Carla Bartosch

Endometrial carcinomas: a review emphasizing overlapping and distinctive morphological and immunohistochemical features.

This review focuses on the most common diagnostic pitfalls and helpful morphologic and immunohistochemical markers in the differential diagnosis between the different subtypes of endometrial carcinomas, including: (1) endometrioid versus serous glandular carcinoma, (2) papillary endometrioid (not otherwise specified, villoglandular and nonvillous variants) versus serous carcinoma, (3) endometrioid carcinoma with spindle cells, hyalinization, and heterologous components versus malignant mixed müllerian tumor, (4) high-grade endometrioid versus serous carcinoma, (5) high-grade endometrioid carcinoma versus dedifferentiated or undifferentiated carcinoma, (6) endometrioid carcinoma with clear cells versus clear cell carcinoma, (7) clear cell versus serous carcinoma, (8) undifferentiated versus neuroendocrine carcinoma, (9) carcinoma of mixed cell types versus carcinoma with ambiguous features or variant morphology, (10) Lynch syndrome-related endometrial carcinomas, (11) high-grade or undifferentiated carcinoma versus nonepithelial uterine tumors. As carcinomas in the endometrium are not always primary, this review also discusses the differential diagnosis between endometrial carcinomas and other gynecological malignancies such as endocervical (glandular) and ovarian/peritoneal serous carcinoma, as well as with extra-gynecologic metastases (mainly breast and colon).

Low-Grade Endometrial Stromal Sarcoma and Undifferentiated Endometrial Sarcoma: A Comparative Analysis Emphasizing the Importance of Distinguishing Between These Two Groups

Endometrial stromal sarcomas (ESSs) are rare tumors whose classification is still controversial. In this study, the authors studied 19 patients diagnosed with ESS at the Hospital S João, Porto, Portugal; reviewed their files and material; and performed immunohistochemical study for CD10, desmin, and smooth muscle actin markers, aiming to compare low-grade endometrial stromal sarcomas (LG-ESSs) and undifferentiated endometrial sarcomas (UESs) using the World Health Organization (WHO) classification. Twelve cases (63%) were classified as LG-ESS and 7 (37%) as UES. The median age at diagnosis was 49 years, and women with LG-ESS tended to be younger than those with UES. Most cases (7/11) had a previous echographic diagnosis of leiomyoma. A biopsy or curettage was performed in 6 cases, providing a definitive diagnosis of malignancy in 4. Frozen section was performed in 4 patients. The majority (63%) of patients were FIGO stage I. Twelve (63%) cases showed diffuse or focal expression of CD10. Desmin and smooth muscle actin expression was focal in 4 (21%) tumors. Patients with LG-ESS had a significant better overall survival than those with UES (P = .026). Mitotic count had no prognostic significance. Our data emphasize the clinical importance of the WHO classification in ESS. It is of utmost importance to establish a proper classification to increase the consistency of data that may be useful for improving clinical and therapeutic management of patients with ESS.

Assessing sirtuin expression in endometrial carcinoma and non-neoplastic endometrium

Sirtuins participate in hormone imbalance, metabolism and aging, which are important processes for endometrial cancer (EC) development. Sirtuins mRNA expression (SIRT1 to 7) was determined in 76 ECs (63 Type I, 12 Type II and one mixed EC), and 30 non-neoplastic endometria (NNE) by quantitative real-time PCR. SIRT1 and SIRT7 protein expression was evaluated by immunohistochemistry using Allred score. Compared to NNE, ECs showed SIRT7 (p < 0.001) mRNA overexpression, whereas SIRT1 (p < 0.001), SIRT2 (p < 0.001), SIRT4 (p < 0.001) and SIRT5 (p < 0.001) were underexpressed. No significant differences were observed for SIRT3 and SIRT6. Type II ECs displayed lower SIRT1 (p = 0.032) and SIRT3 (p = 0.016) transcript levels than Type I ECs. Concerning protein expression, SIRT1 immunostaining median score was higher in ECs compared to NNE epithelium (EC = 5 vs. NNE = 2, p < 0.001), while SIRT7 was lower in ECs (EC = 6 vs. NNE = 7, p < 0.001). No significant associations were found between SIRT1/7 immunoexpression and histological subtype, grade, lymphovascular invasion or stage. Our data shows that sirtuins are deregulated in EC. The diversity of expression patterns observed suggests that sirtuins may have distinctive roles in endometrial cancer similarly to what has been described in other cancer models.

