BRCA-associated homologous recombination deficiency (HRD) is present in ~50% of high-grade serous carcinomas (HGSC) and predicts sensitivity to platinum-based therapy. However, there is little understanding of why some patients with BRCA-deficient tumors experience unexpectedly poor outcomes. We profiled 154 tumors, enriched for patients with BRCA-deficient tumors that experienced short overall survival (≤3 years, n=42), using whole-genome, transcriptome, and methylation analyses. All but one BRCA-deficient tumor exceeded an accepted HRD genomic scarring threshold. However, patients with BRCA1-deficient HGSC with a more elevated HRD score survived significantly longer. Patients with BRCA2-deficient HGSC and loss of NF1 survived twice as long as those without NF1 loss, whereas PIK3CA or RAD21 amplification defined BRCA2-deficient HGSC with exceptionally short survival. BRCA1-deficient tumors in short survivors had evidence of immunosuppressive c-kit signaling and EMT. In a large HGSC cohort (n=1,389) including 282 individuals with pathogenic germline BRCA variants (gBRCApv), the location of the mutation within functional domains stratified clinical outcomes. Notably, residual disease after primary surgery had limited prognostic effect in gBRCApv-carriers compared to non-carriers. Our findings indicate that tumor HR proficiency in the context of therapy response and survival is not a binary property, and highlight genomic and immune modifiers of outcomes in BRCA-deficient HGSC.

Schema of study numbers for each analysis to describe different cohort numbers due to pathology review and missing data. MOC, mucinous ovarian carcinoma; MBOT, mucinous borderline ovarian tumor; LGI, lower gastrointestinal; UGI, upper gastrointestinal; SISH, silver in situ hybridization.

Associations between gene expression and stage group and OS in MOC.

Kaplan–Meier curves of OS in (A) main tumor groups (n = 582)—MBOT, MOC, LGI, and UGI; (B) patients with MOC by FIGO stage (n = 184); (C) patients with MOC by pattern of invasion in all stages (n = 178); and (D) patients with stage I MOC (n = 134), by pattern of invasion.

Heat map of unsupervised clustering analysis. Contains all samples with a concordant pathology diagnosis (n = 497), with MOC grouped by FIGO stage. Labels show main clusters and diagnoses. Gene-expression values are normalized and logarithm base 2 transformed. dx, diagnosis.

Supplementary Figures S1-S13

Overall survival in MOC by pattern of invasion.

Supplementary Tables S1-S11

Patient characteristics and analytical cohorts.

High-grade serous ovarian carcinoma (HGSOC) is genetically unstable and characterised by the presence of subclones with distinct genotypes. Intratumoural heterogeneity is linked to recurrence, chemotherapy resistance, and poor prognosis. Here, we use spatial transcriptomics to identify HGSOC subclones and study their association with infiltrating cell populations. Visium spatial transcriptomics reveals multiple tumour subclones with different copy number alterations present within individual tumour sections. These subclones differentially express various ligands and receptors and are predicted to differentially associate with different stromal and immune cell populations. In one sample, CosMx single molecule imaging reveals subclones differentially associating with immune cell populations, fibroblasts, and endothelial cells. Cell-to-cell communication analysis identifies subclone-specific signalling to stromal and immune cells and multiple subclone-specific autocrine loops. Our study highlights the high degree of subclonal heterogeneity in HGSOC and suggests that subclone-specific ligand and receptor expression patterns likely modulate how HGSOC cells interact with their local microenvironment. Intratumoural heterogeneity in high-grade serous ovarian carcinoma (HGSOC) remains to be explored. Here, the authors perform spatial transcriptomics and reveal a high degree of subclonal heterogeneity in HGSOC.

