A Novel ZIP4-HDAC4-VEGFA Axis in High-Grade Serous Ovarian Cancer

Simple Summary

Despite tremendous research efforts, epithelial ovarian cancer (EOC) remains one of the most difficult cancers to detect early and treat successfully for >5-year survival. We have recently shown that ZIP4, a zinc transporter, is a novel cancer stem cell (CSC) marker and a therapeutic target for EOC. The current work focuses on developing new strategies to target ZIP4 and inhibit its CSC activities in EOC. We found that cells expressing high levels of ZIP4 were supersensitive to a group of inhibitors called HDACis. One of the major targets of these inhibitors is a protein called HDAC4. We revealed the new molecular bases for the ZIP4-HDAC4 axis and tested the efficacies of targeting this axis in the lab and in mouse models. Our study provides a new mechanistic-based targeting strategy for EOC.

Abstract

We have recently identified ZIP4 as a novel cancer stem cell (CSC) marker in high-grade serous ovarian cancer (HGSOC). While it converts drug-resistance to cisplatin (CDDP), we unexpectedly found that ZIP4 induced sensitization of HGSOC cells to histone deacetylase inhibitors (HDACis). Mechanistically, ZIP4 selectively upregulated HDAC IIa HDACs, with little or no effect on HDACs in other classes. HDAC4 knockdown (KD) and LMK-235 inhibited spheroid formation in vitro and tumorigenesis in vivo, with hypoxia inducible factor-1 alpha (HIF1α) and endothelial growth factor A (VEGFA) as functional downstream mediators of HDAC4. Moreover, we found that ZIP4, HDAC4, and HIF1α were involved in regulating secreted VEGFA in HGSOC cells. Furthermore, we tested our hypothesis that co-targeting CSC via the ZIP4-HDAC4 axis and non-CSC using CDDP is necessary and highly effective by comparing the effects of ZIP4-knockout/KD, HDAC4-KD, and HDACis, in the presence or absence of CDDP on tumorigenesis in mouse models. Our results showed that the co-targeting strategy was highly effective. Finally, data from human HGSOC tissues showed that ZIP4 and HDAC4 were upregulated in a subset of recurrent tumors, justifying the clinical relevance of the study. In summary, our study provides a new mechanistic-based targeting strategy for HGSOC.

Vaginal Squamous Cell Carcinoma Develops in Mice with Conditional Arid1a Loss and Gain of Oncogenic Kras Driven by Progesterone Receptor Cre

Oncogenic KRAS mutations are a common finding in endometrial cancers. Recent sequencing studies indicate that loss-of-function mutations in the ARID1A gene are enriched in gynecologic malignant tumors. However, neither of these genetic insults alone are sufficient to develop gynecologic cancer. To determine the role of the combined effects of deletion of Arid1a and oncogenic Kras, Arid1a^flox/flox mice were crossed with Kras^{Lox-Stop-Lox-G12D/+} mice using progesterone receptor Cre (Pgr^Cre/+). Histologic analysis and immunohistochemistry of survival studies were used to characterize the mutant mouse phenotype. Hormone dependence was evaluated by ovarian hormone depletion and estradiol replacement. Arid1a^flox/flox; Kras^{Lox-Stop-Lox-G12D/+}; Pgr^Cre/+ mice were euthanized early because of invasive vaginal squamous cell carcinoma. Younger mice had precancerous intraepithelial lesions. Immunohistochemistry supported the pathological diagnosis with abnormal expression and localization of cytokeratin 5, tumor protein P63, cyclin-dependent kinase inhibitor 2A, and Ki-67, the marker of proliferation. Ovarian hormone deletion in Arid1a^flox/flox; Kras^{Lox-Stop-Lox-G12D/+}; Pgr^Cre/+ mice resulted in atrophic vaginal epithelium without evidence of vaginal tumors. Estradiol replacement in ovarian hormone-depleted Arid1a^flox/flox; Kras^{Lox-Stop-Lox-G12D/+}; Pgr^Cre/+ mice resulted in lesions that resembled the squamous cell carcinoma in intact mice. Therefore, this mouse can be used to study the transition from benign precursor lesions into invasive vaginal human papillomavirus-independent squamous cell carcinoma, offering insights into progression and pathogenesis of this rare disease.

Methylomic Signatures of High Grade Serous Ovarian Cancer

High-grade serous ovarian cancer (HGSOC) harbours aberrant epigenetic features, including DNA methylation. In this study we delineate pathways and networks altered by DNA methylation and associated with HGSOC initiation and progression to a platinum-resistant state. By including tumours from patients who had been treated with the hypomethylating agent (HMA) guadecitabine, we also addressed the role of HMAs in treatment of HGSOC. Tumours from patients with primary (platinum-naïve) HGSOC (n = 20) were compared to patients with recurrent platinum-resistant HGSOC and enrolled in a recently completed clinical trial (NCT01696032). Human ovarian surface epithelial cells (HOSE; n = 5 samples) served as normal controls. Genome-wide methylation profiles were determined. DNA methyltransferase (DNMT) expression levels were examined by immunohistochemistry and correlated with clinical outcomes. Cancer-related and tumorigenesis networks were enriched among differentially methylated genes (DMGs) in primary OC vs. HOSE. When comparing platinum-resistant and primary tumours, 452 CpG island (CGI)-containing gene promoters acquired DNA methylation; of those loci, decreased (P < 0.01) methylation after HMA treatment was observed in 42% (n = 189 CGI). Stem cell pluripotency and cytokine networks were enriched in recurrent platinum-resistant OC tumours, while drug metabolism and transport-related networks were downregulated in tumours from HMA-treated patients compared to HOSE. Lower DNMT1 and 3B protein levels in pre-treatment tumours were associated with improved progression-free survival. The findings provide important insight into the DNA methylation landscape of HGSOC tumorigenesis, platinum resistance and epigenetic resensitization. Epigenetic reprogramming plays an important role in HGSOC aetiology and contributes to clinical outcomes.

