Yolk Sac Differentiation in Endometrial Carcinoma: Incidence and Clinicopathologic Features of Somatically Derived Yolk Sac Tumors Versus Carcinomas With Nonspecific Immunoexpression of Yolk Sac Markers

Endometrial somatically derived yolk sac tumors are characterized by yolk sac morphology with AFP, SALL-4, and/or Glypican-3 immunoexpression. Yolk sac marker expression, however, is not limited to tumors with overt yolk sac histology. Three hundred consecutive endometrial malignancies were assessed for immunomarkers of yolk sac differentiation. Of these, 9% expressed ≥1 yolk sac marker, including 29% of high-grade tumors. Only 3 (1%) met morphologic criteria for yolk sac differentiation; these were originally diagnosed as serous, high-grade NOS, and dedifferentiated carcinoma. Two were MMR-intact and comprised exclusively of yolk sac elements, while the dedifferentiated case was MMR deficient and had a background low-grade endometrioid carcinoma; this case also showed BRG1 loss. All 3 were INI1 intact. Nonspecific yolk sac marker expression was seen in 14 carcinosarcomas, 4 endometrioid, 2 serous, 1 clear cell, 1 dedifferentiated, 1 mixed serous/clear cell, and 1 mesonephric-like carcinoma. INI1 was intact in all cases; one showed BRG1 loss. Twenty were MMR-intact, and 4 were MMR deficient. All MMR-deficient cases with yolk sac marker expression, both with and without true yolk sac morphology, had no evidence of residual disease on follow-up, whereas 82% of MMR-intact cases developed recurrent/metastatic disease. In summary, endometrial somatically derived yolk sac tumors were rare but under-recognized. While AFP immunostaining was specific for this diagnosis, Glypican-3 and SALL-4 expression was seen in a variety of other high-grade carcinomas. INI1 loss was not associated with yolk sac morphology or immunomarker expression in the endometrium, and BRG1 loss was rare. All patients with MMR-deficient carcinomas with yolk sac immunoexpression +/- morphology were disease-free on follow-up, whereas the majority of MMR-intact cancers showed aggressive disease.

Patient-derived response estimates from zero-passage organoids of luminal breast cancer

Background

Primary luminal breast cancer cells lose their identity rapidly in standard tissue culture, which is problematic for testing hormone interventions and molecular pathways specific to the luminal subtype. Breast cancer organoids are thought to retain tumor characteristics better, but long-term viability of luminal-subtype cases is a persistent challenge. Our goal was to adapt short-term organoids of luminal breast cancer for parallel testing of genetic and pharmacologic perturbations.

Methods

We freshly isolated patient-derived cells from luminal tumor scrapes, miniaturized the organoid format into 5 μl replicates for increased throughput, and set an endpoint of 14 days to minimize drift. Therapeutic hormone targeting was mimicked in these "zero-passage" organoids by withdrawing β-estradiol and adding 4-hydroxytamoxifen. We also examined sulforaphane as an electrophilic stress and commercial neutraceutical with reported anti-cancer properties. Downstream mechanisms were tested genetically by lentiviral transduction of two complementary sgRNAs and Cas9 stabilization for the first week of organoid culture. Transcriptional changes were measured by RT-qPCR or RNA sequencing, and organoid phenotypes were quantified by serial brightfield imaging, digital image segmentation, and regression modeling of cellular doubling times.

Results

We achieved >50% success in initiating luminal breast cancer organoids from tumor scrapes and maintaining them to the 14-day zero-passage endpoint. Success was mostly independent of clinical parameters, supporting general applicability of the approach. Abundance of ESR1 and PGR in zero-passage organoids consistently remained within the range of patient variability at the endpoint. However, responsiveness to hormone withdrawal and blockade was highly variable among luminal breast cancer cases tested. Combining sulforaphane with knockout of NQO1 (a phase II antioxidant response gene and downstream effector of sulforaphane) also yielded a breadth of organoid growth phenotypes, including growth inhibition with sulforaphane, growth promotion with NQO1 knockout, and growth antagonism when combined.

Conclusions

Zero-passage organoids are a rapid and scalable way to interrogate properties of luminal breast cancer cells from patient-derived material. This includes testing drug mechanisms of action in different clinical cohorts. A future goal is to relate inter-patient variability of zero-passage organoids to long-term outcomes.

A genetic mosaic mouse model illuminates the pre-malignant progression of basal-like breast cancer

Basal-like breast cancer (BLBC) is highly aggressive, and often characterized by BRCA1 and p53 deficiency. Although conventional mouse models enabled the investigation of BLBC at malignant stages, its initiation and pre-malignant progression remain understudied. Here, we leveraged a mouse genetic system known as mosaic analysis with double markers (MADM) to study BLBC initiation by generating rare GFP+Brca1, p53-deficient mammary cells alongside RFP+ wild-type sibling cells. After confirming the close resemblance of mammary tumors arising in this model to human BLBC at both transcriptomic and genomic levels, we focused our studies on the pre-malignant progression of BLBC. Initiated GFP+ mutant cells showed a stepwise pre-malignant progression trajectory from focal expansion to hyper-alveolarization and then to micro-invasion. Furthermore, despite morphological similarities to alveoli, hyper-alveolarized structures actually originate from ductal cells based on twin-spot analysis of GFP-RFP sibling cells. Finally, luminal-to-basal transition occurred exclusively in cells that have progressed to micro-invasive lesions. Our MADM model provides excellent spatiotemporal resolution to illuminate the pre-malignant progression of BLBC, and should enable future studies on early detection and prevention for this cancer.

The POWER-PAK Score Characterizes Tumor Response to 3 Months of Preoperative Endocrine Therapy

BACKGROUND

The Pre-Operative Window of Endocrine Therapy to Inform Radiation Therapy Decisions (POWER, NCT04272801) trial aims to determine whether 3 months of preoperative endocrine therapy (pre-ET) informs adjuvant radiation therapy decisions among older women with early stage, ER-positive breast cancer. We propose the POWER Pathologic Assessment and Ki-67 (POWER-PAK) scoring system to characterize the histologic effects of pre-ET.

METHODS

Histologic evaluation was performed on core biopsy and lumpectomy specimens from 37 POWER trial participants who completed pre-ET and surgery. The POWER-PAK score consists of tumor regression, decrease in Ki-67 expression, and ER expression, each ranging from 0 to 2. Scores were aggregated to create the POWER-PAK score with a range from 0 to 6. Participants with no residual tumor were labelled 6-NRT.

RESULTS

ER expression did not decrease after pre-ET. Ki-67 decreased from 13% in biopsy specimens to 5% in the lumpectomy specimens (p < 0.001). Cellularity decreased from 40% to 23% (p < 0.001). There was heterogeneity of POWER-PAK scores ranging from 2 to 6-NRT: score of 2, n = 2 (5.4%); 4, n = 8 (21.6%); 5, n = 4 (10.8%); 6, n = 16 (43.2%); and 6-NRT, n = 7 (18.9%). Participants with a score ≥ 5 were more likely to have smaller tumors after pre-ET compared with those with a score < 5 (p = 0.04).

