Neurohormonal peptides in ovarian carcinoids: an immunohistochemical study of 81 primary carcinoids and of intraovarian metastases from six mid-gut carcinoids

Involvement of the Opioid Peptide Family in Cancer Progression

Peptides mediate cancer progression favoring the mitogenesis, migration, and invasion of tumor cells, promoting metastasis and anti-apoptotic mechanisms, and facilitating angiogenesis/lymphangiogenesis. Tumor cells overexpress peptide receptors, crucial targets for developing specific treatments against cancer cells using peptide receptor antagonists and promoting apoptosis in tumor cells. Opioids exert an antitumoral effect, whereas others promote tumor growth and metastasis. This review updates the findings regarding the involvement of opioid peptides (enkephalins, endorphins, and dynorphins) in cancer development. Anticancer therapeutic strategies targeting the opioid peptidergic system and the main research lines to be developed regarding the topic reviewed are suggested. There is much to investigate about opioid peptides and cancer: basic information is scarce, incomplete, or absent in many tumors. This knowledge is crucial since promising anticancer strategies could be developed alone or in combination therapies with chemotherapy/radiotherapy.

Ovarian teratomas: clinical features, imaging findings and management

Ovarian teratomas are the most common type of germ cell tumors. There are three major subtypes of ovarian teratomas including mature, immature, and monodermal teratomas. Ultrasound, computed tomography and magnetic resonance imaging can demonstrate specific imaging findings for mature teratoma. Imaging features of immature and monodermal teratomas are less specific, but a combination of clinical features and imaging findings can help in the diagnosis. Imaging is also very helpful in guiding management. In this article, we review the epidemiology, histopathology, clinical presentation, imaging features and management of ovarian teratomas.

Neurotensin: a neuropeptide induced by hCG in the human and rat ovary during the periovulatory period†

Neurotensin (NTS) is a tridecapeptide that was first characterized as a neurotransmitter in neuronal cells. The present study examined ovarian NTS expression across the periovulatory period in the human and the rat. Women were recruited into this study and monitored by transvaginal ultrasound. The dominant follicle was surgically excised prior to the luteinizing hormone (LH) surge (preovulatory phase) or women were given 250 μg human chorionic gonadotropin (hCG) and dominant follicles collected 12-18 h after hCG (early ovulatory), 18-34 h (late ovulatory), and 44-70 h (postovulatory). NTS mRNA was massively induced during the early and late ovulatory stage in granulosa cells (GCs) (15 000 fold) and theca cells (700 fold). In the rat, hCG also induced Nts mRNA expression in intact ovaries and isolated GCs. In cultured granulosa-luteal cells (GLCs) from IVF patients, NTS expression was induced 6 h after hCG treatment, whereas in cultured rat GCs, NTS increased 4 h after hCG treatment. Cells treated with hCG signaling pathway inhibitors revealed that NTS expression is partially regulated in the human and rat GC by the epidermal-like growth factor pathway. Human GLC, and rat GCs also showed that Nts was regulated by the protein kinase A (PKA) pathway along with input from the phosphotidylinositol 3- kinase (PI3K) and mitogen-activated protein kinase (MAPK) pathways. The predominat NTS receptor present in human and rat GCs was SORT1, whereas NTSR1 and NTSR2 expression was very low. Based on NTS actions in other systems, we speculate that NTS may regulate crucial aspects of ovulation such as vascular permeability, inflammation, and cell migration.

Primary ovarian carcinoid and dotanoc positron emission tomography-computed tomography scan

Primary ovarian carcinoids are very rare tumors, representing only <1% of all carcinoid tumors and <0.1% of all ovarian neoplasm. Here, we present a case report where DOTANOC positron emission tomography-computed tomography scan helped in diagnosis and management of rare entity.

Resection of a mature cystic teratoma of the liver harboring a carcinoid tumor

Cystic teratomas are rare pluripotent embryonic tumors which most commonly originate in gonadal organs. Extra-gonadal cystic teratomas are exceedingly uncommon, accounting for only 1% of all cystic teratomas, and have been reported in unusual locations including the kidney, mediastinum and liver. These extra-ovarian cystic teratomas have also been known to harbor other neoplasms including carcinoid tumors. In this report, we describe a unique case of a hepatic cystic teratoma occurring as a combined tumor with a carcinoid in a young female. The patient underwent elective laparoscopic resection of her tumor after extensive radiographic and endoscopic work-up for chronic, non-localizable abdominal pain. We believe the carcinoid tumor arose de novofrom committed differentiation of a cell line within the teratoma, and not metastatic spread.

