Thymic neuroendocrine carcinomas (NECs) are uncommon, for which there is no established information available because of a limited number of epidemiological study in Asia.
We reviewed 21 cases of surgically resected thymic NECs, and evaluated their pathological and clinical features.
It showed male predominance (male/female ratio, 15/6) with wide age range from 20 to 72 years (mean age, 49 years). All 21 cases were divided into two types according to the World Health Organization criteria: atypical carcinoid (n=18) and large cell NEC (n=3). Three cases of atypical carcinoid (AC) were associated with ectopic Cushing's syndrome. All the patients (3/3) with large cell NEC (3/3) and 16.7% (3/18) of those with AC died of tumor progression. Common sites of metastasis included lung, lymph node, brain, lumbar spine, mediastinum, bone, and liver.
In conclusion, thymic neuroendocrine tumors carry a poor prognosis. Regarding the tumor classification, our results showed that a vast majority of carcinoids in the thymus correspond to ACs. In addition, our results also indicate that typical carcinoid is a very rare entity. Some cases of AC exhibited a large size, solid pattern and they showed aggressive clinical behavior, which highlights the spectrum of histologic appearances of thymic NECs.
Thymus gland; Carcinoid tumor; Carcinoma, neuroendocrine
Cancer diagnosis and classification have traditionally been based on the assessment of morphology by microscopy. However, the histological classification system is challenging and demand for genetic information is increasing in the era of targeted and personalized molecular therapy. Recently accumulated comprehensive genomic data could be used to provide a molecular cancer classification alongside the histological classification. This study identified a 19 gene signature able to classify endometrial cancers into the two major histological subtypes, endometrioid and serous. In addition, when the genomic classifier was applied to endometrioid adenocarcinoma of high grade (EM-HG), a subset (23.6%, 25/106) was predicted to be similar to serous tumors at the molecular level. In analyses of multiple cancers, the classification model may also be applicable to ovarian cancers.
Inactivation of TP53, which occurs predominantly by missense mutations in exons 4–9, is a major genetic alteration in a subset of human cancer. In spite of growing evidence that gain-of-function (GOF) mutations of p53 also have oncogenic activity, little is known about the clinical relevance of these mutations.
The clinicopathological features of high-grade serous ovarian carcinoma (HGS-OvCa) patients with GOF p53 mutations were evaluated according to a comprehensive somatic mutation profile comprised of whole exome sequencing, mRNA expression, and protein expression profiles obtained from the Cancer Genome Atlas (TCGA).
Patients with a mutant p53 protein (mutp53) with a GOF mutation showed higher p53 mRNA and protein expression levels than patients with p53 mutation with no evidence of GOF (NE-GOF). GOF mutations were more likely to occur within mutational hotspots, and at CpG sites, and resulted in mutp53 with higher functional severity (FS) scores. Clinically, patients with GOF mutations showed a higher frequency of platinum resistance (22/58, 37.9%) than patients with NE-GOF mutations (12/56, 21.4%) (p=0.054). Furthermore, patients with GOF mutations were more likely to develop distant metastasis (36/55, 65.5%) than local recurrence (19/55, 34.5%), whereas patients with NE-GOF mutations showed a higher frequency of locoregional recurrence (26/47, 55.3%) than distant metastasis (21/47, 44.7%) (p=0.035). There were no differences in overall or progression-free survival between patients with GOF or NE-GOF mutp53.
This study demonstrates that patient with GOF mutp53 is characterized by a greater likelihood of platinum treatment resistance and distant metastatic properties in HGS-OvCa.
Cervical cytology and human papillomavirus (HPV) DNA co-testing is recommended as a screening method for detecting cervical lesions. However, for women who are HPV-positive but cytology-negative, the appropriate management and significance of HPV-58 infection remain unknown.
