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Endometrial cancer is one of the most common cancers among women. The International Collaboration on Cancer Reporting (ICCR) developed a standardized endometrial cancer data set in 2011, which provided detailed recommendations for the reporting of resection specimens of these neoplasms. A new data set has been developed, which incorporates the updated 2020 World Health Organization Classification of Female Genital Tumors, the Cancer Genome Atlas (TCGA) molecular classification of endometrial cancers, and other major advances in endometrial cancer reporting, all of which necessitated a major revision of the data set. This updated data set has been produced by a panel of expert pathologists and an expert clinician and has been subject to international open consultation. The data set includes core elements which are unanimously agreed upon as essential for cancer diagnosis, clinical management, staging, or prognosis and noncore elements which are clinically important, but not essential. Explanatory notes are provided for each element. Adoption of this updated data set will result in improvements in endometrial cancer patient care.

Purpose: Advanced-stage mucinous ovarian carcinoma (MOC) has poor chemotherapy response and prognosis and lacks biomarkers to aid stage I adjuvant treatment. Differentiating primary MOC from gastrointestinal (GI) metastases to the ovary is also challenging due to phenotypic similarities. Clinicopathologic and gene-expression data were analyzed to identify prognostic and diagnostic features. Experimental Design: Discovery analyses selected 19 genes with prognostic/diagnostic potential. Validation was performed through the Ovarian Tumor Tissue Analysis consortium and GI cancer biobanks comprising 604 patients with MOC (n = 333), mucinous borderline ovarian tumors (MBOT, n = 151), and upper GI (n = 65) and lower GI tumors (n = 55). Results: Infiltrative pattern of invasion was associated with decreased overall survival (OS) within 2 years from diagnosis, compared with expansile pattern in stage I MOC [hazard ratio (HR), 2.77; 95% confidence interval (CI), 1.04–7.41, P = 0.042]. Increased expression of THBS2 and TAGLN was associated with shorter OS in MOC patients (HR, 1.25; 95% CI, 1.04–1.51, P = 0.016) and (HR, 1.21; 95% CI, 1.01–1.45, P = 0.043), respectively. ERBB2 (HER2) amplification or high mRNA expression was evident in 64 of 243 (26%) of MOCs, but only 8 of 243 (3%) were also infiltrative (4/39, 10%) or stage III/IV (4/31, 13%). Conclusions: An infiltrative growth pattern infers poor prognosis within 2 years from diagnosis and may help select stage I patients for adjuvant therapy. High expression of THBS2 and TAGLN in MOC confers an adverse prognosis and is upregulated in the infiltrative subtype, which warrants further investigation. Anti-HER2 therapy should be investigated in a subset of patients. MOC samples clustered with upper GI, yet markers to differentiate these entities remain elusive, suggesting similar underlying biology and shared treatment strategies.

Supplementary Methods

Supplementary Figures S1-S13

Purpose:Advanced-stage mucinous ovarian carcinoma (MOC) has poor chemotherapy response and prognosis and lacks biomarkers to aid stage I adjuvant treatment. Differentiating primary MOC from gastrointestinal (GI) metastases to the ovary is also challenging due to phenotypic similarities. Clinicopathologic and gene-expression data were analyzed to identify prognostic and diagnostic features.Experimental Design:Discovery analyses selected 19 genes with prognostic/diagnostic potential. Validation was performed through the Ovarian Tumor Tissue Analysis consortium and GI cancer biobanks comprising 604 patients with MOC (n = 333), mucinous borderline ovarian tumors (MBOT, n = 151), and upper GI (n = 65) and lower GI tumors (n = 55).Results:Infiltrative pattern of invasion was associated with decreased overall survival (OS) within 2 years from diagnosis, compared with expansile pattern in stage I MOC [hazard ratio (HR), 2.77; 95% confidence interval (CI), 1.04–7.41, P = 0.042]. Increased expression of THBS2 and TAGLN was associated with shorter OS in MOC patients (HR, 1.25; 95% CI, 1.04–1.51, P = 0.016) and (HR, 1.21; 95% CI, 1.01–1.45, P = 0.043), respectively. ERBB2 (HER2) amplification or high mRNA expression was evident in 64 of 243 (26%) of MOCs, but only 8 of 243 (3%) were also infiltrative (4/39, 10%) or stage III/IV (4/31, 13%).Conclusions:An infiltrative growth pattern infers poor prognosis within 2 years from diagnosis and may help select stage I patients for adjuvant therapy. High expression of THBS2 and TAGLN in MOC confers an adverse prognosis and is upregulated in the infiltrative subtype, which warrants further investigation. Anti-HER2 therapy should be investigated in a subset of patients. MOC samples clustered with upper GI, yet markers to differentiate these entities remain elusive, suggesting similar underlying biology and shared treatment strategies.

