LI

LABORATORY INVESTIGATION
THE BASIC AND TRANSLATIONAL PATHOLOGY RESEARCH JOURNAL

VOLUME 100 | SUPPLEMENT 1 | MARCH 2020

ABSTRACTS
GYNECOLOGIC AND OBSTETRIC
PATHOLOGY
(1047-1234)

FEBRUARY 29-MARCH 5, 2020 LOS ANGELES CONVENTION CENTER

LOS ANGELES, CALIFORNIA
 2020 ABSTRACTS | PLATFORM & POSTER PRESENTATIONS

EDUCATION COMMITTEE
Jason L. Hornick, Chair William C. Faquin
Rhonda K. Yantiss, Chair, Abstract Review Board Yuri Fedoriw
and Assignment Committee Karen Fritchie
Laura W. Lamps, Chair, CME Subcommittee Lakshmi Priya Kunju
Anna Marie Mulligan
Steven D. Billings, Interactive Microscopy Subcommittee
Rish K. Pai
Raja R. Seethala, Short Course Coordinator
David Papke, Pathologist-in-Training
Ilan Weinreb, Subcommittee for Unique Live Course Offerings
Vinita Parkash
David B. Kaminsky (Ex-Officio) Carlos Parra-Herran
Anil V. Parwani
Zubair Baloch
Rajiv M. Patel
Daniel Brat
Deepa T. Patil
Ashley M. Cimino-Mathews
Lynette M. Sholl
James R. Cook
Nicholas A. Zoumberos, Pathologist-in-Training
Sarah Dry

ABSTRACT REVIEW BOARD

Benjamin Adam Billie Fyfe-Kirschner Michael Lee Natasha Rekhtman
Narasimhan Agaram Giovanna Giannico Cheng-Han Lee Jordan Reynolds
Rouba Ali-Fehmi Anthony Gill Madelyn Lew Michael Rivera
Ghassan Allo Paula Ginter Zaibo Li Andres Roma
Isabel Alvarado-Cabrero Tamara Giorgadze Faqian Li Avi Rosenberg
Catalina Amador Purva Gopal Ying Li Esther Rossi
Roberto Barrios Anuradha Gopalan Haiyan Liu Peter Sadow
Rohit Bhargava Abha Goyal Xiuli Liu Steven Salvatore
Jennifer Boland Rondell Graham Yen-Chun Liu Souzan Sanati
Alain Borczuk Alejandro Gru Lesley Lomo Anjali Saqi
Elena Brachtel Nilesh Gupta Tamara Lotan Jeanne Shen
Marilyn Bui Mamta Gupta Anthony Magliocco Jiaqi Shi
Eric Burks Gillian Hale Kruti Maniar Gabriel Sica
Shelley Caltharp Suntrea Hammer Emily Mason Alexa Siddon
Barbara Centeno Malini Harigopal David McClintock Deepika Sirohi
Joanna Chan Douglas Hartman Bruce McManus Kalliopi Siziopikou
Jennifer Chapman John Higgins David Meredith Sara Szabo
Hui Chen Mai Hoang Anne Mills Julie Teruya-Feldstein
Beth Clark Mojgan Hosseini Neda Moatamed Khin Thway
James Conner Aaron Huber Sara Monaco Rashmi Tondon
Alejandro Contreras Peter Illei Atis Muehlenbachs Jose Torrealba
Claudiu Cotta Doina Ivan Bita Naini Andrew Turk
Jennifer Cotter Wei Jiang Dianna Ng Evi Vakiani
Sonika Dahiya Vickie Jo Tony Ng Christopher VandenBussche
Farbod Darvishian Kirk Jones Michiya Nishino Paul VanderLaan
Jessica Davis Neerja Kambham Scott Owens Olga Weinberg
Heather Dawson Chiah Sui Kao Jacqueline Parai Sara Wobker
Elizabeth Demicco Dipti Karamchandani Yan Peng Shaofeng Yan
Katie Dennis Darcy Kerr Manju Prasad Anjana Yeldandi
Anand Dighe Ashraf Khan Peter Pytel Akihiko Yoshida
Suzanne Dintzis Francesca Khani Stephen Raab Gloria Young
Michelle Downes Rebecca King Joseph Rabban Minghao Zhong
Andrew Evans Veronica Klepeis Stanley Radio Yaolin Zhou
Michael Feely Gregor Krings Emad Rakha Hongfa Zhu
Dennis Firchau Asangi Kumarapeli Preetha Ramalingam Debra Zynger
Gregory Fishbein Alvaro Laga Priya Rao
Andrew Folpe Steven Lagana Robyn Reed
Larissa Furtado Keith Lai Michelle Reid

To cite abstracts in this publication, please use the following format: Author A, Author B,
Author C, et al. Abstract title (abs#). In “File Title.” Laboratory Investigation 2020; 100 (suppl 1): page#
1047 P120 Catenin Staining Patterns Differentiate Mullerian Carcinosarcoma from its Mimics
Andres Acosta1, Brooke Howitt2, Kyle Strickland3, Jelena Mirkovic4, Carlos Parra-Herran4, Michelle Hirsch5, David Kolin5,
Marisa Nucci1
1
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Stanford University School of Medicine, Stanford,
CA, 3Duke University Medical Center, Durham, NC, 4Sunnybrook Health Sciences Centre, University of Toronto, Toronto,
ON, 5Brigham and Women's Hospital, Boston, MA

Disclosures: Andres Acosta: None; Brooke Howitt: None; Kyle Strickland: None; Jelena Mirkovic: None; Carlos Parra-Herran: None;
Michelle Hirsch: None; David Kolin: None; Marisa Nucci: None

Background: Loss and/or downregulation of E-Cadherin-mediated adhesion, which is a key event in epithelial-to-mesenchymal transition
and the putative mechanism by which sarcomatous components of carcinosarcomas (CS) arise, results in cytoplasmic and/or nuclear
translocation of P120, an integral component of the E-cadherin adhesion complex. Localization of P120 to the cytoplasm can induce a
"mesenchymal" phenotype, and is thought to be one of the factors that underlie the sarcomatous transformation seen in some aggressive
carcinomas. Therefore, we hypothesized that P120 staining patterns may help differentiate mullerian CS from some of its most common
mimics, including corded and hyalinized endometrial carcinoma (CHEC), and dedifferentiated/undifferentiated endometrial carcinomas
(D/UC).

Design: FFPE tissue sections of 29 CS, 24 D/UC and 14 CHEC were obtained from 4 institutions for P120 immunohistochemistry (IHC).
Only the sarcomatous component of CS, the corded and hyalinized areas of CHEC and the undifferentiated component of D/UC were
evaluated. IHC was performed using monoclonal anti-P120 primary antibodies (clone 98/pp120; BD Biosciences, San Jose, CA, USA)
and the Leica Novolink (Leica Biosystems, Buffalo Grove, IL, USA) system.

Results: 24/25 (83%) CS, 14/15 (93%) CHEC and 20/24 (83%) D/UC were positive for P120. In CS, the predominant staining pattern
was cytoplasmic (23/24; 96%), only 1 case was membranous (1/24; 4%). In contrast, most CHEC showed membranous staining (43%),
followed by membranous and nuclear staining (21%). Similarly, the most common staining pattern in D/UC was membranous (50%),
followed by cytoplasmic (25%). Staining for P120 was more often focal in D/UC (75%) and diffuse in both CS (83%) and CHEC (64%).
Although sensitivity was suboptimal (60% for CHEC and 45.8% for D/UC), membranous P120 staining was 96.5% specific for the
distinction of CHEC and D/UC from CS. Cytoplasmic P120 was 79% sensitive for CS, with a specificity of 80% and 75% for the distinction
of CS from CHEC and D/UC, respectively.

CS CHEC P§ D/UC P§

N (%) N (%) N (%)

N 29 15 24
P120 IHC Positive 24 (82.8) 14 (93.3) 0.647 20 (83.3) 1
Negative 5 (17.2) 1 (6.7) 4 (16.7)
COMPARTMENT Membranous only 1 (4.2) *¥ 6 (42.9) *¥ <0.001 10 (50) *¥ <0.001
¥ ¥
Cytoplasmic only 23 (95.8) * 2 (14.3) * 5 (25) *¥
Nucleus only 0¥ 2 (14.3) *¥ 3 (15) *¥
Membrane + nucleus ° 0¥ 3 (21.4) *¥ 1 (5) *¥
¥ ¥
Cytoplasm + nucleus ° 0 1 (7.1) * 1 (5) *¥
EXTENT Focal ¶ 4 (16.7) *¥ 5 (35.7) *¥ 0.245 15 (75) *¥ <0.001
Non-focal ¤ 20 (83.3) *¥ 9 (64.3) *¥ 5 (25) *¥
* Percentages calculated based on the number of positive cases. ¥ The characteristics described in these sections
correspond to the sarcomatous components of CS, the corded and hyalinized or spindle cell components of CHEC
and the differentiated/undifferentiated components of D/UC. § P values reflect the significance of the difference
between CHEC and CS and between D/UC and CS (Fisher's exact test, R version 3.6.1; R Foundation for Statistical
Computing, Vienna, Austria). ¶ Positive staining in less than 10% of the cells of interest. ¤ Positive staining in 10% or
more of the cells of interest. ° Staining patterns that are equally frequent but present in different cell
populations. Abbreviations: CS = carcinosarcoma, CHEC = corded and hyalinized variant of endometrioid endometrial
adencarcinoma, D/UC = Dedifferentiated/undifferentiated endometrial carcinoma.

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 Figure 1 - 1047

Conclusions: Membranous staining for P120 is highly supportive of malignant epithelial differentiation. Conversely, this staining pattern
uncommonly occurs in the sarcomatous component of CS. Thus membranous staining helps differentiate CHEC and D/UC from the
sarcomatous component of CS. Also, nuclear P120 argues against CS. Furthermore, diffuse cytoplasmic staining is significantly more
common in sarcomatous elements of CS, albeit not specific.

1048 Tumors of the Female Genital Tract with Combined Epithelial and Germ Cell or Trophoblastic
Components: A Shared Molecular Profile Supports Origin from the Epithelial Component
Andres Acosta1, Lynette Sholl2, Christopher Otis3, Marisa Nucci1
1
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital, Boston,
MA, 3University of Massachusetts Medical School-Baystate, Srpingfield, MA

Disclosures: Andres Acosta: None; Lynette Sholl: Consultant, LOXO Oncology; Christopher Otis: None; Marisa Nucci: None

Background: Epithelial malignancies of the gynecologic tract associated with germ cell or trophoblastic components are rare, and their
molecular underpinnings remain unknown. Two prevailing hypotheses regarding their ontogenesis propose either divergent differentiation
in a single neoplasm, or alternatively, the collision of 2 pathogenetically independent lesions. In this study, we performed a molecular
characterization of 5 tumors with different combinations of carcinoma and germ cell or trophoblastic neoplasia to determine 1) the
mutational profile of the different components and 2) if the different components have a common origin.

Design: Five cases from 3 institutions were retrieved for the study: Case 1 = ovarian carcinosarcoma (CS) associated with serous
borderline tumor-like components + yolk-sac tumor (YST); case 2 = serous carcinoma of endometrium + epithelioid trophoblastic tumor
(ETT); case 3 = ovarian CS + YST; case 4 = ovarian HGSC + YST; case 5 = ovarian endometrioid adenocarcinoma + YST. FFPE tissue
sections were manually dissected for nucleic acid extraction. In cases 1,2,3 and 5, components of interest present in different blocks were
identified, allowing separation before nucleic acid extraction. In case 5 separation was not attempted because the different components
were present in the same block and closely intermingled. Sequencing was performed using a targeted sequencing panel (Oncopanel).
The current version of this test includes 447 disease-relevant genes and detects single-nucleotide variants, insertions /deletions, copy
number alterations and structural variants.

1003
Results: Results are presented in the figure. Briefly, a specific mutational profile was not identified, and the genetic alterations detected
are those expected according to the epithelial component of the tumors. Identical insertion-deletions and point-mutations are present in
both components. Structural rearrangements were more frequent in the germ cell and trophoblastic components of the tumor.

Figure 1 - 1048

Conclusions: Epithelial malignancies of the female genital tract associated with germ cell or trophoblastic components do not show a
distinct mutational profile, and show mutations expected according to the epithelial component present. Also, both components share an
identical mutational profile, in keeping with a common origin for both components. The most significant difference was the presence of a
higher number of structural variants in the germ cell and trophoblastic components.

1049 Differentiated Verruciform Intraepithelial Lesions of the Vulva: Clinico-Pathologic and Molecular
Analysis Documenting its Relationship with Verrucous Carcinoma
Amir Akbari1, Andre Pinto2, Yutaka Amemiya3, Arun Seth4, Jelena Mirkovic4, Carlos Parra-Herran4
1
University of Toronto, Toronto, ON, 2University of Miami, Miami Beach, FL, 3Sunnybrook Research Institute, Toronto,
ON, 4Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON

Disclosures: Amir Akbari: None; Andre Pinto: None; Yutaka Amemiya: None; Arun Seth: None; Jelena Mirkovic: None; Carlos Parra-
Herran: None

Background: Verruciform proliferations of the vulva unrelated to HPV infection are rare. Watkins et al recently coined the term
differentiated exophytic vulvar intraepithelial lesion (DEVIL) for these proliferations, which harbor recurrent PIK3CA mutations. Verrucous
carcinoma (VC), a neoplasm characterized by persistence and local recurrence but nil risk of distant spread, has been associated
with TP53 and HRAS mutations. It is still unclear whether DEVIL is related to VC.

Design: Material from cases identified using the words “verruciform” and “verrucous” in our database search was strictly reviewed by 2
gynecologic pathologists. For inclusion, diagnosis of DEVIL required verruciform acanthosis, hyper and/or parakeratosis, hypogranulosis,
cytoplasmic pallor and bland nuclei. VC was diagnosed if discontinuous, bulbous, puzzle-like nests of epithelium were seen in the stroma.
Lesions with any significant atypia, proliferation or infiltrative borders were excluded. A 9-gene next-generation sequencing panel was
performed. Data was compared between samples, looking for shared alterations between VC and previous, concurrent or subsequent
DEVIL.

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Results: A total of 18 specimens corresponding to 10 patients with DEVIL and/or VC were included (Table). The cohort included 8
women with DEVIL (median age at presentation 66 years), and 7 with VC (median age at presentation 70 years). A similar spectrum of
prevalent mutations was found, involving HRAS (50% DEVIL, 86% VC), PIK3CA (50% DEVIL, 29% VC), TP53 (25% DEVIL, 43% VC)
and BRAF (13% DEVIL, 14% VC).

In 3 patients (A-C), DEVIL preceded VC with an interval of 65, 22 and 33 months, respectively. In one (D), DEVIL and VC were diagnosed
concurrently. One patient (E) had VC resected and 2 months later developed a DEVIL. In patient A, the same PIK3CA mutation was
detected in VC, adjacent DEVIL and preceding DEVIL. In patients C and D, VC and concurrent DEVIL shared the same mutations
in HRAS and BRAF, respectively. In patient E, both VC and subsequent DEVIL shared the same HRAS mutation.

Patient Age Sample PIK3CA HRAS BRAF TP53 CTNNB1

A 40 Preceding DEVIL p.E542K
VC (65 months later) p.E542K, p.E545K p.R175C
Concurrent DEVIL p.E542K, p.R175C
p.M1043I
B 71 Preceding DEVIL
VC (22 months later) p.E542K
Concurrent DEVIL
C 61 Preceding DEVIL p.E542K p.Q61L
VC (33 months later) p.G12A
Concurrent DEVIL p.G12A
D 81 Concurrent DEVIL p.G466R
VC p.G466R p.R196Q
E 85 VC p.Q61R
DEVIL (2 months later) p.Q61R
F 46 DEVIL p.E542K p.R158C
G 64 DEVIL p.G12D
H 64 DEVIL
I 69 VC p.G12D p.R249N p.M398I
J 54 VC p.Q61L

Conclusions: DEVIL is a rare form of squamous proliferation characterized by prevalent PIK3CA and HRAS mutations. Its temporal
relationship with VC and the shared mutational profile between DEVIL and VC in some patients suggest that DEVIL is related to VC,
potentially as a precursor. Moreover, given the morphologic and molecular overlap between these two lesions and the nil risk of VC for
distant spread, it is conceivable that DEVIL and VC represent a spectrum of the same entity.

1050 Prognostic Significance of Depth and Pattern of Cervical Stromal Invasion in Type 1 Endometrial
Carcinoma
Bassam Alkamachi1, Simeng Zhu1, Mohamed Elshaikh2, Ghassan Allo2
1
Henry Ford Health System, Detroit, MI, 2Henry Ford Hospital, Detroit, MI

Disclosures: Bassam Alkamachi: None; Simeng Zhu: None; Mohamed Elshaikh: None; Ghassan Allo: None

Background: The prognostic significance of cervical stromal invasion (CSI) by endometrial carcinoma is well established, and patients
with this form of invasion are offered similar adjuvant therapy. It is not clear whether characteristics of this form of invasion have
prognostic implications. We aim in this study to investigate the prognostic significance of depth and pattern of cervical stromal invasion in
patients with type 1 endometrial carcinoma.

Design: This is a retrospective study of patients with type 1, FIGO stage 2 endometrial cancer, who were treated at our
institution between 1991 and 2019. After IRB approval, we assessed microscopic depth of CSI (measured as distance from cervical
surface to deepest point of invasion within cervical stroma), cervical stromal thickness, and pattern of invasion (based on endocervical
adenocarcinoma previously described patterns A, B, and C). Clinical data were collected from the medical records. Descriptive analysis
and Cox regression models were produced.

Results: Material and data were available on 50 patients. Median age at diagnosis was 65(41-91) years, of which 30 patients had FIGO
grade 1, 23 showed <50% myometrial invasion, 11 had angioinvasion, 40 had underwent lymph node dissection, and 42 received
adjuvant radiation.

Median depth of CSI was 3.5(0.5-20.0) mm, with median percentage invasion to cervical stromal thickness of 33.3(6.7-100)%. CSI to >2/3
of cervical stroma was found in 8 (16%) of patients, and was associated with worse overall survival (OS) in univariable analysis (HR, 0.22;
95% CI, 0.06-0.75), and after controlling for age, race, grade, depth of myometrial invasion, angioinvasion, peritoneal washings, and
adjuvant radiotherapy (HR, 0.08; 95% CI, 0.01-0.53). CSI of 5.0 mm or more, found in 16(32%) patients, was associated with tendency

1005
towards worse OS (HR, 3.1; 95% CI, 0.96 – 10.2), while CSI of 50% cervical stroma or more (n=17, 34%) or patterns of invasion were not
associated with different OS on univariable analysis.

Recurrence was present in 5(10%) of patients, significantly higher in those with >1/3 CSI (LH, 7.1; 0=0.008).

Figure 1 - 1050 Figure 2 - 1050

Conclusions: A small subset of type 1, FIGO stage 2 endometrial cancers shows extension to more than 2/3 of cervical stroma and
exhibits worse overall survival. Subcategorization of stage 2 and therapy tailoring may be indicated in these patients. Further studies are
needed.

1051 Two versus Four Immunohistochemical Stains for Lynch Syndrome Screening in Gynecologic
Cancers
Shara-Gaye Allen1, Amir Akbari2, Marjan Rouzbahman3, Gulisa Turashvili4, Aaron Pollett4, Alicia Tone5, Sanaz Sanii6, Emily Van
de Laar3, Sarah Ferguson7, Blaise Clarke2
1
Cornwall Regional Hospital, Montego Bay, Jamaica, 2University of Toronto, Toronto, ON, 3Toronto, ON, 4Mount Sinai Hospital,
Toronto, ON, 5Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, 6University Health
Network, St. John'S, NL, 7University Health Network

Disclosures: Shara-Gaye Allen: None; Amir Akbari: None; Amir Akbari: None; Marjan Rouzbahman: None; Gulisa Turashvili: None;
Aaron Pollett: None; Sanaz Sanii: None; Blaise Clarke: None

Background: Reflex testing of endometrial cancer and non-mucinous and non-serous ovarian carcinoma is being adopted in many
centres. Traditionally, screening using all 4 mismatch repair markers (MLH1, PMS2, MSH2 and MSH6) is performed. These proteins form
heterodimers complexes between MLH1 and PMS2 and between MSH2 and MSH6. MLH1 and MSH2 staining is retained in the setting of
alteration of PMS2 and MSH6 respectively. However the secondary proteins, PMS2 and MSH6, are not expressed in the absence of
MLH1 and MSH2 expression. This allows for a 2 marker (PMS2 and MSH6) screening strategy with associated laboratory cost saving.
While this strategy has been validated in colon and endometrial cancer, a recent study highlighted weak MSH6 staining associated with
loss of MSH2 as a possible cause of false negative cases.

Design: We reviewed a retrospective series of endometrial and ovarian cancer cases (220 cases) screened with 4 markers and enriched
for MSH2/MSH6 deficient cases and cases with subclonal loss of MLH1/PMS2. The two markers (PMS2 and MSH6) were reviewed by
three pathologists with variable experience in mismatch repair immunohistochemical screening blinded to the results of the initial four
marker clinical screen.

Results: 160 cases were normal (both markers retained). Of the remaining 60 cases, 44 showed PMS2 loss (4 were isolated PMS2 loss)
and 16 showed MSH6 loss, (8 were isolated MSH6 loss). All cases were interpreted correctly by 2 pathologists but three cases with
MSH6 loss were called equivocal by one pathologist. Subclonal loss was not appreciated by one of the pathologist in one case.

Conclusions: A two marker panel is effective in screening endometrial and ovarian carcinoma for mismatch repair deficiency/ Lynch
Syndrome. It behoves us to be aware of the pitfalls of weak MSH6 staining in the setting of MSH2 loss. Also, one is more likely to miss
subcloncal loss of MLH1/PMS2. While this has no bearing on Lynch syndrome status since these events are secondary to methylation, its
role as a predictive marker for immune checkpoint therapy is unclear. Interobserver study suggests that experience with these markers
allows one to avoid the misinterpretation of weak MSH6 staining as false negative.

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1052 Epigenetic Signatures of Synchronous and Metastatic Endometrioid Adenocarcinomas
Douglas Allison1, Gulisa Turashvili2, Jonathan Serrano3, Britta Weigelt4, Nadeem Abu-Rustum4, Matija Snuderl3, Sarah Chiang4
1
NYU Langone Health, New York, NY, 2Mount Sinai Hospital, Toronto, ON, 3New York University, New York, NY, 4Memorial
Sloan Kettering Cancer Center, New York, NY

Disclosures: Douglas Allison: None; Gulisa Turashvili: None; Jonathan Serrano: None; Jonathan Serrano: None; Britta Weigelt: None;
Nadeem Abu-Rustum: Grant or Research Support, Stryker; Grant or Research Support, GRAIL; Matija Snuderl: None; Sarah Chiang:
None

Background: Clinicopathologic criteria exist to identify synchronous and metastatic endometrioid carcinomas involving endometrium and
ovary. Recent studies utilizing next generation sequencing demonstrated that most clinically suspected synchronous ovarian and
endometrial endometrioid tumors are in fact clonally related. We sought to define epigenetic signatures of FIGO grade 1 endometrioid
carcinomas of endometrial primary, ovarian primary, synchronous endometrial and ovarian primaries, and endometrial primary with
ovarian metastasis.

Design: DNA was extracted from microdissected formalin-fixed, paraffin-embedded tumor tissues from 8 isolated endometrial primaries,
6 isolated ovarian primaries, 5 synchronous endometrial and ovarian primaries and 3 endometrial primaries with ovarian metastasis and
subjected to methylation profiling (Illumina MethylationEPIC array). Methylation data were analyzed with the R Bioconductor package
minfi, including quality control, data normalization and differentially methylated CpG site analysis. Subsequent filtering was performed
using a p-value cutoff = 0.01 and a minimal mean difference of the Beta-value of = 0.1. Copy number alterations were analyzed using
conumee package.

Results: Epigenetic profiling revealed that isolated primary endometrial and ovarian tumors formed two distinct methylation clusters
according to their site of origin (Fig. 1). Similarly, 4/5 synchronous endometrial and ovarian tumors primary pairs clustered away from
each other and by primary site. Both endometrial and ovarian tumors in the remaining synchronous primary pair clustered with isolated
primary ovarian tumors. Finally, endometrial and ovarian tumors in all 3 endometrial primaries with ovarian metastasis clustered by
disease site. (Fig. 1). Copy number changes largely recapitulated the methylation patterns with some synchronous tumors showing
similar profiles and some showing large differences (Fig. 2). Certain copy number alterations (most notably 1q gain) seemed specific to
ovarian tumors, a finding observed across both isolated primary and synchronous tumors.

Figure 1 - 1052

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 Figure 2 - 1052

Conclusions: DNA methylation profiles of synchronous endometrial and ovarian tumors and endometrial primaries with ovarian
metastasis are similar and cluster by disease site. Copy number changes recapitulate methylation results. These findings suggest site
specific effects on tumor development.

1053 B-Catenin and CD10 Expression in Mesenchymal Uterine Tumors: A Canadian Multi-Center
Retrospective Study
Noorah Almadani1, Cecile Le Page2, C. Blake Gilks3, Liliane Meunier4, Lise Portelance5, Anne-Marie Mes-Masson6, Cheng-Han
Lee7, Lynn Hoang7, Kurosh Rahimi8
1
University of British Columbia/Vancouver General Hospital, Vancouver, BC, 2University of Montréal, Montreal, QC, 3Vancouver
General Hospital, Vancouver, BC, 4Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal,
QC, 51 Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM) and Institut du cancer de Montréal,
Montréal, QC, 6Centre de recherche du CHUM, Montreal, QC, 7Vancouver, BC, 8Université de Montreal, Montreal, QC

Disclosures: Noorah Almadani: None; Cecile Le Page: None; C. Blake Gilks: None; Lise Portelance: None; Anne-Marie Mes-Masson:
None; Cheng-Han Lee: None; Lynn Hoang: None; Kurosh Rahimi: None

Background: Beta-catenin has been recently reported in a subset of low-grade endometrial stromal sarcomas (ESS), but few studies
thus far have reported the expression patterns of beta-catenin in other uterine mesenchymal tumors, particularly endometrial stromal
nodules (ESN), adenosarcomas (AS) and undifferentiated uterine sarcoma (UUS). In this study we evaluate the expression of nuclear
beta-catenin as well as CD10, in a variety of uterine mesenchymal tumors to assess their discriminative diagnostic value.

Design: We assessed a retrospective cohort of 74 cases from three institutions in Canada: Vancouver General Hospital
(Vancouver), CRCHUM (Montreal) and Ottawa Hospital Research Institute (Ottawa) between 1988 and 2019. We included ESS, ESN,
AS, UUS, leiomyosarcomas (LMS) and carcinosarcomas (CS). CD10 and nuclear beta-catenin expression (nuclear
or membranous/cytoplasmic) was assessed by immunohistochemistry on tissue microarray and confirmed on whole sections in select
cases. Clinical data was extracted from hospital files. Disease-specific survival (DSS) of patients was calculated from the time of
diagnosis until death or last follow-up. Progression time (PFS) was calculated from first date of treatment to date of first disease
progression.

Results: The immunohistochemical results are summarized in Table 1. Nuclear beta-catenin expression did not significantly correlate
with survival (DSS and PFS had p>0.05).

ESN ESS LMS UUS AS CS

beta-catenin M/C (>30% 1/2 (50%) 31/35 (89%) 5/8 (63%) 5/9 (56%) 11/16 (69%) 3/3 (100%)
positivity)
beta-catenin nuclear 0/2 (0%) 7/29 (24%) 1/8 (13%) 3/9 (30%) 2/16 (13%) 0/3 (0%)
CD10>30% 2/3 (66%) 12/30 (62%) 2/4 (50%) 3/9 (33%) 4/17 (24%) 2/3 (66%)

Conclusions: Nuclear beta-catenin staining is evident in a portion of LG-ESS, LMS, UUS and AS, but not in ESN and CS. A larger
series of ESN, CS as well as HG-ESS will need to be added to substantiate these findings. As expected, CD10 did not discriminate
between the different uterine mesenchymal tumors.

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1054 ProMisE Molecular Classifier for Endometrial Carcinomas in a Saudi Arabian Population
Noorah Almadani1, Jawaher Alsahabi2, Amy Lum3, Abdulmohsen Alkushi4, Angela Cheng5, Jessica McAlpine6, Philip Clement7,
David Huntsman8, Lynn Hoang9, C. Blake Gilks7
1
University of British Columbia/Vancouver General Hospital, Vancouver, BC, 2King Abdulaziz Medical City - CR, Riyadh, Saudi
Arabia, 3British Columbia Cancer Research Centre, Vancouver, BC, 4King Abdulaziz Medical City of National Guard, Riyadh,
Saudi Arabia, 5Genetic Pathology Evaluation Centre, Vancouver, BC, 6University of British Columbia and BC Cancer Agency,
Vancouver, BC, 7Vancouver General Hospital, Vancouver, BC, 8British Columbia Cancer Research Institute, Vancouver,
BC, 9University of British Columbia, Vancouver, BC

Disclosures: Noorah Almadani: None; Jawaher Alsahabi: None; Amy Lum: None; Abdulmohsen Alkushi: None; Jessica McAlpine: None;
David Huntsman: Stock Ownership, Contextual Genomics Inc.; Lynn Hoang: None; C. Blake Gilks: None

Background: Endometrial carcinoma (EC) is the most common malignancy of the gynecological tract with increasing incidence and
mortality rates world-wide and in Saudi Arabia. Inter-observer variability is a well known obstacle for accurate histopathological subtyping.
Furthermore, histomorphological features may not reflect their biological behaviour.

The ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer) is an emerging, well-established molecular risk stratification
system of EC based on The Cancer Genome Atlas (TCGA), and stratifies EC into 4 genomic subtypes: copy number low/p53 wild-type
(p53 wt), copy number high/p53 abnormal (p53 abn), ultramutated/polymerase ε exonuclease domain mutated (POLE EDM), and
hypermutated/mismatch repair deficient (MMR-D).

The molecular subtypes generated by this system can reliably discriminate EC into four different sub-groups that are clinically relevant
to prognosis and management. Our goal was to determine if the ProMisE classifier could be applied to an independent population of
Saudi Arabian patients.

Design: We assessed a retrospective cohort of 106 women from the King Abdulaziz Medical City diagnosed with EC between 2012 and
2018. Next generation sequencing (NGS) and immunohistochemistry (IHC) for MMR proteins and p53 was performed. Cases were
stratified into ProMisE groups: MMR-D, POLE EDM, p53 wt and p53 abn, as previously described (PMID: 26172027). Clinical data were
extracted from hospital files.

Results: The clinical and molecular findings are presented in Table 1.105 cases had complete IHC and NGS, allowing for ProMisE
categorization as follows: MMR-D 24%, POLE EDM 8%, p53 wt 45%, p53 abn 22%. The majority of MMR-D cases were MLH1 and
PMS2 deficient (24/25, 96%) and minority MSH6 deficient (1/25, 4%). 24 cases had abnormal p53 (23 in the p53 abn group, 1 in the
MMR-D group). 9 cases had POLE mutations, 6 categorized under POLE EDM, and 3 under the MMR-D group. The POLE EDM group
had the lowest age and lowest BMI. BMI was highest in the p53 wt group. The p53 wt group had the highest proportion
of PTEN, KRAS and CTNNB1 mutations. Amongst the 4 subgroups, there was a trend towards worse overall survival (Figure 1, p=0.47),
and significant difference in progression free survival (Figure 2, p=0.03).

N Age Body PTEN KRAS PIK3CA CTNNB1 Other

mass
index
(BMI)
MMR-D 25 65.7 40.8 5 (22%) 4 (17%) 10 (43%) 4 (17%) MAP2K1=1, ERBB2=1
(24%)
POLE EDM 6 (6%) 51.1 29.8 1 (16%) 0 2 (33%) 1 (16%) PDGFRA=1

ALK=1
p53 wt 50 62.3 44.4 14 (22%) 15 21 14 GNAS=1
(47%)
(23%) (32%) (21.8%) MAP2K1=1

AKT=1
p53 abn 24 66.2 37.4 2 (25%) 1 (12%) 5 (62%) 0
(22%)

1009
 Figure 1 - 1054 Figure 2 - 1054

Conclusions: Molecular classification of EC using ProMisE can be applied to a Saudi Arabian population, resulting in comparable
distributions and survival curves to that reported previously in North American cohorts.

1055 Invasive Endocervical Adenocarcinoma with Gastric and Intestinal Immunophenotype Correlates
with Adverse Clinicopathological Features and Patient Outcome
Shiho Asaka1, Tomoyuki Nakajima2, Koichi Ida3, Ryoichi Asaka3, Tsutomu Miyamoto4, Takeshi Uehara4, Hiroyoshi Ota5
1
Johns Hopkins University School of Medicine, Baltimore, MD, 2Shinshu University Hospital, Matsumoto, Japan, 3Shinshu
University School of Medicine, Matsumoto, Nagano, Japan, 4Shinshu University School of Medicine, Matsumoto,
Japan, 5Shinshu University School of Health Sciences, Matsumoto, Japan

Disclosures: Shiho Asaka: None; Tomoyuki Nakajima: None; Koichi Ida: None; Ryoichi Asaka: None; Tsutomu Miyamoto: None; Takeshi
Uehara: None; Hiroyoshi Ota: None

Background: A system for classification of invasive endocervical adenocarcinomas (EAs) based on human papillomavirus (HPV)
infection has been recently developed (IECC 2018). However, there are limited immunohistochemical markers for subcategorizing EAs,
especially EAs with gastric and intestinal differentiation. We have previously shown that EAs in situ (AIS) lesions could be subcategorized
into different immunophenotypes using three cell-lineage-specific markers: claudin 18 (CLDN18), gastric cells; cadherin 17 (CDH17),
intestinal cells; PAX8, Müllerian epithelial cells. Each AIS immunophenotype showed distinct histopathological characteristics. Here, we
subclassified EAs by their immunophenotype and analyzed the patient outcome.

Design: Sixty-six cases of EAs were immunohistochemically analyzed using CLDN18, CDH17, and PAX8. We defined each
immunophenotype of EAs as follows: gastric-type (G), diffuse (≥50%) CLDN18 and negative or focal (<50%) CDH17 expression;
intestinal-type (I), diffuse CDH17 and negative or focal CLDN18 expression; gastrointestinal-type (GI), diffuse CLDN18 and CDH17
expression; Müllerian-type (M), diffuse PAX8 and negative or focal CLDN18 and/or CDH17 expression, and not otherwise specified
(NOS), negative or focal expression of all the three markers. High-risk HPV status was analyzed using RNA-ISH (RNAscope system).

Results: By conventional histology, 66 EAs were classified as 34 usual type (52%), 11 gastric type (17%), 8 iSMILE (12%), 8 mucinous,
NOS (12%), and 5 intestinal type (8%). According to the immunophenotype, the cases were categorized as 23 M-type (35%), 15 G-type
(23%), 12 NOS (18%), 9 I-type (14%), and 7 GI-type (11%). High-risk HPV was detected in most M- (91%), I- (89%), GI- (57%), and
NOS- (83%) types but less frequently in G-type (27%). Compared with M-type, G-type was associated with aging (p=0.0068), negative for
high-risk HPV (p<0.0001), concurrent LEGH (p=0.0060), high-grade histology (p=0.0054), advanced FIGO stage (p=0.0001), and lymph
node and/or distant metastasis (p=0.0096). Multivariate analysis revealed that G- and GI+I-types were independent predictor of
progression free survival (p=0.0007 and p=0.0140, respectively) compared with M-type.

1010
 No. of cases [No. of HPV+] Immunophenotype Total
Histology M-type G-type GI-type I-type NOS
Usual 16 [15] 4 [1] 3 [2] 6 [5] 5 [3] 34 [26]
Mucinous, NOS 4 [4] 1 [0] 1 [1] 1 [1] 1 [1] 8 [7]
Mucinous, Intestinal 0 1 [1] 2 [1] 2 [2] 0 5 [4]
iSMILE 2 [1] 0 0 0 6 [6] 8 [7]
Gastric 1 [1] 9 [2] 1 [0] 0 0 11 [3]
Total 23 [21] 15 [4] 7 [4] 9 [8] 12 [10] 66 [47]
Figure 1 - 1055 Figure 2 - 1055

Conclusions: EAs with gastric and intestinal immunophenotype showed aggressive clinicopathological behaviors. Immunohistochemistry
for gastric and intestinal phenotype in EAs may improve diagnostic accuracy and prognostic value of EA subtyping and histopathological
classification.

1056 Telomere Length Alterations in Adenomyosis and Endometriosis

Shiho Asaka1, Lihong Li1, Christine Davis2, Tian-Li Wang3, Christopher Heaphy1, Ie-Ming Shih4
1
Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD, 3Johns
Hopkins Medical Institutions, Baltimore, MD, 4Johns Hopkins Hospital, Baltimore, MD

Disclosures: Shiho Asaka: None; Lihong Li: None; Christine Davis: None; Tian-Li Wang: None; Christopher Heaphy: None; Ie-Ming Shih:
None

Background: Adenomyosis and endometriosis are related gynecologic disorders common in reproductive-age women. Both lesions are
characterized by the ectopic presence of normal-appearing endometrial tissue, including glands and surrounding stroma in myometrium
and outside the uterine corpus, respectively. Their origins and the biological relationship to eutopic endometrium remains largely
unknown. As telomere length can serve as a “molecular clock” and as a marker for the times of (stem) cell division, we analyzed telomere
lengths in glandular epithelium and stroma within adenomyosis and endometriosis.

Design: We applied telomere-specific FISH assay to quantitatively measure telomere lengths of epithelial and stromal cells in 30
adenomyotic and 14 endometriotic lesions, and matched eutopic endometria from 42 women. We used the relative telomere length of the
lesion compared with the matched eutopic endometrium from the same patient as the study outcome measure. Mann-Whitney test was
used to determine the statistical significance (i.e., longer or shorter).

Results: In adenomyosis, 24 (80%) of 30 cases showed significant telomere shortening in epithelial cells, and 21 (70%) showed
significant telomere shortening in stromal cells compared with matched eutopic endometria. No adenomyotic lesions showed significantly
longer telomere than matched eutopic endometria. In contrast, in endometriosis, 2 (14%) of 14 cases showed significant telomere
shortening in epithelial cells and 5 (36%) showed significant telomere shortening in stromal cells. Interestingly, 4 (29%) of 14
endometriotic lesions showed significantly longer telomeres in epithelial cells and 3 (21%) showed significantly longer telomeres in
stromal cells. Both epithelial and stromal cells in endometriosis exhibited relatively longer telomere than those in adenomyosis (p=0.0005
and p=0.0678, respectively).

1011
 Case No. (%) Adenomyosis Endometriosis
Epithelium Stroma Epithelium Stroma
Longer* 0 (0%) 0 (0%) 4 (29%) 3 (21%)
No significant change* 6 (20%) 9 (30%) 8 (57%) 6 (43%)
Shorter* 24 (80%) 21 (70%) 2 (14%) 5 (36%)
Total 30 30 14 14
*Telomere length alteration compared with the matched eutopic endometrium from the same patient by
Mann-Whitney test (p<0.05 was considered statistically significant).
Figure 1 - 1056

Conclusions: Although adenomyosis and endometriosis are thought to be etiologically related to each other, our new data demonstrate
that they are molecularly different at least from the perspective of telomere lengths. The significantly shortened telomeres in adenomyosis
as compared to its eutopic endometrium suggests that more cell divisions have occurred in the progenitor or stem cells that are
responsible for generating adenomyosis. This new study suggests a new research direction to explore the pathobiology of adenomyosis
which has not been well studied in the past.

1057 Minimal Uterine Serous Carcinoma with Concurrent Endometrial Polyp: An Institutional
Reappraisal
Hisham Assem1, Natalia Buza2, Douglas Rottmann3, Nana Matsumoto4, Serena Wong4, Pei Hui2
1
Yale School of Medicine, New Haven, CT, 2Yale University School of Medicine, New Haven, CT, 3Yale School of Medicine,
Hamden, CT, 4Yale New Haven Hospital, New Haven, CT

Disclosures: Hisham Assem: None; Natalia Buza: None; Douglas Rottmann: None; Nana Matsumoto: None; Serena Wong: None; Pei
Hui: None

Background: Minimal uterine serous carcinoma (MUSC) includes serous endometrial intraepithelial carcinoma (SEIC) and superficial
invasive serous carcinoma. Such lesions frequently involve an endometrial polyp (EMP) in postmenopausal women. While non-invasive
or minimally invasive, both types of MUSC can present with extrauterine tumor spread, leading to a dismal clinical prognosis. Recently it
was also suggested that a subset of MUSC involving an EMP may represent a distinct subtype of endometrial serous carcinoma capable
of aggressive behavior. The aim of this study was to summarize our institutional experience by correlating the morphological features of
MUSC involving EMP with extrauterine tumor spread/tumor stage.

Design: Patients who underwent staging hysterectomy with a diagnosis of endometrial serous carcinoma with concurrent presence of an
EMP between 2004-2019 were retrospectively identified. Cases with myometrial invasion were excluded. H&E slides were reviewed to
confirm diagnosis and to assess the extent of tumor involvement (EMP and endometrium) and the scope of tumor spread.
Immunohistochemistry results for p53, p16, WT1 were also retrospectively reviewed.

Results: A total of 84 cases were identified. 83 (98.8%) of these MUSC cases involved an EMP, including 53 cases of polyp confined
tumors and 30 cases of tumors involving an EMP combined with SEIC involving the endometrium. Only one case of SEIC with a benign
endometrial polyp was identified. Among cases confined to an endometrial polyp, 20.8% (11/53 cases) demonstrated extrauterine
involvement compared to 46.7% (14/30 cases) of cases involving both an EMP and the surrounding endometrium (X2 (1, N = 83) =

1012
6.1, p = 0.013). No differences in expression of p53, p16 and WT-1 immunohistochemistry were observed in cases with available
immunostains (Table 1).

MUSC - Polyp Confined (N=53) MUSC - Not Polyp Confined (N=30)

Extrauterine Disease 11/53 14/30
p53 (mutant) 47/47 18/19
p16 (diffusely positive) 15/15 7/7
WT1 (negative) 7/9 3/5

Table 1: Extrauterine disease and immunohistochemistry observed for p53, p16 and WT1 in cases with available immunostains

Conclusions: This is the largest series examining minimal uterine serous carcinoma presenting with concurrent EMP. An EMP was
involved by minimal uterine serous carcinoma in essentially all cases in this study, suggesting that EMP in postmenopausal endometrium
may provide a strong microenvironment for the development of uterine serous carcinoma. More importantly, cases of MUSC involving an
EMP with simultaneous endometrial involvement have a significantly higher risk to present with extrauterine disease compared to cases
of MUSC confined to an EMP, implying careful pathological examination and reporting is essential for risk assessment and prognosis.

1058 MLH1 Loss due to MLH1 Gene Methylation Predicts Worse Survival in Stage I Endometrial
Endometrioid Adenocarcinoma
Monica Avila1, Bryan Fellman1, Russell Broaddus2
1
The University of Texas MD Anderson Cancer Center, Houston, TX, 2University of North Carolina School of Medicine, Chapel
Hill, NC

Disclosures: Monica Avila: None; Bryan Fellman: None; Russell Broaddus: None

Background: In contrast to other common cancers, the annual mortality from endometrial cancer is increasing. There are few reliable
biomarkers to identify early stage patients at risk for recurrence who might benefit from adjuvant therapy. This is a clinically important gap
in knowledge, as many endometrial cancer recurrences outside the vaginal cuff are incurable. Mismatch repair deficiency secondary
to MLH1 gene methylation and subsequent loss of MLH1 protein is one of the most common molecular events in endometrioid
endometrial carcinoma, occurring in 15-20% of cases. We and others have shown that MLH1 loss is associated with worse survival
across all stages. The objective of this study was to determine if MLH1 loss due to MLH1 methylation is associated with increased risk of
recurrence in stage I endometrial cancer patients.

Design: The cohort included 515 endometrial endometrioid carcinoma patients who were screened for Lynch Syndrome
by immunohistochemistry testing for mismatch repair deficiency (MMRd). MMRd for this study was defined as loss of MLH1 expression
due to MLH1 gene methylation. Intact mismatch repair (MMRi) was defined as positive expression of mismatch repair proteins. For stage
I patients, review of the electronic medical records was performed to determine which received adjuvant radiation therapy. Recurrence-
free survival (RFS) and overall survival (OS) were estimated using Kaplan Meier and Cox regression. Median follow-up was 48 months.

Results: Of the 373 stage I patients, 62 (17%) were MMRd and 311 (83%) were MMRi. 32% of stage I patients received some type of
adjuvant radiation therapy based on usual clinical and pathological parameters. Multivariate analysis demonstrated that MMRd was
associated with significantly worse RFS and OS in the stage I patients. Multivariate analysis did not reveal a survival benefit of adjuvant
radiation treatment. The MMRd patients who did not receive adjuvant therapy had the worst RFS (Figure 1).

1013
 Figure 1 - 1058

Conclusions: In this stage I cohort, patients with endometrial cancers with MLH1 hypermethylation had increased risk of recurrence and
decreased overall survival regardless of whether or not they received adjuvant radiation therapy. These data suggest that alternative
adjuvant therapies should be explored for stage I patients with MLH1 tumor loss. One possibility is prospective trials of checkpoint
inhibitors, which are FDA-approved for endometrial cancer patients with advanced disease that is MMR deficient.

1059 Quantification of Primary Tumor-Associated CD3+ Lymphocytes Out-Performs Mismatch Repair

Deficiency in Predicting Recurrence in Endometrioid-Type Endometrial Carcinoma
Monica Avila1, Bryan Fellman1, Suzanne Crumley2, Courtney Hudgens1, Michael Tetzlaff1, Russell Broaddus3
1
The University of Texas MD Anderson Cancer Center, Houston, TX, 2Houston Methodist Hospital, Houston, TX, 3University of
North Carolina School of Medicine, Chapel Hill, NC

Disclosures: Monica Avila: None; Bryan Fellman: None; Suzanne Crumley: None; Courtney Hudgens: None; Michael Tetzlaff: Speaker,
Nanostring; Advisory Board Member, Novartis LLC; Advisory Board Member, Myriad Genetics; Advisory Board Member, Seattle
Genetics; Russell Broaddus: None

Background: In contrast to other common cancers, the annual mortality from endometrial cancer is increasing. The reasons for this are
multifactorial, but one important knowledge gap is that there are few reliable biomarkers that identify early stage patients at risk for
recurrence. Mismatch repair deficient (MMRd) endometrial cancers are associated with higher numbers of tumor-associated lymphocytes,
but the clinical significance of this observation is unknown. Our objective was to quantify CD3+ and CD8+ lymphocytes in different regions
of MMR intact (MMRi) and MMRd endometrioid-type endometrial carcinomas and determine if these counts were associated with
survival.

Design: MMR status was determined by immunohistochemistry. MMRd was defined as endometrial carcinomas with loss of MLH1
expression due to MLH1 gene methylation. MMRi was defined as positive expression of MLH1, MSH2, MSH6, and PMS2.
Immunohistochemistry followed by Aperio image-based quantification was used to assess CD3+ and CD8+ lymphocyte populations in
different regions of the primary endometrial carcinomas, including tumor periphery (tumor-myometrial interface), tumor center (bounded
on all sides by tumor), and tumor hotspot (area with highest number of lymphocytes). Recurrence-free survival was estimated using
Kaplan Meier and Cox regression. Median follow up time was 44 months.

Results: 180 endometrioid grade 2 carcinomas were analyzed, 48 MMRd and 132 MMRi. The MMRd group had significantly higher
levels of CD3+ and CD8+ lymphocytes regardless of which tumor region was assessed. Lymphocyte counts in both MMRd and MMRi
groups had wide standard deviations such that there was some overlap in counts between the groups (Figure 1). Both MMRd and higher

1014
CD3+ counts were associated with worse recurrence-free survival. However, quantification of CD3+ in the tumor periphery captured
21/23 recurrences which included all of the MMRd cases that recurred and 7 MMRi cases with higher numbers of CD3+ lymphocytes that
also recurred. MMRd by itself only captured 14/23 recurrences.

Figure 1 - 1059

Conclusions: Patients with MMRd endometrial cancers have higher numbers of CD3+ lymphocytic infiltrates within the primary tumor.
Irrespective of tumor region, higher CD3+ infiltration is associated with greater risk of recurrence. In predicting tumor recurrence,
lymphocytic quantification performed better than assessment of MMR. Thus, quantification of CD3+ lymphocytes should be explored as a
clinically relevant biomarker.

1060 Evaluation of Saccharomyces Cerevisiae-Like 1 (SEC14L1) in Gynecologic Malignancies Shows

Over-Expression in Endometrial Serous Carcinoma
Natalie Banet1, Max Masnick2, M. Ruhul Quddus3
1
Women and Infants Hospital/Brown University, Providence, RI, 2Geisinger National Precision Health, Rockville, MD, 3Women &
Infants Hospital/Alpert Medical School of Brown University, Providence, RI

Disclosures: Natalie Banet: None; Max Masnick: None; M. Ruhul Quddus: None

Background: Lymph-vascular invasion is a known prognostic factor in varied gynecologic malignancies. Saccharomyces Cerevisiae-Like
1 (SEC14L1), a cytosolic regulator of lipid metabolism, has been identified in breast cancer as a significant gene associated with lymph-
vascular invasion, though its precise function in tumorgenesis is unknown. This gene has not been characterized in gynecologic
malignancies.

Design: A total of 116 cases from 100 patients were included, to include nine different tumors (see Table 1) and were subjected to
immunohistochemical staining for SEC14L1 (Thermo Fisher, PA5-54415). Cytoplasmic expression was scored by intensity and
percentage positivity. These results were multiplied to generate an H score. Pertinent clinical variables, including stage and outcome data
were collected from the patient files. Slides were reviewed for verification of tumor type and presence or absence of lymph-vascular
invasion.

Results: Similar to prior studies, an H score greater than 80 was considered positive; 30% of cases with follow-up were positive. No
association was found between positive H score and progression-free survival using the log-rank test for equality in Kaplan-Meier survival
estimates. Insufficient follow-up was available to conduct overall survival analysis. No significant relation was noted to lymph-vascular

1015
invasion status, tumor size, patient age, or lymph node status. However, mean H scores were substantially higher in Uterine Serous
Carcinoma (mean 181.7; SD 83.0) compared to other 8 tumor types (mean 43.0; SD 61.4; p<0.0001), as noted in Table 1.

SEC14L1 Expression (H Score)

Tumor type # cases Mean SD Positive* (n, %)
Adenosarcoma 5 24 53.7 1 (20.0)
Clear cell carcinoma 11 42.7 45.4 1 (9.1)
Endometrial Stromal Sarcoma 11 12.7 25.7 0 -
Endometrioid Carcinoma 31 68.7 78.3 8 (25.8)
High-grade serous carcinoma, ovary 21 48.7 60.2 4 (19.1)
Leiomyosarcoma 9 11.7 17.7 0 -
Low-grade serous carcinoma 5 6 8.9 0 -
Malignant Mixed Mullerian Tumor/ 11 41.4 64.2 2 (18.2)
Carcinosarcoma
Serous carcinoma, endometrium 12 181.7 83 9 (75.0)

* Positive is defined as H Score > 80

Conclusions: Overall, in this survey of Gynecologic malignancies, SEC14L1 appears to not show a relation to progression-free survival.
However, its over-expression in uterine serous carcinoma warrants further investigation in a larger cohort as a potential prognostic or
therapeutic target.

1061 Unusual Adnexal Tumors with Recurring STK11 Mutations: A Clinicopathological Study of 11
Cases Including 4 in Patients with Peutz-Jeghers Syndrome
Jennifer Bennett1, Emily Meserve2, Brooke Howitt3, Lauren Ritterhouse4, John Schoolmeester5, Sabrina Croce6, Loes
Kooreman7, Mona El-Bahrawy8, Gian Franco Zannoni9, Thomas Krausz10, W. Glenn McCluggage11, Robert Young12, Esther
Oliva4
1
The University of Chicago, Chicago, IL, 2Spectrum Healthcare Partners, Falmouth, ME, 3Stanford University School of
Medicine, Stanford, CA, 4Massachusetts General Hospital, Harvard Medical School, Boston, MA, 5Rochester, MN, 6Institut
Bergonié, Bordeaux, France, 7MUMC, Maastricht, Limburg, Netherlands, 8Imperial College London, London, United
Kingdom, 9Catholic University of Sacred Heart, Rome, Italy, 10University of Chicago Hospital, Chicago, IL, 11The Royal Hospitals,
Belfast, United Kingdom, 12Harvard Medical School, Boston, MA

Disclosures: Jennifer Bennett: None; Emily Meserve: None; Brooke Howitt: None; Lauren Ritterhouse: None; John Schoolmeester:
None; Sabrina Croce: None; Loes Kooreman: None; Mona El-Bahrawy: None; Gian Franco Zannoni: None; Thomas Krausz: None; W.
Glenn McCluggage: None; Robert Young: None; Esther Oliva: None

Background: STK11 mutations have recently been described in a small subset of presumed female adnexal tumors of probable wolffian
origin (FATWO); however, they lack the classic morphology of FATWOs.

Design: We evaluated the morphology, immunoprofile, and molecular phenotype of 11 tumors identified in part because of an association
with Peutz-Jeghers syndrome (PJS) and in part because of uncertainty concerning their specific nature.

Results: Patients, 4 with PJS, ranged from 25 to 66 (mean 44) years. Tumors ranged from 4.5 to 22 (mean 13) cm. Tumors were
paratubal (8), ovarian (2), or pelvic (1) with extra-adnexal disease in 5. Follow-up was available for 9 with 2 alive and well, 4 alive with
disease, 1 dead of disease, and 2 dead from other causes.

Tumors were comprised of variably anastomosing trabeculae, irregular or regularly disposed cords, and anastomosing nests sometimes
associated with tubular (9), papillary (3), or solid (2) growth(s). Tubules were often distended by basophilic (rarely eosinophilic) material. A
loose myxoid to edematous background was striking in 9 tumors. Cells were small (n=3) to medium (n=8) with round to ovoid nuclei,
minimal pleomorphism, prominent nucleoli, and scattered nuclear grooves. Tumors had clear to eosinophilic, vacuolated cytoplasm.
Nuclear to cytoplasmic ratio was increased in 8 tumors and mitoses ranged from 2 to 24 (mean 10) per 10 HPF. Immunohistochemical
results are summarized in the table. Pathogenic STK11 mutations were identified in 8 of 9 tumors with available molecular results, while 1
had a variant of uncertain clinical significance. No other pathogenic variants were identified. No statistical difference in age, tumor size,
extra-adnexal disease at presentation, or tumor recurrences was found between PJS-associated and sporadic tumors.

1016
 Case Cytokeratin Claudin4 EMA MOC31 Calretinin Inhibin SF1 CD10 ER PAX8 GATA3 STK11 Variant
1 ++ - + + ++ + - + + + - p.Y272*
2 ++ - + - ++ + - + ++ - - p.L201Cfs*86
3 ++ NP - NP ++ + - ++ ++ - - c.734+1G>A
4 ++ NP + NP ++ ++ - + ++ - NP p.E145Gfs*10
5# ++ NP - NP ++ + NP + NP NP NP p.P281Rfs*6
6# NP - + - ++ + NP NP ++ - NP p.G163R
7# ++ - + - ++ - - - NP - + p.G187S
(VUS)
8# + - - + ++ - - ++ ++ NP NP p.K84*
9 NP NP - NP ++ + NP + + - - Pending
10 NP NP NP NP NP NP NP NP NP NP NP Pending
11 ++ NP + - ++ + + + ++ - NP p.F255Sfs*32

- = negative, + = focal (<50%), ++ = diffuse (>50%), NP = not performed, # = patient has PJS, VUS = variant of uncertain significance

Conclusions: We describe a series of adnexal tumors with STK11 variants that show characteristic morphological and
immunohistochemical features that differ from surface epithelial (negative claudin-4, focal EMA/MOC31), sex cord (negative SF1), typical
FATWO (negative SF1), and mesothelial (negative/focal EMA, positive ER/inhibin) tumors. They also lack mutations common to the
above entities. Thus, we propose the name STK11-mutated adnexal tumor to classify these neoplasms, a subset being associated with
PJS. Their histogenesis is elusive at this time.

1062 Embryonal Rhabdomyosarcomas of the Uterine Corpus: A Clinicopathological Study of 13

Tumors
Jennifer Bennett1, Zehra Ordulu Sahin2, Andre Pinto3, Eike-Christian Burandt4, Leanne de Kock5, William Foulkes5, W. Glenn
McCluggage6, Robert Young7, Lauren Ritterhouse8, Esther Oliva8
1
The University of Chicago, Chicago, IL, 2Massachusetts General Hospital, Dorchester, MA, 3University of Miami, Miami Beach,
FL, 4University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 5McGill University, Montreal, QC, 6The Royal
Hospitals, Belfast, United Kingdom, 7Harvard Medical School, Boston, MA, 8Massachusetts General Hospital, Harvard Medical
School, Boston, MA

Disclosures: Jennifer Bennett: None; Zehra Ordulu Sahin: None; Andre Pinto: None; Eike-Christian Burandt: None; Leanne de Kock:
None; William Foulkes: None; W. Glenn McCluggage: None; Robert Young: None; Lauren Ritterhouse: None; Esther Oliva: None

Background: Primary embryonal rhabdomyosarcomas of the uterine corpus (ERMS-UC) are rare with fewer than 20 reported. While
ERMS are more common in the cervix, where they are often associated with DICER1 mutations, in both locations, they may be confused
with adenosarcomas due to overlapping features including periglandular cuffing and heterologous elements.
While DICER1 mutations, HMGA2 amplifications, and alterations in the PIK3CA pathway may be seen in adenosarcomas, the molecular
landscape of ERMS-UC has not been studied.

Design: We evaluated clinical, morphological, immunohistochemical, and molecular features of 13 ERMS-UC.

Results: Patients ranged from 28-70 (mean 51) years and follow-up was available for 9 with 5 alive and well and 4 dead of disease.
Tumors ranged from 4-15 (mean 9) cm and 4 extended to the lower uterine segment, 1 to the serosa, and 1 to the ovary.

On low power, destructive invasion was seen in 9, while 3 had minimal invasion, and 1 was endometrial confined. Alternating
hypercellular/hypocellular foci dominated in 7 whereas 6 showed primarily diffuse growth. A cambium layer was noted in 9 and stroma
varied from myxoid/edematous to loosely collagenous. Inactive entrapped glands lacking metaplasia were present in 11, focal
periglandular cuffing in 10, minimal phyllodes architecture in 3, and rare intraglandular projections in 2. Heterologous elements including
fetal-type cartilage in 7 or neuroectoderm in 1 were noted. Most (50-100%) of each tumor was comprised of primitive cells with round to
ovoid nuclei, coarse to vesicular chromatin, and scant cytoplasm, while rhabdomyoblasts and tadpole cells were less frequent. Anaplasia
was noted in 8 with minor foci resembling spindle cell or alveolar rhabdomyosarcoma in 6 and 2 tumors, respectively. Mitoses ranged
from 4-65 (mean 23) per 10 HPF with atypical forms in 3 and brisk apoptoses in 8.

All tumors tested expressed myogenin (3/9 diffuse), myoD1 (1/7 diffuse), and desmin (8/9 diffuse). DICER1 mutations were detected in
6/9, TP53 in 5/8, and KMT2D in 2/8 (Figure 1). Germline data was available in 2 (45 and 47 years), but neither harbored
a DICER1 mutation. ERMS-UC with DICER1 mutations were younger (p=0.024) and more commonly had heterologous elements
(p=0.048).

1017
 Figure 1 - 1062

Conclusions: ERMS-UC show similar clinicopathological features as their cervical counterparts, but typically occur in older females.
Although in our small cohort DICER1 mutations appear sporadic, it is important to recognize this entity and recommend genetics testing.

1063 Inflammatory Myofibroblastic Tumor of the Uterus: An Immunohistochemical Study of 22 Cases

Jennifer Bennett1, Sabrina Croce2, Anna Pesci3, Eike-Christian Burandt4, Eric Burks5, Gian Franco Zannoni6, Joseph Rabban7,
Esther Oliva8
1
The University of Chicago, Chicago, IL, 2Institut Bergonié, Bordeaux, France, 3IRCCS Ospedale Sacro Cuore Don Calabria,
Negrar, Verona, Italy, 4University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 5Boston University Mallory
Pathology Associates, Boston, MA, 6Catholic University of Sacred Heart, Rome, Italy, 7University of California San Francisco,
San Francisco, CA, 8Massachusetts General Hospital, Harvard Medical School, Boston, MA

Disclosures: Jennifer Bennett: None; Sabrina Croce: None; Anna Pesci: None; Eike-Christian Burandt: None; Eric Burks: None; Gian
Franco Zannoni: None; Joseph Rabban: Employee, Spouse is an employee of Merck & Co.; Esther Oliva: None

Background: Inflammatory myofibroblastic tumors (IMT) of the uterus often express desmin, caldesmon, and CD10, which may cause
diagnostic confusion with smooth muscle and stromal tumors. Transgelin, a new smooth muscle marker, has shown high sensitivity and
specificity distinguishing between uterine smooth muscle and stromal tumors while IFITM1, a new endometrial stromal marker, appears to
be more sensitive than CD10 differentiating between stromal and smooth muscle neoplasms. In a recent study, abnormal p53 and p16
expression was described in uterine leiomyosarcomas, but not IMTs, and hence, proposed as useful markers in the differential diagnosis.
Herein we evaluate a series of uterine IMTs for IFITM1 and transgelin, and further explore their reactivity for p53 and p16.

Design: We stained 22 uterine IMTs, including 4 with aggressive behavior, for IFITM1, transgelin, p53, and p16. IFITM1 was scored for
both intensity (0-3) and distribution (0-3) with a combined score >2 considered positive, transgelin as negative, focal (<50% staining), or
diffuse (>50%), and p53/p16 as wildtype or abnormal (strong/diffuse or negative).

Results: Patients ranged from 8 to 59 (mean 40) years and tumors from 2 to 20 (mean 7) cm. Follow-up was available in 16 (73%) with
13 (81%) alive and well (1 with a prior recurrence), 2 (13%) alive with disease, and 1 (6%) dead of disease. IFITM1 had a positive
combined score in 16 (73%) of IMTs, with most showing no difference in staining intensity or distribution between compact and myxoid
patterns. In tumors where CD10 (n=13) was previously performed, it was concordant with IFITM1 in 12 (92%). Transgelin was positive in
21 (95%; 10 focal, 11 diffuse) of IMTs with the staining distribution by histological pattern highly variable. p53 was wildtype in all tumors
whereas p16 was abnormal in 9 (43%; 4 negative, 5 strong and diffuse) IMTs. Notably, all 4 aggressive tumors were p16 negative.

Conclusions: Transgelin and IFITM1 are expressed in most IMTs and thus are not useful markers in differentiating these tumors from
smooth muscle and stromal neoplasms. Unlike a prior study, we found abnormal p16 expression in 43% of uterine IMTs, which argues
against the use of this marker in the distinction from smooth muscle tumors. Interestingly, all aggressive IMTs in this series were negative
for p16 in contrast to patchy or diffuse staining in benign tumors, which could potentially be used as a prognostic marker if corroborated
by other studies.

1064 ALK Immunoexpression in Vulvar Low Grade Myxoid Mesenchymal Neoplasms is Specific for
Inflammatory Myofibroblastic Tumor
Christopher Bowman1, Ankur Sangoi2, Fabiola Medeiros3, Walter Devine4, Andrew Horvai1, Joseph Rabban1
1
University of California San Francisco, San Francisco, CA, 2El Camino Hospital, Mountain View, CA, 3Cedars-Sinai Medical
Center, Los Angeles, CA, 4University of California San Francisco, Berkeley, CA

1018
Disclosures: Christopher Bowman: None; Ankur Sangoi: None; Fabiola Medeiros: None; Walter Devine: None; Andrew Horvai: None;
Joseph Rabban: Employee, Spouse is employee of Merck & Co.

Background: Inflammatory myofibroblastic tumor (IMT) of the uterus has recently been acknowledged to be under-recognized in several
studies that retrospectively examined ALK immunohistochemistry in smooth muscle tumors of uncertain malignant potential (STUMP) and
myxoid smooth muscle neoplasms. Recognition of uterine IMT is important as some have adverse behavior and targeted therapy is
available. In the vulva, a diverse array of mesenchymal tumors may exhibit low-grade morphology and/or myxoid extracellular
matrix. This study used ALK immunostaining to examine the possibility of under-recognized IMT among vulvar mesenchymal tumors.

Design: ALK immunostaining (Leica, Clone 5A4) was performed on 72 primary vulvar mesenchymal tumors with myxoid or low-grade
morphology. Cytoplasmic staining for ALK in the tumor cells was considered a positive result. To confirm a positive ALK IHC
result, ALK gene rearrangement testing was performed by break-apart fluorescence in situ hybridization (FISH).

Results: One vulvar mass that was initially suspected to be IMT (3 cm, circumscribed, without atypia, mitosis or necrosis) demonstrated
diffuse, strong ALK staining and ALK gene rearrangement by FISH. ALK staining was completely negative in all other vulvar tumors: 8
leiomyoma, 2 STUMP, 12 aggressive angiomyxoma, 3 superficial angiomyxoma, 3 superficial myofibroblastoma, 8
angiomyofibroblastoma, 6 cellular angiofibroma, 1 cutaneous angiofibroma, 19 fibroepithelial polyps, 1 myxoid low-grade endometrial
stromal sarcoma, 7 neurofibroma, 1 plexiform schwannoma, and 1 vulvar prepubertal fibroma. The sensitivity and specificity of ALK
staining for vulvar IMT was 100%.

Conclusions: ALK staining is a sensitive and specific test to distinguish IMT from a diverse spectrum of low-grade myxoid mesenchymal
tumors of the vulva. Though primary vulvar IMT is rare (this is the first report of such a case), the diagnosis merits consideration given
the availability of targeted therapy for advanced stage or recurrent disease.

1065 Tubal p53 Signatures in Li-Fraumeni Syndrome (LFS) are Geographically Unique, Multi-Clonal and
Temporally Dynamic
Jan Brouwer1, Ju-Yoon Yoon2, Jingzhong Xie3, Sarah Hill4, Wa Xian5, Christopher Crum6
1
University of Groningen, Groningen, Netherlands, 2Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, 3University of Houston, Houston, TX, 4Brigham and Women's Hospital, 5University of Texas Health Science
Center, 6Brigham and Women's Hospital, Boston, MA

Disclosures: Jan Brouwer: None; Jingzhong Xie: None; Christopher Crum: None

Background: Li-Fraumeni syndrome, with a germ-line TP53 mutation, is susceptible to clonal TP53 inactivating mutations in the
FT resulting in p53 signatures. This study addressed three questions relevant to the biology of p53 signatures including 1) their clonality,
2) distribution in the FT and 3) change in frequency over time.

Design: FTs from four cases of LFS were studied. To determine geographic distribution of clonal TP53 mutations events, DNA from p53
signatures in three separate regions from one FT was subjected to ion torrent NGS and the mutational burden analyzed for regional
differences. Regional variations in distribution of p53 signatures per se were evaluated by mapping frequency of p53 immuno-positive foci
into inner (luminal), middle and outer third of a cross section and fimbria (Fig 1). p53 signatures were recorded and the number(s) of p53+
nuclei counted. An analysis of temporal changes in frequency of p53 signatures was determined in a single case in which right and left
tubes were removed at different times over a span of 10 years.

Results: Sequencing of TP53 mutations in one case confirmed the germ-line mutation (c.A643G). Different somatic mutations were
identified in sites 1 (c.1083delG & c.254delC), 2 (c.304delA), and 3 (c.1083delG) confirming multiple unique genotoxic events. In the
second analysis, the number of p53 signatures per section was markedly higher in the outer 1/3 of the cross sections and in the fimbria.
The mean number of cells per p53 signature varied across all regions. However, the number of p53 signatures with high numbers of p53
positive cells was significantly higher in the outer 1/3 relative to all other regions (p = .0001) and to the inner and middle 1/3 of the tubes
(p = .0097)(Fig 2). Analysis of two fallopian tubes from the same patient disclosed a dramatically higher number of p53 signatures in the
second tube removed 10 years after the first.

1019
 Figure 1 - 1065 Figure 2 - 1065

Conclusions: P53 signatures in fallopian tubes of women with LFS are genetically independent events. The outer one third of the
fallopian tube as well as the fimbria harbor a significantly higher proportion of p53 signatures. This could reflect a higher proportion of
susceptible cells (non-ciliated) as well as the possibility that the peripheral 1/3 of the endosalpinx contains cells with greater capacity for
cell division. The higher number of p53 signatures in the second tube years later in one case suggests that genotoxic injury accumulates
in the tube over time during the reproductive years.

1066 Assessment of Progestin Therapy Response Potential in Grade 2 Endometrial Endometrioid

Carcinoma
Aurelia Busca1, Ekaterina Olkhov-Mitsel2, Yutaka Amemiya3, Jelena Mirkovic4, Carlos Parra-Herran4, Arun Seth4, Bojana
Djordjevic5
1
EORLA- University of Ottawa, Ottawa, ON, 2Sunnybrook Health Sciences Centre, Toronto, ON, 3Sunnybrook Research
Institute, Toronto, ON, 4Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, 5University of Toronto, Toronto,
ON

Disclosures: Aurelia Busca: None; Ekaterina Olkhov-Mitsel: None; Yutaka Amemiya: None; Jelena Mirkovic: None; Carlos Parra-Herran:
None; Arun Seth: None; Bojana Djordjevic: None

Background: Progestin treatment is a known fertility sparing strategy for low grade endometrial lesions (LGELs) such as atypical
hyperplasia and FIGO grade 1 endometrial endometrioid carcinoma. FIGO grade 2 endometrioid carcinoma (EEC2) is currently treated
surgically. There are isolated case reports of successful progestin treatment of patients with EEC2, suggesting that hormonal treatment
may be a viable option if the responsive patients could be correctly identified. We have previously demonstrated that LGELs with
complete (CR), partial (PR) and no response (NR) to progestin therapy have different genomic and transcriptome profiles. In the current
project, we sought to compare the transcriptome profile of CR and NR lesions with that of EEC2.

Design: 20 consecutive cases of EEC2 underwent whole transcriptome profiling (stages T1a=11, T1b=4, T2=4 and T3b=1, LVI in 35%).
We previously identified 119 genes which were differentially expressed between pre-progestin treatment samples of CR and NR LGEL
cases (P≤0.05, >2-fold change). RNA expression data was subjected to unsupervised hierarchical clustering algorithm to compare the
expression of these genes in EEC2 relative to CR (n=6) and NR (n=3) LGELs.

Results: Unsupervised hierarchical clustering of the 119 genes segregated the cohort into two clusters, representing two distinctive gene
expression profiles (see heatmap, Figure 1). The first cluster consisted of 4 EEC2 cases (stages T1a=3, T2=1) segregating with all CR
cases. The second cluster of the remaining 16 EEC2 cases (stages T1a=8; T1b=4; T2=3; T31b=1) segregated with all NR cases.
Compared to EEC2 in the CR-like cluster, EEC2 in the NR-like cluster had higher rates of LVI (0% vs 44%) and greater depth of
myometrial invasion (mean 32%, range 0-63% vs mean 44%, range 0-99%, respectively). Some of the genes with the highest difference
in expression between the CR-like and NR-like EEC2 clusters were DKK4, NOTUM, NKD1 (Wnt signaling
pathway), FGF20 and IGFBPL1 (growth factors), all of which had higher expression in the CR-like cluster.

1020
 Figure 1 - 1066

Conclusions: For the first time, we show that a transcriptome profile characteristic of LGELs responsive to progestin therapy exists in a
subset of EEC2. This suggests that these tumors may be amenable to a trial of progestin therapy, especially if suspected to be stage T1a
on imaging. Further analysis is required to develop sensitive and specific biomarkers of progestin response.

1067 Speckled MLH1 Staining Pattern by Immunohistochemistry in Endometrial Carcinoma

Alain Cagaanan1, Kristen Karasiewicz2, Paul Weisman3, Stephanie McGregor3
1
Madison, WI, 2University of Wisconsin-Madison, Madison, WI, 3University of Wisconsin, Madison, WI

Disclosures: Alain Cagaanan: None; Kristen Karasiewicz: None; Paul Weisman: None; Stephanie McGregor: None

Background: Screening for microsatellite instability using immunohistochemistry (IHC) for mismatch repair (MMR) proteins is an effective
and cost effective method in endometrial cancers. Misinterpretation of these markers can lead to erroneous reporting and has important
prognostic and predictive implications. Speckled (also known as dot-like or punctate) MLH1 staining is common in studies using the M1
clone and has been reported as being associated with MLH1 promoter hypermethylation in colorectal cancers. We characterize MLH1
staining patterns in endometrial cancers with known MLH1 promoter status. We also assess the effect of signal amplification on MLH1
staining.

Design: Endometrial cancer cases (n=34) sent out for MLH1 promoter hypermethylation testing (MLH1HM) were retrieved from our
archives. Hematoxylin and eosin-stained and MMR IHC slides were reviewed. Cases were assessed for presence or absence of speckled
MLH1 staining. Hypermethylation status and original interpretation of the MMR IHC slides were recorded. In 5 cases with prominent
speckled MLH1 staining and positive for MLH1HM, MMR IHC with the anti-MLH1 M1 clone were repeated with and without amplification.

Results: MLH1HM was present in 30 of 34 cases (88%). 23 of 34 cases (68%) showed speckled MLH1 staining ranging from patchy to
diffuse tumoral distribution with fine to dense cellular character. Speckled MLH1 staining was present in 22 of 30 (73%) cases with
MLH1HM and 1 of 4 (25%) cases without MLH1HM. 1 case with speckled MLH1 staining had been reported as intact but MLH1HM status
was positive. Another case with speckled MLH1 was reported as negative but with a comment acknowledging interpretative difficulty due
to the speckled extent. In all 5 cases (3 biopsy specimens, 2 resection specimens) with repeat staining, omitting amplification showed
overall reduced intensity (Figure 1 without amplification, Figure 2 with amplification). Qualitatively, MLH1 IHC interpretation was easier in
the biopsy specimens due to weak internal control staining in resection specimens.

1021
 Figure 1 - 1067 Figure 2 - 1067

Conclusions: Speckled MLH1 staining is a common phenomenon in endometrial cancer that occurs with and without MLH1HM. This
artifact, which appears associated with the M1 clone, can be misinterpreted as intact MLH1 protein expression. Improved MLH1 IHC
interpretation can be achieved by changing staining protocols, tissue processing, and specimen selection.

1068 Hypertrophic Lichen Sclerosus: A Putative Precursor to Squamous Cell Carcinoma in the Vulva
Katelynn Campbell1, Sara Shalin2, Charles Quick2
1
Little Rock, AR, 2University of Arkansas for Medical Sciences, Little Rock, AR

Disclosures: Katelynn Campbell: None; Sara Shalin: None; Charles Quick: None

Background: Women with lichen sclerosus (LS) of the vulva have an increased risk for squamous cell carcinoma (SCC), but LS itself has
not been implicated as a true precursor. Hypertrophic lichen sclerosus (HLS) is a variant of “classic” LS that may represent a distinct
precursor to vulvar SCC. In order to further investigate precursor lesions of vulvar SCC and their oncogenic pathways, we evaluated a
series of invasive vulvar SCC for precursor lesions and the expression of p16 and p53 within such lesions and their corresponding
invasive cancer.

Design: 36 cases of consecutive vulvar SCCs with sections of adjacent uninvolved epidermis (1998-2015) were identified. Epidermis
adjacent to invasive tumor was examined for precursor lesions: differentiated and usual vulvar intraepithelial neoplasia
(dVIN, uVIN), differentiated exophytic vulvar intraepithelial lesion (DEVIL), vulvar acanthosis with altered differentiation (VAAD), and
HLS. HLS is defined in this study as epidermal acanthosis (without exophytic growth), hyperkeratosis, irregular dermal-epidermal junction
(sawtooth or jagged appearance) with a lack of conspicuous cytologic atypia and homogenization of superficial papillary dermis (See
Figure 1). All cases were stained for p53 and p16. p16 staining was scored as positive (block positivity) or negative. p53 staining was
scored as mutant (positive/null) or wild type (WT).

Results: 19/36 (53%) cases had adjacent uVIN. 4/36 (11%) cases had adjacent dVIN. 10/36 (28%) cases had adjacent HLS. 3/36 (8%)
cases were lost to sectioning. No cases of DEVIL or VAAD were identified. Usual VIN and associated SCC were consistently p16 positive
and p53 wild type. Differentiated VIN and associated SCC demonstrated mutant p53 staining in all cases, although the sample size was
small. HLS more commonly occurs in older women (average age 65 (range 44-87)). IHC results of precursors and their adjacent SCC
are shown in Table 1.

1022
 Table 1: Immunohistochemical Profile of Vulvar Squamous Cell Carcinomas (n=36) and Adjacent Precursor Lesions

Precursor Total Cases p16 Positive p16 Negative p53 WT p53 Mutant

Precursor Precursor Precursor Precursor

Cancer Cancer Cancer Cancer

HLS 10 (28%) 0 (0%) 10 (100%) 8 (80%) 2 (20%)

3 (30%) 7 (70%) 6 (60%) 4 (40%)

uVIN 19 (53%) 19 (100%) 0 (0%) 19 (100%) 0 (0%)

19 (100%) 0 (0%) 18 (95%) 1 (5%)

dVIN 4 (11%) 0 (0%) 4 (100%) 0 (0%) 4 (100%)

0 (0%) 4 (100%) 0 (0%) 4 (100%)

WT= wild type, HLS= hypertrophic lichen sclerosus, uVIN= usual vulvar intraepithelial neoplasia, dVIN=differentiated vulvar intraepithelial
neoplasia

Figure 1 - 1068

Conclusions: HLS represents a relatively common, putative precursor to invasive SCC of the vulva. Immunostaining with p53 is not
predictive of malignant potential in HLS, and p16 is consistently negative. Histologic diagnosis of vulvar HLS warrants increased clinical
surveillance of women.

