Ovarian strumal carcinoid with severe constipation: immunohistochemical and mRNA analyses of peptide YY

Clinical characteristics and survival outcomes in patients with primary ovarian carcinoid: A historical cohort study

INTRODUCTION

Primary ovarian carcinoids are extremely rare ovarian tumors, and there is limited data available on their clinical characteristics and survival outcomes.

MATERIAL AND METHODS

We conducted a historical cohort study of 56 patients to investigate their clinical characteristics. The overall survival, disease-specific survival, recurrence-free survival, and potential prognostic factors of these patients were also evaluated.

RESULTS

The median age of these patients was 42.0 years (range: 20-71). The average mass and carcinoid size was 7.3 and 0.4 cm, respectively. Elevated tumor marker levels and ascites were observed in 15 and 10 patients, respectively. In 98.2% of the patients, tumors were confined to the ovary, while only one had metastatic disease. Surgery was the mainstay therapy: 37.5% of the patients underwent unilateral salpingo-oophorectomy, 25.0% underwent hysterectomy with bilateral salpingo-oophorectomy, 21.4% underwent ovarian cystectomy, 10.7% underwent comprehensive staging surgery, and 5.4% underwent bilateral salpingo-oophorectomy. Appendectomy and lymphadenectomy were performed in eight and five patients, respectively, but none showed tumor involvement. Chemotherapy was the only adjuvant treatment utilized, and was administered in four patients. Pathological analysis showed that strumal carcinoid was the most predominant subtype, occurring in 66.1% of the patients. The Ki-67 index was reported in 39 patients, 30 of which had an index of no more than 3%, with a maximum of only 5%. Only one relapse occurred after the initial treatment, and that patient experienced recurrences on two occasions, maintaining stable disease after surgery and octreotide therapy. After a median follow-up of 3.6 years, 96.4% of the patients achieved no evidence of disease, while 3.6% were alive with the disease. The 5-year recurrence-free survival rate was 97.9% and no death occurred. No risk factors for recurrence-free survival, overall survival, or disease-specific survival were identified.

CONCLUSIONS

The Ki-67 indices were extremely low and prognoses were excellent in patients with primary ovarian carcinoids. Conservative surgery, especially unilateral salpingo-oophorectomy, is preferred. Individualized adjuvant therapy may be considered for patients with metastatic diseases.

Clinical characteristics and survival outcomes in patients with ovarian strumal carcinoid

BACKGROUND

Ovarian strumal carcinoid is an extremely rare ovarian malignant tumor with limited data on clinical characteristics and survival outcomes.

METHODS

A retrospective study of 119 patients was conducted, including 98 cases identified from literature review, and their clinical characteristics were investigated. The overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and potential prognostic factors of these patients were also evaluated.

RESULTS

Lesions of 115 cases were confined to the ovarian while four patients presented with extra-ovarian disease upon initial diagnosis. Surgical treatment options performed in this cohort varied, 5.0% received ovarian cystectomy, 36.1% received unilateral salpingo-oophorectomy (USO), 7.6% received bilateral salpingo-oophorectomy (BSO), 42.0% received hysterectomy with BSO, and 8.4% underwent debulking surgery. Moreover, one patient did not undergo any surgery. No postoperative adjuvant therapy was administered in 89.9% patients, while 7.6% and 2.5% received adjuvant radiotherapy and chemotherapy, of which two patients received combined radiation and chemotherapy. At the final follow-up, 89.1% patients showed no evidence of the disease, and 5.0% were alive with the disease. Only seven deaths occurred, with two attributed to the tumor. The 5-year, 10-year, and 20-year OS rates were 96.0%, 85.0%, and 85.0%, respectively, with a 15-year recurrence rate of 4.4%. The 5-year and 20-year DSS rate were 98.5% and 95.9%. Multivariate Cox regression showed age ≥ 55 years was the only risk factor associated with the OS (P = 0.014, OR 7.988; 95% CI 1.519 - 42.004). However, the univariate and multivariate Cox regression showed no potential risk factor for RFS and DSS.

CONCLUSION

Patients with ovarian strumal carcinoid have an excellent prognosis irrespective of the surgical option. Conservative surgery especially USO with individualized adjuvant therapy is recommended.

Ovarian Strumal Carcinoid: Case Report, Systematic Literature Review and Pooled Analysis

BACKGROUND

Ovarian strumal carcinoid is a rare tumor in which thyroid (struma) and carcinoid components coexist. The disease is generally considered to be a borderline malignancy, however, cases with metastatic disease have been described. No data in the literature are available to guide diagnosis and therapy.

