Primary and metastatic mucinous adenocarcinomas in the ovaries: incidence in routine practice with a new approach to improve intraoperative diagnosis

Recent Insights into Mucinous Ovarian Carcinoma

Ovarian mucinous tumors represent a group of rare neoplasms with a still undefined cell of origin but with an apparent progression from benign to borderline to carcinoma. Even though these tumors are different from the other histological subtypes of epithelial ovarian neoplasms, they are still treated with a similar chemotherapeutic approach. Here, we review its pathogenesis, molecular alterations, (differential) diagnosis, clinical presentation and current treatment, and how recent molecular and biological information on this tumor might lead to better and more specific clinical management of patients with mucinous ovarian carcinoma.

Massively parallel sequencing analysis of mucinous ovarian carcinomas: genomic profiling and differential diagnoses

OBJECTIVE

Mucinous ovarian cancer (MOC) is a rare type of epithelial ovarian cancer resistant to standard chemotherapy regimens. We sought to characterize the repertoire of somatic mutations in MOCs and to define the contribution of massively parallel sequencing to the classification of tumors diagnosed as primary MOCs.

METHODS

Following gynecologic pathology and chart review, DNA samples obtained from primary MOCs and matched normal tissues/blood were subjected to whole-exome (n = 9) or massively parallel sequencing targeting 341 cancer genes (n = 15). Immunohistochemical analysis of estrogen receptor, progesterone receptor, PTEN, ARID1A/BAF250a, and the DNA mismatch (MMR) proteins MSH6 and PMS2 was performed for all cases. Mutational frequencies of MOCs were compared to those of high-grade serous ovarian cancers (HGSOCs) and mucinous tumors from other sites.

RESULTS

MOCs were heterogeneous at the genetic level, frequently harboring TP53 (75%) mutations, KRAS (71%) mutations and/or CDKN2A/B homozygous deletions/mutations (33%). Although established criteria for diagnosis were employed, four cases harbored mutational and immunohistochemical profiles similar to those of endometrioid carcinomas, and one case for colorectal or endometrioid carcinoma. Significant differences in the frequencies of KRAS, TP53, CDKN2A, FBXW7, PIK3CA and/or APC mutations between the confirmed primary MOCs (n = 19) and HGSOCs, mucinous gastric and/or mucinous colorectal carcinomas were found, whereas no differences in the 341 genes studied between MOCs and mucinous pancreatic carcinomas were identified.

CONCLUSIONS

Our findings suggest that the assessment of mutations affecting TP53, KRAS, PIK3CA, ARID1A and POLE, and DNA MMR protein expression may be used to further aid the diagnosis and treatment decision-making of primary MOC.

An Evaluation of Frozen Section and Lymph Node Dissection Results for Mucinous Ovarian Tumors

OBJECTIVES

Intraoperative frozen section has greater than 90% accuracy for ovarian tumors; however, mucinous histology has been shown to be associated with increased frozen section inaccuracy. Recent data demonstrate that primary ovarian mucinous carcinomas have no lymph node involvement, even when extraovarian disease is present, and therefore may not require lymph node dissection. Our primary objective is to evaluate the accuracy of identifying mucinous histology on frozen section.

METHODS/MATERIALS

A cross-sectional review of mucinous ovarian tumors in surgical patients at one institution from 2006 to 2016 was performed. Cases reporting a mucinous ovarian tumor on frozen section or final pathology were identified. Frozen section results were compared with final diagnosis to calculate concordance rates. Analyses with χ and t tests were performed to identify variables associated with pathology discordance.

RESULTS

A total of 126 mucinous ovarian tumors were identified. Of these, 106 were reported as mucinous on frozen section and 103 (97.2%) were concordant on final pathology. Discordant cases included 2 serous and 1 clear cell tumor. Among the 103 mucinous tumors, classification as malignant, borderline, or benign was concordant in 74 (71.8%) of 103 cases, whereas 22 (21.4%) of 103 were discordant and 7 (6.8%) were deferred to final pathology. Lymph node dissection was performed in 33 cases; the only case with lymph node metastasis was a gastrointestinal mucinous adenocarcinoma. Discordance between frozen section and final pathology was associated with larger tumor size and diagnosis other than benign: discordant cases had a mean tumor size of 21.7 cm compared with 14.4 cm for concordant cases (P < 0.001), and 93.5% of discordant cases were borderline or malignant, compared with 30.5% of concordant cases (P < 0.001).

CONCLUSIONS

Intraoperative identification of mucinous histology by frozen section is reliable with a concordance rate to final pathology of 97.2%. No lymph node metastases were present in any malignant or borderline primary ovarian cases.

Mucinous Carcinomatosis: A Rare Association between an Ovarian Tumor and an E-GIST

Pseudomyxoma peritonei (PMP) and extragastrointestinal stromal tumors (E-GISTs) are both rare entities. Most of the time, PMP is associated with an appendiceal tumor. An ovarian mucinous tumor can mimic appendiceal metastases. E-GIST is a mesenchymal tumor that can arise from the omentum, retroperitoneum, mesentery, or pleura. We present a case of an 87-year-old woman with mucinous carcinomatosis and acute intestinal occlusion submitted to an emergency laparotomy. She has found to have a borderline mucinous tumor of the ovary from the intestinal type with several lesions of pseudomyxoma peritonei and an E-GIST from the epiploons retrocavity (intermediated risk). In the literature, no relation was found between these two rare tumors. E-GIST was an incidental finding in the context of a mucinous carcinomatosis.

A guided tour of selected issues pertaining to metastatic carcinomas involving or originating from the gynecologic tract

Epithelial metastases originating from the gynecologic tract or secondarily involving it frequently display a different morphology when compared to the primary tumor. Furthermore, issues such as modes of metastasis, appropriate nomenclature and prognostic significance remain subjects of discussion and some skepticism. In this review, we will discuss: metastases to uterine adnexa; serous tubal intraepithelial carcinoma (STIC); serous borderline tumors; metastases from the uterine corpus; and “synchronous” endometrial and ovarian tumors. Three additional themes that will run through the discussions are those that are peculiar, although not restricted to the gynecologic tract: metastasis from non-invasive primary tumors, metastases that look benign and metastases that are benign or clinically indolent.

Early stage mucinous ovarian cancer: A review

Mucinous ovarian carcinomas (MOCs) are an uncommon subset of epithelial neoplasms, both clinically and molecularly distinct from other ovarian cancers. Pathologic diagnosis proves challenging, and metastatic disease from other sites-especially the digestive tract-must be excluded. Fortunately, most patients are diagnosed at an early stage of disease and often present with large, unilateral adnexal masses. Survival for patients with stage IA disease approaches over 90%, and surgery alone is sufficient. Patients with stage IB-II disease should receive adjuvant treatment but the specific regimen is controversial. In the following review, we provide an overview of mucinous ovarian carcinomas, with a particular focus on the treatment of patients with early stage disease.