1023
1069 Role of Ki67 Proliferation Index and CD8 Tumour-Infitrating Lymphocyte Counts in Predicting
Outcome in High-Grade Serous Tubo-Ovarian Carcinoma (HGSC) Showing No/Partial Response
to Neoadjuvant Chemotherapy
Laura Casey1, Aime Powell2, Steffen Böhm3, Ranjit Manchanda4, Michelle Lockley5, Martin Kobel6, Naveena Singh7
1
Royal London Hospital, London, United Kingdom, 2University of Notre Dame of Australia, Fremantle, WA,
Australia, 3Department of Medical Oncology, London, United Kingdom, 4Wolfson Institute of Preventive Medicine, Barts CRUK
Cancer Centre, London, United Kingdom, 5Barts Cancer Institute, London, United Kingdom, 6University of Calgary/Alberta Public
Laboratories, Calgary, AB, 7Barts Health NHS Trust, London, United Kingdom

Disclosures: Laura Casey: None; Aime Powell: None; Steffen Böhm: None; Ranjit Manchanda: Advisory Board Member, Astrazeneca
and MSD; Michelle Lockley: None; Martin Kobel: None; Naveena Singh: None

Background: We have previously shown the prognostic value of the chemotherapy response score (CRS) for measuring response to
neoadjuvant chemotherapy (NACT) in interval debulking surgery specimens of stage IIIC and IV HGSC (CRS1: no or minimal response;
CRS2: partial response; CRS3: total/near total response). Its reproducibility, particularly in those with the best response to chemotherapy
(CRS3), has been aptly demonstrated and, in this group, the CRS correlates with progression-free and overall survival. However, as
currently defined, there is no prognostic distinction between cases showing CRS1 and CRS2, which account for up to 75% cases. It has
been shown that the presence and number of CD8 positive tumour-infiltrating lymphocytes (TILs) in HGSC is directly linked to overall
survival and, furthermore, that low Ki67 expression is associated with resistance to platinum-based chemotherapy and decreased
survival. Our aim was to explore whether Ki67 and/or CD8 TILs predict outcome in HGSC cases showing no/partial response to NACT.

Design: Immunohistochemistry (IHC) was carried out for CD8 and Ki67 on omental sections of HGSC cases showing a partial or no
response to NACT. Ki67 was assessed as a percentage of total tumour cells. Cases were classified into i) <30% Ki67 or ii) >/=30% Ki67.
CD8 TILs were counted as number/high power field and number/20 tumour cells. Survival analysis was performed using Cox proportional
hazards models and the log-rank test.

Results: 39 stage III (n=30) and IV (n=9) HGSC cases were included. Thirty-five patients (90%) had disease recurrence and 20 (51%)
had died at study census. Median PFS and OS were 14.1 months (6.3 to 51.6 months) and 31.0 months (14.6 to 66.8 months),
respectively. Patients with >/=30% Ki67 were significantly associated with PFS in a multivariate survival model adjusting for age, stage
and residual disease (HR 2.9; 95%CI 1.11 – 5.08; p-value 0.025) but not OS (HR 2.1; 95%CI 0.77 – 5.78; p-value 0.144). CD8 TILs were
not identified to be a statistically significant predictor for PFS or OS on univariate or multivariate survival models.

Conclusions: Our results indicate that Ki67 predicts PFS in cases of HGSC showing no/partial response to NACT. This simple
parameter can easily be incorporated into routine diagnostic practice. Unlike chemo-naive HGSC cases, CD8 TILs do not appear to
predict outcome following NACT. Our preliminary findings merit further evaluation in a larger patient cohort.

1070 Next-Generation Sequencing-Based Characterization of Mucinous Ovarian Tumors with

Anaplastic Mural Nodules
David Chapel1, Elizabeth Lee2, Nathan Teschan3, Lynette Sholl1, Panagiotis Konstantinopoulos2, Marisa Nucci4
1
Brigham and Women's Hospital, Boston, MA, 2Dana Farber Cancer Institute, Boston, MA, 3Brigham and Women's Hospital,
Brookline, MA, 4Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Disclosures: David Chapel: None; Elizabeth Lee: None; Nathan Teschan: None; Lynette Sholl: Consultant, LOXO Oncology; Panagiotis
Konstantinopoulos: Advisory Board Member, Tesaro; Marisa Nucci: None

Background: A subset of mucinous ovarian tumors (MOT) harbor anaplastic mural nodules (AMN), which may portend a poor clinical
outcome, even in low-stage tumors. Some molecular data indicate a clonal relationship between AMNs and associated MOTs. However,
genomic profiling of these tumors remains incomplete, and no molecular determinants of prognosis have been reported.

Design: A next-generation sequencing panel of 447 genes was performed on eight cases of MOT with associated AMN. In 3 cases, two
grossly discrete AMNs were sequenced separately. Patient outcomes were compared with clinical, histomorphological, and genomic
findings.

Results: Patient were 16-60 years old at diagnosis. Six were stage IA, one stage IC2, and one stage IV, and all received adjuvant
chemotherapy. One stage IA patient died of disease 9 months after diagnosis. Seven patients were alive without disease over a follow-up
of 6 to 272 months (median, 31 months). The MOT was mucinous borderline tumor (MBT) in 2 patients, MBT with intraepithelial
carcinoma in 2, and mucinous adenocarcinoma in 4. The dominant AMN morphology was rhabdoid in 2 cases, sarcomatoid in 3, and
pleomorphic in 3 (including 1 with bone formation).

Shared pathogenic mutations were seen in the MOT and AMN in all 8 cases, and grossly discrete AMNs within the same ovary had
identical mutational profiles in all 3 tested cases. A shared KRAS mutation was seen in 7 cases and a shared MAP2K1 mutation in 1

1024
case. Additionally, shared KRAS amplification was seen in 2 cases and was present in the AMN of a third. A TP53 mutation was seen in 6
cases (shared in 5 cases; AMN only in 1 case). Shared CDKN2A deletion was seen in 5 cases, whereas a shared CDKN2A single
nucleotide variant was seen in 1, and 2 additional cases had a CDKN2A mutation in only the MOT or AMN component. The only patient
with SMARCB1 mutation (AMN component only) died from disease. Mutations in CDH1 and PTEN were not seen.

Figure 1 - 1070

Figure 2 - 1070

Conclusions: MOTs and associated AMNs are clonally related lesions with broad genomic overlap, and a single recurrent mutation does
not underlie AMN development. RAS pathway mutations appear virtually universal in MOT with AMN, and TP53 mutations
and CDKN2A loss are frequent. SMARCB1 mutation appears to drive AMN development in a minority of cases and may portend a dismal
outcome. INI1 immunohistochemistry may be a useful prognostic test in AMNs, as rhabdoid morphology is not specific
for SMARCB1 mutation.

1025
1071 Integrated 5hmC Immunohistochemistry and 5hmC-Modified Genomic Regions as Prognostic
Biomarkers in Ovarian Clear Cell Carcinoma
David Chapel1, Jason Karpus2, Xiaolong Cui2, Nida Safdar3, Ernst Lengyel2, Esther Oliva4, Jennifer Bennett2
1
Brigham and Women's Hospital, Boston, MA, 2The University of Chicago, Chicago, IL, 3Bedford, MA, 4Massachusetts General
Hospital, Harvard Medical School, Boston, MA

Disclosures: David Chapel: None; Jason Karpus: None; Xiaolong Cui: None; Nida Safdar: None; Ernst Lengyel: None; Esther Oliva:
None; Jennifer Bennett: None

Background: Ovarian clear cell carcinoma (OCCC) is an aggressive and chemoresistant tumor, and stage is the only important
prognostic factor. 5-hydroxymethylcytosine (5hmC) is an intermediate nucleotide produced in the first step of cytosine demethylation.
Preliminary data indicate that 5hmC levels by immunohistochemistry (IHC) have prognostic significance in OCCC, irrespective of tumor
stage. However, correlation of 5hmC IHC, 5hmC molecular studies, and clinical outcomes has not been reported.

Design: We applied genome-wide 5hmC-Seal molecular profiling to 40 OCCCs. For each tumor, the total number of genome-wide 5hmC
peaks was compared to extent and intensity of 5hmC IHC, tumor stage, and patient outcome--favorable (no evidence of disease) vs
adverse (alive with disease/dead of disease). Tumors were sorted by unsupervised clustering to identify differentially hydroxylated genes,
and principal components analysis was performed using the identified gene panel and compared to patient outcome.

Results: Clinicopathologic data are summarized in the table. Over a median follow-up of 30 (range 1-150) months, 15 patients had an
adverse outcome. On genome-wide analysis, total number of 5hmC peaks positively correlated with 5hmC IHC extent and intensity
scores, and negatively with tumor stage. While the number of genome-wide 5hmC peaks was only marginally lower in patients with
adverse outcome, clustering and principal components analyses successfully identified panels of differentially hydroxylated genes for
stratification based on outcome. The 10 loci showing the greatest discrimination between tumors included 7 microRNAs (MIR6820,
MIR92A2, MIR4532, MIR670, MIR572, MIR4685, and MIR5787), as well as SNORD114-28, RN7SK, and GAG12F.

Age (median, years) 56

Outcome Status #
NED 25
AWD/DOD 15

Stage #
IA 3
IC 25
II 1
III 9
IV 2

Tumor 5hmC IHC Extent Score #

1 (<10% staining) 3
2 (10-24%) 6
3 (25-75%) 14
4 (>75%) 17

Tumor 5hmC IHC Intensity Score #

1 (weak) 4
2 (moderate) 23
3 (strong) 13

AWD: Alive with disease; NED: No evidence of disease; DOD: Dead of disease

1026
 Figure 1 - 1071

Figure 2 - 1071

Conclusions: This molecular study of tumor 5hmC profile validates and expands upon previous reports of the prognostic value of 5hmC
IHC. A targeted panel of differentially hydroxymethylated genes applied to tumor specimens and circulating DNA, may permit risk
stratification of OCCC. MicroRNAs are enriched among prognostically discriminatory loci, further suggesting a critical role for regulation of
gene expression in OCCC prognosis. Targeted gene expression profiling, based on the OCCC-specific hydroxymethylation profile, may
reveal molecular pathways critical to outcome, opening the possibility of targeted therapies.

1072 Landscape of Putative Precursors to High Grade Serous Carcinoma (HGSC) in the Female
Genital Tract
David Chapel1, Carrie Robinson2, Emily Goebel3, Thing Rinda Soong4, David Kolin1, Christopher Crum1
1
Brigham and Women's Hospital, Boston, MA, 2Naval Medical Center San Diego, San Diego, CA, 3London Health Sciences
Centre, Kilworth, ON, 4University of Washington, Seattle, WA

Disclosures: David Chapel: None; Carrie Robinson: None; Emily Goebel: None; Thing Rinda Soong: None; David Kolin: None;
Christopher Crum: None

Background: In the now-widely accepted model of high-grade serous carcinoma (HGSC) development, a serous tubal intraepithelial
carcinoma (STIC) develops in the distal tube, and tumor cells spread from the STIC to the peritoneal cavity. A second related model
proposes that inconspicuous early serous proliferations (ESPs) exfoliate ("precursor escape"), spread to the peritoneal cavity, and
progress to HGSC in a subset of cases. Both models may account for a sizable proportion of extrauterine HGSCs but fail to explain every
case. We examined the frequency and histomorphologic features of endometrial ESPs in women with extrauterine HGSC.

1027
Design: The study cohort included two groups. Group 1 comprised consecutive extrauterine HGSCs in which the endometrium and
fallopian tubes were entirely submitted for evaluation (11 cases, 129 endometrial and 72 tubal blocks). Group 2 consisted of cases in
which exhaustive sectioning of entirely submitted fallopian tubes disclosed no STIC or ESP (from prior work, Soong et al 2018). All
endometrial sections from Groups 1 and 2 were immunostained for p53. The frequency of ESPs was recorded and compared to a prior
study of benign polyps (Jarboe et al, 2009).

Results: In Group 1, 3 of 11 (27%) endometria contained an ESP, and 2 of 6 (33%) endometrial polyps harbored an ESP, in contrast to 6
ESPs seen in 137 benign polyps by Jarboe et al (P=0.037). A tubal ESP was identified in 4 of 11 (36%) cases. In Group 2, 2 of 11 (18%)
cases harbored an endometrial ESP. Across both groups, ESPs included two morphologic types: 1) lesions limited to the surface
epithelium (Fig 1) and 2) sub-surface lesions showing endometrioid differentiation (Fig 2).

Figure 1 - 1072 Figure 2 - 1072

Conclusions: This study indicates that ESPs may be more frequent in the endometria of women with extrauterine HGSC than in healthy
women, and that ESPs may be particularly prone to develop in endometrial polyps. Endometrial ESPs show two different morphologic
patterns, correlated to surface versus sub-surface location. Molecular studies are in progress to compare the p53 mutations between
these ESPs and concurrent HGSCs to elucidate the possible role of the endometrial lining and endometrial polyps in extra-uterine HSGC
pathogenesis.

1073 High-Grade Neuroendocrine Carcinoma of the Vulva: A Clinicopathologic Study of 15 Cases

Peter Chen1, Elizabeth Euscher2, Preetha Ramalingam2, Barrett Lawson2, Anais Malpica2
1
Houston, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX

Disclosures: Peter Chen: None; Elizabeth Euscher: None; Preetha Ramalingam: None; Barrett Lawson: None; Anais Malpica: None

Background: High-grade neuroendocrine carcinoma of the vulva (HGNECaV) is rare with most cases reported as Merkel cell carcinoma
(MCC). This study presents the clinicopathologic features of the largest series of such cases.

Design: Fifteen cases from 1985-2019 were reviewed for the following: patient (pt) age, clinical presentation, FIGO stage, treatment (tx),
follow up (f/u), histological features, immunohistochemistry (IHC) and high risk human papilloma virus (HRHPV) results.

Results: Mean age at presentation was 53 yrs (range, 10-90 yrs), and 33% had presenting symptoms related to metastasis. 13/15
(87%) cases were pure HGNECa, mostly small cell type (10/15, 67%) with only 2/15 (13%) being large cell type. 2/15 (13%) were mixed
(squamous Ca or adeno Ca). 43% of the cases were misdiagnosed as non-NECa. All had at least one architectural NECa pattern. All
tumors involved the dermis and/or subcutis, 2 were found adjacent to Bartholin/vestibular glands, and 7 had an epithelial component. IHC
results were as follows: synaptophysin 14/14 (100%); CD56 7/7 (100%); chromogranin 10/14 (71%); and cytokeratin 20 2/10 (20%)– the
“dot-like” pattern was seen in a single case. 2 of 3 cases had signal for HRHPV detected by in situ hybridization. 11/15 (73%) pts.
presented with FIGO stage III or IV disease. Tx and f/u information was available for 10 pts. Of these, 8 underwent vulvar excision with
adjuvant chemotherapy (CTX) and/or radiation therapy (RTX). 2 pts. received CTX and XRT only. Of the 10 pts. with f/u (6-89 months) 6
(60%) died of disease including 2 stage IB pts. Of the 4 living pts., 1 is alive with stable disease at 56 months, and 1 is disease free at 89
months.

Conclusions: HGNECaV is rare, affects pts. with a wide age range, but mostly peri/postmenopausal, and often presents at an advanced
stage. Most cases are small cell type, with an occasional case mixed with another Ca type.Typically, the tumor is in the dermis/subcutis
similar to MCC; however, the expression of CK20 with the characteristic dot-like pattern is rare. Synaptophysin and CD56 were the most

1028
commonly expressed neuroendocrine markers. A subset of HGNECaV is HRHPV-related. HRHPV testing may be considered to
distinguish HGNECaV from MCC, especially given the lack of CK20 expression in this cohort. Proper recognition of this tumor is essential
to ensure its correct treatment as this is an aggressive neoplasm.

1074 TP53-wildtype High-Grade Serous Tubo-Ovarian Carcinomas

M. Herman Chui1, Robert Soslow1
1
Memorial Sloan Kettering Cancer Center, New York, NY

Disclosures: M. Herman Chui: None; Robert Soslow: Speaker, Ebix/Oakstone

Background: High-grade serous ovarian carcinoma is characterized by the near-universal presence of TP53 mutation (>95% frequency).
In this study, we conduct a histopathologic review of tubo-ovarian carcinomas diagnosed as high-grade serous carcinoma (HGSC) and
found to be TP53-wildtype by molecular analysis.

Design: From retrospective review of targeted exome sequencing data of 938 high-grade tubo-ovarian serous carcinomas, we identified
37 (4%) cases that did not harbor a TP53 mutation (tp53wt). These cases, along with 33 HGSCs with TP53 mutation (tp53mut), were
subjected to central pathology review performed by 2 gynecologic pathologists blinded to mutation status. Tumor architectural pattern,
mitotic count and nuclear atypia (3-point scale) were assessed on representative slides. Immunohistochemical stains for p53, WT-1 and
Pax8 are being performed for all cases and are in progress.

Results: Thirty-four of 37 (92%) tp53wt tumors were confirmed to be morphologically consistent with HGSC; the remaining 3 were re-
classified as high-grade adenocarcinoma, NOS (n = 2) or with features of serous and endometrioid carcinoma (n = 1). Notable genetic
alterations found in tp53wt HGSC include MDM2 amplification, as well as mutations in KRAS, NRAS, and NF1/2. There were extensive
copy number alterations, indicative of genomic instability. Compared to tp53mut HGSC, architectural features of low-grade serous
carcinoma - specifically, micropapillary or cribiform architecture or infiltrative nests/inverted micropapillae - were more frequently observed
in tp53wt HGSC [tp53mut vs tp53wt: 5/33 (15%) vs 14/34 (41%), p = 0.03]. While most tumors displayed Grade 3 nuclei, there was a
trend towards a higher proportion of cases with Grade 2 or Grade 2-to-3 nuclei amongst tp53wt HGSCs [tp53mut vs tp53wt: 2/33 (6%) vs
7/34 (21%), p = 0.15]. No significant difference in mitotic count was observed (tp53mut vs tp53wt: mean, 25 vs 21, p = 0.45).
Immunohistochemical staining for p53 on a subset of cases demonstrate wildtype-pattern of expression in most tumors, however some
showed complete or near-complete absence of staining.

Conclusions: High-grade “serous” ovarian carcinomas with wildtype TP53 are rare and constitute a heterogeneous group comprising
high grade Mullerian carcinomas with ambiguous morphology, low-grade serous carcinomas that have undergone high-grade
transformation, and otherwise conventional HGSC with either intact p53 expression or functionally silenced by non-genetic mechanisms.

1075 The Significance of "Recurrence" in Endometrial Polyps: A Clinicopathologic Analysis

Andreas Ciscato1, Somaye Zare2, Oluwole Fadare2
1
University of California San Diego, San Diego, CA, 2University of California San Diego, La Jolla, CA

Disclosures: Andreas Ciscato: None; Somaye Zare: None; Oluwole Fadare: None

Background: "Recurrence" in endometrial polyps has historically been considered a potentially ominous clinical finding due to the
possibility of an undiagnosed adenosarcoma in the original sample. However, the true clinicopathologic significance of endometrial polyp
recurrence has never been comprehensively and systematically studied. The current study is a multifaceted examination of the
phenomenon of recurrence in endometrial polyps.

Design: We reviewed pathologic material for all patients who were diagnosed with an endometrial polyp in a biopsy, curettage or
polypectomy on more than one occasion during a 17-year period (92 patients, 213 polyps). For analytic purposes, we defined a
recurrence as a second polyp diagnosed within 12 months of the first (i.e index) polyp, with the latter diagnosed by curettage or
polypectomy. Recurrent polyps so defined comprised the study group (28 patients). An age matched control group of patients that were
diagnosed with no more than a single polyp by curettage or polypectomy during this period was also established (174 patients). The study
and control groups were compared regarding a wide variety of clinicopathologic features, including follow-up.

Results: 27 (96.4%) of the 28 study group patients had only one recurrence, with the last patient recurring twice. The average duration
between the index and first recurrent polyp was 4.64 months (range 1 to 11.6). The index and the recurrent polyps for a given patient
were generally similar in morphology. A comparison of the study and control groups (n=174) regarding a variety of clinicopathologic
features is presented in the table. Some features, including mild stromal atypia, infarction, and numerous polyp fragments harboring thick
walled vessels, were more likely to be present in the study group. However, upon review, none of the polyps in the study group were
thought to display features diagnostic of adenosarcoma. At an average follow up duration of 14.3 months (range 1 to 112), no malignancy
has been diagnosed in the study group, and all patients show no evidence of disease.

1029
 Comparison of study ("recurrent") and control ("non-recurrent") groups
Feature Study group (n=28) Control group (n=174) p value
Patient age (mean) 53.32 years 49.01 years NS
Follow-up duration and mean 14.37 months mean 27 months (range NA
diagnoses (range 1-112): no 1-204): one endometrioid
malignancies carcinoma
Polyp size (mean) 2.61 cm 2.52 cm NS
Stromal infarction 17.85% 6.32% NS
Mild and focal stromal 7.14% 0% 0.02
atypia
Diffuse stromal 35.71% 20.11% NS
hypercellularity
Focal glandular 25% 11.49% NS
crowding
Prominent thick walled 53.6% 16.7% 0.000085
vessels in most
fragments
Bizarre stromal cells 0% 1.14% NS
Focal periglandular 3.57% 0.57% NS
condensation of stromal
cells
Focal intraglandular 14.28% 1.71% 0.0079
stromal papillation
Presence of stromal 0% 3.44% NS
fragments without
epithelium
Stromal mitotic index 1.25 1.10 NS
(mean)
Clinical history of breast 7% 4% NS
cancer and/or tamoxifen
use

Conclusions: Our data shows that patients whose polyps recur within a year, even though the original polyp was removed by an
endometrial curettage or polypectomy, are no more likely to be subsequently diagnosed with a uterine malignancy than controls.The
precise combination of factors that underlie recurrent potential in endometrial polyps is unclear, but they appear to be mostly unrelated to
underlying neoplasia in an unselected population.

1076 Microcystic Stromal Tumor of the Ovary; Additional Morphologic Nuances

Blaise Clarke1, Anne-Sophie Chong2, W. Glenn McCluggage3, Amir Akbari1, Marisa Nucci4, Esther Oliva5, Sarah Alghamadi6,
Asghar Naqvi7, William Foulkes2, Barbara Riverapolo2
1
University of Toronto, Toronto, ON, 2McGill University, Montreal, QC, 3The Royal Hospitals, Belfast, United Kingdom, 4Brigham
and Women's Hospital, Harvard Medical School, Boston, MA, 5Massachusetts General Hospital, Harvard Medical School,
Boston, MA, 6McMaster University Medical Centre, Hamilton, ON, 7McMaster University, Hamilton, ON

Disclosures: Blaise Clarke: None; Anne-Sophie Chong: None; W. Glenn McCluggage: None; Amir Akbari: None; Marisa Nucci: None;
Esther Oliva: None; Sarah Alghamadi: None; Asghar Naqvi: None; William Foulkes: None

Background: Microcystic stromal tumors of the ovary are rare neoplasms characterized by a histologic triad of microcysts, solid cellular
regions, and hyalinized stroma. These neoplasms have a characteristic immunophenotype with diffuse expression of CD10, WT1, beta-
catenin (nuclear), cyclin D1, FOXL2, and steroidogenic factor-1while inhibin and calretinin are usually negative. Molecular analyses have
disclosed that these tumors have either a CTNNB1 or APC mutation and that these are mutually exclusive with the former being more
common. We sought to further characterize these unusual tumors by studying an additional 7 cases.

Design: Central pathology review of the cases was performed and molecular analysis of CTNNB1 and APC was undertaken.

Results: Four had the typical morphology described above whereas 3 showed additional findings including epithelioid cells with
vacuolation imparting a signet ring appearance (2 cases) and a prominent population of spindle cells and cells with bizarre nuclei (one
case).

In four of these cases CTNNB1 mutations were identified in the hotspot in exon 3. A fifth case lacked CTNNB1 exon 3 mutation and was
wild-type for APC by next generation sequencing. The rest of the CTNNB1 gene is being interrogated in that case and and the sixth case
is currently undergoing molecular analysis.

1030
 Case Morphology Molecular
1 Signet ring like CTNNB1
2 Signet ring like CTNNB1
3 Classic CTNNB1 hotspot and APC, wild
type
4 Classic CTNNB1
5 Classic CTNNB1
6 Spindle and bizarre cells Pending
7 Classic Pending

Conclusions: While often prototypical in terms of histologic features, an expanded morphologic spectrum including bizarre cells, spindle
cells and signet ring cells can occur. Either APC or CTNNB1 mutation is present in almost all cases of ovarian microcystic stromal tumor
and this can be a useful diagnostic tool in cases with unusual morphology. Accurate diagnosis is important as these tumors may rarely be
an extracolonic manifestation of FAP. Given the presence of signet ring cells and the fact that CTNNB1 mutations have been
demonstrated in occasional ovarian signet-ring stromal tumors, we speculate that these tumors may be pathogenetically related.

1077 Mutations in LRRK2 are Associated with Improved Outcomes and Frequent DNA Polymerase
Exonuclease Defects in Endometrial Cancer
Lani Clinton1, Laurie H Sanders2, Edgardo Parrilla Castellar2
1
Duke University Medical Center, Mebane, NC, 2Duke University School of Medicine, Durham, NC

Disclosures: Lani Clinton: None; Laurie H Sanders: None; Edgardo Parrilla Castellar: None

Background: Mutations in LRRK2 are the most common genetic cause of Parkinson’s disease (PD). LRRK2 is a member of the leucine-
rich repeat kinases and is functionally implicated in mitochondrial homeostasis and DNA integrity. LRRK2 mutations were recently
described in ER-positive breast cancer. However, the pathophysiologic relationship between LRRK2 and endometrial cancer, a similarly
hormone-driven malignancy, is not described.

Design: The Genomic Data Commons Data Portal (https://portal.gdc.cancer.gov) from The Cancer Genome Atlas was searched
for LRRK2 single nucleotide variants and small insertions/deletions in 553 unselected cases of endometrial cancer. Digital histopathology
was performed using Slide Image Viewer. Categorical values were compared using the Chi-square test. Overall survival was estimated
using the Kaplan-Meier method and tested using the log-rank test.

Results: 144 LRRK2 mutations were identified in 69 cases of endometrial cancer (median age=59 yrs., median follow up=46 mo.). 53
additional cases had LRRK2 sequence information without a detectable mutation (median age=64 yrs., median follow up=29 mo.).
Inactivating, stop-gain variants (i.e. nonsense, frameshift and splice site) were present in over half of cases (N=38). Endometrioid
morphology prevailed among LRRK2-mutated tumors (N=89%; OR=4.20; P=0.003), whereas LRRK2 alterations were rare in serous
carcinomas (6%; OR=0.15; P<0.001). 5-year overall survival rates were 93% and 71% among patients with endometrial cancers
harboring a LRRK2 mutation (N=69) versus those without (N=53), respectively (P=0.007; Figure 1), with comparable FIGO stage
distribution (P=0.299). Tumors with LRRK2 mutations had frequent hotspot POLE (N=48) or POLD1 (N=4) exonuclease mutations
(OR=10.68, P<0.001), with a mean mutation rate of 13.3 per Mb compared to 1 per Mb in cases without a LRRK2 mutation (P<0.001). Of
note, 87% (N=60) of cases with LRRK2 mutations had a variant that could not be attributed to the TCT > TAT, TCG > TTG or TTT > TGG
mutation patterns.

1031
 Figure 1 - 1077

Conclusions: Somatic LRRK2 mutations occur in endometrial cancer, with frequent loss-of-function alterations and are associated with
prognostically favorable disease. The association of polymerase exonuclease defects and LRRK2 inactivation, seemingly independent of
polymerase proofreading errors, suggests an incipient functional relationship between the two that results in the ultra-mutated phenotype
of endometrial carcinomas.

1078 Looking Past PD-L1: Expression of Immune Checkpoint TIM-3 and its Ligand Galectin-9 in
Cervical and Vulvar Squamous Neoplasia
Jacob Curley1, Mark Stoler2, Anne Mills3
1
University of Virginia Health System, Charlottesville, VA, 2University of Virginia Health System, Earlysville, VA, 3University of
Virginia, Charlottesville, VA

Disclosures: Jacob Curley: None; Mark Stoler: None; Anne Mills: None

Background: Immunotherapies targeting the PD-1/PD-L1 pathway have shown some success in cervical and vulvar squamous cell
carcinomas (SCC), but little is known about the potential vulnerability of these tumors to other checkpoint inhibitors. TIM-3 is a checkpoint
molecule that exerts immunosuppressive function via its interaction with Gal-9. TIM-3 and Gal-9 have been identified on a variety of
malignancies but have not been studied in cervical and vulvar cancers, nor has their relationship to PD-L1 been established.

Design: Sixty-three cervical and vulvar invasive (n=34) and intraepithelial lesions (n=29) were assessed for TIM-3, Gal-9, and PD-L1 in
tumor/lesional cells and associated immune cells.

Results: Tumoral TIM-3 expression was identified in 85% of SCC but only 21% of intraepithelial lesions (p<0.0001). When immune cells
were accounted for, 97% of invasive and 41% of intraepithelial lesions had a TIM-3 combined positive score (CPS) ≥1
(p<0.0001). Tumoral membranous expression of Gal-9 was seen in 82% of SCC and 31% of intraepithelial lesions (p=0.0001); nearly all
cases had Gal-9-positive immune cells. Tumoral PD-L1 was seen in 71% of SCC and 10% of intraepithelial lesions (p<0.0001), while the
PD-L1 CPS was ≥1 in 82% and 24%, respectively (p<0.0001). There were no significant differences in TIM-3-, GAL-9, or PD-L1
expression in cervical vs. vulvar neoplasms, nor was HPV status significantly associated with any of the three markers.

1032
 TIM-3, GAL-9, and PD-L1 Co-Expression using the CPS.

TIM-3+ & GAL-9+ TIM-3+,

CPS≥1 GAL-9+, & PD-L1+
CPS≥1
All Intraepithelial Lesions 41% 7%
(n=29) (12/29) (2/29)
CIN 3 (n=14) 64% 0%
(9/14) (0/14)
VIN 3 (n=13) 23% 15%
(3/13) (2/13)
dVIN (n=2) 0% 0%
(0/2) (0/2)
All Invasive SCC 97% 82%
(n=34) (33/34) (28/34)
Cervical SCC (n=15) 100% 87%
(15/15) (13/15)
Vulvar SCC, HPV-Associated 100% 81%
(n=16) (16/16) (13/16)
Vulvar SCC, dVIN-associated 100% 67%
(n=3) (3/3) (2/3)
Figure 1 - 1078

Conclusions: Dual TIM-3/Gal-9 expression was present in the majority (86%) of PD-L1-positive cases including 100% of PD-L1-positive
SCC, suggesting a possible role for TIM-3 checkpoint inhibition in concert with anti-PD-1/PD-L1.

1033
1079 The Chronology of Development of Endometrioid Endometrial and Ovarian Tumors in Patients
with Synchronous Disease
Arnaud Da Cruz Paula1, Lea Moukarzel2, Nadeem Abu-Rustum1, Jose Palacios Calvo3, Xavier Matias-Guiu4, Jorge Reis-Filho1,
Britta Weigelt1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2Department of Surgery, Memorial Sloan Kettering Cancer Center,
New York, NY, 3Hospital Universitario Ramón y Cajal, Madrid, Spain, 4Hospital U Arnau de Vilanova and Hospital U de Bellvitge,
Lleida, Spain

Disclosures: Arnaud Da Cruz Paula: None; Lea Moukarzel: None; Nadeem Abu-Rustum: Grant or Research Support, Stryker; Grant or
Research Support, GRAIL; Jose Palacios Calvo: None; Xavier Matias-Guiu: None; Jorge Reis-Filho: None; Britta Weigelt: None

Background: Sporadic synchronous endometrioid endometrial (EECs) and endometrioid ovarian cancers (EOCs) have been shown to
be clonally related and to likely constitute metastases from each other. Here we sought to infer the chronology of the development of
EECs and EOCs in patients with sporadic synchronous disease based on bioinformatic approaches.

Design: Sequencing data of 17 previously published sporadic synchronous EECs/EOCs subjected to massively parallel sequencing
targeting 341 cancer-related genes were re-analyzed using validated bioinformatics methods. Clonal composition/ cancer cell fractions of
somatic mutations were inferred using ABSOLUTE, taking purity, ploidy and copy number into account.

Results: All 17sporadic synchronous EECs/EOCs were clonally related and were metastases from each other. Based on a clonal
composition analysis, the chronology of the development of the EECs and EOCs could be inferred in six cases. In these six synchronous
EECs/EOCs, the EOC likely evolved following clonal selection from a subpopulation of the EEC. We observed that either subclonal
mutations present in the EEC became clonal in the respective EOC and/ or additional genetic alterations were acquired in the EOC as
compared to the EEC. For example, in two of these six cases, subclonal PIK3CA hotspot mutations (p.P471L and p.R108H) identified in
the EEC became clonal in the EOC. Similarly, in one case, a subclonal PTEN hotspot mutation (p.R130G) in the EEC was found to be
clonal in the respective EOC. In another case, a subclonal APC frameshift mutation (p.D849Efs*11) detected in the EEC was found to be
clonal in the EOC, and the EOC harbored an 11q13 amplification, encompassing CCND1, not present in the EEC. Of note, in five of the
six cases where chronology could be inferred, no endometriosis was present.

Conclusions: Our findings suggest that in a subset of sporadic synchronous EECs/EOCs these lesions are of endometrial origin with the
endometrial tumor giving rise to the ovarian tumor.

1080 Concordance of p53 Immunohistochemistry and TP53 Mutation Status in Endometrial Cancer
Arnaud Da Cruz Paula1, Deborah DeLair2, Daniel Fix3, Robert Soslow1, Kay Park1, Sarah Chiang1, Jorge Reis-Filho1, Ahmet
Zehir1, Rajmohan Murali1, Vicky Makker1, Karen Cadoo1, Jennifer Mueller1, Mario Leitao1, Nadeem Abu-Rustum1, Carol
Aghajanian1, Britta Weigelt1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2NYU Langone Medical Center, New York, NY, 3Hackensack
University Medical Center, Hackensack, NJ

Disclosures: Arnaud Da Cruz Paula: None; Deborah DeLair: None; Daniel Fix: None; Robert Soslow: Speaker, Ebix/Oakstone; Kay
Park: None; Sarah Chiang: None; Jorge Reis-Filho: None; Ahmet Zehir: Speaker, Illumina; Rajmohan Murali: None; Vicky
Makker: Consultant, Eisai; Grant or Research Support, Eisai; Consultant, Merck; Advisory Board Member, Merck; Grant or Research
Support, Merck; Karen Cadoo: None; Jennifer Mueller: None; Mario Leitao: Speaker, Intuitive Surgical; Nadeem Abu-Rustum: Grant or
Research Support, Stryker; Grant or Research Support, GRAIL; Carol Aghajanian: Advisory Board Member, Eisai/Merck; Grant or
Research Support, Astra Zeneca; Grant or Research Support, Genentech; Grant or Research Support, Abbvie; Grant or Research
Support, Clovis; Britta Weigelt: None

Background: For the clinical identification of the four molecular subtypes of endometrial cancer (EC), which were originally identified
using whole-exome sequencing, surrogates employing immunohistochemistry (IHC) have been implemented. In this surrogate, p53 IHC is
used to identify ‘copy-number high’/ p53 abnormal ECs. We sought to define the concordance of p53 IHC and TP53 mutation status in
ECs.

Design: Patients with newly diagnosed primary EC were prospectively consented to an IRB-approved protocol. ECs were subjected to
p53 and DNA mismatch repair (MMR) protein IHC and to massively parallel sequencing targeting 410-468 cancer-related genes. ECs
were classified based on POLE mutation status and MMR and p53 IHC into the four molecular subtypes: POLE (ultramutated), MMR-
deficient, copy-number low (endometrioid) and copy-number high (serous-like). Concordance between p53 IHC and
somatic TP53 mutation status was defined using Cohen’s Kappa.

Results: 175 ECs were included in this study (116 endometrioid, 17 serous, 11 carcinosarcoma, 13 mixed, 6 clear cell, 7 dedifferentiated,
5 other). 41 (23%) ECs demonstrated aberrant p53 expression by IHC, and of these 36 (88%) harbored a somatic TP53 mutation (Table).
Of the 134 ECs with normal/ wild-type p53 protein expression by IHC, the majority of ECs (115; 86%) were molecularly concordant and
did not harbor a somatic TP53 mutation (Table). The agreement between the two methods was 151/175 (86%), with a Kappa of 0.726

1034
(good agreement). The sensitivity and specificity of p53 IHC for the detection of pathogenic TP53 mutations was 66% and 96%,
respectively. In total, there were 24 (14%) discrepant cases, which had aberrant p53 IHC in the absence of a TP53 mutation (n=5) or
a TP53 mutation but normal p53 protein expression patterns (n=19). Of the 19 TP53-mutant ECs with normal p53 IHC, 10 harbored non-
pathogenic TP53 mutations, 3 harbored subclonal TP53 hotspot mutations, 3 had subclonal TP53 loss of function mutations, and only 3
had clonal TP53 hotspot mutations (Table). Discrepancies were primarily observed in ECs of MMR-deficient (9/19) or POLE (4/19) EC
subtypes.

p53 immunohistochemistry
TP53 Normal Aberrant – null Aberrant –
(n) expression (n) overexpression (n)
Sequencing Mutation type
TP53 wild-type 115 0 5
TP53 hotspot 6 0 26
TP53 loss of function 3 2 6
TP53 other 10 0 2
Mutation clonality
TP53 clonal 9 1 29
TP53 subclonal 10 1 5
Number of hits
TP53 bi-allelic 5 1 22
TP53 mono-allelic 14 1 12

Conclusions: Our findings demonstrate a good concordance between p53 IHC and TP53 mutation status in EC. p53 IHC is a specific
and fairly sensitive surrogate for pathogenic TP53 mutations. The type and clonality of TP53 mutations explain the vast majority of
discrepancies between sequencing and IHC assessment of TP53.

1081 Concordance between Immunohistochemistry for DNA Mismatch Repair Proteins and Next
Generation Sequencing for the Identification of Microsatellite Instability in Endometrial Cancer
Arnaud Da Cruz Paula1, Deborah DeLair2, Daniel Fix3, Robert Soslow1, Kay Park1, Sarah Chiang1, Jorge Reis-Filho1, Ahmet
Zehir1, Diana Mandelker1, Rajmohan Murali1, Vicky Makker1, Karen Cadoo1, Jennifer Mueller1, Mario Leitao1, Nadeem Abu-
Rustum1, Carol Aghajanian1, Britta Weigelt1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2NYU Langone Medical Center, New York, NY, 3Hackensack
University Medical Center, Hackensack, NJ

Disclosures: Arnaud Da Cruz Paula: None; Deborah DeLair: None; Daniel Fix: None; Robert Soslow: Speaker, Ebux/Oakstone; Kay
Park: None; Sarah Chiang: None; Jorge Reis-Filho: None; Ahmet Zehir: Speaker, Illumina; Diana Mandelker: None; Rajmohan Murali:
None; Vicky Makker: Grant or Research Support, Eisai; Consultant, Eisai; Advisory Board Member, Merck; Speaker, Merck; Grant or
Research Support, Merck; Karen Cadoo: None; Jennifer Mueller: None; Mario Leitao: Speaker, Intuitive Surgical; Nadeem Abu-
Rustum: Grant or Research Support, Stryker; Grant or Research Support, GRAIL; Carol Aghajanian: Advisory Board Member,
Eisai/Merck; Britta Weigelt: None

Background: The NCCN currently recommends microsatellite instability (MSI) or mismatch repair (MMR) immunohistochemistry (IHC) for
patients with endometrial cancer (EC) as a screen for Lynch Syndrome and criteria for immune checkpoint inhibitor therapy. Recently,
MSI testing has become available through next generation sequencing (NGS). We sought to compare the concordance of MMR IHC and
MSI status obtained via NGS in EC.

Design: Patients with newly diagnosed primary EC were prospectively consented to an IRB-approved protocol. ECs were subjected to
MMR IHC and targeted NGS with a panel covering over 400 cancer-related genes. MSIsensor was used to bioinformatically infer the MSI
status, with an MSIsensor score ≥10 deemed MSI-high. Tumor cell content was inferred bioinformatically using
ABSOLUTE. Concordance between IHC and sequencing results was defined using Cohen’s Kappa.

Results: 175 ECs were included (116 endometrioid, 17 serous, 11 carcinosarcoma, 13 mixed, 6 clear cell, 7 dedifferentiated, 5 other). 50
(29%) were considered MMRd based on the loss of at least one MMR protein by IHC, of which 30 (60%) ECs were classified as MSI-high
by MSIsensor (Table). Of the 125 ECs with retained MMR expression, the vast majority (123; 98%) was molecularly concordant and was
not MSI-high (Table). The overall agreement between MMRd and MSI-high by MSIsensor was 153/175 (87%), with a Kappa of 0.749
(good agreement). Of the 20 MMRd classified as non-MSI-high, 9 were MSI indeterminate and 11 microsatellite stable. Of these 11
discrepant ECs (i.e. MMRd and microsatellite stable), 4 displayed loss of MLH1 and PMS2 expression, 1 PMS2 loss and 6 MSH6 loss of
expression (Table). The tumor purity was significantly lower in the 20 MMRd non-MSI-high ECs (median 26%, range 19-60%) compared
to the 30 MMRd MSI-high concordant ECs (median 49%, range 20-95%; p<0.001).

1035
 MMR IHC Results MSI Status (MSIsensor)
Microsatellite stable MSI indeterminate MSI-high (MSIsensor
(MSIsensor <3) (n) (MSIsensor 3-9.99) (n) ≥10) (n)
MMR proficient 118 5 2
MMR deficient 11 9 30
MLH1 and PMS2 loss 4 6 29
MSH2 and MSH6 loss 0 1 1
PMS2 only loss 1 1 0
MSH6 only loss 6 1 0

Conclusions: Our findings revealed a good agreement between MMR IHC and MSI status inferred from NGS for EC. Tumor purity may
falsely decrease the degree of MSI in EC. However, in addition to MSI status, multi-gene sequencing assays provide information on
specific somatic/ germline mutations, copy number alterations and tumor mutational burden in a single assay.

1082 Mesonephric and Mesonephric-Like Carcinomas of the Female Genital Tract: Molecular
Interrogation Including Three Cases Mixed with Serous and Mucinous Neoplasms
Edaise M. da Silva1, Daniel Fix2, Ana Paula Martins Sebastiao3, Pier Selenica1, Ferrando Lorenzo1, Simon Lee1, Evan Smith1,
Anthe Stylianou4, Arnaud Da Cruz Paula1, Fresia Pareja1, Sarah Kim1, Jason Konner5, Karen Cadoo1, Nadeem Abu-Rustum1,
Jorge Reis-Filho1, Jennifer Mueller1, Britta Weigelt1, Kay Park1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2Hackensack University Medical Center, Hackensack, NJ, 3Positivo
University, Curitiba, PR, Brazil, 4Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 5Department
of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY

Disclosures: Edaise M. da Silva: None; Daniel Fix: None; Ana Paula Martins Sebastiao: None; Pier Selenica: None; Ferrando Lorenzo:
None; Simon Lee: None; Evan Smith: None; Anthe Stylianou: None; Arnaud Da Cruz Paula: None; Fresia Pareja: None; Sarah Kim:
None; Jason Konner: None; Karen Cadoo: None; Nadeem Abu-Rustum: Grant or Research Support, Stryker; Grant or Research Support,
GRAIL; Jorge Reis-Filho: None; Jennifer Mueller: None; Britta Weigelt: None; Kay Park: None

Background: Mesonephric carcinoma (MC) of the cervix is a rare tumor derived from Wolffian remnants. Mesonephric-like carcinomas
(MLC) of the ovary (MLCO) and endometrium (MLCE), while morphologically similar, do not have obvious Wolffian origin and possibly
represent transdifferentiation of Müllerian tumors. Here, we describe the repertoire of genetic alterations in MC and MLC, including 3
MLCO mixed with Müllerian tumors.

Design: DNA from microdissected tumor and normal tissue from 8 MCs (6 primary and 2 metastatic tumors), 15 MLCOs and 13 MLCEs
were subjected to massively parallel sequencing targeting 468 cancer-related genes. The histologically distinct components of three
mixed MLCOs were analyzed separately.

Results: Recurrent KRAS mutations were present in 100% of MCs, 87% (13/15) of MLCOs and 92% (12/13) of MLCEs
(Table). PIK3CA mutations were identified in 33% (5/15) of MLCOs, in 23% (3/13) of MLCEs and in two metastases (lung and brain) of
MCs. Only MLCs harbored CTNNB1 (MLCO 1/15, 6%; MLCEs 3/13, 23%) and PTEN mutations (MLCEs 3/13, 23%). Copy number
analysis revealed frequent gains of 1q in MCs (7/8, 87%), MLCOs (14/15, 93%) and MLCEs (11/13, 85%). Gains of chromosome 12 were
more frequent in MLCOs (10/15, 67%) than in MLCEs (2/13, 15%) and MCs (3/8, 37%; p<0.05), whereas loss of chromosome 9 was
more frequent in MCs (4/8, 50%) than in MLCOs (1/15, 6%) and MLCEs (1/13, 7%; p<0.05). Three MLCOs were mixed with other
histologies: 2 mucinous borderline tumors (MBT) and 1 serous borderline tumor (SBT). Both MLCO/SBT cases included in this study
harbored NRAS p.Q61R hotspot rather than KRAS mutations. The SBT and MLCO components of one case analyzed separately
harbored similar mutation profiles. In both MLCO/MBT cases, the two separately sequenced components shared KRAS hotspot
mutations. In addition, one of the cases also harbored PIK3CA hotspot mutations, whereas in the other case, CTNNB1 and AKT hotspot
mutations were found to be restricted to the MLCO component.

MCs (n=8) MLCO (n=15) MLCE (n=13)

Histology Mesonephric 6 (75%) - -
Mesonephric-like - 8 (53%) 9 (70%)
Mixed histologies 1 (12.5%) A 6 (40%) B* 2 (15%) C*
Mesonephric MMMT 1 (12.5%) 1 (7%) 2 (15%)
Recurrent KRAS 8 (100%) 13 (87%) 12 (92%)
Mutations PIK3CA 2 (25%) 5 (33%) 3 (23%)
CTNNB1 - 1 (6%) 3 (23%)
PTEN - - 3 (23%)
Recurrent Copy Gain 1q 7 (87%) 14 (93%) 11 (85%)
Number Gain chromosome 12 3 (37%) 10 (67%) 2 (15%)
Alterations Loss Chromosome 9 4 (50%) 1 (6%) 1 (7%)

1036
A. Mixed mesonephric and endometrioid (n=1); B. Mixed mesonephric-like and: endometrioid (n=2), MBT (n=2; *both cases had separate
components sequenced) and SBT (n=2; *1 case had separate components sequenced); C. Mixed mesonephric-like and: endometrioid
(n=1), endometrioid/clear cell carcinoma (n=1)

Conclusions: MLCs are underpinned by somatic KRAS mutations akin to MCs but also harbor genetic alterations that are frequently
reported in Müllerian tumors, such as PIK3CA, PTEN and CTNNB1. Our findings suggest that MLCs harbor features similar to those of
tumors with mesonephric and Mullerian differentiation. The histologically distinct components of mixed MLCs harbor similar patterns of
genetic alterations supporting their clonal relatedness.

1083 Clinicopathologic and Genomic Analysis of Copy Number-High (CN-H) Endometrial Carcinomas
Wissam Dahoud1, Amir Momeni Boroujeni2, Chad Vanderbilt3, Robert Soslow1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2Memorial Sloan Kettering Cancer Center, Brooklyn, NY, 3Memorial
Sloan Kettering Cancer Center, Denver, CO

Disclosures: Wissam Dahoud: None; Amir Momeni Boroujeni: None; Chad Vanderbilt: Consultant, Paige.AI; Consultant, Docdoc
ltd.; Consultant, OncoKB; Robert Soslow: Consultant, Ebix/Oakstone

Background: The TCGA analysis of endometrial carcinomas identified a group of tumors with TP53 mutations, chromosomal instability
and copy number variations (CN-H), The prototypical histotype is serous carcinoma (USC), but there is also a histologically diverse group
of endometrial carcinomas with similar genomic characteristics (CN-H non-serous [CN-H-NS]) such as TP53-mutated FIGO grade 3
endometrioid carcinoma. We aim to compare the clinicopathologic and genomic features of CN-H-NS versus USC.

Design: All archival USC and CN-H-NSs studied by targeted next generation sequencing were selected and molecular, clinical and
pathologic data pertaining to these cases compared. Histotypes were assigned morphologically and in some cases
immunohistochemically by a homogeneous group of expert gynecologic pathologists at a single institution.

Results: 129 cases were included in the study: 32 endometrioid (25%), 53 USC (41%), 6 clear cell carcinomas (4%), 28 mixed
endometrial carcinomas (22%), and 10 high-grade endometrial carcinomas, unclassified (8%). The median survival was 28.93 months.
Histotype did not correlate with survival, but USC was more likely to metastasize to peritoneum and lung. Important predictors of outcome
were FIGO stage (p: 0.005) and molecular findings that adversely affect survival (p: 0.0176): namely, chromosome 11q (FGF cluster
genes) and 8q gains, ERBB2 and MAPK3 amplification, and alterations in CDK12 and CASP8.

Figure 1 - 1083

Conclusions: CN-H-NS and USC have similar clinical outcomes regardless of histotype. FIGO stage and molecular findings are the best
predictors of outcome overall. This suggests that patients with CN-H carcinomas, regardless of histotype or stage, could be managed
similarly to USC, pending studies of chemo- and radio-sensitivity stratified by histotype.

1037
1084 The Prognostic Impact of ARID1A Alteration in a Cohort of Molecular Classified Endometrial
Carcinomas
Antonio De Leo1, Dario de Biase2, Sara Coluccelli3, Giulia Dondi4, Pierandrea De Iaco1, Anna Myriam Perrone1, Donatella
Santini1, Giovanni Tallini5, Claudio Ceccarelli1
1
S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy, 2University of Bologna, Bologna, Italy, 3Gynecologic Oncology
Unit, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy, 4S. Orsola-Malpighi Hospital, University of Bologna,
Modena, Italy, 5University of Bologna School of Medicine, Bologna, Italy

Disclosures: Antonio De Leo: None; Dario de Biase: None; Sara Coluccelli: None; Giulia Dondi: None; Pierandrea De Iaco: None; Anna
Myriam Perrone: None; Donatella Santini: None; Giovanni Tallini: None; Claudio Ceccarelli: None

Background: The Cancer Genome Atlas (TCGA) molecular classification of endometrial carcinomas (EC) into DNA polymerase epsilon
mutant (POLEmut), mismatch repair deficient (MMRd), p53 mutant (p53abn) and no specific molecular profile (NS) groups has relevant
prognostic impact. Our aim is to investigate the clinicopathologic and prognostic impact of ARID1A alteration in a cohort of ECs classified
into TCGA molecular groups.

Design: Clinical and follow-up data, histotype, grade, necrosis, mitoses, Ki-67 proliferation index, pattern of myometrial invasion, lymph
vascular invasion, stromal and intraepithelial tumor-infiltrating lymphocytes (sTILs and iTILs), FIGO stage were analyzed in a cohort of 90
ECs. Immunohistochemistry and/or Next-Generation Sequencing (NGS) were used to assign TCGA groups according to ProMisE
system and to investigate molecular alterations of multiple target genes including POLE, PTEN, ARID1A, ß-catenin, TP53, MLH1, PMS2,
MSH2, MSH6 and L1CAM.

Results: TCGA class assignment: 30 MMRd (33.3%), 7 POLEmut (7.7%), 18 p53abn (20%) and 35 NS (38.9%). TCGA groups are
significantly associated with different grade, sTILs, iTILs, mitoses, Ki-67 index, pattern of invasion, L1CAM expression. Each TCGA class
was further subdivided based on ARID1A loss/mutation (*A) and on ß-catenin nuclear expression/mutation (*ß) as follows: POLEmut,
POLEmut(*A), p53abn, p53abn(*A), MMRd, MMRd(*A), NS, NS(*A), NS(*ß), NS(*ß)(*A). Loss/mutation of ARID1A (*A subgroups) is
associated with higher grade (p<0.0001), increase of sTILs and iTILs (p=0.011 and p=0.0006, respectively), necrosis (p=0.018), higher
mitotic and Ki-67 proliferation indexes (p<0.0001), MELF pattern of invasion (p=0.048), tumor budding (p=0.004), and L1CAM expression
(p<0.0001) in MMRd and NS tumors. ARID1A alteration (*A) is not associated with clinicopathological features or L1CAM expression in
POLEmut and p53abn tumors. Seven of 90 (7.7%) ECs recurred (median follow-up 11 months, range 1-99): 4 NS (*A), 1 MMRd (*A), 2
p53abn.

Figure 1 - 1084

Conclusions: In MMRd and NS groups loss of ARID1A correlates with aggressive clinicopathologic features, including higher grade,
increased proliferation, specific invasion patterns (MELF and/or budding), TILs, and worse disease-free survival. ARID1A analysis
represents a useful tool to stratify EC risk, and it appears particularly promising for the TCGA NS group.

1038
1085 Exploring the Immune Landscape of Squamous Cell Neoplasia of the Vulva
Hany Deirawan1, Saivaishnavi Kamatham2, Joseph Trak2, Nabil Rahoui2, Vishakha Pardeshi3, Mohamad D EL Abdallah4,
Ibrahim Tsolakian5, Andrew Toma2, Michael Salloum6, Kang Chen7, Rouba Ali-Fehmi2
1
Detroit Medical Center/Wayne State University, Detroit, MI, 2Wayne State University, Detroit, MI, 3Westland, MI, 4Wayne State
University, Dearborn Heights, MI, 5Wayne State University/Detroit Medical Center, Livonia, MI, 6Wayne State University,
Bloomfield Hills, MI, 7Wayne State University and National Institutes of Health, Detroit, MI

Disclosures: Hany Deirawan: None; Saivaishnavi Kamatham: None; Joseph Trak: None; Nabil Rahoui: None; Vishakha Pardeshi: None;
Mohamad D EL Abdallah: None; Ibrahim Tsolakian: None; Andrew Toma: None; Michael Salloum: None; Kang Chen: None; Rouba Ali-
Fehmi: None

Background: The overall incidence of vulvar neoplasia has increased multifold, a phenomenon only partially explained by an aging
population and improvements in detection rate. The tumor immune microenvironment (TIME) of vulvar cancer is not well studied and has
lagged behind because of its exclusion from The Cancer Genome Atlas (TCGA) cohort. The exact sequence of events in the
carcinogenesis of vulvar squamous cell carcinoma (vSCC) and the role of the immune response in progression is not fully established.
Studying the immune landscape of vSCC offers an opportunity for identifying novel markers of tumor biology and predicting response to
immune checkpoint blockade.

Design: We retrospectively identified cases of vulvar intraepithelial neoplasia (VIN3) (n=43) and vSCC (n=46). p53 immunohistochemical
labeling was interpreted according to published criteria, and a 1% positivity threshold was adopted for PD-L1. Semi-quantitative
assessment of immune fraction and immune cell localization on routine histology with a threshold of 5% to be considered positive was
used.

Results: Aberrant PD-L1 expression in tumor cells, defined as staining in more than 1% of cases, was evident in 46.51% and 50% of
VIN3 and vSCC cases, respectively. Expression of p53 consistent with non-silent mutations was seen in 23.25% of VIN3 cases and in
21.73% of vSCC cases. There was a strong correlation between p53 mutant vSCC and PD-L1 positivity as shown in Figure 1.

Pattern and extent of immune infiltration was assessed in VIN3 and vSCC. Immune evasion was evident in 47% in VIN3 and 25% of
vSCC, respectively. A higher incidence of intraepithelial tumor-infiltrating lymphocytes (TILsIE) was observed in PD-L1+ vSCC as
illustrated in Table 1. Furthermore, a stromal TIL component was present in 75% of PD-L1+ vSCC vs 31.4% of PD-L1- vSCC cases.
Lymphoid aggregates reminiscent of tertiary lymphoid structures were seen more often in PD-L1+ vSCC (62.5% vs. 22.8%) and with
plasma cells (≥50%) being a significant component of these aggregates in 60% of vSCC cases. Finally, absence of organized lymphoid
structures (OLS) or TILs at the invasive margin in vSCC correlated with an absence of PD-L1 expression as shown in Figure 2.

Table 1. The localization of immune cells in VIN3 and vSCC (expressed as frequency per distinct group)

Cases with immune infiltration

Frequency per group VIN3 PD-L1+ SCC PD-L1- SCC
TILsIE 13 % 50 % 20 %
Lichenoid/invasive margin TILs 53% 75% 22.8%

Figure 1 - 1085

1039
 Figure 2 - 1085

Conclusions: The role of HPV status and p53 in evaluating the treatment modalities and the biologic potential of vSCC can be enhanced
by a robust cost-effective in-situ assessment of the TIME. This can also help identify novel driver mutations and survival mechanisms of
cancer cells.

1086 A Multiplex SNaPshot Assay is a Rapid and Cost-Effective Method for Detecting POLE Mutations
in Endometrial Carcinoma
Kelly Devereaux1, David Steiner2, Chandler Ho3, Adam Gomez4, Linda Gojenola3, C. Blake Gilks5, Teri Longacre6, James
Zehnder1, Brooke Howitt1, Carlos Suarez7
1
Stanford University School of Medicine, Stanford, CA, 2Stanford University School of Medicine, Redwood City, CA, 3Stanford
University Medical Center, Palo Alto, CA, 4Phoenix VA HCS, Phoenix, AZ, 5Vancouver General Hospital, Vancouver,
BC, 6Stanford University, Stanford, CA, 7Stanford University School of Medicine, Palo Alto, CA

Disclosures: Kelly Devereaux: None; David Steiner: Employee, Google; Stock Ownership, Google; Chandler Ho: None; Adam Gomez:
None; Linda Gojenola: None; C. Blake Gilks: None; Teri Longacre: None; James Zehnder: None; Brooke Howitt: None; Carlos Suarez:
None

Background: POLE mutation status in endometrial carcinoma (EC) has important clinical implications, specifically recent evidence
suggests that it defines a prognostically favorable subgroup, even amongst high-grade histotypes. Currently, there are no specific
morphologic or immunophenotypic features that allow accurate detection of POLE-mutated tumors without molecular testing.
Consequently, identifying POLE-mutated tumors has been challenging without employing costly and time consuming DNA sequencing
approaches. Here we developed a novel SNaPshot assay in order to routinely and efficiently test for POLE mutations in ECs.

Design: A custom single nucleotide extension SNaPshot assay was optimized on DNA extracted from FFPE tissue. Exonuclease
domain POLE exons are initially PCR amplified. Hotspot single nucleotide variants are then interrogated by single-base extension,
whereby DNA polymerase adds a single fluorescently-labeled dideoxynucleotide (ddNTP) to the 3’ end of unlabeled, differentially sized
oligonucleotide primers. SNaPshot products are analyzed by capillary electrophoresis and resolved by length and fluorescence.

Results: The SNaPshot assay detects 15 somatic mutation sites within exons 9, 11, 13, and 14 of the POLE exonuclease domain. Sites
were selected based on evidence of functional impact, association with high tumor mutation burden, and/or mutations reported in clinical
outcome studies for ECs. Based on the pathogenic somatic variants previously reported in the literature, the assay is predicted to have a
clinical sensitivity of 90-95% for ECs. Validation studies showed 100% specificity and sensitivity for the variants covered, with expected
genotypic results for both the positive (n=10) and negative (n=20) patient controls. Analytic sensitivity was conservatively approximated at
a 10% variant allele fraction (VAF), with documented detection as low as 5% VAF. As expected, the SNaPshot assay has greater
sensitivity than Sanger sequencing, which can only reliably detect variants down to 20% VAF.

Conclusions: We have developed and validated the first SNaPshot assay to detect hotspot exonuclease domain mutations in POLE.
While NGS and Sanger sequencing-based approaches have also been used to detect POLE mutations, a SNaPshot approach was
chosen to provide a more optimal balance of analytical sensitivity, cost-effectiveness and efficiency in a high-volume case load setting.
This assay is accurate, scalable and may be more suitable for clinical use.

1040
1087 Molecular Classification of Metastatic and Recurrent Endometrial Endometrioid Carcinoma
Kelly Devereaux1, Stephanie Chow1, David Steiner2, Grace Peters-Schulze3, Chandler Ho4, Carlos Suarez5, Ann Folkins1,
Brooke Howitt1
1
Stanford University School of Medicine, Stanford, CA, 2Stanford University School of Medicine, Redwood City, CA, 3Stanford
University, Stanford, CA, 4Stanford University Medical Center, Palo Alto, CA, 5Stanford University School of Medicine,
Palo Alto, CA

Disclosures: Kelly Devereaux: None; Stephanie Chow: None; David Steiner: Employee, Google; Employee, Google; Grace Peters-
Schulze: None; Chandler Ho: None; Carlos Suarez: None; Ann Folkins: None; Brooke Howitt: None

Background: Endometrial endometrioid carcinoma (EEC) has variable clinical outcomes. Molecular classification per The Cancer
Genome Atlas (TCGA) study may improve prognostication in EEC as well as have treatment implications: POLE-mutated, microsatellite
instability (MSI), p53 abnormal (p53 abnl), and no specific molecular profile (NSMP). This study classifies metastatic/recurrent ECC into
molecular groups to examine the correlation with pattern of disease and outcomes.

Design: EECs metastatic at the time of diagnosis or with documented recurrent/metastatic disease were included. Clinicopathologic
features, including clinical status at last follow-up, were recorded. Metastatic/recurrent disease sites were subclassified: vaginal cuff,
adnexal, abdominal, lymph node (LN), or distant. Immunohistochemistry (IHC) for PMS2, MSH6, p53 and POLE sequencing were
performed to establish TCGA molecular classification.

Results: Of 128 patients with EEC, 266 samples (104 primary; 162 metastatic) were included. Primary and matched metastasis was
tested in 97 patients. Cases were classified as POLE-mutated (8; 6%), MSI (41; 32%), p53 abnl (16; 13%), or NSMP (63; 49%) (Table
1). 66 (53%) presented with metastasis at the time of diagnosis, 44 (35%) had recurrence, and 15 (12%) had both. Discordant
classification between primary and metastatic EEC was seen in 4/97 (4%), all related to PMS2/MSH6 IHC. Grade 1 EEC was most likely
to be NSMP (80%), while the majority of grade 2 were MSI (54%) and grade 3 was most commonly p53 abnl (42%). Patterns of
recurrence compared across TCGA classification are demonstrated in Figure 1. Status at last clinical follow-up revealed the majority of
p53 abnl EECs were dead of disease (DOD) or alive with disease (AWD), while the other groups had similar distributions amongst AWD,
DOD, and alive with no evidence of disease (ANED) (Figure 2). Notably, the POLE-mutated group included 2 patients who were DOD.

Grade of Primary EEC

Classification Cases 1 2 3 Unknown
NSMP 63 (49%) 32 (51%) 19 (30%) 7 (11%) 5 (8%)
MSI 41 (32%) 5 (12%) 26 (63%) 9 (22%) 1 (2%)
POLE MUTATED 8 (6%) 2 (25%) 2 (25%) 3 (38%) 1 (13%)
p53 ABNORMAL 16 (13%) 1 (6%) 1 (6%) 14 (88%) 0 (0%)
Total 128 (100%) 40 (31%) 48 (38%) 33 (26%) 7 (5%)

Figure 1 - 1087

1041
 Figure 2 - 1087

Conclusions: TCGA molecular classification in metastatic/recurrent EEC is similar to what is generally reported in EEC. Discrepant
classification between primary and metastatic sites was associated with MSI status, suggesting a relationship with tumor heterogeneity
and hypermutation. Molecular studies to assess for tumor mutational burden are underway. Based on classification as MSI/POLE-
mutated, 38% of metastatic EEC may benefit from immune checkpoint inhibition. Metastatic EEC classified as p53 abnl had the worst
clinical outcomes.

1088 Pregnancy-Associated Inflammatory Myofibroblastic Tumors of the Uterus are Clinically Distinct
and Highly Enriched for ALK-TIMP3 and ALK-THBS1 Fusions
Kelly Devereaux1, Megan Fitzpatrick2, Charles Bangs3, Sara Hartinger4, Carol Jones3, Christian Kunder1, Teri Longacre4
1
Stanford University School of Medicine, Stanford, CA, 2Stanford Health Care, Palo Alto, CA, 3Stanford University, Palo Alto,
CA, 4Stanford University, Stanford, CA

Disclosures: Kelly Devereaux: None; Megan Fitzpatrick: None; Charles Bangs: None; Sara Hartinger: None; Carol Jones: None;
Christian Kunder: None; Teri Longacre: None

Background: As ALK-positive inflammatory myofibroblastic tumors (IMTs) have become more widely recognized in the female genital
tract, an intriguing subset of tumors associated with pregnancy has emerged. Whether IMTs arising in the setting of pregnancy have a
distinct biology and/or disease course compared to non-pregnancy associated IMTs remains unknown. Furthermore, little is known about
the clinical and perinatal factors that may influence the development these tumors. Here we report the largest case series of pregnancy-
associated IMTs to address these outstanding questions.

Design: A total of eight cases of pregnancy-associated IMTs of uterus were retrospectively reviewed for this study. ALK IHC
and fluorescent in situ hybridization (FISH) studies were performed on whole sections. Anchored multiplex PCR and RNA-sequencing
techniques were used to identify gene fusions in each tumor.

Results: Pregnancy-associated IMTs occur in association with pregnancy complications, including abnormal implantation, gestational
diabetes, pre-eclampsia or coagulopathy. Notably, 7 of 8 IMTs were expelled at the time of delivery as either adherent to placenta or
separate, detached tissue. Tumors are small (mean 4 cm), well-circumscribed and histologically show prominent myxoid stroma and a
lymphoplasmacytic infiltrate. Granular cytoplasmic and perinuclear ALK IHC staining and a classic ALK rearrangement break-apart FISH
pattern are seen in 7 out of 8 cases. Of these 7 ALK-rearranged tumors, 5 harbor ALK-TIMP3 and 2 harbor ALK-THBS1 fusion
transcripts. The remaining eighth case has morphologic features of an IMT and is positive by ALK IHC, but lacks ALK rearrangement by
FISH or a detectable fusion transcript by our methodology. Women with pregnancy associated IMTs do not appear to be at risk of
recurrent disease based on short-term follow-up.

Conclusions: Our findings suggest that pregnancy-associated IMTs may arise in association with aberrant endometrial remodeling and
placentation during complications of pregnancy. Interestingly, pregnancy-associated IMTs seem to harbor ALK rearrangements with
genes, such as THBS1 (thrombospondin-1) and TIMP-3 (metalloproteinase inhibitor 3), that are known to be transcriptionally active in
pregnancy and facilitate endometrial remodeling and implantation. Although the length of clinical follow-up in this study is limited, the fact
that the majority of tumors are shed at the time of delivery suggests that these are transient tumors with a particularly indolent clinical
course.

1042
1089 Long Interspersed Element-1 (LINE-1) Protein Expression is Present in Clear Cell Carcinomas and
Early Endometriotic Precursors
Kyle Devins1, Sho Sato2, Lauren Schwartz3, Ronny Drapkin4
1
Hospital of the University of Pennsylvania, Philadelphia, PA, 2Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, 3Perelman School of Medicine at the University of Pennsylvania, Bala Cynwyd, PA, 4Perelman School of
Medicine at the University of Pennsylvania, Philadelphia, PA

Disclosures: Kyle Devins: None; Sho Sato: None; Lauren Schwartz: None; Ronny Drapkin: Advisory Board Member, Repare
Therapeutics; Advisory Board Member, Siamab Therapeutics; Consultant, Mersana Therapeutics

Background: Nearly half of the human genome consists of mobile repetitive DNA elements. The most prevalent is the retrotransposon
Long Interspersed Element 1 (LINE-1) which contains over 500,000 copies and constitutes nearly 17% of the genome. LINE-1 is typically
suppressed to prevent the deleterious consequences of random LINE-1 element insertion into the genome. However, numerous studies
demonstrate LINE-1 reactivation in a variety of epithelial cancers. Herein we demonstrate that LORF1, one of the two open reading
frames (ORF) encoded by LINE-1, is expressed in a subset of ovarian clear cell carcinomas (CCOC) as well as endometriotic precursor
lesions.

Design: Ten CCOC cell lines were cultured to 80% confluence and investigated for LORF1 expression using Western blotting. A tissue
microarray (TMA) was also constructed using archival FFPE tissue from 40 cases of CCOC collected from the institutional pathology
department. Three 1.0 mm cores were obtained per tumor. Cases were reviewed to confirm initial diagnosis. Controls consisted of
numerous benign and malignant human tissues. TMA slides were investigated with LORF1 immunohistochemistry (IHC). Whole-mount
slides of benign endometriosis (BEM) (n=11), atypical endometriosis (AEM) (n=8), ovarian endometrioid carcinoma (OEC) (n=11),
proliferative phase endometrium (n=5), and secretory phase endometrium (n=5) were also stained for LORF1. LORF1 expression by IHC
was scored as follows: 0 (negative), 1+ (weak cytoplasmic positivity), 2+ (moderate staining in >50% of cells), or 3+ (strong,
diffuse)(Figure 1). Scores of 0 and 1+ were considered “LORF1 negative” while scored of 2+ and 3+ were considered “LORF1 positive.”

Results: Western blot analysis showed that LORF1 protein was readily detectable in CCOC cell lines, but absent in non-tumorigenic
fallopian tube cell lines. LORF1 was positive by IHC in 85% of archived cases (See Figure 2 for scoring distribution). A similar rate of
positivity was noted in OEC (8/11). In addition, all 7 cases of AEM and 3/11 cases of BEM stained positive for LORF1. Two cases of
proliferative endometrium showed LORF1 expression, but all cases of secretory endometrium were negative.

Figure 1 - 1089

1043
 Figure 2 - 1089

Conclusions: A subset of CCOC and OEC are marked by LORF1 expression, suggesting reactivation of LINE-1 in these tumors.
Interestingly, LORF1 expression was also noted in endometrioitic lesions as well as benign endometrium. This suggests LINE-1
reactivation is an early event in the progression from endometriosis to carcinoma.

1090 Comparative Proteomics Identifies EMILIN3 and INA as Novel Markers for Low-Grade Endometrial
Stromal Sarcoma
Kyle Devins1, Dylan Marchione2, Li-Ping Wang1, Benjamin Garcia2, Lauren Schwartz3, John Wojcik2
1
Hospital of the University of Pennsylvania, Philadelphia, PA, 2University of Pennsylvania, Philadelphia, PA, 3Perelman School of
Medicine at the University of Pennsylvania, Bala Cynwyd, PA

Disclosures: Kyle Devins: None; Lauren Schwartz: None; John Wojcik: None

Background: Morphologic distinction between LG-ESS and smooth muscle neoplasms, especially highly cellular leiomyoma (HCL), can
prove challenging for the pathologist. Detection of gene fusions, most often involving JAZF1-SUZ12, can confirm the diagnosis of LG-
ESS. However, fusions cannot be detected in all cases due to variant gene partners and availability of testing. Immunohistochemical
(IHC) panels to aid in the diagnosis of LG-ESS rely on expression of CD10 and negativity for smooth muscle markers, but IHC is limited
by overlapping expression. To improve diagnostic accuracy, we used comparative proteomics to identify novel IHC targets.

Design: Seven cases each of LG-ESS and HCL were selected from archived cases and reviewed to confirm diagnoses. Protein was
extracted from FFPE tumor cores using the HYPERsol method and evaluated via liquid chromatography-mass spectrometry. Data was
analyzed using Spectronaut Pulsar X.

Tissue microarrays (TMAs) were constructed to test potential IHC markers using cores from FFPE blocks. The TMAs included 9 cases of
LG-ESS, 10 HCL, 4 standard leiomyomas, 12 uterine leiomyosarcomas (LMS), and 12 extra-uterine LMS. IHC was performed on a Leica
Bond-IIITM instrument using antibodies to EMILIN3 (1:100 dilution, HPA059912, Sigma) and INA (1:200 dilution, HPA008057, Atlas
antibodies) and polymer detection per manufacturer protocol (Leica Microsystems RE7230-CE).

Results: An average of 2886 proteins were identified in LG-ESS and 2892 in HCL. Candidate proteins were sorted based on differential
expression, focusing on proteins with greater abundance in LG-ESS. NEP/MME (CD10) showed high differential expression in LG-ESS
relative to HCL, supporting the utility of our approach. Among novel candidates, elastin microfibril interface-located protein 3 (EMILIN3)
and alpha-internexin (INA) were chosen based on expression levels in the tumor samples and tissue expression profiles from the Human
Protein Atlas (HPA). IHC testing on TMAs revealed INA to be highly sensitive for LG-ESS (8/8 positive). EMILIN3 was less sensitive (6/8
cases positive) but highly specific for LG-ESS compared to smooth muscle tumors, staining negative in all cases of HCL and LMS. One
case of LG-ESS was uninterpretable due to tissue loss.

1044
 IHC Tumor Type Positive Total Percentage
EMILIN3 ESS 6 8 75%
HCL 0 12 0%
Uterine LMS 0 12 0%
EU-LMS 0 12 0%
INA ESS 8 8 100%
HCL 1 12 8%
Uterine LMS 2 12 17%
EU-LMS 2 12 17%

Figure 1 - 1090 Figure 2 - 1090

Conclusions: Comparative proteomics of archival specimens identified EMILIN3 and INA as novel diagnostic markers to discriminate
between LG-ESS and smooth muscle tumors. These markers have been preliminarily validated on TMAs, and await further validation in
larger cohorts.

1091 Ovarian Neuroendocrine Tumors: Pathological and Immunohistochemical Features of a Single-

Center Case Series
Doriana Donatella Di Nanni1, Lucia Domeniconi2, Francesca Ambrosi3, Giulia Girolimetti4, Giacomo Santandrea1, Donatella
Santini1, Giovanni Tallini5, Antonio De Leo1
1
S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy, 2Pathology Unit, S. Orsola - Malpighi Hospital, Imola, BO,
Italy, 3S.Orsola-Malpighi Hospital, University of Bologna, Bari, Italy, 4Department of Medical and Surgical Sciences (DIMEC),
Unit of Medical Genetics, University Hospital S.Orsola-Malpighi, Bologna, Italy, 5University of Bologna School of Medicine,
Bologna, Italy

Disclosures: Doriana Donatella Di Nanni: None; Lucia Domeniconi: None; Francesca Ambrosi: None; Giulia Girolimetti: None; Giacomo
Santandrea: None; Antonio De Leo: None

Background: Primary neuroendocrine neoplasms (NENs) of the ovary are exceptionally rare entities, mostly arising in mature teratomas.
The current pathologic classification of ovarian NENs is morphology-based, a significantly different approach from the standard
terminology of gastroenteropancreatic (GEP) NENs. The aim of this study was to analyze the clinicopathological and
immunohistochemical features of ovarian neuroendocrine neoplasms and to reclassify this series according to GEP NEN classification.

Design: All cases of ovarian NENs were histologically reviewed according to WHO 2014 Female Genital Tract classification. An
immunohistochemical (IHC) panel consisting of Synaptophysin, Chromogranin, Serotonin, Somatostatin Receptor Subtype 2A (SSTR2A),
Somatostatin Receptor Subtype 5 (SSTR5), CDX2, TTF-1 and PAX8 was applied. Ki-67 proliferation index was assessed by digital
imaging analysis according to the GEP NEN classification. Targeted Next-Generation Sequencing (NGS) analysis was performed in 2
particular cases.

1045
Results: A total of 27 cases was collected, including 12 primary and 15 metastatic neoplasms. Patients median age was 43 years old.
According to the WHO 2014 classification, insular carcinoids were 6 cases (50%), trabecular carcinoids 2 (16.7%), strumal-carcinoids 3
(25%), small cell carcinoma of the ovary, pulmonary type (SCCOPT) 1(8.3%). All carcinoids were stage pT1a and were associated with
other ovarian neoplasms. The SCCOPT was the only pure NEN, staged as pT3c. Adopting the GEP NEN classification, 7 (58.3%) cases
were classified as NET G1, 3 (25%) as NET G2, 1 (8.3%) as NET G3 and 1 (8.3%) as NEC. All cases showed a diffuse positivity for
Synaptophysin and Chromogranin. SSTR2A positivity was associated with insular and strumal carcinoids, while SSTR5 and CDX2 was
observed in trabecular carcinoids. SCCOPT showed a diffuse positivity for TTF-1, p53 and p16. The molecular analysis
demonstrated TP53 and IDH1 mutations in one case of NET G3 tumor associated to a Sertoli cell tumor, and TP53 mutation with mTOR
pathway alteration in SSCOPT.

Conclusions: The current WHO 2014 classification showed a consistent immunoprofile for each subtype. The application of GEP NEN
classification, including Ki-67 proliferation index, is feasible and better discriminates tumor grade. This approach substantiates the
importance of a common classification for NENs reducing inconsistencies and contradictions among the various systems currently in use,
allowing a more uniform diagnosis and clinical management.

1092 Loss of MHC Class I Expression in PD-L1-positive HPV-Associated Cervical and Vulvar
Neoplasia: A Mechanism of Resistance to Checkpoint Inhibition?
Megan Dibbern1, Timothy Bullock2, Linda Duska2, Mark Stoler3, Anne Mills2
1
University of Virginia Health System, Charlottesville, VA, 2University of Virginia, Charlottesville, VA, 3University of Virginia
Health System, Earlysville, VA

Disclosures: Megan Dibbern: None; Timothy Bullock: None; Linda Duska: None; Mark Stoler: None; Anne Mills: None

Background: Decreased expression of major histocompatibility complex class I (MHC I) on tumor cells precludes antigen presentation
and therefore prevents immune recognition. Alterations in MHC I expression are thought to compound immune escape and contribute to
immunotherapeutic resistance in PD-L1-positive gastric and non-small cell lung carcinomas, but this has not been previously studied in
cervical and vulvar cancers. Given the recent FDA approval of anti-PD-1 checkpoint inhibition in PD-L1-positive cervical squamous
carcinomas, identifying tumors with loss of MHC I is of clinical interest.

