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In endometriosis, the lymphatic and immune systems are implicated in disease establishment and progression. The objective of this pilot study was to examine endometrial-like, and for the first time, immune cell populations in lymph nodes associated with deep infiltrating endometriosis (DIE) bowel lesions. Premenopausal women undergoing excision of endometriosis and/or hysterectomy were included. DIE bowel lesion-associated (n = 10) and other pelvic (n = 15) lymph nodes were studied. Samples were immunohistochemically stained for endometrial-like cells (CD10), T cells (CD3, CD4, CD8, and FoxP3), dendritic cells (DC; DC-Lamp and DC-Sign), B cells (CD20, CD79 and plasma), macrophages (CD68), and natural killer cells (NK; CD57). Cell abundance (percentage positive area) and antigen expression (optical density; OD) were quantified. Endometrial-like cells and each immune cell population were present in all studied nodes. The DIE bowel lesion-associated nodes showed features of immune activation, with T cell proliferation (CD3+ area p = 0.007, CD4+ area p = 0.015 compared with other pelvic nodes); and a mixture of helper and regulatory T cells, B cells, DCs, macrophages, and plasma cells present in the paracortex. In DIE bowel lesion-associated compared with other pelvic nodes, CD10+ endometrial-like cells were reduced (percentage positive area p

Malakoplakia is a rare histiocytic disease first described in 1902 by Michaelis and Gutmann. It is associated with host immunocompromise including chronic inflammatory conditions, infectious conditions or malnutrition. Here, we report the case of uterine malakoplakia as a rare cause of postmenopausal bleeding in an immunocompromised patient.

Basal-like breast cancer (BLBC) is a poorly characterised, heterogeneous disease. Patients are diagnosed with aggressive, high-grade tumours and often relapse with chemotherapy resistance. Detailed understanding of the molecular underpinnings of this disease is essential to the development of personalised therapeutic strategies. Inhibitor of Differentiation 4 (ID4) is a helix-loop-helix transcriptional regulator required for mammary gland development. ID4 is overexpressed in a subset of BLBC patients, associating with a stem-like poor prognosis phenotype, and is necessary for the growth of cell line models of BLBC, through unknown mechanisms. Here, we have defined a molecular mechanism of action for ID4 in BLBC and the related disease highgrade serous ovarian cancer (HGSOV), by combining RIME proteomic analysis and ChIP-Seq mapping of genomic binding sites. Remarkably, these studies have revealed novel interactions with DNA damage response proteins, in particular, mediator of DNA damage checkpoint protein 1 (MDC1). Through MDC1, ID4 interacts with other DNA repair proteins (γH2AX and BRCA1) at fragile chromatin sites. ID4 does not affect transcription at these sites, instead binding to chromatin following DNA damage and regulating DNA damage signalling. Clinical analysis demonstrates that ID4 is amplified and overexpressed at a higher frequency inBRCA1-mutant BLBC compared with sporadic BLBC, providing genetic evidence for an interaction between ID4 and DNA damage repair pathways. These data link the interactions of ID4 with MDC1 to DNA damage repair in the aetiology of BLBC and HGSOV.

Australia has implemented a high-coverage HPV vaccination program but has not, to date, established the distribution of HPV types that occur in cervical cancers in Australia. This information is important for determining the potential for cervical cancer prevention with both current and broader spectrum HPV vaccines. We analysed 847 cervical cancers diagnosed 2005 to 2015 in tertiary centres in the three most populous Australian states with resolution of specimens containing multiple HPV types using laser-capture microdissection. Archived FFPE tissue was reviewed by specialist pathologists, sandwich sectioned, and initially whole-tissue sections genotyped for HPV. Samples were first genotyped using SPF10-LiPA25 (version 1). Negative samples were screened with DNA ELISA kit HPV SPF10, followed by genotyping with SPF+ LiPA if ELISA positive. If still negative, samples were tested on a qPCR assay targeting the E6 region of HPV16, 18, 45 and 33. Of the 847 cancers (65.1% squamous, 28.7% adenocarcinoma, 4.3% adenosquamous, 2.0% other), 92.9% had HPV detected. Of the HPV-positive cancers, 607 of 787 (77.1%) contained HPV16 or 18, 125 of 787 (15.9%) contained HPV31/33/45/52 or 58, and 55 (7.0%) another HPV type. There was a strong correlation between HPV type and age, with younger women most likely to have HPV16/18 detected and least likely HPV negative. Our findings indicate that cervical cancers diagnosed in Australia more frequently contain HPV16/18 than in international series. This could be due to cervical screening in Australia increasing the proportion of adenocarcinomas, in which types 18 and 16 more strongly predominate, due to prevention of squamous cancers.

