Impact on Radiation Therapy Recommendation and Treatment Modality for Patients with Ductal Carcinoma In Situ Using the 7Gene Biosignature: Analysis of the PREDICT Study

PURPOSE/OBJECTIVE(S)

Breast conserving surgery (BCS) followed by adjuvant radiotherapy (RT) has been a mainstay in the treatment of DCIS based on multiple randomized trials demonstrating a local recurrence benefit with RT. However, these studies have failed to identify subsets of patients who did or did not benefit from adjuvant RT after BCS, raising concerns regarding both over and undertreatment. Thus, better prognostic and predictive tools are needed to appropriately risk stratify patients and understand their benefit of RT. The 7-gene predictive DCIS biosignature provides a validated score (DS) for women undergoing BCS that assesses their 10-year risk of in-breast and invasive recurrence with and without adjuvant RT. This trail was designed to evaluate the decision impact of the 7-gene predictive biosignature score on DCIS treatment recommendations.

MATERIALS/METHODS

The PREDICT study is a prospective, multi-institutional trial for patients who received DCISionRT testing as part of their routine care. The registry includes females 26 and older who are diagnosed with DCIS, are candidates for BCS, and eligible for RT. Treating physicians completed treatment recommendation forms before and after receiving test reports to capture surgical, radiation and hormonal treatment (HT) recommendations and patient preferences. Analysis was performed in 2,012 patients treated at 63 clinical sites.

RESULTS

Median age was 62 years old with 32% grade 3 and 10% size 2.5 cm or greater. Post-test, RT recommendation changed for 38% of patients (p<0.001), with a net reduction of 20% in patients recommended to receive RT(p<0.001). The DCISionRT test results had the greatest impact (OR 26.2, 95% CI 19.1-36.4, when analyzed categorically using DS>3 cut-off; 2.3 per DS, 95% CI 2.1-2.6, when evaluated continuously) on post-test RT recommendation in multivariable analysis when compared to all other factors including patient preference, patient clinical and tumor pathological factors, patient race/ethnicity, treatment facility, physician specialty. The post-test RT recommendation rate increased with increasing DS (0-2, 2-4, 4-10) on a categorical basis, with odds ratios of 6.8 DS (2-4 vs 0-2), and 35.0 for DS (4-10 vs 0-2). After DCISionRT test result, patient preference was the second most important factor in post-testing RT recommendation. There was also a significant change in the modality of RT recommended to 34% of those patients recommended RT pre-test and post-test by radiation oncologists (n = 937), with intensified RT modality for higher DS (p<0.001) and de-escalation for lower DS (p<0.001).

CONCLUSION

This analysis of over 2,000 patients demonstrates significant changes in recommendations to add or omit RT based on the 7-gene predictive. The integration of DCISionRT into clinical decision processes has substantial impact on recommendations aimed at optimal management to prevent over- or under-treatment.

Limitations in the Application of Clinicopathologic Factors Alone in Predicting Radiation Benefit for Women with Low-Risk DCIS after Breast Conserving Surgery: The Impact of a 7-Gene Biosignature Based on 10-Year Ipsilateral Breast Recurrence (IBR) Rates

PURPOSE/OBJECTIVE(S)

Most women diagnosed with ductal carcinoma in situ (DCIS) receive radiotherapy (RT) after breast conserving surgery (BCS); however, clinical trials show that over 70% of women with BCS alone will not have a recurrence and therefore not benefit from RT. Traditionally, clinicopathologic (CP) factors have been used to select for whom to de-escalate treatment, but prospective trials have failed to identify a low risk CP group that did not benefit from RT with respect to local control. This study assessed the re-classification of patients with low-risk CP into Risk groups defined by the 7-gene biosignature and compared to 10-yr IBR rates.

MATERIALS/METHODS

Women (n = 926) from four international DCIS cohorts treated with BCS had formalin-fixed paraffin embedded tissue samples analyzed at a CLIA lab (Laguna Hills, CA). CP low-risk patients were identified using a) RTOG-9804-like criteria [Nuclear Grade 1 or 2 & Size ≤2.5 cm & non-Palpable & Screen Detected & margin negative (no-ink on tumor)] and b) MSKCC-like criteria [low-risk score<220, determined using nomogram weighted factors (excluding: number of re-excisions and RT treatment), and using no-ink-on-tumor instead of close margin]. The 7-gene DCIS biosignature combined biomarkers with CP factors (age, size, palpability, and margin status) using an algorithm reporting a Decision Score (DS) and Residual Risk subtype (RRt). Women with low-risk CP were classified into biosignature Low Risk (DS≤2.8, no RRt) or High Risk (DS>2.8 +/- RRt) groups. 10yr in-breast event (IBR) rates with and without RT were assessed by Kaplan-Meier rates and Cox proportional hazard analyses.

RESULTS

Overall, 37% of all women were classified into the biosignature Low Risk group, while 51% and 34% were classified into CP low-risk groups (RTOG-9804-like, MSKCC-like, respectively). The biosignature Low Risk group (n = 338) had a 10-yr IBR risk of 5.6% after BCS and no significant RT benefit (absolute RT benefit = 0.8%, p = 0.70), 99% negative predictive value (NPV) for RT benefit. CP low-risk groups had 10-yr IBR rates of 12% and 8% after BCS without RT with absolute 6% (p = 0.04) and 4% (p = 0.1) IBR rate reductions with RT. The biosignature reclassified 51% and 63% of CP low-risk patients into the biosignature High Risk group. Importantly, these patients had higher IBR rates without RT (20% and 12%) and significant 13% (p = 0.005) and 8% (p = 0.01) absolute IBR rate reductions from RT. CP low-risk patients with concordant biosignature Low Risk demonstrated no significant RT benefit.

CONCLUSION

The 7-gene predictive biosignature more reliably identified patients with low 10-yr IBR rates and no significant RT benefit than the traditional CP low-risk criteria (RTOG-9804-like, MSKCC-like). Importantly, those CP low-risk patients who were re-classified as biosignature High Risk had increased 10-year IBR rates and significant RT benefit.