Relatively Poor Survival of Mucinous Ovarian Carcinoma in Advanced Stage: A Systematic Review and Meta-analysis

OBJECTIVE

Overall, patients with mucinous ovarian carcinoma (MOC) are considered to have a better prognosis compared with the whole group of nonmucinous carcinomas. However, some studies indicate that patients with advanced-stage MOC might have a worse prognosis than those with advanced-stage serous ovarian carcinoma (SOC). We carried out a systematic review and meta-analysis of the current literature.

MATERIALS AND METHODS

A comprehensive literature search was carried out identifying 19 articles that compare survival of patients with MOC and patients with SOC. Meta-analyses were performed for risk ratio (RR) and hazard ratio (HR) for all International Federation of Gynecology and Obstetrics stages together, as well as for early- and advanced-stage diseases separately.

RESULTS

Overall, patients with MOC showed a lower risk of dying within 5 years (RR, 0.67; 95% confidence interval [CI], 0.64-0.69; n = 45 333) and a longer survival (HR, 0.66; 95% CI, 0.58-0.75; HR, 0.88; 95% CI, 0.78-0.98, for univariate and multivariate analyses, respectively; n = 5540) compared with those with SOC. In contrast, in advanced-stage (International Federation of Gynecology and Obstetrics stages III and IV) disease, patients with MOC have a higher risk of dying within 5 years (RR, 1.15; 95% CI, 1.13-1.17; n = 36 113) and a shorter survival (HR, 1.82; 95% CI, 1.71-1.94; n = 19 907).

CONCLUSIONS

Patients with advanced-stage MOC have a significantly worse prognosis compared with patients with SOC, whereas in early stage, the prognosis of patients with MOC is better.

Update on rare epithelial ovarian cancers: based on the Rare Ovarian Tumors Young Investigator Conference

There has been significant progress in the understanding of the pathology and molecular biology of rare ovarian cancers, which has helped both diagnosis and treatment. This paper provides an update on recent advances in the knowledge and treatment of rare ovarian cancers and identifies gaps that need to be addressed by further clinical research. The topics covered include: low-grade serous, mucinous, and clear cell carcinomas of the ovary. Given the molecular heterogeneity and the histopathological rarity of these ovarian cancers, the importance of designing adequately powered trials or finding statistically innovative ways to approach the treatment of these rare tumors has been emphasized. This paper is based on the Rare Ovarian Tumors Conference for Young Investigators which was presented in Tokyo 2015 prior to the 5th Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup (GCIG).

Mucinous epithelial ovarian carcinoma

Mucinous tumours involving the ovary may be benign, borderline, or malignant. Malignant tumours may be primary or metastatic. Differentiation between primary and metastatic involvement of the ovary is critical for optimal patient management. Even among skilled pathologists, this distinction can be problematic, as can the distinction between borderline ovarian tumour of intestinal type and well-differentiated invasive primary mucinous ovarian carcinoma. Primary invasive mucinous ovarian carcinoma and mucinous carcinoma metastatic to the ovary do have distinct patterns of macroscopic and microscopic involvement which will reveal the correct diagnosis in many cases. There are also well-recognized patterns of immunohistochemical staining that can further assist in this differentiation. As a result of the application of these histopathological techniques, the incidence of primary invasive mucinous epithelial carcinoma has fallen over recent years from ∼12% to ∼3%. However, even in recent multicentre clinical trials such as GOG 182, expert pathological review suggests that ∼60% of tumours originally classified as primary invasive mucinous carcinomas were in fact metastatic tumours to the ovary. Review of outcome data for patients with mucinous carcinoma entered into multicentre trials suggests that this subtype of disease has a particularly poor prognosis in comparison with other subtypes of ovarian carcinoma. Historically, patients with mucinous epithelial ovarian carcinoma (mEOC) have been treated in the same way as other subtypes of ovarian carcinoma. While there is undoubtedly a response rate to platinum-based chemotherapy, retrospective reviews of individual centre experience suggest that this is substantially lower than for high-grade papillary serous carcinoma and in the order of only 30%-40%. The mEOC trial was established to investigate the possibility that the combination of capecitabine and oxaliplatin (chemotherapy drugs more commonly used in colorectal carcinoma) may be superior to conventional carboplatin and paclitaxel chemotherapy. In a 2 × 2 factorial design, there was also a randomization to bevacizumab. Unfortunately, this trial closed early, 5 years after initiation having recruited just 50 of a proposed 322 patients. mEOC is now characterized as a type I tumour with an identifiable stepwise progression from a premalignant lesion, through non-invasive, to invasive malignancy. Molecular characterization of mEOC reveals it to be distinct from other subtypes of the disease with a KRAS mutation occurring in 40%-50% of patients. Other gene abnormalities including HER2 amplification in ∼19% also occur. This raises the possibility of the use of targeted molecular therapies which with molecular analysis of individual patient tumours could form the basis of a future clinical trial. It is, however, clear that if trials are to be conducted in this rare subtype of disease, they will need to be truly international in nature and carefully designed, possibly using an adaptive stepwise approach and will require an appropriate level of funding with a realistic assessment of likely recruitment. Associated translational research will clearly be essential.

Intestinal-Type Adenocarcinoma Arising in a Mature Cystic Teratoma of the Ovary

Here, we present a rare case of intestinal type adenocarcinoma arising in mature cystic teratoma (MCT) and review all previously reported similar cases with emphasis on the immunohistochemical characteristics of prior cases. Nine prior cases of intestinal type adenocarcinoma arising in MCT have been previously reported. Two of the prior cases as well as this case have been associated with CA19-9 elevation. CK20 is consistently strongly positive and CK7 is usually negative in cases of intestinal type adenocarcinoma arising in MCT. This contrasts with mucinous tumors of the ovary which are known to be usually CK7 strongly positive and inconsistently CK20 positive. The pattern of strong CK20 staining and often negative or weak CK7 staining is common to mucinous neoplasms arising in MCT. These findings suggest that the less common subset of primary mucinous ovarian tumors that have strong CK20 staining and partial or negative CK7 staining may represent a group of tumors with germ cell origin rather than the more common surface epithelial origin.

Recent Trends in Ovarian Cancer Incidence and Relative Survival in the United States by Race/Ethnicity and Histologic Subtypes

Background: Incidence and survival rates of nonserous epithelial ovarian cancer in racial/ethnic minorities remain relatively unknown in the United States. We examined the trends in incidence and survival rates for epithelial ovarian cancer by histologic subtypes and race/ethnicity.Methods: Ovarian cancer incidence and mortality data from 2000 to 2013 were obtained from the Surveillance, Epidemiology, and End Results database. Age-adjusted incidence rate, incidence rate ratio, and annual percentage changes (APC) were calculated by histology and race/ethnicity subgroups and stratified by age at diagnosis. Five-year relative survival rates were calculated by stage and race/ethnicity.Results: A small but significant decrease in incidence rates was seen in non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic women (APC -1.58, -0.84, and -1.31, respectively), while incidence rates remained relatively stable in Asian women (APC -0.37). With exception of significant increase in the incidence rate of clear cell carcinoma among Asian woman (APC 1.85), an overall trend toward decreasing incidence rates was seen across histologic subtypes and age-strata, although not all results were statistically significant. Compared with NHW women, NHB women experienced poorer 5-year survival at every stage across histologic subtypes, while Hispanic and Asian women had equivalent or better survival.Conclusions: Over the last decade, incidence rates of epithelial ovarian cancer in the United States have decreased or remained stable across race/ethnic and histologic subgroups, except for clear cell carcinoma. Survival remains poorest among NHB women.Impact: Comparative histologic subtype distribution and incidence trends do not explain the ovarian cancer survival disparity disproportionately affecting NHB women. Cancer Epidemiol Biomarkers Prev; 26(10); 1511-8. ©2017 AACR.

