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Context: Endometrial tissue specimens are commonly encountered in daily practice. It is well known that a number of problematic diagnostic scenarios occur relative to these specimens., Objective: To emphasize practical aspects of endometrial specimen handling and reporting, with selected comments on common diagnostic pitfalls, including (1) the diagnosis of endometrial intraepithelial carcinoma in atrophic endometrial biopsy specimens, (2) evaluation of adequacy of endometrial sampling specimens, (3) problems in diagnosing and measuring the depth of myometrial invasion in endometrial carcinoma, (4) the question of metastasis versus independent primaries in concurrent carcinomas of endometrium and one or both ovaries, (5) the problematic differential diagnoses between type 1 (primarily endometrioid) and type 2 (primarily serous) adenocarcinomas, and (6) atypical hyperplasia and proposed classification systems for its replacement., Data Sources: Published literature, consensus statements, and personal experience., Conclusions: A systematic approach to the handling and reporting of endometrial specimens reduces the potential for omission and error. Recognition of diagnostic pitfalls and practical approaches to their resolution help improve quality.

Eosinophilic cell change is one of the most common endometrial metaplasias occurring in both non-neoplastic and neoplastic endometrium. Its phenotypic characteristics have not still been fully clarified. We examined expression of mucin core proteins in a total of 95 distinct histological areas of endometrial specimens comprising 39 benign nonhyperplastic endometria, 14 endometrial hyperplasias, and 42 endometrial carcinomas. Eosinophilic cell change was very common, seen in 27 endometrial areas (28%); mucinous metaplasia (28%) and ciliated (tubal) change (31%), were also frequently seen. Eosinophilic cell change was more frequently seen in endometrial hyperplasia and carcinoma than in benign nonhyperplastic endometrium. In endometrial carcinomas, eosinophilic cell change was frequently associated with mucinous metaplasia and the two types of metaplastic cells were occasionally intermingled in a single neoplastic gland. A total of 23 (85%) of 27 eosinophilic cell changes and 18 (72%) of 25 mucinous metaplasias showed MUC5AC expression. These frequencies of MUC5AC expression did not differ significantly among benign non-hyperplastic endometrium, endometrial hyperplasia and endometrial carcinoma. Totally, 15 (52%) of 29 ciliated (tubal) changes and two (100%) of two surface syncytial changes, which showed cytoplasmic eosinophilia at least focally, also expressed MUC5AC. Most of the endometrial changes characterized by cytoplasmic eosinophilia may be subtypes of immature mucinous metaplasia which express a mucin core protein but are not fully glycosylated.

Two cases of lobular breast carcinoma metastatic to an endometrial polyp are described. Both patients had been treated with tamoxifen and presented with abnormal uterine bleeding. Histology of endometrial biopsy in both cases showed typical tamoxifen-associated endometrial polyps with focal subtle stromal infiltration by metastatic lobular breast carcinoma. This was confirmed by positive immunohistochemical staining with cytokeratin epithelial markers. Metastatic breast carcinoma may rarely involve tamoxifen-associated endometrial polyps. Because primary endometrial carcinomas may also arise within tamoxifen polyps, these should be extensively sampled. We briefly review polypoid uterine lesions that may occur secondary to tamoxifen therapy.

Context: The endometrium is an intrinsically dynamic tissue with great capability for regeneration and proliferation; consequently, there is some overlap between features seen in benign, premalignant, and malignant lesions. This leads to marked intrabiopsy, interbiopsy, and interobserver variability., Objective: We studied the specificity and sensitivity of computerized image analysis of molecular markers to evaluate its potential use as a diagnostic tool., Design: Specimens from 100 patients were examined and the following histologic diagnoses were assigned: proliferative endometrium (n = 10), secretory endometrium (n = 10), endometrial hyperplasia (n = 40; 30 with no atypia, 10 with atypia), and carcinoma (n = 40; 20 endometrioid, 10 serous, and 10 clear cell). All cases were evaluated immunohistochemically for p53 and proliferating cell nuclear antigen (PCNA) expression. Computerized image analysis was performed with a CAS 200 digital analyzer., Results: Expression of p53 was found only in carcinomas (65%) and endometrial hyperplasia with atypia (30%). Expression of p53 was higher in the poor prognostic categories (serous carcinoma and clear cell carcinoma) than in endometrioid carcinoma. In endometrioid carcinoma, p53 expression correlated with grade. Proliferating cell nuclear antigen showed a similar pattern of results to p53 in the various carcinoma subtypes and endometrioid carcinoma grades. Endometrial hyperplasia PCNA values were the lowest among all the groups. Both carcinomas and proliferative endometrium showed higher glandular and stromal PCNA values, significantly different from endometrial hyperplasia with atypia. In proliferative endometrium, stromal PCNA was the highest among all of the groups. The p53 and PCNA results correlated with each other for carcinoma., Conclusions: Computerized image analysis correlates well with the established morphologic groups of endometrial pathology and yields results consistent with previous studies. Owing to its higher degree of sensitivity, computerized image analysis is of potential use in cases of diagnostic dilemmas and can help objectively allocate the case in the correct category (e.g., proliferative endometrium vs. endometrial hyperplasia, endometrial hyperplasia with atypia vs. endometrioid carcinoma). It is particularly useful in the evaluation of stromal changes.

