Epithelial Inclusion Research Articles

Synucleins are expressed in the majority of breast and ovarian carcinomas and in preneoplastic lesions of the ovary

The synucleins (alpha, beta, and gamma) are a family of small cytoplasmic proteins that are expressed predominantly in neurons. alpha synuclein has attracted considerable attention due to its involvement in neurodegenerative diseases. Abnormal expression of gamma synuclein has recently been reported in some breast tumors. In this study, the authors examined a panel of breast and ovarian carcinomas for expression of alpha, beta, and gamma synucleins. Normal breast and ovary tissue samples, tissue from ovaries of women at high risk of ovarian carcinoma, and tissue from breast and ovarian carcinomas were screened by immunohistochemistry and Western blot analysis for synuclein expression. Synucleins were not detectable by Western blot analysis in normal breast tissue. Eighty-two percent (14 of 17) of Stage III/IV breast ductal carcinomas expressed beta synuclein, gamma synuclein, or both simultaneously. Expression of alpha synuclein was not detected in breast carcinomas by Western blot analysis. Synuclein (alpha, beta, and gamma) expression was not detectable by immunohistochemistry in normal ovarian epithelium. Eighty-seven percent (39 of 45) of ovarian carcinomas were found to express at least 1 type of synuclein, and 42% (19 of 45) expressed all 3 synucleins (alpha, beta, and gamma) simultaneously. Highly punctate gamma synuclein expression was also observed in 20% of preneoplastic lesions of the ovary, including epithelial inclusion cysts, hyperplastic epithelium, and papillary structures, suggesting that gamma synuclein up-regulation may occur early in the development of some ovarian tumors. alpha, beta, and gamma synuclein are expressed in a high percentage of ovarian and breast carcinomas, and abnormal gamma synuclein expression may occur early in the development of ovarian carcinoma.

Ovarian Epithelial Tumor Growth Promotion by Follicle-Stimulating Hormone and Inhibition of the Effect by Luteinizing Hormone

Objectives. The role of gonadotropins in ovarian epithelial cancer development is still controversial. Follicle-stimulating hormone receptor (FSHR) status in ovarian epithelial tumors (OETs) and their presumed precursor lesions has never been studied in detail. The objective of this study was to examine whether FSHR is expressed in OETs and to investigate the possible different roles of the gonadotropins in ovarian cancer development.Methods. Twenty ovarian epithelial inclusions (entrapments or invaginations of ovarian surface epithelium) from benign ovaries and 60 OETs including 12 cystadenomas, 18 borderline tumors, and 30 carcinomas were examined for FSHR expression by using reverse transcription polymerase chain reaction (RT-PCR), in situ hybridization (ISH), and immunohistochemistry (IHC). We also studied the mitogenic activity of FSH on two FSH and luteinizing hormone (LH) receptor-positive ovarian epithelial carcinoma cell lines (AO and 3AO) and on the modifying effect of LH on this activity. Growth-stimulating effects of the gonadotropins were tested in vitro with measurement of cell numbers, S-phase by flow cytometry, and changes in the cellular proliferative marker Ki-67.Results. Positive FSHR mRNA expression by RT-PCR (the most sensitive method) was found in 100% of epithelial inclusions, 100% of cystadenomas, 94% of borderline tumors, and 60% of carcinomas. There was a nonstatistically significant trend of decreasing positivity with increasing carcinoma grade. ISH and IHC gave similar, but somewhat less sensitive, results. A dose–response effect was seen with FSH, with a 1.6-fold increase in cell numbers with a maximally stimulating FSH concentration of 40 IU/L for a period of 48 h. These proliferative cellular effects were not observed when the cells were stimulated by LH in the range 1 to 100 IU/L. Most significantly, the growth stimulating effects of FSH could be blocked by the simultaneous administration of LH.Conclusions. FSHR is present in the majority of ovarian epithelial inclusions and OETs. The steady decline of FSHR expression from benign cystadenoma to borderline tumor to carcinoma suggests that FSH may be needed in early ovarian cancer development. Gonadotropins, FSH and LH, may have different roles in ovarian cancer cell proliferation. FSH, not LH, may be an important ovarian epithelial cell growth-promoting factor. The “opposing” effect of LH on FSH stimulation may explain why high FSH levels at postmenopausal ages are not associated with great increases in ovarian cancer risk.

