A clinicopathologic analysis of atypical proliferative (borderline) tumors and well-differentiated endometrioid adenocarcinomas of the ovary

High-grade Serous Carcinoma can Show Squamoid Morphology Mimicking True Squamous Differentiation

Tubo-ovarian high-grade serous carcinoma (HG-SC) and ovarian endometrioid carcinoma (EC) can show overlapping morphologic features, such as glandular and solid patterns. The differential diagnosis of these subtypes is thus sometimes difficult. The existence of "squamous differentiation" tends to lead to a diagnosis of EC rather than HG-SC. We noticed that HG-SC can contain a "squamoid component," but its nature has been poorly investigated. This study was thus established to clarify the nature of this "squamoid component" in HG-SC by investigating its frequency and immunohistochemical features. We reviewed hematoxylin and eosin-stained slides of 237 primary untreated cases of tubo-ovarian HG-SC and identified 16 cases (6.7%) of HG-SC with "squamoid component." An immunohistochemical staining panel (CK5/6, CK14, CK903, p40, p63, WT1, ER, and PgR) was used to analyze all of these 16 cases. We also selected 14 cases of ovarian EC with "squamous differentiation" as a control. The "squamoid component" in HG-SC was completely p40-negative and showed significantly lower expression of CK5/6, CK14, CK903, and p63 than the "squamous differentiation" in EC. The immunophenotype of the "squamoid component" in HG-SC was concordant with the conventional HG-SC component (WT1-positive/ER-positive). Furthermore, all 16 tumors were confirmed to be truly "HG-SC" by the findings of aberrant p53 staining pattern and/or WT1/p16 positivity, and the lack of mismatch repair deficiency and POLE mutation. In conclusion, HG-SC can on rare occasions show a "squamoid component" mimicking "squamous differentiation." However, the "squamoid component" in HG-SC does not represent true "squamous differentiation." The "squamoid component" is one part of the morphologic spectrum of HG-SC, which should be interpreted carefully for the differential diagnosis of HG-SC and EC. An immunohistochemical panel including p40, p53, p16, and WT1 is a useful adjunct to achieve a correct diagnosis.

Immunohistochemical Evaluation of Notch1 in Ovarian Tumours and Its Prognostic Implications

BACKGROUND

Ovarian cancer is the fifth most common malignancy among women and the second most common gynaecological malignancy. Surface epithelial ovarian tumours constitute two-thirds of all ovarian tumours. Most high-grade serous carcinoma patients gain an initial complete response but eventually succumb to relapse and death leaving the overall survival grim. Therefore, new regimens targeting the pathways involved in metastasis and chemoresistance are essential for the development of more effective therapies. Notch signalling is one of the pleiotropic signalling pathways that plays a key role in differentiation and tissue morphogenesis. It has been observed that this Notch signalling pathway is seen to be deregulated in various cancers. It is thought to have an oncogenic role in ovarian cancer. Our objective in this study is to evaluate the immunohistochemical expression pattern of Notch1 in surface epithelial ovarian tumours and its correlation with the clinicopathological profile.

METHODS

This study includes a total of 100 cases of borderline and malignant surface epithelial ovarian tumours. Clinical data of the patients were obtained from the medical records section. HPE slides were examined and one representative paraffin block was selected for each patient. IHC of Notch1 was performed and analyzed. The staining pattern for Notch1 was calculated using the Q score.

RESULTS

Immunohistochemistry (IHC) evaluation of Notch1 in surface epithelial ovarian tumours in this study showed an increased intensity of Notch1 staining in high-grade serous malignant tumours. The grading and staging of tumours were compared with Notch1 expression. Statistical analysis was performed using Spearman Rank order correlation analysis. There was a significant correlation (0.01 level, two-tailed) between the grading and staging of ovarian tumours and Notch1 expression.

CONCLUSION

Assessing Notch1 expression in ovarian cancer by IHC is a useful tool in view of its clinical applications, development of targeted therapies and as a marker of prognosis. The intensity of the Notch1 stain appears to be directly proportional to the grade of tumour. This may offer a potential targeted therapy against the Notch signalling pathway in tumours that strongly express Notch1.

Endometrioid Borderline Ovarian Tumor: Clinical Characteristics, Prognosis, and Managements

BACKGROUND

Endometrioid borderline ovarian tumor (EBOT) is a rare subtype of borderline ovarian malignancies. This study was designed to determine the prognosis of a series of EBOT.

METHODS

This is a retrospective review of patients with EBOT treated in or referred to our institutions and a centralized, histological review by a reference pathologist. Data on the clinical characteristics, management (surgical and medical), and oncologic outcomes of patients were required for inclusion.

RESULTS

Forty-eight patients were identified. Median age was 52 years (range 14-89). Fourteen patients underwent a conservative surgery and 32 a bilateral salpingo-oophorectomy (unknown in 2 cases). Two patients had bilateral tumors. Forty-three patients had stage I disease, and five patients had stage II disease (10%). Stromal microinvasion and intraepithelial carcinoma was observed in 6 (12%) and 13 (27%) patients respectively. Endometriosis was histologically associated in 12 patients (25%). Synchronous endometrial disease was found in 7 (24%) of 29 patients with endometrial histological evaluation. The median follow-up was 72 months (range 6-146). Two patients developed a recurrence after cystectomy in form of borderline disease (5%). No death related to EBOT occurred.

CONCLUSIONS

Peritoneal restaging surgery should be performed if not realized initially, because 5% of EBOTS are diagnosed at stage II-III. Fertility-sparing surgery seems a safe option in selected patients. Because synchronous endometrial diseases, including endometrial carcinoma are frequent, systematic hysterectomy (or endometrial sampling in case of fertility-sparing surgery) is mandatory. Prognosis is generally excellent. Recurrence is a rare event (6%), but it can occur in the form of invasive disease.

Diagnostic workup for endometrioid borderline ovarian tumors (eBOT) requires histopathological evaluation of the uterus

Background

For young borderline ovarian tumor (BOT) patients, preservation of the uterus was incorporated as an accepted option into treatment guidelines. For the endometrioid subtype (eBOT) however, adequate histological evaluation is challenging and might be associated with synchronous endometrial disorders or misinterpreted as spread from uterine primaries.

Case presentation

We report the cases of two young patients with eBOT who underwent treatment according to current guidelines. In both cases, unexpected findings of invasive uterine carcinomas were established in final histopathological evaluation.

Conclusions

This constellation highlights the challenging diagnostic workup of BOT and underlines that uterine curettage is indispensable for eBOT to exclude uterine primary tumors when fertility preservation is planned. Accordingly, we suggest to include this procedure into recommendations for diagnostic workup and to state the potential risk in treatment guidelines.

Primary endometrioid carcinoma of the uterosacral ligament arising from deep infiltrating endometriosis 6 years after bilateral salpingo-oophorectomy due to atypical proliferative endometrioid tumor of the ovary: a rare case report

BACKGROUND

Endometriosis can potentially lead to the development of a malignant tumor. Most malignant tumors arising from the endometriosis originate from the ovarian endometrioma, whereas those arising from extragonadal lesions are rare. We report a rare case of endometrioid carcinoma that developed from deep infiltrating endometriosis in the uterosacral ligament 6 years after treatment for atypical proliferative endometrioid tumor of the ovary in a 48-year-old woman.