METHODS

We performed a pooled analysis and a systematic review of histopathological-confirmed strumal carcinoid cases published in the literature using the following keywords: "strumal carcinoid of the ovary", "strumal carcinoid case report". A case of strumal carcinoid tumor diagnosed and followed-up at the Medical Oncology Unit of Spedali Civili (Brescia, Italy) was also described and included.

RESULTS

Sixty-six eligible publications were identified, providing data from one hundred and seventeen patients, plus a case diagnosed at our institution. At presentation, among the eighty-eight patients with symptomatic disease, 37% of patients suffered from abdominal distention and 49% from pain due to a growing abdominal tumor mass, 37% from constipation (peptide YY was analyzed in only nine of them, resulting above the physiologic range). Surgery was the primary therapy in 99% of the patients. Three patients had metastatic disease at diagnosis and five patients underwent recurrence after radical surgery. Histology at disease recurrence concerned the thyroid component in two patients, the carcinoid component in two patients, both histologies in one patient. Median disease-free survival and overall survival in this series were not attained.

CONCLUSION

Strumal carcinoid of the ovary generally presents a benign behavior and surgery is curative in most cases. However, a small group of patients with this disease can undergo disease recurrence due to both the thyroid and the neuroendocrine (carcinoid) components. A follow-up in radically operated patients is therefore needed, particularly in those with a voluminous disease at diagnosis.

Clinical Approach to Neuroendocrine Neoplasm Associated With Ovarian Teratoma

BACKGROUND

Neuroendocrine neoplasms are a heterogeneous group of cancers that develop from enterochromaffin cells of the diffuse endocrine system, with an increase in incidents over the last years. Ovarian neuroendocrine tumors (NET) are rare neoplasms, comprising 0.1% of all ovarian neoplasms and less than 5% of all neuroendocrine tumors. They may arise alone (as monodermal, specialized teratoma - ovarian carcinoid) or as a part of other ovarian lesion: cystic mature or immature teratomas. Due to the rarity and limited amount of such cases reported in the literature, there is no consensus on diagnostic and therapeutic procedures in this group of patients.

MATERIALS AND METHODS

The group of 10 patients at the age of 19 to 77 years (mean 42.8 ± 17.9), diagnosed with unilateral NET within ovarian teratoma were analyzed. The histopathological type of tumor, progression free survival after surgical treatment and presence of hormonally active syndrome were assessed.

RESULTS

70% (n=7) of patients was diagnosed with mature cystic teratomas containing NET component and 30% (n=3) with monodermal teratoma (strumal carcinoid). All cases of monodermal teratomas were found in women at premenopausal age. Determined Ki67 ranged from 2% to 9%. Ninety percent of lesions (n=9) stained positive for synaptophysin and chromogranin, while markers: CK20, CK7, TTF-1 and CDX2 were negative in all cases, which ruled out their metastatic nature. None of the patients presented with carcinoid syndrome. All followed-up patients remain progression-free, which confirms surgical intervention being a crucial and sufficient method of treatment.

CONCLUSIONS

The prognosis and clinical behavior of NETs associated with ovarian teratomas are good with long progression-free survival.

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 tumours of the female genital tract: a case-based imaging review with pathological correlation

Background

Both primary and secondary gynaecological neuroendocrine (NE) tumours are uncommon, and the literature is scarce concerning their imaging features.

Methods

This article reviews the epidemiological, clinical and imaging features with pathological correlation of gynaecological NE tumours.

Results

The clinical features of gynaecological NE tumours are non-specific and depend on the organ of origin and on the extension and aggressiveness of the disease. The imaging approach to these tumours is similar to that for other histological types and the Revised International Federation of Gynecology and Obstetrics (FIGO) Staging System also applies to NE tumours. Neuroendocrine tumours were recently divided into two groups: poorly differentiated neuroendocrine carcinomas (NECs) and well-differentiated neuroendocrine tumours (NETs). NECs include small cell carcinoma and large cell neuroendocrine carcinoma, while NETs account for typical and atypical carcinoids. Cervical small cell carcinoma and ovarian carcinoid are the most common gynaecological NE tumours. The former typically behaves aggressively; the latter usually behaves in a benign fashion and tends to be confined to the organ.

Conclusion

While dealing with ovarian carcinoids, extra-ovarian extension, bilaterality and multinodularity raise the suspicion of metastatic disease. NE tumours of the endometrium and other gynaecological locations are very rare.

Teaching Points

• Primary or secondary neurondocrine (NE) tumours of the female genital tract are rare.

• Cervical small cell carcinoma and ovarian carcinoids are the most common gynaecological NE tumours.

• Cervical small cell carcinomas usually behave aggressively.

• Ovarian carcinoids tend to behave in a benign fashion.

• The imaging approach to gynaecological NE tumours and other histological types is similar.