CONCLUSIONS

The tumor responses following treatment with pre-ET are heterogenous. We propose that the POWER-PAK scoring system can be used to quantify response to pre-ET. Future studies will explore the use of POWER-PAK to support informed decision-making for adjuvant therapy options for older women with early stage breast cancer.

Dichotomous ovarian cancer-initiating potential of Pax8+ cells revealed by a mouse genetic mosaic model

Different cellular compartments within a tissue present distinct cancer-initiating capacities. Current approaches to dissect such heterogeneity require cell-type-specific genetic tools based on a well-understood lineage hierarchy, which are lacking for many tissues. Here, we circumvented this hurdle and revealed the dichotomous capacity of fallopian tube Pax8+ cells in initiating ovarian cancer, utilizing a mouse genetic system that stochastically generates rare GFP-labeled mutant cells. Through clonal analysis and spatial profiling, we determined that only clones founded by rare, stem/progenitor-like Pax8+ cells can expand on acquiring oncogenic mutations whereas vast majority of clones stall immediately. Furthermore, expanded mutant clones undergo further attrition: many turn quiescent shortly after the initial expansion, whereas others sustain proliferation and manifest a bias toward Pax8+ fate, underlying early pathogenesis. Our study showcases the power of genetic mosaic system-based clonal analysis for revealing cellular heterogeneity of cancer-initiating capacity in tissues with limited prior knowledge of lineage hierarchy.

A genetic mosaic mouse model illuminates the pre-malignant progression of basal-like breast cancer

Basal-like breast cancer is an aggressive breast cancer subtype, often characterized by a deficiency in BRCA1 function and concomitant loss of p53 . While conventional mouse models enable the investigation of its malignant stages, one that reveals its initiation and pre-malignant progression is lacking. Here, we leveraged a mouse genetic system known as M osaic A nalysis with D ouble M arkers (MADM) to generate rare GFP-labeled Brca1 , p53 -deficient cells alongside RFP+ wildtype sibling cells in the mammary gland. The mosaicism resembles the sporadic initiation of human cancer and enables spatially resolved analysis of mutant cells in comparison to paired wildtype sibling cells. Mammary tumors arising in the model show transcriptomic and genomic characteristics similar to human basal-like breast cancer. Analysis of GFP+ mutant cells at interval time points before malignancy revealed a stepwise progression of lesions from focal expansion to hyper-alveolarization and then to micro-invasion. These stereotyped morphologies indicate the pre-malignant stage irrespective of the time point at which it is observed. Paired analysis of GFP-RFP siblings during focal expansion suggested that hyper-alveolarized structures originate from ductal rather than alveolar cells, despite their morphological similarities to alveoli. Evidence for luminal-to-basal transition at the pre-malignant stages was restricted to cells that had escaped hyper-alveoli and progressed to micro-invasive lesions. Our MADM-based mouse model presents a useful tool for studying the pre-malignancy of basal-like breast cancer.

Summary statement

A mouse model recapitulates the process of human basal-like breast tumorigenesis initiated from sporadic Brca1, p53 -deficient cells, empowering spatially-resolved analysis of mutant cells during pre-malignant progression.

Breast Cancer Antiestrogen Resistance 3 (BCAR3) promotes tumor growth and progression in triple-negative breast cancer

Triple-Negative Breast Cancers (TNBCs) constitute roughly 10-20% of breast cancers and are associated with poor clinical outcomes. Previous work from our laboratory and others has determined that the cytoplasmic adaptor protein Breast Cancer Antiestrogen Resistance 3 (BCAR3) is an important promoter of cell motility and invasion of breast cancer cells. In this study, we use both in vivo and in vitro approaches to extend our understanding of BCAR3 function in TNBC. We show that BCAR3 is upregulated in ductal carcinoma in situ (DCIS) and invasive carcinomas compared to normal mammary tissue, and that survival of TNBC patients whose tumors contained elevated BCAR3 mRNA is reduced relative to individuals whose tumors had less BCAR3 mRNA. Using mouse orthotopic tumor models, we further show that BCAR3 is required for efficient TNBC tumor growth. Analysis of publicly available RNA expression databases revealed that MET receptor signaling is strongly correlated with BCAR3 mRNA expression. A functional role for BCAR3-MET coupling is supported by data showing that both proteins participate in a single pathway to control proliferation and migration of TNBC cells. Interestingly, the mechanism through which this functional interaction operates appears to differ in different genetic backgrounds of TNBC, stemming in one case from potential differences in the strength of downstream signaling by the MET receptor and in another from BCAR3-dependent activation of an autocrine loop involving the production of HGF mRNA. Together, these data open the possibility for new approaches to personalized therapy for individuals with TNBCs.

Pan-Cancer Drivers Are Recurrent Transcriptional Regulatory Heterogeneities in Early-Stage Luminal Breast Cancer

The heterogeneous composition of solid tumors is known to impact disease progression and response to therapy. Malignant cells coexist in different regulatory states that can be accessed transcriptomically by single-cell RNA sequencing, but these methods have many caveats related to sensitivity, noise, and sample handling. We revised a statistical fluctuation analysis called stochastic profiling to combine with 10-cell RNA sequencing, which was designed for laser-capture microdissection (LCM) and extended here for immuno-LCM. When applied to a cohort of late-onset, early-stage luminal breast cancers, the integrated approach identified thousands of candidate regulatory heterogeneities. Intersecting the candidates from different tumors yielded a relatively stable set of 710 recurrent heterogeneously expressed genes (RHEG), which were significantly variable in >50% of patients. RHEGs were not strongly confounded by dissociation artifacts, cell-cycle oscillations, or driving mutations for breast cancer. Rather, RHEGs were enriched for epithelial-to-mesenchymal transition genes and, unexpectedly, the latest pan-cancer assembly of driver genes across cancer types other than breast. These findings indicate that heterogeneous transcriptional regulation conceivably provides a faster, reversible mechanism for malignant cells to evaluate the effects of potential oncogenes or tumor suppressors on cancer hallmarks. SIGNIFICANCE: Profiling intratumor heterogeneity of luminal breast carcinoma cells identifies a recurrent set of genes, suggesting sporadic activation of pathways known to drive other types of cancer.See related articles by Schaff and colleagues, p. 1853 and Sutcliffe and colleagues, p. 1868.

Sporadic activation of an oxidative stress-dependent NRF2-p53 signaling network in breast epithelial spheroids and premalignancies

Breast and mammary epithelial cells experience different local environments during tissue development and tumorigenesis. Microenvironmental heterogeneity gives rise to distinct cell regulatory states whose identity and importance are just beginning to be appreciated. Cellular states diversify when clonal three-dimensional (3D) spheroids are cultured in basement membrane, and one such state is associated with stress tolerance and poor response to anticancer therapeutics. Here, we found that this state was jointly coordinated by the NRF2 and p53 pathways, which were costabilized by spontaneous oxidative stress within 3D cultures. Inhibition of NRF2 or p53 individually disrupted some of the transcripts defining the regulatory state but did not yield a notable phenotype in nontransformed breast epithelial cells. In contrast, combined perturbation prevented 3D growth in an oxidative stress-dependent manner. By integrating systems models of NRF2 and p53 signaling in a single oxidative stress network, we recapitulated these observations and made predictions about oxidative stress profiles during 3D growth. NRF2 and p53 signaling were similarly coordinated in normal breast epithelial tissue and hormone-negative ductal carcinoma in situ lesions but were uncoupled in triple-negative breast cancer (TNBC), a subtype in which p53 is usually mutated. Using the integrated model, we correlated the extent of this uncoupling in TNBC cell lines with the importance of NRF2 in the 3D growth of these cell lines and their predicted handling of oxidative stress. Our results point to an oxidative stress tolerance network that is important for single cells during glandular development and the early stages of breast cancer.

