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High-throughput genomic technologies have identified biomarkers and potential therapeutic targets for ovarian cancer. Comprehensive functional validation studies of the biological and clinical implications of these biomarkers are needed to advance them toward clinical use. Amplification of chromosomal region 5q31-5q35.3 has been used to predict poor prognosis in patients with advanced stage, high-grade serous ovarian cancer. In this study, we further dissected this large amplicon and identified the overexpression of FGF18 as an independent predictive marker for poor clinical outcome in this patient population. Using cell culture and xenograft models, we show that FGF18 signaling promoted tumor progression by modulating the ovarian tumor aggressiveness and microenvironment. FGF18 controlled migration, invasion, and tumorigenicity of ovarian cancer cells through NF-κB activation, which increased the production of oncogenic cytokines and chemokines. This resulted in a tumor microenvironment characterized by enhanced angiogenesis and augmented tumor-associated macrophage infiltration and M2 polarization. Tumors from ovarian cancer patients had increased FGF18 expression levels with microvessel density and M2 macrophage infiltration, confirming our in vitro results. These findings demonstrate that FGF18 is important for a subset of ovarian cancers and may serve as a therapeutic target.

Patients with high-grade subtypes of endometrial carcinoma (grade 3 endometrioid, serous, clear cell, or carcinosarcoma) have a relatively poor prognosis. The specific subtype may be used to guide patient management, but there is little information on the reproducibility of subtype diagnosis in cases of high-grade endometrial carcinoma. Fifty-six cases diagnosed as a high-grade subtype of endometrial carcinoma were identified from the pathology archives of Vancouver General Hospital. All slides for each case were reviewed independently by 3 pathologists, who diagnosed the specific tumor subtype(s) and assigned the percentage of each subtype for mixed tumors. Agreement between observers was categorized as follows: major disagreement: (A) no consensus for low-grade endometrioid versus high-grade carcinoma (any subtype), or (B) no consensus with respect to the predominant high-grade subtype present; minor disagreement: consensus was reached about the cell type of the predominant component of a mixed tumor, but there was disagreement about the subtype of the minor component. A tissue microarray was constructed from these cases and immunostained for p16, ER, PR, PTEN, and p53. In 35 of 56 (62.5%) cases, there was agreement between all 3 reviewers regarding the subtype diagnosis of the exclusive (in pure tumors) or predominant (in mixed tumors) high-grade component. Of these cases, there was a minor disagreement (ie, disagreement about the minor high-grade component subtype in a mixed tumor) in 4 cases (4/56, 7.1%). In 20 of 56 (35.8%) cases there was a major disagreement; in 17 (30.4%) of these cases there was no consensus about the major subtype diagnosis, whereas in 3 (5.4%) cases there was disagreement about whether a component of high-grade endometrial carcinoma was present. In the final case, all 3 reviewers diagnosed the case as low-grade endometrioid carcinoma, disagreeing with the original diagnosis of high-grade carcinoma. The most frequent areas of disagreement were serous versus clear cell (7 cases) and serous versus grade 3 endometrioid (6 cases). Immunostaining results using the 5-marker immunopanel were then used to adjudicate in the 6 cases in which there was disagreement between reviewers with respect to serous versus endometrioid carcinoma, and these supported a diagnosis of serous carcinoma in 4 of 6 cases and endometrioid carcinoma in 2 of 6 cases. Pairwise comparison between the reviewers for the 20 cases classified as showing major disagreement was as follows: reviewer 1 and reviewer 2 agreed in 5/20 cases, reviewer 1 and reviewer 3 agreed in 7/20 cases, and reviewer 2 and reviewer 3 agreed in 8/20 cases, indicating that disagreements were not because of a single reviewer holding outlier opinions. Diagnostic consensus among 3 reviewers about the exclusive or major subtype of high-grade endometrial carcinoma was reached in only 35/56 (62.5%) cases, and in 4 of these cases there was disagreement about the minor component present. This poor reproducibility did not reflect systematic bias on the part of any 1 reviewer. There is a need for molecular tools to aid in the accurate and reproducible diagnosis of high-grade endometrial carcinoma subtype.

A 70-year-old woman was seen in this hospital because of vaginal bleeding. An endometrial-biopsy specimen showed a poorly differentiated malignant neoplasm that was suggestive of mixed mullerian tumor (carcinosarcoma). A diagnostic and therapeutic procedure was performed.

Endometrial carcinosarcomas are aggressive neoplasias composed of high-grade carcinomatous and sarcomatous elements. The pathogenesis and specific genetic alterations underlying these tumors are still not well known. We analyzed alterations in oncogenes involved in the pathogenesis of endometrial carcinomas that might represent predictive markers for specific therapies. Immunohistochemistry for HER2 (tyrosine kinase-type cell surface receptor HER2) and c-KIT (tyrosine-protein kinase Kit) and fluorescence in situ hybridization for EGFR (epidermal growth factor receptor) and ALK (anaplastic lymphoma receptor tyrosine kinase) were carried out for 76 endometrial carcinosarcoma samples on sequential tissue microarray sections. Analysis of 238 mutations across 19 common oncogenes was performed on 34 samples using the Sequenom OncoCarta Panel (Sequenom, Hamburg, Germany). We observed EGFR, HER2, and c-KIT expression in 71%, 1.5%, and 2.7% of tumors, respectively. EGFR amplification was detected in 11 of 76 endometrial carcinosarcomas (14.5%). Four samples showed both amplification and aneuploidy (5.2%). ALK amplification together with chromosome 2 polysomy was found in 1.3% of endometrial carcinosarcomas. In total, 23 mutations in 9 different oncogenes were detected in 15 (44.1%) of 34 endometrial carcinosarcomas. Five endometrial carcinosarcomas (14.7%) had 2 or more mutations. Eleven tumors (32.3%) had mutations affecting the PI3K (phosphoinositide-3-kinase)/AKT (v-akt murine thymoma viral oncogene homolog 1) (6 mutations in PIK3CA (PI3K catalytic alpha polypeptide) and 1 in AKT) and/or RAS/BRAF (serine/threonine-protein kinase B-raf) pathway (3 KRAS [kirsten RAS oncogene homolog], 2 NRAS [neuroblastoma RAS viral oncogene homolog], and 1 BRAF). Mutations in PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) and/or KIT were found in 5 endometrial carcinosarcomas (14.7%). Finally, we found mutations in MET (met proto-oncogene [hepatocyte growth factor receptor]) in 2 tumors (5.9%) and in EGFR in one (2.9%). Our study evidences mutations in oncogenes in endometrial carcinosarcomas that are targets or modulators of response to specific therapies in other human cancers, with PI3K/AKT being the most frequently altered pathway.

The ultimate goal of defining cancer specific precursors is to facilitate early detection and intervention before the development of invasive malignancy. Unlike other malignancies involving the female genital tract such as cervical or endometrial carcinomas, precursor lesions of ovarian carcinomas have not been well characterised, resulting in a failure to develop effective screening programs. Recent clinicopathological and molecular studies have provided new insight into the origin and pathogenesis of ovarian carcinomas. It has been shown that ovarian cancer is comprised of different tumour types differing not only in morphology, but also in pathogenesis, molecular alterations and clinical progression. A dualistic model of ovarian carcinogenesis has been proposed. Type I tumours which include low grade serous, low grade endometrioid, clear cell, mucinous carcinomas and Brenner tumours, are generally indolent and tend to be genetically stable, although clear cell carcinoma would probably belong to an intermediate category. They demonstrate a step-wise progression from a benign precursor such as a benign to borderline tumour or endometriosis and are characterised by genetic aberrations targeting specific cell signalling pathways. Type II tumours comprise high grade serous, high grade endometrioid, and undifferentiated carcinomas as well as malignant mixed mesodermal tumours. They are clinically aggressive and exhibit high genetic instability with frequent p53 mutations. Mounting evidence suggests that many high grade serous carcinomas originate from the epithelium of the distal fallopian tube, and that serous tubal intraepithelial carcinoma (STIC) represents the putative precursor of these neoplasms. Low grade serous carcinomas arise via transformation of benign and borderline serous tumours, thought to be derived from inclusion cysts originating from the ovarian surface or tubal epithelium. Recently it has been suggested that papillary tubal hyperplasia may be a putative precursor lesion for serous borderline tumours. Both endometrioid and clear cell carcinomas develop from endometriosis, via alterations affecting different genetic pathways. The origin of mucinous and transitional cell neoplasms is not well characterised, although new data suggest a possible origin from transitional cell nests present at the tubal-mesothelial junction. Likewise, the pathogenesis of carcinosarcomas is also not well established because of their rarity but there is accumulating evidence that the carcinomatous component determines the course of the disease and gives rise to the malignant mesenchymal component. This review discusses recent developments in the pathogenesis of ovarian carcinoma, with particular emphasis on the putative precursor lesions that give rise to the major histological subtypes. Recognition of these lesions is not only important in improving the understanding of ovarian carcinogenesis, but it will also influence our approach to prevent, detect and treat these tumours.

The objective of this study was to analyze the clinical and pathologic factors in patients with uterine serous carcinoma confined to the endometrium. A total of 236 uterine serous carcinoma patients from the pathology databases of 4 large academic institutions were included in the study. Clinical and pathologic variables were analyzed, including patient demographics, tumor size (?2 vs. >2 cm), myometrial invasion, lymphovascular invasion, lymph node status, tumor location (endometrium vs. polyp), cervical involvement, lower uterine segment involvement, FIGO stage, pelvic washings, recurrence, overall survival, and progression-free survival. Of 236 patients, 55 (23%) had tumors limited to the endometrium. Forty-four patients (80%) had Stage IA tumors. The tumor was confined to a polyp in 17 (30.9%) patients. Twenty patients (36.4%) had tumor sizes >2 cm and 12 (21.8%) exhibited lymphovascular invasion. Only 3 patients (5.4 %) had cervical stromal involvement. Thirty-three (66%) patients underwent pelvic and para-aortic lymphadenectomy with 2 positive para-aortic lymph nodes identified. Seven (12.7%) patients had positive washings, whereas 8 patients (14.5 %) had disease recurrence. At a median follow-up of 46 months, there was no difference in overall survival (P = 0.216) or progression-free survival (P=0.063) between patients with tumors confined to a polyp, patients with tumors confined to the endometrium, and patients with tumors present in both polyp and the endometrium. Uterine serous carcinoma with only endometrial involvement, even when confined to a polyp, can be associated with poor prognosis, further stressing the importance of complete surgical staging and adjuvant treatment in this setting.