Case of peptide-YY-producing strumal carcinoid of the ovary: a case report and review

Ovarian carcinoid is a rare tumor accounting for approximately 0.1% of all ovarian malignancies. We describe a case of peptide-YY-producing strumal carcinoid of the ovary associated with severe constipation. A 48-year-old woman was found to have a pelvic mass on ultrasonography when she visited her primary doctor for a health check-up. She was thus referred to our department. Magnetic resonance imaging revealed a solid right ovarian tumor 60 × 50 mm in size. The patient underwent a right adnexectomy and was histopathologically diagnosed as having strumal carcinoid of the ovary. On immunohistochemical examination, the tumor cells were positive for peptide YY. The patient's constipation resolved rapidly after surgery. Based on her clinical course, her constipation was considered to have been caused by the strumal carcinoid of the ovary. The clinical course of this case supports the previously recognized correlation between peptide-YY-producing ovarian carcinoid and constipation.

Ovarian strumal carcinoid presenting as severe progressive constipation

Strumal carcinoid develops in a germ cell tumor characterized by an intimate mixture of thyroid and carcinoid. Unlike other carcinoid tumors, most patients with strumal carcinoid have no symptoms of carcinoid syndrome; few are reported to cause severe constipation.

We report a case of a 60-year-old female patient presenting with severe progressive constipation and painful defecation for last few years. A right ovarian tumor was discovered during clinical examination. CT scan revealed a large lobulated solid cystic right adenexal mass suggestive of monomorphic teratoma, which was successfully removed surgically. The histopathology confirmed the diagnosis of strumal carcinoid tumor. Her constipation completely disappeared post surgery. These tumors are known to produce a biologically active substance like peptide YY, which has a pharmacologic inhibitory action on intestinal motility. This was presumably the cause of the constipation in this patient rather than a mechanical effect of the tumor.

NPY Y2 receptor agonist PYY(3-36) inhibits diarrhea by reducing intestinal fluid secretion and slowing colonic transit in mice

Peptide YY (PYY)(3-36), a neuropeptide Y (NPY) Y2 receptor agonist, is a powerful inhibitor of intestinal secretion. Based on this anti-secretory effect, NPY Y2 receptor agonists may be useful as novel anti-diarrheal agents, but anti-diarrheal efficacy has yet to be determined. We therefore examined the anti-diarrheal efficacy of PYY(3-36) and a selective Y2 receptor agonist, N-acetyl-[Leu28, Leu31]-NPY(24-36), in experimental mouse models of diarrhea. Intraperitoneal administration of PYY(3-36) (0.01-1mg/kg) and N-acetyl-[Leu28, Leu31]-NPY(24-36) (10mg/kg) significantly inhibited diarrhea (increase in wet fecal weight and diarrhea score) induced by dimethyl-prostaglandin E2, 5-hydroxytryptamine, and castor oil. Anti-diarrheal activities of PYY(3-36) and N-acetyl-[Leu28, Leu31]-NPY(24-36) were comparable to the effects of loperamide (1mg/kg), a widely used anti-diarrheal drug. To clarify the anti-diarrheal mechanisms of NPY Y2 receptor agonists, we investigated the effects of PYY(3-36) and N-acetyl-[Leu28, Leu31]-NPY(24-36) on intestinal fluid secretion and colonic transit. PYY(3-36) (1mg/kg) and N-acetyl-[Leu28, Leu31]-NPY(24-36) (10mg/kg) significantly reduced dimethyl-prostaglandin E2-induced intestinal fluid accumulation in conscious mice, suggesting that NPY Y2 receptor agonists inhibit diarrhea, at least in part, by reducing intestinal secretion. In addition, PYY(3-36) (0.01-1mg/kg) and N-acetyl-[Leu28, Leu31]-NPY(24-36) (10mg/kg) potently inhibited normal fecal output, suggesting that NPY Y2 receptor activation inhibits colonic motor function and NPY Y2 receptor agonists inhibit diarrhea partly by slowing colonic transit. These results indicate that NPY Y2 receptor agonists inhibit diarrhea in mice by not only reducing intestinal fluid secretion, but also slowing colonic transit, and illustrate the therapeutic potential of NPY Y2 receptor agonists as effective treatments for diarrhea.

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.

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.

Malignant struma ovarii mimic clear cell carcinoma

INTRODUCTION

Struma ovarii are quite unusual lesions that represent less than 3% of all teratomas and its malignant transformation is very uncommon. The clinical manifestations are characteristic of pelvic tumor and the hormonal metabolism is not usually modified. Radiography, employing ultrasound procedures, is the most commonly used pre-surgical detection method but only histological examination makes the diagnosis. The malignance recognition by pathological study not always is easy; in this sense, it requires an exhaustive sampling of the lesion, being specially carefully in some aspects related with malignant transformation such as extending beyond the capsula and involving peripheral tissues. A thyroidal differentiation must be confirmed by immunohistochemical study and other local processes with similar histology should be ruled out. Given the exceptional character of malignant forms, there does not appear to be unanimous agreement on a standard therapy with a somewhat uncertain prognosis.