Design: Immunohistochemistry for PD-L1 and MHC I combined A-, B-, and C- heavy chains was assessed in 58 HPV-associated cervical
and vulvar lesions, including squamous intraepithelial lesions (SIL) and invasive squamous cell carcinoma (SCC) (15 CIN3, 13 cervical
SCC, 12 VIN3, and 18 vulvar SCC cases). PD-L1 expression was classified as present or absent using the combined positive score
(CPS) with a threshold of ≥1 required for positivity. MHC I staining was classified as present, clonally lost, or absent.

Results: Although 83.9% of SCC and 22.2% of SIL were PD-L1-positive, 33.5% (11/31) of SCC and 18.5% (5/27) of SIL also showed
clonal or complete loss of MHC Class I. Loss of MHC I expression was more common in PD-L1-positive (10/26, 38.5%) vs. PD-L1-
negative SCC (1/5, 20%). Among PD-L1-positive SCC, loss of MHC I expression is more common in cervical SCC (5/11, 45.5%) than
vulvar SCC (5/15, 33.3%). However, neither of these differences was statistically significant.

MHC Class I Expression Pattern

Intact (%) Clonal Loss (%) Complete Loss (%)
All SCC (n=31) 20 (64.5) 9 (29.0) 2 (6.5)
Cervical SCC (n=13) 8 (61.5) 5 (38.5) 0 (0)
Vulvar SCC (n=18) 12 (66.7) 4 (22.2) 2 (11.1)
All SIL (n=27) 22 (81.5) 5 (18.5) 0 (0)
CIN3 (n=15) 12(80) 3 (20) 0 (0)
VIN3 (n=12) 10 (83.3) 2 (16.7) 0 (0)
PD-L1+ (CPS≥1) PD-L1- (CPS<1)
MHC Class I Intact Clonal Complete MHC Class I Intact Clonal Complete
Expression (%) Loss (%) Loss (%) Expression (%) Loss (%) Loss (%)
Pattern Pattern
All SCC (n=26) 16 (61.5) 8 2 All SCC (n=5) 4 (80.0) 1 0
(30.8) (7.7) (20.0) (0)
Cervical SCC 6 5 0 Cervical SCC 2 0 0
(n=11) (54.5) (45.5) (0) (n=2) (100) (0) (0)
Vulvar SCC 10 (66.7) 3 2 Vulvar SCC 2 (66.7) 1 0
(n=15) (20.0) (13.3) (n=3) (33.3) (0)
All SIL (n=6) 5 1 0 All SIL (n=21) 17 4 0
(80.0) (20.0) (0) (81.0) (19.0) (0)
CIN3 (n=2) 1 1 0 CIN3 (n=13) 11 2 0
(50.0) (50.0) (0) (84.6) (15.4) (0)
VIN3 (n=4) 4 0 0 VIN3 (n=8) 6 (75.0) 2 0
(100) (0) (0) (25.0) (0)

1046
 Figure 1 - 1092 Figure 2 - 1092

Conclusions: Over one-third of HPV-associated cervical and vulvar SCC show clonal or complete loss of MHC I expression. This
suggests that response to therapies targeting the PD-1/PD-L1 axis may be inhibited in a subset of cervical and vulvar neoplasms due to
an impaired ability to engage with the immune system related to loss of MHC Class I expression.

1093 Mismatch Repair Deficiency in Endometrial Carcinosarcomas

Jessica Dillon1, Laura Tafe2
1
Dartmouth Hitchcock Medical Center, Lebanon, NH, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH

Disclosures: Jessica Dillon: None; Laura Tafe: None

Background: Endometrial carcinosarcoma (ECS) is a rare high-grade, biphasic endometrial carcinoma composed of malignant epithelial
and mesenchymal elements derived via divergent differentiation. The carcinoma component is high-grade and may be further classified
as serous-like or endometrioid-like based on molecular findings (PTEN, ARID1A, PPP2R1A and/or TP53 mutations) (PMID:
28292439). The sarcoma component may have homologous or heterologous elements. ECS have aggressive clinical features with high
rates of recurrence and a 5-yr progression free survival of 20-35% with advanced stage disease. Identifying therapeutic vulnerabilities in
ECS are key to improving patient outcomes.

Design: At our institution, mismatch repair (MMR) immunohistochemistry (IHC) analysis with antibodies against MLH1, PMS2, MSH2,
MSH6 was implemented in 2015 as part of Lynch syndrome screening in endometrial cancers. With recent tumor agnostic approval of
certain immunotherapy agents with MMR deficiency or microsatellite instability, MMR screening also plays an important role in
determining eligibility for immunotherapy. MLH1 promoter methylation is reflexively ordered on any tumor that shows loss of MLH1/PMS2
by IHC.

Results: From 2015 to present, 31 cases of ECS were identified in the pathology archives. 22 cases had undergone testing for MMR by
IHC (3.4% of cases tested; 22/653). The patient age range was 52-82 with the exception on one patient who was 25 at diagnosis. Tumor
stage was: IA (6); IB (5); II (1); IIIA (4); IIIC (1); IV (4), and one is not yet staged. Three (13.6%) showed loss of MLH1 and PMS2 in both
the carcinoma and sarcoma components. Somatic MLH1 promoter methylation was identified in all three cases. All three were low stage
(IA/IB/IB) and the sarcomatous component was comprised solely of homologous elements. Morphologically, in two cases the
carcinomatous component had endometrioid features, one with foci of squamous differentiation. The third had a solid growth pattern not
further classifiable by morphology alone. Tumor infiltrative lymphocytes were present in all three cases.

Conclusions: Similar to our findings, the TCGA ECS cohort identified 2/57 cases with loss of MLH1/PMS2 and MLH1 promoter
hypermethylation. Both of these cases were classified as endometrioid-like based on PTEN alterations. MMR deficiency is a rare event in
a subset of ECS with endometrioid-like features. In addition, identification of MMR deficiency offers a new therapeutic opportunity with
available immunotherapies.

1047
1094 Digital Image Analysis for the Diagnosis of Differentiated Vulvar Intraepithelial Neoplasia and
Distinction from Benign Mimickers
Soufiane El Hallani1, Eric Yang2, Kelly Devereaux2, Anita Carraro3, Jagoda Korbelic3, Arash Javanmardi3, Alan Harisson3,
Martial Guillaud4
1
University of Alberta, Edmonton, AB, 2Stanford University School of Medicine, Stanford, CA, 3BC Cancer Agency, Vancouver,
BC, 4Vancouver, AB

Disclosures: Soufiane El Hallani: None; Eric Yang: None; Kelly Devereaux: None

Background: Differentiated vulvar intraepithelial neoplasia (DVIN) possesses a high oncogenic potential but the high degree of
differentiation often results in DVINs being mistakenly diagnosed as benign lesions. The p53 immunohistochemistry marker can be used
to support the DVIN diagnosis; however, the characteristic suprabasal p53 overexpression can be encountered in any benign condition in
which there is increased epithelial proliferation, and the p53 null-pattern can be subtle and difficult to recognize. A more accurate
diagnostic aid tool is needed. We here investigate the role of chromatin-based image analysis in distinguishing DVIN and benign
mimickers.

Design: Eighty-two vulva biopsy specimens with 4 major diagnosis categories are selected: Lichen simplex chronicus (n=34); (2) Lichen
sclerosis (n=21); DVIN (n=10); squamous cell carcinoma (n=17). All diagnoses are verified by subspecialized gynecologic pathologists
based on strict diagnostic criteria and immunohistochemistry. One tissue section is stained with Feulgen-Thionin which binds the nuclear
DNA. The regions of interest are delineated manually by pathologist on the digitalized slides and an in-house image analyzer
software calculate multiple nuclear features including nuclear shapes and chromatin texture (Figure 1). Statistical stides are performed to
compare the performance of combined features to accurately classify the specimens and generate a classifier model.

Results: A total of 44,483 nuclei were individually analysed for over 100 nuclear morphologic and chromatin parameters. The parameter's
average per each specimen is included in a stepwise discriminant analysis. The classifyer model has an overall accuracy of 95.5% in
distinguishing DVIN versus lichen simplex chronicus (table1), and overall accuracy of 96.8% in distinguishing DVIN versus lichen
sclerosis (table 1). The classifier model has a negative predictive value of 96.5% (95% CI: 89% to 99%), positive predictive value of 89%
(95% CI: 53% to 98%), sensitivity of 80% (95% CI: 45% to 98%) and specificity of 98% (95% CI: 90% to 99.9%) in distinguishing DVIN
from lichen simplex chronicus.

Observed
Accuracy Lichen simplex DVIN
Predicted Lichen simplex 100% 34 0
DVIN 80% 2 8
Total 95.50%
Observed
Accuracy Lichen sclerosis DVIN
Predicted Lichen sclerosis 95.30% 20 1
DVIN 100% 0 10
Total 96.80%
Figure 1 - 1094

1048
Conclusions: The chromatin-based image analysis is a promising aid tool to reliably rule out benign mimickers when the diagnosis of
DVIN is considered based on morphology or p53 immunohistochemistry. In the near future, the integration of such image analysis tools in
the pathology practice will be facilitated by further adoption of digital pathology in the workflow environment.

1095 High-Grade Serous Carcinoma (HGSC) of the Ovary: An Immunohistochemical and Molecular
Comparative Study of Long and Short-Term Survivors
Gonçalo Esteves1, Bárbara Mesquita2, Marta Ferreira3, Sara Teles3, Madalena Santos4, António Guimarães4, Carla Oliveira5,
Ana Félix6
1
Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal, 2Instituto de Investigação e Inovação em Saúde
(i3S), Vila do Conde, Porto, Portugal, 3Instituto de Investigação e Inovação em Saúde (i3S), Porto, Portugal, 4Instituto Português
de Oncologia de Lisboa Francisco Gentil (IPOLFG), Lisbon, Portugal, 5Institute of Molecular Pathology and Immunology
(IPATIMUP)/Instituto de Investigação e Inovação em Saúde (i3S), Porto, Portugal, 6Instituto Português de Oncologia de
Lisboa/CEDOC, Lisboa, Portugal

Disclosures: Gonçalo Esteves: None; Bárbara Mesquita: None; Marta Ferreira: None; Sara Teles: None; Madalena Santos: None;
António Guimarães: None; Carla Oliveira: None; Ana Félix: None

Background: HGSC is the most frequent and deadliest ovarian cancer. After surgery and chemotherapy, patients (pts) eventually
relapse with chemoresistant disease, dying within 5 years of diagnosis.

Design: We compared a group of 10-year-long survivors (A; n=14pts), who either never relapsed or had multiple chemosensitive
relapses, with one of ≤3-year-long survivors (B; n=14pts), to elucidate if transcriptomic profiles and epigenetic markers might explain
differences between therapeutic response and survival.

All cases were reviewed and confirmed. HDAC1,2,3,4,6, pHDAC4,5,7 were evaluated in a TMA by IHC. DNA and RNA were extracted
from FFPE tissue (14[A]+14[B] primaries + 9[A] relapses). Fusion transcript and differential gene expression analysis were performed
using Ion AmpliSeq™/Ion Torrent Proton™ technology and the Oncomine Focus assay, followed by bioinformatics analysis with EdgeR
Bioconductor package. BRCA genes were studied in 13[A] tumors by targeted NGS. Differentially expressed genes were validated by RT-
PCR, and BRCA variants by Sanger sequencing.

Results: Complete remission was achieved in 10pts[A] after surgery+chemotherapy. At the end of follow-up, 8pts[A] relapsed up to 8
times; 6[A] were alive without disease and 3[A]+14[B] died of disease. Immunohistochemistry (Table 1) showed HDAC1 expression in all
but 2 primaries (pts with more relapses, having died with active disease). HDAC3 negativity was strongly correlated with survival >3 years
(p=0.0019).

Clustering analysis showed a specific transcriptional profile (25 genes) shared by all relapses and differing from primary cancers (Fig 1).
Expression of 16 genes distinguished primaries with multiple relapses from those without/with a single relapse, and 1 gene was
specifically upregulated in tumors from non-relapsing patients (MCMBP) (Fig 2). Primary tumors from pts with multiple relapses showed
downregulation of mitotic cell division and chromosome segregation associated genes, unlike pts without/with a single relapse. The HLA-
AES fusion transcript was identified in a non-relapsing case. Two BRCA1 mutations were identified in 2pts[A] showing a similar
transcriptomic profile and hinting to BRCA-driven tumorigenesis.

N HDAC1 HDAC2 HDAC3 HDAC4 HDAC4 HDAC6 pHDAC 4, 5, 7

(membrane) (cytoplasm) (cytoplasm)
Primary tumors: 13 11 (85%) 13 (100%) 6 (47 %) 1 (8 %) 9 (70 %) 9 (70 %) 7 (54 %)

Long-term
survivors [A]
Primary tumors: 14 12 (85%) 14 (100%) 14 (100 9 (65 %) 13 (93 %) 13 (93 %) 14 (100 %)
%)
Short-term
survivors [B]
Relapses [A] 9 6 (66%) 9 (100%) 4 (44 %) 1 (11 %) 7 (78 %) 7 (78 %) 6 (66 %)
Metastases [A] 6 6 (100%) 6 (100%) 4 (66 %) 3 (50 %) 2 (33 %) 6 (100 %) 4 (66 %)

(As of first surgery)

1049
 Figure 1 - 1095

Figure 2 - 1095

Conclusions: HDAC expression was similar in both cohorts, yet HDAC3 absence was associated with long survival. Particular
transcription signatures distinguish long survivors’ primary tumors from relapses. Relapse may be predicted based on the expression of a
small gene set.

(Study supported by AstraZeneca, Prod Farm, Lda.)

1050
1096 Molecular Characterization of Smooth Muscle Tumors of Uncertain Malignant Potential (STUMP)
Using Targeted Next Generation Sequencing
Annacarolina Fabiana Lucia Da Silva1, Fei Dong1, Adrian Marino-Enriquez1, Marisa Nucci2, Bradley Quade1
1
Brigham and Women's Hospital, Boston, MA, 2Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Disclosures: Annacarolina Fabiana Lucia Da Silva: None; Fei Dong: None; Adrian Marino-Enriquez: None; Marisa Nucci: None; Bradley
Quade: None

Background: Smooth muscle tumors with uncertain malignant potential (STUMP) are a heterogeneous group of uterine smooth muscle
tumors (SMT) that cannot be classified as either malignant or benign using currently established morphologic criteria. Although efforts
have been made to define the pathogenesis of STUMP, to our knowledge, there are no published studies to date using next generation
sequencing.

Design: Our goal was to determine the molecular characteristics of 15 STUMP relative to a cohort of benign but histologically challenging
SMT (5 intravascular leiomyomatosis [IVL], 6 atypical leiomyoma [AL] and 4 cellular leiomyoma [CL]) as well as to molecularly annotated
uterine leiomyosarcoma (LMS) through the cBioportal public dataset. Tumor sequencing was performed using a hybrid-capture-based,
massively parallel sequencing assay (OncoPanel v.3.1). Data was interpreted with attention to potential molecular-histologic correlates,
including atypia, mitotic index, atypical mitosis, necrosis, tumor border, LVI and size. Clinical status and follow up were recorded.

Results: 2 of 15 subjects with STUMP had adverse outcome (recurred/metastasized as leiomyosarcoma) but none died of disease.
There were no recurrences in other SMT categories. Sequencing data revealed multiple copy number alterations (CNA) in all STUMP.
Chromosome losses, some involving tumor suppressor genes known to play a role in LMS (viz., BRCA2, RB1 and TP53) were more
frequent than gains. CNA were less frequent in other SMT. Of note, amplification of RMRP, which produces a non-coding RNA, was
found in 5/15 of STUMP and 2/6 AL. FH loss was present in 1 STUMP and 1 AL. We did not identify mutational signatures in any SMT
and all were MSS. Occasional mutations in pathogenic genes (TP53, FH, MEN1, ESR1, ALK) were present in STUMP. MED12 mutations
were present in LM (1) and IVL (1) but not STUMP. 1 CL showed unusual KRAS and FGFR1 mutations. Sequencing data was available
for one subject with adverse outcome (case 10, lung metastasis, 5 years after hysterectomy), which showed additional ESR1 mutation
and losses involving TET2, APC and DMD compared to the primary.

Conclusions: Like LMS, STUMP show frequent CNA with copy number losses of 1p and 10q and tumor suppressor RB1 and TP53.
Amplification of RMRP, not previously described in SMT, was common in STUMP and AL. RMRP overexpression is seen carcinomas but
its role in mesenchymal tumors remains to be determined. No mutations were predictive of behavior or correlated with histologic features.

1097 High Grade Endometrial Stromal Sarcoma with YWHAE Rearrangement: A Detailed Histologic
Review of 24 Cases Highlights an Expanded Morphologic Spectrum
Annacarolina Fabiana Lucia Da Silva1, David Chapel1, Kyle Strickland2, Marisa Nucci3
1
Brigham and Women's Hospital, Boston, MA, 2Duke University Medical Center, Durham, NC, 3Brigham and Women's Hospital,
Harvard Medical School, Boston, MA

Disclosures: Annacarolina Fabiana Lucia Da Silva: None; David Chapel: None; Kyle Strickland: None; Marisa Nucci: None

Background: Uterine endometrial stromal sarcomas are a genetically heterogenous group comprising low grade, high grade and
undifferentiated tumors, some of which contain recurrent chromosomal translocations. YWHAE rearranged HGESS was reintroduced into
the 2014 WHO classification and is now well accepted within the diagnostic lexicon; however, it has become evident with recognition of
additional cases that these tumors can show a wider morphologic spectrum. We studied a cohort of primary and recurrent/metastatic
tumors for further characterization.

Design: HGESS with YWHAE rearrangement were retrieved from our internal and consultation files to include 24 primary tumors, 5 of
which also had subsequent recurrence(s)/metastases. Morphologic features were assessed.

Results: Of 24 primary tumors, 16 were biphasic (high- and low-grade components), 2 were conventional/fibromyxoid (low-grade
component only), and 6 were high-grade epithelioid component only. Of the biphasic tumors, 12 showed a sharp demarcation to high-
grade areas, 12 had intermingling of nests, cords and single cells of the high-grade epithelioid with the low-grade spindle component, and
9 had both patterns. The high-grade epithelioid areas were composed of cells with plump ovoid nuclei with irregular nuclear contour,
homogeneously dispersed chromatin and inconspicuous nucleoli with scant (4) to moderate (14) amounts of eosinophilic cytoplasm or
combination (4). The average mitotic index per 10 HPF was 18 (range 4-35), 5 (range 2-11) and 9.7 (range 3-27) in high-grade, low-grade
and recurrent tumors respectively. LVI was present in 9/24 (37%) primary tumors. Other findings included: pseudo-papillary appearance
(7), storiform growth (4), pseudo-glandular spaces (5), sex-cord like foci (SCT) (3), staghorn (5) and chicken wire vessels (2), rhabdoid
morphology (2; 1 with severe nuclear pleomorphism) and spindled hyperchromatic cells (2) (Fig1). Of 11 recurrence/metastasis in 5
patients, 6 were biphasic, 6 conventional/fibromyxoid, and 5 high-grade epithelioid component only with concurrent or subsequent
metastatic/recurrent sites from the same patient showing any of these three appearances (Fig2).

1051
 Figure 1 - 1097

Figure 2 - 1097

Conclusions: YWHAE-rearranged HGESS can show distinctive morphologic features affording its recognition, which is done in
combination with confirmatory immunoperoxidase stains or, if needed, genetic studies. Awareness of its expanded morphologic
appearance will help in recognizing these unusual and diagnostically challenging tumors.

1052
1098 Primary Peritoneal High Grade Serous Carcinoma Revisited: Precursor Frequency and
Implications
Annacarolina Fabiana Lucia Da Silva1, Christopher Crum1, David Kolin1
1
Brigham and Women's Hospital, Boston, MA

Disclosures: Annacarolina Fabiana Lucia Da Silva: None; Christopher Crum: None; David Kolin: None

Background: In the current model for high grade serous carcinogenesis (HGSC) a serous tubal intraepithelial carcinoma (STIC)
develops in the distal tube and tumor cells spread to the peritoneal cavity. A complementary model proposes that early serous
proliferations (ESPs) lead to HGSC via “precursor escape” with HGSC emerging later in he peritoneal cavity. The latter explains "primary
peritoneal" HGSC but is not established. Moreover the validity of every STIC as an invariable "launching point" for HGSC has been
questioned.

Design: Consecutive cases classified as primary peritoneal high-grade serous carcinoma (HGSC) in which tubes were evaluated by the
SEE-FIM protocol were identified from the pathology archives. Diagnosis of PPHGSC based upon the presence of a tumor distribution
confined primarily to the extra tubo-ovarian extraovarian tissues, with involvement of the tubes or ovaries limited to the serosal surfaces.
where available, all histologic material was reviewed with attention to the presence of STIC or ESPs. Tissue blocks resectioned and
immunostained for p53 to maximized identification of any potential precursors. Fallopian tubes from a small group of tumors classified as
"ovarian" HGSC were included.

Results: 43 cases classified by pathology report as PPHGSC were identified over a 10-year interval. STIC was reported in 9 cases
(21%). In 23 of 43 cases with no STIC reported, blocks were available and sections immunostained for p53. Fourteen associated tumors
were strongly p53 positive, 6 displayed a p53 null immunophenotype, one wild type and in two tumors was not available for analysis. 228
tissue sections, including HE and p53 stains were evaluated from the fallopian tubes of the 23 cases. In 2 (9%) a previously
unappreciated STIC was identified following sectioning and immunostaining; 6 (26%) contained an ESP, one with a p53 null
immunophenotype; 15 (65%) did not display a detectible lesion. Of fallopian tubes from 8 cases with extensive ovarian involvement
("ovarian" distribution) on gross exam 3(38%) contained a STIC and 4 (50%) an ESP.

Conclusions: Although estimates of the frequency of STIC in PPHGSC to approach 50%, this followup study has shown the frequency to
be significantly lower (20%). Additional putative precursors (ESPs) were identified in 26% of the remainder but in nearly one-half of
PPHGSCs an origin in the fallopian tube is still not evident. This underscores the importance of evaluating other potential origins
(?endometrial lining) in the gynecologic tract.

1099 Gastrointestinal Stromal Tumors Presenting as Primary Ovarian or Uterine Neoplasms,

Emphasizing Potential Morphological and Immunohistochemical Diagnostic Pitfalls
Daffolyn Rachael Fels Elliott1, Sanjay Kakar1, Joseph Rabban1
1
University of California San Francisco, San Francisco, CA

Disclosures: Daffolyn Rachael Fels Elliott: None; Sanjay Kakar: None; Joseph Rabban: Employee, Spouse is an employee of Merck &
Co.

Background: The clinical presentation of gastrointestinal stromal tumors (GISTs) in women may occasionally simulate a primary ovarian
or uterine neoplasm. Epithelioid and myxoid morphologic variants, in particular, may resemble a primary gynecologic epithelial, sex cord-
stromal, or mesenchymal neoplasm. The clinico-pathologic features of such GISTs and diagnostic specificity of gynecologic
immunohistochemical stains in these cases are not well described.

Design: The study included 155 women with GIST arising at any anatomic site (single institutional database search 1995-2018). Tissue
microarrays (triplicate 2 mm cores per tumor) were constructed for 78 GISTs. Immunostains included mullerian epithelial (PAX8, estrogen
receptor), sex cord stromal (FOXL2, SF-1, WT-1, calretinin, inhibin), endometrial stromal (CD10, BCOR), malignant germ cell (SALL4),
PEComa (HMB-45), inflammatory myofibroblastic tumor (ALK), mesonephric/trophoblast (GATA3), malignant mesothelial (BAP-1) and
GIST markers (DOG1 and CD117). Clinical data from an additional 77 GIST was available.

Results: Among 155 women with GIST (median age 63 y), 11% (17) were clinically suspected to be a primary gynecologic neoplasm and
59% of these (10/17) underwent surgery by a gynecologic surgeon. GISTs presenting as gynecologic tumors were larger (10 cm vs. 3.7
cm, p<0.001), higher stage (18% vs. 5%, NS trend), and more likely to metastasize (35% vs. 17%, NS trend) than typical GISTs.
Epithelioid morphology was present in 9/17 GISTs, either purely (3) or combined with spindled morphology (6). All 78 GISTs were positive
for DOG1 and/or CD117. CD10 was positive in 28%; focal HMB-45 in 10%; focal calretinin in 8%; BAP-1 loss in 6%; BCOR in 1%. All
showed diffuse strong cytoplasmic staining for WT-1, but none showed nuclear staining. None stained for FOXL2, SF-1, SALL4, PAX8,
inhibin, GATA3 or ALK.

1053
Conclusions: GISTs may occasionally clinically and morphologically simulate primary ovarian or uterine neoplasms; these tumors are
often large and may have advanced disease. Although many gynecologic immunohistochemical markers are negative in GISTs, a
minority may exhibit focal CD10, HMB-45, calretinin or loss of BAP-1, potentially leading to misdiagnosis if GIST, albeit rare in the pelvis,
is not included in the differential diagnosis and pursued with DOG1/CD117 staining.

1100 Whole Genome Copy Number Variant Analysis Identifies Novel Biomarker to Help Distinguish
Uterine Smooth Muscle Tumor Types
Brian Finkelman1, Tingting Gao1, Xinyan Lu2, Jian-Jun Wei3
1
Northwestern University Feinberg School of Medicine, Chicago, IL, 2Chicago, IL, 3Northwestern University, Chicago, IL

Disclosures: Brian Finkelman: None; Tingting Gao: None; Xinyan Lu: None; Jian-Jun Wei: None

Background: Leiomyoma with bizarre nuclei (LM-BN) is a rare benign uterine smooth muscle tumor with similar histologic and molecular
features to leiomyosarcoma (LMS). In clinical practice, diagnosing LM-BN is difficult due to limited knowledge of disease biology and of its
relation to LMS. Previous work has suggested that LM-BN can be divided into leiomyoma with fumarate hydratase alteration (LM-FH) and
LM-BN based on morphology and FH expression. Our aim was to find novel biomarkers to help distinguish among LM-FH, LM-BN, and
LMS.

Design: Whole genome copy number variation (CNV) analysis was performed on 10 LM-FH, 15 LM-BN, and 10 LMS cases to identify
candidate tumor suppressor or oncogenes. Tissue microarrays were prepared for 32 LM-FH, 22 LM-BN, and 37 LMS cases, as well as 11
myometrial controls. Semi-quantitative immunohistochemical (IHC) analysis (H-score) was performed for both novel and conventional
biomarkers (p16, p53 and FH). Overall biomarker discrimination was assessed via the multi-class area under the ROC curve (AUC), with
statistical significance based on the likelihood ratio test of multinomial regression models.

Results: Common CNVs included losses of 1p (80%) and 1q (100%) and gains of 8p (40%) in LM-FH, as well as losses of 1p (67%), 13q
(60%), 17p (60%), and 22q (47%) in LM-BN. LMS showed complex CNV changes with some overlap with LM-BN, including losses of 1p,
13q, and 22q. Based on these findings, we identified a set of novel biomarkers (ATAD3, SDCCAG8, PKC, DVL1, COX20, SCO2, and
hnRNP U) to analyze by IHC. The multi-class AUCs for the novel biomarker H-scores ranged from 0.54 to 0.75; however, only ATAD3
was significantly associated with tumor type after adjusting for FH, p53, and p16 (P<0.001). IHC results for FH, p16, p53, and ATAD3 are
summarized by heatmap with unsupervised hierarchical clustering in Figure 1. A multinomial regression model constructed from FH, p16,
p53, and ATAD3 showed excellent overall discrimination among tumor types (multi-class AUC = 0.94), and, importantly, could
discriminate well between LMS and LM-BN among FH+ tumors (AUC = 0.82).

Figure 1 - 1100

Conclusions: Whole genome CNV analysis of LM-FH, LM-BN, and LMS revealed multiple genomic regions of interest. Of the novel
biomarkers, ATAD3, a mitochondrial protein and oncogene, was independently associated with tumor type. A multinomial regression
model including FH, p16, p53, and ATAD3 showed good discrimination even between LM-BN and LMS. Independent model validation is
necessary before use in clinical practice.

1054
1101 PD-L1 Expression in High Grade Serous Carcinoma of the Female Genital Tract - Experience in a
Large Clinical Cohort Reclassified with Immunohistochemistry and NGS
Anna Fischer1, Nina Neudeck2, Marcel Grube3, Irina Bonzheim4, Jana Pasternak5, Franziska Otto1, Karen Greif6, Christine
Beschorner1, Sara Brucker5, Diethelm Wallwiener1, Falko Fend7, Stefan Kommoss3, Annette Staebler8
1
University of Tuebingen, Tuebingen, Baden-Wuerttemberg, Germany, 2University of Tuebingen, Tübingen, Baden-
Wuerttemberg, Germany, 3Tuebingen University Hospital, Tuebingen, Germany, 4University of Tuebingen, Tübingen,
Germany, 5Tuebingen University Hospital, Tübingen, Germany, 6Tübingen University Hospital, Tübingen, BW,
Germany, 7University Hospital of Tuebingen, Tuebingen, Baden-Württemberg, Germany, 8University of Tuebingen, Tuebingen,
Germany

Disclosures: Anna Fischer: None; Nina Neudeck: None; Marcel Grube: None; Irina Bonzheim: None; Jana Pasternak: None; Karen
Greif: None; Christine Beschorner: None; Sara Brucker: None; Diethelm Wallwiener: None; Falko Fend: None; Stefan Kommoss: None;
Annette Staebler: None

Background: High grade serous tubo-ovarian carcinoma (HGSC) is still one of the most lethal carcinomas of the female genital organs.
The presence of high numbers of tumor infiltrating lymphocytes (TILs) has been shown to correlate with prolonged overall survival (OS).
Recent clinical studies compare single checkpoint-inhibitor therapy to combined immune-targeting therapies and adoptive cell therapy.
HGSC may be difficult to distinguish from other histotypes of ovarian carcinoma, specifically high-grade carcinomas. Therefore, we
present a large consecutive cohort of HGSC first re-classified via immunohistochemistry and molecular analyses before investigating for
PD-L1 expression status using the Combined Positivity Score (CPS).

Design: A consecutive series of 420 cases diagnosed as HGSC and treated at the Womens’ Hospital of the University Tuebingen from
2000 until 2016 was reviewed by two independent pathologists. Tissue microarrays (TMAs) were stained for a panel of four markers
including WT1, p53, progesterone receptor and Napsin-A. Cases which were unclassifiable via morphology and immunohistochemistry
will be analyzed by NGS with a panel of known targets in ovarian carcinomas. PD-L1 via CPS was analyzed by two independent
pathologists, one of them accredited for CPS evaluation.

Results: In 89.5% (n= 376/420), diagnosis of HGSC was confirmed (WT1+, p53 aberrant, Napsin-A neg.). 25 cases (5.9%) were
reclassified and excluded: 12 (2.8%) low-grade serous, 9 (2.1%) endometrioid, 2 (0.5%) clear cell carcinoma, 2 (0.5%) atypical
proliferative serous tumors (APSTs), 3 cases for other reasons (0.8%) (2=metastasis of other primary, 1=technical reasons). 16 cases
(3.8%) will be subjected to mutational analysis by NGS. Within the re-classified 376 (100%) HGSC, 131 presented PD-L1 expression
(34.8%), 215 were negative (57.2%), 30 cases were not evaluable for technical reasons ( 8%). For CPS mean value, cut-offs were 0
(n=215, 57.2%), <1 (n=84, 22.3%), 1-25 (n=47, 12.5%), 25 (n=0, 0%).

Conclusions: Within our collective of re-classified HGSC of the female genital tract, PD-L1 expression was found in 34.8%, whereas the
majority showed negative results (57.2%). In summary, PD-L1 is expressed in a subgroup of HGSCs suggesting an important role in the
tumor microenvironment and providing a potential therapeutic target. Further correlation with clinical data will follow.

1102 Expression Analysis of Selected Biomarkers in Müllerian Adenosarcoma

Jean Fischer1, Yanli Ban2, Jian-Jun Wei3
1
McGaw Medical Center of Northwestern University, Chicago, IL, 2Northwestern University Feinberg School of Medicine,
Chicago, IL, 3Northwestern University, Chicago, IL

Disclosures: Jean Fischer: None; Yanli Ban: None; Jian-Jun Wei: None

Background: Müllerian adenosarcoma (MAS) is a rare biphasic malignant neoplasm for which no reliable diagnostic markers have been
reported. Our prior study by whole genome sequencing identified 28 biomarkers within regions of frequent copy number variation (CNV).
Expression analysis by immunohistochemistry (IHC) revealed 10 biomarkers with significant upregulation in MAS compared to
endometrial (EM) controls. In addition, target validation analysis confirmed several frequently mutated genes in MAS
including KDM6B and KMT2C. In this study, we examined IHC for the selected biomarkers which are highly relevant to MAS, and we
correlated with tumor grade, sarcomatous overgrowth (SO), tumor location, and patient age.

Design: A total of 28 MAS were selected after review including 17 low-grade, 11 high-grade, and 15 with SO. Five were from cervix, 19
from endometrium, and 4 from ovary/peritoneum. Seven biomarkers (Cyclin D1, CDK4, KIF14, MDM2, p16, HMGA2, and 14-3-3 ε) from
CNV analysis and 2 markers (KMT2C and KDM6B) from mutation analysis were selected for this study. IHC expression was evaluated in
stroma and epithelium for intensity (0-3+) and extent (0-100%) and H-scores calculated. IHC was correlated with clinicopathological
features using one-way analysis of variance.

Results: Increased stromal expression of the 7 biomarkers from CNV analysis was observed in MAS and demonstrated variation in
stromal expression with different clinicopathologic parameters (Table 1). MDM2 had higher expression in ovarian MAS compared to
uterine MAS. KIF14 had higher expression in high-grade MAS, MAS with SO, and patients ≥50 years old. CDK4 had higher expression in
low-grade MAS as well as MAS without SO. Cyclin D1 was also increased in low-grade MAS. HMGA2 was increased in high-grade MAS

1055
compared to low-grade. Among the markers selected from mutational analysis, KDM6B epithelial expression was significantly decreased
in MAS (p=0.02). No other markers showed significant differences in epithelial expression. KMT2C IHC analysis is ongoing.

Table 1. Immunohistochemistry analysis of stromal expression of selected oncogene/tumor suppressor gene products in Müllerian
adenosarcoma

MAS EM MAS vs. MAS Location SO (Present Tumor Grade Patient Age
EM (Cervix vs. vs. Absent (Low vs. High (<50 yo vs
(n=28) (n=14 KDM6B; Uterus vs. vs. EM) vs. EM) ≥50 yo vs.
n=8 all other Ovary) EM)
stains)
Markers Mean Mean (Median) P value P value P Value P Value P Value
(Median)
KDM6B 38 (15) 49 (45) 0.46 0.28 0.41 0.65 0.45
Cyclin 81 (35) 11 (0) 0.002 0.21 0.10 0.02 0.10
D1
CDK4 69 (30) 10 (5) 0.001 0.73 0.002 0.03 0.06
HMGA2 74 (0) 14 (0) 0.005 0.07 0.09 0.03 0.30
KIF14 107 (80) 31 (40) <0.001 0.60 0.02 0.02 0.04
MDM2 43 (20) 10 (0) 0.02 0.05 0.28 0.13 0.28
p16 130 57 (50) 0.04 0.17 0.15 0.11 0.16
(120)
14-3-3 ε 164 98 (95) 0.006 0.91 0.09 0.08 0.06
(180)

Conclusions: Cyclin D1 and CDK4 were highly expressed in low-grade MAS, and KIF14 was highly expressed in high-grade
MAS. CDK4 was also highly expressed in MAS without SO while KIF14 was highly expressed in MAS with SO. KDM6B was frequently
mutated in MAS with SO, and IHC revealed decreased expression in the epithelial but not stromal component.

1103 DNA Methylation Profiling of Uterine Sarcomas

Erna Forgo1, Anna-Lena Lang2, Vanita Natu3, Teri Longacre3, Jennifer Bennett4, Charles Quick5, Carlos Parra-Herran6, Marisa
Nucci7, David Kolin8, Brooke Howitt1
1
Stanford University School of Medicine, Stanford, CA, 2Stanford University School of Medicine, Mountain View, CA, 3Stanford
University, Stanford, CA, 4The University of Chicago, Chicago, IL, 5University of Arkansas for Medical Sciences, Little Rock,
AR, 6Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, 7Brigham and Women's Hospital, Harvard
Medical School, Boston, MA, 8Brigham and Women's Hospital, Boston, MA

Disclosures: Erna Forgo: None; Anna-Lena Lang: None; Vanita Natu: None; Teri Longacre: None; Jennifer Bennett: None; Charles
Quick: None; Carlos Parra-Herran: None; Marisa Nucci: None; David Kolin: None; Brooke Howitt: None

Background: Uterine sarcomas can be difficult to diagnose due to overlapping morphology and immunophenotype. Identification of gene
rearrangements can help with classification in some cases. DNA methylation is an epigenetic modification important in the regulation of
gene expression. We sought to characterize the epigenetic signatures of uterine sarcomas by DNA methylation profiling in order to
determine if subtypes of uterine sarcomas have tumor-defining epigenetic alterations that can be used for classification and
prognostication.

Design: Uterine sarcomas derived from formalin-fixed paraffin-embedded tissue from 4 institutions were processed using the Illumina
850k Bead Chip Platform. Cases passing all Q/A parameters were included in the preliminary analysis and comprised endometrial
stromal nodules (ESN, n=2), endometrial stromal tumors with limited infiltration (ESTLI, n=2), low-grade endometrial stromal sarcomas
(LGESS, n=45; 40 patients), high-grade endometrial stromal sarcomas (HGESS, n=2), müllerian adenosarcomas (MA, n=14), and
inflammatory myofibroblastic tumors (IMT, n=5). Gene fusion status for JAZF1, PHF1, BCOR and YWHAE was also recorded.

Results: T-distributed stochastic neighbor embedding (t-SNE) dimensionality reduction analysis based on the 20,000 most variable probe
sites revealed clustering into 3 main groups which correlated with histologically diagnosed tumor type (Figure 1). Group 1 included ESN,
ESTLI, and LGESS; Group 2 included MA, and Group 3 included all 5 IMT cases. Additionally, 5 LGESS from 2 patients, all
harboring JAZF1 rearrangements and all metastatic formed a 4th small, but discrete cluster. Two HGESS clustered on the border of
Group 1. Clustering was independent of institutional origin. Within Group 1, LGESS did not appear to form subgroups based on genotype
in the t-SNE plot, but additional analyses are pending. Outlier histologic diagnoses are undergoing additional molecular evaluation to
confirm or refute the original histologic impression.

1056
 Figure 1 - 1103

Conclusions: Uterine sarcomas show distinct DNA methylation profiles that generally correlate with histotype. The presence of outliers in
the otherwise robust t-SNE clustering observed suggests that some tumors may in fact represent misdiagnosed cases. LGESS
with JAZF1 rearrangement that behaved clinically aggressively formed a distinct cluster. This preliminary data shows the potential for
DNA methylation profiling in providing more accurate and clinically relevant diagnostic and prognostic information in uterine sarcomas.

1104 Proportion of Hyperplasia/Carcinoma as a Prognostic Factor for Invasion in Low-Grade

Endometrial Carcinomas in Patients Younger than 40 Years Old
Carolina Fraire Vazquez1, David Cantu de Leon2, Salim Barquet1, Isabel Alvarado-Cabrero3, Guadalupe Moncada1, Lourdes
Peña Torres1, Maria Delia Perez Montiel4
1
Instituto Nacional de Cancerologia, Mexico City, Tlalpan, Mexico, 2Instituto Nacional de Cancerologia, Mexico City, Tlapan,
Mexico, 3Mexican Oncology Hospital SXXI, IMSS, Ciudad de México, MEX, Mexico, 4Instituto Nacional de Cancerologia, Mexico
City, DF, Mexico

Disclosures: Carolina Fraire Vazquez: None; David Cantu de Leon: None; Salim Barquet: None; Isabel Alvarado-Cabrero: None;
Guadalupe Moncada: None; Lourdes Peña Torres: None; Maria Delia Perez Montiel: None

Background: Endometrial carcinoma in young patients is a condition that has been increasing in the past years, many of these women
desire fertility preservation but many undergo to hysterectomy. The objective of the study is to determine if the ratio of hyperplasia in
relation to adenocarcinoma (H/AC) in the dilation and curettage (D&C) is a prognostic factor that could help in the decision of proposing
more conservative treatments in this group of individuals.

Design: A retrospective study was carried out in patients under 40 years of age with a diagnosis of low-grade endometrioid
adenocarcinomas in a D&C as diagnostic procedure, the material was reviewed by two pathologists and the percentage of hyperplasia
(simple and complex) and the percentage of carcinoma (based on WHO criteria) was estimated in percentage. It was correlated with the
findings of a hysterectomy and a ROC curve was performed to determine the cut-off point of the (H/AC) that allows to predict the findings
of the hysterectomy specimen.

Results: From January 2006 to December 2018, 119 cases of patients with G1 endometrioid adenocarcinoma under 40 years were
identified, of these 66 cases underwent a hysterectomy. Mean age was 34 (range 24-39). The D&C biopsy varied from 1 cc to 10 cc and
were included in its entirety. Two patients were re-categorized as G2, by cytologic atypia. The percentage of presence of adenocarcinoma
varied from less than 5% to 100% of the biopsy samples. In hysterectomy specimens the diagnosis was: without evidence of tumor 5
(7.5%), 34 intramucosal carcinomas (51.5%), 19 adenocarcinomas with invasion less than 50% (28.7%) of myometrium, 4 carcinomas
with invasion greater than 50% (6%) of myometrium, 4 cases with infiltration into the cervical stroma (6%). A total of 31 carcinomas
were histologically upgraded (46.97%) in the hysterectomy. When analysis the percentage of adenocarcinoma in the biopsy, we found
that patients without residual neoplasia, microscopic foci or without myometrial invasion correlated with a H/AC of 70/30 (AUC=0.78) or

1057
higher in the biopsy. Patients with an upgrade in the hysterectomy correlated with the H/C 40/60 (AUC=0.71) or more. All, except one
patient, are alive without recurrence.

Conclusions: Reporting the ratio H/C in patients with low-grade adenocarcinoma seems to be a prognostic factor and help in selecting
cases for conservative management. Larger number of cases must be included as well as larger follow-up.

1105 Loss of MHC Class I in Endometrial Carcinoma: A Possible Mechanism of Immunotherapeutic

Resistance in Some MMR-Deficient and PD-L1-Positive Tumors
Lisa Friedman1, Timothy Bullock1, Emily Sloan2, Kari Ring1, Anne Mills1
1
University of Virginia, Charlottesville, VA, 2University of California San Francisco, San Francisco, CA

Disclosures: Lisa Friedman: None; Timothy Bullock: None; Emily Sloan: None; Kari Ring: None; Anne Mills: None

Background: Major histocompatibility complex (MHC) class I is a membrane-bound protein complex ubiquitously expressed on normal
nucleated human cells. MHC class I presents intracellular protein fragments to cytotoxic T cells, allowing these immune cells to detect
neoantigens and destroy abnormal cells. MHC Class I loss has been documented in a variety of tumor types and represents a possible
mechanism of immunotherapy resistance even among cancers that otherwise appear to be good candidates for checkpoint inhibition,
such as mismatch repair (MMR)-deficient and PD-L1-positive malignancies. We herein assess MHC Class I expression in a range of
endometrial carcinomas, including MMR-deficient and PD-L1-positive cancers.

Design: Immunohistochemical staining for combined MHC class I A-, B-, and C-heavy chains was performed on 78 cases of endometrial
carcinoma [29 MMR-intact, 25 MLH1-promoter hypermethylated (MLH1-hm) MMR-deficient, and 24 non-hypermethylated (non-hm)
MMR-deficient]. The degree of MHC class I staining was classified as present, clonally lost, or absent. Tumoral PD-L1 expression and
CD3-positive T lymphocytes were also quantified.

Results: Forty two percent of tumors showed clonal (27%) or complete (15%) loss of MHC class I expression. This included 47% of
MMR-deficient and 28% of PD-L1-positive cancers. However, neither loss pattern was significantly associated with stage, grade, MMR
status, tumoral PD-L1 expression, PD-L1 CPS, or the CD3+ lymphocyte count. (See table)

MHC Class I MHC Class I MHC Class I p-value

Intact (n=45) Clonal Loss (n=21) Complete Loss

(n=12)
MMR-intact (n=29) 19 (66%) 9 (31%) 1 (3%) 0.265
MMR-deficient (n=49) 26 (53%) 13 (27%) 10 (20%)
MLH1-hm (n=25) 14 (56%) 7 (28%) 4 (16%)
Non-hm (n=24) 12 (50%) 6 (25%) 6 (25%)
PD-L1 tumor+ (≥1%) 21 (72%) 6 (21%) 2 (7%) 0.380
(n=29)
PD-L1 CPS+ (≥1) (n=67) 37 (55%) 18 (27%) 12 (18%) 0.290
Mean CD3+ tumor- 194 (165-222) 182 (141-224) 158 (103-213) 0.553
associated lymphocyte
count (mean (95% CI))

1058
 Figure 1 - 1105

Conclusions: Many endometrial carcinomas demonstrate partial or complete loss of classical MHC class I expression, including 47% of
MMR-deficient and 28% PD-L1-positive tumors which might otherwise be considered ideal candidates for immunotherapy. Notably, loss
was also commonly observed in MMR-intact tumors and across tumoral grades and stages. These findings suggest that tumoral MHC
Class I status may be an important factor to consider when selecting endometrial cancer patients for checkpoint inhibition.

1106 Androgenetic/biparental Mosaic Conception: Histological and Immunohistochemical Analyses of

21 Cases
Masaharu Fukunaga, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa, Japan

Disclosures: Masaharu Fukunaga: None

Background: Androgenetic/biparental mosaic conception is very rare and always poses a diagnostic challenge both clinically and
pathologically. It is generally proven by DNA genotyping.

Design: Twenty-one cases of androgenetic/biparental mosaic conception, all of which were in the first trimester, were retrieved from 690
cases with hydropic placental tissue and were histopathologically analyzed by immunostaining for p57 (Kip2) (p57), which is a product of
paternally imprinted, maternally expressed genes. p57-negative cells are generally considered to be androgenetic, while p57-positive
cells are biparental.

Results: Androgenetic/biparental mosaic conception is characterized by discordant p57 immunohistochemical expression in different cell
types based on the presence or absence of maternal genetic material in these cells. p57 expression was detected in 14 cases of mosaic
complete mole (CM) with a placental mesenchymal dysplasia (PMD) component, 4 of mosaic CM with a non-PMD component, in which
almost normal villi were observed, 2 of pure PMD, and 1 of mosaic hydropic abortion. p57-positive and -negative cytotrophoblasts and
villous stromal cells were observed in mosaic CM cases. PMD villi were histologically characterized by stromal cell hyperplasia and the
absence of trophoblastic hyperplasia. A discordant pattern of p57 expression was observed in the PMD component of cases of mosaic
CM with PMD and pure PMD, with positive staining in villous cytotrophoblasts and negative stromal cells, indicating a mixture of
androgenetic and biparental cells. Fetal parts were observed in 3 cases of mosaic CM with PMD. In 1 case of mosaic hydropic abortion,
villi had p57-positive and -negative stromal cells. None of these cases had persistent trophoblastic diseases.

Conclusions: Androgenetic/biparental mosaic conception may be divided into four types: mosaic CM with PMD, mosaic CM with a non-
PMD component, pure PMD, and hydropic abortion. Mosaic CM with PMD was the most common type. Mosaic CM is often associated

1059
with PMD and is associated with a risk of persistent disease. Androgenetic/biparental mosaicism may be the etiology for PMD. p57
immunostaining may be a useful screening tool for cytogenetic analyses of androgenic/biparental mosaic conception.

1107 Endometrioid Carcinoma Associated with Atypical Polypoid Adenomyoma

Masaharu Fukunaga, Shin-Yurigaoka General Hospital, Kawasaki, Kanagawa, Japan

Disclosures: Masaharu Fukunaga: None

Background: Atypical polypoid adenomyoma (APA) has been regarded as a benign tumor; however, it is often associated with
endometrioid adenocarcinoma (EC), and its histologic diagnosis, biologic potential and patients’ management have been controversial.

Design: Thirty-one cases of EC associated with APA were retrieved from 122 cases of APA. Its differential diagnosis, effects of hormonal
(medroxyprogesterone acetate) therapy and biologic behavior were studied.

Results: The patients' ages ranged from 28 to 66 (mean: 35) years. Twenty-seven ECs were observed in the APA and 4 were in the
adjacent endometrium. Thirty cases were grade 1 EC and 1 was dedifferentiated carcinoma. Eleven patients with APA who were initially
treated with curettage or polypectomy followed by hormonal therapy had residual or recurrent APA. Three of them also showed EC.
Hysterectomy was performed in 27 patients with APA because a definite diagnosis could not be made preoperatively, the curettages
raised the possibility of adenocarcinoma, or because there was a high possibility of residual or recurrent lesions. All showed residual or
recurrent APA in hysterectomy specimens and 12 had also EC. Seven had superficial myometrial invasion and 1 showed deep
myometrial invasion. The overall residual or recurrent lesion rate of APA patient was high (32 /65, 49%). Thirty patients with EC were
alive without evidence of disease at 1 to 225 month and one with dedifferentiated carcinoma developed peritoneal implants and was
treated with chemotherapy.

Conclusions: The rate of recurrent or residual APA was high, and the effects of hormonal therapy were limited. The risk EC in women
with APA is also high. Almost all of ECs with APA are well differentiated and may have favorable clinical courses, but there is a risk of
deep myometrial invasion or developing dedifferentiated carcinoma. The findings indicate a continued risk for the development of EC in
patients in whom complete excision of APA cannot be guaranteed. If a definite diagnosis of APA has been made on curettage or
polypectomy, hysterectomy is the treatment of choice. However, patients with APA who wish to preserve fertility and managed by local
excision should be carefully followed-up. In general, substantial number of EC may arise from APA and APA can be completely replaced
by carcinomatous overgrowth. APA areas should be paid attention in cases of EC. APA may be best regarded as analogous to a localized
form of atypical complex edometrial hyperplasia.

1108 Morphologic Features Indicating the Mismatch Repair Protein Status in Ovarian Clear Cell
Carcinoma and Frequent MSH2/MSH6 Deficient Expression: A Cohort of 176 Patients from China
Huijuan Ge1, Yaoxing Xiao2, Guangqi Qin3, Yanzi Gu3, Xu Cai4, Wenhua Jiang3, Xiaoyu Tu4, Wentao Yang4, Rui Bi3
1
Shanghai, China, 2Department of Pathology, Obstetrics & Gynecology Hospital of Fudan University, Shanghai Red House
Obstetrics & Gynecology Hospital, Shanghai, China, 3Fudan University Shanghai Cancer Center; Shanghai Medical College,
Fudan University, Shanghai; Institute of Pathology, Fudan University, Shanghai, Shanghai, China, 4Fudan University Shanghai
Cancer Center, Shanghai, China

Disclosures: Huijuan Ge: None; Yaoxing Xiao: None; Guangqi Qin: None; Yanzi Gu: None; Xu Cai: None; Wenhua Jiang: None;
Wenhua Jiang: None; Xiaoyu Tu: None; Wentao Yang: None; Rui Bi: None

Background: Lynch syndrome (LS) is an autosomal dominant tumor syndrome caused by a germline mutation in one of the DNA
mismatch repair (MMR) genes (MLH1, MSH2, MSH6 and PMS2), which, after a loss-of-function mutation in the normal allele, increases
cancer risk.In the literature, the focus of LS has been predominantly on colorectal carcinoma, but recently, there has been growing
recognition of the role that LS plays in the development of gynecologic malignancies.,including ovarian clear cell carcinoma (OCCC). Little
is known about the pathological features and MMR expression in OCCC. Hence, we performed MMR staining and assessed the
relationship between pathological features and the MMR expression status. We aimed to identify the clinical and histopathological
characteristics of ovarian clear cell carcinoma associated with the MMR status and to further examine the element of surveillance for
OCCC in LS.

Design: We reviewed specific morphologic features, including histology characteristics (nuclear atypia, necrosis, mitosis, stromal
hyalinization, and background precursors) and the host inflammatory response (TILs, PTLs, intratumoral stromal inflammation and
plasma cell infiltration), in 176 OCCCs. Immunohistochemistry for MLH1, PMS2, MSH2, MSH6 and ARID1A was performed on sections
of a triple-core tissue microarray of 176 OCCCs.

Results: Deficient MMR (dMMR) was detected in 10/176 (5.7%) tumors, followed by MSH2/MSH6 (6/176, 3.4%), MLH1/PMS2 (3/176,
1.7%), and MSH6 (1/176, 0.6%). No case of PMS2 or MSH2 loss alone was observed. The average age of patients with dMMR was 46
years, demonstrating that they were significantly younger than patients with intact MMR (46 years vs. 53 years, P = 0.041). Among the
patients with dMMR, 2 had a synchronous malignant tumor, and 2 had a history of HNPCC. Diffuse intratumoral stromal inflammation and

1060
plasma cell infiltration were two unique independent features associated with the dMMR status according to the univariate analysis.
ARID1A expression was lost in 8 patients with dMMR (8/10, 80%), but no significant difference between dMMR and ARID1A expression
was observed. Diffuse intratumoral stromal inflammation correlated only with the expression of dMMR in the multivariate analysis (P =
0.004).

Table 1 pathologic characteristics of clear cell carcinoma and their association with MMR status
MMR-deficient cases（n=10） MMR-intact cases（n=166） P
Age(y) 0.078
<50 6（60%） 54（32.5%）
≥50 4（40%） 112（67.5%）
Median 46 53 0.041
Other tumour 2 39 1.0
HNPCC history 2 20 0.362
Precursor 4（40%） 61（36.7%） 0.987
no 1（10%） 22（13.3%）
Adenofibroma 4（40%） 69（41.6%）
Endometriosis 1（10%） 14（8.4%）
both
Stromal Hyalinizaton 0.671
Focal or absent 8（80%） 139（83.7%）
Diffuse 2（20%） 27（16.3%）
Nuclear Atypia 0.139
High grade 5（50%） 43（25.9%）
Low-medium grade 5（50%） 123（74.1%）
Signet ring cells 0.603
No 10（100%） 147（88.6%）
Yes 0（0%） 19（11.4%）
Peritumoral Lymphocytes 0.127
no 7（70%） 146（88%）
Yes 3（30%） 20（12%）
Intratumoral Stromal Inflammation 0.001
Diffuse 5（50%） 11（6.6%）
Focal 5（50%） 155（93.4%）
Plasma Cell Component 0.037
≤50% 6（60%） 145（87.3%）
>50% 4（40%） 21（12.7%）
Tumor filtrating Lymphocytes（/10HPF） 0.249
<40 8（80%） 151（91%）
≥40 2（20%） 15（9%）
Mitosis（/10HPF） 5.1 6.4 0.499
Necrosis 0.300
No 3（30%） 73（44%）
Yes 7（70%） 93（56%）
ARID1A 0.203
No 8（80%）） 102（61.4%）
Yes 2（20%）） 64（38.6%）
Stage 0.462
I/II 6 110
III-IV 4 56

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 Figure 1 - 1108 Figure 2 - 1108

Conclusions: dMMR in OCCC is not highly frequent. Diffuse intratumoral stromal inflammation suggests the use of the MMR status as a
unique screening histological feature, and MSH2/MSH6 expression is the most frequently deficient and closely associated with LS.

1109 From Liquid-Based Cytology to Liquid-Based Histology of Pap Smear Samples: Are We Ready to
Shift the Paradigm?
Cinzia Giacometti1, Lucetta Vidotto2, Sara Ghiretti1, Mauro Cassaro1
1
ULSS6 Euganea, Camposampiero, Italy, 2Department of Pathology - ULSS6 Euganea, Camposampiero, Italy

Disclosures: Cinzia Giacometti: None; Lucetta Vidotto: None; Sara Ghiretti: None; Mauro Cassaro: None

Background: Cell block (CB) preparations from residual liquid-based Pap samples (LBPS) have been shown to be of diagnostic value.
However, traditional cell block preparation techniques are mostly manual, difficult to standardize, and not feasible for hypocellular
samples. Cytomatrix® is a synthetic matrix that counts among its various characteristics the property to capture and store inside its three-
dimensional structure, the biological material (micro-macro cells and cell aggregates) from needle withdrawal samples. The matrix is then
directly put in formalin and routinely processed to form a paraffin-embedded ensamble of matrix and biological material which can be then
cut and stained.

Design: In this study, the authors investigated the usefulness of Cytomatrix® cell blocks (CyCB) on residual LBPS to assess all the
parameters usually evaluated in Pap samples, according to Bethesda guidelines for interpretation of Pap smears (i.e. adequacy,
inflammation, bacterial/fungi, epithelial/glandular lesions etc), blind of previous Pap smear diagnoses.

p16 immunohistochemistry (IHC) was performed on all samples and high-risk HPV (hrHPV) molecular test was performed in
suspicious/positive CyCB cases, if not previously available. The results of CyCB interpretation, p16 IHC and hrHPV molecular tests were
then compared with the initial diagnoses assessed on LBPS.

Results: One-hundred fifty-nine (159) consecutive Hematoxylin&Eosin-stained CyCB slides prepared from CyCB
from residual LBPS (108 normal, 7 ASC-US, 3 ASC-H, 29 LSIL, 6 HSIL, 3 endometrial cells, 2 AGC and 1 unsatisfactory) were analyzed.
HrHPV molecular biology was available in 100% of cases. The cellular architecture and morphology were well maintained in
all CyCB samples, with excellent consistency.

A total of 18 cases were further categorized/upgraded: 4 cases from normal to LSIL, ASC categories to SIL categories, 2 LSIL to HSIL,
2 AGC and 1 endometrial cells to adenocarcinoma, 1 unsatisfactory to negative (Table 1). HrHPV test were
positive in all upgraded cases.

1062
 INTERPRETATION/RESULT LBPS CyCB
Negative for intraepithelial lesion or malignancies 108 105
ASC-US 7 0
ASC-H 3 0
L-SIL 29 40
H-SIL 6 9
AGC 2 0
Endometrial cells 3 2
Adenocarcinoma 0 3
Unsatisfactory 1 0

Figure 1 - 1109 Figure 2 - 1109

Conclusions: The Cytomatrix® CB system as used in the study allows for the efficient and rapid processing of micro-sized cytology
samples minimizing manual handling. It is a useful technique to further categorize both epithelial and glandular lesion, as the pathologist
has the ability to improve the diagnostic accuracy of Pap smears using ancillary techniques (i.e. IHC, molecular biology), thus eventually
avoiding unnecessary colposcopic evaluation or biopsies.

1110 Detection of TP53 Mutations in the Peritoneal Washings of Women with Germline Mutations in
Ovarian Cancer Susceptibility Genes
Emily Goebel1, Xiaohua Qian2, Jingzhong Xie3, David Chapel2, Sarah Hill4, Judy Garber5, Wa Xian6, Christopher Crum2
1
London Health Sciences Centre, Kilworth, ON, 2Brigham and Women's Hospital, Boston, MA, 3University of Houston, Houston,
TX, 4Brigham and Women's Hospital, 5Dana-Farber Cancer Institute, 6University of Texas Health Science Center

Disclosures: Emily Goebel: None; Xiaohua Qian: None; Jingzhong Xie: None; David Chapel: None; Christopher Crum: None

Background: Women with germline mutations in the BRCA genes are at increased risk for developing high-grade serous carcinoma
(HGSC). The presumed origin for these tumors in many cases is the fallopian tube and the source of the tumor cells is presumed to be
exfoliated cells with TP53 mutations from either intra-mucosal serous carcinomas (STIC) or early serous proliferations (via precursor
escape). Biologic progression of these cells with TP53 mutations thus can result in “primary peritoneal” HGSC. Recent studies of HGSC
cases and controls have confirmed the presence of cells with TP53 mutations in the peritoneal fluid.

Design: The purpose of this pilot study was to determine if healthy women at genetic risk for HGSC harbored cells with TP53 mutations
in the peritoneal cavity. Peritoneal washings from women undergoing risk-reduction salpingo-oophorectomy were selected. Discarded
samples were centrifuged and cell pellets were processed for DNA extraction. DNA was then subjected to next-generation Ion torrent
sequencing and the data were analyzed manually and using the analysis program gatk4 mutect2 (gatkforums.broadinstitute.org). Results
were interpreted with the following conclusions: 1) there is a low possibility that the same mutation would be shared by multiple patients,
2) Ion torrent sequencing platform is prone to homopolymer-sequencing-errors (indels), 3) there is a very low possibility that two
independent mutation events happened in a single cell.

1063
Results: After excluding mutations that were presumed to be germline variants, 5 samples were identified with unique frameshift
mutations in TP53 (Table). One sample contained multiple TP53 mutations, interpreted as likely signifying more than one cell population
with a unique mutation.

TP53 mutations in peritoneal fluid of women at risk for HGSC

Sample Genetics TP53 indel
3 BRCA1 chr17: 7579420
4 BRCA1 chr17:7578280
5 BRCA1 chr17:7577031;7036;8280;8464,9547,9861
6 BRIP1 chr17: 7578474
7 BRCA2 chr17: 7579373

Conclusions: Women at increased genetic risk for HGSC frequently harbor cells with TP53 mutations in their peritoneal fluid. The origin
of the cell populations with these mutations remains unclear. The possibility that these cells share lineage with endometrial or salpingeal
cells with similar mutations is currently under investigation.

1111 Usual Vulvar Intraepithelial Neoplasia with Morphology Mimicking Differentiated Vulvar
Intraepithelial Neoplasia and/or Lichen Sclerosus
Laurie Griesinger1, Richard Lieberman2, Grace Wang1, Heather Walline1, Stephanie Skala1
1
University of Michigan, Ann Arbor, MI, 2Michigan Medicine, Ann Arbor, MI

Disclosures: Laurie Griesinger: None; Richard Lieberman: None; Grace Wang: None; Heather Walline: None; Stephanie Skala: None

Background: Squamous cell carcinoma (SCC) of the vulva can arise through a human papillomavirus (HPV)-dependent pathway (usual
vulvar intraepithelial neoplasia, UVIN) or an HPV-independent pathway (differentiated vulvar intraepithelial neoplasia, dVIN). dVIN is
expected to show more rapid progression to SCC. UVIN with superimposed lichen simplex chronicus (LSC) or inflammation has been
reported to morphologically resemble dVIN. Such cases of UVIN are block positive for p16 and show parabasal and mid-epithelial p53
staining with sparing of the basal layer. The 11 cases (from 2 studies) with reported HPV genotyping results showed HPV 16. To our
knowledge, only 15 cases of UVIN mimicking dVIN have been reported in the literature.

Design: The surgical pathology database of a single large academic institution was searched for vulva specimens with corresponding
p53 and p16 immunohistochemical stains, yielding 30 specimens (from 19 patients) resected between 1991 and 2019. In situ
hybridization for high-risk HPV and HPV multiplex PCR-MassArray (PCR-MA) to identify high and low risk HPV types (with reflex to L1
consensus PCR for invalid results) were performed on at least one block from each patient (24 blocks from 19 patients for ISH, 21 blocks
from 19 patients for PCR).

Results: All cases resembled dVIN morphologically, but with a higher degree of atypia and superimposed chronic inflammation. Nearly all
cases showed block positivity for p16 protein by IHC in combination with mid-epithelial p53 staining (see Figure). Nearly all cases had at
least patchy positivity by HPV ISH. Thirteen cases yielded valid PCR-MA results with L1 consensus PCR yielding results in 2 additional
cases. 9 cases were positive for HPV and 6 cases were negative. Of the positive cases, HPV16 was identified in 5 cases, HPV52 and
HPV58 each identified in 2 cases, and HPV31 in 1 case. There was one co-infection with types 16 and 52.

1064
 Figure 1 - 1111

Conclusions: To our knowledge, this is the largest cohort of UVIN mimicking dVIN reported to date. Contrary to prior studies, which
reported positivity for HPV16 in all 11 cases tested, we found HPV16 in only 5 cases (33% of total; 63% of HPV positive cases), with
other HPV types identified in 3 cases (20% of total; 37% of HPV positive cases), and no HPV identified by PCR in 6 cases (40%). These
results add to the small group of reported cases of UVIN mimicking dVIN, and expand the spectrum of associated HPV types.

1112 The Immune Microenvironment in Low-Grade Endometrial Stromal Sarcomas: The Ratio of CD8+
T-Cells/FOXP3+ Tregs (T Regulatory Cells) is a Significant Prognostic Factor
Elin Hardell1, Jordi Gonzalez-Molina2, Okan Gültekin3, Kaisa Lehti4, Joseph Carlson5
1
Stockholm, Sweden, 2Department of Microbiology, Tumor and Cell Biology and Department of Oncology-Pathology, Karolinska
Institutet, Stockholm, Sweden, 3Karolinska Institutet, Stockholm, Sweden, 4Karolinska Institutet and University of Helsinki,
Stockholm, Sweden, 5Karolinska University Hospital, Stockholm, Sweden

Disclosures: Elin Hardell: None; Jordi Gonzalez-Molina: None; Okan Gültekin: None; Kaisa Lehti: None; Joseph Carlson: None

Background: Low-grade endometrial stromal sarcomas (LGESS) are rare malignant tumors of the uterus. They typically affect young
and perimenopausal woman and are treated with surgery, possibly in combination with anti-estrogen therapy.

The immune microenvironment has an important role in the development and progress of tumors. The amount of different infiltrating
immune cells, including CD8+ T-cells, FOXP3+ Tregs (T regulatory cells) and the ratio of CD8+ T cells/FOXP3+ Tregs has been shown to
be prognostic in different tumors. B7H4 and PD-L1 are immune inhibitory proteins overexpressed in a variety of tumors, and have
emerged as potential therapeutic targets.

Design: Twenty cases of LGESS were included. All cases had follow-up data and paraffin blocks with formalin fixed tumor material. A
tissue micro array was constructed with two core biopsies from each case. Multiplex fluorescent immunohistochemistry in combination
with image analysis in QuPath was used to quantitatively assess the expression of different immune markers, including CD8, FOXP3,
CD68, CD163, IDO1, B7H4 and PD-L1.

1065
Results: The range of number of detected tumor-infiltrating CD8+ T-cells was 10.13-286.04 cells/mm2 (mean 77.62). The range of
FOXP3+ Tregs was 7.13-584.87 cells/mm2(mean 122.35). The cases were divided into high and low expression groups using the mean
of each marker as cutoff. Kaplan-Meier curves of overall survival showed an improved survival for patients with high numbers of CD8+ T-
cells (n=3) compared to patients with low numbers (n=15), figure 1. However, the difference was not statistically significant (p=0.2097).
When comparing the group of patients with a high ratio (n=6) of CD8+/FOXP3+ cells with the group with a low ratio (n=12), the group with
a low ratio had a significant better survival (p=0.0087), figure 2. A better survival was also seen in the group of patients with high numbers
of B7H4+ cells compared to the group with low numbers (range 0-36, mean 5.59, p=0.2358). The quantity of CD68+ macrophages,
CD68+CD163+ M2-type macrophages and IDO1 was not prognostic. No expression of PD-L1 was seen.

Figure 1 - 1112 Figure 2 - 1112

Conclusions: A low ratio of CD8+/FOXP3+ cells is significantly associated with a favorable prognosis in LGESS. For patients with a high
quantity of CD8+ T-cells and B7H4, a trend towards better survival was seen. The expression of B7H4 is also a potential therapeutic
target.

1113 Clinical and Pathological Features of Vitelline Vasculitis

Yuichiro Hatano1, Maho Tamada2, Mikiko Matsuo2, Hiroyuki Tomita2, Nami Asano3, Akira Hara2
1
Gifu University Graduate School of Medicine, Gifu, Japan, 2Gifu University, Gifu, Japan, 3Chuno Kosei Hospital, Seki, Gifu,
Japan

Disclosures: Yuichiro Hatano: None; Maho Tamada: None; Mikiko Matsuo: None; Hiroyuki Tomita: None; Nami Asano: None; Akira
Hara: None

Background: Funisitis is a leading cause of perinatal complications, and in the majority of cases it is caused by chorioamnionitis or
umbilical vasculitis. Recently, the vitelline vessel remnant (VVR) was reported to be associated with neutrophilic infiltration (PMID:
30541420), suggesting that even the supernumerary vessel is involved in acute inflammatory processes associated with the umbilical
cord. However, the detailed characteristics of this newly proposed microscopic lesion remain unclear. Thus, we conducted the first case
series study of vitelline vasculitis to clarify its clinical and pathological features.

Design: In total, 261 obstetric cases were enrolled in this study. CD15 immunostaining was performed to visualize granulocytes in the
umbilical cord. Further, a modified version of the revised Blanc classification (PMID: 28691405) was used to assess the severity of
funisitis. Clinical data, such as data on perinatal complications, maternal serum C-reactive protein (CRP) levels, cord blood pH, and Apgar
score, were obtained from the patients’ medical records. Statistical differences were evaluated using Fisher’s exact test for categorical
variables and Student’s t-test, paired t-test, or Welch’s t-test for continuous variables.

Results: Of the 261 patients, 22 (8.4%) showed VVR (Figure 1). There were no significant differences in clinical features between
patients with and those without VVR. Per the inflammation assessment based on CD15-positive cell distribution, severe funisitis
accounted for 16% of the cases and was significantly associated with chorioamnionitis, elevation of maternal serum CRP levels, and
weight gain of the placenta. Among patients with VVR, 5 (23%) were assessed as having severe funisitis; CD15-positive cells around the
VVR were observed in 20 (91%) patients (Figure 2). Although perivascular granulocytic infiltration corresponds with severe vasculitis per
our assessment system, granulocytic infiltration around the VVR was not associated with the abovementioned clinical and pathological
characteristics.

1066
 Figure 1 - 1113 Figure 2 - 1113

Conclusions: Consistent with previous results, VVR was found to be frequently associated with granulocytic infiltration. Although it is
difficult to identify such perivascular inflammation without immunohistochemical analysis, our investigation revealed that vitelline vasculitis
itself does not affect the maternal and fetal medical condition.

1114 Gene Fusions Characterize a Subset of Uterine Cellular Leiomyomas

Anjelica Hodgson1, David Swanson2, Shangguo Tang3, Brendan Dickson4, Gulisa Turashvili2
1
University of Toronto, Toronto, ON, 2Mount Sinai Hospital, Toronto, ON, 3Burlington, ON, 4Mount Sinai Health System, Toronto,
ON

Disclosures: Anjelica Hodgson: None; David Swanson: None; Shangguo Tang: None; Brendan Dickson: None; Gulisa Turashvili: None

Background: Uterine leiomyoma, the most common gynecological neoplasm, is a benign neoplasm with smooth muscle differentiation.
Studies evaluating the pathogenesis of conventional uterine leiomyoma have shown multiple potential mechanisms including recurrent
gene alterations in MED12 and HMGA2. Cellular leiomyoma, a subtype that may be morphologically confused with low grade endometrial
stromal neoplasms, remains less well-characterized. Following identification of an index patient with a cellular leiomyoma harboring
a HMGA2-TRAF3IP2 fusion, we undertook a retrospective review of additional cases to better assess the prevalence of fusion events in
this tumor type.

Design: A retrospective archival review was performed for cases diagnosed as cellular leiomyoma (2013-2019). Slides were reviewed to
confirm the tumor morphology and immunophenotype were concordant with the diagnosis of cellular leiomyoma. Clinicopathologic data
from each patient was recorded. RNA-sequencing was performed using formalin fixed paraffin embedded tissue and the TruSight RNA
Fusion Panel (Illumina, CA) which evaluates 507 genes for fusions including those typically identified in endometrial stromal neoplasms.

Results: A total of 12 uterine cellular leiomyomas were identified. The median patient age at diagnosis was 52 years (range 35-64).
Patients most commonly presented with abnormal uterine bleeding (n=3), symptoms related to tumor bulk (n=2), or both (n=2). Two
patients were immediately postpartum and one patient had concurrent grade 3 endometrial endometrioid adenocarcinoma; the remaining
2 patients did not have any pre-operative clinical information available. Myomectomy was performed in 5 patients and hysterectomy in 7
patients. The immunohistochemical and molecular findings are summarized in Table 1. Eleven tumors (92%) had sufficient quality RNA
for sequencing. Three tumors harbored gene fusions, two involving the HMGA2 gene (HMGA2-NAA11 and HMGA2-TRAF3IP2) and a
novel TPCN2-YAP1 fusion of uncertain significance. No clinical or pathologic variable was significantly associated with the presence of a
gene fusion.

1067
 Patient CD10 Desmin H-caldesmon Smooth Estrogen Progesterone Fusion
muscle actin receptor receptor
1 Focal, Focal, strong Patchy, strong Diffuse, strong Diffuse, strong Diffuse, strong TPCN2-YAP1
moderate
2 Focal, strong Diffuse, Patchy, moderate Diffuse, strong Diffuse, strong Patchy, strong Failed
moderate sequencing
3 Patchy, Patchy, strong Patchy, strong Diffuse, strong Focal, weak Patchy, weak None identified
strong
4 Diffuse, Patchy, Negative Diffuse, strong Diffuse, strong Diffuse, strong HMGA2-
strong moderate TRAF3IP2
5 Patchy, Patchy, strong Patchy, moderate Diffuse, strong Diffuse, strong Diffuse, moderate None identified
moderate
6 Focal, weak Patchy, Patchy, weak Diffuse, strong Diffuse, strong Diffuse, strong None identified
moderate
7 Focal, strong Patchy, strong Patchy, moderate Diffuse, strong Diffuse, strong Diffuse, strong None identified
8 Patchy, Diffuse, strong Patchy, strong Diffuse, strong Diffuse, strong Diffuse, strong None identified
strong
9 Patchy, Diffuse, strong Diffuse, moderate Diffuse, strong Diffuse, strong Diffuse, strong None identified
moderate
10 Patchy, weak Diffuse, strong Diffuse, strong Diffuse, strong Diffuse, strong Diffuse, strong HMGA2-NAA11
11 Patchy, Diffuse, strong Patchy, strong Diffuse, strong Patchy, Diffuse, strong None identified
strong moderate
12 Patchy, Diffuse, strong Focal, strong Diffuse, Diffuse, strong Diffuse, strong None identified
strong moderate

Conclusions: A subset of cellular leiomyomas harbor HMGA2 rearrangement, suggesting molecular kinship with conventional uterine
leiomyomas. The TPCN2-YAP1 gene fusion may be a novel fusion although additional investigation is required. The results suggest that
identification of these fusions may be useful when the diagnosis of cellular leiomyoma is in question.

1115 Clinicopathologic Features of Endometrial Carcinomas with Heterogeneous Loss of Mismatch

Repair Protein Immunoexpression. Our Institutional Experience
Yanjun Hou1, Longmei Zhao1, Michael Cruise2, Maria Luisa Policarpio-Nicolas1
1
Cleveland Clinic Foundation, Cleveland, OH, 2Cleveland Clinic, Cleveland, OH

Disclosures: Yanjun Hou: None; Longmei Zhao: None; Michael Cruise: None; Maria Luisa Policarpio-Nicolas: None

Background: Lynch syndromes (LS) is an autosomal dominant cancer syndrome caused by mutation in one of the mismatch repair
(MMR) genes MLH1, PMS2, MSH2, MSH6 and EPCAM. Because of the cost and availability, MMR immunohistochemistry (IHC) is
commonly utilized as the initial screening for LS. The common immunoexpression patterns for MMR are either intact or completely
lost. Occasionally, heterogeneous staining pattern can be seen and could cause interpretation difficulties. While some previously
published literature attributed this heterogeneous expression mostly to technical issues, recent publications attributed this to
heterogeneous methylation of the MLH1 promoter or a biological event in tumoral evolution. This study was conducted to review our
cases of endometrial carcinoma with heterogeneous immunoexpression of MMR proteins and correlate these results with the clinical
findings and MLH1 methylation status.

Design: A pathology archive database search was performed from surgical specimens with diagnoses of endometrial adenocarcinoma
and corresponding MMR IHC from 01/2017 to 05/2019. Of the 117 cases, 9 endometrial adenocarcinomas with partial
loss/heterogeneous staining pattern of one of or more of the MMR were identified. The slides were reviewed and the partial
loss/heterogeneous staining pattern was re-classified based on previously reported patterns by Pai et al (abrupt loss) and Joost et al
(intraglandular). The corresponding clinical histories, demographic information and histology were reviewed (Table1).

Results: The patients' age ranged from 43-84 years old (mean=64). Seven of nine (75%) patients were obese. All cases were of
endometrioid histologic type (FIGO Grade 1 [7], Grade 2[2]). Regardless of staining pattern (abrupt or intraglandular), it was concordant
in 5 cases for MLH1 and PMS2. Four cases showed complete loss of PMS2. MLH1 methylation was present in 89% (8/9) of cases and
absent in 1(11%). The latter case was sent for next generation sequencing and showed no alterations of germline or somatic origin.

1068
 Table 1. Clinicopathologic Findings, MMR Immunohistochemistry, MLH1 Methylation and NGS
Results
Cas Ag BM Histologic type Procedur MLH PMS2 MSH MSH6 MLH1 NGS
e e I e 1 2 methylation
1 52 47 Endometrioid TAHBSO A/I A/I intact focal Present
FIGO2 A
2 67 44 Endometrioid curettage I Complete intact intact Present
FIGO1 loss
3 84 28 Endometrioid TAHBSO I Complete intact intact Present
FIGO1 loss
4 78 55 Endometrioid curettage A/I Complete intact intact Present
FIGO1 loss
5 53 44 Endometrioid TAHBSO A Complete intact intact Present
FIGO1 loss
6 49 48 Endometrioid curettage A A intact intact Present
FIGO1
7 43 54 Endometrioid TAHBSO I I intact focal I Absent No germline or somatic
FIGO1 mutation
8 79 29 Endometrioid curettage A A intact focal Present
FIGO1 A
9 67 34 Endometrioid curettage A A intact intact Present
FIGO2
A-abrupt pattern; BMI-body mass index; I-intraglandular pattern, A/I both abrupt and intraglandular pattern, NGS next generation sequencing
TAHBSO-total abdominal hysterectomy with bilateral salpingo-oophorectomy

Conclusions: Heterogeneous MMR IHC pattern in endometrial adenocarcinoma is rare (8.0%, 9/117) and often of the endometrioid
histologic type (FIGO 1). The patients are usually obese without a family or personal history of Lynch syndrome associated cancer. While
our case number is small, our results show that heterogeneous loss of MLH1 is associated with MLH1 promoter methylation. Additional
molecular tests will be helpful in supporting our findings.

