An electron-microscopic study of the endometrioid adenocarcinoma of the ovary and a comparison of its fine structure with that of normal endometrium and of adenocarcinoma of the endometrium

Ciliated adenocarcinoma of the ovary with evidence of serous differentiation: report of a case

A patient with bilateral ovarian adenocarcinomas composed predominantly of ciliated cells incidentally found at autopsy is reported. Although obviously malignant, a majority of the cells expressed well-differentiated cilia with terminal bar formation. In one of the masses, the neoplastic cells seemed to arise from a serous adenofibroma. The tumor was confined to the ovaries without evidence of metastatic spread. Although morphologically resembling an endometrioid-type neoplasm, immunohistochemical and molecular studies were more consistent with a serous phenotype, especially in light of its apparent origination from a serous adenofibroma. We agree with previous observations suggesting that although the neoplasm seems morphologically worrisome, it may actually portend a more benign clinical course.

Coexisting ovarian malignancy in young women with endometrial cancer

OBJECTIVE

In premenopausal women with endometrial cancer, ovarian preservation may be a consideration. Our objective was to examine the occurrence of coexisting ovarian malignancy and to identify predictors of adnexal involvement.

METHODS

With institutional review board approval, a retrospective chart review was conducted of young women with endometrial cancer identified at 4 affiliated institutions from 1996 to 2004.

RESULTS

Among 102 young women (aged 24-45 years) who underwent hysterectomy for endometrial cancer, 26 (25%) were found to have coexisting epithelial ovarian tumors: 23 were classified as synchronous primaries, and 3 as metastases. Ovarian cancer histology was endometrioid in 92% of cases. Among the 26 cases of coexisting ovarian involvement, 12 (46%) had grade 1 endometrial cancer on preoperative biopsy, 4 (15%) had normal preoperative imaging of the adnexa, and 4 (15%) had benign-appearing ovaries at the time of intraoperative assessment. On final pathology, 18 of 26 cases (69%) occurred in patients with grade 1 endometrial cancers, and 15 (58%) occurred with inner myometrial invasion. Our study further highlights the risk of conservative management with 1 case of ovarian cancer diagnosed 9 months after hysterectomy with ovarian conservation for a stage IA, grade 1 endometrial cancer and a case of advanced endometrial cancer metastatic to the ovaries developing 3 years after successful resolution of a grade 1 endometrial cancer treated with megestrol acetate (Megace).

CONCLUSION

Careful preoperative and intraoperative assessment of the adnexa is mandatory in young women with endometrial cancer. Those who desire ovarian preservation should be counseled regarding the high rate of coexisting ovarian malignancy.

Synchronous dual primary ovarian and endometrial carcinomas

OBJECTIVES

The synchronous occurrence of carcinoma confined to the ovary and endometrium presents a diagnostic and therapeutic dilemma. These tumors have been variously staged as FIGO Stage IIA ovarian carcinoma, Stage III endometrial carcinoma, or synchronous dual primary carcinomas. Accumulating evidence suggests such patients have a favorable outcome. This retrospective study was undertaken to review our experience with these fascinating tumors.

METHODS

The clinical records and the pathologic findings of 16 patients with synchronous dual primary ovarian and endometrial carcinomas were reviewed.

RESULTS

The median age was 51 years. Abnormal uterine bleeding was the most common presenting symptom (70%). All patients had Stage I ovarian and endometrial carcinomas. Fourteen patients (88%) had endometrioid carcinoma in both sites, while two patients (12%) had dissimilar histology. For 15 patients (94%), the grade of both tumors was identical. Only three (19%) patients had myometrial invasion, with less than 50% involvement in each case. All patients underwent surgical staging, 11 (70%) of whom received adjuvant radiation or chemotherapy. The five patients treated with surgery alone had Grade 1 endometrioid tumors. The only relapse occurred in a patient with a clear cell component in both sites. No patient has died of disease.

