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Fan R, Lin W, Zhao R, Li L, Xin R, Zhang Y, Liu Y, Ma Y, Wang Y, Wang Y, Zheng W. Morules and β-catenin predict POLE mutation status in endometrial cancer: A pathway to more cost-effective diagnostic procedures. Am J Clin Pathol 2024; 162:141-150. [PMID: 38513273 DOI: 10.1093/ajcp/aqae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/28/2024] [Indexed: 03/23/2024] Open
Abstract
OBJECTIVES The characterization of DNA polymerase epsilon (POLE) mutations has transformed the classification of endometrial endometrioid carcinomas (EECs), highlighting the need for efficient identification methods. This study aims to examine the relationship between distinct morphologic features-namely, squamous morules and squamous differentiation (SD), as well as β-catenin expression-and the POLE mutation status in endometrial cancer (EC). METHODS Our study included 35 POLE-mutated (POLEmut) EC cases and 395 non-POLEmut EEC cases. RESULTS Notably, we observed no presence of morules in POLEmut cases, while SD was identified in 20% of instances. Conversely, morules and SD were identified in 12.7% and 26.1% of non-POLEmut EC cases, respectively, with morules consistently linked to a POLE wild-type status. The nuclear β-catenin expression is typically absent in tumors with wild-type POLE (wt-POLE) status. CONCLUSIONS Our findings suggest that the presence of either morules or nuclear β-catenin expression in EEC could practically rule out the presence of POLE mutations. These morphologic and immunohistochemical features can be used as preliminary screening tools for POLE mutations, offering significant savings in time and resources and potentially enhancing clinical decision-making and patient management strategies. However, further validation in larger, multi-institutional studies is required to fully understand the implications of these findings on clinical practice.
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Affiliation(s)
- Rujia Fan
- Department of Obstetrics and Gynecology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Wanrun Lin
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, US
| | - Ruijiao Zhao
- Department of Pathology, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Li Li
- Department of Pathology, Qilu Hospital, Shandong University, Jinan, China
| | - Rui Xin
- Center for Reproductive Medicine, National Research Center for Assisted Reproductive Technology and Reproductive Genetics, The Key Laboratory of Reproductive Endocrinology, Shandong University, Jinan, China
| | - Yunfeng Zhang
- Department of Obstetrics and Gynecology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yuxin Liu
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, US
| | - Ying Ma
- Department of Obstetrics and Gynecology, Mianyang Central Hospital, Mianyang, China
| | - Yiying Wang
- Department of Obstetrics and Gynecology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Yue Wang
- Department of Obstetrics and Gynecology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, China
| | - Wenxin Zheng
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, US
- Department of Obstetrics and Gynecology, and University of Texas Southwestern Medical Center, Dallas, TX, US
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, US
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Yamakado T, Tanei ZI, Ishikawa Y, Kimura T, Ishida Y, Tanaka S. Sporadic gastric foveolar-type adenoma with morular metaplasia. Pathol Int 2024; 74:489-492. [PMID: 39016619 DOI: 10.1111/pin.13462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 07/18/2024]
Affiliation(s)
- Tetsuhiro Yamakado
- Department of Pathology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Hokkaido, Japan
- Department of Cancer Pathology, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
- Center for Neuromuscular Disease, Child Health and Development, National Hospital Organization, Hokkaido Medical Center, Sapporo, Hokkaido, Japan
| | - Zen-Ichi Tanei
- Department of Cancer Pathology, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yuka Ishikawa
- Center for Neuromuscular Disease, Child Health and Development, National Hospital Organization, Hokkaido Medical Center, Sapporo, Hokkaido, Japan
| | - Taichi Kimura
- Department of Pathology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Hokkaido, Japan
- Department of Cancer Pathology, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yusuke Ishida
- Department of Pathology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Hokkaido, Japan
- Department of Cancer Pathology, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Shinya Tanaka