CTCF is a haploinsufficient tumour suppressor gene with diverse normal functions in genome structure and gene regulation. However the mechanism by which CTCF haploinsufficiency contributes to cancer development is not well understood. CTCF is frequently mutated in endometrial cancer. Here we show that most CTCF mutations effectively result in CTCF haploinsufficiency through nonsense-mediated decay of mutant transcripts, or loss-of-function missense mutation. Conversely, we identified a recurrent CTCF mutation K365T, which alters a DNA binding residue, and acts as a gain-of-function mutation enhancing cell survival. CTCF genetic deletion occurs predominantly in poor prognosis serous subtype tumours, and this genetic deletion is associated with poor overall survival. In addition, we have shown that CTCF haploinsufficiency also occurs in poor prognosis endometrial clear cell carcinomas and has some association with endometrial cancer relapse and metastasis. Using shRNA targeting CTCF to recapitulate CTCF haploinsufficiency, we have identified a novel role for CTCF in the regulation of cellular polarity of endometrial glandular epithelium. Overall, we have identified two novel pro-tumorigenic roles (promoting cell survival and altering cell polarity) for genetic alterations of CTCF in endometrial cancer.

A case of Extramammary Paget's Disease (EMPD) involving the cervix mimicking cervical carcinoma on routine cervical cytology in a 66-year-old woman with a history of recurrent multifocal EMPD involving the vulva, perineum, perianal area, and rectum is reported. The patient had undergone multiple excisions and reconstructions of EMPD, however, had a benign cervical smear history and reported no vaginal bleeding. The conventional papanicolaou smear was reported as concerning for carcinoma with abundant, well preserved material illustrating highly atypical cells with anisonucleosis and dense cytoplasm and focal microacini. Gross anatomical distortion from EMPD and previous surgery precluded satisfactory outpatient colposcopic assessment. Examination under anesthesia was performed and colposcopy revealed a four quadrant high grade lesion extending into the vagina with one area suspicious for malignancy on the cervix. Directed biopsies were taken and histopathology confirmed EMPD with diffuse adenocarcinoma in situ cells infiltrating skin and mucosa of all specimens. These large pale cells were seen both a singly and in clusters of nests within the mucosa. Periodic Acid Schiff staining was positive for intracytoplasmic mucin and supportive immunohistochemistry was performed with strong reactivity in atypical cells for CK7, CEA, and Cam 5.2. There was no evidence of invasive malignancy and the patient remains under clinical surveillance. Cervical EMPD is rare but should be considered in women with abnormal cervical cytology and a history of vulval EMPD. Diagn. Cytopathol. 2016;44:931-934. © 2016 Wiley Periodicals, Inc.

Recurrent miscarriage affects approximately 1% of the population and in half of these cases no cause is found. Abnormally functioning immunocompetent cells, including natural killer (NK) cells, in the endometrium, are thought to be responsible for many such cases and treatment trials including oral prednisolone and intravenous immunoglobulins are now underway. Despite these encouraging developments, there is neither adequate standardization of counting uterine NK cells nor consensus as to what constitutes an abnormal level. To address this issue, immunohistochemistry was used to examine the presence and distribution of selected immune cells and macrophages in the endometrium from 222 women who had a routine endometrial biopsy for investigation of recurrent miscarriage or IVF failure, at various stages of the menstrual cycle, and accessioned prospectively over a 7-month period. Biopsies were examined by H+E and immunostained for CD8(+) T-cells, CD163(+) macrophages, CD56(+) NK cells, and CD57(+) cells. Cell numbers (expressed as immunopositive cells per mm(2)) were determined in the stroma of the functional layer of endometrium and the relative concentrations of some cell types (CD163(+) macrophages, CD56(+) NK cells) were expressed as a percentage of all stromal cells. Routine H+E sections revealed 12 patients with focal "endometritis" without plasma cells. CD8(+) T-cells showed focal perivascular aggregates in most instances, and non-random but scattered cells in all cases, with a twofold increase in the luteal phase. CD163(+) cells were distributed evenly throughout the superficial endometrial stroma and also present as single or clustered macrophages within the lumens of superficial glands, mostly in the luteal phase. CD56(+) NK cells showed "diffuse" but variable distribution throughout the functional layer and perivascular aggregates of various sizes in two thirds of cases. Raw cell counts were low and relatively stable in the proliferative phase, but increased somewhat during the first half of the secretory phase, while in the second half of secretory phase they increased six to tenfold. Percentage counts rose from approximately 5% of stromal cells in the early part of the secretory phase of the cycle to over 35% in premenstrual endometrium. CD57(+) cells were present in very low numbers in most cases. The study illustrates the complexity and variability of immune cell infiltration of endometrium. We stress the need for strict counting protocols and attention to histological criteria if any immunological perturbations potentially responsible for recurrent reproductive failure are to be identified. Reference ranges for individual cell types are only valid for individual "days" of a normalized menstrual cycle.

