HAC at Seoul National University Hospital between January 1996 and December 2008 and conducted a retrospective review. Among 15,253 patients with gastric cancer, 26 patients (0.17%) were diagnosed as gastric HAC.

RESULTS

Among 26 patients, 22 were male and the median age was 63. Stage at diagnosis was stage IB in 3 patients, stage II in 6 patients, stage III in 7 patients, and stage IV in 10 patients. Eight patients out of 18 patients with stage IB, II, III, and IV relapsed after curative surgery. Relapse-free survival for these patients was 16.67 months. The most common metastatic site was intraabdominal lymph nodes (n = 9), followed by the liver (n = 8). Thirteen patients received palliative chemotherapy. The most commonly used regimen was a combination of fluoropyrimidine and platinum. Partial response was observed in one patient and stable disease in 5 patients. Median overall survival and progression free survival of these patients were 8.03 (95% CI: 6.59-9.47) and 3.47 months (95% CI: 0.65-6.29), respectively.

CONCLUSIONS

Gastric HAC is a very rare but unique type of stomach cancer. Early detection of this type of cancer is of critical importance to patient prognosis. Additional studies to reveal the biology of this tumor are warranted.

Primary hepatoid adenocarcinoma of the uterine corpus: A case report with immunohistochemical study for expression of liver-enriched nuclear factors

We report a case of hepatoid adenocarcinoma of the uterus in an 86-year-old woman. Serum AFP was elevated (7824ng/ml) on admission. The surgical specimen obtained by simple hysterectomy and bilateral salpingo-oophorectomy showed an exophytic tumor, 10.5cm×6.0cm×3.7cm in size, in the uterine corpus. Microscopically, tumor cells proliferated in trabecular or cord-like arrangement, which was considered as "hepatoid appearance". An adenocarcinomatous component was intermingled. The expressions of liver-enriched transcription factors, hepatocyte nuclear factor (HNF)-1β, HNF-3, HNF-4α, and CCAAT/enhancer binding protein (C/EBP)-β, were investigated in the present case and in 19 cases of endometrioid adenocarcinoma (11 cases of Grade 2 and 8 cases of Grade 3), because these nuclear factors are involved in embryonal hepatogenesis. HNF-4α was diffusely positive in the present case, but negative in all cases of endometrioid adenocarcinoma. HNF-3 and C/EBP-β were positive for the present case and control adenocarcinoma cases (HNF-3, 36.8% and C/EBP-β, 84.2%). HNF-1β was negative for both the present case and endometrioid adenocarcinomas. This is the first report to demonstrate HNF-4α expression in this rare uterine tumor.

α-fetoprotein-producing endometrial adenocarcinoma without an obvious hepatoid component

Endometrial carcinomas producing α-fetoprotein (AFP) are extremely rare. We report a case of AFP-producing, Grade 2 endometrioid adenocarcinoma without an obvious hepatoid component. A 59-year-old multiparous woman presented with abdominal swelling. The serum level of AFP was 1292.8 ng/ml. Magnetic resonance images of the pelvis showed a markedly enlarged uterus, with a tumor growing exophytically within the endometrial cavity. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. The histopathological examination demonstrated a Stage IIA, Grade 2 endometrioid adenocarcinoma without an obvious hepatoid component. The endometrioid adenocarcinoma cells were partly positive for AFP immunoreactivity. The patient received adjuvant chemotherapy and was disease-free 60 months after the operation. This case confirms the existence of AFP-producing endometrioid adenocarcinomas without hepatoid features.

Alpha-fetoprotein-producing non-germ cell tumours of the female genital tract

Elevated levels of alpha-fetoprotein (AFP), a foetal serum protein, occur mainly on the development of hepatocellular carcinoma (HCC) or germ cell tumours, including yolk sac tumour (YST) and embryonal carcinoma of the ovary. Rarely, other tumours of the female genital tract produce AFP. This article reviews the AFP-producing non-germ cell tumours reported in different parts of the female genital tract to date. These include different types of carcinomas and carcinosarcomas of the uterus, ovary and cervix and sex cord stromal tumours of the ovary. It is important for both pathologists and oncologists to be aware of such cases and the clinicopathological distinction from germ cell tumours, as the diagnosis would affect the management plan for the patient. The reviewed cases suggest that regardless of the patient's age when no lesion is detected in the liver and stomach of a woman whose serum AFP level is abnormally high, the female reproductive system should be examined as a possible site of AFP-producing tumour. Biochemical, physiological and pathological features of AFP are briefly presented.