Effect of a tissue selective estrogen complex on breast cancer: Role of unique properties of conjugated equine estrogen

The Women's Health Initiative studies reported that the menopausal hormone therapy (MHT) regimen containing conjugated equine estrogen (CEE) and medroxyprogesterone acetate increased, whereas CEE alone reduced breast cancer incidence. These observations suggest the possibility that CEE might exert unique actions on breast and also suggest the need to eliminate the progestogen from MHT regimens. A MHT regimen called a tissue selective estrogen complex (TSEC), containing CEE plus bazedoxifene (BZA), to avoid the need for a progestogen, was developed and FDA approved. Our study addressed two questions regarding this TSEC: (i) whether CEE exert effects on breast cancer which differ from those of estradiol (E₂ ) and (ii) whether BZA antagonize the effects of E₂ and CEE on breast cancer? Two rodent models (NMU and ACI) were used to compare the effect of CEE with E₂ on mammary tumor formation, proliferation and apoptosis. In both the NMU and ACI models, E₂ significantly increased tumor incidence and multiplicity whereas in striking contrast CEE did not, even though the estrogenic effects of CEE and E₂ on uterine weight were identical. Mechanistically E₂ blocked whereas CEE stimulated apoptosis (cleaved caspase-3) in ACI animals and only E₂ stimulated proliferation (Ki67). BZA exerted highly potent anti-estrogenic effects on tumors by completely blocking palpable tumor formation. These data suggest that the CEE/BZA TSEC may be a safer, breast-antagonistic, MHT agent for women and might have potential to prevent breast cancer while relieving menopausal symptoms.

Tumor-Suppressor Inactivation of GDF11 Occurs by Precursor Sequestration in Triple-Negative Breast Cancer

Triple-negative breast cancer (TNBC) is an aggressive and heterogeneous carcinoma in which various tumor-suppressor genes are lost by mutation, deletion, or silencing. Here we report a tumor-suppressive mode of action for growth-differentiation factor 11 (GDF11) and an unusual mechanism of its inactivation in TNBC. GDF11 promotes an epithelial, anti-invasive phenotype in 3D triple-negative cultures and intraductal xenografts by sustaining expression of E-cadherin and inhibitor of differentiation 2 (ID2). Surprisingly, clinical TNBCs retain the GDF11 locus and expression of the protein itself. GDF11 bioactivity is instead lost because of deficiencies in its convertase, proprotein convertase subtilisin/kexin type 5 (PCSK5), causing inactive GDF11 precursor to accumulate intracellularly. PCSK5 reconstitution mobilizes the latent TNBC reservoir of GDF11 in vitro and suppresses triple-negative mammary cancer metastasis to the lung of syngeneic hosts. Intracellular GDF11 retention adds to the concept of tumor-suppressor inactivation and reveals a cell-biological vulnerability for TNBCs lacking therapeutically actionable mutations.

Mesothelium expression of vascular cell adhesion molecule-1 (VCAM-1) is associated with an unfavorable prognosis in epithelial ovarian cancer (EOC)

BACKGROUND

Mesothelium vascular cell adhesion molecule-1 (VCAM-1) expression in the metastatic epithelial ovarian cancer (EOC) microenvironment is induced by tumor and mediates tumor cell invasion. VCAM-1 imaging suggests expression during treatment is an indicator of platinum resistance. Here, we assess the potential prognostic significance of mesothelium VCAM-1 expression and prospectively evaluate whether soluble VCAM-1 (sVCAM-1) is a surrogate for mesothelium expression.

METHODS

A retrospective review of EOC patients was performed to evaluate outcomes with mesothelium VCAM-1 expression determined by immunohistochemistry of peritoneum or omentum specimens. A prospective cohort of EOC patients was identified and followed through primary treatment. Serum for sVCAM-1 evaluation, which was performed via enzyme-linked immunosorbent assay, was collected before surgery or neoadjuvant chemotherapy and at each treatment cycle. Peritoneal specimens were obtained during debulking to assess mesothelial VCAM-1 expression.

RESULTS

A retrospective review identified 54 advanced-stage EOC patients. Patients expressing mesothelium VCAM-1 had shortened overall survival (44 vs 79 months, P = 0.035) and progression-free survival (18 vs 67 months, P = 0.010); the median time to platinum resistance was 36 months for VCAM-1-expressing patients and not yet determined for the VCAM-1-negative group. In our prospective observational cohort, 18 EOC patients completed primary treatment; 3 were negative for mesothelium VCAM-1 expression, and sVCAM-1 did not vary between groups.

CONCLUSIONS

Mesothelium VCAM-1 expression is negatively associated with progression-free and overall survival in EOC. This is especially compelling in light of previous data suggesting that persistent VCAM-1 expression during treatment is an indicator of platinum resistance. Our pilot study had insufficient cases to determine whether sVCAM-1 would substitute for mesothelium expression. Cancer 2017;123:977-84. © 2016 American Cancer Society.

Fine Needle Aspiration Cytology of Diffuse-Type Tenosynovial Giant Cell Tumors

BACKGROUND

Tenosynovial giant cell tumor (TSGCT), also known as giant cell tumor of tendon sheath or pigmented villonodular synovitis, is the most common benign tumor of the tendon and synovium. The intra-articular diffuse type can present as a large infiltrative mass involving adjacent soft tissue and sometimes causes secondary destruction of bone, which leads to radiographic and clinical concern for malignancy. The tumor may also be purely extra-articular.

CASE

Here, we report the fine needle aspiration cytology findings of 2 cases of diffuse-type TSGCT with large mononuclear cells with eccentric nuclei, finely granular cytoplasm, and a peripheral well-defined cytoplasmic rim of hemosiderin ("ladybird cells").

CONCLUSION

Although the presence of ladybird cells has been described in tissue sections of TSGCT, their identification in cytological specimens has not been reported to our knowledge. When observed, their presence may aid in differentiating TSGCT from other lesions with multinucleated osteoclast-type giant cells occurring at or near joints.

Abstract P2-04-04: Association of mammographic density and molecular breast cancer subtype

Background: While mammographic density is linked to increased breast cancer risk, limited yet conflicting data exists on an association between density and developing specific molecular subtypes of breast cancer.

Methods: Eligible patients were enrolled in a larger study on breast density, diagnosed with cancer between 2003-2013, and had pathology and films available for review. Density was classified qualitatively from existing radiology reports according to Breast Imaging Reporting and Data System (BIRADS) classification and quantitatively by volumetric breast density measurements using Volpara SolutionsTM software. Subtype was assigned by hormone receptor status, tumor grade and mitotic score (MS). Subtype categories included: Luminal A (ER/PR + & grade 1; ER/PR + & grade 2 & MS=1; ER+/PR- & grade 1); Luminal B (ER+ & grade 3 or MS=3; ER+/PR- & grade 2; ER/PR + & grade 2 & MS=2); Her-2 + (ER+ or ER - & Her-2 +); Triple Negative (ER/PR-, Her-2 -). Relevant pre-cancer factors including patient age, race, BMI, family history of breast cancer, and biopsy showing LCIS were included in analysis.

