Ovarian neoplasms resembling sex cord tumors with annular tubules

Sex Cord Tumor With Annular Tubules-Like Histologic Pattern in Adult Granulosa Cell Tumor: Case Report of a Hitherto Unreported Morphologic Variant

Adult granulosa cell tumor (AGCT) and sex cord tumor with annular tubules (SCTAT) are distinct sex cord stromal tumors with different molecular signatures. We present a unique case of an incidental ovarian tumor with mixed AGCT and SCTAT morphologic patterns. Due to the unusual co-occurrence, molecular testing was separately performed on both components. Despite minimal overlap in morphology, both the SCTAT and AGCT components were found to have an identical mutation profile, including the prototypical FOXL2 p.C134W mutation characteristic of AGCT. We thus present the first report of AGCT with SCTAT-like pattern.

Sex Cord Tumour with Annular Tubules-An Unusual Case of Abdominal Pain

BACKGROUND

Ovarian sex cord tumours with annular tubules (SCTAT) are a very rare type of neoplasm and account for 14% of all sex cord tumours. This tumour was first described in 1970 with histopathology characterized by the presence of both complex and simple annular tubules. The tumour may show features of either granulosa cell tumours or Sertoli cell tumours and differentiation into either type can occur.

CASE

We report an interesting case of SCTAT in a 60-year-old woman who had a primary diagnosis of granulosa cell tumour. Seven years later she experienced a recurrence. Following excision and review of all pathology, the patient was found to have a SCTAT in both the recurrence and the primary tumour.

CONCLUSION

SCTAT is a slow-growing tumour that occasionally exhibits malignant behaviour with metastatic potential, albeit many years following initial diagnosis. SCTAT should be included in the differential diagnosis of sex cord tumours.

Impact of taxane plus bevacizumab for ovarian sex cord tumor with annular tubules

Sex cord tumor with annular tubules (SCTAT) is rare, and 20% of SCTAT cases, excluding those associated with Peutz-Jeghers syndrome, are clinically malignant. Limited data is available regarding the role of chemotherapy in the management of SCTAT. We encountered a 44-year-old woman with recurrent SCTAT complicated by peritoneal dissemination following a right adnexectomy. The surgical resection could not be performed completely due to the wide extension of the tumor. Considering the potential of becoming malignant, we chose a combination of bleomycin, etoposide and cisplatin (BEP) as postoperative chemotherapy treatment. However, the patient showed partial response following a complete BEP regimen. The patient received three courses of chemotherapy with docetaxel and carboplatin plus bevacizumab. After the combination chemotherapy, positron emission tomography-computed tomography scan confirmed a complete response, and is currently continuing bevacizumab treatment without relapsing and having no major adverse effects from complications. This case proved the potential of a combination of taxane and bevacizumab in patients with recurrent SCTAT.

Peutz-Jeghers Syndrome: Pathobiology, Pathologic Manifestations, and Suggestions for Recommending Genetic Testing in Pathology Reports

Peutz-Jeghers syndrome (PJS), in most cases, is attributed to mutation in STK11/LKB1 and is clinically characterized by gastrointestinal hamartomatous polyposis, mucocutaneous pigmentation, and predisposition to certain neoplasms. There are currently no recommended gynecologic screening or clinical surveillance guidelines beyond those recommended for the general population; however, cervical cytology samples must be examined with a high level of suspicion for cervical adenocarcinoma. It is considered prudent to note the established association with PJS and recommend referral for genetic counseling. Complete surgical excision after a diagnosis of atypical lobular endocervical glandular hyperplasia is recommended.

Unusual Sertoli Cell Tumor Associated With Sex Cord Tumor With Annular Tubules in Peutz-Jeghers Syndrome

We report the case of an 11-year-old girl with Peutz-Jeghers syndrome and a unilateral ovarian tumor most consistent with Sertoli cell tumor associated with sex cord tumor with annular tubules. The ovary was replaced by a lobular, solid, yellow tumor. Microscopic examination showed 2 components that focally merged. The first was composed of uniform, cytologically bland cells arranged mostly in diffuse sheets and focally in tubules. The second showed typical sex cord tumor with annular tubules with extensive calcification. The predominant component of the tumor clearly fell in the sex cord category and most closely resembled Sertoli cell tumor. This case adds to the limited information on ovarian sex cord tumors, other than typical sex cord tumor with annular tubules, arising in association with Peutz-Jeghers syndrome, a topic reviewed herein.