A Biosignature Integrating Immune and Metabolic Signaling Axes to Assess Limited Radiation Therapy Response in Early-Stage Breast Cancer from a Low-Risk Cohort

PURPOSE/OBJECTIVE(S)

Radiation therapy (RT) post breast conserving surgery (BCS) reduces in-breast recurrence (IBR) rate in early-stage invasive breast cancer (BC) patients. The RT treatment recommendation is often driven by clinicopathological (CP) factors; however, CP factors alone have limited ability to identify which women significantly benefit from RT, or those with higher IBR risk after BCS plus RT. Biologic factors driving unique phenotypes, in addition to CP, may improve prediction of RT response. In this study we evaluated the role of immune and metabolic signaling axes in predicting RT response in hormone receptor positive, HER2 negative, early-stage BC patients.

MATERIALS/METHODS

Biomarkers from immune and metabolic signaling axes were studied in a cohort of 939 women from Sweden, at a CLIA certified lab (Laguna Hills, CA). Formalin fixed paraffin embedded tissues were assayed for protein expression using multiplex immunofluorescence and multi-spectral imaging. Immune and metabolic axes were assessed using biomarkers combined with a non-linear model, adjusting for patient age. RT prediction by the model was assessed, along and adjusted for CP factors and also among patients over 50-yrs. The model defined patient risk groups that were analyzed for IBR rate using Kaplan Meier analyses and Cox proportional hazards to test for RT-risk group interaction.

RESULTS

Within the cohort, 440 patients had hormone receptor positive, HER2 negative BC treated with BCS (negative margins) and +/- RT without chemotherapy, where 296 patients had complete biomarker data. CP factors individually were not predictive for RT benefit, but grade was prognostic for IBR rate (p = 0.02) after BCS without RT. In multivariable analysis, adjusting for CP factors (grade, palpability, continuous size and age), the model was predictive for RT benefit (p-interaction = 0.046), identifying patients (n = 129) with worse RT benefit (HR = 7.8) compared to baseline RT benefit. The model was not prognostic for IBR rate in patients treated with BCS without RT (16% 10-yr IBR rate) but identified patients with increased IBR rates after BCS plus RT (HR = 3.9, p<0.001), where corresponding 10-yr IBR rates increased from 3% to 15%. The model was also predictive for RT benefit in women over 50-yrs (p-interaction = 0.05). The model identified 28% of women over 50-yrs who had increased IBR rates after BCS plus RT (HR = 4.0, p = 0.004), where corresponding 10-yr IBR rates increased from 3% to 12%.

CONCLUSION

The model incorporating metabolic and immune signaling axes assessed in the study was predictive for RT benefit among women with early-stage hormone receptor positive, HER2 negative BC. While CP factors were not predictive of RT benefit, the inclusion of metabolic and immune signaling axes improved identification of patients with high residual risk after BCS plus RT and can potentially aid in personalized treatment of early-stage breast cancer based on individualized risk.

Multi-fidelity modelling of shark skin denticle flows: insights into drag generation mechanisms

We investigate the flow over smooth (non-ribletted) shark skin denticles in an open-channel flow using direct numerical simulation (DNS) and two Reynolds averaged Navier-Stokes (RANS) closures. Large peaks in pressure and viscous drag are observed at the denticle crown edges, where they are exposed to high-speed fluid which penetrates between individual denticles, increasing shear and turbulence. Strong lift forces lead to a positive spanwise torque acting on individual denticles, potentially encouraging bristling if the denticles were not fixed. However, DNS predicts that denticles ultimately increase drag by 58% compared to a flat plate. Good predictions of drag distributions are obtained by RANS models, although an underestimation of turbulent kinetic energy production leads to an underprediction of drag. Nevertheless, RANS methods correctly predict trends in the drag data and the regions contributing most to viscous and pressure drag. Subsequently, RANS models are used to investigate the dependence of drag on the flow blockage ratio (boundary layer to roughness height ratio), finding that the drag increase due to denticles is halved when the blockage ratio δ/h is increased from 14 to 45. Our results provide an integrated understanding of the drag over non-ribletted denticles, enabling existing diverse drag data to be explained.

New sonographic marker of borderline ovarian tumor: microcystic pattern of papillae and solid components

OBJECTIVE

To describe and evaluate the utility of a new sonographic microcystic pattern, which is typical of borderline ovarian tumor (BOT) papillary projections, solid component(s) and/or septa, as a new ultrasound marker that is capable of distinguishing BOT from other adnexal masses, and to present/obtain histologic confirmation.

METHODS

In this retrospective study, we identified women with a histologic diagnosis of BOT following surgical resection who had undergone preoperative transvaginal ultrasound (TVS) examination. All images were reviewed for presence or absence of thin-walled, fluid-filled cluster(s) of 1-3-mm cystic formations, associated with solid component(s), papillary projections and/or septa. From the same cases, histopathologic slides of each BOT were examined for presence of any of these microcystic features which had been identified on TVS. To confirm that the microcystic TVS pattern is unique to BOTs, we also selected randomly from our ultrasound and surgical database 20 cases of epithelial ovarian cancer and 20 cases of benign cystadenoma, for review by the same pathologists. To confirm the novelty of our findings, we searched PubMed for literature published in the English language between 2010 and 2018 to determine whether the association between microcystic tissue pattern and BOT has been described previously.

