OBJECTIVE:To evaluate the prognostic significance of tumor p16(INK4a) expression in predicting treatment response and survival in patients with locally advanced squamous cell vulvar cancer (LAVC) undergoing chemoradiotherapy (CRT). METHODS:Retrospective data were collected from patients with stage II-IVB disease managed with definitive or neoadjuvant CRT between January 2016 and March 2024. Clinical response to CRT and survival outcomes according to tumor p16 expression were evaluated. RESULTS:Among 61 patients, 39 (63.9%) had p16-negative (p16-) tumors, 22 (36.1%) had p16-positive (p16+) tumors. p16 positivity was linked to higher complete clinical response (cCR) rates (odds ratio [OR]=9.8; p<0.001) and, after adjusting for tumor size, lymph node status and radiation dose, was the only independent predictor of cCR (OR=7.0; p=0.003). The 3-year progression-free survival (PFS), locoregional control (LRC), and overall survival (OS) rates were 12.6%, 17.3%, and 19.5% for p16- tumors, 60.4% (p<0.001), 80.4% (p<0.001), and 64.9% (p<0.001) for p16+ tumors. Among patients who achieved a cCR, the 3-year PFS, LRC and OS were 14.3%, 14.3%, and 33.3% for p16- tumors, 69.6% (p=0.001), 85.7% (p<0.001), and 80.2% (p=0.008) for p16+ tumors. p16 positivity was independently associated with improved PFS (hazard ratio [HR]=0.15, p<0.001), LRC (HR=0.09, p<0.001), and OS (HR=0.16, p<0.001). Larger tumor size adversely affected all outcomes, while age, lymph node status, and RT dose were not significant predictors. CONCLUSION:p16(INK4a) expression predicts treatment response, locoregional disease control and survival in LAVC undergoing upfront CRT. These findings highlight the importance of integrating p16 expression into treatment protocols and future clinical trials.

Background:Triple-negative breast cancer (TNBC) is a heterogeneous disease lacking approved targeted therapies and standardized treatment regimens. Among its molecular subtypes, luminal androgen receptor-positive (LAR+) TNBC is characterized by reduced proliferative activity and a lower sensitivity to chemotherapy. The tumor immune microenvironment (TIME) plays a critical role in shaping treatment responses; however, its spatial organization and cellular composition in LAR+ TNBC remain poorly understood. Methods:In this exploratory study, we performed multiplex immunofluorescence analysis to characterize 18 immune and tumor cell subtypes in paired pre- and post-neoadjuvant therapy (NAT) samples from small, exploratory cohort of patients with LAR+ TNBC, stratified by pathological complete response (pCR). We assessed immune cell composition, expression of exhaustion markers, and spatial relationships among cellular populations to explore TIME features associated with different pathological responses. Results:Patients who achieved pCR displayed higher pre-treatment densities of specific immune subsets, including CD20+PD-1+, CD4+FOXP3+, and CD8+PD-1+TIM3+ cells, consistent with an immune-enriched microenvironment. Spatial analyses revealed distinct patterns between Responders (Resp) and Non-Responders (NoResp). In Resp, tumor cells (PANCK+) were initially located closer to PD-L1-expressing tumor cells (PANCK+PD-L1+), with this proximity decreasing after NAT. In contrast, in non-Resp, immunosuppressive tumor cells moved closer to tumor cells following treatment. Moreover, NAT in Resp was associated with a spatial repositioning of CD4+ and CD8+ T cells toward tumor cells. B cells and regulatory B cells (Bregs) also exhibited differential spatial dynamics between the two groups. Conclusions:This exploratory analysis describes distinct immune compositions and spatial arrangements of the TIME in LAR+ TNBC. Our findings suggest that specific immune enrichments and spatial remodeling patterns may differ between patients with different pathological outcomes, whereas the persistence of immunosuppressive niches characterizes non-Resp. Given the small sample size and the inclusion of immune checkpoint inhibitors in a subset of patients, all of whom achieved pCR, these observations should be considered strictly hypothesis-generating. Larger and more homogeneous cohorts will be required to validate these findings and to determine their potential clinical relevance.