1116 Malignant Mixed Mullerian Tumors: Does the Epidemiology/Prognosis Differ Based on Histology
of Epithelial Component?
K Islam1, Khadijeh Jahanseir2, Katrine Hansen3, C. James Sung1, Kamaljeet Singh4, M. Ruhul Quddus1
1
Women & Infants Hospital/Alpert Medical School of Brown University, Providence, RI, 2Women & Infants Hospital, Providence,
RI, 3Women and Infants Hospital of Rhode Island, Providence, RI, 4Yale School of Medicine, New Haven, CT

Disclosures: K Islam: None; Khadijeh Jahanseir: None; Katrine Hansen: None; C. James Sung: None; Kamaljeet Singh: None; M. Ruhul
Quddus: None

Background: Malignant mixed müllerian tumor (MMMT) also known as carcinosarcoma (CS) is a biphasic tumor with high grade
carcinomatous and sarcomatous component. MMMT is known to be an aggressive disease with poor survival even in early stage
disease. The epithelium component in MMMT is most often of serous (MMMT SC) type but other müllerian types including endometrioid
(MMMT EC) type are rarely seen. The mesenchymal component is either homologous or heterologous which has no influence on disease
outcome. In contrast, high-grade serous or clear cell component correlates with a higher frequency of metastasis. The current study is
designed to compare prognosis and survival outcome of malignant mixed müllerian tumor with serous (MMMT-SC) versus malignant
mixed müllerian tumor with endometrioid (MMMT EC) component.

Design: A total of 57 cases, 51 MMMT-SC and 6 MMMT-EC cases were studied from 1999 to 2019 after IRB approval. The original
diagnoses were reconfirmed and the cases were assigned into two groups based on epithelial component of the MMMT. Patient charts
were reviewed to obtain clinical information regarding age at diagnoses, tumor stage, and treatment types (surgery and postoperative
therapy). Survival outcome was examined in terms of disease-free survival, local and distant recurrence and overall survival. The data
was compared to assess for outcome difference between the groups.

Results: The demographic findings are summerized in Table 1 and the findings are presented in Figure 1.

1069
 Table 1: Demographics and Characteristics of MMMT SC versus MMMT EC

MMMT with SC MMMT with EC

Number (n) 51 06
Age (yr) 53 to 91 56 to 80
Mean: 70.2 Mean: 77
Tumor Location Endometrial: 39 Endometrial: 6
Ovarian: 9
Fallopian: 2
Vaginal: 1
Follow up (months) 4 to 129 8 to 87
Stage : Stage I: 30 Stage I: 04
Stage II: 04 Stage II: 00
Stage III: 16 Stage III: 02
Stage IV: 01 Stage IV: 00
Figure 1 - 1116

Conclusions: Compared to the other group, MMMT EC is diagnosed in older patients (mean age of diagnosis is 77 yr). Although MMMT
EC is diagnosed in older patients compared to MMMT SC, clinical course following treatment is more favorable in MMMT EC (disease
free survival in 66.7%) versus 41.2% in MMMT SC. Disease recurrence and metastasis up to 129 months of follow up shows 33.3%
recurrence in MMMT EC versus 43.1% in MMMT SC. The clinical course of MMMT appears to vary depending on the epithelial
component. Larger multicenter study with additional cases is needed to corroborate our findings.

1117 High Grade Carcinoma of Mullerian Origin with Minor/Focal Sarcoma Component: Are They True
Carcinosarcoma?
Khadijeh Jahanseir1, K Islam2, Natalie Banet3, Katrine Hansen4, Max Masnick5, C. James Sung2, M. Ruhul Quddus2
1
Women & Infants Hospital, Providence, RI, 2Women & Infants Hospital/Alpert Medical School of Brown University, Providence,
RI, 3Women and Infants Hospital/Brown University, Providence, RI, 4Women and Infants Hospital of Rhode Island, Providence,
RI, 5Geisinger National Precision Health, Rockville, MD

Disclosures: Khadijeh Jahanseir: None; K Islam: None; Natalie Banet: None; Katrine Hansen: None; Max Masnick: None; C. James
Sung: None; M. Ruhul Quddus: None

Background: Mullerian carcinonosarcoma (CS) is a malignant biphasic tumor composed of high grade carcinomatous and sarcomatous
elements. The current WHO classification of the tumors of the female genital tract, did not address the exact percentage of sarcomatous
component require to define CS. On a rare occasion a unique tumor comprising mainly of high grade Mullerian carcinoma with only
minor/focal sarcoma (HGC-MS) is encountered. The biological behavior of this subset has not been studied before. Classifying them as
high grade carcinoma (HGC) would make these patients eligible for more clinical trials. We intend to explore that question by comparing
these tumors with CS and HGC.

Design: Hysterectomy specimens of HGC-MS (n=27; Group 1), CS (n=30; Group 2), and HGC (n=27; Group 3) were retrieved from our
archival files, diagnoses confirmed and follow-up recorded from the date of diagnosis to death or last follow-up (2008-2019) after IRB
approval. The overall survival and progression-free survival were compared between these three groups using Kaplan-Meier (KM) curves.

1070
Results: Clinicopathologic data is summarized in Table 1. In HGC-MS, follow-up revealed that 12 patients (44%) developed recurrence
or metastasis; sites include lung (15%) followed by brain, liver and peritoneum (7%, each). The epithelial component of HGCs were
serous (n=18, 62%), endometrioid (n=5, 17%), mixed serous and endometrioid (n=4, 14%), and mixed serous, endometrioid, and clear
cell (n=2, 7%). No statistically significant differences of overall or progression free survival between these three groups were identified
(p=0.97 and p=0.63; respectively); both tested with long-rank test for equality of survivor functions.

Table 1: Clininicopathological Features of All Three Groups

Group 1 Group 2 Group 3
(N=27) (N=30) (N=27)
Age in Yrs.: 53-90 56-91 60-92
Range (Median)
(71) (69) (70)
Site of tumor:

N (%)
Uterus 20 (67) 26 (87) 27 (100)
Ovary 6 (21) 3 (10) -
F/tube 2 (7) 1 (3) -
Vagina 1 (4) - -
FIGO Stage

N (%)
I 15 (52) 20 (67) 18 (67)
II 3 (10) 2 (7) 6 (22)
III 11 (38) 7 (23) 3 (11)
IV - 1 (3) -
Follow/up

N (%)
Alive 13 (48) 10 (33) 5 (18)
w/disease
Died of 3 (11) 5 (17) 5 (18)
disease
Alive without 11 (41) 15 (50) 17 (64)
disease
Recur/Met 12 (44) 15 (50) 8 (30)

Figure 1 - 1117 Figure 2 - 1117

Conclusions: High grade Mullerian carcinoma with minor sarcomatous component had similar biologic behavior to that of CS. Uterine
HGCs had a poor prognosis. The overall survival and progression-free survival between these three groups were not statistically
significant. Nevertheless, the underlying pathogenesis of this unique group of tumor needs to be further investigated in a multicenter
study with more cases. For the time being, we suggest that these tumor should be treated as carcinosarcoma rather that high grade
carcinoma.

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1118 The Combination of Aberrant p53 and Rb Immunohistochemistry is Highly Specific for
Leiomyosarcoma
Tyler Jankowski1, Sarah Umetsu1, Nancy Joseph1, Rebecca Wolsky1, Nicholas Ladwig1
1
University of California San Francisco, San Francisco, CA

Disclosures: Tyler Jankowski: None; Sarah Umetsu: None; Nancy Joseph: None; Rebecca Wolsky: None; Nicholas Ladwig: None

Background: Uterine smooth muscle tumors are further stratified as leiomyoma (LM), smooth muscle tumor of uncertain malignant
potential (STUMP), or leiomyosarcoma (LMS) based on histologic features (tumor-type necrosis, mitotic activity, and nuclear atypia). In
some cases, definitive classification of these tumors is challenging due to subjectivity of these features.

Several recent molecular studies, including the adult soft tissue sarcoma TCGA data demonstrated near-universal inactivation
of TP53 and RB1 with frequent co-inactivation of ATRX in LMS. We sought to investigate the utility of IHC for p53, Rb1, and ATRX as a
surrogate for the underlying genetic alterations in LMS and compare to other entities in the differential diagnosis.

Design: Rb, ATRX, and p53 IHC was performed on tissue microarrays (2-3 mm cores, in triplicate) and whole slide sections from
resection specimens of LMS (n=57, 35 uterine, 22 extra-uterine). Uterine smooth muscle tumors (9 STUMP, 21 LBN, and 49 LM),
carcinosarcoma (n=9), low-grade endometrial stromal sarcoma (LGESS) (n=9), high-grade endometrial stromal sarcoma (HG-ESS) (n=4),
and undifferentiated endometrial sarcoma (UES) (n=1) were included for comparison.

• Aberrant p53 staining is seen in the majority of LMS (39/57; 70%)

• Aberrant Rb staining is seen in the majority of LMS (38/57; 67%)
• Aberrant p53 staining is seen in STUMP (3/9; 33%) and LBN (5/21; 29%)
• Aberrant Rb staining is seen in STUMP (1/9; 11%) and LBN (3/20; 15%)
• Sensitivity (Sen) and Specificity (Spe) for LMS (as compared to STUMP, LBN, LM, LGESS, HG ESS, Carcinosarcoma, and
UES):
o Individual IHC:
§ p53: Sen = 70%; Spe = 86%
§ Rb: Sen = 67%; Spe = 94%
§ ATRX: Sen = 24%; Spe = 100%
o Two IHC in combination:
§ p53 and Rb: Sen = 51%; Spe = 98%
§ p53 and ATRX: Sen = 14%; Spe = 100%
§ Rb and ATRX: Sen = 12%; Spe = 100%
o Three IHC in combination:
§ p53, Rb, and ATRX: Sen = 12%; Spe = 100%

§ Individual IHC IHC in Combination

Aberrant p53 Aberrant Aberrant Aberrant Aberrant Aberrant Aberrant
Rb (Loss) ATRX p53 p53 and Rb and P53, Rb,
(Loss) and Rb ATRX ATRX and
ATRX
LMS 39 38 13 29 8 12 7
(n=57) (70%) (67%) (24%) (51%) (14%) (21%) (12%)
STUMP 3 1 0 1 0 0 0
(n=9) (33%) (11%) (11%)
LBN 5 3 0 1 0 0 0
(n=21) (29%) (15%) (5%)
LM 0 2 0 0 0 0 0
(n=49) (4%)
LGESS 0 0 0 0 0 0 0
(n=16)
HGESS 0 0 0 0 0 0 0
(n=4)
Carcinosarcoma 7 0 0 0 0 0 0
(n=9) (78%)
UES 0 0 0 0 0 0 0
(n=1)

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Conclusions: 1. Aberrant Rb IHC is specific for LMS amongst other uterine mesenchymal tumors. 2. The combination of aberrant p53
and Rb IHC increases specificity for LMS to 98% at the expense of sensitivity, which drops to 51%. 3. The presence of aberrant p53 or
Rb IHC in STUMP and LBN may be a sign of their low malignant potential.

1119 PD-L1 and Mismatch Repair Status in Uterine Carcinosarcomas

Taylor Jenkins1, Mark Stoler2, Leigh Cantrell1, Anne Mills3
1
University of Virginia Health System, Charlottesville, VA, 2University of Virginia Health System, Earlysville, VA, 3University of
Virginia, Charlottesville, VA

Disclosures: Taylor Jenkins: None; Mark Stoler: None; Leigh Cantrell: None; Anne Mills: None

Background: Uterine carcinosarcomas are highly aggressive malignancies with few adjuvant treatment options. Programmed cell death
ligand-1 (PD-L1) expression in these tumors may predict response to checkpoint inhibitor therapies. An increase in PD-L1 expression has
been shown in endometrial carcinomas with mismatch repair (MMR) deficiencies; however, few studies have evaluated PD-L1 expression
in uterine carcinosarcomas. We sought to examine the rate of PD-L1 expression in tumor cells and the immune microenvironment in
carcinosarcomas and correlate expression with MMR status.

Design: A 5-year retrospective database search for uterine carcinosarcomas was performed. The histologic diagnoses, MMR
immunohistochemistry interpretation, p53 expression, and PD-L1 combined percentage scores (CPS) and tumor percentage scores
(TPS) were confirmed by a gynecologic pathologist. In addition to confirming the histologic diagnosis of carcinosarcoma, the epithelial
components were also evaluated by three gynecologic pathologists and tumors were stratified based on morphologic resemblance to
endometrioid or serous endometrial carcinomas.

Results: 41 cases of uterine carcinosarcomas with available MMR immunohistochemistry were stained for PD-L1 and p53. MMR
deficiencies were identified in 7% of cases; all of which were MLH1/PMS2-deficient and MLH1 hypermethylated. 37 cases (90%) were
positive for PD-L1, defined as a CPS score of ≥1 or a TPS score of ≥1%. Only one case, which was MMR intact, showed high expression
of PD-L1 using the thresholds of a CPS score of ≥10 or a TPS score of ≥10%. 90% of cases showed aberrant p53 expression, and the
majority (83%) had a serous, rather than endometrioid (17%) epithelial component.

Conclusions: The majority of uterine carcinosarcomas show some expression of PD-L1, predominantly in tumor-associated immune
cells. Although there was no significant correlation between MMR status and PD-L1 expression, statistical power was limited due to the
low rate of MMR loss in this cohort. In addition, our study reveals that the epithelial component in most carcinosarcomas is serous. Given
that serous uterine carcinomas are not typically MMR-deficient, this may account for the much lower rate of MMR deficiency in uterine
carcinosarcomas as compared to endometrioid and dedifferentiated carcinomas. These findings suggests that for carcinosarcomas, PD-
L1 expression may be a more useful predictive biomarker than MMR status in identifying potential candidates for checkpoint inhibitor
therapy.

1120 The Utility of Next Generation Sequencing in Advanced Breast and Gynecologic Cancers:
Experience of a Large Tertiary Care Women's Hospital
Terrell Jones1, Somak Roy1, Rohit Bhargava2
1
University of Pittsburgh Medical Center, Pittsburgh, PA, 2Magee-Womens Hospital of UPMC, Pittsburgh, PA

Disclosures: Terrell Jones: None; Somak Roy: None; Rohit Bhargava: None

Background: Next generation sequencing (NGS) has the potential to identify genetic alterations that are actionable with targeted or
immunotherapies. This is particularly salient in patients who have advanced cancers. However, NGS testing can have a significant cost
for patients and is infrequently covered by insurance. Here we review the frequency of NGS testing in advanced breast and gynecologic
cancers at our institution and the clinical utility of the results.

Design: A retrospective review identified 108 patients with advanced breast and gynecological cancers who underwent NGS testing
between 2015 and 2019 at a single institution. Medical records were reviewed for demographics, pathologic data, sequencing results,
treatment, and outcome information. The NGS utilization rate was defined by the presence or absence of clinical action or decision-
making documented in the medical records based on NGS results.

Results: The 108 specimens tested included breast (35), cervix (2), endometrium (22), fallopian tube or ovary (47), vagina (1), and vulva
(1), with most of the testing performed at Foundation Medicine (90%). The NGS results are summarized in table 1. The overall utilization
rate of NGS testing was 38%, with a rate of 41% for breast cancer and 36% for gynecologic cancers. The enrollment in clinical trials
based on NGS results was low (5% of cases overall). Overall, 48% patients died, all succumbing to disease. The median survival was
17.2 months for patients with actionable NGS result and targeted treatment, 16.9 months for actionable NGS result but no targeted
treatment, and 12.5 months for patients with non-actionable NGS result. The survival difference was not significant (see figure).

1073
 Table 1: Next Generation Sequencing results
Average alterations per case 5
Average variants of unknown significance per case 8
Cases with microsatellite instability 0
Cases with high mutation burden 0
Cases with intermediate mutation burden (>5 to 12 mutations 19%
per megabase)
Genes most frequently altered in gynecologic cancers TP53 (75%), KRAS (21%), PIK3CA (21%), PPP2R1A (11%),
and CCNE1 (10%)
Genes most frequently altered in breast cancers TP53 (57%), PIK3CA (37%), PTEN, MYC, FGFR1-all
23%, CCND1 (17%), ARID1A, CDN2A, FGF3-all
14%, FGF4 (11%)
Figure 1 - 1120

Conclusions: NGS testing for advanced breast and gynecological cancers at our institution has a 38% utilization rate in clinical decision
making. However, the utilization rate may be impacted by various factors, including low rate of clinical trial enrollment and availability of
clinical trials. Overall, the increased utilization rate over the years did not translate into improved survival.

1121 The Potential Prognostic and Therapeutic Implications of Prolactin Receptor and Growth
Hormone-Releasing Hormone Receptor Expression in Uterine Leiomyosarcomas
Terrell Jones1, Hae-Sun La2, Rohit Bhargava3, Mirka Jones1
1
University of Pittsburgh Medical Center, Pittsburgh, PA, 2Department of Pathology, University of Pittsburgh Medical Center,
Pittsburgh, PA, 3Magee-Womens Hospital of UPMC, Pittsburgh, PA

Disclosures: Terrell Jones: None; Hae-Sun La: None; Rohit Bhargava: None; Mirka Jones: None

Background: The treatment of uterine leiomyosarcomas (uLMS) remains difficult. The rate of recurrence and metastasis is high, with
survival reaching only 40-50% in patients with stage I or II disease. Prolactin receptor (ProR) and growth hormone-releasing hormone
receptor (GHRHR) have been implicated in carcinogenesis of various tumors in the breast, endometrium, ovary, liver, and prostate. It has
also been associated with resistance to chemotherapy. The expression of ProR and GHRHR has not been investigated in uLMS.

Design: Representative sections of twenty-seven uLMS were immunostained with ProR and GHRHR antibodies. Immunoreactivity was
calculated as H-score = 1(% of weakly 1+ staining cells) + 2(% of moderately 2+ staining cells) + 3(% of strongly 3+ staining cells). A
score of 1 to 100 was classified as weakly positive, 101 to 200 as moderately positive, and 201 to 300 as strongly positive.

Results: All 27 uLMS showed positive immunostaining for ProR and GHRHR (see table). Moderate to strong expression of ProR and
GHRHR was observed in 89% and 82% of uLMS, respectively. Patients with tumors showing moderate to strong ProR expression were
more likely to die of their disease (p value = 0.0023, unpaired t-test) and showed a higher tumor stage at diagnosis (p value = 0.0373,
unpaired t-test). Furthermore, in two patients where the primary and recurrent tumors were tested, there was stronger expression of ProR
in the recurrence compared to the primary. This correlation was not found with GHRHR.

Stain H-score 1-100 (weak) H-score 101-200 H-score 201-300

(moderate) (strong)
Prolactin receptor 3/27 (11%) 17/27 (63%) 7/27 (26%)

1074
 Growth hormone- 5/27 (18.5%) 17/27 (63%) 5/27 (18.5%)
releasing hormone
receptor

Conclusions: Both ProR and GHRHR may have tumor promoting effects in uLMS as they have in other neoplasms. In addition,
activation of the ProR pathway may contribute to early recurrences and poor survival in patients with uLMS. Frequent ProR expression in
uLMS makes these tumors potential candidates for hormonal modulating therapies. GHRHR antagonists that inhibit the in-vitro growth of
many human tumors represent a treatment for uLMS that merits further exploration.

1122 RNA Sequencing-Based Immune Signatures Confer Independent Prognostic Value across
Molecular Subtypes of Endometrial Cancer
Julia Joseph1, Corinne Lavasseur1, Xiaohua Yang2, Brian Richardson3, Mark Cameron3, Stefanie Avril4
1
Case Western Reserve University School of Medicine, Cleveland, OH, 2Department of Pathology, Case Western Reserve
University School of Medicine, Willoughby, OH, 3Department of Population and Quantitative Health Sciences, Case Western
Reserve University School of Medicine, Cleveland, OH, 4Cleveland, OH

Disclosures: Julia Joseph: None; Corinne Lavasseur: None; Xiaohua Yang: None; Brian Richardson: None; Mark Cameron: None;
Stefanie Avril: None

Background: Different surrogate measures of increased anti-tumor immune response have demonstrated prognostic value in solid
cancers. A recent publication by Talhouk and colleagues found that molecular subtype was more important than immune response in
driving outcomes of 460 endometrial carcinomas. Experience from other solid cancers indicates that the method for measuring immune
response can largely impact its prognostic or predictive value in a tissue and organ specific manner. We sought to assess the prognostic
value of comprehensive immune-based gene expression signatures across endometrial cancer molecular subtypes.

Design: We analyzed gene-expression based immune signatures of 506 endometrial cancers based on publicly available RNA-
sequencing data from The Cancer Genome Atlas (TCGA). The following parameters were evaluated: 4 distinct immune subtypes as
defined by TCGA, including C1 ‘wound healing’, C2 ‘IFN-γ-dominant’, C3 ‘inflammatory’, and C4 ‘lymphocyte depleted’ subtype; total
leukocyte fraction; abundance of individual immune cell populations by CIBER-SORT algorithm, and molecular subtype. Progression-free
survival (PFS) served as reference endpoint.

Results: The 4 different immune subtypes (C1-C4) showed a different distribution across molecular subtypes, with the C1 ‘wound-
healing’ subtype predominating in CN-low, MSI, and POLE molecular subtypes, whereas the IFN-γ-dominant C2 subtype was enriched in
CN-high. Total leukocyte fraction and abundance of CD4 cells showed no significant difference across molecular subtypes, while CD8
cells were increased in POLE and MSI. Immune subtype was associated with PFS in the entire patient cohort, with C1 and C3 being
associated with the best prognosis, C2 with intermediate prognosis, and C4 with the poorest prognosis (p<0.01). Prognostic value of
immune subtype was independent of molecular subtype by Cox-regression. In contrast, abundance of individual immune cell populations
was not associated with PFS. Interestingly, the prognostic value of immune subtype was molecular subtype dependent, with C1 showing
the best prognosis in CN-low, and C2 showing a trend for better prognosis in CN-high, while there was no prognostic difference between
C1 versus C2 in MSI or POLE tumors.

Conclusions: Anti-tumor immune response assessed by comprehensive RNA-Seq based immune signatures differs across molecular
subtypes of endometrial cancer. Immune subtype conferred independent prognostic value beyond molecular subtype in 506 endometrial
cancers from TCGA.

1123 Conventional Cervical Cytology and Primary HPV Test Results Over a Recent 3-Year Period from
a Routine Laboratory Setting in Kenya
Ahmed Kalebi1, Lucy Muchiri2, Jesca Kirimi2, Charles Wahome2, Rabia Mukadam3
1
Lancet Group of Labs - East Africa, Nairobi, Kenya, 2Pathologists Lancet Kenya, Nairobi, Kenya, 3pLk, Nairobi, Kenya

Disclosures: Ahmed Kalebi: None; Jesca Kirimi: None; Charles Wahome: None; Rabia Mukadam: None

Background: Cervical cancer is the leading cause of cancer related deaths and the 2nd most common cancer among females in Kenya,
after breast cancer, contributing to 13% of the new cancers and 12% of all cancer deaths annually. The Ministry of Health in
Kenya released a National Cancer Screening Guideline in February 2019 recommending HPV Testing as the primary screening method
and VIA only when HPV Testing is unavailable. Pap smear is scarcely available. Our laboratory is one of the very few in the country that
routinely provides Pap smear test and the busiest in terms of annual volumes; we were also the 1st to introduce an FDA-approved HPV
genotyping test in the country in 2016. We hereby share our experience considering the dearth of data from Africa, hoping this will add to
the body of information available for collaborative exchange and research.

1075
Design: We retrospectively retrieved data from our laboratory information system focusing on conventional cervical cytology done over
the recent 3-year period from July 2016 to June 2019 corresponding to the period HPV test on Cobas 4800 platform (Roche) was
introduced in our laboratory, which is ISO15189 accredited for both tests.

Results: A total of 27,447 conventional Pap smears were reported in our laboratory between July 2016 and June 2019. The mean age of
the women who had Pap smear was 39.5 years and a median age of 38 years; the youngest at 11 years and the oldest at 95 years. A
diagnosis of negative for intraepithelial lesions or malignancy (NILM) was rendered in 97.31% of the cases, with a HSIL rate of 1.58%,
LSIL at 0.57% and ASC-H at 0.33%. ASCUS was reported in 0.02% and SCC at 0.04%; 43.3% of the cases had significant cervicitis on
conventional Pap smear and 13.6% had bacterial vaginosis, while 8.9% had atrophic changes. During the corresponding period, a total of
3523 HPV tests were done, with an over two-fold year-on-year increase in numbers tested. A total of 26.6% of tested positive for HR-
HPV, of whom 24.5% tested positive for HPV non-16/18 type, 6.2% type 16 and 3.9% type 18. Infection with multiple HPV types was
noted in 6% of cases.

CONVENTIONAL CYTOLOGY
Year f Months
2016 5445 Jul-Dec
2017 7990 Jan-Dec
2018 8621 Jan-Dec
2019 5391 Jan-Jun
27447
Age
Mean 39.5
Median 38.0
Min 11.0
Max 95.0
Diagnosis
NILM 26129 97.31%
HSIL 423 1.58%
LSIL 153 0.57%
ASC-H 89 0.33%
AGC 37 0.14%
SCC 12 0.04%
ASCUS 5 0.02%
Adenocarcinoma 4 0.02%
Cervicitis 11872 43.25%
Bacterial Vaginosis 3735 13.61%
Atrophic changes 2442 8.90%
Actinomyces 89 0.32%
Trichomomons 68 0.25%
HSV 3 0.01%
HIGH-RISK HPV
Year f
2016 235
2017 434
2018 896
2019 1958
3523
Positive Negative
HPV 16 219 3154
6.2% 89.4%
HPV 18 136 3232
3.9% 91.6%
NON 16/18 866 2504
24.5% 71.0%

1076
 Figure 1 - 1123 Figure 2 - 1123

Conclusions: Positivity for HR-HPV is noticeably high in this general population of women tested in a routine setting, non 16/18 HPV
types being commonest. HPV Test is gaining popularity in Kenya. The rate of ASCUS observed seems unusually low - likely due to dual
reporting by cytologists and pathologists; while HSIL and LSIL rates are comparable to the published literature from Africa and worldwide.

1124 A Refined Cut-Off for p53 Immunohistochemistry Improves Prediction of TP53 Mutation Status in
Ovarian Mucinous Tumors: Implications for Outcome Analyses
Eun-Young Kang1, Dane Cheasley2, Cecile Le Page3, Matthew Wakefield4, Yoland Antill5, Kylie Gorringe6, Martin Kobel1
1
University of Calgary/Alberta Public Laboratories, Calgary, AB, 2Peter MacCallum Cancer Centre, Melbourne, VIC,
Australia, 3University of Montréal, Montreal, QC, 4Walter and Eliza Hall Institute of Medical Research, Parkville, VIC,
Australia, 5Cabrini Health, Malvern, VIC, Australia, 6Peter MacCallum Cancer Center, Melbourne, VIC, Australia

Disclosures: Eun-Young Kang: None; Dane Cheasley: None; Cecile Le Page: None; Matthew Wakefield: None; Yoland Antill: None;
Kylie Gorringe: None; Martin Kobel: None

Background: TP53 mutations appear to be implicated in the progression of mucinous borderline tumors (MBOT) to mucinous ovarian
carcinomas (MOC), since they are significantly enriched in MOC compared to MBOT. We have recently shown that optimized
immunohistochemical staining for p53 is a good proxy for TP53 mutation detection by sequencing, with 100% specificity and 96%
sensitivity in high-grade serous (HGSOC) and endometrioid ovarian carcinomas (EC). We aimed to assess the correlation between
optimized p53 immunohistochemistry (IHC) and mutation status by sequencing, and also evaluate the association with outcome in MBOT
and MOC.

Design: An initial cohort composed of 12 MBOT and 102 MOC was evaluated with TP53 mutation screening using whole genome and
targeted panel sequencing as previously published [PMID: 31477716]. The cases were stained with optimized IHC for p53 using tissue
microarrays (84%) or full sections (16%) and interpreted using established criteria as wild-type or mutant (over-expression, cytoplasmic,
or complete absence). Cases were considered concordant if mutant-type IHC staining predicted deleterious TP53 mutations. Discordant
tissue microarray cases were re-evaluated on full sections. An independent expansion cohort of 112 MBOT and 246 MOC was assessed
by p53 IHC to infer TP53 mutation status. Kaplan-Meier survival analyses were performed.

Results: In the initial cohort, 83/114 (73%) cases were concordant when using the established criteria for interpretation. We observed the
phenomenon of terminal differentiation in MBOT and some MOC, similar to what has been described in squamous cell carcinomas.
Refining the cut-off for over-expression to account for terminal differentiation improved concordance to 95% (108/114 cases). When we
then applied IHC with the refined criteria to the expansion cohort, 21% of MBOT showed a mutant-type p53 staining, which was
associated with a higher risk of all-cause mortality in univariate analysis (Figure 1; HR=3.08, 95%CI 1.01-8.26, p=0.033). Within MOC,
56% of cases showed a mutant-type p53 staining but this was not associated with overall survival (log-rank p=0.94).

1077
 Figure 1 - 1124

Conclusions: p53 IHC is an accurate proxy for TP53 mutation status with refined interpretation criteria accounting for terminal
differentiation in MBOT and MOC. TP53 mutation status inferred by IHC may be a useful biomarker to identify MBOT with a higher risk of
mortality; however, it is not prognostic in MOC.

1125 Gastric-Type Mucinous Carcinoma is an Aggressive Subtype of Endometrial Carcinoma

Fumi Kawakami1, Ken Yamaguchi2, Tamotsu Sudo3, Yoshiki Mikami1
1
Kumamoto University Hospital, Kumamoto, Japan, 2Kyoto University Graduate School of Medicine, Kyoto, Japan, 3Hyogo
Cancer Center, Akashi, Hyogo, Japan

Disclosures: Fumi Kawakami: None; Ken Yamaguchi: None; Tamotsu Sudo: None; Yoshiki Mikami: None

Background: Mucinous carcinoma of the uterine corpus is currently regarded as a variant of low-grade endometrioid carcinoma.
However, it appears a heterogeneous group of neoplasm including aggressive tumors showing gastric differentiation, which have not
been hitherto well characterized.

Design: We retrieved 7 hysterectomy cases of mucinous carcinoma of the uterine corpus, which fulfilled the histopathologic criteria for
gastric-type mucinous carcinoma of the uterine cervix. Cases of synchronous and multifocal mucinous lesions of the female genital tract
and Peutz-Jeghers syndrome were excluded from the study.

Results: The median age of the patients was 68 years (range, 52–76 years). Grossly, 6 cases showed predominantly endophytic growth,
and one showed exophytic growth. The median tumor size was 32 mm (range, 24-80 mm). Microscopically, all tumors were mucinous
carcinoma with voluminous clear or pale eosinophilic cytoplasm and distinct cell border by definition. One case showed focal squamous
differentiation. Lymphovascular invasion was identified in all cases and was prominent in 4 cases. Regional lymph nodes metastasis was
identified in 4 cases. Intraoperative peritoneal washing cytology was positive in 4 cases. Myometrial invasion was seen in all 7 cases and
extended to the outer half in 6 cases. Immunohistochemically, MUC6 was positive in all the cases except 1 and ER was faintly positive in
2 cases with positive rates less than 20% of tumor cells. The pattern of p53 expression was varied. Surrounding non-neoplastic
endometrium was atrophic in all cases and mucinous metaplasia was identified in 2 cases. FIGO stage (2018) was I in 2 cases and III in 5
cases. Adjuvant therapy was given in all 7 cases. The median follow-up period was 53 months (range, 14–80 months). Lung metastasis
was seen in 3 cases. 3 patients with stage III and 1 with stage IB tumors died of recurrent disease, 1 stage IIIB patient is alive with
disease, and 2 patients with stage IA and IIIB disease are alive without disease.

Conclusions: Endometrial mucinous carcinoma with gastric differentiation is characterized by absence of ER expression, higher age,
association with atrophic endometrium with or without mucinous metaplasia, advanced stage at diagnosis, frequent lymph node
metastasis, occasional distal metastasis, and ominous outcome. Therefore, mucinous histology of endometrial carcinoma does not
necessarily mean low-grade and low-stage disease.

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1126 Plasminogen Activator Inhibitor 1 (PAI-1) is a Key Driver of Ovarian Cancer Metastasis
Tanya Kelly1, Mark Ward2, Bashir Mohamed3, Cara Martin4, Cathy Spillane5, Sharon O'Toole4, John O'Leary5
1
Trinity College Dublin, Molecular Pathology, CWIUH, Dublin, Ireland, 2Dublin, Ireland, 3Trinity College, Dublin, Ireland, 4Trinity
St. James's Cancer Institute, Dublin, Ireland, 5Trinity College Dublin, Dublin, Ireland

Disclosures: Tanya Kelly: None; Mark Ward: None; Bashir Mohamed: None; Cara Martin: None; Cathy Spillane: None; Sharon O'Toole:
None; John O'Leary: None

Background: Ovarian cancer is the 7th leading cause of cancer in women worldwide, and is the deadliest of all gynecological cancers.
There are roughly 250,000 new cases diagnosed annually and 140,000 deaths each year. Platelet-cancer cell interactions are intrinsic to
ovarian cancer metastasis, and PAI-1 has been identified as a key gene in wound-healing, invasion, and mitosis. This suggests that PAI-1
plays an essential role in ECM remodeling, intravasation/extravasation of tumor cells, and thereby in hematogenous metastasis.

Design: SKOV3 cells were used as an in vitro model of metastatic ovarian cancer. Wound-healing assays utilized cells treated with
platelets for 24h, or untreated. Wounds were induced at 24h. Untreated cells received fresh medium (FM), one set of cells treated with
platelets received FM, and a second set of cells treated with platelets received platelet releasate (obtained by centrifugation of the
supernatants from those wells). Cells were observed for 24h, photographed at 0h, 6h, 20h, and 24h, and wound closure was assessed
using ImageJ. Flow cytometry was performed to ascertain cell-cycle phase at each time point. Invasion assays were performed using
EHS sarcoma gel-coated membrane inserts. Cells were serum-starved and treated with 10nM PAI-1 siRNA or a negative control (siNEG).
At 24h, platelets were added to half of both treatment groups. Cells were seeded using FBS as chemoattractant, incubated overnight,
fixed, stained, and counted. IF staining was performed using a monoclonal antibody to PAI-1 in cells treated with either PAI-1 siRNA or
siNEG, both with and without platelets.

Results: Platelets and their releasate significantly expedite wound healing in SKOV3 cells, and significantly accelerate mitosis.
Transiently silencing PAI-1 in SKOV3 cells significantly decreases the wound-healing ability of these cells, even in the presence of
platelets. This also significantly impedes their ability to invade (Fig.1). Silencing PAI-1 decreases intracellular PAI-1, and adding platelets
increases it (Fig.2).

Figure 1 - 1126

1079
 Figure 2 - 1126

Conclusions: These results show that platelets and PAI-1 are essential to cell motility, wound healing, invasion, and mitosis. Previous
work by our team and by others has demonstrated that platelets are fundamental to hematogenous metastasis across multiple types of
cancer, and gene expression assays have identified PAI-1 as an integral part of this. Taken together, these experiments suggest that PAI-
1 is a key factor in ovarian cancer metastasis.

1127 The Significance of FIGO Grading in MSI-H and POLE-Mutated Endometrioid Endometrial
Carcinoma
Elizabeth Kertowidjojo1, Amir Momeni Boroujeni2, Robert Soslow1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2Memorial Sloan Kettering Cancer Center, Brooklyn, NY

Disclosures: Elizabeth Kertowidjojo: None; Amir Momeni Boroujeni: None; Robert Soslow: Speaker, Ebix/Oakstone

Background: With the advancement of diagnostic molecular technology and a move toward precision medicine, the interplay between
tumor grading and molecular subtyping has become increasingly complex. The Cancer Genome Atlas studies of endometrial
endometrioid carcinoma (EC) reported four molecular subcategories, including: POLE ultramutated, microsatellite instability-hypermutated
(MSI-H), copy number low, and copy number high. With the integration of genomic data, it remains to be seen whether tumor grade
retains clinical significance in certain molecular subtypes of EC. We studied the significance of FIGO grade in MSI-H and POLE-mutated
EC.

Design: All cases of EC with targeted tumor-sequencing indicating MSI-H or POLE somatic exonuclease domain hotspot mutation from a
single institution were included in the study. FIGO grade was correlated with various tumor characteristics (i.e. molecular subtype, depth
of invasion, FIGO stage, lymphovascular invasion), patient characteristics (i.e. age, BMI), recurrence, and survival.

Results: Of the 319 MSI-H and POLE ECs ascertained, sufficient data were available for analysis in 95 cases, 75 MSI-H (79%) and 20
(21%) POLE. For MSI-H ECs, 24% were FIGO grade 1, 39% FIGO 2, and 37% FIGO 3. There were no statistically significant differences
in FIGO stage, patients’ age, BMI, mutation count, or percentage of myometrial invasion stratified by FIGO grade. Recurrences were
reported in 39%, 45%, and 25% of cases of FIGO grades 1, 2, and 3, respectively. At the time of last follow up (mean of 4 years after
initial diagnosis), survival rates were 89%, 79%, and 82%, respectively. Neither recurrence nor survival was statistically different between
the three grade groups. For POLE-mutated EC, 40% were FIGO grade 1, 30% FIGO 2, and 30% FIGO 3. Compared to MSI-H ECs,
POLE ECs showed similar trends in patient demographics, tumor behavior, and prognosis, though the small number of POLE samples
precluded statistical analysis.

Conclusions: In this preliminary analysis of MSI-H and POLE ECs, FIGO grade was not associated with the evaluated parameters,
including FIGO stage and prognosis. The intrinsic biology of these tumors may override the significance of FIGO grade.

1080
1128 Immunohistochemical Evaluation of FOXL2 in Sex Cord-Stromal Tumors, Germ Cell Tumors and
Normal Tissue of Ovary and Testicle
Patricia Kim1, Fan Lin1, Jianhui Shi1, Haiyan Liu1, Renuka Malenie1
1
Geisinger Medical Center, Danville, PA

Disclosures: Patricia Kim: None; Fan Lin: None; Jianhui Shi: None; Haiyan Liu: None; Renuka Malenie: None

Background: The forkhead box L2 (FOXL2) gene encodes an essential transcription factor in the ovary, and plays an important role in
female sex determination and granulosa cell development. Mutation of FOXL2 was reported being fairly specific for sex cord-stromal
tumors. Published studies have yielded conflicting results as to FOXL2 expression in sex cord-stromal tumors (SCST). Here, we
evaluated FOXL2 expression by immunohistochemistry (IHC) in a series of SCSTs, germ cell tumors (GCT) and normal (NL) tissues of
ovary and testis, to assess the diagnostic utility of FOXL2.

Design: IHC evaluation of FOXL2 (HPA069613, Atlas Antibodies) was performed on 56 SCSTs, including ovarian
fibroma/thecoma/fibrothecoma (23), Sertoli cell (2), Leydig cell (5), granulosa cell (13) tumors and testicular Leydig cell tumor or
hyperplasia (13), 70 cases of testicular GCTs and 98 NL tissues of ovary (63) and testicle (35). The staining intensity was recorded as
strong (S) or weak (W); staining distribution was recorded as negative (<5% cell staining), 1+ (5-25%), 2+ (25-50%), 3+ (50-75%), and 4+
(>75%).

Results: The staining results are summarized in Table 1. Strong and diffuse nuclear expression of FOXL2 was identified in 100% of
ovarian granulosa cell (13/13) (Fig.1) and Sertoli cell (2/2) tumors on tissue sections (TS). Variable pattern of FOXL2 expression was
noted in 95% (22/23) of fibroma/thecoma/fibrothecoma. NL ovarian stromal tissue showed weak to occasional strong expression of
FOXL2 in 32.6% (14/43) of cases (Fig.2). No FOXL2 expression was demonstrated in Leydig cell tumor or hyperplasia of the ovary or
testicle (0/18), testicular GCTs (0/70) and NL testicular tissues (0/35).

Summary of FOXL2 Expression on 57 SCSTs, 70 GCTs and 98 NL Tissues of Ovary and Testicle.

Tissue/IHC 1+ (w/s) 2+ (w/s) 3+ (w/s) 4+ (w/s) % Positive

TS, Fibroma/Thecoma/ 0 2/2 4/4 6/4 95.7% (22/23)

Fibrothecoma (23)
TS, Sertoli cell tumor (2) 0 0 0/1 0/1 100% (2/2)
TS, Ovarian Leydig cell tumor (5) 0 0 0 0 0% (0/5)
TS, Granulosa Cell Tumor (10) 0 0 0/1 0/12 100% (13/13)
and Mets (3)
Testicular Leydig Cell 0 0 0 0 0% (0/13)
Tumor/Nodule (13)
TS (3)
TMA (10)
TMA, Testicular GCT (70) 0 0 0 0 0% (0/70)
Mixed GCT (29)
Seminoma (25)
Yolk sac tumor (7)
Embryonal CA (9)
NL Ovary (43) 0 4/2 4/3 1/0 32.6% (14/43)
TS (23)
TMA (20)
NL Testicle (35) 0 0 0 0 0% (0/35)
TS (4)
TMA (31)

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 Figure 1 - 1128 Figure 2 - 1128

Conclusions: Our data suggested that FOXL2 expression is highly sensitive for characterizing granulosa cell and Sertoli cell tumors of
the ovary. It does have significant cross reactivity with fibromas, thecoma, fibrothecoma, as well as NL ovarian stroma. When used in
conjunction with morphology, FOXL2 is a useful marker for identifying granulosa cell and Sertoli cell tumors. Additional studies are
warranted to validate these findings.

1129 Pathological Chemotherapy Response Score as a Prognostic Marker in Ovarian Cancer: A

Retrospective Analysis
Teresa Kim1, Kari Kubalanza1, Gottfried Konecny2, Jianyu Rao1
1
University of California Los Angeles, Los Angeles, CA, 2David Geffen School of Medicine at UCLA, Los Angeles, CA

Disclosures: Teresa Kim: None; Kari Kubalanza: None; Jianyu Rao: None

Background: Patients with advanced stage ovarian cancer are treated by primary tumor debulking surgery followed by adjuvant
chemotherapy and/or neoadjuvant chemotherapy. The addition of neoadjuvant chemotherapy has been shown to improve the
completeness of surgery and provide less morbidity and mortality. However, there are no standard biomarkers for treatment response and
survival in ovarian cancer. The chemotherapy response score (CRS) is a three tier system that stratifies cases into no or minimal (CRS1),
partial (CRS2), and complete or near-complete (CRS3) response to neoadjuvant chemotherapy based on histological examination (Figure
1). This study aims to evaluate the utility of the CRS as a prognostic biomarker for ovarian cancer in response to neoadjuvant
chemotherapy.

Design: 28 patients with stage IIIC/IV ovarian cancer who received neoadjuvant chemotherapy and with paired pre- and post-therapy
pathological samples were included and information about clinical characteristics, surgical outcome, time to recurrence, and overall
survival were collected. After assigning a CRS to each case, the associations between CRS and progression free survival (PFS) and
overall survival (OS) were examined.

Results: Pathologic response using the CRS was initially assessed in 28 patients with matched diagnostic biopsy and resection
specimens. CRS was significantly associated with OS (Figure 2).

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 Figure 1 - 1129

Figure 2 - 1129

Conclusions: Our study supports prior conclusions that the CRS is an effective biomarker for treatment response and correlates
with overall survival. It may help determine prognosis and potentially guide therapeutic decision making in patients with ovarian cancer
treated with neoadjuvant chemotherapy. Additional cases are being evaluated to add to the dataset. Currently, we are also characterizing
the molecular fingerprints of the initial matched biopsies to identify potential prognostic molecular markers in these tumors.

1130 Evaluation of Claudin-4 in Undifferentiated and Dedifferentiated Endometrial Carcinomas

Kyle Kissick1, Jefree Schulte2, David Chapel3, Andre Pinto4, Ricardo Lastra2, Jennifer Bennett2
1
The University of Chicago Medicine, Chicago, IL, 2The University of Chicago, Chicago, IL, 3Brigham and Women's Hospital,
Boston, MA, 4University of Miami, Miami Beach, FL

Disclosures: Kyle Kissick: None; Jefree Schulte: None; David Chapel: None; Andre Pinto: None; Ricardo Lastra: None; Jennifer Bennett:
None

Background: Endometrial dedifferentiated (DC) and undifferentiated carcinomas (UC) are aggressive tumors that present a diagnostic
challenge. Morphologically, they may appear similar to sarcomas and immunohistochemistry is often needed for diagnosis. If epithelial
markers (CAM 5.2, AE1/AE3, and EMA) are positive, they are often weakly and focally expressed. Claudin-4 has been proposed as a
more specific marker of epithelial differentiation, but only limited studies have been performed assessing its value in UC. Herein we
evaluate claudin-4 expression in a series of DC/UC.

Design: Claudin-4 was evaluated for both extent (0=negative, 1+=<5%, 2+=5-24%, 3+=25-50%, 4+=>50%) and intensity (1+=weak,
2+=moderate, 3+=strong) in UC (n=7) and DC (n=6), and its expression was compared to other endometrial tumors including grade 3
endometrioid carcinoma (n=5), carcinosarcoma (n=3), mixed carcinoma (n=2), and serous carcinoma (n=1). The same criteria were
applied to previously performed cytokeratin and EMA stains. Any degree of expression was considered positive.

Results: Claudin-4 was expressed in 5/7 (71%) UC and in 3/5 (60%) DC (undifferentiated component). The differentiated foci in DC
strongly expressed claudin-4 (all with 4+ extent, 3+ intensity) while the other carcinoma histologic subtypes showed variable claudin-4
expression in extent (range 2+-4+, median 4+) and intensity (range 1+-3+, median 2+).

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 Type Claudin-4 CAM 5.2 AE1/AE 3 EMA Pan-Keratin BRG-1 INI-1
of Extent/Intensity Extent/Intensity Extent/Intensity Extent/Intensity
Tumor Extent/Intensity
DC
1 4+/3+ diff 4+/2+ diff 4+/3+ diff 4+/3+ diff NP Retained Retained

1+/1+ undiff 1+/2+ undiff 1+/2+ undiff 4+/3+ undiff

2 4+/3+ diff 4+/2+ diff 4+/2+ diff PPR NP Lost Retained

4+/2+ undiff 4+/2+ undiff 3+/3+ undiff

3 4+/3+ diff 4+/3+ diff 4+/3+ diff NP NP Retained Lost

3+/2+ undiff 2+/2+ undiff 2+/2+ undiff

4 4+/3+ diff NP 0/0 NP 0/0 Lost NP

0/0 undiff
5 4+/3+ diff NP NP NP 2+/1+ Lost Retained

0/0 undiff
UC
1 4+/2+ 1+/1+ 1+/3+ NP NP NP NP
2 3+/2+ 4+/3+ 2+/3+ NP NP NP NP
3 1+/2+ 2+/2+ 0/0 0/0 NP NP NP
4 3+/2+ NP 0/0 NP 0/0 Equivocal NP
5 0/0 NP 2+/1+ NP 2+/1+ Retained Pending
6 1+/2+ NP NP NP 2+/1+ Lost Retained
7 0/0 NP NP NP NP Pending Pending

NP = not performed, PPR= positive per report, diff = differentiated component, undiff = undifferentiated component

Conclusions: Overall, this study suggests that claudin-4 can be a useful adjunct stain in the differential diagnosis between DC/UC and
sarcoma, as some claudin-4 positive DC/UC are negative for cytokeratins and EMA, and vice versa. The stain seems especially helpful in
the differential diagnosis between carcinomas and the newly described SMARCA4-deficient undifferentiated uterine sarcomas (SDUS), as
claudin-4 has been negative in all reported SDUS.

1131 Mullerian Adenosarcoma: Clinicopathologic Features of 78 cases

David Kolin1, Brooke Howitt2, Michael Nathenson3, Marisa Nucci4
1
Brigham and Women's Hospital, Boston, MA, 2Stanford University School of Medicine, Stanford, CA, 3Dana-Farber Cancer
Institute, Boston, MA, 4Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Disclosures: David Kolin: None; Brooke Howitt: None; Michael Nathenson: None; Marisa Nucci: None

Background: Mullerian adenosarcoma (MA) is a rare biphasic tumor of the female genital tract composed of malignant stroma and
benign epithelium. A subset of patients has an aggressive disease course. We sought to characterize the clinicopathologic features of a
large cohort of MA and to determine features which predict patient outcome.

Design: Cases of MA diagnosed at a single centre were retrospectively re-reviewed by at least one gynecologic pathologist to confirm the
diagnosis. Tumors were evaluated for FIGO stage, sarcomatous overgrowth, myometrial invasion, stromal cytologic atypia at low power
(4X) magnification, mitotic index, necrosis, lymphovascular invasion, and heterologous elements. Immunohistochemical stains for ER,
PR, and p53 were performed on a subset of cases. Univariate analysis was used to examine prognostic features.

Results: The clinicopathologic features of the cohort (n=78) are shown in Table 1. Average tumor size was 6.3 (range 0.7-25) cm.
Median mitotic index was 5 per 10 HPFs (range 0 to 54). Necrosis was present in 13/73 (18%). MA with either myometrial invasion or
sarcomatous overgrowth had a significantly worse overall survival (OS) than those without either feature (Fig 1A, log-rank p<0.005).
Similarly, cases with high grade cytologic atypia also had a worse OS than those with only low or intermediate grade atypia (Fig 1B, log-
rank p<0.005). Heterologous differentiation (usually rhabdomyoblastic) was associated with a worse OS (log-rank p<0.02). Both ER and
PR expression (>10% of tumor cells) were associated with a better OS (p<0.05). However, mutant pattern p53 staining (seen in only
13%) was not associated with a statistically significant difference in OS compared to wild-type staining (p=0.7).

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 n (%)
Patient age (years) Mean 56 (range 21 to 86)
Follow up (years) Median 5.5 (range 0 to 27.4)
FIGO stage 33 (42%)
Ia 25 (32%)
Ib 6 (8%)
Ic 6 (8%)
II 4 (5%)
III 2 (3%)
IV 2 (3%)
Not available
Tumor site 67 (86%)
Uterine corpus 5 (6%)
Cervix 3 (4%)
Ovary 3 (4%)
Other
Histologic features Present Absent
Sarcomatous overgrowth 28 (37%) 47 (63%)
Myometrial invasion 34 (50%) 34 (50%)
Heterologous differentiation 17 (29%) 42 (71%)
Lymphovascular invasion 4 (6%) 63 (94%)
Lymph node metastases 1 (3%) 38 (97%)
High grade cytologic atypia 21 (28%) 53 (72%)
Immunohistochemical stains
ER
Positive (>10%) 24 (62%)
Negative (<10%) 15 (38%)
PR
Positive (>10%) 21 (55%)
Negative (<10%) 17 (45%)
p53
Mutant 7 (13%)
Wild-type 46 (87%)
Figure 1 - 1131 Figure 2 - 1131

Conclusions: Negative prognostic factors of MA include myometrial invasion, sarcomatous overgrowth, and heterologous differentiation.
Those cases without either myometrial invasion or sarcomatous overgrowth are associated with an excellent OS. Tumor grade ("high
grade" or "low grade") has traditionally been reported for cases of adenosarcoma, despite limited evidence for its prognostic
significance. We demonstrate here, in a large series, that high grade cytologic atypia is a negative prognostic marker, supporting its
inclusion as a required reporting element.

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1132 Targeted RNA Sequencing Highlights a Diverse Genomic Landscape in Low-Grade Endometrial
Stromal Sarcoma, including Novel Fusion Genes
David Kolin1, Marisa Nucci2, Sophie Corbett-Burns3, Martin Chang4, William Chapman5, Blaise Clarke6, Elizabeth Demicco7,
Valerie Dube8, Marjan Rouzbahman9, Patricia Shaw10, Gulisa Turashvili7, David Swanson7, Brendan Dickson11
1
Brigham and Women's Hospital, Boston, MA, 2Brigham and Women's Hospital, Harvard Medical School, Boston,
MA, 3Douglass Hanly Moir Pathology, Sydney, NSW, Australia, 4The University of Vermont Medical Center, Burlington,
VT, 5University Health Network, Toronto, ON, 6University of Toronto, Toronto, ON, 7Mount Sinai Hospital, Toronto,
ON, 8Mississauga, ON, 9Toronto, ON, 10Sunnybrook Health Sciences Centre, Toronto, ON, 11Mount Sinai Health System,
Toronto, ON

Disclosures: David Kolin: None; Marisa Nucci: None; Sophie Corbett-Burns: None; Martin Chang: None; William Chapman: None; Blaise
Clarke: None; Elizabeth Demicco: None; Valerie Dube: None; Marjan Rouzbahman: None; Patricia Shaw: None; Gulisa Turashvili: None;
David Swanson: None; Brendan Dickson: None

Background: Low-grade endometrial stromal sarcoma (LGESS) represents a morphologically and genetically heterogenous
mesenchymal neoplasm of the female genital tract. Previous work has shown that approximately half of LGESS are characterized
genetically by JAZF1-SUZ12 fusions, while a smaller proportion involve rearrangement of other genes such as PHF1. However, a
significant subset of cases has no known genetic abnormalities. We sought to better characterize the genomic landscape of LGESS by
examining a modest cohort interrogated with targeted RNA sequencing (RNA-Seq).

Design: A retrospective archival review was performed for cases diagnosed as LGESS. The slides were reviewed to confirm the
diagnosis, and representative formalin-fixed, paraffin embedded tissue blocks selected for RNA-Seq. RNA-Seq libraries were created
using the TruSight RNA Fusion Panel (Illumina, CA).

Results: 43 cases of LGESS were identified; this included cases that had previously been tested in the course of routine clinical practice
(n=28) and a cohort that had not previously been sequenced (n=15). The average patient age was 51 years (range 30-85). Of 43 cases,
39 were successfully sequenced, and 4 failed sequencing due to low quality control metrics. The fusions detected by RNA-Seq are
summarized in Table 1. The most commonly detected fusion was JAZF1-SUZ12, identified in 17 cases (39.5%), followed by BRD8-
PHF1 (n=3, 7%) and JAZF1-PHF1 (n=2, 4.7%). Novel translocations were identified in 2 cases, including: MEAF6-PTGR2, and ANP32E-
KPNB1 & KAT6B-KANSL1. The latter case, in addition to containing two candidate in-frame fusion products, was notable for an unusual
morphology that included areas of sex-cord differentiation.

Fusion n (%)
JAZF1-SUZ12 17 (39.5)
BRD8-PHF1 3 (7.0)
JAZF1-PHF1 2 (4.7)
ANP32E-KPNB1 and KAT6B-KANSL1 1 (2.3)
EPC1-SUZ12 1 (2.3)
HCFC1-PHF1 1 (2.3)
BCORL1-JAZF1 1 (2.3)
MEAF6-PTGR2 1 (2.3)
EPC1-BCOR 1 (2.3)
EPC1-PHF1 1 (2.3)
PHF1-JAZF1 1 (2.3)
MEAF6-PHF1 1 (2.3)
Negative 8 (18.6)
Failed QC 4 (9.3)

Conclusions: Low-grade endometrial stromal sarcoma is a genetically heterogeneous disease characterized by a variety of gene
fusions. The prognostic significance of these translocations, and their associated morphologic features, remain to be fully elucidated.
While targeted RNA-Seq represents a practical diagnostic tool in confirming a diagnosis of LGESS in most cases, it is worth noting that
approximately 20% of cases had no identifiable fusion using this assay. It is presumed this may be attributable to (1) other fusion
products, involving genes that are not covered by the assay and/or (2) other altogether different molecular events (e.g., amplification,
SNV/indel, epigenetic).

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1133 Genome-Wide DNA Methylation Analysis Reveals Epigenetic Signatures Associated with
Molecular Subgroups of Endometrial Carcinoma
Felix Kommoss1, Basile Tessier-Cloutier2, Victor Yuan3, Christian Koelsche4, C. Blake Gilks5, David Huntsman6, Jessica
McAlpine7, Andreas von Deimling8
1
University of Heidelberg, Heidelberg, Germany, 2University of British Columbia, Vancouver, BC, 3BC Children's Hospital
Research Institute, Vancouver, BC, 4Ruprecht-Karls-University Heidelberg, Heidelberg, Germany, 5Vancouver General Hospital,
Vancouver, BC, 6British Columbia Cancer Research Institute, Vancouver, BC, 7University of British Columbia and BC Cancer
Agency, Vancouver, BC, 8Heidelberg University Hospital, Heidelberg, Germany

Disclosures: Felix Kommoss: None; Basile Tessier-Cloutier: None; Victor Yuan: None; Christian Koelsche: None; C. Blake Gilks: None;
David Huntsman: None; Jessica McAlpine: None

Background: Endometrial carcinomas (EC) are complex malignancies with multiple subtypes and a heterogenous survival. Molecular
classifiers such as the Proactive Molecular Risk Classifier (PRoMisE) have improved our ability to better stratify EC patients for clinical
management, however some limitations remain. We analyzed DNA methylation signatures in molecular subtypes of EC to gain new
insights into this disease.

Design: Fifty ECs previously classified according to PRoMisE were selected, including 10 Polymerase-ɛ exonuclease domain
mutated (POLE), 10 mismatch repair deficient (MMR-D), 20 p53 wild-type (p53 wt) and 10 p53 mutated (p53 abn) tumors. Array-based
DNA methylation analysis was performed on all cases using the Illumina Infinium MethylationEPIC 850k BeadChip kit. Differentially
methylated cytosines (DMCs) for each molecular subtype were identified using linear modeling. DMCs were then tested for functional
enrichment using gene ontology analysis.

Results: Of the initial 50 samples, 49 had above 95 % methylation coverage and were included in the analysis. While for POLE
tumors 62 DMCs and for MMR-D tumors 1079 DMCs were identified, p53 wt and p53 abn tumors showed 33269 and 70118 DMCs,
respectively. Most MMR-D DMCs were hypermethylated (99.4 % hypermethylated DMCs), and included several sites in the MLH1 gene,
while for p53 wt and POLE cases hypomethylation was predominant (17.7 % and 29.0 % hypermethylated DMCs, respectively). The
DMCs of p53 abn tumors had a more balanced ratio (62.2 % hypermethylated DMCs). The MMR-D differential methylation profile was
enriched for genes associated with plasma membrane components, RNA polymerase II-specific DNA-binding transcription factor activity
and voltage-gated calcium channel activity (FDR < 0.05). Profiles of p53 wt tumors were enriched for genes associated with extracellular
matrix, actin binding and plasma membrane components (FDR < 0.05) and profiles of p53 abn tumors showed enrichment for genes
associated with ATP binding (FDR < 0.05). No pathways were found to be significantly enriched among the DMCs of POLE tumors.

Conclusions: Array-based DNA methylation analysis is able to identify epigenetic signatures in EC which are associated with molecular
subtypes. These methylation patterns can further inform us on the underlying mechanisms driving tumor biology within molecular
subgroups of EC, which may have treatment implication. The presented data will lay ground for further survival-based DNA methylation
analysis in EC.

1134 Pattern Based Interpretation of p53 Immunohistoschemistry as a Surrogate Marker for TP53
Mutations in Vulvar Squamous Cell Carcinoma
Kim Kortekaas1, Basile Tessier-Cloutier2, Tessa Rutten1, Mariette Poelgeest1, Lynn Hoang3, C. Blake Gilks4, Tjalling Bosse5
1
Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands, 2University of British Columbia, Vancouver,
BC, 3Vancouver, BC, 4Vancouver General Hospital, Vancouver, BC, 5LUMC, Leiden, Netherlands

Disclosures: Kim Kortekaas: None; Basile Tessier-Cloutier: None; Tessa Rutten: None; Mariette Poelgeest: None; Lynn Hoang: None;
C. Blake Gilks: None; Tjalling Bosse: None

Background: TP53 is the most commonly mutated gene in vulvar squamous cell carcinoma (VSCC) and its prognostic value, particularly
in HPV-independent VSCC, is under investigation. In other cancer sites p53 immunohistochemistry (IHC) was shown to be a good
surrogate marker for TP53 mutational status. Here we assess the performance of a pattern-based p53 IHC approach and its interobserver
variability.

Design: In a discovery cohort of 61 VSCC with known TP53 mutational status, we reviewed and defined the different p53 IHC staining
patterns. Using a validation cohort of 59 VSCC, two experienced gynaecologic pathologists scored the predefined p53 IHC patterns
independently and blinded for the molecular data. A next-generation sequencing (NGS) tumor gene panel was used to initially define
the TP53 gene alterations. All variants with an allelic ratio above 5% were called by a molecular biologist blinded to the p53 IHC results. A
chi-square test was used to analyse categorical data, and the agreement was calculated by Cohen’s kappa.

Results: From the discovery cohort two wild-type p53-IHC patterns were identified: 1) scattered expression and 2) mid-epithelial
overexpression (basal sparing), and four mutant patterns; 3) basal overexpression, 4) parabasal/diffuse overexpression 5) absence of
expression with positive internal control and 6) cytoplasmic expression. In the validation set, the agreement of this pattern-based
approach between the two observers was high (k=0.71, p<0.001, figure 1). Independent use of the IHC pattern by both observers showed

1087
good concordance to the TP53 mutation (k=0.718 and k=0.869). When there was a disagreement (n=12) consensus was achieved
between the two pathologists. The final concordance rate, after consensus, between IHC and NGS increased to k=0.874 (figure 2), the
sensitivity was 93%, the specificity was 100%, positive predictive value and negative predictive value were 100% and 83% respectively.
The only two discordant cases had a scattered and mid-epithelial expression pattern of p53 (interpreted as wild-type) and a
pathogenic TP53 mutation (NM_000546.5:c884C>T, c.451C>T).

The pattern-based p53 IHC interpretation accurately reflects TP53 mutational status in VSCC and is highly reproducible. This study offers
guidance to p53 IHC interpretation and provides necessary clarity for resolving the proposed prognostic relevance of p53 status within
HPV-independent VSCC.

Figure 1 - 1134

Figure 2 - 1134

Conclusions: A pattern-based p53 IHC interpretation accurately reflects TP53 mutational status in VSCC and is highly reproducible. This
study offers guidance to p53-IHC interpretation and provides necessary clarity for resolving the proposed prognostic relevance of p53
status within HPV-unassociated VSCC.

1135 SATB2 as a Novel Marker of Neuroendocrine Differentiation in the Gynecologic Tract: A Case
Series
Vimal Krishnan1, Cecile Le Page2, Anne-Marie Mes-Masson3, Charles Leduc4, Kurosh Rahimi5
1
Centre Hospitalier de l`Université de Montréal, Montreal, QC, 2University of Montréal, Montreal, QC, 3Centre de recherche du
CHUM, Montreal, QC, 4University of Montreal Hospital Centre, Montreal, QC, 5Université de Montreal, Montreal, QC

Disclosures: Vimal Krishnan: None; Cecile Le Page: None; Anne-Marie Mes-Masson: None; Charles Leduc: None; Kurosh Rahimi: None

Background: Neuroendocrine tumors (NET) of the gynecologic tract are exceedingly rare, with a reported incidence of less than 2%. The
diagnosis can often be challenging in poorly differentiated tumors, and determining the site of origin can be problematic. Special AT-rich
sequence-binding protein 2 (SATB2) positivity has been recently reported in well-differentiated NETs of the lower gastrointestinal tract
and Merkel cell carcinoma. In this study, we characterize for the first time the immunostaining profile of SATB2 in gynecological NETs.

Design: Patients with a diagnosis on surgical specimen of a gynecological tumor with neuroendocrine differentiation, from 2010 to 2019,
were included in the study (n=11). Patients diagnosed on biopsy specimen, or without focal staining for at least one neuroendocrine
marker (chromogranin, synaptophysin, CD56) were excluded. Diagnosis and SATB2 staining interpretation were performed by a
pathologist with expertise in gynecologic pathology. Positive staining was defined as nuclear staining of at least moderate intensity, in
>25% of tumor cells. Positive cases were graded as follows : 1+ (>25%), 2+ (50-75%), 3+ (>75%).

Results: A total of 11 gynecologic NETs were included. Median age at diagnosis was 59 years old. No evidence of an extra-gynecologic
primary was found on histology or clinical evaluation. Tumor sites were ovarian (n=5), uterine (n=4) and cervical (n=2). Histologic
subtypes included small cell (SCNC) (n=2), large cell (LCNC) (n=1) and poorly differentiated neuroendocrine carcinoma (PDNC) (n=4).
The remainder of the cases were carcinomas with focal neuroendocrine differentiation (n=4). Overall SATB2 positivity was 6/11.
Interestingly, SATB2 was positive in 5/7 high grade NETs. The percentage of tumor cell staining was higher in PDNCs (3+, n=2),

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moderate in LCNC (2+, n=1) and lower in SCNC (1+, n=1). SATB2 was negative in a limited number of non-gynecological poorly
differentiated NETs, including 2 pulmonary SCNC and 1 intestinal LCNC (data not shown).

Table : SATB2 staining in gynecological neuroendocrine tumors (n=11).

Patient Site Diagnosis STAB2 Grade
1 Uterus Endometrioid adenocarcinoma with focal Positive 2+
neuroendocrine differentiation
2 Ovary Poorly differentiated neuroendocrine carcinoma Negative
3 Ovary Carcinosarcoma with focal neuroendocrine Negative
differentiation
4 Uterus Poorly differentiated neuroendocrine carcinoma Positive 3+
5 Ovary Poorly differentiated neuroendocrine carcinoma Positive 3+
6 Cervix Small cell neuroendocrine carcinoma Negative
7 Uterus Endometrioid adenocarcinoma with focal Negative
neuroendocrine differentiation
8 Uterus Endometrioid adenocarcinoma with focal Negative
neuroendocrine differentiation
9 Cervix Small cell neuroendocrine carcinoma Positive 1+
10 Ovary Poorly differentiated neuroendocrine carcinoma Positive 1+
11 Ovary Large cell neuroendocrine carcinoma Positive 2+
Figure 1 - 1135

Figure 2 - 1135

Conclusions: In this case series, we report for the first time SATB2 positivity in poorly differentiated NETs of the gynecological tract. As
the pathogenesis of gynecological NETs have thus far been enigmatic, this could be a stepping stone towards identifying progenitor cells
to these neoplasms. Furthermore, SATB2 could potentially be a powerful marker for the diagnosis of poorly differentiated gynecological
tumors, as well as in the clinical determination of the site of origin.

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1136 MLH1-Hypermethylation and Mutation Status among MLH1/PMS2-Deficient Endometrial
Carcinomas: Results from a Universally Screened Population
Brett Kurpiel1, Kari Ring1, Martha Thomas2, Susan Modesitt1, Anne Mills1
1
University of Virginia, Charlottesville, VA, 2UVA, Charlottesville, VA

Disclosures: Brett Kurpiel: None; Kari Ring: None; Martha Thomas: None; Susan Modesitt: None; Anne Mills: None

Background: Epigenetic hypermethylation of the MLH1 promoter region is the most common cause of mismatch repair deficiency
(MMRd) in endometrial carcinoma, and in most cases provides reassurance against an associated germline mutation. However, rates of
germline mutations have not been well established in this population.

Design: The departmental database of MMRd endometrial carcinomas was searched for all cases with dual MLH1/PMS2 loss, retained
MSH2/6 expression, and available MLH1 promoter hypermethylation (MLH1-hm) results. Clinicopathologic variables and germline and
somatic tumor testing results were obtained.

Results: 117 MLH1/PMS2-deficient ECAs underwent MLH1-hm testing by PCR. MLH1-hm testing could not be completed in seven due
to sample inadequacy. Of the remaining 110 cases, 100 (91%) were MLH1-hm, while three (3%) were low-level/borderline and seven
(6%) were not methylated (nm). 16 cases (12 MLH1-hm, 3 nm, and 1 insufficient for testing) underwent germline testing, and 6 of these
(37.5%) demonstrated germline mutations involving MSH6, POLD1, BRIP1, RAD51D, PMS2, and CHEK2, all of which were variants of
unknown significance (VOUS). The average age among patients with germline mutations was 60 (range 25-72) vs. 65 (range: 52-85) for
germline-normal patients. One non-methylated, germline-normal case underwent somatic tumor testing, and demonstrated a somatic
mutation in MLH1.

Conclusions: In a universally screened population, MLH1-hm accounts for the vast majority of MLH1/PMS2-deficient cancers, although
rare MLH1 somatic mutations can occur. Furthermore, germline mutations in other genes implicated in heritable cancer syndromes occur
in a subset of MLH1-hm carcinomas. However, all germline mutations identified in MLH1-hm endometrial cancer patients were variants
of unknown significance therefore their contribution to tumorigenesis remains uncertain.

1137 DPC4 Loss in Gynecopathology Related Specimens

DongHyang Kwon1, Anais Malpica1, Michael Zaleski1, Elizabeth Euscher1, Preetha Ramalingam1
1
The University of Texas MD Anderson Cancer Center, Houston, TX

Disclosures: DongHyang Kwon: None; Anais Malpica: None; Michael Zaleski: None; Elizabeth Euscher: None; Preetha Ramalingam:
None

Background: The use of DPC4 in gynecologic pathology is restricted to cases where a pancreatic (Pan) origin in a given neoplasm
needs to be excluded. DPC4, which is lost in about 50% of Pan adenocarcinomas (ACas), is part of the battery of immunohistochemical
stains used when encountered with mucinous neoplasms (MNs) i0volving the ovary that show worrisome features for metastatic PanACa.
Furthermore, we have noted the loss of DPC4 in gastric-type cervical adenocarcinoma (GCxACa). In this study, we present our
experience with the loss of DPC4 expression in a cohort of cases referred to a group of gynecopathologists.

Design: A retrospective search of our institutional database was performed to identify tumors that were reported to have a complete loss
of DPC4 expression reviewed in the gynecologic pathology service. 28 of such cases were identified from a total of 255 cases with DPC4
immunostain obtained as part of their workup, from 2008-2019. The histologic, clinical and radiographic findings were reviewed to confirm
the primary site of origin.

Results: 18 of the 28 cases with loss of DPC4 had clinical information, imaging studies, and follow-up. Median patients’ age was 52.2
yrs. (range, 28-86). Additional results are summarized in Table 1. Of the 7 ovarian tumors, 4 were clinically/radiologically or biopsy-
proven metastases from the pancreaticobiliary tract, 1 was an ovarian primary, 1 had a Cx origin, and 1 had an unknown primary (no Cx
or Pan masses). All 4 primary GCxACa showed loss of DPC4. A pelvic biopsy from a Peutz-Jeghers syndrome patient with CxCA showed
loss of DPC4 in the metastatic tumor. The 3 ACas in the vaginal specimens had a urinary tract origin (1), appendiceal origin (1), and
unknown origin (1). Of the other 3 metastatic tumors, 1 was Cx primary, 1 was a Pan primary, and 1 remained as unknown.

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 Table 1. DPC4 Negative Tumors involving the Female Genital Tract Related Cases

Case Specimen Primary site Histotype Pancreas Cervical

DPC4 mass by mass by
staining imaging or imaging
performed biopsy- or
proven biopsy
1 Ovary Pancreas ACa Y N
2 Ovary Pancreas MCa Y N
3 Ovary Pancreas MCa Y N
4 Ovary Bile duct MCa Y N
5 Ovary Ovary MCa N N
(remote
TAH,
LSO)
6 Ovary (B/L) Unknown MCa N N
7 Ovary Cervix ACa N Y
8 Cervix and Cervix GCxACa Not Y
ovary available
9 Cervix Cervix GCxACa Not Y
available
10 Cervix Cervix GCxACa IPMN Y
11 Cervix Cervix GCxACa N Y
12 Pelvic mass Cervix ACa N Y
13 Lung Cervix MCa N Y
14 Vagina Urethra/bladder MCa N N
15 Vagina Appendix ACa N N
16 Vagina Unknown ACa N N
17 Iliac lymph Unknown ACa N N
node
18 Abdominal Pancreatic ACa Y N
mass

ACa: Adenocarcinoma, GCxACa: Endocervical adenocarcinoma, gastric type; IPMN: Intraductal papillary mucinous neoplasm; MCa:
Mucinous adenocarcinoma; TAH-LSO: Total abdominal hysterectomy left salpingo-oophorectomy

Conclusions: Loss of DPC4 expression, though typical of pancreaticobiliary tract primaries, can also be seen in a small subset of
gynecologic tumors including GCxACa and rarely primary ovarian mucinous carcinoma, as well as, non-pancreatic gastrointestinal
tumors. In a female patient, mucinous neoplasms involving the ovary or other metastatic sites with negative DPC4 staining and negative
pancreaticobiliary imaging, should raise the possibility of occult GCxACa.

1138 Clinicopathologic and Molecular Investigation of Steroid Cell Tumors: A Series of 18 Cases
Regina Kwon1, Minghao Zhong2, Deyin Xing3
1
Johns Hopkins University School of Medicine, Baltimore, MD, 2Westchester Medical Center, Valhalla, NY, 3Johns Hopkins
Medical Institutions, Ellicott City, MD

Disclosures: Regina Kwon: None; Minghao Zhong: None; Deyin Xing: None

Background: Steroid cell tumors (SCTs) are a rare subset of sex cord-stromal tumors with a propensity for secreting steroid hormones
and comprising 0.1% of ovarian tumors and 3% of testicular neoplasms. Although they usually behave in a benign fashion, steroid cell
tumors exhibit malignant behavior in approximately 10% to 30% of cases. Little consistent information is available about the molecular
profile of steroid cell tumors. Studies and in vitro experiments have implicated a wide range of molecular alterations, often associated with
pre-existing syndromes. In this study, we review a series of steroid cell tumors and their molecular characteristics in conjunction with
clinical data.

Design: We searched the institutional archives for steroid cell tumors, including Leydig cell tumor, stromal luteoma, hilar cell tumor, and
steroid cell tumor not other specified (NOS), diagnosed during the 25-year period from 1994 to 2019. Clinicopathologic data were
gathered from the electronic medical record. Slides were assessed for histopathological features, and a subset were submitted for
molecular evaluation. The first stage of examination tested nucleic acids extracted from formalin-fixed paraffin tumor samples using the
AmpliSeq for Illumina Focus Panel, a targeted next-generation sequencing assay covering hotspot mutations of 52 genes to detect single-
nucleotide variants (SNV), insertion/deletions, copy number variations (CNV), and gene fusions.

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Results: We identified 50 cases in the institutional archives. The patients ranged in age from 7 to 85 years (median, 63). 22 (44%) of 50
cases were of ovarian origin (female) and 28 (56%) of 50 cases were of testicular origin (male). The most common histopathologic type
was Leydig cell tumor (61%), followed by stromal luteoma (22%) and steroid cell tumor NOS (17%). Two cases were malignant: An 85-
year-old male with testicular Leydig cell tumor (stage pT2) and a 79-year-old female with ovarian Leydig cell tumor with lymph-vascular
space invasion. Two patients (11%) died of unrelated causes, and 33% were lost to follow-up. 18 cases had sufficient tissue for molecular
testing. However, the 52-gene hotspot panel failed to detected somatic mutations or apparent copy number changes.

Conclusions: Steroid cell tumors usually behave in a benign fashion, and these tumors do not demonstrate the most frequent mutations
found in other solid tumors. Additional molecular studies are needed to further characterize these tumors.

1139 Null Pattern Aberrant p53 Staining is more Frequent in Uterine High-Grade Endometrioid
Carcinoma Compared to Serous Carcinoma
Nicholas Ladwig1, Karuna Garg1, Amy Joehlin-Price2
1
University of California San Francisco, San Francisco, CA, 2Cleveland Clinic, Cleveland, OH

Disclosures: Nicholas Ladwig: None; Karuna Garg: None; Amy Joehlin-Price: None

Background: TP53 gene mutations are among the most common alterations in human cancer and its normal tumor suppressor function
can be inactivated by missense, frameshift, or truncating (nonsense/splice site) mutations. Aberrant staining for p53 by
immunohistochemistry (IHC) is a reliable surrogate marker for TP53 mutation with strong diffuse staining seen with missense mutations
and complete absence of staining (null) with truncating mutations. Amongst uterine tumors, TP53 mutations are characteristic of serous
carcinoma (USC) but can also be seen in a subset of endometrioid carcinoma, often FIGO grade 3 (EEC3). In our experience, null pattern
p53 staining is seen in endometrioid carcinomas or high-grade carcinomas that are difficult to classify. This study was undertaken to
formally evaluate and compare the aberrant p53 staining pattern in a cohort of prototypic USC and EEC3. A secondary aim was to
correlate p53 staining patterns with clinical outcomes.

Design: p53 IHC was performed on tissue microarray (TMA) or whole slide sections of EEC3 (n=21) and USC (n=49). The staining
pattern was reported as “null pattern” or “aberrant positive” when there was complete absence of staining or diffuse strong positive
staining (>80% of tumor cells), respectively. Ambiguous IHC results from TMAs were repeated using whole slide sections. A next
generation sequencing panel (including coverage of TP53 and POLE) and MMR protein IHC was performed on all EEC3 and a subset of
USC. Clinical outcomes were collected from the electronic medical record or California Cancer Registry.

Results: 1. In EEC3 with aberrant p53 IHC, null pattern staining was frequent (38%) (one tumor had POLE mutation, MMR was intact in
all cases). 2. USC characteristically shows aberrant positive p53 IHC (92%) and null pattern staining is infrequent (8%). 3. No significant
difference in stage or clinical outcomes was associated with the pattern of p53 IHC within EEC3 or USC.