Pten and Dicer1 loss in the mouse uterus causes poorly differentiated endometrial adenocarcinoma

Endometrial cancer remains the most common gynecological malignancy in the United States. While the loss of the tumor suppressor, PTEN (phosphatase and tensin homolog), is well studied in endometrial cancer, recent studies suggest that DICER1, the endoribonuclease responsible for miRNA genesis, also plays a significant role in endometrial adenocarcinoma. Conditional uterine deletion of Dicer1 and Pten in mice resulted in poorly differentiated endometrial adenocarcinomas, which expressed Napsin A and HNF1B (hepatocyte nuclear factor 1 homeobox B), markers of clear-cell adenocarcinoma. Adenocarcinomas were hormone-independent. Treatment with progesterone did not mitigate poorly differentiated adenocarcinoma, nor did it affect adnexal metastasis. Transcriptomic analyses of DICER1 deleted uteri or Ishikawa cells revealed unique transcriptomic profiles and global miRNA downregulation. Computational integration of miRNA with mRNA targets revealed deregulated let-7 and miR-16 target genes, similar to published human DICER1-mutant endometrial cancers from TCGA (The Cancer Genome Atlas). Similar to human endometrial cancers, tumors exhibited dysregulation of ephrin-receptor signaling and transforming growth factor-beta signaling pathways. LIM kinase 2 (LIMK2), an essential molecule in p21 signal transduction, was significantly upregulated and represents a novel mechanism for hormone-independent pathogenesis of endometrial adenocarcinoma. This preclinical mouse model represents the first genetically engineered mouse model of poorly differentiated endometrial adenocarcinoma.

In vivo modeling of metastatic human high-grade serous ovarian cancer in mice

Metastasis is responsible for 90% of human cancer mortality, yet it remains a challenge to model human cancer metastasis in vivo. Here we describe mouse models of high-grade serous ovarian cancer, also known as high-grade serous carcinoma (HGSC), the most common and deadliest human ovarian cancer type. Mice genetically engineered to harbor Dicer1 and Pten inactivation and mutant p53 robustly replicate the peritoneal metastases of human HGSC with complete penetrance. Arising from the fallopian tube, tumors spread to the ovary and metastasize throughout the pelvic and peritoneal cavities, invariably inducing hemorrhagic ascites. Widespread and abundant peritoneal metastases ultimately cause mouse deaths (100%). Besides the phenotypic and histopathological similarities, mouse HGSCs also display marked chromosomal instability, impaired DNA repair, and chemosensitivity. Faithfully recapitulating the clinical metastases as well as molecular and genomic features of human HGSC, this murine model will be valuable for elucidating the mechanisms underlying the development and progression of metastatic ovarian cancer and also for evaluating potential therapies.

Rarely does an experimental model fully replicate the clinical metastases of a human malignancy. Faithfully representing the clinical metastases of human high-grade serous ovarian cancer with complete penetrance, coupled with histopathological, molecular, and genomic similarities, these mouse models, particularly one harboring mutant p53, will be vital to elucidating the underlying pathogenesis of human ovarian cancer. In-depth understanding of the development and progression of ovarian cancer is crucial to medical advances in the early detection, effective treatment, and prevention of ovarian cancer. Also, these robust mouse models, as well as cell lines established from the mouse primary and metastatic tumors, will serve as useful preclinical tools to evaluate therapeutic target genes and new therapies in ovarian cancer.

Solitary fibrous tumor

Solitary fibrous tumor (SFT) is a rare tumor of mesenchymal origin that account for less than 2% of all soft tissue masses. Initially identified in the pleura, SFT has been identified in multiple anatomic locations and can arise anywhere in the body. The varying histologic features along with non-specific means of identification have led SFT to be associated with several different names. Over the last several decades, sustained advances through research and technology have led to more reliable methods for differentiating this distinct soft tissue tumor. Advances specifically in immunohistochemistry and molecular diagnostics have identified CD34 as the most consistent marker in SFT, however even this lacks specificity to conclusively narrow down the broad differential for exact identification. More recently the discovery of the NAB2-STAT6 fusion gene has led to more precise diagnosis of SFT. Like many other soft tissue tumors, surgical management is the mainstay of treatment for SFT with emphasis on obtaining tumor-negative margins. Radiation therapy and chemotherapy regimens have not demonstrated global effectiveness, and thus no standardized treatments have been identified. Given the rarity of SFT and current supportive evidence for therapies, management should be focused on tumor extirpation. Nonetheless, individualized therapy, determined within a multidisciplinary setting should be considered.

TERT promoter mutation status in sarcomatoid urothelial carcinomas of the upper urinary tract

AIM

To determine TERT promoter mutation status as well as the expression of PAX8, GATA3, p63, p40, p53 and uroplakin III in 17 patients with the upper urinary tract sarcomatoid urothelial carcinoma.

METHODS & RESULTS

 TERT C228T mutations were found in six of 17 cases (35%). p53 was expressed in 77% of these tumors. PAX8, GATA3, p40 and uroplakin III are less frequently expressed. Lymph node metastases were present in ten cases (59%). Eight patients (47%), including all three patients with TERT mutation, died of cancer within 2 years after surgery.

CONCLUSION

Sarcomatoid carcinoma of the upper urinary tract is an aggressive tumor and the presence of TERT mutation may portend poor prognosis.

Solitary fibrous tumour of the genitourinary tract: a clinicopathological study of 11 cases and their association with the NAB2-STAT6 fusion gene

AIMS

To characterise clinicopathological features and clinical outcomes of the genitourinary tract solitary fibrous tumours, incorporating NAB2-STAT6 gene fusion status.

METHODS

The presence of the molecular hallmark NAB2-STAT6 gene fusion and for the defining fusion partner product STAT6 was assessed in 11 cases of the genitourinary tract solitary fibrous tumours. NAB2-STAT6 gene fusion analysis was performed using a break-apart fluorescence in situ hybridisation (FISH) probe using a probe cocktail with Bacterial artificial chromosome (BAC) clones for STAT6 and NAB2.

RESULTS

Eleven solitary fibrous tumours were diagnosed in eight male patients and three female patients with a mean age of 46 years (range: 11-64 years). Four of the tumours had malignant histological features, and three were considered moderate risk for metastasis. With a mean follow-up time of 61 months, 1 recurred locally and 2 presented at distant metastatic sites. Using a break-apart FISH probe cocktail, we found the NAB2-STAT6 gene fusion and nuclear STAT6 expression in 58% and 91% of cases, respectively. However, the NAB2-STAT6 fusion status was not correlated with STAT6 expression or useful in discriminating between malignant histological features or subsequent clinical outcomes in the genitourinary solitary fibrous tumours.

CONCLUSIONS

A subset of solitary fibrous tumours of the genitourinary tract behaved aggressively. Using a break-apart FISH probe cocktail, we found the NAB2-STAT6 gene fusion in 64% of cases. However, the NAB2-STAT6 fusion status was not correlated with STAT6 expression or useful in discriminating between low-risk or high-risk tumours and subsequent clinical outcomes.

Human papillomavirus (HPV)-induced neoplasia in the urinary bladder: a missing link?