Adnexal masses associated with peritoneal involvement: diagnosis with CT and MRI

Given the unique intra-peritoneal anatomic location of the adnexa, tubo-ovarian diseases can commonly spread into the peritoneal cavity. Peritoneal seeding may occur in a spectrum of adnexal conditions including infectious diseases, endometriosis, and benign or malignant primary or secondary ovarian tumors. CT is usually the imaging modality on which the concomitant involvement of the peritoneum and the ovary is depicted. The first diagnosis to be considered by the radiologist is generally peritoneal carcinomatosis from ovarian cancer but other conditions cited above have also to be borne in mind and may be suggested on the basis of careful assessment of CT findings or on further MR findings. MRI may indeed help characterize the lesions in some cases. The purpose of this review is to describe the clinical and imaging patterns of peritoneal involvement that may be found in association with different ovarian lesions. Familiarity with these patterns and diagnoses will help the radiologist narrow the differential diagnosis and make an accurate diagnosis, thus facilitating patient management and avoiding unnecessary invasive treatment.

Cigarette smoking and the association with serous ovarian cancer in African American women: African American Cancer Epidemiology Study (AACES)

BACKGROUND

Smoking is a risk factor for mucinous ovarian cancer (OvCa) in Caucasians. Whether a similar association exists in African Americans (AA) is unknown.

METHODS

We conducted a population-based case-control study of incident OvCa in AA women across 11 geographic locations in the US. A structured telephone interview asked about smoking, demographic, health, and lifestyle factors. Odds ratios and 95% confidence intervals (OR, 95% CI) were estimated from 613 cases and 752 controls using unconditional logistic regression in multivariable adjusted models.

RESULTS

Associations were greater in magnitude for serous OvCa than for all OvCa combined. Compared to never smokers, increased risk for serous OvCa was observed for lifetime ever smokers (1.46, 1.11-1.92), former smokers who quit within 0-2 years of diagnosis (5.48, 3.04-9.86), and for total pack-years smoked among lifetime ever smokers (0-5 pack-years: 1.79, 1.23-2.59; >5-20 pack-years: 1.52, 1.05-2.18; >20 pack-years: 0.98, 0.61-1.56); however, we observed no dose-response relationship with increasing duration or consumption and no significant associations among current smokers. Smoking was not significantly associated with mucinous OvCa. Associations for all OvCa combined were consistently elevated among former smokers. The proportion of ever smokers who quit within 0-2 years was greater among cases (23%) than controls (7%).

CONCLUSIONS

Cigarette smoking may be associated with serous OvCa among AA, which differs from associations reported among Caucasians. Exposure misclassification or reverse causality may partially explain the absence of increased risk among current smokers and lack of dose-response associations. Better characterization of smoking patterns is needed in this understudied population.

A pathological and clinical study of 706 primary tumours of the ovary in the largest tertiary hospital in Ghana

Background

Ovarian tumours are a leading cause of death in Ghana. Even though geographical and racial differences exist in the frequency, types and age distribution of primary ovarian tumours, information about the clinical and pathological characteristics of ovarian tumours in Ghana and its neighboring countries is scanty. We determined the frequency, age distribution, histopathological types and clinical features of primary ovarian tumours diagnosed at the Korle-Bu Teaching Hospital in Ghana to aid in the management of patients.

Method

All pathology records of ovarian tumours diagnosed from January 2001 to December 2010 were reviewed. Histopathologically, tumours were classified according to the then World Health Organization 1999 classification. Biographical and clinical data of patients were also collected and entered into Epi-info to determine the frequency, age distribution and other clinical features of the types of ovarian tumour.

Results

Seven hundred and six ovarian tumours were studied. Germ cell tumours were the most common (41.9%), with mean age of occurrence being 30.7 years (SD 12.7), they were dominated by mature teratomas (39.2%). Surface epithelial tumours were second, and commonly occurred in women aged 35–44years, 77 (26.8%). Sex cord stromal tumours followed with mean age of occurrence of 40.2 years (SD 17.9). The most common malignant tumours were surface epithelial (52.1%) dominated by serous carcinomas with mean age 50.1 years. Most patients (47.7%) presented within 1 month of onset of symptoms, feeling a lower abdominal mass (38.5%).

Conclusion

The most common primary ovarian tumours in this study are Germ cell tumours, dominated by mature teratomas. Adenocarcinomas are mostly serous and occur in younger women compared to findings of other Western studies. The single most common malignant ovarian tumour in children and adolescents is Burkitt lymphoma. Patients who develop ovarian tumours have no specific symptoms or signs at presentation, to aid early diagnosis.

Ovarian borderline tumors in the 2014 WHO classification: evolving concepts and diagnostic criteria

Borderline ovarian tumors (BOT) are uncommon but not rare epithelial ovarian neoplasms, intermediate between benign and malignant categories. Since BOT were first identified >40 years ago, they have inspired controversies disproportionate to their incidence. This review discusses diagnostic criteria for the histologic subtypes of BOT, highlighting areas of diagnostic challenges, ongoing controversies, and changes in terminology implemented by the recent 2014 WHO Classification of Tumours of the Female Genital Organs. Emerging knowledge supports the notion that subtypes of borderline ovarian tumors comprise distinct biologic, pathogenetic, and molecular entities, precluding a single unifying concept for BOT. Serous borderline tumors (SBT) share molecular and genetic alterations with low-grade serous carcinomas and can present at higher stages with peritoneal implants and/or lymph node involvement, which validates their borderline malignant potential. All other (non-serous) subtypes of BOT commonly present at stage I confined to the ovary(ies) and are associated with overall survival approaching that of the general population. An important change in the WHO 2014 classification is the new terminology of non-invasive implants associated with SBT, as any invasive foci (previously called “invasive implants”) are now in line with their biological behavior considered peritoneal low-grade serous carcinoma (LGSC). The controversy regarding the terminology of non-serous borderline tumors, called by some pathologists “atypical proliferative tumor” in view of their largely benign behavior, has not been resolved. The concepts of intraepithelial carcinoma and microinvasion may evolve in further studies, as their presence appears to have no prognostic impact and is subject to considerable inter-observer variability.