Primary hepatoid adenocarcinoma of the uterine cervix

Hepatoid adenocarcinoma is characterized histologically by neoplastic epithelial cells that resemble hepatocellular carcinoma (HCC) and produce alpha-fetoprotein (AFP). We describe a case of hepatoid adenocarcinoma of the uterus that, unlike any other previously reported case, was strictly confined to the cervix. A cervical biopsy demonstrated poorly differentiated adenocarcinoma, and hysterectomy and bilateral salpingo-oophorectomy were subsequently performed. Histologically, the lesion consisted of solid sheets of hepatoid cells accompanied with areas of endometroid adenocarcinoma. The tumor cells showed strong and diffuse cytoplasmic immunoreactivity with AFP in both medullary and adenocarcinoma components. Metastases to bilateral pelvic lymph nodes were detected 12 months after surgery. Since undergoing total pelvic irradiation, the patient has been alive and in full remission for 22 months. To our knowledge, this is the first report of primary hepatoid adenocarcinoma of the uterine cervix.

A case of alpha-fetoprotein-producing adenocarcinoma of the endometrium with a hepatoid component as a potential source for alpha-fetoprotein in a postmenopausal woman

Although case reports of alpha-fetoprotein (AFP)-producing adenocarcinoma other than hepatocellular carcinoma have gradually increased in number, AFP-producing adenocarcinoma of the endometrium is very rare. The patients universally complain of abnormal vaginal bleeding. The patient presented with complaints of epigastric discomfort. No vaginal bleeding was observed. Serum AFP concentration was 453 ng/mL, and lens culinaris agglutinin-reactive AFP percentage of total AFP was increased to 67%. Radiologic imaging and endoscopy did not provide evidence of any primary carcinoma in the liver and gastrointestinal tract. To investigate the unknown origin of high AFP, Pap smear of the endometrium followed by fractional curettage was performed and revealed adenocarcinoma of the endometrium. Radical hysterectomy with pelvic lymph node dissection and partial omentectomy was performed. Histologic study showed a mixture of major AFP-negative endometrioid adenocarcinoma and minor medullary proliferation of the AFP-positive hepatoid adenocarcinoma cells with eosinophilic cytoplasm and hyaline globules. After the surgery followed by four courses of weekly carboplatin and paclitaxel administration, serum levels of AFP dropped into normal range. The possible existence of AFP-producing adenocarcinoma of the endometrium should be considered in a postmenopausal woman even if there is no vaginal bleeding, when AFP-producing tumor is clinically suspected and the imaging studies fail to confirm the diagnosis.

Hepatoid carcinoma of the pancreas: a case report and literature review of a heterogeneous group of tumors

Hepatoid carcinomas are tumors that display, at least focally, cytologic and/or architectural features of hepatocellular carcinoma. They have been described in several organs, most notably in the stomach and ovary. We report a case of hepatoid carcinoma of the pancreas that developed in a 41-year-old woman in association with a pancreatic endocrine carcinoma. The fine needle aspiration material was characterized by the presence of monotonous, small-to-medium sized tumor cells with round nuclei and finely granular chromatin, intermixed with more atypical tumor cells displaying larger nuclei with coarse clumped chromatin, prominent nucleoli, and moderate amounts of foamy cytoplasm. The excised specimen displayed a poorly differentiated pancreatic endocrine carcinoma associated with well-defined islands of larger tumor cells growing in a perisinusoidal pattern which, based on their immunohistochemical profile and the demonstration of bile, proved to represent a hepatoid component. This case and prior examples in the literature suggest that hepatoid carcinomas of the pancreas appear to be a heterogeneous group of tumors (pure or associated with another histologic component) that are often associated with early liver metastasis and a short survival, although those arising as a component of endocrine tumors seem to fare slightly better. Hepatoid carcinoma of the pancreas should be included in the differential diagnosis of pancreatic tumors composed of large eosinophilic cells.

Preliminary study on the clinical and pathological relevance of gastric hepatoid adenocarcinoma

OBJECTIVE

To appraise the histological characteristics and clinical features of gastric hepatoid adenocarcinoma (GHAC) and their relevance with prognosis.

