Metastases to the ovary arising from endometrial, cervical and fallopian tube cancer: recent advances

GLP1R boosts survival, migration and invasion of endometrial cancer cells and protects against ferroptotic cell death

BACKGROUND

Despite the strong evidence concerning carcinogenic roles of glucagon-like peptide 1 receptor (GLP1R), the role of this gene in endometrial cancer (EC) remains elusive. This study investigated the properties of GLP1R on EC in vitro.

METHODS

The expression of GLP1R in EC was detected by RT-qPCR, immunohistochemistry, and western blotting. Cell viability, cell cycle, apoptosis, migration, invasion and ferroptosis were assessed through CCK-8, flow cytometry, wound healing, transwell, DCFH-DA and western blotting, respectively.

RESULTS

We found that GLP1R was up-regulated in EC than normal specimens. It had the highest expression in AN3CA cells. Cell viability, migration and invasion were significantly reduced, while cell cycle arrest and apoptosis were induced following GLP1R knockdown. The malignant biological behaviours of AN3CA cells were investigated when treated with exendin-4 (GLP1R agonist). Moreover, GLP1R lowered intracellular ROS level and expression of SLC7A11, and FTH1, but mitigated GPX4 expression in AN3CA cells.

CONCLUSION

In a word, GLP1R was up-regulated in EC and its up-regulation facilitated the proliferative and metastatic potentials, and protected cells from ferroptosis, thereby accelerating EC progression. These data emphasised the potency of GLP1R as a therapeutic agent against EC.

Whole exome sequencing reveals diverse genomic relatedness between paired concurrent endometrial and ovarian carcinomas

INTRODUCTION

Concurrent non-serous endometrial and ovarian tumours are often managed clinically as two separate primary tumours, but almost all exhibit evidence of a genomic relationship.

METHODOLOGY

This study investigates the extent of relatedness using whole exome sequencing, which was performed on paired non-serous endometrial and ovarian carcinomas from 27 patients with concurrent tumours in a cohort with detailed clinicopathological annotation. Four whole exome sequencing-derived parameters (mutation, mutational burden, mutational signatures and mutant allele tumour heterogeneity scores) were used to develop a novel unsupervised model for the assessment of genomic similarity to infer genomic relatedness of paired tumours.

RESULTS

This novel model demonstrated genomic relatedness across all four parameters in all tumour pairs. Mutations in PTEN, ARID1A, CTNNB1, KMT2D and PIK3CA occurred most frequently and 24 of 27 (89 %) tumour pairs shared identical mutations in at least one of these genes, with all pairs sharing mutations in a number of other genes. Ovarian endometriosis, CTNNB1 exon 3 mutation, and progression and death from disease were present across the similarity ranking. Mismatch repair deficiency was associated with less genomically similar pairs.

DISCUSSION

Although there was diversity across the cohort, the presence of genomic similarity in all paired tumours supports the hypothesis that concurrent non-serous endometrial and ovarian carcinomas are genomically related and may have arisen from a common origin.

Multimodal diagnostic strategies and precision medicine in mucinous ovarian carcinoma: a comprehensive approach

Mucinous ovarian carcinoma (MOC) represents a distinct entity within ovarian malignancies, characterized by diagnostic challenges due to its rarity and the potential overlap with other tumor types. The determination of tumor origin is important for precise postsurgical treatment. This article highlights the accurate diagnosis and management of MOC, including the use of imaging modalities, serological tumor markers, immunohistochemistry, and genomic analyses. Transabdominal and transvaginal ultrasonography, complemented by MRI and CT, plays a pivotal role in differentiating MOC from other mucinous tumors and in surgical planning, particularly for fertility preservation. Serological markers like CA19-9, CA-125, and CEA, though not definitive, provide valuable preoperative insights. Immunohistochemistry aids in distinguishing primary MOC from metastatic mucinous carcinomas, while genomic profiling offers the potential for precision medicine through the identification of specific molecular signatures and treatment susceptibilities. Despite advancements in diagnostic techniques, no single method conclusively differentiates between primary and metastatic tumors intraoperatively. The paper reviews the origins, diagnosis, and differential diagnosis of primary mucinous ovarian carcinoma highlights the need for a multimodal diagnostic approach and advocates for the inclusion of MOC patients in clinical trials for personalized therapies, recognizing the heterogeneity of the disease at the molecular level.