Strumal Carcinoid of the Ovary: An Immunohistochemical and Electron Microscopic Study

A case of strumal carcinoid of the ovary is reported. The follicles contained T4-immunoreactive substance, whereas the carcinoid component of the tumor had a trabecular structure and showed argyrophilic elements. Pancreatic-polypeptide and enteroglucagon were localized in these cells by an immunocytochemical method. The same cells displayed small electrondense endocrine-like granules. A common precursor for the thyroid and carcinoid components is postulated.

Ki67 Proliferative Index in Carcinoid Tumors Involving Ovary

Primary ovarian carcinoid tumors are rare neoplasms that constitute less than 0.1% of all ovarian carcinomas. However, carcinoid tumors metastatic to ovaries are more common. Cell proliferative rate is an important factor in the determination of neuroendocrine tumor prognosis. Limited data are available as regards Ki67 proliferation index in predicting the physiological features of carcinoid tumors involving the ovary. Pathology files of Mayo Clinic Rochester (1995-2014) were searched, and clinical information was collected from medical records. All cases were stained with an antibody against Ki67, and digital analysis was performed with digital imaging analysis. A total of 36 cases (median age 64 years, range 33-83 years), including 9 primary (median age 68 years, range 33-73 years) and 27 metastatic carcinoid cases (median age 64 years, range 36-83 years), were investigated in the current study. Seven out of nine (77.8%) primary ovarian carcinoids are associated with mature teratoma. Twenty two metastatic carcinoids (81.5%) were from the GI tract, four (14.8%) from the pancreas, and one (3.7%) from the posterior thorax location. There was significant difference of Ki67 index between primary (median 2.3%, range, 0.6-8.4%) and metastatic carcinoid tumors (median 9.7%, range, 1.3-46.7%) (p = 0.002). The survival time is much shorter among patients with metastatic carcinoid tumor (median survival 5.8 years) comparing to primary ovarian carcinoid tumor (median 14.2 years) (p = 0.0005). A strong association between Ki67 index and patient survival time was identified (Hazard ratio for 1-percentage point increase 1.11, p = 0.001). Comparing to primary ovarian carcinoid tumor, metastatic carcinoid usually exhibits a higher Ki67 index and a worse outcome.

Hormone producing gynecological tumors: pathologic entities and clinical significance

INTRODUCTION

Due to their derivation from the cell types involved in gynecologic hormonal networks, many gynecologic tumors may produce hormones. In a normal physiological setting, these hormones are essential for regulating the biology and function of gynecological organs, the ovary and uterus in particular. Overproduction of hormones by the tumor may lead to abnormal clinical manifestations of the patients and spillage of excess hormonal products into the blood. Abnormal elevation of serum hormones may be considered as biomarkers that are important to pathologists and clinicians in making precise tumor diagnoses and likely useful in monitoring the tumor burden/recurrence to guide patient treatment options. This review will discuss gynecologic neoplasms that produce hormonal biomarkers and assess their relevance to pathological diagnosis, evaluation for therapeutic response and monitoring disease progression.

AREAS COVERED

Studies involving hormonal production by a gynecologic tumor were candidates for inclusion in this review.

EXPERT COMMENTARY

Serum hormonal biomarkers have clinical utility both in the diagnosis of gynecologic neoplasms and clinical monitoring of treatment efficacy and recurrence.

An Ovarian Carcinoid Tumor With Peptide YY-Positive Insular Component: A Case Report and Review of the Literature

Ovarian carcinoid tumors are uncommon and account for 1% of all carcinoid tumors. The insular type of ovarian carcinoid tumor is common in western countries; in contrast, the strumal and trabecular types seem to be common in Asian countries. Strumal and trabecular types are associated with peptide YY (PYY) production, which may cause constipation. Here, we report the case of a 70-yr-old Japanese woman with chronic constipation who was referred to Kumamoto University Hospital because of a right adnexal mass. Imaging tests suggested that the solid mass might be malignant; therefore, abdominal total hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. A subsequent histopathologic examination confirmed an insular carcinoid tumor with a trabecular component in the right ovary. Both components were positive for PYY but not for serotonin. The patient complained of diarrhea instead of constipation soon after the surgery. Because PYY-positive insular carcinoid tumor in the ovary has not been previously reported, we reviewed 19 reported cases of patients with PYY-positive ovarian carcinoid tumors. The origins, common histologic types and symptoms caused by specific peptides secreted in ovarian carcinoid tumors differ between western and Asian countries.

Neuroendocrine Tumors of the Female Reproductive Tract: A Literature Review

Neuroendocrine tumors of the female reproductive tract are a heterogeneous group of neoplasms that display various histologic findings and biologic behaviors. In this review, the classification and clinicopathologic characteristics of neuroendocrine tumors of the female reproductive tract are described. Differential diagnoses are discussed, especially for non-neuroendocrine tumors showing high-grade nuclei with neuroendocrine differentiation. This review also discusses recent advances in our pathogenetic understanding of these disorders.

