Utility of p16INK4a, CEA, Ki67, P53 and ER/PR in the Differential Diagnosis of Benign, Premalignant, and Malignant Glandular Lesions of the Uterine Cervix and Their Relationship with Silverberg Scoring System for Endocervical Glandular Lesions

Dynamic changes in AI-based analysis of endometrial cellular composition: Analysis of PCOS and RIF endometrium

Background

The human endometrium undergoes a monthly cycle of tissue growth and degeneration. During the mid-secretory phase, the endometrium establishes an optimal niche for embryo implantation by regulating cellular composition (e.g., epithelial and stromal cells) and differentiation. Impaired endometrial development observed in conditions such as polycystic ovary syndrome (PCOS) and recurrent implantation failure (RIF) contributes to infertility. Surprisingly, despite the importance of the endometrial lining properly developing prior to pregnancy, precise measures of endometrial cellular composition in these two infertility-associated conditions are entirely lacking. Additionally, current methods for measuring the epithelial and stromal area have limitations, including intra- and inter-observer variability and efficiency.

Methods

We utilized a deep-learning artificial intelligence (AI) model, created on a cloud-based platform and developed in our previous study. The AI model underwent training to segment both areas populated by epithelial and stromal endometrial cells. During the training step, a total of 28.36 mm2 areas were annotated, comprising 2.56 mm2 of epithelium and 24.87 mm2 of stroma. Two experienced pathologists validated the performance of the AI model. 73 endometrial samples from healthy control women were included in the sample set to establish cycle phase-dependent dynamics of the endometrial epithelial-to-stroma ratio from the proliferative (PE) to secretory (SE) phases. In addition, 91 samples from PCOS cases, accounting for the presence or absence of ovulation and representing all menstrual cycle phases, and 29 samples from RIF patients on day 5 after progesterone administration in the hormone replacement treatment cycle were also included and analyzed in terms of cellular composition.

Results

Our AI model exhibited reliable and reproducible performance in delineating epithelial and stromal compartments, achieving an accuracy of 92.40% and 99.23%, respectively. Moreover, the performance of the AI model was comparable to the pathologists' assessment, with F1 scores exceeding 82% for the epithelium and >96% for the stroma. Next, we compared the endometrial epithelial-to-stromal ratio during the menstrual cycle in women with PCOS and in relation to endometrial receptivity status in RIF patients. The ovulatory PCOS endometrium exhibited epithelial cell proportions similar to those of control and healthy women's samples in every cycle phase, from the PE to the late SE, correlating with progesterone levels (control SE, r2 = 0.64, FDR < 0.001; PCOS SE, r2 = 0.52, FDR < 0.001). The mid-SE endometrium showed the highest epithelial percentage compared to both the early and late SE endometrium in both healthy women and PCOS patients. Anovulatory PCOS cases showed epithelial cellular fractions comparable to those of PCOS cases in the PE (Anovulatory, 14.54%; PCOS PE, 15.56%, p = 1.00). We did not observe significant differences in the epithelial-to-stroma ratio in the hormone-induced endometrium in RIF patients with different receptivity statuses.

Conclusion

The AI model rapidly and accurately identifies endometrial histology features by calculating areas occupied by epithelial and stromal cells. The AI model demonstrates changes in epithelial cellular proportions according to the menstrual cycle phase and reveals no changes in epithelial cellular proportions based on PCOS and RIF conditions. In conclusion, the AI model can potentially improve endometrial histology assessment by accelerating the analysis of the cellular composition of the tissue and by ensuring maximal objectivity for research and clinical purposes.

Diagnostic value of p16 and Ki-67 expression in cervical glandular intraepithelial disease: A review

OBJECTIVES

Cervical adenocarcinoma has been increasing in frequency, particularly among young women. Its diagnosis still presents many challenges. In addition to the difficulty in accessing the lesion, the lack of well-established criterias for cytological and histological diagnosis, and colposcopic images that are often not very clear, there are many benign situations that mimic glandular diseases. Immunohistochemistry has been used to aid this diagnosis. The purpose of this review is to evaluate the data available in the literature related to the use of p16 and Ki-67 as an auxiliary tool in the diagnosis of glandular disease.

METHODS

Original articles were searched in the PUBMED/MEDLINE, EMBASE, SCOPUS and BVS using different combinations of keywords and descriptors.

RESULTS

Of the 83 initial articles, 10 were selected. The criterias used for immunohistochemical interpretation showed many differences. The studies compared benign pathologies to malignant pathologies and some used panels with different immunomarkers while others used only p16. P16 showed an intense staining pattern in malignant pathologies, despite some studies have shown a negative pattern in adenocarcinoma. This can be explained by the histological subtype, not always related to HPV. Some studies have shown immunopositivity for p16 in normal tissues, tubal metaplasia and cervical endometriosis, but the staining pattern was never intense, as in malignant tissues. Ki-67 showed a more intense staining in AIS and adenocarcinoma tissues and was also present in normal tissues, mainly in tubal metaplasia and cervical endometriosis.