Results: Of 604 patients with invasive cancer, 457 had sufficient information for analysis. Among these, 233 (51%) had Luminal A, 79 (17%) Luminal B, 59 (13%) Her-2 +, and 86 (19%) Triple Negative tumors. Younger women and those with denser breasts based on quantitative measurements were more likely to have Her-2+ tumors (Table 1); this association was not seen using the standard BIRADS classification. Triple Negative tumors were less common in patients with LCIS and more common in African Americans. A multinomial logistic regression model controlling for pre-cancer patient factors demonstrated that while quantitative breast density does not significantly differentiate between all molecular subtypes (p=0.140), the association between Her-2+ tumors and denser breasts using continuous quantitative measurements is significant (p=0.035).

Conclusion: Women with denser breasts by continuous-scaled quantitative measurements are at higher risk for Her-2+ tumors; an association not delineated using standard BIRADS density classification. Delineating risk factors specific to molecular breast cancer subtype may promote individualized risk prediction models and prevention strategies.

Table 1. Association between patient factors and molecular breast cancer subtype Molecular SubtypeVariableLuminal ALuminal BHer-2+Triple NegativeP value (n=233)(n=79)(n=59)(n=86) Age (median,IQR)61 (54,70)58 (50,67)54 (46,70)59 (48,67)0.006BMI (median,IQR)27.1 (22.9,30.5)25.7 (23.0,30.0)26.0 (22.7,32.6)28.1 (24.3,32.6)0.173Volpara density (median,IQR)7.18 (4.74,11.25)8.68 (5.68,14.34)10.25 (5.96,16.51)7.00 (4.97,11.89)0.002BIRADS density (n,%)0.183 Fatty42 (18.0%)15 (19.0%)5 (8.5%)16 (18.6%)  Scattered103 (44.2%)27 (34.2%)20 (33.9%)36 (41.9%)  Heterogeneous74 (31.8%)30 (38.0%)25 (42.4%)26 *30.2%)  Extreme14 (6.0%)6 (7.6%)9 (15.2%)7 (8.1%)  Unspecified01 (1.2%)01 (1.2%) Race (n,%)0.002 Caucasian202 (86.7%)65 (82.3%)51 (86.4%)61 (70.9%)  African American23 (9.9%)13 (16.5%)6 (10.2%)23 (26.7%)  Other2 (0.9%)02 (3.4%)0  Unspecified6 (2.6%)1 (1.2%)02 (2.3%) LCIS (n,%)48 (20.6%)8 (10.1%)8 (13.6%)5 (5.8%)0.004Family history of breast cancer (n,%)107 (45.9%)34 (43.0%)21 (35.6%)39 (45.35%)0.625

Citation Format: Brandy L Edwards, Kristen A Atkins, George J Stukenborg, Wendy M Novicoff, Krista N Larson, Wendy F Cohn, Jennifer A Harvey, Anneke T Schroen. Association of mammographic density and molecular breast cancer subtype [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-04-04.

Metabolic vulnerabilities in endometrial cancer

Women with metabolic disorders, including obesity and diabetes, have an increased risk of developing endometrial cancer. However, the metabolism of endometrial tumors themselves has been largely understudied. Comparing human endometrial tumors and cells with their nonmalignant counterparts, we found that upregulation of the glucose transporter GLUT6 was more closely associated with the cancer phenotype than other hallmark cancer genes, including hexokinase 2 and pyruvate kinase M2. Importantly, suppression of GLUT6 expression inhibited glycolysis and survival of endometrial cancer cells. Glycolysis and lipogenesis were also highly coupled with the cancer phenotype in patient samples and cells. To test whether targeting endometrial cancer metabolism could be exploited as a therapeutic strategy, we screened a panel of compounds known to target diverse metabolic pathways in endometrial cells. We identified that the glycolytic inhibitor, 3-bromopyruvate, is a powerful antagonist of lipogenesis through pyruvylation of CoA. We also provide evidence that 3-bromopyruvate promotes cell death via a necrotic mechanism that does not involve reactive oxygen species and that 3-bromopyruvate impaired the growth of endometrial cancer xenografts.

From slide sets to sound bites: teaching and learning pathology in the digital age

Educational evolution is particularly important in pathology, particularly cytopathology, due to the vast amounts of independent learning required to master this field. In this study, learning challenges faced by pathology residents were addressed through a variety of educational modalities including 24 short (∼10 minute) online tutorials (dubbed "Sound Bites") covering selected topics in cytopathology as well as other areas of anatomic and clinical pathology. Additionally, residents were provided with an annotated glass slide set covering pediatric pathology with an associated multiple choice self-assessment as well as multiheaded microscope slide review sessions. Use of these modalities was tracked and residents surveyed about their experiences using them. All 20 residents (100%) reported using Sound Bites either from work computers, home computers, or mobile devices. Residents reported that easy accessibility, brevity, and opportunities for self-assessment were important variables contributing to this use, and that Sound Bite use would make them more likely to benefit from in-person teaching through lectures and/or slide sessions. Within 12 months of the release of the first Sound Bite, individual Sound Bites were accessed a total of 1169 times (mean: 49 times per Sound Bite). In contrast, slide sets were only accessed about once a month and were only employed by 30% of residents (6 of 20) for independent study; only 20% (4 of 20) completed the accompanying multiple choice self-assessment. All residents attended multiheaded microscope slide review sessions. Whereas traditional educational methods remain valuable tools in pathology education, these data suggest that short, web-based tutorials represent a valuable adjuvant teaching tool.

A time- and matrix-dependent TGFBR3-JUND-KRT5 regulatory circuit in single breast epithelial cells and basal-like premalignancies

Basal-like breast carcinoma is characterized by poor prognosis and high intratumour heterogeneity. In an immortalized basal-like breast epithelial cell line, we identified two anticorrelated gene-expression programs that arise among single extracellular matrix (ECM)-attached cells during organotypic three-dimensional culture. The first contains multiple TGF-β-related genes including TGFBR3, whereas the second contains JUND and the basal-like marker KRT5. TGFBR3 and JUND interconnect through four negative-feedback loops to form a circuit that exhibits spontaneous damped oscillations in three-dimensional culture. The TGFBR3-JUND circuit is conserved in some premalignant lesions that heterogeneously express KRT5. The circuit depends on ECM engagement, as detachment causes a rewiring that is triggered by RPS6 dephosphorylation and maintained by juxtacrine tenascin C, which is critical for intraductal colonization of basal-like breast cancer cells in vivo. Intratumour heterogeneity need not stem from partial differentiation and could instead reflect dynamic toggling of cells between expression states that are not cell autonomous.

