Nicole C.M. Visser

L1CAM expression in endometrial carcinomas: an ENITEC collaboration study

Background:Identification of aggressive endometrioid endometrial carcinomas (EECs) and non-endometrioid carcinomas (NEECs) is essential to improve outcome. L1 cell adhesion molecule (L1CAM) expression is a strong prognostic marker in stage I EECs, but less is known about L1CAM expression in advanced-stage EECs and NEECs. This study analyses L1CAM expression in a clinically representative cohort of endometrial carcinomas.Methods:The expression of L1CAM was immunohistochemically determined in 1199 endometrial carcinomas, treated at one of the European Network for Individualized Treatment of Endometrial Cancer (ENITEC) centres. Staining was considered positive when >10% of the tumour cells expressed L1CAM. The association between L1CAM expression and several clincopathological characteristics and disease outcome was calculated.Results:In all, L1CAM was expressed in 10% of the 935 stage I EECs, 18% of the 160 advanced stage EECs, and 75% of the 104 NEECs. The expression of L1CAM was associated with advanced stage, nodal involvement, high tumour grade, non-endometrioid histology, lymphovascular space invasion, and distant recurrences in all cases, and with reduced survival in the EECs, but not in the NEECs.Conclusions:The expression of L1CAM is a strong predictor of poor outcome in EECs, but not NEECs. It is strongly associated with non-endometrioid histology and distant spread, and could improve the postoperative selection of high-risk endometrial carcinomas. The value of L1CAM expression in the preoperative selection of high-risk endometrial carcinomas should be studied.

Factors attributing to the failure of endometrial sampling in women with postmenopausal bleeding

To determine which doctor‐ and patient‐related factors affect failure of outpatient endometrial sampling in women with postmenopausal bleeding, and to develop a multivariable prediction model to select women with a high probability of failed sampling.

Multimodal Imaging of Orthotopic Mouse Model of Endometrial Carcinoma

Background Orthotopic endometrial cancer models provide a unique tool for studies of tumour growth and metastatic spread. Novel preclinical imaging methods also have the potential to quantify functional tumour characteristics in vivo, with potential relevance for monitoring response to therapy. Methods After orthotopic injection with luc-expressing endometrial cancer cells, eleven mice developed disease detected by weekly bioluminescence imaging (BLI). In parallel the same mice underwent positron emission tomography–computed tomography (PET-CT) and magnetic resonance imaging (MRI) employing 18F-fluorodeoxyglocose (18F-FDG) or 18F- fluorothymidine (18F-FLT) and contrast reagent, respectively. The mice were sacrificed when moribund, and post-mortem examination included macroscopic and microscopic examination for validation of growth of primary uterine tumours and metastases. PET-CT was also performed on a patient derived model (PDX) generated from a patient with grade 3 endometrioid endometrial cancer. Results Increased BLI signal during tumour growth was accompanied by increasing metabolic tumour volume (MTV) and increasing MTV x mean standard uptake value of the tumour (SUVmean) in 18F-FDG and 18F-FLT PET-CT, and MRI conspicuously depicted the uterine tumour. At necropsy 82% (9/11) of the mice developed metastases detected by the applied imaging methods. 18F-FDG PET proved to be a good imaging method for detection of patient derived tumour tissue. Conclusions We demonstrate that all imaging modalities enable monitoring of tumour growth and metastatic spread in an orthotopic mouse model of endometrial carcinoma. Both PET tracers, 18F-FDG and 18F-FLT, appear to be equally feasible for detecting tumour development and represent, together with MRI, promising imaging tools for monitoring of patient-derived xenograft (PDX) cancer models.