The adenomatous polyposis coli (APC) tumor suppressor gene is mutationally inactivated in both familial and sporadic forms of colorectal cancers. In addition, hypermethylation of CpG islands in the upstream portion of APC, a potential alternative mechanism of tumor suppressor gene inactivation, has been described in colorectal cancer. Because a subset of both gastric and colorectal cancers display the CpG island methylator phenotype, we hypothesized that epigenetic inactivation of APC was likely to occur in at least some gastric cancers. APC exhibits two forms of transcripts from exons 1A and 1B in the stomach. Therefore, we investigated CpG island methylation in the sequences upstream of exons 1A and 1B, i.e., promoters 1A and 1B, respectively. We evaluated DNAs from 10 gastric cancer cell lines, 40 primary gastric cancers, and 40 matching non-cancerous gastric mucosae. Methylated alleles of promoter 1A were present in 10 (100%) of 10 gastric cancer cell lines, 33 (82.5%) of 40 primary gastric cancers, and 39 (97.5%) of 40 noncancerous gastric mucosae. In contrast, promoter 1B was unmethylated in all of these same samples. APC transcripts from exon 1A were not expressed in nine of the 10 methylated gastric cancer cell lines, whereas APC transcripts were expressed from exon 1B. Thus, expression from a given promoter correlated well with its methylation status. We conclude that in contrast to the colon, methylation of promoter 1A is a normal event in the stomach; moreover, promoter 1B is protected from methylation in the stomach and thus probably does not participate in this form of epigenetic APC inactivation.

Background: E (epithelial)-cadherin, the cell adhesion molecule also considered a potential invasion/metastasis suppressor, is mutationally inactivated in nearly half of all undifferentiated-scattered (diffuse-type) gastric carcinomas. In addition, silencing of E-cadherin by CpG methylation within its promoter region has been reported in several gastric carcinoma cell lines. We investigated the methylation status of the E-cadherin promoter region in 53 primary human gastric carcinomas., Methods: Hypermethylation of the E-cadherin promoter was determined by utilizing methylation-specific polymerase chain reaction (PCR)-single-strand conformation polymorphism (MSP-SSCP) analysis followed by direct sequencing of PCR products. Expression of E-cadherin was studied by western blot analysis. All statistical tests were two-sided., Results: Hypermethylation of the E-cadherin promoter was evident in 27 (51%) of 53 primary gastric carcinomas examined by MSP-SSCP. It occurred more frequently in carcinomas of the undifferentiated-scattered type (in 15 [83%] of 18) than in other histologic subtypes (in 12 [34%] of 35) (P =.0011, Fisher's exact test), and it was present at similar rates in early (in six [60%] of 10) versus advanced (in 21 [49%] of 43) carcinomas (P =.73, Fisher's exact test). Methylation occurring at all cytosine-guanosine sequences (CpGs) near the transcriptional start site was confirmed in six of six tumors examined by bisulfite-DNA sequencing, including two early gastric carcinomas. In addition, loss or diminished expression of E-cadherin was confirmed by western blotting in four of the six tumor tissues demonstrating hypermethylation., Conclusions: The E-cadherin promoter frequently undergoes hypermethylation in human gastric cancers, particularly those of the undifferentiated-scattered histologic subtype. E-cadherin promoter hypermethylation is associated with decreased expression and may occur early in gastric carcinogenesis.