Human peritoneal fluid exerts ovulation- and nonovulation-sourced oncogenic activities on transforming fallopian tube epithelial cells

Secretory cells in the fallopian tube fimbria epithelium (FTE) are regarded as the main cells of origin of ovarian high-grade serous carcinoma (HGSC). Ovulation is the main cause of FTE oncogenesis, which proceeds through a sequence of TP53 mutations, chromosomal instability due to Rb/cyclin E aberration, in situ carcinoma (STIC), and metastasis to the ovary and peritoneum (metastatic HGSC). Previously, we have identified multiple oncogenic activities of the ovulatory follicular fluid (FF), which exerts the full spectrum of transforming activity on FTE cells at different stages of transformation. After ovulation, the FF is transfused into the peritoneal fluid (PF), in which the FTE constantly bathes. We wondered whether PF exerts the same spectrum of oncogenic activities as done by FF and whether these activities are derived from FF. By using a panel of FTE cell lines with p53 mutation (FT282-V), p53/CCNE1 aberrations (FT282-CCNE1), and p53/Rb aberrations plus spontaneous transformation, and peritoneal metastasis (FEXT2), we analyzed the changes of different transformation phenotypes after treating with FF and PF collected before or after ovulation. Similar to effects exhibited by FF, we found that, to a lesser extent, PF promoted anchorage-independent growth (AIG), migration, anoikis resistance, and peritoneal attachment in transforming FTE cells. The more transformed cells were typically more affected. Among the transforming activities exhibited by PF treatment, AIG, Matrigel invasion, and peritoneal attachment growth were higher with luteal-phase PF treatment than with the proliferative-phase PF treatment, suggesting an ovulation source. In contrast, changes in anoikis resistance and migration activities were similar in response to treatment with PF collected before and after ovulation, suggesting an ovulation-independent source. The overall transforming activity of luteal-phase PF was verified in an i.p. co-injection xenograft mouse model. Co-injection of Luc-FEXT2 cells with either FF or luteal-phase PF supported early peritoneal implantation, whereas co-injection with follicular-phase PF did not. This study, for the first time, demonstrates that PF from ovulating women can promote different oncogenic phenotypes in FTE cells at different stages of malignant transformation. Most of these activities, other than anoikis resistance and cell migration, are sourced from ovulation.

Synchronous Endometrial and Ovarian Carcinomas: Pathologic and Molecular Analysis Highlights the Monoclonal Origin of the Lesions

The diagnosis of synchronous carcinomas, involving both the endometrium and ovaries, is not a rare finding in gynecologic pathology and represents a challenge with implications on tumor staging and therapeutic decision-making. A mono-institutional series of 11 metastatic and 6 paired synchronous endometrial and ovarian carcinomas were reviewed by 2 expert pathologists based on previously published histopathologic criteria. The series was investigated for DNA mismatch repair proteins, p53, and POLE status and was subject to DNA-based next-generation sequencing targeting 67 cancer-related genes. Out of 17 pairs, 16 featured the same histotype (10 endometrioid, 4 serous high-grade, and 2 clear cells). By using WHO 2020 criteria, 11 couples of tumors were confirmed as metastatic and 6 couples were confirmed as independent. Based on next-generation sequencing analysis, 16 of 17 cases (11 metastatic and 5 independent) of our series showed evidence of a clonal relationship between endometrial and ovarian carcinomas. In metastatic cases, the adverse outcome was associated with nonendometrioid/high-grade endometrioid histotype and with the p53-abnormal molecular subtype. Four cases originally fulfilling clinicopathological criteria of independent endometrial and ovarian carcinomas were clonally related, low-grade endometrioid histotype and POLE -mut, mismatch repair deficient, and no specific molecular profile molecular subtypes; no adverse event was recorded in this group. In summary, the molecular characterization of synchronous gynecologic carcinomas confirms their clonal origin in most cases. However, the results of our study point out that the clinical behavior of these tumors seems to be determined by the presence of high-risk WHO 2020 histologic criteria and molecular features (i.e. p53-abnormal), rather than the monoclonal origin.

Low-grade endometrioid endometrial cancer with adnexal only metastasis: Evaluation of de-escalation of adjuvant therapy

OBJECTIVE

To assess survival outcomes of stage IA3 endometrial cancer and the association of adjuvant therapy and survival.

METHODS

The National Cancer Database was retrospectively queried to examine 594 and 1455 patients with stage IA3 and IIIA1 endometrial cancer, respectively, from 2010-2015. Overall survival (OS) was examined based on adjuvant therapy: multimodal combination chemotherapy and external beam radiotherapy, chemotherapy alone, external beam radiotherapy alone, and none.

RESULTS

For stage IA3 disease, 109 (18.4%) patients did not receive adjuvant therapy. The 5-year OS rates for the no adjuvant therapy group and the combination group were 86.3% and 91.4%, respectively (adjusted-hazard ratio [aHR] 1.23, 95% confidence interval [CI] 0.70-2.18). This survival association was consistent when compared to chemotherapy alone (5-year OS rates 86.3% vs 86.3%, aHR 1.11, 95%CI 0.67-1.83). The results were similar among those who underwent nodal evaluation (5-year OS rates, 92.6%, 86.6%, and 89.4% for combination therapy, chemotherapy alone, and no adjuvant therapy), including grade 1 lesions (96.2%, 89.4%, and 100%, respectively). In grade 2 lesions, 5-year OR rates was modestly lower for no adjuvant therapy than combination therapy (89.4%, 84.0%, and 82.7% for combination, chemotherapy alone, and no adjuvant therapy, P = 0.03). For stage IIIA1 disease, omission of adjuvant therapy was associated with decreased OS compared to combination therapy (43.2% vs 73.1%, aHR 1.65, 95%CI 1.30-2.11) or chemotherapy alone (43.2% vs 67.1%, aHR 1.62, 95%CI 1.32-1.99).