BACKGROUND:Cyclin E1 (CCNE1) is a potential predictive marker and therapeutic target in tubo-ovarian high-grade serous carcinoma (HGSC). Smaller studies have revealed unfavorable associations for CCNE1 amplification and CCNE1 overexpression with survival, but to date no large-scale, histotype-specific validation has been performed. The hypothesis was that high-level amplification of CCNE1 and CCNE1 overexpression, as well as a combination of the two, are linked to shorter overall survival in HGSC. METHODS:Within the Ovarian Tumor Tissue Analysis consortium, amplification status and protein level in 3029 HGSC cases and mRNA expression in 2419 samples were investigated. RESULTS:High-level amplification (>8 copies by chromogenic in situ hybridization) was found in 8.6% of HGSC and overexpression (>60% with at least 5% demonstrating strong intensity by immunohistochemistry) was found in 22.4%. CCNE1 high-level amplification and overexpression both were linked to shorter overall survival in multivariate survival analysis adjusted for age and stage, with hazard stratification by study (hazard ratio [HR], 1.26; 95% CI, 1.08-1.47, p = .034, and HR, 1.18; 95% CI, 1.05-1.32, p = .015, respectively). This was also true for cases with combined high-level amplification/overexpression (HR, 1.26; 95% CI, 1.09-1.47, p = .033). CCNE1 mRNA expression was not associated with overall survival (HR, 1.00 per 1-SD increase; 95% CI, 0.94-1.06; p = .58). CCNE1 high-level amplification is mutually exclusive with the presence of germline BRCA1/2 pathogenic variants and shows an inverse association to RB1 loss. CONCLUSION:This study provides large-scale validation that CCNE1 high-level amplification is associated with shorter survival, supporting its utility as a prognostic biomarker in HGSC.

Abstract 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.

Embryonal rhabdomyosarcoma of the uterine cervix is a rare neoplasm which is almost invariably associated with pathogenic somatic or germline DICER1 mutations; patients with germline mutations have DICER1 syndrome. We report 2 subtle cervical embryonal rhabdomyosarcoma, one occurring in a 21-yr-old woman with a known history of DICER1 syndrome and the other in a 19-yr-old woman with no history of DICER1 syndrome or DICER1-associated neoplasms. Both neoplasms focally involved otherwise benign endocervical polyps and were characterized histologically by subtle areas of increased stromal cellularity, nuclear atypia and mitotic activity; there was focal nuclear staining of these areas with the skeletal muscle markers myogenin and myoD1. In both cases, demonstration of a somatic DICER1 RNase IIIb mutation in the tumor was instrumental in establishing the diagnosis. We believe these neoplasms represent the earliest discernible phase of cervical embryonal rhabdomyosarcoma. Pathologists should have a high index of suspicion when atypical stromal elements are present in endocervical polyps and immunohistochemistry together with DICER1 sequencing will assist in diagnosis.