METHODS

From January 2001 to December 2003, six patients were diagnosed and confirmed pathologically in Ruijin Hospital as having a gastric hepatoid carcinoma. All these six patients, together with 30 randomly selected patients with gastric poorly differentiated adenocarcinoma (GPDA) and 30 with a primary hepatocellular carcinoma (HCC) who served as controls, were studied and analyzed clinically, histologically and immunohistologically.

RESULTS

The average age of the six patients with GHAC was 66.8 years, and their serum alpha fetoprotein (AFP) level was 84-2230 ng/mL. Of these six patients, two had a recurrence of cancer and two had liver metastasis. Their average survival period was 17 months. Morphologically, the histological appearance was similar to that of HCC, with glycogen granules and hyaline globules arranged in a solid or trabecular pattern and an abundance of blood vessels and sinusoids, while blood vessel or lymphatic invasion were more often seen. Immunohistological staining showed that the tumor cells were positive for AFP and negative for Hepatocyte paraffin 1 (HepPar1), and the tumor cells were separated by CD34-positive blood vessels into a small trabecular pattern. The GPDA had a solid nest or diffuse distribution pattern and was negative for both AFP and HepPar1. In the HCC, the histological feature was manifested as solid, small and large trabecular patterns with abundance of blood vessels and sinusoids; immunohistochemical staining showed the tumor cells were positive for HepPar1.

CONCLUSION

Serum AFP-positive GHAC occurred more frequently in older patients with higher rates of recurrence and liver metastasis and a poor prognosis. Histologically, GHAC was similar to HCC. The tumor cells that were positive for AFP but negative for HerPar1 could be used to differentiate with GPDA (both AFP and HerPar1 negative) and primary HCC (most AFP and HerPar1 positive).

Alpha-Fetoprotein-Producing Serous Carcinoma of the Uterus Metastasizing to the Ovaries, Mimicking Primary Ovarian Yolk Sac Tumor

In the uterus, most alpha-fetoprotein (AFP) producing neoplasms belong to the categories of malignant mixed muellerian tumor, hepatoid carcinoma, and yolk sac tumor. We describe the case of a 44-year-old woman who presented with vaginal bleeding, pelvic mass, and preoperative elevated AFP serum level, clinically suggestive of a primary ovarian yolk sac tumor. However, histological examination revealed a uterine AFP-producing papillary serous carcinoma, which has metastasized to the ovaries. Upon review of the literature on primary endometrial neoplasms with AFP production, 2 categories with possibly different histogenesis and biological behavior become evident: the primary yolk sac tumor of the uterus in young patients (range, 24-49 years; mean, 34 years) and the common high grade endometrial carcinoma with yolk sac dedifferentiation or aberrant AFP production in elderly patients (range, 55-69 years; mean, 63.7 years). In addition to being only the second case of uterine AFP-producing papillary serous carcinoma, this case is unusual for its clinical and radiological presentation as well as the relatively young age of the patient.

Hepatoid Carcinoma With Serous Component of the Fallopian Tube

A very rare case of hepatoid carcinoma with serous component arising in the fallopian tube of a 79-year-old woman is presented. The lesion was a 5.0-cm unencapsulated, yellowish-white soft mass. The tumor was composed of hepatoid carcinoma (90%) and serous carcinoma (10%) components. The hepatoid carcinoma was histologically characterized by a proliferation of round to polygonal cells arranged in a trabecular, tubular, sinusoidal, papillary, or solid pattern. The serous component in the fallopian tube also showed in situ lesions. Both components showed an infiltration into the surface of the left ovary, omentum, peritoneum including the pouch of the Douglas, and serosa of the colon. Immunohistochemically, the hepatoid carcinoma was positive for alpha-fetoprotein, polyclonal carcinoembryonic antigen (CEA), hepatocyte paraffin 1, albumin, epithelial membrane antigen, and cytokeratin (CAM5.2). Ultrastructurally, the cytoplasm contained abundant ribosomes, moderate amounts of mitochondria, and rough endoplasmic reticulum that developed into a meshwork and contained mitochondria within it. Microbile channel-like structures and desmosomes were occasionally observed. The association with serous carcinoma indicates mullerian origin rather than germ cell origin. The patient received chemotherapy and was alive without disease at 10 months after surgery.