The discovery that the role human papillomavirus (HPV) plays in the induction of human cancer represents an important achievement in oncologic research. It has taken on even greater importance since the development of vaccines, which promise the hope of preventing these cancers from ever occurring. Because of these important implications, many have attempted to determine a possible role for the virus in cancers of the urinary bladder-an organ in close anatomic proximity to the primary sites of HPV-induced neoplasia and one which already has an established oncogenic infectious agent in Schistosoma haematobium. Here we review the current literature exploring this possible role in the most common subtype of cancer of the urinary bladder, urothelial carcinoma, and two much more rare histologic subtypes that have well established roles for HPV-induced neoplasia in other anatomic sites-squamous cell carcinoma and adenocarcinoma.

In vivo tumor growth of high-grade serous ovarian cancer cell lines

OBJECTIVE

Genomic studies of ovarian cancer (OC) cell lines frequently used in research revealed that these cells do not fully represent high-grade serous ovarian cancer (HGSOC), the most common OC histologic type. However, OC lines that appear to genomically resemble HGSOC have not been extensively used and their growth characteristics in murine xenografts are essentially unknown.

METHODS

To better understand growth patterns and characteristics of HGSOC cell lines in vivo, CAOV3, COV362, KURAMOCHI, NIH-OVCAR3, OVCAR4, OVCAR5, OVCAR8, OVSAHO, OVKATE, SNU119 and UWB1.289 cells were assessed for tumor formation in nude mice. Cells were injected intraperitoneally (i.p.) or subcutaneously (s.c.) in female athymic nude mice and allowed to grow (maximum of 90 days) and tumor formation was analyzed. All tumors were sectioned and assessed using H&E staining and immunohistochemistry for p53, PAX8 and WT1 expression.

RESULTS

Six lines (OVCAR3, OVCAR4, OVCAR5, OVCAR8, CAOV3, and OVSAHO) formed i.p xenografts with HGSOC histology. OVKATE and COV362 formed s.c. tumors only. Rapid tumor formation was observed for OVCAR3, OVCAR5 and OVCAR8, but only OVCAR8 reliably formed ascites. Tumors derived from OVCAR3, OVCAR4, and OVKATE displayed papillary features. Of the 11 lines examined, three (Kuramochi, SNU119 and UWB1.289) were non-tumorigenic.

CONCLUSIONS

Our findings help further define which HGSOC cell models reliably generate tumors and/or ascites, critical information for preclinical drug development, validating in vitro findings, imaging and prevention studies by the OC research community.

Small cell carcinoma of the prostate: molecular basis and clinical implications

Small cell carcinoma of the prostate (PSCC) is a rare and highly aggressive malignancy with a dismal prognosis. Most patients present with advanced disease, including metastases to bone, viscera, and the central nervous system. Histologically, PSCC is indistinguishable from its pulmonary counterpart. Although PSCC may occur in pure form, as in small cell lung carcinoma, it also occurs in conjunction with conventional glandular prostate carcinoma, and may evolve from conventional adenocarcinoma during the course of hormonal therapy. Immunohistochemical staining is extremely helpful in establishing the diagnosis, a prerequisite, as in small cell lung cancer, for optimal therapeutic strategy. Currently, combinations of surgical resection, chemotherapy, and radiation therapy represent the main treatment options. Improvement in survival may depend upon the identification of new molecular markers to facilitate earlier diagnosis and the development of novel targeted therapies. This review will discuss general aspects of PSCC, focusing on ways in which our understanding of PSCC has been advanced by studies of the histopathologic, immunohistochemical and molecular alterations in this disease.

Frequent TMPRSS2-ERG rearrangement in prostatic small cell carcinoma detected by fluorescence in situ hybridization: the superiority of fluorescence in situ hybridization over ERG immunohistochemistry

Small cell carcinoma of the prostate is both morphologically and immunohistochemically similar to small cell carcinoma of other organs such as the urinary bladder or lung. TMPRSS2-ERG gene fusion appears to be a highly specific alteration in prostatic carcinoma that is frequently shared by small cell carcinoma. In adenocarcinoma, immunohistochemistry for the ERG protein product has been reported to correlate well with the presence of the gene fusion, although in prostatic small cell carcinoma, this relationship is not completely understood. We evaluated 54 cases of small cell carcinoma of the prostate and compared TMPRSS2-ERG gene fusion status by fluorescence in situ hybridization (FISH) to immunohistochemical staining with antibody to ERG. Of 54 cases of prostatic small cell carcinoma, 26 (48%) were positive for TMPRSS2-ERG gene fusion by FISH and 12 (22%) showed overexpression of ERG protein by immunohistochemistry. Of the 26 cases positive by FISH, 11 were also positive for ERG protein by immunohistochemistry. One tumor was positive by immunohistochemistry but negative by FISH. Urinary bladder small cell carcinoma (n = 25) showed negative results by both methods; however, 2 of 14 small cell carcinomas of other organs (lung, head, and neck) showed positive immunohistochemistry but negative FISH. Positive staining for ERG by immunohistochemistry is present in a subset of prostatic small cell carcinomas and correlates with the presence of TMPRSS2-ERG gene fusion. Therefore, it may be useful in confirming prostatic origin when molecular testing is not accessible. However, sensitivity and specificity of ERG immunohistochemistry in small cell carcinoma are decreased compared to FISH.

Novel markers of squamous differentiation in the urinary bladder

Urinary bladder squamous cell carcinoma and urothelial carcinoma with squamous differentiation are often high-grade and high-stage tumors that are thought to be associated with a poorer prognosis and response to therapy compared with urothelial carcinoma without divergent differentiation. Therefore, recognition of a squamous component is increasingly important in guiding prognosis and therapy. We investigated the expression of MAC387, desmoglein-3, and TRIM29 in pure squamous cell carcinoma and urothelial carcinoma with squamous differentiation to determine whether they have utility as diagnostic biomarkers for squamous differentiation. Eighty-four cases were retrieved from participating institutions including 51 pure urinary bladder squamous cell carcinomas and 33 urothelial carcinomas with squamous differentiation. MAC387, desmoglein-3, and TRIM29 antibodies demonstrated positive staining in pure squamous cell carcinoma in 51 (100%), 46 (90%), and 48 (93%) cases, respectively. Urothelial carcinoma with squamous differentiation showed reactivity for MAC387, desmoglein-3, and TRIM29 in the squamous component for 32 (97%), 26 (79%), and 32 (97%) cases, respectively. MAC387 demonstrated a sensitivity of 99% and a specificity of 70% for squamous differentiation, whereas desmoglein-3 yielded a sensitivity of 86% and a specificity of 91%. No urothelial component showed greater than 10% labeling for desmoglein-3. TRIM29 labeling showed a sensitivity of 95%, but a poorer specificity of 33%. In summary, MAC387 and desmoglein-3 are reliable diagnostic markers for supporting the morphologic impression of squamous differentiation in urinary bladder carcinoma. Desmoglein-3 shows high specificity, whereas TRIM29 was most likely to demonstrate labeling in areas without light microscopically recognizable squamous differentiation.