Human endometrium ultrastructure during the implantation window: a new perspective of the epithelium cell types.

The human endometrium is a hormonally regulated tissue that cyclically growths and differentiates in order to become a structure adequate for implantation. Molecular studies have shown some contradicting results and thus a reappraisal of the endometrium ultrastructure is warranted. In our study, endometrium biopsies were taken during the implantation window of 10 healthy women of reproductive age and analyzed using electron microscopy. Our results showed that during implantation window, the endometrial epithelium encompassed 4 cell types: microvilli-rich cells, pinopode cells, vesiculated cells, and ciliated cells. These cells showed signs of active communication with their external environment and neighboring cells, such as endocytosis, transcytosis and exocytosis. We highlighted important differences between surface and glandular epitheliums and characterized apocrine and holocrine secretion. It is likely that the features described reflect distinct functions in endometrium physiology that should be taken into account in the evaluation of the endometrium during the implantation window.

Distant Metastases in Uterine Leiomyosarcomas: The Wide Variety of Body Sites and Time Intervals to Metastatic Relapse.

Uterine leiomyosarcoma (U-LMS) is the most frequent malignant gynecologic mesenchymal tumor, often develops distant metastases and has a dismal prognosis. In this study we aim to characterize the body sites and time to metastasis in women with U-LMS. We evaluated 130 U-LMSs with distant metastases including a series of patients diagnosed at 2 tertiary centers, as well as cases published in the literature, found using a PubMed query. Data collected included clinic-pathologic features, time to first metastasis, and survival. Survival analysis was performed using univariable and multivariable Cox regression model. The most frequent metastatic sites were: lung (67.7%), cranial/intracranial (16.2%), skin/soft tissues (15.3%), and bone (13.8%). Other sites included thyroid, salivary gland, heart, liver, pancreas, adrenal gland, bowel, and breast. Metastases were histologically identical to primary tumors. Median time to first metastasis was highly variable (median: 24 mo; range, 1 mo to 26 y). Lung and peritoneum were the earlier metastatic sites; 21.4% of patients with U-LMS limited to the pelvis develop metastasis >5 yr after diagnosis. Lung metastases significantly associated with other distant metastases. Regarding treatment, only resection of metastases significantly influenced postmetastasis survival in multivariable analysis (hazard ratio: 0.49, P=0.015). In conclusion, U-LMS display highly variable sites of distant metastases. Metastases in unusual locations are sometimes the first to be detected, and not uncommonly, single and prone to surgical resection. There is also a wide range of time intervals to first metastasis, highlighting the need of long-term follow-up, high level of suspicion, and appropriate diagnostic confirmation.

Pathologic Findings in Prophylactic and Nonprophylactic Hysterectomy Specimens of Patients With Lynch Syndrome.