Preservation of fertility in non-Peutz-Jegher syndrome-associated ovarian sex cord tumour with annular tubules

We report the successful conservative management of a non-Peutz-Jegher syndrome-associated ovarian sex cord tumour with annular tubules in a 32-year-old patient. The patient underwent a unilateral salpingo-oophorectomy by laparoscopy, and conceived spontaneously approximately 6 months after the diagnosis. After a normal term pregnancy, she underwent a contralateral laparoscopic salpingo-oophorectomy with hysterectomy. The patient is now on hormone replacement therapy and, after 30 months of follow-up, continues to present no sign of disease recurrence.

An unusual case of sex cord tumor with annular tubules with malignant transformation in a patient with Peutz-Jeghers syndrome

We report a case of a 54-year-old Caucasian woman with an earlier diagnosis of Peutz-Jeghers Syndrome (PJS) and sex cord tumor with annular tubules (SCTAT). The sex cord stromal tumors showed aggressive malignant behavior with repeated recurrence and metastasis. This is an unusual behavior of SCTAT in patients with PJS, with only 2 such cases reported earlier. Genetic analysis revealed that the patient has a new (unreported earlier) missense mutation of the LKB1 gene. A review of the literature reporting the clinicopathologic features and biologic behavior of SCTAT in patients with and without PJS is presented. We discuss the presentation and management of this case and highlight the importance of considering the possibility of aggressive behavior of these tumors in the management of patients with PJS.

Recent Advances in the Pathology and Classification of Ovarian Sex Cord-Stromal Tumors

In recent years, our knowledge of ovarian sex cord-stromal tumors has increased, and their classification has evolved. In this review, recent advances in the classification and pathology of ovarian sex cord-stromal tumors are discussed, and the controversy regarding the classification of sex cord tumor with annular tubules is addressed. The current classification is built on those of the past, and future classifications should improve on what is now in place incorporating new knowledge from more sophisticated clinicopathologic studies and advanced molecular techniques. This review emphasizes articles written in the 21st century as well as those that have significantly advanced our knowledge of sex cord-stromal tumors in past decades. The tumors in this group occur over a wide age range and are often unilateral. In difficult cases, immunocytochemistry provides improved diagnostic accuracy. The most useful immunohistochemical marker for their identification is alpha-inhibin, which is positive in most neoplasms in the sex cord-stromal group. The article concludes with a section discussing the pathogenesis of sex cord-stromal tumors.

The Prolonged Gestation, Birth, and Early Life of the Sex Cord Tumor with Annular Tubules and How it Joined a Syndrome

The sex cord tumor with annular tubules was discovered as a distinctive entity when its unusual-appearing microscopic pattern was encountered repetitively in a pathology consultation practice. The author was stimulated to describe the clinicopathological features of the tumor and assign it a specific name when a minority of the cases in his series were found to be associated with the rare Peutz-Jeghers syndrome. Both these tumors and those occurring in the absence of the syndrome have been shown to have distinctive clinicopathological features that differ from those of other tumors in the sex cord-stromal category. Int J Surg Pathol 8(3):233-238, 2000

Malignant ovarian sex cord tumor with annular tubules in a patient with Peutz-Jeghers syndrome: a case report