CONCLUSIONS

Biomarkers have proved to be important tools in aiding the diagnosis of glandular lesions, either alone or in panels. Standardization in the interpretation of immunochemistry is required.

New Insights in the Diagnosis of Rare Adenocarcinoma Variants of the Cervix—Case Report and Review of Literature

We report the case of a 29-year-old patient with low-grade squamous intraepithelial lesion (L-SIL), negative human papilloma virus (HPV), positive p16/Ki-67 dual-staining and colposcopy suggestive for severe dysplastic lesion. The patient underwent a loop electrosurgical excision procedure (LEEP), the pathology report revealing mesonephric hyperplasia and adenocarcinoma. The patient also opted for non-standard fertility-sparing treatment. The trachelectomy pathology report described a zone of hyperplasia at the limit of resection towards the uterine isthmus. Two supplementary interpretations of the slides and immunohistochemistry (IHC) were performed. The results supported the diagnosis of mesonephric adenocarcinoma, although with difficulty in differentiating it from mesonephric hyperplasia. Given the discordant pathology results that were inconclusive in establishing a precise diagnosis of the lesion and the state of the limits of resection, the patient was referred to a specialist abroad. Furthermore, the additional interpretation of the slides and IHC were performed, the results suggesting a clear cell carcinoma. The positive p16/Ki-67 dual-staining prior to LEEP, the non-specific IHC and the difficulties in establishing a diagnosis made the case interesting. Given the limitations of cytology and the fact that these variants are independent of HPV infection, dual staining p16/Ki-67 could potentially become useful in the diagnosis of rare adenocarcinoma variants of the cervix, however further documentation is required.

Patient-derived organoids model cervical tissue dynamics and viral oncogenesis in cervical cancer

Cervical cancer is a common gynecological malignancy often caused by high-risk human papillomavirus. There is a paucity of human-derived culture systems to study the cervical epithelium and the cancers derived thereof. Here we describe a long-term culturing protocol for ecto- and endocervical epithelia that generates 3D organoids that stably recapitulate the two tissues of origin. As evidenced for HSV-1, organoid-based cervical models may serve to study sexually transmitted infections. Starting from Pap brush material, a small biobank of tumoroids derived from affected individuals was established that retained the causative human papillomavirus (HPV) genomes. One of these uniquely carried the poorly characterized HPV30 subtype, implying a potential role in carcinogenesis. The tumoroids displayed differential responses to common chemotherapeutic agents and grew as xenografts in mice. This study describes an experimental platform for cervical (cancer) research and for future personalized medicine approaches.

Parameters of simultaneous 18F-FDG-PET/MRI predict tumor stage and several histopathological features in uterine cervical cancer

The purpose of this study was to analyze associations between apparent diffusion coefficient (ADC) and standardized uptake values (SUV) values and different histopathological parameters in uterine cervical cancer. 21 patients with primary uterine cervical cancer were involved into the study. All patients underwent a whole body simultaneous¹⁸F-FDG PET/MRI. Mean and maximum SUV were noted (SUV_mean and SUV_max). In all tumors minimal, mean, and maximal ADC values (ADC_min, ADC_mean, and ADC_max) were estimated. Combined parameters were calculated: SUV_max/SUV_mean, ADC_min/ ADC_mean, SUV_max/ADC_min and SUV_max/ADC_mean. In all cases the diagnosis was confirmed histopathologically by tumor biopsy. Histological slices were stained by hematoxilin and eosin, MIB 1 monoclonal antibody, and p16. All histopathological images were digitalized and analyzed by using a ImageJ software 1.48v. The following parameters were estimated: cell count, proliferation index KI 67, total and average nucleic areas, epithelial and stromal areas. Spearman's correlation coefficient was used to analyze associations between ADC and SUV values and histological parameters. P values ≤ 0.05 were considered as statistically significant. ADC_min and ADC_min/ ADC_mean were statistically significant lower in N positive tumors. KI 67 correlated statistically significant with SUV_max (r = 0.59, p = 0.005), SUV_mean (0.45, p = 0.04), ADC_min (r = −0.48, p = 0.03), SUV_max/ADC_min (r = 0.71, p = 0.001), SUV_max/ADC_mean (0.75, p = 0.001). SUV_max correlated well with epithelial area (r = 0.71, p = 0.001) and stromal areas (r = −0.71, p = 0.001). SUV values, ADC_min, SUV_max/ADC_min and SUV_max/ADC_mean correlated statistically significant with KI 67 and can be used to estimate the proliferation potential of tumors. SUV values correlated strong with epithelial area of tumor reflected metabolic active areas.

Interobserver reproducibility of cytologic p16INK4a /Ki-67 dual immunostaining in human papillomavirus-positive women

BACKGROUND

The accumulation of cyclin-dependent kinase inhibitor 2A (p16^ink4a ) protein in a cell is associated with neoplastic progression in precancerous cervical lesions. Dual staining for p16^ink4a and Ki-67 has been proposed as a triage test in cervical cancer screening for women who test positive for human papillomavirus DNA. In this study, interobserver reproducibility of the interpretation of this test was assessed.