Supplementary Tables S1-S11

Background Australian Cervical Screening Program guidelines no longer recommend colposcopy and cytology at six months following treatment of cervical intraepithelial neoplasia (CIN2/3) and a co-test of cure can be performed at 12 months without colposcopy. Aims To determine the usefulness of six-month colposcopy and cytology and routine colposcopy with co-testing at 12 months in detecting persistent or recurrent disease in patients treated for CIN2/3. Materials and methods We conducted a review of all patients with histologically proven CIN2/3 who underwent a cervical excisional procedure between March 2012 and March 2017 in one specialised centre. Results We examined 1215 cases and 750 remained after exclusions for analysis. At six months (722 cases, 96.2%) seven of 42 (16.7%) patients with high-grade cytology had a high-grade colposcopy and 24 of 42 (57.1%) had a normal colposcopy. Persistent CIN2/3 was diagnosed in 12 cases (1.7%) and only 1/3 had a high-grade colposcopy. Cytology was more useful than colposcopy in detecting persistent disease. At 12 months (638 cases, 85%) routine colposcopy at the time of co-testing had a high false positive rate with all high-grade changes negative on biopsy and co-test. Recurrent CIN2/3 was diagnosed in five cases, and four had normal colposcopy at co-testing. Conclusions There may be a delay in detection of persistent/recurrent CIN2/3 in a small number of cases without six-month colposcopy and cytology; however, it is not likely to negatively impact overall clinical outcome. Co-testing at 12 months following treatment of CIN2/3 without colposcopy is safe and routine colposcopy at collection of the co-test can be omitted.

Granular cell tumours (GCTs) are uncommon neuroectodermally derived tumours. Vulvar location is rare with 134 reported cases presenting as a non-specific vulvar mass. They are of low malignant potential and management is local excision. They have a high local recurrence rate if incompletely excised. The GCT diagnosis is often retrospective due to its rarity, its non-specific presenting symptoms and numerous differentials. Here we descibe the case of a 31-year-old woman presenting after an asymptomatic right labium majus mass was noted during a postnatal visit. This was imaged with magentic resonance imaging (MRI) and a biopsy was inconclusive. She was referred for subspecialty consultation at the Chris O’Brien Lifehouse. The lesion was five centimetres, overlying the pubis and inferolateral to the clitoris with no skin changes or epidermal attachment. Wide local excision was performed. Histopathology showed GCT features with no malignant characteristics, but positive margins. Despite positive margins, the decision was made to not complete re-excision and observe for recurrence. This was an unusual case in a young postpartum woman. It highlights the need for clinical suspicion of this tumour type during a postpartum examination and the need for nuanced decision making regarding re-excision based on individual patient needs despite recurrence risk.

Although rare and unusual occurrences, a ruptured ectopic molar pregnancy (MP) and a ruptured uterine fibroid can lead to significant maternal morbidity and mortality. We present a unique case of these complications developing concurrently—resulting in the haemodynamic compromise of an otherwise healthy young female patient. The patient underwent a diagnostic laparoscopy which converted into a laparotomy, salpingectomy and myomectomy. Comprehensive histopathology confirmed the diagnosis of a ruptured ectopic complete MP and ruptured uterine fibroid. The patient recovered quickly within days. Prompt definitive management, conclusive histopathology and adequate follow-up were the hallmarks of this singular case. These key factors lead to the rare diagnosis of ruptured ectopic MP and uterine fibroid, prevention of adverse outcomes and provision of comprehensive patient care.