The challenge of diagnosing a malignancy metastatic to the ovary: clinicopathological characteristics vary and morphology can be different from that of the corresponding primary tumor

An accurate diagnosis of metastases to the ovary is essential for adequate patient management. The aim of this retrospective study was to characterize clinicopathological features of metastatic malignancies that presented as an ovarian mass and compare them with their corresponding primary tumors. We reviewed clinical files and histological material of 120 patients with metastases to the ovary, diagnosed in our center between 2000 and 2014. Metastases were diagnosed before (18 %), synchronously (33 %), or after (49 %) the primary tumor was identified; 25 % were single, 40 % were unilateral; 47 % were ≥13 cm. Most originated from the gastrointestinal tract (73 %), followed by breast (13 %), and female reproductive organs (10 %). Gross features varied with primary tumor site. Metastases from gastrointestinal malignancies were significantly larger and frequently showed necrosis. Metastases to the appendix were cystic (94 %), and almost all metastases to the stomach (96 %) and breast (87 %) were solid. The predominant histological pattern was discordant in 44 % cases, mostly due to cystic changes in ovarian metastases which were observed across several histological types. Other metastases showed a predominant histological pattern which was present only focally in the primary tumor. Metastases showed significantly more edema, necrosis, and hemorrhage, but less lymphovascular invasion and inflammatory infiltrate than the corresponding primary tumors. Metastases to the ovary present highly variable clinicopathological features which frequently differ from those of the corresponding primary tumor. A metastasis should always be considered in the differential diagnosis of an ovarian mass. All clinical, imaging, macroscopic, and histological aspects must be taken into account to establish a correct diagnosis which is essential for adequate treatment.

The effect of time on racial differences in epithelial ovarian cancer (OVCA) diagnosis stage, overall and by histologic subtypes: a study of the National Cancer Database

PURPOSE

Previous studies assessing racial and ethnic differences in ovarian cancer (OVCA) diagnosis stage fail to present subtype-specific results and provide historic data on cases diagnosed between 10 and 20 years ago. The purpose of this analysis is to assess non-Hispanic Black (NHB) and non-Hispanic White (NHW) differences in late-stage diagnosis including; (1) factors associated with late-stage diagnosis of invasive epithelial OVCA overall and by histologic subtypes, (2) potential changes across time and (3) current patterns of trends in a national cancer registry in the USA and Puerto Rico between 1998 and 2011.

METHODS

NHB and NHW OVCA cases were derived from the National Cancer Database (NCDB). Diagnosis stage was analyzed as a dichotomous and a four level-category variable, respectively; early (stages I and II; localized) versus late (stages III and IV; regional and distant) and stages I, II, III and IV. Diagnosis period was trichotomized (1998-2002, 2003-2007, 2008-2011). Racial differences in stage were tested using Chi-square statistics. Odds ratios (OR) and 95 % confidence intervals (95 % CI) were estimated using multivariable binomial and generalized ordered logistic regressions. Interactions between race and diagnosis period were evaluated.

RESULTS

Between 1998 and 2011, 11,562 (7.8 %) NHB and 137,106 (92.2 %) NHW were diagnosed with OVCA. In adjusted models, NHB were significantly more likely diagnosed with late-stage OVCA than NHW (ORadj 1.26, 95 % CI 1.19-1.33). Interaction between race and diagnosis period was marginally significant (p value = 0.09), with racial differences in stage decreasing over time (1998-2002: ORadj 1.36, 95 % CI 1.23-1.49; 2003-2007: ORadj 1.27, 95 % CI 1.15-1.39; 2008-2011; ORadj 1.15, 95 % CI 1.05-1.27). NHB were also more likely to be diagnosed with stage 4 high-grade serous (ORadj 1.46, 95 % CI 1.22-1.74), clear cell (ORadj 2.71, 95 % CI 1.94-3.79) and mucinous (ORadj 2.78, 95 % CI 2.24-3.46) carcinomas than NHW.

CONCLUSIONS

Racial differences in late-stage OVCA diagnosis exist; however, these differences are decreasing with time. Within NCDB, NHB are significantly more likely diagnosed with late-stage OVCA and more specifically high-grade serous, clear cell and mucinous carcinomas than NHW.

Timing and patterns of recurrence in epithelial ovarian cancer patients with no gross residual disease after primary debulking surgery

OBJECTIVE

The aim of this study was to analyse patterns and timing of recurrence and their association with clinical outcomes in recurrent epithelial ovarian cancer (EOC) patients with no gross residual disease after primary debulking surgery (PDS).

METHODS

This study was conducted on 303 EOC patients with no residual disease after PDS who were treated at the Samsung Medical Center from 2002 to 2012. By reviewing electronic medical records, information on date of clinical/pathological recurrence and pattern of disease presentation for each relapse were retrieved.

RESULTS

Within a median follow-up of 53 months (range 3-156), 88 recurrences (29.0%) and 28 cancer-related deaths (9.2%) were observed. Most of the recurrences were distant, discrete and transcoelomic. After complete cytoreduction, the initial stage was associated with location of recurrence, but not with recurrence patterns. Complete cytoreduction reduced the number of recurrences, but it did not affect timing of recurrence. In multivariate analysis for overall survival (OS), patients with distant recurrence, diffuse carcinomatosis and mixed spread pattern of transcoelomic, lymphatic and haematogenous recurrence were found to have higher risk.

CONCLUSIONS

We found that timing of recurrence was not affected by complete cytoreduction. Location, type and pattern of recurrence were also significant prognostic factors for OS, in addition to known prognostic predictors such as platinum sensitivity.

Secondary Involvement of the Adnexa and Uterine Corpus by Carcinomas of the Uterine Cervix: A Detailed Morphologic Description

Cervical carcinoma infrequently involves the uterine corpus or adnexa. Metastatic adenocarcinoma (AC) to the ovaries can be difficult to distinguish from primary ovarian tumors, and metastatic squamous cell carcinoma (SCC) to these sites has not been well described. Our aim was to provide a detailed description of the morphologic patterns of adnexal and corpus involvement by cervical carcinoma. Cases were identified over a 15-yr period and the following features were recorded: visible lesion, depth of invasion, lymphovascular invasion, and patterns of spread. Only usual human papillomavirus-associated tumors were included. Twenty cases with available slides were identified (2 in situ and 8 invasive SCC; 10 AC); 17 had visible lesions, usually with deep cervical and lymphovascular invasion. Sixteen involved the corpus (1 in situ, 7 SCC, 8 AC), all colonizing endometrium and 10 invading myometrium. SCC involved the ovary and fallopian tube in 4 and 6 cases, respectively, whereas AC involved the ovary in 4 (2 unilateral, 2 bilateral) and the tube in 8 cases. SCC in the ovary usually showed parenchymal invasion, and parenchymal and mucosal involvement in the tube. AC in the ovary ranged from small nodules to confluent expansile growth, whereas in the tube it often showed mucosal colonization mimicking a primary tubal process. Adnexal metastasis of cervical carcinoma is rare and usually coexists with endometrial and myometrial extension from the cervix. Both squamous and ACs can colonize tubal and endometrial mucosa; AC in particular can mimic primaries at those sites. Bilaterality is not a common feature of metastatic endocervical AC.