CASE PRESENTATION

Six years ago, the patient underwent laparoscopic bilateral salpingo-oophorectomy for her right ovarian tumor with atypical proliferative (borderline) endometrioid tumor accompanied by ovarian endometrioma. The solid tumor in the cul-de-sac was detected during follow-up using magnetic resonance imaging. Positron emission tomography/computed tomography revealed an abnormal accumulation of ¹⁸F-fluorodeoxyglucose at the tumor site. Thus, tumor recurrence with borderline malignancy was suspected. The patient underwent diagnostic laparoscopy followed by hysterectomy and partial omentectomy. Retroperitoneal pelvic lymphadenectomy and para-aortic lymphadenectomy were also performed. The cul-de-sac tumor at the left uterosacral ligament was microscopically diagnosed as invasive endometrioid carcinoma arising from deep infiltrating endometriosis. The final diagnosis was primary stage IIB peritoneal carcinoma. The patient received six courses of monthly paclitaxel and carboplatin as adjuvant chemotherapy. The patient showed no evidence of recurrence for 2 years after the treatments.

CONCLUSION

This study reports a rare case of metachronous endometriosis-related malignancy that developed 6 years after treatment for borderline ovarian tumor. If endometriosis lesions remain after bilateral salpingo-oophorectomy, the physician should keep the malignant nature of endometriosis in mind.

[Borderline ovarian tumours: CNGOF Guidelines for clinical practice - Biopathology of ovarian borderline tumors]

OBJECTIVES

Ovarian borderline tumors (OBT) represent a heterogeneous group of lesions with specific management for each histological subtype. Thus, the correct histological diagnosis is mandatory.

MATERIAL AND METHODS

References were searched by PubMed from January 2000 to January 2018 and original articles in French and English literature were selected.

RESULTS AND CONCLUSIONS

OBT should be classified according to the last WHO classification. Any micro-invasion (foci<5mm) or microcarcinoma (foci<5mm with nuclear atypia and desmoplastic stromal reaction) should be indicated in the pathology report. In case of serous OBT, variants (classical or the micropapillary/cribriform) should be indicated (grade C). The peritoneal implants associated with OBT, should be classified as invasive or noninvasive, according to the extension into the underlying adipous tissue. If no adipous tissue is seen the term undetermined should be used (grade B). In case of mucinous OBT bilateral and/or with peritoneal implants or peritoneal pseudomyxoma a search for primitive gastrointestinal, appendiceal or biliopancreatic tumor should be performed (grade C). In case of OBT, a thorough sampling of the tumor is recommended, with 1 block/cm and 2 blocks/cm in case of mucinous OBT, serous OBT micropapillary variant, OBT with intraepithelial carcinoma or/and micro-invasion. Peritoneal implants should be examined in toto. Omentum without macroscopic lesion should be sampled in 4 to 6 blocks (grade C). In case of ovarian cyst suspicious for OBT, fine needle aspiration is not recommended (grade C). In case of ovarian tumor suspicious for OBT, intraoperative examination should be performed by a gynecological pathologist (grade C).

Ultraconservative, Fertility Sparing Treatment of Bilateral Borderline Ovarian Tumors: A Case Report of a 26-Year-Old, 0-Gravida with an Endometrioid Borderline Ovarian Tumor of the Right Ovary and a Sero-Mucinous Borderline Ovarian Tumor of the Left Ovary and a Review of the Literature

Endometrioid borderline ovarian tumors are rare, entailing a lack of data on their natural history as well as the safety of conservative and ultraconservative surgical management, especially in cases with bilateral borderline ovarian tumors including one of endometrioid differentiation. Therefore, we present such a case and provide a review of the literature on endometrioid borderline ovarian tumors. We report the case of a 26-year-old, 0-gravida with an endometrioid borderline ovarian tumor of the right and a sero-mucinous borderline ovarian tumor of the left ovary treated by fertility sparing, ultraconservative surgery with bilateral cystectomy, completed by staging procedures including omentectomy and peritoneal sampling, as well as endometrial sampling by means of curettage. Reviewing the literature and taking into account the course of our case, we propose the feasibility of an ultraconservative management, including endometrial sampling, in young patients with bilateral borderline ovarian tumors including one of endometrioid differentiation who desire to preserve fertility, followed by a closely monitored follow-up.

Pathology of Endometrioid and Clear Cell Carcinoma of the Ovary

This review is an appraisal of the current state of knowledge of 2 enigmatic histotypes of ovarian carcinoma: endometrioid and clear cell carcinoma. Both show an association endometriosis and the hereditary nonpolyposis colorectal cancer (Lynch) syndrome, and both typically present at an early stage. Pathologic and immunohistochemical features that distinguish these tumors from high-grade serous carcinomas, each other, and other potential mimics are discussed, as are staging, grading, and molecular pathogenesis.

Uncommon borderline ovarian tumours: A clinicopathologic study of seventeen patients

Objective

To evaluate uncommon types of borderline ovarian tumors (BOT) and define the clinical, surgical, and pathologic features.

Material and Methods

Seventeen patients who were treated in our hospital between 1990 and 2017 were identified. Patients’ data were collected from the gynecologic oncology clinic electronic database, patients’ files, and pathology reports. Conservative surgery was defined as preservation of the uterus and at least part of one ovary.

Results

The mean age was 47 (range, 22-70) years. Based on histopathologic tumor type, there was mixed tumor in five (29.4%) patients, endometrioid-type in nine (52.9%), seromusinous-type in two (11.8%), and Brenner-type in one (5.9%). Conservative surgery was performed in 4 patients. Two patients with endometrioid BOT had synchronous endometrial pathology, including one (11%) patient with endometrial cancer, one (11%) with endometrial hyperplasia without atypia, and 3 (33%) patients had endometriosis. The median follow-up was 19 (range, 1-137) months. No recurrence was observed during the follow-up period.

Conclusion

In our small volume case series, it could be said that non-serous/non-mucinous BOT has excellent prognosis. However, endometrial pathology should be checked in endometrioid type.

Ovarian tumors: a survey of selected advances of note during the life of this journal

The author reviews highlights of advances in knowledge concerning ovarian tumor pathology since the time of an essay in the first issue of this Journal written by Dr Robert E. Scully, who, both before and for several decades after the Journal was instituted, made many original contributions to the field and was the major architect of the 1973 World Health Organization classification of ovarian tumors which was much more clear and logical than prior ones. The current review considers the neoplasms in essentially the same order as was done in the first issue of this journal and presents a personal look at the highlights of new information concerning various well-known categories, surface epithelial, germ cell, sex cord-stromal, metastatic neoplasms and briefly, benign so-called tumor-like lesions. Some of the most notable developments are as follows: (1) an orderly approach to the classification of implants of serous borderline tumors into noninvasive and invasive categories; (2) recognition of distinctive micropapillary patterns seen in some borderline tumors and low-grade carcinomas; (3) a remarkable propensity for some endometrioid carcinomas to mimic sex cord- stromal tumors; (4) appreciation of the differences between primary mucinous tumors of intestinal and müllerian types; (5) the importance of distinguishing within primary mucinous carcinomas between expansile and destructive stromal invasion; (6) emphasis on the diagnosis of immature teratoma being based on the presence of primitive-embryonic-appearing tissues; (7) appreciation of variant morphology of cases of struma ovarii which may lead to significant diagnostic problems; (8) subdivision of granulosa cell tumors into adult and juvenile types because of the differing features of the two groups including in the second category the propensity for more malignant neoplasms to be mimicked; (9) recognition of a distinctive form of Sertoli-Leydig cell tumor, the retiform variant, with a propensity to occur in the young; (10) appreciation of a unique highly malignant neoplasm that typically afflicts the young and may be associated with hypercalcemia, so-called small cell carcinoma of hypercalcemic type; (11) greater awareness than was hitherto the case of the propensity for metastatic intestinal adenocarcinoma to mimic primary endometrioid carcinoma and similarly for metastatic mucinous carcinomas to simulate primary mucinous cystic tumors; (12) recognition of the distinctive features of low-grade appendiceal mucinous neoplasms that spread to the ovary and are typically associated with pseudomyxoma peritonei; and (13) appreciation that the histologic spectrum seen in cases of Krukenberg tumor is broader than often previously thought.