Aim The objective of this study was to assess whether maternal characteristics, placental size or histological chorioamnionitis was associated with newborn body composition. Furthermore, we sought to determine whether placental weight may mediate the association between maternal pre-pregnancy weight and age with newborn body composition. Methods A cross-sectional study was conducted at Royal Prince Alfred Hospital, Sydney, Australia. This study included 136 healthy, singleton, term-born newborns. Recruitment was stratified by newborn body fat percentiles (gender and gestational adjusted). Body fat was assessed by air displacement plethysmography. Placental examination was conducted by an anatomical pathologist. Maternal (chorioamnionitis) and fetal (chorionic and umbilical vasculitis, funisitis) inflammatory responses were classified according to Redline criteria. Results Maternal pre-pregnancy weight, parity, labour, placental weight and surface area were associated with newborn fat mass and fat-free mass. Gestational diabetes and maternal age were associated with newborn fat mass but not fat-free mass. There was no association between histological chorioamnionitis and newborn body composition; however, spontaneous onset of labour was strongly associated with the presence of histological chorioamnionitis. Only 25-31% of the association of maternal weight and age with newborn fat mass was mediated via the placenta. Conclusions Maternal factors associated with newborn fat mass and fat-free mass differed, indicating that different mechanisms control fat mass and fat-free mass. Our mediation analysis suggests that placental weight partly mediates the association of maternal factors with newborn body composition. Histological chorioamnionitis was not associated with newborn body composition.

Absolute uterine factor infertility (AUFI) is defined as the absence of a uterus or the presence of a non-functional uterus. Before the first live birth from a uterus transplant in 2014, the only fertility options for women with AUFI were surrogacy and adoption. In November 2019, our team was granted approval for the first uterus transplant trial in Australia using known living donors. Our program is based on that of our overseas collaborators in Dallas, Texas; this team will also be proctoring us for our first two cases.

Background: Absolute Uterine Factor infertility (AUFI) can be congenital such as Mayer-Rokitansky Küster syndrome (MRKH), or acquired resulting from conditions rendering the uterus non-functional or following a hysterectomy. In 2014 the first successful uterus transplant (UT) was achieved in Sweden. This sparked widespread interest, and many countries have established UT trials. In 2019 Royal Prince Alfred hospital was the first site in Australia to receive ethical approval for a UT protocol. As part of this trial research outcomes will be collected. Aim: • To determine if UT is an effective, safe, and operationally viable option for women with AUFI in order to achieve live birth. • To collect research outcomes which will contribute to an international bio-bank for future research opportunities. Method: Approved donor/recipient pairs will be invited to participate in the research components of the trial. This will involve completing various questionnaires to assess clinical outcomes before and after the procedure, as well as providing additional blood and cervical tissue samples which will be stored for future research projects. Conclusion: UT is a relatively new procedure, with significant scope for basic research opportunities. Due to the infancy of UT it is pivotal that all centers are diligent in collecting research outcomes and contributing to an international data registry to aid in proving the necessity of UT as a clinical treatment for woman with AUFI.

Highlights • Bovine pericardium for IVC reconstruction has significant advantages comparing to vascular ligation, autogenous or PTFE grafts. • En-bloc resection of metastatic precaval lymph nodes and reconstruction of the IVC is feasible. • Recurrence of endometrial cancer at para-aortic lymph nodes is good candidate for secondary cytoreduction with MDT approach.

Objective Adenocarcinoma in situ (AIS) of the cervix is a precursor to cervical adenocarcinoma. When AIS is detected by cervical screening an excision biopsy is mandatory to exclude invasion. We aimed to compare margins status, specimen size and fragmentation after loop electrosurgical excision procedure (LEEP) and ‘cold knife cone biopsy’ (CKC). Methods The EXCISE Trial was an investigator-initiated, multicenter, open-label, parallel-group, phase 2, randomized study. Patients were enrolled at seven hospitals in Australia and New Zealand. We randomly assigned women aged ≥18 to ≤45 years with screen detected AIS to LEEP or CKC. Co-primary endpoints were margin status, specimen size and fragmentation. Analysis was by intention-to-treat. Results Between August 2, 2017 and September 6, 2019, 40 patients were randomly assigned 2:1 to LEEP or CKC. Margin status was evaluable in 36 cases. The proportion of patients with involved margins did not differ between groups. 25 of 26 LEEP and all 14 CKC biopsies were excised as single specimens (p = 1·00). There were no differences in specimen dimensions. Patients in the CKC group had more post-operative complications (64.3% compared to 15.4% for LEEP p = ·00). There were no differences in grade three complications (p = ·65). Conclusions LEEP was not associated with a greater likelihood of positive margins, specimen fragmentation or smaller excision compared to CKC when performed according to a standardized protocol. However, the study was not powered to establish non-inferiority of LEEP and a definitive phase 3 trial to compare margin status and rates of treatment failure after LEEP and CKC is warranted.