CONCLUSION

The results of this investigation suggest that survival effects of adjuvant therapy differ for stage IA3 and IIIA1 diseases. Patients with stage IA3 disease have overall good prognosis regardless of adjuvant therapy particularly grade 1 lesions, partly supporting the FIGO committee suggestion for adjuvant therapy de-escalation in stage IA3 endometrial cancer.

The pregnancy and oncology outcome of fertility-sparing management for synchronous primary neoplasm of endometrium and ovary

PURPOSE

To investigate the efficacy of fertility-preserving treatment for young women with synchronous primary neoplasm of endometrium and ovary.

METHODS

We retrospectively reviewed eight patients with concurrent primary grade 1 presumed stage IA endometrioid endometrial adenocarcinoma (EEA) or endometrial atypical hyperplasia (EAH) and primary stage I ovarian tumors who underwent fertility-sparing treatment in the Obstetrics and Gynecology Hospital of Fudan University between April 2016 and December 2022.

RESULTS

Synchronous endometrial and ovarian cancers (SEOC) accounted for 50% of these eight patients. The median age of patients was 30.5 years (range, 28-34 years). None of them received chemotherapy. The median treatment time was 4 months (range, 3-8 months). 87.5% (7/8) cases achieved complete response (CR), and the median time to CR was 3.8 months (range, 1.5-7.7 months). Among patients who got CR, none of them showed any signs of recurrence. Pregnancies and successful deliveries were achieved in 4 of 5 patients. Till September 2023, the median follow-up period was 50.5 months (range:15.2-85.2 months).

CONCLUSION

Fertility-sparing treatment is feasible for highly selected patients with synchronous neoplasm of the endometrium and ovary, but strict screening and monitoring are mandatory. Though the results of our limited cases are encouraging, long follow-up and more clinical data are required. Enrolled patients must be fully informed of the risks during conservative treatment.

The research progress on synchronous endometrial and ovarian carcinoma

Synchronous endometrial and ovarian carcinoma (SEOC) is the most common combination of primary double cancer in the female reproductive system. The etiology and pathogenesis of SEOC remain unclear, and clinically, it is often misdiagnosed as metastatic cancer, affecting the formulation of treatment plans and prognosis for patients. This article provides a review of its epidemiology, pathological and clinical characteristics, risk factors, pathogenesis, diagnosis, treatment, and prognosis.

DNA Methylation Signature of Synchronous Endometrioid Endometrial and Ovarian Carcinomas

Next-generation sequencing (NGS) studies have demonstrated that co-occurring sporadic endometrioid endometrial carcinoma (EEC) and endometrioid ovarian carcinoma (EOC) are clonally related, suggesting that they originate from a single primary tumor. Despite clonality, synchronous EEC and EOC when diagnosed at early stage behave indolently, similar to isolated primary EEC or isolated primary EOC. In the present study, we compared the DNA methylation signatures of co-occurring EEC and EOC with those of isolated primary EEC and isolated primary EOC. We also performed targeted NGS to assess the clonal relatedness of 7 co-occurring EEC and EOC (4 synchronous EEC and EOC and 3 metastatic EEC based on pathologic criteria). NGS confirmed a clonal relationship in all co-occurring EEC and EOC. DNA methylation profiling showed distinct epigenetic signatures of isolated primary EEC and isolated primary EOC. Endometrial tumors from co-occurring EEC and EOC clustered with isolated primary EEC while their ovarian counterparts clustered with isolated primary EOC. Three co-occurring EEC and EOC cases with peritoneal lesions showed a closer epigenetic signature and copy number variation profile between the peritoneal lesion and EOC than EEC. In conclusion, synchronous sporadic EEC and EOC are clonally related but demonstrate a shift in DNA methylation signatures between ovarian and endometrial tumors as well as epigenetic overlap between ovarian and peritoneal tumors. Our results suggest that tumor microenvironment in the ovary may play a role in epigenetic modulation of metastatic EEC.

Recent Advances in the Classification of Gynecological Tract Tumors: Updates From the 5th Edition of the World Health Organization "Blue Book"

CONTEXT.—

The World Health Organization Classification of Tumours: Female Genital Tract Tumors, 5th edition, published in September 2020, comes 6 years after the 4th edition, and reflects the monumental leaps made in knowledge about the biology of gynecological tumors. Major changes include revised criteria for the assignment of the site of origin of ovarian and fallopian tube tumors, a revision in the classification of squamous and glandular lesions of the lower genital tract based on human papillomavirus association, and an entire chapter devoted to genetic tumor syndromes. This article highlights the changes in the 5th edition relative to the 4th edition, with a focus on areas of value to routine clinical practice.