[Pitfalls and common problems in the differential diagnosis of epithelial ovarian tumors]

Epithelial ovarian tumors may cause various diagnostic problems of practical relevance. For the distinction between cystadenomas and borderline tumors/atypically proliferative tumors, a minimum extent of 10% of the atypical epithelial proliferation has been suggested by the WHO. The micropapillary variant of serous borderline tumors is more frequently associated with invasive growth and extraovarian lesions. Extraovarian lesions of borderline tumors are relevant for prognosis and cause a higher stage; their classification is crucial. Traditionally, they were classified into noninvasive and invasive implants based on their morphology. Based on the 2014 WHO classification, invasive lesions should be designated as low-grade serous carcinomas whereas only noninvasive lesions are considered implants. The most frequent invasive growth pattern in low-grade serous carcinomas consists of haphazardly arranged tumor cell nests and small papillae in clefts, whereas mucinous and endometrioid carcinomas mainly show a confluent glandular pattern with maze-like and cribriform structures. For metastatic mucinous tumors a nodular growth pattern is characteristic; ruling them out requires clinical information including imaging and immunohistochemistry. Differential diagnosis between low-grade and high-grade serous carcinoma is based on the degree of nuclear polymorphism and mitotic count. The seromucinous tumor category replaces the endocervical subtype of mucinous tumors and resembles histologically, biologically, and on the molecular level serous and endometrioid tumors. Endometrioid tumors with fibromatous stroma need to be distinguished from tumors with Sertoli cell differentiation and well-differentiated neuroendocrine tumors. For differential diagnosis of epithelial ovarian tumors, in particular carcinomas, a panel of antibodies for immunohistochemistry is very useful under consideration of histomorphology.

Intraoperative consultation for ovarian tumors

The primary function of intraoperative frozen consultation is to provide an as accurate and prompt diagnosis as possible during surgery and to guide the surgeon in further management. However, the evaluation of frozen section (FS) is sometimes difficult because of suboptimal tissue quality and frozen artifacts compared with routinely processed tissue section. The pathologist responsible for the FS diagnosis requires experience and good judgment. Ovarian tumors are a heterogeneous group of tumors including primary surface epithelial tumors, germ cell tumors and sex cord-stromal tumors, secondary tumors, and other groups of tumors of uncertain histogenesis or nonspecific stroma. Intraoperative FS is a very important and reliable tool that guides the surgical management of ovarian tumors. In this review, the diagnostic key points for the pathologist and the implication of the FS diagnosis on the operator’s decisions are discussed.

Tumors of low malignant potential a single institution experience

•

The tumors of low malignant potential are an independent group of ovarian epithelial tumors.

•

The overall survival at 5 and 10 years was respectively of 96,9% and 92,8%.

•

After a mean follow up of 10 years, we report 7 cases of locoregional relapse.

•

After conservative surgery two patients achieved full term pregnancies.

•

More studies are required for a higher grade of recommendation.

Background

The tumors of low malignant potential are an independent group of the ovarian epithelial tumors. They represents 10–20% of all ovarian epithelial tumors.

Our aim through this study to determine how to treat this disease in the most suitable way.

Methods

A retrospective study involving 73 patients diagnosed with TLMP and treated at our Institute between September 1975 and June 2010.

Results

The median age was 49 years. In 33% of the cases, the patients were younger than 40 years. Our study included 38 mucinous tumors, 30 serous and 5 mixed. The tumors were stage I in 69% of the cases, stage II in 11% and stage III in 20%.

All patients had surgery as a primary treatment. The surgery was radical in 77% of the cases. Five patients had an adjuvant chemotherapy. After a mean follow up of 10 years, we reported 7 cases of local relapses. The prognostic factors for a disease free survival were: the stage of the tumor and the presence of invasive implants. The overall survival at 5 and 10 years was respectively of 96.9% and 92.8%. The prognostic factors for overall survival were: the age, the stage, the existence of a residual tumor, the presence of pseudomyxoma or peritoneal implants. After having a conservative surgery two patients achieved full term pregnancies.

Conclusion

Randomized studies are required to back-up our findings and give a higher grade of recommendation to the actual standard of care.

Safety and fertility outcomes after the conservative treatment of endometrioid borderline ovarian tumours

Background

Because of the rarity of endometrioid borderline ovarian tumours (EBOTs), there is a paucity of data concerning the natural history and prognosis of this condition. Thus, the objective of our study was to establish the feasibility of fertility preservation in young women with EBOTs, as well as their oncological and reproductive outcomes.

Methods

Consecutive patients with EBOTs, treated at a tertiary referral centre during a span of 22 years, were retrospectively analysed. Recurrence-free interval, as well as its association with the type of surgery and with other clinical and pathological features, was assessed using the Kaplan-Meier and Cox proportional hazards methods.

Results

Of the 59 patients studied, the median follow-up time was 30 months (range, 6–177 months). Nine (15.3%) patients developed 13 recurrences 6–137 months after the initial surgeries, including three patients (5.1%; n = 3/59) who developed six invasive recurrences 8, 18 and 68 months after their initial surgeries. Conservative surgery showed a tendency towards a high recurrence rate (17.2% versus 13.3%); however, this difference was not significant (p = 0.45). The 5-year recurrence-free survival rate was significantly higher in the oophorectomy group than in the cystectomy group (p = 0.001). Cox regression analysis showed that none of the variables assessed were associated with an increased hazard ratio for recurrence, except for a younger age at diagnosis (p = 0.021). Of 20 patients who attempted to conceive, three pregnancies among two patients (10.0%) resulted in two live births.

Conclusions

Conservative surgery with unilateral adnexectomy can be proposed for young women with EBOTs with fertility desire; however, the reproductive result is not satisfactory. In addition, careful evaluations of the endometria should be offered during the initial surgery and follow-up period.

Trial registration

Retrospectively registered.

Algorithms Used in Ovarian Cancer Detection: A Minireview on Current and Future Applications

BACKGROUND

Ovarian cancer is the 5th most common cause of cancer death among women in the US. Currently, there is no screening algorithm for asymptomatic women that has been shown to lower mortality rates. Screening is currently not recommended and has been shown to increase harm. Epithelial ovarian cancer (EOC) detection is reviewed, with a focus on high-grade serous, clear-cell, and endometrioid histotypes.

CONTENT

A review of current literature surrounding tools used in detection of ovarian cancer will be presented. CA 125, HE4, risk of ovarian cancer algorithm (ROCA), risk of malignancy algorithm (ROMA), risk of malignancy (RMI), OVA1, and future potential biomarkers are reviewed.

