HPV-independent Precursors Mimicking High-grade Squamous intraepithelial Lesions (HSIL) of the Vulva

Two etiopathogenic types of vulvar squamous cell carcinoma (VSCC) have been described: human papillomavirus (HPV)-associated and HPV-independent. Precursor lesions, frequently identified in the adjacent skin, are also distinct in the 2 types of VSCC: high-grade squamous intraepithelial lesions (HSILs) in HPV-associated VSCC and differentiated vulvar intraepithelial neoplasia (dVIN) or vulvar acanthosis with altered differentiation in HPV-independent VSCC. Although HPV-independent precursors mimicking HSIL have been described in the vulva, their frequency and morphologic spectrum have not been completely characterized. We explored, in a large series of HPV-independent VSSC, the frequency and the histologic features of precursors mimicking HSIL. We included 779 DNA HPV-negative/p16-negative VSCC with at least 1\xE2\x80\x89cm of adjacent skin. We evaluated the histologic and immunohistochemical (p16 and p53) characteristics of the intraepithelial lesions, focusing on precursors mimicking HPV-associated vulvar HSIL. A total of 254 tumors (33%) had adjacent premalignant lesions. Of them, 186 (73%) had dVIN, 22 (9%) had vulvar acanthosis with altered differentiation, and 46 (18%) had lesions that mimicked HSIL. The mean age of the patients with these HSIL-like lesions was 72\xC2\xB115 years. Twenty-six of these HSIL-like lesions had basaloid morphology, 13 warty, and 7 mixed basaloid/warty features. All the HSIL-like precursors were DNA HPV-negative/p16-negative; 74% of them showed p53 abnormal staining and 35% of them had areas of conventional dVIN. In conclusion, about one fifth of the HPV-independent precursors mimic HSIL, showing either basaloid or warty features. Older age and the presence of areas of typical HPV-independent intraepithelial lesions, together with p16 negativity, should raise suspicion of an HPV-independent etiology

P53 in Penile Squamous Cell Carcinoma : A Pattern-Based Immunohistochemical Framework with Molecular Correlation

Penile squamous cell carcinomas harbouring mutations of TP53 have an increased risk of lymph node metastases and an impaired prognosis, but the mutational analysis of the TP53 gene is not available in many pathology laboratories. Although p53 immunohistochemistry (IHC) has been proposed as an alternative to the molecular analysis, the current method of evaluation of p53 IHC has many inaccuracies. The aim of our study was to determine, in a series of 40 penile tumours, if a recently described pattern-based framework of p53 IHC evaluation correlates better than the classical method with the TP53 mutational status. Our results show that the new method has a very good correlation with TP53 mutations (95% sensitivity; 92% specificity), higher than that of the classical method, and can be considered as a reliable surrogate of the TP53 mutational status. This new framework can help clinicians to better define risk groups and refine treatment strategies. p53 immunohistochemistry (IHC) has been proposed as a surrogate for TP53 mutations in penile squamous cell carcinomas (PSCC). We aimed to evaluate the performance of a pattern-based evaluation of p53 IHC in PSCC. Human papilloma virus (HPV) DNA testing, p16 and p53 IHC, and whole exome sequencing were performed in a series of 40 PSCC. p53 IHC was evaluated following a pattern-based framework and conventional p53 IHC evaluation. Out of 40 PSCC, 12 (30.0%) were HPV-associated, and 28 (70.0%) were HPV-independent. The agreement between the p53 IHC pattern-based evaluation and TP53 mutational status was almost perfect (k = 0.85). The sensitivity and accuracy of the pattern-based framework for identifying TP53 mutations were 95.5% and 92.5%, respectively, which were higher than the values of conventional p53 IHC interpretation (54.5% and 70.0%, respectively), whereas the specificity was the same (88.9%). In conclusions, the pattern-based framework improves the accuracy of detecting TP53 mutations in PSCC compared to the classical p53 IHC evaluation

BCL3-rearrangements in B-cell lymphoid neoplasms occur in two breakpoint clusters associated with different diseases

