Sumalee Siriaunkgul

HPV genotyping in cervical cancer in Northern Thailand: Adapting the linear array HPV assay for use on paraffin-embedded tissue

OBJECTIVES The aims of this study were to determine the prevalence of HPV infection and distribution of HPV genotypes in Northern Thai women and thereby estimate the benefit of administering the HPV vaccine in the population. METHODS Formaldehyde-fixed, paraffin-embedded samples of invasive squamous cell carcinoma from 99 patients were tested for HPV genotypes using the Linear Array HPV Genotyping Test. RESULTS HPV was detected in 96/99 (96.9%) cases. Seventy-five (78.1%) cases were single infections and 21 (21.9%) multiple. HPV16 and HPV18 were the most common subtypes, detected in 62/96 (64.4%) cases. HPV52 and HPV58 infections were found in 17/96 (17.7%) cases. Co-infection always involved HPV16. The most common co-infection was HPV16 and 52 (7 cases) but never HPV16 and 18. CONCLUSIONS Although the prevalence of HPV infection in cervical cancer of Northern Thai women is comparable to the other regions worldwide, the distribution of HPV subtypes differs with lower frequencies of HPV16 and 18, and higher frequencies of HPV52 and 58. Moreover, multiple infections are common. The vaccine against HPV16 and HPV18 can be estimated to prevent approximately two thirds of the cervical cancer cases in Northern Thailand. Although designed for use on unfixed tissue, this study shows that the Linear Array HPV Genotyping Test can be successfully used for HPV genotyping on paraffin-embedded archival tissue. This methodology also provides a means for retrospective studies on serial samples for a greater understanding of HPV genotypes, co-infections, and relationship to cervical cancer.

Mucinous tumor of low malignant potential ("borderline" or "atypical proliferative" tumor) of the ovary: a study of 171 cases with the assessment of intraepithelial carcinoma and microinvasion.

Mucinous tumors of the ovary are a continuing source of controversy in the field of gynecologic pathology. We examined a series of 171 intestinal-type mucinous tumors of low malignant potential (“borderline” or “atypical proliferative” tumors) to clarify the clinical significance of intraepithelial carcinoma (IECA) and microinvasion (area ⩽10 mm2). The diagnosis of IECA was based on the presence of marked nuclear atypia (grade 3). Stromal microinvasion was classified as low grade and high grade (with nuclear grade 3). IECA was observed in 67 of 171 cases (39.2%). Microinvasion was identified in 31 (18.1%) cases, low grade in 22 (12.9%) cases, and high grade in 9 (5.3%) cases. Follow-up status was known in 144 cases and tumor recurrence was observed in 6 patients (4.2%). The risk factors for recurrence included International Federation of Gynecology and Obstetrics stage ≥IC (P=0.002), microinvasion (P=0.013), age less than 45 years (P=0.032), and IECA (P=0.042). The amount of IECA ≥10% was also associated with the risk of recurrence (P=0.007). Among tumors with microinvasion, there was no significant association between the clinicopathologic variables and recurrence. When considering tumors with stage ≥IC, tumor recurrence was significantly associated with IECA ≥10% (P=0.031) and age less than 45 years (P=0.047). It is important that mucinous tumors of low malignant potential should be staged and be optimally sampled for pathologic examination to document the status of the external surface or peritoneal involvement and to identify the worst degree of epithelial proliferation. Tumor stage ≥IC, IECA ≥10%, microinvasion, and age less than 45 years were the features that were associated with tumor recurrence. The study results also support the use of nuclear grade 3 as the sole criterion of IECA.

