Faculty of Medicine

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Endometrial adenocarcinoma occuring in young women
(Hellenic Division of International Academy of Pathology, 2003-05)
Kubelka-Sabit, Katerina
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Prodanova, Irina
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Yashar, Genghis
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Zografski, George
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Background: Endometrial adenocarcinoma (EA) primarily occurs in postmenopausal women. Only 1-8% of the cases are diagnosed in women under forty years of age, while this neoplasm is extremely rare in the third decade. Hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy (HSOPL) is the treatment of choice for older or patients with invasive EA. However, in young women with non-invasive well-differentiated EAs, who wish to preserve their fertility, conservative treatment with progestins can be tried. Aims: The purpose of this retrospective study is to present the clinical and morphologic characteristics, as well as the immunohistochemical profile of 3 cases of well-differentiated EAs, that occurred in women in their third decade of life. Since the neoplasms were non-invasive, an attempt to preserve their fertility has been made. Methods and patients: Six of the 1081 cases (0.5%) of EA diagnosed at the Department of Histopathology and Clinical Cytology in the last 14-year period (1989-2002), occurred in patients younger than 35 years. Three of them (1.4%, 3/206), have been diagnosed in the last two years (2001-2002). The youngest of the last three patients (age 21), had a genetic abnormality (45X/47XXX) and experienced prolonged and heavy uterine bleedings that required explorative curettage. The second patient (age 25) had a history of diabetes and infertility. The neoplasm was found in the endometrial biopsy that was taken for evaluation of the endometrial response to hormonal stimulation. In the third patient (age 27) the neoplasm was an accidental finding in the cervical curettage material that was submitted to our department, for histopathologic reevaluation of the previously diagnosed moderate dysplasia of the epithelium of the uterine cervix. The materials, obtained either by dilatation and curettage (3 cases) or HSOPL (one case), were submitted to our department and were routinely processed. Standard hematoxylin and eosin (H&E) stained slides were prepared from paraffin blocks, whereas additional histochemical (PAS, alcian blue, azan, silver by Jones) and immunohistochemical stains (estrogen-ER, progesterone-PgR, p53, Ki-67) were performed on selected paraffin blocks that contained the neoplastic tissue. Results: In the curettage materials of the three patients, fragments of endometrial polyp were identfied, that contained areas of simple, complex and atypical hyperplasia. In each of these cases, only few small (1-3-millimetre in diameter) foci of well-differentiated EA were detected. Fragments of functional endometrium were also present. All three patients had hormone (ER, PgR) responsive neoplasms, whereas Ki-67 proliferative index was significantly higher in the neoplastic tissue (30-40%), compared to the zones of atypical hyperplasia (10-20%). The suppressor gene protein product p53 was negative in all three EAs. Subsequent dilatation and curettage to remove the residual parts of the polyp was performed in two of the patients. Conservative 5-6-month treatment with progestins led to regression of the disease in all patients, documented by endoscopy and curettage in two patients. As for the youngest patient, clinical decision for HSOPL has been made, and multiple sections of the operative material did not show any residual EA. Conclusions: Even though extremely rare, EAS may occur in asymptomatic patient and/or in young women without clinical evidence of polycystic ovary disease. In these patients careful histopathologic evaluation of the curettage material is essential, in order to select the ones to whom conservative fertility-preserving treatment can be offered.
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HER2/neu expression in correlation with p53 and Ki-67 immunoreactivity and clinicopathological parameters in breast cancer patients.
(Blackwell Publishing, 2002-10)
Yashar, Genghis
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Ivkovski, Ljube
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Kraleva, Slavica
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Prodanova, Irina
Introduction: Although the role of HER2/neu status is still unsettled, its determination is valuable in selecting breast carcinoma patients for adequate Herceptin therapy. Aims: The purpose of this study was to evaluate the association among HER2/neu, p53 and Ki-67 immunoreactivity, as well as clinicopathological parameters (tumour size, histopathologic grade, nuclear grade, tumour type. lymph-node status and age) in breast cancer patients. Materials and methods: HER2/neu, p53 and Ki-67 expression was determined in 169 post-operative stage I-III (UICC. 1997) breast cancer patients using the standardized DAKO HercepsTest and by immunoperoxidase technique. respectively. The results were evaluated by performing the standardized scoring system. Discussion and conclusion: HER2/neu expression was positive in 66 patients (37%). There was no association between HER2/neu expression and p53 or Ki-67 immunoreactivity as well as any clinicopathological parameter, while the values of Ki-67 and p53 were strongly interrelated (P < 0.001). Ki-67 was also in significant correlation to tumour size, lymph-node involvement and tumour type (P<0.001), while p53 was only related to patients' age (P <0.01). These results indicate that HER2/neu is an independent prognostic marker in differentiating a subgroup of high-risk breast cancer patients. Additional studies are required to adjust HER2/neu testing results to clinical outcome.