Heterotopic Epithelium in an Intramammary Lymph Node.

Heterotopic squamous-lined cysts and ductal epithelium occurring in an intramammary lymph node from a 23-year-old woman are described. The lesion presented as a 3 cm x 2 cm well-circumscribed mass lying anterior to the left anterior axillary line. Careful examination of the breast revealed no other clinically apparent lesions. The nodule was thought to represent a benign neoplasm and excisional biopsy was performed. Pathologic examination revealed a lymph node whose architecture was distorted by multiple squamous-lined cysts. The squamous epithelium demonstrated a prominent granular cell layer. No evidence of nuclear atypia was found within the squamous lining. Only rare cases of epithelial inclusions within axillary lymph nodes have been described. The majority have been unrelated to a breast malignancy and have followed a benign clinical course. Because these inclusions may lead to significant axillary or intramammary lymphadenopathy, they may be mistaken clinically for metastatic carcinoma. Disclosure of intranodal epithelial deposits on pathologic examination may result in an incorrect diagnosis of metastatic disease. However, careful evaluation of the epithelial nests will establish their benign character. Benign epithelial deposits within intramammary and axillary lymph nodes must be added to the list of heterotopic benign epithelial structures found in lymph nodes.

Sentinel Node Localization in Breast Cancer Patients Using Intradermal Dye Injection

In a series of 161 consecutive breast cancer operations, intradermal injection of Patent Blue was used to localize the sentinel node (SN). The surgical localization rate was 60%. Including the blue lymph nodes found by the pathologist, localization rate was 70%. After the first 103 operations, the surgical procedure was changed, resulting in a localization rate of 83%. Ten surgeons participated, but only one had previous experience with SN dissection. The others experienced a steep learning curve. Metastasis was found in 42 of 97 SNs (43%). In 15 cases (36%) metastasis was recognized only after step-sectioning and immunohistochemical staining for cytokeratin. In one case a benign epithelial inclusion was found. The sentinel node was false negative in 9.1% of cases. The consensus from the literature is that the best results are achieved using a combination of dye and isotopic techniques.

IS MODIFIED IN SITU VAGINAL WALL SLING OPERATION THE TREATMENT OF CHOICE FOR RECURRENT GENUINE STRESS INCONTINENCE?

We evaluate objectively the results of a modified in situ vaginal wall sling operation for recurrent genuine stress incontinence and whether it is a substitute for the traditional sling procedure. A total of 23 patients with urodynamically proved recurrent genuine stress urinary incontinence were recruited in this study. Patients were treated with a modified needle urethropexy technique using an island of in situ vaginal skin as a sling to support the bladder neck and urethra. Surgical outcome was evaluated subjectively and objectively at a median of 15 months. A total of 42 patients who underwent a traditional polytetrafluoroethylene sling operation served as controls. The cure rate of the vaginal wall sling operation was 34.8% by objective assessment, which was lower than that of the traditional sling procedure (88.1%, p <0.05). The subjective success rate demonstrated the same results (vaginal sling 60.9% versus traditional sling 92.9%, p <0.05). The risk factors for operation failure were lower maximal urethral pressure, lower urethral closing pressure, narrow vaginal capacity and previous anterior colporrhaphy or a Stamey operation (all p <0.05). In 3 cases suburethral epithelial inclusion cysts were specific complications of the operation. There was no prolonged urinary retention or urethral erosion. Based on our results, we do not believe that the vaginal wall sling operation should be recommended for all recurrent genuine stress urinary incontinence cases and especially not for those with factors predictive of surgical failure. Further studies are needed to investigate and clarify the possible causes of failure.

Histopathologic features of ovaries at increased risk for carcinoma. A case-control analysis.