How does secondary neoplasm arise from mature teratomas in growing teratoma syndrome of the ovary? A report of two cases

Development of secondary neoplasm in mature teratomas is a long-term potential risk in growing teratoma syndrome (GTS) of the ovary. The origin or histogenesis of the secondary neoplasm, however, is scarcely understood. We herein report two cases of GTS that began secondary neoplastic change 10 and 22 years after initial presentation. In one case, microscopic carcinoids were scattered over various mature elements derived from three germ cell layers: some were close to the intestinal-type glands or adipose tissue and others lay in the glia. This implies that these carcinoids multicentrically originated from pluripotent stem cells that had been latent in various mature tissues. In contrast, the other case had only one focus of intestinal-type tubular adenocarcinoma, measuring 5 mm in diameter, adjacent to the intestinal-type glands. Malignant transformation of intestinal-type glands is most likely to account for this adenocarcinoma. In both cases, peritoneal mature teratomas also contained foci of endometriosis, almost exclusively in their glial components. In conclusion, the present cases suggest two diverse histogenesis of secondary neoplasm in GTS and a specific role of glia in the development of endometriosis in peritoneal teratomas.

Cushing's syndrome due to a pancreatic neuroendocrine tumor metastatic to the ovaries: a clinicopathological description of a case

We report the case of a 36-year-old woman with Cushing's syndrome caused by a malignant unresectable neuroendocrine carcinoma of the pancreas that developed bilateral ovarian metastases 7 years after diagnosis. In November 2001, because of abdominal pain and jaundice, the patient underwent radiological investigations and exploratory laparotomy that demonstrated the presence of a 3-cm mass of the head of the pancreas, infiltrating the superior mesenteric vein, associated with enlargement of multiple abdominal lymph nodes and with a liver nodule. Histological examination of one lymph node and of the liver nodule demonstrated the presence of metastases from a well-differentiated neuroendocrine carcinoma showing corticotropin immunoreactivity. A few months later, the patient started to show the clinical symptoms of Cushing's syndrome and underwent steroid-blocking ketoconazole therapy. The clinical endocrine picture was controlled until the end of 2008, when the endocrine symptoms of the Cushing's syndrome worsened and bilateral ovarian tumors appeared. Hysteroannexectomy was performed and ovarian tumors were found to be metastases from a well-differentiated neuroendocrine carcinoma with morphological and immunohistochemical features overlapping those observed in 2002. The clinical situation worsened and the patient died in November 2009. The clinical aspects and the problems in the differential diagnosis are discussed.

Case report: primary ovarian carcinoid: a rare tumor causing unexpected manifestations in a previously undiagnosed woman

Although carcinoid tumors arising from midgut structures are rare, the existence of these tumors is well documented. However, carcinoid tumors arising from the reproductive organs, such as primary ovarian carcinoids, are rare and sparsely documented. Because of this rarity, a small percentage of women may present with ovarian masses that are not properly diagnosed as carcinoid tumor creating unexpected hemodynamic changes under general anesthesia. However, prior knowledge of the clinical manifestations of this rare entity may improve the sensitivity of the preoperative evaluation and allow the anesthesiologist to take precautions as a result of the suspicion of ovarian carcinoid.

Primary carcinoid tumor of the ovary: a case report

INTRODUCTION

Carcinoid tumors commonly occur in the gastrointestinal tract and lungs. However, carcinoid tumors of the ovary are rare, primary carcinoid tumors being even rarer, forming 0.3% of all carcinoid tumors.

CASE REPORT

We present a case of a 55-year-old woman presented with symptoms of abdominal discomfort, weakness and fatigue. Pelvic ultrasound revealed a left-sided lobulated ovarian mass, which was solid with occasional internal scattered fluid areas. No other abnormality was detected on pelvic and abdominal ultrasonography. The findings of biochemical investigations were within normal limits. The patient underwent total abdominal hysterectomy and bilateral salphingo-oophorectomy for a clinical suspicion of ovarian tumor. Gross examination revealed a large tumor completely replacing the ovary, which was predominantly solid with few cystic areas and yellowish in color. Microscopically, the tumor was composed of uniform population of polygonal cells with abundant granular cytoplasm, arranged in small acini, solid sheets, ribbons and trabecular pattern. No teratomatous component was seen either grossly or microscopically. The tumor cells showed the strong expression of Chromogranin A and synaptophysin on immunohistochemistry. On the basis of this, a diagnosis of primary ovarian carcinoid was made.