Diagnosis p53 IHC Age (yr) Stage Clinical Follow up

I-II III-IV NED AWD DOD LTF
Endometrioid Null 69.2 5 3 3 0 5 0
adenocarcinoma, (n=8; 38%) (63%) (37%) (38%) (62%)
FIGO grade 3 Aberrant + 69.0 7 6 8 1 4 0
(n = 21) (n=13; 62%) (54%) (46%) (61%) (8%) (31%)
Serous endometrial Null 64.5 3 1 2 1 1 0
carcinoma (n=4; 8%) (75%) (25%) (50%) (25%) (25%)
(n=49) Aberrant + 67.7 22 23 19 3 15 8
(n=45; 92%) (49%) (51%) (42%) (7%) (33%) (18%)

Conclusions: 1. Amongst uterine high-grade EEC with aberrant p53 IHC, null pattern p53 staining is relatively common. 2. Amongst
USC, aberrant positive p53 IHC is common while null pattern staining is uncommon. 3. Aberrant positive p53 staining in USC may relate
to hotspot mutations with additional oncogenic biologic implications, as TP53 mutations are often seen in isolation in USC while EEC3
typically harbor additional mutations4. The pattern of p53 staining showed no correlation with clinical outcomes

1140 Chemotherapy Response Score in Extrauterine High Grade Serous Carcinoma and Association
with Mutation Status by Next-Gen Sequencing
Barrett Lawson1, Richard Yang1, Elizabeth Euscher1, Preetha Ramalingam1, Anais Malpica1
1
The University of Texas MD Anderson Cancer Center, Houston, TX

Disclosures: Barrett Lawson: None; Richard Yang: None; Elizabeth Euscher: None; Preetha Ramalingam: None; Anais Malpica: None

Background: Chemotherapy response score (CRS) in extrauterine high-grade serous carcinoma (EHGSCa) has been shown to correlate
with disease progression and platinum resistant disease (PRD). The CRS has been included for reporting in the CAP and NCCN

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guidelines, though current treatment decisions are not based on the CRS. We seek to determine if the CRS correlates with molecular
data.

Design: A retrospective study using a cohort of 151 pts with EHGSCa treated with neoadjuvant chemotherapy, previously scored for
the CRS on the omentum, adnexa and as a combined score, of which 35 had Next-Gen Sequencing (NGS) performed. Clinical data
recorded included age, date of dx, tumor stage, start and end date of chemotherapy, date of interval debulking surgery, status of optimal
tumor reduction, number of chemotherapy cycles, BRCA status, dates of recurrence/progression, date of last follow up and vital status.
NGS was performed using a 141 gene Ion AmpliSeq Oncomine panel with the number of somatic mutations and specific variant calls
recorded. Fisher exact tests were performed using GraphPad Prism v8.1.2 software.

Results: Median age 61 yrs (42-78). The omental CRS was 1 in 9 cases, 2 in 20, and 3 in 6. Adnexal CRS was 1 in 15, 2 in 15 and 3 in
5. The combined CRS was 2 in 8, 3 in 7, 4 in 12, 5 in 6 and 6 in 2. Of all 35 cases sequenced, all had at least 1 detected mutation (mtn),
with 20 cases having 1 mtn, 11 with 2 mtns, 3 with 3 mtns, and 1 with 4 mtns. The most common mtn was TP53 (34 cases, 97.1%), with 4
cases having mtns for BRCA2, 2 with PIK3CA, 2 with ARID1A, and 1 of each of the
following: ERBB2, NTRK3, STK11, NTRK2, WT1, ATM, TSC1, PIK3R1, NF1, NOTCH3, CDK2, SMAD4 and PMS2. Of the 4 cases with 3
mtns or more, all scored 1 or 2 on the adnexal and omental CRS and scored 4 or less by combined CRS. Using Fisher exact test
when combining the CRS1/2 vs.CRS 3 for number of mtns detected, there was no statistically significant association between the number
of genes mutated and the omental or adnexal CRS (p=0.56). For the combined CRS, CRS 2 to 4 and CRS 5/6 were combined for
comparison with no statistically significant association seen between the combined CRS and number of genes mutated (p=0.55). 11
cases clinically had PRD, of which only 1 case had more than 2 mtns.

Conclusions: While cases with more mtns detected by NGS have low CRS, these findings were not statistically significant, likely due to
small sample size. Further studies are warranted to determine the impact of mutational burden on CRS.

1141 Assessment of Indoleamine 2,3-dioxygenase Expression in the Tumor Cells and Tumor Infiltrating
Immune Cells in Cervical Carcinomas
Christine Lee1, Neda Moatamed2
1
University of California Los Angeles, Los Angeles, CA, 2David Geffen School of Medicine at UCLA, Los Angeles, CA

Disclosures: Christine Lee: None; Neda Moatamed: None

Background: Indoleamine 2,3-dioxygenase (IDO) is an enzyme involved in tryptophan metabolism. IDO has immune-regulating effects
in fetal and allograft protection as well as cancer progression. IDO expression in tumor cells promotes immunosuppression and tumor
progression. Similarly, dendritic cells that express IDO inhibit T-cells whereas IDO-negative dendritic cells activate T-cells. IDO inhibitors,
such as 1-methyltryptophan, may have immunotherapeutic potential. The purpose of this study is to investigate IDO expression in cervical
cancer cells and tumor infiltrating immune cells.

Design: We evaluated the expression of IDO immunohistochemical stain in a tissue microarray consisting of 102 cores: 95 cores of
squamous cell carcinoma, 5 cores of adenocarcinoma, and 2 cores of benign cervix. IDO rabbit polyclonal antibody was used and a
granular cytoplasmic expression was considered a positive reaction. Results for IDO were scored the in tumor infiltrating immune cells
(Figure 1) and in the tumor cells (Figure 2).

Results: In cervical squamous cell carcinoma, 92% (87 of 95) of tumor infiltrating immune cells and 31% (29 of 92) of tumor cells showed
IDO expression. In cervical adenocarcinoma, IDO was present in 60% (3 of 5) of tumor infiltrating immune cells and 40% (2 of 5) of tumor
cells. There was no IDO expression in either infiltrating immune cells or in the tumor cells of benign cervical tissues. Table 1 summarizes
these findings.

Table 1. Summary of the IDO expression in tissue microarray of the uterine cervical
epithelial neoplasms both in the tumor infiltrating immune and the tumor cells
Total Cores (n) = 102 IDO+, Immune IDO+ Tumor cells
cells
n n % n %
Squamous cell carcinoma 95 87 92% 29 31%
Adenocarcinoma 5 3 60% 2 40%
Benign 2 0 0% N/A N/A
DO+, IDO positive; N/A, not applicable

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 Figure 1 - 1141 Figure 2 - 1141

Conclusions: This study shows that the cervical cancers may express IDO both in the tumor cells as well as the tumor infiltrating
immune cells. These findings support a possible therapeutic role for IDO inhibitors in a subset of cervical carcinomas.

1142 Ataxia–Telangiectasia Mutated (ATM) Protein Expression in Uterine Smooth Muscle Tumors
Horace Hok-Yeung Lee1, Kin Long Chow2, Ho-Shing Wong3, Tsz Yan Chong3, Tse Ka-Yu4, Philip Ip5
1
University of Hong Kong, Hong Kong, Hong Kong SAR, 2Hong Kong, Hong Kong SAR, 3Department of Pathology, The
University of Hong Kong, Hong Kong, Hong Kong SAR, 4Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong,
Hong Kong SAR, 5The University of Hong Kong, Hong Kong, Hong Kong SAR

Disclosures: Horace Hok-Yeung Lee: None; Kin Long Chow: None; Ho-Shing Wong: None; Tsz Yan Chong: None; Tse Ka-Yu: Speaker,
Zai Lab; Primary Investigator, Pfizer; Philip Ip: None

Background: Ataxia-telangiectasia-mutated (ATM) is one of the key kinase involved in cellular response to double-strand DNA damage.
When ATM is functional, cells can respond to stress using the DNA damage response pathway. Dysregulation of this pathway in uterine
leiomyosarcoma may result in genomic instability. Analysis of ATM protein expression in uterine smooth muscle tumors has not been
investigated.

Design: Expression of ATM and phosphorylated ATM (p-ATM) was evaluated on 66 uterine leiomyosarcomas, 18 leiomyomas and 28
myometrium. Immunohistochemistry was performed by using monoclonal antibodies for ATM (Clone Y170, Abcam) and p-ATM (Clone
EP1890Y, Abcam) on formalin-fixed paraffin embedded tissue. Staining of the nucleus was considered positive. Lymphocytes served as
internal positive controls. Immunohistochemical expression was analysed by using a histoscore, generated by multiplying the intensity (0,
1, 2, 3) with the extent (0, 10%, 25%, 50%, 75% and 100%). The final score ranged from 0 to 300, with 0 being complete loss of staining.

Results: Median age of leiomyosarcoma patients was 50 years (range 33–80). All patients underwent hysterectomy with bilateral
salpingo-oophorectomy and without preoperative chemo or radiation therapy. All tumors showed spindle cell differentiation, with diffuse
nuclear atypia and >10 mitoses per 10 high power fields (0.55 mm field diameter). Tumor cell necrosis was present in 46 (70%). Thirty-
seven (56%) and 36 (54.5%) of leiomyosarcomas had a complete loss of ATM and p-ATM expression, respectively. Although the median
score for either marker was 0, the range of expression was 0 to 300. In leiomyomas, there was immunoreactivity for ATM (median 225,
range 25-300) and p-ATM (median 300, range 100-300). In the myometrium, there was also positive staining for ATM (median 175, range
25-300) and p-ATM (median 300, range 100-300). There was a significant difference in ATM/p-ATM expression between myometrium
and leiomyosarcoma, and between leiomyoma and leiomyosarcoma (p<0.05).

Conclusions: ATM and p-ATM were both expressed in all leiomyomas and normal myometrium. Complete loss of expression for both
markers was observed in approximately 55% of leiomyosarcomas. The remaining 45% of cases had retained ATM and p-ATM staining at
various intensities and extents. Whether this subset of leiomyosarcoma with retained ATM and p-ATM expression had a better prognosis
remains to be further evaluated.

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1143 Importance of Histological Subtyping in TP53 Mutant Endometrial Carcinomas
Alicia Leon-Castillo1, Stephanie de Boer1, Naveena Singh2, Linda Mileshkin3, Anthony Fyles4, Alexandra Leary5, Christine Haie-
Meder6, Vincent Smit7, Godfrey Wilson8, Remi Nout9, Nanda Horeweg1, Carien Creutzberg1, Tjalling Bosse10
1
Leiden University Medical Center, Leiden, South Holland, Netherlands, 2Barts Health NHS Trust, London, United
Kingdom, 3Peter MacCallum Cancer Centre, Melbourne, VIC, Australia, 4University of Toronto, Toronto, ON, 5Gustave Roussy,
Villejuif Cedex, Île-de-France, France, 6Gustave Roussy, Villejuif, Île-de-France, France, 7Leiden University Medical Center,
Leiden, Netherlands, 8Manchester, United Kingdom, 9Erasmus University Medical center, Rotterdam, South Holland,
Netherlands, 10LUMC, Leiden, Netherlands

Disclosures: Alicia Leon-Castillo: None; Stephanie de Boer: None; Naveena Singh: None; Linda Mileshkin: None; Anthony Fyles: None;
Alexandra Leary: None; Christine Haie-Meder: None; Vincent Smit: None; Godfrey Wilson: None; Remi Nout: None; Nanda Horeweg:
None; Carien Creutzberg: None; Tjalling Bosse: None

Background: The molecular classification of endometrial cancer (EC) based on the TCGA has proven to yield well-defined prognostic
subgroups. Interestingly, within the molecularly defined subgroup TP53 mutant EC (p53mut EC), both endometrioid (p53mut EEC) and
serous (p53mut SEC) histologies are identified. In this study we assessed whether this distinction has prognostic relevance.

Design: Available H&E slides were reviewed from collected tissue samples of consenting PORTEC-3 trial participants, identifying 311
EEC and 68 SEC. These EC were molecularly classified by targeted DNA-sequencing for pathogenic POLE-exonuclease domain
mutations (EDM) and immunohistochemistry for p53 and mismatch repair (MMR) proteins. In addition, 307 EEC and 53 SEC from the
TCGA were included. Other histologic subtypes were excluded. P53mut EEC and p53mut SEC were defined as having a p53 mutant
staining pattern or a TP53 mutation, and being MMR proficient or microsatellite stable and without POLE EDM. Mann-Whitney, χ2 and
Fisher exact tests were used to compare clinicopathological and molecular features. The Kaplan-Meier method, log-rank test and Cox
proportional-hazard model were used for survival analysis.

Results: Comparing histological types, EEC (n=618) and SEC (n=121) had significantly different clinical outcomes: 5-year recurrence
free survival (RFS) of EEC 76% versus SEC 55%, p log-rank< 0.01; 5-year overall survival (OS) 85% versus 61%, p log-rank < 0.01.

From this cohort, a total of 150 (24%) p53mut EC were identified, 58 (39%) EEC and 92 (61%) SEC. No significant differences in age and
stage distribution between the subtypes were found. Mutational data available from TCGA EC (n=59) revealed a significant higher
proportion of PTEN mutations in p53mut EEC compared to p53mut SEC (23% versus 3% respectively, p=0.01), while amplification of
Her2/neu was more frequent in p53mut SEC (8% versus 33%, p=0.02). 5-year RFS and OS were similar for both groups: RFS of p53mut
EEC 51% versus p53mut SEC 55%, p log-rank= 0.32; OS was 61% versus 60%, p log-rank= 0.82, respectively). Corrected for age and
stage by multivariable analysis, histotype did not significantly impact clinical outcome (table 1).

Table 1. Uni- and multivariable analysis of clinicopathological features.

Recurrence Free Survival Overall Survival
57 events 49 events
Univariable analysis Multivariable analysis Univariable analysis Multivariable
analysis
Total HR p- HR (95%CI) p- HR (95%CI) p- HR (95%CI) p-
n (95%CI) value value value value
Histo-
molecular
subgroups
P53mut 58 1 1 1 1
EEC
p53mut 92 0.77 (0.45- 0.316 0.71 (0.42- 0.206 1.07 (0.60- 0.820 0.89 (0.48- 0.700
SEC 1.29) 1.21) 1.92) 1.63)
Stage
I-II 86 1 1 1 1
III 64 3.38 (1.96- <0.001 3.38 (1.96- <0.001 2.49 (1.41- 0.002 2.49 (1.41- 0.002
5.81) 5.81) 4.40) 4.40)
Age 150 0,99 (0,95- 0.494 1.00 (0.96- 0.986 1.04 (1.00- 0.057 1.04 (1.00- 0.056
1,03) 1.04) 1.08) 1.08)

Conclusions: Despite both histologic and genomic differences, clinical outcome did not show significant differences between p53mut
EEC and p53mut SEC. Expanding these findings will be critical in order to define the relative weight of histologic subtyping within the
molecular classification.

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1144 Genome-Wide Mutation Analysis in Endometrial Atypical Hyperplasia
Lihong Li1, Pinli Yue1, Tian-Li Wang2, Ie-Ming Shih3, Yan Song1
1
National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences
and Peking Union Medical College, Beijing, China, 2Johns Hopkins Medical Institutions, Baltimore, MD, 3Johns Hopkins Hospital,
Baltimore, MD

Disclosures: Lihong Li: None; Pinli Yue: None; Tian-Li Wang: None; Ie-Ming Shih: None; Yan Song: None

Background: Endometrial atypical hyperplasia or endometrial intraepithelial neoplasia (AH/EIN) are widely thought to be the precursor of
uterine endometrioid carcinoma (EC) based on clinicopathological features. However, the process of clonal evolution and the molecular
alterations that contribute to tumor progression from AH/EIN to EC remains unclear.

Design: We analyzed microdissected paired AH/EIN and EC lesions from 30 hysterectomy specimens by whole-exome sequence
(WES). Biospecimens were collected from patients with new EC diagnosis who had not received prior treatment. WES data of matched
AH/EIN/EC and normal samples were aligned to the human reference genome and analyzed to identify somatic mutations in AH/EIN and
EC.

Results: Among 30 ECs, 9 (30%) had microsatellite instability-high (MSI-H) status. The other 21 cases were microsatellite stable (MSS).
Interestingly, 2 (22%) of these 9 MSI-H cases had MSS status in AH/EIN counterparts, indicating MSI developed during tumour
progression from AH/EIN to EC. We observed that 18 (60%) of 30 cases had a significant percentage (> 35%) of shared somatic
mutations between AH/EIN and matched EC, while the remaining cases harboured fewer shared mutations. This observation suggests
that the majority of ECs were derived from extant AH/EINs and both lesions co-developed to acquire their own private
mutations. Alternatively, AH/EIN may be genetically heterogeneous and EC subsequently arose from a geographically distinct AH/EIN
area. The average cancer driver mutations in AH/EIN and EC were 6.7 and 8.8, respectively. As compared to AH/EINs, 15 (71%) /21
MSS ECs had new cancer driver mutations, among which the most common are PTEN, ARID1A, PIK3CA and CHD4. Analysis of
mutational signature profile indicated that both AH/EIN and EC shared a similar signature profile except 2 cases exhibiting distinct
mutational signatures which also had fewer shared somatic mutations.

Figure 1 - 1144

Conclusions: In general, AH/EIN shared several molecular genetic features with EC and the great majority of CAs developed from
AH/EIN. Importantly, 71% of MSS ECs harbored new cancer driver mutations which were absent in AH/EIN, suggesting that these genes
play a critical role in tumor progression. Our results shed new light into the pathogenesis of tumor progression of EC and have
implications in its early detection.

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1145 Genomic Profiling of BCOR-Rearranged Uterine Sarcomas Reveals Novel Gene Fusion Partners
and Frequent CDK4 Activation
Douglas Lin1, Amanda Hemmerich2, Claire Edgerly2, Eric Severson2, Richard Huang3, Shakti Ramkissoon2, Jonathan Hecht4,
Jeffrey Ross5, Julia Elvin1
1
Foundation Medicine, Inc., Cambridge, MA, 2Foundation Medicine, Inc., Morrisville, NC, 3Foundation Medicine, Inc., Cary,
NC, 4Beth Israel Deaconess Medical Center, Boston, MA, 5Upstate Medical University, Syracuse, NY

Disclosures:Douglas Lin: Employee, Foundation Medicine, Inc.; Amanda Hemmerich: Employee, Foundation Medicine, Inc; Claire
Edgerly: Employee, Foundation Medicine, Inc.; Eric Severson: Employee, Foundation Medicine; Richard Huang: Employee,
Roche/Foundation Medicine; Shakti Ramkissoon: Employee, Foundation Medicine; Jonathan Hecht: None; Jeffrey Ross: Employee,
Foundation Medicine; Julia Elvin: Employee, Foundation Medicine; Employee, Hoffman La Roche

Background: Metastatic high grade endometrial stromal sarcomas (ESS) have a poor prognosis with limited therapeutic
options. Genomic alterations of BCOR via either gene rearrangement or internal tandem duplication (ITD) define a subset of
ESS. However, the molecular landscape of BCOR-rearranged ESS has not been established. The goals of this study were to: 1)
determine the molecular landscape of BCOR-rearranged ESS, 2) to identify the novel BCOR fusion gene partners in ESS and associated
clinicopathological characteristics, and 3) to potentially unravel targetable genomic alterations in BCOR-rearranged ESS.

Design: A retrospective database search of our molecular laboratory was performed for clinically advanced ESS that
contained BCOR gene rearrangements or BCOR ITD. The cases were previously assayed with comprehensive genomic profiling via
both DNA- and RNA-based targeted next generation sequencing during the course of clinical care. Clinicopathological and genomic
profiling data was centrally re-reviewed.

Results: Here we present the molecular characteristics of the largest cohort of BCOR-rearranged ESS to date (n=40), and we compare
them to an independent cohort of uterine sarcomas harboring BCOR ITD (n=15). This cohort included 31 cases with canonical ZC3H7B-
BCOR fusion as well as 8 cases with novel BCOR gene rearrangement partners, such as BCOR-L3MBTL2, EP300-BCOR, BCOR-
NUTM2G, BCOR-RALGPS1, BCOR-MAP7D2, RGAG1-BCOR, ING3-BCOR, BCOR-NUGGC, KMT2D-BCOR, CREBBP-BCOR and 1
case with BCOR internal rearrangement. Re-review of cases with novel rearrangements demonstrated sarcomas with spindle, epithelioid
or small round cell components and varying degrees of fascicular growth pattern, myxoid or collagenous stromal change. Comprehensive
genomic profiling revealed high frequency of CDK4 and MDM2 amplification in 38% and 45% of BCOR-rearranged cases,
respectively. Other recurrent targetable alterations included homozygous deletion of CDKN2A, which encodes an inhibitor of CDK4 in
28% of cases, and amplification of PDGFRA and ERBB3 in 8% and 5% of cases, respectively. Notably, CDK4 and MDM2 amplification
was absent in all cases from an independent cohort of 15 ESS harboring BCOR ITD (0%, 0 of 15).

Conclusions: Activation of the CDK4 pathway for which targeted therapy is clinically available (i.e. palbociclib), via cyclin D1
overexpression, CDK4 amplification and CDKN2A loss, contributes to the pathogenesis of BCOR-rearranged ESS, which may have both
diagnostic and therapeutic implications.

1146 Diffuse Intratumoral Stromal Inflammation in Ovarian Clear Cell Carcinoma is Associated with
Loss of Mismatch Repair Protein and High PD-L1 Expression
Shih-Yao Lin1, Jen-Fan Hang1, Chiung-Ru Lai2, Teh-Ying Chou1
1
Taipei Veterans General Hospital, Taipei, Taiwan, 2Taipei, Taiwan

Disclosures: Shih-Yao Lin: None; Jen-Fan Hang: None; Chiung-Ru Lai: None; Teh-Ying Chou: None

Background: Ovarian clear cell carcinoma (OCCC) is a chemotherapy-resistant cancer with limited treatment options. OCCC is
associated with Lynch syndrome. Emerging evidence reveals that deficient mismatch repair (MMR) phenotype brings susceptibility to
anti-PD-1/PD-L1 therapy in various types of cancers, and certain histological features are associated with MMR protein deficiency.
However, only few studies have addressed this in OCCC. The aims of this study were to evaluate the expression of MMR protein and PD-
L1 in OCCC and to correlate the results with histological features.

Design: A retrospective search of OCCC cases from surgical pathology archives between 2009 and 2019 was performed. Clinical
histories were collected. All pathologic slides were reviewed to confirm the diagnosis of OCCC and to evaluate the presence of diffuse
intratumoral stromal inflammation (brisk inflammation obliterating the tumor-stroma interfaces) and peritumoral lymphocytes (lymphoid
aggregates cuffing the tumor edges). Tissue microarray was constructed for immunohistochemistry of MSH2, MSH6, MLH1, PMS2, and
PD-L1 (clone SP263). Loss of MMR protein expression (MMR-loss) was determined by loss of nuclear staining for any MMR protein in all
tumor cells. PD-L1 staining in tumor (membranous) and tumor-associated immune cells (membranous or cytoplasmic) were scored and
grouped to <1%, ≥1-24%, 25-49%, and ≥50%.

Results: A total of 76 OCCC cases were included. None of them met the Amsterdam II criteria for the diagnosis of Lynch syndrome.
There were four cases (5.3%) showing diffuse intratumoral stromal inflammation. None of the cases had peritumoral lymphocytes. MMR-
loss was seen in two cases (2.6%), loss of MLH1 and PMS2 in one and loss of MSH2 and MSH6 in the other. They both had diffuse

1097
intratumoral stromal inflammation and tumoral PD-L1 expression ≥50%. Among the 74 MMR-intact OCCC cases, only two (2.7%) had
diffuse intratumoral stromal inflammation, five (6.8%) showed PD-L1 expression ≥25% in tumor or immune cells, and none had tumoral
PD-L1 expression ≥50%. By Fisher exact test, diffuse intratumoral stromal inflammation was significantly associated with MMR-loss (P =
0.021) and tumoral PD-L1 expression ≥25% (P = 0.0006) and ≥50% (P = 0.0001).

Conclusions: Our study demonstrated a small subset of OCCC showing diffuse intratumoral stromal inflammation associated with MMR-
loss and high tumoral PD-L1 expression. Histological evaluation is helpful in selecting MMR-loss OCCC for subsequent anti-PD-1/PD-L1
therapy.

1147 Identification of a Hydatidiform Mole in Twin Pregnancy Following Assisted Reproduction

Yan Liu1, Congrong Liu1
1
Beijing, China

Disclosures: Yan Liu: None; Congrong Liu: None

Background: The aim of this study was to identify a co-existing hydatidiform mole (HM) in twin pregnancy from the abnormal mixed-
genomic products of conception (POC) after assisted reproduction by the combination of morphology, immunohistochemistry and
molecular genotyping.

Design: A total of 37 patients were collected with suspicion for HM by pathological morphology. They had two embryos individually
transferred to their uterus after in vitro fertilization and presented two gestational sacs with undeveloped embryos or one sac with an
abnormal area by ultrasonography. The diagnosis of HM was confirmed by histopathological review, evaluation of p57kip2 immunostaining
pattern and short tandem repeat genotyping on the POC and maternal specimens.

Results: Thirty patients were diagnosed as singleton pregnancy, including twenty-two non-molar gestations, six trisomy gestations, one
homozygous complete mole and one heterozygous partial mole. Although six patients had ultrasonic imaging of two gestational sacs, the
embryonic components in the vacant sac might fade away after transferring. Other seven patients were considered as twin pregnancy by
the allelic genotype from two individual conceptions. For the patients with uniform p57kip2 positivity, excessive paternal alleles indicated
the potential partial HM in the twin pregnancy. For the patients demonstrated divergent and/or discordant p57kip2 immunostaining, twin
pregnancy with co-existing complete HM or mosaic conception were confirmed by genotyping of different villi population respectively.
These patients were monitored by serum β-HCG, while one twin pregnancy with complete mole suffered invasive mole and received
chemotherapy.

Table 1 Diagnosis of 37 patients following assisted reproduction.

Diagnosis One sac Two Total

sacs
without abnormal with abnormal
echogenicity echogenicity
Singleton pregnancy
Non-molar gestation 15 2 5 22
Trisomy 5 0 1 6
Hydatidiform mole 0 2 0 2
Twin pregnancy
Both non-molar gestation 0 0 1 1
Including one complete mole 1 1 0 2
Including one suspected partial mole 0 0 3 3
Including one mosaic pregnancy 1 0 0 1
Total 22 5 10 37

Conclusions: A strategy composed of selective clinicopathological screening, immunohistochemical interpretation and accurate
genotyping is recommended for diagnostically challenging mixed-genomic POC of potential twin pregnancy with HM, especially to
differentiate a non-molar mosaic conception from a partial mole.

1098
1148 Genomic Signatures and Clinicopathological Correlation in Uterine Smooth Muscle Tumors of
Uncertain Malignant Potential, Leiomyosarcoma, and Leiomyoma with Bizarre Nuclei
Ying Liu1, Jong Kim2, Fabiola Medeiros2, Bonnie Balzer2, Eric Vail3, Jianbo Song2, Kevin Baden2, Gaurav Khullar4, David
Engman2, Jean Lopategui3
1
University of California Davis Medical Center, Sacramento, CA, 2Cedars-Sinai Medical Center, Los Angeles, CA, 3Cedars-Sinai
Medical Center, West Hollywood, CA, 4Sands Point, NY

Disclosures: Ying Liu: None; Jong Kim: None; Fabiola Medeiros: None; Bonnie Balzer: None; Eric Vail: None; Jianbo Song: None; Kevin
Baden: None; Gaurav Khullar: None; David Engman: None; Jean Lopategui: None

Background: Differentiating uterine smooth muscle tumors of uncertain malignant potential (STUMP), atypical leiomyoma (LEIO), and
leiomyosarcoma (LMS) is challenging. In addition, prognostic genomic biomarkers are not available for these entities. Using copy number
variation (CNV) chromosomal microarrays (CMA), we investigated the genomic landscape of these tumors. Our goal was to identify
genetic alterations in oncogenes and tumor suppressor genes and evaluate how these genomic signatures may correlate
clinicopathologically in patients with STUMP, LEIO, and LMS.

Design: We retrospectively reviewed the pathology and follow up on 20 patients, including 10 STUMP, 5 LMS, and 5 LEIO, and
correlated with CMA result. For each patient sample, the results were filtered to only include 720 genes from the COSMIC 2 tier cancer
gene census, causally implicated in cancer. The cases were grouped by tumor type (LMS, STUMP, LEIO) and subsequently the net
frequency of gene gains and losses within each group was calculated. These lists were then filtered to include genes that were lost or
gained only in LMS, only in STUMP, and only in LEIO.

Results: The average age at diagnosis was 66 years for LMS, 50 years for LEIO and 44.9 years for STUMP. The average size of the
dominant tumor for LMS was 8.5 cm, 7.3 cm for LEIO and 5.8 cm for STUMP. TSG loss was the predominant CNV in all STUMP. Four of
10 STUMP had a unique 1p loss. Similarly, in LMS, TSG loss was the predominant CNV (CBFB, CTCF, FAT1, KLF6, LARP4B and
LRP1B). TP53 loss and gain of oncogenes were only observed in LMS. One case with high nuclear grade, increased mitotic count, and
coagulative necrosis had a hybrid genomic fingerprint with loss of 1p only seen in STUMP and loss of TSG CBFB and CTCF also seen in
LMS. 17 patients had follow-up ranging from 2 months to 108 months with an average of 37.6 months. Four of 5 LMS patients presented
with distant metastases including one who died of the disease. No metastases or death was reported among the STUMP and
LEIO patients.

Conclusions: The results of this pilot study suggest that LMS display a unique loss of TP53, loss of other TSG, and gain of oncogenes.
STUMP is associated with a unique loss of 1p and loss of TSG. High grade STUMP displays loss of CBFB and CTCF observed in LMS,
in addition to 1p loss typically associated with STUMP. Additional studies with a larger cohort and longer clinical follow-up are needed to
further ascertain genomic markers of biologic behavior in uterine smooth muscle tumors.

1149 Metastases of Uterine Serous Carcinoma Often Show a HER2 Expression Profile Different from
the Biopsy and Hysterectomy Specimens
Valeria Maffeis1, Carrie Robinson2, Azra Ligon3, Beth Harrison3, Marisa Nucci4, David Kolin3
1
University of Padova, Padova, PD, Italy, 2Naval Medical Center San Diego, San Diego, CA, 3Brigham and Women's Hospital,
Boston, MA, 4Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Disclosures: Valeria Maffeis: None; Carrie Robinson: None; Azra Ligon: None; Beth Harrison: None; Marisa Nucci: None; David Kolin:
None

Background: Uterine serous carcinoma (USC) accounts for approximately half of endometrial carcinoma-related mortality. A subset of
USC shows human epidermal growth factor receptor 2 (HER2) amplification, and these patients benefit from treatment with trastuzumab.
Therefore, accurate assessment of HER2 status is critical to properly select patients for targeted therapy. However, previous work has
shown that there is significant intratumoral heterogeneity of HER2 amplification in USC. This study investigated the potential clinical
impact of this heterogeneity by examining HER2 expression in paired endometrial biopsies (B), hysterectomy specimens (H), and
metastatic lesions (M) from patients with USC.

Design: Cases of USC were retrospectively identified, for which B, H, and/or M samples were available from the same patient. HER2
status was assessed by IHC (clone SP3) on all samples and scored independently by two pathologists using the updated 2018
ASCO/CAP guidelines for testing in breast cancer as negative (0, 1+), equivocal (2+), or positive (3+). All cases which were scored as 2+,
or those with a discordance between paired samples (e.g., 1+ in B and 3+ in H), were tested by FISH.

Results: 59 patients were selected, with 35 B, 58 H, and 73 M (multiple M from the same patient were available in 24 of 42 cases). By
HER2 IHC, paired B and H were discordant in 2/35 (6%). Specifically, 2 B were negative (1+) but had a corresponding H with either 3+ or
2+ with amplification by FISH. 7 H with HER2 amplification had at least one negative M, while one case was negative on the B and H, but
had three different positive M (Figure 1). H and M pairs showed discordance in 8/39 (20%) of cases. Discordance between multiple M

1099
lesions was found in 5/24 (21%). Heterogeneity in HER2 amplification within a single stained slide was present in 3/35 B (8.5%), 18/58 H
(31%) and 2/73 M (3%).

Fig 1. Case #54: (A & B) biopsy (HER2: 0), (C & D) hysterectomy (HER2: 1+), (E & F) lymph node metastasis (HER2: 0), (G & H)
omental metastasis (HER2: 3+).

Figure 1 - 1149

Conclusions: Despite significant HER2 overexpression heterogeneity in over 30% of slides from hysterectomy specimens, there was
excellent overall agreement (94%) in HER2 scores between biopsy and hysterectomy specimens. However, HER2 overexpression is
discordant in up to 20% of hysterectomy-metastasis pairs, suggesting that testing should be performed on a site of metastatic disease
prior to the initiation of targeted therapy.

1150 Frequency of Molecular Alterations Using a Targeted RNA Sequencing Approach in Uterine
Mesenchymal Tumors
Leonel Maldonado1, Amir Momeni Boroujeni2, Ryma Benayed1, Martee Hensley1, Marc Ladanyi1, Kay Park1, Robert Soslow1,
Sarah Chiang1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2Memorial Sloan Kettering Cancer Center, Brooklyn, NY

Disclosures: Leonel Maldonado: None; Amir Momeni Boroujeni: None; Ryma Benayed: None; Martee Hensley: None; Marc Ladanyi:
None; Kay Park: None; Robert Soslow: Speaker, Ebix/Oakstone; Sarah Chiang: None

Background: Recurrent translocations resulting in gene fusions underpin a wide variety of uterine mesenchymal tumors, particularly
endometrial stromal sarcomas (ESS) and some leiomyosarcoma (LMS) variants. We aimed to determine the frequency and types of
fusions detected by targeted RNA sequencing performed as part of the diagnostic evaluation of various uterine mesenchymal tumor
subtypes.

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Design: Fusion status of all uterine endometrial stromal and smooth muscle tumors, malignant PEComas, uterine tumor resembling
ovarian sex cord tumor (UTROSCT) and inflammatory myofibroblastic tumors (IMT) submitted for targeted RNA sequencing as part of
their diagnostic evaluation in 2015-2019 was retrospectively reviewed. Re-review of pathology slides was performed when sequencing
results and diagnosis were discordant.

Results: Targeted RNA sequencing results were available in 69 uterine mesenchymal tumors, including 1 endometrial stromal nodule
(ESN), 10 low-grade ESS (LGESS), 15 high-grade ESS (HGESS), 5 ESS not otherwise specified (NOS), 2 smooth muscle tumors of
uncertain malignant potential (STUMP), 12 LMS, 11 myxoid LMS, 2 epithelioid LMS, 6 malignant PEComa, 3 intravenous leiomyomatosis
(IVL), 1 IMT and 1 UTROSCT. Fusions were detected in 100% of ESN and IMT; 93% of HGESS; 90% of LGESS; 60% of ESS NOS; 9%
of LMS and 36% of myxoid LMS; no fusions were detected in STUMP, epithelioid LMS, PEComa and UTROSCT (Table 1). Sequencing
results permitted reclassification of 1 myxoid LMS and 1 LMS, as IMT and fibrosarcoma-like uterine sarcoma, respectively, as well as
upgrade of 1 LGESS and 1 ESS NOS found to have ZC3H7B-BCOR and YWHAE-NUTM2B fusions. Novel JAZF1-RADIL, EPC1-
CXorf67, AEBP2-ETV6 and FOXO1-ATP7B fusions were detected in 3 HGESS and 1 myxoid LMS, respectively.

Tumor type Fusion frequency, % Gene fusion Reclassification

ESN 100 (1/1) JAZF1-SUZ12
LGESS 90 (9/10) JAZF1-SUZ12 HGESS

JAZF1-PHF1

YWHAE-NUTM2
HGESS 93 (14/15) YWHAE-NUTM2A/B

ZC3H7B-BCOR

JAZF1-PHF1

MEAF6-PHF1

EPC1-PHF1

JAZF1-RADIL

EPC1-CXorf67

AEBP2-ETV6
ESS NOS 60 (3/5) JAZF1-SUZ12 HGESS

MEAF6-PHF1

ZC3H7B-BCOR
LMS 9 (1/12) NTRK1-LMNA Fibrosarcoma-like
uterine sarcoma
Myxoid LMS 36 (4/11) TRPS1-PLAG1 IMT

FAM110B-PLAG1

FN1-ALK

FOXO1-ATP7B
IMT 100 (1/1) IGFBP5-ALK
Epithelioid LMS 0 (0/2)
PEComa 0 (0/6)
IVL 0 (0/3)
UTROSCT 0 (0/1)
STUMP 0 (0/2)

Conclusions: Targeted RNA sequencing confirmed fusion status in most ESS and a large subset of myxoid LMS. This method allowed
modification of tumor classification or grade in rare lesions diagnosed LMS or its morphologic variants and ESS that are difficult to grade.

1101
1151 Prevalence of Lynch Syndromein Synchronous Endometrial and Ovarian Carcinoma Patients
Tibiletti Maria Grazia1, Di Lauro Eleonora2, Ghezzi Fabio3, Anna Chiaravalli1, Nicoletta Donadello4, Fausto Sessa5
1
Ospedale di Circolo ASST Settelaghi Varese, Varese, Italy, 2Dept. of Pathology ASST Settelaghi, Varese, Varese, Italy, 3Dept.
of Obstetrics and Gynecology Ospe. Del Ponte ASST Settelaghi, University of Insubria, Varese, Varese, Italy, 4Dept. of
Obstetrics and Gynecology Ospedale del Ponte ASST Settelaghi, Solbiate Arno, Varese, Italy, 5Dept. of Pathology ASST
Settelaghi, University of Insubria, Varese, Varese, Italy

Disclosures: Tibiletti Maria Grazia: None; Di Lauro Eleonora: None; Ghezzi Fabio: None; Anna Chiaravalli: None; Nicoletta Donadello:
None; Fausto Sessa: None

Background: Synchronous endometrial and ovarian carcinomas (SEO) represent approximately 5% of endometrial and 10-20% of
ovarian carcinomas, respectively. Few data are available in literature about the involvement of SEOs in inherited cancer syndromes;
recently two SEOs showing germline pathogenetic BRCA variant identified on tumor tissue were described.

Design: Here we describe 28 SEOs from 28 patients (mean age 50.1) studied for Mismatch repair (MMR) defects using both
Immunohistochemical and molecular approach and for germline mutations of MMR and BRCA genes.

Results: Interestingly 14 out of 28 SEOs (50%) were MMR defective and 11 out of 28 patients carried MMR pathogenetic germline
mutations. Seven out of 11 MMR defective SEOs displayed endometrioid endometrial and ovarian cancers. Patients with proficient MMR
SEOs were tested for BRCA germline mutations and 2 carriers of BRCA1 and 2 pathogenetic mutations were identified. SEOs of BRCA
mutated patients were endometrioid endometrial/ovarian cancers and endometrioid endometrial and serous ovarian cancers.

Conclusions: Somatic testing including Immunohistochemical and microsatellite instability analyses on SEOs are useful to identify
patients affected by inherited cancer syndromes. Our data demonstrate a high incidence of Lynch syndrome in SEOs patients. SEOs
patients could benefit from PARP-inhibitor therapy when BRCA mutated and from immunotherapy when MMR mutated.

1152 Comparative Assessment of p53 Immunohistochemistry and TP53 Mutation Status by Next
Generation Sequencing in High Grade Endometrial Carcinomas
Nana Matsumoto1, Douglas Rottmann2, Hisham Assem3, Serena Wong1, Pei Hui4, Natalia Buza4
1
Yale New Haven Hospital, New Haven, CT, 2Yale School of Medicine, Hamden, CT, 3Yale School of Medicine, New Haven,
CT, 4Yale University School of Medicine, New Haven, CT

Disclosures: Nana Matsumoto: None; Douglas Rottmann: None; Hisham Assem: None; Serena Wong: None; Pei Hui: None; Natalia
Buza: None

Background: Evaluation of TP53 mutation status by p53 immunohistochemistry (IHC) is frequently used in the diagnostic work-up of high
grade endometrial carcinomas to aid the distinction between histologic subtypes and help predict clinical outcome. Although p53 IHC has
been regarded as a reliable surrogate marker, studies validating its concordance with TP53 mutations, particularly by Next Generation
Sequencing (NGS) methods, have been limited in endometrial carcinomas. We aimed to evaluate the correlation between different p53
IHC patterns and TP53 mutations by NGS in high grade endometrial carcinomas.

Design: High grade endometrial carcinomas diagnosed between 2011 and 2019 with available NGS data were retrospectively identified
in our departmental archives. H&E slides were reviewed and a representative tissue block was selected for IHC. P53 IHC (DO7 clone)
was performed in each case and categorized into one of four staining patterns: (1) normal/wild-type, (2) “all” (strong, diffuse) (3) “null”
(complete absence) (4) cytoplasmic with variable nuclear staining. TP53 sequencing results were retrieved from the NGS reports in the
patients’ electronic medical records.

Results: A total of 44 endometrial tumors were included in the study: 22 pure serous carcinomas, 9 mixed carcinomas with a serous
component, 3 carcinosarcomas with a serous component, and 10 FIGO grade 3 endometrioid carcinomas. TP53 mutation was identified
by NGS in all tumors with a serous component and in 2 of 10 high grade endometrioid carcinomas. Aberrant p53 IHC staining pattern was
observed in 33 of 34 (97%) tumors with a serous component showing “all” pattern in 27 cases, “null” pattern in 2 cases, and cytoplasmic
and strong nuclear staining in 4 cases. Among endometrioid carcinomas, one of the 2 tumors with TP53 mutation showed a “null” IHC
pattern, all other tumors displayed wild-type p53 IHC (Table 1).

1102
 Table 1. Correlation between p53 IHC pattern and TP53 mutation type

P53 IHC pattern (All tumors, n=44) TP53 mutation type by NGS
“All” (Diffuse, strong nuclear) n=27 Missense, loss of function n=25
Splice site n=2
“Null” (Complete absence) n=3 Splice site n=1
Deletion, frameshift n=1
Nonsense, premature truncation n=1
Aberrant cytoplasmic/nuclear n=4 Nonsense, premature truncation n=2
Missense, loss of function n=2
Wild-type n=10 No mutation n=8
Nonsense, premature truncation n=1
Deletion, frameshift n=1

Conclusions: Our results showed a 95% overall concordance rate between p53 IHC and TP53 mutation in high grade endometrial
carcinomas. The concordance was highest among tumors with a serous component (97%), while grade 3 endometrioid carcinomas
showed a 90% concordance rate, confirming that p53 IHC is a reliable surrogate for assessing the TP53 mutation status in endometrial
carcinomas. The most common aberrant p53 IHC pattern (“all”) resulted from missense, loss of function mutations in most tumors, while
less common p53 staining patterns (“null”, cytoplasmic/nuclear) showed association with splice site and truncating mutations.

1153 The Impact of the LAST Recommendations on Cervical Biopsy Diagnoses at a Tertiary Care
Academic Center
Chelsea Mehr1, Amrom Obstfeld2
1
Dallas, PA, 2The Children's Hospital of Philadelphia, Philadelphia, PA

Disclosures: Chelsea Mehr: None; Amrom Obstfeld: None

Background: In 2012, the Lower Anogenital Squamous Terminology Standardization Project (LAST) guidelines were published providing
consensus recommendations regarding the evaluation and reporting of squamous lesions. Recommendations regarding the use of p16
immunostaining were a significant part of the LAST recommendations. Since LAST publication, concerns about misdiagnosis due to
overinterpreation of the p16 stain have been raised. The goal of this study was to examine the use of the p16 immunostain and to
evaluate changes in rates of diagnoses associated with immunostain usage, potentially identifying trends suggesting p16 misuse.

Design: Pathology reports for cervical biopsy diagnoses rendered between 2006 and 2017 were extracted from a local pathology report
database. The statistical programming language R was used to parse this text and analyze the findings. The diagnoses made as well as
the presence or absence of the term p16 were determined for each year. Rates of diagnoses (no CIN lesion, low-grade, or high-grade
dysplasia) were subgrouped by year as well as presence or absence of p16 immunostaining. Findings for the years before 2012 and after
2012 (2012 was used as a washout period) were compared using chi-squared testing.

Results: Within the study period 20,646 cervical biopsy diagnoses were analyzed prior to 2012 and 15,491 were analyzed after 2012.
After the publication of the LAST criteria, there was a 6% decline in the rate of low-grade diagnoses and a 5.4% increase in non-CIN
diagnoses (p<0.001 for both) with no significant change in high-grade diagnoses (Figure 1). The fraction of high grade diagnoses did not
increase with p16 use following the publication of the LAST criteria (Figure 2).

1103
 Figure 1 - 1153 Figure 2 - 1153

Conclusions: Given the LAST criteria recommendations, changes in the diagnoses and habits of pathologists are expected. Our data
suggest significant changes in the frequency of diagnoses following the publication of the LAST criteria. Immunostaining for p16 does not
seem to be associated with an increase in high grade diagnosis, arguing against overdiagnosis facilitated by misinterpretation of the
immunostain. Finally, this study demonstrates the potential utility of using warehoused pathology data and a robust statistical
programming language to provide insight into the day to day workflows and diagnostic trends of a pathology service.

1154 African-American Women with Cervical Cancer have a Predominance of Non-Vaccine Targeted
HPV Type 35 which is Associated with Their Poor Survival
Rachelle Mendoza1, Elmer Gabutan1, Tahmineh Haidary2, Mouyed Alawad1, Raag Agrawal3, M. Haseeb1, Raavi Gupta1
1
SUNY Downstate Medical Center, Brooklyn, NY, 2Great Neck, NY, 3SUNY Downstate, Brooklyn, NY

Disclosures: Rachelle Mendoza: None; Elmer Gabutan: None; Tahmineh Haidary: None; Mouyed Alawad: None; Raag Agrawal: None;
M. Haseeb: None; Raavi Gupta: None

Background: Infection with high-risk human papilloma virus (HPV) is one of the definitive events linked to cervical carcinogenesis. Since
the introduction of the HPV vaccine 2006 there has been marked reduction in the incidence and mortality of cervical cancer. As the
vaccine targets nine high-risk HPV types, the non-targeted types continue to spread and cause disease. Here, we aimed to investigate
the prevalence of high-risk HPV types in cervical cancer in our patient population.

Design: Forty-nine patients with squamous cell carcinoma of cervix were identified and their clinicopathological data were recorded. DNA
was extracted from formalin-fixed paraffin-embedded tissues and subjected to multiplex PCR using 33 HPV primers, and gel
electrophoresis. Correlations between different parameters were determined by Pearson’s Chi-squared or Fisher's exact test. Cumulative
5-year disease-free (DFS) and overall survival (OS) were calculated by Kaplan-Meier method and analyzed by log-rank test.

Results: Forty-five of the 49 patients were American-American (83%). 34 of 49 were diagnosed at an early clinical stage (69%) and 24 of
49 had poor histologic grade (48%). HPV non-16/18 types were present in 38 (78%) patients and HPV 16/18 were present in 11 (22%).
Most frequently isolated HPV types were 35 (13.3%), and 18 and 16 (12% each). Mixed HPV infections (>2 types) were found in 11 (22%)
patients. 19 (39%) patients were infected with at least 1 non-vaccine targeted HPV type. Patients infected with HPV type 35 (87.5%) and
HPV type 18 (85.7%) were diagnosed in early clinical stage, but most had poor tumor histologic grade (p=0.036). Patients with non-16/18
infections had shorter mean DFS (26.9 months) and OS (31.3 months) than those with HPV 16/18 (29.5 and 35 months) among those
diagnosed at an early stage. Also, patients with HPV type 35 had shorter mean OS (14.8 months) compared to those infected with other
types (35.9 months) in early clinical stage (p=0.021) (Figure).

1104
 Figure 1 - 1154

Conclusions: HPV 35 was the most common genotype isolated in our predominantly African-American study population. This finding is
remarkable as HPV type 35 is not included in the HPV vaccine in use in the U.S. HPV non-16/18 types were predominant in this cohort
and many had mixed HPV infection. Patients diagnosed at an early stage with non-16/18 types and HPV 35 infection had shorter mean
DFS and OS. These results warrant expanding HPV targets in the HPV vaccine in current use.

1155 Immunohistochemical Expression of SOX10 in Ovarian Epithelial Malignant Tumors

Jelena Mirkovic1, Dina Bassiouny1, Fang-I Lu1, Bojana Djordjevic2, Carlos Parra-Herran1, Sharon Nofech-Mozes1
1
Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, 2University of Toronto, Toronto, ON

Disclosures: Jelena Mirkovic: None; Dina Bassiouny: None; Fang-I Lu: None; Bojana Djordjevic: None; Carlos Parra-Herran: None;
Sharon Nofech-Mozes: None

Background: Immunohistochemistry expression of SOX10, a marker of peripheral neural tumors, melanocytic tumors and neural crest-
derived tumors, has also been reported in several carcinomas, notably in a significant proportion of triple negative breast
cancers. SOX10 immunohistochemical expression in ovarian epithelial malignant tumors was previously evaluated in small cohorts with
variable results. Our aim was to comprehensively analyze SOX10 immunohistochemical expression in a large cohort of ovarian epithelial
malignant tumors.

Design: Tissue microarrays consisting of 1 mm tissue cores in duplicate per case were stained for SOX10. We included high grade
serous (HGSC), low grade serous (LGSC), high grade endometrioid (HGEC), low-grade endometrioid (LGEC), clear cell (CCC), and
mucinous (MC) carcinomas. Nuclear staining intensity (weak, moderate, strong) and percentage of tumor cells staining was recorded.
Any moderate or strong staining, as well as weak staining in ≥10% of cells, was considered positive.

Results: Cohort consisted of 405 ovarian epithelial malignant tumors including 186 HGSC, 33 LGSC, 51 HGEC, 37 LGEC, 58 CCC, and
40 MC. Overall, 30/405 (7%) of cases demonstrated SOX10 expression, all with focal distribution. Moderate expression was seen in a
total of 17/405 (4%) cases in up to 15% of tumor cells, predominantly in high-grade carcinoma categories. Only 2/405 cases showed
strong staining in up to 5% of tumor cells, both in HGSC category.

1105
 Table 1. SOX10 immunohistochemistry expression in ovarian epithelial malignant tumors: Intensity and percentage of tumor cells
staining

Diagnosis Weak % of Mod. % of Strong % of Total

(≥10%) cells (up to) cells (up to) cells (up to)
HGSC (n=186) 6 35% 11 15% 2 5% 19 (10%)
LGSC (n=33) 0 - 0 - 0 - 0
HGEC (n=51) 1 10% 2 8% 0 - 3 (6%)
LGEC (n=37) 1 10% 0 - 0 - 1(3%)
CCC (n=38) 3 15% 3 10% 0 - 6(10%)
MC (n=40) 0 - 1 2% 0 - 1(2.5%)
All (n=405) 11 35% 17 15% 2 5% 30 (7%)

Conclusions: SOX10 is uncommonly expressed in ovarian epithelial malignancies (only 7% of the cases in our cohort). Positive cases
showed focal, predominantly weak or moderate staining. Diffuse, moderate to strong SOX10 immunohistochemical expression is not
compatible with primary ovarian epithelial malignancy, and could be a useful marker when differential diagnosis includes SOX10 positive
carcinomas, such as triple negative breast cancer.

1156 Frequent NTRK Expression in High-Grade Endometrial Stromal Sarcoma Harboring

BCOR/BCORL1 Genetic Alterations
Nissreen Mohammad1, Robert Wolber2, Stephen Yip1, Martin Kobel3, Brendan Dickson4, Cheng-Han Lee5
1
University of British Columbia, Vancouver, BC, 2University of British Columbia, North Vancouver, BC, 3University of
Calgary/Alberta Public Laboratories, Calgary, AB, 4Mount Sinai Health System, Toronto, ON, 5Vancouver, BC

Disclosures: Nissreen Mohammad: None; Stephen Yip: Advisory Board Member, Bayer; Pfizer; Roche; Speaker, Roche; Martin Kobel:
None; Brendan Dickson: None; Cheng-Han Lee: None

Background: NTRK-associated genetic fusions were recently reported in a subset of uterine sarcomas with features of fibrosarcoma,
and pan-Trk immunohistochemistry appears to be a sensitive method for identifying these tumors. These cellular spindle cell sarcomas
exhibit morphologic overlap with high-grade endometrial stromal sarcomas showing predominantly, or exclusively, a spindle cell
morphology, such as those with BCOR/BCORL1rearrangement. The purpose of this study was to examine NTRK expression, using pan-
TRK immunohistochemistry, in a series of molecularly confirmed spindle cell endometrial stromal sarcomas
with BCOR/BCORL1alterations, to confirm whether expression is restricted to NTRK-associated tumors.

Design: We performed Pan-Trk immunohistochemistry (Abcam, clone EPR 17341) on hysterectomy whole sections of 9 high-grade
endometrial stromal sarcomas that were molecularly confirmed by either RNA-sequencing (TruSight RNA fusion panel, Ilumina, CA) or by
Sanger sequencing for exon 15 of BCOR. Staining intensity and percent tumor cell staining were evaluated (NM, CHL).

Results: All 9 high-grade endometrial stromal sarcoma exhibited a pure monomorphic spindle cell morphology, with at least focally
cellular and mitotically active areas that resembled fibrosarcoma. RNA-sequencing identified ZC3H7B-BCOR fusions in 5 cases, EPC1-
BCOR, ECP1-BCORL1and JAZF1-BCORL1fusion in 1 case each. The remaining case (#1) did not harbor demonstrable fusion by RNA-
sequencing, but was found to harbor internal tandem duplication in exon 15 of BCOR(93 base duplication). None of these 9 tumours
demonstrated concurrent genetic fusions involving NTRK1/2/3. By pan-Trk immunohistochemistry, 8 of 9 tumours showed NTRK
expression, ranging from weak focal staining in 10% of tumor cells to moderate-to-strong staining in 80-100% of tumor cells (Table 1).

Case Fusion NTRK Intensity Percent

1 BCOR ITD Positive 2 30
2 EPC1-BCOR Positive 1 60
3 EPC1-BCORL1 Positive 3 30
4 JAZF1-BCORL1 Positive 1 10
5 ZC3H7B-BCOR Positive 3 80
6 ZC3H7B-BCOR Negative 0 0
7 ZC3H7B-BCOR Positive 2 80
8 ZC3H7B-BCOR Positive 1 80
9 ZC3H7B-BCOR Positive 2 100

1106
Conclusions: We identified frequent NTRK immunoexpression in high-grade endometrial stromal sarcoma with a spindle cell morphology
harboring BCOR or BCORL1 alterations. This is in keeping with a recent report of NTRK expression in 3 of 5 high-grade endometrial
stromal sarcoma with ZC3H7B-BCOR fusion (PMID: 31375766). Together, these findings highlight a potential diagnostic pitfall and
underscore the need for further molecular characterization of pan-Trk immunopositive uterine spindle cell sarcomas.

1157 HER2 Expression in Endometrial Serous Carcinomas

Ioana Moisini1, Huina Zhang1, Alexandra Danakas2, David Hicks1, Bradley Turner1
1
University of Rochester Medical Center, Rochester, NY, 2University of Rochester Medical Center, Greece, NY

Disclosures: Ioana Moisini: None; Huina Zhang: None; Alexandra Danakas: None; David Hicks: None; Bradley Turner: None

Background: Uterine papillary serous carcinomas (UPSC) are type II endometrial carcinomas associated with advanced stage, poor
overall survival and more importantly, chemo resistance to known therapies, with response rates of only 20-50% to standard
chemotherapy regimens. Addition of Transtuzumab to carboplatin-paclitaxel in UPSC has been shown to increase progression-free
survival. The human epidermal growth factor receptor 2 (HER2) has been reported to be overexpressed in over 30% of UPSC and
addition of HER2-targeted therapy Transtuzumab to carboplatin-paclitaxel in UPSC has been shown to increase progression-free
survival; however, the concordance of HER2 protein expression by immunohistochemistry (IHC) and HER fluorescence in-situ
hybridization (FISH) continues to be a subject of debate. Our goal in this study is to further evaluate the concordance of HER2 protein
expression and HER FISH.

Design: The database at the University of Rochester Medical Center was searched for all cases of UPSC since 2016. A total of 34 cases
with available tissue were retrieved (27 cases of pure UPSC carcinoma and 7 cases of mixed serous/endometrioid or clear cell). HER2
IHC and HER2 FISH were performed on all cases. In cases showing tumor heterogeneity, multiple areas were counted on FISH. HER2
IHC was evaluated based on the ASCO/CAP 2007 criteria, while HER2 FISH was evaluated based on the more current ASCP/CAP 2018
criteria.

Results: HER2 was positive in 17.6% of our cases when evaluated by IHC and/or FISH. 23/24 (96%) cases of HER2 negative (score 0 or
1+) or HER2 positive (score 3+) IHC cases were concordant with FISH (Table 1). 100% of IHC positive cases were also concordant with
FISH. One IHC negative (score 1+) case was FISH amplified and only 2/8 (25%) of HER2 equivocal cases were FISH amplified.

Table 1: Correlation of HER2 IHC and HER FISH

HER2 FISH
Type of carcinoma Cases (n) Non- amplified (n) Amplified (n)
Uterine papillary serous carcinoma
HER2 IHC score
0 5 5 0
1+ 11 10 1
2+ 8 6 2
3+ 3 0 3
Mixed serous/other type carcinoma
HER2 IHC score
0 1 0 0
1+ 3 0 0

Conclusions: Our study supports that there is an overall concordance between HER2 protein expression and HER FISH based on the
ASCO/CAP 2007 and the ASCO/CAP 2018 criteria. Additional studies on larger populations are currently being pursued. We are currently
developing an algorithmic approach for evaluation of HER2 by FISH based on the ASCO/CAP 2018 FISH criteria which can be reliably
applied in pure or mixed UPSC.

1158 Molecular Subclassification of Copy Number-Low Endometrial Carcinomas

Amir Momeni Boroujeni1, Bastien Nguyen2, Britta Weigelt2, Chad Vanderbilt3, Robert Soslow2
1
Memorial Sloan Kettering Cancer Center, Brooklyn, NY, 2Memorial Sloan Kettering Cancer Center, New York, NY, 3Memorial
Sloan Kettering Cancer Center, Denver, CO

Disclosures: Amir Momeni Boroujeni: None; Bastien Nguyen: None; Britta Weigelt: None; Chad Vanderbilt: Consultant, Docdoc ltd.
(Singapore); Consultant, Paige AI; Consultant, OncoKB; Robert Soslow: Speaker, Ebix/Oakstone

Background: Molecular genomic studies of endometrial carcinomas (ECs) have identified a group of copy number-low (CN-L) tumors
lacking hyper/ultramutation, chromosomal instability or TP53 mutation. The aim of this study was to define the molecular characteristics of
CN-L ECs and their association with outcome.

1107
Design: CN-L ECs subjected to clinical next generation sequencing were analyzed, and clinico-pathologic data pertaining to these cases
assessed. All ECs were reviewed and histologically typed by expert gynecologic pathologists at a single institution. Non-linear
dimensionality reduction using T-SNE on non-negative matrix factorized (NMF) copy number and mutation data followed by K-means
unsupervised clustering was used to cluster tumors into 3 molecular subgroups.

Results: In total, 394 CN-L ECs were studied, including 375 endometrioid (95%), 13 mixed (3%), 6 high-grade carcinomas and
unclassified (1.5%) carcinomas. The median survival was 34.59 months. Based on clustering of copy number and mutational data, three
molecular subgroups were identified: C1, with PTEN and PIK3R1 mutations; C2, with PTEN and PIK3CA mutations; and C3,
with AKT1 mutations and 1q and 8q gains in absence of PTEN mutations. Log-rank analysis showed significant differences between the
clusters, with C1 having the best outcomes (>90% survival at 4 years), C2 with intermediate outcomes and C3 with the worst outcomes
(p=0.0001).

Figure 1 - 1158

Conclusions: CN-Ls form the largest group of ECs and are heterogenous at the genetic and clinical level. CN-L ECs can be
subclassified into 3 molecularly distinct subgroups with important outcome differences. This approach can potentially be used in risk-
stratification of patients for therapeutic and management purposes.

1159 Alterations in Chromatin Remodeling Genes in Endometrial Epithelial Tumors are Associated with
Prognosis
Amir Momeni Boroujeni1, Chad Vanderbilt2, Rajmohan Murali3
1
Memorial Sloan Kettering Cancer Center, Brooklyn, NY, 2Memorial Sloan Kettering Cancer Center, Denver, CO, 3Memorial
Sloan Kettering Cancer Center, New York, NY

Disclosures: Amir Momeni Boroujeni: None; Chad Vanderbilt: Consultant, Docdoc ltd. (Singapore); Consultant, Paige AI; Consultant,
OncoKB; Chad Vanderbilt: Consultant, Docdoc ltd. (Singapore); Consultant, Paige AI; Consultant, OncoKB; Rajmohan Murali: None

Background: Chromatin remodeling genes (CRG) are components of epigenetic regulatory mechanisms and alterations in these genes
have been identified in several tumor types, including gynecologic tumors. In this study, we sought to investigate the prevalence and
clinicopathological associations of CRG alterations in epithelial tumors of the endometrium (ETs) and adnexa (ATs).

Design: We performed a retrospective analysis of ET and AT specimens sequenced using a targeted clinical next generation sequencing
panel targeting up to 468 genes, including the CRGs: ARID1A, ARID1B, ARID2, ATRX, BAP1, CREBBP, CTCF, EP300, IKZF1, KMT2A,
KMT2B, KMT2C, NCOR1, RAD54L, RB1, SMARCA4, and SMARCD1. Cases with microsatellite instability or POLE mutation were
excluded. We analyzed associations of CRG alterations with clinicopathologic findings.

Results: A total of 1147 ETs and 1114 ATs consisting of various diagnoses including endometrioid, serous, clear cell, mesonephric, and
carcinosarcoma were evaluated. Up to 45% of ET and 37% of AT harbored at least one pathogenic CRG alteration, the most common
being ARID1A (ET: 25%, AT: 11%) followed by CTCF in ET (7%) and RB1 in AT (7%). In ETs, some CRG alterations (ATRX, SMARCA4,
RB1) were associated with higher FIGO stage (~50% stage III or IV) and poor overall survival, regardless of presence or absence of other
CRG alterations (p=0.006) (G1). Conversely, alterations in the other CRGs (ARID1A, ARID1B, ARID2, BAP1, CREBBP, CTCF, EP300,
IKZF1, KMT2A, KMT2B, KMT2C, NCOR1, RAD54L and SMARCD1) without alterations of ATRX, SMARCA4 and RB1 was associated

1108
with lower stage at presentation (~70% stage I) and improved survival outcomes (p=0.007) (G2) even compared to the group without any
CRG alterations (G3). While similar trends were observed in ATs, these failed to reach statistical significance.

Endometrial Adnexal (n=412)

(n=516)
Tumors with at Most common CRG Tumors with at Most common CRG
least 1 CRG mutations (n, %) least 1 CRG mutations (n, %)
alteration (n, %) alteration (n, %)
Endometrioid 262 (51%) ARID1A (196, 75%) 19 (5%) ARID1A (12, 63%)
adenocarcinoma CTCF (66, 25%) CREBBP (3, 16%)
KMT2D (19, 7%) RB1 (2, 11%)
Serous carcinoma 71 (14%) ARID1A (16, 23%) 235 (59%) ARID1A (30, 13%)
SMARCA4 (8, 11%) KMT2C (29, 12%)
EP300 (7, 10%) RB1 (28, 12%)
Clear cell carcinoma 17 (3%) ARID1A (4, 24%) 60 (15%) ARID1A (54, 90%)
KMT2C (4, 24%) ARID1B (5, 8%)
EP300 (3, 18%) KMT2C (5, 8%)
Carcinosarcoma 56 (11%) ARID1A (12, 21%) 22 (6%) RB1 (5, 23%)
CREBBP (6, 11%) ARID1A (5, 23%)
RB1 (6, 11%) KMT2C (2, 9%)

Figure 1 - 1159

Conclusions: CRG alterations are common in ETs and ATs and are associated with clinicopathologic features and survival. Our data
suggest that CRG alterations modulate the behavior of tumors, likely through epigenetic mechanisms.

1160 High NTRK3 Expression in High-Grade Endometrial Stromal Sarcomas with BCOR Abnormalities
Amir Momeni Boroujeni1, Ryma Benayed2, Martee Hensley2, Cristina Antonescu2, Marc Ladanyi2, Sarah Chiang2
1
Memorial Sloan Kettering Cancer Center, Brooklyn, NY, 2Memorial Sloan Kettering Cancer Center, New York, NY

Disclosures: Amir Momeni Boroujeni: None; Ryma Benayed: None; Martee Hensley: None; Cristina Antonescu: None; Marc Ladanyi:
None; Sarah Chiang: None

Background: A subset of high-grade endometrial stromal sarcomas harbor rearrangements involving the BCL-6 corepressor (BCOR)
gene, manifesting as ZC3H7B-BCOR fusion or BCOR internal tandem duplication (ITD) involving exon 15. BCOR plays a role in
suppressing gene transcription and maintaining tissue homeostasis and gene silencing through epigenetic mechanisms. NTRK3 mRNA
upregulation was previously reported in soft tissue sarcomas harboring BCOR-CCNB3 fusion and BCOR ITD. Here, we aim to evaluate
NTRK expression in high-grade endometrial stromal sarcomas with BCOR genetic alterations.

1109
Design: Pan-NTRK immunohistochemistry targeting NTRK1, NTRK2 and NTRK3 was performed on paraffin-embedded, formalin-fixed
tumoral tissue sections of 8 high-grade endometrial stromal sarcomas with BCOR rearrangement (7 ZC3H7B-BCOR fusion, 1 BCOR ITD)
previously confirmed by fluorescence in situ hybridization or a targeted RNA capture fusion assay. An RBPMS-NTRK3 fusion-positive
uterine sarcoma served as a positive control. NTRK RNA expression data from the RNA capture fusion assay was extracted from
5 ZC3H7B-BCOR and 1 RBPMS-NTRK3 fusion-positive uterine sarcomas and compared.

Results: Strong cytoplasmic pan-NTRK staining in ≥95% of cells was seen in the tumor harboring BCOR ITD. Cytoplasmic staining in
≥50% of cells was moderate in 4 and weak in 3 BCOR fusion-positive tumors. Significant mRNA upregulation of NTRK3 was seen in all
tested tumors with either conventional gene fusion or ITD, the latter comparable with that seen in the NTRK3 fusion-positive tumor.
mRNA Expression of NTRK1 and NTRK2 was not increased.

Figure 1 - 1160

Conclusions: BCOR genetic alterations lead to upregulation of NTRK3 at mRNA and protein levels in high-grade endometrial stromal
sarcoma. Further investigation of NTRK3 overexpression serving as a potential therapeutic target in these tumors is required.

1161 FOXL2 Mutation Status in Ovarian Adult Granulosa Cell Tumors with an Extensive
Fibrothecomatous Component
Paloma Monroig-Bosque1, Erika Walker2, Donna Coffey3, Suzanne Crumley2, Michael Deavers4, Randall Olsen5, Ramya
Masand6, Ekene Okoye2
1
Houston Methodist Hospital, Pearland, TX, 2Houston Methodist Hospital, Houston, TX, 3The Methodist Hospital, Houston,
TX, 4Houston Methodist, Houston, TX, 5Houston, TX, 6Baylor College of Medicine, Houston, TX

Disclosures: Paloma Monroig-Bosque: None; Erika Walker: None; Donna Coffey: None; Suzanne Crumley: None; Michael Deavers:
None; Randall Olsen: None; Ramya Masand: None; Ekene Okoye: None

Background: Nearly all adult granulosa cell tumors (AGCT) harbor a mutation in the FOXL2 gene, whereas most fibromas/thecomas do
not. Accurate classification of AGCT with an extensive fibrothecomatous component (AGCT-FTC; 10-50% granulosa cells), referred to as
“mixed granulosa theca cell tumors" can be challenging by histology and reticulin stain. We sought to characterize FOXL2 mutation status
in these diagnostically challenging tumors.

Design: Retrospective review of AGCT-FTC and molecular testing for FOXL2 was performed (largest series to date, n=15).
Diagnostically challenging fibrothecomas with sex cord elements (granulosa cell proliferation) (FT-SCE) were included. Reticulin stains
were reviewed. FFPE tissue microdissection was performed, and FOXL2 mutation status was tested in both components independently.

Results: We identified 15 cases classified as AGCT-FTC and 3 classified as FT-SCE. Mean patient age was 54 yrs; 11 were Stage IA &
4 were Stage IC. Follow-up data was available for 12/18 patients, all of whom had no evidence of disease at last follow-up (mean follow-
up time 51.8 mo.). Reticulin stains were reviewed in 13/15 AGCT-FTC and showed loss of fibers in areas of GCT and preservation in
areas of FTC. Three cases of FT-SCE showed preserved reticulin with only focal loss. FOXL2 mutation was detected in 8/15 AGCT-FTC
(53.3%), and 1/3 FT-SCE (33.3%), with concordance in both granulosa and fibrothecomatous components. FOXL2 mutation was

1110
detected in 6/8 (75 %) cases with ≥35% granulosa cells in AGCT-FTC, and in 2/7 (28.5%) of AGCT-FTC cases with < 35% granulosa
cells (Table 1).

Figure 1 - 1161

Conclusions: FOXL2 mutation status is concordant in both granulosa and fibrothecomatous components of AGCT-FTC, suggesting that
the FTC represents a variant histologic pattern in AGCT. Although there is a rough correlation between the percentage of granulosa cells
and the presence of a FOXL2 mutation, the % granulosa cells do not reliably predict FOXL2 mutation. AGCT-FTC appears to present at
an early stage and behave indolently.

1162 The Targetable Immune Checkpoint VISTA is Highly Expressed in a Subset of Endometrial
Carcinomas, Particularly Those Exhibiting Mismatch Repair Deficiency and PD-L1 Expression
Margaret Moore1, Lisa Friedman1, Kari Ring1, Emily Sloan2, Anne Mills1
1
University of Virginia, Charlottesville, VA, 2University of California San Francisco, San Francisco, CA

Disclosures: Margaret Moore: None; Lisa Friedman: None; Kari Ring: None; Emily Sloan: None; Anne Mills: None

Background: Mismatch repair-deficient (MMRd) endometrial carcinomas (ECs) possess higher neoantigen loads than mismatch repair-
intact (MMRi) ECs, and targetable immune modulatory molecules —including PD-L1, IDO-1, LAG-3, and TIM-3—exhibit differential
expression across mismatch repair groups. V-domain Ig suppressor of T cell activation (VISTA) is a B7 protein that represents another
immunosuppressive checkpoint molecule which may have immunotherapeutic value in these tumors. However, little is known about
VISTA expression in ECs or its relationship to MMR status and PD-L1 expression.

Design: Immunohistochemistry for VISTA, CD3, and PD-L1 was performed on representative whole sections of 78 ECs [29 intact
carcinomas, 25 MLH1-hypermethylated MMRd carcinomas, and 24 unmethylated MMRd carcinomas]. VISTA-positive (VISTA+) and
CD3-positive (CD3+) lymphocytes were separately enumerated. Membranous tumoral PD-L1 staining was scored using a semi-
quantitative scale (<1%, 1-5%, 6-10%, 11-25%, 26-50%, and >50%). Due to the therapeutic significance of a combined positive score
(CPS) [CPS=(#PD-L1+ tumor cells, lymphocytes, & macrophages)/(# tumor cells) x 100 ] of ≥ 1 in some tumor types, cases with a CPS ≥
1 were also identified.

Results: No statistical difference in age, stage, or grade at presentation was identified between MMR groups. VISTA+ lymphocytes were
observed in all cases; no tumoral expression of VISTA was seen. MMRd ECs demonstrated higher levels of VISTA expression than
MMRi ECs (p=0.00004), with both hypermethylated and unmethylated ECs demonstrating increased expression relative to intact ECs
(p=0.001, p=0.001). Greater numbers of CD3+ lymphocytes were present in the MMRd subset (p=0.00005). The VISTA:CD3 ratio was
significantly higher in MMRd versus MMRi ECs (p=0.04). Tumoral PD-L1 expression was not significantly correlated with VISTA
expression, however a PD-L1 CPS ≥ 1 was significantly associated with increased VISTA expression (p=0.0002), greater numbers of
CD3+ lymphocytes (p=0.0001), and an increased VISTA:CD3 ratio (p=0.04).

1111
 Median VISTA+ Mean CD3+ Median VISTA: CD3
lymphocytes/HPF lymphocytes/HPF Ratio (VISTA+lymphocytes/HPF)/

(CD3+lymphocytes/HPF)
MMR Status
MMRd 12.9 217 0.065
MMRi 2.6 131 0.022
p value 0.00004 0.00005 0.04
PD-L1 Status
PD-L1 CPS≥ 1 9.2 201 0.056
PD-L1 CPS <1 1.3 82 0.013
p value 0.0002 0.0001 0.04

Conclusions: VISTA+ lymphocytes are common in endometrial carcinomas. VISTA and CD3 expression are more robust in MMRd ECs
than MMRi ECs, and in cases with a PD-L1 CPS ≥ 1 versus <1. The increased VISTA:CD3 ratio in MMRd ECs suggests that increased
VISTA expression is not merely attributable to the higher absolute number of inflammatory cells in these cancers. These findings suggest
that MMRd ECs may be good candidates for therapeutic agents targeting VISTA.

1163 Five Year Experience of Pathologic Ultrastaging of Endometrial Cancer Sentinel Lymph Nodes: A
Focus on Prevalence, Treatment and Outcome of Patients with Isolated Tumor Cells
Samaneh Motanagh1, Jessica Dillon2, Kristen Muller3, Jorge Gonzalez2, Laura Tafe3
1
Lebanon, NH, 2Dartmouth Hitchcock Medical Center, Lebanon, NH, 3Dartmouth-Hitchcock Medical Center, Lebanon, NH

Disclosures: Samaneh Motanagh: None; Jessica Dillon: None; Kristen Muller: None; Jorge Gonzalez: None; Laura Tafe: None

Background: Endometrial cancer is the most frequent uterine malignancy in the United States, with prognosis largely dependent on
stage. Sentinel lymph node (SLN) mapping is an established technique for identifying low volume nodal disease in endometrial
carcinomas. At this time, few studies have provided follow-up data to assess the utility of SLN biopsies and clinical management of low
volume disease, particularly isolated tumor cells (ITCs). We report follow-up data examining the prevalence of low volume disease in our
patient cohort, the clinical treatment of all SLN cases with ITCs and patient outcome.

Design: From 2014 to August 2019, the gynecologic oncologists at our institution performed SLN mapping on 451 women with newly
diagnosed endometrial carcinoma. Of those, 437 cases underwent pathologic examination using the MSKCC protocol for lymph node
ultrastaging consisting of two additional deeper recuts and paired pancytokeratin stains (PMID: 23694985).

Results: Of 437 cases, a total of 14 macrometastases (3%, 14/437) and 2 micrometastases (<1%, 2/437) were identified on the initial
H&E slides. An additional 2 micrometastases and 37 ITCs (8.5%, T1a – 11; T1a – 20; T2 – 3; T3a – 2; T3b - 1) were identified on
cytokeratin stain using pathologic ultrastaging. 40 patients with micrometastases and ITCs had endometrioid histology (grade I/II – 33,
grade III – 7), 1 with mixed. In patients with ITCs, treatments were rendered as follows: 9 brachytherapy, 13 radiotherapy (RT), 1
chemotherapy (CT), 4 (CT+RT) and 6 patients did not receive further care (T1a – 3; T1b – 2; T2 – 1). Four patients were lost to follow up.
To date, only one ITC patient (FIGO grade III, T1b) (2%, 1/37) experienced a recurrence in the omentum at 11 months post-surgery
despite hormone and brachytherapy.

1112
 Table. The pathologic features and treatment of the 37 patients with ITCs. All tumors were endometrioid histology.

PATIENT TUMOR SIZE GRADE STAGE LVI TREATMENT RECURRENCE F/U

(CM) (2019)
1 4.0 II T1A NO None NONE NED
2 1.5 II T1A NO Brachy NONE NED
3 3.7 II T1A NO Brachy NONE NED
4 5.5 II T1A NO RT NONE NED
5 7.1 I T1A NO Brachy NA NA
6 7.7 II T1B NO CT + RT NONE NED
7 4.0 I TIB NO Brachy NONE NED
8 3.0 II T1B NO Brachy NONE NED
9 3.0 III T1B NO Brachy NA NA
10 8.0 II T1B NO Brachy NONE NED
11 10.5 II T1B NO RT NA NA
12 3.0 III T1B SUSP Brachy + hormonal POS; 11 mos., omental mass DOD
13 3.7 III T2 NO CT + RT NONE NED
14 4.5 I T1B NO RT NONE NED
15 7.0 I T1B NO RT NA NA
16 1.8 I T1A NO None N/A RECENT
17 6.5 I T3A POS NA N/A RECENT
18 9 III T1B POS NA N/A RECENT
19 4.5 III T1B POS RT N/A RECENT
20 3.7 I T1A POS RT N/A RECENT
21 3 II + undiff T1B POS CT + RT N/A RECENT
22 6 III T1B POS None N/A N/A
23 6 II T1B POS RT NONE NED
24 8.5 II T3B POS CT NONE NED
25 4.1 II T2 POS None - declined NA NA
26 10 II T2 NO NA NA NA
27 5.5 I T1B NO RT NONE NED
28 4.5 I T1A NO RT NONE NED
29 8 I T3A POS NA NA NA
30 4.5 I T1B POS RT NONE NED
31 5.3 III T1B POS None NONE NED
32 1 II T1B NO RT NONE NED
33 5 I T1A POS RT NA NA
34 3.3 I T1A NO None NONE NA
35 5.1 II T1B NO Brachy NA NA
36 5.3 II T1B NO RT NA NA
37 1.5 I T1A NO CT + RT NONE NED

Conclusions: SLN mapping decreases the morbidity and mortality associated with lymphadenectomy and our surgeons are appropriately
selecting patients for SLN with low-risk of bulky lymph node disease. However SLN ultrastaging is resource intensive and, the
predominant finding is ITCs. Clinical treatment of ITCs remains variable without a consensus in the oncologic community, which is
reflected in our data. Our results further question the utility of SLN ultrastaging, given the continued controversy of clinical management of
ITCs and low yield of detecting micrometastatic disease and predicting tumor recurrence.