In this study, the pathogenesis of ovarian carcinoma was investigated by performing a masked histopathologic comparison of benign ovaries removed from 61 women predicted to be at increased risk for developing carcinoma (cases) with ovaries removed from 121 women without known predisposing conditions (controls). The cases included 26 women who had a unilateral invasive carcinoma and 35 women undergoing prophylactic oophorectomy for a family history of ovarian cancer. As predicted by previously developed models, epithelial inclusion cysts were identified more frequently with advancing age in both cases and controls. However, the mean and maximum number of cysts per slide in a woman were not increased among cases. Surface epithelial "atypia," a designation based on a composite impression of multiple features, was found in 13% of cases compared with 3% of controls (relative risk 7.1; 95% confidence interval, 1.9 to 26.1), but this result was based on small numbers. None of the other histologic features examined was found more often in cases following age-adjustment. Reexamination of sections with well-preserved surface epithelium or inclusion cysts under oil immersion demonstrated several differences in the detection of specific features between cases and controls and increased detection of "atypia" among cases, but none of these findings reached statistical significance. It is concluded that there may be subtle differences in the surface epithelium of ovaries predisposed to developing cancer as compared with controls, but these changes are difficult to identify reliably with light microscopy. Future etiologic studies should attempt to optimize specific handling and include molecular studies and epidemiologic analyses.

Epithelial Inclusion in Axillary Lymph Node Associated with a Breast Carcinoma: Report of a Case with a Review of the Literature

Since epithelial inclusions in axillary lymph nodes are rare, some diagnostic problems concerning their nature have arisen. We report a case of a cystic squamous epithelial inclusion in an axillary lymph node of a patient affected by a high grade breast carcinoma with focal squamous differentiation. Although the lesion was histologically benign, the possibility that it represents a well-differentiated squamous metastasis cannot be completely ruled out. To our knowledge, this is the first case of an epithelial lymph node inclusion associated with a breast carcinoma showing morphological evidence of squamous differentiation. Here, we discuss the diagnostic problems and give a review of the literature.

Hormonal etiology of epithelial ovarian cancer, with a hypothesis concerning the role of androgens and progesterone.

In the United States, ovarian cancer is the fourth most frequent cause of cancer death among women, following lung, breast, and colorectal cancers. Each year, approximately 26,000 women are diagnosed with ovarian cancer and 14,000 die of it. Germline mutations in BRCA1, BRCA2, or other genes have been implicated in a small fraction of cases. However, it has been suggested that, for the great majority of patients, the risk of epithelial ovarian cancer could be related to "incessant ovulation" (i.e., to the chronically repeated formation of stromal epithelial clefts and inclusion cysts following ovulation) or to some type of hormonal stimulation of ovarian epithelial cells, either on the surface of the ovary or within ovarian inclusion cysts, possibly mediated through excessive gonadotropin secretion. From the evidence to date, the relative importance of these two hypotheses--incessant ovulation and gonadotropin stimulation--cannot be distinguished. While either or both may play a role in the development of ovarian cancer, it appears that an additional major factor must also be involved. The purpose of this review is to evaluate evidence for and against the incessant ovulation and gonadotropin hypotheses, as well as to consider the possibility that risk of ovarian cancer may be increased by factors associated with excess androgenic stimulation of ovarian epithelial cells and may be decreased by factors related to greater progesterone stimulation. Many features of the evidence bearing on the pathophysiology of ovarian cancer appear to support a connection with androgens and progesterone.

Histological Features of the Contralateral Ovary in Patients with Unilateral Ovarian Cancer: A Case Control Study

Objective.Most of the surface epithelial–stromal tumors of the ovary are thought to arise from epithelial inclusion cysts, thus these cysts, and the original surface epithelium, are precursor lesions of ovarian carcinoma.Material and methods.The histological features in contralateral ovary from 20 patients with unilateral ovarian carcinoma were compared with 20 ovaries of patients without ovarian pathology and with 12 normal ovaries of women with contralateral benign ovarian pathology.Results.Cortical invaginations were more frequent and numerous in ovaries of patients with contralateral ovarian carcinoma. The presence of cortical invaginations and epithelial inclusion cysts showed correlation in patients with cancer and in those without ovarian pathology, but there were no differences in the number of inclusion cysts when the three groups were compared. Mild cytological atypia was detected more frequently in the surface epithelium of contralateral ovaries of patients with ovarian carcinoma. Ovarian size, cortical thickness, stromal hyperplasia, psammoma bodies, and surface papillae did not show differences when comparing patients with cancer and control groups.Conclusion.Cortical invaginations, a previous step in the formation of epithelial inclusion cysts, can also play an important role in the genesis of ovarian carcinoma.

Transvaginal sonographic evaluation of multiple peripherally distributed echogenic foci of the ovary: prevalence and histologic correlation.