Objectives Uterine leiomyosarcoma (uLMS) was staged using the FIGO system for endometrial cancers. The new FIGO system takes into consideration tumor size disregarding myometrial and cervical involvement. We aimed to compare the two systems and see which more accurately predicts overall survival (OS). Methods 86 patients with uLMS (1984–2010) were retrospectively staged using both FIGO systems. Mean OS rates were estimated using the Kaplan–Meier method. Results More patients had stage-I disease by the new FIGO system (42 versus 33). Five versus 18 and 27 versus 5 had old and new stage-II and III diseases respectively. Five and 4 patients with old stage II and III uLMS respectively were downstaged to stage I while 18 with old stage III were downstaged to stage II. Median follow-up was 23.5months with a median OS of 114 (95% CI, 61–166) months. Although patients with stage I tumors had a higher mean OS rate compared to those with higher stage disease by either system, patients with old stage II–IV disease showed similar mean OS rates, with stage III–IV patients having a slightly better mean OS and a similar trend was observed with the new system. Patients with new FIGO stage III had a higher mean OS rate than those with stage II or IV disease (37.6 versus 28.1 and 34.3months). Nonetheless, no statistical significant differences were seen in OS according to stage using either system (p=0.786 and p=0.400 respectively). Conclusion Neither FIGO staging system is ideal in classifying patients into four clinically significant stages.

The molecular events implicated in the development of endometrial carcinosarcoma remain poorly understood. Using complementary DNA microarrays, we analyzed a group of 15 endometrial carcinosarcomas and compared their gene expression profiles with those obtained from a group of 23 endometrioid endometrial carcinomas. We demonstrated changes in the expression of genes modulating processes such as the epithelial to mesenchymal transition, muscle differentiation, the expression of cancer/testis antigens, and immune response in endometrial carcinosarcomas. The high mobility group AT-hook 2 gene is an embryonic nuclear factor that mediates epithelial to mesenchymal transition in various tumor models, and it was among the genes overexpressed in endometrial carcinosarcomas. High mobility group AT-hook 2 overexpression was confirmed in 54% of endometrial carcinosarcomas by quantitative real time-polymerase chain reaction and immunohistochemistry. Moreover, we found a significant inverse correlation between the expression of high mobility group AT-hook 2 and let-7b, a member of the let-7 family of microRNAs that represses high mobility group AT-hook 2 expression. These changes were also associated with overexpression of Lin28B, a suppressor of microRNA biogenesis that is implicated in cancer progression and metastasis. Finally, high mobility group AT-hook 2 overexpression, which was detected in less than 3% of endometrioid endometrial carcinomas, was observed in many nonendometrioid carcinomas (46% of 28 samples). This pattern of expression, restricted to nonendometrioid carcinomas and endometrial carcinosarcomas, reflects a role for high mobility group AT-hook 2 in endometrial carcinogenesis that is associated with aggressive phenotypes and points to its potential use as a marker to distinguish between endometrioid and nonendometrioid tumors. © 2013 Elsevier Inc., This work was supported by grants from the Instituto de Salud Carlos III (ISCIII; grant nos. PI07/90324 and PI080971) and the Ministerio de Ciencia e Innovación (MCINN), cofinanced by the European Development Regional Fund “A way to achieve Europe” EDRF (grant no. RD06/0020/0013); the Junta de Andalucía (Consejería de Salud, grant nos. PI-0384/2007 and PI0581/2009) and the Consejería de Innovación (Proyecto de Excelencia, grant no. P07-CVI-03100) to J. Pa.; grants FISPI10/00922, 2009SGR794, and RD06/0020/134 to X. M-G. and RD/0020/15 to J. Pr.; and by a grant from the Asociación Española Contra el Cáncer, Red de Grupos estables en Oncología (AECC-2011) to X. M-G., J. Pr., and G. M-B. L. R-P. is a PhD student and a recipient of a PFIS fellowship (grant no. F109/00193). M. A. C. and J. D. are PhD researchers funded by the ISCIII (grant no. RD06/0020/0013) and the Consejería de Salud de la Junta de Andalucía (PI0581/2009), respectively. M. B. is a researcher funded by the ISCIII-Red de Biobancos RD09/0076/00085. S. R-F. works as a laboratory technician supported by the ISCIII (PI080971). Tumor samples were obtained with the support of Xarxa Catalana de Bancs de Tumors, the Tumor Bank Platform of RTICC RD09/0076/00085 and RD09/0076/00059.

Uterine serous carcinoma (USC) constitutes 10% of uterine cancers but ~40% of deaths. Tumor size is a known prognostic factor in other solid tumors. In endometriod cancers it is one element used to identify the need for complete staging, while its significance in USC is debated. Therefore tumor size was examined as an independent prognostic factor.Clinical and pathologic variables were recorded for 236 institutional patients, and those patients in the SEER database with USC. Chi-square and Fisher exact t-tests were utilized and survival data generated via Kaplan-Meier method; multivariate analysis was performed via cox-regression.The patients' mean age was 67.2 years (range 40-91). Survival ranged from 0 to 184 months (mean 42.8). We used a tumor size cut-off of 1cm and noted significant associations with myometrial invasion (p0.0001), angiolymphatic invasion (p0.0001), peritoneal washings (p=0.03), stage (p=0.015) and positive lymph nodes (p=0.05). Furthermore, recurrence was associated with larger tumors (p=0.03). In multivariate analysis, extra-uterine disease was the only factor associated with both recurrence and survival. Review of the SEER database noted association of larger tumors with lymph node involvement and a significant survival advantage with tumors1cm in both univariate and multivariate analysis.Treatment options for USC are often predicated on the surgical stage and therefore components of the staging are vitally important. The 1cm tumor-size cut-off should be studied prospectively as a prognostic indicator of survival and recurrence in USC and considered for inclusion in USC staging.

Smooth muscle and endometrial stromal tumours represent the two most common uterine mesenchymal neoplasms that may present diagnostic dilemmas for the practising surgical pathologist. Recent changes in morphological and staging criteria, as well as the discovery of new immunohistochemical markers, have improved the diagnosis and classification of these tumours. We highlight the difficulty in distinguishing tumour cell necrosis from infarct-type necrosis and the limited utility of p16 immunohistochemical expression in the diagnosis of leiomyosarcoma. We also discuss the controversial use of mitotic activity and necrosis as prognostic factors in endometrial stromal sarcomas. Emerging genetic information has also greatly expanded our understanding of 'sarcomagenesis' in both tumour types and may provide insight into potential therapeutic targets for the treatment of leiomyosarcoma and endometrial stromal sarcomas, harboring MED12 (mediator complex subunit 12) mutations and recurrent gene rearrangements, respectively. In this review, we discuss the core updates in the diagnosis and classification of uterine leiomyosarcomas and endometrial stromal sarcomas, highlighting new and important molecular genetic findings that may drive pathogenesis.

The World Health Organization (WHO) released a new tumour classification for the genitourinary system in early 2016 after consensus by pathologists with expertise in these organs. It utilized the framework of the 2004 classification, and incorporated the most up-to-date information concerning these tumours. In testicular tumours, the majority of the changes occurred in the nomenclature and classification of germ cell tumours; however, several modifications were also made for non-germ cell tumours. Among sex cord-stromal tumours, sclerosing Sertoli cell tumour (SCT) is no longer recognized as a separate entity but as a morphological variant of SCT not otherwise specified (NOS), as CTNNB1 gene mutations have been noted in both neoplasms but not in the other forms of SCT. Similarly, the lipid cell variant is not separately classified, but is considered to be a morphological variant of SCT NOS. Large-cell calcifying SCT is recognized as a distinct entity that occurs either sporadically or in association with Carney complex, with the latter patients having a distinct germline PRKAR1A gene mutation. Intratubular large-cell hyalinizing Sertoli cell neoplasia is also accepted as a separate entity linked with Peutz-Jeghers syndrome. The subcategories of 'mixed' and 'incompletely differentiated' forms of sex cord/gonadal stromal tumours have been replaced by 'mixed and unclassified sex cord-stromal tumours'. New entities introduced in the latest WHO revision include: myoid gonadal stromal tumour and 'undifferentiated gonadal tissue', a putative precursor lesion of gonadoblastoma, whereas juvenile xanthogranuloma and haemangioma are included in the miscellaneous category of tumours.

Currently, uveal melanoma is not considered within the Lynch syndrome tumor spectrum. However, there are studies suggesting a contribution of microsatellite instability in sporadic uveal melanoma tumorigenesis. We report a 45-year-old woman who was referred for genetic counseling due to a family history of Lynch syndrome caused by a MLH1 mutation. She originally underwent enucleation of the right eye secondary to a uveal spindle cell melanoma diagnosed at age 25. The tumor recurred 22 years later presenting as an ovarian metastasis and concurrently a microscopic endometrial endometrioid carcinoma, grade 1/3 was diagnosed. Subsequent studies highlighted that the uveal melanoma showed high microsatellite instability and loss of MLH1 and PMS2 protein expression, with no MLH1 promoter methylation or BRAF mutation. Additionally, a GNAQ mutation was found. We conclude that our patient’s uveal melanoma is most likely related to MLH1 germline mutation and thus Lynch syndrome related. To the best of our knowledge, this is the first report of uveal melanoma showing MLH1/PMS2 protein loss in the context of Lynch syndrome.

Primary lymphoma of the endometrium is exceptionally rare. Several cases of distinctly nodular lymphoid proliferations confined to the endometrium have previously been described and reported as lymphomas of mucosa-associated lymphoid tissue (MALT). We report the largest series (n=8) of these lymphomas, further defining their morphologic, immunohistochemical, and molecular spectrum. Patients ranged in age from 50 to 87 (median, 62) years. None had a prior history of lymphoma, and lesions were incidental in all but 1 in which a polyp was noted on macroscopic examination. Nodules ranged from small, round, and uniform with minimal architectural effacement to large, expansile, and coalescing with foci of diffuse growth. In the majority, the nodules were confined to the endometrium; however, 2 cases showed myometrial involvement, 1 of which also had extensive extrauterine disease. The nodules comprised monomorphic populations of mature CD20 B lymphocytes with pale scant cytoplasm, CD43, BCL2, and IgM coexpression, and absence of CD10, CD23, and IgD expression. The nodules were associated with CD21/CD23 follicular dendritic meshworks. Clonality was detected in 6 lesions, in 4 by polymerase chain reaction for clonal IGH rearrangement and in 3 by in situ hybridization for immunoglobulin light chains. All were negative for IGH and MALT1 rearrangements by fluorescence in situ hybridization. None of the patients received additional therapy after resection, and most (7/8) are alive with no evidence of disease at last follow-up (mean 4.2 y), whereas the remaining patient is alive with stable disease. These findings demonstrate the unique clinical and pathologic features that characterize primary MALT lymphoma of the endometrium.

Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) is a rare ovarian neoplasm that occurs in young women and has a poor prognosis. The histologic diagnosis of SCCOHT can be challenging due to its rarity and relatively nonspecific histologic features, which range from the classic, first-described small cell morphology to a pattern in which there are large cells with abundant eosinophilic cytoplasm. Many entities can be in the differential diagnosis and to date, immunohistochemical stains have shown no distinctive profile and have been of limited aid. SMARCA4 (also known as BRG1) mutations have recently been reported at high frequency in these tumors. SMARCA4 is an important component of the SWI/SNF complex that regulates gene expression through alteration of nucleosome conformation. Studies to date have suggested that immunohistochemical loss of expression of SMARCA4 is associated with the presence of a SMARCA4 mutation in most cases. In this study, the sensitivity and specificity of the immunohistochemical loss of SMARCA4 expression for the diagnosis of SCCOHT is examined in the context of the differential diagnosis with other primary or metastatic ovarian tumors. All but one of the SCCOHT showed loss of SMARCA4 expression (16/17; 94%), while of 279 other tumors tested, only two tumors (one clear cell carcinoma and one ovarian melanoma) showed loss of SMARCA4 expression. We conclude that SMARCA4 immunohistochemistry is highly sensitive and specific for a diagnosis of SCCOHT and is of clinical utility in the differential diagnosis of poorly differentiated ovarian tumors.

Endometrial/ioid stromal tumors comprise a spectrum of mesenchymal neoplasms, ranging from benign to low-grade malignancy to undifferentiated sarcomas, which occur predominantly in the uterus but may rarely originate at extrauterine sites, most commonly in the ovary. These tumors and their morphologic variants are important to recognize as they often cause diagnostic difficulties. This review focuses on the diagnostic criteria and differential diagnosis, including the role of immunohistochemistry.

Aims Sex cord stromal tumours (SCSTs) of the ovary encompass several histological tumour subtypes that are defined by characteristic histological features. Some can show morphological overlap with other subtypes of SCSTs, as well as with non-SCSTs. The E-cadherin/catenin complex constitutes the adherens junction, which is well developed in epithelial tissue, but the constituent molecules are also expressed in several non-epithelial tumours. The aim of this study was to determine whether the expression patterns of E-cadherin and catenins in ovarian SCSTs can be of diagnostic utility. Methods and results We studied the expression of E-cadherin, α-, β- and γ-catenin in 55 tumours using immunohistochemistry. We found that all tumour subtypes showed nuclear expression of E-cadherin, while only microcystic stromal tumours (MCSTs) displayed a distinct profile, with nuclear localization of all three catenins in almost all cases. Conclusions We conclude that the E-cadherin expression profile in SCSTs can assist in distinguishing between SCSTs and non-SCSTs in which there is no nuclear expression of E-cadherin. The nuclear localization of catenins may be of potential use in distinguishing MCST from other subtypes of SCST.

Endometrial stromal sarcoma (ESS) characterized by YWHAE-FAM22 genetic fusion is histologically higher grade and clinically more aggressive than ESS with JAZF1-SUZ12 or equivalent genetic rearrangements, hence it is clinically important to recognize this subset of ESS. To identify diagnostic immunomarkers for this biologically defined ESS subset, we compared gene expression profiles between YWHAE-FAM22 ESS and JAZF1-rearranged ESS. These studies showed consistent upregulation of cyclin D1 in YWHAE-FAM22 ESS compared with JAZF1-SUZ12 ESS. Immunohistochemically, the high-grade round cell component of all 12 YWHAE-FAM22 ESS demonstrated diffuse (≥70%) moderate to strong nuclear cyclin D1 staining, and this diffuse positivity was not seen in 34 ESSs with JAZF1 and equivalent genetic rearrangements or in 21 low-grade ESS with no demonstrable genetic rearrangements. In a series of 243 non-ESS pure uterine mesenchymal and mixed epithelial-mesenchymal tumors, only 2 of 8 undifferentiated endometrial sarcomas with nuclear uniformity and 1 of 80 uterine leiomyosarcomas demonstrate diffuse cyclin D1 immunoreactivity. Both cyclin D1-positive undifferentiated endometrial sarcomas showed diffuse strong CD10 staining, which is consistently absent in the high-grade round cell component of YWHAE-FAM22 ESS. The low-grade spindle cell component of YWHAE-FAM22 ESS showed a spatially heterogenous cyclin D1 staining pattern that was weaker and less diffuse overall. Our findings indicate that cyclin D1 is a sensitive and specific diagnostic immunomarker for YWHAE-FAM22 ESS. When evaluating high-grade uterine sarcomas, cyclin D1 can be included in the immunohistochemical panel as an indicator of YWHAE-FAM22 ESS.

Two types of endometrial carcinoma (EC) have been delineated on the basis of clinicopathologic studies. Low-grade endometrioid carcinoma (EEC) is the prototype of type I EC and is characterized by microsatellite instability and PTEN, K-ras, and/or β-catenin gene mutations, whereas type II EC is typically represented by serous and clear cell carcinomas (SCs/CCCs), the former frequently showing p53 mutations and c-erb-2 overexpression; however, the molecular profile of grade 3 EEC has not yet been well characterized. The goal of this study was to define the immunohistochemical and molecular profile of grade 3 EEC. We studied 25 patients with grade 3 EEC ranging in age from 35 to 87 (mean 61) years. At the time of initial diagnosis, 16 patients had stage I tumors, whereas 3, 5, and 1 had stages II, III, and IV tumors, respectively. Only 1 patient with stage IV tumor had disease in the peritoneum because of direct extend of tumor through the uterine wall. Two tissue microarrays were constructed from paraffin-embedded blocks and stained for MLH-1, MSH-2, p16, cyclin D1, C-erb-B2, WT-1, and p53. Loss of MLH-1 and MSH-2 was seen in 3 of 25 and 1 of 24 tumors, respectively; none showed loss of both. Diffuse p16 nuclear expression was found in 7 of 23 cases; diffuse and strong nuclear immunostaining for p53, cyclin D1, and Her-2 was seen in 9 of 24 neoplasms, 9 of 25, and 3 of 25 carcinomas, respectively. WT-1 was negative in all 25 tumors. One of the 3 grade 3 EECs with Her-2 overexpression showed gene amplification by fluorescence in situ hybridization analysis. No gene amplification for cyclin D1 was found. Follow-up information was available for all patients. Sixteen had stage I tumors. Of these patients, 11 were alive and well (AW), 3 died of disease (DOD), and 2 died of unrelated causes (DUC), with a mean follow-up time of 56 months (range, 24 to 96 mo); 2 of 3 patients with stage II tumors DOD, and 1 was AW with a mean follow-up time of 81 months (range, 6 to 66 mo); of the 5 patients with stage III tumors, 2 DOD, 1 was AW, 1 was alive with lung metastases, and 1 DUC [mean follow-up of 29 months (range, 12 to 74 mo)]; the only patient who had a stage IV tumor DOD 12 months later. Interestingly, patients with grade 3 EECs showing loss of MLH-1/MSH-2 had stage I tumors, and all were AW (60 to 84 mo). Seventy-seven percent (7 of 9) of patients with tumors showing cyclin D1 overexpression were stage I, and none died of disease, whereas 85% (6 of 7) of patients with p16-positive tumors were high stage (2 stage II, 3 stage III, and 1 stage IV), and 5 DOD. All but one of these patients had tumors that also had p53 overexpression. All 3 patients with Her-2 overexpression DOD (stages I, III, and IV). In conclusion, this study shows that grade 3 EEC shares with low-grade EEC the overexpression but not amplification of cyclin D1 and low frequency of Her-2 overexpression and amplification. Grade 3 EEC shares with SC the relatively common p53 and p16 overexpression and low frequency of loss of mismatch repair genes. However, in contrast to SC ECs, which often show WT-1, cyclin D1 amplification, and Her-2 overexpression and/or amplification, grade 3 EECs rarely overexpressed any of these markers. Moreover, in this study, patients with tumors showing loss of MLH-1/MSH-2 or cyclin D1 overexpression were more likely to have low-stage tumors (stage I), whereas patients with tumors that overexpressed p53, p16, or Her-2 were frequently associated with high-stage tumors.

Santacana M, Yeramian A, Velasco A, Bergada L, Gatius S, Garcia V, Azueta A, Palacios J, Dolcet X, Oliva E & Matias-Guiu X (2012) Histopathology 60, 460–471 Immunohistochemical features of post-radiation vaginal recurrences of endometrioid carcinomas of the endometrium: role for proteins involved in resistance to apoptosis and hypoxia Aims: Endometrioid carcinoma of the endometrium (EEC) is treated with surgery and radiotherapy. Post-radiation recurrences are associated with increased risk of metastases. Comparison of the expression of genes important in the development and progression of EEC, and others involved in resistance to apoptosis and hypoxia and adaptation to radiation, was performed between post-radiation vaginal recurrences (PVRs) and primary EECs. We tried to reproduce the results by exposing an EEC cell line to hypoxia and radiation. Methods and results: Immunohistochemistry and tissue microarrays were used to compare 24 PVRs with 82 primary EECs. PVRs exhibited increased expression of p53 (P

The Wilms tumor gene 1 (WT1) has been reported in normal tissues and many neoplasms of the female genital tract. This review discusses WT1 expression in the female genital tract and its potential utility in the differential diagnosis of neoplasms that occur at this location. WT1 is of value in the differential diagnosis of synchronous serous carcinomas arising in the ovary/fallopian tube/peritoneum and endometrium, as strong WT1 positivity in both tumors points toward an extrauterine origin. In addition, WT1 can be used to distinguish sex cord stromal tumors (WT1 positive) from endometrioid carcinomas (OECs). WT1 expression is not helpful in the differential diagnosis of ovarian serous carcinomas (OSCs) and transitional carcinomas, as both are typically positive and has limited value in the distinction of serous tumors arising in the ovary/fallopian tube/peritoneum from mesotheliomas. WT1 is also not helpful to differentiate small cell carcinoma of hypercalcemic type from juvenile granulosa cell tumor, a common diagnostic problem. Intra-abdominal desmoplastic round cell tumor reacts to WT1 (C-terminal) in contrast to all other tumors discussed which helps to separate this rare tumor from most other small round cell tumors that may involve, primarily or secondarily, the ovary with the exception of small cell carcinoma of hypercalcemic type that typically reacts with the N-terminal of WT1.

Uterine leiomyosarcomas (Ut-LMSs) are aggressive tumors with an overall poor prognosis (15% to 25% 5-year survival rate). However, patients with stage I Ut-LMSs are reported to have a relatively better outcome when compared with the overall group with a 5-year survival rate ranging from 25% to 75%. The purpose of this study was to evaluate the histopathologic parameters that may impact outcome in stage I Ut-LMSs. Twenty-seven patients with stage I Ut-LMSs were identified from the files of 5 tertiary care hospitals between 1974 and 2006. Tumors were primarily staged based on pathologic information, supplemented with radiologic findings (10 cases) and clinical records (1 case). Patients with stage I tumors with no additional clinical or radiologic staging information were included in the study if no recurrence was documented after 6 months from the initial staging operation (16 cases). Clinicopathologic parameters that were statistically evaluated included age [mean, 54 y (37 to 73)], tumor size [mean, 9.5 cm (5.5 to 16)], cell type (17 spindled, 5 epithelioid, 2 myxoid, and 3 mixed), mitotic activity [mean count, 24 (4 to 69)/10 high-power fields], marked cytologic atypia (26 of 27 cases), tumor cell necrosis (12 of 27 cases), and lymphovascular invasion (6 of 27 cases). Follow-up was available for all the patients. Poor outcome was defined when patients either died of disease or were alive with disease. Overall, accounting for any length of follow-up, 16 of 27 (59%) patients with stage I Ut-LMSs had poor outcome; 7 died of disease (mean follow-up, 13 mo) and 9 were alive with disease (mean follow-up, 31 mo). The remaining 11 patients were alive and well with a mean follow-up of 48 months. However, at 2 years of follow-up by univariate analysis, only nonspindle morphology (P

Objective The objective of this article is to discuss malignant tumors of the female pelvic floor and the imaging features that determine therapy. Conclusion After completing this article, the reader should have an improved ability to explain the clinically important anatomic structures of the female pelvic floor and the malignant tumors that arise from each of them; identify the tumor growth patterns on CT, MRI, and PET that preclude complete surgical resection; and recognize malignant transformation of endometriosis on MRI.