The majority of ovarian sex cord tumors with annular tubules (SCTAT) are benign neoplasms that arise sporadically. In patients who have Peutz-Jeghers syndrome (PJS), ovarian SCTAT is often an incidental finding. Malignant behavior in SCTAT has heretofore been reported only in sporadic cases. We report a case of bilateral, malignant SCTAT developing in a 47-year-old woman who had PJS, originally diagnosed as adenocarcinoma on cervicovaginal cytology. Cervicovaginal and peritoneal fluid cytologic preparations were characterized by pseudopapillary clusters and three-dimensional tubes of tumor cells with scanty cytoplasm and high nuclear: cytoplasmic ratio. Examination of surgical resection specimens revealed bilateral, solid ovarian tumors composed of simple and complex annular tubules with hyaline cores, typical of SCTAT. Tumor emboli were present within salpingeal lymphovascular spaces and in both right and left pelvic lymph nodes. Flow cytometry of tumor cells demonstrated a diploid phenotype. This case represents the first documented example of bilateral, malignant SCTAT arising in a patient who had PJS, presenting with an atypical cervicovaginal smear.

Malignancy in Peutz-Jeghers syndrome? The pitfall of pseudo-invasion

Peutz-Jeghers syndrome is a malignancy-associated polyposis syndrome. We describe a histopathologic phenomenon easily encountered when examining the nature of Peutz-Jeghers polyps but that is underreported in the literature. This phenomenon of "pseudo-invasion" may mimic invasive carcinoma due to epithelial displacement and erroneously give the impression, both macroscopically and microscopically, that a malignancy is involved. This potential pitfall is illustrated by the case of a patient with Peutz-Jeghers syndrome who was thought to harbor a metastasizing adenocarcinoma in his small bowel with peritoneal metastasis as a perioperative finding. Histologic examination, however, revealed pseudo-invasion.

Ovarian sex cord-stromal tumours in cattle, with particular reference to the lamination of basal laminae

Three cases of bovine sex cord-stromal tumours, including a sex cord tumour with annular tubules and two granulosa cell tumours, are described. These tumours had tubular structures and hyaline or eosinophilic bodies, composed of multilayered basal laminae. The present study suggests that bovine granulosa cell tumours of the ovary are able to show morphology similar to that of Sertoli cell tumours of the testis and that sex cord tumours with annular tubules arise from granulosa cells but indicate Sertoli cell differentiation.

Mucinous neoplasm in the cervix associated with a mucinous neoplasm in the ovary and concurrent bilateral sex cord tumors with annular tubules: immunohistochemical study

The patient described synchronous mucinous tumors of the cervix and ovary and concurrent annular tubules, but without the classical stigmata of Peutz-Jeghers syndrome. The cervical tumor was an invasive mucinous adenocarcinoma with mixed components of minimal deviation and less-well-differentiated endometrioid morphology. The ovarian tumor had the benign appearance of a mucinous adenoma but histologically revealed areas of invasive carcinoma. Immunohistochemical studies of the mucinous neoplasms of the cervix and ovary are discussed. Neither the staining properties of mucin, the pattern of immunostaining for carcinoembryonic antigen, nor any other common markers were helpful in distinguishing the mucinous neoplasms. Positive immunostaining for low-molecular-weight cytokeratin in the filament profile of sex cord tumors with annular tubules was of particular interest since it has not to our knowledge been previously described.

Ovarian sex cord tumor with annular tubules. Report of a case

A 23-year-old woman underwent resection of a tumorous right ovary after long-standing irregular genital bleeding. The tumor measured 50 x 30 mm and had a yellowish-white solid cut surface with scattered small cysts. The light microscopic diagnosis was a sex cord tumor with annular tubules. Ultrastructurally, the tumor cells had Charcot-Boettcher filaments and showed vimentin positivity by immunohistochemistry. A three-dimensional reconstruction study proved that the tumor cell nests had a ovoid outer margin and contained blind-ended ellipsoid hyaline bodies. This tumor is presumed to be a variant of sex cord/stromal tumor showing differentiation predominantly to Sertoli cells.

