Selective breast/gynecologic pathology fellowship training in the United States: Experience of program directors

Published data on combined breast and gynecologic [breast/gyn] surgical pathology fellowship training programs are limited. Our study aimed to survey the landscape of such fellowships in the United States (US), including specific information about their characteristics and the educational activities therein. Using web searches, we identified programs offering combined breast/gyn surgical pathology fellowship training. We developed a 26-item questionnaire asking program directors to report on the characteristics of their fellowship training structure. The search revealed 25 academic based programs offering one-year combined breast/gyn fellowship training, predominantly located (40 %) in the Northeast area. The following data was obtained: 44 % of the programs were accredited by the ACGME, 82 % required >19 weeks of breast and gyn service, and 69.6 % accepted the common application, 54.5 % of programs require completion of a research project for graduation. An annual average of 3000 breast and 3000 gyn cases appears to be the usual volume of cases. Interestingly, only 36 % of the program directors are graduates of a combined breast/gyn fellowship program. In conclusion, we present the most comprehensive and up-to-date census of combined breast/gyn pathology fellowships in the US. Our study provides valuable information on the current state of combined breast/gyn pathology fellowship training. The information will be helpful to current and prospective trainees, as well as program leaders.

Utility of a custom designed next generation DNA sequencing gene panel to molecularly classify endometrial cancers according to The Cancer Genome Atlas subgroups

BACKGROUND

The Cancer Genome Atlas identified four molecular subgroups of endometrial cancer with survival differences based on whole genome, transcriptomic, and proteomic characterization. Clinically accessible algorithms that reproduce this data are needed. Our aim was to determine if targeted sequencing alone allowed for molecular classification of endometrial cancer.

METHODS

Using a custom-designed 156 gene panel, we analyzed 47 endometrial cancers and matching non-tumor tissue. Variants were annotated for pathogenicity and medical records were reviewed for the clinicopathologic variables. Using molecular characteristics, tumors were classified into four subgroups. Group 1 included patients with > 570 unfiltered somatic variants, > 9 cytosine to adenine nucleotide substitutions per sample, and < 1 cytosine to guanine nucleotide substitution per sample. Group 2 included patients with any somatic mutation in MSH2, MSH6, MLH1, PMS2. Group 3 included patients with TP53 mutations without mutation in mismatch repair genes. Remaining patients were classified as group 4. Analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, North Carolina, USA).

RESULTS

Endometrioid endometrial cancers had more candidate variants of potential pathogenic interest (median 6 IQR 4.13 vs. 2 IQR 2.3; p < 0.01) than uterine serous cancers. PTEN (82% vs. 15%, p < 0.01) and PIK3CA (74% vs. 23%, p < 0.01) mutations were more frequent in endometrioid than serous carcinomas. TP53 (18% vs. 77%, p < 0.01) mutations were more frequent in serous carcinomas. Visual inspection of the number of unfiltered somatic variants per sample identified six grade 3 endometrioid samples with high tumor mutational burden, all of which demonstrated POLE mutations, most commonly P286R and V411L. Of the grade 3 endometrioid carcinomas, those with POLE mutations were less likely to have risk factors necessitating adjuvant treatment than those with low tumor mutational burden. Targeted sequencing was unable to assign samples to microsatellite unstable, copy number low, and copy number high subgroups.

CONCLUSIONS

Targeted sequencing can predict the presence of POLE mutations based on the tumor mutational burden. However, targeted sequencing alone is inadequate to classify endometrial cancers into molecular subgroups identified by The Cancer Genome Atlas.

Proposal for a Risk-Based Categorization of Uterine Carcinosarcoma

PURPOSE

To propose a categorization model of uterine carcinosarcoma (UCS) based on tumor cell types (carcinoma and sarcoma) and sarcoma dominance.

METHODS

This secondary analysis of a prior multicenter retrospective study examined 889 cases of UCS with available histologic evaluation. Based on survival outcome, cases were clustered into three groups: low-grade carcinoma with nondominant homologous sarcoma [type A, n = 96 (10.8%)], (1) low-grade carcinoma with heterologous sarcoma or any sarcoma dominance and (2) high-grade carcinoma with nondominant homologous sarcoma [type B, n = 412 (46.3%)], and high-grade carcinoma with heterologous sarcoma or any sarcoma dominance [type C, n = 381 (42.9%)]. Tumor characteristics and outcome were examined based on the categorization.

RESULTS

Women in type C category were more likely to be older, obese, and Caucasian, whereas those in type A category were younger, less obese, Asian, and nulligravid (all P < 0.01). Type C tumors were more likely to have metastatic implants, large tumor size, lymphovascular space invasion with sarcoma cells, and higher lymph node ratio, whereas type A tumors were more likely to be early-stage disease and small (all P < 0.05). On multivariate analysis, tumor categorization was independently associated with progression-free survival (5-year rates: 70.1% for type A, 48.3% for type B, and 35.9% for type C, adjusted P < 0.01) and cause-specific survival (5-year rates: 82.8% for type A, 63.0% for type B, and 47.1% for type C, adjusted P < 0.01).