The t(14;19)(q32;q13) often juxtaposes BCL3 with IGH resulting in overexpression of the gene. In contrast to other oncogenic translocations, BCL3-rearrangement (BCL3-R) has been associated with a broad spectrum of lymphoid neoplasms. Here we report an integrative whole-genome sequence, transcriptomic, and DNA methylation analysis of 13 lymphoid neoplasms with BCL3-R. The resolution of the breakpoints at single base-pair revealed that they occur in two clusters at 5' (n=9) and 3' (n=4) regions of BCL3 associated with two different biological and clinical entities. Both breakpoints were mediated by aberrant class switch recombination of the IGH locus. However, the 5' breakpoints (upstream) juxtaposed BCL3 next to an IGH enhancer leading to overexpression of the gene whereas the 3' breakpoints (downstream) positioned BCL3 outside the influence of the IGH and were not associated with its expression. Upstream BCL3-R tumors had unmutated IGHV, trisomy 12, and mutated genes frequently seen in CLL but had an atypical CLL morphology, immunophenotype, DNA methylome, and expression profile that differ from conventional CLL. In contrast, downstream BCL3-R neoplasms were atypical splenic or nodal marginal zone lymphomas (MZL) with mutated IGHV, complex karyotypes and mutated genes typical of MZL. Two of the latter 4 tumors transformed to a large B-cell lymphoma. We designed a novel FISH assay that recognizes the two different breakpoints and validated these findings in 17 independent tumors. Overall, upstream or downstream breakpoints of BCL3-R are mainly associated with two subtypes of lymphoid neoplasms with different (epi)genomic, expression, and clinicopathological features resembling atypical CLL and MZL, respectively

Papel del factor de transcripción SOX11 en la caracterización del linfoma de células del manto