METHODS

Forty-two immunostained, liquid-based cytology slides were divided into 2 sets and were interpreted by 17 to 21 readers from 9 different laboratories, yielding a total of 816 reports. Immunostaining results were classified as positive, negative, inconclusive, or inadequate. After evaluation of the first set of slides and before circulation of the second set, the results were discussed in a plenary meeting. The 10 slides with the most discordant results were evaluated again by selected expert cytopathologists.

RESULTS

The overall κ value was 0.612 (95% confidence interval [CI], 0.523-0.701), it was higher for the positive and negative categories (κ = 0.692 and κ = 0.641, respectively), and it was almost null for the inconclusive category (κ = 0.058). Considering only readers from laboratories with documented experience, the κ value was higher (κ = 0.747; 95% CI, 0.643-0.839) compared with nonexperienced centers (κ = 0.498; 95% CI, 0.388-0.616). The results were similar in both sets of slides (κ = 0.505 [95% CI, 0.358-0.642] and κ = 0.521 [95% CI, 0.240-0.698] for the first and second sets, respectively). Reinterpretation of the slides with the most discordant results did not provide any improvement (first evaluation, κ = 0.616 [95% CI, 0.384-0.866]; second evaluation, κ = 0.403 [95% CI, 0.182-0.643]).

CONCLUSIONS

Dual staining for p16 ^ink4a and Ki-67 demonstrated good reproducibility, confirming its robustness, which is a necessary prerequisite for its adoption as a triage test in cervical cancer screening programs that use human papillomavirus DNA as a primary test. Cancer Cytopathol 2017;125:212-220. © 2016 American Cancer Society.

Efficacy of p16 and Ki-67 immunostaining in the detection of squamous intraepithelial lesions in a high-risk HPV group

p16 and Ki-67 immunohistochemistry can be used as an ancillary method for the diagnosis of squamous intraepithelial lesion (SIL) versus atrophic change and atypical squamous metaplasia. The aim of the present study was to evaluate the efficacy of these two immunohistochemical markers in the accurate interpretation of cervical biopsies and correlate this data with human papilloma virus (HPV) infection status. The study included 103 formalin-fixed cervical punch and cone biopsy samples, with corresponding HPV DNA test data. Histopathological staining with hematoxylin and eosin, and immunohistochemical staining for p16 and Ki-67 were reviewed by two pathologists. The positivity of p16 and Ki-67 increased significantly with the severity of the cervical lesion in patients with a high-risk-HPV (HR-HPV) infection status (P<0.001). However, there was discordance in the HPV-negative group. Furthermore, concomitant diffuse, strong and block positive staining of p16, and a high Ki-67 index were implicated in high-grade SIL in the HR-HPV group. Thus, the two markers were efficient in advancing the diagnostic accuracy of cervical biopsies in the HR-HPV group; however, application of immunohistochemical results should be carefully considered in the HPV-negative group.

Efficacy of p16 and Ki-67 immunostaining in the detection of squamous intraepithelial lesions in a high-risk HPV group

p16 and Ki-67 immunohistochemistry can be used as an ancillary method for the diagnosis of squamous intraepithelial lesion (SIL) versus atrophic change and atypical squamous metaplasia. The aim of the present study was to evaluate the efficacy of these two immunohistochemical markers in the accurate interpretation of cervical biopsies and correlate this data with human papilloma virus (HPV) infection status. The study included 103 formalin-fixed cervical punch and cone biopsy samples, with corresponding HPV DNA test data. Histopathological staining with hematoxylin and eosin, and immunohistochemical staining for p16 and Ki-67 were reviewed by two pathologists. The positivity of p16 and Ki-67 increased significantly with the severity of the cervical lesion in patients with a high-risk-HPV (HR-HPV) infection status (P<0.001). However, there was discordance in the HPV-negative group. Furthermore, concomitant diffuse, strong and block positive staining of p16, and a high Ki-67 index were implicated in high-grade SIL in the HR-HPV group. Thus, the two markers were efficient in advancing the diagnostic accuracy of cervical biopsies in the HR-HPV group; however, application of immunohistochemical results should be carefully considered in the HPV-negative group.