Objectives: The study objective was to assess whether moderate-to-vigorous intensity physical activity (MVPA) change in cancer survivors (n = 68, mean age = 64 years) was maintained 12-weeks following the Wearable Activity Technology and Action Planning (WATAAP) intervention. Secondary aims were to assess the effects of the intervention on blood pressure (BP) and body mass index (BMI), and to explore group differences between baseline and 24-weeks. Design: Randomized controlled trial. Methods: MVPA and sedentary behaviour were assessed using an accelerometer at baseline, the end of the intervention (12-weeks), and at 24-weeks. Generalised linear mixed models with random effects were used to examine between-group and within-group changes in MVPA, sedentary behaviour, BP and BMI. Results: MVPA was significantly higher in the intervention group compared with the control group at 24-weeks following adjustment for known confounders (141.4 min/wk. (95% CI = 9.1 to 273.8), p = 0.036). At 24-weeks participants in the intervention group had maintained their increased levels of MVPA (change from 12-weeks = 8.8 min/wk.; 95% CI = -43 to 61; p = 0.74). The reduction in MVPA in the control group over the first 12-weeks was also maintained at 24-weeks (5.4 min/wk.; 95% CI = -3.6 to 4.6; p = 0.80). Secondary outcomes did not differ between groups at 24-weeks. Conclusions: Our results suggest distance-based interventions using wearable technology produce increases in MVPA that endure at least 12-weeks after the intervention is completed. (c) 2021 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Microcystic stromal tumour (MST) is a rare ovarian stromal neoplasm initially described by Irving and Young in 20091Irving J.A. Young R.H. Microcystic stromal tumor of the ovary: report of 16 cases of a hitherto uncharacterized distinctive ovarian neoplasm.Am J Surg Pathol. 2009; 33: 367-375Crossref PubMed Scopus (65) Google Scholar and characterised morphologically by a triad of microcysts, solid cellular areas and hyalinised fibrous stroma. These elements were present in variable proportion in individual cases and some tumours showed a predominant solid growth pattern. The cells typically demonstrate epithelioid morphology with bland cytological appearances and infrequent mitotic activity, but focal degenerative ‘symplastic’ nuclear atypia may be seen as in other ovarian sex cord stromal tumours (SCSTs). Recently, the histological spectrum of MST has been expanded to include cases lacking these archetypal features, and such cases are likely to present greater diagnostic difficulty.2McCluggage W.G. Chong A.S. Attygalle A.D. et al.Expanding the morphological spectrum of ovarian microcystic stromal tumour.Histopathology. 2019; 74: 443-451Crossref PubMed Scopus (10) Google Scholar,3Stewart C.J.R. Amanuel B. De Kock L. et al.Evaluation of molecular analysis in challenging ovarian sex cord-stromal tumours: a review of 50 cases.Pathology. 2020; 52: 686-693Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Nevertheless, accurate diagnosis is important in view of the generally benign clinical behaviour of MST and its occasional association with familial adenomatous polyposis (FAP).4Lee S.H. Koh Y.W. Roh H.J. Cha H.J. Kwon Y.-S. Ovarian microcystic stromal tumor: a novel extracolonic tumor in familial adenomatous polyposis.Genes Chromosomes Cancer. 2015; 54: 353-360Crossref PubMed Scopus (23) Google Scholar, 5Liu C. Gallagher R.L. Price G.R. et al.Ovarian microcystic stromal tumor: a rare clinical manifestation of familial adenomatous polyposis.Int J Gynecol Pathol. 2016; 35: 561-565Crossref PubMed Scopus (18) Google Scholar, 6McCluggage W.G. Irving J.A. Chong A.-S. et al.Ovarian microcystic stromal tumors are characterized by alterations in the beta-catenin-APC pathway and may be an extracolonic manifestation of familial adenomatous polyposis.Am J Surg Pathol. 