BACKGROUND:The American Cancer Society recommends physicians inform average-risk women about endometrial cancer risk on reaching menopause, but new diagnoses are rising fastest in women aged younger than 50 years. Educating these younger women about endometrial cancer risks requires knowledge of risk factors. However, endometrial cancer in young women is rare and challenging to study in single study populations. METHODS:We included 13 846 incident endometrial cancer patients (1639 aged younger than 50 years) and 30 569 matched control individuals from the Epidemiology of Endometrial Cancer Consortium. We used generalized linear models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for 6 risk factors and endometrial cancer risk. We created a risk score to evaluate the combined associations and population attributable fractions for these factors. RESULTS:In younger and older women, we observed positive associations with body mass index and diabetes and inverse associations with age at menarche, oral contraceptive use, and parity. Current smoking was associated with reduced risk only in women aged 50 years and older (Phet < .01). Body mass index was the strongest risk factor (OR≥35 vs<25 kg/m2 = 5.57, 95% CI = 4.33 to 7.16, for ages younger than 50 years; OR≥35 vs<25 kg/m2 = 4.68, 95% CI = 4.30 to 5.09, for ages 50 years and older; Phet = .14). Possessing at least 4 risk factors was associated with approximately ninefold increased risk in women aged younger than 50 years and approximately fourfold increased risk in women aged 50 years and older (Phet < .01). Together, 59.1% of endometrial cancer in women aged younger than 50 years and 55.6% in women aged 50 years and older were attributable to these factors. CONCLUSIONS:Our data confirm younger and older women share common endometrial cancer risk factors. Early educational efforts centered on these factors may help mitigate the rising endometrial cancer burden in young women.

PDF file - 14KB, Supplementary Table 1. Mutation List for Pairmax paired protein null samples n = 31.

Overall survival benefits of cancer therapies have, in general, fallen short of what was expected from them. By examining the many parallels that exist between embryogenesis and carcinogenesis, we discuss how clinical and fundamental cancer research can benefit from computational morphogenesis (CM) insofar as carcinogenesis is causally related to altered mechanisms underlying embryogenesis and post-embryonic tissue homeostasis. We also discuss about the critical role played by digital pathology (DP) since it constitutes the main source of data for the model-fitting and validation of CM-generated virtual tissues. Conversely, we outline how CM can provide support to DP by generating annotated synthetic 2D and 3D data that can be fed into machine-learning methods dedicated to the automated diagnosis of DP slides.

Abstract Endometrial carcinoma (EC), a malignancy that arises from the epithelial lining of the uterus, is heterogeneous at histologic and molecular levels. Risk factors and outcomes also differ by type. Though prior studies characterized the genomic landscape of endometrial carcinoma, few integrated histologic, clinical, and prospectively collected epidemiologic data into the analysis. We collected formalin-fixed paraffin embedded tumor tissue from women enrolled in the Nurses’ Health Study who were diagnosed with EC between 1976 and 2012. We targeted 50 cancer related genes for high-throughput sequencing to identify genetic variants in 37 ECs and correlate findings with immunohistochemical, histologic, and epidemiologic data. Case selection was designed to include maximal power to discover genetic changes associated with p53 immunohistochemical status and clinical stage of disease at diagnosis. Mutations most frequently occurred in TP53 (57%), PTEN (46%), and PIK3CA (38%). TP53 mutations were seen in 83% of ECs that immunostained positive for mutant p53, with the most frequent TP53 mutations occurring in R248. Well-differentiated endometrioid tumors had elevated frequencies of PTEN and PIK3CA mutations compared to less differentiated tumors (p < 0.05). The mutation profiles of these samples are consistent with previous studies, supporting the viability of archival paraffin-embedded tissue in mutation detection. This study’s interdisciplinary approach to tumor characterization may help inform future development of personalized models for EC. Citation Format: Maxine Chen, Marta Crous-Bou, Michael J. Downing, Evan L. Busch, Kimberley Glass, Jennifer Prescott, George L. Mutter, Immaculata De Vivo. Mutation analysis of endometrial cancer in a population-based study by targeted next-generation sequencing [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1291. doi:10.1158/1538-7445.AM2017-1291