The differential diagnosis of endometrial hyperplasia and well-differentiated endometrioid adenocarcinoma is complicated not only by the resemblance of these lesions to each other, but also by their tendency to be overdiagnosed (particularly hyperplasia) on the background of polyps, endometritis, artifacts, and even normally cycling endometrium. Atypical hyperplasia may also be overdiagnosed when epithelial metaplastic changes occur in simple or complex hyperplasia without atypia. Low-grade adenocarcinomas are best recognized by architectural evidence of stromal invasion, usually in the form of stromal disappearance, desmoplasia, necrosis, or combinations of these findings between adjacent glands. Endometrioid adenocarcinomas are usually Type 1 cancers associated with manifestations of endogenous or exogenous hyperestrogenic stimulation and a favorable prognosis. Subtypes include adenocarcinomas with squamous differentiation and secretory, ciliated cell and villoglandular variants. Rules and pitfalls in the grading of endometrioid adenocarcinomas and the estimation and reporting of myometrial invasion are presented.

Objective: To report a case of secondary amenorrhea and infertility caused by an inhibin-B-producing ovarian fibrothecoma., Design: Case report., Setting: Academic medical center., Patient: A 37-year-old woman with a 2-year history of secondary amenorrhea and infertility., Intervention(s): Operative removal of a 5-cm ovarian fibrothecoma., Main Outcome Measure(s): Luteinizing hormone, FSH, E2, inhibin-B, TSH, and prolactin measured preoperatively and postoperatively. Immunostaining of tumor cells for inhibin and LH., Result(s): Preoperative hormone levels were as follows: FSH, 1.7 mIU/mL; LH, 23.4 mIU/mL; E2, 31 pg/mL; and inhibin B, 1,154 pg/mL. Three weeks postoperatively, the FSH was 1.5 mIU/mL, LH decreased to 7.1 mIU/mL, E2 increased to 276 pg/mL, and inhibin-B decreased to 17 pg/mL. The fibrothecoma did not stain for LH but was strongly positive for inhibin. Regular menstrual cycles resumed 28 days postoperatively., Conclusion(s): Inhibin-B produced by an ovarian tumor profoundly suppressed FSH levels and resulted in secondary amenorrhea and infertility. Use of sensitive and specific immunoassays for inhibin-A and -B may aid in the differential diagnosis of hormonally active ovarian tumors.

To assess the hypothesis that oral contraceptives (OCs) increase the risk of cervical adenocarcinomas, we conducted a six-center case-control study of 124 patients with adenocarcinomas, 139 with squamous cell carcinomas, and 307 population controls. Women between the ages of 18 and 69 who were newly diagnosed with cervical adenocarcinomas between 1992 and 1996 were eligible. Healthy female controls and a second case group of incident cervical squamous cell carcinomas were matched to the adenocarcinoma cases. All participants were interviewed regarding OCs, other risk factors for cervical carcinoma, and utilization of cytological screening, and a PCR-based test determined HPV genotype of cervical samples for both case groups and controls. Use of OCs was positively and significantly associated with adenocarcinomas and positively but weakly associated with squamous cell carcinomas. Associations between OCs and invasive adenocarcinomas (n = 91), squamous cell carcinoma in situ (n = 48), and invasive squamous cell carcinomas (n = 91) disappeared after accounting for HPV infection, sexual history, and cytological screening, but a positive association remained between current use of OCs and cervical adenocarcinoma in situ (n = 33). This association persisted after stratification by screening and sexual history and after restriction according to HPV status, but small numbers made it difficult to exclude detection bias, selection bias, or residual confounding by HPV as potential explanations Current OC use was associated with cervical adenocarcinomas in situ, but we saw no other evidence that OCs independently increase the risk of cervical carcinomas.

Currently, molecular pathology plays a limited role in improving patient outcome in gynecologic oncology. However, molecular investigation is providing important insights into the epidemiology, pathogenesis, and progression of female genital cancers. Future roles should include prediction of poor outcome in low-risk cases, more accurate staging of multifocal tumors, identification of new precursor lesions, and prediction of response to specific therapeutic regimens. Gene therapy of some malignant tumors may become important in the near future. In the immediate future, however, the most significant role of molecular pathology may be in the screening and triage of putative cervical cancer precursors and in the possible prophylaxis of these lesions by means of a vaccine or vaccines against human papillomaviruses.