We describe the case of a 41-year-old woman undergoing hysteroscopic resection of a submucosal uterine mass, histologically consistent with a cellular leiomyoma. Immunohistochemistry showed diffuse cyclin D1 expression, an unexpected finding in leiomyomas and typically seen in high-grade endometrial stromal sarcomas. Targeted RNA sequencing revealed a novel HMGA2::PLCZ1 fusion transcript, not previously described in leiomyomas or other tumors. Given the known role of HMGA2 in regulating cyclin D1 transcription, this mechanism may plausibly account for the aberrant immunoprofile, although cyclin D1 expression has not been systematically evaluated in cellular leiomyomas. This case brings forward two key considerations: (i) cyclin D1 expression may, in rare cases, reflect HMGA2 rearrangements in leiomyomas; (ii) cyclin D1 positivity alone should not prompt misdiagnosis of high-grade endometrial stromal sarcoma, particularly in fragmented hysteroscopic specimens. To our knowledge, this is the first report of an HMGA2::PLCZ1 rearrangement, expanding the molecular spectrum of uterine smooth muscle tumors. This case also emphasizes the biological link between HMGA2 activation and cyclin D1 overexpression, providing new insights into the molecular mechanisms underlying uterine smooth muscle tumorigenesis.

OBJECTIVE:This retrospective study and systematic review of the literature aimed to investigate the oncologic outcomes of sentinel node biopsy (SNB) procedure in patients with invasive Vulvar Paget's Disease (iVPD). METHODS:Patients with iVPD who underwent a preoperative lymphatic mapping with [99mTc]Tc-nanocolloid, followed by SNB between January 2015 and July 2024 were analyzed. A comprehensive search of PubMed/MEDLINE and Scopus was conducted. Original articles evaluating SNB in iVPD patients were eligible. RESULTS:A total of 27 patients were included, 16 (59.3%) had a depth of stromal invasion ≤1 mm (microinvasive disease). SNs were identified preoperatively in 26 available cases (41/44 groins, 93.2%) and intra-operatively in 26/27 cases (44/45 groins, 97.8%). Four groins (8.9%) had metastatic SNs, two with micrometastases and two with macrometastases. Among 16 patients with microinvasive VPD, 2 (12.5%) had metastastic SNs. No groin recurrences were observed in the whole population after a median follow-up of 36 months (95% CI: 27-49 months). The 5-years disease-free survival and overall survival were 74.3% and 83.7%, respectively. A total of 12 studies (100 iVPD patients) were included after systematic review of the literature. Metastatic SNs were reported in 22 patients (22.0%). Among 9 patients with microinvasive disease, 3 (33.3%) had metastatic SNs. Among the 23 patients with available follow-up data, one case of locoregional lymph-node recurrence occurred. CONCLUSIONS:Our data, together with evidence from the literature, suggest that SNB technique may be an acceptable approach for nodal staging in iVPD patients, opening the way for an expansion of SN indications in vulvar neoplasms. Microinvasive VPD is associated with a significant rate of metastatic SNs, thus inguino-femoral surgical staging is recommended in this clinical setting.

This review examines the clinical and practical implications of embedding molecular profiles directly into the 2023 FIGO staging system for endometrial carcinoma, in the context of the 2025 ESGO/ESTRO/ESP guidelines. The primary purpose is to navigate a central conflict in modern oncology: how to deliver increasingly personalized care while maintaining a globally accessible, equitable, and standardized cancer classification system. The 2023 FIGO update represents a paradigm shift from the traditional dualistic model (Type I versus Type II) by allowing molecular findings to redefine stage itself. While this integration offers clear benefits, it introduces significant challenges. First, the system depends on advanced molecular testing, creating a “rich-poor” divide where patients in resource-limited settings are systematically overtreated because testing is unavailable. Second, stage becomes unstable, changing with sequential histologic and molecular re-review, which causes confusion for patients and clinicians. Third, the system lumps prognostically distinct histotypes (Serous, Clear Cell, Carcinosarcoma, and Grade 3 Endometrioid) into a single aggressive stage, obscuring meaningful differences in survival. Fourth, it relies on subjective parameters such as “substantial” lymphovascular space invasion, for which no standardized definition exists, leading to high inter-observer variability. After analyzing these controversies, the review proposes a pragmatic solution: decouple anatomical staging from molecular risk stratification. Staging should remain a purely anatomical, universally applicable descriptor of tumor extent, while molecular and histologic data are used separately within a dynamic risk assessment model, as suggested by the European guidelines. This dual-track approach preserves global comparability, reduces inequity, and maintains diagnostic stability, while still enabling personalized treatment where advanced diagnostics are available.