Metastatic Ovarian Tumors Originating From a Small Bowel Adenocarcinoma - A Case Report and Brief Literature Review

Approximately 1.6% of tumors metastatic to the ovary of nongynecologic origin are from a small bowel adenocarcinoma (SBA). However, the incidence of SBA is extremely rare (0.23 cases/100,000 people), which suggests a high frequency of ovarian metastasis, although the reason is unknown. To identify the characteristics of ovarian tumor metastasis from SBA, we reviewed 72 cases reported in the English literature, including the case presented in this report. The mean age of the patients was 46.7 yr. Solitary ovarian metastasis was observed in 67% of the cases, and ovarian metastasis was accompanied by peritoneal dissemination in 33% of the cases. Although duodenal adenocarcinoma has the highest incidence among the SBAs, jejunal adenocarcinoma, particularly that at the proximal end, is the type of SBA that most frequently metastasizes to the ovary. Among the cases of ovarian metastasis from SBA, 51% were bilateral, 33% were unilateral to the right ovary, and 16% were unilateral to the left ovary.

Survival of Patients With Mucinous Ovarian Carcinoma and Ovarian Metastases: A Population-Based Cancer Registry Study

OBJECTIVES

Patients with mucinous ovarian carcinoma (MOC) generally have a favorable prognosis, although in advanced stage, prognosis is significantly worse compared to patients with serous ovarian carcinomas (SOCs). This might be due to the difficulties in distinguishing MOC from metastatic tumors. In the current study, we investigate prognosis of MOC compared to other types of ovarian cancer and to synchronous metastases to the ovary (sMO).

MATERIALS AND METHODS

Age, laterality, International Federation of Gynecology and Obstetrics stage, tumor grade, treatment, and survival were extracted from the Eindhoven Cancer registry for all patients diagnosed with ovarian carcinomas or sMO between 1990 and 2012. Five-year survival analysis and Cox proportional hazards analysis were conducted.

RESULTS

A total of 3556 patients with primary ovarian carcinoma (of which 474 mucinous) and 289 with sMO were identified. In advanced stage, 5-year survival of patients with MOC was comparable to survival of patients with sMO (11% vs 11%, P = 0.32) and decreased compared to patients with SOC (26%, P < 0.01). For MOC, there was no clinically significant effect on 5-year survival of either debulking (12% vs 8%, P < 0.01) or chemotherapy (12% vs 10%, P = 0.02).

CONCLUSIONS

Patients with advanced stage MOC have a worse prognosis than advanced stage SOC. Survival is almost identical to that of patients with sMO. Effects of chemotherapy and debulking are limited in patients with MOC, which may be explained by suboptimal treatment due to the admixture of metastases in advanced stage MOC. Methods to differentiate between primary MOC and metastatic disease are needed to provide optimal treatment and insight in prognosis.

Fertility-sparing surgery for early stage epithelial ovarian cancer

Discussion of fertility-sparing treatment is an important part of pretreatment counseling for young patients with early epithelial ovarian cancer. As a result of late childbearing nowadays, fertility preservation has become a major issue in ovarian cancer patients. The purpose of this review is to update current knowledge on fertility-sparing treatment for early stage epithelial ovarian cancer, which may be useful for pretreatment counseling for reproductive-age patients. The multicenter study data on the fertility-sparing treatment published by Japan Clinical Oncology Group in 2010 confirmed that fertility-sparing surgery is a safe treatment for Stage IA patients with non-clear cell histology and Grade 1 or 2 and suggested that Stage IA patients with clear cell histology and Stage IC patients with non-clear cell histology and Grade 1 or 2 can be candidates for fertility-sparing surgery followed by adjuvant chemotherapy. In the current review, we added the recent case series and review, and discussed the fertility-sparing treatment on young patients with early epithelial ovarian cancer. We need not to change the proposal by the Japan Clinical Oncology Group study, but we should wait for the results of an ongoing prospective study to strongly recommend the proposal of the Japan Clinical Oncology Group study.

Low-grade epithelial ovarian cancer: a number of distinct clinical entities?

PURPOSE OF REVIEW

The purpose of this study is to summarize the contemporary understanding of low-grade epithelial ovarian cancers.

RECENT FINDINGS

Low-grade serous ovarian cancer is biologically distinct from high-grade serous ovarian cancer. It is associated with a high incidence of K-RAS and B-RAF mutations. Although described as indolent due to median progression-free and overall survivals of 20 and 99 months, respectively, with a median age of diagnosis of 43 years, it accounts for a significant number of patient-years lost. Retrospective studies suggest response rates of 5% for chemotherapy and 9% for antioestrogen therapy. A prospective study of the mitogen-activated protein kinase kinase inhibitor selumetinib (response rate 15%) and retrospective bevacizumab studies suggest that these may be more effective approaches.Limited retrospective clinical data and even more sparse molecular data suggest that similar distinctions may exist between low-grade endometrioid and mucinous ovarian cancers and their respective high-grade counterparts, but more research is required in order to clarify the biological differences and the implications that these have for management.

SUMMARY

The results of phase III mitogen-activated protein kinase kinase inhibitor studies in low-grade serous ovarian cancer and further clinical and biological assessment of low-grade endometrioid and mucinous ovarian cancers are urgently required.

Regulation of multidrug resistance 1 expression by CDX2 in ovarian mucinous adenocarcinoma

Epithelial ovarian cancer is an aggressive gynecological malignancy with a high mortality rate. Resistance against chemotherapeutic agents often develops in ovarian cancer patients, contributing to high recurrence rates. The multidrug resistance 1 (MDR1/ABCB1) gene encodes P‐glycoprotein, which affects the pharmacokinetic properties of anticancer agents. We previously reported that the Caudal‐related homeobox transcription factor CDX2 transcriptionally regulates MDR1 expression in colorectal cancer. CDX2 is a factor that influences cancer cell differentiation, malignancy, and cancer progression. We hypothesized that profiling of CDX2 and MDR1 expression could be an effective strategy for predicting anticancer drug resistance. We studied the expression of these factors in clinical samples from ovarian cancer patients. We found that endogenous MDR1 expression was positively associated with CDX2 expression in ovarian mucinous adenocarcinoma. Using ovarian mucinous adenocarcinoma cell lines, we also observed decreased MDR1 expression following inhibition of CDX2 by RNA interference. In addition, CDX2 overexpression in MN‐1 cells, which display low endogenous CDX2, resulted in upregulation of MDR1 expression. CDX2 induced MDR1‐dependent resistance to vincristine and paclitaxel, which was reversed by treatment with the MDR1‐specific inhibitor verapamil. Our findings show that CDX2 promotes upregulation of MDR1 expression, leading to drug resistance in ovarian mucinous adenocarcinoma. Therefore, our study demonstrates the potential of novel chemotherapy regimens based on CDX2 status and MDR1 expression in ovarian mucinous adenocarcinoma.