Endocrine and morphological study of a case of ovarian sex-cord tumor with annular tubules in a woman with Peutz-Jeghers syndrome

A bilateral ovarian sex-cord tumor with annular tubules (SCTAT) was incidentally discovered in an amenorrheic patient with Peutz-Jeghers syndrome during conservative surgery in which a small non-capsulated mass was removed from each ovary. Ovulation was then induced over two consecutive cycles with urinary gonadotropins; the couple did not conceive because of a male infertility factor. Hysterectomy and bilateral oophorectomy were performed to prevent recurrence and avoid the possibility of a cervical malignant adenoma. Immunohistochemistry of the SCTAT showed positivity for estradiol and testosterone similar to that of Sertoli and granulosa cell tumors; progesterone was not detected in any cellular component of the neoplasia. Electron microscopy showed that the neoplasm consisted of numerous solid cords of cells surrounded by fibrillary layers of basal lamina, as well as central hyaline bodies. Two types of cells, clear and dark, were noted; clear cells were predominant and intermixed with scattered dark cells. No crystalloids or Charchot-Bottcher filaments were detectable in the tumors.

Extragonadal sex cord tumor with annular tubules in an umbilical hernia sac: a unique presentation with implications for histogenesis

A sex cord tumor with annular tubules (SCTAT) was found incidentally in an umbilical hernia sac excised from a 66-year-old female. No ovarian lesions were visualized on a computerized tomographic (CT) scan of the pelvis. An exploratory laparotomy with total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymph node biopsies, and omentectomy likewise showed no gross evidence of tumor. Histologic examination revealed foci of SCTAT scattered in the omentum. The peritoneal washings were positive. The ovaries and pelvic lymph nodes were free of tumor. A second-look laparotomy following six courses of chemotherapy with cyclophosphamide, actinomycin D, and vincristine revealed microscopic tumor deposits in the base of the omental remnant, small bowel mesentery, anterior abdominal peritoneum, and meso-appendix. Clinically, the patient remains well following treatment with whole-abdominal radiation. To our knowledge, this is the first report of SCTAT in the umbilical region and the only case of SCTAT without an identifiable ovarian primary. The literature is reviewed, and the possible histogenesis of the tumor in this location is discussed.

Structures mimicking sex cord-stromal tumours and gonadoblastomas in the ovaries of normal infants and children

A chance finding of structures resembling gonadoblastomas in the ovaries of a child with lissencephaly prompted a detailed review of all ovarian histology obtained at autopsy over a 12 month period. Fifty-five stillbirths, infants and children were studied ranging from 20 weeks gestational age to 2.5 years post-natal age. In 19 infants structures mimicking gonadoblastomas and sex cord tumours with annular tubules were seen. In all but one case these structures were found in association with follicular cysts and they closely resembled the atretic follicles often seen in the stroma surrounding the follicular cysts. They differed from the atretic follicles only by virtue of their being larger. In addition, in several infants structures resembling Sertoli cell tubules or clusters of Leydig cells were found. When present, these structures always co-existed with sex cord tumours with annular tubules and gonadoblastoma-like lesions. The abnormal stromal lesions and follicular cysts were found most frequently at the stage of development when a massive 'physiological' reduction of oocytes occurs. It is suggested that the 'abnormal' structures identified in this report represent the 'first hit' of oncogenesis and could serve as the precursor of many of the sex cord-stromal tumours, and possibly germ cell neoplasms, seen in childhood.

Ovarian sex cord tumor with annular tubules

A pathologic study was done on four cases of ovarian sex cord tumor with annular tubules. All four tumors occurred in young women (11-24 years of age) and were not associated with the Peutz-Jeghers syndrome. Two patients had evidence of hyperestrinism. One patient who had metastasis to the retroperitoneum, left supraclavicular lymph node, and liver confirmed the malignant potential of this tumor. Gross examination revealed tumors that were solid, yellowish, and unilateral, with varying degrees of cystic degeneration. Microscopic examination showed simple or complex annular tubules with prominent basement membranes. Many tumor cells contained lipid in the cytoplasm. Ultrastructural study showed Charcot-Bottcher filaments in all four cases, indicating Sertoli cell differentiation. True lumens and microvilli were identified in one case. The classification of the sex cord tumor with annular tubules as a Sertoli cell tumor, annular tubular type was proposed on the basis of ultrastructural findings.

