Age contrast in ovarian pathology

Ovarian Masses in Children and Adolescents: A Review of the Literature with Emphasis on the Diagnostic Approach

Most abdominal masses in the pediatric population derive from the ovaries. Ovarian masses can occur in all ages, although their incidence, clinical presentation and histological distribution vary among different age groups. Children and adolescents may develop non-neoplastic ovarian lesions, such as functional cysts, endometrioma, torsion, abscess and lymphangioma as well as neoplasms, which are divided into germ cell, epithelial, sex-cord stromal and miscellaneous tumors. Germ cell tumors account for the majority of ovarian neoplasms in the pediatric population, while adults most frequently present with epithelial tumors. Mature teratoma is the most common ovarian neoplasm in children and adolescents, whereas dysgerminoma constitutes the most frequent ovarian malignancy. Clinical manifestations generally include abdominal pain, palpable mass, nausea/vomiting and endocrine alterations, such as menstrual abnormalities, precocious puberty and virilization. During the investigation of pediatric ovarian masses, the most important objective is to evaluate the likelihood of malignancy since the management of benign and malignant lesions is fundamentally different. The presence of solid components, large size and heterogenous appearance on transabdominal ultrasonography, magnetic resonance imaging and computed tomography indicate an increased risk of malignancy. Useful tumor markers that raise concern for ovarian cancer in children and adolescents include alpha-fetoprotein, lactate dehydrogenase, beta subunit of human chorionic gonadotropin, cancer antigen 125 and inhibin. However, their serum levels can neither confirm nor exclude malignancy. Management of pediatric ovarian masses needs to be curative and, when feasible, function-preserving and minimally invasive. Children and adolescents with an ovarian mass should be treated in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome.

The Histopathological Patterns of Ovarian Neoplasms in Different Age Groups: A Retrospective Study in a Tertiary Care Center

Objectives Ovarian cancer is one of the most prevalent neoplasms worldwide and it affects women of all ages. This study aimed to identify the common histopathological patterns of ovarian cancer among different age groups in the western region of Saudi Arabia. Methods This was a retrospective study that reviewed all ovarian specimens diagnosed as "ovarian tumors" by the Pathology Department from January 2016 to December 2020 at King Abdulaziz University Hospital, Saudi Arabia. The frequencies of ovarian neoplasm subtypes and their frequencies in different age groups were calculated. Results Out of 565 ovarian specimens studied, 63.2% were ovarian neoplasms while 36.8% were non-neoplastic functional cysts. Benign neoplasms 64.4% were more common than borderline 6.2% and malignant ones 29.4% in all age groups, except above the age of 60. Collectively as a category, surface epithelial neoplasms were the most common (59.4%). However, germ cell tumor in the form of mature cystic teratoma was the most common benign neoplasm 33.9% and the most common malignant was serous cystadenocarcinoma (40%). Conclusion Documenting new trends of histopathological patterns of ovarian neoplasms helps to detect variation among different age groups and to understand probable predisposing factors. This study found that the percentage of ovarian malignancy has increased over the years in the western region of Saudi Arabia. This signifies the need to increase awareness in order to achieve timely diagnosis and management.

Ovarian tumors among Nigerian females: A private practice experience in Benin-City, Nigeria

Background:

Ovarian tumors ranked high among gynecological tumor globally. Reports have it that ovarian tumors cut across all age groups, but more common in adult females. Currently, ovarian cancer is the 4^th most common cancer in terms of incidence and mortality patterns in women globally. To highlight the frequency and histological types of ovarian tumors in a private practice establishment in Benin-City, Southern Nigeria.

Materials and Methods:

Hematoxylin and eosin stained-slides of ovarian biopsies diagnosed at the Ashamas Foundation Diagnostic Centre, Benin-City for 10 years were archived and studied. Request forms were analyzed for clinical bio-data, diagnosis and nature of biopsies. Ovarian tumors were classified according to the World Health Organization manual series.

Results:

A total of 236 of all ovarian lesions were encountered in this study. Of these, 200 (84.7%) were benign lesions while malignant lesions accounted for 36 (15.3%). Of this, 200 benign lesions 79 accounting for (39.5%) were a benign neoplastic tumor. The ratio of benign to malignant tumors was 5.6:1.0. The mean age of benign neoplastic tumor was 31.6 years ± 10.4 standard deviation (SD). Out of the 79 benign neoplastic tumors; germ cell tumors was the most common accounting for 49 (62%). The mean age of the 36 malignant ovarian tumors was 40.1 years ± 16.2 SD with the majority as malignant surface epithelial tumors accounting for (n = 16; 44.4%). The malignant germ cell tumor was the most common constituting 10 (27.7%).