[spa] El Linfoma de células del Manto (LCM) es un linfoma B maduro, con una característica sobreexpresión de la proteína nuclear Ciclina D1. Se caracteriza por presentar un curso clínico agresivo, aunque se ha observado que algunos pacientes tienen un curso clínico más indolente. Recientemente se ha observado que el factor de transcripción SOX11 tiene una sobreexpresión específica en este tipo de linfoma. El diagnóstico diferencial entre el LCM y otros tipos de linfoma B puede ser difícil. Un problema es el diagnostico diferencial entre el Linfoma Difuso de Célula B Grande (LDCBG) Ciclina D1 positivo y las variedades pleomórfica y blastoide del LCM. Dado que los pacientes se tratan de forma diferente es importante identificar parámetros que permitan establecer el diagnostico diferencial. Estudios recientes han identificado algunos LCM que de forma peculiar presentan una diferenciación plasmocelular. Recientes trabajos han implicado SOX11 en el bloqueo de la diferenciación B terminal a través de la expresión forzada de PAX5. Así pues estas observaciones permiten postular que la diferenciación plasmocelular y más ampliamente el inicio de la diferenciación B-terminal en LCM se debe producir preferentemente en LCM SOX11 negativos. En esta Tesis doctoral hemos estudiado el papel del factor de transcripción SOX11 en el LCM. La intención era poder encontrar herramientas prácticas que nos ayuden a poder identificar y caracterizar mejor al LCM. En este sentido hemos estudiado el valor de SOX11 y otros parámetros en el diagnostico diferencial entre el LCM y el LDCBG Ciclina D1 positivo y por otra parte hemos analizado la diferenciación B-terminal en LCM y su relación con la expresión de SOX11. En el primer manuscrito de esta Tesis hemos teñido 206 LDCBG para Ciclina D1 e identificamos tres casos (1.5%) positivos. Los tres casos eran SOX11 negativos y por FISH se confirmó la ausencia de aberraciones de CCND1. Se estudiaron 22 LCM, todos expresando Ciclina D1 con 89% de los casos expresando SOX11, una frecuencia estadísticamente significativa en relación al LDCBG Ciclina D1 positivo. Una cohorte separada de 98 LDCBG resulto negativa para SOX11, con solo un caso Ciclina D1 positivo. Este LDCBG Ciclina D1 positivo tampoco presento aberraciones de CCND1 por estudios de FISH. En el segundo manuscrito de esta Tesis hemos investigado el fenotipo de diferenciación terminal de células B en 60 LCM 41 SOX11-positivos y 19 SOX11-negativos. Se observaron células plasmáticas monotípicas y células linfoides con diferenciación plasmocítica expresando Ciclina D1 en 7 (37%) casos SOX11-negativos, pero en ninguno de los 41 casos SOX11-positivos (p<0.001). Los tumores SOX11-negativos tenían más frecuentemente una expresión intensa citoplasmática con restricción de una cadena ligera de inmunoglobulina que los positivos (58% vs 13%) (p=0.001). Similarmente los casos SOX11-negativos tenían una expresión de BLIMP1 y XBP1 significativamente más frecuente que en los casos positivos (83% vs 34% y 75% vs 11%, respectivamente) (p=0.001). Sin embargo, no se observaron diferencias en la expresión de IRF4/MUM1 entre estos subtipos de LCM. En resumen, las conclusiones principales de esta Tesis son que el LDCBG Ciclina D1 positivo es poco frecuente, es negativo para SOX11 o aberraciones de CCND1. Por tanto SOX11 es útil en el diagnostico diferencial entre LDCBG Ciclina D1 positivo y LCM. Además el LCM SOX11-negativo puede ser un subtipo específico de este tumor que se caracteriza por presentar con mayor frecuencia características morfológicas e inmunofenotípicas de diferenciación terminal de células B, que pueden ser facilitadas por la ausencia del factor de transcripción SOX11.[eng] Mantle cell lymphoma (MCL) is characterized by a proliferation of malignant B lymphocytes, presenting an aggressive clinical course, although some patients have a more indolent presentation. The genetic hallmark of this lymphoma is the t(11;14)(q13;q32) leading to the overexpression of Cyclin D1. SOX11 is new and specific diagnostic marker for MCL. Cyclin D1 overexpression can also be seen in other hematological malignancies such as Diffuse Large B Cell Lymphoma (DLBCL). These cases may pose diagnostic challenges and are difficult to differentiate from MCL. In the first study of this Thesis we stained 206 DLBCLs for Cyclin D1 and identified 1.5% positive cases. These DLBCLs showed SOX11 negativity and absence of CCND1 aberrations. Also 22 MCLs were studied, with 89% cases expressing SOX11. A separate cohort of 98 DLBCLs was negative for SOX11, with only one case expressing Cyclin D1. Experimental studies have shown that silencing of SOX11 in MCL cells promotes the shift from a mature B cell into an early plasmacytic differentiation phenotype suggesting that SOX11 may contribute to tumor development by blocking the B-cell differentiation program. In the second study of this Thesis we have investigated the terminal B-cell differentiation phenotype in 60 mantle cell lymphomas. Monotypic plasma cells and lymphoid cells with plasmacytic differentiation expressing Cyclin D1 were observed in 37% SOX11-negative cases but in none of the SOX11-positive MCLs (p<0.001). BLIMP1 and XBP1 expression was also significantly more frequent in SOX11-negative than positive cases (83% vs 34% and 75% vs 11%, respectively) (p=0.001). These results indicate that SOX11-negative MCL may be a particular subtype characterized by more frequent morphological and immunophenotypic terminal B-cell differentiation features that may be facilitated by the absence of this transcription factor. In summary, the main conclusions of this Thesis are that Cyclin D1-positive DLBCLs are rare and negative for SOX11 or CCND1 aberrations. There fourth SOX11 is useful in differentiating Cyclin D1-positive DLBCL from MCL. We also demonstrated that SOX11-negative MCL is a particular subtype of this tumor characterized by more frequent morphological and immunophenotypic terminal B-cell differentiation features

Assessment of SOX11 expression in routine lymphoma tissue sections: characterization of new monoclonal antibodies for diagnosis of mantle cell lymphoma