2018; 42: 137-139Crossref PubMed Scopus (15) Google Scholar Herein we describe a further case of ‘variant’ MST that presented as a solid nodule within the wall of an ovarian serous cystadenoma. A 57-year-old nulliparous woman presented with intermittent left sided abdominal pain. She had a past medical history of diabetes, hypertension and hysterectomy for benign reasons. An ultrasound scan showed a 4 cm complex but non-sinister appearing ovarian cyst with a normal serum CA125. Examination revealed mild tenderness in the left pelvis. Surgery was delayed due to COVID restrictions and a repeat ultrasound 3 months later showed a marginal increase in size of the ovarian lesion. The patient underwent uneventful laparoscopic bilateral salpingo-oophorectomy. The ovaries were up to 35 mm and 32 mm in size and both showed multicystic cut surface appearances with a 9 mm solid pale nodule in one ovary. Histologically, the cysts were lined by benign serous epithelium. The nodule was composed of a lobulated to sheet-like arrangement of plump epithelioid cells with moderate pale to eosinophilic cytoplasm (Fig. 1). The cells displayed round to oval nuclei, often with small but prominent nucleoli, and there were rare nuclear grooves. Occasional cells showed spindled appearances and delicate blood vessels were present. Focal cytoplasmic vacuolation was present but there was no distinct microcystic component and stromal hyalinisation was not observed. The tumour abutted the serous-lined cysts but did not involve the ovarian capsular surface. The fallopian tubes were normal grossly and microscopically. The initial differential diagnosis of the nodular tumour included luteinised adult granulosa cell tumour (AGCT), thecoma, steroid cell tumour, solid pseudopapillary neoplasm (SPN), and MST. Immunohistochemistry demonstrated diffuse cytoplasmic CD10 expression and nuclear steroidogenic factor 1 (SF1), Wilms tumour 1 gene product (WT1), cyclin D1 and beta-catenin (nucleocytoplasmic) staining (Fig. 2). There was no expression of calretinin, inhibin, actin, desmin, oestrogen receptor (ER), progesterone receptor (PR), human melanoma black 45 (HMB45) or neural cell adhesion molecule (CD56). Reticulin encircled individual cells. The overall findings were consistent with the diagnosis of ‘solid’ (non-microcystic) variant MST. Although rare, MST is not likely to present diagnostic difficulty when demonstrating typical histological features. However, McCluggage and colleagues recently presented four cases of MST that demonstrated variant morphology including corded, nested or tubular architectural patterns with limited or absent microcysts; one tumour showed focal spindled cell appearances.2McCluggage W.G. Chong A.S. Attygalle A.D. et al.Expanding the morphological spectrum of ovarian microcystic stromal tumour.Histopathology. 2019; 74: 443-451Crossref PubMed Scopus (10) Google Scholar A further case of entirely solid MST was included amongst a series of diagnostically problematic ovarian SCSTs that were subject to molecular analysis.3Stewart C.J.R. Amanuel B. De Kock L. et al.Evaluation of molecular analysis in challenging ovarian sex cord-stromal tumours: a review of 50 cases.Pathology. 2020; 52: 686-693Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In these morphologically unusual cases the final diagnosis of MST was supported by the characteristic immunophenotype including CD10, WT1, SF1, beta-catenin (nucleocytoplasmic) and cyclin D1 positivity, and the lack of expression of ER/PR, inhibin and calretinin. Furthermore, the four cases that underwent molecular analysis demonstrated alterations in CTNNB1 (beta-catenin) which appears to be the most common genetic alteration in these tumours, with a minority of cases exhibiting mutually exclusive mutations in APC.6McCluggage W.G. Irving J.A. Chong A.-S. et al.Ovarian microcystic stromal tumors are characterized by alterations in the beta-catenin-APC pathway and may be an extracolonic manifestation of familial adenomatous polyposis.Am J Surg Pathol. 2018; 42: 137-139Crossref PubMed Scopus (15) Google Scholar, 7Irving J.A. Lee C.-H. Yip S. et al.Microcystic stromal tumor: a distinctive ovarian sex cord-stromal neoplasm characterized by FOXL2, SF-1, WT-1, Cyclin D1, and beta-catenin nuclear expression and CTNNB1 mutations.Am J Surg Pathol. 2015; 39: 1420-1426Crossref PubMed Scopus (44) Google Scholar, 8Rabban J.T. Karnezis A.N. Devine W.P. Practical roles for molecular diagnostic testing in ovarian adult granulosa cell tumour, Sertoli-Leydig cell tumour, microcystic stromal tumour and their mimics.Histopathology. 