Conclusion:

Germ cell tumor was the most common with the majority occurring in reproductive age. Our finding is a reversal of what obtains in the western countries where surface epithelial tumor was the most common with the majority occurring in elderly females.

Epithelial ovarian tumors: Clinicopathological correlation and immunohistochemical study

Background:

Ovarian cancer is the third leading site of cancer among women, trailing behind cervix and breast cancer.

Aim:

This study was undertaken to analyze the immunohistochemical (IHC) profile of estrogen receptors (ER), progesterone receptors (PR), Ki-67, and p53 in various ovarian epithelial tumors and attempt correlation with clinical and histopathological findings.

Materials and Methods:

The present study was conducted over a period of 4 years. A technique of manual tissue array was employed for cases subjected for IHC. The primary antibodies used were ER, PR, p53, and Ki-67. A correlation was attempted between histopathological and IHC findings. Results were subjected to statistical analysis. Software program “the primer of biostatistics 5.0” was used for calculation of interrelationships between the analyzed ER, PR, p53, and Ki-67 expression and histological factors by Pearson's Chi-square test. The results were considered to be significant when the P < 0.05.

Results:

There were 110 cases of surface epithelial ovarian tumors (SEOT) encountered over the period of 4 years. The expression of ER was more in malignant tumors (13/16, 81.25%) than borderline (9/12, 75%) and benign (20/82, 24.39%). As compared to ER, the expression of PR was more in benign (51/82, 62.19%) than borderline (8/12, 66.67%) and malignant tumors (9/16, 56.25%). The expression of PR was more in benign tumors than borderline and malignant tumors. However, this was not statistically significant (Chi-square = 0.335 with 2 degrees of freedom; P = 0.846). The expression of p53 was less in benign (5/82, 6.1%) than borderline (9/12, 75%) and malignant tumors (13/16, 81.25%). The expression of Ki-67 was more in malignant (4/82, 4.88%) than borderline (10/12, 83.33%) and benign tumors (15/16, 93.75%). In all the above cases, the difference was statistically significant (P < 0.05). There was statistically significant difference in the expression of ER, PR, p53, and Ki-67 in the patients with age <40 years and above 40 years (P = 0.912). A positive correlation was observed in p53 expression and tumor grade. Similar correlation was seen in Ki-67 and tumor grade. It was also noted that mean Ki-67 labeling index (Li) had also increased with tumor grade. In the case of serous tumors, ER was expressed in all high- and low-grade tumors. The expression of PR was more in low-grade tumors than high-grade ones. P53 expression was seen in all high-grade tumors and 33.34% of low-grade tumor. The Ki-67 Li was more in high-grade tumors than low-grade tumors. Expression of ER, p53, and Ki-67 was higher in tumor showing metastasis. The mean Ki-67 Li was also higher in metastasizing tumors. However, PR expression was less in metastasizing tumors than nonmetastasizing tumors.

Conclusion:

IHC marker report of ER, PR status, and Ki-67 if included in each pathology report will pave the way for better understanding of biological behavior and modify treatment strategies.

A synchronous presentation of two different ovarian tumors: a rare occurrence

Approximately 60% of all ovarian tumors are epithelial in origin, and these neoplasms are thought to arise from the ovarian surface epithelium or small epithelial inclusion cysts. Surface epithelium is capable of differentiating into serous (tubal), mucinous, endometrioid or transitional epithelium. Serous and mucinous cystadenomas are the most common epithelial tumors and, together, account for about 30% of ovarian tumors We report a case of a 29-year-old lady P1L1 presenting with the chief complaints of pain abdomen off and on since the last 1 year. Ultrasonography revealed normal uterus with enlarged right ovary, with a cyst measuring 46 mm × 36 mm × 55 mm showing internal echoes with volume of 50 cc., left ovary also enlarged with multiple well-defined cysts measuring 34 mm × 44 mm × 69 mm with volume of 55 cc and the largest cyst measuring 37 mm. Bilateral ovarian cystectomy was done and sent for histopathology. To our surprise, both the ovaries revealed different histopathological pictures, with the right ovary revealing serous cystadenoma and the left ovary showing mucinous cystadenoma. This rare occurrence has never been reported so far in the literature to the best of our knowledge.