OBJECTIVE.—

To provide a comprehensive update on the World Health Organization classification of gynecological tumors, highlighting in particular updated diagnostic criteria and terminology.

DATA SOURCES.—

The 4th and 5th editions of the World Health Organization Classification of Tumours.

CONCLUSIONS.—

The World Health Organization has made several changes in the 5th edition of the update on female genital tumors. Awareness of the changes is needed for pathologists' translation into contemporary practice.

Isolated tubal metastasis from an incidental HPV-associated endocervical adenocarcinoma presented as an adnexal mass: A case report

Tubal metastasis from endocervical adenocarcinoma is uncommon and is discovered as an incidental finding on routine sampling of fallopian tubes. In this paper, we present the case of an 81-year-old woman who presented with an adnexal mass during investigations of postmenopausal bleeding. Hysterectomy and bilateral salpingo-oophorectomy with excision of the left adnexal mass were performed, which led to the diagnosis of an incidental HPV-associated endocervical adenocarcinoma with secondary, macroscopic tubal involvement. The patient received adjuvant pelvic radiotherapy and remained well after three months of follow-up, with no evidence of recurrence. Only a few cases of endocervical adenocarcinoma with tubal metastasis have been reported in the literature, which are commonly associated with ovarian, uterine corpus, and/or parametrial tissue involvement. To date, there are only two reported cases of isolated tubal metastasis, and in both cases, tubal involvement was discovered microscopically. Data on the impact of secondary tubal involvement on patient outcomes are limited.

Molecular Classification of Endometrial Cancer and the 2023 FIGO Staging: Exploring the Challenges and Opportunities for Pathologists

This commentary explores the complexities of the FIGO 2023 staging system and the inclusion of The Cancer Genome Atlas's (TCGA) molecular classification in the management of endometrial cancer. It highlights the importance of histology as a prognostic tool, while scrutinizing the merits and demerits of its application to aggressive endometrial cancers. The commentary review sheds light on the recent introductions of lymphovascular space invasion (LVSI) and lymph node metastasis size in cancer staging. It outlines the difficulties in differentiating between synchronous and metastatic endometrial and ovarian cancers, underlining their implications on treatment strategies. Furthermore, the commentary discusses the integration of molecular classifications within the FIGO 2023 framework, emphasizing the pivotal yet challenging implementation of the pathogenic POLE mutation test. The commentary concludes by reaffirming the vital role of pathologists in executing the FIGO 2023 staging system.

Recent Advances in Cervical Cancer Management: A Review on Novel Prognostic Factors in Primary and Recurrent Tumors

BACKGROUND

Several pathological parameters, including tumor size, depth of stromal invasion, lympho-vascular space invasion and lymph node status, have been proposed as prognostic predictors in cervical cancer. However, given the high mortality and recurrence rate of cervical cancer, novel parameters that are able to provide additional prognostic information are needed in order to allow a better prognostic stratification of cervical cancer patients.

METHODS

A search was conducted on PubMed to identify relevant literature data regarding prognostic factors in cervical cancer. The key words "cervical cancer", "prognostic factors", "pathology", and "outcome" were used.

RESULTS

The novel pathological grading system based on tumor budding and cell nest size appeared the most relevant prognostic factor in primary neoplasms. Moreover, other potentially useful prognostic factors were tumor size, depth of stromal invasion, lympho-vascular space invasion, perineural invasion, tumor-free distance and tumor-infiltrating lymphocytes. Prognostic factors related to advanced-stage cervical cancer, including lymph-nodes status, endometrial and cervical involvement as well as distant metastases, were also taken into consideration.

CONCLUSIONS

According to our findings, tumor budding and cell nest size grading system, depth of stromal invasion, lympho-vascular space invasion, perineural invasion, tumor-free distance and tumor-infiltrating lymphocytes appeared the most relevant factors included in the pathology report.

Curious Case of Superfitial Spreading Cervical Squamocellular Carcinoma with Adnexal Involvement

Background and Objectives: Cervical squamous cell carcinoma (SCC) usually showed an infiltrative growth pattern into endocervical stroma. In rare cases, SCC spreads superficially as an intraepithelial lesion to proximal uterine segments, and more rarely, involves invasive and more aggressive behavior on secondary sites. Materials and Methods: In this study, we present the case of an interesting form of cervical SCC growth and we discuss the possible reasons for that presentation. Results: After clinical examination and repeated histomorphological analysis, we found remarkable cervical epithelial dysplasia (a high-grade squamous intraepithelial lesion-H-SIL). A histopathology report after conization and hysterectomy showed squamocellular carcinoma with microinvasive focuses. Interestingly, squamocellular carcinoma was found in the proximal uterine and adnexal structure, as well as intraepithelial and microinvasive lesions. Conclusions: Our study described a rare presentation of primary cervical SCC with unusual adnexal involvement. This pattern of tumor growth should be especially considered for patients who are proposed for sparing surgical procedures. A detailed and multidisciplinary approach for every patient is very important because unpredictable cases are present. However, they are rare.