Evaluation of cytopathology fellow performance for rapid on-site evaluations of fine-needle aspirates over a 6-year period

INTRODUCTION

Rapid on-site evaluation (ROSE) of fine-needle aspirates is an invaluable teaching tool for a cytopathology (CyP) fellowship. The ability of fellows to accurately perform ROSEs without direct attending supervision is not well documented in the literature. This study reviewed ROSEs performed independently by CyP fellows and focused on diagnostic discrepancies with managerial implications.

MATERIAL AND METHODS

All fine-needle aspirates with ROSE documentation performed at the University of Virginia from October 1, 2007 to March 31, 2013 were reviewed and compared with the final diagnosis. Cases were only included if a CyP fellow performed the ROSE. Discrepancy between ROSE and final diagnosis was categorized according to the change. Numbers of false positive (FP) and false negative diagnoses, organ site, and recurrent interpretative pitfalls were noted.

RESULTS

CyP fellows performed 6815 ROSEs in 6 years. An attending cytopathologist was present 8% of the time. Of ROSEs without direct attending supervision (6224 fine-needle aspirates), the preliminary and final diagnoses were identical in 95% of cases. FP rate was 1.06%. The most frequent categorical change occurred from ROSE of "atypical" to final diagnosis of "malignant." The most common sites involved in FP diagnoses were pancreas/biliary tract, lung, and lymph node. Experience gained over the fellowship year did not significantly affect the FP rate. Errors encountered are known interpretative challenges.

CONCLUSIONS

This is the largest study addressing discrepancies between ROSE and final diagnosis and the first study examining CyP fellow performance. Our results affirm that fellows perform extremely well when performing ROSEs independently.

Interactive case review of radiologic and pathologic findings from breast biopsy: are they concordant? How do I manage the results?

The number of imaging-guided percutaneous breast biopsies performed has steadily increased as imaging techniques have improved. Percutaneous biopsy is becoming more commonplace and supplanting excisional biopsy as the preferred diagnostic tool. The radiologist's role in caring for patients who undergo breast biopsy extends beyond imaging to identifying lesions for biopsy and then performing the procedure. Radiologists must also be cognizant of radiologic-pathologic correlation to determine whether biopsy results are concordant with imaging findings and make management recommendations. Management of microcalcifications, masses, and areas of asymmetry begins with recognizing and characterizing the findings with the proper Breast Imaging Reporting and Data System (BI-RADS) lexicon. Determining concordance between imaging findings and histologic results is equally important. The decision to recommend surgical excision or short-term follow-up relies heavily on whether the histologic diagnosis correlates with the imaging findings, a determination that is part of the radiologist's responsibilities if he or she performs the biopsy. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.334125123/-/DC1.

Inhibition of α4β1 integrin increases ovarian cancer response to carboplatin

OBJECTIVE

The inability to successfully treat women with ovarian cancer is due to the presence of metastatic disease at diagnosis and the development of platinum resistance. Ovarian cancer metastasizes throughout the peritoneal cavity by attaching to and invading through the mesothelium lining the peritoneum using a mechanism that involves α4β1 integrin and its ligand (vascular cell adhesion molecule) VCAM-1. Integrin α4β1 expression on tumor cells is known to confer protection from therapy in other cancers, notably multiple myeloma. We evaluated the role of α4β1 integrin in response to platinum-based therapy in a mouse model of peritoneal ovarian cancer metastasis by treatment with a humanized anti-α4β1 integrin function-blocking antibody.

METHODS

Integrin α4β1 expression on primary human ovarian cancer cells, fallopian tube and ovarian surface epithelia and fresh tumor was assessed by flow-cytometry. The therapeutic impact of anti-α4β1 treatment was assessed in murine models of platinum-resistant peritoneal disease and in vitro using the platinum resistant ovarian cancer cell lines.

RESULTS

Treatment of tumor-bearing mice with human-specific α4β1 integrin function-blocking antibodies, anti-VCAM-1 antibody or carboplatin alone had no effect on tumor burden compared to the IgG control group. However, the combined treatment of anti-α4β1 integrin or anti-VCAM-1 with carboplatin significantly reduced tumor burden. In vitro, the combination of carboplatin and anti-α4β1 integrin antibodies resulted in increased cell death and doubling time.

CONCLUSIONS

Our findings support a role for α4β1 integrin in regulating treatment response to carboplatin, implicating α4β1 integrin as a potential therapeutic target to influence platinum responsiveness in otherwise resistant disease.

Leiomyoma presenting as a massive calcified circumferential esophageal mass

Esophageal leiomyoma is the most common benign esophageal neoplasm and often presents as an incidental finding or with nonspecific symptoms such as dysphagia or chest pain. Surgical enucleation is the mainstay of treatment and may be accomplished using both open and thoracoscopic approaches. We present a case of a 57-year-old man who presented with a massive circumferential calcified leiomyoma.

Atypical lobular hyperplasia and lobular carcinoma in situ at core breast biopsy: use of careful radiologic-pathologic correlation to recommend excision or observation

PURPOSE

To assess the utility of precise radiologic and pathologic correlation for establishing imaging-histologic concordance or discordance as a method to limit the number of patients requiring surgical excision when atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) is diagnosed at core biopsy.

MATERIALS AND METHODS

This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The pathology database was searched from 2000 to 2010 for core biopsies yielding ALH or LCIS devoid of any additional lesion that independently necessitated excision. All cases had to have either subsequent surgical excision or a minimum of 2 years of imaging follow-up. This yielded 50 cases from 49 women aged 40-73 years (mean age, 59 years). The authors performed detailed radiologic-pathologic analysis while blinded to subsequent follow-up information, comparing all biopsy-related images with the histologic findings at core biopsy and then designating each core biopsy finding as concordant or discordant. Then, results of subsequent surgery or extended follow-up for each case were unblinded and compared with original concordant or discordant designations. Outcomes and confidence intervals (CIs) were calculated.

RESULTS

Of the 43 benign concordant core biopsy findings, none were upgraded at surgery (n = 38) or extended follow-up (n = 5) (95% CI: 0%, 8%). Of the seven discordant biopsy findings, two were upgraded to ductal carcinoma in situ at surgery (n = 5); none of the cases were upgraded at follow-up (n = 2).

CONCLUSION

When careful radiologic-pathologic correlation is performed and concordance is achieved, women with ALH or LCIS at core biopsy can be observed.

Abstract A62: Imaging the tumor micro-environment to monitor ovarian cancer metastasis

The inability to successfully treat women with ovarian cancer is due in large part to the advanced stage of disease at diagnosis, the development of platinum resistance, and the lack of sensitive methods to monitor tumor progression and response to treatment. Vascular cell adhesion molecule-1 (VCAM-1) is expressed on the mesothelium of ovarian cancer patients. We investigated VCAM-1 expression as a marker of peritoneal metastasis and tumor response to platinum-based chemotherapy. Immunohistochemical staining of peritoneal or omental biopsies obtained from women diagnosed with Stage I, Stage II or Stage III/IV ovarian cancer demonstrated that VCAM-1 expression correlated with tumor stage. All specimens from Stage I patients were negative, while 29% of Stage II patients and the 73% of Stage III/IV patients were positive. While the majority of women with advanced stage disease expressed VCAM-1, the incidence of expression was reduced among women who received neoadjuvant chemotherapy, suggesting a role for chemotherapy in regulating VCAM-1 expression. The effects of carboplatin on mesothelial VCAM-1 expression were determined in a mouse model of ovarian cancer peritoneal metastasis using radiolabeled VCAM-1-specific peptide imaging probes and single photon emission computed tomography (SPECT). This approach showed that 1) VCAM-1 is a viable imaging target in ovarian cancer metastasis, 2) maximal expression was detected with microscopic tumor burden, and 3) VCAM-1 expression reflected the effect of platinum-based treatment on tumor burden. Specifically, carboplatin treatment of mice with platinum-sensitive tumors showed reduced VCAM-1 expression, which correlated with reduced tumor burden; mice with platinum-resistant tumors retained elevated VCAM-1 expression and tumor burden following treatment. These observations support testing the utility of VCAM-1 imaging probes to monitor treatment response in ovarian cancer patients, thus providing the potential to improve management of women with this disease.