SUMMARY

Screening and early identification of EOC is currently managed as a single disease entity. However, recent evidence has shown ovarian cancer varies with relation to cellular origin, pathogenesis, molecular alterations, and prognosis, depending on histotype. There is a clear need for future studies identifying histotype-specific preclinical tumor markers to aid in detection and improvement of survival rates.

Comparative study of endometrioid borderline ovarian tumor with and without endometriosis

Background

Synchronous endometriosis has been poorly studied in women with endometrioid borderline ovarian tumors (EBOTs). The aims of this study were to compare the clinicopathological features and prognosis of EBOTs with or without endometriosis.

Results

Of 52 patients diagnosed with EBOTs, no death was observed and only one case had successful pregnancy during the follow-up period. Older, menopausal EBOT patients, EBOT patients with small tumors and relatively low CA125 level probably had better progression-free survival (PFS) outcomes. About 1/3 of EBOTs had concomitant endometrial lesions. Approximately 1/3 of EBOTs were associated with endometriosis. Patients were divided into two groups according to the presence or not of endometriosis in this retrospective cohort study. Patients with endometriosis-associated endometrioid borderline ovarian tumor (EAEBOT) were more likely to be younger and premenopausal. Variables such as PFS outcomes, endometrial lesions did not differ statistically between groups. However, in specific EBOT patients like parous patients, patients with CA125 ≥ 140 U/ml or patients without fertility sparing surgery, coexisting endometriosis perhaps predicted worse PFS outcomes.

Conclusion

We considered EAEBOT as an entity similar to non-EAEBOT. Closely follow-up for some particular patients with concomitant endometriosis was necessary.

Genetic analysis and phosphoinositide 3-kinase/protein kinase B signaling pathway status in ovarian endometrioid borderline tumor samples

Ovarian endometrioid borderline tumors (EBTs) are extremely rare, and are thought to be precursors of endometrioid carcinoma, beginning as adenofibroma or endometriosis and progressing in a slow, stepwise manner. In endometrioid carcinomas, a high frequency of activating mutations in phosphatase and tensin homolog (PTEN), β-catenin or AT-rich interaction domain 1A (ARID1A) genes, and the activation of the phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT) signaling pathway have been observed. However, the frequency of these alterations in EBTs and how they contribute to tumor progression remain unclear. To the best of our knowledge, this is the first study to assess the status of the PI3K/AKT signaling pathway in EBTs, in association with PTEN and ARID1A mutations. PTEN mutations were observed in EBTs and also in the area of endometriosis without atypia. However, the PI3K/AKT signaling pathway was revealed to be activated only in EBTs. The observations of the present study suggest that the PTEN mutation represents an early event in EBT tumorigenesis, while additional genetic alterations may be necessary to activate the PI3K/AKT signaling pathway and induce the development of the invasive carcinoma.

Risk of synchronous endometrial disorders in women with endometrioid borderline tumors of the ovary

Background

Synchronous endometrial disorders have been poorly studied in women with endometrioid borderline ovarian tumors (EBOT). The aims of this study were to investigate the risk of endometrial disorders among women with EBOT and associated factors, as well as their oncological and fertility outcomes.

Results

This retrospective study included 33 women with EBOT. Their mean age was 41.9 years, and endometria were evaluated in 25 of these patients. The prevalence of synchronous endometrial disorders was 52.0% (n = 13/25) and this incidence was 41.4% (n = 46/111) after systematic analysis. Univariable analysis showed that EBOT patients who were younger, nulliparous, and had experienced abnormal vaginal bleeding were more likely to have synchronous endometrial disorders. The median follow-up was 54 months (range: 14-250 months), and three patients (10.3%) developed recurrences. No deaths due to EBOT were recorded. Among the nine nulliparous women treated conservatively who were attempting to conceive, only one (11.1%) pregnancy resulted in a live birth.

Conclusions

Synchronous endometrial disorders are common in women with EBOT, especially in those who are younger, nulliparous, and have experienced abnormal vaginal bleeding. Thus, endometrial sampling should be performed in women with EBOT undergoing conservative surgery, and a hysterectomy should be performed in cases requiring radical treatment.

Endometriosis-associated ovarian neoplasia

This article reviews the most relevant pathological and molecular features of ovarian tumours that are associated with endometriosis. Endometriosis is a common condition, affecting 5-15% of all women, and it has been estimated that 0.5-1% of cases are complicated by neoplasia. The most common malignant tumours in this setting are endometrioid adenocarcinoma and clear cell adenocarcinoma, each accounting for approximately 10% of ovarian carcinomas in Western countries. A minority of cases are associated with Lynch syndrome. These carcinomas are often confined to the ovaries at presentation in which case they have relatively favourable outcomes. However, high-stage tumours, particularly clear cell carcinomas, generally have a poor prognosis and this partly reflects relative resistance to current treatment. Histological diagnosis is straightforward in the majority of cases but some variants, for example endometrioid carcinomas with sex cord-like appearances or oxyphil cells, may create diagnostic difficulty. Similarly, clear cell carcinomas can show a range of architectural and cytological patterns that overlap with other tumours, both primary and metastatic, involving the ovaries. Endometriosis-associated borderline tumours are less common, and they often show mixed patterns of differentiation (seromucinous tumours). Atypical endometriosis may represent an intermediate step in neoplastic progression and some of these lesions demonstrate immunohistological and molecular alterations similar to those observed in endometriosis-related tumours. ARID1A mutations are relatively common in all of these tumours, but each has additional characteristic molecular alterations which are likely to be of increasing clinical relevance as targeted therapies are developed. Less is known of the pathogenesis of rarer endometriosis-associated ovarian tumours including endometrioid stromal sarcoma, mesodermal (Müllerian) adenosarcoma, and carcinosarcoma. This article also briefly reviews the issue of synchronous endometrioid carcinomas of the endometrium and the ovary, including the most recent developments on pathogenesis.

Four cases of endometrioid borderline ovarian tumour: case reports and literature review

Endometrioid borderline tumours (EBTs) of the ovary are uncommon tumours of low malignant potential. They consist of atypical endometrioid cells lacking destructive stromal invasion. As the prognosis of EBT is excellent, excessive treatment should be avoided and preoperative diagnosis is important. Here we report four cases of ovarian EBTs along with imaging findings and a review of literature. The average patient age was 52 years. They presented with abdominal discomfort or abnormal vaginal bleeding. The final diagnoses for all four cases were EBT Stage IA with endometriosis. Pathologically, one case was an adenofibromatous type tumour, and three cases were intracystic type tumours. Two patients had concurrent endometrial cancer. MRI of the tumours showed enhanced solid components. The intracystic type tumours presented a dendritic structure in the cyst; fine papillary branches surrounded a low-signal trunk on T₂ weighted imaging. Positron emission tomography demonstrated marked fluorodeoxyglucose uptake in the solid component. One case with MRI 3 years before diagnosis indicated that the tumour arose in ovarian endometriotic cyst. EBT cases were difficult to distinguish from malignant ovarian tumours preoperatively. Intraoperative frozen section analysis may aid to determine treatment. Prognoses were excellent. Care should be taken for co-existing endometrial cancer.