Clinical, Morphologic, and Molecular Features Associated With Ovarian Metastases From Pattern A Endocervical Adenocarcinomas

Ovarian metastases from endocervical adenocarcinomas (EAs) are rare but well-described. Silva Pattern A tumors have been reported to pose essentially no risk of lymph node metastases or recurrence. We describe a cohort of patients with Silva Pattern A EAs with ovarian metastases, as well as involvement of other sites. Eight pattern A EAs with ovarian metastases (4 synchronous, 4 metachronous) were identified from our institution's pathologic archives (2008-2021). Clinicopathologic and molecular features for each case were recorded. All patients were treated by hysterectomy; in each case, the entire tumor was submitted for histologic evaluation. The synchronous metastases were all clinically suspected to be ovarian primary tumors; EAs with metachronous ovarian involvement were confined to the uterus at initial diagnosis, with ovarian metastasis occurring 5 to 171 months after hysterectomy. Morphologically, all tumors were predominantly gland-forming, 5/8 (63%) displayed prominent mucinous differentiation, and 5/8 (63%) involved the corpus. All EAs were either noninvasive (exophytic/papillary/more complex than adenocarcinoma in situ) or showed nondestructive cervical stromal invasion to a depth of 5 mm or less. In the 5 tumors tested by next-generation sequencing, ARID1A, GNAS, and KRAS mutations were detected in 2 (40%), 3 (60%), and 4 (80%) cases, respectively. All 6 patients with follow-up (range, 32 to 181 mo; median, 99.5 mo) had at least 1 recurrence. All but one are without evident disease at last clinical assessment. In an otherwise typical Silva Pattern A EA, corpus involvement, mucinous differentiation, and certain gene mutations may be associated with risk for synchronous or metachronous ovarian metastases.

Key changes to the world health organisation (who) classification of female genital tumours introduced in the 5TH edition (2020)

An updated World Health Organisation (WHO) Classification of Female Genital Tumours was published in Autumn 2020. We discuss the major new additions and changes from the prior 2014 Classification with discussion of the reasons underlying these. A feature of the new Classification is the greater emphasis on key molecular events with integration of morphological and-molecular features. Most of the major changes from the prior Classification pertain to uterine (corpus and cervix) and vulval tumours but changes in all organs are covered.

Molecular Pathology of Human Papilloma Virus-Negative Cervical Cancers

Cervical cancer is the fourth most common cancer in women worldwide and is predominantly caused by infection with human papillomavirus (HPV). However, a small subset of cervical cancers tests negative for HPV, including true HPV-independent cancers and false-negative cases. True HPV-negative cancers appear to be more prevalent in certain pathological adenocarcinoma subtypes, such as gastric- and clear-cell-type adenocarcinomas. Moreover, HPV-negative cervical cancers have proven to be a biologically distinct tumor subset that follows a different pathogenetic pathway to HPV-associated cervical cancers. HPV-negative cervical cancers are often diagnosed at an advanced stage with a poor prognosis and are expected to persist in the post-HPV vaccination era; therefore, it is important to understand HPV-negative cancers. In this review, we provide a concise overview of the molecular pathology of HPV-negative cervical cancers, with a focus on their definitions, the potential causes of false-negative HPV tests, and the histology, genetic profiles, and pathogenesis of HPV-negative cancers.

Progress in the pathological arena of gynecological cancers

This review covers the significant new developments in the pathological classification of gynecological tumors. Many of these were included in the updated World Health Organization Classification of Female Genital Tract Tumours, published in 2020. Topics include the compelling evidence that a large majority of extrauterine high‐grade serous carcinomas arise from the fallopian tube; the Cancer Genome Atlas (TCGA) Classification of endometrial carcinomas; the discovery that most so‐called synchronous endometrial and ovarian endometrioid carcinomas represent metastasis from the endometrium to the ovary; and the division of cervical, vaginal, and vulval carcinomas into clinically meaningful HPV‐associated and HPV‐independent types. Newly described tumor types are covered, including endometrial and ovarian mesonephric‐like adenocarcinoma, uterine sarcoma types associated with specific molecular abnormalities, and gastric (gastrointestinal)‐type adenocarcinomas of the endometrium and vagina. Important molecular events in ovarian sex cord–stromal tumors are also discussed.

Review of significant new developments in the classification of gynecological tumors; many are included in the 2020 World Health Organization Classification of Female Genital Tract Tumours.

Developing a validated nomogram for predicting ovarian metastasis in endometrial cancer patients: a retrospective research

OBJECTIVE

To explore risk factors and develop a prediction model for ovarian metastasis in endometrial cancer (EC), as well as providing provide a reference for clinical ovarian preservation.

METHODS

We conducted a retrospective observational study enrolling 1496 EC patients having received complete staging surgery from Qilu Hospital of Shandong University from 2012 to 2018. These patients were randomly divided into two cohorts: training cohort (n = 1046) and validation cohort (n = 448). A nomogram prediction model was developed based on univariate, least absolute shrinkage and selection operator (Lasso), and multivariate logistic regression. Then, the nomogram model's performance was evaluated in discrimination, calibration, and clinical utility three aspects.