Expression of L1CAM in curettage or high L1CAM level in preoperative blood samples predicts lymph node metastases and poor outcome in endometrial cancer patients

Background:Several studies have identified L1 cell adhesion molecule (L1CAM) as a strong prognostic marker in endometrial cancer. To further underline the clinical usefulness of this biomarker, we investigated L1CAM as a predictive marker for lymph node metastases and its prognostic impact in curettage specimens and preoperative plasma samples. In addition, we aimed to validate the prognostic value of L1CAM in hysterectomy specimen.Methods:Immunohistochemical staining of L1CAM was performed for 795 hysterectomy and 1134 curettage specimen from endometrial cancer patients. The L1CAM level in preoperative blood samples from 372 patients was determined using ELISA.Results:Expression of L1CAM in curettage specimen was significantly correlated to L1CAM level in corresponding hysterectomy specimen (P<0.001). Both in curettage and preoperative plasma samples L1CAM upregulation was significantly associated with features of aggressive disease and poor outcome (P<0.001). The L1CAM was an independent predictor of lymph node metastases, after correction for curettage histology, both in curettage specimen (P=0.002) and plasma samples (P=0.048). In the hysterectomy samples L1CAM was significantly associated with poor outcome (P<0.001).Conclusions:We demonstrate that preoperative evaluation of L1CAM levels, both in curettage or plasma samples, predicts lymph node metastases and adds valuable information on patient prognosis.

Added Value of Estrogen Receptor, Progesterone Receptor, and L1 Cell Adhesion Molecule Expression to Histology-Based Endometrial Carcinoma Recurrence Prediction Models: An ENITEC Collaboration Study

Objectives Endometrial carcinoma mortality is mainly caused by recurrent disease, and various immunohistochemical markers to predict recurrences have been studied. Loss of the estrogen receptor (ER) and progesterone receptor (PR) and the presence of the L1 cell adhesion molecule (L1CAM) are promising markers, but their combined value has not been studied. Materials and Methods Expression of ER, PR, and L1CAM was immunohistochemically determined in 293 endometrial carcinomas from 11 collaborating European Network for Individualized Treatment of Endometrial Cancer centers. Estrogen receptor, PR, or L1CAM staining was considered positive or negative when expressed by greater than or equal to 10% or less than 10% of the tumor cells, respectively. The association between these markers and clinicopathological markers, and their combined value in predicting survival were calculated, both in the entire cohort and in a selected groups of stage I endometrioid and low-risk stage I endometrioid carcinomas. Results Estrogen receptor and PR were negative in 19% and 28% of the cases, respectively, and L1CAM was positive in 18%. All 3 were associated with advanced stage, high-grade, nonendometrioid histology, lymphovascular space invasion (LVSI), and reduced disease-free survival. Only advanced stage, loss of PR, and LVSI were associated with reduced disease-free survival in multivariate analysis. A prognostic model including these 3 markers was superior to 1 including only the 3 immunohistochemical markers, which was superior to the traditional model. In both the stage I endometrioid and the low-risk stage I endometrioid groups, only loss of PR was associated with reduced disease-free survival. Conclusions Loss of ER and PR, and the presence of L1CAM are associated with high risk characteristics, and loss of PR is the strongest predictor of recurrent disease. Although a combination of these 3 markers is slightly superior to the traditional histological markers, a prognostic model including stage, PR expression, and LVSI is the most promising model in the identification of high risk carcinomas. In the stage I endometrioid carcinomas, PR immunohistochemistry appears to be of additional value in predicting recurrences.

Diagnostic accuracy of endometrial biopsy in relation to the amount of tissue

Aims For the diagnostic workup of postmenopausal bleeding, histological examination of the endometrium is frequently performed. Failure of endometrial sampling due to insufficient material is often reported but objective criteria for quality assessment of endometrial biopsies are lacking. The aim of the present study is to evaluate the association between the amount of tissue obtained by endometrial sampling and the diagnostic accuracy, and to establish a cut-off level for a minimal amount of tissue required for a conclusive diagnosis. Methods For this retrospective cohort study, clinicopathological data and Pipelle endometrial sampling slides of 139 patients who were treated with hysterectomy were collected. The surface of evaluable endometrial tissue was measured by means of structured digital assessment. The correlation between the predictive values in relation to the endometrial tissue surface was calculated for different cut-off values. Results The median endometrial tissue surface was 4.7 mm2 (range 0.4–156.4) for benign endometrium, 27.8 mm2 (range 0.0–208.4) for premalignant endometrium and 43.8 mm2 (range 0.0–223.6) for malignant endometrium. There was a significant association between the endometrial tissue surface and the correctness of diagnosis. A minimal endometrial tissue surface of 35 mm2 could be defined, for positive and negative predictive values of 92.6% and 85.7%, respectively. Conclusions The diagnostic accuracy of Pipelle endometrial sampling is associated with the amount of endometrial tissue surface, with a minimal cut-off value of 35 mm2 required to classify an endometrial sample as conclusive. Quantification of endometrial tissue can contribute to standardisation of quality assessment of endometrial samplings.

