Dysgerminoma of the ovary with rhabdomyosarcoma. Report of a case

Dysgerminoma of the Ovary: An Analysis of 140 Cases Emphasizing Unusual Microscopic Findings and Resultant Diagnostic Problems

One-hundred fourty pure dysgerminomas were evaluated with particular focus on the microscopic features as seen in 125 cases with available slides. The patients ranged from 8 to 59 years of age (mean, 24.1 y). The tumors, bilateral in 4% of the cases and with a mean tumor diameter of 13 cm, were typically soft, lobulated, homogeneous, and creamy white to tan to yellow but necrosis was found in 13%, hemorrhage in 20%, and focal cystic change in 15%. On microscopic examination, the patterns and other notable features encountered, including their frequency, were as follows: an alveolar pattern resulting from delicate fibrovascular septa (51%), diffuse (33%), macronodular (14%), insular (26%), cords (28%), solid tubular (17%), microspaces (sometimes simulating glands) (12%), follicle-like spaces (5%), prominent fibrous bands (65%), stromal edema (56%), stromal luteinization (9%), granulomatous infiltrate (46%), lymphocytic infiltrate (100%), Langhans cell type giant cells (35%), syncytiotrophoblast giant cells (6%), prominent population of cells with pale to clear cytoplasm (73%), cells with amphophilic to eosinophilic cytoplasm (53%) and vacuolated occasionally signet ring-like cells (7%). Various constellations of the above findings often resulted in an appearance different from that usually portrayed in the literature and certain tumors of very different nature being in the differential such as undifferentiated carcinoma not otherwise specified, small cell carcinoma of hypercalcemic type, and malignant lymphoma. The correct diagnosis can be arrived at by considering the usual relative youth of the patient, often rather characteristic gross features, and most crucially careful attention to the microscopic features and awareness of variant morphologic findings. Those that are particularly problematic based on this study are diffuse growth with inconspicuous fibrovascular septa, macronodules, cords, solid tubular formations, spaces ranging from small to large, and mimicking glands or follicles, prominent fibrous to edematous stroma, and cells with amphophilic to eosinophilic cytoplasm. According to the degree of difficulty and confidence of the interpreter, well-known immunohistochemical features of dysgerminoma, which largely differ from those of other neoplasms in the differential, will aid if felt indicated.

Embryonal Rhabdomyosarcoma of the Ovary and Fallopian Tube: Rare Neoplasms Associated With Germline and Somatic DICER1 Mutations

DICER1 mutations (somatic or germline) are associated with a variety of uncommon neoplasms including cervical and genitourinary embryonal rhabdomyosarcoma (ERMS). We report a primary ovarian and 2 primary fallopian tube ERMS occurring in 60-, 13-, and 14-year-olds, respectively. The 3 neoplasms exhibited a similar morphologic appearance being polypoid and containing edematous hypocellular areas and hypercellular foci composed of small cells with scant cytoplasm exhibiting rhabdomyoblastic differentiation (desmin, myogenin, myoD1 positive). There was cellular cartilage in all cases and extensive foci of anaplasia, eosinophilic globules, and bone/osteoid in 1 case each. All 3 neoplasms exhibited DICER1 mutations; in 1 of the tubal cases, the patient had a germline mutation and in the other 2 cases, the DICER1 mutations were somatic. Accompanying DICER1 "second hits" were identified in all cases. In 2 of the neoplasms, SALL4-positive glandular structures were present which we speculate may represent an unusual primitive "metaplastic" phenomenon. Our study adds to the literature on ERMS at unusual sites associated with DICER1 mutations. ERMS arising at such sites, especially when they contain cartilage or bone/osteoid, are especially likely to be associated with DICER1 mutations. Pathologists should be aware of this as these may be the sentinel neoplasms in patients with DICER1 syndrome and confirming a germline mutation can facilitate the screening of the individual and affected family members for other neoplasms which occur in this syndrome.

Rhabdomyosarcoma Originating From an Ovarian Immature Teratoma

We report a rare case with unique histologic findings in the extra-abdominal metastases from an ovarian immature teratoma in a 33-year-old Japanese woman. The primary ovarian tumor was a grade 2 immature teratoma that contained a small aggregate of recognizable rhabdomyoblasts in addition to other immature and mature teratomatous elements. After three courses of chemotherapy, metastatic tumors were identified in the para-aortic area and a right cervical lymph node. Histologically, the para-aortic tumor was predominantly a typical embryonal rhabdomyosarcoma with minor foci of mature teratoma, whereas the cervical tumor consisted only of mature teratomatous elements without any evident immature elements. Int J Surg Pathol 2(3):245-250, 1995

Ovarian germ cell tumors with rhabdomyosarcomatous components and later development of growing teratoma syndrome: a case report

Introduction

Development of a sarcomatous component in a germ cell tumor is an uncommon phenomenon. Most cases reported have a grim prognosis. Growing teratoma syndrome is also an uncommon phenomenon and occurs in approximately 2% to 7% of non seminomatous germ cell tumors and should be treated surgically.