Does ovarian sex cord tumour with annular tubules produce progesterone?

Probable progesterone production was identified by an immunoperoxidase assay in a case of an ovarian sex cord tumour with annular tubules. The tumour was associated with a serous cystadenofibroma in the opposite ovary and with adenoma malignum (adenocarcinoma) of the cervix.

Progesterone secreting Sertoli cell tumor of the ovary

A 33-year-old woman presenting with secondary amenorrhea and galactorrhea was found to have a Sertoli cell tumor of the ovary. The neoplasm also had a sex cord tumor with annular tubules (SCTAT) component. Further investigations revealed that in many respects the patient was endocrinologically pregnant. She had markedly elevated serum estrogen and progesterone levels and the endometrium demonstrated pronounced decidualization, but there was no evidence of actual pregnancy. Estrogen and progesterone were demonstrated by immunohistochemistry to be present in both the Sertoli cell and SCTAT portions of the tumor.

A testicular tumor resembling the sex cord with annular tubules in a case of the androgen insensitivity syndrome

Sex cord tumor with annular tubules (SCTAT) is a distinctive neoplasm with indifferent cells of sex cord derivation in a characteristic arrangement of ring-like tubules. Much attention has been drawn to its association with the Peutz-Jeghers syndrome (PJS) with reported occurrence of the tumor in the testis of a boy with PJS. The authors present two cases of the androgen insensitivity syndrome (AIS), one of the cases being distinctive in having a large multicystic tumor resembling the SCTAT in the immature gonad. Additionally, the focal areas of the tumor, the large Sertoli cells lining the tubules, resembled those of a large cell calcifying Sertoli cell tumor (LCCSCT) although no calcific areas were discernible. Although the occurrence of neoplasms like germinomas and tubular adenomas is well known in the AIS, SCTAT has hitherto not been reported in a gonad of the AIS. SCTAT has been placed under an "unclassified sex cord-stromal" category in the World Health Organization (WHO) Classification, yet, opinions are divided as to its origin from a granulosa or Sertoli cell, although an overlap in the histologic features of the two cell categories is to be anticipated in view of their homologous nature. In the case presented, the close resemblance of the tumor cells to the Sertoli cells of the uninvolved gonad would further support the concept of a Sertoli line of differentiation of the SCTAT.

Sex cord-stromal tumours of the ovary

The aim of this review is to give a reasonably concise resumé of our knowledge of the sex cord-stromal tumours of the ovary. Lipoid cell tumours of the ovary are often included within this broad category but this poorly defined and heterogenous group of neoplasms will not be considered here. This review is a selective one and no attempt is made to cover all aspects of sex cord-stromal tumours or to provide a complete bibliography. The histological features of many of the neoplasms in this group, particularly those which have been recently defined, are discussed but a consideration of differential histological diagnosis is excluded. The ultrastructural characteristics of the various neoplasms are considered only in terms of their relevance to histogenesis or metabolic activity.

Peutz-Jeghers syndrome and cancer

A 27-year-old white woman with Peutz-Jeghers syndrome (PJS) associated with a rare but distinctive ovarian tumor, the sex cord tumor with annular tubules (SCTAT), is discussed. Pertinent oral manifestations of PJS and chemotherapy complications are illustrated by the case report. Traditionally, patients exhibiting PJS have not been considered at increased risk of cancer development. This case, coupled with a review of the recent literature, suggests that these patients are, indeed, at increased risk of malignant lesions of several organ systems.

Ovarian sex-cord tumor with annular tubules. Case report with ultrastructural findings

An ovarian sex-cord tumor with annular tubules (SCTAT) and with Charcot-Böttcher bodies in a 29-year-old woman with primary infertility, secondary amenorrhea, and without evidence of the Peutz-Jeghers syndrome was studied by light and electron microscopy. At laparotomy, a right ovarian tumor was removed, and there was no evidence of metastases. The patient has been well and disease free for a period of 3 months after surgery. The tumor was histologically composed of nests of cells arranged in complex tubules with hyaline bodies. Ultrastructurally, cells were joined by specialized junctions along their lateral adjacent borders. Microvilli and cilia were absent. Concentrically arranged membranes were seen in the cytoplasm. Charcot-Böttcher filaments were seen in paranuclear region. The findings of Charcot-Böttcher filament in an ovarian SCTAT support the hypothesis of the Sertoli nature of this neoplasm.