CONCLUSIONS

Patients with synchronous dual primary carcinomas appear to have a more favorable prognosis than that expected with Stage IIA ovarian or Stage III endometrial carcinoma (100% vs. 63% or 42% survival at 3 years, respectively). The excellent survival for patients with Grade 1 dual endometrioid tumors treated with surgery alone suggests that adjuvant therapy may not be necessary for this sub-group.

Ultrastructural study of glandular epithelium in adenomyosis in comparison with those of proliferative endometrium and well-differentiated endometrial cancer

Adenomyotic glandular tissue from five patients underwent electron microscopic investigation to observe its ultrastructural characteristics. The adenomyotic epithelium was compared with that of proliferative normal epithelium (two patients) and well-differentiated endometrial adenocarcinoma (two patients). The results revealed that morphologically the adenomyotic glandular epithelium is somewhat less differentiated than proliferative endometrium and that its cytoplasmic organelles have some similarities with those of endometrial cancer. Whether these similarities predispose the adenomyotic glandular tissue to malignant degeneration remains to be elucidated.

Endometrioid carcinoma of the ovary: retrospective review of 145 cases

From 1967 through December 1987, 145 patients with endometrioid carcinoma of the ovary were treated at the University of Texas M. D. Anderson Cancer Center. Thirty-eight patients (26.2%) had stage I disease, 28 (19.3%) stage II, 60 (41.4%) stage III, and 11 (7.6%) stage IV; 8 patients (5.5%) were unstaged. Grade 2 or 3 histology was seen in 119 patients (82.1%). In addition to surgical therapy, 128 patients underwent chemotherapy, including single-agent therapy, noncisplatin combination therapy, and cisplatin-based therapy. No statistically significant improvement in median survival was noted among these three chemotherapy groups for stages II, III, and IV (P = 0.22). A significant improvement in median survival was noted for those patients who achieved a complete clinical response, regardless of type of chemotherapy (96 or more months for single-agent therapy, P = 0.001; 31.5 months for noncisplatin combination therapy, P = 0.016; and 85 months for cisplatin-based therapy, P = 0.0001). Synchronous ovarian and uterine malignancies were seen in 18 patients (12.4%). No difference in survival was seen for patients with endometriosis (P = 0.13) or endometrial cancer (P = 0.09) when compared with those who did not have these histologic findings.

Endometrioid carcinoma of the ovary: a retrospective study

Thirty-nine women with endometrioid carcinoma of the ovary were studied for factors relating to their presentation, treatment and survival. Nine of the women (23%) had a concomitant adenocarcinoma of the endometrium at the time of presentation. There were no significant differences in age at presentation or menopausal status between the two groups. The actuarial 5-year survival for women with endometrioid carcinoma of the ovary alone was 43%, 95% confidence interval (CI) 24% to 62% (stage I 80%, CI 45% to 100%, stage II 62%, CI 27% to 97%, and stage III 21%, CI 0% to 42%). The 5-year survival for women with concomitant endometrial tumours was 62.5% (CI 28.5% to 96.5%). The difference in the overall survival rate between the two groups was not significant.

Coexpression of cytokeratins and vimentin in common epithelial tumours of the ovary: an immunocytochemical study of eighty-three cases

An immunocytochemical investigation has been performed on 83 common epithelial tumours of the ovary, to ascertain their capability of expressing vimentin in addition to cytokeratins. Our results demonstrate that vimentin coexpression is related to the tumour histotype and -to a lesser extent- to the degree of differentiation of malignant variants. Indeed, most serous tumours (80%), some endometrioid adenocarcinomas, and all the clear cell carcinomas investigated exhibited a variable number of neoplastic cells co-synthesizing the two distinct intermediate filament (IF) proteins, whereas only one of 29 mucinous tumours and none of the Brenner tumours displayed vimentin-immunoreactive cells. Moreover, in serous and endometrioid carcinomas, the expression of vimentin was related to the degree of tumour differentiation, being consistently identifiable in the better differentiated cases. The immunocytochemical findings of a parallel investigation on IF expression in the ovarian coelomic epithelium and in the müllerian-derived epithelia of the female genital tract allowed us to ascertain that ovarian epithelial tumours (with the possible exception of poorly differentiated carcinomas) maintain the pattern of IF expression typical of the normal epithelia. This investigation emphasizes the usefulness of IF typing as a tool for the more precise characterization of the origin and differentiation of human neoplasms.