2020; 76: 11-24Crossref PubMed Scopus (10) Google Scholar As noted above, the initial differential diagnosis considered in the current case included a number of other ovarian neoplasms mainly within the sex cord stromal category and importantly including potentially malignant neoplasms such as AGCT. Most of these could be excluded based upon the immunohistological findings but one tumour worthy of specific consideration is SPN which usually presents in the pancreas but rarely arises in the ovary.9Deshpande V. Oliva E. Young R.H. Solid pseudopapillary neoplasm of the ovary: a report of 3 primary ovarian tumors resembling those of the pancreas.Am J Surg Pathol. 2010; 34: 1514-1520Crossref PubMed Scopus (61) Google Scholar,10Komforti M.K. Edelman M. Fan C. Liang S.X. Solid pseudopapillary neoplasm presenting as a primary ovarian mass in an eighteen-year-old female: report of a case and review of the literature.Virchows Arch. 2018; 472: 285-291Crossref PubMed Scopus (2) Google Scholar Microcystic stromal tumour and SPN share morphological and immunohistochemical features (CD10, cyclin D1 and nucleocytoplasmic beta-catenin staining). However, unlike SPN, MST typically demonstrates nuclear WT1, SF1 and FOXL2 expression with negative CD56, CD99 and PR staining.7Irving J.A. Lee C.-H. Yip S. et al.Microcystic stromal tumor: a distinctive ovarian sex cord-stromal neoplasm characterized by FOXL2, SF-1, WT-1, Cyclin D1, and beta-catenin nuclear expression and CTNNB1 mutations.Am J Surg Pathol. 2015; 39: 1420-1426Crossref PubMed Scopus (44) Google Scholar The present case was also unusual in that the MST presented as a nodule within an otherwise typical ovarian serous cystadenoma, an association that has not been described previously to our knowledge. Possible explanations include the juxtaposition of two pathogenically unrelated neoplasms (‘collision tumours’), or heterologous epithelial differentiation within a stromal neoplasm. The latter phenomenon is a well-recognised feature of other ovarian SCSTs, particularly Sertoli–Leydig cell tumour, and has also been reported occasionally in AGCT.11McKenna M. Kenny B. Dorman G. McCluggage W.G. Combined adult granulosa cell tumor and mucinous cystadenoma of the ovary: granulosa cell tumor with heterologous mucinous elements.Int J Gynecol Pathol. 2005; 24: 224-227Crossref PubMed Scopus (32) Google Scholar However, in most such cases the epithelium demonstrates mucinous rather than serous differentiation. We believe that the association of MST and serous cystadenoma in our case was most likely coincidental, an interpretation supported by the presence of a serous cystadenoma in the contralateral ovary. While MST is generally considered benign, there is one reported case of recurrence more than 10 years after initial resection in a 33-year-old patient.12Zhang Y. Tao L. Yin C. et al.Ovarian microcystic stromal tumor with undetermined potential: case study with molecular analysis and literature review.Hum Pathol. 2018; 78: 171-176Crossref PubMed Scopus (7) Google Scholar The tumour demonstrated an APC mutation and the patient also had multiple adenomatous colonic polyps raising the possibility of FAP. Three of four additional MSTs demonstrating APC mutations have been associated with FAP, suggesting that MST is a rare extracolonic manifestation of this condition.4Lee S.H. Koh Y.W. Roh H.J. Cha H.J. Kwon Y.-S. Ovarian microcystic stromal tumor: a novel extracolonic tumor in familial adenomatous polyposis.Genes Chromosomes Cancer. 2015; 54: 353-360Crossref PubMed Scopus (23) Google Scholar, 5Liu C. Gallagher R.L. Price G.R. et al.Ovarian microcystic stromal tumor: a rare clinical manifestation of familial adenomatous polyposis.Int J Gynecol Pathol. 2016; 35: 561-565Crossref PubMed Scopus (18) Google Scholar, 6McCluggage W.G. Irving J.A. Chong A.-S. et al.Ovarian microcystic stromal tumors are characterized by alterations in the beta-catenin-APC pathway and may be an extracolonic manifestation of familial adenomatous polyposis.Am J Surg Pathol. 2018; 42: 137-139Crossref PubMed Scopus (15) Google Scholar,8Rabban J.T. Karnezis A.N. Devine W.P. Practical roles for molecular diagnostic testing in ovarian adult granulosa cell tumour, Sertoli-Leydig cell tumour, microcystic stromal tumour and their mimics.Histopathology. 2020; 76: 11-24Crossref PubMed Scopus (10) Google Scholar While molecular analysis was not performed in the case presented here, the patient had no other significant medical history and recent colonoscopy showed no adenomatous polyps. The authors state that there are no conflicts of interest to disclose.