High-grade endometrial carcinomas are a heterogeneous group of clinically aggressive tumors. They include FIGO grade 3 endometrioid carcinoma, serous carcinoma, clear cell carcinoma, undifferentiated carcinoma, and malignant mixed Müllerian tumor (MMMT). Epidemiologic, genetic, biologic prognostic and morphologic differences between these entities are striking in prototypic cases, yet substantial overlap exists and diagnostic criteria and therapeutic approaches that account for the group's diversity are currently insufficient. FIGO grade 3 endometrioid carcinoma demonstrates solid, trabecular or nested growth and may resemble poorly differentiated squamous cell carcinoma. Endometrioid glandular differentiation is usually focally present. Serous carcinoma usually displays papillary architecture but glandular and solid patterns may predominate. Tumor cells typically display diffuse and severe atypia. Clear cell carcinoma should be diagnosed by recognizing characteristic papillary or tubulocystic architecture with cuboidal tumor cells showing atypical but uniform nuclei. Cells with clear cytoplasm are frequently but not always present. On the other hand, clear cells may be encountered in endometrioid and serous carcinomas. Immunohistochemical stains for p53, p16, ER, PR, mib-1, hepatocyte nuclear factor 1β and pan-cytokeratin can be helpful in classifying these high-grade carcinomas. They should be used in concert with thorough morphologic examination, as part of a rational panel of markers and only in specific circumstances. Although these tumors may appear clinically and even morphologically similar, demographic and epidemiologic features as well as patterns of spread and treatment modalities differ.

Received November 4, 2009; accepted after revision January 6, 2010. 1Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, White 270, Boston, MA 02114. Address correspondence to S. I. Lee (slee0@partners.org). 2Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA. 3Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA. AJR 2011; 196:S24–S27 0361–803X/11/1963–S24 © American Roentgen Ray Society ABSTRACT The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of malignant tumors of the female pelvic floor and the imaging features that determine therapy.

The histologic assessment of cervical involvement in endometrial carcinoma may be problematic for a number of reasons, but an accurate evaluation of this is important for correct staging, dictating the need for adjuvant therapy, and prognostication. In this study, we assessed interobserver variation in the evaluation of cervical involvement in hysterectomy specimens of endometrial carcinoma among 6 specialist gynecologic pathologists. Seventy-six cases of endometrial carcinoma enriched for cases exhibiting some perceived issue in the assessment of cervical involvement were used. In all the cases, a single slide of the primary tumor in the uterine corpus and a single slide of the cervix were circulated among the 6 participants who filled in a proforma. On the basis of the responses, the tumors were staged according to the 1988 International Federation of Gynecology and Obstetrics (FIGO) staging system (I, IIA, IIB) and the 2009 FIGO staging system (I, II). Using the 1988 FIGO staging system, the unweighted and weighted κ values between individual observers ranged from 0.3115 to 0.6139 (average 0.4675) and from 0.3492 to 0.6533 (average 0.5065), respectively. The κ values between observers for the 2009 FIGO staging system ranged from 0.3481 to 0.6862 (average 0.4908). Although enriched for problematic cases, our study shows that there is at most a fair-to-good agreement among specialist gynecologic pathologists in the assessment of cervical involvement in endometrial carcinoma. Problematic factors include determination of the junction between the lower uterine segment and upper endocervix, the distinction between "floaters" and true cervical glandular involvement, the distinction between cervical glandular involvement and stromal involvement, and the distinction between cervical glandular involvement and reactive non-neoplastic lesions of the endocervical glands. There is a need for specialist pathology groups dealing with gynecologic cancers to develop and disseminate recommendations regarding the assessment of cervical involvement in endometrial carcinoma.

Primary sarcomas of the uterus are uncommon, leiomyosarcoma being the most frequent. Most uterine sarcomas arise de novo, with malignant transformation of a benign mesenchymal tumor being a very rare event, and is reported only in leiomyomata.The clinicopathologic features of 3 uterine liposarcomas arising in association with a lipoleiomyoma were studied. Immunohistochemistry for desmin, h-caldesmon, S100, and MDM2, and fluorescence in situ hybridization for the t(12;16) (q13;p11) were performed in all cases.Patients ranged in age from 49 to 70 (mean, 59) years. The tumors were centered in the myometrium, ranged in size from 10 to 18.5 cm, and showed a gelatinous cut surface with foci of necrosis. On microscopic examination, the tumors had well-circumscribed pushing margins. One neoplasm was uniformly hypocellular with a prominent myxoid background, and a striking delicate vascular network. Another neoplasm showed alternating hypocellular (myxoid) and hypercellular areas, whereas the third tumor was uniformly hypercellular with a hyalinized background. In the myxoid areas, the cells were small and spindle with oval nuclei and inconspicuous nucleoli. In the hypercellular areas, the cells were pleomorphic with large, hyperchromatic nuclei. Mitotic activity ranged from3 to 7/10 high-power fields. Lipoblasts were present in all tumors but were more common in the hypercellular areas. Two tumors merged imperceptibly with a lipoleiomyoma (1 typical and 1 with bizarre nuclei), whereas the third tumor showed an infarcted area composed of ghost mature adipocytes admixed with hyalinized smooth muscle most consistent with an infarcted lipoleiomyoma. Tumors were classified as myxoid, mixed myxoid and pleomorphic, and pleomorphic liposarcoma, respectively. The benign and malignant adipose components were positive for S100, whereas the benign smooth muscle component stained for desmin and h-caldesmon. MDM2 immunostain was positive in the 2 cases with a pleomorphic liposarcoma component. Fluorescence in situ hybridization analysis was successfully completed in only 1 of 3 tumors (pure pleomorphic liposarcoma), which failed to show the t(12;16) and HMAG2 amplification. The patients are alive and well 1, 2, and 20 years after initial surgery with no adjuvant therapy.Primary liposarcomas of the uterus are extremely rare and are most likely to arise from malignant transformation of a lipoleiomyoma. These tumors should be added to the differential diagnosis of benign lipomatous tumors, myxoid mesenchymal tumors, and malignant mixed Müllerian tumors (if pleomorphic) of the uterus.

Establishing a diagnosis of ovarian clear cell carcinoma (O-CCC) can be subject to significant interobserver variation. Accurately diagnosing this tumor is important because of its chemoresistance and reported association with Lynch syndrome. The spectrum of the morphologic features of O-CCC has not been well described in a series composed of immunohistochemically characterized cases. A total of 155 cases diagnosed as O-CCC were retrieved from the files of 3 institutions to analyze architectural and cytologic features. The immunohistochemical features of these cases have been reported earlier. A comprehensive list of features was recorded, including, but not limited to, architectural patterns, nuclear appearance, cytoplasmic characteristics, and mitotic index. Between 1 and 13 slides were available for review for each case. The cases were divided into 2 groups based on morphologic characteristics, those with features shared by the large majority (the first group, n=138) and those that showed unusual characteristics (second group, n=17). Tumors in the first group typically showed a mixture of architectural patterns, the most frequent being papillary and tubulocystic. Papillae, usually small and round and lacking hierarchical branching and tufting or stratification of more than 3 cells, were present at least focally in almost 3 of 4 cases. The cell shape was predominantly cuboidal, not columnar. Nuclear pleomorphism and prominent nucleoli were frequently present, but never diffusely. Clear cytoplasm was found in nearly every case and hobnail cells were common. Mitoses exhibited a range from 0 to 13 with an average of 3 to 4 per 10 high power fields. The second group of tumors showed numerous unusual morphologic characteristics, despite the presence of clear cytoplasm, including those typically seen in other ovarian epithelial tumors, such as serous and endometrioid carcinoma. Eighty-nine percent of tumors from the first group showed the expected "O-CCC immunophenotype" [hepatocyte nuclear factor (HNF) positive, and estrogen receptor (ER), progesterone receptor (PR), Wilms tumor 1 (WT1) and p53 negative], whereas 4% of tumors showed HNF positivity along with focal ER or PR expression. Seven percent of tumors were not immunoreactive with these markers. Twenty-nine percent of tumors in the second group showed the O-CCC immunophenotype, whereas 24% of tumors were p53 positive, 5% of tumors were WT1 positive, and the remaining cases were negative for all markers. Ninety-seven percent (112 of 117) of HNF-positive tumors in this series were classical O-CCC. Therefore, O-CCC has characteristic morphologic features and a specific, if not unique, immunophenotype in the vast majority of the cases. Clear cell-rich tumors with features that depart from the classical morphologic appearances described herein should suggest the possibility of an alternative diagnosis.