p16 expression is not associated with human papillomavirus in urinary bladder squamous cell carcinoma

Squamous cell carcinoma of the urinary bladder is unusual and of unknown etiology. There is a well-established association between human papillomavirus (HPV) infection and the development of cervical and head/neck squamous cell carcinomas. However, the role of HPV in the pathogenesis of squamous cell carcinoma of the urinary bladder is uncertain. The purposes of this study were to investigate the possible role of HPV in the development of squamous cell carcinoma of the urinary bladder and to determine if p16 expression could serve as a surrogate marker for HPV in this malignancy. In all, 42 cases of squamous cell carcinoma of the urinary bladder and 27 cases of urothelial carcinoma with squamous differentiation were investigated. HPV infection was analyzed by both in situ hybridization at the DNA level and immunohistochemistry at the protein level. p16 protein expression was analyzed by immunohistochemistry. HPV DNA and protein were not detected in 42 cases of squamous cell carcinoma (0%, 0/42) or 27 cases of urothelial carcinoma with squamous differentiation (0%, 0/15). p16 expression was detected in 13 cases (31%, 13/42) of squamous cell carcinoma and 9 cases (33%, 9/27) of urothelial carcinoma with squamous differentiation. There was no correlation between p16 expression and the presence of HPV infection in squamous cell carcinoma of the bladder or urothelial carcinoma with squamous differentiation. Our data suggest that HPV does not play a role in the development of squamous cell carcinoma of the urinary bladder or urothelial carcinoma with squamous differentiation. p16 expression should not be used as a surrogate marker for evidence of HVP infection in either squamous cell carcinoma of the urinary bladder or urothelial carcinoma with squamous differentiation as neither HVP DNA nor protein is detectable in these neoplasms.

Intratubular germ cell neoplasia of the testis and its associated cancers: the use of novel biomarkers

Recent advances in the understanding of the molecular pathology of testicular tumours have led to the identification of several new immunohistochemical markers for invasive and in situ germ cell neoplasms. OCT3/4 and NANOG are nuclear stains that have high sensitivity and specificity for the identification of intratubular germ cell neoplasia as well as seminoma and embryonal carcinoma. A potential pitfall in their application to the detection of intratubular germ cell neoplasia, as in other markers that represent oncofetal antigens, is their expression in non-neoplastic germ cells with 'delayed maturation'. SALL4, another nuclear stain, is positive for most germ cell tumours as a group and may be especially helpful in the distinction of these tumours from somatic carcinomas in non-testicular sites. Glypican 3 is a more sensitive marker for yolk sac tumour than alpha-fetoprotein. SOX2 and SOX17 may be useful for differentiating seminoma and embryonal carcinoma, especially following chemotherapy as embryonal carcinoma may lose CD30 expression in this setting. This article reviews the application of these immunohistochemical markers and others to the diagnosis of germ cell neoplasia with reference to older immunohistochemical stains when appropriate. Suggested immunohistochemical panels are described for individual tumour types.

A prospective study comparing rapid assessment of smears and ThinPrep for endoscopic ultrasound-guided fine-needle aspirates

BACKGROUND AND STUDY AIMS

ThinPrep is often used for endoscopic ultrasound fine-needle aspiration (EUS-FNA) samples but the sensitivity of this method is unknown. The objective of the study was to compare sensitivity and accuracy of ThinPrep versus the smear method in pancreas and lymph node samples obtained by EUS-FNA.

PATIENTS AND METHODS

Patients with suspected malignancy in the pancreas or lymph node underwent EUS-FNA. On-site rapid assessment of all aspirates using the smear method was performed. After rapid assessment, three additional passes from each site were submitted into ThinPrep liquid medium. Cytopathologists interpreting the smear method and ThinPrep slides were blinded to each other. The gold standard was final cytology or pathology results.

RESULTS

A total of 130 patients (36 % women, mean age 63 years) underwent EUS-FNA of 139 sites (50 pancreas, 89 lymph node). Malignancy was confirmed in 47 pancreas samples (94 %) and 48 lymph node samples (54 %). Mean +/- SD number of passes made for the smear method was 2.6 +/- 1.3. For pancreatic cancer, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the ThinPrep versus the smear method were: 62 % versus 98 %, 100 % versus 100 %, 100 % versus 100 %, 14 % versus 75 %, and 64 % versus 98 %, respectively. For lymph nodes the values were 67 % versus 92 %, 100 % versus 98 %, 100 % versus 98 %, 72 % versus 72 %, and 82 % versus 94 %, respectively.

CONCLUSIONS

The smear method is more sensitive and accurate than ThinPrep in detecting malignancy from EUS-FNA samples of the pancreas and lymph nodes. Smear method with on-site rapid assessment should be favored over ThinPrep in suspected malignancy.

Imatinib mesylate in combination with docetaxel for the treatment of patients with advanced, platinum-resistant ovarian cancer and primary peritoneal carcinomatosis : a Hoosier Oncology Group trial

BACKGROUND

Ovarian tumors frequently express c-Kit and/or platelet-derived growth factor receptors (PDGFRs). Imatinib mesylate blocks the growth of ovarian cancer cells in vitro and may enhance the activity of chemotherapy. This study was conducted to determine the activity of imatinib in combination with docetaxel in patients with recurrent, platinum-resistant epithelial ovarian cancer (EOC).

METHODS

Eligible patients had recurrent, platinum-resistant, or refractory EOC that expressed PDGFRalpha or c-kit, as determined by immunohistochemistry. Imatinib mesylate at a dose of 600 mg orally once daily was administered continuously with docetaxel at a dose of 30 mg/m(2) given intravenously once weekly in Weeks 1 through 4 of every 6-week cycle. The primary endpoint was objective response rate (ORR) as assessed by the Response Evaluation Criteria in Solid Tumors (RECIST).

RESULTS

Thirty-four patients were screened for PDGFRalpha and c-kit expression to enroll 23 patients between December 2003 and October 2005. Four patients had c-kit-positive/PDGFR-negative tumors, 11 patients had PDGFR-positive/c-kit-negative tumors, and 8 patients had c-kit-positive/PDGFR-positive tumors. The median patient age was 56 years (range, 33-76 years). Patients had received a median of 3 prior treatments. The ORR was 21.7% and included 1 complete and 4 partial responses. An additional 3 patients had stable disease for more than 4 months. Expression of PDGFR, c-kit, phosphatase and tensin homolog (PTEN), and phosphorylated protein kinase B (Akt) did not predict response to therapy. The most common adverse events encountered were fatigue (83%), nausea (74%), diarrhea (61%), anorexia (52%), and edema (65%), and the majority of those events were graded as grade 1 or 2.