Doublet chemotherapy in the elderly patient with ovarian cancer

The aging of the population has focused on the need to evaluate older patients with cancer. Approximately 50% of patients with ovarian cancer will be older than age 65 years. Increasing age has been associated with decreased survival. It is uncertain whether this relates to biologic factors, treatment factors, or both. There is concern that undertreatment may be associated with decreased survival. Older patients with ovarian cancer have been underrepresented in clinical trials. Therefore, the evidence base on which make decisions is lacking. Clinicians need to be aware of the currently available data to aid in treatment decisions. Doublet therapy is the most common standard treatment in epithelial ovarian cancer. It usually consists of a taxane and a platinum compound. A series of cooperative group studies in both the United States and Europe established intravenous paclitaxel and carboplatin as the most common standard in optimally debulked patients. The recent introduction of intraperitoneal therapy has complicated decision making in terms of which older patients would benefit from this more toxic therapy. In relapsed patients, the issue of platinum sensitivity is critical in deciding whether to reutilize platinum compounds. It is unclear whether single agents or combinations are superior, particularly in older patients. Geriatric assessment is an important component of decision making. Prospective studies are needed to develop strategies to determine the optimal treatment for older patients with ovarian cancer.

Cathepsins B, L and cystatin C in cyst fluid of ovarian tumors

Introduction

In cancer, an extracellular and membrane bound localization of cathepsins contribute to the invasion of tumor cells at the basement membrane.

Methods

This is the first study that explored levels of cathepsins B (CatB), L (CatL) and their inhibitor cystatin C (CysC) in the cystic fluid (CF) of ovarian tumors (n = 110).

Results

CF contained considerable amounts of CatB, CatL and CysC. Remarkable differences in CatB and CatL and CysC CF levels were found between different histopathological tumor subtypes. Levels of CatB and CysC were significantly higher in CF of malignant serous tumors compared to those found in benign serous tumors (p = 0.010 and p = 0.001 respectively), whereas levels of CatL were significantly higher in CF of malignant mucinous tumors compared to those found in benign mucinous tumors (p = 0.035). CatB and CysC showed a strong correlation in the group of patients with malignant serous tumors (p < 0.001; R = 0.921) suggesting that the increase in CatB might be balanced by a corresponding increase in CysC.

Conclusion

Further studies are warranted to investigate cathepsins as possible prognostic biomarkers for the aggressiveness of ovarian cancer.

Factors associated with non-epithelial ovarian cancer among Mexican women: A matched case-control study

The purpose of this study was to identify risk factors associated with the development of non-epithelial ovarian cancer in Mexican women. A case-control study was carried out on women registered with the Mexican Institute of Social Security in Mexico City over a period of two years (1995-97). Twenty-eight new cases were recruited from the Gynecology and Obstetrics Hospital no. 4, "Luis Castelazo Ayala", and were matched by age with 84 controls selected randomly. Eighteen (64.3%) cases of germ cell tumors and 10 (35.7%) stromal sex cord tumors were found. The number of full term pregnancies was associated inversely to development of stromal sex cord tumors with lower risk in women with more than three full term pregnancies (odds ratio, 0.02: 95% confidence interval, 0.001-0.56) compared to nulliparous women. No associations were found respecting to germ cell tumors. Parity was inversely associated to development of stromal sex cord tumors, probably as a result of the endocrine system's influence on the ovaries. The development of germ cell tumors could be associated to factors not evaluated in this study.

Comparative analysis of loss of heterozygosity of specific chromosome 3, 13, 17, and X loci and TP53 mutations in human epithelial ovarian cancer

