CCNE1 and survival of patients with tubo-ovarian high-grade serous carcinoma: An Ovarian Tumor Tissue Analysis consortium study

BACKGROUND

Cyclin E1 (CCNE1) is a potential predictive marker and therapeutic target in tubo-ovarian high-grade serous carcinoma (HGSC). Smaller studies have revealed unfavorable associations for CCNE1 amplification and CCNE1 overexpression with survival, but to date no large-scale, histotype-specific validation has been performed. The hypothesis was that high-level amplification of CCNE1 and CCNE1 overexpression, as well as a combination of the two, are linked to shorter overall survival in HGSC.

METHODS

Within the Ovarian Tumor Tissue Analysis consortium, amplification status and protein level in 3029 HGSC cases and mRNA expression in 2419 samples were investigated.

RESULTS

High-level amplification (>8 copies by chromogenic in situ hybridization) was found in 8.6% of HGSC and overexpression (>60% with at least 5% demonstrating strong intensity by immunohistochemistry) was found in 22.4%. CCNE1 high-level amplification and overexpression both were linked to shorter overall survival in multivariate survival analysis adjusted for age and stage, with hazard stratification by study (hazard ratio [HR], 1.26; 95% CI, 1.08-1.47, p = .034, and HR, 1.18; 95% CI, 1.05-1.32, p = .015, respectively). This was also true for cases with combined high-level amplification/overexpression (HR, 1.26; 95% CI, 1.09-1.47, p = .033). CCNE1 mRNA expression was not associated with overall survival (HR, 1.00 per 1-SD increase; 95% CI, 0.94-1.06; p = .58). CCNE1 high-level amplification is mutually exclusive with the presence of germline BRCA1/2 pathogenic variants and shows an inverse association to RB1 loss.

CONCLUSION

This study provides large-scale validation that CCNE1 high-level amplification is associated with shorter survival, supporting its utility as a prognostic biomarker in HGSC.

MCM3 is a novel proliferation marker associated with longer survival for patients with tubo-ovarian high-grade serous carcinoma

Tubo-ovarian high-grade serous carcinomas (HGSC) are highly proliferative neoplasms that generally respond well to platinum/taxane chemotherapy. We recently identified minichromosome maintenance complex component 3 (MCM3), which is involved in the initiation of DNA replication and proliferation, as a favorable prognostic marker in HGSC. Our objective was to further validate whether MCM3 mRNA expression and possibly MCM3 protein levels are associated with survival in patients with HGSC. MCM3 mRNA expression was measured using NanoString expression profiling on formalin-fixed and paraffin-embedded tissue (N = 2355 HGSC) and MCM3 protein expression was assessed by immunohistochemistry (N = 522 HGSC) and compared with Ki-67. Kaplan-Meier curves and the Cox proportional hazards model were used to estimate associations with survival. Among chemotherapy-naïve HGSC, higher MCM3 mRNA expression (one standard deviation increase in the score) was associated with longer overall survival (HR = 0.87, 95% CI 0.81-0.92, p < 0.0001, N = 1840) in multivariable analysis. MCM3 mRNA expression was highest in the HGSC C5.PRO molecular subtype, although no interaction was observed between MCM3, survival and molecular subtypes. MCM3 and Ki-67 protein levels were significantly lower after exposure to neoadjuvant chemotherapy compared to chemotherapy-naïve tumors: 37.0% versus 46.4% and 22.9% versus 34.2%, respectively. Among chemotherapy-naïve HGSC, high MCM3 protein levels were also associated with significantly longer disease-specific survival (HR = 0.52, 95% CI 0.36-0.74, p = 0.0003, N = 392) compared to cases with low MCM3 protein levels in multivariable analysis. MCM3 immunohistochemistry is a promising surrogate marker of proliferation in HGSC.

A combination of the immunohistochemical markers CK7 and SATB2 is highly sensitive and specific for distinguishing primary ovarian mucinous tumors from colorectal and appendiceal metastases