Carcinoma of Extrahepatic Bile Ducts and Gallbladder Metastatic to the Ovary : A Report of 16 Cases

Information on ovarian metastasis of carcinoma of the extrahepatic bile ducts and gallbladder is limited. Sixteen examples are reported; 3 primary tumors were hilar cholangiocarcinomas, 5 common bile duct carcinomas, and 8 gallbladder carcinomas. The patients ranged from 21 to 87 years (mean, 59 years); 7 presented to gynecologists with nonspecific pelvic symptoms similar to primary ovarian neoplasms. The primary tumor was identified before the detection of the ovarian lesions in 5 cases, was simultaneously detected with the ovarian metastases in 9, and was diagnosed postoperatively in 2. All but one case had bilateral ovarian involvement. The thirty-one ovarian lesions included twenty-nine grossly abnormal ovaries that were enlarged (range, 3.0–16.5 cm, mean, 9.4 cm) and 2 ovaries with only microscopic involvement. The sectioned surface was solid in 9, solid-cystic in 15, and multicystic in 5. Microscopically, ovarian surface implants were seen in 66%, multinodular growth in 58%, and infiltrative stromal invasion in 81%. Mucinous epithelial differentiation was seen in 81%, sometimes with foci of benign-like or borderline-like epithelium simulating primary ovarian mucinous neoplasia. Cystadenoma and cystadenofibroma of nonmucinous type was even mimicked strikingly in some cases because of flattening of epithelium lining glands and cysts. Signet ring cells were present in sufficient quantity for a diagnosis of Krukenberg tumor in four tumors. Colloid-type carcinoma was observed at least focally in 3 tumors. Nonmucinous carcinomatous components included adenocarcinoma with high-grade endometrioid-like morphology in 2 cases, papillary adenocarcinoma simulating mixed müllerian epithelial adenocarcinoma in 1, and undifferentiated carcinoma in 2. Immunohistochemical studies in 8 cases showed a positive reaction for cytokeratin 7 in all and for cytokeratin 20 in 4 cases. The high rate of bilaterality, surface involvement, multinodular growth, and heterogeneity of patterns were the most helpful features for indicating a metastatic nature, with signet ring cells also being helpful in the minority of cases in which they were present. Although the diagnosis of a metastatic tumor to the ovary is possible in most of the cases based on standard diagnostic criteria, problems in the differential diagnosis may be posed by morphologic patterns that overlap strikingly with primary ovarian neoplasms, benign, borderline, and malignant, as discussed herein.

Cervical intraepithelial neoplasia II-III with endocervical cone margin involvement after cervical loop conization : Is there any predictor for residual disease?

Aim:  To determine the clinicopathological predictors for residual disease in women who have had cervical intraepithelial neoplasia (CIN) II‐III with endocervical cone margin involvement after loop electrosurgical excision procedure (LEEP).

Association of human papillomavirus type 16 long control region mutation and cervical cancer

BackgroundThe variation of human papillomavirus (HPV) genes or HPV variants demonstrates different risks of cervical cancer. Mutation in the long control region (LCR) at YY1-motifs is one of the mechanisms for enhancing viral oncogene expression during the course of cancer cell progression. In Thai women, cervical cancers are almost always associated with HPV16 variant sub-lineage Asian (HPV16As); however, the mechanism involved remains elusive. The aim of this study was to understand further the oncogenic potential of HPV16As.MethodsA total of 82 HPV16-positive specimens from Thai women were selected from formalin-fixed paraffin-embedded cervical tissues, and the full length E6 gene of each specimen was amplified and sequenced. LCRs of the HPV16As-positive cases were amplified and sequenced to analyze their polymorphisms. Transcriptional activities of the HPV16As LCRs were then compared with sub-lineage European (EUR), sub-lineage Asian-American 1 (AA1) and HPV16 prototype by insertion of the LCRs into the pGL3-Basic vector.ResultsThe HPV16 DNA sequences were classified as HPV16 prototype (18.3%), Asian (As, 61%), Asian American-1 (AA1, 8.5%), European (EUR, 7.3%), Asian African-2 (AFR2, 3.7%) and Java-135C (J135C, 1.2%). The prevalence of HPV16As was 30% in low-grade squamous intraepithelial lesion (LSIL), while that in high-grade squamous intraepithelial lesion (HSIL) and squamous cell cervical carcinoma (SCC) were 63.9% and 66.7%, respectively, which demonstrates a significant association of HPV16As with the disease severity. LCR polymorphisms from 43 HPV16As positive cases were analyzed by PCR-sequencing. Thirty-eight nucleotide variation positions spanned nucleotide positions 7157–82. Ten new mutations found in the HPV16As LCRs were located predominantly at the enhancer and proximal to the 3’-end of the early promoter. The LCRs of the common HPV16As, EUR and AA1 showed 5, 13 and 23-fold higher activity than the HPV16 prototype LCR, while those of the new nucleotide variations of As showed 19 (As-sv1) and 30 (As-sv14) -fold higher activity than the HPV16 prototype.ConclusionsHPV16As DNA sequence variation, especially at the proximal to early promoter in the LCR, enhances transcriptional activity. This could be one of the possible mechanisms for HPV16As-associated cervical cancer development.