This study of prevalent HPV detected at baseline with a median follow-up of 3.2 years evaluated the risk factors associated with cervical abnormalities and assessed the significance of HPV-58 infection. A total of 265 women were enrolled. All high-grade squamous intraepithelial lesions (HSIL) that were detected by cytology were confirmed by histology. Histological diagnoses of cervical intraepithelial neoplasia 2/3 were classified as HSIL. Women were classified into four groups according to the HPV genotype that was detected at their first visit: HPV-58 (n = 27), HPV-16 (n = 52; 3 women had HPV-58 co-infection), ten other high risk (HR) types (n = 79), or low/undetermined risk types (n = 107).
Of 265 women, 20 (7.5%) had HSIL on their follow-up examinations. There were significant differences in the cumulative incidence of HSIL between the four groups (p<0.001). The 5-year cumulative incidence rates of HSIL were 34.0% (95% CI: 17.3–59.8%) in HPV-58 positive cases, 28.0% (95% CI: 13.8–51.6) in HPV-16 positive cases, 5.5% (95% CI: 2.1–14.0%) in one of the ten other types of HR-HPV positive cases, and 0% in women with low/undetermined risk HPV. When seen in women with HR-HPV (n = 158), persistent HPV infection was a significant factor associated with the development of HSIL (hazard ratio = 15.459, 95% CI: 2.042–117.045). Women with HPV-58 had a higher risk (hazard ratio = 5.260, 95% CI: 1.538–17.987) for the development of HSIL than women with HPV-16 (hazard ratio = 3.822, 95% CI: 1.176–12.424) in comparison with women with other types of HR-HPV.
HPV-58 has a high association with the development of HSIL in women who are HPV-positive and cytology-negative.
Recent high-throughput sequencing technology has identified numerous somatic mutations across the whole exome in a variety of cancers. In this study, we generate a predictive model employing the whole exome somatic mutational profile of ovarian high-grade serous carcinomas (Ov-HGSCs) obtained from The Cancer Genome Atlas data portal.
A total of 311 patients were included for modeling overall survival (OS) and 259 patients were included for modeling progression free survival (PFS) in an analysis of 509 genes. The model was validated with complete leave-one-out cross-validation involving re-selecting genes for each iteration of the cross-validation procedure. Cross-validated Kaplan-Meier curves were generated. Cross-validated time dependent receiver operating characteristic (ROC) curves were computed and the area under the curve (AUC) values were calculated from the ROC curves to estimate the predictive accuracy of the survival risk models.
There was a significant difference in OS between the high-risk group (median, 28.1 months) and the low-risk group (median, 61.5 months) (permutated p-value <0.001). For PFS, there was also a significant difference in PFS between the high-risk group (10.9 months) and the low-risk group (22.3 months) (permutated p-value <0.001). Cross-validated AUC values were 0.807 for the OS and 0.747 for the PFS based on a defined landmark time t = 36 months. In comparisons between a predictive model containing only gene variables and a combined model containing both gene variables and clinical covariates, the predictive model containing gene variables without clinical covariates were effective and high AUC values for both OS and PFS were observed.
We designed a predictive model using a somatic mutation profile obtained from high-throughput genomic sequencing data in Ov-HGSC samples that may represent a new strategy for applying high-throughput sequencing data to clinical practice.
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare group of tumors with a wide spectrum of clinical behavior. However, there are no known clinically relevant biomarkers to predict metastasis.
To investigate differential gene expression signatures of metastatic vs non-metastatic NETs, we studied cell cycle regulatory genes in 19 metastatic and 22 non-metastatic colorectal NETs by PCR arrays. Immunohistochemistry (IHC) and quantitative real-time RT-PCR were performed to verify the results and another set of 38 GEP-NETs were further studied for validation.
We first delineated six candidate genes for metastasis including ATM, CCND2, RBL2, CDKN3, CCNB1, and GTSE1. ATM was negatively correlated with metastatic NETs (p<0.001) with more than 2-fold change compared to non-metastatic NETs. Overexpression of ATM protein by IHC was strongly correlated with high ATM mRNA levels and low Ki-67 labeling index. Patients with ATM-negativity by IHC showed significantly decreased overall survival than patients with ATM-positivity (median OS, metastatic vs non-metastatic NETs; 2.7 years vs not reached; p = 0.003) and 85.7% of metastatic NETs were ATM-negative. In another validation set of GEP-NETs, decreased mRNA of ATM gene was associated with metastasis and remained significant (p = 0.023).