CONCLUSIONS

The combination imatinib and docetaxel was tolerated in patients with heavily pretreated EOC that expressed c-kit or PDGFRalpha. Few patients had sustained responses or stable disease.

Molecular genetic evidence supporting the neoplastic nature of the Leydig cell component of ovarian Sertoli-Leydig cell tumors

Sertoli-Leydig cell tumors (SLCT) comprise less than 1% of ovarian tumors. The nature of the Leydig cells has been a subject of controversy and it is unclear whether they are clonally related to the neoplasm or instead proliferate as a non-neoplastic response to the Sertoli-cell component. Twelve ovarian SLCT were identified and hematoxylin and eosin and unstained sections were prepared from formalin-fixed, paraffin-embedded tissue blocks. Tissue samples were microdissected from normal tissue, the Sertoli cell component, and the Leydig cell tumor component using the laser capture microdissection method. If present, tissue was also obtained from any heterologous component. Genomic DNA was extracted from the samples and polymerase chain reaction was used to amplify polymorphic sites at 5 loci: D16S402, TP53, IFNA, D17S855, and D11S1318. X-chromosome inactivation (HUMARA) analysis was also performed. LOH and/or nonrandom X-chromosome inactivation was observed in at least 1 of the 6 amplified loci in the Leydig cell component of 10 of the 12 tumors. LOH and nonrandom X-chromosome inactivation patterns of the Sertoli cell component and Leydig cell component were compared. Concordant allelic loss and/or matching X-chromosome inactivation patterns were observed in 8 (67%) of the 12 tumors. In 7 of these tumors similar LOH or X-chromosome inactivation was observed at 1 site. In 1 tumor similar LOH and/or X-chromosome inactivation was observed at 2 sites. Three tumors had heterologous components. The heterologous components similarly shared LOH/X-chromosome inactivation with the Sertoli cell components at 1 site in 1 case and 2 sites in 2 cases. These data suggest that, at least in some cases, the Leydig cell component of SLCT is neoplastic rather than reactive in nature, and shares a common clonal origin with the coexisting Sertoli cell component. Similarly, the heterologous components, when present, appear to share clonal origin with the Sertoli cell components.

Molecular Genetic Evidence of an Independent Origin of Serous Low Malignant Potential Implants and Lymph Node Inclusions

Patients with ovarian serous tumors of low malignant potential (LMP) are commonly found to have peritoneal implants. Less commonly, similar lesions are seen in lymph nodes, sometimes in association with endosalpingiosis. We compared these lesions to the coexisting ovarian LMP tumors to determine whether they are clonally related to the ovarian neoplasm. Seventeen patients with serous LMP tumors present at 2 or more sites were identified. Tissue samples were microdissected from formalin-fixed paraffin-embedded tissue blocks. Samples of normal tissue, the ovarian LMP tumors, peritoneal LMP implants, and LMP inclusions within lymph nodes were obtained. Genomic DNA was extracted from the samples, and polymerase chain reaction and X-chromosome inactivation (human androgen receptor assay) analysis were performed. The pattern of X-chromosome inactivation could be determined in 15 of the 17 cases, and nonrandom X-chromosome inactivation was observed in 13 of these cases. Twelve of these cases included both ovarian and extraovarian LMP tumors. In 9 of these 12 cases, the extraovarian LMP tumor shared a similar pattern of nonrandom X-chromosome inactivation with the ovarian tumor. In these cases, the shared inactivation pattern was seen at 1 extraovarian site (3 cases), 2 extraovarian sites (4 cases), 5 extraovarian sites (1 case), and 7 of 8 extraovarian sites (1 case). In the remaining 3 cases, opposite patterns of nonrandom X-chromosome inactivation were seen. These data suggest that, in most cases, serous LMP tumor implants and lymph node inclusions share a common clonal origin with the associated ovarian tumors. However, in at least some cases, the implants and inclusions seem to arise independently from the associated ovarian serous LMP tumors.

PDGF BB induces VEGF secretion in ovarian cancer

We identified the platelet derived growth factor receptor (PDGFR) as a potential target in epithelial ovarian carcinoma (EOC). This led us to test whether inhibition of the PDGFR affects ovarian cancer cell proliferation and survival and regulates other processes critical to tumor growth and metastasis. We postulated that there is a correlation between the PDGF-PDGFR axis and the secretion of VEGF in EOC. VEGF secretion in ovarian tumors, cancer cells, serum and ascites fluid was measured by IHC, Western Blot and ELISA. We found increased VEGF expression and secretion in most ovarian tumors (by IHC), in EOC malignant ascites and in the conditioned media of primary ovarian cancer cells (quantified by ELISA). In malignant ascites, the levels of secreted PDGF BB and VEGF were strongly correlated (Pearson coefficient of correlation R = 0.728), suggesting that the two pathways interconnect. In PDGFR expressing immortalized ovarian cancer cells, PDGF potently induced VEGF secretion, while imatinib mesylate (Gleevec), a partially selective PDGFR inhibitor, reduced PDGF stimulated VEGF production to basal state. In ovarian cancer cells overexpressing constitutively active Akt, imatinib inhibited partially VEGF secretion, suggesting that the PI3K/Akt pathway is implicated in PDGF-stimulated VEGF secretion. In summary, these results suggest a correlation between the PDGF and VEGF networks in ovarian cancer cells and tumors. The effects of imatinib on VEGF secretion in tumor cells may affect the tumor microenvironment in a manner detrimental to tumor progression.

Morphological approach to tumours of the testis and paratestis

Most neoplastic scrotal masses ultimately prove to be germ cell tumours and are recognisable with routine haematoxylin and eosin-stained sections. The differential diagnosis may be focused, even before reviewing histological sections, by knowledge of patient age, medical history, tumour site (testicular vs paratesticular) and gross findings. Some cases may prove to be diagnostically challenging, including rare tumours, a common tumour with an unusual pattern, a metastatic tumour, or a neoplasm with features that mimic another tumour. Several morphological patterns are seen with some frequency and these generate recurring sets of differential diagnostic considerations. These common patterns include testicular tumours with a predominant diffuse arrangement of cells with pale to clear cytoplasm, tumours with a glandular/tubular pattern, tumours with a microcystic pattern and tumours composed of oxyphilic cells. Intratubular proliferations of atypical cells, paratesticular glandular and/or papillary tumours, or tumours with spindle cell morphology can also be challenging to diagnose correctly. In some problematic cases, immunohistochemical staining may be useful to resolve these differential diagnoses.