RESULTS

Included in the final analysis were 62 patients (67 ovaries) with preoperative TVS and surgically confirmed BOT on pathologic examination. The mean patient age at surgery was 39.8 years. The mean BOT size at TVS was 60.7 mm. Of the 67 BOTs, 47 (70.1%) were serous, 15 (22.4%) were mucinous and five (7.5%) were seromucinous. We observed on TVS a microcystic pattern in the papillary projections, solid component(s) and/or septa in 60 (89.6%) of the 67 BOTs, including 46 (97.9%) of the 47 serous BOTs, 11 (73.3%) of the 15 mucinous BOTs and three (60.0%) of the five seromucinous BOTs. On microscopic evaluation, 60 (89.6%) of the 67 samples had characteristic 1-3-mm fluid-filled cysts similar to those seen on TVS. In seven cases there was a discrepancy between sonographic and histologic observation of a microcystic pattern. The 20 cystadenomas were mostly unilocular and/or multilocular and largely avascular. None of them or the 20 epithelial ovarian malignancies displayed microcystic characteristics, either on TVS or at histology. On review of 23 published articles in the English medical literature, containing 163 sonographic images of BOT, we found that, while all images contained it, there was no description of the microcystic tissue pattern.

CONCLUSION

We report herein a novel sonographic marker of BOT, a 'microcystic pattern' of BOT papillary projections, solid component(s) and/or septa. This was seen in the majority of both serous and mucinous BOT cases. Importantly, based on comparison of sonographic images and histopathology of benign entities and malignancies, the microcystic appearance seems to be unique to BOTs. No similar description has been published previously. Utilization of this new marker should help to identify BOT correctly, discriminating it from ovarian cancer and benign ovarian pathology, and should ensure appropriate clinical and surgical management. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Abstract P5-18-02: A quantitative centrosomal amplification score (CAS) predicts local recurrence in ductal carcinoma in situ

Background: About 60-80% of ductal carcinoma in situ (DCIS) cases are high-grade (HG) DCIS with an elevated risk of local recurrence (LR) even after a lumpectomy. Patients are often under or over treated due to the lack of accurate recurrence risk prediction models. Current prognostic models such as OncotypeDX and Van Nuys Prognostic Index (VNPI) lack consistency and are limited to a specific subset of patients. Here in this study, we show that the extent of centrosome amplification (CA) in a DCIS lesion can predict the risk of LR after lumpectomy. CA refers to presence of supernumerary or large centrosomes and is a characteristic of pre-invasive lesions, and breast tumors, and promotes erroneous mitoses and chromosomal instability.

Methods: We have pioneered a semi-automated pipeline that integrates immunofluorescence confocal microscopy with digital image analysis and yields a quantitative Centrosomal Amplification Score (CAS) for each patients' tumor sample by evaluating severity and frequency of centrosomal aberrations therein. To this end, we first immunofluorescently stained centrosomes in formalin fixed paraffin embedded resection samples from DCIS patients (discovery cohort n=133 and a validation cohort n=119) using an antibody against γ-tubulin, and co-stained nuclei with DAPI. Next, we imaged the slides and processed the raw 3D image data using IMARIS Biplane 8.2 3D volume rendering software. Finally, we calculated centrosome numbers and volume in ˜250 cells from each patient sample. Using a mathematical algorithm, we generated a composite CAS score for each patient sample by integrating the numerical (CASi) and structural (CASm) aberrations.

Results: We found that DCIS patients with recurrence exhibited higher CAS. Intriguingly, higher CAS was also associated with greater risk of developing ipsilateral breast events [Hazard ratio (HR) =7.58 for discovery cohort and HR=5.8 for validation cohort, p&lt;0.0001] which remained significant (HR=8.5 for discovery and HR=3.39, p&lt;0.0001) after accounting for the confounding factors like age, tumor size, comedo necrosis and radiotherapy. Kaplan Meir survival analysis indicated that high CAS was associated with poor recurrence-free survival (RFS) (p&lt;0.001). For the high and low CAS groups, the 5-year risk of recurrence was 87.5% and 12.5% respectively (p&lt;0.001). In our discovery cohort, a head-to-head comparison of the ability of VNPI and CAS to predict recurrence illuminated that CAS was able to stratify the DCIS group in recurrence and recurrence-free group with much higher significance (p&lt;0.0001) than the Van Nuys Prognostic Index (VNPI) (HRs for CAS- 8.8 vs. VNPI 0.959). Finally, the Harrell's concordance index using SAS PROC PHREG tests yielded that the probability of a patient with poorer/lower RFS to be in the high CAS group is 76.2%.

Conclusion: Our data compellingly show that CAS quantifies the risk of recurrence in DCIS patients with the highest concordance and provides a novel and innovative tool to tailor their treatment based on their risk profile.

Citation Format: Mittal K, Kaur J, Wei G, Toss MS, Osan RM, Janssen EA, Søiland H, Rakha EA, Rida PC, Aneja R. A quantitative centrosomal amplification score (CAS) predicts local recurrence in ductal carcinoma in situ [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-18-02.

Abstract P1-01-23: Hypoxia induced centrosome amplification via HIF-1α/Plk4 signaling axis associates with poorer overall survival in TNBC

Background: Centrosome amplification (CA) which refers to presence of supernumerary or abnormally large centrosomes drives tumor progression by promoting chromosomal instability and the generation of aggressive tumor clones. Although the role of CA in cancer progression is well-defined, no studies have yet discussed how CA is induced in tumor cells. We report here that intra-tumoral hypoxia, which is considered one of the major contributors to intratumor heterogeneity, induces CA via HIF-1α.

Methods: We first immunohistochemically labeled 24 breast carcinoma and uninvolved adjacent normal tissue samples for HIF-1α and calculated weighted indices (WIs) for nuclear HIF-1α. Adjacent serial sections from the same tumors were also immunofluorescently labeled for γ-tubulin and CA was calculated. Using public microarray datasets (Kao dataset, n=327), we investigated whether centrosomal gene expression is enriched in breast tumors characterized by a hypoxia gene expression signature. Finally, to determine the role of hypoxia in CA induction we exposed cultured TNBC cells (MDA-MB-231 and MDA-MB-468) to hypoxia and overexpressed (OE) and knocked out (KO) HIF-1α in TNBC cells and quantitated CA. Additionally, to discern the biological pathway through which HIF-1α induces CA we performed ChIP assay and in silico analyses to identify the possible targets of HIF-1α.