To determine the prognostic significance of signet ring cells in infiltrating lobular carcinomas, the percentage of signet ring cells in 99 infiltrating lobular carcinomas was correlated with the patients' clinical outcomes (mean follow-up interval of 4.8 years). When the carcinomas were divided into those with 0%, 1-9%, and 10% or more signet ring cells, 57% (26/46) of patients with 10% or more signet ring cells had experienced recurrences or metastases compared with 40% (2/5) and 31% (15/48) with 0% and 1-9%, respectively. A similar analysis performed with breakpoints at 20% or 30% failed to yield any statistically significant associations. When patients were stratified by pathologic stage, patients with stage I disease and 10% or more signet ring cells were more likely to have recurrences or metastases than those patients with stage I tumors and fewer than 10% signet ring cells. There was no relationship between signet ring cells and disease progression in stages II, III, and IV. These results indicate that the presence of 10% or more signet ring cells represents a poor individual prognostic factor in stage I infiltrating lobular carcinomas.

As a quality assurance measure, the usefulness of transmission electron microscopy (EM) and immunohistochemistry (IHC) in our surgical pathology laboratory was compared. The surgical pathology reports from 150 consecutive neoplasms that were examined by both EM and IHC were reviewed. Based on the reported clinical histories, final diagnoses, light microscopy results, and the findings by EM or IHC, the contributions of EM and IHC were classified as "helpful" or "not helpful" for each specimen. Electron microscopy was helpful (92%) more often than was IHC (73%). Electron microscopy was most useful in further classifying poorly differentiated carcinomas, while IHC was particularly useful in classifying poorly differentiated neoplasms. Electron microscopy and IHC were of limited value in identifying the origin of metastatic carcinomas of an uncertain primary. All cases determined to be "not helpful" by either modality were further analyzed to establish a reason for the lack of information provided in each case. This analysis demonstrated a need for improved technical quality and ordering patterns of immunohistochemical stains in our laboratory.

Abnormalities of p53, a tumor suppressor gene, have been considered to play an important role in tumorigenesis. Clinically, overexpression of p53 has been reported to correlate with poor prognosis in several types of tumors. In this study, we examined 221 cases of endometrioid endometrial carcinoma for overexpression of p53 using immunohistochemistry in patients with a median follow-up of 41 months. Immunohistochemical analysis was performed with monoclonal antibody pAb1801. Overexpression of p53 was detected in 47 of 221 cases (21.3%). There was a statistically significant correlation between p53 overexpression and poor prognosis (P < .0001). In the early stages of cancer (stages 1 and 2), p53 was overexpressed in 11 of 22 patients (50%) who died or had a recurrence during follow-up. In contrast, overexpression was detected in only 14.7% of the 156 disease-free patients during the same period (P < .0001). In advanced stages (stages 3 and 4), tumors from patients with recurrent disease had a higher frequency of overexpression (41.2%; 7 of 17) than those of disease-free patients (23.1% 6 of 26). However, the difference between these frequencies was not statistically significant. In multivariate analysis using the Cox proportional hazard model, p53 overexpression was an independent risk factor when compared with clinical stage, nuclear grade, and patient age. Our results indicate that p53 immunohistochemical evaluation of the most common form of endometrial cancer may be useful in identifying cases of aggressive carcinoma, especially in the early stages.

Tumorigenesis in humans and experimental animals appears to involve the activation of ras protooncogenes for a number of organ systems and seems to be important to the development of the metastatic phenotype in several model systems. Clinically, the presence of activated ras protooncogenes has been reported to be a negative prognostic factor in the myelodysplastic syndrome and in adenocarcinoma of the lung. In the present study we examined 49 cases of endometrial carcinoma for mutations in the first exon of K-ras using the polymerase chain reaction and direct sequencing. Mutations in codon 12 or 13 of K-ras were detected in 6 of 49 cases (12.2%). These six cases consisted of five endometrioid endometrial carcinomas, each of which had a mutation in codon 12, and one case of clear cell carcinoma, which had a mutation in codon 13. In our study the presence of mutations in K-ras appeared to be an unfavorable prognostic factor. Three of six patients with the mutation died during follow-up, while only 7% of the 43 patients without K-ras mutations expired during this same period. In multivariate analysis using the Cox proportional hazard model, K-ras activation appeared to be an independent risk factor when compared with clinical stage, depth of myometrial invasion, and patient age. Thus, our findings support the hypothesis that K-ras protooncogene activation plays an important role in determining the aggressiveness of endometrial carcinoma.