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.

Background: Approximately 20% of women with gynecologic cancers are under age 40 and with delayed childbearing, women may be diagnosed before their first pregnancy. Although fertility preservation is a priority for many women, attitudes to conception have not previously been investigated in these patients or their partners. We explored attitudes to conception in partners and young women, following fertility preserving treatment for gynecologic cancers. Methods: A total of 16 telephone interviews were conducted with a purposive sample of patients who had had an early stage gynecologic cancer or borderline ovarian tumor treated by fertility sparing surgery in Western Australia between January 1st, 2005 to December 31st, 2016. The interviews were audio recorded, transcribed and thematic analysis was conducted. Results: Four main themes were identified: (i) Emotions at diagnosis and perception of information given; (ii) Discussions of fertility and factors affecting childbearing; (iii) Role of partners in decision making and relationship pressures; (iv) Decision for treatment and postoperative regrets. Conclusions: Regret and relationship breakdown were commonly reported. Women need appropriate support including inviting their partners to attend clinic appointments and may need several appointments before treatment. Regret was commonly reported by women who opted for completion surgery.

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. (C) 2020 Elsevier Inc. All rights reserved.

Anastomosing haemangioma (AH) is a recently described rare benign vascular tumour that can mimic angiosarcoma histologically. Anastomosing haemangioma was described initially in the kidney and testis but has since been reported in multiple additional parenchymal sites with a propensity to involve the paravertebral soft tissue.1Montgomery E. Epstein J.I. Anastomosing hemangioma of the genitourinary tract: a lesion mimicking angiosarcoma.Am J Surg Pathol. 2009; 33: 1364-1369Crossref PubMed Scopus (106) Google Scholar, 2John I. Folpe A.L. Anastomosing hemangiomas arising in unusual locations: a clinicopathologic study of 17 soft tissue cases showing a predilection for the paraspinal region.Am J Surg Pathol. 2016; 40: 1084-1089Crossref PubMed Scopus (39) Google Scholar, 3Lappa E. Drakos E. Anastomosing haemangioma. Short review of a benign mimicker of angiosarcoma.Arch Pathol Lab Med. 2020; 144: 240-244Crossref PubMed Scopus (16) Google Scholar Bilateral, multifocal and/or recurrent cases have been described and there may be intravascular growth, features that further potentiate misclassification as a malignant process.2John I. Folpe A.L. Anastomosing hemangiomas arising in unusual locations: a clinicopathologic study of 17 soft tissue cases showing a predilection for the paraspinal region.Am J Surg Pathol. 2016; 40: 1084-1089Crossref PubMed Scopus (39) Google Scholar, 3Lappa E. Drakos E. Anastomosing haemangioma. Short review of a benign mimicker of angiosarcoma.Arch Pathol Lab Med. 2020; 144: 240-244Crossref PubMed Scopus (16) Google Scholar, 4Burton K. Jakate K. Pace K. et al.A case of recurrent, multifocal anastomosing haemangiomas.BMJ Case Rep. 2017; (Jun 18: bcr-2017-220076)Crossref Scopus (11) Google Scholar There is an overall male predominance of approximately 2:1 and involvement of the female genital tract is rare with almost all reported cases arising in the ovary. Interestingly, ovarian AHs are often associated with prominent stromal luteinisation,5Kryvenko O.N. Gupta N.S. Meier F.A. et al.Anastomosing hemangioma of the genitourinary system: eight cases in the kidney and ovary with immunohistochemical and ultrastructural analysis.Am J Clin Pathol. 2011; 136: 450-457Crossref PubMed Scopus (70) Google Scholar, 6Metodiev D. Ivanova V. Omainikova B. et al.Ovarian anastomosing hemangioma with stromal luteinization: a case report.Akush Ginekl (Sofia). 2015; 54: 58-61PubMed Google Scholar, 7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar, 8Bean G.R. Joseph N.M. Gill R.M. et al.Recurrent GNAQ mutations in anastomosing hemangiomas.Mod Pathol. 2017; 30: 722-727Crossref PubMed Scopus (39) Google Scholar, 9Subbarayan D. Devaraji A. Senthilnayagam B. et al.Anastomosing hemangioma of the ovary clinically masquerading as epithelial malignancy: a rare case report.J Midlife Health. 2019; 10: 48-50PubMed Google Scholar, 10Gunduz M. Hurdogan O. Onder S. et al.Cystic anastomosing hemangioma of the ovary: a case report with immunohistochemical and ultrastructural analysis.Int J Surg Pathol. 