1164 Evaluation of Histologic Size of High Grade Squamous Intraepithelial Lesion (HSIL) with
Preceding Abnormal Cytology versus HSIL with Preceding Negative Cytology
Shima Mousavi1, Dina Mody1, Suzanne Crumley1, Ekene Okoye1
1
Houston Methodist Hospital, Houston, TX

Disclosures: Shima Mousavi: None; Dina Mody: None; Suzanne Crumley: None; Ekene Okoye: None

Background: HSIL can be preceded by a negative (neg) Papanicolaou (Pap) test, usually with a concurrent positive HRHPV test. The
purpose of this study was to assess if there is a histologic size difference between HSIL cases with preceding neg cytology (NILM) vs
those with preceding abnormal cytology (ASCUS and above), and to evaluate the significance of HRHPV genotype on the size of HSIL
seen on histology.

Design: We retrospectively reviewed our Laboratory database for liquid-based Pap tests performed on a low risk screening population
over a period of one year (2017). Of 189,243 pap tests, 6,755 had follow up biopsy, with 294 having a HSIL diagnosis. 245 of HSIL cases
had a preceding abnormal pap test (ASCUS and above), and 49 of HSIL cases had a neg preceding Pap test (NILM). Histologic review
of 72 HSIL cases, with slides available, (combination of cervical biopsies and LEEPs), including 27 with preceding NILM Pap/positive
HRHPV (NILM arm) and 45 patients (pts) with ASCUS and above cytology (ASCUS+ arm) was conducted. HSIL size was measured
using a calibrated microscope camera. Statistical analysis was performed using the t-test.

1113
Results: Mean age of pts with preceding neg cytology was 45 yrs (24- 66) vs. 33 yrs (21-57) in those with preceding abnormal cytology;
(p < 0.0004). The average size of HSIL in the NILM arm was 4.53 vs 6.22 mm in the ASCUS+ arm; (p < 0.311). In the NILM arm, the
majority of cases were HR HPV 16 positive (17/27; 62.9%); and 22/27;81.5% were HPV 16 and/or 18 positive. The remaining 5/27 cases
were HRHPV non-16/18 positive. The size of HRHPV 16/18 positive HSILs was larger than the HRHPV non-16/18 positive HSILs (5.42
vs. 0.78 mm); (p < 0.004). However, in the ASCUS+ arm there was no significant difference between size of HRHPV16/18 positive HSILs
and HPV non16/18 positive group HSILs, 5.84 vs. 5.17mm (p < 0.77).

Conclusions: Negative cytology more frequently precedes the biopsy diagnosis of HSIL in an older population. The size of HSIL in cases
with preceding negative versus positive cytology did not show a significant difference. However, the size of the HRHPV 16/18 HSILs was
smaller as compared to the HR HPV non-16/18 HSILs in the NILM arm. These findings suggest that the non-16/18 HR HPV types may
induce smaller lesions, and have important implications for screening in the HPV vaccination era with an anticipated decrease in HRHPV
16/18-related cases. In these cases, the smaller HSIL lesions associated with HR HPV non-16/18 types may be more challenging to
detect.

1165 Comparison of the New CAP-ACP Consensus Guidelines for Endometrial Biopsy Reporting to
Current Practice in Ethiopia: Are Guidelines From High Income Countries Applicable in Low- and
Middle-Income Countries?
Zewditu Nigatu1, Zemen Asmare2, Dana Razzano3, Joseph Rabban4
1
St. Paul’s Hospital Millennial Medical College, Addis Ababa, Gulele, Ethiopia, 2SPHMMC, Addis Ababa, Ethiopia, 3New York
Medical College, Valhalla, NY, 4University of California San Francisco, San Francisco, CA

Disclosures: Zewditu Nigatu: None; Zemen Asmare: None; Dana Razzano: None; Joseph Rabban: Employee, Spouse is an employee
of Merck & Co.

Background: Standardized classification and reporting of endometrial pathology is essential for optimal patient management. Recently,
consensus recommendations from high-income countries have been published for endometrial biopsy reporting (CAP-ACP guidelines,
PMID: 29369922) and for endometrial cancer reporting (ISGyP guidelines, PMID: 30550479). The feasibility of applying these guidelines
in low-middle income countries (LMIC) has not been evaluated. As the first of a multi-step evaluation, this study examined endometrial
biopsy reporting practices in one of the largest centers in Ethiopia and correlated with the new CAP-ACP reporting guidelines.

Design: Endometrial biopsy, polypectomy and curettage reports from Jan 2014 to Feb 2018 from one of the largest centers in Ethiopia
(patient catchment population over 5 million) were reviewed for the submitted clinical history and final diagnosis, then correlated with the
CAP-ACP reporting guidelines.

Results: 1,590 endometrial biopsy reports were evaluated. Abnormal uterine bleeding (65%) was the leading indication; clinical history
was not provided for 20%. The diagnoses were 81.4% benign, 0.4% atypical hyperplasia, 2% carcinoma, 10% trophoblastic disease, and
6.2% inadequate for diagnosis. The leading benign diagnoses were normal functioning endometrium (32%), polyps (30%) and retained
products of conception (29%) while 1% were acute or granulomatous endometritis. The diagnostic sub-categories aligned well with
those of the CAP-ACP guidelines with minor exceptions: 1.) diagnoses of hormonal imbalance were not sub-classified as disordered
proliferative pattern, irregular secretory pattern or progestin-treatment effect. 2.) non-diagnostic specimens were not stratified as to the
cause for inadequacy. 3.) extra-uterine tissues were not noted in any case.

Conclusions: Current endometrial biopsy reporting practices for benign disease in Ethiopia align well with new CAP-ACP
guidelines. Minor opportunities exist for fine-tuning classification of hormonal alterations, describing reasons for a non-diagnostic biopsy,
and recoqnizing extra-uterine tissue. The next step is to evaluate our endometrial cancer reporting practices in comparison to the new
ISGyP recommendations to identify further opportunities for optimization. We recommend that other LMIC also perform similar
correlations as awareness of regional variations between LMIC may be of value in designing future international guidelines.

1166 Expression of B7-H4 and IDO1 is Associated with Drug Response and Prognosis of High Grade
Ovarian Serous Carcinoma
Na Niu1, Yanping Zhong1, Amir Jazaeri1, Anil Sood1, Jinsong Liu1
1
The University of Texas MD Anderson Cancer Center, Houston, TX

Disclosures: Na Niu: None; Yanping Zhong: None; Amir Jazaeri: Grant or Research Support, Iovance; Grant or Research Support,
AstraZeneca; Grant or Research Support, BMS; Grant or Research Support, Aravive; Grant or Research Support, Pfizer; Anil Sood:
None; Jinsong Liu: None

Background: High grade ovarian serous carcinoma (HGOSC) is the most lethal gynecologic malignancy. Immune checkpoint inhibitors
against PD-L1 and CTLA-4 have shown significant efficacy in multiple tumor types, however, the effectiveness of these drugs in treating
HGSOC has been limited. This is probably due to the intrinsic immune suppressive status of ovary and low expression of PD-L1 and
CTLA4 in HGOSC. Therefore, alternative targets or markers are needed to guide therapeutic strategies.

1114
Design: 24 drug (paclitaxel and carboplatin) sensitive and 24 resistant samples were selected from 660 archived HGSOC cases in
Department of Pathology in MDACC and clinical information was extracted. Nanostring including 33 immune-related genes was used to
determine the immune status between the sensitive and resistant groups. 4 genes of most significant difference in expression were
selected and verified further with multiplex immunohistochemical staining on 222 HGSC samples obtained from primary surgery between
2009 and 2015 at MDACC. The relationship between different checkpoint inhibitors and clinicopathologic features and the inter-variates
correlation were analyzed.

Results: Intrinsic drug resistant HGSOC samples had higher levels of B7-H4 and IDO1, in addition to inflammatory factors such as IL-6
and IL-8 (Figure 1). B7-H4 (68.5%) and IDO1 (71.6%) were diffusively expressed in tumor cells in HGSOC samples, respectively, and
their overexpression in tumor cells was associated with higher Tim3 positivity in stromal components, advanced pTNM stage and
significantly impaired overall survival and disease free survival (Figure 2), while the expression of PD-L1 (3.8%, locally) in tumor cells and
CTLA4 (2.2%, in stromal cells) is low and does not correlate with survival. Co-expression of B7-H4 and IDO1 was found in 49.1% studied
cases, suggesting their important role in immune suppressive microenvironment.

Figure 1 - 1166

Figure 2 - 1166

Conclusions: B7-H4 and IDO1 may present novel targets for immune therapy in ovarian cancer.

1115
1167 Comprehensive Genomic Characterization of Primary Ovarian Mucinous Carcinoma
Carlos Parra-Herran1, Sharon Nofech-Mozes1, Jasmina Uzunovic2, Fabien Lamaze2, Ilinca Lungu2, Carolyn Ptak2, Bernard
Lam2, Paul Krzyzanowski2, Aurelia Busca3, Dina Bassiouny1, Jane Bayani2, Philip Awadalla2,
John Bartlett2
1
Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, 2Ontario Institute for Cancer Research, Toronto,
ON, 3EORLA- University of Ottawa, Ottawa, ON

Disclosures: Carlos Parra-Herran: None; Sharon Nofech-Mozes: None; Jasmina Uzunovic: None; Fabien Lamaze: None; Ilinca Lungu:
None; Carolyn Ptak: None; Bernard Lam: None; Paul Krzyzanowski: None; Aurelia Busca: None; Dina Bassiouny: None; Jane Bayani:
None; Philip Awadalla: None; John Bartlett: Consultant, Insight Genetics, BioNTech AG, Biotheranostics, Pfizer, RNA Diagnostics,
OncoXChange; Grant or Research Support, Thermo Fisher Scientific, Genoptix, Agendia, NanoString Technologies, Stratifyer GmbH,
Biotheranostics

Background: Compared to other types of ovarian cancer, primary ovarian mucinous carcinoma (pOMC) is rare and underrepresented in
molecular ovarian cancer studies. Our main goal was to study the genetic profile of pOMC using next generation sequencing in order to
integrate this entity into our current molecular-based classification and pathogenesis models for ovarian cancer.

Design: Whole exome sequencing of tumor and normal tissue was performed in 40 cases with confirmed diagnosis of pOMC after
secondary review of archival material and clinical information (pre- and post-surgery) to exclude metastases. Patient outcome was
recorded. Through a multi-step bioinformatics approach, prevalent single nucleotide variations (SNVs), insertions and deletions (indels)
and affected pathways were identified.

Results: Median patient age was 54 years (range 17-86). Most cases were FIGO stage I (33, 82%) at presentation; remaining were stage
II (4, 10%) or III (3, 7%). A high spectrum of mutations was identified (Figure 1). Mutational burden was on average 94 mutations / case
(range 19-300). Prevalent mutations included KRAS (70%); TP53 (60%); FLG (15%); CDKN2A, TNN and MYO15A (12% each); RNF43,
RNF213 and POLE (10% each). KRAS and TP53 mutations coexisted in 14 (35%) lesions. A total of 311 genes, mutated in 2 or more
tumors, were used for pathway network analysis. Pathways recurrently affected included NCAM, cadherin and Wnt signaling, extracellular
matrix organization, DNA damage and Beta1 integrin cell surface interactions. Around 60% of the genes identified in these pathways are
known to be involved in oncogenesis. With a median follow-up of 40 months (mean 47, range 1-169), adverse events were documented
in 4 (10%) patients. None of the SNVs identified correlated with adverse outcome.

Figure 1 - 1167

1116
Conclusions: The mutational landscape of pOMC is heterogeneous, with predominance of KRAS and TP53 mutations as peviously
reported by other groups. Although no single mutation of oncogenic pathway was predominant in our sample, we identified several
alterations that can help elucidate the pathogenesis of pOMC and potentially separate this tumor from its mimickers. It provides a
rationale to examine the role of new targeted therapies against KRAS in advanced mutated pOMC. The prognostic and predictive role of
gene sequencing in this tumor type remains to be fully characterized.

1168 Immunohistochemical Predictors of Aggressive Endometrial Adenocarcinoma from Low Grade

Biopsy Specimens
Danielle Petty1, Omer Hassan1, Harrison Martin1, Antonio de las Morenas1
1
Wake Forest Baptist Medical Center, Winston-Salem, NC

Disclosures: Danielle Petty: None; Omer Hassan: None

Background: International Federation of Gynecology and Obstetrics (FIGO) grades for endometrial adenocarcinoma are based on %
solid tumor and are used along with measures such as myometrial invasion >50% for surgical planning (grade 3 or >50% invasion
generally undergo extensive pelvic and/or para-aortic lymph node dissection). Though a morbid procedure, thorough sampling provides
prognostic and therapeutic guidance. Low-grade biopsies lead to limited nodal sampling, though resection specimens sometimes reveal a
higher grade or more invasive lesion than anticipated. Quality predictors for aggressive lesions would improve patient care.

Increased immunohistochemical (IHC) human epididymis protein 4 (HE4) expression has been associated with increased clinical stage in
endometrial adenocarcinoma. High Ki67 is also generally associated with more aggressive neoplasms. We hypothesized these markers
would help predict high-grade processes for proper surgical intervention.

Design: Ten years of CoPath records were searched to identify FIGO graded endometrial biopsy specimens diagnosed as endometrioid
adenocarcinoma. Extent of myometrial invasion and biopsy and resection grades were recorded. Many biopsies were consult cases; as
such, obtainable cases that were upgraded and/or had >50% myometrial invasion were selected for the study group, and obtainable
cases that remained grade 1 with minimal invasion were controls. Biopsy slides for both groups were examined by 4 pathologists using
IHC for HE4 and Ki67. Membranous/cytoplasmic staining was considered positive for HE4; intensity was scored 1-5 (pale focal=1,
moderate focal=2, moderate diffuse=3, dark focal=4, dark diffuse=5). Ki67 was scored by % nuclear positivity in neoplastic cells.

Results: 301 H&E diagnoses of FIGO graded endometrial adenocarcinoma on biopsy with corresponding resection were identified. HE4
and Ki67 IHC for 13 controls and 13 study cases were scored as outlined. Of 138 cases that remained grade 1 on resection, 23 had
>50% myometrial invasion. Using univariate analysis of variance, increased HE4 staining was associated with a higher level of % invasion
(p=0.0008) and higher resection grade (p=0.036). Ki67 was similarly significant with p=0.023 for higher % invasion and p=0.015 for higher
resection grade.

Table 1. Biopsy and Resection FIGO Grades n (%)

Resection Grade
1 2 3
Biopsy 1 138 (46) 46(15) 6(2)
Grade 2 10(3) 62(21) 14(5)
3 0 1(0) 24(8)

Conclusions: Intensity of HE4 staining of endometrial glands and elevated Ki67 on endometrial biopsy specimens can aid in predicting
that a FIGO grade 1 endometrial adenocarcinoma may exhibit more aggressive features than anticipated.

1169 Nodal Metastasis Detection in Endometrial Carcinoma with Microcystic, Elongated, and
Fragmented Pattern is Markedly Increased by Cytokeratin Immunostaining
Kimmie Rabe1, Sayak Ghatak2, Irina Stout2, Britt Erickson2, Mahmoud Khalifa1
1
University of Minnesota - Twin Cities, Minneapolis, MN, 2University of Minnesota, Minneapolis, MN

Disclosures: Kimmie Rabe: None; Sayak Ghatak: None; Irina Stout: None; Irina Stout: None; Britt Erickson: None; Mahmoud Khalifa:
None

Background: While there is growing acceptance of sentinel lymph node biopsy in the staging and management of endometrial
carcinoma, there are currently no universal guidelines for processing and pathologic examination of lymph nodes in this setting. The
microcystic, elongated, and fragmented (MELF) pattern of myoinvasion in endometrial carcinoma has been associated with an increased
risk of lymph node metastasis. Our aim is to assess the need for cytokeratin immunohistochemical (IHC) stains in detecting nodal
metastasis, sentinel and non-sentinel, in the MELF setting with a focus on isolated tumor cells (ITCs).

1117
Design: From the 2009-2019 pathology database of our institution, we recovered 18 cases of FIGO grade 1 endometrial carcinoma with
a MELF pattern of myoinvasion. Three cases were excluded from the study since no lymphadenectomy was performed. A total of 15
hysterectomy specimens with lymphadenectomy, 3 sentinel, 1 sentinel and non-sentinel, and 11 non-sentinel, were identified. Lymph
nodes removed were pelvic and para-aortic. All H&E stained slides from lymph nodes were reviewed and negative nodes were subjected
to cytokeratin AE1/AE3 IHC stains. All cytokeratin-positive lymph nodes were subsequently stained for calretinin to exclude the possibility
of mesothelial inclusions.

Results: Of the 15 cases of endometrial carcinoma, 5 cases (33%) had positive lymph nodes based on H&E stained sections at the time
of their initial diagnosis. With the addition of IHC stains, 4 previously negative cases were found to have positive non-sentinel lymph
nodes. This included 3 cases with newly discovered ITCs and one case with ITCs and a micro-metastasis. Therefore, this cohort went
from 5/15 (33%) positive lymph nodes to 9/15 (60%) with the addition of IHC. Additionally, IHC staining revealed more areas of non-
sentinel metastases in 2 cases that were initially node-positive. In one of these patients, 3 additional micro-metastases were found.

Figure 1 - 1169

Conclusions: Cytokeratin IHC staining of lymph nodes is important since it nearly doubled the detection rate of lymph node metastases
in our sample of women with MELF pattern of myoinvasion. While we work toward accepted guidelines for lymph node sampling and
handling in endometrial carcinoma, immunohistochemical stains should be routinely performed on MELF positive cases in order to detect
occult lymph node metastases.

1170 ConCerv: A Prospective Trial of Conservative Surgery for Low-Risk Early Stage Cervical Cancer-
Assessment of Pathologic Parameters
Preetha Ramalingam1, Rene Pareja2, Aldo Lopez3, Jose Fregnani4, Andre Lopes5, Myriam Perrotta6, Audrey Tsunoda7, Lois
Ramondetta1, Tarinee Manchana8, David Crotzer9, Orla McNally10, Martin Riege11, Julian Di Guilmi12, Gabriel Rendon13, Bryan
Fellman1, Maria Delia Perez Montiel14, Jose Manuel Carvajal15, Giovanni Scambia16, Robert Coleman1, Kathleen Schmeler1
1
The University of Texas MD Anderson Cancer Center, Houston, TX, 2Clinica de Oncologia Astorga, Esmeraldal, Antioquia,
Colombia, 3Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru, 4A.C.Camargo Cancer Center, Liberdade, Sao Paulo,
Brazil, 5Instituto Brasileiro de Controle do Cancer, São Paulo, SP, Brazil, 6Hospital Italiano de Buenos Aires, Buenos Aires,
Argentina, 7Hospital Erasto Gaertner, Curitiba, PR, Brazil, 8Chulalongkorn University, Bangkok, Bangkok, Thailand, 9Nebraska
Methodist Hospital, Omaha, NE, 10Royal Women’s Hospital, Parkville, VIC, Australia, 11Instituto de Ginecologia, Rosario, Santa
Fe, Argentina, 12Hospital Britanico de Buenos Aires, Buenos Aires, Argentina, 13Instituto de Cancerologia, Medellin, Antioquia,
Colombia, 14Instituto Nacional de Cancerologia, Mexico City, DF, Mexico, 15General Hospital Doctor Alfredo Punarejo H.,
Matamoros, Tamaulipas, Mexico, 16Policlinico Gemelli, Rome, Italy

Disclosures: Preetha Ramalingam: None; Rene Pareja: None; Andre Lopes: None; Audrey Tsunoda: Speaker, Roche; Speaker, Astra
Zeneca; Tarinee Manchana: None; Gabriel Rendon: None; Bryan Fellman: None; Maria Delia Perez Montiel: None; Kathleen Schmeler:
None

Background: The standard of care for early stage cervical cancer is radical hysterectomy (RH) or radical trachelectomy (RT) in women
desiring future fertility. A multi-institutional study was performed to prospectively evaluate the safety, feasibility and oncologic outcomes of
conservative surgery in women with early stage cervical cancer. The aim of this analysis is to characterize the pathologic features by
central review of this cohort, and determine its impact on eligibility and outcomes.

1118
Design: A prospective, multicenter study evaluated conservative surgery (either cone or simple hysterectomy with lymph node (LN)
assessment) in 100 eligible women with FIGO (2009) stage IA2 or IB1 cervical cancer. Pathologic parameters that would result in
ineligibility include 1) high grade non-squamous cell carcinoma (SCC) or adenocarcinoma histology; 2) lymphovascular invasion (LVI); 3)
change in pathologic stage, 4) absence of invasive carcinoma. Initial pathology review was performed at participating sites with central
pathology review (CR) determining final eligibility.

Results: Of the 100 cases 48 were SCC and 52 were adenocarcinoma. Discrepancy in one or more pathologic parameters was noted in
45 cases (26%) of 169 enrolled patients (24 opted out for other reasons). Discrepancies altered eligibility in a subset of patients.
Histologic discrepancy (1 adenosquamous carcinoma; 1 mixed SCC and neuroendocrine carcinoma, 1 adenoid basal carcinoma (ABC)
and 5 CIN-3), and definite/suspicious for LVI (15 cases, 8%) made pts ineligible. 5 cases were downgraded from SCC (3 IB1, 1 1A1, 1
1A2, to CIN-3), 8 had pathologic stage downgraded to IA1 (5 from IB1 and 3 from IA2) and making pts. ineligible for study. 4 cases were
downgraded from 1B1 to 1A2 and 5 cases were upgraded from IA2 to IB1 but neither excluded eligibility.

Conclusions: Pathologic review is critical to determine eligibility for conservative surgery. CR altered eligibility of ~20% of the total cases
enrolled for conservative surgery in cervical cancer. The most important reasons for discrepancies of pathologic review from participating
centers and CR included 1) distinguishing LVI from retraction artifact, 2) identifying non-squamous histology or unusual tumors such as
ABC, and 3) overcalling CIN-3 involving endocervical glands as invasive carcinoma. Differences in measurement of horizontal extent due
to presence of CIN3 involving glands or AIS and/or depth of invasion did not affect eligibility.

1171 Next Generation Sequencing in Peritoneal versus Pleural Mesotheliomas-Commonalities and

Differences
Preetha Ramalingam1, Richard Yang1, Barrett Lawson1, Elizabeth Euscher1, Anais Malpica1
1
The University of Texas MD Anderson Cancer Center, Houston, TX

Disclosures: Preetha Ramalingam: None; Richard Yang: None; Barrett Lawson: None; Elizabeth Euscher: None; Anais Malpica: None

Background: Peritoneal and pleural mesotheliomas (MM) are typically high grade malignancies with tendency for poor outcomes. In the
current targeted therapy era, few molecular targets have thus far been identified in these tumors. The aim of this study is to elucidate the
spectrum of molecular changes in a cohort of pleural and peritoneal MM with emphasis on differences in these two patient populations
and correlation with outcomes.

Design: 70 cases of pleural (37) and peritoneal (33) MM, who had molecular testing were identified (2008 to 2019). All cases were
confirmed by immunohistochemical staining at the time of original diagnosis. The following data was collected: patient (pt) age, gender,
histologic subtype, next generation sequencing (141 gene Oncomine AmpliSeq panel) and outcome. Follow up was available in 68 pts.
Kaplan Meier curves and Fisher’s exact tests were performed in GraphPad Prism v8.1.2.

Results: Pleural MM: 26 (70%) male (M) and 11 (30%) female (F); mean age at presentation (AAP) 67yrs (range, 26-84). Peritoneal MM:
20 F (60%), 13 (40%) M; AAP 55 yrs (range, 3-77). 56 were epithelioid MM (80%), 9 sarcomatoid (13%) and 5 (7%) biphasic. Molecular
alterations (MA) in pleural MM: NF2 16/37 (43%), TP53 12/37 (32%), BAP1 11/37(30%), miscellaneous (FANCD2, SETD2, SF3B1,
FANC1 FGFR1, NOTCH3M ERBB4, FBXW7) 14/37(38%), no mutations (muts) 7/37 (19%); 67% of pts. with no muts. died of disease
(DOD) and 50% of pts. with muts. DOD. 50% of F pts. DOD in 5 yrs. compared to 54% of M pts. Pleural pts showed higher rates of NF2
muts. (p<0.0001). MAs in peritoneal MM: no muts. 19/33 (58%); TP53 4/33 (12%), BAP1 4/33(12%), NF2 0/33 (0%), miscellaneous (VHL,
CSF1R, MAX, PIK3CS, FGFR3, MET, MDM2, TET2); 14/37(38%). Only 21% of pts. without muts. DOD, however, 69% of pts. with muts
DOD. 32% of F pts. DOD within 5 yrs. compared to 46% of M pts. Peritoneal MM had improved overall (OS) (p=0.0084) and disease free
survival (DFS) (p=0.0006).

Characteristics Pleural Peritoneal

Number of cases N=37 N=33
Age, mean (range) 67 (26-84) 55 (3-77)
Male: Female 2.36:1 1.53:1
No mutation 7 (19%) 19 (58%)
NF2 16 (43%) 0 (0%)
TP53 12 (32%) 4 (12%)
BAP1 11 (30%) 4 (12%)
Misc. mutations 14 (38%) 8 (24%)
>1 mutation 13 (35%) 3 (9%)
Dead of Disease with 50% 69%
mutations
Dead of Disease 67% 21%
without mutations

1119
 Figure 1 - 1171

Figure 2 - 1171

Conclusions: NGS testing showed important difference between pleural and peritoneal MM. Pleural MM has a high frequency of somatic
muts. with NF2 being the most common; however, there was no association of mut. status with clinical outcome. In contrast peritoneal
MM has a much lower mut. rate however, pts. with muts. are more likely to DOD within 5yrs. Pleural MM have worse OS and DFS
compared to peritoneal MM, independent of mut. status. There appears to be no significant gender differences in either pleural or
peritoneal MM.

1172 Evaluation of HPV RNA In-Situ Hybridization (ISH) and p16 Immunohistochemistry (IHC)
Concordance in Endocervical Adenocarcinomas
Hezhen Ren1, Jennifer Pors2, Christine Chow3, Monica Ta3, Simona Stolnicu4, Robert Soslow5, David Huntsman6, C. Blake
Gilks7, Lynn Hoang1
1
University of British Columbia, Vancouver, BC, 2Vancouver, BC, 3Genetic Pathology Evaluation Centre, Vancouver,
BC, 4University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Mures, Romania, 5Memorial Sloan Kettering
Cancer Center, New York, NY, 6British Columbia Cancer Research Institute, Vancouver, BC, 7Vancouver General Hospital,
Vancouver, BC

Disclosures: Hezhen Ren: None; Jennifer Pors: None; Christine Chow: None; Monica Ta: None; Simona Stolnicu: None; Robert
Soslow: Speaker, Ebix/Oakstone; David Huntsman: None; C. Blake Gilks: None; Lynn Hoang: None

Background: The concordance between high-risk human papillomavirus (HR-HPV) infection and p16 (a cyclin dependent kinase inhibitor
and surrogate biomarker for HR-HPV) has been well-documented in squamous neoplasms of the uterine cervix and head and neck. Few
studies, however, have assessed the concordance in glandular neoplasms of the uterine cervix. Recent studies have shown 5 cases of

1120
p16 positive gastric-type cervical adenocarcinomas but most were HPV negative by DNA testing. Therefore, the study aims to examine
the concordance of p16 with HPV RNA ISH in endocervical adenocarcinoma, including a larger set of gastric-type.

Design: p16 and HPV-ISH concordance was assessed in endocervical adenocarcinomas using a tissue microarray, and equivocal
staining was repeated using whole sections. p16 IHC was scored as positive if there was diffuse, strong cytoplasmic and nuclear staining.
HPV RNA in-situ hybridization was performed using ACD RNAscope and scored positive if there was dot-like nuclear staining.

Results: We included 113 endocervical adenocarcinomas, grouped by the IECC: 94 HPVA (HPV-associated) cases (63 usual-type, 4
intestinal, 4 villoglandular, 1 iSMILE, 22 mucinous NOS), 18 NHPVA (non-HPV-associated) cases (9 gastric, 4 minimal deviation,
5 mesonephric), and 1 adenocarcinoma NOS. p16-HPV-ISH was concordant in 107 (95%) cases and histotype was concordant with HPV
status in 100 (88%) cases. In the discordant cases, 5 were initially diagnosed as HPVA mucinous NOS by morphology, but were
p16+/HPV- or p16-/HPV- and therefore re-classified as NHPVA mucinous NOS. On review, these cases did not exhibit classic features of
HPVA (i.e. apical mitoses, apoptotic bodies). 1 other case was initially diagnosed as NHPVA gastric but was p16+/HPV+. Histology of this
case showed hybrid features and it was re-classified as HPVA mucinous NOS. 3 cases of NHPVA gastric-type had equivocal HPV-ISH
(exhibited odd background stromal staining), and p16 was negative in 1 and patchy in 2. These 3 cases were likely HPV negative (HPV-
PCR pending). 5 HPVA were p16-/HPV-, despite classic HPV histology.

Number of Cases IECC Classification

P16+/HPV+ 87 86 HPVA 61 Usual-type
(concordant) 3 Mucinous, intestinal-type
17 Mucinous NOS
4 Villoglandular
1 iSMILE
1 NHPVA 1 Gastric
P16-/HPV- 20 5 HPVA 2 Usual-type
(concordant) 1 Mucinous, intestinal-type
2 Mucinous NOS
14 NHPVA 5 Gastric-type
5 Mesonephric
4 Minimal deviation
1 Adenocarcinoma NOS
P16+/HPV- 3 3 HPVA 3 Mucinous NOS
(discordant)
P16-/HPV+* 3 3 NHPVA 3 Gastric-type
(discordant)
Excluded 16 12 Post-treatment
1 Metastasis
2 Adenosquamous
1 Technical/Missing
Total 129 (113 included)
*Odd background staining, likely HPV negative by PCR

Conclusions: Most p16-ISH and histotype-HPV discordant cases were mucinous (mucinous NOS and gastric-types). In HPVA and
NHPVA mucinous cases, pathologists should exercise caution in looking for classic HPV-related histologic features. Ambiguous cases
may warrant referral for HPV-ISH or PCR (in equivocal HPV-ISH cases, such as gastric-types). Histology alone accurately predicts IECC
group in 100/113 (88%) of cases.

1173 International Endocervical Adenocarcinoma Criteria and Classification (IECC): An Independent

Cohort with Clinical and Molecular Relevance
Hezhen Ren1, Noorah Almadani2, Jennifer Pors2, Julie Ho3, Christine Chow4, Kay Park5, Simona Stolnicu6, Robert Soslow5,
David Huntsman7, C. Blake Gilks8, Lynn Hoang1
1
University of British Columbia, Vancouver, BC, 2Vancouver, BC, 3Vancouver Coastal Health, Vancouver, BC, 4Genetic
Pathology Evaluation Centre, Vancouver, BC, 5Memorial Sloan Kettering Cancer Center, New York, NY, 6University of Medicine,
Pharmacy, Sciences and Technology, Targu Mures, Mures, Romania, 7British Columbia Cancer Research Institute, Vancouver,
BC, 8Vancouver General Hospital, Vancouver, BC

Disclosures: Hezhen Ren: None; Noorah Almadani: None; Jennifer Pors: None; Julie Ho: None; Christine Chow: None; Kay Park: None;
Simona Stolnicu: None; Robert Soslow: Speaker, Ebix/Oakstone; David Huntsman: None; C. Blake Gilks: None; Lynn Hoang: None

Background: The IECC was a multi-institutional collaborative effort published in 2018 to provide a morphologic, etiologic (HPV-status)
and clinically meaningful classification framework for endocervical adenocarcinomas. In this study, we re-examine the IECC using an
independent cohort of cases and provide further molecular insights using targeted next generation sequencing (NGS).

1121
Design: Consecutive cases of endocervical adenocarcinomas were collected from a single institution and classified into the IECC
categories using morphologic, p16 immunohistochemistry (IHC) and HPV in-situ hybridization (ISH) data. Clinical information was
collected and NGS was performed encompassing 33 known cancer genes.

Results: We included a total of 112 cases, 90 HPVA (HPV-associated: 64 usual, 4 intestinal, 4 villoglandular, 1 iSMILE, 17 mucinous
NOS) and 22 NHPVA (non-HPV-associated: 12 gastric/minimal deviation, 5 mesonephric, 5 mucinous NOS). Patients in the NHPVA
group had worse progression free survival (PFS, HR: 10.86; p<0.001) and worse overall survival (OS, HR: 14.65; p<0.001), compared to
the HPVA group (Figures 1 and 2). 71 cases had sufficient tissue for NGS. The HPVA group had a higher number of somatic mutations
(29/55, 53%) compared to the NHPVA (6/16, 38%). STK11 was unique to the NHPVA group, while PIK3CA and GNAS were confined to
the HPVA group. NHPVA had more frequent TP53 mutations. KRAS and PIK3CA were not identified in any of the gastric/minimal
deviation carcinomas. ERBB2 was seen in a minor portion of HPVA and NHPVA, which may have therapeutic implications.

IECC Subtype KRAS PIK3CA TP53 GNAS ERBB2 STK11 BRAF MET AKT1 ROS1 IDH2
HPVA Usual (n=40) 10* 10* 2 5 2* 1 3 1 1 1
(n=91) (25%) (25%) (5%) (13%) (5%) (3%) (8%) (3%) (3%) (3%)
Intestinal 1
(n=2) (50%)
Villo-glandular 2 1 1 1
(n=4) (50%) (25%) (25%) (25%)
Mucinous 1 2
NOS (n=9) (11%) (22%)
NHPVA Gastric/ 2 1 1
(n=19) Minimal (20%) (10%) (10%)
Deviation
(n=10)
Mesonephric 1 2
(n=5) (20%) (40%)
Mucinous
NOS
(n=1)
*One case had multiple mutations in the same gene
Figure 1 - 1173

Figure 2 - 1173

Conclusions: Our study reconfirms the clinical relevance of the IECC framework, with NHPVA tumors having worse OS and PFS
compared to the HPVA. While the molecular landscape of the HPVA and NHPVA did mostly overlap, there were some differences: HPVA

1122
had a higher number of somatic mutations, STK11 mutations were confined to NHPVA, PIK3CA and GNAS were confined to
HPVA. While KRAS mutations are common in mucinous carcinomas in general, our limited number of NHPVA gastric types did not
harbor KRAS mutations.

1174 SATB2 Overexpression in a Subset of High-Grade Endometrial Stromal Sarcomas

Armando Reques1, Ursula Acosta2, Luisa Sofía Silva Alcoser1, Ana Aula Olivar3, Santiago Ramon Y Cajal1, Ángel García1,
Josep Castellvi1
1
Vall d'Hebron University Hospital, Barcelona, Spain, 2Hospital Universitari Vall d'Hebron, Barcelona, Spain, 3Vall d'Hebron
University Hospital (HUVH), Barcelona, Spain

Disclosures: Armando Reques: None; Ursula Acosta: None; Luisa Sofía Silva Alcoser: None; Ana Aula Olivar: None; Santiago Ramon Y
Cajal: None; Ángel García: None; Josep Castellvi: None

Background: Endometrial stromal sarcoma (ESS) accounts for <10% of uterine sarcomas. Nowadays, it can be classified according to
the degree of differentiation in two grades: low grade (LG-ESS) and high grade (HG-ESS). In some high-grade cases it is not possible to
demonstrate its differentiation and are classified as undifferentiated uterine sarcoma (UUS). The identification of molecular alterations is
fundamental in the classification of sarcomas including ESS. Rearrangements of BCOR fusions have been identified in some types of
sarcomas such as small round cell tumors, and classify ESS in a specific subtype. In the same way, SATB2 detection is useful for
classification of some sarcomas and its overexpression correlates with BCOR in some of them.

Design: We have reviewed 37 consecutive cases of ESS diagnosed in our hospital between 2001 and 2019, and tissue microarrays were
constructed. The grade of the ESS, lymphovascular invasion, lymph node metastasis, the presence of recurrences and the survival time
were recorded. Immunohistochemistry for CD10, cyclin D1, SATB2 and BCOR was performed.

Results: In our series, we found 19 LG-ESS (51%), 4 of them showed endometrioid-type glands, and 18 HG-ESS (49%). In the
immunohistochemical study, 3 HG-ESS cases showed BCOR nuclear overexpression (16%) and 5 HG-ESS cases (28%) had SATB2
nuclear expression [Figure 1]. None of these SATB2 positive cases showed overexpression of BCOR, but in 4 of them, cytoplasmic
expression of BCOR was observed. None of the LG-ESS cases, showed BCOR or SATB2 expression. Aside from the relation with BCOR
and SATB2 expression with high-grade ESS, we have not found any correlation with other clinico-pathological features.

Figure 1 - 1174

Conclusions: We have identified a subgroup of high-grade ESS with SATB2 expression that has not been described previously, and it
accounts for the 28% of cases in our series. Interestingly, we have found no correlation with BCOR expression and, surprisingly, a BCOR
cytoplasmic immunoreactivity was observed in these cases, that it has not been described previously. More studies are needed to
elucidate the clinical and prognostic relevance of this subgroup of ESS.

1123
1175 Digital Quantification of PHH3 and KI-67 in Characterization of Uterine Smooth Muscle Tumors
Jesus Rico Castillo1, Joanna Chan1, Dan DeCotiis2, Connie Cao1
1
Thomas Jefferson University Hospital, Philadelphia, PA, 2Einstein Medical Center

Disclosures: Jesus Rico Castillo: None; Joanna Chan: None

Background: Uterine smooth muscle tumors (USMT) are the most common lesion of the female genital tract and occur in nearly 40% of
women older than 35 years of age. USMT are classified as leiomyosarcoma (LS), smooth muscle tumors of uncertain significance
(STUMP), symplastic leiomyoma (SYM) or benign leiomyoma (LM) based on atypia, necrosis, and mitotic count. Visual assessment of
mitotic count is time consuming and subject to misinterpretation. In this study we correlate classification of USMT and mitotic count to
digital quantification of mitosis specific marker PHH-3 and proliferation marker KI-67.

Design: 17 LMS, 5 STUMP, 8 SYM, 2 atypical leiomyoma (AL) and 7 LM were reviewed. 50 high powered fields (5mm2) were visually
analyzed for mitotic count (MC). Standard staining for PHH3 and Ki-67 was done on one section from each case. Three 65mm2 areas
were selected for digital analysis of PHH3 and Ki-67 in each case. The PHH3 and Ki-67 counts were correlated to each other, to MC, and
to the diagnosis. Data was analyzed with R statistical programing language. Correlation analysis was done using Pearson correlation
tests, group analysis was done using one way ANOVA.

Results: Digital quantification of PHH3 is significantly different between LMS compared to STUMP and SYM (p=0.006). Digital
quantification of Ki-67 is significantly different between LMS, STUMP, SYM, and LM (p<0.01). Using ROC curves, KI-67 is a more
sensitive and specific discriminator than MC. There is no statistically significant correlation between MC and PHH3 or between MC and
Ki-67. On a total sample basis, there is also no significant correlation between digital quantification of PHH3 and Ki67.

Conclusions: Accurate assessment of proliferation is crucial in diagnosis of USMT. Visual analysis of mitotic index is time consuming
and subjective. Fast, objective measurement of proliferation can be done using digital quantification of proliferation markers such as
PHH3 and Ki-67. This study suggests that digital quantification with PHH3 or Ki-67 may be a viable alternative to visual assessment of
counting mitoses. Visual analysis of mitotic figures and digital quantification with Ki-67 can discriminate between all classifications of
USMTs, however digital quantification of KI-67 is more sensitive and specific. Digital quantification of PHH3 can reliably detect LMS
compared to other USMT with atypia such as STUMP and SYM. Further studies include correlating digital quantification of PHH-3 and Ki-
67 with clinical outcomes.

1176 Associations between Patterns of Intraluminal Tumor Cell Involvement in SEE-FIM Examined
Tubes and Endometrial Carcinoma Characteristics and Outcomes
Monica Rodriguez1, Ashley Felix2, Mary Anne Brett3, Goli Samimi4, Mark Sherman5, Maire Duggan3
1
Cumming School of Medicine, University of Calgary, Calgary, AB, 2The Ohio State University, Columbus, OH, 3University of
Calgary, Calgary, AB, 4National Cancer Institute, Bethesda, MD, 5Mayo Clinic, Jacksonville, FL

Disclosures: Monica Rodriguez: None; Mary Anne Brett: None; Maire Duggan: None

Background: Endometrial carcinoma cells in the fallopian tube lumen (Intraluminal Tumor Cells-ILTCs) are associated with non-
endometrioid histotypes and higher stage. In the absence of mural invasion (FIGO stage 3A), their prognostic role is controversial. The
impact of SEE-FIM examination on the detection of ILTCs and associations with clinico-pathological features and outcomes are
unknown.

Design: Glass slides of tubes from 50 non-endometrioid and 222 endometrioid carcinomas were independently reviewed by 2
pathologists to categorize ILTCs as; 1) floating in the lumen, 2) attached to the mucosa, 3) size, 4) stroma present, and 5) mural invasion.
Disagreements were reviewed by a third pathologist and final status was based on agreement between any 2. Clinical, pathological, and
outcome variables were extracted from the cancer centre data base. Chi-square tests compared characteristics of women stratified by
ILTC categories (floating vs. attached to the mucosa). Significant variables (p<0.05) were included in a multivariable logistic regression
model. Kaplan–Meier estimates and log-rank tests compared survival distributions according to ILTCs. Cox proportional regression
estimated multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).

Results: ILTCs were present in 56 (15.1%); 55 floating, 24 attached to the mucosa, 36 had more than 50 cells, 24 had stroma, and 35
(62.5%) had mural invasion. ILTCs floating in the lumen or attached to the mucosa were non-significantly more common among women
age > 55 years, and being overweight or obese. Detection of carcinoma cells in tubes was significantly associated with FIGO stage 3/4,
LVI, myometrial invasion of 50% or more, and a non-endometrioid histotype. Of 345 women with follow-up, 34 (9.8%) died of their
disease. Identification of ILTCs was non-significantly associated with higher mortality {HR1.64 (95% CI= 0.74-3.63)} and the association
was further attenuated when adjusted for stage and histotype. There was insufficient data to analyze outcome by category of ILTCs.

Conclusions: Approximately 15% of SEE-FIM examined tubes demonstrated ILTCs and similar to other studies, ILTCs were associated
with higher stage and non-endometrioid histotypes. A prognostic effect independent of stage and histotype was not found in this limited
dataset. Analysis of larger series is needed to more definitively assess whether ILTCs are an independent prognostic factor.

1124
1177 A First and Second Line Marker Panel for the Distinction of Clear Cell from Endometrioid
Carcinoma of the Ovary: Implications for Mismatch Repair Deficiency Testing
Monica Rodriguez1, Jonathan Slack2, Martin Kobel3
1
Cumming School of Medicine, University of Calgary, Calgary, AB, 2Alberta Health Services, Calgary, AB, 3University of
Calgary/Alberta Public Laboratories, Calgary, AB

Disclosures: Monica Rodriguez: None; Jonathan Slack: None; Martin Kobel: None

Background: Distinction between ovarian clear cell carcinoma (CCC) and endometrioid carcinoma (EC) is critical because CCCs have
poor response to platinum-based therapies and ECs are universally screened for Lynch syndrome. Recent studies have identified
problems with reproducibility in cases with ambiguous morphology. Our goal was to establish an efficient and accurate
immunohistochemical (IHC) panel for the distinction of CCC from EC.

Design: Cases with a confirmed diagnosis of EC (N=183) or CCC (N=164), each represented by 3 cores in four tissue microarrays
(TMAs), were obtained from the Alberta Ovarian Tumor Type (AOVT) tumor bank. From the literature, we identified 8 markers with
discriminatory potential. IHC expression was categorized dichotomously (absent vs. present); except for HNF1B (>50% moderate
intensity), and CTNNB1 (only nuclear staining was considered positive). Nominal logistic regression modeling (NLMR), hierarchical
clustering and recursive partitioning were used to evaluate marker combinations.

Results: Using NMLR, 5 markers (HNF1B, PR, Napsin A, CDX2, and AMCAR) contributed significantly to the prediction with an area
under the curve of 0.995, correctly classifying 95% of cases. Using the top 3 markers (HNF1B, PR, Napsin A), supervised hierarchical
clustering of the 8 possible combinations demonstrated that the 2 prototypical combinations, combined accounting for 76% of total cases,
were 100% accurate in predicting either CCC (Napsin A present, HNF1B diffuse, PR absent, N=132, 38%) or EC (Napsin A absent,
HNF1B non-diffuse, PR present, N=129, 38%). The remaining 83 cases (24% of total), had equivocal IHC combinations and as such
required additional workup. Recursive partitioning in this group was further able to correctly classify 69/83 cases using the hormone
response marker KIAA1324, CDX2 and AMACR. Mismatch repair deficiency (MMRd) was lower in cases of CCC with a prototypical IHC
profile (2%) than in prototypical EC (12%) or cases with equivocal immunohistochemistry (13%).

CCC N=163 EC N=183 Difference

PR present 6.1% 86.8% 80.7%
Napsin A present 92.1% 11.5% 80.6%
HNF1B diffuse 92.7% 13.3% 79.4%
KIAA1324 present 14.2% 89.4%% 75.2%
ER present 15.4% 87.4% 72%
CDX2 present 3.7% 56.4% 52.7%
CTNNB1 nuclear 1.2% 46.5% 45.3%
AMCAR present 83.3% 42.2% 41.1%

Conclusions: A first line panel consisting of Napsin A, HNF1B, and PR can accurately distinguish CCC and EC in three-quarters of
cases. The remaining equivocal combinations required additional, second-line biomarkers. MMR deficiency in prototypical CCC is low;
universal testing is not warranted. However, carcinomas with non-prototypical Napsin A, HNF1B and PR combinations had a similar rate
of MMR deficiency as prototypical EC, and should also be tested for Lynch syndrome.

1178 Ovarian Clear Cell Carcinoma: Analysis of POLE Mutations, p53 and DNA Mismatch Repair
Protein Expression
Juan Rong1, Charles Quick2, Krisztina Hanley3, Farnaz Hasteh1, Somaye Zare1, John Thorson1, Oluwole Fadare1
1
University of California San Diego, La Jolla, CA, 2University of Arkansas for Medical Sciences, Little Rock, AR, 3Emory
University, Atlanta, GA

Disclosures: Juan Rong: None; Charles Quick: None; Krisztina Hanley: None; Farnaz Hasteh: None; Somaye Zare: None; John
Thorson: None; Oluwole Fadare: None

Background: The Cancer Genome Atlas (TCGA) molecular classification of endometrial carcinoma has provided a valuable framework
for prognosticating patients with endometrial cancers, and may ultimately direct management. The aim of this study is to determine, using
a TCGA surrogate classifier, whether TCGA-like subgroups are discernible in ovarian clear cell carcinoma (OCCC).

Design: 47 archived cases of OCCC were retrieved from three institutions. Cases were required to show characteristic morphology as
well as Napsin A immunoreactivity. Representative formalin-fixed paraffin-embedded blocks that harbored at least a 40% tumor load were
selected for DNA extraction. PCR for POLE exons 9 and 13, which cover the hotspot mutations (P286R and V411L) in endometrial
carcinoma, was performed; PCR amplicons were confirmed by gel electrophoresis, followed by direct Sanger
sequencing. Immunohistochemical studies for p53, MSH6, MSH2, MLH1 and PMS2 were performed on the corresponding sections.

1125
Results: The mean age at diagnosis for the 47 patients was 55 years (range: 31 to 84 years, median 55 years). 49% had accompanying
endometriosis. Mean tumor size at excision was 12 cm (range: 1-25). 26, 3 and 18 cases were FIGO stage I, II and III respectively. None
of the 30 cases wherein POLE sequencing was completed demonstrated mutations in exon 9 or 13. A single nucleotide variance
(rs56367014) with no known functional significance was detected in one case. None of the 47 cases showed loss of MSH6 or
MSH2 expression; one case showed loss of PMS2 and MLH1 expression. This case was p53-wild type. A p53 mutation-type staining
pattern was present in 6 (12.8 %) cases (4 null and 2 overexpression). At a mean follow-up of 44 months (range: 0-181, median 31 mo),
both p53 mutation-type staining and FIGO stage were significantly associated with worse overall survival on multivariate analysis (Cox
regression: p53, p=0.025; Stage I vs II/III, p=0.007).

Conclusions: In this cohort of OCCC, we identified no case with a hotspot POLE mutation, and the group showed a low (2.1%)
frequency of DNA MMR deficiency. p53 mutation-type staining was found in 12.8% and may be of adverse prognostic significance.
Therefore, the full quartet of TCGA-like molecular subclasses of endometrial carcinoma are not present in OCCC, and surrogate
classifiers may not be ideally applicable to this histotype. Future studies may help to define whether the improved prognostication in
OCCC is achieved by simply subclassifying them based on p53 status.

1179 Does Specimen Type Have an Impact on HER2 Status in Endometrial Serous Carcinoma?
Douglas Rottmann1, Nana Matsumoto2, Hisham Assem3, Serena Wong2, Pei Hui4, Natalia Buza4
1
Yale School of Medicine, Hamden, CT, 2Yale New Haven Hospital, New Haven, CT, 3Yale School of Medicine, New Haven,
CT, 4Yale University School of Medicine, New Haven, CT

Disclosures: Douglas Rottmann: None; Nana Matsumoto: None; Hisham Assem: None; Serena Wong: None; Pei Hui: None; Natalia
Buza: None

Background: A recent clinical trial showed prolonged progression-free survival in HER2-overexpressing endometrial serous carcinomas
(ESC) when trastuzumab was added to traditional cisplatin-based chemotherapy. Approximately one third of ESC are HER2 positive, and
recent studies identified significant intratumoral heterogeneity of HER2 overexpression and/or amplification in over 50% of HER2 positive
cases. We aimed to evaluate the concordance of HER2 status between endometrial curettage and subsequent hysterectomy specimens
in ESC.

Design: Patients diagnosed with ESC between 2014-2018 at our institution with available tumor tissue from endometrial curettage and
hysterectomy specimens were included. H&E slides were reviewed to confirm the diagnosis and select representative tissue blocks.
HER2 immunohistochemistry (IHC) (EP3 clone) was performed on a selected block from both specimen types in each case. HER2 FISH
has been evaluated on a subset of cases. HER2 immunostaining was evaluated for intratumoral heterogeneity and HER2 scores were
assigned using a modified version of the 2007 ASCO/CAP breast cancer guidelines. The HER2 immunohistochemical score and HER2
status were compared between the two specimen types.

Results: A total of 42 cases were included in the final analysis. Fourteen cases (14/42, 33%) were HER2 positive on the hysterectomy,
including eight cases of 3+ IHC and six cases with 2+ IHC and amplification on FISH. The HER2 status of the curettage and hysterectomy
was concordant (both HER2 positive or negative) in 95% of cases (40/42), with identical HER2 IHC scores in 64% (27/42) of tumors. The
two cases with discordant HER2 status were both positive on the curettage (3+ IHC, and 2+ IHC with FISH amplification) and negative on
the hysterectomies (1+ IHC in both cases). Intratumoral heterogeneity of HER2 staining was appreciated in 10 tumors (23%), including
one of the two discordant cases.

HER2 IHC Score Curettage/Biopsy (n=42) Hysterectomy (n=42)

0 7 6
1+ 8 15
2+ 18 13 (6 FISH amplified)
3+ 9 8

Table. HER2 IHC of biopsy/curettage and hysterectomy specimens.

Conclusions: The concordance rate of HER2 status between the two specimen types of ESC is high (95%). All discordant cases in our
cohort were HER2 positive on endometrial curettage and HER2 negative on hysterectomy, while no reverse change in HER2 status was
noted. Given the frequent heterogeneity of HER2 expression in ESC, the potential for a spatially more heterogeneous sampling of
endometrial cavity in curettage may provide a possible explanation for our findings. HER2 testing of ESC performed on endometrial
curettage may help identify a greater proportion of patients eligible for trastuzumab therapy.

1126
1180 Molecular Landscape of HPV Negative Vulvar Squamous Cell Carcinoma including NOTCH
Alterations
Abeer Salama1, Amir Momeni Boroujeni2, Chad Vanderbilt3, Robert Soslow1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2Memorial Sloan Kettering Cancer Center, Brooklyn, NY, 3Memorial
Sloan Kettering Cancer Center, Denver, CO

Disclosures: Abeer Salama: None; Amir Momeni Boroujeni: None; Chad Vanderbilt: Consultant, Docdoc. ltd. (Singapore); Consultant,
Paige AI; Chad Vanderbilt: Consultant, Docdoc. ltd. (Singapore); Consultant, Paige AI; Consultant, OncoKB; Robert Soslow: Speaker,
Ebix/Oakstone

Background: Vulvar squamous cell carcinoma can be HPV driven or alternatively can occur independently of HPV (HPV Neg VSCC) and
in the setting of differentiated vulvar intraepithelial carcinoma. The latter often harbors TP53 mutations, however, there is only limited
information about other molecular alterations. The aim of this study is to characterize the molecular landscape of HPV Neg VSCC.

Design: All HPV Neg VSCC cases from a single institution that underwent targeted hybrid capture next generation sequencing panel
were evaluated; HPV status was determined using mRNA ISH for high risk HPV as well as bioinformatically through off-target capture
DNA sequenced by the NGS panel. Clinicopathologic data were evaluated.

Results: 14 HPV Neg VSCC cases were sequenced. The most common genomic alterations were TP53 mutations (93%, n=13), TERT
promoter mutations (85.7%, n=12), NOTCH pathway alterations (71%, n=9), CDKN2A (deep deletion or mutation) (50%, n=7), FAT1
mutations (43%, n=6), JAK3 (21%, n=3), and PIK3CA mutations (14%, n=2). 11q gain was also seen (2 cases) but only in the setting of
NOTCH alterations. All patients suffered a recurrence. Overall survival was adversely affected by NOTCH alterations (P value 0.04), even
in the setting of FIGO stage I disease.

Figure 1 - 1180

Conclusions: HPV Neg VSCC tumorogenesis differs from HPV driven vulvar squamous cell carcinomas with TP53 and TERT alterations
being the main drivers. However, it appears NOTCH pathway alterations play an important role in tumor progression with tumors
harboring these alterations having worse clinical outcomes. This is a novel finding.

1127
1181 Clinicopathologic Analysis of Necrosis in Ovarian Fibromas: Frequency, Pathology, and
Clinical Outcomes
Christine Salibay1, Somaye Zare2, Oluwole Fadare2
1
University of California San Diego Health, La Jolla, CA, 2University of California San Diego, La Jolla, CA

Disclosures: Christine Salibay: None; Somaye Zare: None; Oluwole Fadare: None

Background: Most fibromas of the ovary display characteristic macroscopic and morphologic features, and accordingly pose minimal to
no diagnostic difficulty. However, we have encountered occasional fibromas that display necrosis, with associated alterations that deviate
from the typical appearances of the neoplasm. In this study, we report findings from an institutional review of necrosis in ovarian
fibromas.

Design: A review of clinicopathologic records was performed on 95 fibromatous ovarian neoplasms, including 75 ovarian fibromas, 15
fibrothecomas, 4 cellular fibromas, and 1 mitotically active cellular fibroma (MACF). Clinical and pathologic data were collected from
cases showing necrosis of any extent or type.

Results: Necrosis was identified in 15% (14/95) of all cases, including 13%(10/75) of typical fibromas. Infarcted and non-infarcted
fibromas showed no significant differences in patient age and tumor size. Torsion was clinically suspected in 2%. Grossly, the cut
surfaces of infarcted fibromas were described as solid (93%), pedunculated (29%), cystic (43%), white or yellow (64%) and reddish
(14%). As determined microscopically, the proportion of tumor that was necrotic ranged from 12 to 97% (mean 54.6%). Necrotic zones
showed complete devitalization of tumor cells and lesional vessels (7%), “ghost” outlines of tumor cells (21%) or both. The demarcation
between the necrotic and viable areas were sharp (14%), indistinct (57%) or in some tumors, both. The areas adjacent to necrosis
showed no increased mitotic activity, and infarcted fibromas as a group were no more mitotically active than non-infarcted fibromas. None
showed cytologic atypia. Other common features in infarcted fibromas include edema (72.2%), hemorrhage (55.6%), hemosiderin
(72.2%), calcifications (66.7%), hyalinization (66.7%), and histiocytic aggregates (33.3%). Only 2 cases showed coagulative necrosis of
the type that is characteristic of malignant smooth muscle neoplasia: one fibrothecoma [associated with Meigs syndrome] and a MACF.
None of the patients with follow-up have experienced a recurrence.

Conclusions: A subset of otherwise typical fibromas show necrosis. Although the necrosis may distort the gross and microscopic
appearances of fibromas, they typically retain their characteristic features in the viable areas. Awareness of the potential for fibromas to
display necrosis may prevent their misclassification as "atypical" or even malignant, especially during intraoperative assessments.

1182 Expression of Immune Checkpoint Regulators, Cytotoxic T Lymphocyte Antigen 4 (CTLA-4),

Programmed Death-Ligand 1 (PD-1/PD-L1), and Indolaimine-2, 3-Deoxygenase (IDO) in Uterine
Mesenchymal Tumors
Alireza Samiei1, Itsushi Shintaku2, Jennifer Katzenberg3, Neda Moatamed4
1
Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 2University of
California Los Angeles, Los Angeles, CA, 3San Diego, CA, 4David Geffen School of Medicine at UCLA, Los Angeles, CA

Disclosures: Alireza Samiei: None; Itsushi Shintaku: None; Jennifer Katzenberg: None; Neda Moatamed: None

Background: Immune checkpoint inhibitors such as cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed death 1/ programmed
death-ligand 1 (PD-1/PD-L1), in combination with the immunosuppressive molecule indolaimine-2, 3-deoxygenase (IDO), have recently
emerged as effective candidate treatments against a range of human malignancies. Here, we have investigated their expression in the
uterine mesenchymal tumors.

Design: We assessed CTLA-4, PD-1, PD-L1, and IDO expression on paraffin embedded tissue blocks, comprising of 11 uterine
leiomyomas, 17 uterine leiomyosarcomas (LMS), 8 recurrent/ metastatic uterine LMS, and 8 endometrial stromal sarcomas (ESS).
Immunohistochemical (IHC) staining with PD-L1 (SP142), PD-1 (Nat105), CTLA-4 (F8) and IDO (ab106134) antibodies were performed.
The IHC was classified as positive when staining was present in the following pattern: PD-L1: cell membrane of the tumor (Figure 1A),
PD-1: cell membrane of peri/intra tumoral lymphoid cells (Figure 1B), CTLA-4 and IDO: strong granular cytoplasmic reactions of the tumor
cells (Figure 1C & 1D, respectively).

Results: Table 1 summarizes the frequency of PD-L1, PD-1, CTLA-4, and IDO positivity in uterine mesenchymal tumors. PD-L1 was
positive in 29% (5/17) of uterine LMS, 63% (5/8) of recurrent/metastatic LMS, and 13% (1/8) of ESS. PD-1 was positive in 24% (4/17) of
uterine LMS, 38% (3/8) of recurrent/metastatic LMS, and 13% (1/8) of ESS. CTLA-4 was positive in 18% (3/17) of uterine LMS, 38% (3/8)
of recurrent/metastatic LMS, and 13% (1/8) of ESS. IDO was positive in 6% (1/17) of uterine LMS, 38% (3/8) of recurrent/metastatic LMS,
and none of ESS. Leiomyomas had no expression of the aforementioned molecules.

1128
 Table 1. Summary of the immunohistochemistry reactions in the tumors
n PD-L1 PD-1 CTLA- IDO
4
Uterine leiomyoma 11 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Uterine leiomyosarcoma 17 5 4 3 1 (6%)
(29%) (24%) (18%)
Uterine leiomyosarcoma, 8 5 3 3 3
recurrent/metastatic (63%) (38%) (38%) (38%)
Endometrial stromal sarcoma 8 1 1 1 0 (0%)
(13%) (13%) (13%)
Figure 1 - 1182

Conclusions: We report that a noticeable number of uterine and recurrent/metastatic LMS, as well as a small percentage of ESS,
demonstrate PD-L1, PD-1, and CTLA-4 expression. A smaller percentage of uterine and recurrent/metastatic uterine LMS also express
IDO. The highest expression was seen in metastatic/recurrent LMS. Our findings provide support for the use of immune checkpoint
inhibitors in the malignant uterine mesenchymal tumors.

1183 Clear Cell Carcinoma of Uterine Cervix: A Clinicopathologic Review and Molecular
Characterization
Sanaz Sanii1, Niki Esfahanian2, Blaise Clarke3, Joerg Schwock4, Liat Hogen5, Kathy Han5, Stephanie Lheureux5, Nicole Park5,
Tracy Stockley6, Marjan Rouzbahman7
1
University Health Network, St. John's, NL, 2McMaster University, Hamilton, ON, 3University of Toronto, Toronto, ON, 4University
Health Network, University of Toronto, Toronto, ON, 5University Health Network, Toronto, ON, 6Genome Diagnostics University
Health Network, Toronto, ON, 7Toronto, ON

Disclosures: Sanaz Sanii: None; Niki Esfahanian: None; Blaise Clarke: None; Joerg Schwock: None; Liat Hogen: None; Kathy Han:
None; Nicole Park: None; Tracy Stockley: None; Marjan Rouzbahman: None

Background: Clear cell carcinoma of uterine cervix (CCCUC) is a rare variant of cervical adenocarcinoma unrelated to Human Papilloma
Virus (HPV) unlike most primary malignancies of cervix. With a global trend towards HPV testing instead of cytology for the purpose of
cervical cancer screening, prevention and/or early detection of the less common HPV-unrelated cervical cancer variants requires better
understanding of their underlying biology.

Design: Ten CCCUCs were identified during a 15-year period. Clinicopathological characteristics were studied. Immunohistochemistry
(IHC), Linear Array HPV Genotyping, and next generation sequencing (NGS) was performed in 6 cases with available material.

Results: Mean age of patients was 39.6 (range of 18-82). All presented with vaginal bleeding. Six out of ten cases were diagnosed at
FIGO stage IB. Eight patients had initial surgery, with lymph nodes dissection in 7. Adjuvant therapy followed in 5 cases. One patient had
neoadjuvant radiation therapy followed by surgery. One patient had only brachytherapy. Median follow up period was 38 months.
Clinicopathologic findings are presented in table 1.

1129
In 6 cases with available material, Linear Array HPV Genotyping proved negative HPV status and IHC showed wild type p53 expression,
positive PAX8 and HNF1β, and negative ER/PR. MMR protein expression in IHC was intact in 4 cases. Two cases had lost/equivocal
MSH2/MSH6 expression, one of which as well as other 4 cases proved negative for microsatellite instability in NGS. According to both
breast cancer and gastric adenocarcinoma scoring guidelines for Her2 expression by IHC, all 6 cases showed score 2+.

NGS identified 70 gene variants across 6 CCCUC samples. Two cases had null (nonsense) variants in ATM, CHEK2, KDM5C, and
KMT2C. One case had an SPOP M117V variant which has been previously reported in endometrial cancer. Overall, variants in genes
with roles in apoptosis, DNA repair, cell cycle, PI3K-AKT signaling, and transcriptional regulation were identified in this data set.

Clinicopathological characteristic of clear cell carcinoma of the Number of cases

uterine cervix
(total = 10)
Age Age <=30 5
Distribution Range: 18-82 years
Age >30 5
Mean: 39.6 years

Median: 31 years
Pap test result prior to diagnosis Normal 2

Abnormal (AGC) 3

Unknown 5
Stage (FIGO) IB 6

IIA1 1

IIB 2

Unknown 1
Lymphovascular space invasion Positive 4
Negative 6
Lymph node metastasis at presentation Positive 2
Negative 8
Recurrence during follow up Pelvic 1
Distant 1
Pelvic & Distant 2
Negative 6
Patient status at the end of follow up period Alive without disease 5
Alive with disease 2
Expired of disease 3
AGC: atypical glandular cells; FIGO: International Federation of Gynecology and Obstetrics

Conclusions: Our study further elucidates the clinicopathological features of CCCUC and is the first to investigate its molecular
characteristics. Potentially actionable molecular alterations were detected. Further study of CCCUC molecular profile is required to better
characterize this rare malignancy and to allow development of novel diagnostic and therapeutic techniques.

1184 Massively Parallel Sequencing Analysis of Gastric-Type Cervical Adenocarcinomas Reveals

Mutations in Cell Cycle-Related Genes and Rare Potentially Targetable ERBB2 Mutations
Pier Selenica1, Barbara Alemar1, Karen Talia2, W. Glenn McCluggage3, Yoshiki Mikami4, Takako Kiyokawa5, Britta Weigelt1, Kay
Park1, Rajmohan Murali1
1
Memorial Sloan Kettering Cancer Center, New York, NY, 2The Royal Women's Hospital, Melbourne, VIC, Australia, 3The Royal
Hospitals, Belfast, United Kingdom, 4Kumamoto University Hospital, Kumamoto, Japan, 5The Jikei University School of
Medicine, Minato-ku, Japan

Disclosures: Pier Selenica: None; Barbara Alemar: None; Karen Talia: None; W. Glenn McCluggage: None; Yoshiki Mikami: None;
Takako Kiyokawa: None; Britta Weigelt: None; Kay Park: None; Rajmohan Murali: None

Background: Gastric-type cervical adenocarcinoma (GCA) is a clinically aggressive subtype of endocervical mucinous adenocarcinoma
characterized by gastric-type mucin, lack of association with human papillomavirus (HPV) and resistance to chemo/radiotherapy. Here,

1130
we sought to characterize the landscape of genetic alterations in a large cohort of GCAs, and to compare it to those of usual-type HPV-
associated endocervical adenocarcinomas (UEAs) and adenocarcinomas of gastric and pancreatic origin, which show some morphologic
overlap with GCAs.

Design: GCAs (n=79) were subjected to massively parallel sequencing targeting 410-468 cancer-related genes. Somatic mutations and
copy number alterations (CNAs) were determined using validated bioinformatics methods, and statistical comparisons were evaluated
with a two-tailed Fisher exact test. Mutational data for UEAs (n=21), pancreatic adenocarcinomas (PAs, n=178) and intestinal gastric
adenocarcinomas (IGAs, n=148) from The Cancer Genome Atlas (TCGA) were obtained from cBioPortal.

Results: GCAs harbored a median of 4 non-synonymous somatic mutations (range 0-23) with the most frequent somatic mutations
affecting TP53 (38%), CDKN2A (20%), KRAS (18%) and STK11 (11%). Rare, potentially targetable mutations in ERBB2 (9%) were
identified. All GCAs displayed low levels of CNAs with no recurrent high-level amplifications or homozygous deletions detected. In
comparison to UEAs, GCAs harbored a higher frequency of mutations affecting cell cycle related genes including TP53 (38% vs 4%,
p<0.01) and CDKN2A (20% vs 0%, p=0.01); however fewer mutations in PIK3CA (6% vs 25%, p=0.01) were detected. In
contrast, TP53 mutations were found to be less prevalent in GCAs compared to both PAs (38% vs 56%, p<0.01) and IGAs (38% vs 57%,
p<0.01). GCAs also showed a higher frequency of STK11 mutations than PAs (11% vs 2%, p<0.01) and IGAs (11% vs 1%, p<0.01).
Additionally, mutations in ERBB2 and ERBB3 (9% vs 1%, and 10% vs 0.5%, both p<0.01) were enriched in GCAs compared to PAs
whereas CDKN2A and KRAS mutations (20% vs 1%, p<0.01, and 18% vs 6%, p<0.01) were enriched in GCAs compared to IGAs.

Conclusions: Our findings suggest that GCAs are underpinned by somatic mutations in cell cycle-related genes and in potentially
targetable genes (e.g. ERBB2). Importantly, certain genes that are enriched for somatic mutations in GCAs such
as CDKN2A and STK11 could be used as biomarkers to distinguish them from other tumor types with similar histologic features.

1185 Rare Driver Mutations in the Intermediate Trophoblastic Tumors

Maryam Shahi1, Rena Xian1, Brigitte Ronnett2, Deyin Xing3
1
Johns Hopkins Medical Institutions, Baltimore, MD, 2Johns Hopkins Hospital, Baltimore, MD, 3Johns Hopkins Medical
Institutions, Ellicott City, MD

Disclosures: Maryam Shahi: None; Rena Xian: None; Brigitte Ronnett: None; Deyin Xing: None

Background: Intermediate trophoblastic tumors, which include placental site trophoblastic tumor (PSTT) and epithelioid trophoblastic
tumor (ETT), are uncommon, with nearly all assumed to be gestational in origin. Most occur in the uterus and those in extra-uterine sites
are considered metastatic or ectopic gestational trophoblastic tumors but rare non-gestational types have been encountered. Since these
tumors are relatively resistant to chemotherapy and because gestational and non-gestational types have different pathogenesis and
require different therapy, identification of genetic alterations that might be amenable to pathway/molecule-based therapeutic approaches
would be useful.

Design: Next-generation sequencing using a large (637) gene panel was performed using genomic DNA extracted from paraffin-
embedded tumor tissues of 8 intermediate trophoblastic tumors (4 ETT, 3 PSTT, 1 ETT with choriocarcinomatous (CC) differentiation).
DNA genotyping was performed on 4 ovarian tumors to determine their gestational versus non-gestational status. Clinicopathologic
features were analyzed.

Results: In 6 tumors, copy number variations (CNVs) were identified, including gains of 5p,7,8q,11q,12,14,20 and losses of
2,7,8p,9,16p,19. Somatic mutations (from 2-6) were identified in 5 tumors, including oncogenic driver mutations involving EGFR, HRAS,
and ERBB4 in individual tumors; however, recurrent somatic mutations were not identified (see table)

1131
 Age Diagnosis Site Genotyping Aneuploidy CNVs Notable mutation
25 ETT Uterus Presumed gestational Absent None SUFU
(molar pregnancy) PIK3C2B
FANCC
ARID1A
41 ETT Uterus Presumed gestational Present (+20) GSK3B
ECT2L
TRAF5
39 ETT Ovary Non-gestational Present (+5p, maybe also Not available
+20p)
36 ETT Ovary Gestational Absent None None
55 ETT-CC Ovary Gestational Present (+1q, +3p, HRAS
CTNNB1 amp, +7, CD22
+8q, +11q, +12, PPP2R1A
+14) MLH1
PHF6
BRD4
31 PSTT Uterus Presumed gestational Present (-8p,-16) EGFR
(missed abortion) LRP1B
37 PSTT Uterus Presumed gestational Present (-2, -16p, -19) GSK3B
(recent normal term ECT2L
pregnancy) TRAF5
30 PSTT Ovary Non-gestational Present possible -9p None

Conclusions: The finding of genetic alterations involving EGFR, HRAS, and ERBB4 in some intermediate trophoblastic tumors offers the
potential for individualized management strategies using pathway/molecular-based targeted therapies for treatment of these
chemoresistant tumors.

1186 IDO Expression in Uterine Smooth Muscle Tumors: Implications for Immunotherapy
Elisheva Shanes1, Lisa Friedman2, Anne Mills2
1
Northwestern University, Chicago, IL, 2University of Virginia, Charlottesville, VA

Disclosures: Elisheva Shanes: None; Lisa Friedman: None; Anne Mills: None

Background: Immunotherapies targeting the IDO checkpoint axis have recently become available. Given the poor prognosis of uterine
leiomyosarcoma (LMS) and the paucity of available therapeutic options, the potential impact of immunotherapy in this patient population
may be significant. IDO expression patterns in uterine LMS, as well as in lower grade uterine smooth muscle tumors (USMT), have not
been investigated.

Design: 50 USMT comprised of 22 LMS, 8 smooth muscle tumors of uncertain malignant potential (STUMP), 10 atypical leiomyomas
(AL), and 9 benign leiomyomas (BL) were immunostained for IDO, CD8, and FoxP3. Tumoral IDO expression was semi-quantitatively
scored by extent (negative, 1-5%, 6-10%, >10%) and IDO-positive tumor-associated immune (TAI) infiltrates were scored as absent,
focal, moderate, or brisk. Endothelial cell staining with IDO was scored as absent, focal, moderate, or extensive. CD8-positive and FoxP3-
positive lymphocytes were manually enumerated and averaged across 5 to 10 high-power fields. Follow-up status and therapeutic history
was recorded where available.

Results: Tumor IDO expression was not seen in any smooth muscle tumors. IDO positivity was seen in TAI in 32% of LMS, 25% of
STUMP, 50% of AL, and 22% of BL. IDO positivity in endothelial cells within the tumor was seen in 82% of LMS, 63% of STUMP, 70% of
AL, and 67% of BL.

1132
 Tumor Type TAI IDO+ Endothelial IDO+ Average Average
CD8+/HPF FoxP3+/HPF
(range) (range)
LMS Overall: 7 (32%) Overall: 18 (82%) 90 (0 – 300) 9 (0 – 45)
Focal: 7 (32%) Focal: 6 (27%)
Moderate: 0 (0%) Moderate: 1 (5%)
Brisk: 0 (0%) Extensive: 11
(50%)
STUMP Overall: 2 (25%) Overall: 5 (63%) 10 (1 – 41) 1 (0 – 8)
Focal: 1 (13%) Focal: 1 (13%)
Moderate: 1 (13%) Moderate: 3
Brisk: 1 (13%) (38%)
Extensive: 2
(25%)
AL Overall: 5 (50%) Overall: 7 (70%) 10 (2 – 30) 2 (0 – 9)
Focal: 4 (40%) Focal: 1 (10%)
Moderate: 0 (0%) Moderate: 1
Brisk: 1 (10%) (10%)
Extensive: 5
(50%)
BL Overall: 1 (11%) Overall: 6 (67%) 29 (2 – 165) 0 (0 – 2)
Mild: 1 (11%) Focal: 4 (44%)
Moderate: 0 (0%) Moderate: 0 (0%)
Brisk: 0 (0%) Extensive: 2
(22%)

Conclusions: A significant percentage of uterine smooth muscle tumors demonstrate IDO expression in the endothelial cells of
intratumoral vessels, including 82% of LMS. While 32% of LMS have IDO expression within TAIs, this is limited to only focal expression.
USMTs do not express IDO in tumor cells. These data suggest that directed therapy towards IDO may have limited utility in the treatment
of LMS.

1187 Low-Grade, Low-Stage Endometrioid Endometrial Adenocarcinoma: A Morphological and

Molecular Study of 19 Cases
Aarti Sharma1, Angelica Moran1, Sahana Somasegar1, David Chapel2, Ricardo Lastra1, Nita Lee1, Lauren Ritterhouse3, Jennifer
Bennett1
1
The University of Chicago, Chicago, IL, 2Brigham and Women's Hospital, Boston, MA, 3Massachusetts General Hospital,
Harvard Medical School, Boston, MA

Disclosures: Aarti Sharma: None; Angelica Moran: None; Sahana Somasegar: None; David Chapel: None; Ricardo Lastra: None; Nita
Lee: None; Lauren Ritterhouse: None; Jennifer Bennett: None

Background: Most low-grade, low-stage endometrioid endometrial adenocarcinomas (EEC) have an excellent prognosis; however
recurrences occur in a small subset with several studies reporting an increase in CTNNB1 mutations in this cohort. Herein we evaluated
19 low-grade, low-stage EECs, including 10 that recurred, to further characterize their morphological features and molecular phenotype.

Design: A retrospective cohort of 300 patients with low-grade (FIGO 1-2), low-stage (FIGO IA) EEC were identified. The medical record
was reviewed to identify those with biopsy-proven recurrences. Morphologic examination of the primary and recurrent tumors was
performed to confirm the diagnosis. This resulted in a total of 10 cases (R-EEC), and all primary tumors underwent next generation
sequencing on a 1213 gene panel. Nine non-recurrent low-grade, low-stage EECs (NR-EECs) that had been previously sequenced were
included as controls.

Results: Clinicopathological features are summarized in the table. Of all examined features, only depth of invasion was found to be
significantly different (p=0.0347) between the 2 groups with deeper invasion occurring in R-EECs. Evaluation of sequencing data revealed
62 pathogenic mutations in R-EECs and 64 in NR-EECs. ARID1A (8/10), PTEN (8/10), and FGFR2 (4/10) mutations were most frequent
in R-EECs versus PTEN (8/9), ARID1A (5/9), and PIK3CA (5/9) in NR-EECs (Figure 1). CTNNB1 mutations were detected in 3 R-EECs
versus 1 in NR-EECs, but this difference was not significant (p=0.5820). Similarly, no other mutations were significant between the 2
groups.

1133
 Clincopathological R-EEC NR-EEC p-value
Feature
Age (years) 37-76 (61) 51-71 (63) 0.9822
Size (cm) 2.2-6.5 (4.0) 1.0-4.5 (3.0) 0.2108
Depth of Invasion (mm) 0-45 (15) 0-12 (3.6) 0.0347*
Pattern of Invasion Conventional - 6 Conventional - 4 0.4965
MELF - 3 MELF - 0
Metaplastic Changes 6 6 0.986
Mitoses/10 HPF 0-11 (3) 0-6 (2) 0.4283
PTL 6 3 >0.9999
TILs/HPF 3-22 (13) 4-23 (14) 0.7954
Unstable Microsatellite 0.9-64 (18) 5-56 (26) 0.1564
Loci (%)

R-EEC: Recurrent EEC, NR-EEC: Non-Recurrent EEC

MELF: Microcystic, ELongated, and Fragmented, HPF: high-power fields
PTLs: PeriTumoral Lymphocytes, TILs: Tumor-Infiltrating Lymphocytes
Figure 1 - 1187

Conclusions: Unlike other studies, we did not identify CTNNB1 mutations to be significantly associated with recurrent low-grade, low-
stage EECs in our cohort. While we identified an association between deeper myometrial invasion and recurrence, our sample size is
small, and this feature needs to be corroborated by larger studies. Nonetheless, while CTNNB1 mutations contribute to recurrence in a
subset of EECs, other molecular alterations and epigenetic modifications likely play an important role and remain to be elucidated.