The diagnosis of mantle cell lymphoma (MCL) can be difficult, especially when no t(11;14) translocation and cyclin D1 overexpression can be detected. In such cases, the transcription factor SOX11 represents an important diagnostic marker, as it is expressed in most MCLs and, in particular, in all cyclin D1-negative MCLs reported so far. A reliable anti-SOX11 antibody is therefore a very useful tool for routine diagnosis. Here, we characterize the new monoclonal anti-SOX11 antibodies, suitable for Western blot assay and immunohistochemistry (IHC) on formalin-fixed paraffin-embedded tissue; we tested them on a large series of primary lymphoid tumors and compared these results with those of other routinely used antibodies. Moreover, we show that IHC results depend on transcription levels of SOX11, which suggests that posttranscriptional and posttranslational modifications do not significantly affect cutoff levels for IHC detection of SOX11

Penile Squamous Cell Carcinomas in Sub-Saharan Africa and Europe: Differential Etiopathogenesis

Penile squamous cell carcinomas (PSCC) are classified by the World Health Organization into two categories based on their relationship with the human papillomavirus (HPV): HPV-associated and HPV-independent. We compared a cohort of PSCC from Mozambique, a sub-Saharan country in southeast Africa with a high prevalence of HPV and HIV infection, and Spain, a country in southwestern Europe with a low prevalence of HPV and HIV, to study the distribution of the etiopathogenic categories of these tumors in both sites. A total of 79 PSCC were included in the study (28 from Mozambique and 51 from Spain). All cases underwent HPV-DNA polymerase chain reaction (PCR) testing, genotyping, and immunohistochemistry for p16 and p53. Any PSCC showing either p16 overexpression or HPV-DNA in PCR analysis was considered HPV-associated. Overall, 40/79 (50.6%) tumors were classified as HPV-associated and 39 (49.4%) as HPV-independent. The two sites showed marked differences: 25/28 (89.3%) tumors from Mozambique and only 15/51 (29.4%) from Spain were HPV-associated (p p = 0.8). On average, patients from Mozambique were almost two decades younger than those from Spain (mean age 50.9 ± 14.9 and 69.2 ± 13.3, respectively [p < 0.001]). In conclusion, significant etiopathogenic differences between PSCC in Mozambique and Spain were observed, with a remarkably high prevalence of HPV-associated tumors in Mozambique and a relatively low prevalence in Spain. These data may have important consequences for primary prevention of PSCC worldwide

p53 immunohistochemical patterns in HPV-independent squamous cell carcinomas of the vulva and the associated skin lesions: a study of 779 cases

Human papillomavirus (HPV)-independent vulvar squamous cell carcinomas (VSCC) and its precursors frequently harbour TP53 mutations. Recently, six p53 immunohistochemical (IHC) patterns have been defined, which have shown strong correlation with TP53 mutation status. However, few studies have applied this new six-pattern framework and none of them exhaustively compared p53 IHC positivity and patterns between invasive VSCC and adjacent skin lesion. We performed p53 IHC in a series of 779 HPV-independent VSCC with adjacent skin and evaluated the IHC slides following the newly described classification. Some 74.1% invasive VSCC showed abnormal p53 IHC staining. A skin lesion was identified in 450 cases (57.8%), including 254 intraepithelial precursors and 196 inflammatory/reactive lesions. Two hundred and ten of 450 (47%) VSCC with associated skin lesions showed an abnormal p53 IHC stain, with an identical staining pattern between the VSCC and the adjacent skin lesion in 80% of the cases. A total of 144/450 (32%) VSCC showed wild-type p53 IHC both in the invasive VSCC and adjacent skin lesion. Finally, 96/450 (21%) VSCC showed p53 IHC abnormal staining in the invasive VSCC but a wild-type p53 staining in the skin lesion. Most of the discordant cases (70/96; 73%) showed adjacent inflammatory lesions. In conclusion, the p53 IHC staining and pattern are usually identical in the VSCC and the intraepithelial precursor