Benign glandular inclusions a rare cause of a false positive sentinel node

An 84-year-old female underwent a wire-guided lumpectomy and sentinel lymph node biopsy. Two sentinel nodes were identified and sent for immediate pathological evaluation. One of the nodes was reported as "glandular epithelium consistent with metastatic adenocarcinoma." Permanent sections of the sentinel node initially considered positive revealed glandular structures primarily within the fibrous capsule of the involved lymph node. These glands were lined by tall columnar epithelial cells, which had cilia on the luminal surface and did not show significant cytologic atypia. The limitations of intra-operative evaluation of sentinel nodes make differentiation of uncommon pathology difficult. A conservative approach should be taken with these lesions as permanent sections will often elucidate the diagnosis.

Endoscopic ultrasound-guided fine-needle aspiration cytology diagnosis of intraductal papillary mucinous neoplasm of the pancreas is highly predictive of pancreatic neoplasia

Intraductal papillary mucinous neoplasms (IPMN) have been considered difficult to diagnose by fine-needle aspiration (FNA) cytology. We identified 57 cases diagnosed as IPMN or consistent with IPMN by endoscopic ultrasound (EUS)-guided FNA over a 9-yr period. Histologic follow-up was available for 20 patients (35%). Pancreatic neoplasia was demonstrated in 18 of these cases (90%). The histologic diagnoses were IPMN (16 cases), pancreatic intraductal neoplasia (grade 1b, 1 case), invasive mucin-producing adenocarcinoma (1 case), and chronic pancreatitis with a pseudocyst (2 cases). Sixty-two cases of IPMN without coexisting adenocarcinoma were diagnosed by histology during this time period. Of these, 35 (56%) had a preceding EUS-guided FNA. The diagnosis made by EUS-guided FNA in these 35 cases was negative or nondiagnostic (6 cases), benign cyst (1 case), chronic pancreatitis (2 cases), atypical ductal cells (2 cases), adenocarcinoma or suspicious for adenocarcinoma (3 cases), consistent with mucinous cystic neoplasm (4 cases), and IPMN or consistent with IPMN (16 cases). An EUS FNA diagnosis of probable or definite neoplasia was, therefore, made in 71% of cases of histologically proven IPMN.

Autocrine activation of PDGFRalpha promotes the progression of ovarian cancer

Platelet-derived growth factor receptor (PDGFR)alpha expression was found in ovarian cancer cells and tumors by microarray hybridization. This led us to test whether ovarian cancers also produce ligands for this receptor, as this would demonstrate that such malignancies support their own growth and spread through autocrine activation. We assayed the expression of ligands for the PDGFR in ovarian tumors, cell lines and peritoneal fluid using RT-PCR, immunohistochemistry (IHC) and ELISA. We detected strong mRNA expression for the PDGFRalpha ligands in most ovarian tumors. Receptor and ligand expressions (PDGFRalpha and PDGF AB) were also detected by IHC in, respectively, 34 and 32 of 47 ovarian tumors. The stainings for PDGFRalpha and PDGF AB were strongly correlated (P-value=0.014), suggesting that an autocrine loop is functional in ovarian cancer. PDGF AA and BB were quantified in peritoneal fluid by ELISA. Both ligands are secreted at higher levels in ovarian cancer ascites specimens (n=54) than in fluid from nonmalignant disorders (n=8). PDGF was detected in media conditioned by ovarian cancer cells. Such conditioned media induced activation of the PDGFR, Akt and MAPK and stimulated cell proliferation. A neutralizing PDGF antibody blocked these effects. Specific PDGFR inhibition by siRNA or a neutralizing antibody to the receptor inhibited PDGF-stimulated receptor activation and cell proliferation, suggesting that receptor targeting has a role in ovarian cancer treatment.

Chromosome 12p abnormalities in dysgerminoma of the ovary: a FISH analysis

Dysgerminoma is the most common malignant ovarian germ cell tumor and shares histological and immunophenotypical features with its testicular counterpart, seminoma. Chromosome 12p abnormalities are genetic hallmarks of testicular seminomas. Little is known about these genetic changes in dysgerminoma. We performed dual color fluorescence in situ hybridization (FISH) analyses with a centromeric alpha-satellite probe for chromosome 12 and a subtelomeric probe for 12p on paraffin-embedded tissue sections from 21 dysgerminomas and two gonadoblastomas. Chromosome 12p abnormalities were detected in 81% of dysgerminomas. In all, 57% of cases had only isochromosome 12p and 5% had only 12p overrepresentation. In all, 19% had both isochrome 12p and 12p overrepresentation. Gonadoblastomas were negative for isochromosome 12p or 12p overrepresentation. Chromosome 12p abnormalities are common in dysgerminoma of the ovary. FISH analyses for chromosome 12p abnormalities may be a useful diagnostic adjunct for confirming the diagnosis of dysgerminoma and for distinguishing it from nongerm cell malignancies that enter into the differential diagnosis.

The use of immunohistochemistry in the differential diagnosis of tumors of the testis and paratestis

Although most testicular and paratesticular tumors can be recognized by their light microscopic features, some raise significant differential diagnostic questions. Immunohistochemical staining has proved of significant value in this situation. There is still a role for the traditional markers, including placental-like alkaline phosphatase and alpha-fetoprotein, but newer markers provide additional support and often have greater sensitivity and specificity for many diagnoses. OCT4 is virtually 100% sensitive and specific for seminoma, embryonal carcinoma, and intratubular germ cell neoplasia, unclassified type. Inhibin-alpha, among testicular tumors, is limited to those in the sex cord-stromal category or those having adrenocortical-type differentiation (testicular tumor of the adrenogenital syndrome) or of trophoblastic lineage. Calretinin is another positive marker for the sex cord-stromal tumors but has less specificity. Additional markers, including differential cytokeratins, c-kit, CD30, epithelial membrane antigen, S-100, melan-A, and others, are useful in specific situations. This article reviews the application of immunohistochemical markers for a number of differential diagnostic considerations in the testis and paratestis categorized according to their light microscopic patterns.

Immunohistochemical markers in the evaluation of tumors of the urinary bladder: a review

The clinical utility of immunohistochemistry in the diagnosis of tumors of the urinary bladder is well established. With recent advances in molecular biology and novel technologies, several biomarkers have emerged as important adjuncts in the diagnosis of lesions of the bladder. When used in conjunction with careful histologic examination, immunohistochemistry can be a valuable aid in classifying adenocarcinoma presenting in the bladder and mesenchymal lesions of the bladder and in establishing the urothelial origin of a metastatic tumor. In addition, a number of biomarkers may prove to be important indicators of prognosis or response to chemotherapy.

The influence of extent of surgical margin positivity on prostate specific antigen recurrence

BACKGROUND

Positive surgical margins are an adverse prognostic factor in patients undergoing prostatectomy for prostate cancer. The extent of margin positivity varies and its influence on clinical outcome is uncertain.