The Putative Role of TP53 Alterations and p53 Expression in Borderline Ovarian Tumors - Correlation with Clinicopathological Features and Prognosis: A Mini-Review

Borderline ovarian tumors (BOTs) represent an independent group among ovarian malignancies, being diagnosed at clinical stage earlier than invasive ovarian carcinomas (OCs) and characterized by a rather favorable outcome after careful surgical management. Data published worldwide showed a substantial discordance of p53 expression in BOTs. The purpose of this work was to present the current status of knowledge on the significance of TP53 gene and p53 protein product alterations in BOTs. In general, higher p53 expression patterns were reported for ovarian malignancies compared to BOTs. Serous, mucinous, and endometrioid BOTs differ substantially in relation to p53 immunostaining, but data concerning the relationship between the protein's immunoreactivity and other clinico-pathological variables are scarce. Finally, reports published to date support the view that TP53 alterations may not be commonly associated with the borderline phenotype of ovarian tumors but they probably occur during the development of invasive OCs. In light of these uncertainties, the impact of TP53 alterations and p53 expression on overall survival in women affected by BOTs requires further multi-institutional studies in large cohorts of patients.

Ovarian borderline tumors in the 2014 WHO classification: evolving concepts and diagnostic criteria

Borderline ovarian tumors (BOT) are uncommon but not rare epithelial ovarian neoplasms, intermediate between benign and malignant categories. Since BOT were first identified >40 years ago, they have inspired controversies disproportionate to their incidence. This review discusses diagnostic criteria for the histologic subtypes of BOT, highlighting areas of diagnostic challenges, ongoing controversies, and changes in terminology implemented by the recent 2014 WHO Classification of Tumours of the Female Genital Organs. Emerging knowledge supports the notion that subtypes of borderline ovarian tumors comprise distinct biologic, pathogenetic, and molecular entities, precluding a single unifying concept for BOT. Serous borderline tumors (SBT) share molecular and genetic alterations with low-grade serous carcinomas and can present at higher stages with peritoneal implants and/or lymph node involvement, which validates their borderline malignant potential. All other (non-serous) subtypes of BOT commonly present at stage I confined to the ovary(ies) and are associated with overall survival approaching that of the general population. An important change in the WHO 2014 classification is the new terminology of non-invasive implants associated with SBT, as any invasive foci (previously called “invasive implants”) are now in line with their biological behavior considered peritoneal low-grade serous carcinoma (LGSC). The controversy regarding the terminology of non-serous borderline tumors, called by some pathologists “atypical proliferative tumor” in view of their largely benign behavior, has not been resolved. The concepts of intraepithelial carcinoma and microinvasion may evolve in further studies, as their presence appears to have no prognostic impact and is subject to considerable inter-observer variability.

Low-grade epithelial ovarian cancer: a number of distinct clinical entities?

PURPOSE OF REVIEW

The purpose of this study is to summarize the contemporary understanding of low-grade epithelial ovarian cancers.

RECENT FINDINGS

Low-grade serous ovarian cancer is biologically distinct from high-grade serous ovarian cancer. It is associated with a high incidence of K-RAS and B-RAF mutations. Although described as indolent due to median progression-free and overall survivals of 20 and 99 months, respectively, with a median age of diagnosis of 43 years, it accounts for a significant number of patient-years lost. Retrospective studies suggest response rates of 5% for chemotherapy and 9% for antioestrogen therapy. A prospective study of the mitogen-activated protein kinase kinase inhibitor selumetinib (response rate 15%) and retrospective bevacizumab studies suggest that these may be more effective approaches.Limited retrospective clinical data and even more sparse molecular data suggest that similar distinctions may exist between low-grade endometrioid and mucinous ovarian cancers and their respective high-grade counterparts, but more research is required in order to clarify the biological differences and the implications that these have for management.

SUMMARY

The results of phase III mitogen-activated protein kinase kinase inhibitor studies in low-grade serous ovarian cancer and further clinical and biological assessment of low-grade endometrioid and mucinous ovarian cancers are urgently required.

Atypical proliferative endometrioid tumor of ovary: Report of a rare case

Borderline ovarian tumors represent 10-20% of epithelial ovarian neoplasms that typically have an excellent prognosis. Both the oncological behavior of this group of tumors and also the diagnostic histological criteria are intermediate between the specific criteria of benign and malignant. They usually occur in the third to fourth decade of women's lives and are limited to the ovary in 80% of cases. Atypical proliferative or borderline ovarian tumors constitute a group of epithelial tumors with an excellent prognosis due to the low aggressiveness, microscopic examination is mandatory in order to establish an accurate histological diagnosis in all cases of borderline ovarian tumors and to differentiate from well differentiated adenocarcinoma. We report a case of a 45 year old female who presented with irregular bleeding per vaginum and underwent hysterectomy with bilateral salpingo-oophorectomy. Atypical proliferative endometrioid tumor of the left ovary was an incidental finding, which is a very rare occurrence.

A meta-analysis on the impact of platinum-based adjuvant treatment on the outcome of borderline ovarian tumors with invasive implants

BACKGROUND

Treatment of borderline ovarian tumors (BOTs) remains contentious, and there is no consensus regarding therapy for BOTs with invasive implants (BOTi). The benefits of platinum-based adjuvant treatment were evaluated in patients with BOTi at primary diagnosis.

METHODS

The PubMed database was systematically searched for articles using the following terms: ((borderline) OR (low malignant potential) AND (ovarian)) AND ((tumor) OR (cancer)) AND (invasive implants) AND ((follow-up) OR (survival) OR (treatment) OR (chemotherapy) OR (adjuvant treatment) OR (surgery) OR (surgical treatment)).

RESULTS

We identified 27 articles including 3,124 patients, 181 with invasive implants. All studies provided information regarding mortality or recurrence rates. Central pathological examination was performed in 19 studies. Eight studies included more than 75% stage I patients; 7 included only advanced-stage patients, and 14 included only serous BOT. The pooled recurrence estimates for both treatment groups (adjuvant treatment: 44.0%, upfront surgery: 21.3%) did not differ significantly (p = .114). A meta-analysis of the 6 studies providing separate mortality data for both treatment groups favored surgical treatment only, but this difference did not reach statistical significance (.05 < p < .1; odds ratio: 0.33; 95% confidence interval: 0.09-1.71; p = .086). We were unable to pool the results of the included studies because not all studies registered events in both treatment groups. Egger's regression indicated low asymmetry of the studies (p = .39), and no heterogeneity was found (I(2) = 0%).

CONCLUSION

We did not find evidence supporting platinum-based adjuvant therapy for BOT with invasive implants.

Borderline ovarian tumour: pathological diagnostic dilemma and risk factors for invasive or lethal recurrence

By comparison with ovarian carcinomas, borderline ovarian tumours are characterised clinically by superior overall survival, even in women with peritoneal spread. In this Review, we aimed to clarify the histological and clinical factors potentially defining a high-risk group in whom disease is likely to evolve to invasive disease. Invasive peritoneal implants (in serous borderline ovarian tumours) and residual disease after surgery were the two factors clearly identified. Other factors are controversial owing to increased risk of invasive recurrence: micropapillary patterns in serous borderline ovarian tumour, intraepithelial carcinoma in mucinous lesions, stromal microinvasion in serous lesions, and use of cystectomy in mucinous borderline ovarian tumours. The pathologist has a pivotal role in assessment of the borderline nature of ovarian tumours and in identification of high-risk criteria, most of which are histological. But, reproducibility of the histological interpretation of some of these potential criteria--eg, classification of peritoneal implants (particularly in desmoplastic subtype), stromal microinvasion, micropapillary patterns, and intraepithelial carcinoma in mucinous borderline ovarian tumours--remains unclear, and should be investigated.