CONCLUSION

Characteristic differences in clinicopathological factors and outcomes in UCS imply that different underlying etiologies and biological behaviors may be present, supporting a new classification system.

Significance of Lymphovascular Space Invasion by the Sarcomatous Component in Uterine Carcinosarcoma

OBJECTIVE

The aim of this study was to examine the significance of lymphovascular space invasion (LVSI) with a sarcomatous component on the tumor characteristics and clinical outcomes of women with uterine carcinosarcoma (UCS).

METHODS

This was a secondary analysis of a prior multicenter retrospective study that examined women with stage I-IV UCS who underwent primary hysterectomy. Archived histopathology slides were reviewed and LVSI was scored as follows: LVSI with a carcinomatous component alone (LVSI-carcinoma; n = 375, 76.8%) or LVSI containing a sarcomatous component with or without a carcinomatous component (LVSI-sarcoma; n = 113, 23.2%). Qualitative metrics of LVSI were correlated to clinicopathological factors and survival outcome.

RESULTS

Tumors in the LVSI-sarcoma group were more likely to have sarcoma dominance (82.1 vs. 26.4%) heterologous sarcomatous component (51.3 vs. 37.9%), low-grade carcinoma (42.5 vs. 22.4%), and large tumor size (81.0 vs. 70.2%) in the primary tumor site compared with tumors in the LVSI-carcinoma group (all p < 0.05). On multivariate analysis, LVSI-sarcoma was independently associated with decreased progression-free survival (5-year rates: 34.9 vs. 40.8%, adjusted hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.36-2.50, p < 0.001), and cause-specific survival (5-year rates: 41.8 vs. 55.9%, adjusted HR 1.95, 95% CI 1.39-2.75, p < 0.001) compared with LVSI-carcinoma. Postoperative radiotherapy for women with LVSI-sarcoma had a higher reduction rate of recurrence/progression of disease (54% reduction, p = 0.04) compared with postoperative radiotherapy for women with LVSI-carcinoma (26% reduction, p = 0.08).

CONCLUSION

In UCS, the presence of a sarcomatous component in LVSI is particularly prevalent when a tumor has sarcoma dominance. Our study suggests that LVSI containing a sarcomatous component may be a predictor of decreased survival for women with UCS.

Characterizing sarcoma dominance pattern in uterine carcinosarcoma: Homologous versus heterologous element

OBJECTIVE

To examine significance of sarcoma dominance (SD) patterns in uterine carcinosarcoma (UCS).

METHODS

This is a secondary analysis of multicenter retrospective study examining women with stages I-IV UCS who underwent primary surgery. SD was defined as >50% of sarcoma component in uterine tumor. SD patterns were grouped as homologous sarcoma without SD (homo/non-dominance, n = 351), heterologous sarcoma without SD (hetero/non-dominance, n = 174), homologous sarcoma with SD (homo/dominance, n = 175), and heterologous sarcoma with SD (hetero/dominance, n = 189), and correlated to tumor characteristics and survival.

RESULTS

SD patterns were significantly associated with age, body habitus, carcinoma type, tumor size, depth of myometrial invasion, and nodal metastasis (all, P < 0.05). On univariate analysis, SD was associated with decreased progression-free survival (PFS) and cause-specific survival (CSS) in homologous cases (both, P < 0.05) but not in heterologous cases. On multivariate models, both homologous and heterologous SD patterns remained independent prognostic factors for decreased PFS (adjusted-hazard ratio [HR] ranges: homo/dominance 1.35-1.69, and hetero/dominance 1.47-1.64) and CSS (adjusted-HR ranges: 1.52-1.84 and 1.66-1.81, respectively) compared to homo/non-dominance (all, P < 0.05). Among stage I-III disease, when tumors had SD, adding radiotherapy to chemotherapy was significantly associated with improved PFS (adjusted-HR: homo/dominance 0.49, and hetero/dominance 0.45) and CSS (0.36 and 0.31, respectively) compared to chemotherapy alone (all, P < 0.05); contrary, this association was not observed with absence of SD (all, P > 0.05).

CONCLUSION

In UCS, SD impacts survival in homologous but not in heterologous type. Regardless of sarcoma types, SD was associated with decreased survival in UCS; adding radiotherapy to chemotherapy may be an effective postoperative strategy.