Mucinous ovarian cancer: A therapeutic review

Mucinous ovarian cancer represents approximately 3% of epithelial ovarian cancers (EOC). Despite this seemingly low prevalence, it remains a diagnostic and therapeutic conundrum that has resulted in numerous attempts to adopt novel strategies in managing this disease. Anecdotally, there has been a prevailing notion that established gold standard systemic regimens should be substituted for those utilised in cancers such as gastrointestinal (GI) malignancies; tumours that share more biological similarities than other EOC subtypes. This review summarises the plethora of small studies which have adopted this philosophy and influenced the design of the multinational GOG142 study, which was ultimately terminated due to poor accrual. To date, there is a paucity of evidence to support delivering 'GI style' chemotherapy for mucinous ovarian cancer over and above carboplatin-paclitaxel doublet therapy. Hence there is an urge to develop studies focused on targeted therapeutic agents driven by refined mutational analysis and conducted within the context of harmonised international collaborations.

Early stage primary ovarian mucinous carcinoma: Outcome-based clinicopathological study in comparison with serous carcinoma

OBJECTIVE

To compare clinicopathological characteristics and survival rates between patients with primary ovarian mucinous carcinoma and those with primary ovarian serous carcinoma.

METHODS

This retrospective study reviewed archival tumour specimens, originally diagnosed as primary ovarian mucinous carcinoma, using refined histological criteria. All patients were contacted to establish survival status. Clinicopathological characteristics and patient survival data were compared with a group of control patients with primary ovarian serous carcinoma.

RESULTS

Of the 33 patients originally diagnosed with primary ovarian mucinous carcinoma, this diagnosis was only confirmed in 18. Primary ovarian mucinous carcinoma was more commonly associated with early International Federation of Gynecology and Obstetrics tumour stages and low-grade histology than primary ovarian serous carcinoma. Patients with primary ovarian mucinous carcinoma had a significantly higher overall 5-year survival rate than those with primary ovarian serous carcinoma (12/12 [100%] versus 14/24 [58%]). Kaplan-Meier survival plots demonstrated that patients with primary ovarian mucinous carcinoma had a survival advantage over patients with primary ovarian serous carcinoma.

CONCLUSIONS

Primary ovarian mucinous carcinomas are frequently low-grade, stage I tumours and have an excellent prognosis.

Incidence of epithelial ovarian cancer according to histologic subtypes in Korea, 1999 to 2012

OBJECTIVE

To investigate trends in the incidence of epithelial ovarian cancer (EOC), according to histologic subtypes, in Korean women between 1999 and 2012.

METHODS

Data from the Korea Central Cancer Registry recorded between 1999 and 2012 were evaluated. The incidences of EOC histologic subtypes were counted. Age-standardized incidence rates (ASRs) and annual percentage changes (APCs) in incidence rates were calculated. Patient data were divided into three groups based on age (<40, 40 to 59, and >59 years), and age-specific incidence rates were compared.

RESULTS

Overall, the incidence of EOC has increased. Annual EOC cases increased from 922 in 1999 to 1,775 in 2012. In 1999, the ASR was 3.52 per 100,000 and increased to 4.79 per 100,000 in 2012 (APC, 2.53%; p<0.001). The ASRs in 2012 and APCs between 1999 and 2012 for the four major histologic subtypes were as follows (in order of incidence): serous carcinoma (ASR, 2.32 per 100,000; APC, 4.34%; p<0.001), mucinous carcinoma (ASR, 0.73 per 100,000; APC, -1.05%; p=0.131), endometrioid carcinoma (ASR, 0.51 per 100,000; APC, 1.48%; p=0.032), and clear cell carcinoma (ASR, 0.50 per 100,000; APC, 8.13%; p<0.001). In the sub-analyses based on age, clear cell carcinoma was confirmed as the histologic subtype whose incidence had increased the most since 1999.

CONCLUSION

The incidence of EOC is increasing in Korea. Among the histologic subtypes, the incidence of clear cell carcinoma has increased markedly across all age groups since 1999.

Genome-wide significant risk associations for mucinous ovarian carcinoma

Genome-wide association studies have identified several risk associations for ovarian carcinomas but not for mucinous ovarian carcinomas (MOCs). Our analysis of 1,644 MOC cases and 21,693 controls with imputation identified 3 new risk associations: rs752590 at 2q13 (P = 3.3 × 10(-8)), rs711830 at 2q31.1 (P = 7.5 × 10(-12)) and rs688187 at 19q13.2 (P = 6.8 × 10(-13)). We identified significant expression quantitative trait locus (eQTL) associations for HOXD9 at 2q31.1 in ovarian (P = 4.95 × 10(-4), false discovery rate (FDR) = 0.003) and colorectal (P = 0.01, FDR = 0.09) tumors and for PAX8 at 2q13 in colorectal tumors (P = 0.03, FDR = 0.09). Chromosome conformation capture analysis identified interactions between the HOXD9 promoter and risk-associated SNPs at 2q31.1. Overexpressing HOXD9 in MOC cells augmented the neoplastic phenotype. These findings provide the first evidence for MOC susceptibility variants and insights into the underlying biology of the disease.

Data set for reporting of ovary, fallopian tube and primary peritoneal carcinoma: recommendations from the International Collaboration on Cancer Reporting (ICCR)

A comprehensive pathological report is essential for optimal patient management, cancer staging and prognostication. In many countries, proforma reports are used but these vary in their content. The International Collaboration on Cancer Reporting (ICCR) is an alliance formed by the Royal College of Pathologists of Australasia, the Royal College of Pathologists of the United Kingdom, the College of American Pathologists, the Canadian Partnership Against Cancer and the European Society of Pathology, with the aim of developing an evidence-based reporting data set for each cancer site. This will reduce the global burden of cancer data set development and reduplication of effort by different international institutions that commission, publish and maintain standardised cancer reporting data sets. The resultant standardisation of cancer reporting will benefit not only those countries directly involved in the collaboration but also others not in a position to develop their own data sets. We describe the development of a cancer data set by the ICCR expert panel for the reporting of primary ovarian, fallopian tube and peritoneal carcinoma and present the 'required' and 'recommended' elements to be included in the report with an explanatory commentary. This data set encompasses the recent International Federation of Obstetricians and Gynaecologists staging system for these neoplasms and the updated World Health Organisation Classification of Tumours of the Female Reproductive Organs. The data set also addresses issues about site assignment of the primary tumour in high-grade serous carcinomas and proposes a scoring system for the assessment of tumour response to neoadjuvant chemotherapy. The widespread implementation of this data set will facilitate consistent and accurate data collection, comparison of epidemiological and pathological parameters between different populations, facilitate research and hopefully will result in improved patient management.

Persistent low expression of hZip1 in mucinous carcinomas of the ovary, colon, stomach and lung

BACKGROUND

Mucinous carcinomas from different organs are morphologically similar and might share similarities at the molecular and biochemical levels that may illuminate their pathogenesis and influence management. The factors involved in the pathogenesis of mucinous carcinomas remain unknown; which is likely one contributor to the current dearth of biomarkers for detection. Because zinc changes are implicated in some cancers e.g., prostate; we assessed the possibility of a similar role in mucinous carcinomas.