CONCLUSION

We conclude that it is important to be aware of this entity in the pathological diagnosis of ovarian tumors, even in the absence of any clinical indicator of carcinoid tumor/syndrome, as it carries a markedly better prognosis and clinical outcome in comparison with most other malignant ovarian tumors.

The enigma of struma ovarii

Since its first description in the early part of the twentieth century, struma ovarii has elicited considerable interest because of its many unique features; however, at present a number of aspects remain enigmatic. Although the typical presentation is that of a pelvic mass, unusual clinical manifestations such as hyperthyroidism, ascites, and Meigs' syndrome have been recognised. Uncommon macroscopic and especially histological patterns in struma can cause difficulties in diagnosis. Cystic strumas are challenging to diagnose both macroscopically and histologically. Proliferative changes within struma can be misdiagnosed as cancer. In regard to the occurrence of thyroid-type carcinoma in struma ovarii, precise terminology should be utilised, and the term 'malignant struma ovarii' should be avoided because it has been used for several different pathological entities. Papillary carcinoma is the most commonly occurring thyroid-type carcinoma in ovarian struma; however, cases of follicular carcinoma are not infrequent. Histological malignancy in struma does not necessarily equate with biological malignancy, and the majority of thyroid-type carcinomas do not spread beyond the ovary. Strumal carcinoid, a neoplasm apparently unique to the ovary containing elements of both struma and carcinoid, has been misdiagnosed as 'malignant struma ovarii' in the past. The differential diagnosis of extra-ovarian spread of struma includes the usual types of thyroid cancer, minimal deviation follicular carcinoma, and peritoneal strumosis. This review emphasises articles both recent and past that have significantly advanced our knowledge of struma ovarii and related neoplasms.

Recent Advances in the Pathology and Classification of Ovarian Germ Cell Tumors

In recent years, our knowledge of ovarian germ cell tumors has increased, and their classification has evolved. The introduction of cisplatin-based chemotherapy and the discovery of tumor markers, including alpha-fetoprotein and human chorionic gonadotropin, have dramatically changed the clinical outlook for most of these patients. In this review, recent advances in the classification and pathology of ovarian germ cell tumors are discussed. Where appropriate, comparisons are made with testicular germ cell tumors. The last section of the article discusses the pathogenesis of germ cell tumors. This review will emphasize the articles written in the last 10 years and those that have significantly advanced our knowledge of germ cell tumors in past decades.

Primary ovarian trabecular carcinoid tumour: a case report with an immunohistochemical study and a review of the literature

INTRODUCTION

Primary ovarian carcinoid tumours are uncommon neoplasias. There are distinct histological types with different behaviours: insular, trabecular, mucinous and mixed. The trabecular subtype is very rare and unlike other carcinoid subtypes, it is characterised by the absence of a clinical carcinoid syndrome and has been related with a better prognosis than the others. No distant metastases have yet been reported.

CASE REPORT

We present a case of a 76-year-old woman diagnosed with a left ovarian tumour. She underwent a radical hysterectomy with bilateral salpingo-oophorectomy and regional lymph node clearance. Histology revealed an ovarian trabecular carcinoid tumour and no adjuvant treatments were performed. The patient is alive and free of disease 70 months following diagnosis.

DISCUSSION

Immunohistochemical staining for p53 protein, and a comparative study with other subtypes of ovarian carcinoid tumours (insular and mucinous) is discussed in this report.

Patients with ovarian cancer have elevated (51)Cr-EDTA plasma clearance early post-operatively

Plasma clearance of (51)Cr-EDTA (Clp(EDTA)) is widely used to determine glomerular filtration rate prior to carboplatin based chemotherapy. We have observed that many patients with ovarian cancer have elevated Clp in the early post-operative phase compared to later phases. The purpose of this study was to examine whether this observation reflects a systematic difference. We retrospectively analysed data from 53 patients who had undergone surgery for ovarian cancer. Twenty-six patients had Clp(EDTA) measured early after the operation (mean, 8 days (range, 3-16 days)) (early group), and 27 patients had Clp(EDTA) measured late post-operatively (mean, 32 days (range, 19-48 days)) (late group). Clp(EDTA) values was measured before the first, third and fifth course of chemotherapy. Additionally, age, height, weight, cancer stage, ascites and tumour histology were noted. Mean Clp(EDTA) in the early group was significantly higher than in the late group (104+/-4.4 vs 89+/-3.5 ml.min(-1) per 1.73 m(2); P =0.005). Clp(EDTA) declined significantly in the early group from the first measurement after the operation until measurement before the third course of chemotherapy but remained constant in the late group. Clp(EDTA) was not correlated to ascites, cancer stage or tumour histology. It is concluded that patients with ovarian cancer have significantly higher Clp(EDTA) in the early post-operative phase than similar patients with Clp(EDTA) measured late post-operatively.