Results: A strong positive correlation between nuclear HIF-1α WI and CA was found in breast tumor samples (Spearman's rho p=0.722, p&lt;0.001). In addition, we found that higher nuclear HIF-1α was associated with worse overall survival (p=0.041; HR=1.03). Our in silico findings suggest that breast tumors with high expression of hypoxia-associated genes exhibited higher expression of centrosomal genes than breast tumors with low expression of hypoxia-associated genes. In addition, cells cultured in hypoxic conditions exhibited ˜1.5 fold higher (p&lt;0.05) CA when compared to the cells cultured in normoxic conditions. Interestingly level of CA decreased when HIF-1α KO TNBC cells were exposed to hypoxia and it increased when HIF-1α OE TNBC cells were culture in normoxic conditions. Furthermore, we discovered that HIF-1α induced CA by directly regulating the expression of Plk4 which was confirmed by performing ChIP assay. Our results indicated HIF-1α interaction with the motif in the PLK4 promoter from genomic DNA of MDA-MB 231 cells under hypoxic conditions, was significantly (p=0.04) higher when compared with the cells cultured under normoxic conditions. Plk4 mRNA expression was assessed using the online BC gene expression data sets (n=25). We found significantly higher expression of Plk4 in TNBC (n=374) when compared with non-TNBC (n=4098) and it was associated with poor overall survival (HR=1.76; p=0.054) in TNBC.

Conclusion: Collectively our findings suggest that hypoxia drives CA in TNBC via HIF-1α and contribute to poor outcomes. Thus, determination of CA and HIF-1α can help risk stratification in TNBC patients for more personalized treatments.

Citation Format: Mittal K, Choi DH, Maganti N, Ogden A, Melton BD, Kaur J, Gupta MV, Jonsdottir K, Janseen EAM, Aleskandarany MA, Rakha EA, Rida PCG, Aneja R. Hypoxia induced centrosome amplification via HIF-1α/Plk4 signaling axis associates with poorer overall survival in TNBC [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-01-23.

A 2 weeks on and 1 week off schedule of sunitinib is associated with decreased toxicity in metastatic renal cell carcinoma

Treatment of metastatic renal cell carcinoma (mRCC) with sunitinib is often associated with toxicity necessitating dose reduction. Maintaining adequate dosing and drug levels are essential for optimising clinical efficacy. Standard sunitinib schedule is 4 weeks of treatment and 2 weeks of rest (schedule 4/2). Empirically, several mRCC patients at The Cleveland Clinic (CCF) have been changed from schedule 4/2 to 2 weeks of treatment/1 week off (schedule 2/1) after experiencing toxicity, in an attempt to maintain daily dosing. The medical records of 30 mRCC patients on sunitinib who were changed from schedule 4/2 to schedule 2/1 at CCF were retrospectively reviewed. Toxicity on each schedule was recorded during routine clinic visits and graded using Common Toxicity Criteria, version 4.0. 97% of patients on schedule 4/2 had grade 3 or 4 toxicity that led to changing to schedule 2/1. There were no grade 4 toxicities on schedule 2/1, and 27% of patients experienced grade 3 toxicity (p=0.0001). Two of the most common toxicities, fatigue and hand-foot syndrome (HFS), were significantly less frequent on schedule 2/1 than on schedule 4/2 (p=0.0003; p=0.0004, respectively). Median overall treatment duration on schedule 4/2 was 12.6 months (range 1.2 months-5.1 years) and median overall treatment duration on schedule 2/1 was 11.9 months (range 0.9+ to 73.3+ months). Treatment with sunitinib on schedule 2/1 is associated with significantly decreased toxicity in patients who experience grade 3 or greater toxicity on schedule 4/2, and can extend treatment duration considerably. Prospective clinical trials are required to define the optimal sunitinib schedule to balance efficacy and toxicity.

Comparison of estimation of volume of fetomaternal hemorrhage using Kleihauer-Betke test and microcolumn gel method in D-negative nonisoimmunized mothers

In this study we assessed the efficay of the microcolumn gel method in the detection and quantification of the volume of fetomaternal hemorrhage (FMH) in comparison with the Kleihauer-Betke test (KB) in nonisoimmunized D- mothers. We collected blood samples from 80 D- indirect antiglobulin test-negative mothers over a span of more than 1 year. FMH was determined by KB and microcolumn gel method, and the results were compared. FMH was recorded as less than 4 mL by KB if no fetal cells were seen after examining 25 fields using 10x objective. If fetal cells were seen, slides were examined furhter to quantify FMH. By microcolumn gel method, FMH was reported as less than 0.1 percent, 0.1 percent, 0.2 percent, and 0.4 percent or greater. None of the patients had FMH greater than 15 mL by KB . Sixty-two patients (77.5%) had FMH less than 4mL by KB. In all these cases , FMH was less than or equal 0.2 percent (approximately 4mL) by microcolumn gel method. The mean volume of FMH in the remaining 18 (22.5%) cases by KB was 8.3 ± 1.7 mL. Fifteen (83.3%) of these 18 cases had FMH of at least 0.4 percent (approximately 8 mL) by gel technology. Three cases (16.7%) that differed from KB results had FMH of 0.2 percent by microcolumn gel method with a maximal FMH of 6.4 mL by KB. FMH was significanlty increased in cesarean delivery (mean FMH 9.5 ± 0.8 mL, range 7.9-10.4 mL, p=0.001) abd abtepartum hemorrahge (mean FMH 9.5 ± 0.9 mL, range 7.9-10.4 mL, p< 0.001). Microcolumn gel method is an effective screening test . Technologies like KB and flow cytometry are better options for detecting a large volume of FMh. Antepartum hemorrhage and cesarean delivery are risk factors for FMH. the 300-µg dose of cases. We need to analyze the relative cost-effectiveness of universal administration of 300µg of Rh immune globulin vs. FMH quantitation with subsequent administration of titrated doses.