Citation Format: Jill K. Slack-Davis, Jennifer M. Scalici, Stephanie Thomas, Christine Harrer, Timothy A. Raines, Joanna Curran, Kristen A. Atkins, Mark R. Conaway, Linda Duska, Kimberly A. Kelly. Imaging the tumor micro-environment to monitor ovarian cancer metastasis. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research: From Concept to Clinic; Sep 18-21, 2013; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2013;19(19 Suppl):Abstract nr A62.

Imaging VCAM-1 as an indicator of treatment efficacy in metastatic ovarian cancer

The inability to successfully treat women with ovarian cancer is due in large part to the advanced stage of disease at diagnosis, the development of platinum resistance, and the lack of sensitive methods to monitor tumor progression and response to treatment. Vascular cell adhesion molecule-1 (VCAM-1) is expressed on the mesothelium of ovarian cancer patients. We investigated VCAM-1 expression as a marker of peritoneal metastasis and tumor response to platinum-based chemotherapy.

METHODS

Peritoneal or omental biopsies obtained from women diagnosed with stage I, stage II, or stage III/IV ovarian cancer were evaluated by immunohistochemistry. The effects of carboplatin on mesothelial VCAM-1 expression were determined in cultured cells by Western blot. Radiolabeled VCAM-1-specific peptide imaging probes and SPECT were used in a mouse model of ovarian cancer peritoneal metastasis to identify VCAM-1 as a viable imaging target.

RESULTS

VCAM-1 expression correlated with tumor stage. All specimens from stage I patients were negative, whereas 29% of stage II patients and 73% of stage III/IV patients were positive. Although most women with advanced stage disease expressed VCAM-1, the incidence of expression was reduced among women who received neoadjuvant chemotherapy, suggesting a role for chemotherapy in regulating VCAM-1 expression. Treatment of mesothelial cells in culture with carboplatin resulted in a transient decrease in VCAM-1 expression 4 h after treatment that returned to baseline within 16-24 h. In vivo imaging of VCAM-1 also demonstrated an acute decrease in expression 4 h after carboplatin administration that recovered within 48 h in mice harboring platinum-resistant tumors. Chronic VCAM-1 expression reflected the effect of platinum-based treatment on tumor burden. Specifically, carboplatin treatment of mice with platinum-sensitive tumors showed reduced VCAM-1 expression, which correlated with reduced tumor burden; mice with platinum-resistant tumors retained elevated VCAM-1 expression and tumor burden after treatment.

CONCLUSION

Clinically relevant VCAM-1-specific imaging probes identify VCAM-1 expression as an indicator of ovarian cancer peritoneal metastasis and therapeutic response to platinum-based agents. These observations support testing the utility of VCAM-1 imaging probes to monitor treatment response in ovarian cancer patients, thus providing the potential to improve management of women with this disease.

Atypical lobular hyperplasia and lobular carcinoma in situ at core breast biopsy: use of careful radiologic-pathologic correlation to recommend excision or observation

PURPOSE

To assess the utility of precise radiologic and pathologic correlation for establishing imaging-histologic concordance or discordance as a method to limit the number of patients requiring surgical excision when atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) is diagnosed at core biopsy.

MATERIALS AND METHODS

This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The pathology database was searched from 2000 to 2010 for core biopsies yielding ALH or LCIS devoid of any additional lesion that independently necessitated excision. All cases had to have either subsequent surgical excision or a minimum of 2 years of imaging follow-up. This yielded 50 cases from 49 women aged 40-73 years (mean age, 59 years). The authors performed detailed radiologic-pathologic analysis while blinded to subsequent follow-up information, comparing all biopsy-related images with the histologic findings at core biopsy and then designating each core biopsy finding as concordant or discordant. Then, results of subsequent surgery or extended follow-up for each case were unblinded and compared with original concordant or discordant designations. Outcomes and confidence intervals (CIs) were calculated.

RESULTS

Of the 43 benign concordant core biopsy findings, none were upgraded at surgery (n = 38) or extended follow-up (n = 5) (95% CI: 0%, 8%). Of the seven discordant biopsy findings, two were upgraded to ductal carcinoma in situ at surgery (n = 5); none of the cases were upgraded at follow-up (n = 2).

CONCLUSION

When careful radiologic-pathologic correlation is performed and concordance is achieved, women with ALH or LCIS at core biopsy can be observed.

Abstract 5225: Single-cell gene-expression programs and basal-like breast cancer

Basal-like carcinoma is a subtype of breast cancer that is characterized by poor prognosis and high intratumor heterogeneity. In basal-like breast epithelia, we have identified two anticorrelated gene-expression programs that arise among single extracellular matrix (ECM)-attached cells during organotypic 3D culture. The first program contains multiple TGFβ-related genes including TGFBR3, and its heterogeneous induction is critical to suppress ductal branching. The second program contains JUND together with the basal-like marker, KRT5. Homogenizing JUND expression in single cells leads to 3D acini with bridged lumina that are similar to cribiform ductal carcinoma in situ. TGFBR3 and JUND together comprise a circuit that is interconnected via four negative-feedback loops. Computational modeling of the circuit predicts damped, antiphase oscillations upon stimulation with endogenous impulses of TGFβ-like ligand, and we directly observe these spontaneous responses in 3D culture by live-cell imaging. The TGFBR3-JUND circuit is remarkably conserved in early basal-like tumors that heterogeneously express KRT5, suggesting that asynchronous circuit dynamics are active in this patient subset. We further show that the circuit is strongly dependent on ECM engagement, as detachment leads to a rewiring that is triggered by RPS6 dephosphorylation and maintained by juxtacrine signaling from tenascin C. Breast tumor heterogeneity need not stem from partial basal-like differentiation and could instead reflect dynamic toggling of individual cells between expression states.