Breast and ovarian cancers: a survey and possible roles for the cell surface heparan sulfate proteoglycans

Tumor markers are widely used in pathology not only for diagnostic purposes but also to assess the prognosis and to predict the treatment of the tumor. Because tumor marker levels may change over time, it is important to get a better understanding of the molecular changes during tumor progression. Occurrence of breast and ovarian cancer is high in older women. Common known risk factors of developing these cancers in addition to age are not having children or having children at a later age, the use of hormone replacement therapy, and mutations in certain genes. In addition, women with a history of breast cancer may also develop ovarian cancer. Here, the authors review the different tumor markers of breast and ovarian carcinoma and discuss the expression, mutations, and possible roles of cell surface heparan sulfate proteoglycans during tumorigenesis of these carcinomas. The focus is on two groups of proteoglycans, the transmembrane syndecans and the lipid-anchored glypicans. Both families of proteoglycans have been implicated in cellular responses to growth factors and morphogens, including many now associated with tumor progression.

Morphological subtypes of ovarian carcinoma: a review with emphasis on new developments and pathogenesis

Ovarian carcinomas comprise a heterogeneous group of neoplasms, the four most common subtypes being serous, endometrioid, clear cell and mucinous. In recent years, our understanding of the underlying pathogenesis and initiating molecular events in the different tumour subtypes has greatly increased, and although ovarian carcinoma is often considered clinically as one disease, there is now a much greater realisation that the various subtypes have a different natural behaviour and prognosis. At present, adjuvant therapy is mainly dependent upon tumour stage and grade rather than type; however, this is likely to change in the future with the development of new chemotherapeutic agents and targeted therapies and clinical trials are necessary to evaluate the efficacy of different agents in clear cell, mucinous and low grade serous carcinomas, neoplasms which are considered relatively resistant to traditional chemotherapeutic regimes. In this review, the major subtypes of ovarian carcinoma are discussed. It is now firmly established that there are two distinct types of ovarian serous carcinoma, low grade and high grade, the former being much less common and arising in many cases from a serous borderline tumour. Low grade and high grade serous carcinoma represent two distinct tumour types with a different underlying pathogenesis rather than low grade and high grade variants of the same neoplasm. Both are usually advanced stage (stage III or IV) at diagnosis. B-raf and k-ras mutations are important molecular events in low grade serous carcinomas while high grade serous carcinomas are almost always associated with TP53 mutation. There is now emerging and compelling evidence that many high grade serous carcinomas (by far the most common subtype of ovarian carcinoma) actually arise from the epithelium of the distal fallopian tube. Future studies regarding the initiating molecular events in the development of this aggressive neoplasm should concentrate on this site. Primary ovarian mucinous carcinomas are uncommon, almost always unilateral and stage I, and largely of so-called intestinal or enteric type. Most arise in a stepwise manner from a pre-existing mucinous cystadenoma and mucinous borderline tumour. Endometrioid and clear cell carcinomas typically present as low stage neoplasms and in many, or most, cases arise from endometriosis; the former are usually well differentiated and there is now evidence that the majority of neoplasms reported in the past as high grade endometrioid carcinoma are of serous type. WT1 is useful in this regard since it is a relatively specific marker of a serous phenotype. It is recommended that different subtypes of ovarian carcinoma are graded using different systems rather than employing a universal grading system.

Metastatic Neoplasms Involving the Ovary

In this review, ovarian metastatic carcinomas from various sites, as well as other neoplasms secondarily involving the ovary, are discussed. As well as describing the morphology, the value of immunohistochemistry in distinguishing between primary and metastatic neoplasms in the ovary is discussed. While immunohistochemistry has a valuable role to play and is paramount in some cases, the results should be interpreted with caution and with regard to the clinical picture and gross and microscopic pathologic findings.

Nonserous Ovarian Epithelial Tumors

This review covers the group of relatively uncommon nonserous ovarian epithelial tumors. The authors focus on the group's distinctiveness from the much more common serous tumors and show the similarities across entities. Diagnostic criteria that separate the different entities are currently being debated. Particular problems include the reproducible diagnosis of high-grade endometrioid, transitional cell, mixed epithelial and undifferentiated carcinomas. Furthermore, despite recognition that most malignant mucinous tumors involving ovary represent metastases from extraovarian primary sites, many misdiagnoses still occur. The authors discuss their rationale behind their opinions about these problematic topics.

Characterization of the molecular differences between ovarian endometrioid carcinoma and ovarian serous carcinoma

The histopathological diagnosis of high-grade endometrioid and serous carcinoma of the ovary is poorly reproducible under the current morphology based classification system, especially for anaplastic, high-grade tumours. The transcription factor Wilms' tumour-1 (WT1) is differentially expressed among the gynaecological epithelia from which epithelial ovarian cancers (EOCs) are believed to originate. In EOCs, WT1 protein is observed in the majority of serous carcinomas and in up to 30% of endometrioid carcinomas. It is unclear whether the latter is a reflection of the actual incidence of WT1 protein expression in endometrioid carcinomas, or whether a significant number of high-grade serous carcinomas have been misclassified as endometrioid carcinoma. Several genetic aberrations are reported to occur in EOCs. These include mutation of the TP53 gene, aberrant activation of beta-catenin signalling and loss of PTEN protein expression, among others. It is unclear whether these aberrations are histotype-specific. The aim of this study was to better define the molecular characteristics of serous and endometrioid carcinomas in an attempt to address the problems with the current histopathological classification methods. Gene expression profiles were analysed to identify reproducible gene expression phenotypes for endometrioid and serous carcinomas. Tissue microarrays (TMA) were used to assess the incidence of TP53, beta-catenin and PTEN aberrations in order to correlate their occurrence with WT1 as an immunohistochemistry based biomarker of serous histotype. It was found that nuclear WT1 protein expression can identify misclassified high-grade endometrioid carcinomas and these tumours should be reassigned to serous histotype. Although low-grade endometrioid carcinomas rarely progress to high-grade carcinomas, a combined WT1-negative, TP53-positive immunophenotype may identify an uncommon high-grade subtype of ovarian endometrioid carcinoma. GEO database: array data accession number GSE6008.

Ovarian cancer

Ovarian carcinomas are a heterogeneous group of neoplasms and are traditionally subclassified based on type and degree of differentiation. Although current clinical management of ovarian carcinoma largely fails to take this heterogeneity into account, it is becoming evident that each major histological type has characteristic genetic defects that deregulate specific signaling pathways in the tumor cells. Moreover, within the most common histological types, the molecular pathogenesis of low-grade versus high-grade tumors appears to be largely distinct. Mouse models of ovarian carcinoma have been developed that recapitulate many of the morphological features, biological behavior, and gene-expression patterns of selected subtypes of ovarian cancer. Such models will likely prove useful for studying ovarian cancer biology and for preclinical testing of molecularly targeted therapeutics, which may ultimately lead to better clinical outcomes for women with ovarian cancer.