RESULTS

Parametrium invasion, lymph node metastasis, and oviduct metastasis were finally contained in the nomogram prediction model. The AUC of the model in the training cohort was 0.85 compared with 0.72 in the validation cohort. It also behaved well in calibration and had good clinical utility. With a threshold probability of 20% ~ 80%, the nomogram increased the net benefit by 0 ~ 13.6 per 100 patients than surgery for all patients upon validation.

CONCLUSIONS

We develop a nomogram with good performances for predicting ovarian metastasis in EC patients, which may help clinicians identify candidate patients appropriate for ovarian preservation in premenopausal EC patients.

Ovarian Metastasis by Gastric-type Endocervical Adenocarcinoma: A Clinicopathologic Description of 12 Cases

Cervical gastric-type adenocarcinoma has a propensity for ovarian metastasis, but the clinicopathologic findings and possible routes of tumor spread have not been well characterized to date. To address these points, we reported 12 cervical gastric-type adenocarcinomas with ovarian metastases from a single institution. Seven patients with gastric-type adenocarcinoma had concurrent endometrial fallopian tube involvement, 5 of which showed tumors confined to the fallopian tube mucosa. Two of these 5 patients died of disease at 2 and 16 mo, and 1 recurred at 18 mo. In the remaining 5 patients, 3 had wide pelvic/peritoneal spread while the other 2 showed no evidence of uterine or tubal involvement. Among them, 1 died of disease at 94 mo, and another relapsed at 20 mo. Morphologically, ovarian tumors frequently had surface involvement consistent with metastasis, but also mimicked a primary tumor with a mixture of benign/borderline/intraepithelial carcinoma-like areas, as well as carcinoma with expansile or destructive stromal invasion. The tubal lesions were predominantly in the form of mucosal colonization without invasion of the underlying structures. Block p16 and high-risk human papillomavirus mRNA signals were not detected in cervical gastric-type adenocarcinomas and ovarian metastatic tumors. We conclude that fallopian tube spread may be associated with ovarian metastasis of cervical gastric-type adenocarcinomas that have bad clinical outcomes. Ovarian involvement may be a part of the aggressive nature of these tumors.

Cervical stromal involvement by endometrial 'hyperplasia': a previously unreported phenomenon with recommendations to report as stage II endometrial carcinoma

A subtle 'burrowing' pattern of cervical stromal involvement by low-grade endometrioid adenocarcinoma of the uterine corpus is described in the literature. We report a small case series in which this pattern of cervical stromal involvement, warranting a diagnosis of endometrioid adenocarcinoma in the cervix, occurred in association with sometimes subtle endometrioid proliferations within the endometrium which fall short of the criteria for endometrioid adenocarcinoma and are in keeping with atypical hyperplasia or hyperplasia without atypia. In reporting this phenomenon, which has not been described previously, we highlight the importance of immunohistochemistry in the differential diagnosis, particularly in the exclusion of primary cervical glandular lesions, including those of mesonephric type. We discuss the differential with primary endometrioid adenocarcinoma (including minimal deviation type) of the cervix and other lesions and stress the importance of sampling the endometrium and lower uterine segment in their entirety in order to exclude an atypical hyperplasia or an adenocarcinoma in these locations. Although the pathogenesis of the cervical lesion we report is controversial, we believe that it is most likely a result of spread from the endometrium and results in the unusual occurrence of the malignant nature of the lesion being only apparent in the secondary rather than the primary lesion. We provide recommendations for reporting such cases and recommend designating them as stage II endometrial carcinoma, although the prognostic and management implications of such cases will only be clear once further cases with follow-up are reported.

Ovarian mucinous and seromucinous neoplasms: problematic aspects and modern diagnostic approach

The morphological spectrum of primary ovarian mucinous and seromucinous tumours is broad and presents an array of diagnostic challenges, many unique to these tumour types. This reflects the heterogeneous nature of these lesions, their varied histogenesis and evolving classification systems over recent decades, with further modification to the seromucinous category incorporated in the recently published 5^th edition of the WHO Classification of Female Genital Tumours. In this review we provide an update on the classification of these neoplasms and discuss their histogenesis and diverse morphology, focusing on areas which are diagnostically problematic. We also cover tumour grading, differential diagnosis, immunohistochemistry, the recent elucidation of the molecular underpinnings of ovarian mucinous neoplasia and discuss the gross and intraoperative handling of these tumours. A number of diagnostic issues remain unresolved highlighting the importance of further research on this front, as well as a multidisciplinary approach in the care of patients with ovarian mucinous and seromucinous neoplasia.

A Rare Case of Primary Signet-Ring Cell Cervical Carcinoma: Early Stage with Independent Bilateral Ovarian Metastases

Background

Primary signet-ring cell carcinoma of the uterine cervix (PSRCCC) is defined as a mucinous carcinoma. PSRCCC with independent bilateral ovarian metastases has not been previously reported in the literature.