CASE REPORT

We show a case of a 22-year-old patient with an ovarian tumor that was discovered by ultrasound examination and surgically removed. The histologic study revealed struma ovarii with malignant transformation towards follicular carcinoma and unlike previously published cases, had a prevalence of clear cells. The patient was submitted to a second surgical staging intervention, with conservative surgery and follow-up controls being considered given that was a young woman with a desire to have children. Laparoscopy was employed as the best method capable to facilitate shorter convalescence.

OUTCOME

Clinical and analytical controls, measuring thyroglobulin levels, has been satisfactory up to the present.

Carcinoid--a comprehensive review

Carcinoid tumors originate from the neuroendocrine cells throughout the body and are capable of producing various peptides. Their clinical course is often indolent but can also be aggressive and resistant to therapy. We examined all aspects of carcinoid tumors including the molecular biology oncogenesis, role of angiogenesis, recent advances in imaging, and therapy. The Medline and Cancerlit databases were searched using carcinoid as the keyword. English language manuscripts were reviewed and relevant references from a total of 7741 were found. All titles were screened and all the relevant manuscripts were analyzed; we found 307 references pertinent to the history, epidemiology, clinical behavior, pathology, pathophysiology, molecular biology, radiologic imaging, supportive care of carcinoid syndrome, and results of therapeutic clinical trials. Management of patients with carcinoid tumors requires an understanding of the disease process and a multimodality approach. Introduction of long-acting somatostatin analogues has resulted in significant advances in the palliative care of patients with carcinoid syndrome. However, advanced carcinoid tumor remains incurable. Existing therapies for advanced disease have low biologic activity, high toxicity, or both. Clearly, more research is necessary in the areas of molecular biology, targeted therapy, and development of new drugs Future advances in this field need to focus on clinical and biological predictors of outcome. Early works in the area of tumor biology such as the role of p53, bcl-2, bax, MEN1, FGF TGF PDGF and VEGF expression are of interest and need to be explored further.

Ovarian carcinoid exhibiting double function

A case of a 58-year-old woman with ovarian carcinoid exhibiting double function is reported. She had suffered from constipation and hirsutism before surgery. Pathological examination revealed that many carcinoid tumor cells were immunohistochemically positive for peptide YY, which inhibits intestinal motility and many peripheral steroid cells. After surgery the patient recovered from constipation immediately. Although the serum level of testosterone also immediately decreased, hirsutism remained for about 2 years. These clinical manifestations are considered to be due to peptide hormone-producing tumor parenchymal cells and testosterone-producing functioning stromal cells. This is the first report of clinically manifested double-functioning ovarian carcinoid; one function is due to tumor cells themselves and another function is due to stromal cells.

Strumal carcinoid tumor of the ovary: a case exhibiting severe constipation associated with PYY

BACKGROUND

Primary carcinoid tumor of the ovary is uncommon and represents less than 0.1% of ovarian malignancy. Recently, it was reported that the strumal carcinoid tumor may be complicated by severe constipation as one symptom of the carcinoid syndrome.

CASE

A 50-year-old nulliparous woman complained of persisting constipation and abdominal distention with pelvic mass, raising the possibility of ovarian tumor. The sugically resected tumor was diagnosed as strumal carcinoid tumor. Her long-lasting severe constipation completely disappeared after tumor removal but recurred with recurrent hepatic disease. The tumor cells were positive for PYY, a peptide hormone that has a strong inhibitory effect on intestinal motility, by immunohistochemical stain.

CONCLUSION

Our case provides the more convincing information to indicate that PYY protein, produced by ovarian tumor cells in the trabecular carcinoid component, may be associated with severe constipation.

Peptide YY and cancer: current findings and potential clinical applications

Peptide YY (PYY) is a naturally occurring gut hormone with mostly inhibitory actions on multiple tissue targets. PYY has been identified in several carcinoid tumors and a decreased expression of PYY may be relevant to the development and progression of colon adenocarcinoma. Treatment with PYY decreases growth in pancreatic and breast tumors, most likely through a reduction in intracellular cAMP. In cancer patients, PYY may also improve malnutrition that results from iatrogenic causes or cachexia associated with advanced disease. PYY plays a significant role in multiple aspects of cancer from regulation of cell growth to potential therapeutic applications.

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.