Peutz-Jeghers syndrome. A clinicopathologic study of a large family with a 27-year follow-up

A family group of ten patients with the Peutz-Jeghers syndrome has been followed for a 27-year period. Eight members of the family had one or more manifestations of the syndrome. One member of the family died following a bypass procedure of a nonresectable carcinoma of the jejunum. Postmortem examination revealed this to be an adenocarcinoma of the jejunum arising in a Peutz-Jeghers polyp and metastases were present in the mesenteric lymph nodes. Two members of the family developed breast carcinomas, one arising in a fibroadenoma; both patients died, one of metastatic breast carcinoma, the other of a second primary malignancy (adenocarcinoma of the jejunum arising in a Peutz-Jeghers polyp). Three family members had benign ovarian tumors, one patient had a benign breast tumor and another patient had a benign colloid thyroid nodule. While the authors of this report believe that they have added a documented case of an adenocarcinoma of the jejunum arising in a Peutz-Jeghers polyp to the literature, the exact risk of intestinal cancer in the Peutz-Jeghers syndrome is unknown, but probably very small. Gastrointestinal surgery should continue to be performed in symptomatic patients and all patients should be followed closely at regular intervals.

Peutz-Jeghers syndrome. A clinicopathologic study of a large family with a 27-year follow-up

A family group of ten patients with the Peutz-Jeghers syndrome has been followed for a 27-year period. Eight members of the family had one or more manifestations of the syndrome. One member of the family died following a bypass procedure of a nonresectable carcinoma of the jejunum. Postmortem examination revealed this to be an adenocarcinoma of the jejunum arising in a Peutz-Jeghers polyp and metastases were present in the mesenteric lymph nodes. Two members of the family developed breast carcinomas, one arising in a fibroadenoma; both patients died, one of metastatic breast carcinoma, the other of a second primary malignancy (adenocarcinoma of the jejunum arising in a Peutz-Jeghers polyp). Three family members had benign ovarian tumors, one patient had a benign breast tumor and another patient had a benign colloid thyroid nodule. While the authors of this report believe that they have added a documented case of an adenocarcinoma of the jejunum arising in a Peutz-Jeghers polyp to the literature, the exact risk of intestinal cancer in the Peutz-Jeghers syndrome is unknown, but probably very small. Gastrointestinal surgery should continue to be performed in symptomatic patients and all patients should be followed closely at regular intervals.

Ovarian sex cord tumor with annular tubules: review of 74 cases including 27 with Peutz-Jeghers syndrome and four with adenoma malignum of the cervix

The sex cord tumor with annular tubules (SCTAT) is a distinctive ovarian neoplasm the predominant component of which has morphologic features intermediate between those of the granulosa cell tumor and those of the Sertoli cell tumor; focal differentiation into either granulosa cell or Sertoli cell tumor may occur. Of the 74 cases that form the basis of this investigation 27 were associated with the Peutz-Jeghers syndrome; these tumors were all benign and were typically multifocal, bilateral, very small or even microscopical in size and calcified. Twelve of the 27 patients had symptoms suggestive of hyperestrinism attributable to the SCTAT; menstrual irregularity had occurred in eleven cases and postmenopausal bleeding in one. Four of the 27 patients had "adenoma malignum" of the cervix and two of them died of it. The 47 tumors from patients without evidence of the Peutz-Jeghers syndrome were unilateral and usually large. Twenty-five of them were accompanied by symptoms suggestive of hyperestrinism, such as menstrual irregularity, postmenopausal bleeding or sexual precocity; seven were malignant and four of these were fatal.