1188 5-hmC Immunohistochemistry is a Reliable Marker for Predicting Leiomyomas with Fumarate
Hydratase Mutations
Aarti Sharma1, Erna Forgo2, Brooke Howitt2, Joseph Rabban3, Karuna Garg3, Jennifer Bennett1
1
The University of Chicago, Chicago, IL, 2Stanford University School of Medicine, Stanford, CA, 3University of California San
Francisco, San Francisco, CA

Disclosures: Aarti Sharma: None; Erna Forgo: None; Brooke Howitt: None; Joseph Rabban: Employee, Spouse is employee of Merck &
Co.; Karuna Garg: None; Jennifer Bennett: None

Background: Fumarate hydratase deficient (FH-d) leiomyomas (LM) have characteristic morphological features, and when present can
alert the pathologist to a potential FH germline mutation. FH immunohistochemistry (IHC) has low sensitivity/specificity and has not
proven complementary to morphologic evaluation. Thus, there is a need for reliable IHC markers to supplement morphology. FH
inactivation results in inhibition of demethylases and decreased levels of the epigenetic marker 5-hydroxymethylcytosine (5hmC); thus we
interrogated a series of LMs with FH-d morphology for 5hmC expression.

Design: LMs with FH-d morphology (n=17) as well as conventional (n=10) and variant (n=15) LMs were stained with 5hmC. Nuclear
5hmC expression was scored semi-quantitatively (1: <10%, 2: 10-25%, 3: 26-75%, and 4: >75%) as previously published, and univariate
analyses were performed.

Results: Patients with FH-d LMs had a mean age of 35 (range 27-52) vs 44 (range 29-76) years in non-FH-d LMs (p=0.0119). Overall, 13
(76%) FH-d LMs had 5hmC scores of 1-2 while all non-FH-d LMs had scores of 3-4 (p<0.0001) (Figure 1). Germline FH mutations were

1134
identified in 8 of 9 patients tested (89%), all of whom had 5hmC scores of 1-2. Conversely, the patient without a germline FH mutation
had a 5hmc score of 3. FH IHC was previously performed in 14 (82%) of FH-d LMs and was lost in 8 (57%), retained in 4 (29%), and
heterogeneously expressed in 2 (14%). No correlation was noted between 5hmC and FH IHC (p=0.3044; Figure 2). Morphologic and IHC
results of FH-d LMs are summarized in the table.

Case Age Extent of Well Staghorn Alveolar Chain- Bizarre Eosinophilic Nucleoli/ Halos 5hmc FH Germline
FH-d Developed Vessels Edema Like Nuclei Cytoplasmic Score IHC FH
Morphology FH-d Nuclei Inclusions Status
Morphology
1 31 Focal + + + + + + + 1 Het +
2 28 Diffuse + + + + + + + 1 Ret +
3 30 Diffuse - + + + - + + 1 Ret +
4 30 Diffuse + + + + - + + 1 Lost +
5 43 N/A N/A N/A N/A N/A N/A N/A N/A 1 Lost NP
6 31 Diffuse + + + + - + + 1 Lost +
7 29 Diffuse - + + + - + + 1 NP NP
8 35 Diffuse + + + + + + + 1 Lost NP
9 33 Diffuse + + + - + + + 1 Lost +
10 27 Diffuse + + - - - - + 1 Ret NP
11 44 Diffuse + + + - - + + 1 Lost NP
12 34 Diffuse + + + + + + + 2 Het +
13 39 Diffuse + + + + + + + 2 Lost +
14 44 N/A N/A N/A N/A N/A N/A N/A N/A 3 Ret NP
15 52 Focal + + + - + + + 3 Lost -
16 47 Focal - + - - - + + 4 NP NP
17 37 Focal - + - - + + + 4 NP Pending
+ = Present, - = Absent, NP = not performed, N/A = not available, Het: Heterogenous, Ret: Retained

Figure 1 - 1188

Figure 2 - 1188

Conclusions: LMs with FH-d morphology are significantly associated with low 5hmC expression (< 25% staining) compared to
conventional and variant LMs. As FH IHC is unreliable, this study supports a role for 5hmC as an adjunct to morphology in triaging
patients for genetic testing. Additional studies evaluating 5hmC in LMs with known somatic FH mutations are in process.

1135
1189 Immunohistochemistry for MDM2 is a Useful Tool in the Diagnosis of Malignant Brenner Tumors?
Sindhu Shetty1, Amy Joehlin-Price1, Omar Habeeb1
1
Cleveland Clinic, Cleveland, OH

Disclosures: Sindhu Shetty: None; Amy Joehlin-Price: None; Omar Habeeb: None

Background: Malignant Brenner tumors (MBT) are typically diagnosed in the setting of a high grade carcinoma with transitional cell
morphology and the presence of a benign Brenner tumor (BBT) in the background. While MBT are rare, there is no marker that permits
diagnosis of MBT with certainty outside of this specific histologic scenario. MDM2 amplification was recently reported as part of a
massive parallel sequencing study on a small number of MBT. This is significant not only for diagnostic purposes, but also shows
potential for targeted therapy, as MDM2 inhibitors are being tested in early clinical trials for multiple tumor types with MDM2
amplification. Immunohistochemistry for MDM2 is widely available and is a candidate immunohistochemical (IHC) stain to aid in the
diagnosis of MBT.

Design: We performed MDM2 IHC on whole sections of 4 MBT, 2 borderline Brenner tumors (BLBT), 25 BBT, and 22 epithelial ovarian
tumors, most of which exclusively or in part showed transitional cell morphology. Additionally, MDM2 IHC was performed on triplicate core
tissue microarrays (TMAs) containing 204 cases of high grade serous carcinomas (HGSC) and 52 high grade urothelial carcinomas
(HGUC). MDM2 IHC was considered positive with diffuse (>50%) nuclear reactivity; in cases of patchy staining (20-50% nuclear
reactivity) MDM2 was considered equivocal. Less than 20% of cells staining positively was considered negative. In equivocal cases,
MDM2 FISH is pending.

Results: Three MBT showed diffuse nuclear reactivity for MDM2. One MBT showed patchy nuclear reactivity, with up to 50% of cells
staining in some areas, and is interpreted as equivocal. It is of note, however, that this MBT demonstrates more typical architecture of a
BLBT and was diagnosed as a MBT secondary to cytology. One BLBT showed patchy nuclear reactivity and was interpreted as
equivocal, and the other BLBT was negative (<5% nuclear reactivity). While rare nuclei showed positivity in 9/25 BBT (<5% of cells), all
25 BBT are negative for MDM2. Whole sections of epithelial ovarian carcinoma with transitional cell morphology, as well as all HGSC
and HGUC in TMA sections, are also negative for MDM2.

Conclusions: Diffuse MDM2 expression is 75% sensitive and 100% specific for MBT. MDM2 IHC was not useful in the two cases of
BLBT. IHC expression of MDM2 can therefore be a useful diagnostic tool in identifying MBT. Although it requires further study, this
finding suggests that MBT may be a candidate for targeted molecular therapy.

1190 Evaluation of Dual MMR IHC and MSI PCR Testing for Gynecologic Cancers
Marie Smithgall1, Helen Remotti2, Mahesh Mansukhani2, Susan Hsiao3, Helen Fernandes4, Xiaolin Liu-Jarin2
1
New York-Presbyterian/Columbia University Medical Center, New York, NY, 2Columbia University Medical Center, New York,
NY, 3New York-Presbyterian/Columbia University Medical Center, Flushing, NY, 4Columbia University, New York, NY

Disclosures: Marie Smithgall: None; Helen Remotti: None; Mahesh Mansukhani: Speaker, Promega; Susan Hsiao: None; Helen
Fernandes: None; Xiaolin Liu-Jarin: None

Background: A subset of gynecologic cancers harbor mutations in DNA mismatch repair (MMR) genes, including both germline (Lynch
Syndrome) and sporadic cases. Both immunohistochemistry (IHC) of MMR proteins or MSI (microsatellite instability) testing by PCR can
be used to detect MMR deficient (dMMR)/MSI-High (MSI-H) tumors which may benefit from treatment with immune checkpoint inhibitors.
Recent recommendations from the European Society for Medical Oncology (ESMO), suggest that molecular tests be used for
confirmatory analysis of MMR. This study reviewed MMR/MSI test results in gynecologic cancers to evaluate their correlation.

Design: The pathology case database at a large academic medical center was queried to identify gynecological cancer cases between
1/1/2014 and 8/9/2019 with both IHC for MMR proteins and MSI PCR analysis. Cases were reviewed to determine the concordance rate
between these methods. Discordant cases were re-reviewed by 2 pathologists, blindly and independently.

Results: 206 gynecologic cancer cases (173, 84% endometrial) with both IHC MMR and MSI results were identified (178 primary and 28
metastatic cases). There were 201 (97.6%) concordant cases. 157 (76.2%) cases were microsatellite stable (MSS) with preserved MMR
(pMMR) and 44 (21.4%) cases were MSI-H with dMMR, for three of these cases their MSI status was confirmed with next generation
sequencing (NGS). Three endometrial cases (1.4%) showed dMMR but were MSS. For all three, IHC was performed on the initial biopsy
and MSI on the resection. IHC re-testing performed on the resection concurred with the original biopsy showing dMMR for MLH1 and
PMS2. Two endometrial cases (1.0%) showed pMMR but were MSI-H. For one, IHC was performed on an initial biopsy and MSI on the
resection. IHC on the resection showed pMMR. The other case showed clear geographic heterogeneity within the tumor with distinct
dMMR and pMMR areas. MSI testing performed on the dMMR area alone, was positive.

1136
 Figure 1 - 1190

Conclusions: Concordance between MMR IHC and MSI testing among gynecologic cancers was high (98%). Three dMMR cases that
were MSS and one case of a MSI-H tumor with pMMR IHC were discordant. Our results highlight the benefit of dual testing with MSI
PCR and MMR IHC. Further investigation on the heterogeneity of MMR IHC expression may help understand the importance of
appropriate sampling for molecular testing.

1191 Significance of Immunotyping by CD8 and PD-L1 Immune Checkpoint Inhibitor in Epithelial
Ovarian Carcinoma
Radhika Srinivasan1, Akriti Bansal1, Manish Rohilla1, Bhavana Rai1, Arvind Rajwanshi1, Vanita Suri1, Subhas Saha2
1
Postgraduate Institute of Medical Education & Research, Chandigarh, India, 2Department of Obstetrics and Gynecology,
Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India

Disclosures: Radhika Srinivasan: None; Akriti Bansal: None; Manish Rohilla: None; Bhavana Rai: None; Arvind Rajwanshi: None; Vanita
Suri: None; Subhas Saha: None

Background: High Grade Serous carcinoma [HGSC] of the ovary is one of the most common and lethal carcinomas among women in
spite of multimodality treatment. The aim of this study was to evaluate the interplay of tumor infiltrating lymphocytes [TILs] and PD-L1, an
immune check point inhibitor in HGSC and evaluate the clinical significance of ‘immunotyping’ in HGSC.

Design: A total of 100 cases of HGSC ovary were included in this retrospective analysis. Out of these, 50 underwent upfront surgery
(HGSC-upfront) and 50 underwent interval debulking surgery following neoadjuvant chemotherapy (HGSC-post-NACT group). TIL density
was scored from 0-3+ on whole tissue sections. Tissue microarrays were constructed from the areas with maximum TILs and evaluated
by immunohistochemistry for CD4 and CD8 lymphocytes, CD68 tumour associated macrophages (TAMs), and PD-L1. The cases were
then divided into four immunotypes based on PD-L1 (≥10%) and CD8+ T-cell (≥5%) expression (Type I-PDL1+/CD8+; Type II-PDL1-
/CD8-; Type III-PD-L1+/CD8-; Type IV-PD-L1-/CD8+) and correlated to disease-free survival (DFS), overall survival and platinum-free
interval.

Results: Majority (77%) of HGSC ovary were in FIGO stage 3 with median DFS of 196 days without any difference in survival among the
two groups. HGSC-post-NACT had higher TILs and CD8+T cells with no difference in TAMs and CD4+ cells. Overall 60% HGSC showed
PD-L1 expression of any degree in tumour and TAMs. The HGSC-post-NACT group showed increased PD-L1 levels as compared to the
HGSC-upfront group (p=0.01). PD-L1 levels showed a linear association with immune cell infiltration. At 10% cut-off, PD-L1 expression
alone did not show any association with DFS. Immunotyping (Fig.1) revealed frequency of Type I, II, III and IV immunotypes in HGSC-
upfront group to be 2%, 60%, 16% and 20% whereas in the HGSC-post-NACT group it was 22%, 54%, 2% and 20% respectively. Log-
rank test and Kaplan-Meier analysis revealed that immunotype I (PD-L1+/CD8+) showed worst outcome (p=0.04) (Fig.2) with the
difference in DFS between type I and type III immunotypes highly significant (p=0.01).

1137
Figure 1 - 1191

Figure 2 - 1191

1138
Conclusions: Immunotyping based on PD-L1 and CD8+ T cell levels stratifies patients based on prognosis better than PD-L1 scoring
alone. Further, immunotyping helps in selection of patients for treatment and type I (PD-L1+/CD8+) cases may be potential candidates for
anti-PD-L1 therapy.

1192 HER2 Expression in Endometrial Cancers Diagnosed as Clear Cell Carcinoma

Bradly Stelter1, Nhu Vu2, Alain Cagaanan3, Ahmed Al-Niaimi2, Paul Weisman4, Stephanie McGregor4
1
University of Wisconsin-Madison, Fitchburg, WI, 2University of Wisconsin-Madison, Madison, WI, 3Madison, WI, 4University of
Wisconsin, Madison, WI

Disclosures: Bradly Stelter: None; Nhu Vu: None; Alain Cagaanan: None; Paul Weisman: None; Stephanie McGregor: None

Background: There is increasing evidence from immunophenotypic and molecular studies that a large proportion of cases diagnosed as
clear cell carcinoma (CC) may be better regarded as either endometrioid (EmC) or serous (SC). A diagnosis of CC in such cases has the
potential to exclude patients from targeted regimens or clinical trials that may be of therapeutic benefit, such as HER2-targeted therapy,
which has been approved for SC but not for CC. Here we present an assessment of HER2 expression in endometrial cancers in relation
to original diagnosis and immunophenotype.

Design: A tissue microarray of archived endometrial cancers was created (1 mm punches in duplicate). Stains for p53, p16, ER, and
HER2 were performed in our clinical lab. Representation of all relevant stains was achieved for 26 CC, 78 SC, and 133 EmC (93 FIGO
grade 1, 40 FIGO grade 3), according to original diagnosis. Stains were scored as: p53 mutant/null vs. wild type, ER high (>10%) vs.
low/negative (10% or less), and p16 strong and diffuse (>90%) vs. patchy/negative. HER2 was scored according to 2007 guidelines for
breast carcinoma. Cases were assessed for HER2 expression according to original diagnosis, p53/p16 status, or a dichotomized
classification of endometrioid or serous based on immunophenotype according to p53, p16, and ER.

Results: According to original diagnosis, HER2 was 3+ in 7/78 SC (9%) and in 5/26 CC (19%) but in 0/133 EmC (0%). Of the 12 cases
that were 3+ for HER2, 11 were p53 mutant/null (92%) and 10 had strong/diffuse expression of p16 (83%). Among p53 mutant/null cases,
11 of 95 (12%) were 3+. When dichotomized as being more similar to serous or endometrioid, all 12 cases were regarded as serous
(13%).

Conclusions: Though current recommendations are to test for HER2 in SC, in this series HER2 is more common in cases initially
regarded as CC. Irrespective of initial diagnosis, HER2 3+ cases demonstrated serous-like immunophenotype. Though additional study is
necessary to determine the utility of HER2-targeted therapy in cases diagnosed as CC, identifying patients with a diagnosis of CC that are
HER2+ may open avenues with higher likelihood of therapeutic benefit than those that are otherwise currently available. Such overlap in
expression also underscores the biologic similarity between a subset of cases regarded as CC and SC.

1193 Clinical and Pathological Determinants of Outcome in Invasive Stratified Mucinous Carcinoma
(iSMILE) of the Cervix: An International Multicentric Study
Simona Stolnicu1, Monica Boros2, Carlos Parra-Herran3, Esther Oliva4, Nadeem Abu-Rustum5, Robert Soslow5, Kay Park5
1
University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Mures, Romania, 2Faculty of Medicine and
Pharmacy, University of Oradea, Oradea, BH, Romania, 3Sunnybrook Health Sciences Centre, University of Toronto, Toronto,
ON, 4Massachusetts General Hospital, Harvard Medical School, Boston, MA, 5Memorial Sloan Kettering Cancer Center, New
York, NY

Disclosures: Simona Stolnicu: None; Monica Boros: None; Carlos Parra-Herran: None; Esther Oliva: None; Nadeem Abu-Rustum: Grant
or Research Support, Stryker, GRAIL; Robert Soslow: Speaker, Ebix/Oakstone; Kay Park: None

Background: iSMILE, a tumor characterized by hybrid morphology thought to arise from human papillomavirus (HPV) infected reserve
cells of the transformation zone, may represent an aggressive subtype with worse outcomes compared to usual HPV associated (HPVA)
cervical adenocarcinoma. We sought to investigate the outcomes in iSMILE and determine which clinical and pathological parameters
may influence the prognosis.

Design: Slides from 52 cases of iSMILE were collected and classified as follows: pure iSMILE (>90% of the entire tumor) and iSMILE
mixed with other HPVA components (miSMILE) (>10% but <90% of the entire tumor). The following parameters were evaluated: age,
FIGO stage, treatment, HPV status, tumor size, lympho-vascular involvement (LVI), Silva pattern of invasion, lymph node metastases
(LNM), local/pelvic recurrence, overall survival (OS) and recurrence free survival (RFS).

Results: In most cases (80%) iSMILE occurred in patients <50y and were Silva pattern C. One third of patients with iSMILE presented
with LNM and 25% developed local recurrences while 4 developed distant recurrences. 29 cases (55.76%) were pure iSMILE while 23
cases (44.23%) were miSMILE: 13 with usual-type adenocarcinoma, 6 with adenosquamous carcinoma, 3 with mucinous
adenocarcinoma NOS and 1 with neuroendocrine carcinoma. Kaplan Meier survival analysis revealed 5-year OS of 78.8% and RFS of
63.6%. OS was 74.7% in pure iSMILE versus 85.2% in miSMILE but not statistically significant (p: 0.267). RFS was 56.5% in pure iSMILE
and 72.9% in miSMILE (p: 0.185). OS at 5 years in stage I was 88.9% vs. stage II-IV 30% (p: 0.004). RFS at 5 years in stage I was 73.9%

1139
vs. stage II-IV 38.1% (p: 0.02). Using Log rank Mantel Cox analysis, OS was influenced by FIGO stage (p: 0.013), tumor size (p: 0.02),
LNM (p: 0.015) and local recurrence (p:0.022), while RFS was influenced by FIGO stage (p: 0.031), tumor size (p: 0.001), local
recurrence (p: 0.009) and LNM (p: 0.008) (Table 1).

OS RFS
HR CI 95% p HR CI 95% p
Tumor type (pure iSMILE vs 2.444 0.471-12.675 0.287 2.158 0.663- 0.201
miSMILE) 7.020
Age 50<;>50 years 1.834 0.347-9.702 0.476 1.379 0.160- 0.676
3.273
FIGO stage (I vs II-IV) 6.765 1.490-30.500 0.013 3.469 1.120- 0.031
10.746
Surgical treatment (without vs with 57.526 0.077-42858,438 0.23 4.782 1.041- 0.044
lymph node dissection) 21.974
Adjuvant treatment (yes vs no) 3.382 0.378-28.493 0.281 3.324 0.700- 0.131
15.792
Tumor size (<4cm vs >=4cm) 32.114 3.583-287.821 0.02 10.261 2.619- 0.001
41.794
HPV status (pos vs neg) 3.69 0.055-1.347 0.111 2.197 0.112- 0.273
1.856
Tumor grade (1,2 vs 3) 2.032 0.244-16.923 0.512 3.841 0.495- 0.198
29.831
Silva pattern (A, B vs C) 22.565 0.000-8545346.7 0.634 1.187 0.109- 0.869
6.494
Lympho-vascular invasion (yes vs 3.289 0.633-17.093 0.157 2.998 0.893- 0.076
no) 10.071
Lymph node metastasis (yes vs 14.95 1.694-131.912 0.015 5.52 1.569- 0.008
no) 19.424
Local/pelvic pelvic recurrences 12.323 1.436-105.770 0.022 18.089 2.040- 0.009
(yes vs no) 160.361

Conclusions: iSMILE is an aggressive cervical tumor biologically different from other HPVA adenocarcinomas due to propensity for
LNM, local/distant recurrence. FIGO stage, tumor size, LNM and presence of local/pelvic recurrences are determinants of outcome in
iSMILEs.

1194 FIGO (2018) Stage IB Endocervical Adenocarcinomas: A Detailed Study of Clinical Outcomes
Informed by Clinico-Pathological Parameters, including HPV Status
Simona Stolnicu1, Monica Boros2, Lynn Hoang3, Louise De Brot4, Glauco Baiocchi4, Graziele Bovolim4, Carlos Parra-Herran5,
Esther Oliva6, Kay Park7, Nadeem Abu-Rustum7, Robert Soslow7
1
University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Mures, Romania, 2Faculty of Medicine and
Pharmacy, University of Oradea, Oradea, BH, Romania, 3Vancouver, BC, 4A.C.Camargo Cancer Center, São Paulo, SP,
Brazil, 5Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, 6Massachusetts General Hospital, Harvard
Medical School, Boston, MA, 7Memorial Sloan Kettering Cancer Center, New York, NY

Disclosures: Simona Stolnicu: None; Monica Boros: None; Lynn Hoang: None; Louise De Brot: None; Glauco Baiocchi: None; Graziele
Bovolim: None; Carlos Parra-Herran: None; Esther Oliva: None; Kay Park: None; Nadeem Abu-Rustum: Grant or Research Support,
Stryker; Grant or Research Support, GRAIL; Robert Soslow: Speaker, Ebix/Oakstone

Background: FIGO stage and HPV status pattern are prognostic in endocervical adenocarcinomas (ECAs). 2018 FIGO stage IB is
heterogeneous, posing clinical management challenges for gynecologists. We aimed to determine parameters that associate with overall
survival (OS) and recurrence free survival (RFS) in stage IB ECAs.

Design: Stage IB ECAs with at least 5-year follow-up were collected from 12 international institutions, all with lymph node evaluation.
Preoperative radio- and/or chemotherapy was exclusionary. Full slide sets (n=421) were used to assign microscopic type (IECC
classification), HPV status, lympho-vascular invasion (LVI) and lymph node metastases (LNM). Kaplan-Meier survival analysis and Cox
regression were used for statistical analysis.

Results: 45.6% were stage IB1, 38.47% IB2 and 14.96% IB3. 7.12% died of disease and 14.25% suffered a recurrence. OS at 5- and 10-
years did not differ across substages (p: 0.339), whereas RFS across substages at 5- and 10-years differed (p: 0.012).On univariate
analysis, there was a higher risk of recurrence for stage IB3 versus IB2 (p:0.05; HR=1.848). OS was significantly associated with LVI
(p:0.021; HR=2.62), LNM (p:0.02, HR=3.825) and local recurrence (p:0.001: HR=32.308), while RFS was associated with HPV
status (p=0.017; HR=2.24), LVI (p:0.001; HR=3.614) and LNM (p:0.001; HR=5.696).

1140
Conclusions: Beyond depth of invasion and tumor diameter, HPV-negative Stage IB ECAs with LVI and LNM have the highest
recurrence risk, especially in the IB3 subgroup. These parameters are important to be included in any future sub-staging modification of
stage IB cervical adenocarcinoma.

1195 Persistent Expression Pattern of Biomarkers in Endometrial Intraepithelial Lesions in Consecutive

Biopsies and its Clinical Implications: A Longitudinal Study
Amanda Strickland1, Hao Chen2, Elena Lucas3, Katja Gwin1, Glorimar Rivera- Colón1, Shuang Niu4, Kelley Carrick3, Diego
Castrillon3, Wenxin Zheng1
1
University of Texas Southwestern Medical Center, Dallas, TX, 2Coppell, TX, 3University of Texas Southwestern, Dallas,
TX, 4UTSW Medical Center, Frisco, TX

Disclosures: Amanda Strickland: None; Hao Chen: None; Elena Lucas: None; Katja Gwin: None; Glorimar Rivera- Colón: None; Shuang
Niu: None; Kelley Carrick: None; Diego Castrillon: None; Wenxin Zheng: None

Background: Hyperplasia with atypia (HA), or endometrial intraepithelial neoplasia (EIN), is known as the precursor of endometrioid
adenocarcinoma. Progestin treatment is common for young patients desiring future fertility. It is thus routine to evaluate progestin-
treated endometrial specimens for residual disease, but this may be challenging due to the lack of well-established diagnostic criteria.
Biomarkers like PAX2 and PTEN have proved useful in facilitating diagnosis of HA/EIN. Whether the expression pattern of these two
biomarkers persists after progestin treatment, and whether biomarker expression can be restored after progestin treatment, are two
currently unanswered questions investigated in this study.

Design: 21 patients with initial diagnosis of EIN and n≥2 follow-up (f/u) endometrial biopsies (n=85) were divided into 3 categories based
on clinical outcome: A) persistent disease group (8 patients, 26 biopsies); B) recurrent disease group (5 patients, 24 biopsies); C)
optimally treated (complete response, CR) group (8 patients, 35 biopsies). PAX2 and PTEN immunohistochemistry (IHC) was performed
on all biopsies.

Results: Loss of PAX2 and/or PTEN expression was identified in 19 (90.5%) of 21 available primary biopsies. 19 (90.5%) cases showed
lost PAX2 expression, 8 (38.1%) cases exhibited lost PTEN expression, and 2 cases retained both markers (9.5%). All 19 f/u cases
(100%) with residual or recurrent EIN had the same expression pattern of PAX2 and PTEN (p<0.00001) in the involved areas as in the
initial biopsies. Completely restored PAX2 and PTEN expression was found in all 30 (100%) CR biopsies (p<0.00001) (Figure 1). Five
(71.4%) of 7 f/u biopsies not completely meeting EIN diagnostic criteria showed concordant PAX2 and PTEN expression patterns,
whereas 2 cases (28.6%) showed normal expression of PAX2 and PTEN. 3 cases (8.8%) initially diagnosed as “no residual hyperplasia
identified” were re-classified as “residual hyperplasia identified” based on morphologic features and IHC staining pattern with PAX2 and
PTEN. One case with uncertain status regarding residual hyperplasia based on morphologic features was re-classified as “no residual
hyperplasia identified”.

Figure 1 - 1195

1141
 Figure 2 - 1195

Conclusions: 1) PTEN/PAX2 expression patterns in HA/EIN persist across serial biopsies. 2) Restored PTEN/PAX2 expression is
observed in cases with a CR to progestin treatment. 3) PTEN/PAX2 staining in initial and follow-up biopsies is useful in evaluating
questionable residual HA/EIN (Figure 2).

1196 FOXO1 Expression and its Potential Role in Endocervical Carcinogenesis

Amanda Strickland1, Hao Chen2, Elena Lucas3, Shuang Niu4, Diego Castrillon3, Glorimar Rivera- Colón1
1
University of Texas Southwestern Medical Center, Dallas, TX, 2Coppell, TX, 3University of Texas Southwestern, Dallas,
TX, 4UTSW Medical Center, Frisco, TX

Disclosures: Amanda Strickland: None; Hao Chen: None; Elena Lucas: None; Shuang Niu: None; Diego Castrillon: None; Glorimar
Rivera- Colón: None

Background: FOXO1 is largely considered a tumor suppressor due to its inhibition of cancer cell growth and induction of apoptosis.
FOXO1 has been implicated in cervical carcinogenesis. We investigated the presence and quality of FOXO1 expression in endocervical
adenocarcinomas.

Design: Thirty-eight (38) cervical adenocarcinoma cases were reviewed by three gynecologic pathologists and classified using the three-
tiered Pattern Based Classification System (PBCS). Unstained slides from each case were made, and immunohistochemical (IHC)
analysis of FOXO1 antibody (Cell Signaling Technology, catalog # 2880) was performed on a Dako Autostainer Link 48 system at 1:50
antibody dilution. FOXO1 IHC expression was evaluated and results were recorded. Statistical analysis was performed to compare
FOXO1 expression in relation to the patterns of invasion.

Results: After the evaluation of 38 cervical adenocarcinoma cases, 6 (16%) were classified as pattern A, 6 (16%) as pattern B and 26
(68%) as pattern C. In all cases, FOXO1 was weak/multifocally positive (n=28; 74%) or lost (n=10; 26%). 22 out of 26 (85%) cases that
were classified as pattern C expressed FOXO1 (p=0.024). Importantly, there was also an association between FOXO1 glandular
expression and the presence of intraluminal tumor apoptosis (p=0.0026). Additionally, only pattern C cases showed intraluminal
apoptotic/ghost cells [Figure 1] with expression of FOXO1 [Figure 2] (p=0.0011

Conclusions: Our results show a likely correlation of pattern C endocervical adenocarcinoma with positive expression of FOXO1. This
finding may have an impact on the evaluation of cervical adenocarcinoma because it could help predict the tumor behavior. In addition,
the association between FOXO1 glandular expression and presence of intraluminal tumor apoptosis implies increased apoptotic activity
and tumor turnover in FOXO1 expressing tumor cells. This could help explain the more aggressive biologic behavior of this subtype. Our
findings suggest that FOXO1 may be a potential prognostic marker of cervical adenocarcinoma.

1142
1197 Endometrial Serous Carcinoma with Shared Features of Ovarian High-Grade Serous Carcinoma:
A Distinct Subset of Tumors?
Amanda Strickland1, Hao Chen2, Yiying Wang3, Shuang Niu4, Elena Lucas5, Glorimar Rivera- Colón1, Katja Gwin1, Kelley
Carrick5, Anais Malpica6, Wenxin Zheng1
1
University of Texas Southwestern Medical Center, Dallas, TX, 2Coppell, TX, 3Henan Provincial People's Hospital, Zhengzhou,
China, 4UTSW Medical Center, Frisco, TX, 5University of Texas Southwestern, Dallas, TX, 6The University of Texas MD
Anderson Cancer Center, Houston, TX

Disclosures: Amanda Strickland: None; Hao Chen: None; Yiying Wang: None; Shuang Niu: None; Elena Lucas: None; Glorimar Rivera-
Colón: None; Katja Gwin: None; Kelley Carrick: None; Anais Malpica: None; Wenxin Zheng: None

Background: Typical endometrial endometrioid (EEC) and serous carcinomas (ESC) have distinct morphologic and immunophenotypic
features. WT1 expression in ESC has been reported to range from 0% to 30% while estrogen receptor (ER) expression is variable, up to
80% in a recent study. This causes diagnostic challenges in assigning histologic type (EEC versus ESC) and primary site (endometrium
versus ovary) for these cancers. Any implication conferred by ER and WT1 expression in ESC is also unclear. We assessed WT1
expression in whole tumor sections and ascertained whether such expression correlates with ER expression in ESC. We also included a
cohort of EEC for comparison.

Design: 84 endometrial cancers were retrieved and re-reviewed. Whole tumor sections were obtained and used for
immunohistochemistry (IHC) studies for p53, p16, ER/PR, PTEN, Pax2, mismatch repair proteins (MMR), and WT1. The histotype was
confirmed using morphological features and IHC results. Among the 84 cases, 39 were EEC, 43 ESC, 1 true mixed EEC and ESC, and 1
dedifferentiated. To address the above questions, we only present data regarding ER and WT1 in this study. ER high expression and
WT1 positivity was each defined as 50% or more tumor cells showing strong positive nuclear staining. Benign fallopian tube sections with
positive expression for both ER and WT1 served as positive controls.

Results: 21/43 (48.8%) ESCs were positive for WT1 and the same number of ESCs was positive for ER expression. Among the 21 ESCs
with positive ER, 18 (86%) were positive for WT1, while only 3 of 22 (14%) ESCs with negative ER expression were positive for WT1 (p <
0.00001). In contrast, 5 of the 39 (13%) EECs were WT1 positive, while the remaining 34 (87%) were WT1 negative (p < 0.0001). The
mixed EEC-ESC showed WT1 positivity in the serous component only while ER was positive in both components. One dedifferentiated
EEC showed WT1 expression in the low-grade cancerous area. The data is summarized in Table 1.

Table 1. WT1 and ER expression in endometrial cancers

IHC Biomarkers WT1 positive WT1 negative

EEC 5 34
ESC ER positive 18 3
ER negative 3 19
Mixed EEC-ESC 1 (in serous only)
Dedifferentiated 1 (in low-grade area)

Note: EEC: endometrial endometrioid carcinoma; ESC: endometrial serous carcinoma

Conclusions: For the first time, we show that approximately half of ESCs are positive for both WT1 and ER. This finding indicates the
need for caution in using these biomarkers to determine the primary site of a serous carcinoma (uterine versus extra-uterine). In addition,
WT1 expression in ESCs correlates with a high ER expression, which may suggest the existence of an ovarian high-grade serous
carcinoma-like subset within ESCs.

1198 Stratified Mucin-Producing Intraepithelial Lesion (SMILE) of the Uterine Cervix: Squamous
Immunohistochemical Phenotype Related to Variable High Risk HPV Genotypes
Margareta Strojan Flezar1, Neza Nedelko2, Mario Poljak2, Anja Oštrbenk Valenčak2, Helena Gutnik2
1
Institute of Pathology, Faculty of Medicine University, Ljubljana, Slovenia, 2Faculty of Medicine, University of Ljubljana,
Ljubljana, Slovenia

Disclosures: Margareta Strojan Flezar: None; Neza Nedelko: None; Mario Poljak: None; Anja Oštrbenk Valen?ak: Speaker,
Abbott; Speaker, Qiagen; Speaker, Seegene; Helena Gutnik: None

Background: Stratified mucin producing intraepithelial lesion (SMILE) is a rare presumably high grade cervical precancerous lesion
designated as a variant of AIS in 2014 WHO classification. Histomorphology of SMILE indicates both squamous and glandular
differentiation. We analysed immunohistochemical phenotype, mucin presence and HPV genotypes of SMILE.

1143
Design: SMILE was diagnosed in 34 of 6958 (0,5 %) cervical biopsies in 23 patients between 2010 and 2018. Only 26 tissue samples (13
with SMILE alone, 7 with SMILE and SIL (1 LSIL, 6 HSIL), 4 with SMILE and AIS, 1 with SMILE, HSIL and AIS, 1 with SMILE, HSIL, AIS
and adenocarcinoma) from 21 patients were available for further studies. Immunohistochemical staining to p16, Ki-67, CK7 and CK19
(both present in endocervical columnar, reserve and basal layer squamous cells), p40 (highly sensitive and specific squamous marker:
ΔNp63 - a p63 isoform) and mucin stain (Alcian Blue) were conducted. HPV genotyping was performed using a clinically validated real-
time polymerase chain reaction-based Seegene Anyplex II HPV 28 Assay capable of detecting 28 alpha-HPV genotypes.

Results: All SMILEs showed strong positive reaction to p16, CK7, CK19 and high Ki67 proliferation index, also comparable to adjacent
HSIL and/or AIS if present. SMILE showed mucin presence that was statistically significantly different from HSIL. Moreover, SMILE
showed strong p40 positive staining comparable to HSIL and statistically significantly different from AIS. HPV was detected in 24/26 (92.3
%) cases. In 22 cases, single HPV genotype was identified and in one sample each 2 and 3 HPV genotypes. All HPV genotypes but one
were high-risk (23/24, 95.8 %) We have identified 6 different high-risk HPV genotypes (16, 18, 31, 33, 39, 51), the most common being
HPV16 (10/23 cases, 43.5 %), HPV18 (8/23 cases, 34.8 %), HPV 31 (5/23 cases, 21.7 %).

Conclusions: Although mucin is an integral glandular marker of SMILE, we found strong expression of p40, confirming squamous
differentiation in SMILE and suggesting it is a separate entity from AIS. We confirmed that SMILE is predominantly associated with high-
risk HPV infection, but HPV genotypes do not differ from those commonly associated with HSIL and AIS.

1199 Integrative Molecular Profiling of Uterine Smooth Muscle Tumors (USMT) Highlights Potential
Utility for Targeted Next-Generation Sequencing (NGS) of Histologically Challenging Cases
Julianne Szczepanski1, Andrew Sciallis2, Scott Tomlins2, Aaron Udager3
1
University of Michigan, Lake Orion, MI, 2University of Michigan, Ann Arbor, MI, 3University of Michigan Medical School, Ann
Arbor, MI

Disclosures: Julianne Szczepanski: None; Andrew Sciallis: None; Scott Tomlins: Employee, Strata Oncology; Stock Ownership, Strata
Oncology; Aaron Udager: None

Background: Histologic classification of USMTs may be difficult for tumors with unusual combinations of increased mitotic activity,
cytologic atypia, and/or geographic tumor necrosis – morphologic features that are subject to inter- and intra-pathologist variability. In
addition, intravascular growth and/or distant metastatic dissemination without other overt histologic features of malignancy is present in
rare subsets of cases. Despite these clear challenges, few ancillary tools are available to aid pathologists in the evaluation of USMTs with
atypical features.

Design: 10 USMTs were retrospectively identified from the surgical pathology records database at a single large academic institution: 3
conventional leiomyomas (LM), 1 intravascular leiomyoma (IVLM), 1 benign metastasizing leiomyoma (BMLM), 2 atypical USMT, and 3
leiomyosarcomas (LMS). Targeted NGS was performed on an Ion Torrent S5 sequencer using custom AmpliSeq panels and FFPE-
extracted tumor DNA and RNA. NGS data was processed using in-house bioinformatics pipelines; log2-transformed normalized RNAseq
data was visualized using unsupervised hierarchical clustering.

Results: Targeted NGS revealed MED12 mutations without significant copy number alterations (CNA) in all LM samples; in contrast, all
LMS samples harbored frequent high-level CNA and/or deleterious tumor suppressor gene mutations (i.e., TP53 and/or RB1). RNAseq
data highlighted clear transcriptomic differences between LM and LMS, including higher expression of cell cycle/proliferation (CCP)
genes. The BMLM showed intermediate CCP gene expression without identifiable molecular alterations, while the IVLM demonstrated
intermediate CCP gene expression with scattered low-level CNA. One atypical USMT demonstrated focal deep deletion of the FH gene
and low CCP gene expression, while the other atypical USMT harbored a MED12 mutation with high CCP gene expression but without
significant CNA.

Conclusions: These data highlight distinct molecular features of unequivocally benign and malignant USMT, including MED12 and tumor
suppressor gene mutation status, CNA patterns and genomic complexity, and CCP gene expression levels. In contrast, the molecular
spectrum of unusual leiomyoma variants (IVLM and BMLM) and other atypical USMT is heterogeneous and highly idiosyncratic, indicating
that integrative targeted NGS may be important to provide a common molecular framework upon which to evaluate USMT in future
studies.

1200 Universal Screening for Lynch Syndrome using Mismatch Repair Protein Immunohistochemistry
in an Asian Cohort of Endometrial Carcinomas
Nicholas Jin Hong Tan1, Tuan Zea Tan2, David Tan3, Diana Lim1
1
National University Hospital, Singapore, Singapore, 2Cancer Science Institute of Singapore, National University of Singapore,
Singapore, Singapore, 3National University Cancer Institute of Singapore, Singapore, Singapore

Disclosures: Nicholas Jin Hong Tan: None; Tuan Zea Tan: None; David Tan: Consultant, MSD; Grant or Research Support,
AZD; Consultant, ROCHE; Consultant, Bayer; Diana Lim: None

1144
Background: Patients with Lynch Syndrome (LS) carry a significantly elevated lifetime risk for several malignancies including
endometrial carcinomas (EC). Universal LS screening for patients with EC has been proposed to maximize detection of LS in this
population. We examined the clinicopathologic features of EC with mismatch repair protein (MMR) protein deficiency that were identified
on universal screening at a single Asian institution.

Design: Slides from all EC screened between January 2016 and December 2018 using MMR immunohistochemistry (IHC) were
reviewed and correlated with clinicopathological features including age at diagnosis, tumor type, size, site, grade, stage, tumor-infiltrating
lymphocytes (TILs), presence of Crohn’s-like lymphoid reaction (CLR) and family/personal history of cancer.

Results: A total of 162 EC were screened with MMR IHC. Deficiency in ≥1 MMR protein was observed in 33 cases (20.3%) and they
include cases with: MLH1 and PMS2 loss (16), MSH2 and MSH6 loss (9), PMS2 loss (4) and MSH6 loss (4). These patients ranged in
age from 37 to 70 (mean 55.2) years. Thirty-one patients had endometrioid carcinomas (16 G1, 6 G2, 9 G3), 1 had clear cell carcinoma
and 1 had MMMT. Twenty-seven patients were stage I, 1 was stage II, 3 were stage III and 2 were stage IV at presentation. One patient
had a history of breast and renal cancers and 9 had family histories of LS-related cancers. There were no significant differences in the
clinicopathological characteristics of EC with intact and deficient MMR immunoexpression except more TILs (mean 46/10 HPFs versus
19/10 HPFs, p<0.005) and a higher incidence of CLR (p <0.005) were seen in tumors with loss of MMR proteins.

Conclusions: Most patients with loss of MMR immunoexpression do not fulfill the Amsterdam II or Bethesda criteria for LS testing. The
presence of increased TILs or CLR can help to identify EC with MMR protein deficiency. Our findings support universal LS screening for
Asian patients with EC, as the majority of potential LS patients in this cohort would have been missed by conventional screening
algorithms based solely on age at diagnosis and significant personal or family history of cancers.

1201 Size of Lymph Node Metastasis Significantly Affects Overall Survival but not Recurrence-Free
Survival in a Cohort of 182 Single-Institution Endometrial Carcinomas
Matthew Thomas1, Scott Robertson2, Amy Joehlin-Price2
1
Cleveland, OH, 2Cleveland Clinic, Cleveland, OH

Disclosures: Matthew Thomas: None; Scott Robertson: None; Amy Joehlin-Price: None

Background: The 8th Edition of the AJCC Cancer Staging Manual adopted size of lymph node (LN) metastasis in the pN staging of
endometrial cancer (EC). Little data exist to suggest whether this information has an impact on outcomes of EC.

Design: We reviewed consecutive EC with LN metastases that were diagnosed at our institution between 2002-2015. Sizes of the largest
LN metastases were measured histologically and classified as isolated tumor cells (≤0.2 mm), micrometastases (≥0.2 mm to 2 mm) and
macrometastases (>2 mm). Clinical outcome data were obtained from the institutional electronic medical records and tumor
registry. Logrank tests were performed and Kaplan Meier curves were constructed for both overall survival and recurrence-free survival
using Stata version 15.1 (Statacorp, College Station, TX).

Results: 182 EC with LN metastases were identified in patients that ranged from 43 to 84 years (median 63). Cases included 66 (36%)
low grade EC, 32 (18%) high grade endometrioid EC, 34 (19%) serous carcinomas, 11 (6%) clear cell carcinomas, 16 (9%)
carcinosarcomas, 20 (11%) mixed epithelial carcinomas, and 3 (2%) dedifferentiated or undifferentiated carcinomas. Sixteen (9%)
demonstrated ITCs, 27 (15%) demonstrated micrometastases, and 139 (76%) demonstrated macrometastases (ranging from 2.1 mm to
70 mm, median 12 mm). Follow up time ranged from <1 month to 172 months (median 44 months). At the end of the follow up period, 76
(42%) patients remained free of disease, 8 (4%) patients were alive with disease, and 79 (43%) died of disease. The remaining 19 (10%)
patients were dead of unrelated or unknown causes. During the follow up period, 71 (39%) patients experienced recurrences; of these,
14 (20%) were local recurrences and 57 (80%) were distant. Overall survival differed significantly between the three groups of EC
patients with LN metastases, but recurrence-free survival only trended towards a difference (see Figure 1). Recurrence free survival
remained insignificant when considering only distant metastases (as opposed to either local/vaginal or distant metastases) and when the
tumor type was restricted to only low grade EC.

1145
 Figure 1 - 1201

Conclusions: Size of LN metastasis, when classified according to the 8th Edition of the AJCC Cancer Staging Manual, significantly
affects overall survival but not recurrence-free survival. Further study is necessary to determine the impact these measurements should
have on clinical treatment decisions.

1202 Endometrial Carcinoma Molecular Subtype is Associated with Pathologic and Prognostic Indices:
Findings from a National Study
Emily Thompson1, Samuel Leung2, Amy Lum3, Janine Senz4, Jutta Huvila5, Marilyn Kinloch6, Saul Offman7, Monalisa Sur8, Alice
Lytwyn9, Katherine Grondin10, Chantale Morin11, Carlos Parra-Herran12, Francois Gougeon13, Lynn Hoang14, Jessica McAlpine5,
C. Blake Gilks15
1
Vancouver General Hospital/University of British Columbia, Vancouver, BC, 2University of British Columbia and British
Columbia Cancer Agency, Vancouver, BC, 3British Columbia Cancer Research Centre, Vancouver, BC, 4University of British
Columbia, Vancouver, BC, 5University of British Columbia and BC Cancer Agency, Vancouver, BC, 6Saskatoon, SK, 7Dalhousie
University, Halifax, NS, 8McMaster University, Burlington, ON, 9Juravinski Hospital, Hamilton, ON, 10Quebec, QC, 11Levis,
QC, 12Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, 13CHUM, Montreal, QC, 14Vancouver,
BC, 15Vancouver General Hospital, Vancouver, BC

Disclosures: Emily Thompson: None; Samuel Leung: None; Amy Lum: None; Janine Senz: None; Jutta Huvila: None; Marilyn Kinloch:
None; Saul Offman: None; Monalisa Sur: None; Alice Lytwyn: Grant or Research Support, Astra Zeneca; Chantale Morin: None; Carlos
Parra-Herran: None; Francois Gougeon: None; Lynn Hoang: None; Jessica McAlpine: None; C. Blake Gilks: None

Background: Inconsistencies in the management of endometrial carcinoma (EC) persist in part due to inter-observer variability in grading
& histotype designation, and thus risk assignment. TCGA-informed molecular classification of EC is reproducible and provides prognostic
and predictive information while also identifying women who may have inherited cancer syndromes. Herein we describe the molecular
subtype distribution and histo-morphologic correlates in a nation-wide cohort of ECs.

Design: We collected representative tumour samples and clinicopathologic data for all ECs diagnosed in the calendar year 2016 from 24
participating centers. Proactive Molecular risk classifier for Endometrial Cancer (ProMisE) subtype was determined by
immunohistochemistry for mismatch repair (MMR) and p53 proteins performed on whole stained sections, and by focused sequencing for
mutations in polymerase epsilon (POLE) gene.

Results: 1453 ECs from 24 centers have been identified for entry into this study. Complete molecular and clinical outcome data is
available on 278 cases at time of this submission. The distribution of ProMisE subtypes and clinicopathologic features associated with
molecular subtype are outlined in Table 1 and depicted in Figure 1.

1146
Highlights

• ProMisE subtype associated with progression-free survival (p=0.047).

• We observed a significant association between MMRd and presence of lymphvascular invasion (LVI) (p=0.002).
• Variation in the routine use of MMR and p53 IHC, and reporting of extent of LVI (i.e. focal versus extensive), was notable across
participating sites.

Table 1. Histopathologic characteristics by molecular subtype

Total * MMRd p53abn p53wt POLE
Number of Evaluated cases * 278 86 (30.9%) 57 (20.5%) 127 (45.7%) 8 (2.8%)
Histotype Endometrioid 209 (75.3%) 74 (86.0%) 7 (12.3%) 122 (96.1%) 6(75.0%)
Serous 33 (11.8%) 3 (3.5%) 29 (50.9%) 1 (0.8%) 0 (0.0%)
Mixed 15 (5.4%) 2 (2.3%) 9 (15.8%) 2 (1.6%) 2 (25.0%)
Dediff/undiff 8 (2.9%) 6 (7.0%) 2 (3.5%) 0 (0.0%) 0 (0.0%)
MMMT 6 (2.2%) 0 (0.0%) 6 (10.5%) 0 (0.0%) 0 (0.0%)
CCC 4 (1.4%) 0 (0.0%) 3 (5.3%) 1 (0.8%) 0 (0.0%)
Other** 3 (1.1%) 1 (1.2%) 1 (1.8%) 1 (0.8%) 0 (0.0%)
Tumor grade Grade 1/2 185 (66.3%) 63 (73.3%) 3 (5.3%) 115 (89.8%) 4 (50.0%)
Grade 3 94 (33.7%) 23 (26.7%) 56 (98.2%) 12 (9.4%) 4 (50.0%)
FIGO stage I 211 (75.6%) 66 (76.7%) 33 (57.9%) 106 (83.5%) 7 (87.5%
II-IV 55 (19.7%) 17 (19.8%) 23 (40.4%) 15 (11.8%) 1 (12.5%)
LVI Negative 169 (60.6%) 41 (47.7%) 36 (63.2%) 88 (69.3%) 5 (62.5%)
Positive 95 (34.1%) 41 (47.7%) 20 (35.1%) 32 (25.2%) 3 (37.5)
+ focal 7 (2.5%) 4 (4.7%) 1 (1.8%) 1 (0.8%) 1 (12.5%)
+ extensive 11 (3.9%) 3 (3.5%) 1 (1.8%) 5 (3.9%) 2 (25.0%)
+ not specified 77 (27.6%) 34 (39.5%) 1 (1.8%) 26 (20.5%) 0 (0.0%)
Local MMR testing performed 45 (16.1%) 17 (19.8%) 5 (8.8%) 22 (17.3%) 1 (12.5%)
Local p53 testing performed 62 (22.2%) 14 (16.3%) 31 (54.4%) 13 (10.2%) 0 (0.0%)
* Indicates columns and rows where percentages have been expressed by total number of evaluated cases. All
remaining percentages are expressed by total number of cases per molecular subtype
** ‘Other’ histology included intestinal differentiated mucinous adenocarcinoma of the endometrium, a mixed
endometrioid and MMMT and dedifferentiated carcinoma and a mixed serous and clear cell carcinoma.
*** Missing data (FIGO stage, LVI, LND status) for non-surgically managed patients were considered in the
calculations for percentage values above.
Figure 1 - 1202

Conclusions: The molecular subtype of EC is of prognostic significance and correlates with histotype, with the most variation in
molecular subtype seen in endometrioid carcinomas. We identified considerable variability in the use of immunomarkers that allow for
molecular subclassification of EC at the time the cases in this study were reported (2016), and little uptake in the reporting of LVI as focal
or extensive.

1147
1203 Subclonal p53 Expression in a National Cohort of Endometrial Carcinomas
Emily Thompson1, Amy Lum2, Janine Senz3, Jamie Vanden Broek3, Samuel Leung4, Jutta Huvila5, Jessica McAlpine5,
C. Blake Gilks6
1
Vancouver General Hospital/University of British Columbia, Vancouver, BC, 2British Columbia Cancer Research Centre,
Vancouver, BC, 3University of British Columbia, Vancouver, BC, 4University of British Columbia and British Columbia Cancer
Agency, Vancouver, BC, 5University of British Columbia and BC Cancer Agency, Vancouver, BC, 6Vancouver General Hospital,
Vancouver, BC

Disclosures: Emily Thompson: None; Amy Lum: None; Janine Senz: None; Jamie Vanden Broek: None; Samuel Leung: None; Jutta
Huvila: None; Jessica McAlpine: None; C. Blake Gilks: None

Background: Immunohistochemistry (IHC) for p53 is used as a surrogate marker for TP53 mutations, and as part of the TCGA-based
molecular sublassification of endometrial carcinoma (EC). p53 staining with abrupt transition between mutational and wild-type patterns,
termed ‘subclonal’ staining, can be observed but the significance of this finding is unclear. Herein we describe a series of cases with
subclonal p53 IHC staining encountered as part of a national study assessing the potential clinical impact of molecular subtyping in EC.

Design: We collected representative tumor specimens for all ECs diagnosed in the calendar year 2016 from 24 centers across
Canada. IHC was performed at our institution on whole stained sections. The Proactive Molecular risk classifier for Endometrial Cancer
(ProMisE) subtype was determined using p53 IHC in conjunction with MMR IHC and targeted POLE mutation testing. Cases showing
subclonal p53 expression were interpreted by one resident (ET) and two gynecologic pathologists (CBG, JH). We interpreted any abrupt
change in pattern of p53 staining as subclonal.

Results: Complete molecular results from 278 ECs were reportable at the time of this submission. Subclonal p53 IHC staining was
observed in 19 (6.8%) of cases. Subclonal p53 staining was observed at levels ranging from 0.5% to 95% (median 11%). 7 of the 19
cases (37%) were classified as MMRd EC, 6 of which showed subclonal p53 expression at rates of <10%. An additional 5 cases (26%)
tumors contained pathogenic POLE mutations. The remaining 7 tumors (37%) were MMR intact/POLE wild type, and 6/7 contained
a TP53 mutation, the only exception being a tumor where the subclonal loss was only present in 3% of the tumor cells, and below the limit
of detection of the assay used.

Conclusions: Subclonal p53 IHC staining is relatively uncommon, and is most frequently encountered in the context of EC with
molecular features known to carry high mutational burden (MMRd, POLE), where TP53 mutation is a secondary event and not associated
with an adverse prognosis. There remain, however, cases (7/278, 2.5%) showingwith subclonal mutant expression pattern and an
underlying TP53 mutation, a pattern suggestive of tumor progression, and the significance of this finding warrants further study.

1204 Tumor BRCA Testing in High Grade Serous Carcinoma: Somatic BRCA Mutation Rates and
Optimal Tissue Requirements
Gulisa Turashvili1, Shengjie Ying2, Conxi Lazaro3, George Charames1, Aaron Pollett1, Andrew Wong1, Jordan Lerner-Ellis4
1
Mount Sinai Hospital, Toronto, ON, 2Department of Laboratory Medicine and Pathobiology, University of Toronto, North York,
ON, 3Catalan Institute of Oncology, Barcelona, Spain, 4Sinai Health System, Toronto, ON

Disclosures: Gulisa Turashvili: None; Shengjie Ying: None; Conxi Lazaro: None; George Charames: None; Aaron Pollett: None; Andrew
Wong: None; Jordan Lerner-Ellis: None

Background: Mutations in the BRCA1 and BRCA2, genes essential in the repair of DNA double-strand breaks by homologous
recombination (HR), have been reported in up to 25% of high grade serous carcinomas (HGSC). In BRCA-mutation carriers, poly (ADP-
ribose) polymerase (PARP) inhibitors selectively target HR-deficient cancer cells, and tumor tissue can also be tested to identify
additional patients for drug eligibility. We set out to characterize somatic BRCA mutation rates and optimal tissue requirements for
tumor BRCA testing.

Design: A total of 291 HGSC patients from 15 hospitals underwent somatic BRCA testing in October 2018-May 2019. Formalin-fixed
paraffin-embedded tissue samples were sequenced using a multiplexed polymerase chain reaction-based approach (Illumina AmpliSeq
Library PLUS for BRCA panel kit) on an Illumina MiSeq instrument. All reported variants had a minimum sequencing depth of 500X and
an allele frequency of >5%. Variants were assessed based on the American College of Medical Genetics and Genomics guidelines.
Pathogenic and likely pathogenic variants were reported as clinically significant.

Results: There were 253 surgical samples (87%), 35 biopsies (12%) and 3 cytology cell blocks (1%). Most patients (207, 71%) were
chemotherapy naïve. Nine cases (3%) had insufficient tumor, while 16 (6%) had poor DNA quality. Sequencing was successful in 228
cases (78%), failed in 25 (9%) and deemed incomplete in 38 (13%) due to failed exons or variants below the detection limit. Of 42
retested samples, 23 (55%) were successful. Subsequently, a total of 251 cases were successfully reported (86%). Pathogenic or likely
pathogenic variants were found in 48 patients (17%), including 30 in BRCA1 and 18 in BRCA2. Successful sequencing was dependent on
sample type (p=0.001), tumor cellularity (p=0.003) and tumor size (p<0.0001) but not on neoadjuvant chemotherapy (p>0.05), with failure

1148
rates at 26%, 33% and 6% in biopsies, cytology and surgical samples, respectively; 29%, 11% and 4% in samples with ≥50%, 20-40%
and 10% cellularity, respectively; and 7% and 39% in samples with ≥20% and 10% cellularity, respectively.

Conclusions: Our study shows a 17% somatic BRCA mutation rate. Success rates range from 78% on initial testing to 86% following
repeat testing. The success rate on repeat testing is 55% suggesting that suboptimal samples should be retested when possible. Biopsy
and cytology samples and post-chemotherapy specimens can be used, and optimal tumor should measure >5 mm with >10% cellularity.

1205 Recurrent Chromatin Remodeling Pathway Mutations Identified in Ovarian Juvenile Granulosa
Cell Tumors
Theodore Vougiouklakis1, Varshini Vasudevaraja2, Guomiao Shen1, Xiaojun Feng3, Sarah Chiang4, Julieta Barroeta5, Kristen
Thomas6, Lauren Schwartz7, Rebecca Linn8, Esther Oliva9, Pratibha Shukla10, Anais Malpica11, Deborah DeLair12, Matija
Snuderl13, George Jour6
1
New York University Langone Health, New York, NY, 2New York University Medical Center, New York, NY, 3NYU Langone,
New York, NY, 4Memorial Sloan Kettering Cancer Center, New York, NY, 5Cooper University Hospital, Philadelphia, PA, 6NYU
Langone Health, New York, NY, 7Perelman School of Medicine at the University of Pennsylvania, Bala Cynwyd, PA, 8Children's
Hospital of Philadelphia, Philadelphia, PA, 9Massachusetts General Hospital, Harvard Medical School, Boston, MA, 10NYU
School of Medicine, New York, NY, 11The University of Texas MD Anderson Cancer Center, Houston, TX, 12NYU Langone
Medical Center, New York, NY, 13New York University, New York, NY

Disclosures: Theodore Vougiouklakis: None; Varshini Vasudevaraja: None; Guomiao Shen: None; Xiaojun Feng: None; Sarah Chiang:
None; Julieta Barroeta: None; Kristen Thomas: None; Lauren Schwartz: None; Rebecca Linn: None; Esther Oliva: None; Pratibha Shukla:
None; Anais Malpica: None; Deborah DeLair: None; Matija Snuderl: None; George Jour: None

Background: The somatic missense mutation FOXL2 c.C402G (p.C134W) is harbored in 95-97% of adult granulosa cell tumors (AGCTs)
and functions as a pathognomonic oncogenic driver. More recently, KMT2D and TERT promoter mutations have been reported to
associate with recurrence in AGCTs. While the molecular pathogenesis of AGCTs has been well investigated, comprehensive genomic
analysis of juvenile granulosa cell tumors (JGCTs) is currently lacking.

Design: A total of seventeen (n=17) JGCTs were selected for this study. Cases were selected and analyzed based on JGCT
histomorphology and lack of FOXL2 c.C402G (p.C134W) mutational status. Slides were reviewed by two experienced gynecologic
pathologists. Formalin-fixed paraffin embedded (FFPE) tissues were subjected to DNA extraction for next generation sequencing (NGS)
using our customized NGS580 panel targeting all exonic and select intronic areas in 580 cancer related genes. Matched tumors against
normal pools were analyzed and manually curated to filter out single nucleotide polymorphisms (SNPs) and retain pathogenic variants by
a molecular pathologist.

Results: Clinical information and follow-up was available for eleven patients. Age at diagnosis ranged from 13 to 65 years of age
(median: 28). Fifteen cases (n=15) harbored callable mutations while 2 cases only had copy number (CN) losses. Recurrent mutational
events were identified in KMT2C (73%), RECQL4 (67%), FANCD2 (67%), KMT2D (53%), and RAD21 (47%).
Recurrent FANCD2 c.1278_1278del (p.L426fs) frameshift deletions were identified in ten of fifteen cases (67%), and RAD21 c.A49T
(p.I17F) single nucleotide variants (SNVs) in seven of fifteen cases (47%). Deleterious events included PALB2 in two cases (13%).
Recurrent homozygous CN losses in ATR (n=3), CDKN2A (n=2), SUFU (n=3), RB1 (n=4) and NF1 (n=3) were present in up to 30% of the
cases. EP400 and EGFR CN gains were seen in two cases [Figure 1]. The tumor mutational burden (TMB) ranged from 2.85 to 33.74
mut/mb. Four cases (27%) with a high TMB (>16.0 mut/mb; median cutoff) were associated with mutations in CD79A (p.A32G). One
case with FIGO stage II and one metastatic to the mesentery were also associated with KMT2D mutations.

1149
 Figure 1 - 1205

Conclusions: Our findings suggest that JGCTs shows a distinct genomic landscape compared to AGCTs. Alterations affecting chromatin
remodeling and hedgehog signaling pathways contribute to the pathogenesis of JGCTs. These findings provide novel insight into the
pathogenesis of a rare entity.

1206 Clinicopathologic Analysis and Morphologic Variants of Ovarian Juvenile Granulosa Cell Tumors
Theodore Vougiouklakis1, Sarah Chiang2, Pratibha Shukla3, Kristen Thomas4, Julieta Barroeta5, Lauren Schwartz6, Rebecca
Linn7, Esther Oliva8, Anais Malpica9, Matija Snuderl10, George Jour4, Deborah DeLair11
1
New York University Langone Health, New York, NY, 2Memorial Sloan Kettering Cancer Center, New York, NY, 3NYU School of
Medicine, New York, NY, 4NYU Langone Health, New York, NY, 5Cooper University Hospital, Philadelphia, PA, 6Perelman
School of Medicine at the University of Pennsylvania, Bala Cynwyd, PA, 7Children's Hospital of Philadelphia, Philadelphia,
PA, 8Massachusetts General Hospital, Harvard Medical School, Boston, MA, 9The University of Texas MD Anderson Cancer
Center, Houston, TX, 10New York University, New York, NY, 11NYU Langone Medical Center, New York, NY

Disclosures: Theodore Vougiouklakis: None; Sarah Chiang: None; Pratibha Shukla: None; Kristen Thomas: None; Julieta Barroeta:
None; Lauren Schwartz: None; Rebecca Linn: None; Esther Oliva: None; Anais Malpica: None; Matija Snuderl: None; George Jour: None;
Deborah DeLair: None

Background: Juvenile granulosa cell tumors (JGCTs) are rare neoplasms associated with a favorable prognosis, however, a subset of
patients develop recurrences. Morphologic overlap frequently renders a diagnostic challenge on account of the rarity of these tumors.

Design: A total of 29 cases from multiple institutions were identified. Select slides were reviewed by two experienced gynecologic
pathologists. Paired primary and metastatic tumors were reviewed, except in two cases where only recurrent/metastatic tumors were
available. All but one were pure JGCTs. Clinicopathologic features, including morphologic appearance, immunophenotype, and clinical
follow-up, when available, were recorded.

Results: Patient age ranged from 2-65 years (mean: 23; median: 16), and tumor size from 4-34 cm (mean: 16; median: 14). Stage at
presentation was: I (90%), II (5%), III (5%). Accompanied genetic disorders, Ollier disease and Donahue syndrome, were identified in two
patients; the latter associated with bilateral tumors. Morphology showed at least one of these accompanied architectural patterns:
follicular (83%), solid (62%), multinodular (31%), cystic (24%) and papillary (10%). Additional recognized features included foamy/bubbly
cytoplasm (70%), cells with a rhabdoid appearance (57%) and prominent cell borders (39%). Nuclear atypia was as follows: mild (n=6),
moderate (n=17), and moderate with focal severe/severe (n=6). Mitotic index ranged from 1-76/10 HPFs (mean: 12; median: 7). Inhibin
(18/18), calretinin (12/12), CD99 (7/7), CD56 (4/4) and WT1 (2/2) were positive when applied. Nuclear grooves were seen in two cases,
and no Call-Exner bodies were identified. Clinical follow-up was available for 20 patients (range 1-132 months), and identified four cases
with recurrence. Two patients had recurrence in the ovary; one contralaterally at 26 months and one ipsilaterally after cystectomy at 2
months. The remaining two recurred in the colonic serosa. One patient with bilateral tumors died of disease one month after surgery.

1150
Conclusions: JGCTs display a spectrum of morphologic features with variable mitotic activity and nuclear atypia. Recurrent/metastatic
disease developed in 20% of patients with available follow-up and 5% died (14% and 3%, respectively, in total series). Recognition of
these growth patterns and variable morphology is critical to render the correct diagnosis. Additional outcome data will be forthcoming.

1207 NF1 Mutations Are More Frequent in Metastatic vs. Primary-Site Cervical Squamous Cell
Carcinoma Specimens: A Case for NF1 Mutation Testing in Metastatic Squamous Cell Carcinoma
of the Cervix
John Wallbillich1, Radhika Gogoi1, Joseph Trak2, Saivaishnavi Kamatham2, Christopher Walker1, Rouba Ali-Fehmi2
1
Wayne State University School of Medicine, Detroit, MI, 2Wayne State University, Detroit, MI

Disclosures: John Wallbillich: None; Radhika Gogoi: None; Joseph Trak: None; Saivaishnavi Kamatham: None; Christopher Walker:
None; Rouba Ali-Fehmi: None

Background: Metastatic squamous cell carcinoma of the cervix (SCC-Cx) is a clinical challenge with poor survival and limited options for
effective second- or later-line systemic treatment. We sought to investigate whether there were differences in next generation sequencing
(NGS) genomic profiling results between primary squamous cell carcinoma of the cervix (SCC-Cx:primary) and metastatic-site squamous
cell carcinoma of the cervix (SCC-Cx:met).

Design: Data for this analysis was obtained from AACR’s Project GENIE (Cancer Discov. 2017 Aug;7[8]:818-831), a multi-Institutional
dataset of clinical-grade NGS genomic profiling results for many cancer sites and histologic
subtypes, through cBioPortal (http://genie.cbioportal.org). Patient/specimen groups used for analysis were SCC-Cx:primary and SCC-
Cx:met. The SCC-Cx:met group included lymph node and distant metastases. Mutation frequencies for all available genes were
calculated. For each gene, the difference in mutation frequencies between the two groups was evaluated using Fisher’s exact test. The
threshold for statistical significance was p-value < 0.05.

Results: In the SCC-Cx:primary group, there were 86 samples from 86 patients. In the SCC-Cx:met group, there were 54 samples from
53 patients. 1 patient with SCC-Cx had both primary and met samples in the dataset; that patient was excluded from patient-level
analyses. Median age (in years) was 47 and 50 in the SCC-Cx:primary and SCC-Cx:met groups, respectively. 322 genes were available
for analysis. PIK3CA was the gene with the highest mutation frequency in both the SCC-Cx:primary (35.2%) and SCC-Cx:met (33.7%)
groups. NF1 was the only gene with significantly different mutation frequencies between the SCC-Cx:primary (1.2%) and SCC-Cx:met
(11.3%) groups as illustrated in Figure 1 (p-value = 0.013).

Figure 1 - 1207

Conclusions: These data suggest NF1 mutations are more frequent in metastatic vs primary SCC-Cx tumors analyzed by NGS genomic
profiling. NF1 mutations appear sufficiently prevalent in this setting to merit strong consideration of NF1 testing and targeting in future
clinical trial development for metastatic SCC-Cx.

1151
1208 The Combination of p16, IGF2BP3 and p53 Identifies Low Risk Patients with Stage I Ovarian Clear
Cell Carcinoma
Linyuan Wang1, Katharina Wiedemeyer2, Martin Kobel3
1
University of Calgary, Calgary, AB, 2Calgary Laboratory Services/University of Calgary, Calgary, AB, 3University of
Calgary/Alberta Public Laboratories, Calgary, AB

Disclosures: Linyuan Wang: None; Katharina Wiedemeyer: None; Martin Kobel: None

Background: Among ovarian carcinomas, together with endometrioid carcinoma, clear cell carcinoma (CCC) is the second most
common histotype and it frequently presents at low stage, particular among young women. However, due to its resistance to the standard
platinum-based chemotherapy, there is a need to refine the therapeutic threshold and to identify new therapeutic targets. p16, IGF2BP3
and p53 have all been shown to be individual prognostic markers in all comers of CCC. In this study, we sought to evaluate whether a
combination of these 3 biomarkers can identify low risk patients within stage I CCC. Additionally, we screened stage II-IV CCC for
expression of existing theranostic markers.

Design: Tissue microarrays were constructed using 156 ovarian CCC (53 stage I, 61 stage II, 35 stage III and 8 stage IV).
Immunohistochemical (IHC) expression for p53 was categorized as mutant-type versus wild type, while p16 and IGF2BP3 as strong block
versus less. IHC status and survival was assessed using Kaplan survival analysis with the endpoint of 5-year ovarian cancer-specific
survival (5-Y OCSS). The expression frequency of common theranostic markers including MET, ER, PR, VEGFR2, ALK, ROS1, TRKA-C
(NTRK), and BRAF were assessed by IHC. ERBB2 (HER2) was assessed by IHC and SISH.

Results: During univariate analysis of 53 stage I CCC, p16, p53 and IGF2BP3, all identified cases with worse 5-Y OCSS but only p16
reached significance (log rank p = 0.0032). When analyzed in combinations, cases with various combinations of 2 or 3 abnormal markers
showed similar survival. Cases with at least 2-marker abnormality showed 5-year OCSS of 33%, while cases with one or no abnormal
biomarker expression showed 5-year OCSS of 91% (log rank <0.0001) (Figure 1). Among stage II-IV tumors, the frequency of MET
overexpression is 57%, ERBB2 amplification is 6%, expression of ER is 15% and PR is 4%. The remaining theranostic biomarkers were
not expressed in CCC.

Figure 1 - 1208

Conclusions: Normal expression in at least 2 of the 3-marker panel (p16, IGF2BP3 and p53) will identify stage I CCC with a survival
threshold where clinician may consider withholding adjuvant chemotherapy. We confirm a small proportion of ERBB2 amplification in
CCC that might be viable therapeutic option for high stage disease. The expression of hormone receptors is low in CCC and thus does
not warrant hormonal therapy. The value of MET overexpression remains elusive. Other theranostic targets are absent and shotgun
testing is discouraged.

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1209 A Five-Year Retrospective Clinicopathological Analysis of Vulvar Squamous Cell Carcinoma in a
Large Tertiary Care Women’s Hospital
Tiannan Wang1, Rohit Bhargava2, Cheng Zhiqiang3, Chengquan Zhao4
1
Department of Pathology, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, 2Magee-Womens
Hospital of UPMC, Pittsburgh, PA, 3Shenzhen People's Hospital, Shenzhen, Guangdong, China, 4Pittsburgh, PA

Disclosures: Tiannan Wang: None; Rohit Bhargava: None; Cheng Zhiqiang: None; Chengquan Zhao: None

Background: Vulvar squamous cell carcinoma (v-SCCa) is an uncommon malignant neoplasm representing approximately 6% of all
female genital cancer in US. HPV associated high grade usual intraepithelial neoplasm (uVIN) and HPV independent differentiated VIN
(dVIN) are the two major precursor lesions driven by different pathways and are conclusively linked to v-SCCa carcinogenesis. This study
aimed to analyze the clinicopathological features of v-SCCa and its precursor lesions, and to evaluate the clinical significance of two
different pathways.

Design: A series of 210 v-SCCa were identified from archived pathology reports during the period July 2014 to June 2019.
Clinicopathological features of dVIN associated v-SCCa vs. uVIN associated v-SCCa were analyzed with regard to patient age, tumor
size, depth of invasion (DI), lymphovascular invasion (LVI), lymph node status (LN) if sampled, whether associated with adjacent lichen
sclerosus, and pathologic stage.

Results: Total 210 v-SCCa cases from 65 (31%) biopsies, 28 (13.3%) excisional biopsies and 117 (55.7%) vulvectomies were
retrospectively reviewed. Median age of women with dVIN associated v-SCCa (98 of 210, 46.7%) was 71 years (range: 34-92) vs 60
years (range: 33-98) of women with uVIN associated v-SCCa (p<0.001). 50.26% of v-SCCa women aged >50 years had d-VIN related
disease as compared to 14.29% in women aged <50 years. Additionally, tumor size was larger in d-VIN associated v-SCCa cases and
dVIN related v-SCCa tends to present at higher FIGO stage. Lastly, 39 of 98 (39.8%) d-VIN cases showed adjacent lichen sclerosus.
1.4% of v-SCCa showed background of low grade VIN (VIN1).

Table1. Summarized Clinicopathological Features of v-SCCa

Invasive v-SCCa No. (%)

Total Negative / VIN-1 uVIN dVIN

210 13 (6.2%) 99 (47.1%) 98 (46.7%)

Mean±SE /Median age 66.1 ±1.0 / 65 69.7±3.0 / 67 61.9±1.4 / 60 70.1±1.3* / 71
Tumor size (mm) 16.7±1.6 n/a 16.6±2.9 17.2±1.9
Depth of Invasion (mm) 5.3±0.7 4.33±1.2 5.23±1.0 5.76±0.6
Lymphovascular Invasion 26 (12.4%) 1 (6.7%) 12 (12.1%) 13 (13.3%)
Positive Lymph Node 21 (10%) 1 (6.7%) 9 (9.1%) 11 (11.2%)
FIGO Stage Stage IA 48 (22.9%) 2 1 (50%) 81 33 (40.7%) 84 14 (16.7%)
(AJCC 8th) Stage 1B 88 (41.9%) 1 (50%) 33 (40.7%) 54 (64.3%)
Stage II 12 (5.7%) 0 7 (8.6%) 5 (6.0%)
Stage III 19 (9.0%) 0 8 (9.9%) 11 (13.1%)

*p<0.01

Conclusions: Our data elaborate the important clinicopathologic features of v-SCCa and its association with precursor lesions. In
summary, dVIN associated v-SCCa occurs in older populations, behaves in a more aggressive manner and presents at higher clinical
stage. Moreover, aforementioned age-related disease prevalence is more prominent in our study. P53 and P16 stains can further specify
a particular pathway if morphology is ambiguous.

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1210 Protein Tyrosine Kinase 2 (PTK2) Overexpression in Ovarian Carcinoma is Associated with Poor
Pprognosis and Distant Metastasis
Yaohong Wang1, Yongchao Li1, Shuyu E1, Sonali Lanjewar1, Jie Zhang1, Ian Clark2, Robert Bradley3, Farhan Khan3, Joel
Gradowski4, David Robins5, David McGregor3, Rodolfo Laucirica1, Junming Yue1, Mahul Amin6
1
University of Tennessee Health Science Center, Memphis, TN, 2University of Tennessee, Memphis, TN, 3The University of
Tennessee Health Science Center, Memphis, TN, 4University of Tennessee Health Sciences Center, Germantown, TN, 5West
Cancer Clinic, Memphis, TN, 6Methodist University Hospital, Memphis, TN

Disclosures: Yaohong Wang: None; Yongchao Li: None; Shuyu E: None; Sonali Lanjewar: None; Ian Clark: None; Farhan Khan: None;
Joel Gradowski: None; David McGregor: None; Rodolfo Laucirica: None; Junming Yue: None; Mahul Amin: Consultant,
Urogen; Consultant, Advanced Clinical; Advisory Board Member, Cell Max; Advisory Board Member, Precipio Diagnostics

Background: Ovarian carcinoma is among the leading causes of cancer death in women. The high-grade serous carcinoma is the most
common malignant ovarian tumor and initially presents with advanced stage with widespread intrabdominal metastasis. The prognosis is
poor with the five-year survival rate of less than 30% because of relapse and aggressive metastasis. There are no specific biomarkers for
ovarian carcinoma with prognostic and therapeutic significance. Protein tyrosine kinase 2 (PTK2) is a member of focal adhesion kinase
(FAK), which is upregulated or amplified in a variety of cancers including breast, lung, liver and colon cancer and is associated with
cancer patient poor survival, tumor recurrence and metastasis. However, role of PTK2 in ovarian cancer is still largely unknown.

Design: TCGA database, SurvExpress database and Kaplan-Meier Survival database were used for gene expression profiling of human
PTK2 expression. An orthotopic ovarian cancer mouse model was used for assessment of in-vivo primary tumor growth and
metastasis. A complementary part of our study involved tissue selections of patients with ovarian serous carcinoma from Methodist
University Hospital and West Cancer Center were stained with PTK2, PCNA, WT-1, P53, P16 and Pax8.

Results: Gene expression profiling from TCGA database shows PTK2 mRNA expression was significantly increased (p < 0.01) in ovarian
carcinoma (n = 606) compared with control normal ovary surface epithelium (n = 10). High PTK2 mRNA expression is correlated with
poor patient progress free survival (PFS) and overall survival (OS) based on Kaplan-Meier Survival database (n = 1435, p < 0.01).
Knockout of PTK2 resulted in the inhibition of primary tumor growth and metastasis in an orthotopic ovarian cancer mouse model.
Immunostaining showed increased PTK2 expression in ovarian cancer patients compared to normal ovarian surface epithelium. Further
clinical data analysis showed that high PTK2 expression associates with advanced surgical stage, higher tumor grade, increased lymph
node metastases, more disease relapse and poor patient survival.

Conclusions: We report for the first time that PTK2 expression is significantly upregulated in serous ovarian carcinoma promoting
ovarian tumor invasion and metastasis and is associated with poor prognosis. PTK2 might be useful for risk stratification and prognostic
evaluation of serous ovarian carcinoma and is a potential marker for targeted therapy.

1211 Folate Receptor Alpha Signatures in Mucosal Epithelial Cells of the Fallopian Tube: Further
Evidence Supporting Tubal Origin of “Ovarian” Endometriosis
Yiying Wang1, Yue Wang2, Yan Wang3, Wanrun Lin3, Hao Chen4, Oluwole Fadare5, Wenxin Zheng3
1
Henan Provincial People's Hospital, Zhengzhou, China, 2Henan Provincial People's Hospital, People's Hospital of Zhengzhou
University, School of Clinical Medicine, Henan University, Zhengzhou, Henan, China, 3University of Texas Southwestern Medical
Center, Dallas, TX, 4Coppell, TX, 5University of California San Diego, La Jolla, CA

Disclosures: Yiying Wang: None; Yue Wang: None; Yan Wang: None; Wanrun Lin: None; Hao Chen: None; Oluwole Fadare: None;
Wenxin Zheng: None

Background: Endometriosis is a puzzling and debilitating disease that affects millions of women around the world. Ovary is the most
common organ site involved by endometriosis. Despite various hypotheses about its cell of origin, uncertainty remains. Based on our
clinicopathologic observations, we hypothesize that fallopian tube contributes the histogenesis of ovarian endometriosis.