Localisation of somatostatin and somatostatin receptors in benign and malignant ovarian tumours

Somatostatin has been identified as having anti-proliferative, anti-angiogenic and pro-apoptotic actions in many tumour systems, and these effects are mediated through a family of five transmembrane G-protein coupled SRIF receptors. Ovarian cancer is the commonest gynaecological malignancy in the UK and maintenance therapy is urgently required. Native somatostatin expression and its receptors sst(1,2,3 and 5) were studied with immunohistochemistry in 63 malignant and 35 benign ovarian tumours of various histological types. Fifty-seven out of 63 (90%) of malignant and 26/35 (74%) benign tumours expressed somatostatin. Receptors sst(1,2,3 and 5) were expressed variably in epithelial, vascular and stromal compartments for both benign and malignant tumours. Somatostatin was found to correlate significantly with stromal sst(1) (P=0.008), epithelial sst(1) (P<0.001), stromal sst(2) (P=0.019), vascular sst(2) (P=0.026), epithelial sst(3) (P=0.026), stromal sst(5) (P=0.013) and vascular sst(5) (P=0.038). Increased expression of native somatostatin correlating with somatostatin receptors in malignant ovarian tumours raises the possibility that either synthetic somatostatin antagonists or receptor agonists may have therapeutic potential.

Expression of thyroid transcription factor-1 in strumal carcinoid and struma ovarii: an immunohistochemical study

Strumal carcinoid is an ovarian teratoma composed of thyroid tissue and carcinoid, intimately admixed in variable proportions. To further elucidate the histogenesis of strumal carcinoid, the expression pattern of thyroid transcription factor-1 (TTF-1) was evaluated in two cases of strumal carcinoid using immunohistochemical techniques. TTF-1 is a nuclear transcription protein that is selectively expressed in the thyroid and respiratory epithelium, and is thought to be expressed specifically in pulmonary and thyroid neoplasms. While the follicular lining cells of the strumal carcinoid showed positive staining for TTF-1, the carcinoid element was, for the most part, negative. These results confirm that TTF-1 is expressed in the thyroidal element of ovarian teratomas and also provide further evidence that the carcinoid component of the strumal carcinoid bears no relation to thyroidal differentiation.

Pancreatic polypeptide-related tumors

PP-producing tumors are mostly located in the pancreas and may present as three pathologic lesions: pure PP-omas, mixed tumors with minor PP cell population, and PP-cell hyperplasia. These tumors are among the most common multiple adenomas frequently found in patients with multiple endocrine neoplasia type 1. Hypersecretion and high circulating levels of PP are frequently found. They are symptomless but may be useful for the identification of the pancreatic tumors. Numerous types of extrapancreatic endocrine tumors are able to synthesize and secrete PP. They occur mostly but not exclusively in the gastrointestinal tract, particularly in the rectum. The inactivation of the MEN 1 gene at 11q13 appears to be involved in the development of pancreatic but not of rectal PP-producing tumors.

Hormonally Functional Ovarian Neoplasms

Hormonally functional ovarian neoplasms are those tumors that secrete one or more hormones that are clinically manifested in the patient. The hormone production may have implications for the diagnosis, management or treatment of the patient. Hormonally functional ovarian neoplasms include tumors that belong to various histologic categories and produce a variety of hormonal effects. Functional ovarian tumors most commonly produce steroid hormones, and such tumors frequently belong in the sex cord-stromal and steroid cell categories. In addition, a wide variety of peptide hormones may be produced by ovarian tumors. Although in most instances the neoplastic cells themselves produce the hormones, a wide variety of tumors may induce their stroma to produce steroid hormones. The stroma of ovarian tumors is derived from the ovarian stroma and may, on occasion, resemble specialized ovarian stroma and its derivatives. Cells resembling luteinized stromal cells or luteinized theca cells may be present and appear to be responsible for the resultant hormone secretion.

Pituitary adenylate cyclase activating polypeptide (PACAP) in human ovarian cancers

Synthesis of regulatory peptides has been described in a number of ovarian tumours. The recently isolated neuropeptide pituitary adenylate cyclase activating polypeptide (PACAP) is expressed transiently in steroidogenic cells of normal rat ovary. In order to evaluate if ovarian tumours also synthesize PACAP, we investigated the expression and processing of pro-PACAP in 11 serous cystadenocarcinomas, one non-differentiated carcinoma, one borderline malignant and four adenomas. Using sequence specific radioimmunoassays and gel chromatography, we found that all tumours expressed PACAP-38 immunoreactivity. Ovarian cancers contained higher (P < 0.03) concentrations (median 0.9 pmol/g, range 0.5-1.6 pmol/g, n = 13) than benign tumours (median 0.5 pmol/g, range 0.4-0.6 pmol/g, n = 4). Chromatography showed that the tumours contained PACAP-38 and PACAP-31-38 suggesting a rather complete processing. By immunohistochemistry, few scattered PACAP positive cells in small clusters or as single cells were identified in the tumours.