Disseminated histoplasmosis and nocardiosis typically affect immunocompromised hosts. We report a case of gastrointestinal and adrenal histoplasmosis, presenting as protein-losing enteropathy and hypogammaglobulinaemia, coincident with Nocardia infection, in a HIV-negative patient in whom a specific immunological defect could not be identified. Clinicians in areas of non-endemicity should be vigilant for rare manifestations of histoplasmosis.

Objective: Endometrial polyps are localised growths of endometrial tissue containing glands, stroma and blood vessels, covered with epithelium. The reported prevalence of endometrial polyps is dependent upon the population being studied and the uterine imaging technique utilised. The light microscopy literature provides very little information regarding their microvasculature and lymphatic systems; however, a plethora of ultrasound data demonstrating single central arteries in most medium- or large-sized endometrial polyps are well documented. Methods: Archived formalin-fixed paraffin-embedded blocks of endometrial curettings were retrieved from files for women with confirmed endometrial polyps ( n = 20) and women with normal endometrium (control endometrium; n = 32). Immunohistochemistry was performed with the antibodies CD31 (blood vessels) and D2-40 (lymphatics). Blood vessels and lymphatics were quantified in endometrial polyps and adjacent, distant and control endometrium. Results: CD31 and D2-40 staining was present in all specimens, although there were no significant differences in blood vessel ( F(3,70) = 2.36, p = 0.079) and lymphatic ( F(3,70) = 0.16, p = 0.920) densities between endometrial polyps as well as adjacent, distant and control endometrium. There were also no significant differences in women with endometrial polyp-associated bleeding and those with no bleeding. In relation to infertility, there were no significant differences found in blood and lymphatic densities between women with endometrial polyps who were infertile and those with endometrial polyps who were fertile. Conclusion: Small blood vessel wall and perivascular structures rather than the distribution of vessels may be associated with abnormal bleeding.

IntroductionAdenocarcinoma in situ (AIS) of the uterine cervix is the precursor to invasive endocervical adenocarcinoma. An excisional biopsy such as a cold knife cone biopsy (CKC) should be performed to exclude invasive adenocarcinoma. Loop electrosurgical excision procedure (LEEP) is an alternative modality to CKC but is controversial in AIS. There is a perception that there is a greater likelihood of incomplete excision of AIS with LEEP because the depth of excised tissue tends to be smaller and the tissue margins may show thermal artefact which can interfere with pathology assessment. In the USA, guidelines recommend that any treatment modality can be used to excise AIS, provided that the specimen remains intact with interpretable margins. However, there are no high-quality studies comparing LEEP with CKC and well-designed prospective studies are needed. If such a study were to show that LEEP was non-inferior to CKC for the outcomes of post-treatment persistence, recurrence and adenocarcinoma, LEEP could be recommended as an appropriate treatment option for AIS in selected patients. This would benefit women because, unlike CKC, LEEP does not require general anaesthesia and may be associated with reduced morbidity.Methods and analysisThe proposed exploratory study is a parallel group trial with an allocation ratio of 2:1 in favour of the intervention (LEEP: CKC). Participants are women aged ≥18 to ≤45 years diagnosed with AIS on cervical screening and/or colposcopically directed biopsy in Australia and New Zealand, who are to receive excisional treatment in a tertiary level centre.Ethics and disseminationEthical approval for the study has been granted by the St John of God Healthcare Human Research Ethics Committee (reference number #1137). Results from the study will be presented at conferences and published in a peer-reviewed scientific journal.RegistrationANZCTR registration number ACTRN12617000132347https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372173&isReview=true