OBJECTIVE: To estimate cancer outcome and outcome predictors of women with endometrial intraepithelial neoplasia (EIN). METHODS: Outcomes of women with first diagnosis of EIN (“index biopsy”) were determined by follow-up pathology. Patient characteristics were correlated with EIN regression, EIN persistence, and progression to cancer. RESULTS: Fifteen percent (95% confidence interval [CI] 9.8–20.8%, 26 of 177) of index EIN biopsy samples had concurrent cancer. Of the women with cancer-free index EIN biopsy samples and follow-up by hysterectomy or more than 18 months of surveillance, 25% (95% CI 18.4–33.3%, 36 of 142) showed regression, 35% (95% CI 27.4–43.7%, 50 of 142) showed persistence, and 39% (95% CI 31.3–48.0%, 56 of 142) showed progression. Nonwhite ethnicity and progestin treatment reduced cancer outcomes (odds ratio [OR] 0.16, 95% CI 0.03–0.84 and OR 0.24, 95% CI 0.08–0.70, respectively), whereas body mass index greater than 25 increased malignant outcomes (body mass index 25 or higher, OR 3.05, 95% CI 1.10–8.45). CONCLUSION: Endometrial intraepithelial neoplasia confers a high risk of cancer, but individual patient outcomes cannot be predicted. Management should include exclusion of concurrent carcinoma and consideration of hysterectomy. LEVEL OF EVIDENCE: II

Most serous adenocarcinomas involving both the endometrium and ovary are presumed to arise in the endometrium. Recently, serous tubal intraepithelial carcinoma (STIC) has been implicated in the pathogenesis of pelvic serous carcinoma. This study explored the potential relationship between STIC and uterine serous carcinoma. Twenty-two consecutive cases of serous carcinoma involving the endometrium were studied. In each case, fallopian tubes were submitted in toto according to the protocol for sectioning and extensive examination of the fimbriated end. Extent of the endometrial tumor and presence/absence of STIC were documented. Immunostaining for p53 and Wilms tLImor-1 was performed on all cases with STIC. p53 mutation analysis was performed in a subset of matched STICs and endometrial tumors. Eleven cases showed concurrent endometrial and adnexal involvement, including 6 with endosalpingeal involvement: STIC was confirmed in 5. In all 5, the concurrent endometrial tumor was either noninvasive, or exhibited only superficial (<5%) myometrial invasion. In 2 cases, identical p53 mutations were shared by both tubal and endometrial lesions. This Study shows that noninvasive, genetically related serous carcinomas may coexist in both tube and endometrium. As management of serous neoplasms is predicated on site of origin, we propose that the sectioning and extensively examining the fimbria protocol be applied to all endometrial serous carcinomas and that tumors with concurrent STIC be classified as a distinct subset of pelvic serous carcinomas pending a clearer understanding of tumor origin.

CS18-01 Endometrioid endometrial adenocarcinoma is a common gynecologic cancer associated with antecedent unopposed estrogen exposure and monoclonal genetically mutated precancerous lesions. Histologic examination of genetically defined monoclonal precancers has led to improved cancer outcome prediction through routine pathologic diagnosis of premalignant Endometrial Intraepithelial Neoplasia (EIN) lesions (OR 89). The PTEN tumor suppressor gene, inactivated by somatic mutation and/or deletion in up to 80% of endometrioid carcinomas and 68% of premalignant EIN lesions, is the earliest known step in endometrial carcinogenesis. Surprisingly, PTEN inactivation occurs in morphologically unremarkable endometrial glands (latent precancers) in half of normal women, but the lifetime cancer risk is only 2%. A high rate of PTEN-null endometrial gland emergence in the reproductive years, combined with clonal persistence for years thereafter, links these early events with subsequent carcinoma. One possible modifier of risk is specific interaction between pre-existing mutated cells and hormones. In fact, physiologic requirements for the PTEN tumor suppressor protein are modulated by sex hormones, which act as positive or negative selection factors for these quite common Nongenetic exposures known to diminish endometrial cancer risk, such as administration of progestins and placement of inert intrauterine devices, are accompanied by declines in the prevalence of latent precancers. Latent endometrial precancers, as detectible by PTEN immunohistochemistry, are the target for, and mediators of, some nongenetic endometrial cancer risk factors.

