Functional ovarian tumors of stromal and sex cord origin

Brenner Tumor of the Ovary in a Patient With Postmenopausal Bleeding: A Case Report

Brenner tumors are ovarian epithelial tumors that can be benign, borderline, or malignant. This report highlights a case of a patient with postmenopausal bleeding and elevated estradiol associated with a Brenner tumor. A 59-year-old woman, menopausal for seven years, presented with postmenopausal bleeding for the past month. An ultrasound done four years prior to presentation revealed a right adnexal mass likely to be a fibrous lesion. An office endometrial biopsy done at the time of presentation showed a weakly proliferative endometrium. The patient was then prescribed a course of medroxyprogesterone acetate therapy. Because of persistent bleeding, the patient was scheduled for a hysteroscopy and dilation and curettage. An exam under anesthesia confirmed a firm, palpable mass in the right adnexa and a normal uterine cavity. Endometrial curetting indicated proliferative endometrium. After hysteroscopy and biopsy, a pelvic sonogram showed a 5.8 x 4.3 x 4.2 cm solid right adnexal mass. Serum estradiol was measured at 137.0 pg/mL. The patient was then scheduled for a laparoscopic hysterectomy with bilateral salpingo-oophrectomy, with final pathology of the right adnexal mass revealing a Brenner tumor. The patient had an uncomplicated postoperative course. Patients with persistent postmenopausal bleeding require further evaluation; if not caught early, postmenopausal estrogen production by tumors may be associated with concomitant endometrial cancer.

Evidence that Leydig cells in Sertoli-Leydig cell tumors have a reactive rather than a neoplastic profile

BACKGROUND

Leydig cells are a variable and an inconstant feature of Sertoli-Leydig cell tumors (SLCT). Controversy exists regarding their neoplastic versus reactive nature, and their molecular biologic profile is unknown.

METHODS

Six SLCT and one pure Leydig cell tumor were studied. Mitotic counts and immunohistochemistry for Ki-67 were performed in all cases. Leydig cells, neoplastic tissues, and normal nonneoplastic tissues were microdissected. DNA extracts of these samples were assessed for loss of heterozygosity (LOH) by polymerase chain reaction amplification with ten polymorphic DNA markers that have shown high rates of LOH in a variety of human tumors. Three SLCT and the Leydig cell tumor were assessed for clonality by examining the DNA methylation pattern at a polymorphic site on the androgen receptor gene.

RESULTS

Leydig cells in SLCT had a low mitotic count (0-1/50 high-power fields [HPF]) compared with the neoplastic stroma (median, 40/50 HPF). Ki-67 was positive in < 2% of Leydig cells in all SLCT, compared with a median of 7% in the neoplastic stroma. Clonality analysis confirmed the monoclonality of the neoplastic cells in the Leydig cell tumor. However, the Leydig cells from three SLCT were polyclonal, whereas the monoclonal nature of the neoplastic Sertoli tubules was confirmed in one of these cases and that of mucinous heterologous elements in another case. The Leydig cell tumor showed LOH at four of the eight loci evaluated. Leydig cells from five SLCT were evaluated: one showed LOH at one locus, two showed LOH at two loci, and the remaining two showed no LOH.

CONCLUSIONS

The demonstration that Leydig cells from SLCT are polyclonal strongly suggests that they are nonneoplastic in nature. This is supported by a low proliferation fraction and a lower fraction of LOH compared with the truly neoplastic Leydig cells.

Adult-type granulosa cell tumor, presenting as extraovarian metastases: ultrastructural diagnosis

All granulosa cell tumors have the potential to recur locally or metastasize, in spite of apparent complete surgical excision. Long-term follow-up is particularly important in these tumors, since recurrences may occur many years after the initial diagnosis. This report highlights the ultrastructural findings that led to the diagnosis of metastatic granulosa cell tumor in two patients presenting with extraovarian masses. In patient 1 the information about an ovarian granulosa cell tumor removed 9 years before the current admission was obtained only after the metastatic tumor was correctly diagnosed. In patient 2 the ovarian primary was found after abdominal wall involvement by granulosa cell tumor was diagnosed. Thus, in both cases the clinical circumstances were atypical and electron microscopic examination of the tumors was essential to make the diagnosis of granulosa cell tumor with confidence. Based on the features observed in these two extraovarian tumors as well as eight other primary ovarian granulosa cell tumors from our files, a consistent ultrastructural profile is identified that can be very useful for diagnosis.