High-grade endometrial stromal sarcoma (HGESS), which was not recognized as a distinct entity in the third edition of the World Health Organization (WHO) classification and was therefore included in the undifferentiated uterine sarcoma (UUS) category, was reestablished as a separate entity in the fourth edition. HGESS shares BCL-6 corepressor (BCOR) alterations with undifferentiated small round-cell sarcoma (USRCS) of the soft tissue and clear cell sarcoma of the kidney (CCSK). This study aims to perform a comparative morphological, immunohistochemical, and molecular analysis of HGESS, UUS, USRCS, and CCSK. Consecutive uterine sarcomas diagnosed as HGESS or UUS were reviewed and compared to BCOR-altered USRCS (n = 28) and CCSK (n = 10) (including both previously published and new cases). Molecular, DNA methylome (DNAm), and copy number variation (CNV) analyses were performed. DNAm data of 93 previously analyzed uterine and round-cell tumors of several different types were used for clustering analysis. Twenty-five uterine sarcomas (six HGESS and 19 UUS) were included; five of six HGESS cases showed fusions associated with BCOR alterations (YWHAE::NUTM2A/B, EPC1::KDM2B, ZC3H7B::BCOR); UUS showed no fusions (n = 15) or fusions unrelated to BCOR alterations (n = 4). All USRCS and CCSK cases showed either BCOR-ITD or BCOR alteration-related fusions. BCOR-altered HGESS showed broad morphological and immunophenotypic overlap with USRCS and CCSK. DNAm analysis showed that BCOR-altered HGESS, USRCS, and CCSK clustered together, separately from all other tumor types. The non-BCOR-altered HGESS showed a JAZF1::SUZ12 fusion and arose from a low-grade endometrial stromal sarcoma component. CNVs were found in 15/16 uterine sarcomas and in 16/36 USRCS/CCSK cases. BCOR-altered HGESS appeared to be closely related to BCOR-altered USRCS and CCSK rather than to other uterine sarcomas. We suggest that HGESS with BCOR alterations may warrant reclassification as 'BCOR-altered uterine sarcomas'. © 2026 The Pathological Society of Great Britain and Ireland.

BACKGROUND:In hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) metastatic breast cancer (mBC), the prognostic significance of estrogen receptor (ER), progesterone receptor (PgR), and HER2 immunohistochemical expression levels in patients treated with cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) remains unclear. The CYCLHER study was designed to evaluate treatment outcomes and identify biologically driven prognostic factors. METHODS:CYCLHER (NCT06243432) is a retrospective, multicenter study conducted across 16 Italian oncology centers. Patients with HR+/HER2- mBC who received first-line endocrine therapy (ET) plus CDK4/6i between November 2016 and May 2023 were included. ER, PgR and HER2 status were assessed on metastatic or primary tumor samples. The primary endpoint was real-world progression-free survival (rwPFS). Secondary endpoints included overall survival (OS), objective response rate (ORR), disease control rate (DCR), duration of response (DoR), and attrition rate. Optimal cut-off values for ER and PgR expression were determined using Cut-off Finder v1.0. RESULTS:Among 597 eligible patients, median rwPFS was 28.1 months at a median follow-up of 41 months. HER2-low status emerged as a negative prognostic factor, being independently associated with shorter rwPFS compared to HER2-0 (p = 0.02). ER ≥ 87% and PgR ≥60% were associated with improved rwPFS, DCR, and 5-year OS rates. A prognostic score derived from the three biomarkers identified four groups with significantly different rwPFS outcomes (global log-rank p < 0.0001). The first-to-second line attrition rate was 16.2% (95% CI 12.4-20.0). The identified biomarkers did not significantly impact treatment outcomes in the second-line setting. CONCLUSIONS:CYCLHER confirms the prognostic relevance of ER, PgR, and HER2 expression in patients with HR+/HER2-mBC treated with CDK4/6i. HER2-low status was associated with poorer outcomes, supporting its potential role as a negative prognostic marker. The proposed score may facilitate personalized treatment strategies and enhance risk stratification in clinical practice.