Differential expression of various clones of estrogen receptor in cell block preparation of lung adenocarcinoma

BACKGROUND

Women treated for breast cancer are at increased risk of developing pulmonary nodules which could represent new primary lung carcinomas or metastatic breast carcinoma. The FNA biopsy is frequently the first diagnostic choice in determining the primary site of the tumor. Estrogen receptor (ER) positivity in diagnostic tissue is generally used to favor breast over lung primary. However, the recent studies have shown a wide range of ER antibody cross reactivity with lung adenocarcinoma. We studied the frequency of ER expression in cytology samples of lung adenocarcinoma using antibodies to three different ER clones.

METHODS

Cytology cell block preparations, including 22 lung FNAs and 19 malignant pleural effusions (PE) from 41 patients, with clinically documented primary lung adenocarcinomas were selected for this study. All cases were stained with monoclonal antibodies to ER clones 6F11 and 1D5. Twenty nine cases with remaining available material (15 FNA and 14 PE) were stained with a third antibody to ER clone SP1. The extent of ER nuclear staining was scored as 3+ (50%-100% of tumor cells), 2+ (11%-49%), and 1+ (≤10%).

RESULTS

Positivity for ER-6F11 clone was present in 4 of 22 lung FNAs (18.2%, 2+ staining). Two of the four 6F11 positive FNAs also co-expressed ER-1D5 (9.1%, 2+ staining). No immunoreactivity was observed for ER clones 6F11 and 1D5 in all 19 malignant PEs. In addition, none of the remaining 15 FNAs and 14 PEs showed immunoreactivity for ER-SP1 clone.

CONCLUSIONS

A small subset of pulmonary adenocarcinomas shows immunoreactivity for ER clones 6F11 and 1D5 in FNA samples (18.2% and 9.1%, respectively). The absence of immunoreactivity for ER-SP1 clone indicates higher specificity of this clone in non-breast tissue. The differential diagnostic value of all ER clones in malignant PEs appears to be secure. Larger studies are necessary to validate this observation.

Impact of lympho-vascular space invasion on tumor characteristics and survival outcome of women with low-grade serous ovarian carcinoma

BACKGROUND AND OBJECTIVES

To examine association of lympho-vascular space invasion (LVSI) with clinico-pathological factors and to evaluate survival of women with low-grade serous ovarian carcinoma containing areas of LVSI.

METHODS

This is a multicenter retrospective study examining consecutive cases of surgically treated stage I-IV low-grade serous ovarian carcinoma (n = 178). Archived histopathology slides for the ovarian tumors were reviewed, and LVSI was scored as present or absent. LVSI status was correlated to clinico-pathological findings and survival outcome.

RESULTS

LVSI was seen in 79 cases (44.4%, 95% confidence interval [CI] 37.1-51.7). LVSI was associated with increased risk of omental metastasis (87.0% vs 64.9%, odds ratio [OR] 3.62, P = 0.001), high pelvic lymph node ratio (median 12.9% vs 0%, P = 0.012), and malignant ascites (49.3% vs 32.6%, OR 2.01, P = 0.035). On multivariable analysis, controlling for age, stage, and cytoreductive status, presence of LVSI in the ovarian tumor remained an independent predictor for decreased progression-free survival (5-year rates 21.0% vs 35.7%, adjusted-hazard ratio 1.57, 95%CI 1.06-2.34, P = 0.026). LVSI was significantly associated with increased risk of recurrence in lymph nodes (OR 2.62, 95%CI 1.08-6.35, P = 0.047).

CONCLUSION

LVSI in the ovarian tumor is associated with adverse clinico-pathological characteristics and decreased progression-free survival in women with low-grade serous ovarian carcinoma.

The role of skin ulceration in breast carcinoma staging and outcome

Breast carcinoma with skin ulceration (SU) is considered a locally advanced disease. The purpose of the study is to investigate if SU is an independent adverse factor. Breast carcinoma patients with SU (n=111) were included in the study. A subset (n=38, study cohort) was matched with cases that had no SU (n=38, matched cohort); the survival analyses were compared between these groups. Then, cases (n=80) were staged independent from SU into stage I, II or III. Disease free survival (DFS) and overall survival (OS) were analyzed. Patients with larger tumors tended to present with distant metastases more often than patients with smaller tumors (P=.004). In the matched cases, the 5-year DFS probability was 53% for the study cohort and 58% for the matched cohort; and for OS 75% for the study cohort and 84% for the matched cohort with no statistical significant difference. However, there was a trend towards worse DFS for the patients whose tumors had SU. When the cases were staged based on tumor size and node status (I, II or III), the OS was statistically significant (P=.047) but not the DFS (P=.195). Relatively small tumors with SU had an extent of disease similar to that observed in patients with early stages disease. The survival analysis suggests that SU may not be an adverse factor. However, more cases are needed to further examine this finding.