Case presentation

We report the case of a 12-year-old Asian girl with an ovarian mixed germ cell tumor containing a rhabdomyosarcomatous component. She was treated with a germ cell tumor chemotherapy regimen and rhabdomyosarcoma-specific chemotherapy. Towards the end of her treatment, she developed a retroperitoneal mass that was increasing in size. It was completely resected, revealing a mature teratoma, consistent with growing teratoma syndrome. She is still in complete remission approximately three years after presentation.

Conclusion

The presence of rhabdomyosarcoma in a germ cell tumor should be treated by a combined chemotherapy regimen (for germ cell tumor and rhabdomyosarcoma). In addition, development of a mass during or after therapy with normal serum markers should raise the possibility of growing teratoma syndrome that should be treated surgically.

[Mixed germ cell tumor of the ovary with rhabdomyosarcomatous component. A case report]

Malignant germ cell tumors of the ovary are rare representing 3% of all ovarian neoplasms. Hence, they are the most common ovarian malignancy in girls and young women and account for approximately two-thirds of the ovarian cancers that occur in the first two decades of life. Germ cell tumors constitute a heterogeneous group of tumors and are often mixed associating at least two different tumoral components. Exceptionally, sarcomatous areas can be found. We present a case of a 15-year old girl admitted for a voluminous left ovarian mass revealed by pelvic pain. Pathological examination of the dissected material revealed the tumor to be a mixed germ cell tumor (immature teratoma and yolk sac tumor) with rhabdomyosarcomatous component of embryonal type. Clinico-pathological characteristics of such ovarian tumors will be discussed with emphasis on diagnostic difficulties.

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.

Mixed germ cell tumor of the ovary with sarcomatous component

Germ cell tumors constitute a very complicated group of tumors of the ovary and their histogenesis is not yet clarified. Besides their histological heterogeneity, sarcomatous areas have also been described. A right ovarian mass was found in a 23-year-old female, who was being treated in the hospital for miscarriage. Disseminated omental metastases were detected during abdominal laparotomy. Pathological examination of the dissected material revealed the tumor to be a mixed germ cell tumor (immature teratoma and dysgerminoma) with sarcomatous component. Areas resembling granulosa cell tumor were also encountered. This ovarian tumor with many different histopathological features is presented with a review of the literature. The importance of thorough sampling in determining the type and extent of the malignant components is also emphasized due to their direct relation with the prognosis.

Small cell neuroendocrine carcinoma with skeletal muscle differentiation: report of three cases

Three cases of neuroendocrine carcinoma showing skeletal muscle differentiation are presented. The tumors were located in the skin and subcutaneous tissue, the urinary bladder, and the nasal cavity respectively, and were composed by two cell types admixed intimately with each other. One cell type had features identical to those seen in conventional small cell neuroendocrine carcinoma, including scanty cytoplasm, round nuclei with fine granular chromatin, immunohistochemical reactivity for neuron-specific enolase, chromogranin and cytokeratins, and electron-dense granules on ultrastructural examination. The second cell type was either plasmacytoid or elongated and straplike, with abundant eosinophilic cytoplasm and irregular nuclei with prominent nucleoli. These cells showed immunohistochemical positivity for desmin, sarcomeric actin, myoglobin, and myogenin. They also exhibited ultrastructural evidence of rhabdomyoblastic differentiation in the form of contractile filaments with abortive Z-band formation. An origin from a cell capable of dual differentiation toward neuroendocrine and rhabdomyoblastic elements is postulated for these tumors.

Spermatocytic seminoma

Spermatocytic seminoma is a rare testicular neoplasm that occurs only in adults (range, 25 to 87 years; mean, 54). It has no ovarian homologue and is found only in descended testes. It is not associated with other types of germ cell neoplasia. Orchiectomy is curative in virtually all cases; of more than 200 known cases, only one has metastasized. In a dozen cases sarcomas have arisen in the testes in association with spermatocytic seminoma; most of these patients have died of metastatic sarcoma after short intervals. The gross appearance is characteristically edematous or gelatinous and more than half the tumors have been more than 5 cm in diameter. Microscopically, they are composed of sheets of small, medium, and large cells with spherical nuclei. The chromatin is dense in the small cells and filamentous in the medium and large ones. The cytoplasm is eosinophilic to amphophilic and lacks glycogen. It is not associated with intratubular germ cell neoplasia of the undifferentiated type. Analyses of DNA content have failed to show haploid populations and the lectin binding does not show maturation toward spermatocytes. Differing from seminoma in essentially all characteristics, it is not a variant of seminoma.

Juvenile granulosa cell tumor

A 2-year-old girl presented with isosexual precocity, and a juvenile granulosa cell tumor of the left ovary was removed. The tumor was unusual in that striated muscle differentiation of the tumor cells was demonstrated. This suggests that the mesenchymal cells retain the potential for divergent differentiation.