Adenocarcinoma arising in urinary bladder endocervicosis

Endocervicosis is a rare benign condition characterized by the presence of endocervical-type mucinous glands. Urinary bladder endocervicosis forms an elevated lesion in the posterior wall of the urinary bladder and is sometimes misdiagnosed as a malignant tumor clinically and pathologically. Herein we describe the first case of adenocarcinoma arising in urinary bladder endocervicosis. The patient, a 58-year-old woman, presented with asymptomatic hematuria. Cystoscopy revealed a nodular mass measuring 4 cm in diameter in the posterior wall, and total cystectomy was performed. Histology revealed that the elevated lesion of the bladder wall was composed of haphazard proliferation of cystic glands lined by benign endocervical-type epithelium. An adenocarcinoma arose at the center of this endocervicosis. Mucin histochemistry revealed the presence of sulfomucin in both the endocervicosis and adenocarcinoma components. Immunohistochemically, the endocervicosis was positive for cytokeratin (CK) 7, AE1/AE3, CAM5.2, HBME1, CA19-9, and estrogen receptor (ER), and negative for CK20, CDX2, progesterone receptor (PR), MUC5AC, and β-catenin. The adenocarcinoma showed similar immunohistochemical results, except for loss of ER expression and a slight increase in the ratio of Ki-67-positive cells. This case indicates that endocervicosis, known as a benign lesion, harbors the possibility of malignant transformation.

Increased RIPK4 expression is associated with progression and poor prognosis in cervical squamous cell carcinoma patients

Aberrant expression of receptor interacting protein kinase 4 (RIPK4), a crucial regulatory protein of Wnt/β-catenin signaling, has recently been reported to be involved in several cancers. Here, we report the potential clinical implication and biological functions of RIPK4 in cervical squamous cell carcinoma (CSCC). One hundred and ninety-eight CSCC cases, 109 low-grade squamous intraepithelial lesions (LSILs), 141 high-grade squamous intraepithelial lesions (HSILs) and 63 chronic cervicitis were collected. The expression of RIPK4 was detected by immunohistochemistry (IHC), and its clinical value and oncogenic functions were further assessed. RIPK4 expression increased significantly with disease progression from 3.2% in chronic cervicitis, 19.3% in LSILs and 85.1% in HSILs to 94.4% in CSCCs (P < 0.001). Moreover, RIPK4 may serve as a useful biomarker to distinguish HSIL from chronic cervicitis/LSIL, which are two different clinical types for therapeutic procedures, with a high sensitivity and specificity (85.1% and 86.6%, respectively) and the performance improved when combined with p16^INK4a. Further, RIPK4 overexpression was associated with overall (HR = 2.085, P = 0.038) and disease-free survival (HR = 1.742, P = 0.037). Knockdown of RIPK4 reduced cell migration and invasion via inhibition of Vimentin, MMP2 and Fibronectin expression in cervical cancer cells. RIPK4 might act as a potential diagnostic and independent prognostic biomarker for CSCC patients.

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.

p16 INK4a and Ki67 expression in normal, dysplastic and neoplastic uterine cervical epithelium and human papillomavirus (HPV) infection

Cellular cycle proteins like the p16(INK4a) and the Ki67 proliferation nuclear antigen have been used as oncogenicity cellular markers. The E6 and E7 oncoproteins interact with tumor suppressor genes p53 and pRb, culminating with the p16(INK4a) overexpression. The objective of this study was to evaluate the presence of HPV-DNA in 174 cervical biopsies and correlate the different histological grades with the p16(INK4a) and Ki67 immunohistochemical expression (IHC). A cross-sectional study that enrolled a total of 174 women who underwent uterine cervical biopsies between February 2003 and December 2006, in southern Brazil, was performed. Cervical smear samples were analyzed for the presence of HPV-DNA through polymerase chain reaction (PCR), and biopsy samples were examined for p16(INK4A) and Ki67 expression through IHC techniques. The presence of HPV-DNA was observed in 89% of the tested patients, among which 52% were positive for high-risk (HR) viral types [16, 18 and 31]. Regarding p16(INK4a), an expression of 69% was observed, being expressed in 100% of the high-grade squamous lesions (HSIL) and HR-HPV-DNA positives. Ki67 expression was associated with the lesion grade, being more expressive in the most severe lesions (p<0.001). p16(INK4A) and Ki67 markers coexpression was present in 86% of the samples (p<0.001), being 100% among those positive to HR-HPV-DNA with HSIL (p<0.001). The results suggest an association between the presence of HR-HPV infection and the p16(INK4a) and Ki67 expression and which is even stronger among women with HSIL.

Impact of p16(INK4a) immunohistochemistry staining on interobserver agreement on the diagnosis of cervical intraepithelial neoplasia

OBJECTIVES

This study aimed to compare the interobserver Cohen κ on H&E staining and on H&E plus p16(INK4a) staining of all cervical biopsy specimens in a population-based screening program.

METHODS

All the colposcopy-guided biopsies generated by the routine screening of 23,258 women aged 25 to 64 years were stained with H&E and H&E plus p16. Biopsy specimens were reviewed by six external experts.

RESULTS

The four diagnoses were available in 441 cases. The interobserver κ values were 0.52 (95% confidence interval [CI], 0.45-0.58) and 0.48 (95% CI, 0.42-0.56) with H&E and H&E + p16, respectively, when using a five-group classification (normal, CIN 1, CIN 2, CIN 3, and cancer); adopting a two-group classification (≤CIN 1 and ≥CIN 2), the values were 0.75 (95% CI, 0.66-0.82) and 0.70 (95% CI, 0.61-0.79), respectively.