Assessment of a custom designed next generation DNA sequencing gene panel to profile endometrial cancers

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Background: Using whole genome sequencing (WGS), the Cancer Genome Atlas (TCGA) identified four genomic subtypes of endometrial cancer (EC) with survival differences. Limited clinical data is available in the TCGA dataset restricting correlation of WGS with clinical endpoints. We sought to determine if high depth target sequencing allows for genomic classification of EC and prediction of the tumor biology when clinical variables are known. Methods: Using a custom designed sequencing panel targeting the coding regions of 156 EC genes we analyzed 47 EC samples and matching normal controls. Variants were annotated for pathogenicity. Charts were reviewed for clinicopathologic data. Routine statistical analyses were applied. Results: Endometrioid (EEC) tumors had a significantly higher frequency of total and pathogenic SNVs than serous (USC). Pathogenic PTEN and PIK3CA SNVs were more common in EEC while pathogenic TP53 SNVs were more frequent in USC. The presence of pathogenic TP53 SNVs was significantly associated with disease recurrence/progression. A pathogenic SNV at PTEN locus chr10:89692904 was associated with grade 1 EEC. Six hypermutated specimens were identified with 99-272 SNVs (mean 185.8 v 8.7 in non-hypermutated samples). All 6 were grade 3 EEC, of which 4 patients are alive without clinical evidence of disease (mean follow up 35 months). NTRK3, LRP1B, SLIT2, APC, RAD50, PIK3R1, and JAK2 SNVs were more common in grade 3 EEC than the other histologies. Conclusions: Pathogenic variants in EC associated with PTEN, PIK3CA, and TP53 and the number of somatic variants, as identified by a targeted sequencing, can predict histologic features and clinical behavior. Targeted sequencing panels may be a useful tool to predict the clinical phenotype and guide individualized therapeutic intervention. [Table: see text]

Uterine sarcoma with ambiguous histomorphology: A case report

Background

Leiomyosarcomas (LMS) and endometrial stromal sarcomas (ESS) may display overlapping histomorphology, which may challenge diagnostic accuracy. Since LMS and ESS have vastly different clinical behavior and adjuvant therapy recommendations, accurate diagnosis is critical.

Case

We present the case of an 83-year-old female with postmenopausal bleeding who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy for clinically atypical appearing leiomyomata. Histologically, dual populations of cells with morphologic features of low-grade ESS and high-grade spindle cell sarcoma were seen. Immunohistochemistry and molecular studies revealed the cells to be of smooth muscle derivation, rendering a diagnosis of high-grade LMS with heterogeneous morphology (stage IB). The patient received adjuvant gemcitabine plus docetaxel. She recurred 8 months after completion of chemotherapy and was transferred to hospice care.

Conclusion

Ancillary studies, such as immunohistochemistry and molecular testing, aid in accurate subcategorization of uterine sarcomas with ambiguous histomorphology.

•

LMS and ESS may display overlapping histomorphology.

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Immunohistochemistry and molecular testing aid classification of uterine sarcomas.

•

Classification of uterine sarcomas is critical for selection of adjuvant therapy.

Significance of histologic pattern of carcinoma and sarcoma components on survival outcomes of uterine carcinosarcoma

BACKGROUND

To examine the effect of the histology of carcinoma and sarcoma components on survival outcome of uterine carcinosarcoma.

PATIENTS AND METHODS

A multicenter retrospective study was conducted to examine uterine carcinosarcoma cases that underwent primary surgical staging. Archived slides were examined and histologic patterns were grouped based on carcinoma (low-grade versus high-grade) and sarcoma (homologous versus heterologous) components, correlating to clinico-pathological demographics and outcomes.