Background Strongyloidiasis is caused by the helminth Strongyloides stercoralis and is well-recognised amongst transplant recipients. Serious complications, including Strongyloides hyperinfection which is a syndrome of accelerated autoinfection, or disseminated disease, can occur post-transplantation, resulting in significant morbidity and mortality. Here we present the first published case we are aware of, describing post-transplant Strongyloides hyperinfection in an HIV-positive kidney transplant patient. We discuss the diagnostic challenges and the role of pre-transplant screening. Case presentation A 58-year-old African-American male, originally from the Caribbean, received a deceased donor kidney transplant for presumed focal segmental glomerulosclerosis. He was known to be HIV-positive, with a stable CD4 count, and an undetectable viral load. Five months post-transplant, he developed gastrointestinal symptoms and weight loss. He had a normal eosinophil count (0.1–0.2 × 109/L), negative serum cytomegalovirus DNA, and negative blood and stool cultures. His Strongyloides serology remained negative throughout. A diagnosis of Strongyloides hyperinfection was made by the histological examination of his duodenum and lung, which identified the parasites. He completed his course of treatment with Ivermectin but exhibited profound deconditioning and required a period of total parenteral nutrition. He was subsequently discharged after a prolonged hospital admission of 54 days. Conclusions This case highlights the challenges in diagnosing Strongyloides infection and the need to maintain a high index of clinical suspicion. Non-invasive techniques for the diagnosis of Strongyloides may be insufficient. Routine pre-transplant serological strongyloidiasis screening is now performed at our centre.

Immunotherapy with checkpoint inhibitors is well established as an effective treatment for non-small cell lung cancer and melanoma. The list of approved indications for treatment with PD-1/PD-L1 checkpoint inhibitors is growing rapidly as clinical trials continue to show their efficacy in patients with a wide range of solid tumours. Clinical trials have used a variety of PD-L1 immunohistochemical assays to evaluate PD-L1 expression on tumour cells, immune cells or both as a potential biomarker to predict response to immunotherapy. Requests to pathologists for PD-L1 testing to guide choice of therapy are rapidly becoming commonplace. Thus, pathologists need to be aware of the different PD-L1 assays, methods of evaluation in different tumour types and the impact of the results on therapeutic decisions. This review discusses the key practical issues relating to the implementation of PD-L1 testing for solid tumours in a pathology laboratory, including evidence for PD-L1 testing, different assay types, the potential interchangeability of PD-L1 antibody clones and staining platforms, scoring criteria for PD-L1, validation, quality assurance, and pitfalls in PD-L1 assessment. This review also explores PD-L1 IHC in solid tumours including non-small cell lung carcinoma, head and neck carcinoma, triple negative breast carcinoma, melanoma, renal cell carcinoma, urothelial carcinoma, gastric and gastroesophageal carcinoma, colorectal carcinoma, hepatocellular carcinoma, and endometrial carcinoma. The review aims to provide pathologists with a practical guide to the implementation and interpretation of PD-L1 testing by immunohistochemistry.

Funder: National Health and Medical Research Council; doi: http://dx.doi.org/10.13039/501100000925, Background: 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. Methods: Here, we have defined unique molecular insights into the function of ID4 in BLBC and the related disease high-grade serous ovarian cancer (HGSOC), by combining RIME proteomic analysis, ChIP-seq mapping of genomic binding sites and RNA-seq. Results: These studies reveal 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. Analysis of clinical samples demonstrates that ID4 is amplified and overexpressed at a higher frequency in BRCA1-mutant BLBC compared with sporadic BLBC, providing genetic evidence for an interaction between ID4 and DNA damage repair deficiency. Conclusions: These data link the interactions of ID4 with MDC1 to DNA damage repair in the aetiology of BLBC and HGSOC.