CONCLUSIONS

The use of p16 on all cervical biopsy specimens in a screening program showed virtually no effect on reproducibility of the histologic diagnosis.

Cervical adenocarcinoma identification by testing for chromosomal abnormalities

We report on a case of cervical adenocarcinoma in situ in a 42-year-old woman with a history of human papillomavirus infection. Repeat cytology, human papillomavirus testing, and colposcopy failed to identify the lesion. Testing of the cervical cell DNA identified chromosomal abnormalities, prompting a cervical cone biopsy, which identified adenocarcinoma in situ.

A clinicopathological and immunohistochemical study of minimal deviation adenocarcinoma of the uterine cervix

OBJECTIVE

To investigate the clinical, pathological and immunohistochemical features of minimal deviation adenocarcinoma (MDA) of the uterine cervix by conducting a retrospective study of 25 cases consecutively treated in three institutes over a 10 years period.

METHODS

Of 25 cases with MDA, clinical features were retrospectively reviewed, gross and micro appearances of surgical specimens of 17 operative cases were observed. Ki67, SMA, p53, PCNA, Vimentin, CEA, ER, CA125 and PR were detected on tissues from MDA and 50 cases common adenocarcinomas of the uterine cervix (AUCs) (differentiation rank: high 16, moderate 20, low 14). Their expressions were assessed in paraffin sections using the immunohistochemistry method.

RESULTS

MDA accounted for only 1.2% of adenocarcinomas of the uterine cervix. The main clinical manifestations were vaginal profuse, watery or mucoid discharge and irregular bleeding. Signs were cervical hypertrophy or thickening. The gross appearance showed many similarities with common AUCs. Immunohistochemical results: the positive rates for p53 and Ki67 in >50% of the cell nuclei (Ki67/50(+)) were 88% and 64% in MDA respectively, significantly higher than common AUCs (38%, 18%, P<0.01), CA 125 was 18% in MDA, clearly lower than common AUCs (58%, P<0.01). There was no difference between MDA and common AUCs for CEA, PR, Vimentin, ER, PCNA and SMA (P>0.05). No significant difference was noticed among the high, moderate and low differentiation groups in common AUCs (P>0.05).

CONCLUSIONS

For early stage diagnoses, MDA should be considered when cervical hypertrophy is present in patients complaining of a vaginal profuse watery or mucoid discharge and irregular bleeding. Positive immunohistochemical staining for p53, Ki67/50(+) and negative for CA125 can assist diagnosis and discrimination.

CINtec PLUS immunocytochemistry as a tool for the cytologic diagnosis of glandular lesions of the cervix uteri

Cytologic findings of glandular lesions of the cervix uteri are often difficult to evaluate. We studied the usefulness of CINtec PLUS p16/Ki-67 double stain (mtm laboratories, Heidelberg, Germany) for the diagnosis of glandular lesions. The study included 47 abnormal results on liquid-based cytologic tests with a subsequent histologic diagnosis of adenocarcinoma in situ or with early invasion, and 16 samples with negative results on follow-up. All samples were stained with CINtec PLUS p16/Ki-67 double stain. Of the neoplastic samples, 7 were excluded because of insufficient residual cellularity or loss of neoplastic cells. Of the samples that were adequate, 92.5% were stained with CINtec PLUS, whereas 7.5% were judged inconclusive. All inconclusive cases were at least 3 years old. Of the 16 negative samples, 15 (93.8%) stained negative and only 1 (6.2%) showed several positive clusters of cells. Our study shows that CINtec PLUS is a robust and useful tool for the diagnosis of glandular lesions of the cervix uteri.

Gynecologic cytology on conventional and liquid-based preparations: a comprehensive review of similarities and differences

Liquid-based preparations (LBPs) have largely replaced conventional Papanicolaou smears (CPS) for cervical samples in the United States and in many other industrialized countries. The two FDA-approved LBP currently in use include ThinPrep (TP), (Hologic Inc., Bedford, MA) and SurePath (SP), (BD Diagnostic, Burlington, NC). Split-sample and direct-to-vial studies have shown that LBPs show an overall improvement in sample collection and processing, reduce artifacts that interfere in diagnosis, are more sensitive, can be utilized for ancillary tests and are a cost-effective replacement for CPS. Comparative analyses of diagnostic accuracy indicate that LBPs perform at least as well as CPS. However, the added advantages of standardized, automated preparations and screening, reduced unsatisfactory rate, improved specimen adequacy and ability to perform human papillomavirus (HPV) test, are enough to continue use of LBP. The cytologic features in LBP are similar to CPS with subtle differences, particularly in background information. There are also subtle differences between the two LBPs, SP and TP, which are reflective of different sampling devices, collection media, and processing techniques. Architecturally, LBP shows smaller cell clusters and sheets and more dyscohesion. Cytologically, enhanced nuclear features and smaller cell size are more prominent. Advances in liquid-based Papanicolaou's (Pap) test have lead to well-defined patient management guidelines by the American Society for Colposcopy and Cervical Pathology. Herein, we review these aspects of Pap test including, morphology, automation, ancillary tests (HPV and immunochemistry), pertinent QA/QC monitors, patient management guidelines, and review of pertinent literature.