Strumal carcinoid of the ovary associated with hyperinsulinaemic hypoglycaemia and cutaneous melanosis

Using immunohistochemical techniques ovarian carcinoid tumours can be shown to contain a wide variety of neuro-hormonal peptides but clinical effects, apart from the carcinoid syndrome, are very rare. Non-islet cell tumours with documented hyperinsulinaemic hypoglycaemia are also rare. This is the first recorded case of an ovarian strumal carcinoid associated with hyperinsulinaemic hypoglycaemia. Concurrent skin hyperpigmentation is believed to have resulted from the effects of tumour derived alpha-melanocyte stimulating hormone or an antigenically similar, biologically active peptide.

Reproduction and the APUD system

Substantial evidence for involvement of the APUD system in the normal reproductive tract is limited to the prostate gland and uterine cervix. Most supportive data simply documents the presence of neuro-endocrine cells in these tissues. A biological product(s) or role(s) remains to be discovered, but appears likely in the prostate. Tumors possessing cells with APUD characteristics have been described in many reproductive tissues including the prostate, cervix, endometrium, ovary, and testes. These tumors are generally aggressive in behavior, and optimum therapy needs to be determined.

Prostatic acid phosphatase in strumal carcinoids of the ovary. An immunohistochemical study

BACKGROUND

Strumal carcinoids (SC) are ovarian tumors containing thyroid parenchyma admixed with carcinoid elements. Microscopically, the carcinoid component of SC usually presents a ribbon or trabecular pattern similar to the pattern exhibited by hindgut carcinoids. The authors designed an immunohistochemical study to ascertain further similarities of the carcinoid component of SC to rectal carcinoids.

METHODS

Five cases of SC were examined by light microscopic study with hematoxylin and eosin and immunoperoxidase staining with a group of neurohormonal peptides, thyroglobulin, prostatic acid phosphatase, and prostate specific antigen.

RESULTS

All tumors were positive for thyroglobulin, chromogranin, prostatic acid phosphatase (PAP), and glucagon. They were consistently negative for prostate specific antigen and variably positive to the other antibodies.

CONCLUSIONS

The consistent positivity of the carcinoid component of SC to PAP immunostaining is a further similarity of these tumors to rectal carcinoids, in which positive immunostaining to PAP has been observed. The similarity is not well understood, however, as all evidence points to the origin of SC from germ cells in mature cystic teratomas without any embryologic relationship to the hindgut.

Functioning ovarian carcinoids induce severe constipation

Five patients with ovarian carcinoid who had severe constipation for a long period preoperatively showed marked reduction of this symptom postoperatively. Because this phenomenon was believed to be caused by some biologically active substance rather than a mechanical effect of the tumor, reactivity to 17 amine and peptide hormones was studied immunohistochemically in these patients. Numerous peptide YY (PYY)-positive cells were detected, with PYY-positive cells representing more than 50% of all carcinoid tumor cells in each patient. PYY, which has a pharmacologic inhibitory action on intestinal motility, was presumably the cause of the constipation in these patients.

Malignant ileal carcinoid with metastasis to adenocarcinoma of the ovary

Metastasis of one tumor to another is an intriguing and rare phenomenon. Lung and breast malignancies are common donor tumors, while renal cell carcinoma and meningioma serve as frequent recipients. We report a case of malignant carcinoid of the ileum with metastasis to adenocarcinoma of the ovary. Histologic examination of the ovary showed a clear dimorphic pattern consisting of uniform polygonal cells arranged in an insular pattern and highly pleomorphic epithelioid cells forming small glands or solid nests. Immunocytochemical studies firmly established the distinct identity of the two tumors.

Peptide tyrosine tyrosine-positive ovarian carcinoid tumor arising from a dermoid cyst

A case of ovarian carcinoid tumor of the trabecular type is presented. The small carcinoid tumor was found incidentally in a resected dermoid cyst. Histologically, the tumor was surrounded by a smooth muscle layer with focal stromal invasion. Non-carcinoid papillary mucosa and a few small glands, simulating the mucosa of the fallopian tube and remnant müllerian glands, respectively, were also present adjacent to the carcinoid tumor and enclosed by the same smooth muscle layer. The tumor cells revealed argyrophilia, and were positive for peptide tyrosine tyrosine (PYY) in the cytoplasm and for CEA in part of the luminal surface. This case was considered to be a rare ovarian carcinoid tumor arising from a dermoid cyst, without association of struma ovarii. PYY may be a potential marker for determining the histogenesis of ovarian carcinoid tumors.