Paraneoplastic hypercalcemia in clear cell ovarian adenocarcinoma

Background:

Hypercalcemia has been reported in association with a number of malignancies, but it is an unusual manifestation of ovarian cancer. This finding at presentation (possibly aggravated by oral calcium intake) led to discovery of a clear cell carcinoma of the ovary. The implications and pathophysiology of this association are reviewed.

Case report:

Following presentation with abdominal symptoms, this premenopausal woman was found to have bilateral adnexal masses and hypercalcemia. Her parathormone-related polypeptide was found to be elevated. After surgery and staging, she received adjuvant carboplatin and paclitaxel (later substituted by docetaxel). She has done well on her long-term follow-up.

Conclusions:

This rare paraneoplastic manifestation of ovarian cancer may be associated with long-term survival if discovered at an early stage. In this instance, further benefit may have been obtained from adjuvant platinum-based chemotherapy.

Prenatal diagnosis of unilateral proximal femoral focal deficiency at 19 weeks' gestation: case report and review of the literature

Proximal femoral focal deficiency (PFFD) represents a rare and complex deformity manifested by hypoplasia of a variable portion of the femur with shortening of the entire limb. The condition may be unilateral or bilateral and is often associated with other congenital anomalies. Recent technological advances in ultrasound imaging offer the opportunity to detect an increasing number of rare skeletal malformation syndromes whose correct diagnosis is essential for adequate counseling and management of the pregnancy. We report a case of fetal non-familial PFFD diagnosed prenatally using two-dimensional and three-dimensional images. Clinical findings, differential diagnosis and management of this rare skeletal dysplasia are discussed and a review of the recent literature is given.

Pandemic influenza A (H1N1) 2009 vaccine: an update

The world witnessed a the first influenza pandemic in this century and fourth overall since first flu pandemic was reported during the World War I. The past experiences with influenza viruses and this pandemic of H1N1 place a consider-able strain on health services and resulted in serious illnesses and a large number of deaths. Develop-ing countries were declared more likely to be at risk from the pandemic effects, as they faced the dual problem of highly vulnerable populations and limited resources to respond H1N1. The public health experts agreed that vaccination is the most effective ways to mitigate the negative effects of the pandemic. The vaccines for H1N1 virus have been used in over 40 countries and administered to over 200 million people helped in a great way and on August 10, 2010, World Health Organization (WHO) announced H1N1 to be in postpandemic period. But based on knowledge about past pandemics, the H1N1 (2009) virus is expected to continue to circulate as a seasonal virus and may undergo some agenic-variation. As WHO strongly recommends vaccination, vigilance for regular updating of the composition of influenza vaccines, based on an assessment of the future impact of circulating viruses along with safety surveillance of the vaccines is necessary. This review has been done to take a stock of the currently available H1N1 vaccines and their possible use as public health intervention in the postpandemic period.

Entamoeba histolytica: lipid rafts are involved in adhesion of trophozoites to host extracellular matrix components

Adhesion is an important virulence function for Entamoeba histolytica, the causative agent of amoebic dysentery. Lipid rafts, cholesterol-rich domains, function in compartmentalization of cellular processes. In E. histolytica, rafts participate in parasite-host cell interactions; however, their role in parasite-host extracellular matrix (ECM) interactions has not been explored. Disruption of rafts with a cholesterol extracting agent, methyl-beta-cyclodextrin (MbetaCD), resulted in inhibition of adhesion to collagen, and to a lesser extent, to fibronectin. Replenishment of cholesterol in MbetaCD-treated cells, using a lipoprotein-cholesterol concentrate, restored adhesion to collagen. Confocal microscopy revealed enrichment of rafts at parasite-ECM interfaces. A raft-resident adhesin, the galactose/N-acetylgalactosamine-inhibitable lectin, mediates interaction to host cells by binding to galactose or N-acetylgalactosamine moieties on host glycoproteins. In this study, galactose inhibited adhesion to collagen, but not to fibronectin. Together these data suggest that rafts participate in E. histolytica-ECM interactions and that raft-associated Gal/GalNAc lectin may serve as a collagen receptor.

Extrauterine low-grade endometrial stromal sarcoma with florid endometrioid glandular differentiation

Endometrial stromal sarcoma of the uterus (ESS) is a rare lesion that can cause diagnostic difficulty especially when it presents with unusual histologic features such as diffuse endometrioid glandular differentiation. Only three such cases have been reported, all primary in the uterus. We report the first case of an extrauterine low-grade ESS with extensive glandular differentiation that appeared to arise in endometriosis.

MIB-1 (Ki-67), p53, estrogen receptor, and progesterone receptor expression in uterine smooth muscle tumors

The diagnosis of benign, uncertain malignant potential, and malignant uterine smooth muscle tumors depends on mitotic counts, nuclear atypia, and other morphologic features. This study was undertaken to evaluate the utility of selected immunohistochemical markers in differentiating these tumors. Fifteen cases of cellular leiomyoma, 7 cases of smooth muscle tumor of uncertain malignant potential (STUMP), and 12 cases of leiomyosarcoma were immunostained for MIB-1 (Ki-67), p53, estrogen receptor and progesterone receptor (PR) using monoclonal antibodies and the avidin-biotin-peroxidase method. The percentage of cells stained was subjectively assessed to the nearest 5%. One percent was used for rare positive cells. MIB-1 expression of > or =15% was seen in 11 and expression of p53 in > or =15% cells was present in 5 of 12 leiomyosarcomas. MIB-1 and/or p53 expression of >15% was seen in all 12 leiomyosarcomas but in none of the 7 STUMP or 15 cellular leiomyomas. PR was absent in 10 of 12 leiomyosarcomas but present in 7 of 7 STUMP and 14 of 15 cellular leiomyomas. MIB-1 of 5% to 10% was seen in 6 of 7 STUMP but in only 1 of 15 cellular leiomyomas. MIB-1, p53, and PR are useful in differentiating leiomyosarcoma from STUMP and cellular leiomyoma. MIB-1 is useful in distinguishing STUMP from cellular leiomyomas.