Background: Adenocarcinoma in situ (AIS) of the cervix is a precursor to cervical adenocarcinoma. When AIS is detected by cervical screening an excision biopsy is mandatory to exclude invasion. Two common procedures are loop electrosurgical excision procedure (LEEP) and ‘cold knife cone biopsy’ (CKC), yet no randomised trials have compared these modalities. We aimed to compare margins status, specimen size and fragmentation after LEEP and CKC. Methods: The EXCISE Trial was an investigator-initiated, multicentre, open-label, parallel-group, phase 2, randomised study. Patients were enrolled at seven hospitals in Australia and New Zealand. We randomly assigned women aged ≥18 to ≤45 years with screen detected AIS to LEEP or CKC by computer generated random numbers. Co-primary endpoints were margin status, specimen size and fragmentation. Analysis was by intention-to-treat. Findings: Between August 2, 2017 and September 6, 2019, 40 patients were randomly assigned 2:1 to LEEP or CKC. All patients were included in the analysis. Margin status was evaluable in 36 cases. The proportion of patients with involved margins did not differ between groups. 25 of 26 LEEP and all 14 CKC biopsies were excised as single specimens (p=1.00). There were no differences in specimen dimensions. Patients in the CKC group had more post-operative complications (64.3% compared to 15.4% for LEEP p=.00). There were no differences in grade three complications (p=.65). Interpretation: LEEP was not associated with a greater likelihood of positive margins, specimen fragmentation or smaller excision compared to CKC when performed according to a standardised protocol. However, the study was not powered to establish non-inferiority of LEEP and a definitive phase 3 trial to compare margin status and rates of treatment failure after LEEP and CKC is warranted. Trial Registration: The study is registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR registration number ACTRN12617000132347). Funding Statement: Australia New Zealand Gynaecological Oncology Group [#FNR2016/03]. Declaration of Interests: PAC and CDHW have received honoraria from Seqirus unrelated to this work. All other authors declare no competing interests. Ethics Approval Statement: Ethical approval for the study was granted by the St John of God Healthcare Human Research Ethics Committee (Reference number #1137) and approvals were obtained at all participating sites.

Additional file 1: Figure S1. Analysis of ID4 protein expression across a panel of breast and ovarian cell lines. (A) Western blotting analysis of ID4 protein expression across a panel of breast (top) and ovarian (bottom) normal and cancer cell lines. A rabbit monoclonal antibody specific to ID4 (Biocheck, BCH-9/82–12) was used for detection [11]. Two isoforms of ID4 are detectable across the panel. β-Actin is shown as a loading control. Modifications to images indicated with vertical black line. Cell lines selected for further analysis are indicated with a black square. Breast cancer subtypes and ovarian cancer histotypes indicated [82, 83]. (B) Western blot validation of RIME protocol. MDA-MB-468 cells were processed using the RIME protocol. Antibodies targeting ID4 (pooled polyclonal antibodies) and IgG (rabbit species matched control) control were used for immunoprecipitation. Western blot analysis for ID4 protein expression, using an independent ID4 monoclonal antibody, following immunoprecipitation. Figure S2. ID4 ChIP-sequencing analysis of HCC70 cell line identifies reproducible ID4-chromatin binding sites. (A) Table summarising three biological replicates of ID4 ChIP-seq analysis in HCC70 cell line. (B) 10,000 bp resolution image of ID4 ChIP-seq technical replicate #1 binding to MALAT1 gene. Red sequencing reads are aligned to the positive strand (5′ - 3′), and blue to the negative strand of DNA (3′ - 5′). ID4 binding to (C) left to right: GBA, FAIM, MIRLET7BHG, NEAT1 and ZFP36L1. The chromosomal location, size of the gene and Refseq, human reference genome, are displayed at the top of the image. Reads have been aligned to the human reference genome Hg19 and peaks called using MACs peak calling algorithm (v2.0.9) [38]. Images contain ChIP-seq coverage data and the peaks called for each ID4 technical replicate and the consensus peaks called for all three ID4 ChIP-seq biological replicate for selected gene regions. ID4 binding is shown in comparison to IgG and Input data for the same region. Data visualised using IGV [56, 57]. Transcription Start Site (TSS) indicated with black arrow. Figure S3. ID4 ChIP-exonuclease sequencing analysis of HCC70 and HCC1954 cell lines reproduces ChIP-seq analysis. (A) Table summarising ChIP-exonuclease sequencing analysis of ID4 and IgG binding events in HCC70 and HCC1954 breast cancer cell lines. ID4 binding normalised as for ChIP-seq analysis. ChIP-exo analysis of the HCC70 and HCC1954 breast cancer cell lines showing ID4 binding to NEAT1, MALAT1 and GBA (B), ZFP36L1 and ELF3 (C), and KDM4C and ERRFI1 (D). Reads have been aligned to the human reference genome Hg19 and peaks called using MACs peak calling algorithm (v2.0.9) [38]. Images contain ChIP-exo coverage data and the peaks called for each ID4 technical replicate and the consensus peaks called for both ID4 ChIP-exo technical replicate for selected gene regions. ID4 binding is shown in comparison to IgG and input data for the same region. Data visualised using IGV [56, 57]. The chromosomal location and size of the gene are displayed at the top of the image. Below this, Refseq, human reference genome, displays the gene corresponding to particular genomic loci. Transcription Start Site (TSS) indicated with black arrow. Figure S4. Validation of ID4 binding to specific loci in HCC70, MDA-MB-468 and HCC1954 cell lines. (A) Schematic of primer binding across ELF3 gene region. Primers 1–5 are scattered along the length of the ELF3 gene ID4. ChIP-qPCR analysis in (B) HCC70 (n = 2–8), (C) MDA-MB-468 (n = 2) and (D) HCC1954 (n = 2) cells. Multiple primers were designed to tile across the large ID4 binding sites. ID4 binding normalised to input DNA and to a region not bound by ID4 (negative region) and represented as fold-change over IgG control. 1-Way-ANOVA of ID4 binding across all primers compared to negative region: HCC70 p = 0.0001, MDA-MB-468 p = 0.549, HCC1954 p = 0.519. Figure S5. ID4 knockdown using SMARTChoice inducible lentiviral knockdown system. Representative western blot showing ID4 and β-Actin protein expression in wild-type HCC70 cell line and HCC70 cells stably transfected with SMARTChoice vectors containing doxycycline-inducible shRNAs targeting ID4 (shID4 #1, #2 and #3) or non-targeting control region (shNTC). Cells treated with and without DOX for 72 h. (B) Western blotting densitometry quantification of ID4 protein expression across six biological replicates of ID4 knockdown following treatment with and without DOX for 72 h. ID4 expression normalised to β-ACTIN and no DOX control. Error bars measure standard error, n = 4–6. (C) qRT-PCR analysis of ID4 RNA expression matched to cells in (B). Data normalised to B2M housekeeping gene and no DOX control. Error bars measure standard error, n = 4–6. Student’s t-test compares shNTC with the other modified cell lines. ** p