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Association between Her2/neu expression and hormon receptor status in breast cancer patients.
(2002-06)
Yashar, Genghis
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Kraleva, Slavica
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Vasev, Nikola
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Ivkovski, Ljube
Determination of HER2/neu expression by immunohistochemistry is mandatory for application of Herceptin® therapy in breast cancer patients. The purpose of this study was to investigate the association between HER2/neu expression and hormone receptor status, as well as with other clinicopathological parameters in breast cancer patients. HER2/neu, p53 and Ki-67 expression was determined in 169 postoperative stage I-III (UICC, 1997) breast cancer patients using the standardized DAKO HercepsTest® and immunoperoxidase technique, respectively. The results of HER2/neu immunoreactivity were evaluated by performing the standardized scoring system (0 = negative, 1+ = weakly positive, 2+ = positive, 3+ = strongly positive staining), while ER and PgR were scored in a semiquantitative fashion (ER-ICA and PR-ICA). The results from HER2/neu expression were correlated to hormonal receptor status and clinicopathological parameters (tumor size, histopathologic grade, nuclear grade, histologic type of the tumor, lymph node status and patient age). Statistical significance was determined with χ2 and Fisher’s exact test. HER2/neu expression was positive in 66 patients (37%). There was no significant association between the values of HER2/neu and ER/PgR status, or with any other clinicopathological parameter. ER status significantly correlated with PgR status (p<0.01), tumor size (p<0.01), lymph-node involvement (p<0.01) and tumor type (p<0.01). PgR status was related to the histopathologic grade (p<0.01), lymph-node status (p<0.01), tumor type (p<0.01) and patient age (p<0.01). HER2/neu is a relatively new promising marker in predicting the response to target specific therapy. However, its predictive value remains a complex and inconclusive subject. According to our results, the prognostic potential of HER2/neu seems to be independent from hormone receptor status and any other clinicopathological parameter in breast cancer patients.
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Her2/neu expression in breast cancer patients - Correlation with estrogen and progesterone receptor status, p53 and Ki-67 immunoreactivity and clinicopathological parameters
(Institute of Oncology, Sremska Kamenica, Yugoslavia, 2002-09)
Yashar, Genghis
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Prodanova, Irina
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Vasev, Nikola
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Kraleva, Slavica
Although the role of HER2/neu status is still unsettled, its determination is valuable in selecting breast carcinoma patients for adequate Herceptin¨ therapy. The purpose of this study was to investigate the association between HER2/neu expression with estrogen (ER) and progesterone (PgR) receptor status, p53 and Ki-67 immunoreactivity, as well as with other clinicopathological parameters in breast cancer patients. HER2/neu, ER/PgR status, p53 and Ki-67 expression was determined in 169 postoperative stage I-III (UICC, 1997) breast cancer patients using the standardized DAKO HercepsTest¨ and by the immunoperoxidase technique, respectively. The results were evaluated by performing the standardized scoring system. The values of HER2/neu expression were correlated to ER/PgR status, p53 and Ki-67 immunoreactivity and to clinicopathological parameters (tumor size, histopathologic grade, nuclear grade, tumor type, and lymph node status and patients’ age). The statistical significance was determined with c2 and Fisher’s exact test. HER2/neu expression was positive in 66 patients (37%). There was no significant association between the values of HER2/neu and ER/PgR status, p53 or Ki-67 immunoreactivity, neither with any other clinicopathological parameter. ER is associated with PgR, tumor size, tumor type and lymph node status (p<0.01); PgR with histopathologic grade, tumor type and lymph node status (p<0.01) and Ki-67 with p53 immunoreactivity, tumor size and patients’ age (p<0.01). The results of the current study indicate that HER2/neu is an independent prognostic marker in differentiating a subgroup of high-risk breast cancer patients. Additional studies are required to adjust HER2/neu testing results to the clinical outcome.