Underlying pathology of women with “atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion” smears, in a region with a high incidence of cervical cancer

Aim:  To evaluate the histopathology of women who had “atypical squamous cells, cannot exclude high‐grade squamous intraepithelial lesions” (ASC‐H) on cervical cytology in a region with high incidence of cervical cancer.

Prognostic Impact of Histology in Patients with Cervical Squamous Cell Carcinoma, Adenocarcinoma and Small Cell Neuroendocrine Carcinoma

BACKGROUND Clarifying the prognostic impact of histological type is an essential issue that may influence the treatment and follow-up planning of newly diagnosed cervical cancer cases. This study aimed to evaluate the prognostic impact of histological type on survival and mortality in patients with cervical squamous cell carcinoma (SCC), adenocarcinoma (ADC) and small cell neuroendocrine carcinoma (SNEC). MATERIALS AND METHODS All patients with cervical cancer diagnosed and treated at Chiang Mai University Hospital between January 1995 and October 2011 were eligible. We included all patients with SNEC and a random weighted sample of patients with SCC and ADC. We used competing-risks regression analysis to evaluate the association between histological type and cancer-specific survival and mortality. RESULTS Of all 2,108 patients, 1,632 (77.4%) had SCC, 346 (16.4%) had ADC and 130 (6.2%) had SNEC. Overall, five-year cancer-specific survival was 60.0%, 54.7%, and 48.4% in patients with SCC, ADC and SNEC, respectively. After adjusting for other clinical and pathological factors, patients with SNEC and ADC had higher risk of cancer-related death compared with SCC patients (hazard ratio [HR] 2.6; 95% CI, 1.9-3.5 and HR 1.3; 95% CI, 1.1-1.5, respectively). Patients with SNEC were younger and had higher risk of cancer-related death in both early and advanced stages compared with SCC patients (HR 4.9; 95% CI, 2.7-9.1 and HR 2.5; 95% CI, 1.7-3.5, respectively). Those with advanced-stage ADC had a greater risk of cancer-related death (HR 1.4; 95% CI, 1.2-1.7) compared with those with advanced-stage SCC, while no significant difference was observed in patients with early stage lesions. CONCLUSION Histological type is an important prognostic factor among patients with cervical cancer in Thailand. Though patients with SNEC were younger and more often had a diagnosis of early stage compared with ADC and SCC, SNEC was associated with poorest survival. ADC was associated with poorer survival compared with SCC in advanced stages, while no difference was observed at early stages. Further tailored treatment-strategies and follow-up planning among patients with different histological types should be considered.

Intrahepatic cholangiocarcinoma metastatic to the ovary: a report of 16 cases of an underemphasized form of secondary tumor in the ovary that may mimic primary neoplasia.