Metastatic and independent cancers of the endometrium and ovary: a clinicopathologic study of 34 cases

Twenty-one of 34 simultaneous cancers involving the endometrium and ovary were classified as endometrial primary tumors with ovarian metastases. The criteria for this classification were either a multinodular ovarian pattern (major criterion) or two or more of the following minor criteria: small (less than 5 cm) ovary(ies), bilateral ovarian involvement, deep myometrial invasion, vascular invasion, and tubal lumen involvement. Twelve cancers were classified as independent neoplasms, primarily by the absence of the above criteria. Although they were classified as independent, the histologic features of the endometrial and ovarian tumors were the same in 11 of these 12 cases. Only one case represented an ovarian primary tumor with an endometrial metastasis. Both the group believed to have endometrial primaries with ovarian metastases and that with independent primaries showed high incidences of associated endometrial hyperplasia, supporting the belief that the endometrium is a primary site in both groups. The cancers classified as metastatic, with no known spread outside the endometrium-myometrium and ovary, were found to involve other sites significantly (P less than 0.01) more frequently than those classified as independent. Grade 3 endometrioid carcinoma, adenosquamous carcinoma, and malignant mixed müllerian tumors occurred only in the metastatic group, whereas the independent group had a variety of endometrioid and nonendometrioid tumors.

On the histogenesis and morphology of ovarian carcinomas

The modern classification of ovarian tumors based on histogenetic principles is clinically important in the evaluation of prognosis and differential therapy. Ninety percent of malignant ovarian tumors belong to the category of "common carcinomas." All of these tumors originate from the coelomic epithelium at any of various stages of its differentiation into the derivatives of the Müllerian duct, giving rise to a large group of tumors that can be subdivided into serous papillary cyst-adenocarcinomas arising from surface-like epithelium, mucinous cystadenocarcinomas arising from endocervical-like epithelium, endometrioid carcinomas from endometrium-like epithelium, clear-cell carcinomas from endocervical or endometrium-like epithelium, malignant cystadenofibromas from undetermined pluripotent Müllerian epithelium, and (malignant) Brenner tumors from heterotopic epithelium resembling Wolffian differentiation, as seen in the urothelium. The well differentiated stages of these carcinomas can be readily distinguished by comparing them with the derivates of the Müllerian epithelium. The poorly differentiated types, on the other hand, may provide no criteria for comparison, but can still be classified as belonging to the group of common epithelial tumors. Adenocarcinomas of one type may also contain portions of another related type, e.g., serous papillary carcinomas may contain mucinous glands or groups of clear cells and vice versa. Serous papillary carcinomas form the largest group containing about 50% of all ovarian carcinomas. The endometrioid carcinomas comprise roughly 20%, the mucinous carcinomas 10%, and the VXGHb-cell carcinomas roughly 10%. Five percent of all carcinomas are unclassifiable and the remaining 5% constitute the group of rare ovarian carcinomas: the malignant cystadenofibromas, adenosarcomas, malignant mesenchymal mixed tumors, and malignant Brenner tumors. The three main groups can be histologically subdivided into three grades: those of high, moderate and poor differentiation. In addition, a borderline tumor representing a pre-stage of invasion and metastasis has been recognized. The prognosis with serous papillary carcinomas is poor, with an overall 5-year survival rate of 20%; the 5-year survival rate for mucinous carcinomas is 40%-60%, for endometrioid carcinomas 55%, and for clear-cell carcinomas 40%. Statistically significant data for predicting the prognosis for rare carcinomas are not available.