- Department of Cancer Pathology, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
- Institute for Chemical Reaction Design and Discovery (WPI-ICReDD), Hokkaido University, Sapporo, Hokkaido, Japan
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Tahir M, Samankan S, Huang M, Pinto A. Endometrioid Squamous Proliferations of the Endometrium Express Alpha-Methylacyl-CoA Racemase (P504s). Int J Gynecol Pathol 2023; 42:576-581. [PMID: 37562065 DOI: 10.1097/pgp.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Squamous morular metaplasia is closely associated with endometrioid proliferative lesions such as endometrial intraepithelial neoplasia, whereas endometrioid adenocarcinoma may also demonstrate squamous differentiation (morular or nonmorular). Alpha-methylacyl-CoA racemase (AMACR; P504s) is an immunohistochemistry marker expressed in many tumors, including prostate adenocarcinoma, renal cell carcinoma, and in a subset of gynecologic carcinomas, predominantly of clear cell histology. In small biopsy samples, the distinction between cervical high-grade squamous intraepithelial lesions (HSILs) involving endocervical glands from endometrioid squamous proliferations can be challenging, given their anatomic vicinity and some degree of morphologic overlap. Following the observation of AMACR positivity by immunohistochemistry within squamous morules in an index case, 35 endometrial samples containing squamous morular metaplasia (25) and nonmorular squamous metaplasia (10), and 32 cases of cervical HSIL involving endocervical glands were stained with AMACR. The endometrial cohort consisted of 2 benign anovulatory endometrium, 7 endometrial polyps, 7 endometrial intraepithelial neoplasia, 4 atypical polypoid adenomyomas, and 15 endometrioid adenocarcinomas. Positive cases were scored as diffuse (≥50%) or focal (<50%). AMACR staining was present in 96.7% of endometrial squamous lesions, including 14 (93.3%) of endometrioid carcinomas, and in all cases of endometrial intraepithelial neoplasia, endometrial polyps, atypical polypoid adenomyomas, and anovulatory endometrium with squamous morular metaplasia or nonmorular squamous metaplasia. In comparison, only 2 cases (5.8%) of cervical HSIL demonstrated positivity for AMACR. In conclusion, AMACR can reliably differentiate the cervical versus endometrial origin of squamous lesions in small biopsy specimens.
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Lucas E, Niu S, Aguilar M, Molberg K, Carrick K, Rivera-Colon G, Gwin K, Wang Y, Zheng W, Castrillon DH, Chen H. Utility of a PAX2, PTEN, and β-catenin Panel in the Diagnosis of Atypical Hyperplasia/Endometrioid Intraepithelial Neoplasia in Endometrial Polyps. Am J Surg Pathol 2023; 47:1019-1026. [PMID: 37314146 DOI: 10.1097/pas.0000000000002076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The diagnosis of atypical hyperplasia/endometrioid intraepithelial neoplasm (AH/EIN) within endometrial polyps (EMPs) often poses a diagnostic conundrum. Our previous studies demonstrated that a panel of immunohistochemical (IHC) markers consisting of PAX2, PTEN, and β-catenin can be effectively utilized for the identification of AH/EIN. A total of 105 AH/EIN within EMP were analyzed using the 3-marker panel. We also evaluated these cases for the presence of morules. Benign EMP (n=90) and AH/EIN unassociated with polyp (n=111) served as controls. Aberrant expression of PAX2, PTEN, or β-catenin was observed in AH/EIN in EMP in 64.8%, 39.0%, and 61.9% of cases, respectively. At least 1 IHC marker was abnormal in 92.4% of cases. Overall, 60% of AH/EIN in EMP demonstrated abnormal results for≥2 IHC markers. The prevalence of PAX2 aberrancy was significantly lower in AH/EIN in EMP than in nonpolyp AH/EIN (64.8% vs. 81.1%, P =0.007), but higher than in benign EMP (64.8% vs. 14.4%, P <0.00001). The prevalence of β-catenin aberrancy was significantly higher in AH/EIN in EMP than in nonpolyp AH/EIN (61.9% vs. 47.7%, P =0.037). All control benign EMP demonstrated normal expression of PTEN and β-catenin. Morules were present in 38.1% of AH/EIN in EMP versus 24.3% in nonpolyp AH/EIN, and absent in benign EMP. A strong positive association was found between β-catenin and morules (Φ=0.64). Overall, 90% cases of atypical polypoid adenomyoma (n=6) and mucinous papillary proliferation (n=4) showed IHC marker aberrancy. In conclusion, the 3-marker IHC panel (PAX2, PTEN, and β-catenin) is (1) a useful tool in the diagnosis of AH/EIN in EMP; (2) PAX2 loss should be interpreted with caution and in combination with morphology and other markers.