Hormone-producing tumors of the ovary

The ovary is an endocrine organ that gives rise to a wide variety of neoplastic and tumorlike nonneoplastic conditions, some of which are associated with endocrine activity. The hormones produced may be steroidal or nonsteroidal. The ovary is unique among endocrine organs in reacting to the presence of nonendocrine tumors within it by abnormal or inappropriate production of sex steroidal hormones. A classification of hormone-producing ovarian lesions is proposed based on the World Health Organization's histologicai typing of ovarian tumors.

Aberrant hormone production from ovarian neoplasms: strategies for diagnosis and therapy

Syndromes involving peptide or nonsex steroid hormone secretion due to aberrantly located tumors are rare. We report a collected series of 16 patients with ectopic hormone production from ovarian neoplasms, including 3 patients recently encountered at our institution as well as 13 additional cases identified in the recent literature. These tumors included 2 insulin-producing ovarian carcinoids, 1 ACTH-producing pituitary adenoma within a benign ovarian cystic teratoma, 2 cortisol-producing ovarian neoplasms, 8 gastrin-producing ovarian cystadenomata or cystadenocarcinomata, and 3 thyroxine-producing ovarian strumal carcinoids. All patients presented with syndromes of hormone excess. Only 62% of all tumors were localized preoperatively. Following ovarian resection, 87% of patients remained disease-free with a median follow-up period of 1.5 years. In addition to ovariectomy, 8 additional unnecessary ablative procedures were performed in 7 patients. These included distal pancreatectomy, pancreaticoduodenectomy, adrenalectomy, total gastrectomy, selective vagotomy, and subtotal thyroidectomy. Failure to localize the ovarian neoplasm preoperatively was associated with a significantly higher risk of subsequent unnecessary ablative procedures. Because of the potential for the ovary to act as a source of aberrant hormone secretion, we recommend complete preoperative evaluation of the pelvis in female patients presenting with nonlocalizable endocrine tumors.

Ovarian carcinoma as a cause of Zollinger-Ellison syndrome. Natural history, secretory products, and response to provocative tests

Zollinger-Ellison syndrome is usually caused by a gastrin-secreting tumor in or near the pancreas. We describe a patient in whom an ovarian cystadenocarcinoma was the cause of the syndrome. The patient presented with a short history of peptic ulceration and development of a large pelvic mass. Investigations demonstrated a basal acid output of 37.8 mEq/h and a maximal acid output of 36.0 mEq/h, and the plasma concentration of gastrin was 830 pg/ml (normal less than 100). Secretin and calcium infusion tests were positive, and a meal test was compatible with Zollinger-Ellison syndrome. Imaging studies demonstrated a normal liver and pancreas but a large cystic right ovarian mass. Resection of the mass resulted in a marked reduction in gastric acid output, a fall in plasma gastrin concentration to normal, negative calcium and secretin tests, and a normal (positive) meal test. Histology of the mass showed it to be a mucinous cystadenocarcinoma. The tumor stained with immunoperoxidase technique was positive for gastrin, and the cyst fluid contained high concentrations of gastrin and calcitonin. One year later, the patient has no biochemical or imaging evidence of tumor. Ovarian, gastrin-producing tumors and pancreatic gastrinomas cannot be distinguished by provocative tests, and negative imaging studies do not exclude a pancreatic tumor. Patients with an ovarian mass and Zollinger-Ellison syndrome should have a bilateral oophorectomy and a careful exploration of the pancreatic area.

Immunoreactive substance P in the human ovary

Although substance P has been demonstrated in the nonhuman ovary, it has not previously been identified in normal human ovarian tissue. We examined ovarian surgical specimens from 30 women for the presence of immunoreactive substance P. With the use of a specific radioimmunoassay, immunoreactive substance P was identified in these ovarian extracts. The geometric mean of the immunoreactive substance P concentration was 0.55 pg/mg wet weight (95% confidence limits 0.04 and 6.15). Thecal and stromal concentrations of immunoreactive substance P were greater than those in the corpora lutea and tunica albuginea. Large follicles had a lower concentration of immunoreactive substance P than did small follicles. We conclude that the neuropeptide substance P is present in some normal human ovaries and may be a modulator of ovarian function.