Atypical endometrioid cystadenofibroma with Meigs' syndrome: ultrastructure and S-phase fraction

A case of an ovarian endometrioid cystadenofibroma with epithelial atypia and Meigs' syndrome is described. The patient had a large pleural effusion that resolved rapidly after extirpation of the tumor. The S-phase fraction, measured by in vitro incorporation of tritiated thymidine, was extremely low, suggesting that this unusual tumor has a limited growth potential despite its atypical features. Ultrastructurally, the epithelial component has few features described in other ovarian endometrioid tumors. The cells have deeply clefted nuclei and numerous secondary cytolysosomes, features more commonly seen in Brenner tumors; the morphologic similarities may reflect a low epithelial turnover rate. Despite a review of the literature and an analysis of the case, the authors were unable to determine the pathogenetic mechanism of Meigs' syndrome.

Ultrastructure of clear cell carcinoma of the ovary. Case report and review of the literature

The fine structure of an ovarian clear cell carcinoma in a 65 year old woman was analysed. The tumor cells were of both clear and "hobnail" types. Both were characterized by the presence of short microvilli, abundant glycogen granules, a well-developed granular endoplasmic reticulum and Golgi apparatus, scanty lysosomes and very few lipid bodies. The tubules and gland-like spaces were always separated from the stroma by a basement membrane. At ultrastructural level the tumor cells do not resemble at all those of cleaar cell renal carcinomas. On the other hand, their submicroscopic features are strongly similar to those of the clear cell tumors found elsewhere in the female genital tract, emphasizing therewith their very probable müllerian origin. It is recommended to eliminate the term "mesonephroma ovarii" to designate the clear cell carcinomas of the ovary.

Significance of squamous components in endometrioid carcinoma of the ovary

Forty-nine cases of ovarian endometrioid carcinoma with squamous foci were reviewed. Of particular interest was the biologic behavior of the neoplasms in relation to the appearance of the epithelium. As previously noted for the analogous uterine endometrial tumors, the ovarian adenosquamous lesions occurred later in life, were more advanced, were associated with less differentiated adenocarcinomatous components, and had a poorer prognosis. The five-year survival rate for patients with adenosquamous endometrioid ovarian carcinoma was 21% in comparison with the 90% survival found in patients with ovarian endometrioid adenocanthoma.

Pathology of mucinous ovarian cystadenomas. 2. Ultrastructural findings

Fourteen mucinous ovarian cystadenomas of different grades of malignancy (7 benign, 4 borderline and 3 malignant) were investigated by electron microscopy. The main tumour cell type was a columnar mucous epithelial cell with short microvilli. With increasing grade of malignancy the shape and size of these cells became more irregular and the number of mucous granules in them decreased. Most of the mucous granules had a dense core and a less dense reticular component, which stained well with the periodic acid-silver methenamine (PASM) technique. Goblet cells with the usual ultrastructure were found rather frequently. The tumours in a given group of malignancy were relative similar to each other in their light and electron microscopic appearance. However, a number of tumours contained argyrophil and argentaffin cells in addition to the columnar and goblet cells. The findings of the present study support the view that the mucinous ovarian cystadenomas arise from the ovarian surface epithelium via a metaplastic process.

The ultrastructural morphology of gynecologic neoplasms

Our knowledge of the morphology and pathogenesis of malignant neoplasms of the female genital tract has traditionally depended heavily on their light microscopic characteristics. The introduction of transmission, and most recently, scanning electron microscopy, into the field of gynecologic pathology has resulted in a considerable improvement in the diagnosis of genital cancers that are difficult to classify and has provided valuable information for a better understanding of their subcellular dynamics and pathogenetic development. This paper describes and illustrates the ultrastructural alterations that are considered specific for the most common malignant and potentially malignant neoplasms of the genital system in this context. The value of electron microscopy in the morphologic study of genital cancers warrants its increased use in routine diagnostic pathology, as well as further evaluation of it in basic research in this challenging area of investigation.