2019; 27: 437-440Crossref PubMed Scopus (7) Google Scholar and this finding has also been reported in cases of ovarian capillary haemangioma which arguably represents the same process.7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar Herein we describe an ovarian AH that was associated with hilus cell hyperplasia and stromal hyperthecosis, and which also demonstrated focal extramedullary haematopoiesis. A 48-year-old female with an elevated body mass index of 48 underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for abnormal uterine bleeding. Prior ultrasound scan had shown a bulky fibroid uterus and a suspected ovarian cyst. The patient had a history of diverticular disease, ischaemic heart disease and had undergone laparoscopic gastric band surgery for weight reduction. There were no specific endocrine symptoms clinically. On pathological examination the uterine corpus demonstrated multiple typical leiomyomas up to 40 mm dimeter while the cervix and fallopian tubes were normal. The ovaries were mildly enlarged without cystic change but on section the left ovary demonstrated an 8 mm circumscribed brown nodular lesion that mainly involved the medulla. Histologically, this demonstrated a central vascular proliferation reminiscent of splenic parenchyma at scanning magnification comprising anastomosing, small sinusoidal-like vessels that were lined by plump endothelial cells showing focal hobnail appearances (Fig. 1). Intracytoplasmic eosinophilic inclusions were prominent in some areas (Fig. 2). There was no significant cellular stratification or cytological atypia in the endothelial cells and no mitotic figures were identified. The vessels were separated in most areas by scant fibrous stroma but there was focal stromal hyalinisation and evidence of recent and previous haemorrhage. Towards the periphery were occasional larger thin-walled ectatic vessels some of which were partly occluded by thrombi in varying stages of organisation. One peripheral vessel included a small intraluminal cluster of cells consistent with immature myeloid precursors. Surrounding the vascular lesion there was an almost circumferential rim of large luteinised appearing cells with vesicular nuclei, central nucleoli and abundant eosinophilic or vacuolated cytoplasm (Fig. 1). Higher magnification demonstrated elongated cytoplasmic Reinke crystals in some of the cells confirming hilus/Leydig cell differentiation (Fig. 2). Both ovaries also showed background stromal hyperthecosis.Fig. 2(A) Higher magnification than Fig. 1 showing small sinusoidal-like vascular channels lined by plump endothelial cells (left) and adjacent, focally vacuolated hilus cells (right). (B) Intracytoplasmic eosinophil globules (arrow) are focally prominent. (C) Reinke crystals (arrow) are present within many of the hilus cells.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Immunohistochemistry demonstrated CD31, CD34 and ERG staining in the cells lining the vessels whereas there was no expression of D2-40, oestrogen receptor (ER) or progesterone receptor (PR). The peripheral hilus cells were strongly inhibin and calretinin positive (Fig. 1). Ovarian AHs have been reported mainly in post-menopausal women (range 43–81 years), and as with cases arising in other anatomical sites, many have been detected incidentally during radiological investigations or surgery for unrelated conditions.5Kryvenko O.N. Gupta N.S. Meier F.A. et al.Anastomosing hemangioma of the genitourinary system: eight cases in the kidney and ovary with immunohistochemical and ultrastructural analysis.Am J Clin Pathol. 2011; 136: 450-457Crossref PubMed Scopus (70) Google Scholar,7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar However, occasional ovarian AHs have been associated with ascites and/or elevated serum CA125 levels raising concern for an epithelial malignancy.7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar,9Subbarayan D. Devaraji A. Senthilnayagam B. et al.Anastomosing hemangioma of the ovary clinically masquerading as epithelial malignancy: a rare case report.J Midlife Health. 2019; 10: 48-50PubMed Google Scholar A distinctive feature of many ovarian AHs is the presence of associated stromal luteinisation.5Kryvenko O.N. Gupta N.S. Meier F.A. et al.Anastomosing hemangioma of the genitourinary system: eight cases in the kidney and ovary with immunohistochemical and ultrastructural analysis.Am J Clin Pathol. 2011; 136: 450-457Crossref PubMed Scopus (70) Google Scholar, 6Metodiev D. Ivanova V. Omainikova B. et al.Ovarian anastomosing hemangioma with stromal luteinization: a case report.Akush Ginekl (Sofia). 2015; 54: 58-61PubMed Google Scholar, 7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar,9Subbarayan D. Devaraji A. Senthilnayagam B. et al.Anastomosing hemangioma of the ovary clinically masquerading as epithelial malignancy: a rare case report.J Midlife Health. 2019; 10: 48-50PubMed Google Scholar,10Gunduz M. Hurdogan O. Onder S. et al.Cystic anastomosing hemangioma of the ovary: a case report with immunohistochemical and ultrastructural analysis.Int J Surg Pathol. 