BCL3 rearrangements in B-cell lymphoid neoplasms occur in two breakpoint clusters associated with different diseases

The t(14;19)(q32;q13) often juxtaposes BCL3 with immunoglobulin heavy chain (IGH) resulting in overexpression of the gene. In contrast to other oncogenic translocations, BCL3 rearrangement (BCL3-R) has been associated with a broad spectrum of lymphoid neoplasms. Here we report an integrative whole-genome sequence, transcriptomic, and DNA methylation analysis of 13 lymphoid neoplasms with BCL3-R. The resolution of the breakpoints at single base-pair revealed that they occur in two clusters at 5' (n=9) and 3' (n=4) regions of BCL3 associated with two different biological and clinical entities. Both breakpoints were mediated by aberrant class switch recombination of the IGH locus. However, the 5' breakpoints (upstream) juxtaposed BCL3 next to an IGH enhancer leading to overexpression of the gene whereas the 3' breakpoints (downstream) positioned BCL3 outside the influence of the IGH and were not associated with its expression. Upstream BCL3-R tumors had unmutated IGHV, trisomy 12, and mutated genes frequently seen in chronic lymphocytic leukemia (CLL) but had an atypical CLL morphology, immunophenotype, DNA methylome, and expression profile that differ from conventional CLL. In contrast, downstream BCL3-R neoplasms were atypical splenic or nodal marginal zone lymphomas (MZL) with mutated IGHV, complex karyotypes and mutated genes typical of MZL. Two of the latter four tumors transformed to a large B-cell lymphoma. We designed a novel fluorescence in situ hybridization assay that recognizes the two different breakpoints and validated these findings in 17 independent tumors. Overall, upstream or downstream breakpoints of BCL3-R are mainly associated with two subtypes of lymphoid neoplasms with different (epi)genomic, expression, and clinicopathological features resembling atypical CLL and MZL, respectively

Increased risk of revision of cementless stemmed total hip arthroplasty with metal-on-metal bearings

<div><p><b>Background and purpose —</b> Data from the national joint registries in Australia and England and Wales have revealed inferior medium-term survivorship for metal-on-metal (MoM) total hip arthroplasty (THA) than for metal-on-polyethylene (MoP) THA. Based on data from the Nordic Arthroplasty Register Association (NARA), we compared the revision risk of cementless stemmed THA with MoM and MoP bearings and we also compared MoM THA to each other.</p><p><b>Patients and methods —</b> We identified 32,678 patients who were operated from 2002 through 2010 with cementless stemmed THA with either MoM bearings (11,567 patients, 35%) or MoP bearings (21,111 patients, 65%). The patients were followed until revision, death, emigration, or the end of the study period (December 31, 2011), and median follow-up was 3.6 (interquartile range (IQR): 2.4–4.8) years for MoM bearings and 3.4 (IQR: 2.0–5.8) years for MoP bearings. Multivariable regression in the presence of competing risk of death was used to assess the relative risk (RR) of revision for any reason (with 95% confidence interval (CI)).</p><p><b>Results —</b> The cumulative incidence of revision at 8 years of follow-up was 7.0% (CI: 6.0–8.1) for MoM bearings and 5.1% (CI: 4.7–5.6) for MoP bearings. At 6 years of follow-up, the RR of revision for any reason was 1.5 (CI: 1.3–1.7) for MoM bearings compared to MoP bearings. The RR of revision for any reason was higher for the ASR (adjusted RR = 6.4, CI: 5.0–8.1), the Conserve Plus (adjusted RR = 1.7, CI: 1.1–2.5) and “other” acetabular components (adjusted RR = 2.4, CI: 1.5–3.9) than for MoP THA at 6 years of follow-up.</p><p><b>Interpretation —</b> At medium-term follow-up, the survivorship for cementless stemmed MoM THA was inferior to that for MoP THA, and metal-related problems may cause higher revision rates for MoM bearings with longer follow-up.</p></div