Case Presentation

Herein we describe a case of PSRCCC with ovarian involvement. The patient underwent a detailed complete physical examination, and surgery was then performed to resect all of the tumors. All tumors expressed human papillomavirus 18 no distant tumors were detected, and estrogen receptor and progesterone receptor testing were negative, suggesting that the cervix was the primary site.

Conclusion

This is the first report of a case of PSRCCC metastasis to bilateral ovaries only. Conservative management of human papillomavirus-associated type endocervical adenocarcinomas with independent ovarian metastases should be considered.

Primary mucinous ovarian tumors vs. ovarian metastases from gastrointestinal tract, pancreas and biliary tree: a review of current problematics

Background

Making the distinction between primary mucinous and metastatic ovarian tumors is often difficult, especially in tumors with a primary source from the gastrointestinal tract, pancreas and biliary tree. The aim of the following paper is to provide an overview of the problematics, with a focus on the possibilities of the differential diagnosis at the macroscopic, microscopic and immunohistochemical level.

Main body

The three main aspects of mucinous ovarian tumors are described in detail, including the comparison of the available diagnostic algorithms based on the evaluation of mostly macroscopic features, characterization of the spectrum of microscopic features, and a detailed analysis of the immunophenotype comparing 20 antibodies with the assessment of their statistical significance for differential diagnosis purposes. Specific features, including Krukenberg tumor and pseudomyxoma peritonei, are also discussed.

Conclusion

Despite the growing knowledge of the macroscopic and microscopic features of ovarian mucinous tumors and the availability of a wide range of immunohistochemical antibodies useful in this setting, there still remains a group of tumors which cannot be precisely classified without close clinical-pathological cooperation.

Chemoresistance in Ovarian Cancer: Prospects for New Drugs

This review focuses on the conventional treatment, signaling pathways and various reasons for drug resistance with an understanding of novel methods that can lead to effective therapies. Ovarian cancer is amongst the most common gynecological and lethal cancers in women affecting different age groups (20-60). The survival rate is limited to 5 years due to diagnosis in subsequent stages with a reoccurrence of tumor and resistance to chemotherapeutic therapy. The recent clinical trials use the combinatorial treatment of carboplatin and paclitaxel on ovarian cancer after the cytoreduction of the tumor. Predominantly, patients are responsive initially to therapy and later develop metastases due to drug resistance. Chemotherapy also leads to drug resistance causing enormous variations at the cellular level. Multifaceted mechanisms like drug resistance are associated with a number of genes and signaling pathways that process the proliferation of cells. Reasons for resistance include epithelial-mesenchyme, DNA repair activation, autophagy, drug efflux, pathway activation, and so on. Determining the routes on the molecular mechanism that target chemoresistance pathways are necessary for controlling the treatment and understanding efficient drug targets can open light on improving therapeutic outcomes. The most common drug used for ovarian cancer is Cisplatin that activates various chemoresistance pathways, ultimately causing drug resistance. There have been substantial improvements in understanding the mechanisms of cisplatin resistance or chemo sensitizing cisplatin for effective treatment. Therefore, using therapies that involve a combination of phytochemical or novel drug delivery system would be a novel treatment for cancer. Phytochemicals are plant-derived compounds that exhibit anti-cancer, anti-oxidative, anti-inflammatory properties and reduce side effects exerted by chemotherapeutics.

Tumor Staging of Endocervical Adenocarcinoma: Recommendations From the International Society of Gynecological Pathologists

The International Federation of Gynecology and Obstetrics (FIGO) updated its staging system for cervical cancer in 2018 with changes that affect size criteria for early stage disease, as well as including pathology and radiology in addition to clinical assessment to be used in staging. Lymph node involvement was also included in the staging system. In early stage disease, pathologic findings are crucial in determining stage, which in turn determine treatment and prognosis for the patient. Therefore, it is imperative that there are unified and consistent methods and recommendations for assessing and reporting pathologic parameters for accurate staging. We describe the changes in the revised FIGO staging scheme and discuss controversial issues in cervical cancer staging from a pathologic perspective. We also provide practical recommendations regarding these parameters based on literature review and/or expert opinion/consensus.

Immunohistochemical Biomarkers as a Surrogate of Molecular Analysis in Ovarian Carcinomas: A Review of the Literature

The term "ovarian carcinoma" encompasses at least five different malignant neoplasms: high-grade serous carcinoma, low-grade serous carcinoma, endometrioid carcinoma, mucinous carcinoma, and clear cell carcinoma. These five histotypes demonstrated distinctive histological, molecular, and clinical features. The rise of novel target therapies and of a tailored oncological approach has demanded an integrated multidisciplinary approach in the setting of ovarian carcinoma. The need to implement a molecular-based classification in the worldwide diagnostic and therapeutic setting of ovarian cancer demanded a search for easy-to-use and cost-effective molecular-surrogate biomarkers, relying particularly on immunohistochemical analysis. The present review focuses on the role of immunohistochemistry as a surrogate of molecular analysis in the everyday diagnostic approach to ovarian carcinomas.