A testosterone-producing tumour in the mesovarium

An androgen-secreting adnexal tumour is presented. The tumour was a steroid cell tumour of the mesovarium, without crystals of Reinke, hence the diagnosis was a steroid cell tumour (lipid cell tumour), not otherwise specified (in this case, because of its location in the mesovarium, an adrenal rest tumour). The clinical presentation, diagnosis, prognosis and differential diagnosis of virilizing adnexal tumours are discussed.

Bilateral stromal Leydig cell tumour of the ovary. Case report and literature review

The stromal Leydig cell tumour of the ovary is a very rare benign neoplasm which usually occurs in postmenopausal women. Due to a significant production of androgens by the tumour, it is frequently associated with symptoms of virilization. To our knowledge only 7 cases have been reported in the literature, one of them with bilateral manifestation. We report an additional case affecting both ovaries in a 59-year-old nun with long-standing virilism, review the literature, and discuss the histomorphological features for differential diagnosis.

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.

AFP-producing Sertoli-Leydig cell tumor of the ovary

A tumor of the right ovary in a 21-year-old single woman is reported. Secondary amenorrhea, hirsutism, acne and deepening of the voice were associated with the tumor. Light and electron microscopic examinations showed that the tumor was composed of cells resembling Sertoli and Leydig cells of the testis in their cytology features and growth patterns. High levels of circulating dehydroepiandrosterone, androstenedione, testosterone and alpha-fetoprotein (AFP) were found preoperatively. Preoperative estrogen and progesterone levels were all slightly above the upper limits of normal for females. These hormone and AFP levels fell to within the normal range after removal of the tumor. Direct hormone and AFP production of this tumor was confirmed by immunohistochemical techniques and long-term cell cultures in vitro. This is possibly the first report on a Sertoli-Leydig cell tumor in which AFP has been identified in the patient's plasma, in part of the tumor cells and the culture fluid.

Sex cord-stromal tumours of the ovary

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

Massive edema of the ovary associated with hydrothorax and ascites

A 29-year-old woman with massive edema of the ovary which was grossly mistaken for neoplasia because it was associated with large volumes of both pleural effusion and ascites is described. The ovarian mass measured 10 X 10 X 8 cm and weighed 850 g. Total hysterectomy and bilateral salpingo-oophorectomy were performed. Microscopically, the ovary consisted of diffusely edematous stroma enveloping nests of hyperplastic theca cells or showing a loose myxomatous contexture. However, no endocrine activity of the ovary was demonstrated on the basis of laboratory endocrine values obtained by radioimmunoassay techniques.

Ultrastructure and immunohistochemical localization of estradiol in three thecomas

Three ovarian thecomas were studied by ultrastructural and immunohistochemical techniques. In each tumor, a small number of tumor cells stained for estradiol. Vacuolated as well as plump non-vacuolated tumor cells were positive, but spindle-shaped cells were negative. Ultrastructural examination showed two principle cell types. Type I cells were immature mesenchymal cells that differed from typical steroid-secreting cells because only a minority had conspicuous smooth endoplasmic reticulum, although mitochondria often had tubular cristae. Type II cells were distinguished by abundant intermediate (10-nm) microfilaments and round mitochondria with incomplete cristae and empty centers. Focal smooth muscle differentiation was present in each tumor. Adherens-type intercellular junctions, including desmosomes in one case, and degenerate cells with markedly vesiculated cytoplasmic membrane systems were also present. Lipid was not abundant, but it was more conspicuous in degenerate cells and in type II cells. Thecoma cells thus closely resemble both ovarian stromal cells and theca interna cells, which are known to be capable of steroidogenesis. The localization of estradiol in a minority of tumor cells in each thecoma suggests that thecoma cells, too, are capable of steroid synthesis and supports the popular concept that hyperestrogenism in patients with thecomas may be the result of estradiol secretion by these tumors.