Immunohistochemical characterization of mullerian mucinous borderline tumors: possible histogenetic link with serous borderline tumors and low-grade endometrioid tumors

Mullerian mucinous borderline tumor and gastrointestinal mucinous borderline tumor are considered mucinous tumor subtypes. However, it has been reported that mullerian mucinous borderline tumor shares many clinicopathologic features with serous borderline tumor. Furthermore, some investigators have explained the histogenesis of mullerian mucinous borderline tumor by metaplastic and hyperplastic transformation of endometriosis (Fukunaga M, Ushigome S. Epithelial metaplastic changes in ovarian endometriosis. Mod Pathol. 1998;11:784-788). The purpose of this study is to substantiate the concept that mullerian mucinous borderline tumor is histogenetically closer to serous borderline tumor or low-grade endometrioid tumor than to gastrointestinal mucinous borderline tumor by directly comparing their immunophenotype. A total of 80 cases of low-grade ovarian tumors composed of 20 mullerian mucinous borderline tumors, 20 gastrointestinal mucinous borderline tumors, 20 serous borderline tumors, and 20 low-grade endometrioid tumors were immunohistochemically evaluated for the expression of estrogen receptor, progesterone receptor, vimentin, WT-1, beta-catenin, and PTEN. Almost all cases of mullerian mucinous borderline tumor, serous borderline tumor, and low-grade endometrioid tumor showed diffuse and strong nuclear expression of estrogen receptor and progesterone receptor. In addition, about half of the mullerian mucinous borderline tumor, serous borderline tumor, and low-grade endometrioid tumor cases showed focal but strong vimentin cytoplasmic expression. In contrast, gastrointestinal mucinous borderline tumor showed no expression of estrogen receptor, progesterone receptor, or vimentin, except for 1 case in which estrogen receptor expression was very focally and weakly observed. WT-1 nuclear expression was observed in most serous borderline tumors and only 15% of low-grade endometrioid tumor, but mullerian and gastrointestinal mucinous borderline tumor cases were completely negative. beta-Catenin nuclear expression was significantly more frequent in low-grade endometrioid tumor than in mullerian mucinous borderline tumor, gastrointestinal mucinous borderline tumor, or serous borderline tumor. PTEN expression was significantly lower in low-grade endometrioid tumor than in mullerian mucinous borderline tumor, gastrointestinal mucinous borderline tumor, and serous borderline tumor. Multiple comparisons of quantitative immunoreactivities of estrogen receptor, progesterone receptor, and vimentin revealed that the gastrointestinal mucinous borderline tumor expression profiles were significantly different from those of mullerian mucinous borderline tumors, serous borderline tumors, and low-grade endometrioid tumors. The immunohistochemical expression profiles of estrogen receptor, progesterone receptor, and vimentin substantiate the concept that the histogenesis of mullerian mucinous borderline tumor is closer to those of serous borderline tumor and low-grade endometrioid tumor than to that of gastrointestinal mucinous borderline tumor. However, aberrant beta-catenin and PTEN protein expression, both of which are known to contribute to the tumorigenesis of low-grade endometrioid tumor, appeared to be less important for the tumorigenesis of mullerian mucinous borderline tumor.

WT1 expression in endometrioid ovarian carcinoma with and without associated endometriosis

AIMS

To determine how frequently endometrioid ovarian carcinomas (EOC) express WT1 protein, and to correlate the results with the presence of endometriosis and p53 immunoreactivity.

METHODS

Forty-one grade 1-2 EOC were stained immunohistochemically for WT1 and p53 proteins. Twenty-one tumours were associated with endometriosis and 20 cases lacked such an association. WT1 expression in the tumour cell nuclei and/or cytoplasm was recorded. Nuclear p53 staining was assessed as diffuse (>50% cells positive), focal, or negative.

RESULTS

Four of the 20 (20%) tumours in the endometriosis negative group showed nuclear WT1 staining, while none of the endometriosis-associated EOC was positive (p < 0.05). Two of the immunoreactive cases exhibited sertoliform/sex cord-like patterns. Focal cytoplasmic WT1 labelling was present in seven EOC, three of which showed sertoliform, spindle cell or corded and hyaline patterns. There was no correlation between WT1 expression and p53 immunoreactivity.

CONCLUSIONS

Nuclear WT1 expression is present in a minority of EOC and this should be considered if immunohistochemistry is used as an adjunct in sub-typing ovarian carcinomas. The negative correlation of WT1 staining with endometriosis supports the possibility that some EOC, including unusual histological variants, arise from the ovarian surface epithelium. Further studies of EOC should document any association with endometriosis.

Endometrioid Neoplasms With Clear Cells

The presence of clear cells in genital tract neoplasms often reflexly prompts the diagnosis of a clear cell tumor but clear cells may be seen in many other neoplasms. In one such, those of endometrioid type, they are well known and generally readily characterized when they have the secretory pattern that recapitulates the well-known morphology of early secretory endometrium. In this report, we describe various clear cell morphologies, some possibly related to the secretory variant, but others not, and all potentially the source of significant diagnostic difficulty. We reviewed 21 endometrioid tumors that occurred in patients from 27 to 88 (median 64) years. Most had an adnexal mass (13) or abdominal swelling (4), but 4 presented with vaginal bleeding. One tumor formed a cystic mass in the pelvis, 1 tumor involved the right fallopian tube, 1 the endometrium, and 18 the ovary. One tumor was a cystadenofibroma, 1 a borderline tumor, and 19 were adenocarcinomas. Twelve patients had stage I, 4 stage III, 1 stage IV, and 4 were unstaged. One patient who had a previous hysterectomy and salpingo-oophorectomy underwent resection of a cystic pelvic mass; others all were treated with abdominal hysterectomy and salpingo-oophorectomy. All the neoplasms had the typical architecture of endometrioid tumors but differed markedly in their cytoplasmic features. In 18 of the tumors at least one-third of the cells had clear cytoplasm and 3 had only clear cells. The clear cytoplasm varied from foamy to empty and the nuclei had a variable location, basilar, central, and apical. The clear cells were associated with squamous differentiation in only 1 case in which the change appeared hydropic. By immunohistocytochemistry, the clear cells were focally positive for epithelial markers in most cases but in some cases one or more of these immunostains were negative. Tubulocystic, solid, and papillary patterns of clear cell carcinoma were absent. Periodic acid-Schiff was focally positive for glycogen in the cytoplasm in 5 cases. Although a few cases had a focal slight resemblance to secretory endometrioid carcinoma most did not and the orderly morphology of classic secretory carcinoma was noteworthy for its absence. The nature of the cytoplasmic clarity is usually uncertain but is likely variably owing to lipid, mucin or glycogen accumulation, or is a hydropic change. The distinction from clear cell carcinoma depends on awareness of this unusual variant of endometrioid neoplasia and a lack of the distinctive patterns of clear cell carcinoma; at this time, special studies, including immunohistochemistry, do not aid significantly although certainly negative reactions, such as for thyroglobulin protein (arguing against clear cell struma ovarii) may play a role in some differential diagnostic considerations. There are prognostic and therapeutic implications in the distinction with clear cell carcinoma.

Primary Ovarian Adenofibromatous Neoplasms With Mucin-Containing Signet-ring Cells

The presence of mucin-containing signet-ring cells in an ovarian neoplasm is considered strong evidence for a metastatic rather than primary tumor. The clinicopathologic features of 2 ovarian adenofibromatous neoplasms with mucin-containing signet-ring cells (AFN-SRs), proven by the long-term follow-up of 10 and 15 years to be primary tumors, are presented as exceptions to this general guideline. Both of these tumors were initially strongly favored to be metastatic adenocarcinoma by expert consultants in gynecologic pathology, which underscores the diagnostic difficulty that these rare and unusual neoplasms can pose. Although long-term follow-up of AFN-SRs is still necessary to exclude the possibility of metastases, the following constellation of features can correctly suggest a primary neoplasm rather than a Krukenberg-like metastatic process at the time of presentation: (i) the appearance of fibromatous stroma as an integral part, as opposed to reactive part, of the neoplasm, (ii) a semiorganized rather than completely haphazard pattern to the placement of the epithelial elements, with a circumscribed noninfiltrative interface with ovarian parenchyma, (iii) the absence of angiolymphatic invasion, (iv) tumor unilaterality, and (v) the lack of a known primary source. The virtual absence of literature on these low-grade malignancies, coupled with the occurrence of 2 such tumors within a 7-year period at a single community hospital, suggests that many AFN-SRs continue to be misdiagnosed as metastatic adenocarcinoma.