Pelvic and Ovarian Recurrence of Small HPV-associated Cervical Adenocarcinoma With Transformation to Neuroendocrine Carcinoma

The phenomenon of small human papillomavirus-associated cervical adenocarcinomas involving the ovary via a transuterine and transtubal route is uncommon but well described in the literature. We report a unique case of a small human papillomavirus-associated cervical adenocarcinoma spreading to both ovaries and the pelvis via this route 22 mo after loop excision and trachelectomy and developing into a high-grade neuroendocrine carcinoma in the metastasis.

Analysis of Clinicopathological Features of Cervical Mucinous Adenocarcinoma with a Solitary Ovarian Metastatic Mass as the First Manifestation

Purpose

To avoid misdiagnosis, clinicopathological features were analyzed in cases of cervical mucinous adenocarcinoma with solitary ovarian metastatic masses.

Patients and Methods

Three cases misdiagnosed as primary ovarian adenocarcinoma before surgery were filtered from the database of the Cancer Hospital/Chinese Academy of Medical Sciences from January 1998 to December 2016. The clinical data were thoroughly collected and compared, and both frozen and paraffin-embedded pathological sections were reviewed by two expert pathologists.

Results

None of the patients experienced cervical contact bleeding, and no typical cervical neoplasms were found. The cervical canals were slightly thickened in two patients, as detected by either palpation or imaging. The high-risk human papillomavirus (HPV) test results were all negative, and the thin-prep cytologic test (TCT) screened only one case of atypical glandular epithelial cells. All cases were indicative of higher serum CA19-9 levels (79.49-6124 U/mL). The ovarian masses showed no regular laterality, while they were all cystic or solid-cystic. Their pathological sections indicated a benign appearance of the capsule tissue with well-differentiated mucinous glands infiltrating the ovarian cortex with focal necrosis.

Conclusion

Attention should be paid to cervical examinations before and during surgery for cervical mucinous adenocarcinoma with a metastatic ovarian mass as the first manifestation. Such patients may gain a better prognosis after active treatment.

The Evolving Spectrum of Precursor Lesions of Cervical Adenocarcinomas

Modern classification schemes divide cervical adenocarcinomas into human papillomavirus (HPV)-associated and HPV-independent types. The precursor lesions of the former are well known and comprise HPV-associated (usual/endocervical) adenocarcinoma in situ (AIS) and the much less common stratified mucin-producing intraepithelial lesion (SMILE). The precursor lesions of HPV-independent cervical adenocarcinomas are much less well known, although postulated precursors of gastric-type adenocarcinoma include atypical lobular endocervical glandular hyperplasia and gastric-type AIS. In this review, we cover HPV-associated and HPV-independent precursor lesions of cervical adenocarcinomas concentrating on diagnostic criteria (morphology and immunophenotype) and differential diagnosis. We propose a uniform terminology and diagnostic criteria for precursor lesions showing intestinal differentiation with goblet cells because this may be a feature of both HPV-associated and HPV-independent AIS.

Somatic tumour testing establishes that bilateral DICER1-associated ovarian Sertoli-Leydig cell tumours represent independent primary neoplasms

AIMS

Sertoli-Leydig cell tumours (SLCTs) are rare ovarian neoplasms that are commonly associated with somatic or germline DICER1 mutations, especially when of the moderately or poorly differentiated type. A large majority are unilateral, but bilateral neoplasms have been reported, sometimes in the context of germline DICER1 mutations (DICER1 syndrome). It is currently unknown whether these represent independent neoplasms or metastasis from one ovary to the other and we aimed to elucidate this.

METHODS AND RESULTS

We report three cases of bilateral ovarian SLCT (all in patients with DICER1 syndrome) and review all reported cases of bilateral neoplasms. In the three cases (all moderately or poorly differentiated neoplasms), the time interval between the discovery of the tumours in each ovary ranged from 2.7 years to 6 years. In all cases, different DICER1 somatic hotspot mutations within the two tumours provided definitive proof that they represent independent neoplasms; this may be important clinically. Our literature review revealed that, when this information was available, all patients with bilateral SLCT had a germline DICER1 mutation.

CONCLUSIONS

Bilateral ovarian SLCTs represent independent rather than metastatic neoplasms, and essentially always occur in the context of DICER1 syndrome.

Highlighted issues from the second edition RCPA Endometrial Cancer Structured Reporting Protocol

Endometrial cancer is the most common malignancy of the female genital tract in the Western world. The second edition Endometrial Cancer Structured Reporting Protocol was published to the Royal College of Pathologists of Australasia (RCPA) website in December 2019, and relates to the reporting of endometrial cancer in hysterectomy specimens. This editorial discusses selected key issues from the second edition of the RCPA protocol, and addresses future challenges in pathology reporting of endometrial cancer.