AIMS

To evaluate the linear extent of margin positivity and the number and location of positive sites as prognostic indicators in a series of prostatectomy specimens evaluated with the whole mount technique.

METHODS

Eighty six consecutive margin positive prostatectomy specimens were evaluated, and all pathology data were collected prospectively. The linear extent of margin positivity was measured with an ocular micrometer and the total extent of all positive sites was summed. The total number of sites with positive margins and anatomical sites of the positive margins were analysed.

RESULTS

The linear extent of margin positivity ranged from 0.01 to 68 mm (mean, 6.8; median, 3.0) and was associated with prostate specific antigen (PSA) recurrence in univariate logistic regression (p = 0.031). In addition, the extent of margin positivity weakly correlated with preoperative PSA (p = 0.017) and tumour volume (p = 0.013), but not with age, prostate weight, Gleason score, pathological stage, or perineural invasion. The total number of positive sites was significantly higher in patients with PSA recurrence (p = 0.037). The location of the positive margin site was not associated with PSA recurrence. The extent of margin positivity correlated with PSA recurrence in univariate analysis, although it had only marginal predictive value when adjusted for Gleason score (p = 0.076).

CONCLUSIONS

The extent of margin positivity correlates with PSA recurrence in univariate analysis, although it has no predictive value independent of Gleason score.

Expression of CD117 (c-kit) receptor in dysgerminoma of the ovary: diagnostic and therapeutic implications

The proto-oncogene c-kit encodes a tyrosine kinase receptor, c-kit (CD117), which has been implicated in the development of a number of human malignancies. While the preferential expression of this protein has been well documented in testicular seminomas, there is little data concerning its expression in dysgerminomas of the ovary. We examined the expression of c-kit in 30 cases of ovarian dysgerminomas using immunohistohemical staining with a polyclonal anti-CD117 antibody. Staining was graded in a semiquantitative manner as follows: negative (no staining), 1+(1-10% staining), 2+(10-29% staining), 3+(30-50% staining), or 4+ (>50% staining). Of the 30 cases examined, 26 (87%) demonstrated immunoreactivity for CD117. In total, 10 (33%) demonstrated 4+ staining; 9 (30%) demonstrated 3+staining; 3 (10%) demonstrated 2+staining; 4 (13%) demonstrated 1+staining; and 4 (13%) demonstrated no staining. In conclusion, CD117 immunoreactivity was detected in 87% of ovarian dysgerminomas, a finding that correlates with previously reported frequencies of CD117 expression in seminomas (78-100%). Thus, antibodies to c-kit may be a useful diagnostic marker for ovarian dysgerminoma. Although the prognosis of patients with dysgerminoma is generally good, this receptor could potentially serve as a target for site-specific immunotherapy as an alternative and/or complement to conventional treatment options.

Randomized phase II trial of the anti-angiogenic potential of doxorubicin and docetaxel; primary chemotherapy as Biomarker Discovery Laboratory

PURPOSE

Primary chemotherapy provides an ideal opportunity to correlate potential non-invasive surrogate markers of angiogenesis with tumor microvessel density (MVD) and response.

PATIENTS AND METHODS

Patients with newly diagnosed stages II or III breast cancer were treated with sequential doxorubicin 75 mg/M2 q2 wks x 3 and docetaxel 40 mg/M2 weekly x 6; treatment order was randomly assigned. Potential serologic and imaging markers of angiogenesis were obtained pre-treatment, at crossover and completion of chemotherapy. Non-invasive biomarkers were correlated with MVD and pathologic response.

RESULTS

From June 1999 to October 2002, 70 patients were entered. Median pretreatment tumor diameter was 6.0 cm with clinically involved axillary nodes in 33 (47%) patients; 20% had inflammatory disease. Clinical response rate was 91%, including 46% clinical complete responses. Pathologic complete response (pCR) was confirmed in 9 (12.8%) patients. Baseline MVD did not correlate with clinical or pathologic response. Serologic markers were obtained in all patients; basic fibroblast growth factor (bFGF) was lower at baseline and increased during treatment in patients with a pCR but did not correlate with MVD. Color Doppler ultrasound (CDUS) was completed in 47 patients; no parameter reliably correlated with MVD or response. Positron emission tomography (PET) with [F-18]-fluoro-deoxyglucose, [O-15]-water and [C-11]-carbon monoxide were completed in 19 patients; uptake of all tracers decreased during treatment in virtually all patients.

CONCLUSION

Sequential doxorubicin and docetaxel is generally well tolerated and highly active. Serum angiogenic factors and imaging parameters frequently varied throughout treatment but did not correlate with MVD or consistently predict response.

Closest Distance Between Tumor and Resection Margin in Radical Prostatectomy Specimens

Complete removal of the tumor by surgery offers the best chance for cancer cure; however, many prostate cancer patients who have negative surgical margins at radical prostatectomy will still experience local and distant tumor recurrence. In other organs, the closest distance between tumor and resection margin has prognostic significance. This has not been adequately studied in prostatectomy specimens. We undertook a prospective study of 278 consecutive margin-negative whole-mount prostatectomy cases. The anatomic location and closest distance between tumor and resection margin, measured with an ocular micrometer, were analyzed. All the slides were reviewed by a single pathologist, and data were collected prospectively. The closest distance between tumor and resection margin ranged from 0.02 to 5.0 mm (mean, 0.7 mm; median, 0.5 mm) and correlated with patient age (P = 0.03), prostate weight (P = 0.002), Gleason score (P = 0.001), pathologic stage (P = 0.01), tumor volume (P < 0.001), and perineural invasion (P < 0.001). The closest distance between tumor and resection margin was not a significant predictor of PSA recurrence in univariate or multivariate logistic regression; and we do not, therefore, advocate reporting the closest distance between tumor and resection margin as a standard part of the surgical pathology report on prostatectomy specimens.

Enterogenous cysts of the spinal canal and cerebellopontine angle

Enterogenous cysts are rare, benign lesions involving the spinal canal or the cerebellopontine angle. Typically they present with compression of the spinal cord or cranial nerves. They are usually 1 cm or less in size and are typically lined by columnar mucin-producing epithelium resembling enteric epithelium or columnar ciliated epithelium resembling respiratory epithelium. The case records of the Division of Neuropathology at Indiana University were reviewed for cystic lesions of the spinal canal and cranial cavity for a 26-year period. Seven surgically resected enterogenous cysts were identified. The original slides were studied. Additional sections were stained with mucicarmine, and immunohistochemical stains including thyroid transcription factor 1, epithelial membrane antigen, and cytokeratin 5/6 (CK5/6) were performed. Electron microscopy was performed in 1 case. The cysts ranged in size from 4 to 10 mm. One had stratified cuboidal epithelium, 1 had ciliated columnar and stratified squamous epithelium, 1 had columnar mucinous epithelium, and 4 had ciliated columnar epithelium. Epithelial membrane antigen and CK5/6 positivity were observed in all cases. Strong CK5/6 positivity was seen in the basal cells, with little or no immunoreactivity in the ciliated cells. Mucicarmine positivity was observed in 4 cases, and thyroid transcription factor 1 positivity was observed in 2 cases. Electron microscopy demonstrated well-developed stereocilia, distinct basal cells, and a thin basement membrane. The histopathologic, ultrastructural, and immunologic findings in these lesions are similar to those present in the bronchial epithelium, supporting the hypothesis of endodermal origin for these lesions.