Glutamine commonly becomes a conditionally essential amino acid in cancer. Glutamine is supplied to the cell by transporters such as ASCT2 (SLC1A5), which is frequently upregulated in multiple cancers. Here we investigated the expression of ASCT2 in endometrial carcinoma, and evaluated the contribution of ASCT2 to glutamine uptake and endometrial cancer cell growth. Analysis of human gene expression data showed that ASCT2 was significantly upregulated in both endometrioid and serous subtypes of endometrial carcinoma, compared to normal, age-matched endometrium. Furthermore, immunohistochemical staining of primary human endometrioid adenocarcinomas showed that tumours stain positive for ASCT2 in either a uniform or mosaic expression pattern, while normal adjacent glands appeared predominantly negative for ASCT2 staining. Chemical inhibition of glutamine transport by benzylserine or GPNA led to a significant decrease in endometrial cancer cell growth and spheroid cross-sectional area. ASCT2 knockdown recapitulated the decrease of cell growth and spheroid cross-sectional area in HEC1A cells, suggesting a reliance on ASCT2-mediated glutamine uptake. ASCT2 knockdown in Ishikawa cells led to lower glutamine uptake and cell growth, but did not affect spheroid area. Ishikawa cells express higher levels of the glutamine transporter SNAT1 compared to HEC1A cells, suggesting these cells may rely on both ASCT2 and SNAT1 for glutamine uptake. Since SNAT1 is also significantly upregulated in the endometrioid and serous subtypes, these data indicate that ASCT2 and SNAT1 could be used as markers of malignancy, and/or potential therapeutic targets in patients with endometrial carcinoma.

Background Urinary cytology is an uncommon investigative tool for pediatric tumors. Case A 16-month-old infant presented for investigation of hematuria and blood clots into diapers. Urinary cytology showed a population of small, round, ] blue cells with little cytoplasm and high nuclear/cytoplasmic ratios. The cells were positive fir desmin and negative for cytokeratin. A cytologic diagnosis of embryonal rhabdomyosarcoma was offered and subsequently confirmed by histopathology. Conclusion Embryonal rhabdomyosarcomas are not uncommon in the pediatric population. Urinary cytology may be useful for rapid diagnosis and early management of such cases.

Sir,The co‐incidence of two uncommon entities, or of common entities in an unusual setting, is a challenge to pathologists, whose immediate instinct is to seek a causal link between them. We report...

Primary peritoneal cancer is rare and considered equivalent to stage III/IV ovarian cancer, but questions remain concerning its underlying biology, prognosis and optimal management.Clinico-pathological and treatment details of primary peritoneal (n=120) and ovarian cancer (n=635) were obtained on women recruited to the Australian Ovarian Cancer Study. Log-rank test was used to compare survival and cox proportional hazards models were fitted to obtain hazard ratios and 95% confidence intervals, both unadjusted and adjusted for age, grade, FIGO stage, residual disease and treatment with neoadjuvant chemotherapy. Molecular subtype was determined by gene expression profiling using published data.Compared with advanced serous ovarian cancer, primary peritoneal cancer patients were older (mean age 65.5 vs. 60.2years, p0.001), more often treated with neoadjuvant chemotherapy (38.4% vs. 11.4%, p0.001). Gene expression profiling classified a substantially higher proportion of primary peritoneal carcinomas as C1 (mesenchymal, reactive stromal infiltration) subtype (70.6% vs. 32.1%, p=0.029), which was associated with lower complete surgical resection rate. Women with primary peritoneal cancer had significantly shorter progression-free (11.6 vs. 13.6months, p=0.007) and overall survival (31.7 vs. 39.8months, p=0.012). In multivariate analysis, residual disease and neoadjuvant chemotherapy were both independently associated with increased risk of progression and death.Primary peritoneal cancer patients were more frequently treated with neoadjuvant chemotherapy and had inferior survival. Different tumor biology characterized by activated stromal fibrosis in primary peritoneal cancer may underlie the differences in treatment and clinical outcome.