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Affiliation(s)
- Elena Lucas
- Department of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Shuang Niu
- Department of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | | | - Kyle Molberg
- Department of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Kelley Carrick
- Department of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | | | - Katja Gwin
- Department of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | | | - Wenxin Zheng
- Department of Pathology
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Diego H Castrillon
- Department of Pathology
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Hao Chen
- Department of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
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Morules but Not Squamous Differentiation are a Reliable Indicator of CTNNB1 (β-catenin) Mutations in Endometrial Carcinoma and Precancers. Am J Surg Pathol 2022; 46:1447-1455. [PMID: 35834400 DOI: 10.1097/pas.0000000000001934] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although collectively regarded as "squamous differentiation (SD)" in endometrial endometrioid carcinoma (EEC) and atypical hyperplasia/endometrioid intraepithelial neoplasia (AH/EIN), morules (often referred to as "squamous morules") and true SD may represent two distinct phenomena. Here, we explored the distinction between morules versus SD and investigated the association of morules and SD with CTNNB1 mutations. A total of 270 cases of EEC and AH/EIN were studied, including EEC with (n=36) or without (n=36) morules and AH/EIN with (n=80) or without (n=118) morules. Cases were analyzed by immunohistochemistry and selected cases (n=20) by targeted next-generation sequencing panel. Near-perfect agreement was found between morules and glandular β-catenin nuclear staining in AH/EIN and EEC. A strong positive association was found between morules and glandular β-catenin nuclear staining (P<0.0001, Φ=0.59 in AH/EIN; P<0.0001, Φ=0.85 in EEC). There was no association between (1) morules and glandular PAX2 or PTEN aberrant expression or (2) SD and aberrant expression of β-catenin, PAX2 or PTEN (Φ=0.09, β-catenin; Φ=0.16, PAX2; Φ=0.13, PTEN). CTNNB1 mutations were identified in all 20 selected morule-containing cases (100%). Next-generation sequencing was performed on 2 (preprogestin and postprogestin treatment) biopsies from 1 patient, revealing identical mutational profile in morules and glands. In conclusion, (1) SD and morules are distinct biological phenomena; (2) the presence of morules, but not SD, is a reliable indicator of CTNNB1 mutations in EEC and AH/EIN. Our findings demonstrate that SD and morules are distinct biological phenomena. Since morules but not SD are associated with β-catenin mutations, the distinction is clinically relevant and should be included in diagnostic reports.
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ARCIUOLO D, TRAVAGLINO A, RAFFONE A, SANTORO A, INZANI F, PIERMATTEI A, BUI L, SCAGLIONE G, D’ALESSANDRIS N, VALENTE M, FULGIONE C, GUIDA M, MOLLO A, INSABATO L, ZANNONI GF. P504S/alpha-Methylacyl-CoA racemase, HNF1β and Napsin A in morular metaplasia and clear cell carcinoma of the endometrium: an immunohistochemical analysis. Pathol Res Pract 2022; 236:153953. [DOI: 10.1016/j.prp.2022.153953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/22/2022] [Accepted: 05/25/2022] [Indexed: 11/27/2022]
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Wu P, Lv Q, Guan J, Shan W, Chen X, Zhu Q, Luo X. Clinical implications of morular metaplasia in fertility-preserving treatment for atypical endometrial hyperplasia and early endometrial carcinoma patients. Arch Gynecol Obstet 2022; 306:1135-1146. [PMID: 35246715 PMCID: PMC9470654 DOI: 10.1007/s00404-021-06382-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/27/2021] [Indexed: 11/28/2022]
Abstract
Objective Morular metaplasia (MM) is a benign epithelial metaplasia that sometimes appears in atypical endometrial hyperplasia (AEH) and endometrioid endometrial carcinoma (EEC). However, the clinical implications of MM for fertility-preserving treatment in AEH and EEC patients are unclear. This study investigated the clinical features and impact of MM on the efficacy of fertility-preserving treatment. Methods We retrospectively studied 427 AEH and EEC patients who received fertility-preserving treatment. Clinical features, treatment efficacy, and onco-fertility results were compared between patients with and without MM. Results MM appeared in 147 of 427 (34.4%) patients. Among them, 49 (33.3%) had MM only before treatment (BEF group), 32 (21.8%) had sustained MM before and during treatment (SUS group), and 66 (44.9%) had MM only during treatment (DUR group). The BEF group had a higher 12-month CR rate (98.0% vs 85.7%, p = 0.017) and shorter therapeutic duration to achieve CR (4.0 vs 5.7 months, p = 0.013) than the non-MM group had. In comparison with the non-MM group, the SUS and DUR groups had a lower CR rate after 7 months of treatment (SUS vs non-MM, 37.5% vs 61.1%, p = 0.010; DUR vs non-MM 33.3% vs. 61.1%, p < 0.001), and a longer median therapeutic duration to achieve CR (SUS vs non-MM, 7.6 vs. 4.0 months, p = 0.037; DUR vs non-MM, 7.9 vs. 4.0 months, p < 0.001). Conclusion Appearance of MM only before treatment was positively correlated with outcome of fertility-preserving treatment, while sustained MM or appearance of MM only during treatment implied poorer outcome of fertility-preserving treatment in AEH and EEC patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00404-021-06382-3.