Hepatoid adenocarcinoma of the stomach

A 54-year-old man presented to his doctor with hematemesis and was found at endoscopy to have an ulcerated lesion in his stomach. A computed tomography scan was performed and revealed a mass in the fundus of the stomach. Multiple other lesions were identified in the liver, lungs, retroperitoneal space, and mesentery. Gross examination showed two separate gastric lesions containing nests and single cells with mucin intermixed with sheets of tumor cells with abundant eosinophilic cytoplasm invading throughout the wall of the stomach. Immunohistochemical studies were performed and the cells were positive for hepatocyte, MOC 31, cytokeratin A1/A3, and CK 7, and were negative for CK 20, alpha-fetoprotein, and thyroid transcription factor. The histologic features together with the immunohistochemical findings were diagnostic of a hepatoid adenocarcinoma of the stomach. Hepatoid adenocarcinoma is a rare tumor associated with a very poor prognosis. Immunohistochemical studies may help to identify the characteristic features of hepatoid differentiation and prevent mistaking this tumor for other types of carcinoma.

Serum tumor markers in the management of ovarian, endometrial and cervical cancer

CA 125 is the most reliable serum marker for ovarian carcinoma. Whereas its role in the screening of the malignancy is controversial, serum CA 125 assay is very useful for both the differential diagnosis of ovarian masses, particularly in postmenopause, and the monitoring of the response to chemotherapy and follow-up of patients with histologically proven ovarian carcinoma. Tumor-associated antigens other than CA 125, such as CA 19.9, CA 15.3 and TAG.72, firstly identified in gastro-intestinal or breast malignancies, have been detected also in tissue and serum samples from patients with ovarian carcinoma. In particular CA19.9 offers the advantage of high sensitivity for mucinous histotype, which often fails to express CA 125. Serum CA 125 correlates with the clinical course of disease better than the other antigens, and in patients with positive CA 125 assay at diagnosis the concomitant evaluation of CA 19.9 or CA 72.4 or CA 15.3 does not offer any additional benefit for monitoring ovarian carcinoma. Conversely, the serial measurements of these other antigens may represent an interesting biochemical tool for the management of patients with negative CA 125 assay. Serum alphaFP and betaHCG are very useful in the preoperative evaluation and management of nondysgerminomatous ovarian germ cell tumors, whereas elevated serum inhibin levels can be detected in patients with granulosa cell tumors of the ovary. As for endometrial carcinoma, preoperative serum CA 125 levels correlate with stage, depth of myometrial invasion, histologic grade, cervical invasion, peritoneal cytology, lymph node status and clinical outcome. Moreover, serial CA 125 assay is a good indicator of disease activity and a useful biochemical tool for post-treatment surveillance of patients with endometrial carcinoma. SCC is the most reliable serum marker for squamous cell cervical carcinoma, and in patients with this malignancy pretreatment SCC levels are related to tumor stage, tumor size, depth of cervical invasion, lymph-vascular space involvement, lymph node status and clinical outcome. Serial SCC measurements parallel the response to radiotherapy and chemotherapy as well as the clinical course of disease after the completion of treatment. Serum CYFRA 21.1 seems to be less sensitive than serum SCC for squamous cell cervical carcinoma. Elevated CA 125 levels can be often detected in patients with cervical adenocarcinoma. The future for tumor marker research is represented by the emerging technologies of transcriptional profiling and proteomics.

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

This review considers the clinical and pathologic features of the various histologic subtypes of endometrial carcinoma excluding those of pure endometrioid type, as the latter tumors were the subject of a previous contribution in the Journal (Vol. 9, No. 2). Non-endometrioid carcinomas, which account for about 10% of endometrial carcinomas, may pose a great array of problems in differential diagnosis, including their distinction not only from benign lesions but also endometrioid carcinoma and various tumors that may secondarily involve the uterine corpus. The most common subtypes are serous, mucinous, and undifferentiated. Rarer tumors are clear cell, squamous, transitional cell carcinomas, and a variety of poorly differentiated carcinomas with unusual forms of differentiation, such as hepatoid carcinoma, carcinomas with trophoblastic elements, and giant cell carcinoma. Mixed carcinomas, which are common, are also discussed, including those with a component of endometrioid carcinoma. The final section deals with endometrial involvement by metastatic tumors, lesions that, albeit rare, are sometimes neglected in the differential diagnosis of endometrial carcinomas. Important aspects emphasized are: (1) The potential for serous carcinoma to be mimicked by various forms of papillary endometrioid carcinoma. (2) The rarity of clear cell carcinoma and the greater frequency of clear cells in endometrioid carcinoma. (3) The frequency of mucinous epithelium in tumors of mixed cell type. (4) The frequency with which neoplastic mucinous epithelium originates from the endometrium. (5) The striking degree of differentiation of some squamous cell carcinomas. (6) The occasional predominance of non-endometrioid carcinomas (especially serous or undifferentiated carcinoma) within malignant mullerian mixed tumors. (7) The spectrum of reactive epithelial changes and other non-neoplastic abnormalities that may mimic serous or clear cell carcinoma.