Women with Lynch syndrome (LS) have a high risk of developing endometrial carcinoma (EC) and, less frequently, ovarian carcinoma. As EC not uncommonly is the first malignancy, prophylactic hysterectomy (PH) has been increasingly implemented. In this study, we report the clinicopathologic features of a series of 70 LS patients who underwent either PH (n=39) or nonprophylactic hysterectomy (NPH) (n=31) at 3 tertiary referral centers. Among the 39 patients with PH, 2 had endometrial tumors seen grossly, whereas 37 showed no macroscopic lesions. Total inclusion of the endometrium was performed in 24/39 (61.5%). Abnormal histologic findings were identified in 9/39 (23.1%) PHs: 3 endometrial endometrioid carcinomas (EECs), including the 2 macroscopic and 1 microscopic (0.6 cm), and 4 atypical and 6 nonatypical hyperplasias. NPH included those performed for endometrial and ovarian cancer treatment. Tumor sampling followed standard protocols. ECs comprised 26 EECs and 1 clear cell carcinoma, with a median size of 3.7 cm. Hyperplasia was observed in 10 (33.3%) as background in EC, in 4 showing atypia. Eight (29.6%) tumors were centered in the lower uterine segment (all EECs). EECs were predominantly well differentiated (53.8%) and FIGO stage I (77.8%). A papillary architecture was common (51.9%) and associated with microcystic elongated and fragmented foci in 4. Mucinous differentiation was observed in 25.9% of endometrial tumors, typically representing <10%. Most endometrial tumors (81.5%) showed tumor-infiltrating lymphocyte counts ≥42/10 high-power fields. Four tumors showed extensive necrosis. Eight patients had ovarian tumors (4 synchronous), including 2 endometrioid carcinomas, 2 clear cell carcinomas, 1 borderline clear cell adenofibroma, 1 Müllerian carcinoma of mixed cell types, 1 primitive neuroectodermal tumor, and 1 metastatic melanoma. Total inclusion of the endometrium should be done in all LS patients’ surgical specimens without macroscopic lesions as some of these patients harbor preneoplastic or neoplastic conditions treatable at an early stage. The phenotype of LS-associated endometrial and ovarian tumors is variable and frequently includes features not commonly observed in sporadic cancers, but in our experience carcinomas were in general low grade and low stage.

Morphological features and mucin expression profile of breast carcinomas with signet-ring cell differentiation.

Signet-ring cells are relatively common in breast cancers but are frequently overlooked. Although previously defined as a subtype of mucin producing carcinomas, breast carcinomas with signet-ring cell (SRC) differentiation nowadays are not considered a distinct entity. The objective of the present study was to characterize the morphological features and mucin expression profile of breast carcinomas with SRC differentiation. All breast carcinomas diagnosed at Centro Hospitalar S. Joao between 1996 and 2006 in which the pathology report mentioned the presence of SRCs (n=11) and four mucinous carcinomas were included in the study. The frequency of SRCs and immunohistochemistry expression of MUC1/MUC2/MUC5AC/MUC6 were evaluated. We confirmed that SRC differentiation can occur in different histological types, including ductal, lobular, mucinous and metaplastic carcinomas. The proportion of SRCs was highly variable (range: 8-70%). Tumors encompassed SRCs of intracytoplasmic lumina and goblet-cell type. A higher percentage of SRCs was associated with lymphovascular invasion (p=0.047). All tumors expressed cytoplasmic and membranous MUC1. Secretory mucins were more frequent in mucinous carcinomas and in carcinomas with extensive SRC differentiation. We conclude that besides the usefulness of mucin immunodetection for the differential diagnosis of carcinomas with SRC differentiation of breast origin, it is important to report SRC differentiation regardless of histological type because of its intrinsic prognostic value.

Endometrial Endometrioid Carcinoma Metastases Show Decreased ER-Alpha and PR-A Expression Compared to Matched Primary Tumors

Patients with endometrial endometrioid carcinoma (EEC) that present with advanced primary disease and develop recurrences have a poor outcome. The phenotype of EEC metastases and recurrences is poorly studied. We evaluated the morphological features and ER-alpha/PRA/p53 immunohistochemical expression of a sample of 45 EEC metastases compared to matched primary tumors. Additionally, we studied methylation levels of ER-alpha/PRA gene promoters. The distribution of histological FIGO grade was significantly different in metastases, which disclosed higher grade than primary tumors (p = 0.005). Mitotic index was significantly lower in metastases compared to matched primary tumors (p<0.001). ER-alpha (p = 0.002) and PRA (p<0.001) median H-scores were significantly lower in metastases than in matched primary EECs, but there was no significant difference concerning p53 expression (p = 0.056). ER-alpha/PRA expression differences did not correlate with differences in metastases morphology. ER-alpha/PRA gene promoter levels were globally low (range: 0% to 11.9%). One case showed higher ER-alpha gene promoter methylation in metastasis compared to matched EEC primary tumor. Regarding PRA, there was a significant higher frequency of its promotor methylation in metastases compared to primary tumors (51.6% vs. 22.7%, p = 0.022). In conclusion, EEC metastatic disease displays phenotypic changes along with ER-alpha and PRA decreased expression compared to primary tumors. ER-alpha and PRA gene promoter methylation seems to play a limited role in the etiology of these alterations. PR expression assessment for hormonal treatment decision of patients with advanced tumors, may be more adequate in metastases than in EEC primary tumors.