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Uterine myxoid leiomyosarcoma arising in a leiomyoma - A case report.
(Institute of Oncology, Sremska Kamenica, Yugoslavia, 2002-09)
Hadzi-Nicheva, Biljana
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Prodanova, Irina
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Yashar, Genghis
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Kubelka, Katerina
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Grncharovska, Zlata
Myxoid leiomyosarcoma of the uterus (MLU) is a very rare neoplasm. We report a case of MLU arising from a pre-existing leiomyoma. Between 1989 and 2001, 45 uterine leiomyosarcomas were diagnosed in our laboratory and MLU was established in one case only (2.1%). Subtotal hysterectomy was performed on a 56-year woman with clinical diagnosis of a uterine myoma. The histopathological processing included hematoxylin-eosin, histochemical and immunohistochemical staining of selected specimens. Macroscopically, the uterus measured 15 x 12 x 11 cm, with an indistinctly circumscribed multi-nodular tumorous mass 10.5 cm in diameter, and infiltrative satellite nodules in the surrounding myometrium. The morphology of the neoplasm showed a leiomyoma with distinct degenerative changes, necrosis and hemorrhage. In some areas the cells were round or oval with a vacuolated cytoplasm, slight atypia and rare mitoses. The mitotic count was 1-3 cells/10 HPF. Due to the presence of an abundant mucoid substance, these areas appeared as hypocellular. The additional processing confirmed the smooth muscular origin of the neoplasm (Masson trichrome, azan, desmine, alfa-smooth muscle actin and vimentine positive). The areas of the myxomatose nodules were characterized with hormone independence (estrogen and progesterone receptors negative), high proliferative activity (Ki-67 - 30%) and the presence of p53 protein product (45%). The areas of the pre-existing leiomyoma showed hormone dependence, low proliferative activity and absence of p53 protein product. Additional immunostaining is useful in supporting a diagnosis of MLU in myxoid uterine smooth-muscle tumors with a low mitotic rate.
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Lipoleiomyoma of the uterus: Immunohistochemical analysis of 11 cases.
(Institute of Oncology, Sremska Kamenica, Yugoslavia, 2002-09)
Prodanova, Irina
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Hadzi-Nicheva, Biljana
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Yashar, Genghis
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Kubelka, Katerina
The histogenesis of uterine lipoleiomyomas (UL), which are commonly considered to be rare tumors, has not been fully clarified. The purpose of this study is to ascertain the actual incidence of UL, and to establish the origin of the lipomatous component in UL. Out of the total of 812 uterine smooth muscle neoplasms diagnosed over the period between May 2001 and May 2002, 11 were UL (1.4%). The tissue samples from all cases were routinely processed, and the lipid content was histochemically demonstrated with Oilred-O. This method was performed in areas, which were macroscopically suspected to contain fatty tissue. Selected sections were immunostained. Ten leiomyomas and one smooth muscle neoplasm of uncertain malignant potential, with various amounts of the lipomatous component were identified. In three tumors the lipomatous component consisted of mature lipocytes. In eight tumors, the perivascularly localized focal areas of cells with pale abundant cytoplasm similar to smooth muscle cells or to fibrocytes containing cytoplasmatic lipid droplets were found. Immunohistochemically, the cells in the perivascular areas were positive for S-100 protein, desmin, vimentin, neuron specific enolase, alpha 1-antitrypsin, CD 34 and collagen IV and were negative for alpha-smooth muscle actin. Additionally, these cells and mature lipocytes were negative for estrogen and progesterone receptors. Our results suggest that UL are not rare neoplasms and that lipomatous differentiation in leiomyomas can be found more frequently than expected. Immunohistochemical results indicate that lipomatous cells, as well as smooth muscle cells, derive from multi-potential undifferentiated mesenchymal cells.
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Small and large cell neuroendocrine carcinomas of the uterine cervix. A report of 10 cases.