Our aim was to determine the prevalence, histopathologic correlation, and clinical significance of multiple peripherally distributed echogenic foci seen within ovaries on transvaginal sonography. Transvaginal sonograms of 264 ovaries in 135 patients were prospectively analyzed for the presence of peripheral echogenic foci that were then characterized as linear, punctate, or globular. Previous examinations, when available, were reviewed for this sonographic feature, and the time interval between studies was recorded as a measure of stability. Sonograms were correlated with available surgical specimens in six patients, five of whom underwent hysterectomy and bilateral oophorectomy and the remaining patient who underwent laparoscopic ovarian wedge biopsy. Multiple peripheral echogenic foci were common and were found in 66 patients (49%) and 97 ovaries (37%). The punctate pattern was seen in 63 (95%) of 66 patients. The linear and globular patterns were present in only three and four patients, respectively. These echogenic foci were found on previous examinations in 18 patients. No suspicious sonographic features were seen in the ovaries of any of these patients. Histologic evaluation revealed multiple superficial epithelial inclusion cysts and associated psammomatous calcifications in all five patients who underwent bilateral oophorectomy. An additional finding in one of these patients was extensive endosalpingiosis. Multiple peripheral echogenic foci involving the ovaries is a common incidental finding on routine transvaginal sonography of the pelvis. Our data suggest that this sonographic finding represents psammomatous calcifications associated with superficial epithelial inclusion cysts.

Histochemical analysis of estrogen and progesterone receptors and gastric‐type mucin in mucinous ovarian tumors with reference to their pathogenesis

BACKGROUND Mucinous tumors of the ovary have been thought to originate in two ways: by müllerian-type metaplasia of surface epithelium, and as monodermal teratomas. To gain a better understanding of their pathogenesis, the authors analyzed these tumors for their expression of estrogen receptors (ER) and progesterone receptors (PR) as markers of müllerian-type differentiation and for their content of gastric-type mucin as a marker of gastric differentiation. METHODS The histochemical expression of ER, PR, and gastric-type mucin was studied in 10 specimens of the cervix with normal endocervical glands (as a representative of müllerian-derived mucin-containing cells), 3 ovary specimens with surface epithelial inclusion cysts that contained endocervical-like mucin-containing cells (representing müllerian-type metaplasia), and 47 mucinous tumors of the ovary (29 benign, 8 with low malignant potential, and 10 malignant). RESULTS Normal endocervical glands expressed ER and PR and rarely expressed gastric-type mucin. Ovarian inclusion cysts showed strong expression of ER and PR in the cuboidal cells and drastically reduced expression in the endocervical-like mucin-containing cells. The cuboidal cells were negative for gastric-type mucin, but the endocervical-like mucin-containing cells expressed gastric-type mucin. Endocervical-like mucinous cells in benign and borderline mucinous tumors showed expression of PR and/or gastric-type mucin in all cases. CONCLUSIONS The staining results for the inclusion cysts support the thesis that the endocervical-like mucinous cells encountered in the ones that express ER and PR weakly or not at all and have histochemical properties of normal gastric epithelium have their origin in metaplasia of müllerian-type epithelium. Application of the same staining methods to benign ovarian tumors and those with low malignant potential suggests strongly that similar müllerian-type metaplasia is a major pathway in their pathogenesis. Cancer 1997; 80:908-16. © 1997 American Cancer Society.

Histochemical analysis of estrogen and progesterone receptors and gastric‐type mucin in mucinous ovarian tumors with reference to their pathogenesis

Mucinous tumors of the ovary have been thought to originate in two ways: by müllerian-type metaplasia of surface epithelium, and as monodermal teratomas. To gain a better understanding of their pathogenesis, the authors analyzed these tumors for their expression of estrogen receptors (ER) and progesterone receptors (PR) as markers of müllerian-type differentiation and for their content of gastric-type mucin as a marker of gastric differentiation. The histochemical expression of ER, PR, and gastric-type mucin was studied in 10 specimens of the cervix with normal endocervical glands (as a representative of müllerian-derived mucin-containing cells), 3 ovary specimens with surface epithelial inclusion cysts that contained endocervical-like mucin-containing cells (representing müllerian-type metaplasia), and 47 mucinous tumors of the ovary (29 benign, 8 with low malignant potential, and 10 malignant). Normal endocervical glands expressed ER and PR and rarely expressed gastric-type mucin. Ovarian inclusion cysts showed strong expression of ER and PR in the cuboidal cells and drastically reduced expression in the endocervical-like mucin-containing cells. The cuboidal cells were negative for gastric-type mucin, but the endocervical-like mucin-containing cells expressed gastric-type mucin. Endocervical-like mucinous cells in benign and borderline mucinous tumors showed expression of PR and/or gastric-type mucin in all cases. The staining results for the inclusion cysts support the thesis that the endocervical-like mucinous cells encountered in the ones that express ER and PR weakly or not at all and have histochemical properties of normal gastric epithelium have their origin in metaplasia of müllerian-type epithelium. Application of the same staining methods to benign ovarian tumors and those with low malignant potential suggests strongly that similar müllerian-type metaplasia is a major pathway in their pathogenesis.