A 9-protein biomarker molecular signature for predicting histologic type in endometrial carcinoma by immunohistochemistry.

Histologic typing may be difficult in a subset of endometrial carcinoma (EC) cases. In these cases, interobserver agreement improves when immunohistochemistry (IHC) is used. A series of endometrioid type (EEC) grades 1, 2, and 3 and serous type (SC) were immunostained for p53, p16, estrogen receptor, PTEN, IMP2, IMP3, HER2, cyclin B2 and E1, HMGA2, FolR1, MSLN, Claudins 3 and 4, and NRF2. Nine biomarkers showed significant differences with thresholds in IHC value scale between both types (p53 ≥ 20, IMP2 ≥ 115, IMP3 ≥ 2, cyclin E1 ≥ 220, HMGA2 ≥ 30, FolR1 ≥ 50, p16 ≥ 170, nuclear PTEN ≥ 2 and estrogen receptor ≤ 50; P < .005). This combination led to increased discrimination when considering cases satisfying 0 to 5 conditions predicted as EEC and those satisfying 6 to 9 conditions predicted as SC. This signature correctly predicted all 48 EEC grade 1-2 cases and 18 SC cases, but 3 SC cases were wrongly predicted as EEC. Sensitivity was 86% (95% confidence interval [CI], 64%-97%), and specificity was 100% (95% CI, 89%-100%). The classifier correctly predicted all 28 EEC grade 3 cases but only identified the EEC and SC components in 4 of 9 mixed EEC-SC. An independent validation series (29 EEC grades 1-2, 28 EEC grade 3, and 31 SC) showed 100% sensitivity (95% CI, 84%-100%) and 83% specificity (95% CI, 64%-94%). We propose an internally and externally validated 9-protein biomarker signature to predict the histologic type of EC (EEC or SC) by IHC. The results also suggest that mixed EEC-SC is molecularly ambiguous.

Endometrial carcinoma in Portugal: demographic, diagnostic and treatment changes in the last 5 decades.

Endometrial carcinoma (EC) is nowadays the most frequent gynecologic malignancy. Incidence is increasing, but studies characterizing the changes in demographics, diagnosis, and treatment over the years are scarce. We performed a retrospective observational study of a consecutive series of EC patients (n=188) diagnosed at a Portuguese tertiary hospital between 2000 and 2010. Clinical data were reviewed, and pathologic material was reevaluated according to the current diagnostic and staging guidelines. In addition, we performed a comprehensive PubMed and IndexRMP search that identified 2 previous Portuguese endometrial cancer studies: Study 1 referred to cases from 1963 to 1968 (n=260) and Study 2 to cases from 1991 to 1993 (n=57). Results from the present and the previous studies were compared. An increased proportion (present study vs. Study 1/Study 2) of elderly women (70.2% vs. 55.0%/57.0%) as well as comorbidities like obesity (54.3% vs. 44.2%/36.4%), hypertension (66.4% vs. 33.8%/42.1%), and diabetes (29.8% vs. 18%/8.7%) was observed over the years. There was a trend (present study vs. Study 1) to increased use of surgical staging (surgery 90.4% vs. 78.2%; lymphadenectomy 27.7% vs. 16.9%) and decreased use of radiotherapy (52.7% vs. 89.6%). The overall 5-yr survival in our series (78.4%) was better than that in Study 1 (57.3%; absent in Study 2). This study provides a perspective of the endometrial cancer epidemiology, diagnosis, and treatment changes that occurred in Portugal during the last 5 decades, these most probably reflecting what happened in other European countries. Substantial improvement in diagnosis and treatment of EC ensued, having a positive impact on survival, even though nowadays patients are older and with additional comorbidities.