We previously reported the identification of three minimal regions of deletion on the short arm of chromosome 3 (3p) in epithelial ovarian tumor specimens, suggesting that the inactivation of tumor-suppressor genes in these regions may be important in terms of ovarian tumorigenesis. Another previous study of ovarian cancer observed that allele loss of chromosome 179 was frequently found in ovarian tumors that also showed loss of heterozygosity (LOH) of chromosomes 3p, 13q, 17p, and Xp. In an independent study, we also reported a high frequency of LOH for selected chromosome 17 loci in high-grade and late-stage ovarian tumors. We have extended our LOH analysis of chromosome 3p to include 102 ovarian tumor specimens (29 and 73 samples were previously examined for LOH of chromosome 3p and 17 markers, respectively), using additional polymorphic markers, to assess the coordinate LOH of loci representing the three chromosome 3p minimal regions of deletions [von Hippel-Lindau syndrome (VHL), thyroid hormone receptor beta, and fragile histidine triad (FHIT)] and LOH of other important loci [tumor protein 53 (TP53), breast cancer 1 early onset (BRCA1), breast cancer 2 early onset, retinoblastoma 1, ornithine carbamoyltransferase, and androgen receptor] or somatic mutations in TP53. There was a significant association between LOH of any chromosome 3p marker and LOH of any chromosome 17 marker (P = 0.026). The frequency of LOH at the TP53 locus was higher in the group of samples that displayed LOH of a 3p marker (P = 0.019), as was the frequency of LOH at the BRCA1 locus (P = 0.014). LOH of chromosome 3p was noted in four specimens that did not display LOH of either the BRCA1 or the TP53 locus, indicating that LOH of these loci need not precede LOH of the chromosome 3p loci. We found a significant association between LOH of the VHL (3p25) locus and LOH of any chromosome 17 marker (P = 0.005), suggesting that there may be an important relationship, in the tumorigenesis of epithelial ovarian cancer, between a gene at 3p25 and a gene located on chromosome 17. Our results indicate that inactivation of p53 by somatic mutation is unlikely to be a prerequisite to chromosome 3p LOH, because we found no significant association between mutations in TP53 and LOH of the three chromosome 3p loci. The frequency of LOH at the FHIT locus at 3p14 increased significantly with advancing age at diagnosis (P = 0.018), as did the frequency of somatic TP53 mutations (P = 0.008).

Ovarian pathology and high incidence of sex cord tumors in follitropin receptor knockout (FORKO) mice

In this investigation we describe our observations of the status of the aging ovary in mice with disruption of the receptor for FSH. Knockout mice at 3-5 months of age are acyclic and sterile, with very small, underdeveloped ovaries. Thus, they exhibit hypergonadotropic-hypogonadism with high levels of circulating FSH similar to the postmenopausal state in women. By 12 months more than 92% of these animals developed various kinds of ovarian pathology, including neoplasms of sex cord-stromal type as well as cysts. Interestingly, the majority of tumors were located in the right ovary, with the contralateral ovary remaining unaffected but atrophic. The ovary from heterozygotes also showed pathology after 15 months. None of the age-matched wild-type mice that remained fertile developed any sign of ovarian tumors. Circulating LH and FSH levels were increased in follitropin receptor knockout mice and remained severalfold higher in tumor-bearing animals. The histological appearances of ovarian tumors were similar to the pathology observed in some types of sex cord-stromal neoplasms in women. The tumor burden caused weight loss and cachexia in follitropin receptor knockout mice. Based on these characteristics as well as the high incidence of ovarian pathology in the aging mutant, we propose that the loss of the FSH receptor signaling mechanisms predispose the ovary to molecular and structural changes leading to tumor formation. Hence, in the intact and fertile animal, FSH receptor signaling offers a protective mechanism that is lost upon reproductive senescence (menopause in women). Further studies are warranted in this genetic model to explore the molecular changes underlying the development of ovarian neoplasia.

Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators

BACKGROUND

The behavior of ovarian serous borderline tumors (SBTs) and significance of various prognostic factors are unclear and difficult to evaluate because of inconsistencies and confusion in the literature. Recent studies have suggested that the morphological features of the primary tumor (presence or absence of micropapillary features) and the peritoneal "implants" (presence or absence of invasive features) can reliably subclassify SBTs into benign and malignant types. The aim of the current review was to test two hypotheses. First, that the alleged malignant behavior of SBTs is poorly documented, and second, that the morphological features of the primary ovarian tumors and the associated peritoneal implants are sufficient to separate SBTs into benign and malignant types, thereby obviating the need for the category.

METHODS

245 studies reporting approximately 18,000 patients with borderline ovarian tumors were reviewed. After excluding series that lacked clinical follow-up or were not analyzable for other reasons, there remained 97 reports that included 4,129 patients. In addition to recurrences and survival, we evaluated the type of peritoneal implants, microinvasion, lymph node involvement, late recurrences, and progression to carcinoma, as these features have served as the underpinning of the concept of "borderline malignancy" or "low malignant potential."