Background: Myelodysplastic syndromes (MDS) comprise a group of hematological malignancies that prevail in elderly patients. MDS patients require regular monitoring and personalised treatment, which is generally not curative. Access to specialized MDS centers is warranted. In the UK, the level of support to improve quality of care and quality of life (QoL) for such patients is poorly understood. We performed a survey in MDS patients to better evaluate the level of satisfaction of current care and unmet needs. Materials and Methods: A paper based survey was conducted in the UK in MDS patients referring to the MDS UK Patient Support Group. Total of 962 questionnaires were distributed (862 by newsletter; 100 posted to a random set of MDS UK members). Patients willing to take part sent back the completed survey by prepaid envelope. The survey covered 139 items on demographics, referrals, access to health care, financial impact, disease information, treatment and patient reported outcomes (PRO), including the instrument QOL-E. Results: One hundred seventy one patients of mean age 69±10 years (95 males, 76 females) completed the survey. Median duration of MDS was 3 (IQR 1-5) years. Level of education was secondary school in 30%, college degree in 33%, and university degree in 37%. Sixty-six percent was living with a spouse, 12% with others, while 23% lived alone. Seventy-eight percent was retired. Thirty-four percent lived in rural vs 67% in urban areas. Thirty-three percent had other long-standing illness. While most patients were referred to hematologists within 8 weeks, 13% had a referral > 26 weeks from first signs and symptoms. Most saw a hematologist after 1 to 3 visits but for 25% of patients this required at least 4 General Practitioner (GP) visits. With GPs unfamiliar with MDS, 35% took 4 or more visits to refer their patients. One third of patients does not know or recall their initial diagnosis and 38 continue to not know their MDS subtype. Knowledge of disease type and prognosis was poorer in those with lower incomes. Staff explained MDS as bone marrow failure to 62%, a blood disorder to 42% and refractory anemia to 29%, while the terms pre-leukemia/blood cancer/malignant condition was used for only 43%. Satisfaction with the level of verbal information at diagnosis was experienced in 39%, associated with income (p=0.048). Most patients received written information and found it useful. Change of employment due to MDS occurred in 19% and 15 cases retired because of disease. At the time of the survey, almost half of the patients referred absence of symptoms or only mild symptoms that did not impact on abilities while 15% required assistance. However, 65% referred symptoms at diagnosis that consisted of fatigue in 76%, dyspnea in 62%, bruising in 32%, infections in 18%, and bleeding in 12%. Ninety seven cases had received transfusions and 60 were red blood cell transfusion dependent (RBC-TD) at the time of the survey, declaring compromised abilities, compared to 41% of the transfusion free (RBC-TF) patients (p QOL-E showed good reliability in all domains (Cronbach alfa >0.7) except sexual domain. Scores were significantly lower (worse QoL) in RBC-TD patients in all domains. Physical issues caused by MDS as perceived by patients strongly correlated with all QOL-E domains (P Conclusions: Overall, MDS patients in the UK were dissatisfied with the verbal information provided at diagnosis, leading them to look up potentially unreliable information online. However, written information was useful. Most patients stated that their GP was unfamiliar with MDS at diagnosis thus increasing time to referral. RBC-TD patients experienced MDS as a worrisome disease, with a high emotional burden, resulting in a significantly worse QoL. TD patients have unmet needs requiring additional support and time from staff, but also carers and support groups, showing a clear demand for more discussions between healthcare staff, patients and support sources, to maximise the care and advice available. Disclosures Oliva: Novartis: Consultancy, Speakers Bureau; Celgene: Consultancy, Other: Royalties, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; Sanofi: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; La Jolla: Consultancy. Agberemi:Novartis: Research Funding; Janssen: Research Funding; Celgene: Research Funding. Wintrich:Janssen: Research Funding; Novartis: Research Funding; Celgene: Research Funding, Speakers Bureau.

Background: Patient reported outcome (PRO) assessments, which include quality of life (QoL) and symptoms, have become increasingly important, aiding in identifying and informing patient needs. Patients with acute myeloid leukemia (AML) have poor clinical prognosis and outcomes. There is insufficient knowledge about the impact of disease and treatment on AML patients' lives. Methods: A multicentre study was performed in the UK to assess PROs in patients with haematological malignancy using a novel hematological malignancy (HM) specific PRO tool, HM-PRO, recently developed for use in daily clinical practice. The HM-PRO is a composite measure consisting of two scales: Part A-measuring the 'impact on patients' quality of life (QoL); and Part B-measuring the effect of 'signs and symptoms' experienced by the patients. Part A consists of domains: physical behaviour (PB), social well-being (SWB), emotional behaviour (EB) and eating and drinking habits (ED). All scales have linear scoring system ranging from 0 to 100, with higher scores representing greater impact on QoL and symptom burden. All data were analyzed by descriptive statistics. Parametric and non-parametric tests at a significance level of P Results: Thirty-one patients, mean age 61 ± 16 years, 17 males, completed the assessment. Sixteen cases were > 60 years of age. Median time from diagnosis was 261 (IQR 131-790) days. Two cases were at diagnosis, 4 were resistant/refractory, 7 were stable, 15 were in remission (9 still receiving treatment, including stem cell transplantation), and 3 cases were long-term survivors. Ten cases had additional co-morbidities (5 patients in remission). HM-PRO showed good intraclass correlation and Cronbach's alpha > 0.80 in all dimensions (except for social well-being domain which comprised the item "I have problems with my sex life"). Median scores with interquartile ranges were: PB 36 (14-64); SWB 16 (0-33); EB 41 (14-59); ED 25 (25-75); symptom score 22 (17-33). Scale scores were independent of age, gender and comorbidities. PB score was associated with AML status, patients in remission fairing better (p=0.036). The PB item which was most affected was difficulty with physical activities in 77% of cases. EB was affected by 87% worried about future health, 80% worried about being a burden to others; 77% lamenting changes in sleeping pattern, 74% having difficulty concentrating, 67% feeling anxious, 60% worried about dying, 58% about treatment and 42% feeling distressed. ED was strongly associated with the impact of symptoms (p=0.001), with 63% affected by a change of taste so that most patients experienced a change in eating habits. Energy level was compromised (63% mildly, 33% severely) and 52% felt mildly and 38% severely tired. Difficulty with personal relationships present in 23% of cases correlated with distress (r=0.397, p=0.025), anxiety (r=0.471, p=008), lack of confidence (r=0.640, p Conclusions: AML has a strong impact on patients' lives. QoL is highly compromised, especially at a physical and emotional level, and seems to be independent of age, gender and comorbidities. Worry and anxiety are prevalent conditions. HM-PRO is a useful tool in clinical practice to identify relevant issues which should be considered during decision-making and addressed to individualize care of AML patients. Disclosures Oliva: La Jolla: Consultancy; Janssen: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; Novartis: Consultancy, Speakers Bureau; Celgene: Consultancy, Other: Royalties, Speakers Bureau; Sanofi: Consultancy, Speakers Bureau. Ionova:Takeda: Research Funding; BMS: Research Funding.

Background: The responsiveness of a patient-reported outcome (PRO) measure is an important measurement property which is required to show that the instrument is capable of detecting change over time or after a therapeutic intervention. Minimal clinically important difference (MCID) on the other hand is the smallest change in the scores that is meaningful from a patient's perspective. Evaluating both responsiveness and MCID of a newly developed PRO instrument is a measurement necessity. A novel hematological malignancy (HM) specific PRO tool, HM-PRO, has been developed for use in daily clinical practice as well as clinical research. The HM-PRO is a composite measure consisting of two scales: Part A-measuring the impact on patients' quality of life (QoL); and Part B-measuring the effect of signs and symptoms experienced by the patients. The aims of this study were to evaluate the responsiveness and estimate the MCID of the newly developed HM-PRO. Methods: In a prospective multi-center cross-sectional study, a total of 299 patients: male 167 (55.9%); mean age 64.9 (±11.5) years, range 17.9-88.5 years; mean time since diagnosis 4.9 (±4.8) years, range 0.003 - 27.4 years; with different HM's (acute lymphoblastic leukemia n=8, acute myeloid leukemia n=18, aggressive non Hodgkin lymphoma n=21, chronic lymphocytic leukemia n=24, chronic myeloid leukemia n=11, Hodgkin lymphoma n=12, indolent non Hodgkin lymphoma n=8, myelodysplastic syndrome n=-65, multiple myeloma=85, myeloproliferative neoplasm n=47); in different disease states (stable-139, remission-82, progressing-78) were recruited. Patients were asked to complete the HM-PRO at baseline (t0) and after three months (t1). Data analysis was performed using IBM SPSS 23 statistical software. Paired t-test, effect size and standard response mean (SRM) analysis were performed to test HM-PRO's responsiveness as the ability to detect change. An anchor question (5-point Likert scale from 'much worse to much better') measuring change in HRQoL from patients' perspective was used. Distribution-based approach was used to estimate the MCID, using standard deviation (SD) and standard error of measurement (SEM). Results: Both parts of HM-PRO were assessed individually for responsiveness. The paired sample t-test was significant in the 'slightly better' group for Part A (mean score change=6.8, SD=13.7, t=3.343, df=44, p=0.002; Cohen's d= 0.35; SRM =0.50), and Part B (mean score change=3.68, SD=8.7, t=2.7, df=42, p=0.009; Cohen's d=0.31; SRM=0.42) showing significant decrease in score over time and with moderate effect size. This was followed by 'much worse' and 'much better'. In contrast, patient group with 'about the same' and 'slightly worse' HRQoL did not show significant change in scores over time for both Part A (mean score change=1.7, SD=12.7, t=1.7, df=154, p=0.09; Cohen's d=0.08; SRM=0.13) and Part B (mean score change=0.57, SD=8.93, t=0.80, df=153, p=0.42; Cohen's d=0.04; SRM=0.06) (Table 1). In order to establish MCID, statistical characteristics of the sample of baseline patient response were studied for both Part A and Part B. The analysis of Part A showed a SEM of 6.2 and ½ SD of 11.2, and for Part B showed a SEM of 5.9 and ½ SD of 7.3 (Table 2). Conclusion: This study has established the responsiveness and MCID for both Part A and Part B of HM-PRO. The HM-PRO is capable of detecting small but clinically important changes in patients' HRQoL over time. The MCID for Part A based on SEM was 6.2 and for PART B 5.9 points. It would therefore be prudent, for practical reasons, to propose a MCID of '6' for the HM-PRO. Disclosures Oliva: Sanofi: Consultancy, Speakers Bureau; La Jolla: Consultancy; Amgen: Consultancy, Speakers Bureau; Celgene: Consultancy, Other: Royalties, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; Novartis: Consultancy, Speakers Bureau. Ionova:BMS: Research Funding; Takeda: Research Funding.