Hep Par 1 expression in carcinoma of the cervix: implications for diagnosis and prognosis

AIMS

To determine the frequency and pattern of Hep Par 1 expression in cervical carcinomas of various histological types and to correlate expression with prognostic parameters.

METHODS

Twenty nine cervical carcinomas were analysed for tumour type, hepatoid and neuroendocrine differentiation, and vascular invasion. A semiquantitative analysis was performed for Hep Par 1, alpha fetoprotein, chromogranin, and synaptophysin immunoreactivity.

RESULTS

Hep Par 1 expression was seen in seven of the 29 cervical carcinomas (three of seven adenocarcinomas, one of 17 squamous cell carcinomas, one of two adenocarcinomas with adenocarcinoma in situ, one of two adenocarcinomas in situ, and one of one large cell neuroendocrine carcinoma with adenocarcinoma in situ). Normal looking endocervical epithelium was also positive in one case. Cases expressing Hep Par 1, with or without neuroendocrine coexpression, were associated with a higher rate of vascular invasion and a worse prognosis. Three of the five cases expressing neuroendocrine markers also coexpressed Hep Par 1.

CONCLUSIONS

Hep Par 1 expression in carcinoma of the cervix is not uncommon and is present in a variety of histological types. Expression of this marker appears to be associated with more aggressive biological behaviour and a worse prognosis. The uterine cervix is another site that may express Hep Par 1 and hence the use of this antibody in situations of diagnostic difficulty, especially involving lesions within the liver, have to be coupled with the knowledge of the range of tissues it may stain.

Hepatoid adenocarcinoma with liver metastasis mimicking hepatocellular carcinoma: an immunohistochemical and molecular study of eight cases

Hepatoid adenocarcinoma (HAC) is a special type of extrahepatic adenocarcinoma, which has a striking morphologic similarity to hepatocellular carcinoma. Seven HACs arising in the stomach and one in the lung, all with liver metastasis, were studied. They shared clinical features, such as old age, high serum alpha-fetoprotein level, aggressive behavior, and hepatic tumor in absence of risk factors for hepatocellular carcinoma (HCC). Morphologically, tumors were characterized by an admixture of tubulo-and/or papillary adenocarcinoma with hepatoid foci. In six cases, liver metastases showed an exclusive hepatoid differentiation, virtually indistinguishable from HCC with solid growth pattern. As HAC and HCC cannot be differentiated on the basis of morphology alone, differences in immunohistochemical reaction patterns would be of considerable diagnostic help. Immunostaining for CK7, CK8, CK18, CK19, CK20, alpha-fetoprotein, p-CEA, and HepPar1 revealed that hepatoid areas of both primary and metastatic HAC have a specific immunoprofile, distinctive of this entity. On the one hand, positivity of virtually all HACs for alpha-fetoprotein, CK8, CK18, and the membranous, canalicular staining for polyclonal carcinoembryonic antigen underline its hepatoid nature. On the other hand, positive staining for CK19 and CK20 and frequent negativity for HepPar1 in both primary tumors and their metastases were distinctive features of HAC. Furthermore, HAC differs from combined hepatocellular cholangiocarcinoma, being negative for CK7. In addition, for comparison of immunohistochemical results, we stained with the same antibody panel a tissue microarray of 121 HCCs. Comparative genomic hybridization study of three HAC supports their hepatoid differentiation as aberrations found in HAC are common in HCC (4q-, 8p-), and hepatoblastoma (Xq+), respectively.