RESULTS

Among 4,129 patients with SBTs reviewed, the recurrence rate after a mean follow-up of 6.7 years was 0.27% per year for stage I tumors, the disease-free survival was 98.2%, and the overall disease-specific survival rate was 99.5%. For patients with advanced-stage tumors, the recurrence rate was 2.4% per year. However, the majority (69%) of reported recurrences were not pathologically documented, and only 26 cases (8.4% of all recurrences) were documented to have recurred from an adequately sampled ovarian tumor. The most reliable prognostic indicator for advanced stage tumors was the type of peritoneal implant. After 7.4 years of follow-up, the survival of patients with noninvasive peritoneal inplants was 95.3%, as compared with 66% for invasive implants (P < .0001). Microinvasion in the primary ovarian tumor was associated with a 100% survival rate at 6.7 years, and lymph node involvement was associated with a 98% survival rate at 6.5 years. The few reported cases of stage IV disease, progression to invasive carcinoma, and very late (>20 years) recurrences were poorly documented. The survival for all stages among approximately 373 patients in 6 prospective randomized trials followed for a mean of 6.7 years was 100%.

CONCLUSION

Surgical pathological stage and subclassification of extraovarian disease into invasive and noninvasive implants are the most important prognostic indicators for SBTs. Survival for stage I tumors is virtually 100%. Survival for advanced stage tumors with noninvasive implants is 95.3%, whereas survival for tumors with invasive implants is 66%. Invasive implants behave as carcinomas and are most likely metastatic. The precise nature of so-called noninvasive implants is not clear, but they behave in a benign fashion. The presence of a micropapillary architecture in the primary ovarian tumor is a strong predictor of invasive implants. These data support the recommendation that ovarian tumors with a micropapillary architecture be designated "micropapillary serous carcinomas," and those lacking these features, "atypical proliferative serous tumors."

Ovarian cancer in young women in Sweden, 1989-1991

The present study is an evaluation of the symptoms and gynecological status, at the time of seeking medical advice, among women of reproductive age diagnosed with ovarian malignancies. The study was based on the medical records of all women in Sweden between 15 and 40 years of age who were diagnosed with ovarian malignancies during a 3-year period (1989-1991). The study focused on the diagnosis and panorama of symptoms. These data were compared to the records of more than 10,000 women in this age group during the same period of time who underwent surgery for ovarian changes that resulted in benign diagnoses. The 152 cases of ovarian cancer included only 1 patient who was without symptoms, had normal pelvic status upon manual examination, and a sonographically diagnosed simple cyst. These data support the conclusion that the majority of young women with ovarian cancer have symptoms and/or clinically detectable adnexal masses at the time when medical advice is sought. These studies suggest that diagnosis of ovarian cancer is unlikely in young healthy women lacking subjective symptoms and an adnexal mass upon pelvic examination. In conclusion, programs for the management of simple cysts and development of noninvasive diagnostic methods for ovarian changes found in patients in the reproductive age group are needed in order to reduce the number of patients subjected to operative intervention.

Evaluation of adnexal masses in adolescents

The detection of adnexal masses in adolescents is worrisome to patients, their families, and physicians. Reassurance can be given that the vast majority of these lesions are benign. Furthermore, a significant fraction of benign masses are functional ovarian cysts, most of which resolve spontaneously and never need surgery. Imaging is critical in determining the management of these patients. Sonography is the preferred first-line diagnostic tool. When surgery is necessary, physicians must recognize the importance of conserving the ovaries and uterus to avoid the loss of reproductive and endocrine function.

Age at diagnosis and multiple primary cancers of the breast and ovary

This nested case-control study assessed the relationship between a woman's age at the time of her initial primary breast or ovarian cancer diagnosis and the risk of a second primary cancer at the other of these two sites. Multiple primary breast and ovarian cancer cases whose initial breast or ovarian diagnosis occurred in 1970-1989 and a random sample of single primary breast or ovarian cancer controls diagnosed in the same years were identified through tumor registries at Duke University Medical Center and the University of North Carolina. Women diagnosed with an initial primary breast cancer at age < or = 50 years were 4.3 times (95% CI: 1.8-10.6) more likely to have developed a subsequent ovarian cancer compared to those diagnosed after age 50. A relationship between an early age at diagnosis (< or = 50) of ovarian cancer and subsequent diagnosis of breast cancer was not found (odds ratio (OR) = 0.6; 95% CI: 0.2-2.0). Adjustment for stage at diagnosis, treatment, year of diagnosis and length of follow-up using Cox Proportional Hazards modeling techniques supported these relationships, yielding a hazard ratio (HR) for the development of a second primary cancer at the alternate site of 4.6 (95% CI: 1.8-11.5) for women with an initial breast cancer diagnosis and 0.6 (95% CI: 0.2-2.2) for women with an initial ovarian cancer diagnosis. Multiple primary breast and ovarian cancer patients diagnosed with an initial breast cancer at or prior to age 50 may represent a distinct subgroup of women with a germline mutation that confers susceptibility to both breast and ovarian cancers.