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Current Concepts in Gynecologic Pathology

Rouzan G Karabakhtsian, MD, PhD

Assistant Professor

University of Kentucky Medical Center

October 15, 2011


Fall Meeting

Educational Objectives

Ovarian Pathology 1. New Approach to Ovarian Carcinogenesis

2. Ovarian Borderline Tumors; Diagnostic Challenges

Endometrial Pathology

3. Immunophenotypic Approach to High-Grade

Endometrial Carcinomas

4. Histologic Basis of Biological Behavior of Selected

Endometrial & Mixed Tumors

Cervical Pathology

5. High Grade Cervical Intraepithelial Lesions: How to

Avoid Over- & Underdiagnosis in Everyday Practice


Epithelial ovarian cancer EOC

Carcinoma CA

Serous carcinoma SC

Mucinous carcinoma MUC

Endometrioid carcinoma EMC

Clear cell carcinoma CCC

Transitional cell carcinoma TCC

Malignant mixed mllerian tumor MMMT

Carcinosarcoma CS

Undifferentiated carcinoma UDCA

Dedifferentiated carcinoma DDCA Cystadenofibroma CAF

Low malignant potential LMP

Borderline tumor BT

Atypical proliferative tumor APT

Micropapillary serous ca MPSC

Intraepithelial carcinoma IEC

1. New Approach to

Ovarian Carcinogenesis

Dualistic Model

Operative (Limited) Paradigm of

Ovarian Carcinogenesis

EOC regarded as a single disease

- composed of several different types, but majority HG SC

- differences between other types obscured

Regarded as ovarian in origin

- CAs in the pelvis tend to involve the ovary

- often as dominant ovarian mass

Classification based on histomorphologic findings (WHO 1973)

- provided basis for performing clinicopathologic studies

- molecular tools to study pathogenesis not available

- failure to identify the precursor of EOC

- limited understanding of ovarian carcinogenesis

Empirical management

- no change in overall survival in >50 yrs

(despite advances in radical surgery and cytotoxic CTX)

- early detection strategy (last 2 decades) failed to provide survival benefit

Serov, Scully, Sobin 1973 (WHO); Kurman, Shih 2011

Serous Carcinoma:

Evolution of Concepts

Traditionally graded as WD/ MD/ PD

Spectrum of same disease - WD SC (LG) progression to PD (HG)

Advances in molecular biology & tissue sampling methodology

Recent data based on combination of morphologic, IHC, molecular

genetic studies

Culminate in proposal of a dualistic model of ovarian carcinogenesis

Linking APST (typical SBT) to APMT (M-SBT) to LG SC

LG SC - distinct entity different from HG SC (2-tier grading system)

Malpica 2004; Shih, Kurman 2004

Precursors of LG SC


- morphologic continuum

- supported by shared distinctive mutational & genetic alterations,

& similar DNA methylation profiles (different from HG SC)*

- LG SC appears to develop in a stepwise fashion from SBT

APMT (Non-invasive MPSC), (Micropapillary SBT):

- closer molecularly to invasive LG SC than to APST**

*Shih, Kurman 2004, Meinhold 2005, Bonome 2005,

Gilks 2005, Dehari 2007, **May 2010, Kurman, Shih 2011


APT/ BT/ LMP acceptable terms

BT preferred term

Tumor of LMP accepted synonym (WHO, 2003)

APT first used by Russell in the 1970s,

gaining more support recently (Kurman group, etc)

Most common types: APST & APMT

Seidman 2000, Lee 2003

Dualistic Model of

Ovarian Carcinogenesis

Based on distinctive clinicopathologic & molecular genetic features

Provides new insights into the molecular pathogenesis of EOC

Accommodates & confirms the heterogeneous nature of EOC

Places the major histologic types into 2 groups (types I & II)

Links specific histologic types with their putative precursors

Emerging concepts are novel and highly provocative

Awaiting confirmation, modification, or revision

Dualistic Model of Carcinogenesis

Type I tumors:



CCC (mixed features)


Malignant Brenner tumor

Type II tumors:





Kurman, Shih 2011

Dualistic Model

Type I tumors:

- generally indolent - large cystic masses/ unilateral

(bilateral-MPSC, APMT-seromuc)

- lower stage: Ia (confined to ovary)

- display frequent somatic mutations

of genes participating in signal transduction pathways (SC 75%,

mutually exclusive)


- relatively stable genetically

- favorable prognosis

Type II tumors:

- highly aggressive - small size/ solid/ bilateral

- advanced stage: II-IV (>75%)

extraovarian spread

- harbor TP53 mutations (>95%)**

- inactivation of BRCA 1/2 exp (~50%)

(gene mutation or promoter methyl)**

- chromosomally highly unstable:

diffuse & high levels of DNA copy

number gains or losses at loci

CCNE1 (cyclin E1), NOTCH3, AKT2, RSF1, PIK3CA

(compared to Type I)

*Singer 2003, **Senturk 2010

Prevalence of Histologic Types of EOC &

Associated Molecular Genetic Changes

Downloaded from Kurman, Shih 2011 (Hum Pathol)

Pathway Alterations Involved in the Development of LG SC

Cardinal molecular genetic changes include somatic mutations in KRAS, BRAF, &

occasionally ERBB2 & PIK3CA. Mutated gene products activate the signaling pathways

that regulate cellular proliferation & survival, and promote tumor initiation & progression


Kurman, Shih

2011 (Hum Path)

Pathway Alterations Involved in the Development of Other EOC


- mutations that deregulate PI3K/ PTEN signaling pathway

- mutations of CTNNB1 gene (encodes b-catenin)


- activating mutation of PIK3CA

- somatic inactivity mutation of ARID1A (tumor suppressor gene)


- mutation in KRAS gene

Do LG & HG SC Coexist?

210 SC retrieved & reviewed from pathology archival files at

Johns Hopkins Hospital

3 HG SC associated w/ APST (typical SBT)

3 HG SC w/ LG invasive MPSC

Mutational analysis for KRAS, BRAF & p53 genes performed


- Identical KRAS mutations in both HG SC & APST components (2)

- remaining cases were negative for KRAS mutations (4)

(only 2 cases informative from a molecular genetic standpoint)

- none of 6 cases had p53 mutation in both LG & HG components

Dehari 2007

Can LG SC Progress to HG SC?

Rarely (~2%) LG and HG serous tumors do coexist

presence of identical KRAS mutations in both LG & HG components

indicates a common lineage/clonality

HG SC presumably develops along the LG (type 1) pathway

& have different molecular pathogenesis compared w/ conventional

HG SC (type II pathway)

The possibility of independent synchronous tumors highly unlikely

- lack of p53 mutation in all 6 cases

- additional studies needed to determine the validity of this hypothesis

Parker 2004, Dehari 2007

Dualistic Model

Type I tumors:

- develop slowly in a stepwise fashion - ass. w/ well recognized precursors:

cystadeno(fibro)ma/BT- LG SC/ MUC

endometriosis(ma) - LG EMC/ CCC


Stage I: >95% (MUC), 70% (CCC)

Stage I: 100% (APST & MPSC)

99% (APMT-GI)

Stage II-III: 70% (APST)


Type II tumors:

- rapidly growing - not ass. w/ morphologically

recognizable precursor lesions

- develop de novo from ovarian inclusion cysts


Stage I: >90%

Stage II-III: 20-30%

Riopel 1999, Seidman 2000, Kurman 2008


Exhibit features of both type I & type II tumors

Similarity to Type I:

- develop from well characterized precursors

- large cystic tumors

- Stage I at presentation (70%) (Veras 2009)

Similarity to Type II:

- typically HG, very aggressive at higher stage (30%)

So where does CCC belong?

- chromosomal instability index very similar to that of LG SC

- frequent PIK3CA activating & rare TP53 mu


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