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Affiliation(s)
- Pengfei Wu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, No. 419, Fangxie Road, Shanghai, 200011, People's Republic of China
| | - Qiaoying Lv
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, No. 419, Fangxie Road, Shanghai, 200011, People's Republic of China
| | - Jun Guan
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, No. 419, Fangxie Road, Shanghai, 200011, People's Republic of China
| | - Weiwei Shan
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, No. 419, Fangxie Road, Shanghai, 200011, People's Republic of China
| | - Xiaojun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, No. 419, Fangxie Road, Shanghai, 200011, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, 200011, People's Republic of China
| | - Qin Zhu
- Department of Pathology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, 200011, People's Republic of China
| | - Xuezhen Luo
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, No. 419, Fangxie Road, Shanghai, 200011, People's Republic of China. .,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, 200011, People's Republic of China.
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8
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Chang RJ, Rivera-Colon G, Chen H, Niu S, Carrick K, Lucas E, Gwin K, Zheng W. Navigating through perplex morphologic changes after exogenous hormone usage. Semin Diagn Pathol 2021; 39:148-158. [PMID: 34782217 DOI: 10.1053/j.semdp.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/20/2021] [Indexed: 11/11/2022]
Abstract
Clinical application of exogenous hormone as a method of contraception and/or treatment of various gynecologic disorders is exceedingly common. Unfortunately, the concurrent use of these agents also complicates the interpretation of pathology specimens. Various studies have shown that morphologic changes induced by hormonal therapies are present in both non-neoplastic and neoplastic tissues within the women's reproductive tract. It is important to understand the exogenous hormone induced morphologic changes, as it helps the pathologists make the accurate diagnosis, and in turn, guide clinicians to make optimal clinical decisions. In this review, we summarize the morphologic changes in both neoplastic and non-neoplastic endometrial, cervical, and myometrial surgical specimens after hormonal therapies, particularly after progestin treatment. In the endometrium, particularly in the scenario of progestin-treated atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (AEH/EIN), there is notoriously poor interobserver agreement and difficulty in assessing for the residual disease. We summarize current literature and propose our recommended approach in assessing these challenging endometrial biopsies, including a diagnostic algorism, the use of PAX-2, PTEN, beta-catenin immunohistochemistry panel, as well as consistency in diagnostic wording of the report. In the cervix, progestin makes dysplastic lesions appear metaplastic, thus high-grade squamous dysplastic lesions may be easily missed. Within the myometrium, lesions such as adenomyosis may show various degree of decidualization, while smooth muscle neoplasms may show apoplectic changes, and stromal lesions including endometrial stromal sarcoma may show more eosinophilic cytoplasm. All such changes may pose more or less diagnostic challenges in our daily practice. However, most are readily recognizable when we understand particular hormone related scenarios.
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Affiliation(s)
- Ruby J Chang
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Glorimar Rivera-Colon
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hao Chen
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shuang Niu
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kelley Carrick
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Elena Lucas
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katja Gwin
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wenxin Zheng
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Harold C Simmons Comprehensive Cancer Center at University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Immunophenotype of Atypical Polypoid Adenomyoma of the Uterus: Diagnostic Value and Insight on Pathogenesis. Appl Immunohistochem Mol Morphol 2021; 28:646-653. [PMID: 31855579 DOI: 10.1097/pai.0000000000000780] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Atypical polypoid adenomyoma (APA) is a rare uterine lesion constituted by atypical endometrioid glands, squamous morules, and myofibromatous stroma. We aimed to assess the immunophenotype of the 3 components of APA, with regard to its pathogenesis and its differential diagnosis. A systematic review was performed by searching electronic databases from their inception to January 2019 for immunohistochemical studies of APA. Thirteen studies with 145 APA cases were included. APA glands appeared analogous to atypical endometrial hyperplasia (endometrioid cytokeratins pattern, Ki67≤50%, common PTEN loss, and occasional mismatch repair deficiency); the prominent expression of hormone receptors and nuclear β-catenin suggest that APA may be a precursor of "copy number-low," CTNNB1-mutant endometrial cancers. Morules appeared as a peculiar type of hyperdifferentiation (low KI67, nuclear β-catenin+, CD10+, CDX2+, SATB2+, p63-, and p40-), analogous to morular metaplasia in other lesions and distinguishable immunohistochemically from both conventional squamous metaplasia and solid cancer growth. Stroma immunphenotype (low Ki67, α-smooth-muscle-actin+, h-caldesmon-, CD10-, or weak and patchy) suggested a derivation from a metaplasia of normal endometrial stroma. It was similar to that of nonatypical adenomyoma, and different from adenosarcoma (Ki67 increase and CD10+ in periglandular stroma) and myoinvasive endometrioid carcinoma (h-caldesmon+ in myometrium and periglandular fringe-like CD10 pattern).