Design: To examine if the hypothesis, tubal origin of ovarian endometriosis, has scientific supporting evidence, we identified a set of
novel genes which are either highly expressed in the normal fallopian tube or in the endometrium through a gene differential array
study. We then detailed examined one of the top differentially expressed gene FOLR1 (real time qPCR) and its corresponding protein
FRA expression (Western blot and immunohistochemistry) in a total of 114 formalin fixed paraffin embedded tissue sections of the
fallopian tube, endometrium, and ovarian endometriosis.

Results: The differentially expressed gene FOLR1 was validated in ovarian sections with foci of endometriosis by comparing their
expression levels in the fallopian tube and the endometrium within the same patients with real-time PCR, Western blot and
immunohistochemistry analysis. FOLR1 was highly expressed in the tubal epithelia as well as in the ovarian endometriosis, while low in
the paired endometrium. Results of the protein FRA expression were similarly seen by using Western blot and
immunohistochemistry. Both the gene FOLR1 and the protein FRA expression in the tissues (the fallopian tube or the ovarian
endometriosis vs the endometrium) were significantly different (p < 0.001).

1154
Conclusions: The study provided additional evidence supporting that ovarian endometriosis is likely derived from the fallopian tube
instead of the endometrium through a retrograde menstruation. Understanding of tubal contribution to the ovarian endometriosis will
certainly illicit ideas of searching for alternative ways of prevention and treatment of endometriosis.

1212 Fumarate Hydratase-Deficiency Should be Considered in the Differential Diagnosis of Uterine and
Extra-Uterine Smooth Muscle Tumors of Uncertain Malignant Potential (STUMP)
Julianna J Weiel1, Kelly Devereaux2, Ann Folkins2, Teri Longacre1
1
Stanford University, Stanford, CA, 2Stanford University School of Medicine, Stanford, CA

Disclosures: Julianna J Weiel: None; Kelly Devereaux: None; Ann Folkins: None; Teri Longacre: None

Background: Fumarate hydratase-deficient (dFH) leiomyomas are recognized as a distinct clinicopathologic entity occurring in the
context of Hereditary Leiomyomatosis and Renal Cell Carcinoma (HLRCC) syndrome as well as the sporadic setting. Detection of dFH
leiomyomas by pathologic screening can prospectively identify women at increased risk for HLRCC who may benefit from genetic
counseling and surveillance for aggressive RCC.

We have recently encountered several smooth muscle tumors with atypical features for which the diagnosis of STUMP was considered;
each showed at least focal morphologic features suggestive of dFH. Loss of FH expression by IHC supported classifying these tumors as
atypical leiomyomas with dFH rather than STUMP and prompted review of archived STUMP cases to assess the prevalence of dFH
tumors in this cohort.

Design: 48 tumors previously diagnosed as a STUMP in 40 cases from 38 patients (2007-2016) with available FFPE material were
included in this retrospective study. FH IHC was performed on whole sections, with granular cytoplasmic staining of tumor cells
interpreted as intact and absence of cytoplasmic staining interpreted as deficient. Normal myometrium and intratumoral vessels served as
positive internal controls.

Results: Three of the 48 tumors (6.3%) were deficient for FH. These occurred in 2 patients (5.3%) including a 40-year-old with multiple
abdominopelvic tumors and a 71-year-old with a uterine tumor, both with a history of prior myomectomy. One uterine tumor with
dFH features in a 39 year-old showed heterogeneous loss of FH with patchy internal control staining; this was interpreted as an equivocal
result (FH eq). None of the tumors with aberrant FH recurred, with a mean follow-up of 81 months.

Table 1: STUMP Cohort Features and Clinicopathologic Characteristics of Cases with Aberrant FH

Total dFH FH eq
STUMP Tumors 48 3 1
NOS 31 3 1
Epithelioid 9 0 0
Myxoid 8 0 0
Site
Uterus 36 1 1
Pelvis 5 1 0
Abdomen 5 1 0
Retroperitoneum 2 0 0
Case 1 (dFH) Case 2 (dFH) Case 3 (FH eq)
Age (years) 40 71 39
Site Pelvis, abdomen Uterus, LUS Uterus, Corpus
Size (cm) 9.0, 4.5 - 7.8
Multiple Yes No No
Procedure Excision Hysterectomy Hysterectomy
Prior myomectomy Yes Yes Yes
Follow-up Length (months) 96 51 97
Recurrence No No No
RCC No No No
Features
HPC-Like vessels Yes Yes Focal
Edema Yes Yes Yes
Atypia Focal Diffuse No
Necrosis No Yes (Indeterminate-type) No
Mitoses (per 10 HPF) 4 1 1
Macronucleoli Focal Focal Rare
Hyaline Globules No Focal No

1155
Conclusions: 6.3% of tumors for which STUMP is a diagnostic consideration show aberrant loss of FH by IHC. Although data are limited,
dFH should be considered in the differential diagnosis of STUMP when suggestive features are present, even in the context of extensive
extra-uterine disease. Prospective screening for dFH in these cases may identify women at increased risk for HLRCC who may benefit
from genetic counseling. Given that loss of FH is reported to occur rarely, if at all, in clinically aggressive smooth muscle tumors, the
finding of dFH may support a low biologic potential for a neoplasm otherwise regarded as a STUMP. Indeed, patients with dFH tumors in
this study had a benign course after complete resection with no evidence of recurrence on long term follow-up.

1213 PAX7 is a Sensitive Marker of Skeletal Muscle Differentiation in Rhabdomyosarcoma of the

Female Gynecologic Tract
Julianna J Weiel1, Dina Kokh2, Gregory Charville3, Teri Longacre1
1
Stanford University, Stanford, CA, 2Mountain View, CA, 3Stanford University School of Medicine, Stanford, CA

Disclosures: Julianna J Weiel: None; Gregory Charville: None; Teri Longacre: None

Background: Rhabdomyosarcoma (RMS) is a clinically aggressive and histologically diverse mesenchymal tumor characterized by
skeletal muscle differentiation. In the gynecologic tract, RMS may occur rarely in a “pure” form or more commonly as a heterologous
constituent of a biphasic neoplasm such as carcinosarcoma or adenosarcoma. Discriminating RMS from its histologic mimics often relies
on confirmation of skeletal muscle differentiation by morphology or immunohistochemistry (IHC) for myogenin, which can be challenging
to interpret in some cases owing to limited expression. We hypothesized that IHC detection of PAX7, a paired box transcription factor
involved in early lineage specification of muscle progenitor cells, may augment current approaches to the identification of RMS in
gynecologic malignancies.

Design: A total of 39 cases (2010-2019) previously diagnosed as RMS in a gynecologic site were included. Cases underwent
microscopic review to confirm classification. PAX7 and myogenin were assessed by IHC on whole tissue sections. MyoD1 and desmin
IHC were also reviewed if available. A positive result was defined as nuclear immunoreactivity for PAX7 or myogenin in at least 5% of
tumor cells; less than 5% was regarded as focal. Pattern and percentage of positive staining was recorded.

Results: Positive PAX7 expression was observed in 95% (37/39) of all gynecologic RMS (Table 1) occurring in 36 patients aged 4 to 82
(mean 56.7) years. PAX7 was positive in a greater percentage of tumor cells than myogenin in 19 cases (51%). On average, 52% of
tumor cells were positive for PAX7 vs. 47% for myogenin. In most cases, both PAX7 and myogenin were expressed; however, two
myogenin-negative tumors expressed PAX7 in 30-50% of cells. No cases exhibited complete absence of both markers. PAX7 expression
was localized to primitive-appearing round to spindled cells, whereas myogenin was more commonly detected in maturing
rhabdomyoblasts including strap cells. Cytoplasmic immunoreactivity for PAX7 was not observed.

Table 1: Immunohistochemical Expression of Skeletal Muscle Markers in Gynecologic Rhabdomyosarcoma

Case (n) PAX7 Positive Myogenin MYOD1 Desmin

Positive Positive Positive
Gynecologic Rhabdomyosarcoma (All) 39 37 (95%) 37 (95%) 4/6 (67%) 21/23 (91%)
Pure Rhabdomyosarcoma 15 14 (93%) 14 (93%) 1/3 (33%) 10/11 (91%)
Embryonal 10 10 (100%) 9 (90%) 1/2 (50%) 6/7 (86%)
Pleomorphic 4 4 (100%) 4 (100%) - 3/3 (100%)
Alveolar (Fusion-Negative) 1 0 1 0 1
Carcinosarcoma 19 18 (95%) 17 (89%) 2/2 (100%) 9/10 (90%)
Adenosarcoma 3 3 (100%) 3 (100%) - -
Sertoli-Leydig Cell Tumor 1 1 1 - -
Indeterminate (Scant Sample) 1 1 1 1/1 1/1
Site of Origin
Vagina 4 4 (100%) 4 (100%) - 2/2 (100%)
Cervix 4 4 (100%) 3 (75%) 0/1 3/4 (75%)
Uterus 20 18 (90%) 20 (100%) 1/2 (50%) 13/13 (100%)
Ovary 7 7 (100%) 6 (86%) 1/1 1/2 (50%)
Fallopian Tube 1 1 1 - -
Pelvic Mass 3 3 (100%) 3 (100%) 2/2 (100%) 2/2 (100%)
Limited Biopsies (i.e. EMB or FNA) 7 6 (86%) 6 (86%) 1/1 6/6 (100%)

Conclusions: Our findings highlight the utility of PAX7 as a diagnostic marker of skeletal muscle differentiation across a broad spectrum
of rhabdomyosarcomatous gynecologic tumors. We advise that PAX7 be used in combination with other markers of skeletal muscle
differentiation, namely myogenin; it may be particularly helpful in cases where myogenin, MYOD1, and desmin expression is limited. The
consistently low background and nuclear localization allow for straightforward interpretation of PAX7 IHC.

1156
1214 Association between Fallopian Tubal Precursors and Adnexal Carcinosarcoma with Serous and
Non-Serous Epithelial Components
Arielle Weiss1, Barbara Norquist1, Elizabeth Swisher1, Thing Rinda Soong1
1
University of Washington, Seattle, WA

Disclosures: Arielle Weiss: None; Barbara Norquist: None; Elizabeth Swisher: None; Thing Rinda Soong: None

Background: Pelvic carcinosarcoma (CS) has been suggested to be clonally linked to serous tubal intraepithelial carcinoma (STIC), the
latter of which is known to be a precursor to high-grade serous carcinoma. Previous reports of CS with STICs were described in CS with
high-grade serous carcinoma being the sole epithelial component. It is unclear whether the association is restricted to STICs or if it is
affected by the extent of serous component in the tumor. We aimed to characterize the spectrum of tubal intraepithelial lesions associated
with adnexal CSs that exhibit serous, mixed or non-serous epithelial differentiations.

Design: Eleven adnexal CS resection cases with serous, clear cell, and/or endometrioid epithelial components were retrospectively
examined. Histologic review and p53 immunohistochemical study of all tubal blocks were performed to assess for the presence of tubal
intraepithelial proliferations, including STICs, p53 signatures or serous tubal intraepithelial lesions (STILs) with atypia that did not meet
the diagnostic threshold of STIC.

Results: Most (10/11) cases were stage 3 at diagnosis and occurred in post-menopausal BRCA-negative women. All presented as
expansile masses involving bilateral adnexa. STICs were identified in the fimbriae in 7/11 cases, of which 2 involved the fallopian tubes
bilaterally. STICs extended to the proximal fallopian tubes in 2 cases, and were present at multiple tubal sites in 4 patients. P53
signatures and STILs were seen in 4 subjects, with 1 being an isolated lesion in a STIC-negative resection. High-grade serous
morphology was identified in 10/11 cases but its extent varied from minimal (<10%) to prominent (>90%) in the tumors. Clear cell and
endometrioid morphologies were present as the predominant (>90%) epithelial component in 3 and 2 cases respectively. The majority of
tubal intraepithelial lesions shared identical p53 staining profile with the concurrent tumors in the adnexa (Table 1).

Figure 1 - 1214

Conclusions: Our series reveals a spectrum of tubal intraepithelial lesions ranging from p53 signatures to STICs in more than 50% of
adnexal CS cases with matching p53 profiles. The association is present even in tumors with minor serous component at the time of
resection. The observation suggests that a significant portion of CSs might have been derived from serous tubal precursors. The findings
have implications for treatment, as well as early detection and prevention of these highly aggressive tumors.

1157
1215 Molecular Triage Strategies for HPV Primary Screening
Christine White1, Stephen Reynolds2, Padmaja Naik3, Roisin O' Brien3, Trinh Pham4, Helen Keegan3, Niamh Kernan3, Loretto
Pilkington5, Imogen Sharkey Ochoa1, Fiona Wright6, Prerna Tewari1, Sharon O'Toole7, Charles Normand1, Linda Sharp8,
Grainne Flannelly9, Cara Martin7, John O'Leary1
1
Trinity College Dublin, Dublin, Ireland, 2CERVIVA, Dublin, Ireland, 3Coombe Women & Infants University Hospital, Dublin,
Ireland, 4Beacon Hospital, Dublin, Lenster, Ireland, 5Coombe Women & Infants University Hospital, Dublin, Dublin,
Ireland, 6National Cervical Screening Programme, Limerick, Limerick, Ireland, 7Trinity St. James's Cancer Institute, Dublin,
Ireland, 8Newcastle University, United Kingdom, 9National Maternity Hospital, Sandymount, Ireland

Disclosures: Christine White: None; Stephen Reynolds: None; Padmaja Naik: None; Roisin O' Brien: None; Trinh Pham: None; Helen
Keegan: None; Niamh Kernan: None; Loretto Pilkington: None; Imogen Sharkey Ochoa: None; Fiona Wright: None; Prerna Tewari: None;
Sharon O'Toole: None; Cara Martin: None; John O'Leary: None

Background: Appropriate triage of HPV primary cervical screening is a key challenge. This study investigates a panel of molecular triage
options including HPV16/18 genotyping, cytology, p16/Ki-67 and methylation markers [CADM1, MAL, miR1-124] in women who test
positive for HPV in primary screening.

Design: In partnership with CervicalCheck, The National Cervical Screening programme, CERVIVA are undertaking a longitudinal
observational HPV primary screening study which will evaluate different triage strategies for management of a HPV-positive primary
screening test. Cervical cytology samples from approximately 13,000 women undergoing routine cervical screening are tested for HPV
DNA (cobas 4800 HPV test) and mRNA (Aptima HPV assay). All HPV-positive women are further assessed with HPV16/18 genotyping,
cytology, p16/Ki-67 dual staining and methylation markers [CADM1, MAL, miR1-124]. The performance of different triage strategies will
be examined both cross-sectionally and longitudinally over two screening rounds for detection of CIN2+.

Results: From the overall study population 15.7% (1653/10,528) tested positive for HPV DNA and 12.8% (1613/12,601) tested positive
for HPV mRNA. Overall, 31.2% (514/1650) of HPV DNA positive women were positive for HPV16/18, 33.2% (548/1650) had an
abnormality on cytology, 36.6% (404/1104) tested positive for p16/Ki-67 and 39.9% (393/993) tested positive for methylation markers
[CADM1, MAL, miR1-124]. Clinical performance was assessed in a range of combinations for detection of CIN2+, sensitivity ranged from
57-96% and specificity from 46-96%.

Conclusions: Here we present an update on the longitudinal follow up and clinical performance in relation in to each of the putative
triage tests.

1216 Combined CCNE1 High-Level Amplification and Overexpression is Associated with Unfavorable
Outcome in Tubo-Ovarian High-Grade Serous Carcinoma
Nicholas Wiebe1, Angela Chan2, Emeka Enwere1, John McIntyre1, Linda Cook3, Martin Kobel4
1
University of Calgary, Calgary, AB, 2Alberta Health Services, Caglary, AB, 3University of New Mexico Health Sciences Center,
Albuquerque, NM, 4University of Calgary/Alberta Public Laboratories, Calgary, AB

Disclosures: Nicholas Wiebe: None; Angela Chan: None; Emeka Enwere: None; John McIntyre: None; Linda Cook: None; Martin Kobel:
None

Background: CCNE1 amplification is one of the few recurrent alterations in chromosomally unstable tubo-ovarian high-grade serous
carcinoma (HGSC). High level CCNE1 amplifications are mutually exclusive to germline BRCA1/2 mutations and associated with
unfavorable outcome. We investigated whether immunohistochemistry (IHC) can be used to identify CCNE1 amplification status and
whether CCNE1 high-level amplification status and overexpression can be prognostic in high-grade serous carcinoma.

Design: A training set of 528 tubo-ovarian high-grade serous carcinoma samples were stained via two optimized IHC assays then
subjected to digital image analysis and visual scoring. DNA and RNA CISH for CCNE1 were performed. Receiver operating characteristic
(ROC) curves were used to identify optimal cut-offs. Using the optimal cut offs identified from the training set, survival analyses were
performed and validated in an independent testing set of 764 tubo-ovarian high-grade serous carcinomas. Combined
amplification/expression status was evaluated in a combined set with complete data (N=1114).

Results: CCNE1 high-level amplification was present in 10.2% of cases in the training set and 11.2% in the combined cohort. ROC curve
analyses identified 60% positive tumor cells by immunohistochemistry as the optimal cut-off to correlate CCNE1 high-level amplification
with 81.6% sensitivity and 77.2% specificity. CCNE1 high-level amplification and overexpression were associated with survival in both the
training and the testing set. The combination CCNE1 high-level amplification and overexpression was observed in 8.3% of patients and
are significantly associated with a higher risk of ovarian cancer caused death in multivariate analysis adjusted for age, stage and
cohort (HR=1.78, 95 CI% 1.38-2.26, p<0.0001). There were no significant difference among the other three combinations (high-level
amplification/low expression; low-level amplification/high expression; low-level amplification/low expression).

1158
 Figure 1 - 1216

Conclusions: Our results suggest that CCNE1 immunohistochemistry can serve as a prognostic marker because only high-grade serous
carcinomas patients whose tumors show the combination of high-level CCNE1 amplification with overexpression can be expected to have
an unfavorable outcome. This may also define a group of patients that require new treatment regimens.

1217 Recurrent Intrachromosomal FOXO1-LINC00598 Rearrangement Characterize a Novel Subtype of

Leiomyosarcoma with Variant Cell Morphology
Erik Williams1, Meagan Montesion2, Radwa Sharaf2, Nikunj Shah2, Julie Tse1, Vincent Miller2, Dean Pavlick2, Natalie Danziger3,
Jo-Anne Vergilio2, Keith Killian2, Siraj Ali4, Julia Elvin2, Douglas Lin2
1
Boston, MA, 2Foundation Medicine, Inc., Cambridge, MA, 3Foundation Medicine, Inc., Somerville, MA, 4Cambridge, MA

Disclosures: Erik Williams: Stock Ownership, F. Hoffman La-Roche, Ltd.; Employee, Foundation Medicine, Inc.; Meagan
Montesion: Employee, Foundation Medicine; Stock Ownership, Roche; Radwa Sharaf: Employee, Foundation Medicine; Nikunj Shah:
None; Julie Tse: Employee, Foundation Medicine, Inc.; Consultant, Pathology Watch, LLC.; Vincent Miller: Employee, Foundation
Medicine / Roche; Stock Ownership, Foundation Medicine / Roche; Advisory Board Member, Revolution Medicines; Stock Ownership,
Revolution Medicines; Dean Pavlick: Employee, Foundation Medicine; Stock Ownership, F. Hoffmann-La Roche AG; Natalie
Danziger: Employee, Foundation Medicine Incorporated; Jo-Anne Vergilio: Employee, Foundation Medicine, Inc; Employee, Foundation
Medicine, Inc; Keith Killian: Employee, FMI; Siraj Ali: Employee, Foundation Medicine; Advisory Board Member, INcysus
Therapeutics; Consultant, Takeda; Julia Elvin: Employee, Foundation Medicine, Inc; Employee, Hoffman La Roche; Douglas
Lin: Employee, Foundation Medicine

Background: Due to their biological significance and tumor-specific expression, gene rearrangements and fusions are often defining
molecular events of specific tumor types, particularly in sarcomas. Alveolar rhabdomyosarcoma is characterized by PAX3-
FOXO1 and PAX7-FOXO1 fusions, where breakpoints occur in FOXO1 intron 1, and reciprocal transcripts are often expressed. In the
current study, we identity a novel recurrent FOXO1 rearrangement in a subset of leiomyosarcoma (LMS).

Design: Our case archive of >200,000 clinical samples that had undergone comprehensive genomic profiling using a hybrid capture
based sequencing platform was searched for leiomyosarcoma with structural variants in FOXO1. Pathology reports and histopathology
were reviewed. Patient clinical data was collected.

Results: 16 of 2359 (0.7%) soft tissue and visceral LMS had a structural variant in FOXO1. All FOXO1 breakpoints occurred in intron 1. A
recurrent intrachromosomal rearrangement involving 5’ FOXO1 and 3’ LINC00598, a long noncoding RNA gene, was identified in 7 LMS.
Additional non-recurrent FOXO1 partners were identified in remaining 9 LMS, 4 fused with the 5’ end of FOXO1 and 5 with the 3’ end. No
reciprocal transcript was identified in any LMS. The FOX01 fusion-positive LMS was observed to occur exclusively in female adults
(median age=54, range 45-78 years). 12 of 16 were of known uterine or pelvic origin. The most frequent other genomic alterations (GA)
observed in the FOX01 fusion-positive LMS were in TP53 (75%), RB1 (56%), and ATRX (50%), and PTEN (25%). 11/16
(69%) FOX01 fusion-positive LMS displayed at least one form of variant-cell morphology: 8 of 16 (50%) with areas of rhabdoid
morphology (p<0.05, as compared to 20 FOX01 fusion-negative LMS; Fig 1) and 7/16 with areas of pleomorphic giant cells (Fig 2). In 10
of the 11 variant-cell cases, we identified 5’ FOXO1 fusion transcripts.

1159
 Figure 1 - 1217 Figure 2 - 1217

Conclusions: Non-canonical FOXO1 rearrangements, particularly FOXO1-LINC00598, are recurrently identified in female adult LMS,
and the majority show variant morphologic features, specifically, focal areas of rhabdoid and/or pleomorphic giant cell morphology. The
identification of this fusion may offer insights into the biology of LMS and suggests the need for focused investigation to delineate the pro-
oncogenic functions of these novel rearrangements, along with possible sensitivity to targeted therapies.

1218 SATB2 May Be Useful in Distinction of Atypical Polypoid Adenomyoma from Benign
Adenomyomatous Polyps and Myoinvasive Carcinoma on Biopsy
Helen Worrell1, Andrew Sciallis2, Stephanie Skala2
1
Michigan Medicine, University of Michigan, Novi, MI, 2University of Michigan, Ann Arbor, MI

Disclosures: Helen Worrell: None; Andrew Sciallis: None; Stephanie Skala: None

Background: Atypical polypoid adenomyoma (APAM) is an uncommon uterine lesion composed of complex endometrioid glands,
frequent squamous morular metaplasia, and smooth muscle stroma with short interlacing fascicles. On endometrial curettage, biopsy, or
polypectomy specimens, the presence of endometrioid glands and smooth muscle stroma raises the differential diagnosis of myoinvasive
endometrioid carcinoma. APAM is thought to behave similar to complex atypical hyperplasia; recurrence is not uncommon and
endometrial carcinoma is subsequently diagnosed in approximately 9% of patients. Reproductive age patients with APAM have the option
of preservation of fertility, whereas myoinvasive endometrioid carcinoma is treated by hysterectomy. One study has reported an incidental
finding that the stroma of APAM is positive for SATB2, whereas the stroma of other polypoid lesions is not. We aim to assess whether
SATB2 is useful stain for distinction of APAM from myoinvasive endometrioid carcinoma on endometrial biopsies or curettings.

Design: The surgical pathology and consultative archives of a single large academic institution was searched for cases of “atypical
polypoid adenomyoma” (n=27), “adenomyomatous polyp” (n=45), and “myoinvasive endometrioid carcinoma” (n=16) sampled between
1989 and 2019. Study pathologists reviewed all cases to confirm the diagnosis and assess various morphologic features. The intensity
and extent of nuclear SATB2 expression in the epithelial and stromal components of each lesion were recorded.

Results: SATB2 expression was seen in the stromal component of 25/27 (93%) APAM, compared to 0/45 (0%) benign adenomyomatous
polyps and 4/16 (25%) myoinvasive endometrioid carcinomas. Stromal SATB2 reactivity in myoinvasive carcinomas was limited to
rounded stromal cells in the surface component of the tumor; stroma surrounding invasive foci was negative for SATB2. Weak/moderate
nuclear SATB2 staining was occasionally seen in vessel walls (focal), lipoleiomyomas, and flat endometrium adjacent to a polyp. All
entities showed frequent SATB2 reactivity in squamous morules (when present), as well as scattered positive cells in areas of tubal
metaplasia.

Conclusions: Based on our data, SATB2 reactivity in fibromuscular stroma separating atypical endometrioid glands may support a
diagnosis of APAM rather than myoinvasive endometrioid carcinoma. SATB2 immunohistochemistry shows potential to be a useful
adjunct tool accompanying careful morphologic evaluation of endometrial biopsies or curettings.

1160
1219 Beta-Catenin Expression in Endometrioid Intraepithelial Neoplasia (Atypical Hyperplasia)
Martha Wright1, Sarah Fitzlaff2, Autumn Wyeth3, Matthew Zaragoza-Watkins4, Mirna Podoll1, Charles Quick5, Jaclyn Watkins1
1
Vanderbilt University Medical Center, Nashville, TN, 2Vanderbilt University School of Medicine, Nashville, TN, 3University of
Arkansas for Medical Science (UAMS), Little Rock, AR, 4Vanderbilt University, Nashville, TN, 5University of Arkansas for Medical
Sciences, Little Rock, AR

Disclosures: Martha Wright: None; Sarah Fitzlaff: None; Autumn Wyeth: None; Matthew Zaragoza-Watkins: None; Mirna Podoll: None;
Charles Quick: None; Jaclyn Watkins: None

Background: Beta-catenin (BC) mutations are associated with a high risk of recurrence in otherwise low-grade, early stage endometrioid
adenocarcinomas. Recent literature suggests nuclear BC expression by immunohistochemistry is highly sensitive and specific for BC
mutations. The significance of BC expression in endometrioid intraepithelial neoplasia (EIN/atypical hyperplasia) has yet to be explored.

Design: Cases meeting current diagnostic criteria for EIN based on H&E examination were obtained from two institutions (years 1999-
2014). Patterns of altered differentiation (e.g., tubal, squamous morular, mucinous, secretory) were noted. Representative blocks were
stained for BC and PAX2, and expression patterns recorded. Follow-up and demographic data was obtained from the electronic medical
record where available.

Results: 99 cases were included (86 biopsies, 13 hysterectomies). BC nuclear expression outside of squamous morules was identified in
36% of cases. Patients with non-morular nuclear BC staining were significantly younger (mean 44.8 vs 56.7, p<0.005). Non-morular
nuclear BC expression in biopsies was not significantly associated with the presence of carcinoma on subsequent hysterectomy
(p=0.5). Cases with tubal and mucinous differentiation were significantly less likely to demonstrate non-morular nuclear BC staining than
cases with no specific pattern of differentiation (p<0.005, p=0.016, respectively). Results were equally robust when limiting analyses to
cases of EIN with PAX2 loss (72% of cases).

Conclusions: EIN, especially in young women and in cases without tubal or mucinous differentiation, commonly demonstrates non-
morular nuclear BC positivity. This finding suggests that BC mutation may be an early event in the progression towards endometrioid
adenocarcinoma. Further, our data suggests that tubal and mucinous differentiation may be morphologic correlates of non-BC mutated
EIN.

1220 Genetic Alterations in Mullerian adenosarcoma with High-Grade Sarcoma Components

Xinyu Wu1, Amir Momeni Boroujeni2, Robert Soslow3, Britta Weigelt3
1
New York, NY, 2Memorial Sloan Kettering Cancer Center, Brooklyn, NY, 3Memorial Sloan Kettering Cancer Center, New York,
NY

Disclosures: Xinyu Wu: None; Amir Momeni Boroujeni: None; Robert Soslow: Speaker, Ebix/Oakstone; Britta Weigelt: None

Background: Mullerian adenosarcoma (AS) is a biphasic tumor composed of benign epithelial and neoplastic mesenchymal elements.
These uncommon tumors generally have a low malignant potential. However, patients with high-grade sarcoma component often have
poor outcome. We aimed to investigate the clinico-pathologic and molecular characteristics of ASs with high-grade sarcoma components.

Design: A total of 10 ASs with high-grade sarcoma components were included in this study and evaluated using a next-generation-
sequencing panel targeting cancer-related genes. Cases were reviewed in detail to evaluate their clinico-pathologic features and
outcome.

Results: The patients’ age at diagnosis ranged from 23 to 71 years (mean 46 years). Stromal overgrowth was seen in nine cases (90%)
and the mitotic index ranged from 6 to 58/10 HPFs. Myometrial invasion was present in 50% (4/8) of tumors with uterine corpus
involvement. Three AS showed heterologous elements (chondroid, n=1; rhabdomyosarcoma n=2). Six patients (60%) developed
metastatic disease. The ASs harbored few non-synonymous mutations, but were genetically heterogeneous. DICER1 and ARID1A were
the most frequently mutated genes (30% each). Two ASs harbored CDKN2A deletions (20%), which were mutually exclusive
with TERT amplification/ promoter mutation in two other Ass (20%). SMARCB1 loss-of-function mutations were present in one case,
and BAP1 deletions were found in two ASs. ARID1A, KRAS and PIK3CA mutations were found in 20% of ASs with metastasis. Two ASs
with rhabdomyosarcomous differentiation harbored DICER1 mutations.

1161
 Figure 1 - 1220

Conclusions: In this series, mullerian AS with high-grade sarcoma components showed high mitotic index and myometrial invasion along
with lymphovascular invasion and heterologous elements. ASs were genetically heterogeneous and included DICER1 mutation,
alterations of chromatin remodeling genes (ARID1A, BAP1, SMARCB1) as well as TERT and CDKN2A alterations.

1221 Mutational Analysis of Ovarian Thecomas Suggests Molecular Kinship to Granulosa Cell
Tumours
Ellen Yang1, Anjelica Hodgson2, Sasha Blay3, David Swanson3, George Charames3, Gulisa Turashvili3
1
Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, ON, 2University of
Toronto, Toronto, ON, 3Mount Sinai Hospital, Toronto, ON

Disclosures: Ellen Yang: None; Anjelica Hodgson: None; Sasha Blay: None; David Swanson: None; George Charames: None; Gulisa
Turashvili: None

Background: Alterations in FOXL2 are commonly identified in a number of ovarian sex cord-stromal tumours, especially granulosa cell
tumours (GCTs). There is considerable debate regarding the genesis of thecomas (TCs) and fibrothecomas (FTCs) and how they relate
to pure morphological fibromas and GCTs. With this background information in mind, we aimed to genomically interrogate these tumours,
in order to establish any evident mutational relationship.

Design: The study cohort includes 33 tumours originally diagnosed as GCT (n=14), TC (n=8), FTC (n=8) and cellular fibroma (CF; n=3).
All cases were reviewed to confirm the original morphological diagnoses and reticulin staining was evaluated in all non-GCTs. TruSight
Tumor 15 next generation sequencing assay was used to assess 15 genes commonly mutated in cancers. Detected mutations were
confirmed as likely pathogenic or pathogenic based on review of ClinVar and COSMIC databases. P53 immunohistochemistry was
performed in all cases with a pathogenic TP53 mutation and staining was assessed as normal (wild-type) and aberrant (overexpressed or
null).

Results: Most (12/19) non-GCTs displayed pericellular reticulin staining pattern around individual cells while focal nested staining pattern
was seen in 7 cases including 5/8 TCs and 2/8 FTCs. All 33 tumours were successfully sequenced. CFs did not harbor any mutations in
genes surveyed by the TruSight 15 panel. FOXL2 mutation (all c.402C>G, p.Cys134Trp) was detected in a total of 19 cases including 12
GCTs (86%), 6 TCs (75%), and 1 FTC (13%). Most (6/7) morphological non-GCT tumors with focal nested staining pattern were FOXL2-
mutated. Only 1 FOXL2-mutated TC showed pericellular staining pattern. A variety of TP53 mutations were identified in 9 cases (8 GCTs,
1 FTC), of which 6 had concurrent FOXL2 mutations. EGFR mutation (c.2369C>T; p.Thr790Met) was detected in 1 GCT which also
harbored concurrent TP53 mutation. P53 protein was expressed in a wild-type pattern in all cases with TP53 mutation with the exception
of 1 GCT which showed a null phenotype.

Conclusions: We confirm that the majority of GCTs harbor mutations in FOXL2, in addition to a significant proportion of morphological
TCs, most of which show at least focally altered reticulin staining; these tumours may represent GCTs with prominent TC-like foci. In
these tumours, TP53 mutations do not seem to correlate with abnormal p53 protein expression as assessed by immunohistochemistry.
CFs and FTCs appear to be mostly unrelated to GCTs and TCs.

1162
1222 Retrospective Review of Products of Conception with Atypical Villous Morphology: Histological,
Immunohistochemical and Genetic Features with Clinical Correlation
Ellen Yang1, William Parks2, Gulisa Turashvili3
1
Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, ON, 2University of
Toronto, Toronto, ON, 3Mount Sinai Hospital, Toronto, ON

Disclosures: Ellen Yang: None; William Parks: None; Gulisa Turashvili: None

Background: The finding of chorionic villi with non-specific changes, such as edema, irregular shape, trophoblast pseudoinclusions and
focal trophoblast hyperplasia, typically raises a broad differential diagnosis including partial hydatidiform mole (PHM), hydropic abortus
(HA), non-molar aneuploidy (NMA), and placental mesenchymal dysplasia (PMD). Distinguishing between PHM and its mimics often
requires ancillary studies. We set out to review the clinical, pathologic and genetic features of AVM with the intent of improving
diagnostics and use of genotyping in the future.

Design: A retrospective analysis of products of conception (POC) at a large tertiary hospital identified 200 cases of AVM (complete moles
excluded) that underwent quantitative fluorescence-polymerase chain reaction analysis (QF-PCR) with molar genotyping. Blinded to the
original diagnoses, 180 cases with available slides were reviewed. Clinical findings, p57 immunohistochemistry (IHC) and cytogenetic
reports were also assessed.

Results: The cohort includes 93 HAs, 45 PHMs, 34 NMAs, 2 PMDs, and 6 cases with no diagnosis favored. The median maternal age
was 33 years (16-49), and the median gestational age was 9 weeks (5-19). Clinical presentations included 57 missed abortions, 6
incomplete abortions, 22 miscarriages (including 7 recurrent miscarriages), 6 pregnancy terminations, and 3 in vitro fertilizations. A total of
36 cases (20%) failed cytogenetic testing, with maternal cell contamination being the culprit in 47%. The presence of diandric triploidy by
QF-PCR supported the diagnosis of PHM in 69% of cases, whereas PHM was favored based on the morphology in the remaining 31%
with failed QF-PCR. Both PMD cases showed normal genotype with retained p57 in cytotrophoblast and lack of staining in villous stroma.
All diagnostic categories showed overlapping morphologic features. The diagnosis of PHM was associated with biphasic morphology
(91%), ≥30% villous edema (100%), >50% edematous villi (73%), cistern formation (60%) and trophoblast pseudoinclusions (87%)
(p≤0.037).

Partial Hydatidiform Hydropic Aneuploidy Non- Placental Unclassifiable All

Mole Abortus molar Mesenchymal
Dysplasia
Number of Cases, % 45 (25%) 93 (52%) 34 (19%) 2 (1%) 6 (3%) 180
Maternal Age, median (range); years 31 (20-42) 33.5 (23-49) 37.5 (20-45) 33 (33-33) 27.5 (16-35) 33 (16-49)
Gestational Age, median (range); weeks 11 (6-13) 9 (5-18) 13 (7-19) 7 (5-9) 8 (6-8) 9 (5-19)
Microscopic Description
Biphasic 41 (91%) 22 (24%) 14 (41%) 2 (100%) 3 (50%) 82
Hydropic (>3 mm/villus) 45 (100%) 83 (89%) 29 (85%) 2 (100%) 4 (67%) 163
Hydropic (% on low power field)
80-90% 2 (4%) 1 (1%) 0 0 0 3
70-80% 14 (31%) 3 (3%) 0 0 1 (17%) 18
60-70% 7 (16%) 6 (6.5%) 4 (12%) 0 0 17
50-60% 10 (22%) 6 (6.5%) 5 (15%) 1 (50%) 0 22
40-50% 6 (14%) 12 (13%) 5 (15%) 0 0 23
30-40% 2 (4%) 12 (13%) 6 (17%) 0 0 20
20-30% 4 (9%) 22 (24%) 8 (24%) 1 (50%) 2 (33%) 37
10-20% 0 16 (17%) 3 (9%) 0 2 (33%) 21
0-10% 0 15 (16%) 3 (9%) 0 1 (17%) 19
Cistern Formation 27 (60%) 19 (20%) 6 (18%) 1 (50%) 1 (17%) 54
Irregular Shape 45 (100%) 92(99%) 33 (97%) 2 (100%) 6 (100%) 178
Trophoblast Pseudoinclusions 39 (87%) 32 (34%) 17 (50%) 1 (50%) 3 (50%) 92
Trophoblast Hyperplasia (focal) 10 (22%) 25 (27%) 6 (18%) 0 1 (17%) 42
Stromal Karyorrhexis 4 (9%) 7 (7.5%) 6 (17%) 0 0 17
Nucleated Red Blood Cells 9 (20%) 12 (13%) 2 (6%) 0 1 (17%) 24
P57 Immunohistochemistry
Retained in Both Cytotrophoblast 39 (87%) 74 (80%) 15 (44%) 0 5 (83%) 133
and Villous Stroma
Retained in Cytotrophoblast, 1 (2%) 0 0 2 (100%) 0 3
Lost in Villous Stroma
Retained in Cytotrophoblast, 2 (4%) 2 (2%) 1 (3%) 0 0 5
reduced in Villous Stroma
Not performed 3 (7%) 17 (18%) 18 (53%) 0 1 (17%) 39
Quantitative Fluorescence-Polymerase Chain Reaction
Trisomy 4 0 0 1 (3%) 0 0 1
Trisomy 13 0 0 5 (15%) 0 0 5
Trisomy 18 0 0 10 (24%) 0 0 10
Trisomy 21 0 0 7 (21%) 0 0 7
Trisomy 22 0 0 2 (6%) 0 0 2
Monosomy X 0 0 5 (15%) 0 0 5
Monosomy 16 and trisomy 21 0 0 1 (3%) 0 0 1
Diandric Triploidy 31 (69%) 0 0 0 0 31
13q14 Deletion 0 0 1 (3%) 0 0 1
Xp22.31 Deletion 0 0 2 (6%) 0 0 2
Normal 0 77 (83%) 0 2 (100%) 0 79
Failed 14 (31%) 16 (17%) 0 0 6 (100%) 36

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Conclusions: Most POCs with AVM represent non-molar HAs. Both HA and NMA exhibit morphologic features closely mimicking PHM.
Although the presence of some features may indicate a higher likelihood of PHM, p57 IHC in conjunction with QF-PCR is crucial for
accurate diagnosis of PHM and recognition of its mimics. A low threshold should be maintained for these ancillary studies and/or
subspecialty consultation when the diagnosis of PHM is in question.

1223 Distinct Clinicopathological Features of Endometrial Mesonephric-like Adenocarcinoma

Mitsutake Yano1, Tomomi Katoh1, Akira Yabuno1, Naoki Ogane2, Kozue Ito1, Mariko Miyazawa3, Masaki Miyazawa3, Kosei
Hasegawa1, Hisashi Narahara4, Masanori Yasuda1
1
Saitama Medical University International Medical Center, Hidaka, Japan, 2Kanagawa Prefectural Ashigarakami Hospital,
Ashigarakami, Japan, 3Tokai University School of Medicine, Isehara, Japan, 4Oita University Faculty of Medicine, Yufu, Japan

Disclosures: Mitsutake Yano: None; Tomomi Katoh: None; Akira Yabuno: None; Naoki Ogane: None; Kozue Ito: None; Mariko
Miyazawa: None; Masaki Miyazawa: None; Kosei Hasegawa: None; Hisashi Narahara: None; Masanori Yasuda: None

Background: Endometrial mesonephric-like adenocarcinoma is morphologically and immunophenotypically similar to mesonephric

carcinoma. Diffuse positive reaction of GATA binding protein 3 (GATA3) or transcription termination factor 1 (TTF-1) is of diagnostic
significance for mesonephric-like adenocarcinoma. However, its clinicopathological features have not yet been clarified.

Design: 533 cases of endometrial carcinoma were recruited to analyze their clinical, morphological, and immunohistochemical features.
Immunohistochemical analysis was performed to evaluate GATA3, TTF-1, estrogen receptor, and TP53 expression using tissue
microarray sections.

Results: Mesonephric-like adenocarcinoma, low-grade endometrial carcinomas (endometrioid carcinoma G1/2), and high-grade
endometrial carcinomas (endometrioid carcinoma G3, serous carcinoma, clear cell carcinoma, and others) accounted for 3.2% (17
cases), 75% (401 cases), and 22% (115 cases), respectively. Mesonephric-like adenocarcinoma was closely associated with advanced
age (p = 0.012), high lymphovascular invasion (p = 0.048), deep myometrial invasion (p = 0.038), and mortality (p = 0.032) compared with
low-grade endometrial carcinoma. Patients with mesonephric-like adenocarcinoma showed unfavorable progression-free survival and
overall survival compared with patients with low-grade endometrioid carcinoma (p = 0.048 and p = 0.032, respectively). However, there
were no significant associations between mesonephric-like adenocarcinoma and high-grade endometrial carcinomas with regard to
clinicopathological characteristics, and no significant differences in progression-free or overall survival were observed. In multivariate
survival analyses, independent prognostic factors included histology of mesonephric-like adenocarcinoma in comparison with low-grade
endometrial carcinoma (progression-free survival, hazard ratio: 2.73, p = 0.037; overall survival, hazard ratio: 3.06, p = 0.028), high-grade
endometrial carcinoma compared with low-grade endometrial carcinoma (progression-free survival, hazard ratio: 2.52, p < 0.001; overall
survival, hazard ratio: 3.62, p < 0.001), myometrial invasion, and FIGO stage.

Conclusions: We would like to emphasize that endometrial mesonephric-like adenocarcinoma may be not infrequent (approximately 3%)
among variable endometrial carcinomas and that it is potentially identical to high-grade endometrial carcinoma. Therefore, it should be
distinguished from low-grade endometrial carcinoma in order to select an appropriate therapy.

1224 Mutational Spectrum in Clinically Aggressive Low-Grade Serous Carcinoma/Serous Borderline

Tumors of the Ovary
Ju-Yoon Yoon1, Kyle Devins2, Emily Ko3, Robert Burger2, Carolina Reyes4, Ronny Drapkin1, Lauren Schwartz5
1
Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 2Hospital of the University of Pennsylvania,
Philadelphia, PA, 3University of Pennsylvania Health System, Philadelphia, PA, 4University of Pennsylvania, Philadelphia,
PA, 5Perelman School of Medicine at the University of Pennsylvania, Bala Cynwyd, PA

Disclosures: Ju-Yoon Yoon: None; Kyle Devins: None; Robert Burger: Consultant, Tesaro; Consultant, Merck; Consultant,
Morphotek; Consultant, Roche; Carolina Reyes: None; Ronny Drapkin: Advisory Board Member, Repare Therapeutics; Advisory Board
Member, Siamab Therapeutics; Consultant, Mersana Therapeutics; Lauren Schwartz: None

Background: While reported to be generally driven by mutations in the Ras/MAPK signaling pathway genes, the mutational spectra of
low-grade serous carcinoma (LGSC) and serous borderline tumors (SBTs) of the ovary remain poorly characterized. We present a case
series of clinically aggressive LGSC/SBT with comprehensive molecular profiling.

Design: Molecular profiling of 17 LGSCs/SBTs (13 LGSC, 4 SBTs) was performed, all with FIGO stage III disease. 15/17 cases were
profiled using a 592 gene panel (Caris Molecular Intelligence), and 2 cases by a 46-gene panel (Caris, including BRCA1/2). Retrospective
chart review was performed for clinico-patho-molecular correlations.

Results: Tumor mutational burdens (TMB) were generally low, with mean TMB of 5.2 mutation/Mb (range 3-10, based on 14 cases).
Microsatellites were stable in 12/12 cases examined. Driver mutations were identified in 11/17 cases, namely in KRAS (5
cases), BRAF (2), NRAS (2), and ERBB2 (2). Among the cases without a clear driver mutation, one case harbored a
pathogenic NF2 mutation (p.Y192X) with an FGFR4 kinase domain alteration. Surprisingly, 5/17 cases harbored BRCA2 alterations, all

1164
variants of unknown significance (VUSs), with allele frequencies ranging 11-51%. 2/3 of those patients tested were found to harbor
germline BRCA2 alterations. In other cases, VUSs in additional genes in the homologous recombination DNA repair pathway were found,
including BARD1, BRIP1, and CHEK2. During the median follow-up period of 3.6 years, two patients had succumbed to their disease,
both of whom had received a PARP inhibitor during the terminal disease course.

Conclusions: In our series, besides the previously reported driver mutations, we identified NF2 and FGFR4 alterations.
Unexpectedly, BRCA2 was the second most commonly altered gene, some being confirmed be germline. The benefit of targeting VUSs in
the homologous recombination DNA repair pathway genes by PARP inhibition appears unclear.

1225 Histopathological Scoring of Activated Stromal Reaction and its Associations with Tumor
Molecular Subtypes and Prognosis in High-Grade Serous Ovarian Carcinoma
Lin Yuan1, Ruifeng Guo2, Chen Wang3, Yajue Huang2
1
Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Hongkou District, Shanghai, China, 2Mayo Clinic,
Rochester, MN, 3Mayo Clinic College of Medicine, Rochester, MN

Disclosures: Lin Yuan: None; Ruifeng Guo: None; Chen Wang: None; Yajue Huang: None

Background: As a leading lethal women malignancy, high grade serous ovarian carcinoma (HGSOC) has been previously characterized
as four tumor transcriptome subtypes: proliferation (PRO), differentiated (DIF), immunoreactive (IMM) and mesenchymal (MES) subtypes.
Among which, MES subtype has been associated with the worst survival outcome and extensive desmoplasia. The purpose of this study
is to establish a systematic histopathological criterion for scoring of activated stroma in tumor areas and to investigate associations of
stromal reactions with HGSOC molecular subtypes and clinical outcomes.

Design: Totally 298 advanced-stage (FIGO stage III/IV) treatment-naïve HGSOC cases underwent surgery between 1990 and 2009 were
recruited from the institutional surgical pathology archives. Tumor molecular subtypes were previously characterized according to
transcriptome profiling of primary tumors. H&E slides of primary tumor were reviewed by at least two pathologists independently.
Activated stroma was defined as reactive desmoplastic stroma of HGSOC with fibroblasts and/or myofibroblasts proliferation. According
to proportion of activated stroma component in examined slides, the stroma reaction of tumors were scored as 1 (<5%), 2 (5-10%), 3 (10-
30%) and 4 (>30%). Score =3 or 4 were categorized as strong stroma reaction (SSR) and rest as weak stroma reactions (WSR) groups.

Results: Statically significant association (p=1.6e-5) was found between molecular subtypes and scored stromal reactions (SSR or
WSR). As shown in table 1, PRO subtype was over-represented in WSR group (44.1%) comparing to other three subtypes; MES subtype
had the highest percentage in SSR group (35.7%). When evaluating prognosis associations using 242 cases with available follow-up,
median survivals of SSR group was 11 months shorter than WSR group (median survival =36.7 and 47.8 months, respectively; Hazard-
ratio = 1.37, p-value = 9.7e-3).

Table 1: Scored Stromal Reactions in Different Molecular Subtypes of High Grade Serous Ovarian Carcinoma

Molecular Subtypes/Score 1 2 WSR（%） 3 4 SSR（%）

PRO 24 21 45（44.1） 22 17 39（19.9）
DIF 8 15 23（22.5） 33 11 44（22.4）
IMM 9 10 19（18.6） 28 15 43（21.9）
MES 6 9 15（14.7） 37 33 70（35.7）

Conclusions: We defined scoring system to characterize activated stromal reactions and found statistically significant associations
between stromal reactions and tumor molecular subtypes. In addition, we showed that stromal reaction had significant associations with
patient prognosis in HGSOCs. This pilot study suggests that activated stroma scoring can serve as prognostic factor for HGSOC; upon
further validations, it can be reported as a routine assessment in pathological diagnosis for advanced stage HGSOC.

1226 Gastric Type Cervical Adenocarcinoma: The Spectrum of Molecular Alterations and Strong
Association with Family History of Cancer
Michael Zaleski1, Anais Malpica1, DongHyang Kwon1, Elizabeth Euscher1, Preetha Ramalingam1
1
The University of Texas MD Anderson Cancer Center, Houston, TX

Disclosures: Michael Zaleski: None; Anais Malpica: None; DongHyang Kwon: None; Elizabeth Euscher: None; Preetha Ramalingam:
None

Background: Gastric type endocervical adenocarcinoma (GECA) is an aggressive subtype of non-HPV associated CxCa, which has a
worse outcome and increased recurrence rate compared to usual type CxCa. Up to 10% of GECAs are associated with Peutz-Jeghers
syndrome (PJS) while rare case are seen in the context of Lynch syndrome. However, no study has reported the incidence of familial

1165
history (FH) of Ca in patients (pts) with GECA. In addition, limited information is available on the molecular landscape of this tumor. The
aims of this study are to present a clinicopathology study on a cohort of GECAs with emphasis on the incidence of FH of Ca and to
describe the molecular findings obtained by next generation sequencing (NGS).

Design: 39 cases of GECAs were identified from our database (2012-2019). The following information was collected: age, FH, stage,
molecular testing (MT), and overall survival. MT was performed using NGS platform for detection of somatic mutations (mut) in the
coding sequence of 50 genes.

Results: Mean age at diagnosis was 52 yrs (range 27-88). FH was available in 36 cases; 29 (81%) had a family member with cancer.
Total number of family members with Ca was 63; ranged from 1-6 (mean 2.3) per pt. The most common Cas were breast (13/63; 21%),
prostate (8/63; 13%), colon (7/63; 11%), melanoma (7/63; 11%), uterine 4/63; 6%), miscellaneous (16/63; 25%) and unknown (8/63;
13%). 5/39 (12%) pts. had a personal history (PH) of Ca (1, pulmonary large cell neuroendocrine Ca, 1 vulvar squamous cell Ca, 2
reported ovarian Ca (5 and 13 yrs. prior to GECA). One pt. had PJS (molecular testing not performed).13/39 (33%) pts. presented with
FIGO stage III or IV. 11/39 (28%) had biopsy proven metastatic Ca (5 to ovary/adnexa, 4 omentum, 2 liver). Molecular studies were
available for 11/39 (28%) cases. 81% (9/11) of cases had mut. [TP53 (78%), KRAS (44%), STK11
(18%), SMAD4 (18%) CDKN2A (18%), PTEN (9%), MSH6 (9%)]. 5/9 (55%) pts.with muts. had FH of breast Ca.

Conclusions: GECA of the cervix is an uncommon aggressive tumor with advanced stage at presentation and frequent ovarian
metastases. A novel finding is that the majority of our pts. have FH and or PH of Ca, most commonly breast, especially in those with
molecular alterations. As reported there is genetic heterogeneity in GECA with TP53 being the most frequent mutation followed
by KRAS and CDKN2A. SMAD4 mutation in 2 of our cases is also a novel finding. The 2 pts. with STK11 somatic
mut. were postmenopausal and did not have clinically known PJS.

1227 Tumor Budding Activity and Cell Nest Size are Strong Determinants of Patient Outcome in
Squamous Cell Carcinoma of the Uterine Cervix: Independent Validation of a Novel
Grading System
Somaye Zare1, Omonigho Aisagbonhi2, Farnaz Hasteh1, Oluwole Fadare1
1
University of California San Diego, La Jolla, CA, 2University of California San Diego, Inglewood, CA

Disclosures: Somaye Zare: None; Omonigho Aisagbonhi: None; Farnaz Hasteh: None; Oluwole Fadare: None

Background: Novel grading systems that are based on tumor budding and cell nest size have been proposed for squamous cell
carcinomas (SCC) of various sites, including lung, oral cavity, and esophagus. A similar grading scheme has recently been proposed for
SCC of the uterine cervix (PMID: 29665323). In this study, we appraise this grading system in an institutional cohort of cervical SCC to
assess its prognostic value in an independent dataset.

Design: Our study cohort included 94 cases of cervical SCC with clinical follow-up whose slides were available for review. Tumor
budding activity and cell nest size were scored and cases were stratified using a 3-tiered grading system that includes level of budding
per 10 HPF and nest size (see PMID: 29665323). In addition, a variety of other tumoral histomorphologic parameters, including
keratinization, differentiation by WHO criteria, nuclear size, mitotic activity, and stroma content, were evaluated and correlated with
clinicopathologic factors and outcome.

Results: High tumor budding and small cell nest size were strongly associated with poor prognosis, including reduced overall survival
(OS), disease-specific survival (DSS), and disease-free survival (DFS) (p<0.001). The novel grading scheme showed excellent prognostic
separation of Grade 1, 2, and 3 cases (p<0.001). The strong prognostic impact of the grading scheme was independent of age, pathologic
stage, and lymph node status for OS, DSS, and DFS (OS: p <0.0001). Multivariate statistical analysis showed a hazard ratio (HR) for OS
of 2.2 for Grade 2 and 4.3 for Grade 3, in comparison to Grade 1 tumors (p=.02). Among the other potentially prognostic factors, higher
pathological stage and nodal metastasis correlated with decreased survival (p<.001 and =.004). However, histomorphologic factors,
including keratinization, nuclear size, mitotic count and WHO-based 3-tiered grading system were not significantly associated with
survival. Higher grade tumors in the novel system were significantly associated with higher stage and lymph node metastasis (p=.03 and
p=.01 respectively).

1166
 Figure 1 - 1227

Conclusions: The proposed 3-tiered grading system, which is based on tumor budding activity and cell nest size, is an excellent
prognostic indicator and outperforms the widely used, WHO grading systems. Our findings validate the previous study that proposed this
system for prognostically stratifying cervical SCC.

1228 Application of a Novel Histological Grading System in Squamous Cell Carcinoma of the Uterine
Cervix: Interobserver Reproducibility
Somaye Zare1, Omonigho Aisagbonhi2, Farnaz Hasteh1, Oluwole Fadare1
1
University of California San Diego, La Jolla, CA, 2University of California San Diego, Inglewood, CA

Disclosures: Somaye Zare: None; Omonigho Aisagbonhi: None; Farnaz Hasteh: None; Oluwole Fadare: None

Background: Histopathological grading of cervical squamous cell carcinomas (SCC) is currently performed using WHO guidelines, which
imprecisely combine the extent of squamous differentiation, nuclear pleomorphism, nucleoli size, necrosis, and mitotic activity. However,
this system has been found to suboptimally stratify patients regarding prognosis and outcome. A novel histopathological 3-tiered grading
system based on tumor budding and cell nest size has recently been proposed for grading SCC of various sites, including the uterine
cervix, and has been proffered to be superior to the WHO system. We assess herein the diagnostic reproducibility of this system

Design: 22 cases of cervical SCC with clinical follow-up were selected from a cohort of 94 resected cervical SCCs. The 4 observers were
gynecologic pathologists at various levels of experience that practice in an academic medical center. Blinded to FIGO stage and clinical
outcomes, the 4 pathologists were asked to independently review one representative slide on each case, score tumor budding and cell
nest size and assign the grade of tumor using the 3-tiered budding/nest system (see PMID: 29665323). Briefly, in the budding/nest
system, a score is assigned (1 to 3) based on the degree of budding in 10 HPF, with a bud being defined as <5 cells. Another score is
assigned based on the smallest nest size (1 to 4). The budding and nesting scores are then added to generate a final score (grade I: 2
and 3; grade 2: 4 and 5; grade 3: 6 and 7). Additionally, observers assigned a separate grade on each case based on the WHO system
as they apply it in their routine practice. Interobserver agreement was assessed with the κ statistic (Fleiss' kappa).

Results: The overall agreement in assigning the tumors to grade 1, 2, and 3 based on the budding/nest system was 74.24%. The overall
chance-adjusted agreement was substantial (κ = 0.61), with a Cronbach's alpha of 0.83. Observers showed better agreement in
evaluation of budding activity (overall agreement: 59.85%, κ = 0.40) than in scoring cell nest size (overall agreement: 48.48%, κ = 0.31).
Participants had a moderate agreement in stratifying the tumors by WHO-based grading system (overall agreement= 77.27%, κ = 0.55).

1167
Conclusions: There is substantial reproducibility between gynecologic pathologists in assigning grade for cervical SCC using a 3-tiered
grading system that is based on tumor budding activity and nest size, which enhances its potential applicability in routine practice.

1229 Morphological and Immunohistochemical Screening of FH-deficiency in Atypical Leiomyomas

Gloria Zhang1, Bin Yang1
1
Cleveland Clinic, Cleveland, OH

Disclosures: Gloria Zhang: None; Bin Yang: None

Background: The hereditary leiomyomatosis and renal cell carcinoma syndrome (HLRCC) is an autosomal dominant syndrome that
results from germline mutations in the fumarate hydratase (FH) gene. FH-deficient (FH-d) uterine leiomyomas display characteristic
morphologic features. However the interobserver reproducibility based on morphology alone varies and therefore hinders its effectiveness
as a universal tool for screening. Immunohistochemistry for FH can help detect loss of FH protein in leiomyomas. But
immunochemical staining for FH may be retained in the presence of an FH gene mutation. Combining immunohistochemistry for FH with
morphological screening may help enhance the sensitivity and specificity of identification of FH-d leiomyomas and trigger the genetic
consultation.

Design: We studied the FH-d morphologic features and immunohistochemical patterns on 50 cases of atypical leiomyoma, leiomyoma
with bizarre nuclei and smooth muscle tumors of uncertain malignant potential (STUMP). Fifty cases consist of 28 atypical leiomyoma, 15
bizarre leiomyomas, and 7 STUMPs. Patient's age arranges from 25 to 72 years with a median of 44.

Results: Histopathologically we assessed five key FH-d features, including staghorn vessels, patchy alveolar edema, nuclei arranged in
chains or palisading, macronucleoli with peri-nucleolar halos, and eosinophilic cytoplasmic inclusions. We identified 15 (30%) cases with
at least three FH-d features. Among FH-d features, macronucleoli with halos, eosinophilic cytoplasmic inclusions, and staghorn vessels
were consistently present in all 15 cases. Three cases did not show patchy alveolar edema, and four cases did not show nuclei arranged
in chains or palisading. Immunohistochemical staining showed that 13 out of 15 cases with FH-d morphology had complete loss of FH
staining in neoplastic smooth muscle cells while FH staining in intratumor vessels retained. None of the atypical leiomyomas lack of FH-d
morphology showed loss of FH protein immunohistochemically.

Conclusions: Our study showed that FH-d morphology can be seen in as high as 30% of atypical leiomyomas. Careful evaluation of key
FH-d features is important in identifying suspicious cases. Our study found that FH immunohistochemistry had approximately 87%
concordance with FH-d morphology. Since immunohistochemistry has a relatively high specificity and positive predictive value, it could be
an excellent tool to confirm the morphological impression especially when FH-d features are less fulfilled.

1230 Podoplanin and Collagen IV are Potential Diagnostic Markers for Early Invasion of Squamous Cell
Carcinoma in Uterine Cervix
Wanyu Zhang1, Sufang Tian2
1
Wuhan, Hubei, China, 2Wuhan University Zhongnan Hospital, Los Angeles, CA

Disclosures: Wanyu Zhang: None; Sufang Tian: None

Background: Cervical squamous cell carcinoma (CSCC) is usually developed from high grade squamous intraepithelial lesion (HSIL).
Diagnosis of early invasion is difficult but vital for patients' treatment and survival. Podoplanin (PDPN, D2-40 clone) is a specific marker
for lymphatic endothelium; collagen IV is an important component of basal membrane network structure. Both may be essential to restrict
tumor progression and metastasis.

Design: 34 cases diagnosed of HSIL with suspicious for early invasion were collected. The H&E slides were reviewed by 2 pathologists
independently, one with more than 10-year experience and the other 5 years, and classified into negative (no early invasion), positive
(early invasion) and uncertain (hard to judge). All the cases were subjected to immunohistochemistry staining (IHC) for D2-40 and
collagen IV. Comprehensive interpretation (combining H&E and IHC) was analyzed by two additional pathologists with more than 10-year
experience. The results were divided into positive (basement membranes/ basolateral staining completely or intermittently, no invasion)
and negative (no staining, invasion) expression.

Results: For H&E review, concordance of 34 cases between the two pathologists was 85.3% (29/34, 20 positive, 8 negative and
1 uncertain). For comprehensive interpretation, concordance between the two pathologists was 100%. Concordance between
comprehensive interpretation and at least one pathologist who reviewed H&E sections only was 94.1% (32/34). Statistically, the sensitivity
and specificity of D2-40 were 75.9% and 75%, respectively; those of collagen IV were 91.3% and 90.9%, respectively; those of
combined use of D2-40 and collagen IV were both 100% (24 cases expressed in consistent pattern and 10 cases in complementary
pattern).

1168
 Figure 1 - 1230

Conclusions: Diagnosis of CSCC with early invasion based on H&E alone lacks objective features. We propose that the combination of
morphology and IHC of D2-40 and collagen IV can provide a strong and objective reference for accurate diagnosis of CSCC with early
invasion.

1231 p53, but not BRCA Mutational Status, Affects the p16 Immunostaining Patterns in High-Grade
Serous Carcinoma of the Ovary
Longmei Zhao1, Gloria Zhang2, Bin Yang2
1
Cleveland Clinic Foundation, Cleveland, OH, 2Cleveland Clinic, Cleveland, OH

Disclosures: Longmei Zhao: None; Gloria Zhang: None; Bin Yang: None

Background: Immunohistochemical staining for p53 is used as a surrogate for mutational analysis in the diagnostic workup of high-grade
serous carcinomas (HGSC) of the ovary. Overexpression of p16 is also seen in HGSC and is useful in differential diagnosis from
endometrioid carcinoma. However, p16 staining is not always diffuse and strong in ovarian HGSC in our practice. This study is aimed at
assessing whether the mutational status of p53 and BRCA genes has an impact on the p16 staining patterns in ovarian HGSC.

Design: A total of 78 cases of ovarian high-grade serous carcinoma was selected for the study. Germline mutations of BRCA1 and
BRCA2 have been charactered in 44 cases. Immunohistochemical study for p53 and p16 were performed on selected tissue blocks. For
p53, diffuse strong nuclear positivity involving >85% of the tumor cells was considered as positive representing missense mutations and
lack of p53 staining was considered as negative representing nonsense mutations. For p16, strong nuclear and cytoplasmic staining
involving >85% of tumor cells was considered as diffuse positivity and otherwise was considered as patchy positivity.

Results: Immunohistochemical abnormality of p53 protein was seen in all cases of ovarian HGSC, including 74.4% cases with diffuse
staining pattern and 25.6% cases with negative staining. Immunostaining for p16 showed 70.5% cases with diffuse staining pattern and
29.5% cases with patchy staining pattern. When correlates with p53 status, p16 patchy staining pattern is seen in 90% of cases with p53
nonsense mutations, compared to only 10% in those cases with p53 missense mutations (p<0.001, Table 1). We further correlated p53
and p16 staining patterns with BRCA1/2 germline mutations. Although HGSC harboring BRCA1/2 germline mutations had a higher
frequency of p53 negativity compared to those with wild type BRCA1/2 (35.7% vs 16.7%), there is no significant statistical difference in
each p53/p16 staining patterns between groups of HGSC with wild type and germline BRCA1/2 mutations (p>0.05, Table 2).

Table 1. p53 and p16 Immunostaining Patterns in Ovarian High-Grade Serous Carcinoma

Immunostaining Patterns p16 Diffuse p16 Patchy Total Cases

p53 Diffuse (Missense) 53 (91.4%) 5 (9.6%) 58 (74.4%)
p53 Negative (Nonsense) 2 (10%) 18 (90%) 20 (25.6%)
Total Cases 55 (70.5%) 23 (29.5%) 78

1169
 Table 2. Impact of BRCA1/2 Germline Mutational Status on P53 and P16 Immunostaining Patterns

BRCA1/2 Mutations BRCA1/2 Wild type Total cases

Diffuse p53 / Diffuse p16 8 (57.2%) 22(73.3%) 30
Diffuse p53 / Patchy p16 1 (7.1%) 3 (10%) 4
Negative p53/ Diffuse p16 0 (0%) 1 (3.4%) 1
Negative p53/ Patchy p16 5(35.7%) 4 (13.3%) 9
Total cases 14 30 44

Conclusions: Our study shows that diffuse p53 and diffuse p16 immunostaining patterns are seen in the vast majority of ovarian high-
grade serous carcinoma. However patchy p16 staining pattern can be seen in up to 30% of cases. We found that patchy p16 staining
pattern correlates significantly with null p53 status. Ovarian HGSC harboring germline mutations of BRCA1/2 have a higher frequency of
p53 null status but have no impact on p16 staining pattern.

1232 Association of Obesity and Diabetes Mellitus with High-Grade Serous Carcinoma: Does the Risk
Vary with Population? A Study in a Safety-Net Hospital
Xiaofeng Zhao1, Congli Wang1, Suad Taraif2
1
Temple University Hospital, Philadelphia, PA, 2Temple University Hospital, Conshohocken, PA

Disclosures: Xiaofeng Zhao: None; Congli Wang: None; Suad Taraif: None

Background: Obesity and Diabetes Mellitus are epidemic public health problems in the United States and worldwide. In contrast to their
established role as risk factors in endometrioid carcinoma, the role of obesity and Diabetes Mellitus in high-grade serous carcinoma is
debated. The purpose of our study was to examine the association between obesity and/or Diabetes and high-grade serous carcinoma of
various sites in our high-risk patient population.

Design: We retrospectively retrieved from the departmental pathology archives all cases diagnosed as high-grade serous carcinoma over
a ten-year period including concurrent/subsequent cytopathology samples. Patient demographics, including age, BMI, and diabetic status
were obtained from electronic medical records.

Results: Between June 2008 and June 2018, a total of 84 patients were diagnosed with high-grade serous carcinoma (median age 61-
year old, range 34-89 years). 38% of our patients were Caucasians, 32.14% were African Americans, 8.33% were Hispanics, and the rest
were among other ethnic minorities or of unknown ethnicity. The majority of serous carcinomas originated from the ovary, followed by the
endometrium. 25 of our patients were diabetics (29.76%) and 25 were obese defines as BMI>30 (29.76%). The prevalence of diabetes in
our study population is 60% and 26.5% among patients with endometrial and ovarian serous carcinomas, respectively. Peritoneal fluid
cytology was available for 44 cases (Table 1). Out of 6 diabetic patients with ovarian serous carcinoma, 5 had positive peritoneal fluid
cytology (83.3%). 8 patients with ovarian serous carcinoma were deceased, 4 of which had diabetes and one was obese.

High-grade serous carcinoma

Ovary Endometrium Fallopian tube Ovary and Peritoneum Unknown Total
tube
34 20 (23.81%) 8 10 (11.90%) 3 9 (10.71%) 84
(40.47%) (9.52%) (3.51%)
diabetes 9 12 1 1 0 2 25
obesity 7 13 1 3 0 1 25
overweight 14 5 3 5 1 3 31
Normal BMI 8 2 3 0 1 3 17
Peritoneal fluid 20 14 3 4 0 3 44
Positive 13 4 2 4 0 3 26
cytology
Rate of 65% 28.6% 66.7% 100% N/A 100% 59.1%
positivity
Overall Diabetic BMI
Race Obese Overweight (BMI Normal (BMI Unknown
(BMI ≥30) 25-29.9) <25)
African 27 12 12 9 3 3
American
Caucasian 32 6 3 16 12 1
Hispanic 7 4 3 3 0 1
Other 8 2 5 1 1 1
Unknown 10 1 2 2 1 5
Total 84 25 25 31 17 11

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Conclusions: Patients with ovarian and endometrial serous carcinomas were more likely to be diabetics compared to serous carcinomas
of other sites. Patients with diabetes were more likely to present with advanced stage disease. For ovarian and endometrial serous
carcinoma, diabetes seems to be an independent risk factor from obesity. Although rates of diabetes and obesity are higher among
African American patients, our study population seems to have a higher number of Caucasian patients which makes the likelihood of race
as a confounding factor less likely. Obesity and diabetes may be associated with serous carcinoma of the ovary and endometrium in high-
risk populations. Additional studies are needed to further explore this association.

1233 CTNNB1 Mutations and Aberrant β-Catenin Expression in Ovarian Endometrioid Carcinoma:
Correlation with Patient Outcome
Roman Zyla1, Yutaka Amemiya2, Ekaterina Olkhov-Mitsel3, Dina Bassiouny4, Arun Seth4, Bojana Djordjevic5, Sharon Nofech-
Mozes4, Carlos Parra-Herran4
1
Toronto, ON, 2Sunnybrook Research Institute, Toronto, ON, 3Sunnybrook Health Sciences Centre, Toronto, ON, 4Sunnybrook
Health Sciences Centre, University of Toronto, Toronto, ON, 5University of Toronto, Toronto, ON

Disclosures: Roman Zyla: None; Yutaka Amemiya: None; Ekaterina Olkhov-Mitsel: None; Dina Bassiouny: None; Arun Seth: None;
Bojana Djordjevic: None; Sharon Nofech-Mozes: None; Carlos Parra-Herran: None

Background: CTNNB1 mutations are associated with worse survival in patients with early-stage, low-grade endometrial carcinoma.
Interestingly, it has been recently shown that nuclear β-catenin (βCAT) expression is a good prognostic factor in ovarian endometrioid
carcinoma (OEC). The prognostic value of the CTNNB1 mutational status and its relationship with other clinical and pathologic variables
in OEC has not been documented.

Design: We performed immunohistochemistry for βCAT (M3539, Dako) and a 9-gene next-generation sequencing panel in 51 OECs,
previously classified as per the PROMISE classifier as: p53 wild-type (wt, n=31), p53 abnormal (abn, n=10), POLE-abn (n=6) and MMR-
abn (n=4). The panel included whole-exome sequencing of CTNNB1, PTEN and TP53, and hotspot coverage of PIK3CA, KRAS, HRAS,
BRAF and CDKN2A. Results were correlated with clinic-pathologic variables including disease-free survival (DFS) and disease-specific
survival (DSS).

Results: Median patient age was 55 years (range 36-89). Median follow-up period was 61 months (range 3-176). Tumor recurrence was
documented in 14 patients (27%), and OEC-related death in 8 (16%). CTNNB1 mutations were found in 22 cases (43%), and nuclear
βCAT in 12 (24%). Mutated CTNNB1 status was statistically associated with better DFS (p=0.04, log rank test) and approached
significance for better DSS (p=0.07, Figure 1). It also correlated with nuclear βCAT expression, no surface involvement and early FIGO
stage (p<0.05, Chi-square test). There was no association between CTNNB1 status and PROMISE group. On univariate Cox regression
analysis, CTNNB1 mutations, TP53 mutations, age, PROMISE group, surface involvement, tumor grade and stage correlated with DFS.
There was no correlation between nuclear βCAT expression and DFS (p=0.1) or DSS (p=0.4). There was no statistical association
between CTNNB1 mutations and survival when analysis was restricted to patients in p53-wt, low grade and FIGO stage I groups.

Figure 1 - 1233

Conclusions: CTNNB1 mutations are associated with better progression-free survival in patients with OEC, unlike those with endometrial
carcinoma. This relationship may be in part due to a trend of CTNNB1-mutated tumors to present at early stage. This is in keeping with
previous observations of better survival in OECs with nuclear βCAT (although we did not observe such association in our study). Further
investigation in larger samples is required to establish whether this relationship is independent from other variables.

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1234 Horizontal Tumor Extent is an Independent Prognostic Variable in Cervical Cancer: Implications
for the 2018 FIGO Staging Update
Roman Zyla1, Ekaterina Olkhov-Mitsel2, Lilian Gien3, Jelena Mirkovic4, Sharon Nofech-Mozes4, Bojana Djordjevic5, Carlos Parra-
Herran4
1
Toronto, ON, 2Sunnybrook Health Sciences Centre, Toronto, ON, 3Sunnybrook Odette Cancer Center, Toronto,
ON, 4Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, 5University of Toronto, Toronto, ON

Disclosures: Roman Zyla: None; Ekaterina Olkhov-Mitsel: None; Lilian Gien: None; Jelena Mirkovic: None; Sharon Nofech-Mozes:
None; Bojana Djordjevic: None; Carlos Parra-Herran: None

Background: The FIGO 2018 update on staging of cervical cancer (CxCA) removes horizontal tumor extent (HZTE) as a staging
variable, arguing that it is a poorly reproducible metric without providing data against its prognostic significance. As evidence to support
this shift is needed, we aimed to determine the association of HZTE with patient outcome.

Design: We identified patients with CxCA from 01/2009 to 12/2017 in our institution, where HZTE is routinely reported. When
documented, the % of cervix circumference involved by tumor (%CIR) was also recorded. Pathologic variables were extracted from
synoptic reports including lymphovascular invasion (LVI) and grade (G1-G3). Only squamous cell, adenocarcinoma, adenosquamous and
glassy cell carcinomas were included. HZTS and %CIR were correlated with other clinical and pathologic variables including recurrence-
free (RFS), overall (OS) and disease-specific survival (DSS). Stage as per 2018 FIGO recommendations was determined for each case
(thus not using the horizontal extent metric).

Results: After exclusion of lesions with no HZTE recorded and/or no follow-up, a total of 400 patients were included. Median follow-up
was 40 months (mean 41, range 1-123). Both HZTE (in mm) and %CIR correlated with FIGO 2018 tumor stage (p<0.001, log rank test).
HZTE also correlated with lymph node metastases (p<0.001). On KM curve analysis (Figure 1) and univariate Cox regression, HZTE
correlated with worse RFS, OS and DSS (p≤0.001). Indeed, none of the women with HZTE <7 mm had recurrence or cancer-related
death. Other variables correlating with DFS, OS and DSS included invasive depth, grade, LVI and 2018 FIGO stage (IA1-IB2 vs IB3-IV).
%CIR and histotype correlated with RFS. On multivariate analysis of variables significant on univariate regression (Table 1), HZTE was
associated with worse OS [hazard ratio (HR) 1.05, 95% confidence interval (CI) 1-1.1, p=0.02] and approached significance for RFS
(p=0.07); RFS also correlated with grade (G2 vs G1 p=0.03; G3 vs G1 p=0.02) and histotype (p=0.04).

Univariate Cox Regression Analysis

RFS OS DSS
HR 95% CI P-value HR 95% CI P-value HR 95% CI P-value
Horizontal extent 1.08 1.06 1.10 <0.001 1.06 1.04 1.08 <0.001 1.06 1.04 1.08 <0.001
% circumference 1.02 1.01 1.04 0.008 1.02 0.99 1.04 0.15 1.02 0.99 1.04 0.15
Age 1.00 0.98 1.03 0.73 1.01 0.98 1.04 0.55 1.01 0.97 1.04 0.77
Histotype 0.001 0.06 0.08
SCC vs HPV adenoCA 0.81 0.33 2.01 0.65 0.27 0.06 1.22 0.09 0.29 0.06 1.34 0.11
SCC vs adenosquamous CA 4.27 1.72 10.59 0.002 2.06 0.65 6.50 0.22 1.77 0.49 6.46 0.39
SCC vs glassy CC 5.21 0.68 39.94 0.11 6.22 0.80 48.48 0.08 6.56 0.84 51.43 0.07
SCC vs non-HPV adenoCA 6.32 1.43 27.85 0.015 2.46 0.32 19.14 0.39 2.78 0.35 21.82 0.33
Grade 0.001 0.03 0.05
G2 vs G1 9.34 2.14 40.87 0.003 5.93 1.28 27.46 0.02 5.24 1.11 24.69 0.04
G3 vs G1 16.17 3.65 71.69 0.0002 7.91 1.68 37.29 0.01 7.06 1.47 34.01 0.02
Depth 1.11 1.08 1.15 <0.001 1.07 1.04 1.10 <0.001 1.07 1.04 1.10 <0.001
LVI 3.79 1.82 7.91 <0.001 7.31 2.42 22.06 <0.001 6.44 2.10 19.79 0.001
FIGO 2018 5.49 2.71 11.14 <0.001 8.88 3.37 23.38 <0.001 9.89 3.48 28.09 <0.001

(IA1-IB2 vs IB3-IV)
Multivariate Cox Regression Analysis
RFS OS DSS
HR 95% CI P-value HR 95% CI P-value HR 95% CI P-value
Horizontal extent 1.07 0.99 1.14 0.07 1.06 1.01 1.10 0.02 1.04 0.99 1.09 0.12
% circumference 1.00 0.98 1.02 0.87
Histotype 0.05
SCC vs HPV adenoCA 2.81 0.84 9.42 0.10
SCC vs adenosquamous CA 2.72 0.56 13.20 0.22
SCC vs glassy CC 0.00 0.00 . 0.99
SCC vs non-HPV adenoCA 126.6 5.08 3155 0.003
Grade 0.07 0.66 0.73
G2 vs G1 23.86 1.20 472.92 0.04 1.87 0.36 9.78 0.46 1.84 0.35 9.81 0.48
G3 vs G1 31.28 1.69 578.25 0.02 2.17 0.42 11.35 0.36 1.94 0.36 10.54 0.44
Depth 1.02 0.93 1.12 0.71 0.96 0.90 1.03 0.25 0.98 0.91 1.05 0.56
LVI 0.87 0.25 3.01 0.83 2.73 0.79 9.46 0.11 2.30 0.65 8.22 0.20
FIGO 2018 (IA1-IB2 vs IB3-IV) 1.08 0.33 3.51 0.90 2.42 0.71 8.21 0.16 3.45 0.94 12.71 0.06

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 Figure 1 - 1234

Conclusions: Based on this large retrospective series, horizontal tumor size is an important prognostic variable in cervical cancer,
predictive of overall survival independent from other factors including the 2018 FIGO stage. The % of circumferential tumor involvement
may also have a prognostic role. Despite recent recommendations by FIGO, our findings support continuing to include these variables in
the pathologic assessment and management of patients with cervical cancer.

1173