There have been rapid and significant advances in diagnostic and predictive molecular techniques in recent years with profound impact on patient care. In situ hybridization (ISH) studies have become well entrenched in surgical pathology practice and their role in the evaluation of HER2 in breast carcinoma and their diagnostic utility in soft tissue pathology are well known. Fluorescent ISH is being increasingly used in other sites such as the head and neck and the gynecologic tract. Like most tests in surgical pathology, ISH studies require good quality tissue, correlation with clinical and histopathologic findings, and adherence to guidelines for optimal assay performance and interpretation. Although ISH studies are largely performed in tertiary centers, the tissue is often processed by a variety of laboratories and the referring pathologists are required to discuss the need, relevance, and significance of these tests and the results with their clinical colleagues. Here we review the predictive and diagnostic utility of fluorescent ISH studies in a variety of organ systems, the preanalytical factors that may affect the results, and the pitfalls in the interpretation that all practicing surgical pathologists should be aware of.

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.

The prediction of lymph node metastasis using clinic-pathological data and molecular information from endometrial cancers lacks accuracy and is therefore currently not routinely used in patient management. Consequently, although only a small percentage of patients with endometrial cancers suffer from metastasis, the majority undergo radical surgery including removal of pelvic lymph nodes. Upon analysis of publically available data and published research, we compiled a list of 60 proteins having the potential to display differential abundance between primary endometrial cancers with versus those without lymph node metastasis. Using data dependent acquisition LC-ESI-MS/MS we were able to detect 23 of these proteins in endometrial cancers, and using data independent LC-ESI-MS/MS the differential abundance of five of those proteins was observed. The localization of the differentially expressed proteins, was visualized using peptide MALDI MSI in whole tissue sections as well as tissue microarrays of 43 patients. The proteins identified were further validated by immunohistochemistry. Our data indicate that annexin A2 protein level is upregulated, whereas annexin A1 and α actinin 4 expression are downregulated in tumours with lymph node metastasis compared to those without lymphatic spread. Moreover, our analysis confirmed the potential of these markers, to be included in a statistical model for prediction of lymph node metastasis. The predictive model using highly ranked . m/z values identified by MALDI MSI showed significantly higher predictive accuracy than the model using immunohistochemistry data. In summary, using publicly available data and complementary proteomics approaches, we were able to improve the prediction model for lymph node metastasis in EC. Refereed/Peer-reviewed