Partly luteinized theca cell tumor of the ovary

The partly luteinized theca cell tumor is a variant of the theca cell tumor in which extensive foci of luteinization occur. This neoplasm belongs to a set of tumors, which includes the theca cell tumor, that is believed to be derived from mature ovarian stroma. This tumor can be classified as a tumor of specialized gonadal stroma of "ovarian cell type" intermediate between the theca cell tumor and the stromal luteoma. Two patients were virilized, and one had evidence of endometrial hyperplasia, whereas in the fourth no endocrine function was evident. None of the patients were pregnant at the time of discovery of the tumor. On gross examination these tumors consisted of a mixture of firm gray-white and yellow tissue. The presence of multiple yellow nodules in two tumors distinguished it from the usual theca cell tumor. A third tumor was distinctly lobulated. The tumor in only one of the cases arose in a background of ovarian stromal hyperplasia. Although the number of cases reported up to now is small and variability exists, the tumors tend to occur in patients in the early reproductive age group, often produce significant quantities of steroid hormones, and the clinical course has been benign.

Sertoli cell and sertoli-Leydig cell tumors of the ovary. A report of three cases with ultrastructural findings

Three tumors of the ovary containing Sertoli cells were studied by light and electron microscopy. Two of these tumors were well-differentiated neoplasms with epithelial cells often forming tubules. These cells were cylindrically shaped, contained round to oval nuclei and stood on a thin basement membrane. The cytoplasm was fibrillary and showed rough and smooth endoplasmic reticulum, lipid droplets and secretory granules. At the luminal borders the cells were often irregular and displayed apocrine-like activity. Having compared our data with results of studies from the literature of normal Sertoli cells, Sertoli cell adenomas of the testis and cells from other parts of the male reproductive system and those of normal ovarian stroma, we conclude that the Sertoli cell is most probably the cell of origin of these tumors. The third tumor was undifferentiated with a sarcomatoid appearance and contained islands of cartilage, which we consider to be metaplastic.

The pathological assessment of ovarian neoplasms. IV: The sex cord-stromal tumours

All neoplasms of the ovary encountered in a 25-yr study period at the King George V Memorial Hospital were classified according to the World Health Organisation (WHO) Histological Classification of Ovarian Tumours. Of just less than 1700 tumours, 168 fell into the category designated as sex cord-stromal tumours, this report analysing their major clinical and pathological correlates. A detailed histological assessment is then presented, including 4 cases of the recently separated subcategory of sclerosing stromal tumour of the ovary.

Sclerosing stromal tumours of the ovary

Sclerosing stromal tumours of the ovary have recently been described as a histologically and clinically distinct subgroup within the thecoma-fibroma spectrum of benign ovarian sex cord stromal tumours. Reported cases occurred predominantly in young women and only occasional tumours showed evidence of hormonal activity. The present series of five cases expands the spectra of both histological patterns and clinical presentations and suggests that the entity of sclerosing stromal tumours may not be as clearly circumscribed as has been previously reported.

Ovarian sex cord tumor with annular tubules. Clinicopathologic report of two benign and one malignant cases with long follow-ups

The clinicopathologic features of three new cases of ovarian sex cord tumors with annular tubules are presented, thereby increasing to 23 the number of the published cases in the world literature. These three observations, along with another one which was previously published, were found in the files of the Institute of Pathology of the University of Lausanne from 1939 to 1978. Forty-seven granulosa cell tumors and eight Sertoli and/or Leydig cell tumors of the ovary were found during the same 40-year period. The patients were 48, 64 and 71 years of age. No sign of the Peutz-Jeghers syndrome was noticed in the three patients. All three tumors caused metrorrhagias as a cardinal sign. They were bulky, unilateral and were formed by solid tissue with cystic spaces. Histologically, the most characteristic pattern consisted of simple and complex tubular structures as described by Scully in 1970. Two patients, in which the mitotic indexes of the tumors were lower than 5 mitoses per 10 HPF, died without evidence of a recurrence 36 and 37 years after surgical ablation of the tumor. The third patient, whose neoplasm featured fewer well differentiated tubular structures than the two previous ones and had a mitotic index of over 70 mitoses per 10 HPF, died from massive abdominal recurrence after 5 years and 5 months.