Dual stain immunohistochemical localization of p16INK4A and ki-67: a synergistic approach to identify clinically significant cervical mucosal lesions

BACKGROUND

The primary goal of this study was to assess the clinical utility of a multiplexed immunohistochemical method using colocalization of p16 and Ki-67 in identifying high-grade cervical mucosal lesions.

DESIGN

The study included formalin-fixed cervical biopsy specimens, representative of 297 diagnostic regions. They were subjected to 2 colors immunohistochemical staining for p16 and Ki-67 using an EnVision polymer-based method. The chromogens used were of DAB brown for the detection of p16 and alkaline phosphatase blue for Ki-67. Histologic regions were scored positive for either marker based on the detection of p16 or Ki-67 in >10% of the cells of interest.

RESULT

Positive test results with colocalization of p16/Ki-67 were found in 20 of 40 cases of cervical intraepithelial neoplasia 1 (n=40) and in all cases of cervical intraepithelial neoplasia 2/3 (n=32), squamous cell carcinoma (n=11), adenocarcinoma in situ (n=10), and invasive adenocarcinoma (n=8). Colocalization of p16/Ki-67 was also detected in few cells in 1 of 19 sections with tuboendometrial metaplasia but was not detected in normal squamous mucosa (n=78), normal endocervical mucosa (n=76), immature squamous metaplasia (n=13), or in microglandular hyperplasia (n=9).

CONCLUSIONS

The p16 and Ki-67 are coexpressed in virtually 100% of cases of high-grade squamous and glandular lesions, but they are rarely coexpressed in normal tissues or in benign lesions of the squamous and glandular mucosa. Thus, multiplexed colocalization of p16 and Ki-67 is a practical and potentially powerful diagnostic approach to enhance the accuracy of cervical histopathologic diagnosis.

Human papillomavirus and cervical cancer: biomarkers for improved prevention efforts

While organized screening programs in industrialized countries have significantly reduced cervical cancer incidence, cytology-based screening has several limitations. Equivocal or mildly abnormal Pap tests require costly retesting or diagnostic work-up by colposcopy and biopsy. In low-resource countries, it has been difficult to establish and sustain cytology-based programs. Advances in understanding human papillomavirus biology and the natural history of human papillomavirus-related precancers and cancers have led to the discovery of a range of novel biomarkers in the past decade. In this article, we will discuss the potential role of new biomarkers for primary screening, triage and diagnosis in high-resource countries and their promise for prevention efforts in resource constrained settings.

Human papillomavirus (HPV) detection using in situ hybridization in histologic samples: correlations with cytologic changes and polymerase chain reaction HPV detection

Although in situ hybridization (ISH) and polymerase chain reaction (PCR) have extensively been used on cytology specimens, there have been limited reports of the usefulness of these techniques in relation to confirmed histologic findings. In this study, we used PCR and ISH to detect human papillomavirus (HPV) in cytologic and histologic specimens, respectively. By using positive and negative likelihood ratios, we attempted to identify any predictive role of ISH testing alone or in combination with PCR for the development of high-grade histologic lesions (cervical intraepithelial neoplasia [CIN] 2+). In our study, ISH was a useful method for detection of HPV, even in a large fraction of samples with normal cytologic or biopsy findings. We suggest that when used together and evaluated in conjunction with histologic sections, ISH is a useful tool for ancillary molecular testing of HPV infection in cervical lesions, especially in CIN 2+ histological lesions where its analytic sensitivities and specificities were as good as those of PCR testing.

Fascin is a predictor for invasiveness and recurrence of urothelial carcinoma of bladder

OBJECTIVES

To evaluate the expression of fascin in bladder urothelial carcinoma, and to analyze its association with clinicopathologic features and prognosis of urinary bladder urothelial carcinoma.

MATERIALS AND METHODS

Immunohistochemistry was used to detect the expression of fascin, Ki-67, p53, CK20, and multidrug resistance gene (MDR) in 111 bladder urothelial carcinoma and 42 normal epithelial tissues. The association between fascin expression and clinicopathologic parameters and prognostic factors on tumor recurrence was analyzed by Kaplan-Meier method, log-rank test, and Cox proportional hazards model.

RESULTS

Ninety-four of 111 cases of bladder urothelial carcinoma showed positive fascin expression, while no fascin expression was detected in normal transitional epithelium. There was a significant difference in the expression of fascin in normal epithelium and bladder urothelial carcinoma (P = 0.000). Fascin expression was positively correlated with pT stage (P = 0.001) and tumor size (P = 0.011), while it had no association with age, gender, and tumor grade (P > 0.05). pT stage and the expression of fascin, Ki-67, p53, and CK20 were significantly correlated with urothelial carcinoma recurrence, and fascin expression was an independent factor predicting tumor recurrence.