BACKGROUND. The objective of this study was to compare the accuracy of disease progression prediction of the molecular genetics and morphometry-based Endometrial Intraepithelial Neoplasia (EIN) and World Health Organization 1994 (WHO94) classification systems in patients with endometrial hyperplasias.METHODS. A multicenter, multivariate analysis was conducted on 477 patients with endometrial hyperplasia who were required to have a 1-year minimum disease-free interval from the time of the index biopsy (1-18 years of follow-up). The results from that analysis were compared with the results from 197 patients who had < 1 year of follow-up.RESULTS. Twenty-four of 477 hyperplasias (5.0%) progressed to malignant disease over an average of 4 years (maximum, 10 years). According to the WHO94 classification, 16 of 123 atypical hyperplasias (13%) and 8 of 354 nonatypical hyperplasias (2.3%) progressed (hazard ratio [HR] = 7). Twenty-two of 118 EINs (19%) and 2 of 359 non-EINs (0.6%) progressed (HR = 45). FIN was prognostic within each WHO94 subcategory. Progression rates were 3% in simple hyperplasias, 22% in complex hyperplasias, 17% in simple atypical hyperplasias, and 38% in complex atypical hyperplasias with EIN, compared with progression rates of 0.0-2.0% in all hyperplasias if EIN was absent. EIN detected precancerous lesions (sensitivity, 92%) better than WHO94 atypical hyperplasias collectively (67%) or complex atypical hyperplasias alone (46%). In a Cox regression analysis, EIN was the strongest prognostic index of future endometrial carcinoma. The same was true for patients with < 1 year of follow-up (HR for EIN, atypical hyperplasia, and complex atypical hyperplasia: 58, 7, and 8, respectively).CONCLUSIONS. The EIN classification system predicted disease progression more accurately than the WHO94 classification and identified many women with benign changes that would have been regarded as high risk according to the WHO94 classification system.

Endometrial hyperplasia (EH) is a common disease. An estimated 180,000–200,000 new cases occur annually in the Western world; approx 39,200 new cases and 6600 deaths were expected in the United States in 2002 (1). About 8–20% of all EH is associated with subsequent endometrial cancer of the endometrioid type. Major problems in treating EH include poor diagnostic reproducibility and inaccurate prediction of cancer progression. This has resulted in enormous overtreatment. The World Health Organization (WHO)’s 1994 histologic classification is widely used but is not reproducible, does not adequately predict the risk of cancer progression, and lacks a molecular and cell biology basis. Computerized morphometric analysis has identified a multivariate combination of architectural and nuclear features, called the DS, which is reproducible, fits with therapeutic options, and accurately predicts cancer outcome. Cases with DS ≥1 have a negligible progression risk (0.3%), contrasting with a 37% progression risk for those with DS < 1 found in a large multicenter study with more than 18 yr of follow-up. Moreover, molecular-genetic studies have found a {tly|464-1} strong correlation between clonality and DS; monoclonal cases nearly always have DS < 0; cases with DS ≥ 1 are mostly polyclonal. This has resulted in a new classification, endometrial intraepithelial neoplasia (EIN), which does not mimic subjective WHO hyperplasia diagnoses but rather uses new criteria for prognostic prediction of cancer endpoints. Moreover, high-risk EIN-DS lesions often show clonal inactivation of the phosphatase and tensin homologue (PTEN) tumor-supressor gene by immunohistochemistry. Based on EIN-DS, patients can now be reproducibly assigned with high accuracy to high- and low-risk categories, permitting appropriate management. EIN-DS application is easy, can be done on standard histologic sections, and has reasonable cost. EIN-DS thus can be assessed in any pathology laboratory, but sections can also be sent to reference laboratories for measurement if necessary.

Until recently, the histologic diagnosis of obstetrical and gynecologic neoplasia was based principally on morphologic criteria. However, interobserver reproducibility for entities such as squamous intraepithelial, endometrial, and trophoblastic disease varies widely between observers. This inherent variability in interpretation between individuals has led to wide ranges in diagnostic precision between practices, and in many cases, between recognized experts. The advent of immunohistochemistry, and the more recent accelerated discovery of new genes and their functions has resulted in the discovery of cellular proteins or nucleic acids that are differentially expressed in tumors. When applied in conjunction with existing histologic criteria, these "biomarkers" have the potential to enhance diagnostic consistency and reproducibility. The gains expected are to practicing diagnostic pathologists (who will enjoy greater diagnostic consistency) and to academics (for whom biomarkers may uncover new pathways unappreciated by histologic diagnosis alone). However, fundamental to the success in both arenas will be critical analysis of the potential pitfalls in immunohistochemistry, strict validation of new markers as they arrive in the field, and a realistic view of their value in the laboratory management of obstetrical and gynecologic diseases.