Summary Human papillomavirus (HPV) is a highly transmissible infection responsible for a range of diseases in women including cervical carcinomas, vulval carcinomas, anogenital carcinomas and genital warts. In men it is associated with penile carcinomas, anogenital carcinomas and oropharyngeal carcinomas. The history of the development of HPV vaccines includes a significant Australian input and represents a tremendous advancement in our understanding of HPV virology as well as further elucidating the overall contribution of viruses to carcinogenesis. Prophylactic HPV vaccines were licensed for use in Australia in 2007 in order to protect against development of future cases of cervical carcinoma and early results are promising. The benefit of the vaccine will not be restricted to cervical lesions and cross protection amongst a variety of HPV subtypes is described. The development of the HPV vaccine and its ultimate incorporation into our National Immunisation Schedule is reviewed.

Recurrent miscarriage affects approximately 1% of the population and in half of these cases no cause is found. Abnormally functioning immunocompetent cells, including natural killer (NK) cells, in the endometrium, are thought to be responsible for many such cases and treatment trials including oral prednisolone and intravenous immunoglobulins are now underway. Despite these encouraging developments, there is neither adequate standardization of counting uterine NK cells nor consensus as to what constitutes an abnormal level. To address this issue, immunohistochemistry was used to examine the presence and distribution of selected immune cells and macrophages in the endometrium from 222 women who had a routine endometrial biopsy for investigation of recurrent miscarriage or IVF failure, at various stages of the menstrual cycle, and accessioned prospectively over a 7-month period. Biopsies were examined by H+E and immunostained for CD8(+) T-cells, CD163(+) macrophages, CD56(+) NK cells, and CD57(+) cells. Cell numbers (expressed as immunopositive cells per mm(2)) were determined in the stroma of the functional layer of endometrium and the relative concentrations of some cell types (CD163(+) macrophages, CD56(+) NK cells) were expressed as a percentage of all stromal cells. Routine H+E sections revealed 12 patients with focal "endometritis" without plasma cells. CD8(+) T-cells showed focal perivascular aggregates in most instances, and non-random but scattered cells in all cases, with a twofold increase in the luteal phase. CD163(+) cells were distributed evenly throughout the superficial endometrial stroma and also present as single or clustered macrophages within the lumens of superficial glands, mostly in the luteal phase. CD56(+) NK cells showed "diffuse" but variable distribution throughout the functional layer and perivascular aggregates of various sizes in two thirds of cases. Raw cell counts were low and relatively stable in the proliferative phase, but increased somewhat during the first half of the secretory phase, while in the second half of secretory phase they increased six to tenfold. Percentage counts rose from approximately 5% of stromal cells in the early part of the secretory phase of the cycle to over 35% in premenstrual endometrium. CD57(+) cells were present in very low numbers in most cases. The study illustrates the complexity and variability of immune cell infiltration of endometrium. We stress the need for strict counting protocols and attention to histological criteria if any immunological perturbations potentially responsible for recurrent reproductive failure are to be identified. Reference ranges for individual cell types are only valid for individual "days" of a normalized menstrual cycle.

Urinary cytology is an uncommon investigative tool for pediatric tumors.A 16-month-old infant presented for investigation ofhematuria and blood clots into diapers. Urinary cytology showed a population of small, round, blue cells with little cytoplasm and high nuclear/cytoplasmic ratios. The cells were positive for desmin and negative for cytokeratin. A cytologic diagnosis of embryonal rhabdomyosarcoma was offered and subsequently confirmed by histopathology.Embryonal rhabdomyosarcomas are not uncommon in the pediatric population. Urinary cytology may be useful for rapid diagnosis and early management of such cases.

Muir-Torre syndrome (MTS) is a rare autosomal dominant disorder. It is characterised by the presence of sebaceous gland neoplasms and visceral malignancies; such as gastrointestinal and genitourinary cancers. MTS is thought to be a clinical variant of hereditary non-polyposis colorectal cancer leading to a deficiency in mismatch repair genes. The diagnosis of MTS warrants screening of the patients and their family members for associated malignancies. We present a case report of a 67-year-old man with past history of two colonic carcinomas and newly diagnosed sebaceous lesions. The sebaceous lesions were found to have abnormal mismatch repair proteins demonstrated by loss of MSH2 and MSH6 stain on immunohistochemistry. Sebaceous lesions that are difficult to classify or show mixed features should always raise the possibility of MTS, and mismatch repair enzyme immunohistochemistry should be performed. If losses are demonstrated, referrals to a Family Cancer Clinic for further investigations and management are recommended.