Introduction: Patient-reported outcome (PRO) measures not only have been widely used in clinical research but also increasingly employed in daily clinical practice to understand the health outcomes of medical interventions. A novel hematological malignancy (HM) specific PRO tool, HM-PRO, has been recently developed for use in daily clinical practice. The HM-PRO is a composite measure consisting of two scales: Part A - measuring the 'impact on patients' quality of life (QoL); and Part B-measuring the effect of 'signs and symptoms' experienced by the patients. Both scales have linear scoring system ranging from 0 to 100, with higher scores representing greater impact on QoL and symptom burden. The assessment of the "meaningfulness" of HM-PRO scores is essential if clinicians are to be able to use the instrument to understand patient health outcomes to aid their clinical decision-making and encourage better patient engagement. One way of enhancing the clinical utility of scores on multi-item questionnaires is by investigating the importance (to patients and clinicians) of cross-sectional differences by anchoring those differences and changes to clinically familiar events that are related to patient well-being. The aims of the present study were to determine the relationship between the HM-PRO scores and a Global Question (GQ) measuring the impact on a patient's life from patients' perspective and to identify bands of HM-PRO scores equivalent to each GQ descriptor, reflecting patients' global rating of PROs. Methods: In this multicenter cross-sectional study, 905 patients: male 486; mean age 64.3 (±12.4, years; mean time since diagnosis 4.6 (±5.2) years; with different HM's ( acute lymphoblastic leukemia n=29, acute myeloid leukemia n=67, aggressive non Hodgkin lymphoma n=54, chronic lymphocytic leukemia n=64, chronic myeloid leukemia n=45, Hodgkin lymphoma n=37, indolent non Hodgkin lymphoma n=41, myelodysplastic syndrome n=158, multiple myeloma n=296, and myeloproliferative neoplasm n=114); in different disease states (stable-399, remission-277, and progressing - 229) were recruited from seven secondary hospitals and five patient organizations in the UK. All patients were asked to complete the HM-PRO and answer the global question as an anchor. Anchor-based differences were determined cross-sectionally (differences between clinically-defined groups at one time point) to determine clinically important differences in scores. The data analysis was carried out using IBM SPSS 23, a statistical software. Results: The mean HM-PRO score for Part A was 31.7 (±21.6) with median of 28.3 (IQR 13.6-46.6), for Part B was 20.9 (±14.2) with median of 17.6 (IQR 8.8 - 29.4), and the mean GQ score was 3.2 (±1.19) with range 1-5. The mean, mode, and median of the GQ scores for each HM-PRO score for both scales of HM-PRO were used to devise the bands (Figure 1) and intra-class correlation coefficient (ICC) was calculated for level of agreement. The set of scores proposed for adoption included: for Part A HM-PRO scores 0-7 = 'no impact' on patients' QoL (GQ=1, n=64), scores 8-25 = 'a small impact' on patients' QoL (GQ=2, n=133), scores 26-41 = 'moderate impact' on patients' QoL (GQ=3, n=97), scores 42-74 = 'very large impact' on patients' QoL (GQ=4, n=111), and scores 75-100 = 'extremely large impact' on patients' QoL (GQ=5, n=18), with ICC =0.80 (95% CI-0.77 - 0.83); for Part B HM-PRO scores 0-3 = 'no effect' of signs and symptoms on patient's life (GQ=1, n=56), scores 4-16 = 'a small effect' of signs and symptoms on patient's life (GQ=2, n=133), scores 17-29 = 'a moderate effect' of signs and symptoms on patient's life (GQ=3, n=122), scores 30-65 = 'very large effect' of signs and symptoms on patient's life (GQ=4, n=104), and scores 66-100 = 'extremely large effect' of signs and symptoms on patient's life (GQ=5, n=3), with ICC =0.75 (95% CI- 0.71-0.78), respectively (Table 1). Conclusion: This study employed the anchor-based approach for devising a set of score banding for both Part A and Part B of HM-PRO. The proposed bands (Part A=0-7, 8-25, 26-41, 42-74, 75-100; Part B=0-3, 4-16, 17-29, 30-65, 66-100) had the highest agreement and number of patients in the individual bands. The proposed bands could be applied independent of gender and different age groups. The findings of this study will help the clinician and the care team to interpret the HM-PRO scores to aid their clinical decision-making process in daily routine practice. Disclosures Oliva: Sanofi: Consultancy, Speakers Bureau; Celgene: Consultancy, Other: Royalties, Speakers Bureau; La Jolla: Consultancy; Amgen: Consultancy, Speakers Bureau; Novartis: Consultancy, Speakers Bureau; Janssen: Consultancy, Speakers Bureau. Ionova:Takeda: Research Funding; BMS: Research Funding.

Background. MDS may be characterized by hypocellular marrow, irrespective of their WHO classification or molecular characteristics. Their prognostic weight must still be completely evaluated. MDS with hypocellular marrow tend to be considered an aplastic anemia "overlap syndrome" or a pre-aplastic anemia stage. There are no strong specific therapy recommendations, and large studies analyzing the outcome of hypocellular MDS are lacking. While selective sensitivity to immunosuppressive therapy is suggested, evidence in this sense is controversial. Aims. We wanted to evaluate the clinical characteristics, outcome and choice of therapy of patients with hypocellular MDS and compare them with normocellular MDS. Methods. We analyzed 2559 MDS cases with complete clinical annotations and with evaluable bone trephine biopsy, enrolled in our Italian National Registry FISMonlus. In this cohort of patients, 438 had a bone marrow cellularity Results. In FISM cohort median age was 72.5 yrs in the hypocellular group and 72,3 yrs in the normocellular group; M/F were 53.2%/46.8% for hypocellular MDS vs 62.6%/37.4% in normocellular MDS. IPSS-R risk categories were distributed as follows: Hypocellular MDS Very Low 15.5%, Low 35.1%, Intermediate 30.1%, High 11.3%, Very high 8%; Normocellular MDS Very Low 12.8%, Low 37.2%, intermediate 23.7%, High 15.5%, Very High 11.4%. Global median overall survival (OS) was 77 months for hypocellular MDS and 56 months for normocellular MDS. When OS was evaluated in the different IPSS-R risk groups, Lower risk MDS cases with hypocellular BM had a median OS of 125 mos while normocellular had a median OS of 74 mos (p< .001). Higher risk MDS with hypocellular BM had 19 mos median OS vs 20 mos OS in normocellular MDS. Regarding the first line therapy, the comparison of hypocellular MDS with normocellular ones yielded the following: watch and wait 33.8% vs 31.6% for IPSS-R lower risk, 12.1% vs 16% for higher risk cases; AML like chemotherapy and HSCT were chosen for< 1% of lower risk cases overall, and in 1.7% of higher risk hypocellular MDS, while higher risk MDS with normocellular marrow received it in 6.2% of the cases. Azacitidine was first line treatment for 36.2% of the higher risk MDS patients with hypocellular BM and 25% of normocellular BM. Immunosuppressive treatments were emploied for < 1% and 1.5% respectively in lower risk cases only. Erythroid stimulating agents were administered in 42.6% and 41.2% MDS IPSS-R lower risk, hypo- and normocellular, respectively. We then focused on the validation cohort (REL registry). Median age was 74 yrs in the hypocellular group IPSS-R risk categories were distributed as follows: Very Low risk 9 %, Low 36%, Intermediate 39%, High 17 %, Very high 9%. Global median overall survival (OS) was 79 months for hypocellular MDS and 64 months for normocellular MDS. The difference was significant in very low/low IPSS-R risk groups, cases with hypocellular BM having a median OS of 103 mos vs. 69 mos of normocellular cases (p=.011). No significant differences were present in higher disease risk categories. No significant difference was noticed on first line treatment of choice between hypocellular an normocellular MDS. Immunosuppressive treatments were used in a very low proportion of cases (2% and 3% respectively). Conclusion. Our results are based on an unbiased analysis of "real life" MDS patients with hypocellular BM compared to normocellular ones. Clinical characteristics between the two groups were not significantly different in terms of age, gender, and distribution in the various IPSS-R risk categories. The outcome of the hypocellular marrow-MDS cases was better in comparison with that of normocellular MDS, with significantly longer OS in IPSS-R lower risk cases. The advantage in OS for hypoplastic MDS wasn't present for IPSS-R higher risk cases. Finally, the choice of first line therapy doesn't seem to be influenced by the BM cellularity, with a surprising very low proportion of patients receiving immunosuppressive agents, despite several guideline recommend of this treatment for hypoplastic MDS. Disclosures Santini: Novartis: Honoraria; Otsuka: Consultancy; Celgene: Honoraria, Research Funding; AbbVie: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees. Finelli:Novartis: Consultancy, Speakers Bureau; Celgene: Research Funding, Speakers Bureau; Janssen: Consultancy, Speakers Bureau. Gaidano:Janssen: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria; Gilead: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Morphosys: Honoraria; Roche: Consultancy, Honoraria. Oliva:Celgene: Consultancy, Other: Royalties, Speakers Bureau; Novartis: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; La Jolla: Consultancy; Sanofi: Consultancy, Speakers Bureau. Cilloni:celgene: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees.

Clinicopathologic studies support a classification of endometrial carcinoma into two main categories (type I and type II). Type I cancers consist of endometrioid and mucinous carcinomas, with the former being the most common, whereas serous and clear cell carcinomas are the so-called "prototype" of type II cancers. Nonendometrioid carcinomas account for approximately 10% of endometrial carcinomas and differ from endometrioid carcinomas in terms of patient demographics, morphologic features, and biological behavior. Molecular studies have provided further insights into the differing alterations involved in the development and progression of these tumors. This review summarizes the characteristic clinical, morphologic, immunophenotypic, and molecular features of the various subtypes of nonendometrioid carcinomas and also highlights relevant conditions (both nonneoplastic and neoplastic) that should be considered in the differential diagnosis of these tumors.

Endometrial carcinosarcomas (ECSs) undergo a true epithelial-mesenchymal transition (EMT). The molecular determinants of the EMT in vivo are unclear, although a role for some miRNAs, mainly involving the miR-200 family, was recently suggested from in vitro cellular models. We analysed the microRNA (miRNA) signatures associated to EMT in human carcinosarcomas, and determined their relationships with EMT markers and repressors of E-cadherin transcription. The expression of E-, P- and N-cadherin, cadherin-11, p120, vimentin, SPARC, fascin and caveolin-1 was studied in a group of 76 ECS by immunohistochemistry. In addition, real-time PCR was used to measure the differences in the expression of 384 miRNAs, E-cadherin, cadherin-11, SPARC, SNAIL, ZEB1, ZEB2, TWIST-1, TCF4, TGFβ1 and TGFβ2 between the epithelial and mesenchymal components of 23 ECSs. A loss of epithelial characteristics, including cadherin switching and the acquisition of a mesenchymal phenotype, was accompanied by changes in the profile of miRNA expression and the up-regulation of all the E-cadherin repressors analysed. A greater than five-fold difference in the expression of 14 miRNAs between both neoplastic components was seen. Members of the miR-200 family were down-regulated in the mesenchymal part of the ECS. In addition, miR-23b and miR-29c, which are involved in the inhibition of mesenchymal markers, and miR-203, which is involved in the inhibition of cell stemness, were also down-regulated. Up-regulated miRNAs included miR-155, miR-369-5p, miR-370, miR-450a and miR-542-5p. These data suggest that in human ECS, the interplay between transcriptional repressors of E-cadherin and miRNAs provides a link between EMT-activation and the maintenance of stemness.

We report 3 cases of a hitherto undescribed ovarian tumor histologically and immunohistochemically identical to pancreatic solid pseudopapillary neoplasms. The patients were aged 17, 21, and 57 years of age. Two tumors involved the left ovary and 1 the right ovary. They ranged from 3 to 25.5 cm and were confined to the ovary. Radiologic investigations did not show an alternative primary site. Grossly the neoplasms were solid and cystic. On microscopic examination they had mostly diffuse and pseudopapillary growth patterns. Other patterns included nested and microcystic, including cysts filled with colloid-like material. The tumor cells were monotonous and the nuclei were round to oval with pale chromatin and occasional longitudinal nuclear grooves. Clear intracytoplasmic vacuoles were noted in 2 cases, and all 3 cases showed eosinophilic globules. Mitoses and atypia were virtually absent. Immunohistochemically, all 3 neoplasms showed intranuclear positivity for β-catenin and loss of E-cadherin reactivity. All 3 tumors were negative for chromogranin, inhibin, and calretinin, although both cases evaluated for thyroglobulin were found negative. One patient has been followed for 6 years and is free of disease. The other 2 cases are recent. The tumors likely to enter into the differential diagnosis include sex-cord stromal tumors, steroid cell tumors, and struma ovarii. The morphologic and immunohistochemical similarity to pancreatic solid pseudopapillary neoplasm facilitates the accurate diagnosis of this rare ovarian neoplasm.