ATM down-regulation was strongly associated with metastatic NETs when compared with non-metastatic NETs and ATM may be a potential predictive marker for metastasis as well as a novel target in metastatic GEP-NETs.
This is a case report about benign metastasizing leiomyoma with multiple lymph node metastasis. A 34-year-old woman received an abdominal myomectomy for a suspicious leiomyoma. On the pathology report, atypical leiomyoma was suspected. Due to the suspicion of multiple lymph node metastasis on pelvis computed tomography (CT) 1 year after the operation, she was transferred to the Samsung Medical Center on October, 2009 for further work up. According to original slide review, it was determined to be a benign leiomyoma with a mitotic count <5/10 high-power fields, little cytological atypia and no tumor cell necrosis. Additional immunostaining was done. Multiple lymph node metastasis and a small lung nodule were identified on positron emission tomogarphy-CT and chest CT. Extensive debulking surgery and diagnostic video-assisted thoracoscopic surgery (VATS) wedge resection were subsequently done. Metastatic lesions were reported to have a histology similar to that of the original mass. VATS right upper lobectomy with mediastinal lymph node dissection was performed because of the pathology result of VATS (adenocarcinoma). She started taking an aromatase inhibitor (Letrozole®) and there was no evidence of recurrence of disease on an imaging study and no post-operative complications until recently.
Benign metastasizing leiomyoma; Leiomyoma; Lymphatic metastasis
Hypoxia has been established as a key factor influencing the pathophysiology of malignant growth. Hypoxia-induced changes in gene expression are coordinated primarily by hypoxia inducible factor-1 alpha (HIF-1α) and HIF-2α. The purpose of this study was to determine whether or not HIF-2α expression is associated with survival and response to radiation in patients with cervical cancer.
After reviewing the medical records of 119 patients treated in our institution by primary therapy for stage IIB-IVA cervical cancer, we performed a case-control study. Cases (n=12) were selected from patients with local recurrence or radiation failure after primary radiation therapy with or without concurrent chemoradiation. For each case, we selected two controls from patients who had no evidence of local recurrence. Using pre-treatment paraffin-embedded tissues, we evaluated the expression of HIF-2α by immunohistochemistry. Staining was scored based on intensity (intensity score [IS], 0-3) and proportion (proportion score [PS], 0-100). The results were analyzed by the Student t-test, Mann-Whitney U test, Fisher's exact test, and Cox proportional hazards regression model.
Cytoplasmic expression of HIF-2α, representing the degree of hypoxia, had a relationship with poor response to radiotherapy. The hazard ratio of recurrence was 1.71 for the HIF-2α IS (p=0.110) and 1.04 for the HIF-2α PS (p<0.001), indicating that the HIF-2α staining area correlates weakly with the risk for recurrence.
The HIF-2α expression area may have an important role in radioresistance in patients with locally advanced cervical cancer. We conclude that a wider area of hypoxia predicts an increased probability of radioresistance.
Cervical neoplasm; Radiation; HIF-2α; Survival; Hypoxia
A diffuse sclerosing variant of papillary thyroid carcinoma is uncommon and has a tendency for rapid growth and a higher incidence of cervical lymph node metastases. We experienced a case of a diffuse sclerosing variant of papillary thyroid carcinoma in a 48-year-old man. This case showed benign features on initial ultrasonography and positron emission tomography (PET) scan. A new nodule was detected on follow-up ultrasonography that showed rapid enlargement. This case was confirmed by surgical excision. We herein describe the initial and follow-up ultrasonographic findings of a diffuse sclerosing variant of papillary thyroid carcinoma.
Papillary thyroid carcinoma; Diffuse sclerosing variant; Ultrasonography
Although gastric hyperplastic polyps are usually considered as benign lesions, a low risk of carcinomatous conversion is currently recognized. We aimed to identify the characteristics of hyperplastic polyps undergoing neoplastic transformation.