Endometriosis and the development of malignant tumours of the pelvis. A review of literature

For several decades, endometriosis has been suspected of playing a role in the aetiology of ovarian cancer. The literature concerning a possible histogenesis of ovarian cancer from benign endometriosis is reviewed in this chapter. Epidemiological evidence from large-cohort studies confirms endometriosis as an independent risk factor for ovarian cancer. Further circumstantial evidence for this link was found in the common risk factors for ovarian cancer and endometriosis. These risk factors influence retrograde menstruation and endometriosis in the same positive or negative way. Based on data in the literature, the prevalence of endometriosis in epithelial ovarian cancer has been calculated to be 4.5, 1.4, 35.9, and 19.0% for serous, mucinous, clear-cell and endometrioid ovarian carcinoma, respectively. The risk of malignant transformation in ovarian endometriosis was calculated at 2.5% but this might be an underestimate. In addition, some authors described atypical endometriosis in a spatial and chronological association with ovarian cancer. Finally, molecular studies have detected common alterations in endometriosis and ovarian cancer. These data suggest that some tumours, especially endometrioid and clear-cell carcinomas, can arise from endometriosis. Moreover, endometriosis-associated ovarian cancer represents a distinct clinical entity, with a more favourable biological behaviour, given a lower stage distribution and better survival than non-endometriosis-associated ovarian cancer.

Relationship of benign gynecologic diseases to subsequent risk of ovarian and uterine tumors

OBJECTIVE

Although endometriosis and uterine leiomyomas are common conditions, the extent to which either is associated with certain types of malignancies remains uncertain.

METHODS

Using record linkage techniques, we assessed the relationships between hospital and outpatient admissions for endometriosis or leiomyomas and the development of ovarian and uterine cancers in Denmark between 1978 and 1998. Based on a population-based cohort exceeding 99,000 women, including 2,491 ovarian cancers, 860 borderline ovarian tumors, and 1,398 uterine cancers, we derived relative risks (RR) and 95% confidence intervals (95% CI) associated with overall and histology-specific tumor risks after adjustment for calendar time and reproductive characteristics.

RESULTS

Endometriosis seemed to predispose to the development of ovarian cancer, with the association restricted to endometrioid or clear cell malignancies. Five or more years after the diagnosis of endometriosis, the RRs (95% CIs) were 2.53 (1.19-5.38) for endometrioid (7 exposed cases) and 3.37 (1.24-9.14) for clear cell (4 exposed cases) malignancies. Uterine leiomyomas were associated with increases in the risk of uterine malignancies, particularly sarcomas, where the RRs (95% CIs) were 20.80 (11.32-38.22) for women with 1 to 4 years of follow-up (11 exposed cases) and 5.70 (2.27-14.32) for those with more extended follow-up (5 exposed cases).

CONCLUSION

In combination with clinical, pathologic, and molecular data, our results support that some endometriotic lesions may predispose to clear cell and endometrioid ovarian cancers. Uterine leiomyomas also showed a strong connection with subsequent uterine sarcomas, although it was difficult to decipher whether this reflected detection bias, shared risk factors, or an etiologic relationship.

High frequency of β-catenin mutations in borderline endometrioid tumours of the ovary

Some low-grade endometrioid carcinomas arise from a background of endometrioid tumours of borderline malignancy. To determine the molecular mechanisms involved in the initiation of endometrioid carcinoma, the present study investigated whether the genetic alterations reported in these tumours (mutations in PTEN, KRAS, and beta-catenin genes, and microsatellite instability) are already present in endometrioid tumours of borderline malignancy. Eight endometrioid tumours of borderline malignancy were studied. By immunohistochemistry, beta-catenin was expressed in the nuclei of all tumours, suggesting the presence of stabilizing beta-catenin mutations. By mutational analysis, five different beta-catenin mutations were found in seven of eight cases (90%), affecting codons 32, 33, and 37. In contrast, only one tumour harboured a PTEN mutation, which affected codon 130. Neither KRAS mutations nor microsatellite instability was detected. A review of the literature indicated that beta-catenin mutations are characteristic of well-differentiated endometrioid carcinomas, since they were present in nearly 60% of grade I but in less of 3% of grade III tumours. In conclusion, the present study identifies beta-catenin mutation as a nearly constant molecular alteration in borderline endometrioid tumours, whereas PTEN and KRAS mutations and microsatellite instability are very infrequent. The findings in the present study, and previously reported data, strongly suggest that beta-catenin mutation is an early event in endometrioid ovarian carcinogenesis, and that it is involved in the development of low-grade endometrioid tumours.

Invasion patterns in stage I endometrioid and mucinous ovarian carcinomas: a clinicopathologic analysis emphasizing favorable outcomes in carcinomas without destructive stromal invasion and the occasional malignant course of carcinomas with limited destructive stromal invasion

Stage I, low-grade endometrioid and mucinous ovarian carcinomas have an excellent prognosis. Published data have suggested that destructive stromal invasion, a relatively uncommon finding in these tumors, is a poor prognostic factor. We investigated this by studying all FIGO stage I, grades 1 and 2 (of 3) endometrioid and mucinous ovarian carcinomas that were surgically staged at the Memorial Sloan-Kettering Cancer Center from 1980 to 2000. We undertook a careful review of all available slides using current diagnostic criteria and correlated histopathologic indices with clinical outcome data. Cases studied included 13 endometrioid ovarian carcinomas (stage IA, eight; stage IC, five) and six intestinal mucinous ovarian carcinomas (stage IA, three; stage IC, three). All of the tumors contained areas of expansile invasion, greater than that acceptable for microinvasion, and were thus diagnosed as carcinomas instead of borderline tumors. Nevertheless, nearly all demonstrated borderline tumor (noninvasive) components. Six tumors contained at least one focus of destructive stromal invasion (two endometrioid and four mucinous ovarian carcinomas). Four additional cases showed a focus suspicious for but not diagnostic of destructive invasion ('indeterminate for destructive invasion') (two endometrioid and two mucinous ovarian carcinomas). Follow-up data were available for 17 patients. The median follow-up was 81 months (range, 9-161 months). In all, 14 patients were alive with no evidence of disease (expansile invasion alone, eight; destructive stromal invasion, four; and indeterminate for destructive invasion, two). Three patients died of their disease (destructive stromal invasion, two; and indeterminate for destructive invasion, one). The size, number, and nuclear grade of destructive stromal invasion foci did not appear to have an impact on survival in this relatively limited number of patients. Outcome data in patients with stage I, low-grade endometrioid and mucinous ovarian carcinomas without destructive stromal invasion indicate that these tumors have a very limited malignant potential. The literature has not documented recurrences in this setting when the staging has been complete, the sampling adequate, and the cytologic features no more than grade 2, and metastasis to the ovary has been excluded. In contrast, carcinomas harboring even limited foci of destructive stromal invasion, although frequently cured surgically, can pursue a malignant clinical course.