The telomerase reverse transcriptase (TERT) gene is highly expressed in stem cells and silenced upon differentiation. Cancer cells can attain immortality by activating TERT to maintain telomere length and telomerase activity, a crucial step of tumorigenesis. Two somatic mutations in the TERT promoter (C228T; C250T) have been identified in multiple cancers, such as melanoma and glioblastoma, as gain-of-function mutations that promote transcriptional activation of TERT. A recent study investigating TERT promoter mutations in ovarian carcinomas found mutations in 15% of clear cell carcinomas. However, it is unknown whether these mutations are prevalent in adult-type granulosa cell tumors (AGCTs) of the ovary, Sertoli-Leydig cell tumors (SLCTs), and other malignant sex cord-stromal tumors. We performed whole-genome sequencing on ten AGCT cases with matched normal and identified the TERT C228T promoter mutation in 50% of cases. We found that AGCT cases with mutated TERT promoter have increased expression of TERT mRNA compared to those with wild-type TERT promoter. All five TERT promoter mutated cases had high levels of TERT mRNA expression, whereas three of the five wild-type TERT cases had no measurable TERT mRNA expression. There was a tendency towards longer telomere lengths in AGCT cases with the TERT promoter mutation relative to those without, although it was not statistically significant. These results suggest that telomerase may be activated by a different method in the cases with no TERT promoter mutations but have TERT mRNA expression. The remaining cases with neither TERT promoter mutations nor TERT mRNA expression likely maintain their telomeres using a telomerase-independent method, such as the alternative lengthening of telomeres pathway. TERT C228T allelic discrimination analysis of 331 AGCTs, 5 SLCTs, and 18 other malignant sex cord-stromal tumors detected the mutation in 56/247 (23%) of primary AGCTs, 22/84 (26%) of recurrent AGCTs, 1/5 (20%) of SLCTs and (0/18) 0% of other malignant sex cord-stromal tumors. The single SLCT case with the TERT promoter mutation was poorly differentiated and harbored the pathognomonic FOXL2 mutation of AGCT, suggesting this SLCT case may actually be an AGCT. In 204 AGCT cases with available survival data, there was a trend towards worse disease-specific survival in patients with the TERT promoter mutation compared to those without; however, statistical significance was not reached (p = 0.128, log-ranked test). In 5 AGCT cases with primary and recurrent tissues, we found that the TERT promoter mutation was absent in the primary tumors but present in the recurrent tumors, suggesting that TERT C228T mutation may play an active role in progression of AGCTs. Overall, we found that TERT C228T promoter mutation was most common in AGCTs among the different malignant sex cord-stromal tumors. Our data confirm the activation of telomerase in AGCTs via TERT C228T promoter mutation, although alternative telomerase activation methods in AGCTs may exist. Our results suggest that TERT activation may play a role in AGCT recurrence. As such, telomere biology may be important for the progression of AGCTs. This abstract is also being presented as Poster B54. Citation Format: Jessica A. Pilsworth, Dawn R. Cochrane, Zhouchunyang Xia, Geraldine Aubert, Anniina E. M. Färkkilä, Hugo M. Horlings, Satoshi Yanagida, Winnie Yang, Jamie L. P. Lim, Yikan Wang, Ali Bashashati, Jacqueline Keul, Adele Wong, Esther Oliva, Sohrab P. Shah, Stefan Kommoss, Friedrich Kommoss, Peter M. Lansdorp, Duncan M. Baird, David G. Huntsman. TERT is frequently mutated in adult-type granulosa cell tumors of the ovary compared to other malignant sex cord-stromal tumors. [abstract]. In: Proceedings of the AACR Conference: Addressing Critical Questions in Ovarian Cancer Research and Treatment; Oct 1-4, 2017; Pittsburgh, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(15_Suppl):Abstract nr PR13.

Background: Haploinsufficiency of the ribosomal protein S14 RPS14 gene, located in the common deleted region of chromosome 5q, is a potential causal factor of 5q− syndrome. Lenalidomide elicits high response rates and morphological improvements in myelodysplastic syndrome (MDS) patients with chromosome 5q deletion [del(5q)]. Methods: To further evaluate the role of RPS14, its transcription was tested in bone marrow cells from 17 patients with International Prognostic Scoring System defined Low- or Intermediate-1-risk MDS with del(5q) as a single or additional cytogenetic abnormality receiving treatment with lenalidomide. Results: After 12 wk of lenalidomide treatment, erythroid responses were observed in all cases with an increase in hemoglobin levels of 2.7 ± 2.5 g/dL (up to a mean 11.8 ± 1.9 g/dL; P = 0.001). Before treatment, RPS14 expression levels were under-expressed in 15 patients with respect to normal controls. After 12 wk of lenalidomide treatment, all patients had an erythroid response. There was a significant increase in median RPS14 expression from baseline 0.01 (IQR 0.05–0.31) to 12 wk 204.71-fold (2.86–446.32; P

To evaluate efficacy, safety, changes in biological features, and quality of life (QoL) in low-risk anemic patients with MDS treated with darbepoetin alfa (DPO), 41 patients received DPO 150 microg weekly for 24 weeks. The dose was increased to 300 microg weekly in non-responsive patients. During treatment, 10/17 (59%) transfusion-dependent (TD) and 13/23 (56%) transfusion-free (TF) patients responded. In TF patients, Hb increased from 9.2 +/- 0.9 g/dL to 10.3 +/- 1.4 g/dL by 24 weeks (p = 0.004). The mean response duration was 22 weeks (95% CI: 19.7-24.0) in TF patients compared with 15.1 weeks (95% CI: 13.3-17.5) in TD patients. Response to treatment was associated with increases in QoL. Decreases in the percentage of apoptotic progenitor cells (p = 0.007) and CD34+ cells (p = 0.005) were observed. These results confirm previous studies demonstrating the safety and efficacy of DPO in anemic patients with MDS. Biological changes and improvement in QoL were associated with response. Adequate dosing is to be determined.

A candidate early precursor to pelvic serous cancer, the 'p53 signature', is commonly found in the benign mucosa of the distal Fallopian tube and harbours p53 mutations and evidence of DNA damage. We examined tubes from women with pre-existing (germ-line) mutations in p53 [Li-Fraumeni syndrome (LFS)] for evidence of this precursor. Fallopian tubes from two cases of LFS were immunostained for p53, Ki-67 (proliferation) and H2AX (DNA damage response) and analysed for p53 mutations by laser capture microdissection (LCM) and p53 genomic sequencing (exons 2-11). A common single nucleotide repeat (snp) in exon 3 (rs1042522) and deletion sequencing chromatograms in exon 4 were examined in combination to estimate LOH in both LFS tubes and advanced serous carcinomas from the general population. LFS tubal epithelium contained abundant (10-20 per section) p53 signatures with evidence of DNA damage and low proliferative activity. Six of 11 LFS microdissected p53 signatures (55%) and 15 of 21 serous carcinomas (71%) revealed LOH at the p53 locus, relative to background epithelium. The LFS model confirms prior observations that the distal Fallopian tube is particularly prone to focal epithelial p53 gene inactivation-p53 mutation and LOH-in the absence of malignancy or increased epithelial proliferation. The fact that the LFS is not associated with ovarian cancers is consistent with the concept that loss of p53 function must be accompanied by at least one more genotoxic event (including BRCA1/2 functional inactivation) to produce the malignant phenotype. This is in keeping with a general model of carcinogenesis, in which different and often independent risk factors operate at multiple points in the serous carcinogenic spectrum.

Introduction. Chronic iron overload may represent a serious complication of potentially lifesaving blood transfusions in different haematological diseases. Excess iron deposits in various tissues of the body, particularly the liver, heart, and endocrine organs (Cappellini. Thalassaemia International Federation, 2014). This process leads to tissue damage and ultimately to significant morbidity and mortality (Musallam. Haematologica 2013). Indeed, organ failure due to chronic iron overload may represent the major cause of death in patients with different haematological diseases who receive blood transfusions regularly without appropriate chelation therapy (Inati. Pediatr Blood Cancer 2011; N Engl J Med 2000; Cleve Clin J Med 2005). The main aim of this study was to look for the relationships between changes in LIC and changes in serum ferritin (SF) level, during real life experience with larger setting of patients with haematological diseases and different chelation regimens, previously described at baseline, according to the LICNET protocol (Vitrano et al., Eur J Haematol 2016). Methods. This was a cross-sectional study of patients with haematological disorders attending 9 Italian centres participating in the LICNET. The LICNET protocol was approved on December 4, 2012 by our Ethical Committee. The underlying diagnoses were regularly transfused Thalassemia Major (TM), Thalassemia Intermedia (TI), Sickle Cell Disease (SCD), Myelodysplastic Syndrome (MDS), Diamond-Blackfan Anemia (DBA). Transfused status was defined as receipt of ≥7 mL/kg/month of packed red blood cells. The inclusion criteria for the cross-sectional analysis were: 1) underlying diagnosis above described; 2) determination of two R2-MRI scans performed as part of the network, for those patients presenting between February 2013 and December 2016; 3) transfusion dependence; 4) same chelation treatment at T0 (MRI1) and T1 (MRI2) . The settled R2-MRI protocol at the Centre follows that of St Pierre et al. (St Pierre et al. Magn Reson Med 2014). Descriptive analysis was provided as means, standard deviations, medians or percentages. Three classes of risk (low, intermediate and high), on the basis of LIC values ( 15 mg Fe/g dw ) were considered to evaluate the control of iron body burden during the study period. LIC comparisons at MRI1 and MRI2 were made using t -test and/or Wilcoxon test. All p -values are two sided with the level of significance set at Results. A total of 130 patients were evaluated, with a median age of 35 years (range: 6-78). The median duration (range) between MRI1 and MRI2 days was 483 (184-1076). Patients' characteristics for the considered chelation regimens are summarized in Table 1. Overall patients, across all chelation regimens, showed a statistically significant difference in variation of LIC between MRI1 and MRI2 (p=0.011, Table 2). Overall variation of LIC, during a period of 483 (184-1076) days, was -0.8 (-29.0-33.0) mg Fe/g dw. Median changes in LIC (range), mg Fe/g dw for single chelation regimen are reported on Tab. 2. Changes in LIC determinations, during the period of the study, according to the baseline values, are shown on Fig. 1: Overall 7.7% of patients, across different chelation regimens and during a period of 483 (184-1076) days, moved from high risk group (LIC >15 mg Fe/g dw) to intermediate risk group (LIC 7-15 mg Fe/g dw) with stabilization of iron overloading in patients in low risk group at baseline; all chelation regimens were able to move LIC from high risk group to intermediate risk group. In the other combination group, the patients moved from the intermediate risk group to the low risk group. Median changes in SF level (range), ng/ml for overall patients and for single chelation regimen are reported on Tab. 2: Overall patients, across all chelation regimens, did not show any statistically significant difference in variation of SF between MRI1 and MRI2 (p= 0.566, Table 2). Conclusions. In conclusion, SF level trends are unable to predict changes in LIC, even in well chelated patients with haematological disorders. Therefore, variations of SF level must be interpreted with caution and confirmed, when it is possible, by direct measurement of LIC for more correct management of chelation treatment. Disclosures Oliva: Celgene: Consultancy; Amgen Inc.: Consultancy; La Jolla: Consultancy; Novartis: Consultancy; Janssen: Consultancy.