(Springer, 2005-08)
Kubelka-Sabit, Katerina
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Plaseska-Karanfilska, Dijana
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Prodanova, Irina
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Yashar, Genghis
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Hadzi-Nicheva, Biljana
BACKGROUND: Small (SCC) and large cell (LCC) neuroendocrine carcinomas of the uterine cervix are rare and highly aggressive neoplasms. Their association with the integration of human papilloma virus (HPV) DNA of the types 16 or 18 has been documented in many studies. AIMS: The purpose of this study is to present the clinical, histopathological, immunohistochemical characteristics and the presence of HPV DNA in ten cases of SCCs and LCCs of the uterine cervix. METHODS: Seven patients with primary SCCs and three patients with LCCs of the uterine cervix were diagnosed at our department between 1989 and 2004. Clinical data were retrieved from the patients’ files and included age, recurrence and survival. Routinely processed operative and/or biopsy specimens were used for immunohistochemical stains and hybridization procedures. Primary antibodies against several epithelial, neuroendocrine, mesenchimal and proliferative markers were included. The presence of HPV DNA was assessed by conventional in situ hybridization (ISH) using probes for HPV 16/18 and 31/33/51 and polymerase chain reaction (PCR), using three primers (MY09/11, GP5+/GP6+, E6). Six of the patients were surgically treated. Postoperatively, four received chemo and/or radiotherapy, two rejected further treatment and one patient was lost to follow-up. The other four patients underwent conservative treatment due to advanced disease. RESULTS: The patients’ age ranged from 25 to 71 years. Histologically, the tumors showed trabecular, nesting or a sheet-like pattern, with areas of necrosis and frequent mitoses. Their neuroendocrine nature was confirmed by diffuse positive immunostaining for neuron-specific enolase and low-molecular weight cytokeratins. Focal positivity for chromogranin, synaptophysin and S100, together with pancytokeratin and EMA, was evident in the majority of the tumors. Their aggressive potential was confirmed by high Ki-67 proliferative index (50-90%). HPV types 16/18 were found in 4 tumors using ISH, and HPV 16 in additional 3, using PCR (type 16). 3 of the patients developed distant metastases and died 7-48 months after receiving partial or full treatment, while 6 are alive and without evidence of disease after 4-38 months. CONCLUSIONS: SCCs and LCCs are highly aggressive neoplasms. However, early diagnosis and combined therapy may improve survival in some patients. Although mainly a morphologic diagnosis, immunohistochemistry may help in the diagnosis of SCC and LCC.
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Ki-67 expression in the invasion front as an additional independent significant prognostic factor influencing reccurence in early stage cervical carcinomas.
(Springer, 2005-08)
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Prodanova, Irina
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Kubelka-Sabit, Katerina
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Yashar, Genghis
INTRODUCTION: The attempts to determine the prognostic significance of biological markers and their relation to human papillomavirus (HPV) infection in cervical cancer have yielded controversial results. AIMS: The aims of this retrospective study were to correlate alterations of cell proliferation, growth, differentiation and apoptosis regulatory proteins in early stage cervical carcinomas with HPV infection, histopathological and clinical parameters, and to estimate their prognostic significance. METHODS: Expression of Ki-67, p53, mdm-2, bcl-2, c-erbB-2, EGFR protein, as well as estrogen and progesterone receptors was evaluated by immunohistochemistry in operative specimens of 83 patients with early stage cervical carcinoma. The results were assessed semiquantitatively in the surface area, center and invasion front of each tumor as a percentage of the immunostained cells and/or intensity of immunostaining for each protein. The presence of HPV was assessed by conventional in situ hybridization (ISH) technique and catalyzed reporter deposition signal amplification ISH using mixed biotinylated probes to identify types 6/11, 16/18 and 31/33 or 31/33/51. RESULTS: In our case series 73 patients had a tumor limited to the uterine cervix less than 4 cm in diameter (pT1b1), while 10 patients had larger neoplasms belonging to pT1b2 category. Pelvic lymph node involvement was found in 20 patients. During the follow-up period (range, 65 -181, mean, 121 months) recurrences were observed in 9 patients. The 5, 10 and 15-year disease-free survival rate was 92.7%, 90.8% and 86.6%, respectively. Among the 18 variables pelvic lymph node involvement (P=0.0008), tumor diameter (P=0.035), depth of stromal invasion (P=0.029), histotype (P=0.0009), grade (P=0.056), HPV DNA presence (P=0.056), HPV type (P=0.043), as well as bcl-2 (P=0.035), mdm-2 (P=0.051), EGFR (P<0.0001), and Ki-67 (P=0.031) expression in the tumor’s invasion front were identified as important predictive indicators of recurrence in the univariate analysis. Independent significant prognostic factors for disease-free survival in multivariate analysis were the histotype, HPV DNA presence and Ki-67 expression. CONCLUSIONS: The invasive front of carcinomas proved to be the most important area for tumor prognosis. In addition to the detection of HPV presence and morphological parameters, Ki-67 evaluation could be used in selecting appropriate therapeutical approaches in patients with early stage cervical cancer.