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Travaglino A, Raffone A, Gencarelli A, Saracinelli S, Zullo F, Insabato L. Diagnostic Pitfalls Related to Morular Metaplasia in Endometrioid Carcinoma: An Underestimated Issue. Pathobiology 2021; 88:261-266. [PMID: 33887731 DOI: 10.1159/000515491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/25/2021] [Indexed: 11/19/2022] Open
Abstract
Here, we present a case that highlights the crucial pitfalls related to the presence of morular metaplasia (MM) in endometrioid carcinoma, which are insufficiently recognized in the routine pathology practice. A 45-year-old woman underwent hysterectomy with rectosigmoidectomy due to a 11-cm mass involving uterus, right ovary, and rectosigmoid colon. Histologically, the lesion appeared as a predominantly solid carcinoma with a minor glandular component. Results of the first immunohistochemical analysis suggested a colorectal origin (PAX8-, CK7-, WT1-, hormone receptors-, and CDX2+ in the absence of mucinous features). Subsequent immunohistochemistry (nuclear β-catenin+, CD10+, and low ki67 in the solid areas) supported a diagnosis of endometrioid carcinoma with diffuse MM. This case remarks that morphological and immunohistochemical features of MM may conceal the glandular architecture and the typical immunophenotype of endometrioid carcinomas. Acknowledging the diagnostic issues related to MM appears crucial to avoid misdiagnosis and inappropriate patient management.
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Affiliation(s)
- Antonio Travaglino
- Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples "Federico II", Naples, Italy
| | - Annarita Gencarelli
- Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Serena Saracinelli
- Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy.,Gynecology and Obstetrics Unit, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples "Federico II", Naples, Italy
| | - Fulvio Zullo
- Gynecology and Obstetrics Unit, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples "Federico II", Naples, Italy
| | - Luigi Insabato
- Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
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11
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Does endometrial morular metaplasia represent odontogenic differentiation? Virchows Arch 2021; 479:607-616. [PMID: 33666744 PMCID: PMC8448715 DOI: 10.1007/s00428-021-03060-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/29/2021] [Accepted: 02/14/2021] [Indexed: 12/01/2022]
Abstract
The nature of endometrial morular metaplasia (MorM) is still unknown. The nuclear β-catenin accumulation and the not rare ghost cell keratinization suggest a similarity with hard keratin-producing odontogenic and hair matrix tumors rather than with squamous differentiation. We aimed to compare MorM to hard keratin-producing tumors. Forty-one hard keratin-producing tumors, including 26 hair matrix tumors (20 pilomatrixomas and 6 pilomatrix carcinomas) and 15 odontogenic tumors (adamantinomatous craniopharyngiomas), were compared to 15 endometrioid carcinomas with MorM with or without squamous/keratinizing features. Immunohistochemistry for β-catenin, CD10, CDX2, ki67, p63, CK5/6, CK7, CK8/18, CK19, and pan-hard keratin was performed; 10 cases of endometrioid carcinomas with conventional squamous differentiation were used as controls. In adamantinomatous craniopharyngiomas, the β-catenin-accumulating cell clusters (whorl-like structures) were morphologically similar to MorM (round syncytial aggregates of bland cells with round-to-spindled nuclei and profuse cytoplasm), with overlapping squamous/keratinizing features (clear cells with prominent membrane, rounded squamous formations, ghost cells). Both MorM and whorl-like structures consistently showed positivity for CD10 and CDX2, with low ki67; cytokeratins pattern was also overlapping, although more variable. Hard keratin was focally/multifocally positive in 8 MorM cases and focally in one conventional squamous differentiation case. Hair matrix tumors showed no morphological or immunophenotypical overlap with MorM. MorM shows wide morphological and immunophenotypical overlap with the whorl-like structures of adamantinomatous craniopharyngiomas, which are analogous to enamel knots of tooth development. This suggests that MorM might be an aberrant mimic of odontogenic differentiation.
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12
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Domeniconi L, Amadori A, Maniglio P, Saragoni L. Atypical polypoid adenomyoma of the endometrium: diagnosis and treatment. A case report. Pathologica 2020; 112:214-218. [PMID: 33393525 PMCID: PMC8183343 DOI: 10.32074/1591-951x-112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022] Open
Abstract
Atypical polypoid adenomyoma (APA) is a rare uterine lesion that commonly recurs after local excision and is occasionally associated with or anticipates the development of atypical hyperplasia or endometrioid adenocarcinoma. We report a case of a 45-year-old woman affected by APA treated with local resection.