Endometrial brush biopsy for the diagnosis of endometrial cancer

OBJECTIVE

To evaluate a new technique for processing endometrial cytology for the diagnosis and exclusion of endometrial cancer.

STUDY DESIGN

All women at risk for endometrial cancer with clinical indications for endometrial biopsy were evaluated by endometrial brush biopsy (Tao Brush, Cook OB-GYN, Bloomington, Indiana) and Pipelle (Cooper Surgical, Shelton, Connecticut) endometrial biopsies during one office visit. Patients were followed longitudinally for the development of endometrial cancer or until undergoing dilatation and curettage or hysterectomy. All comparisons were analyzed using the chi 2 or t test.

RESULTS

One hundred one women (mean age, 58; range, 35-86) had endometrial biopsies performed. Median follow-up was > 21 months (range, 3-29). Twenty-two had cancer or atypia, while the remaining had benign diagnoses. When correlated with the final diagnosis, the Tao Brush had 95.5% sensitivity and the Pipelle, 86% sensitivity. Both devices had 100% specificity, positive predictive value of 100% and negative predictive value of 98%. When the results of the two biopsy devices are considered together, the positive and negative predictive value for detecting or excluding endometrial cancer was 100%. Based on 1998 Medicare reimbursements, a simultaneous second office biopsy using the Tao brush could save approximately $67 per case as compared to a sonohistogram and much more when compared to dilatation and curettage.

CONCLUSION

Endometrial cancer can be reliably detected and excluded using these two distinct office biopsy devices simultaneously during one office visit. In patients with an indication for endometrial biopsy, no further diagnostic test may be necessary to exclude or diagnose endometrial cancer or atypia.

Uterine myxoid leiomyosarcoma within a leiomyoma

A case of myxoid leiomyosarcoma of the uterus arising in a leiomyoma is reported. Although the tumor showed very low mitotic activity ranging from zero to 2/10 HPF, the presence of infiltrative pattern of growth and a high MIB-1 index (60% of cells positive) established the diagnosis. Myxoid leiomyosarcoma may arise in leiomyoma.

BK virus infection in AIDS

The BK virus (BKV) belongs to the family of the polyoma group, which contains three species: JC, which is responsible for progressive multifocal leukoencephalopathy in acquired immunodeficiency syndrome (AIDS); simian virus 40 (SV40), which is a simian virus of little pathologic significance in humans; and BKV, which is usually not pathogenic and is found in the urine of asymptomatic individuals. Recently BKV has been reported to cause symptomatic infection in renal transplant patients. The authors report a rare case of a 14-year-old boy with AIDS who developed a BKV infection of the lung and kidney that progressed to diffuse alveolar damage and death. The infected type II pneumocytes in the lung and the tubular epithelial cells in the kidney showed large, homogenous purple intranuclear inclusions. The absence of necrosis and destruction made it possible to distinguish BKV infection from herpes simplex. The size of the infected cells and the lack of a halo around the nuclear inclusion helped rule out cytomegalovirus as the cause of infection. Electron microscopy detected the presence of 40-nm intranuclear viral particles compatible with BKV, and in situ hybridization established the diagnosis.

Utility of proliferation-associated marker MIB-1 in evaluating lesions of the uterine cervix

Various cervical lesions at times may be difficult to distinguish from one another on routine hematoxylin and eosin stains, and immunostaining for the proliferation-associated antigen Ki-67, using monoclonal antibody MIB-1, can aid their distinction. The reduced MIB-1 expression in atrophy and increased MIB-1 expression in dysplasia permits easy distinction between these conditions. Presence of MIB-1 in more than 15% of basal cells and/or in surface half of the epithelium favor a diagnosis of condyloma over squamous metaplasia or inflammatory changes. Normal endocervix shows MIB-1 positivity in less than 10% of the cells, but usually in more than 20% of cells in cervical adenocarcinoma. With increasing grade of dysplasia, the percentage of MIB-1 positive cells is increased, and positive cells are seen in the higher levels of the epithelium. Presence of more than 20% MIB-1 positive cells in Pap smears showing atypical cells of uncertain significance is associated with a diagnosis of dysplasia on subsequent biopsies. Cauterized tissues with dysplasia show MIB-1 expression similar to adjacent noncauterized dysplastic areas. MIB-1 expression is, therefore, useful in evaluating various cervical lesions.

Utility of MIB-1 in evaluating cauterized cervical cone biopsy margins

Interpretation of cervical cone biopsy margins removed by loop electrosurgical excision procedure is often problematic as a result of cautery artifacts. In this study, MIB-1 expression in cauterized tissues was almost identical to that in the adjacent noncauterized epithelium (correlation coefficients 0.97-0.98). Cauterized dysplastic/condylomatous epithelium showed significantly greater expression of MIB-1 than cauterized normal epithelium (p < or = 0.004) at all levels of the epithelium. Cut-off points for distinguishing dysplastic/condylomatous epithelium from normal epithelium were >15%, 30%, 5%, and 1% of cells in the basal, basal one-third, middle one-third, and surface one-third of epithelium, respectively.

Immunohistochemical comparison of uterine papillary serous and papillary endometrioid carcinoma: clues to pathogenesis

Twenty-four predominantly papillary carcinomas of the endometrium, 10 serous and 14 endometrioid, were compared using a variety of immunohistochemical antibodies, including p53, estrogen and progesterone receptors, carcinoembryonic antigen, and E-cadherin. These were selected to attempt to find clues to explain the disparate behavior of these two tumor subtypes. We found that 6 of 8 (75%) serous carcinomas had a p53 reactivity score of 300, whereas 90% of endometrioid tumors had a p53 reactivity score of less than 20 (p = 0.0008). Combined estrogen and progesterone hormone reactivity was positive in 13 (100%) of endometrioid lesions compared with 4 of 8 (50%) of serous lesions (p = 0.0117). The significantly greater p53 expression and its significantly diminished hormone receptor expression indicate that papillary serous carcinomas belong to the type II group of endometrial carcinomas that occur in a background of atrophic endometrium, are high grade, present with high stage disease, and have a poor prognosis. In contrast, papillary endometrioid carcinomas, which belong to type I carcinomas, often arise in a background of estrogen-stimulated endometrial hyperplasia, are usually well-differentiated, and have a good prognosis. Early p53 mutations in papillary serous carcinoma as well as in endometrial intraepithelial serous carcinoma may partially explain their proclivity for early intra-abdominal dissemination. Carcinoembryonic antigen expression was similar in both groups and therefore is not useful to characterize possible differences in the cell of origin. The reactivity scores for E-cadherin were also similar in the two tumor subtypes, thus not supporting the hypothesis that decreased cell to cell adhesion molecules might contribute to early dissemination of serous lesions.