p63 is a p53 homologue required for cutaneous development that is expressed in immature squamous epithelium and reserve cells of the cervix. Humans with p63 mutations exhibit defects in limb, accessory organ (skin appendage, breast, prostate), and genitourinary development. Because p63 expression patterns imply a strong role of the gene in the female genital tract development, newborn female p63-/-, +/-, and +/+ mice were examined in situ, dissected, and compared. Nuclear p63 protein was localized to the skin, vagina, bladder, urethra, and basal columnar cells of the caudal uterus in p63+/+ and +/- animals. p63-/- mice exhibited abnormal genital morphogenesis with hypoplastic genitalia, a single cloacal opening, and persistence of columnar epithelium at lower genital tract sites that normally undergo squamous and urothelial differentiation. The defects observed support p63-dependent pathways of genital tract development that permit externally, ectodermal basal cell replenishment integral to reciprocal epithelial stromal signaling, urorectal septation, and modeling of the external genitalia; and internally, the emergence of basal epithelial cell populations capable of divergent epithelial cell differentiation in the vagina, cervix, and urinary tract. Defects in the first pathway explain imperforate anus, vaginal septum, genital hypoplasia, and micropenis reported in humans with p63 mutations. The second is necessary for the generation of multipotential reserve cells in the cervix and may be operative in other epithelial stromal interactions integral to the emergence of uterine basal cells later in life.

BACKGROUND:Metaplastic differentiation, including squamous, mucinous, and tubal (ciliated), is common in both benign and neoplastic endometrium, and the cell of origin for this pathway is poorly understood. In this study, expression of a marker for basal and reserve cells in cervical squamous mucosa, designated p63, was investigated in a spectrum of endometrial alterations.METHODS:One hundred ninety different endometria from 132 patients were examined, including fetal (6), premenarchal (3), benign cyclic (29) and noncyclic (54), hyperplastic (14), and neoplastic (93) endometrial glandular epithelia. The latter included conventional endometrioid carcinomas with and without mucinous, ciliated, and squamous metaplasia, and uterine papillary serous carcinoma (UPSC).RESULTS:p63 expression was identified in basal/subcolumnar cells in the fetal endometrium in a distribution similar to that in basal/reserve cells of the cervix. Staining was confined to individual scattered basal and suprabasal cells in cycling endometrium. In polyps and postmenopausal endometria, focal clusters of p63-positive cells were identified in inactive glands or surface epithelium. Metaplastic (squamous or mucinous) epithelia, either alone or in conjunction with hyperplasias or carcinomas, exhibited the most intense staining, primarily in basal or subcolumnar cells. In some cases, immediately adjacent nonmetaplastic columnar epithelium also stained positive. UPSCs contained only rare scattered p63-positive cells.CONCLUSIONS:Cells with a basal or reserve cell phenotype exist in the endometrium during fetal life, are not conspicuous during the reproductive years, but may emerge during shifts in differentiation. Whether these cells signify specialized multipotential endometrial cells is not clear, but the similarity of these cells to basal/reserve cells of the cervix and their association with neoplasia merit further study.