CONCLUSIONS

Fascin expression was up-regulated in bladder urothelial carcinoma. Over-expression of fascin might play an important role in invasiveness and recurrence of bladder urothelial carcinoma. Fascin may be used as a prognostic marker and a new target for the treatment of bladder urothelial carcinoma.

Using biomarkers as objective standards in the diagnosis of cervical biopsies

Histopathologic diagnosis of cervical biopsies determines clinical management of patients with an abnormal cervical cancer-screening test yet is prone to poor interobserver reproducibility. Immunohistochemical staining for biomarkers related to the different stages of cervical carcinogenesis may provide objective standards to reduce diagnostic variability of cervical biopsy evaluations but systematic, rigorous evaluations of their potential clinical utility are lacking. To address diagnostic utility of human papillomavirus (HPV) L1, p16(INK4a), and Ki-67 immunohistochemical staining for improving diagnostic accuracy, we conducted a community-based and population-based evaluation using 1455 consecutive cervical biopsies submitted to the Department of Pathology at the University of Virginia during a period of 14 months. Thin-sections of each biopsy from 1451 of 1455 (99.7%) biopsies underwent evaluation of immunohistochemical stains for the 3 biomarkers, masked to the original diagnosis, and the results were compared with an adjudicated, consensus diagnosis by 3 pathologists. p16 immunostaining, using the strongest staining as the cutpoint, was 86.7% sensitive and 82.8% specific for cervical intraepithelial neoplasia (CIN) grade 2 or more severe (CIN2(+)) diagnoses. The performance of p16(INK4a) was more sensitive (P<0.001), less specific (P<0.001), and of similar overall accuracy for CIN2(+) compared with the combined performance of all pathologist reviews in routine clinical diagnostic service (sensitivity=68.9%, specificity=97.2%). Ki-67 immunostaining was also strongly associated with a CIN2(+) diagnosis but its performance at all staining intensities was inferior to p16 immunostaining, and did not increase the accuracy of CIN2(+) diagnosis when combined with p16(INK4a) immunostaining compared with p16(INK4a) immunostaining alone. We found no utility for L1 immunostaining in distinguishing between CIN and non-CIN. In conclusion, with a rigorous evaluation, we found immunohistochemical staining for p16 to be a useful and reliable diagnostic adjunct for distinguishing biopsies with and without CIN2(+).

Overexpression of c-erbB-2 and loss of p16 have molecular diagnostic relevance but no prognostic value in lung cancer

This study was designed to evaluate the expression of C-erbB-2 and p16 in lung cancers using tissue microarray technology and to determine their clinical and pathological significance. Immunohistochemical C-erbB-2 and p16 expressions and their associations with clinical and pathological features were analyzed in two tissue microarrays. The membranous and cytoplasmic expression rates of C-erbB-2 were 40.5 and 66.5% in non-small cell lung cancers (NSCLCs), and 0 and 9.5% in small cell lung cancers (SCLCs), respectively. The nuclear and cytoplasmic expression rates of p16 were 11.5 and 32.2% in NSCLs, and 45 and 80% in SCLCs, respectively. The cytoplasmic expression of both C-erbB-2 and p16 was more frequent than the membranous expression of C-erbB-2 and the nuclear expression of p16. The rates of overexpression of C-erbB-2 and loss of p16 expression were significantly higher in NSCLCs than in SCLCs (P < 0.05). Neither C-erbB-2 nor p16 expression was significantly associated with age, tumor grade or stage, presence of lymph node metastasis or survival duration. The abnormal expressions of p16 and C-erbB-2 may play a role in the progression of lung cancers. The variations in the expression patterns of C-erbB-2 and p16 between NSCLCs and SCLCs may aid the molecular classification of lung cancer. The abnormal expression of p16 may be involved in the development of NSCLCs, and the overexpression of C-erbB-2 in NSCLCs indicates that it can be a candidate target for gene therapy.

Fascin over expression is associated with dysplastic changes in sinonasal inverted papillomas: a study of 47 cases

Sinonasal inverted papilloma (IP) is a primary benign lesion with a tendency for local recurrence. Malignant transformation may develop in up to 15% of cases. Fascin (Fascin 1) is an actin cross-link binding protein required for the formation of actin-based cell-surface protrusions and cell motility. Fascin up-regulation in lung, gastric, breast and hepatobiliary carcinomas correlates with aggressiveness and decreased survival. Here we evaluate immunohistochemical expression of fascin in 47 sinonasal IPs from 34 patients. Fascin over-expression is significantly more common in sinonasal IP with high-grade dysplasia than in those with no dysplastic or low-grade dysplastic epithelium (P = 0.0001). No significant change in fascin expression is seen with recurrence. Over expression of fascin in high-grade dysplastic epithelium in IP may be associated with tumor progression and malignant transformation.

p16(INK4a) immunostaining in cytological and histological specimens from the uterine cervix: a systematic review and meta-analysis

BACKGROUND

P16(INK4a) is a biomarker for transforming HPV infections that could act as an adjunct to current cytological and histological assessment of cervical smears and biopsies, allowing the identification of those women with ambiguous results that require referral to colposcopy and potentially treatment.