MIB-1 expression is useful in distinguishing dysplasia from atrophy in elderly women

Both atrophic and dysplastic cervical squamous epithelia show lack of maturation, nuclear crowding, and increased nuclear/cytoplasmic ratio. Because of these similarities, distinguishing dysplasia from atrophy in cervical biopsies from elderly patients is often problematic. Because dysplasia shows increased proliferation and atrophy has decreased proliferation, the possible utility of MIB-1 in distinguishing dysplasia from atrophy was evaluated. One or more of the following criteria were present in all nine cases with dysplasia and in none of the 17 cases with atrophy: MIB-1 expression in > 20% of cells in the basal one-third of the epithelium, > 5% of cells in the middle one-third of the epithelium, and > 1% of cells in the upper one-third of the epithelium. MIB-1 immunostaining is useful in distinguishing dysplasia from atrophy.

Aborted leiomyosarcoma after treatment with leuprolide acetate

BACKGROUND

Leuprolide acetate has been used to decrease uterine size and shrink leiomyomata. In carefully selected patients, its treatment benefits are well recognized. However, if leuprolide acetate is inadvertently given to a patient with an unsuspected leiomyosarcoma, complications may occur.

CASE

A patient presumed to have leiomyomata was treated with monthly injections of leuprolide acetate. In the third month of treatment, unusual manifestations, including increased bleeding, aborting mass, urinary retention, and severe pain, occurred suggesting a possible malignancy and requiring immediate operation.

CONCLUSION

The use of leuprolide acetate can delay the diagnosis and treatment of leiomyosarcoma and thus may increase the risk of morbidity and affect the treatment outcome of patients with leiomyosarcoma. The histologic changes ascribed to leuprolide acetate treatment in leiomyomata also were seen in this leiomyosarcoma.

Cervical condylomas show higher proliferation than do inflamed or metaplastic cervical squamous epithelium

Changes of condyloma are sometimes difficult to distinguish from changes seen with inflammation or with squamous metaplasia (SM) in the uterine cervix. Cervical condylomas show increased proliferative activity, so we sought to discover whether this increased activity is more than that seen in SM or with inflammation. Mitotic activity per 10 high power fields was measured in 22 cases with SM, 22 cases with exocervix only, 26 cases with inflammation, and 34 cases with condylomas. The percentage of basal cells staining for MIB-1 was compared between 27 cases with condyloma, 11 cases each with SM and inflammation, and 13 cases with exocervix. Mitotic activity was significantly increased in cervical condylomas (7.6 +/- 6.6, mean +/- standard deviation) compared with SM (1.4 +/- 1.4, P < .0001), inflamed epithelium (1.6 +/- 1.4, P < .0001), and exocervix (1.4 +/- 1.5, P < .0001). More than 15% of basal cells stained for MIB-1 in 18 of the 27 condylomas, 1 of 11 cases with SM, 1 of 11 cases with inflammation, and none of the 13 cases with exocervix (P = .003, .003, and .0006 respectively). Expression of MIB-1 in the surface half of the epithelium was seen in 18 (66%) of the 27 cases with condyloma but in none of the 24 controls (P < .00001). MIB-1 in the surface half of the epithelium and/or in more than 15% of the basal cells was seen in 24 (90%) of the 27 condyloma cases and 1 (4%) of the 24 control cases (P < .00001). A finding of 6 or more mitoses per 10 high power fields, expression of MIB-1 in the surface half of the epithelium, and more than 15% of basal cells staining for MIB-1 should support a diagnosis of condyloma over metaplastic or inflammatory changes.

A comparison of proliferative activity and atypical mitoses in cervical condylomas with various HPV types

Cervical condylomas associated with HPV types 6/11 rarely progress to dysplasia; this progression is more commonly seen in cervical condylomas with HPV types 16/18/31/33/35. This investigation was undertaken to determine if more frequent atypical mitotic figures (MFs) and higher proliferative activity are seen in high-risk condylomas. HPV types present in cervical condylomas were determined by in situ hybridization with biotinylated probes. The cases were also stained immunohistochemically for MIB1. The percentage staining of basal, parabasal, and suprabasal cells was determined by counting 100 cells in the most intensely stained areas. MFs and atypical MFs were counted per 10 high-power-fields (HPFs). Condylomas with HPV 6/11 showed higher MIB1 expression in the basal layer than condylomas with HPV 16/18 and 31/33/35 (p = 0.013). Atypical MFs were seen more frequently in condylomas with HPV types 16/18/31/33/35 (p = 0.02). Differences in mitotic activity and in MIB1 expression in parabasal and suprabasal layers did not reach statistical significance. The presence of atypical MFs may make a greater contribution than increased proliferative activity to progression to dysplasia in cervical condylomas.

Estrogen and progesterone receptors in the uterosacral ligament

OBJECTIVE

To evaluate steroid hormone receptor status in the uterosacral ligament, a structure that contributes to pelvic support.

METHODS

A descriptive study was conducted by sampling the uterosacral ligaments from 25 consecutive women undergoing hysterectomy by the primary author for nonmalignant conditions. Using immunohistochemical staining techniques, uterosacral ligaments were assessed for the presence and location of estrogen and progesterone receptors. Positive and negative controls were used. Confirmation of the uterosacral ligament was performed histologically.