2019; 27: 437-440Crossref PubMed Scopus (7) Google Scholar Indeed, this has prompted consideration whether ovarian AH is in fact the primary pathological process with a secondary luteinised stromal reaction as may be seen with many ovarian mass lesions, or whether a primary stromal cell proliferation could induce the vascular proliferation, possibly via endocrine effects.7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar,9Subbarayan D. Devaraji A. Senthilnayagam B. et al.Anastomosing hemangioma of the ovary clinically masquerading as epithelial malignancy: a rare case report.J Midlife Health. 2019; 10: 48-50PubMed Google Scholar The latter hypothesis is supported by a report of hormone receptor expression in an ovarian capillary haemangioma,11Miliaras D. Papaemmanouil S. Blatzas G. Ovarian capillary hemangioma and stromal luteinization: a case study with hormonal receptor evaluation.Eur J Gynaecol Oncol. 2001; 22: 369-371PubMed Google Scholar but the endothelial cells in the current case and other reported ovarian AHs were ER and PR negative.7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar,10Gunduz M. Hurdogan O. Onder S. et al.Cystic anastomosing hemangioma of the ovary: a case report with immunohistochemical and ultrastructural analysis.Int J Surg Pathol. 2019; 27: 437-440Crossref PubMed Scopus (7) Google Scholar Furthermore, the predominant distribution of AHs in extra-gonadal sites independent of apparent hormonal stimulation and the recent demonstration of somatic GNAQ mutations in these lesions supports their neoplastic nature.8Bean G.R. Joseph N.M. Gill R.M. et al.Recurrent GNAQ mutations in anastomosing hemangiomas.Mod Pathol. 2017; 30: 722-727Crossref PubMed Scopus (39) Google Scholar In most respects the current case demonstrated similar histological findings to AHs involving the ovary and other sites including the presence of vascular thrombi, extramedullary haematopoiesis and eosinophilic hyaline inclusions.1Montgomery E. Epstein J.I. Anastomosing hemangioma of the genitourinary tract: a lesion mimicking angiosarcoma.Am J Surg Pathol. 2009; 33: 1364-1369Crossref PubMed Scopus (106) Google Scholar,3Lappa E. Drakos E. Anastomosing haemangioma. Short review of a benign mimicker of angiosarcoma.Arch Pathol Lab Med. 2020; 144: 240-244Crossref PubMed Scopus (16) Google Scholar Occasional cases with cystic change or including a component of fat have also been described.7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar,10Gunduz M. Hurdogan O. Onder S. et al.Cystic anastomosing hemangioma of the ovary: a case report with immunohistochemical and ultrastructural analysis.Int J Surg Pathol. 2019; 27: 437-440Crossref PubMed Scopus (7) Google Scholar The most important differential diagnosis is angiosarcoma which has been initially considered in some cases of AH in view of the hobnail-like appearance of the endothelial cells and the occasional presence of local extension into surrounding tissues or intravascular growth. While vascular tumours in general are rare in the ovary, primary ovarian angiosarcoma is well-described.12Nielsen G. Young R.H. Prat J. et al.Primary angiosarcoma of the ovary. A report of 7 cases and review of the literature.Int J Gynecol Pathol. 1997; 16: 378-382Crossref PubMed Scopus (56) Google Scholar However, AHs lack the 'dissecting', frankly infiltrative pattern of most angiosarcomas, and the endothelial cells show at most only mild nuclear atypia without significant cellular stratification or mitotic activity. The present case was associated with a prominent hilus cell proliferation, confirmed by the presence of cytoplasmic Reinke crystals, which we consider most likely a reactive process given its close microanatomical relationship to the AH. To our knowledge hilus cell hyperplasia has been reported only once previously in ovarian AH where the Reinke crystals were described as 'rare'.7Dundr P. Nemejcova K. Laco J. et al.Anastomosing hemangioma of the ovary: a clinicopathological study of six cases with stromal luteinization.Pathol Oncol Res. 2017; 23: 717-722Crossref PubMed Scopus (10) Google Scholar In an additional case, eosinophilic inclusions were noted within the steroid cells on light microscopy but Reinke crystals were not confirmed on ultrastructural analysis.10Gunduz M. Hurdogan O. Onder S. et al.Cystic anastomosing hemangioma of the ovary: a case report with immunohistochemical and ultrastructural analysis.Int J Surg Pathol. 2019; 27: 437-440Crossref PubMed Scopus (7) Google Scholar It seems possible that some other previously reported AHs with 'stromal luteinisation', particularly those with a medullary location, in fact demonstrated a hilus cell proliferation in which Reinke crystals were inconspicuous. While both ovaries in our patient also demonstrated stromal hyperthecosis, this finding was probably not related to the AH in view of its typically symmetrical and bilateral distribution. The authors state that there are no conflicts of interest to disclose.