Primary ovarian mucinous tumors can be difficult to distinguish from metastatic gastrointestinal neoplasms by histology alone. The expected immunoprofile of a suspected metastatic lower gastrointestinal tumor is CK7-/CK20+/CDX2+/PAX8-. This study assesses the addition of a novel marker SATB2, to improve the diagnostic algorithm. A test cohort included 155 ovarian mucinous tumors (105 carcinomas and 50 borderline tumors) and 230 primary lower gastrointestinal neoplasms (123 colorectal adenocarcinomas and 107 appendiceal neoplasms). All cases were assessed for SATB2, PAX8 CK7, CK20, and CDX2 expression on tissue microarrays. Expression was scored in a 3-tier system as absent, focal (1-50% of tumor cells) and diffuse ( >50% of tumor cells) and then categorized into either absent/present or nondiffuse/diffuse. SATB2 and PAX8 expression was further evaluated in ovarian tumors from an international cohort of 2876 patients (expansion cohort, including 159 mucinous carcinomas and 46 borderline mucinous tumors). The highest accuracy of an individual marker in distinguishing lower gastrointestinal from ovarian mucinous tumors was CK7 (91.7%, nondiffuse/diffuse cut-off) followed by SATB2 (88.8%, present/absent cut-off). The most effective combination was CK7 and SATB2 with accuracy of 95.3% using the 3-tier interpretation, absent/focal/diffuse. This combination outperformed the standard clinical set of CK7, CK20 and CDX2 (87.5%). Re-evaluation of outlier cases confirmed ovarian origin for all but one case. The accuracy of SATB2 was confirmed in the expansion cohort (91.5%). SATB2 expression was also detected in 15% of ovarian endometrioid carcinoma but less than 5% of other ovarian histotypes. A simple two marker combination of CK7 and SATB2 can distinguish lower gastrointestinal from ovarian primary mucinous tumors with greater than 95% accuracy. PAX8 and CDX2 have value as second-line markers. The utility of CK20 in this setting is low and this warrants replacement of this marker with SATB2 in clinical practice.

The relationship between circulating concentration of AMH and LH content in the follicle stimulating hormone (FSH) preparations on follicular growth and ovulatory response to superovulation in water buffaloes

The relationship between circulating concentration of anti-mullerian hormone (AMH) and the LH content of follicle stimulating hormone (FSH) preparation on follicular growth and ovulatory response in water buffaloes was evaluated. A single blood sample was taken from cows (N=31; age: 9.06±0.98years) to determine systemic AMH. Animals with concentrations higher or lower than 194±30pg/ml were placed into LOW and HIGH AMH groups and were assigned randomly to be superovulated FSH containing either a high (FSHp, HLH) or low (FolltropinV, LLH) LH content. Follicular growth and ovulation were monitored using transrectal ultrasonography. In animals with HIGH systemic AMH, treatment with FSH with a high LH content was associated with more small follicles (AMH X FSH; P=0.02). AMH had no effect on small follicles in animals treated with LLH. Females with a HIGH AMH had greater numbers of small follicles (P=0.01) and total follicles (P=0.005) than LOW AMH cows. Animals treated with HLH had more small follicles (P=0.001) but fewer large (P<0.001) and total follicles (P=0.0005) than those treated with LLH. Among animals with HIGH AMH, those treated with LLH, ovulated more follicles than those treated with HLH. (AMH X FSH; P=0.03). In conclusion, selecting animals with high AMH concentration and the use of FSH preparations with a lower LH content may improve the superovulatory response in water buffaloes.

Looking beyond human papillomavirus (HPV) genotype 16 and 18: Defining HPV genotype distribution in cervical cancers in Australia prior to vaccination

Australia has implemented a high-coverage HPV vaccination program but has not, to date, established the distribution of HPV types that occur in cervical cancers in Australia. This information is important for determining the potential for cervical cancer prevention with both current and broader spectrum HPV vaccines. We analysed 847 cervical cancers diagnosed 2005 to 2015 in tertiary centres in the three most populous Australian states with resolution of specimens containing multiple HPV types using laser-capture microdissection. Archived FFPE tissue was reviewed by specialist pathologists, sandwich sectioned, and initially whole-tissue sections genotyped for HPV. Samples were first genotyped using SPF10-LiPA25 (version 1). Negative samples were screened with DNA ELISA kit HPV SPF10, followed by genotyping with SPF+ LiPA if ELISA positive. If still negative, samples were tested on a qPCR assay targeting the E6 region of HPV16, 18, 45 and 33. Of the 847 cancers (65.1% squamous, 28.7% adenocarcinoma, 4.3% adenosquamous, 2.0% other), 92.9% had HPV detected. Of the HPV-positive cancers, 607 of 787 (77.1%) contained HPV16 or 18, 125 of 787 (15.9%) contained HPV31/33/45/52 or 58, and 55 (7.0%) another HPV type. There was a strong correlation between HPV type and age, with younger women most likely to have HPV16/18 detected and least likely HPV negative. Our findings indicate that cervical cancers diagnosed in Australia more frequently contain HPV16/18 than in international series. This could be due to cervical screening in Australia increasing the proportion of adenocarcinomas, in which types 18 and 16 more strongly predominate, due to prevention of squamous cancers.