Citation Format: Chun-Chao Wang, Leen Jamal, Sameer S. Bajikar, Kristen A. Atkins, Kevin A. Janes. Single-cell gene-expression programs and basal-like breast cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 5225. doi:10.1158/1538-7445.AM2013-5225

Assessing endometrial hyperplasia and carcinoma treated with progestin therapy

The effects of increased amounts of progesterone on the endometrium, including such features as eosinophilic cytoplasmic metaplasia, glandular atrophy, and decidualized stroma, are well-known among surgical pathologists. These changes are typically seen as secondary effects of pregnancy or exogenous hormone therapy for birth control purposes or abnormal bleeding. Treatment with progesterone has become a viable alternative to hysterectomy in some patients with complex atypical hyperplasia (CAH) and well-differentiated endometrial carcinoma (WDC), especially those who are poor surgical candidates or those wishing to preserve fertility. To date, only 1 study has specifically examined the effects of progestin therapy on patients with a previous diagnosis of CAH or WDC. That study proposed a classification scheme for the assessment of treated CAH and WDC. The authors concluded that after 6 months of treatment, endometrial biopsy findings of persistent cytologic atypia and architectural abnormalities were associated with treatment failure. This current study aims to assess the previously proposed criteria in a cohort of 30 patients (18 with a diagnosis of CAH and 12 with a diagnosis of WDC), and determine the usefulness of these criteria in clinical practice. Our study confirms that cytologic atypia after 6 months of therapy is strongly associated with treatment failure, and should be an indication to pursue definitive surgical treatment in these patients.

Abstract 4949: A dynamic TGFBR3-JUND expression circuit in single basal-like breast epithelial cells

Basal-like carcinoma is a subtype of breast cancer that is characterized by poor prognosis and high intratumor heterogeneity. In basal-like breast epithelia, we have identified two anticorrelated gene-expression programs that arise among single extracellular matrix (ECM)-attached cells during organotypic 3D culture. The first program contains multiple TGFβ-related genes including TGFBR3, and its heterogeneous induction is critical to suppress ductal branching. The second program contains JUND together with the basal-like marker, KRT5. Homogenizing JUND expression in single cells leads to 3D acini with bridged lumina that are similar to cribiform ductal carcinoma in situ. TGFBR3 and JUND together comprise a circuit that is interconnected via four negative-feedback loops. Computational modeling of the circuit predicts damped, antiphase oscillations upon stimulation with endogenous impulses of TGFβ-like ligand, and we directly observe these spontaneous responses in 3D culture by live-cell imaging. The TGFBR3-JUND circuit and its ECM-dependent regulation are remarkably conserved in early basal-like tumors that heterogeneously express KRT5, suggesting that asynchronous circuit dynamics are active in this patient subset. Preliminary studies suggested this intrinsic single-cell expression circuit might be regulated by a transcription factor, Nrf2, and a tumor suppressor, menin. Together, breast tumor heterogeneity need not stem from partial basal-like differentiation and could instead reflect dynamic toggling of individual cells between expression states.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4949. doi:1538-7445.AM2012-4949

Abstract 4922: A single-cell TGFbetaR-JUND dichotomy and its role in basal-like breast cancer

Basal-like carcinoma is a subtype of breast cancer with poor prognosis that is characterized by pronounced cell-to-cell non-uniformities. Intratumor heterogeneity could involve sporadic single-cell activation of key pathways implicated in cancer progression, but it has not been possible to identify such pathways in an unbiased way. Our lab has developed a new approach for globally identifying coregulated, heterogeneously expressed genes among single cells (Nat Methods 7:311 [2010]). In a 3D in vitro culture model of a basal-like breast epithelial cell line (MCF10A), we stochastically profiled 4557 transcripts for heterogeneity and identified 547 that were predicted to be strongly dichotomous among extracellular matrix (ECM)-attached cells in the developing acinus. Hierarchical clustering of the heterogeneous transcripts revealed a group of ∼15 biosynthetic genes that contained the transcription factor, JUND, and the basal-cell cytokeratin, KRT5. In the same dataset, we identified a second group of genes-containing a transforming growth factor-beta (TGF-beta) family ligand (GDF11), a TGF-beta receptor (TGFBR3), and a TGF-beta marker protein (TGFBI)-with strong sampling fluctuations that were opposite to those of JUND cluster. Here, we show that perturbation of JUND or TGFBR3 expression profoundly disrupts 3D morphogenesis. Constitutive JUND expression causes stable cribiform-like bridges across the acinar lumen, whereas TGFBR3 knockdown induces a ductal-branching phenotype. These perturbations further revealed that JUND and TGFBR3 are reciprocally coupled by interlinked positive and negative feedback loops that could give rise to asynchronous oscillations during morphogenesis. Live-cell imaging with a fluorescently tagged Smad2 revealed sporadic pulses of TGF-betaR signaling in matrix-attached cells during morphogenesis. Last, in clinical specimens of breast cancer with dichotomous basal cytokeratin expression, we find that junD and Krt5 proteins are correlated in ECM-attached cells. Interestingly, junD and Krt5 are anticorrelated in cells not directly in contact with stromal ECM, and this regulation is mimicked in 3D culture of MCF10A cells. Together, our results raise the possibility that heterogeneous basal-like breast cancers switch between two states that depend critically on the ECM context.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4922. doi:10.1158/1538-7445.AM2011-4922

Tetra-methoxystilbene modulates ductal growth of the developing murine mammary gland

Extensive data suggest that estradiol contributes to the development of breast cancer by acting as a mitogen and exerting direct genotoxic effects after enzymatic conversion to 4-hydroxyestradiol (4-OHE2) via cytochrome P450 1B1 (CYP1B1). The mammary gland, ovary, and uterus all express CYP1B1. Overexpression of this enzyme has been associated with an increased risk of breast cancer and blockade might reduce this carcinogenic effect. For this reason, we conducted systematic in vitro and in vivo studies of a CYP1B1 inhibitor, TMS (2,3',4,5'-tetramethoxystilbene). We found that TMS blocked the enzymatic conversion of radiolabeled estradiol to both 2-hydroxyestradiol (2-OHE2) and 4-OHE2, but did not inhibit Cyp1b1 message formation. In vivo studies using mass spectrometry showed that TMS inhibited formation of 2-OHE2 and 4-OHE2 and the resulting estrogen-DNA adducts. To examine its biologic actions in vivo, we investigated whether TMS could block the hyperplastic changes that occur in the developing breast of aromatase-transfected mice. We found that TMS induced a significant reduction of ductal structures in mice less than 6 months in age. In older mice, no reduction in breast morphology occurred. These latter studies uncovered unexpected estrogen agonistic actions of TMS at high doses, including a paradoxical stimulation of breast ductal structures and the endometrium. These studies suggest that the enzyme inhibitory properties of TMS, as well as the effects on developing breast, could implicate a role for TMS in breast cancer prevention, but only in low doses and on developing breast.

The effect of intraoperative specimen inking on lumpectomy re-excision rates

Background

Lumpectomy re-excision to obtain negative margins is common. We compare the effect of two specimen orientation approaches on lumpectomy re-excision rates.

Methods

All women undergoing lumpectomy for breast cancer by a single surgeon between 03/2007 - 02/2009 were included. Lumpectomies underwent standard inking (SI) after surgery by a pathologist from 03/2007-02/2008 while intraoperative inking (II) with direct surgeon input was done from 03/2008-02/2009. Rates of margin positivity and re-excision were compared between these methods.

Results

65 patients were evaluated, reflecting SI in 39 and II in 26 cases. Margin positivity rates of 46% [SI] vs. 23% [II] (p = 0.06) and re-excision rates of 38% [SI] vs. 19% [II] were observed. Residual disease at re-excision was found in 27% [SI] vs. 67% [II] of cases.