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Affiliation(s)
| | - Andrea Amadori
- Gynecology Unit, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
| | - Paolo Maniglio
- Gynecology Unit, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
| | - Luca Saragoni
- Department of Pathology, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
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Relationship between morular metaplasia and squamous differentiation in endometrial carcinoma. Pathol Res Pract 2020; 217:153307. [PMID: 33316539 DOI: 10.1016/j.prp.2020.153307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 11/22/2022]
Abstract
Morular metaplasia (MM) is a peculiar type of metaplastic change commonly observed in endometrial lesions, which is defined by the absence of overt squamous features and a characteristic immunophenotype. The nature of MM and its relationship with conventional squamous differentiation (SD) is still undefined. Here, we present a morphological and immunophenotypical study of cases with mixed MM/SD and conventional SD, providing new insights on this field. Twenty cases of endometrioid carcinoma (10 with mixed MM and SD and 10 with conventional SD) were assessed by immunohistochemistry for β-catenin, CD10, CDX2, ki67, p63, p40, estrogen receptor (ER), progesterone receptor (PR) and cytokeratins (CK) 5/6, 7, 8/18 and 19. In mixed MM/SD cases, SD was mostly located within the MM areas; several degrees of SD development were observed within MM, from cells with larger cytoplasm and prominent membrane, to overt SD with morular shape and ghost cell keratinization. In the MM→SD transition, there was progressive loss of nuclear β-catenin, CD10, CDX2 and CK8/18 expression, increase of CK5/6 and CK7 expression, and stable CK19 positivity. ER, PR and ki67/MIB1 expression was low-to-negative in both MM and SD. The squamous cell markers p63 and p40 were mostly expressed at the interfaces between MM and SD. Conventional SD cases showed direct transition from glandular epithelium to SD with a surface growth and no ghost cell keratinization; immunohistochemistry showed strong positivity for ER, PR and all CKs, basal positivity for p63, p40 and ki67/MIB1, negativity for nuclear β-catenin, CD10 and CDX2. In conclusion, MM appears as the precursor of a peculiar form of SD, which differs morphologically and immunophenotypically from conventional SD. Defining MM based on the absence of overt squamous might not be meaningful. Further studies are necessary to clarify the nature of MM.
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SATB2 is Consistently Expressed in Squamous Morules Associated With Endometrioid Proliferative Lesions and in the Stroma of Atypical Polypoid Adenomyoma. Int J Gynecol Pathol 2019; 38:397-403. [DOI: 10.1097/pgp.0000000000000544] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Abstract
In this review, we highlight the benign and premalignant lesions of the endometrium that the pathologist may encounter in daily practice. We begin by detailing our current understanding of excess estrogen in the progression of endometrial neoplasia. We outline the currently accepted terminology to be used when evaluating proliferative endometrial lesions, while highlighting their key features. Attention is then turned to the molecular underpinnings of neoplastic progression and how this can be exploited with immunohistochemical stains when appropriate. Finally, we discuss types of metaplasia and their associations, including so-called papillary proliferations of the endometrium.
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Affiliation(s)
- Wesley Daniel Mallinger
- Department of Pathology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 517, Little Rock, AR 72205, USA
| | - Charles Matthew Quick
- Department of Pathology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 517, Little Rock, AR 72205, USA.
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16
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Lu B, Yu M, Shi H, Chen Q. Atypical polypoid adenomyoma of the uterus: A reappraisal of the clinicopathological and immunohistochemical features. Pathol Res Pract 2019; 215:766-771. [DOI: 10.1016/j.prp.2019.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/19/2018] [Accepted: 01/12/2019] [Indexed: 02/07/2023]
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17
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Nakamura T. Shadow Cell Differentiation: A Comparative Analysis of Modes of Cell Death with Apoptosis and Epidermal/Trichilemmal Keratinization. Dermatopathology (Basel) 2018; 5:86-97. [PMID: 30197883 PMCID: PMC6120400 DOI: 10.1159/000490491] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/29/2018] [Indexed: 11/19/2022] Open
Abstract
Shadow cells are characterized by an eosinophilic cytoplasm and a ghost-like nuclear contour; the cell shape is preserved, in spite of nuclear disappearance. Shadow cell nests (SCNs) are frequently observed in pilomatricoma (PMX), where the transitional cells immediately adjacent to SCNs often have a crescent-shaped nucleus showing fragmentation similar to that of apoptotic bodies. They show nuclear accumulation of beta-catenin and DNA double strand breaks (as revealed by in situ 3′-tailing reaction or immunohistochemistry for single-stranded DNA [ssDNA]), while they are negative for cleaved caspase-3 or cleaved lamin A, suggesting that shadow cell differentiation (SCD) is a caspase-independent programmed cell death. SCD can be differentiated from epidermal keratinization (EK) and trichilemmal keratinization (TK) based on the expression pattern of beta-catenin, ssDNA, and caspase-14/CD138. SCD is observed not only in PMX, but also sometimes in basal cell carcinomas, gonadal teratomas, and various extra-cutaneous carcinomas. In particular, SCNs are found in 24$ of endometrial adenoacanthoma and are derived from squamoid morules. This establishes a link between basaloid cells in PMX and squamoid morules in endometrial adenoacanthomas as common precursors of shadow cells. Overall, it is suggested that SCD is different from, but partly similar to, apoptosis and that SCD and EK/TK should be differentiated from the standpoint of cell death/differentiation.