A total of 269 gastric hyperplastic polyps from 216 patients removed by endoscopic polypectomy (EP) or surgical resection were enrolled in this study, and their endoscopic pictures and pathology slides were reviewed.
Neoplastic transformation was detected on forceps biopsy specimen in 11 cases. However, the pathology findings from the EP or surgical specimen revealed neoplastic transformation in 14 cases (5.2%; 4 with dysplasia and 10 with adenocarcinoma). No significant difference was found between hyperplastic polyps with and without neoplastic transformation in age, sex, location, number of polyps or gross appearance. However, neoplastic transformations were more frequently found in gastric hyperplastic polyps >1 cm than in polyps ≤1 cm (12 of 143; 8.4% vs. 2 of 126; 1.6%) (p=0.013).
Neoplastic transformations were more frequently found in gastric hyperplastic polyps >1 cm. Therefore, EP should be considered for gastric hyperplastic polyps >1 cm for the accurate diagnosis and definitive treatment.
Hyperplastic polyp; Neoplastic transformation; Endoscopic polypectomy
Multiple primary cancer is defined as the multiple occurrence of malignant neoplasms in the same individual. Due to the development of new diagnostic techniques and the rise in long-term survival of cancer, reports of multiple primary cancers have gradually increased. Herein, we describe the case of a 68-year-old female patient with quadruple primary cancer of the breast, rectum, ovary, and endometrium. For its great rarity, we report this case with a review of the literature.
Multiple primary cancer; Quadruple cancer
Granulocytic sarcoma is a rare extramedullary tumor composed of myeloid progenitor cells. Primary involvement of the biliary tract without evidence of leukemia is exceedingly rare. Here, we report an isolated biliary granulocytic sarcoma in a 30-yr-old man who presented with jaundice, fever, and chill without any evidence of leukemia. However, five months after the diagnosis, he developed acute myelogenous leukemia with multilineage dysplasia and chromosomal abnormality. A rare possibility of biliary granulocytic sarcoma should be considered as a differential diagnosis in patients with obstructive jaundice. A histologic evaluation by aggressive diagnostic intervention is important and may improve prognosis.
Sarcoma, Granulocytic; Leukemia; Jaundice, Obstructive; Bile Ducts
To verify the spectrum of CD99-expressing lymphoid malignancy, an immunohistochemical study for CD99 was carried out in 182 cases of non-Hodgkin's lymphoma, including 21 lymphoblastic lymphomas, 11 small lymphocytic lymphomas, 9 mantle cell lymphomas, 12 follicular lymphomas, 37 diffuse large B cell lymphomas, 18 Burkitt's lymphomas, 28 NK/T-cell lymphomas, 8 angioimmunoblastic T-cell lymphomas, 23 peripheral T-cell lymphomas, unspecified, and 15 systemic anaplastic large cell lymphomas. CD99 was positive in all T-lymphoblastic lymphomas and in 60% of B-lymphoblastic lymphomas. Majority of T and NK cell lymphomas were negative for CD99, except anaplastic large cell lymphomas (ALCLs). Eight of 15 cases (54%) of ALCLs reacted with anti CD99 antibody. Seven of 10 (70%) ALK positive ALCLs expressed CD99, whereas only 1 of 5 (20%) ALK negative ALCLs were positive. Of the mature B-cell lymphomas, 5.4% (2/37) of diffuse large B cell lymphomas and 11.1% (2/18) of Burkitt's lymphomas expressed CD99. In conclusion, CD99 is infrequently expressed in mature B and T cell lymphomas, except ALK-positive ALCL. High expression of CD99 in ALK-positive ALCL is unexpected finding and its biologic and clinical significances have yet to be clarified.