Prostate-specific acid phosphatase in carcinoid tumors

Although prostate-specific acid phosphatase (PASP) has been recognized as a specific marker of tissue of prostatic origin, several investigators have pointed out that some of the carcinoid tumours and islet cell tumours of the pancreas reacted immunohistochemically to PSAP. We investigated 50 cases immunohistochemically comprising 44 carcinoids of the G-I tract, 3 of the bronchus, 1 each of the ovary, kidney and middle ear. PSAP positive cases were, 30 in G-I tract, one each in ovary and kidney. Eighty percent of tumours of hindgut origin were positive. Apart from the immunohistochemical study, the content of PSAP in preoperative serum and tumour tissue was estimated in a case with a rectal carcinoid. Extremely elevated PSAP was confirmed in both the serum and tumour tissue. Neuroendocrine tumours such as pheochromocytoma, medullary thyroid carcinoma, and islet cell carcinoma were investigated as controls. No cells immunoreactive to PSAP were observed in these control cases. Prostate specific antigen was definitely negative in carcinoids. We would emphasize that PSAP may be an excellent marker of carcinoids especially when derived from hindgut.

Ectopic G-29 and G-37 glucagon secretion by hypercalcemic infantile renal tumors

Four hypercalcemic infantile renal tumors were shown to secrete glucagon-like peptides. These unusual tumors were histologically classified as rhabdoid tumors of the kidney (3 cases) and a cellular mesoblastic nephroma (1 case). Elevated G-29 and G-37 glucagon levels were detected in the plasma and tumor extracts as well as in the supernatants of cultured tumor explants. Three of these tumors were heterotransplanted into the nude mice and serially passaged from a mouse to another. The glucagon level decreased in the transplanted tumor extracts with the number of passage.

Ovarian strumal carcinoid tumor with amyloid stroma--report of a case with 20-year follow-up

We report a case of strumal carcinoid tumor arising in the left ovary of a 20-year-old woman. Histologically, microfollicular, solid, and trabecular areas were present, and amyloid stroma was demonstrated. Many cells contained argyrophilic granules, and thyroglobulin and calcitonin were demonstrated immunohistochemically in several areas. Ultrastructurally the cells resembled thyroid follicular cells and contained neurosecretory granules. It is concluded that strumal carcinoid is of endodermal origin, and shows evidence of thyroid and C-cell differentiation.

Immunohistochemical demonstration of neuron-specific enolase in gynecologic malignant tumors

Gynecologic malignant tumors were studied by the immunoperoxidase method for neuron-specific enolase (NSE). They included 22 argyrophil cell carcinomas of the endometrium, 6 argyrophil small cell carcinomas of the cervix, 21 argyrophil cell adenocarcinomas of the ovary (endometrioid type, 10; mucinous type, 11) and 3 ovarian carcinoids (strumal type, 2; insular type, 1). NSE was demonstrated in all cases of argyrophil small cell carcinomas of the cervix and ovarian carcinoids. On the other hand, NSE was positive only in four cases of endometrial carcinomas with argyrophil cells. Argyrophil cell adenocarcinomas of the cervix and the ovary were immunohistochemically negative for NSE. The current results suggest that argyrophil small cell carcinoma of the cervix, ovarian carcinoid, and some endometrial argyrophil cell carcinomas are related to APUDoma.

Large glucagon-like immunoreactivity in a primary ovarian carcinoid

A primary ovarian carcinoid composed of both trabecular and strumal types was studied by histochemical, immunocytochemical, and biochemical techniques. High contents of glucagon, secretin, and calcitonin were demonstrated in the tumor homogenate. All of the tumor cells, irrespective of histologic type, showed properties of argyrophilia and neurosecretory granules on electron microscopy. Glucagon-producing cells were positive in trabecular carcinoid by immunoperoxidase techniques. Bio-Gel P10 gel filtration showed that the molecular weight of major immunoreactive glucagon in tumor was 20,000. It migrated faster than true glucagon after polyacrylamide gel electrophoresis. No clinical symptoms of glucagonoma developed.

Immunohistochemical demonstration of peptide hormones in endometrial carcinomas

Sixty-eight endometrial carcinomas were examined histochemically and immunohistochemically for the presence of amine-containing or neurohormonal peptide-containing cells, particularly in relation to argyrophil cells. Argyrophil cells, detected in 43 of the 68 endometrial carcinomas by the Grimelius method, were subgrouped into two types according to the distribution of argyrophil granules and the shape of the tumor cells. Type I was found in 7 tumors and type II in 39; 3 tumors contained both cell types. The argyrophilia of type II cells was diminished in varying degrees in some tumors by diastase digestion, although it was unchanged in type I argyrophil cells. Indoleamine was detected by the formaldehyde-induced fluorescence method in type I argyrophil cells of four carcinomas. Immunohistochemically, somatostatin-reactive cells were found in two well-differentiated adenocarcinomas with argyrophilia; many of these cells corresponded to some of the type I argyrophil cells, although some were non-argyrophilic. Two adenosquamous cell carcinomas with type II argyrophil cells also contained cells that were immunoreactive with antisera against gastrin; however, they were non-argyrophilic.