Malignant mixed Mullerian tumor of the uterine corpus with alpha-fetoprotein-producing hepatoid adenocarcinoma component

OBJECTIVES

Hepatoid adenocarcinoma is a rare tumor and has the histological coexistence of well-differentiated adenocarcinoma and nests of hepatoid cells with immunoreactivity for alpha-fetoprotein (AFP). A case of hepatoid adenocarcinoma in malignant mixed Mullerian tumor of the uterus is presented with a review of the literature.

CASE

The patient is a 63-year-old woman who complained of abnormal genital bleeding. Serum AFP concentration was 5060 ng/ml. Histologically, the tumor was composed of endometrioid adenocarcinoma, neoplastic hepatoid cells, and sarcoma component including leiomyosarcoma and rhabdomyosarcoma. After operation followed by six courses of platinum-based chemotherapy, serum levels of AFP dropped into normal range.

CONCLUSIONS

This is, to our knowledge, the first report of malignant mixed Mullerian tumor of the uterus with an AFP-producing hepatoid adenocarcinoma component.

Hepatoid carcinoma of the uterus that collided with carcinosarcoma

The case of a 68-year-old woman who was seen at Tokyo Kousei Nenkin Hospital because of abnormal genital bleeding is described. A malignant uterine tumor was suspected based on biopsy results. Hysterectomy and bilateral salpingo-oophorectomy were performed. Grossly, a solid whitish tumor occupied the area from the endocervix to the uterine body. On the consecutive fundal side, a whitish tumor protruded into the uterine cavity. Histologically, the tumor occupying the endocervical side showed a trabecular growth pattern. Many periodic acid-Schiff (PAS)-positive hyaline globules were observed. The cytoplasm of the tumor cells and the hyaline globules were immunohistochemically positive for alpha-fetoprotein (AFP). The tumor occupying the fundal side was identified as having endometrioid adenocarcinoma and spindle cell sarcoma components. The two tumors collided at a clear boundary. The present case was pathologically diagnosed as a collision cancer involving a hepatoid carcinoma and a carcinosarcoma. To our knowledge, this is the fourth reported case of a hepatoid carcinoma of the uterus. When no lesion is detected in the liver and stomach of a patient whose serum AFP level is abnormally high, the female reproductive system, such as the ovaries and uterus, should be examined as a possible site of AFP-producing cancer.

Endometrioid carcinoma of the uterine corpus: a review of its pathology with emphasis on recent advances and problematic aspects

This review considers the pathologic features of endometrioid carcinoma of the uterine corpus, which accounts for approximately 80% of endometrial adenocarcinomas, with an emphasis on its histologic features, recent advances, and problematic aspects. In addition to typical endometrioid carcinoma, the variants of endometrioid carcinoma covered include secretory carcinoma, villoglandular endometrioid carcinoma, endometrioid carcinoma with small nonvillous papillae, endometrioid carcinomas with microglandular and sertoliform patterns, and endometrioid carcinomas with metaplastic changes. These changes include a variety of different appearances of squamous epithelia (ranging from mature and keratinizing to immature with only subtle evidence of a squamous nature), clear cells, surface changes resembling syncytial metaplasia or microglandular hyperplasia, ciliated cells, oxyphilic cells, and spindled epithelial cells (sarcomatoid carcinoma). The last is one of several variants that may cause a biphasic appearance, all of which should be distinguished from the malignant müllerian mixed tumor. Rare findings in endometrioid carcinomas include hyalinization, psammoma bodies, and foci of stromal metaplasia such as osteoid. Unusual growth patterns of endometrioid carcinomas include involvement of adenomyosis, the "diffusely" infiltrating pattern of myoinvasion, and a previously unemphasized pattern of myoinvasion with "pinched off" glands that may be cystic or have a pseudovascular appearance, often with a myxoid stromal reaction. Other aspects of endometrioid carcinoma discussed are its immunoprofile, grading, cervical involvement (including a hitherto undescribed "burrowing" pattern of extension within the cervix that can result in underdiagnosis of stage IIB disease), carcinoma arising in the lower uterine segment, carcinoma arising in polyps and adenomyomas, carcinoma in young women, tamoxifen-related carcinoma, associated ovarian endometrioid carcinoma, and peritoneal keratin granulomas. Finally, the differential diagnosis of endometrioid carcinoma is briefly considered with a section on benign mimics, including curettage-related changes, menstrual changes, adenomyosis-related problems, metaplastic changes, atypical polypoid adenomyoma, radiation atypia, and papillary proliferations, and a section on metastatic colonic carcinoma.