Vulvar intraepithelial neoplasia (VIN) is a precursor to vulvar squamous cell carcinoma and is defined histopathologically by the presence of atypia. VIN has been classified into two types: usual vulvar intraepithelial neoplasia (uVIN), which is also referred to as a vulvar high-grade squamous intra-epithelial lesion (HSIL), and differentiated VIN (dVIN). The former is associated with chronic infection by sub-types of the human papilloma virus (HPV), whereas dVIN is HPV-independent and frequently associated with lichen sclerosus. The distinction is important because dVIN has a greater risk of, and more rapid transit to, vulvar squamous cell carcinoma. Furthermore, dVIN-associated vulvar cancers have an increased risk of recurrence and higher mortality than those arising from HSIL. Molecular characterization of vulvar squamous cell carcinoma precursors using next-generation sequencing is a relatively novel, but rapidly advancing field. This review appraises recent studies that have investigated the risks of progression to vulvar malignancy associated with HSIL and dVIN, the prognosis of HPV-dependent and HPV-independent vulvar squamous cell carcinomas, and conducted next generation sequencing mutation analyses to elucidate the genomic profiles underlying VIN. These studies suggest that HSIL and dVIN are characterized by different underlying molecular alterations that may have important implications for treatment and follow-up of women diagnosed with vulvar squamous cell cancer.

Glomus tumor is an uncommon, benign, soft-tissue lesion in which the cells recapitulate the structure of the normal modified smooth muscle cells of the glomus body. Glomus tumors usually occur in tissues that normally contain glomus bodies; only rarely can they develop in sites where glomus bodies are normally sparse or absent. There are three subtypes of glomus tumor, with glomangiomyoma being the rarest. No more than 10 cases of glomus tumor in female genitalia have previously been reported, involving the vulva, vaginal area, periurethral area and clitoris. A clitoral glomangiomyoma is extremely rare. This is a case report of a glomangiomyoma in the clitoral area. Published reports of glomus tumor in the female external genitalia are reviewed., Highlights • We report a rare case of glomangiomyoma of the clitoris. • Magnetic resonance imaging is valuable in characterizing the soft-tissue mass of the clitoris and assisting surgical planning. • Excision of a clitoral lesion entails consideration of the risk of bleeding, cosmetic results, and potential sexual dysfunction.

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.

Metastasis is a crucial step of malignant progression and is the primary cause of death from endometrial cancer. However, clinicians presently face the challenge that conventional surgical-pathological variables, such as tumour size, depth of myometrial invasion, histological grade, lymphovascular space invasion or radiological imaging are unable to predict with accuracy if the primary tumour has metastasized. In the current retrospective study, we have used primary tumour samples of endometrial cancer patients diagnosed with (n = 16) and without (n = 27) lymph nodemetastasis to identify potential discriminators. Using peptide matrix assisted laser desorption/ionisation mass spectrometry imaging (MALDI-MSI), we have identified m/z values which can classify 88% of all tumours correctly. The top discriminative m/z values were identified using a combination of in situ sequencing and LC-MS/MS from digested tumour samples. Two of the proteins identified, plectin and alpha-Actin-2, were used for validation studies using LC-MS/MS data independent analysis (DIA) and immunohistochemistry. In summary, MALDI-MSI has the potential to identify discriminators of metastasis using primary tumour samples. Refereed/Peer-reviewed

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) syndrome secondary to germline fumarate hydratase (FH) mutation presents with cutaneous and uterine leiomyomas, and a distinctive aggressive renal carcinoma. Identification of HLRCC patients presenting first with uterine leiomyomas may allow early intervention for renal carcinoma. We reviewed the morphology and immunohistochemical (IHC) findings in patients with uterine leiomyomas and confirmed or presumed HLRCC. IHC was also performed on a tissue microarray of unselected uterine leiomyomas and leiomyosarcomas. FH-deficient leiomyomas underwent Sanger and massively parallel sequencing on formalin-fixed paraffin-embedded tissue. All 5 patients with HLRCC had at least 1 FH-deficient leiomyoma: defined as completely negative FH staining with positive internal controls. One percent (12/1152) of unselected uterine leiomyomas but 0 of 88 leiomyosarcomas were FH deficient. FH-deficient leiomyoma patients were younger (42.7 vs. 48.8 y, P=0.024) and commonly demonstrated a distinctive hemangiopericytomatous vasculature. Other features reported to be associated with FH-deficient leiomyomas (hypercellularity, nuclear atypia, inclusion-like nucleoli, stromal edema) were inconstantly present. Somatic FH mutations were identified in 6 of 10 informative unselected FH-deficient leiomyomas. None of these mutations were found in the germline. We conclude that, while the great majority of patients with HLRCC will have FH-deficient leiomyomas, 1% of all uterine leiomyomas are FH deficient usually due to somatic inactivation. Although IHC screening for FH may have a role in confirming patients at high risk for hereditary disease before genetic testing, prospective identification of FH-deficient leiomyomas is of limited clinical benefit in screening unselected patients because of the relatively high incidence of somatic mutations.