Nephroblastoma Arising in a Germ Cell Tumor of Testicular Origin

We report a nephroblastoma arising in a germ cell tumor of testicular origin occurring in a 22-year-old man. Orchiectomy demonstrated a malignant mixed germ cell tumor composed of mature and immature teratoma with nephroblastoma and rhabdomyosarcoma. Following chemotherapy, the patient developed supraclavicular and retroperitoneal lymphadenopathy. Excision demonstrated metastatic teratoma at both sites. No recurrence was noted with 21 months of additional follow-up. Using tissue microdissection and loss of heterozygosity analysis, we investigated the clonality of the mature teratoma, immature teratoma, nephroblastoma, and rhabdomyosarcoma components of the primary tumor and of the metastatic mature teratoma at the two separate distant sites. Nine microsatellite polymorphic makers were used to examine the pattern of allelic loss in both primary and metastatic tumors. Loss of heterozygosity was found in 4 DNA loci, and the same pattern of allelic loss was demonstrated at all 4 loci in all of the different components of the primary tumor and the metastatic mature teratomas, supporting the germ cell tumor origin of the nephroblastoma component. Loss of heterozygosity on chromosome 17p13 (TP53) was detected in metastatic mature teratoma, but not in the primary tumor. Loss of heterozygosity was observed at 11p13, the locus of WT1 inactivation in patients genetically predisposed to nephroblastoma, and this loss may be an important genetic mechanism in nephroblastomatous differentiation of germ cell tumors. These data support a common clonal origin for nephroblastoma and the other germ cell tumor components.

Ovarian endometrioid tumors of low malignant potential: a clinicopathologic study of 30 cases with comparison to well-differentiated endometrioid adenocarcinoma

Thirty cases of ovarian endometrioid tumor of low malignant potential (ETLMP) were studied and compared with 32 cases of well-differentiated endometrioid adenocarcinoma. ETLMP was distinguished from well-differentiated endometrioid adenocarcinoma by the absence of destructive stromal invasion, glandular confluence, or stromal disappearance. Intraepithelial carcinoma in a low malignant potential tumor was defined as areas showing grade 3 nuclei, sometimes associated with an intracystic villoglandular or cribriform pattern. Microinvasion in an ETLMP was defined as one or more areas of invasion with an area of < or =10 mm2. Because a cribriform pattern may be seen in purely intraglandular proliferations, the latter was not taken as evidence of invasion. The patients with ETLMP ranged from 28 to 86 years of age (mean 54.9 years), and only one patient (3%) had other than stage I disease at presentation. The patients with well-differentiated endometrioid carcinoma ranged from 26 to 87 years of age (mean 51.1 years), and three patients (9%) had stage II disease at presentation. An adenofibromatous pattern was present in 47% of cases of ETLMP and squamous differentiation in 47%; intraepithelial carcinoma occurred in 7% of cases and stromal microinvasion in 7%. None of these findings appeared to influence the prognosis because all patients with ETLMP were free of recurrent disease or metastasis on follow-up, whereas 20% of patients with well-differentiated endometrioid adenocarcinoma followed for >6 months developed recurrent disease. Thus, the prognosis of ETLMP, when defined by the above criteria, is favorable and is superior to that of well-differentiated endometrioid adenocarcinoma.

Long-term follow-up of women with atypical squamous cells of undetermined significance (ASCUS)

ASCUS is the most common epithelial abnormality diagnosed in cytology laboratories in the US. Recently, the clinical importance of this diagnosis has been seriously questioned, with some investigators advocating elimination of this diagnostic category. This might be inappropriate if the ASCUS designation does define a population that is at significant risk for the development of dysplasia. Cytology and surgical pathology reports for all patients diagnosed as ASCUS in our laboratory during 1990 were reviewed. Patients with previous dysplasia or carcinoma were excluded from analysis. The pathology reports for the subsequent 9.1 yr were obtained and follow-up data collected. In 1990, 15,860 cervical cytology cases were examined in our laboratory. A diagnosis of ASCUS was made in 1,117 cases (7.0%). After excluding 345 patients with previous dysplasia or human papillomavirus-related diagnoses and 129 patients with no follow-up specimens, 643 study patients remained. Among these, the mean number of subsequent cervical smears was 4.3 (range, 1-18). Subsequent histologic material was available for 134 (20.8%) patients and the mean number of surgical specimens was 1.5 (range, 1-10). Squamous intraepithelial lesion (SIL) or dysplasia was subsequently diagnosed in 197 patients (30.6%). High-grade squamous intraepithelial lesion (HSIL) or at least moderate dysplasia was diagnosed in 64 patients (10.0%). In 21 cases (3.3%) the high-grade dysplasia developed more than 2 yr after the first ASCUS diagnosis. Follow-up disclosed no cases of invasive carcinoma. Among ASCUS patients followed for up to 9 yr, 20% develop only low-grade SIL or mild dysplasia and 10% develop HSIL or moderate or severe dysplasia. ASCUS should be retained as a diagnostic category since it identifies a significant percentage of patients who are at an increased risk for the development of cervical dysplasia.

Predicting cancer progression in patients with penile squamous cell carcinoma: the importance of depth of invasion and vascular invasion

The ability to predict cancer progression may help the clinical management of patients with penile squamous cell carcinoma. We studied 22 cases of squamous cell carcinoma of the penis diagnosed between 1989 and 1998. The depth of invasion was measured from the basement membrane of the squamous epithelium to the deepest invasive cancer cells. Cancer progression was defined as the development of lymph node metastasis or distant metastasis. The mean patient age was 63 years and the mean follow-up was 28 months. Ten patients developed cancer progression. The mean depth of invasion among patients with cancer progression was 9.8 mM, as compared to the mean depth of invasion of 4.0 mM among those patients without cancer progression (P =.02). Vascular invasion was also predictive of cancer progression (P =.02). Metastases developed in the majority (6 out of 7) of cases invading more than 6 mM, but developed only in a minority (4 out of 15) of cases invading 6 mM or less. We conclude that depth of invasion and vascular invasion are significant predictors of cancer progression for penile squamous cell carcinoma.