MATERIAL AND METHODS

We conducted a systematic review of all studies that evaluated the use of p16(INK4a) in cytological or histological specimens from the uterine cervix. We also estimated the mean proportion of samples that were positive for p16(INK4a) in cytology and histology, stratified by the grade of the lesion.

RESULTS

Sixty-one studies were included. The proportion of cervical smears overexpressing p16(INK4a) increased with the severity of cytological abnormality. Among normal smears, only 12% (95% CI: 7-17%) were positive for the biomarker compared to 45% of ASCUS and LSIL (95% CI: 35-54% and 37-57%, respectively) and 89% of HSIL smears (95% CI: 84-95%). Similarly, in histology only 2% of normal biopsies (95% CI: 0.4-30%) and 38% of CIN1 (95% CI: 23-53%) showed diffuse staining for p16(INK4a) compared to 68% of CIN2 (95% CI: 44-92%) and 82% of CIN3 (95% CI: 72-92%).

CONCLUSION

Although there is good evidence that p16(INK4a) immunostaining correlates with the severity of cytological/histological abnormalities, the reproducibility is limited due to insufficiently standardized interpretation of the immunostaining. Therefore, a consensus needs to be reached regarding the evaluation of p16(INK4a) staining and the biomarker needs to be assessed in various clinical settings addressing specific clinical questions.

Diagnostic utility of p16INK4a: a reappraisal of its use in cervical biopsies

p16(INK4a), an indirect marker of cell cycle dysregulation, is commonly expressed in cervical dysplasias and carcinomas associated with high risk human papillomavirus (HR-HPV) infections. Although p16(INK4a) immunohistology is routinely used as a cost effective surrogate marker, many of the published articles are confusing and contradictory. The discrepancies can be ascribed to a multitude of factors operating at the molecular, technical and interpretative levels. In the first place, our simplistic model of viral mediated oncogenesis is speculative and fails to account for all the known biomolecular changes. Unresolved technical issues include the variables of tissue fixation, antibody dilution, antibody isotype and clone, and the sensitivity of the particular detection method. Within any controlled staining method, strong diffuse or 'block' immunoreactivity in squamous cells may be found in moderate/severe dysplasia (CIN 2/3) and invasive squamous carcinoma. In contrast, focal or multifocal reactivity in squamous cells may be artefactual, related to low risk or HR-HPV. p16(INK4a) is less reliable when dealing with glandular lesions since considerable overlap exists between reactive and dysplastic lesions. In addition not all glandular dysplasias/carcinomas are HR-HPV related, nor are all p16(INK4a) immunoreactive lesions associated with HR-HPV. We conclude that p16(INK4a) immunoperoxidase shows greater specificity than sensitivity for squamous lesions; in comparison, glandular dysplasias/carcinomas show reduced specificity and sensitivity. Like all cell cycle regulatory proteins, the future diagnostic role of p16(INK4a) is limited. The ideal diagnostic molecular test for cervical dysplasias will detect a HR-HPV related product after, but not before, cell transformation and will reliably predict those cases yet to experience disease progression.

Frozen-section evaluation of cervical adenocarcinoma at time of radical trachelectomy: pathologic pitfalls and the application of an objective scoring system

OBJECTIVE

To analyze the incidence of diagnostic discrepancy between frozen-section and final diagnosis of the endocervical margin at time of radical trachelectomy and to apply an objective scoring system to non-invasive endocervical glandular atypia to determine its utility in distinguishing benign from malignant lesions.

METHODS

Histologic slides from 19 cases of radical trachelectomy performed for invasive endocervical adenocarcinoma were evaluated for correlation between the frozen and permanent sections of the endocervical margin. An objective scoring system for grading non-invasive endocervical glandular lesions proposed by Ioffe et al. was also applied to the frozen and permanent section slides and compared to the final diagnosis.

RESULTS

There was 84% concordance between the frozen-section and final diagnosis using histology alone, vs. 95% concordance using the Ioffe scoring system. One trachelectomy was converted to completion hysterectomy for what was presumed to be adenocarcinoma in situ at the margin, which in retrospect, was a benign lesion and was correctly classified using the Ioffe system. Most of the discrepancies were due to misinterpretation of tubal metaplasia, tubo-endometrioid metaplasia, and atypical tubal metaplasia as adenocarcinoma in situ.

CONCLUSION

Benign mimics of endocervical adenocarcinoma in situ can be difficult to distinguish from malignant lesions, especially during frozen-section evaluation of the trachelectomy. Correctly diagnosing the margin status intraoperatively has great clinical impact and the application of an objective scoring system, like that proposed by Ioffe et al., can increase diagnostic accuracy when applied to frozen-section slides and better correlates with final diagnosis when compared to histology alone.