RESULTS

Among 1192 cases identified, 906 cases were evaluated for histologic patterns (carcinoma/sarcoma) with high-grade/homologous (40.8%) being the most common type followed by high-grade/heterologous (30.9%), low-grade/homologous (18.0%), and low-grade/heterologous (10.3%). On multivariate analysis, high-grade/heterologous (5-year rate, 34.0%, P = 0.024) and high-grade/homologous (45.8%, P = 0.017) but not low-grade/heterologous (50.6%, P = 0.089) were independently associated with decreased progression-free survival (PFS) compared with low-grade/homologous (60.3%). In addition, older age, residual disease at surgery, large tumor, sarcoma dominance, deep myometrial invasion, lymphovascular space invasion, and advanced-stage disease were independently associated with decreased PFS (all, P < 0.01). Both postoperative chemotherapy (5-year rates, 48.6% versus 39.0%, P < 0.001) and radiotherapy (50.1% versus 44.1%, P = 0.007) were significantly associated with improved PFS in univariate analysis. However, on multivariate analysis, only postoperative chemotherapy remained an independent predictor for improved PFS [hazard ratio (HR) 0.34, 95% confidence interval (CI) 0.27-0.43, P < 0.001]. On univariate analysis, significant treatment benefits for PFS were seen with ifosfamide for low-grade carcinoma (82.0% versus 49.8%, P = 0.001), platinum for high-grade carcinoma (46.9% versus 32.4%, P = 0.034) and homologous sarcoma (53.1% versus 38.2%, P = 0.017), and anthracycline for heterologous sarcoma (66.2% versus 39.3%, P = 0.005). Conversely, platinum, taxane, and anthracycline for low-grade carcinoma, and anthracycline for homologous sarcoma had no effect on PFS compared with non-chemotherapy group (all, P > 0.05). On multivariate analysis, ifosfamide for low-grade/homologous (HR 0.21, 95% CI 0.07-0.63, P = 0.005), platinum for high-grade/homologous (HR 0.36, 95% CI 0.22-0.60, P < 0.001), and anthracycline for high-grade/heterologous (HR 0.30, 95% CI 0.14-0.62, P = 0.001) remained independent predictors for improved PFS. Analyses of 1096 metastatic sites showed that carcinoma components tended to spread lymphatically, while sarcoma components tended to spread loco-regionally (P < 0.001).

CONCLUSION

Characterization of histologic pattern provides valuable information in the management of uterine carcinosarcoma.

Impact of adding the multikinase inhibitor sorafenib to endocrine therapy in metastatic estrogen receptor-positive breast cancer

BACKGROUND

Targeting growth factor and survival pathways may delay endocrine-resistance in estrogen receptor-positive breast cancer.

MATERIALS & METHODS

A pilot Phase II study adding sorafenib to endocrine therapy in 11 patients with metastatic estrogen receptor-positive breast cancer was conducted. Primary end point was response by RECIST after 3 months of sorafenib. Secondary end points included safety, time to progression and biomarker modulation. The study closed early owing to slow accrual.

RESULTS

Eight out of 11 patients had progressive disease on study entry and three had stable disease. Of the ten evaluable patients, seven experienced stable disease (70%) and three experienced progressive diseas (30%), with a median time to progression of 6.1 months (8.4 months in the seven patients on tamoxifen). The serum samples demonstrated a significant reduction in VEGF receptor 2 and PDGF receptor-α. Microarray analysis identified 32 suppressed genes, no induced genes and 29 enriched Kyoto Encyclopedia of Genes and Genomes pathways.

CONCLUSION

The strategy of adding a targeted agent to endocrine therapy upon resistance may be worthwhile testing in larger studies.

Naive and radiolabeled antibodies to E6 and E7 HPV-16 oncoproteins show pronounced antitumor activity in experimental cervical cancer

BACKGROUND

In spite of profound reduction in incidence, cervical cancer claims >275,000 lives annually. Previously we demonstrated efficacy and safety of radioimmunotherapy directed at HPV16 E6 oncoprotein in experimental cervical cancer.

MATERIALS & METHODS

We undertook a direct comparison of targeting E7 and E6 oncoproteins with specific (188)Rhenium-labeled monoclonal antibodies in CasKi subcutaneous xenografts of cervical cancer cells in mice.

RESULTS

The most significant tumor inhibition was seen in radioimmunotherapy-treated mice, followed by the unlabeled monoclonal antibodies to E6 and E7. No hematological toxicity was observed. Immunohistochemistry suggests that the effect of unlabeled antibodies is C3 complement mediated.

CONCLUSION

We have demonstrated for the first time that radioimmunotherapy directed toward E7 oncoprotein inhibits experimental tumors growth, decreases E7 expression and may offer a novel approach to cervical cancer therapy.

Principles of analytic validation of immunohistochemical assays: Guideline from the College of American Pathologists Pathology and Laboratory Quality Center

CONTEXT

Laboratories must validate all assays before they can be used to test patient specimens, but currently there are no evidence-based guidelines regarding validation of immunohistochemical assays.

OBJECTIVE

To develop recommendations for initial analytic validation and revalidation of immunohistochemical assays.

DESIGN

The College of American Pathologists Pathology and Laboratory Quality Center convened a panel of pathologists and histotechnologists with expertise in immunohistochemistry to develop validation recommendations. A systematic evidence review was conducted to address key questions. Electronic searches identified 1463 publications, of which 126 met inclusion criteria and were extracted. Individual publications were graded for quality, and the key question findings for strength of evidence. Recommendations were derived from strength of evidence, open comment feedback, and expert panel consensus.

RESULTS

Fourteen guideline statements were established to help pathology laboratories comply with validation and revalidation requirements for immunohistochemical assays.