Objective Pregnancy induces physiological and microbiological changes in the cervicovaginal environment, which may affect the interpretation of cervical cytology. Accurate screening in this population is essential to identify both benign and pathological alterations. Methods We conducted a retrospective monocentric study on 58 conventional Pap smears performed during pregnancy. Cytological findings were classified according to the Bethesda System, and available microbiological and HPV data were analyzed to explore potential relationships. Results Among the 58 Pap smears, 46.6% were negative for intraepithelial lesions or malignancy (NILM), while 12.1% showed ASC-US, 10.3% LSIL, 5.2% ASC-H, and 25.9% HSIL. Candida infection and Döderlein-related cytolysis were observed in 8.6% and 8.6% of cases, respectively. HPV genotyping, available in 24 patients, identified several high-risk HPV types. Among cases with available HPV data, high-risk HPV types were more frequently observed in high-grade cytological categories, although this association did not reach statistical significance. Culture-based microbiological data were available only in a very limited subset of patients (n = 6). Conclusions Cervical cytology during pregnancy remains a valuable screening tool, but its interpretation requires awareness of pregnancy-related changes and potential diagnostic pitfalls. The integration of HPV and microbiological data may provide additional contextual information; however, larger prospective studies with systematic testing are required to clarify the relationship between microbiota, HPV infection, and cytological abnormalities in pregnant women.

BACKGROUND:The prognostic role of lymphovascular space invasion (LVSI) in endometrial cancer (EC) remains poorly defined across molecular subgroups. We evaluated the impact of LVSI extent in a large cohort of stage I-II EC classified according to molecular profiling. METHODS:Patients with stage I-II EC who underwent complete primary surgical staging were retrospectively included. According to WHO criteria, cases were classified as LVSI-negative, focal LVSI, or substantial LVSI. Molecular classification was performed using next-generation sequencing and immunohistochemistry, identifying the following groups: POLE-mutated (POLEmut), mismatch repair-deficient (MMRd), p53-abnormal (p53abn), low-risk no specific molecular profile (NSMP-LR), and high-risk NSMP (NSMP-HR). RESULTS:Among 2374 patients, LVSI was absent in 73.7% (n = 1750), focal in 11.5% (n = 273), and substantial in 14.8% (n = 351). Any LVSI was associated with larger tumor size, deeper myometrial invasion, and cervical involvement (all p < 0.001). Substantial LVSI was additionally associated with non-endometrioid histology, grade 3 disease, ER < 10%, and higher prevalence of p53abn and NSMP-HR tumors (all p < 0.001). On multivariable Cox analysis, substantial LVSI independently predicted worse disease-free survival in NSMP-LR, MMRd, and p53abn subgroups, whereas focal LVSI did not affect disease-free survival. No significant survival association was found in POLEmut or NSMP-HR tumors. Nevertheless, substantial LVSI was consistently associated with higher recurrence risk across all molecular classes (RR 2.5-2.8). CONCLUSIONS:In stage I-II EC, focal LVSI does not worsen oncologic outcomes across molecular subgroups. In contrast, substantial LVSI associates with aggressive clinicopathologic features and independently predicts poorer disease-free survival in selected molecular groups, increasing recurrence risk by approximately 2.5-2.8-fold.

Granular cell tumors (GCTs) are rare neoplasms, typically of Schwannian origin, with generally a benign and indolent clinical behavior. However, a small subset exhibits malignant behavior, often without clear histologic features. We report a rare case of a vulvar granular cell tumor in a 21-yr-old woman with subsequent pulmonary metastasis. The patient presented with a slowly growing vulvar nodule and a subcutaneous lesion on the left flank. Imaging studies revealed residual disease in the vulva and a suspicious lung nodule, both of which were surgically resected. Histopathologic examination confirmed features consistent with granular cell tumor in both primary and metastatic sites, despite the absence of cytologic atypia, necrosis, or elevated mitotic activity. Immunohistochemistry revealed positivity for S100, CD68, NSE, and inhibin, with a low Ki-67 index (<1%). Next-generation sequencing identified a CHEK2 p.I200T mutation in both lesions, suggesting a shared clonal origin. This variant lies within the kinase domain of CHK2, a key mediator of the DNA damage response, and is of uncertain but potentially pathogenic significance. No microsatellite instability or homologous recombination deficiency was observed. This case highlights the diagnostic challenges in GCTs, particularly in distinguishing benign from malignant forms in the absence of classic histologic criteria. The presence of metastasis remains the most definitive indicator of malignancy. Our findings underscore the importance of integrating molecular profiling into the diagnostic and prognostic workup of GCTs and raise the question about the potential role of CHEK2 alterations as additional molecular determinants of aggressiveness beyond conventional histology. Long-term follow-up is warranted given the unpredictable clinical behavior of malignant GCTs.