Atypical Teratoid Rhabdoid Tumor: Two Case Reports and an Analysis of Adult Cases with Implications for Pathophysiology and Treatment

We present the first quantitative analysis of atypical teratoid rhabdoid tumors (ATRT) in adults, including two patients from our own institutions. These are of interest as one occurred during pregnancy and one is a long-term survivor. Our review of pathological findings of 50 reported cases of adult ATRT leads us to propose a solely ectodermal origin for the tumor and that epithelial–mesenchymal transition (EMT) is a defining feature. Thus, the term ATRT may be misleading. Our review of clinical findings shows that ATRT tends to originate in mid-line structures adjacent to the CSF, leading to a high rate of leptomeningeal dissemination. Thus, we hypothesize that residual undifferentiated ectoderm in the circumventricular organs, particularly the pituitary and pineal glands, is the most common origin for these tumors. We note that if growth is not arrested soon after diagnosis, or after the first relapse/progression, death is almost universal. While typically rapidly fatal (as in our first case), long-term remission is possible (as in our second). Significant predictors of prognosis were the extent of resection and the use of chemotherapy. Glial differentiation (GFAP staining) was strongly associated with leptomeningeal metastases (chi-squared p = 0.02) and both predicted markedly worse outcomes. Clinical trials including adults are rare. ATRT is primarily a disease of infancy and radiotherapy is generally avoided in those aged less than 3 years old. Treatment options in adults differ from infants in that cranio-spinal irradiation is a viable adjunct to systemic chemotherapy in the adult population. Given the grave prognosis, this combined approach appears reasonable. As effective chemotherapy is likely to cause myelosuppression, we recommend that stem-cell rescue be available locally.

Histological analysis of surgical samples and a proposed scoring system for infections in intervertebral discs

Back pain remains one the most prevalent types of pain and disability worldwide. Infection is estimated to be the underlying cause in approximately 0.01% of patients. Despite recent evidence demonstrating prominent infection rates, a standardised algorithm for diagnosis of disc infection is lacking. Histopathological evaluation can aid in confirming inflammatory changes and also in identifying degenerative changes. Hence, standardising practice through a clear scoring system with regards to inflammation and degeneration may have some utility in the clinical setting. To our knowledge no such systems exist specifically for intervertebral disc infection. A literature review of current methods of scoring inflammation and degeneration in spine surgery and orthopaedic surgery was performed. Based on the current evidence, a scoring system for disc inflammatory and degenerative changes was proposed. We propose four domains for consideration: (1) granulation tissue, (2) dense fibrosis, (3) chronic inflammatory cells, and (4) neutrophil count. The non-standardised nature of diagnosing infections and degeneration in the spinal surgery literature means that this scoring system is currently of particular value. Based on a literature review, our proposed method for diagnosis incorporates a combination of histopathological criteria expected to increase diagnostic sensitivity in the setting of disc infection. Overall, scoring can be applied to surgically obtained material and integrated directly into routine pathological practice.

Gram stain, culture, and histopathological examination findings for heart valves removed because of infective endocarditis

Retrospective chart review was undertaken for 480 patients who underwent a total of 506 valve replacements or repair procedures for infective endocarditis. The influence of preoperative antimicrobial treatment on culture, Gram stain, and histopathological examination findings for resected valve specimens was examined. When valves were removed before the end of treatment, organisms were seen on the Gram stain of ground valve material performed in the microbiology laboratory and on Gram-stained histopathological sections in 231 (81%) of 285 and 140 (67%) of 208 specimens, respectively (P=.0007). Gram-positive cocci were either cultured from or observed in excised valve tissue in 42 (67%) of 63 episodes involving negative preoperative blood cultures. Positive Gram stain results for microbiological specimens should be reintroduced into the definite pathological criteria for infective endocarditis. When deciding on how long to continue antimicrobial therapy after valve replacement for endocarditis, valve culture results should be the only laboratory finding taken into account, because it takes months for dead bacteria to be removed from sterile vegetations.

Immunohistochemical staining for Chlamydia pneumoniae is increased in lung tissue from subjects with chronic obstructive pulmonary disease

The seroprevalence of Chlamydia pneumoniae is increased in chronic obstructive pulmonary disease (COPD), and subjects with COPD are more likely to have a positive polymerase chain reaction for C. pneumoniae in their sputum. It has been suggested that C. pneumoniae may have a role in the pathogenesis of COPD. We undertook immunohistochemistical staining for C. pneumoniae in archival tissue from subjects who had undergone lobectomy for bronchial carcinoma. There were 16 subjects with COPD (FEV(1) = 64 +/- 8% [mean +/- SD] predicted) and 21 subjects with normal lung function (FEV(1) = 95 +/- 11% predicted). There was no difference between the two groups in age or smoking history. Tissues from all of the subjects stained positively for C. pneumoniae, but in the subjects with COPD there were 14.5 positive cells per field (magnification x400), as compared with 9.3 cells per field in the control subjects (p = 0.02). Fifty-four percent of the macrophages from the subjects with COPD stained positively for C. pneumoniae, as compared with 29% from the control subjects (p < 0.001). A second control group consisted of 18 younger individuals (mean age: 32 yr) who died accidentally. Only 44% of these subjects had positive staining for C. pneumoniae, and the mean number of cells per field was 0.4. These findings suggest that persistent infection with C. pneumoniae is common, and that there is increased immunostaining for C. pneumoniae in COPD. Further studies are necessary to determine whether chronic infection with C. pneumoniae is important in the pathogenesis of COPD.