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18
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Abstract
CONTEXT Developed in conjunction with molecular and progression data, the sequence classification schema for endometrial intraepithelial neoplasia (EIN)/benign hyperplasia (BH) provides an easy to adopt and reproducible method for classification of endometrial biopsies. OBJECTIVE To review current data supporting the use of BH/EIN to classify endometrial biopsies, and to discuss the hormone-driven endometrial sequence from anovulation/disordered proliferative endometrium through BH and EIN and their diagnostic difficulty. DATA SOURCES A comprehensive review of EIN literature based on literature indexed by PubMed (National Library of Medicine) and Google Scholar. CONCLUSIONS The BH/EIN schema is gaining wider acceptance among pathologist and clinicians. The research leading to the EIN criteria is based on molecular and progression data. The BH/EIN schema has better reproducibility among pathologists, is intuitively easy to use, and requires understanding of endometrial physiology and neoplasia.
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Affiliation(s)
- Richard A Owings
- From the Department of Pathology, University of Arkansas for Medical Sciences, Little Rock
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19
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Loureiro J, Oliva E. The spectrum of cervical glandular neoplasia and issues in differential diagnosis. Arch Pathol Lab Med 2014; 138:453-83. [PMID: 24678677 DOI: 10.5858/arpa.2012-0493-ra] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Joana Loureiro
- From the Department of Pathology, Instituto Português de Oncologia, Porto, Portugal (Dr Loureiro); and the Department of Pathology, Massachusetts General Hospital, Boston (Dr Oliva)
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20
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Blanco LZ, Heagley DE, Lee JC, Gown AM, Gattuso P, Rotmensch J, Guirguis A, Dewdney S, Bitterman P. Immunohistochemical Characterization of Squamous Differentiation and Morular Metaplasia in Uterine Endometrioid Adenocarcinoma. Int J Gynecol Pathol 2013; 32:283-92. [DOI: 10.1097/pgp.0b013e31826129e1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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21
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Bartosch C, Manuel Lopes J, Oliva E. Endometrial carcinomas: a review emphasizing overlapping and distinctive morphological and immunohistochemical features. Adv Anat Pathol 2011; 18:415-37. [PMID: 21993268 DOI: 10.1097/pap.0b013e318234ab18] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This review focuses on the most common diagnostic pitfalls and helpful morphologic and immunohistochemical markers in the differential diagnosis between the different subtypes of endometrial carcinomas, including: (1) endometrioid versus serous glandular carcinoma, (2) papillary endometrioid (not otherwise specified, villoglandular and nonvillous variants) versus serous carcinoma, (3) endometrioid carcinoma with spindle cells, hyalinization, and heterologous components versus malignant mixed müllerian tumor, (4) high-grade endometrioid versus serous carcinoma, (5) high-grade endometrioid carcinoma versus dedifferentiated or undifferentiated carcinoma, (6) endometrioid carcinoma with clear cells versus clear cell carcinoma, (7) clear cell versus serous carcinoma, (8) undifferentiated versus neuroendocrine carcinoma, (9) carcinoma of mixed cell types versus carcinoma with ambiguous features or variant morphology, (10) Lynch syndrome-related endometrial carcinomas, (11) high-grade or undifferentiated carcinoma versus nonepithelial uterine tumors. As carcinomas in the endometrium are not always primary, this review also discusses the differential diagnosis between endometrial carcinomas and other gynecological malignancies such as endocervical (glandular) and ovarian/peritoneal serous carcinoma, as well as with extra-gynecologic metastases (mainly breast and colon).