Benign and malignant soft tissue tumors and pseudotumors can rarely arise anywhere in the female genital tract. Their pathologic features as well as behavior typically overlap with those described in tumors involving typical locations. However, due to their rarity, not infrequently these tumors represent a diagnostic challenge. Their diagnosis should be based on careful gross examination, thorough sampling, and morphologic evaluation, applying a selected immunohistochemical panel and molecular studies. Accurate classification of these tumors is important because their clinical behavior, prognosis, and therapy differ markedly. This article outlines several mesenchymal lesions reported in the female genital tract, encompassing recent histologic, immunohistochemical, and molecular findings, with special emphasis on problems in the differential diagnosis.

Spindle cell lesions of the urinary bladder are uncommon, but when encountered in clinical practice, pose a difficult diagnostic challenge as the differential diagnostic considerations are vast. Pseudosarcomatous processes significantly overlap with malignant tumors (sarcomatoid urothelial carcinoma and leiomyosarcoma) in their morphology and published immunohistochemical profile [pancytokeratin pan (CK), smooth muscle actin (SMA), and desmin]. p63 has been studied rarely and CK 5/6 and CK 34betaE12 have not been analyzed in the bladder in this diagnostic context. In the current study, 45 typical examples of spindle cell lesions [10 pseudosarcomatous myofibroblastic proliferations (PMP), 22 sarcomatoid urothelial carcinomas, and 13 smooth muscle tumors] of the urinary bladder were immunostained with a panel containing broad spectrum anticytokeratin antibodies (OSCAR or AE1/AE3), as well as antibodies to CK 34betaE12, CK 5/6, p63, SMA, and anaplastic lymphoma kinase (ALK). The immunoreactivity was as follows: PMP-CK (OSCAR) 7/10 (70%), CK (AE1/AE3) 7/9 (78%), CK 34betaE12 0/10 (0%), CK 5/6 0/9 (0%), p63 0/9 (0%), SMA 10/10 (100%), ALK 2/10 (20%); sarcomatoid urothelial carcinoma-CK (OSCAR) 15/22 (68%), CK (AE1/AE3) 14/20 (70%), CK 34betaE12 5/20 (25%), CK5/6 6/22 (27%), p63 11/22 (50%), SMA 16/22 (73%), ALK 0/22 (0%); and smooth muscle tumors-CK (OSCAR) 7/13 (54%), CK (AE1/AE3) 7/12 (58%), CK 34betaE12 0/12 (0%), CK 5/6 0/12 (0%), p63 3/13 (23%), SMA 11/13 (85%), ALK 0/13 (0%). Positivity for keratin was typically focal to moderate in smooth muscle tumors and more commonly moderate to diffuse in sarcomatoid carcinomas and PMP. Our data indicate that there is significant immunohistochemical overlap between the different spindle cell lesions, each of which has unique clinicopathologic, prognostic, and therapeutic ramifications. Within the context of morphology, an immunohistochemical panel composed of broad-spectrum antibodies to cytokeratin as well as antibodies to SMA, ALK, p63, and CK 5/6 will be a useful diagnostic adjunct: a combination of pankeratin, SMA, and ALK positivity favors PMP; expression of several cytokeratin and especially CK 34betaE12 and CK 5/6 with p63 favors sarcomatoid carcinoma and SMA positivity with overall absence of other markers favors leiomyosarcoma.

The distinction of ovarian clear cell carcinomas (CCCs) from high-grade serous carcinomas (HG-SCs) is sometimes a diagnostic challenge. With the recognition that CCCs respond poorly to conventional chemotherapy there are efforts to initiate clinical trials for CCC, making accurate diagnosis critical. The purpose of this study was to test and validate a set of antibodies that could aid in the diagnosis of CCC, using a series of cases from different centers in North America. Using a test set of 133 CCCs, we identified the following markers: Cyclin E, estrogen receptor, hepatocyte nuclear factor (HNF)-1beta, Ki-67, p21, p53, and Wilms tumor (WT)1 that show significant discrimination from 200 HG-SCs. For validation, these markers were characterized on an independent set of 104 CCCs from 3 other centers. There were no significant differences in expression of these 7 markers between the independent test and validation sets of CCC. Combining all CCC cases (N=237), HNF-1beta showed the highest sensitivity (82.5%) and specificity (95.2%) for CCC, and WT1 for HG-SC (sensitivity: 79.9%, specificity: 97.4%). A diagnostic panel consisting of WT1, ER, and HNF-1beta demonstrated nearly identical performance as a panel using all 7 markers in distinguishing CCCs from HG-SCs, correctly classifying 84% of cases. Three percent of cases were misclassified and 13% carried an uninformative triple negative immunophenotype. CCCs show a distinct, reproducible immunophenotype, compared with HG-SCs, and a panel of 3 immunomarkers can serve as a diagnostic aid in problematic cases.

Objective. We undertook an extensive molecular characterization of the epidermal growth factor receptor (EGFR) gene in vulvar squamous cell carcinomas to investigate EGFR mutation and/or genomic amplification and its association with EGFR protein expression, high-risk human papillomavirus (HPV) status and clinical outcome. Methods. A cohort of 51 vulvar cancer patients distributed across all FIGO stages was selected for immunohistochemistry (IHC) and fluorescence in situ hybridization. EGFR expression and gene amplification were correlated with high-risk HPV status, EGFR mutational status and clinical prognostic variables. Fisher's exact tests, Kaplan–Meier survival estimates and a Cox proportional-hazards model were utilized. Results. EGFR gene amplification and chromosome 7 high polysomy were observed in 12% and 6% of cases, respectively. IHC of malignant tissue with 3+ staining demonstrated 100% sensitivity and 79% specificity to detect EGFR gene amplification, yielding a 39% positive predictive value. Decreased survival (pb0.025) was observed in patients with gene amplification, and was associated with a more statistically robust 3.3 hazard ratio (pb0.005) in the Cox proportional-hazards model that controlled for age at diagnosis, stage and lymph node metastasis. Univariate analysis confirmed that EGFR gene amplification was associated with the absence of high-risk HPV (pb0.001). Common activating EGFR gene mutations were not identified. Conclusion. A subset of patients with vulvar squamous cell carcinoma was identified with EGFR gene amplification that was HPV-independent and associated with poor prognosis. Given the association of EGFR amplification with response to targeted therapy in other tumor types, these patients may be candidates for therapeutic strategies that target the EGFR pathway.

Use of tamoxifen for treatment and prevention of breast cancer is becoming increasingly common. Tamoxifen has been associated with increased risk of endometrial carcinoma, although the exact mechanism of action is unknown. The aim of our study was to seek a possible correlation between endometrial carcinoma, tamoxifen exposure and MSI, PTEN, β-catenin and K-ras abnormalities. A group of 18 patients with endometrial carcinoma following treatment with tamoxifen were selected. A control group included 15 patients with endometrial carcinoma and associated ovarian hyperthecosis and one patient with endometrial carcinoma and adult granulosa cell tumor of the ovary, chosen because both conditions are associated with increased production of estrogen and increased risk of endometrial carcinoma development. The second control group included 27 randomly selected consecutive patients with endometrial carcinoma without identifiable associated conditions. Immunostaining for β-catenin was performed on all cases; DNA was extracted and amplified by PCR with primers for β-catenin, K-ras and PTEN genes. BAT-25 and BAT-26 were analyzed to assess for MSI. There were 16 endometrioid endometrial carcinomas, one mixed carcinoma and one clear cell carcinoma among patients in the tamoxifen group. All patients with ovarian hyperthecosis and adult granulosa cell tumor had endometrioid endometrial carcinoma. In the random control group, there were 26 endometrioid endometrial carcinomas and one carcinosarcoma. Immunohistochemical and mutational analysis for β-catenin showed abnormalities in 4/11 (36%) and 3/10 (30%) informative cases in the tamoxifen group; 7/16 (44%) and 4/15 (27%) informative cases, respectively in the ovarian hyperthecosis group and 1/27 random control cases (4%) (P, This work was partially supported by research Grants RETICS RD06/0020/0015, Department of Health, Spain and Fundació La Marató de TV3-Proyecto: 050432. GM is a junior investigator of the ‘Ramón y Cajal Program’ of the Spanish Ministry of Education and Science (2004).

Mullerian adenosarcomas (MAs) are rare mixed mesenchymal and epithelial neoplasms that occur most commonly in the uterus. Although the epithelial component is typically benign, the mesenchymal component of most adenosarcomas morphologically resembles that observed in endometrial stromal tumors and is responsible for their clinical behavior. Thus, the differential diagnosis usually includes not only low-grade endometrial stromal tumors, but also adenofibroma, carcinosarcoma, and embryonal rhabdomyosarcoma especially in small samples. The objective of this study was to ascertain the immunophenotypic profile of the epithelial and mesenchymal components of MAs and delineate possible differences between conventional mesenchymal areas and areas of sarcomatous overgrowth. Representative sections from 35 MAs, 28 of them without sarcomatous overgrowth (MA-NSO) and 7 with sarcomatous overgrowth (MA-SO), were included in the study. Thirty tumors arose in the uterus, 4 were pelvic, and 1 originated in the colon. Adequate blocks were selected and immunostained for estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), CD10, WT1, smooth muscle actin, desmin, AE1/3 cytokeratin, CD34, calretinin, inhibin, c-kit, and Ki-67. The mesenchymal component expressed ER in 21/27 MA-NSOs but in only 1/7 MA-SOs (65% overall). PR was expressed in 21/26 MA-NSOs and 4/7 MA-SOs (76% overall), whereas AR was positive in 10/27 MA-NSOs and 5/7 MA-SOs (35% overall). CD10 was expressed in 23/28 MA-NSOs but in only 2/7 MA-SOs (71% overall), and WT1 positivity was seen in 22/27 MA-NSOs and 6/7 MA-SOs (79% overall). Sixty-seven percent of MAs expressed smooth muscle actin, 32% desmin, including both examples of MA-SOs with rhabdomyoblastic differentiation, and 25% expressed AE1/3 cytokeratin. CD34 expression was found in 35% of the tumors, but it was almost always patchy in distribution and weak in intensity, as was calretinin expression, seen only in 12% of the cases. Expression of c-kit and inhibin in greater than 5% of the tumor cells was not encountered. The median and mean Ki-67 labeling indices were 10% and 12%, respectively (range