Increased E-cadherin expression in ovarian surface epithelium: an early step in metaplasia and dysplasia?

Ovarian surface epithelium (OSE), the source of common epithelial carcinomas, is a simple mesothelium that during carcinogenesis acquires complex epithelial characteristics normally found in tubal, endometrial, and endocervical epithelia. These characteristics include the intercellular adhesive molecule E-cadherin. We examined cryostat sections of 12 normal ovaries by immunofluorescence and immunocytochemistry to determine whether E-cadherin is a component of normal OSE that is retained in ovarian cancers or whether it, like many other epithelial characteristics, is acquired in the course of metaplasia and neoplastic progression. E-cadherin expression by OSE varied with its location within the ovary and with cell shape. It was present inconsistently on the ovarian surface but was increased in surface invaginations and particularly in epithelial inclusion cysts. Independent of location, E-cadherin was most prominent in columnar, variable in cuboidal, and absent in flat OSE. This relationship to cell morphology accounts for the increased E-cadherin expression in inclusion cysts, which are sites of frequent metaplastic and dysplastic changes. These results suggest that the morphologic variation of OSE reflects differences in E-cadherin-mediated intercellular adhesion. Thus, the appearance of this adhesion molecule in columnar OSE may represent an early step in the increased commitment to epithelial phenotypes that accompanies metaplasia and neoplastic progression of OSE.

Histology of the perforated tympanic membrane and its muco-epithelial junction.

A histological study was performed on total human tympanic membranes with a central perforation. The specimens originated from 30 consecutive and unselected operations in which a total myringectomy was performed prior to reconstruction by means of a tympanic allograft. Beside excessive thickening of the tympanic membrane in 73%, all membranes showed other histological abnormalities: inflammation (97%), excessive fibrosis (97%), tympanosclerosis (80%), hyperkeratosis (83%), rete riges (43%) and epithelial inclusions (6%). Histological localisation of the muco-epithelial junction showed a medial position in 30%, with extensive middle ear invasion by squamous epithelium in 7%. The surgeon performing myringoplasty should keep these findings in mind and he should closely examine the medial side of the perforated tympanic membrane in order to remove any ingrowing epithelium that otherwise would be trapped.

Epithelial Inclusion Cyst Formation After Free Vaginal Wall Swing Sling Procedure for Stress Urinary Incontinence

Since the full thickness vaginal wall sling procedure for stress urinary incontinence was first described, concern has been raised regarding the potential formation of inclusion cysts due to buried vaginal mucosa.1 To our knowledge we report the first case of inclusion cyst formation after a full thickness, free vaginal wall urethral sling procedure. CASE REPORT

Epithelial Inclusion Cyst Formation After Free Vaginal Wall Swing Sling Procedure for Stress Urinary Incontinence

Epithelial Inclusion Cyst Formation After Free Vaginal Wall Swing Sling Procedure for Stress Urinary Incontinence

Recurrent intrascleral cyst after strabismus surgery

Intrascleral epithelial inclusion cysts have been described after ocular trauma, scleral buckling and strabismus surgery. They are usually small, asymptomatic and located anteriorly. The clinical history of a 9-year-old girl who developed a huge epi- and retrobulbar intrascleral cyst in both the upper and the lower nasal quadrants after multiple strabismus operations is described. Surgical resection of the cyst wall was twice unsuccessful. Drainage of the cyst, followed by the injection of tetracycline (30 mg/ml) in the cyst site, led to complete recovery. Recurrent posteriorly located intrascleral cyst can occur after strabismus surgery. Therapy consisting of drainage combined with intrascleral administration of tetracycline solution (30 mg/ml) to induce sclerodesis appeared to be effective during a 2-year follow-up period.