A Structured Assessment to Decrease the Amount of Inconclusive Endometrial Biopsies in Women with Postmenopausal Bleeding.

Objective. To determine whether structured assessment of outpatient endometrial biopsies decreases the number of inconclusive samples. Design. Retrospective cohort study. Setting. Single hospital pathology laboratory. Population. Endometrial biopsy samples of 66 women with postmenopausal bleeding, collected during the usual diagnostic work-up and assessed as insufficient for a reliable histological diagnosis. Methods. Endometrial biopsy samples were requested from the pathology laboratories. The retrieved samples were systematically reassessed by a single pathologist specialized in gynecology. Main Outcome Measure. Disagreement between initial assessment and conclusion after structured reassessment. Results. We retrieved 36 of 66 endometrial biopsy samples from six different pathology laboratories. Structured reassessment of the retrieved samples by a single pathologist specialized in gynecology did not change the conclusion in 35 of the 36 samples. The remaining sample contained a large amount of endometrial tissue and the diagnosis at reassessment was endometrial hyperplasia without atypia. All other samples contained insufficient material for a reliable diagnosis. Conclusion. A structured reassessment of endometrial biopsies samples, which were classified as inconclusive due to insufficient material, did not change the conclusion. Although it might be helpful for pathologists to have diagnostic criteria for adequacy and/or inadequacy of an endometrial biopsy sample, the gain in efficiency is likely to be small.