Although prostate cancers initially respond favorably to androgen deprivation, regrowth of androgen-independent tumors is very common.The molecular mechanisms involved in the regression and regrowth of prostate cancers are unknown.We applied complementary DNA microarrays containing 6,605 genes to identify gene expression changes in the CWR22 human prostate cancer xenograft model system 12 h to 16 d after androgen deprivation, as well as in recurrent androgen-independent CWR22R tumors.We identified 59 genes whose expression levels decreased threefold in response to castration, including several cell cycle regulators.In the recurrent tumors, expression levels of 57 of these genes (96.6%) were restored, suggesting reactivation of androgen signaling in the absence of ligand.Of the 6,605 genes, 251 (3.8%) were differentially expressed between primary and recurrent prostate cancers.These genes included those coding for transcription factors, signal transducers, growth and survival factor receptors and cell cycle regulators.One of the most overexpressed genes in the recurrent tumors was S100P, which encodes a calcium-binding signaling protein.The role of S100P in the progression of prostate cancers in vivo was further suggested by in situ hybridization of messenger RNA and protein immunostaining of 440 clinical tumor specimens in a tissue microarray format.Tissue microarray analysis indicated that S100P expression increased significantly (P<0.0001)during the progression of prostate cancers in vivo, with the highest levels seen in hormonerefractory and metastatic prostate cancers.The cDNA microarray data may also suggest targets for therapeutic intervention.For example, several direct and indirect rapamycin targets were differentially expressed in recurrent tumors.Rapamycin also inhibited CWR22R prostate cancer cell growth in vitro.Tissue and cDNA microarrays enable rapid identification, prioritization and validation of gene targets that may have diagnostic and therapeutic significance in the management of patients with hormone-refractory human prostate cancer.Hormoneindependent prostate cancer growth seems to require re-expression of androgendependent signaling pathways as well as altered expression of several other genes.

BACKGROUND:Phytoestrogens are increasingly used by patients as "natural" alternatives to hormone replacement. Attention in scientific and lay literature has focused on their potential to prevent menopausal symptoms, bone loss, heart disease, or breast cancer. Less is known about effects on the endometrium, specifically, whether prolonged exposure to phytoestrogens could promote hyperplasia or neoplasia, as does unopposed estrogen. CASE:We report the case of a woman diagnosed with grade 1 endometrioid adenocarcinoma of the endometrium whose history was notable for extensive use of supplemental phytoestrogens. CONCLUSION:The effects of phytoestrogens on endometrial tissue are not known. Given their increasing popularity and availability in concentrated form as dietary supplements, additional research is warranted before we can counsel our patients regarding the safety of such supplements.

Endometrial precancers are monoclonal, benign neoplasms prone to malignant transformation. A type collection (deposited at www.endometrium.org) of confirmed precancers has been identified by their monoclonal growth and continuity of acquired genetic markers that occur between premalignant and malignant phases of tumorigenesis. Computerized morphometry of these premalignant lesions, designated endometrial intraepithelial neoplasia (EIN), has disclosed new architectural criteria and revised cytologic criteria for their diagnosis. EIN lesions originate focally and expand in size over time, in keeping with a proliferative monoclonal origin. They are characterized by closely packed glands (volume percentage stroma < 55%) with cytology that is clearly demarcated from that of the adjacent field. A minimum homogeneous field of cytologically demarcated glands is required to accurately assess the architecture diagnostic of EIN, and morphometry-diagnosed lesions with a largest diameter of at least 1 to 2 mm have previously been shown to predict the relevant clinical outcome of concurrent or future endometrial adenocarcinoma. Nonphysiologic loss of the PTEN protein, a tumor suppressor gene mutated in many endometrioid adenocarcinomas, is seen in individual glands of endometrium exposed to unopposed estrogens and in packed clusters of EIN glands. The isolated PTEN-free glands in anovulatory endometria may be the earliest stage of endometrial tumorigenesis, but they are not readily distinguishable by routine histology, nor do they have a defined natural history.

Mutation or overexpression of certain host genes, including c-myc, Ha-ras, and Ki-ras, have been associated with genital squamous neoplasia, specifically in the cervix, and have been implicated in the natural history of these tumors. The relationship of these host gene alterations to vulvar squamous cell carcinomas has not been previously studied. We analyzed archival material from 13 human papillomavirus-positive and-negative vulvar squamous cell carcinomas for mutations in Ha-, Ki-, and N-ras genes, and a smaller number of flesh samples for c-myc amplification, using PCR-based assays. For comparison, eight cervical squamous cell carcinomas (three fixed and five fresh) were also analyzed. Analysis for ras mutations revealed a previously reported silent allelic variant at nucleotide 1744 in the Ha-ras gene, but no mutations in codons 12, 13, or 61. Similarly, genomic amplification of c-myc beyond a maximum of three haploid copies was not identified in the cases. These findings indicate that alterations in myc or ras sequences are not linked to vulvar squamous cell carcinomas or to the presence or absence of HPV nucleic acids. Moreover, they apparently will not distinguish vulvar from cervical carcinomas, both groups appearing to be unlikely to harbor these sequence alterations.