RESULTS

Using commercially available monoclonal antibodies, estrogen and progesterone receptors were detected in the nuclei of smooth muscle cells of the uterosacral ligament in all patients, regardless of variations in age, race, menopausal status, parity, body mass index, and medications affecting serum steroid hormone levels. Hormone receptors were not found in the collagen, vascular, or neuronal components.

CONCLUSION

The presence of estrogen and progesterone receptors in the uterosacral ligaments means that this structure may be a target for estrogen and progesterone. This finding might suggest a possible role for steroid hormones in pelvic support.

Immunohistochemistry of vascular changes in leuprolide acetate-treated leiomyomas

We report two cases of leuprolide acetate-treated leiomyomas with striking vascular changes and histologic features of vasculitis and atherosclerosis. These changes may cause ischemic damage if they occur in other organs. We describe the histologic findings and discuss their clinical implications.

Alterations in steroid hormone receptors in the tamoxifen-treated endometrium

OBJECTIVE

Our purpose was to evaluate whether tamoxifen has estrogenic endometrial effects as defined by histologic study or alterations in steroid hormone receptor expression.

STUDY DESIGN

Nineteen postmenopausal tamoxifen-treated breast cancer patients who also had endometrial sampling were identified from files in the Department of Obstetrics and Gynecology. To examine the subgroup of 15 polyps, age-matched, non-hormonally treated patients with polyps (n = 8) or atrophic endometria (n = 5) served as comparison groups. Proliferative (n = 3) and secretory (n = 5) endometria served as procedural controls. Immunohistochemical studies for steroid receptors (estrogen, progesterone) were performed.

RESULTS

Glandular cell progesterone receptor was significantly increased and stromal cell estrogen receptor was significantly decreased in tamoxifen-treated versus atrophic endometria. Progesterone receptor staining was not significantly different in tamoxifen-treated versus control polyps, although staining was high in both groups. Stromal cell estrogen receptor staining was significantly reduced in tamoxifen-treated versus control polyps, although there were no histologic differences. Reduced stromal cell estrogen receptor and increased glandular cell progesterone receptor staining was found in all tamoxifen-treated endometria regardless of the diagnosis.

CONCLUSION

The tamoxifen-associated changes in endometrial steroid receptors support an estrogenic effect that is independent of histologic diagnosis and duration of use. This may contribute to the pathogenesis of tamoxifen-associated polyps and carcinomas.

Estrogen and progesterone receptor expression in endometrial polyps

Endometrial polyps are a frequent cause of abnormal uterine bleeding, but their pathogenesis is poorly understood. This study was undertaken to investigate if endometrial polyps result from localized overexpression of estrogen receptors (ERs) or reduced expression of progesterone receptors (PRs). Fourteen cases of endometrial polyps, in which normal cycling endometrium was also present on the same slide, were immunostained for ERs and PRs. Percentages of positive cells in glands and stroma for each receptor were subjectively assessed to the nearest 5%. The intensity of staining was recorded on a scale from 1+ to 4+. The level and intensity of staining in polyps were compared with the staining in normal endometrium. Fewer stromal cells in polyps expressed ERs and PRs compared with cycling endometrium (% ER = 55.9 +/- 25.8 vs. 74.3 +/- 25.8, p = 0.03; % PR = 56.1 +/- 28.2 vs. 87.5 +/- 10.1, p = 0.002). Stroma in polyps also had significantly reduced intensity of staining for PRs, but not for ERs (intensity PR = 2.7 +/- 1.4 vs. 3.5 +/- 0.7, p = 0.015; intensity ER = 2.1 +/- 0.7 vs. 2.4 +/- 0.8, p = 0.45). There were no significant differences in expression of ERs and PRs in the endometrial glands in endometrial polyps compared with normal endometrium (% ER = 75.4 +/- 32.5 vs. 70.7 +/- 39.2. p = 0.25; % PR = 79.6 +/- 32.8 vs. 80.4 +/- 34.4, p = 0.8; intensity ER = 2.7 +/- 0.9 vs. 2.4 +/- 1, p = 0.15; intensity PR = 2.9 +/- 1.4 vs. 3.4 +/- 0.7, p = 0.15). We conclude that endometrial polyps may result from a decrease in ER and PR expression in stromal cells. Because of these receptor-negative stromal cells, endometrial polyps may be relatively insensitive to cyclic hormonal changes.

Papillary carcinoma of the endometrium: morphometric predictors of survival

This study compares morphometric features of endometrial papillary carcinomas, serous and endometrioid types, in an effort identify characteristics that predict clinical outcome. Fifty-one consecutive patients with papillary carcinoma were identified at NYU Medical Center from January 1979 through December 1991 and were followed through 1994. Morphologic analysis was conducted by investigators (R.D. and K.M.) blinded as to original diagnosis, depth of invasion, stage and outcome. Of 25 variables analyzed, six were significantly associated with reduced survival, namely marked nuclear pleomorphism, multinucleated cells, hobnail cells, psammoma bodies, uneven papillary borders, and inflammation. Serous carcinomas showed a highly significant (p = 0.0001) association with reduced length of recurrence-free survival, with a median survival of 27 months (mean +/- SE, 38.9 +/- 7.0) versus 95 months (106.7 +/- 15.3) for patients with endometrioid types. Of six morphologic characteristics that correlated with reduced recurrence-free survival by univariate analyses, only one, nuclear pleomorphism, showed a significant association with an adverse outcome in a multivariate regression analysis (p = 0.0020), even after adjustment for the effect of tumor stage. Therefore, we believe that the presence of marked nuclear pleomorphism should serve as the major criterion for making a diagnosis of serous carcinoma. In tumors with moderate nuclear pleomorphism, a diagnosis of serous carcinoma is aided by the presence of multinucleated cells, uneven papillary borders, high nuclear/cytoplasmic ratio, apical location of the nucleus, and hobnail cells. These features were significantly associated with a diagnosis of serous carcinoma in our patients.