CONCLUSIONS

Laboratories must document successful analytic validation of all immunohistochemical tests before applying to patient specimens. The parameters for cases included in validation sets, including number, expression levels, fixative and processing methods, should take into account intended use and should be sufficient to ensure that the test accurately measures the analyte of interest in specimens tested in that laboratory. Recommendations are also provided for confirming assay performance when there are changes in test methods, reagents, or equipment.

Abstract LB-89: Germ-line and somatic SMARCA4 mutations characterize small cell carcinoma of the ovary, hypercalcemic type

Small-cell carcinoma of the ovary, hypercalcemic type (SCCOHT) is an aggressive tumor and the most common type of undifferentiated ovarian malignancy presenting at less than 40 years of age. Its cause and histogenesis remain unknown. We sequenced the exomes of individuals from three familial cases of SCCOHT. Subsequently, we used whole exome sequencing, Sanger sequencing and immunohistochemistry to analyze germline and tumor DNA from three additional familial cases, 35 non-familial cases and one SCCOHT cell line (BIN-67). DNA sequencing revealed likely deleterious germ-line mutations in the chromatin remodeling gene SMARCA4 in all four familial cases of SCCOHT where DNA was available. This was accompanied by either a somatic mutation or loss of the wild-type allele in the tumor. BIN-67 contained bi-allelic deleterious mutations in SMARCA4. Sequencing of 24 non-familial pathologically-confirmed SCCOHT cases revealed at least one germ-line or somatic likely deleterious SMARCA4 mutation in 22 cases. Immunohistochemical (IHC) analyses of these and an additional 11 tumors showed loss of BRG1 protein in 38/40 cases. Our findings identify alterations in SMARCA4 as a major cause of SCCOHT, which could pave the way for genetic counseling and new treatment approaches.

Citation Format: Leora Witkowski, Jian Carrot-Zhang, Steffen Albrecht, Nancy Hamel, Eva Tomiak, David Grynspan, Emmanouil Saloustros, Catherine Gilpin, Rachel Silva-Smith, François Plourde, Barbara Rivera, Ester Castellsagué, Mona Wu, Somayyeh Fahiminiya, Javad Nadaf, Avi Saskin, Madeleine Arseneault, Rouzan G. Karabakhtsian, Elizabeth A. Reilly, Frederick R. Ueland, Anna Margiolaki, Kitty Pavlakis, Sharon M. Castellino, Janez Lamovec, Lawrence M. Roth, Thomas M. Ulbright, Tracey Bender, Michel Longy, Andrew Berchuck, Marc Tischkowitz, Reiner Siebert, Inga Nagel, Vassilis Georgoulias, Colin J.r. Stewart, Glenn McCluggage, Jocelyne Arseneau, Blaise A. Clarke, Yasser Riazalhosseini, Martin Hasselblatt, Jacek Majewski, William D. Foulkes. Germ-line and somatic SMARCA4 mutations characterize small cell carcinoma of the ovary, hypercalcemic type. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-89. doi:10.1158/1538-7445.AM2014-LB-89

Pleomorphic lobular carcinoma in situ of the breast: clinicopathological review of 47 cases

AIMS

Pleomorphic lobular carcinoma in situ (PLCIS) of the breast is a distinctive entity, but its behaviour and management are unclear. The purpose of this study was to review a relatively large number of cases and to evaluate the risk of recurrence.

METHODS AND RESULTS

Cases of PLCIS (n = 47) from a 12-year period were reviewed. The clinical, radiological and pathological findings were recorded. Immunohistochemistry for oestrogen receptor (ER), progesterone receptor (PR) and HER2 was performed. Thirty-one patients had no concurrent breast cancer or past history of breast cancer, and six (19.4%) of these had local recurrence; all tumours (four invasive carcinoma and two PLCIS) were ipsilateral. Younger age at presentation was a risk factor for local recurrence: patients with recurrence had a mean age (range) of 52.5 years (44-59 years), versus 60.6 years (40-81 years) for those without (P = 0.03). Three of 31 patients were treated with radiation therapy (RT), and none of these developed local recurrence. PLCIS had an adverse ER/PR/HER2 molecular profile, with at least 41.2% of the cases overexpressing HER2. Moreover, at least 11.7% of the cases were triple-negative.

CONCLUSIONS

This study included the largest number of patients who had no concurrent breast cancer or past history of breast cancer with the longest clinical follow-up, providing insights into management practices for PLCIS and the risk of recurrence.