Low-grade salivary duct carcinoma in the bronchus

colon and rectum. A clinicopathologic, ultrastructural, and immunohistochemical study of 24 cases. Am. J. Surg. Pathol. 1990; 14; 1010–1023. 10. Petrelli M, Tetangco E, Reid JD. Carcinoma of the colon with undifferentiated, carcinoid, and squamous cell features. Am. J. Clin. Pathol. 1981; 75; 581–584. 11. Travis W, Nicholson S, Hirsch FR et al. Small cell carcinoma. In Travis WD, Brambilla E, M€ uller-Hermelink HK, Harris CC eds. World Health Organization classification of tumors. Pathology and genetics of tumours of the lung, pleura, thymus and heart. Lyon: International Agency for Research on Cancer, 2004; 31–34. 12. Ramage JK, Ahmed A, Ardill J et al. Guidelines for the management of gastroenteropancreatic neuroendocrine (including carcinoid) tumours (NETs). Gut 2012; 61; 6–32. 13. Terry J, Leung S, Laskin J, Leslie KO, Gown AM, Ionescu DN. Optimal immunohistochemical markers for distinguishing lung adenocarcinomas from squamous cell carcinomas in small tumor samples. Am. J. Surg. Pathol. 2010; 34; 1805– 1811. 14. Kaufmann O, Fietze E, Mengs J, Dietel M. Value of p63 and cytokeratin 5/6 as immunohistochemical markers for the differential diagnosis of poorly differentiated and undifferentiated carcinomas. Am. J. Clin. Pathol. 2001; 116; 823–830. 15. McCluggage WG, Kennedy K, Busam KJ. An immunohistochemical study of cervical neuroendocrine carcinomas: neoplasms that are commonly TTF1 positive and which may express ck20 and p63. Am. J. Surg. Pathol. 2010; 34; 525– 532. 16. Briggs JC, Ibrahim NB. Oat cell carcinomas of the oesophagus: a clinico-pathological study of 23 cases. Histopathology 1983; 7; 261–277. 17. Mori M, Matsukuma A, Adachi Y et al. Small cell carcinoma of the esophagus. Cancer 1989; 63; 564–573. 18. Takubo K, Nakamura K, Sawabe M et al. Primary undifferentiated small cell carcinoma of the esophagus. Hum. Pathol. 1999; 30; 216–221. 19. Mills SE, Allen MS Jr, Cohen AR. Small-cell undifferentiated carcinoma of the colon. A clinicopathological study of five cases and their association with colonic adenomas. Am. J. Surg. Pathol. 1983; 7; 643–651. 20. Stelow EB, Moskaluk CA, Mills SE. The mismatch repair protein status of colorectal small cell neuroendocrine carcinomas. Am. J. Surg. Pathol. 2006; 30; 1401–1404. 21. Ross JS, Wang K, Elkadi OR et al. Next-generation sequencing reveals frequent consistent genomic alterations in small cell undifferentiated lung cancer. J. Clin. Pathol. 2014; 67; 772– 776. 22. Rekhtman N, Paik PK, Arcila ME et al. Clarifying the spectrum of driver oncogene mutations in biomarker-verified squamous carcinoma of lung: lack of EGFR/KRAS and presence of PIK3CA/AKT1 mutations. Clin. Cancer Res. 2012; 18; 1167– 1176. 23. Han B, Mori I, Wang X, Nakamura M, Nakamura Y, Kakudo K. Combined small-cell carcinoma of the stomach: P53 and kras gene mutational analysis supports a monoclonal origin of three histological components. Int. J. Exp. Pathol. 2005; 86; 213–218. 24. Fu K, Tsujinaka Y, Hamahata Y, Matsuo K, Tsutsumi O. Squamous metaplasia of the rectum associated with ulcerative colitis diagnosed using narrow-band imaging. Endoscopy 2008; 40 (Suppl. 2); E45–E46. 25. Zirkin RM, McCord DL. Squamous cell carcinoma of the rectum: report of a case complicating chronic ulcerative colitis. Dis. Colon Rectum 1963; 6; 370–373. 26. Kong CS, Welton ML, Longacre TA. Role of human papillomavirus in squamous cell metaplasia–dysplasia–carcinoma of the rectum. Am. J. Surg. Pathol. 2007; 31; 919–925. 27. Wiener MF, Polayes SH, Yidi R. Squamous carcinoma with schistosomiasis of the colon. Am. J. Gastroenterol. 1962; 37; 48–54. 28. Yurdakul G, de Reijke TM, Blank LE, Rauws EA. Rectal squamous cell carcinoma 11 years after brachytherapy for carcinoma of the prostate. J. Urol. 2003; 169; 280. 29. Ouban A, Nawab RA, Coppola D. Diagnostic and pathogenetic implications of colorectal carcinomas with multidirectional differentiation: a report of 4 cases. Clin. Colorectal Cancer 2002; 1; 243–248. 30. Wong NACS, Gonzalez D, Salto-Tellez M et al. RAS testing of colorectal carcinoma – a guidance document from the association of clinical pathologists molecular pathology and diagnostics group. J. Clin. Pathol. 2014; 67; 751–757.

Long-term risk of endometrial cancer following postmenopausal bleeding and reassuring endometrial biopsy.

Women with postmenopausal bleeding and endometrial thickness >4 mm undergo endometrial sampling to exclude endometrial cancer. The aim of this study is to investigate the relative risk of developing endometrial cancer in a prospective cohort after initial work‐up for postmenopausal bleeding showing reassuring histology or insufficient sampling.

Does probability guided hysteroscopy reduce costs in women investigated for postmenopausal bleeding

Objective. To evaluate whether a model to predict a failed endometrial biopsy in women with postmenopausal bleeding (PMB) and a thickened endometrium can reduce costs without compromising diagnostic accuracy. Design, Setting, and Population. Model based cost-minimization analysis. Methods. A decision analytic model was designed to compare two diagnostic strategies for women with PMB: (I) attempting office endometrial biopsy and performing outpatient hysteroscopy after failed biopsy and (II) predicted probability of a failed endometrial biopsy based on patient characteristics to guide the decision for endometrial biopsy or immediate hysteroscopy. Robustness of assumptions regarding costs was evaluated in sensitivity analyses. Main Outcome Measures. Costs for the different strategies. Results. At different cut-offs for the predicted probability of failure of an endometrial biopsy, strategy I was generally less expensive than strategy II. The costs for strategy I were always € 460; the costs for strategy II varied between € 457 and € 475. At a 65% cut-off, a possible saving of € 3 per woman could be achieved. Conclusions. Individualizing the decision to perform an endometrial biopsy or immediate hysteroscopy in women presenting with postmenopausal bleeding based on patient characteristics does not increase the efficiency of the diagnostic work-up.