The potential for adenocarcinoma metastatic to the ovary to mimic primary mucinous neoplasms is a well-known issue to surgical pathologists, most of the recent literature emphasizing pancreatic and various other origins for the ovarian metastases. Although an origin in the gallbladder or extrahepatic bile ducts is acknowledged for some cases little information exists on tumors originating within the intrahepatic bile ducts. Sixteen cases of this type were retrieved from the surgical pathology files of the Chiang Mai University Hospital between January 1992 and December 2006. The patients ranged from 38 to 74 years (mean 52). Thirteen presented with nonspecific pelvic symptoms similar to primary ovarian neoplasms. The hepatic tumors were radiologically detected before the ovarian lesion in 2 cases. Hepatic and ovarian masses were simultaneously detected by preoperative radiologic studies or at exploratory laparotomy in 10 cases. In the remaining 4 cases, the hepatic lesions were detected postoperatively. There were a total of 26 metastatic ovarian lesions which included 22 clinically recognized ovarian masses (range 3 to 20 cm, mean 11.8 cm). Bilateral involvement was present in 10 cases (62%) and unilateral involvement in 6 (38%). The cut surfaces of the 22 grossly enlarged ovaries were predominantly solid in 5, solid-cystic in 10, and multicystic in 7. Microscopically, surface implants were observed in 80% of tumors, multinodular growth in 48%, and infiltrative stromal invasion (including microinvasionlike foci as it would be applied if the tumors were primary) in 86%. The neoplastic epithelium typically formed glands that ranged from small to large and cystically dilated, but small clusters of cells and individual cells were also seen. The epithelium ranged from tall, columnar, and mucinous in appearance to cuboidal or flattened and nonspecific. The tumors most closely mimicked primary mucinous neoplasms although a resemblance to other mullerian neoplasms was also seen. Foci often mimicked mucinous borderline tumors of typical type or with intraepithelial carcinoma and benign-appearing mucinous epithelium was seen in 62% of tumors. Immunohistochemical studies in 15 cases showed a positive reaction for cytokeratin 7 in all and for cytokeratin 20 in 5 cases. Intrahepatic cholangiocarcinoma should be included in the list of origins of possible ovarian metastatic tumors that mimic primary ovarian mucinous neoplasia, particularly in parts of the world where cholangiocarcinoma of the liver is relatively common.

Accuracy of Frozen-section Diagnosis of Ovarian Mucinous Tumors

Objective The objective of the study was to evaluate the diagnostic accuracy of intraoperative frozen sections of ovarian mucinous tumors and to identify the features associated with an inaccurate diagnosis. Methods Cases of ovarian mucinous tumors (benign, low malignant potential [LMP] or borderline, primary malignant, and metastatic) diagnosed by frozen section or final histology were recruited. Frozen-section diagnoses were compared with the final histologic diagnoses. Possible variables associated with diagnostic discrepancy were analyzed. Results A comparison of the diagnoses was done in 195 cases (102 benign, 61 LMP, 18 primary malignant, and 14 metastatic). Diagnostic agreement was observed in 164 cases (84.1%) and discrepancy in 31 cases (15.9%). The sensitivity of frozen-section diagnosis was low in LMP (67.2%) and malignant tumors (55.6%). The specificity was the lowest in the benign category (78.5%). The positive predictive values of all categories were less than 90% (range, 83.3%–85.7%). Diagnostic discrepancy was associated with tumor size of greater than 13 cm (P = 0.019) and the number of frozen sections of 4 or more (P = 0.035). However, in a multivariate analysis, there was no independent predictor of diagnostic discrepancy. The number of frozen sections 4 or more was strongly associated with tumor size of greater than 13 cm (P = 0.004). Conclusions The sensitivity of frozen-section diagnosis of LMP and malignant mucinous tumors was low. The inaccuracy of a frozen-section diagnosis of ovarian mucinous tumors may be related to a tumor size of greater than 13 cm. Increasing the number of intraoperative samples over 3 sections per case may not effectively increase the accuracy of frozen-section diagnosis in mucinous tumors.

HPV genotyping in neuroendocrine carcinoma of the uterine cervix in northern Thailand

To determine the distribution of HPV genotypes in cervical neuroendocrine carcinoma (NECA) in northern Thailand, and evaluate the correlation between HPV genotype and clinicopathologic features.