Low-thiamine diet increases mammary tumor latency in FVB/N-Tg(MMTVneu) mice

We have previously described the down-regulation of thiamine transporter gene expression in breast cancer, and others have shown an epidemiologic relationship between obesity and breast cancer. To further explore the relationship of thiamine, fat, and breast cancer, we exposed FVB/N-Tg(MMTVneu)202Mul/J female mice to four diets that varied in fat and thiamine content (15 mice per group). The high-fat (HF) diet contained 60 % of calories from fat and the normal-fat (NF) diet contained 10 % of calories from fat. The normal-thiamine (NT) diet contained 6 mg thiamine per 4057 kcal and the low-thiamine (LT) diet contained 2 mg thiamine/4057 kcal. Tumor latency was 203 days from date of birth for the HF/NT group, 210 days for the HF/LT group, 225 days for the NF/NT group, and 295 days for the NF/LT group (p = 0.01). The time to endpoint of a mammary tumor volume > 1000 mm3 was 231 days for the HF/NT group, 238 days for the HF/LT group, 257 days for the NF/NT group, and undefined (>310 days) for the NF/LT group (p < 0.001). The high-fat groups were heavier than the normal-fat groups, and the low-thiamine group had a lower serum thiamine level than the normal-thiamine group. There were no differences in the number of pulmonary metastases between groups. This study demonstrates a potential role for dietary thiamine, and an interaction between thiamine and fat, in breast cancer progression.

Small cell carcinoma of the ovary of hypercalcemic type: a case report

The authors report a case of small cell carcinoma of the ovary, hypercalcemic type (SCCOHT), in a mother and daughter and discuss the possibility of a heritable risk. Both mother and daughter were treated at the same institution for SCCOHT. A 23-year-old woman presented with hypercalcemia 4 months after giving birth to her daughter. She was diagnosed as having SCCOHT. Despite surgery, chemotherapy, and radiation, she died of the disease 11 months after diagnosis. Eleven years later, her daughter presented with a histologically and immunophenotypically identical SCCOHT tumor. She received postoperative chemotherapy and radiation but, eventually, relapsed and died of the disease at 27 months after the initial diagnosis. Small cell carcinoma of the ovary, hypercalcemic type, is an uncommon and aggressive malignancy that occurs in young women, which is associated with a solid ovarian tumor and hypercalcemia. Despite aggressive multimodality treatment, most patients die within 2 years of diagnosis. Genetic counseling, sonographic ovarian surveillance and serum calcium monitoring at early age, and even prophylactic oophorectomy should be considered for surviving at-risk family members.

Nuclear protein in testis midline carcinomas: a lethal and underrecognized entity

A 54-year-old woman presented with a nasal mass. Biopsy demonstrated undifferentiated tumor cells with extensive apoptosis and necrosis. Chromosome analysis identified a 46,XX,t(15;19)(q13;p13.1) pattern. Nuclear protein in testis (NUT) immunohistochemistry and fluorescence in situ hybridization confirmed NUT rearrangement. A Ewing sarcoma-based chemotherapy regimen and concurrent irradiation obtained a dramatic response; however, the patient died of her disease less than 7 months after initial diagnosis. NUT midline carcinomas are rare, aggressive tumors defined by rearrangement of the NUT gene on 15q14. A solitary translocation involving 15q14 is usually the sole chromosomal abnormality in these carcinomas. Immunohistochemical expression of NUT in the nuclei of non-germ cell tumors is theoretically diagnostic. More widespread use of a newly available NUT immunohistochemical stain will facilitate the diagnosis of NUT rearranged carcinomas. From the growing numbers of identified cases, effective targeted therapies can be developed.

Disparity between tissue and serum calcitonin and carcinoembryonic antigen in a patient with medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor of parafollicular or C-cells of thyroid that comprises 5-10% of all thyroid cancers [1, 2]. The neoplastic cells secrete calcitonin, carcinoembryonic antigen (CEA), and chromogranin A. Typically, increased serum levels of these tumor markers permit them to be used for initial diagnosis and long-term disease status surveillance. This article reports a case of sporadic MTC (pT2N0M0) in a young patient with normal serum tumor markers. A 16-year-old woman presented with MTC without evidence for this to be a familial case due to the absence of germline mutations in the RET proto-oncogene and negative family history. Surprisingly, there were normal preoperative serum levels of calcitonin, CEA, and chromogranin A, despite the immunohistochemistry showing strong and diffuse positive staining for these markers. This disparity between serum levels and tumor expression of calcitonin and CEA in MTC is quite rare. The relevant features of this case are discussed in consideration of the published experiences. This case may represent an unique subgroup of MTC with abnormal secretory capacity that requires reliance upon radiological evaluation for evidence of recurrent or disseminated disease, without the diagnostic benefit of serum tumor markers.

Should Histologic Grade Be Incorporated into the TNM Classification System for Small (T1, T2) Node-Negative Breast Adenocarcinomas?