Conclusions

Intraoperative inking in this practice offered a simple way to reduce re-excision rates after lumpectomy and affect an improvement in quality of patient care.

Vascular cell adhesion molecule-1 is a regulator of ovarian cancer peritoneal metastasis

Ovarian cancers metastasize by attaching to and invading through the mesothelium, a single layer of mesothelial cells lining the peritoneal cavity. The presence of invasive peritoneal metastases is associated with a poor prognosis for ovarian cancer (5-year survival <25%). Vascular cell adhesion molecule-1 (VCAM-1) is a cell surface receptor that mediates leukocyte attachment and extravasation across endothelial and mesothelial monolayers at sites of inflammation. Membranous VCAM-1 expression was observed on the mesothelium of 13 of 14 women with ovarian cancer compared with 6 of 15 who were cancer-free. Using a cell culture model system of mesothelial invasion, highly tumorigenic SKOV-3 and ES-2 cells were 2.5 to 3 times more efficient in transmigration through the mesothelial monolayer compared with poorly tumorigenic OVCAR-3 cells. Blocking antibodies to, or small interfering RNA knockdown of, VCAM-1 or its ligand alpha(4)beta(1) integrin significantly decreased, but did not completely inhibit, transmigration of SKOV-3 cells through mesothelial monolayers. Furthermore, using a mouse model of ovarian cancer metastasis, treatment with VCAM-1 function-blocking antibodies decreased tumor burden and increased survival. Together, these observations implicate VCAM-1-alpha(4)beta(1) integrin interactions in the regulation of ovarian cancer cell mesothelial invasion and metastatic progression and offer the possibility of novel therapeutic targets.

Utilization of a uniform grading system for interpreting serous ovarian cancer

OBJECTIVE

The purpose of the study was to implement a uniform system for assigning tumor grade in serous ovarian cancer and evaluate its correlation with response to conventional chemotherapy.

STUDY DESIGN

Serous ovarian cancer tumor samples were retrospectively reviewed by 3 pathologists who were blinded to the original report. Samples were scored for architectural pattern, nuclear pleomorphism, and mitotic activity. Sum scores from these 3 indices were used to classify tumors as low grade or high grade.

RESULTS

A total of 21 patients were identified as low-grade tumors and 21 were identified as high-grade tumors. Of low-grade tumors, 16 (76%) were found to be platinum resistant, defined as recurrent or persistent disease, 180 days from completion of the final cycle of chemotherapy, Of 21 patients defined as high grade, 9 (43%) were platinum resistant (P = .028).

CONCLUSION

Utilization of a uniform grading system retrospectively correlates with platinum sensitivity.

Clinical applications of immunohistochemistry in gynecological malignancies

Over the past two decades, immunohistochemical techniques have improved to such a degree that it is now a common adjuvant test to the traditional hematoxylin and eosin-stained histologic sections. It is used in most realms of surgical pathology and can often aid in final diagnosis and, in some cases, prognosis. However, immunohistochemistry (IHC) is not always helpful and many pitfalls to its use exist. Understanding the basics of IHC, its utility and difficulties will aid clinicians in better understanding how diagnoses are rendered. This study reviews the general principles of IHC and demonstrates its utility with several commonly encountered problematic areas in gynecological pathology.

Cytology of desmoplastic small round-cell tumor: comparison of pre- and post-chemotherapy fine-needle aspiration biopsies

BACKGROUND

Desmoplastic small round-cell tumor (DSRCT) is an aggressive malignancy of young adults, which is amenable to fine-needle aspiration biopsy (FNAB). As this entity is increasingly recognized and biopsied, cytopathologists are compelled to become familiar with the range of cytologic features of DSRCT. In addition, postchemotherapy tumors may be sampled to confirm disease recurrence before planning additional therapy. This study was designed to compare prechemotherapy and postchemotherapy cytomorphology of DSRCT and to evaluate for distinct chemotherapy-induced changes.

METHODS

The authors searched their respective institutional databases for all DSRCT cases with an associated FNAB. FNAB slides, immunocytochemistry, and cytogenetic results were reviewed.

RESULTS

Six aspirates from 5 patients were identified, 3 of which were postchemotherapy. The postchemotherapy cases demonstrated cytologic findings not typically described in DSRCTs, including prominent and conspicuous nucleoli, discohesive single-cell architecture, and slightly larger cell size.

CONCLUSIONS

Cytomorphologic variability was prominent in prechemotherapy cases, and no case could be classified as DSRCT on cytology alone; immunohistochemistry was necessary for definitive diagnosis. Chemotherapy increased the spectrum of cytologic features. The most notable difference between the 2 groups was a predominantly discohesive single-cell pattern with conspicuous nucleoli in the postchemotherapy group, instead of the clustering pattern of medium-sized cells with inconspicuous nucleoli typically attributed to de novo cases reported in the literature.

Description of patients with squamous cell carcinoma in the atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion triage study

BACKGROUND

The Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion Triage Study (ALTS) accumulated information regarding conventional and liquid-based Papanicolaou (Pap) cytology, 2 kinds of human papillomavirus (HPV) DNA testing, cervicography, and colposcopically directed biopsy. The prevalence of squamous cell carcinoma in these women, the efficacy of tests, and the time to detection were reviewed.

METHODS

The ALTS data base was reviewed for all women with invasive carcinoma. All results of colposcopy, HPV testing, cytology, biopsies, and cervigrams were reviewed for all women in the ALTS trial who were diagnosed with squamous cell carcinoma.

RESULTS

There were 7 diagnoses of invasive cancer (all squamous cell) during the 2 years of the ALTS trial. Although the enrollment studies isolated many high-grade lesions, none of those results were diagnostic of the underlying carcinoma.

CONCLUSIONS

The prevalence of squamous cell carcinoma in the setting of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion cytology interpretation appears to be low (approximately 1 per 1000 women in the ALTS trial). Many of the carcinomas were not visible on the ectocervix by cervicography or colposcopy, which may explain in part the paucity of atypical cells detected on the Pap tests and the finding that the presenting cytology, although abnormal, was never diagnostic of cancer. HPV DNA tests were positive in all 7 cancers. Type-specific testing identified HPV type 16 in 6 of 7 cancers and HPV type 18 in 1 of 7 cancers.

Mass-forming extramedullary hematopoiesis diagnosed by fine-needle aspiration cytology

Extramedullary hematopoiesis (EMH) is usually a microscopic finding. However, it may present as a mass-forming lesion making it amenable to fine-needle aspiration biopsy (FNAB). When mass-forming EMH occurs, it can simulate a neoplasm clinically and radiologically. Additionally, the megakaryocytes can mimic malignant neoplastic cells, particularly if EMH is not a considered diagnosis. We report six cases of mass-forming EMH diagnosed by FNAB and evaluate the utility of FNAB in diagnosing EMH. Four patients had prior diagnoses of hematologic disorders, one patient had malignant mastocytosis who presented with lymphadenopathy and one patient had a history of carcinoma. The patients' ages ranged from 46 to 78 yr with an equal sex distribution. Aspirate smears showed trilineage hematopoiesis. The cytomorphologic differential diagnosis included metastatic carcinoma, Hodgkin lymphoma and myeloid sarcoma. No special stains were necessary due to the classic cytologic findings and prior hematologic history.