CD99 protein, human; Lymphoma, Non-Hodgkin; Lymphoma, Large-Cell, Ki-1
Pulmonary metastases of uterine endometrial stromal sarcoma (ESS) are uncommon. The patterns of uterine ESS metastasis to the lung are multiple pulmonary nodules, single nodule, or cystic lesions. Pulmonary intraalveolar micronodular metastases of uterine ESS are unusual and have not been reported. We experienced a case of metastatic uterine ESS presenting as pulmonary diffuse micronodules with ground glass opacities on chest computed tomography of a 37-yr-old woman who previously underwent hysterectomy due to low grade ESS of the uterus four years ago. The histologic findings of video assisted thoracotomy biopsy showed numerous intraalveolar polypoid micronodules protruding from the alveolar septums. All tumor nodules were composed of short spindle cells arranged in ill-defined whorls, and nuclear feature and sparse cytoplasm were seen in uterine ESS. Immunohistochemically, these cells showed strong nuclear staining for estrogen receptor and progesterone receptor, and diffuse cytoplasmic staining for CD10.
Sarcoma, Endometrial Stromal; Neoplasm Metastasis; Lung Neoplasms
Angiosarcoma of the thyroid has long been a controversial entity, and it is histologically defined as cleft-like anastosmosing spaces lined by large, atypical cells of endothelial lineage. However, clear-cut separation between the angiosarcoma and anaplastic carcinoma of the thyroid is difficult because they yield nearly the same clinical prognosis and overlapping histologic findings. We report a case of thyroid neoplasm composed of minimally invasive well differentiated follicular carcinoma and angiosarcoma with intervening transitional area. Immunohistochemically, the angiosarcomatous portion showed focal immunoreactivity for endothelial markers such as CD31, CD34, Ulex europaeus 1 lectin, factor VIII-related antigen, and immunonegativity for epithelial markers including pancytokeratin, epithelial membrane antigen and thyroglobulin, whereas the reverse was demonstrated in the minimally invasive follicular carcinomatous portion. The follicular carcinoma portion was positive for thyroid transcription factor-1 (TTF-1). Each component showed ultrastructural findings of epithelial and endothelial differentiation, respectively. The present case was unique in that angiosarcoma of the thyroid was confirmed by immunohistochemistry and electron microscopy, as well as light microscopy, and also coexisted with a minimally invasive well differentiated follicular carcinoma in the same mass. This combination has never been described in the literature. Although restricted to a single case, the present case further supports that angiosarcoma is a true existent entity rather than a variant of anaplastic carcinoma.
Scrotal leiomyomas with atypical bizarre nuclei are rare, which might be misdiagnosed as malignant tumor. We describe a case of scrotal bizarre leiomyoma in a 65-yr-old man. The tumor was a 1 cm-sized, well circumscribed, oval mass arising from the tunica dartos muscle. Histologically, it was formed by whorling bundles of fusiform cells with occasional atypical, pleomorphic nuclei and pseudo-inclusions. Mitosis was not found. Although morphologically atypical, scrotal bizarre leiomyomas take on a biologic behavior not different from that of conventional leiomyoma, they should be distinguished from leiomyosarcoma to avoid unnecessary treatment.
The degree of correlation between sequencing and immunohistochemisty (IHC) for detecting mutations of p53 has not been well established in human hepatocellular carcinoma (HCC). We analyzed 36 HCCs from Korean people for p53 mutation at exons 4-10 by PCR-SSCP and sequencing, and compared the results with the IHC positivity. p53 mutations were identified in 7 out of 36 HCCs (19.4%). These mutations were found widely throughout exons 4-8. No mutation was detected in codon 249. Among the 7 mutations, 6 missense mutations were detected in 15 HCCs with > or =5% immunoreactive tumor cells and one nonsense mutation was in 21 HCCs with <5% immunoreactive tumor cells. The sensitivity for p53 mutation was 85.7% (6/7), the specificity 69.0% (20/29), the predictive value of positive IHC 40.0% (6/15), and the predictive value of negative IHC 95.2% (20/21). Two missense mutations were detected in 25 cases with <10% immunoreactive tumor cells. Predictive values of both positive IHC and negative IHC were higher in > or =5% overexpression group than in > or =10% overexpression group or >0% overexpression group. This study suggests that 5% immunoreactivity is a reliable immunohistochemical threshold value to detect p53 mutations in HCCs and the spectrum of p53 mutations in HCCs in Korean people is different from that of high aflatoxin B1 exposure areas.