Prognosis of invasive ductal carcinoma (IDC) strongly correlates with tumor grade as determined by Nottingham combined histologic grade. While reporting grade as low grade/favorable (G1), intermediate grade/moderately favorable (G2), and high grade/unfavorable (G3) is recommended by American Joint Committee on Cancer (AJCC) staging system, existing TNM (Primary Tumor/Regional Lymph Nodes/Distant Metastasis) classification does not directly incorporate these data. For large tumors (T3, T4), significance of histologic grade may be clinically moot as those are nearly always candidates for adjuvant therapy. However, for small (T1, T2) node-negative (N0) tumors, grade may be clinically relevant in influencing treatment decisions, but data on outcomes are sparse and controversial. This retrospective study analyzes clinical outcome in patients with small N0 IDC on the basis of tumor grade. Our results suggest that the grade does not impact clinical outcome in T1N0 tumors. In T2N0 tumors, however, it might be prognostically significant and relevant in influencing decisions regarding the need for additional adjuvant therapy and optimal management.

WT1 immunoreactivity in breast carcinoma: selective expression in pure and mixed mucinous subtypes

Current literature suggests that strong WT1 expression in a carcinoma of unknown origin virtually excludes a breast primary. Our previous pilot study on WT1 expression in breast carcinomas has shown WT1 expression in approximately 10% of carcinomas that show mixed micropapillary and mucinous morphology (Mod Pathol 2007;20(Suppl 2):38A). To definitively assess as to what subtype of breast carcinoma might express WT1 protein, we examined 153 cases of invasive breast carcinomas. These consisted of 63 consecutive carcinomas (contained 1 mucinous tumor), 20 cases with micropapillary morphology (12 pure and 8 mixed), 6 micropapillary 'mimics' (ductal no special type carcinomas with retraction artifacts), 33 pure mucinous carcinomas and 31 mixed mucinous carcinomas (mucinous mixed with other morphologic types). Overall, WT1 expression was identified in 33 carcinomas, that is, 22 of 34 (65%) pure mucinous carcinomas and in 11 of 33 (33%) mixed mucinous carcinomas. The non-mucinous component in these 11 mixed mucinous carcinomas was either a ductal no special type carcinoma (8 cases) or a micropapillary component (3 cases). WT1 expression level was similar in both the mucinous and the non-mucinous components. The degree of WT1 expression was generally weak to moderate (>90% cases) and rarely strong (<10% cases). None of the breast carcinoma subtype unassociated with mucinous component showed WT1 expression.

The Clinical Significance of Lobular Neoplasia on Breast Core Biopsy

A core biopsy diagnosis of atypical ductal epithelial hyperplasia is upstaged on follow-up excisional biopsy (FUEB) to in situ or invasive carcinoma in about 20% of cases, thus prompting a FUEB. In contrast, upstaging information for a core biopsy diagnosis of pure lobular neoplasia (LN), without mass lesions or other risk-associated lesions is less clear. In this retrospective study, we report the largest consecutive series of patients who had a breast core biopsy diagnosis of LN and a FUEB. Core needle breast biopsies with a diagnosis of LN were retrieved from our files for the period 1999 to 2005, yielding 110 patients. One hundred and one patients had a follow-up surgical excision. Cases of LN with coexisting high-risk lesions (n=9, 10%) were excluded from the study. Patients with associated mass lesions all had benign findings (n=15, 16%) and had no impact on the study results. The remaining 77 core biopsies had no masses or risk lesions and were mammographically Breast Imaging Reporting and Data System 4 (BIRADS) for microcalcifications. Overall, 8/77 (10%) of patients with a radiographic BIRADS 4 image with calcifications and a core biopsy diagnosis of LN on core biopsy were upstaged on FUEB to ductal carcinoma in situ or invasive carcinoma. The numbers upstaged from core biopsies were as follows: atypical lobular hyperplasia (ALH) 4/52 (8%), mixed ALH/lobular carcinoma in situ (LCIS) 1/9 (10%), and pure LCIS 3/16 (19%). A core biopsy of LCIS with neoplastic epithelial calcifications was nearly 3 times more likely to be upstaged on FUEB compared with ALH. We conclude that a finding of LN on breast core biopsy in a patient with a BIRADS 4 image and calcifications is associated with a risk of 8% to 19% of upstaging to a treatable disease on FUEB.

[Urinary catecholamine excretion and blood serotonin content in juvenile hypothalamic syndrome]

Daily urinary adrenalin, noradrenaline, dopamine excretion and blood levels of serotonin were measured over the course of the cycle in 8 healthy girls and in 52 patients with the juvenile hypothalamic syndrome in the acute and chronic stages. These parameters were found virtually the same in healthy girls and in those suffering from the hypothalamic syndrome in the course of the cycle or in patients during the acute and chronic stages of the condition. Urinary catecholamine excretion and blood serotonin levels were increased by 1.5-2 times in the acute stage of the syndrome and somewhat reduced in the chronic stage; this appears to be due to reduced activity of the sympathoadrenal system in the course of disease progress.