ObjectivesIntraoperative frozen section (IFS) offers a rapid test to guide the extent of surgery, which is essential for optimal treatment of ovarian cancer. This study evaluated the diagnostic performance and influence of IFS in the surgical management of ovarian tumors.MethodsA retrospective review was conducted of IFS of adnexal lesions from 2008 to 2013, with diagnoses classified as benign, borderline, or malignant. The diagnostic performance of IFS was calculated, with a focus on primary epithelial tumors. In discordant cases, it was determined whether the results of the IFS influenced the nature of the primary surgery.ResultsThere were 277 consecutive cases over the study period. The overall sensitivity for diagnosing malignant disease was 75.9% and the specificity was 100%. With a benign IFS result, there was a 6.25% (9/144) chance that the final diagnosis would be malignant, and a 7.6% (11/144) chance that the final diagnosis would be borderline, resulting in the potential for understaging. The predictive values for benign, borderline, and malignant IFS results were 86.1%, 66.6%, and 100%, respectively. For a borderline IFS result, there was a 33.3% chance that the final diagnosis would be malignant disease, and this was higher in older patients (53.3%). There were no instances of overdiagnosis in this series. Of 37 cases underdiagnosed, 19 received incomplete primary staging surgery guided by the IFS, and most of these were mucinous tumors.ConclusionsIntraoperative frozen section is most valuable for its high specificity in diagnosing malignancy. It should be interpreted with caution in borderline tumors, particularly in older patients and in mucinous tumors. Overdiagnosis did not occur in this series; however, in younger patients, the limitations of IFS must be considered before surgery that would result in loss of fertility.

Plus ca change, plus c’est la meme chose. It is rapidly closing in on a century since John Sampson’s brace of seminal publications in the mid 1920s concerning the nature and origin of endometriosis and endosalpingiosis. While his terminology and pathogenetic concepts may seem a little quaint by current standards, they were the beginnings of our understanding the derivation of heterotopic endometrial and endosalpingeal tissues, i.e., beyond the anatomical limits in which they were normally found. Thus, local invasion (Sampson’s first category) would correspond to acquired adenomyosis and salpingitis isthmica nodosa. Everywhere else (outside the uterus and fallopian tubes), such ectopic but benign endometrial tissue was ascribed to processes of implantation or metastasis on the one hand or developmental misplacement on the other. Some 20 years later, Goodall added ‘endocervicosis’ to complete the mullerianosis triptych, with local invasion being what we now also think of as deep endocervical glands (deep Nabothian cysts) or cervical endocervicosis and implantation/metastasis equating to peritoneal endocervicosis. There was no proposed developmental misplacement for endocervicosis. Sampson’s original concept of mullerianosis (specifically endometriosis) was of normally sited endometrial tissue with the sometime capacity to transport itself to a variety of ectopic positions by the same mechanisms with which we are familiar in relation to malignant disease and ‘developmentally misplaced endometrial tissue’ was regarded by him as only a theoretical and unsupported pathogenetic possibility. However, others have espoused this latter concept as a valid, if not all-encompassing explanation for ectopic mullerian type tissue, the secondary mullerian system of Lauchlan, a molecular genetic explanation for which is provided by Gaetje et al. It might be only semantics which separates developmentally misplaced tissue of mullerianosis and the mullerian choristoma championed by Batt et al. and of which endocervical examples include lesions reported in the posterior wall of the bladder and small intestine. Endosalpingeal examples would include, but are not limited to, those reported in the appendix and bladder, perhaps also including cystic endosalpingiosis in a variety of intrauterine and extrauterine circumstances and when it occurs in combination with other choristomatous tissues. The parallel concepts of congenital (developmental, ‘embryologically patterned’, choristomatous) and acquired (implantational, metastatic) origins of various forms of