Ten granulosa cell tumors of the ovary were investigated using clinicopathologic and flow cytometric parameters. Three of the patients had recurrent or metastatic lesions 3 to 9 years after resection of the primary ovarian tumor. These three cases demonstrated diploidy in both the primary tumor and metastatic or recurrent lesions. Among the seven cases without recurrence, five had diploid DNA indexes. One case was characterized by a high degree of cytologic atypia and tetraploidy (DNA index, 1.98); this patient died of metastatic breast cancer 4 years after resection of the ovarian tumor. Another case demonstrated a high mitotic rate and exhibited aneuploidy (DNA index, 1.33); this woman was alive and well at 5 years of follow-up. In this study, no correlation was found between the recurrence rate and ploidy but, in view of the small numbers and limited follow-up, we cannot definitively analyze these prognostic factors. It does not appear feasible to predict the clinical course of granulosa cell tumors by DNA flow cytometry. However, it can be concluded that: (1) most granulosa cell tumors have diploid DNA content and (2) DNA ploidy correlates well with histologic factors, such as cellular anaplasia and high mitotic activity, which may have predictive prognostic value for granulosa cell tumors.

Primary oncocytic carcinoma of the breast was diagnosed in a 76-year-old man. The histologic and electron microscopic features are characteristic of oncocytic neoplasms that occur at other sites, such as salivary glands and endocrine organs. The pathologic features and the presence of estrogen receptors biochemically are distinct from apocrine carcinoma. The patient is alive 7 years after modified radical mastectomy without additional chemotherapy or radiotherapy.

The autopsy plays an important role in neoplastic disease. Over one third of all adult autopsies disclose cancer, and clinical diagnostic errors are disclosed in approximately 40% of these. There is no evidence that diagnostic accuracy has improved in recent years. In addition to monitoring diagnostic accuracy--particularly with reference to new technologies--the autopsy is also important in detecting both new types of cancer and new causative agents and patterns of incidence and behavior in "old" types of cancer. It also plays a major role in characterizing the toxic effects of new therapeutic regimens and in establishing true causes of death (including accurate primary cancer sites) for setting local, national, and international research and health care priorities.

Immunohistochemical localization of cholesterol side-chain-cleavage, 17 alpha-hydroxylase and aromtase cytochromes P-450 was performed in 35 morphologically normal human premenopausal ovaries by using specific antibodies against the enzymes. In well-developed ovarian follicles in the late stages of follicular growth, immunoreactivity of P-450AROM was only seen in granulosa cells while P-450(17 alpha) and P-450SCC activity was confined to theca interna cells, confirming that follicular oestrogen is produced in granulosa cells by the aromatization of androgens derived from the theca interna cells. In the corpus luteum, this functional differentiation is maintained, since immunoreactivity of P-450AROM was exclusively present in luteinized granulosa cells while that of P-450(17 alpha) was present in luteinized theca calls. Immunoreactivity of P-450SCC was present in both types of cells in the corpus luteum.

The lectin binding properties of ten cases each of adenomatoid nodule, follicular adenoma, and papillary carcinoma and five cases of microinvasive follicular carcinoma were examined histochemically and compared with adjacent normal thyroid tissue. Wheat germ agglutinin, concanavalin A, Ulex europaeus agglutinin I, peanut agglutinin, soybean agglutinin, Dolichos biflorus agglutinin, Ricinus communis agglutinin, and Helix pomatia agglutinin were employed. All the lectins but Ulex europaeus agglutinin I, peanut agglutinin, and Helix pomatia agglutinin were bound to thyroid parenchymal cells, colloid and stromal cells, but none uniquely to thyroid parenchymal cells. Helix pomatia agglutinin binding was present in stromal cells but not in parenchymal cells. Ulex europaeus agglutinin I binding to parenchymal cells was weakly positive only in five cases of papillary carcinoma. The binding in adenomatoid and neoplastic cells and their colloid was stronger than in adjacent normal thyroid tissue in all cases examined. Wheat germ agglutinin and concanavalin A binding was most intense among the lectins examined. In papillary carcinoma, lectin binding was observed mostly in the apical cytoplasm of carcinoma cells, whereas a diffuse surface binding pattern was predominant in follicular adenoma and carcinoma, adenomatoid nodules and normal thyroid gland. No consistent differences in lectin binding were found between follicular adenoma and carcinoma, or between adenomatoid nodules and follicular neoplasia.