HLA-B27 associated spondyloarthropathy and severe ascending aortitis

We describe a young woman who developed early and severe aortic regurgitation and subsequent aortitis with aneurysm formation requiring surgery.

Bronchiolitis obliterans organising pneumonia associated with the use of nitrofurantoin

The spectrum of nitrofurantoin lung injury continues to widen. The case histories are presented of two patients who developed lung disease associated with the use of nitrofurantoin with histological features of bronchiolitis obliterans organising pneumonia (BOOP), a rare but recognised form of drug induced injury. The two middle aged women presented with respiratory symptoms after prolonged treatment with nitrofurantoin. Both had impaired lung function and abnormal computed tomographic scans, and their condition improved when nitrofurantoin was withdrawn and corticosteroid treatment commenced. The favourable outcome in these two patients contrasts with the fatal outcome of the two other reported cases of nitrofurantoin induced BOOP. We suggest that the previous classification of nitrofurantoin induced lung injury into "acute" and "chronic" injury is an oversimplification in view of the wide variety of pathological entities that have subsequently emerged.

Retrospective study on Escherichia coli infection in broilers subjected to postmortem examination and antibiotic resistance of isolates in Trinidad

An 8-yr retrospective study was conducted to evaluate the rate of Escherichia coli infection and antibiotic resistance of isolates from diseased broilers submitted for diagnosis in Trinidad from 1990 to 1997. Of a total of 906 cases of diseased birds subjected to postmortem examination, 603 (66.6%) had E. coli infection. The number of cases increased over the years from 16 in 1990 to a peak of 294 in 1996. For every year, at least 50% of all broiler cases had E. coli infection. The rate of infection was significantly higher during the rainy season (74.1 +/- 6.9%) than during the dry season (57.8 +/- 7.0%). Approximately 50% of all E. coli isolates were resistant to 9 out of a total of 11 antimicrobial drugs selected for the study. The isolates showed an increasing trend of resistance to amoxicillin, apramycin, gentamicin, nitrofurantoin, norfloxacin, and sulfamethoxazole-trimethoprim. However, only the trends of resistance to apramycin and norfloxacin were statistically significant. Overall, of the antimicrobial drugs selected, norfloxacin relatively appeared as the best choice for treatment. From this study, we conclude that the high rate of E. coli infection in broilers submitted for diagnosis along with the high resistance of isolates to antimicrobial drugs constitute a threat to the poultry industry on the island.

Bronchiectasis following colectomy for Crohn's disease

Bronchiectasis developing following colectomy for ulcerative colitis has been reported in a few cases. This may be the first report of bronchiectasis developing after colectomy for Crohn's disease. The close temporal relationship to colectomy, lack of bacterial pathogens in the sputum, and an impressive response to oral steroids suggest a difference in pathogenesis from idiopathic bronchiectasis.

Primary plexogenic pulmonary hypertension shows imperfect formation of the internal elastic lamina of the pulmonary arteries

Lung tissue from subjects dying from primary plexogenic pulmonary hypertension (PPH) has shown defects of elastin formation of the lung arteries. Lung vessels from 5 cases of PPH were compared with those of 9 age-matched normal subjects, and 24 individuals having secondary pulmonary hypertension (2 degrees PH). PPH cases and those with 2 degrees PH due to congenital heart disease with left-to-right shunts (2 degrees PH, LRS), showed active proliferation of medial smooth muscle cells (SMC) through defects of the internal elastic lamina (IEL) into the arterial lumen to form typical plexiform lesions. Larger arteries showed accelerated intimal thickening similar to normal aging. Plexiform lesions were not seen in normal subjects or in those developing high pulmonary pressures later in life. The observations showed that the development of discontinuities of the IEL of the pulmonary arteries and intimal thickening is accelerated in normal subjects by high pulmonary artery pressure, especially when this is established at a very young age. They suggest that such discontinuities occur in PPH due to inherent abnormality of the elastin of the arterial walls, with advanced early proliferation of medial SMC and obstruction of the pulmonary arterial circulation.