Spindle Epithelial Tumor with Thymus-like Element (SETTLE), a Primary Thyroid Tumor

A 49-year-old female presented with a nontender mass in the neck. Fine-needle aspirate revealed spindle cells in a vaguely whorled pattern. The cells were fairly uniform and had elongated nuclei with fine chromatin. It was diagnosed as a cellular spindle cell neoplasm of uncertain histogenesis. Total thyroidectomy was performed revealing a well-circumscribed mass in the right lower pole extending substernally for 2 cm. The tumor was highly cellular and characterized by fascicles of spindle cells, focally displaying a biphasic pattern. The glandular component had a tubopapillary pattern. Occasional small mucous cysts were found adjacent to the tumor and in the opposite lobe, suggesting that the tumor might have arisen from the epithelial inclusions or remnants of branchial pouch within the thyroid. The spindle cells were immunoreactive for cytokeratin, epithelial membrane antigen, and vimentin and negative for thyroglobulin, calcitonin, chromogranin, desmin, myoglobin, and actin. Ultrastructurally, the spindle cells had abundant tonofilaments and well-developed desmosomes. These findings are consistent with a newly described entity, spindle epithelial tumor with thymus-like element (SETTLE), an intrathyroid lesion with a potential for delayed metastasis. Int J Surg Pathol 4(3):00-00, 1997

Vascular endothelial growth factor localization in human ovary and fallopian tubes: possible role in reproductive function and ovarian cyst formation.

Vascular endothelial growth factor (VEGF) is a potent angiogenic factor that also increases vascular permeability. We hypothesized that VEGF plays a role in the regulation of cyclic ovarian angiogenesis in women, and that its ability to increase vascular permeability may be an important factor in the production of fallopian tube effluent and fluid formation in ovarian cysts. To examine these hypotheses, we assessed VEGF expression in ovaries and fallopian tubes from premenopausal (n = 10) and postmenopausal (n = 4) women. Immunohistochemical analysis for VEGF was performed using a rabbit polyclonal antibody directed against human VEGF. In normal ovaries from premenopausal women, VEGF within healthy follicles was localized to the thecal cell layer, with minimal VEGF peptide detected in the granulosa cell layer. VEGF was not expressed in atretic follicles or a degenerating corpus luteum. However, intense VEGF immunostaining was observed within the highly vascularized corpora lutea in all specimens examined. In normal ovaries from postmenopausal women, VEGF was detected only in epithelial inclusion cysts and a serous cystadenoma. In specimens from both pre- and postmenopausal women, the luminal epithelium of the fallopian tube as well as smooth muscle cells and pericytes lining small and large blood vessels within the tube and hilum of the ovary exhibited specific staining for VEGF. Based on these data, we suggest that during reproductive life, VEGF plays a role in the growth and maintenance of the ovarian follicle and corpus luteum by mediating angiogenesis. In addition, VEGF within the fallopian tube luminal epithelium may increase vascular permeability and modulate tubal luminal secretions. Similarly, VEGF in the epithelial lining of benign ovarian neoplasms may contribute to fluid formation in ovarian cysts.

Lateral canthal tendon suspension using the carbon dioxide laser. A modified technique.

The "tarsal strip" procedure was developed to correct lower eyelid ectropion caused by lateral canthal tendon laxity. The "tarsal strip" procedure is improved by using the carbon dioxide (CO2) laser. The CO2 laser was used to perform lateral canthotomy. Patients were evaluated postoperatively for subjective improvement in preoperative symptoms. Complications such as epithelial inclusion cysts were actively sought. Thirty-one patients (60 lids) were followed for an average of 12 months. Preoperative symptoms resolved in 86% (N = 27), improved in 7% (N = 2), and did not change in 7% (N = 2). Two patients required additional surgery. Complications were not observed in this study. The modified "tarsal strip" procedure using the CO2 laser provides many advantages compared with the original procedure. A clean dissection improves visibility and allows easy identification of the lateral tarsal plate. The lateral canthal angle is preserved and epithelial inclusions are prevented because the conjunctival mucosa is not violated.