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Stewart CJR, Crook ML, Manso L. Fascin expression in low-grade uterine endometrioid adenocarcinoma: correlation with microcystic, elongated and fragmented (MELF)-type alteration at the deep invasive margin. Histopathology 2011; 59:73-80. [DOI: 10.1111/j.1365-2559.2011.03893.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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23
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Thyroid transcription factor 1 expression in endometrioid tumors: a note of caution—reply. Hum Pathol 2011. [DOI: 10.1016/j.humpath.2011.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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Cameselle-Teijeiro J, Abdulkader I, Piso-Neira M, Reyes-Santías R, Alfonsin-Barreiro N, Alfonsín-Barreiro N. Thyroid transcription factor-1 expression in endometrioid tumors: a note of caution. Hum Pathol 2011; 42:1053-5; author reply 1055-6. [DOI: 10.1016/j.humpath.2011.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 01/28/2011] [Indexed: 11/15/2022]
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Polypoid Endometriosis of the Uterine Cervix With Arias-Stella Reaction in a Patient Taking Phytoestrogens. Int J Gynecol Pathol 2010; 29:185-8. [DOI: 10.1097/pgp.0b013e3181b7015e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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CD10 Immunostaining distinguishes atypical polypoid adenomyofibroma (atypical polypoid adenomyoma) from endometrial carcinoma invading the myometrium. Hum Pathol 2008; 39:1446-53. [DOI: 10.1016/j.humpath.2008.02.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Revised: 02/12/2008] [Accepted: 02/18/2008] [Indexed: 11/19/2022]
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28
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Houghton O, Connolly LE, McCluggage WG. Morules in endometrioid proliferations of the uterus and ovary consistently express the intestinal transcription factor CDX2. Histopathology 2008; 53:156-65. [DOI: 10.1111/j.1365-2559.2008.03083.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Carlson JW, Mutter GL. Endometrial intraepithelial neoplasia is associated with polyps and frequently has metaplastic change. Histopathology 2008; 53:325-32. [PMID: 18637968 DOI: 10.1111/j.1365-2559.2008.03104.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS Endometrial intraepithelial neoplasia (EIN) is a monoclonal precursor to endometrioid endometrial adenocarcinoma characterized by a geographic cluster of crowded glands with epithelial cytology altered relative to the background. It may demonstrate epithelial metaplastic changes, or arise within polyps, but the frequencies of these features as encountered in practice is unknown. The aim was to report the epithelial differentiation state and polyp context of 83 sequential EIN lesions diagnosed over a 2-year period. METHODS AND RESULTS EIN is a rare lesion, seen in only 1.4% of endometrial biopsy specimens in a busy hospital-based practice. Of 83 EIN cases, 39 contained metaplastic changes (18% squamous morular, 14% tubal secretory and 5% each of secretory, mucinous or ciliated change). Endometrial polyps were more likely (odds ratio 5.2, P < 0.001) to occur in the endometrial biopsy specimens of women with EIN lesions (43.3%), compared with the background polyp rate (12.9%) of comparable specimens from the same patient population. CONCLUSIONS Non-endometrioid differentiation and occurrence within polyps are frequent presentations of EIN lesions. Possible mechanisms of polyp association with EIN include: non-shedding of polyp tissue creating a shelter for persistence of pre-existing neoplastic glands, or promotion of premalignant glandular clones by unique polyp stroma.
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Affiliation(s)
- J W Carlson
- Department of Pathology, Division of Women's and Perinatal Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA
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30
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Cameselle-Teijeiro J, Alberte-Lista L, Chiarelli S, Buriticá C, Gonçalves L, González-Cámpora R, Nogales FF. CD10 is a characteristic marker of tumours forming morules with biotin-rich, optically clear nuclei that occur in different organs. Histopathology 2008; 52:389-92. [DOI: 10.1111/j.1365-2559.2007.02911.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stolnicu S, Borda A, Radulescu D, Puscasiu L, Berger N, Nogales FF. Metastasis from papillary renal cell carcinoma masquerading as primary ovarian clear cell tumor. Pathol Res Pract 2007; 203:819-22. [PMID: 17905525 DOI: 10.1016/j.prp.2007.07.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 07/10/2007] [Accepted: 07/25/2007] [Indexed: 11/18/2022]
Abstract
A 73-year-old female presented with a left ovarian tumor mass. Microscopic examination disclosed cystic spaces lined by abundant clear and eosinophilic tumor cells with pleomorphic nuclei. Differential diagnosis included primary ovarian oxyphilic-type clear cell carcinoma and sex-cord tumor with extensive luteinization. However, analysis of the patient's past history revealed that in 2003, she had undergone nephrectomy for a papillary renal cell carcinoma, and a histological comparison between the primary and the present tumor exhibited in the latter a substantially larger number of clear cells and loss of papillary architecture. Immunohistochemistry demonstrated a characteristic renal immunophenotype for a type II tubulopapillary tumor metastatic to ovary. The tumor cells were strongly positive for CD10 and AMACR, and negative for cytokeratin 7. This confirmed the renal origin of the ovarian tumor despite its divergent morphology of the renal primary. This is the first reported case of ovarian metastases of type II tubulopapillary carcinoma of the kidney.
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Affiliation(s)
- Simona Stolnicu
- Department of Pathology, University of Medicine, Targu Mures, Romania.
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