METHODS

The goal of the current work is to study the expression of hZip1 by immunohistochemistry in mucinous carcinomas as compared with non-neoplastic epithelia and conventional carcinomas. Tissue microarray slides containing mucinous carcinomas of the ovary (n = 35), colon (n = 51), stomach (n = 32) and lung (n = 21) were used.

RESULTS

hZip1 showed persistent low expression in mucinous compared to ovarian serous carcinomas and normal tissue (P < 0.05), colonic adenocarcinoma and normal mucosa (P < 0.001), and gastric adenocarcinoma and normal epithelium (P < 0.05). hZip1 also showed low expression in pulmonary mucinous carcinomas.

CONCLUSIONS

hZip1 is consistently decreased in mucinous carcinomas from a variety of organs. Despite the fact that these preliminary findings are unlikely to be of much diagnostic significance, these findings suggest that hZip1 plays a fundamental role in the carcinogenesis of mucinous tumors.

Epidemiology in ovarian carcinoma: Lessons from autopsy

OBJECTIVE

We challenge epidemiologic knowledge regarding ovarian carcinoma (OC) by bridging the gap between clinical and autopsy data.

METHODS

Autopsy reports, histological slides and clinical files from 660 patients in whom OC was diagnosed from 1975-2005 were studied (autopsy cohort, n=233; Clinical Cancer Registry from the local gyneco-oncologic center, n=427).

RESULTS

Out of the autopsy cohort, we identified four distinct subgroups of patients: 1) OC was diagnosed before autopsy, n=156 (67.0%). 2) OC was an incidental finding, n=16 (6.8%). 3) The ovarian tumors were not primary OC but rather metastases from other primary tumors; this revised diagnosis was first made by using current histopathological knowledge/techniques, n=24 (10.3%). 4) Death was directly due to OC in its final stage and OC was first diagnosed by autopsy, n=37 (15.9%); when these cases were added to the Clinical Cancer Registry to an adjusted OC incidence model, the autopsy cases comprised 8.8% of the adjusted cohort and almost doubled the percentage of oldest patients (≥80 years at diagnosis) from 4.9% to 9.3% (p=0.013).

CONCLUSIONS

Epidemiological data from the 1970s-1990s may overestimate true incidence because up to 10% of carcinomas in the ovary were not properly classified. Patients who were first diagnosed with OC by autopsy comprise a distinct subgroup. These are patients who have not been seen by specialized oncologists and thus play no role in their perception of the disease. Nevertheless, these cases have impact on prevalence and incidence data of OC and in an era of reduced autopsy rates will probably be overlooked.

Targeted deep sequencing of mucinous ovarian tumors reveals multiple overlapping RAS-pathway activating mutations in borderline and cancerous neoplasms

BACKGROUND

Mucinous ovarian tumors represent a distinct histotype of epithelial ovarian cancer. The rarest (2-4 % of ovarian carcinomas) of the five major histotypes, their genomic landscape remains poorly described. We undertook hotspot sequencing of 50 genes commonly mutated in human cancer across 69 mucinous ovarian tumors. Our goals were to establish the overall frequency of cancer-hotspot mutations across a large cohort, especially those tumors previously thought to be "RAS-pathway alteration negative", using highly-sensitive next-generation sequencing as well as further explore a small number of cases with apparent heterogeneity in RAS-pathway activating alterations.

METHODS

Using the Ion Torrent PGM platform, we performed next generation sequencing analysis using the v2 Cancer Hotspot Panel. Regions of disparate ERBB2-amplification status were sequenced independently for two mucinous carcinoma (MC) cases, previously established as showing ERBB2 amplification/overexpression heterogeneity, to assess the hypothesis of subclonal populations containing either KRAS mutation or ERBB2 amplification independently or simultaneously.

RESULTS

We detected mutations in KRAS, TP53, CDKN2A, PIK3CA, PTEN, BRAF, FGFR2, STK11, CTNNB1, SRC, SMAD4, GNA11 and ERBB2. KRAS mutations remain the most frequently observed alteration among MC (64.9 %) and mucinous borderline tumors (MBOT) (92.3 %). TP53 mutation occurred more frequently in carcinomas than borderline tumors (56.8 % and 11.5 %, respectively), and combined IHC and mutation data suggest alterations occur in approximately 68 % of MC and as many as 20 % of MBOT. Proven and potential RAS-pathway activating changes were observed in all but one MC. Concurrent ERBB2 amplification and KRAS mutation were observed in a substantial number of cases (7/63 total), as was co-occurrence of KRAS and BRAF mutations (one case). Microdissection of ERBB2-amplified regions of tumors harboring KRAS mutation suggests these alterations are occurring in the same cell populations, while consistency of KRAS allelic frequency in both ERBB2 amplified and non-amplified regions suggests this mutation occurred in advance of the amplification event.

CONCLUSIONS

Overall, the prevalence of RAS-alteration and striking co-occurrence of pathway "double-hits" supports a critical role for tumor progression in this ovarian malignancy. Given the spectrum of RAS-activating mutations, it is clear that targeting this pathway may be a viable therapeutic option for patients with recurrent or advanced stage mucinous ovarian carcinoma, however caution should be exercised in selecting one or more personalized therapeutics given the frequency of non-redundant RAS-activating alterations.

A national population-based study provides insight in the origin of malignancies metastatic to the ovary

A significant proportion of ovarian malignancies consists of metastatic tumors, with a wide variety in site of origin. Differentiating between a primary and metastatic malignancy of the ovaries can be difficult and misdiagnosis might have considerable impact on both treatment and prognosis. To further examine the origin of malignancies metastatic to the ovary, we performed a large-scale, nationwide search for ovarian metastases in the Dutch Pathology Registry (PALGA). All pathology reports concerning malignancies metastatic to the ovary and associated primary tumors in the Netherlands between 2000 and 2010 were collected. Age, year of diagnosis, tumor type, location of the primary tumor, and side of the ovarian tumor were extracted from the database. We identified 2312 patients fulfilling our selection criteria. The most common primary malignancy sites were colon (33.2 %), endometrium (17.1 %), breast (14.3 %), appendix (7.3 %), and stomach (4.5 %). The metastases were most frequently bilateral (46.3 %) followed by unilateral metastases in the right (26.7 %) and left ovary (19.8 %), while side was unknown in 7.2 % of cases. Of colorectal carcinomas, only 40.2 % metastasized bilaterally, compared to 63.9 % of breast, 62.9 % of gastric, and 58.9 % of appendix carcinomas. Left-sided colorectal carcinomas most often metastasized to the left ovary (p < 0.0001). We found colon carcinomas to be most frequently responsible for metastases to the ovaries, followed by endometrial and breast carcinomas. Metastases from breast, stomach, and appendix carcinomas were mostly bilateral, whereas metastases from colorectal carcinomas were mostly unilateral. The mechanisms underlying preferred sites for metastasis or side remain unclear.