POLE-mutated endometrial carcinomas are typically associated with favorable prognosis, yet marked spatial heterogeneity may complicate biological and clinical interpretation. We report a unique triphasic carcinoma composed of endometrioid, dedifferentiated-like, and sarcomatoid-like components with distinct morphologic and immunophenotypic profiles. Multiregional sequencing demonstrated a shared pathogenic POLE V411L mutation across all components, confirming a common clonal origin. Progressive molecular divergence was observed, with subclonal MSH6 alteration in the endometrioid region, complete MSH6 loss and dramatic tumor mutational burden escalation in the dedifferentiated-like and sarcomatoid-like components, and acquisition of TP53 and ARID1A truncating mutations restricted to the sarcomatoid-like compartment. Despite high-grade transformation and stage IIC disease, microsatellite stability was maintained, supporting a POLE-driven hypermutator phenotype. This case provides direct morphologic and molecular evidence of spatial clonal evolution in a multiple-classifier endometrial carcinoma. The clinical implications of this spatial heterogeneity remain uncertain and warrant further investigation.

Assessment of mismatch repair (MMR) function provides critical guidance for diagnosis, prognosis, and therapeutic decision making in colorectal and endometrial cancers. Mismatch repair immunohistochemistry (IHC) is the routine clinical test for identifying MMR deficiency, while microsatellite instability (MSI) serves as its surrogate, detected by polymerase chain reaction or next-generation sequencing (NGS). Available data indicate a high concordance rate between these approaches in colon cancer, whereas a lower concordance has been reported in endometrial cancer. We aimed to assess the concordance rate between MMR-IHC and MSI-NGS from patients with colorectal or endometrial cancer, using IHC as the gold standard. A cohort of 520 patients (352 with endometrial cancer and 168 with colorectal cancer) were included. MMR‑IHC assessed MLH1, MSH2, MSH6, and PMS2 expression, while MSI‑NGS was determined by profiling 130 homopolymer repeat loci using the TruSight Oncology 500 panel from Illumina. While concordance was high in the colorectal cancer cohort (99

Endometrial stromal sarcoma (ESS) is a rare uterine malignancy with limited treatment options. We performed integrated whole-genome, whole-exome, and transcriptome sequencing on 80 ESS tumors, comprising 32 low-grade (LG) and 48 high-grade (HG) tumors, to characterize their genetic landscape. The overall mutation burden was modest, with no significant difference between grades; however, we identified six hypermutated cases (7.5%) harboring POLE or mismatch repair mutations, genomic features predictive of immunotherapy response. We identified focal RAD54B amplifications in 15 tumors (18.8%), leading to elevated RAD54B expression and significantly shorter survival. This establishes RAD54B as an oncogenic driver in ESS. Known tumor suppressors (PTEN, TP53) were frequently mutated in HG-ESS but rare in LG-ESS, highlighting distinct grade-specific drivers of malignancy. HG-ESS exhibited widespread chromosomal gains, frequent loss of cell-cycle regulators (RB1, CDKN2A), and numerous private gene fusions arising from complex DNA rearrangements. In contrast, LG-ESS were defined by canonical fusions (e.g., JAZF1-SUZ12) and co-occurring deletions in metabolic regulator genes (TSC2, STK11). Finally, in an activating NRAS-mutant (p.Q61R) HG-ESS xenograft, the combination of MEK and FAK inhibition dramatically suppressed tumor growth and prolonged survival, highlighting a promising targeted treatment strategy. Overall, our comprehensive analysis defines the molecular basis of ESS and provides a strong preclinical rationale for precision therapies in this aggressive cancer.