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Benign and malignant pigmented lesions of the female genital tract (FGT). Report of 15 cases.
(Springer, 2001-09)
Kubelka, Katerina
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Yashar, Genghis
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Prodanova, Irina
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Ivkovski, Ljube
Introduction: Benign and malignant pigmented lesions (PL) of the FGT are uncommon, predominantly affecting the vulva. Methods: We report the clinical and pathological features of the 15 PL of the FGT retrieved in a 12-year, retrospective analysis at our Department. Patient records and archival pathology specimens of 7 benign and 8 malignant PL of the FGT, were reviewed. Results: The mean age of all patients was 47 (range, 28-67). Three patients had vulvar nevi (2 intradermal and 1 dysplastic), while blue nevi ranging 2-10 mm in diameter were accidentally discovered in the endocervix of the hysterectomy specimens in four other patients. Vulvar primary malignant melanomas (PMMs) were uncommon (4 cases), comprising 2.5% of female PMMs and 4.3% of all vulvar malignancies diagnosed between 1989 and 2000. Contrary to other studies, all vulvar PMM in our series were of nodular type, ranging 3-13 mm in depth according to Breslow and III-IV level according to Clark. Within the same period, two patients with malignant PL of the uterine cervix were detected, accounting for 0.13% of all females with malignant cervical neoplasms. One of them had a PMM diagnosed in advanced clinical stage (FIGO III), and the other patient had an unusual pigmented squamous cell carcinoma in liB postoperative stage. There were also 2 cases of delayed unilateral ovarian metastases of cutaneous PMM. The diagnosis in all cases of non-vulvar pigmented lesions was confirmed by immunohistochemistry. Conclusions: Although uncommon, PL especially those affecting rare localizations must be considered as diagnostic possibility in FGT.
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Myoepithelial carcinoma of the breast arising in adenomyoepithelioma. A case report.
(Springer, 2001-09)
Yashar, Genghis
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Ivkovski, Ljube
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Kubelka, Katerina
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Zografski, George
Introduction: Adenomyoepithelioma (AME), and especially myoepithelial carcinoma (MC), the malignant variant of this tumor, is a rare breast neoplasm. This report comprises the pathological features of a breast MC arising in AME with an aggressive clinical course. Case report: A 48-year old woman with a palpable mass in the right breast was admitted in November 1998. A month later following FNAB, surgical excision was performed. During the follow-up period of 17 months, until the patient's death, two local recurrences developed. Despite the aggressive chemotherapy, administrated after the first recurrence, subsequently bone, pulmonary and brain metastases appeared. Results: The primary tumor was an ovoid, white-grey, encapsulated mass measuring 4x3,5x1,5 cm. Microscopically, this biphasic tumor was composed of rare tubules surrounded by interlacing bundles of spindle cells exhibiting mild atypia. It was initially classified as a benign phyllodes tumor. The immunohistochemical analyses performed after the second recurrence proved the myoepithelial origin of the neoplasm (S-100, cytokeratin and alpha-SMA positive cells), with a high mitotic index (11 MF/10 HPF), and an immunophenotype indicating aggressive biological potential (steroid receptor negative, 50% Ki-67 and 30% p53 positive cells). Therefore, it was reclassified as MC arising in spindle cell type of AME. Conclusion: The histopathological diagnosis of AME could be very difficult, especially when a distinction from other spindle cell breast neoplasms must be done. Immunohistochemistry is essential to confirm the diagnosis, having in mind the reported pathological characteristics and the immunohistochemical profile of recurrent and malignant tumors of this type.

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