[Morphology of secondary ovarian tumors and metastases]

The distinction between primary and secondary (metastatic) ovarian tumors is essential for the selection of appropriate surgical interventions, chemotherapeutic treatment and prognostic evaluation for the patient. Metastatic tumors of the ovary range between 5 % and 30 %. The majority of ovarian metastases in Europe and North America derive from colorectal (25-50 %) and breast cancers (8-25 %). A major issue is the differential diagnosis of mucinous tumors. Major features favoring metastasis include bilaterality, size < 10 cm, ovarian surface involvement, extensive intra-abdominal spread, and infiltrative growth within the ovary involving the corpus albicans and corpora lutea. An algorithm using bilaterality and tumor size (cut-off 10 cm) allows correct categorization in approximately  85 % of the cases. Although immunohistochemistry (especially CK7 and CK20 in mucinous tumors) using a panel of antibodies plays a valuable role and is paramount in the diagnosis, the results must be interpreted with caution and within the relevant clinical and histopathological context. It is necessary to note that the correct diagnosis of ovarian metastases always needs interdisciplinary and multidisciplinary approaches.

Differentiating primary and extragenital metastatic mucinous ovarian tumours: an algorithm combining PAX8 with tumour size and laterality

AIMS

Our aim was to analyse the utility of the algorithm combining PAX8 with clinicopathological characteristics (tumour size, laterality and patient age) in differentiating primary ovarian mucinous tumours (POMTs) from extragenital metastatic mucinous carcinomas involving the ovary (eMOMCs).

METHODS AND RESULTS

Immunohistochemical staining for PAX8 was performed on formalin fixed, paraffin embedded tissues from 47 POMTs, 18 eMOMCs and 70 extragenital primary mucinous carcinomas (ePMCs) using anti-PAX8 rabbit polyclonal antibody (pAb) and anti-PAX8 rabbit monoclonal antibody (mAb). PAX8 (pAb) positive signals were found in 3/18 eMOMCs and in 32/70 ePMCs. PAX8 (mAb) demonstrated superior specificity, with 0% positivity in both eMOMCs and ePMCs, but unfavourable sensitivity, with 60.9% in ovarian mucinous borderline tumours and 45.8% in POMCs. Although PAX8 (mAb) immunostaining status (66.2%), tumour size (75.4%) and laterality (84.6%) demonstrated unsatisfactory accuracy when they were evaluated individually in differentiating POMTs from eMOMCs, a combination of PAX8 (mAb) immunostaining status, tumour size and laterality markedly increased accuracy (86.2%), with a satisfactory Youden Index (63.7%).

CONCLUSIONS

PAX8 (mAb) was a specific marker in differentiating POMTs from eMOMCs. As a simple, convenient and high performance to price ratio algorithm, a combination of PAX8 (mAb) immunostaining with tumour size and laterality will improve the diagnostic criteria of ovarian mucinous metastasis.

Dual inhibition of phosphatidylinositol 3'-kinase and mammalian target of rapamycin using NVP-BEZ235 as a novel therapeutic approach for mucinous adenocarcinoma of the ovary

Ovarian mucinous adenocarcinoma (MAC) resists standard chemotherapy and is associated with poor prognosis. A more effective treatment is needed urgently. The present study assessed the possibility of molecular-targeted therapy with a novel dual inhibitor of phosphatidylinositol 3'-kinase (PI3K) and mammalian target of rapamycin (mTOR), NVP-BEZ235 (BEZ235) to treat of MAC. Seven human MAC cell lines were used in this study. The sensitivity of the cells to BEZ235, temsirolimus, and anticancer agents was determined with the WST-8 assay. Cell cycle distribution was assessed by flow cytometry, and the expression of proteins in apoptotic pathways and molecules of the PI3K/Akt/mTOR signaling pathways was determined by Western blot analysis. We also examined the effects of BEZ235 on tumor growth in nude mice xenograft models. The cell lines showed half-maximal inhibitory concentration values of BEZ235 from 13 to 328 nmol/L. Low half-maximal inhibitory concentration values to BEZ235 were observed in MCAS and OMC-1 cells; these 2 lines have an activating mutation in the PIK3CA gene. NVP-BEZ235 down-regulated the protein expression of phosphorylated (p-) Akt, p-p70S6K, and p-4E-BP1, suppressed cell cycle progression, up-regulated the expression of cleaved PARP and cleaved caspase 9, and increased apoptotic cells. Synergistic effects were observed on more than 5 cell lines when BEZ235 was combined with paclitaxel or cisplatin. The treatment of mice bearing OMC-1 or RMUG-S with BEZ235 significantly suppressed tumor growth in MAC xenograft models without severe weight loss. We conclude that the PI3K/Akt/mTOR pathway is a potential therapeutic target and that BEZ235 should be explored as a therapeutic agent for MAC.

Updates and emerging therapies for rare epithelial ovarian cancers: one size no longer fits all

Epithelial ovarian carcinoma consists of not one, but several, entities. A number of subtypes exist, including high-grade and low-grade serous carcinomas, clear cell, endometrioid carcinoma and mucinous carcinoma. Historically, women with epithelial ovarian cancer have been treated similarly and "lumped" in the same cooperative group treatment trials, irrespective of their tumor subtype. Recently, however, differences in epidemiology, tumor biology, tumor marker expression and treatment responses have been elucidated among the histologic subtypes, with a clear distinction emerging between the Type I, lower grade tumors and Type 2, higher grade epithelial malignancies. A mounting body of research demonstrates that a "one-size-fits-all" treatment approach to epithelial ovarian tumors is no longer relevant, especially for the Type I subtypes. Indeed, with the exception of high-grade serous carcinoma, most other epithelial subtypes exhibit some degree of chemotherapy resistance, rendering treatment problematic, especially in the setting of advanced disease. This review summarizes the genetic, molecular, and clinical differences of the more rare, but clinically important, Type I epithelial ovarian tumors. Additionally, a critical appraisal of both historical and contemporary treatment approaches and the rationale for targeted therapies are emphasized.

The Utility of Immunohistochemistry in the Differential Diagnosis of Gynecologic Disorders

Context

Immunohistochemistry has assumed an increasing role in the identification and characterization of gynecologic disorders including lesions with deceptively bland morphology, uncommon and underdiagnosed neoplasms, and neoplasms with specific genetic alterations associated with overexpression or loss of expression of specific proteins. The diagnostic accuracy has been significantly improved owing to the discovery and increasing experience with the tumor-associated biomarkers, and the increasing demand for precise tumor classification to assess suitability for the expanding therapeutic modalities including clinical trials.

Objective

To differentiate lesions of the gynecologic tract through the use of effective immunohistochemical panels.

Data Sources

Literature review and authors' personal practice experience.

Conclusions

The application of diagnostic and prognostic immunohistochemical panels has enabled pathologists to better guide therapeutic decisions and to better predict the clinical outcome. It is now well established that the use of ancillary testing, including immunohistochemistry, has a significant power in the identification, differentiation, and classification of reactive, premalignant, and malignant gynecologic disorders. This article discusses the utilities and pitfalls of the commonly used immunohistochemical markers in the context of overlapping morphologic features encountered in the uterus, ovaries, and fallopian tubes.