Clinicopathologic analysis of early-stage sporadic ovarian carcinoma

Electrochemical immunosensing by carbon ink/carbon dot/ZnO-labeled-Ag@polypyrrole composite biomarker for CA-125 ovarian cancer detection

In this work, we demonstrated a novel cancer antigen 125 (CA125) biomarker detection based on electrochemical immunosensor. The biomarker on conductive composite materials of carbon ink/carbon dot/zine oxide (C-ink/CD/ZnO) was employed as an electrode platform by using ITO substrate to enhance the interaction of antibodies (Ab) with supporting catalytic performance of ZnO as a labeling signal molecule. They were a scientist attention for biosensor with chemical stability, strong biocompatibility, high conductive signal, and accuracy. Moreover, the nanocomposite of silver@polypyrrole (Ag@PPy) was used as a potential redox mediator. The labeled construction with Ag@PPy was more accuracy than that of a free-labeled. The created immunosensor was a wide linear range as 1 ag·mL^-1 - 100 ng·mL^-1 and a low limitation of detection as 0.1 fg·mL^-1 under the optimal condition. This suggested that the immunosensor is considered to be an accurate and efficient diagnostic tool for CA125 and other biomarkers detection in actual sample analysis for clinic.

Potential histological discordance revealed by second review in the national rare gynecological cancer network (TMRG)

INTRODUCTION

Since 2010, the network of rare malignant tumors of the ovary (TMRG) was developed to optimize the management of patients, also allowing a histological second opinion of rare ovarian tumors. The aim of this work was to study the contribution of second opinion to improve histological diagnostic accuracy on ovarian rare malignant tumors included in the TMRG database.

MATERIAL AND METHODS

Histological data of patients diagnosed with a rare ovarian tumor included in TMRG network over a one-year period (2018) were collected. Initial diagnoses were compared with second opinion from national gynecological pathologist experts. The modalities of histological second opinion requests were studied, as well as the histological characteristics of the tumors. The discordances were classified as minor (if the modification of histological diagnosis did not change patient management) and major (if the patient management can be modified).

RESULTS

Of 1185 included patients, 937 matched the inclusion criteria. Full concordance between primary diagnosis and expert second opinion was reached in 611 cases (65,3%), minor discordance was seen in 114 (12,2%) and major discordance in 209 (22,3%) of cases. In systematic review requested by the network, 26% (n = 137) of cases were reported with a change in histological diagnosis, while the change concerned 44% (n = 186) of cases for a second opinion spontaneously requested by the initial pathologist. The discrepancies concerned all categories of ovarian tumors, with a majority of mucinous tumors (43% of major discordances), followed by stromal and sex-cord tumors (13.8% of major discordances) and clear cell tumors (12,4% of major discordances).

CONCLUSION

This analysis confirms the diagnostic difficulty of ovarian tumors, due to their rarity and morphological heterogeneity. French pathologists are aware of these difficulties and spontaneously refer ovarian tumors with unusual histology for a second opinion and collaborate with rare tumor networks for systematic review.

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.

TP53 mutations in epithelial ovarian cancer

Genomic sequencing analyses of a variety of human cancers have revealed that massive mutations of cancer-relevant genes are the major alterations in cancerous cells, and their mutation frequencies or rates are highly associated with the development, progression, metastasis, and drug resistance of cancers as well as their clinical outcomes and prognosis. One predominant genetic alternation in human epithelial ovarian cancer (EOC) is the mutation of TP53 that encodes the tumor suppressor p53 protein. This essay will review the most recent progress in understanding the role of TP53 mutations in development, progression, and metastasis of EOC, and discuss the potential of TP53 mutations as diagnostic and prognostic biomarkers as well as therapeutic targets for EOC.

Vitamin D receptor FokI, BsmI, ApaI, and TaqI polymorphisms and susceptibility to ovarian cancer: a meta-analysis

OBJECTIVE

The goal of this study was to explore whether vitamin D receptor (VDR) polymorphisms are associated with susceptibility to ovarian cancer.

METHODS

Meta-analyses were conducted on the associations between the VDR FokI, BsmI, ApaI, and TaqI polymorphisms and ovarian cancer.

RESULTS

A total of 12 comparison studies were considered in the meta-analysis, which involved 3716 patients and 5059 controls. Meta-analysis of the VDR FokI polymorphism showed an association between ovarian cancer and the f allele in European populations (OR = 1.094, 95% CI = 1.028-1.163, p = 0.004). Meta-analysis revealed an association between ovarian cancer and the ApaI A allele in all study subjects and Europeans as a sub-group (OR = 1.235, 95% CI = 1.019-1.497, p = 0.032 and OR = 1.287, 95% CI = 1.029-1.609, p = 0.027, respectively). No association was found between ovarian cancer and the BsmI and Taq polymorphisms (OR for B allele = 1.084, 95% CI = 0.936-1.255, p = 0.280, OR for the T allele = OR = 0.847, 95% CI = 0.706-1.270, p = 0.716).

CONCLUSIONS

This meta-analysis suggests that the VDR FokI and ApaI polymorphisms are associated with susceptibility to ovarian cancer in European populations.

Ovarian cancer evolution through stochastic genome alterations: defining the genomic role in ovarian cancer

Ovarian cancer is the fifth leading cause of death among women worldwide. Characterized by complex etiology and multi-level heterogeneity, its origins are not well understood. Intense research efforts over the last decade have furthered our knowledge by identifying multiple risk factors that are associated with the disease. However, it is still unclear how genetic heterogeneity contributes to tumor formation, and more specifically, how genome-level heterogeneity acts as the key driving force of cancer evolution. Most current genomic approaches are based on 'average molecular profiling.' While effective for data generation, they often fail to effectively address the issue of high level heterogeneity because they mask variation that exists in a cell population. In this synthesis, we hypothesize that genome-mediated cancer evolution can effectively explain diverse factors that contribute to ovarian cancer. In particular, the key contribution of genome replacement can be observed during major transitions of ovarian cancer evolution including cellular immortalization, transformation, and malignancy. First, we briefly review major updates in the literature, and illustrate how current gene-mediated research will offer limited insight into cellular heterogeneity and ovarian cancer evolution. We next explain a holistic framework for genome-based ovarian cancer evolution and apply it to understand the genomic dynamics of a syngeneic ovarian cancer mouse model. Finally, we employ single cell assays to further test our hypothesis, discuss some predictions, and report some recent findings.

Accelerating type-specific ovarian carcinoma research: Calculator for Ovarian Subtype Prediction (COSP) is a reliable high-throughput tool for case review

AIMS

The recent recognition that ovarian carcinoma is composed of five distinct disease entities has served to increase the value of accurate histotyping. Reliable identification of histotypes is essential for the success of studies testing novel therapies, as well as for biomarker discovery research. The aim of this study was to examine the utility of a nine-marker immunohistochemical (IHC) panel, designated the Calculator for Ovarian Subtype Prediction (COSP), to reliably reproduce the consensus diagnosis of two expert gynaecological pathologists.

METHODS AND RESULTS

A total of 423 cases from the AGO-OVAR11 trial were evaluated using the COSP IHC panel, and compared to original diagnoses from >100 local contributing pathologists and independent expert gynaecopathology review. The overall concordance between COSP and expert review was 89%; in cases where a local pathologist's diagnosis was confirmed by COSP, the expert gynaecopathologist also agreed in 97.5% of cases.

CONCLUSIONS

The incorporation of COSP into a high-throughput diagnostic review algorithm will decrease the need for expert review by identifying a small number of difficult cases that truly require expert review. This modification will serve to increase the efficiency of the diagnostic review process, which will probably serve to reduce operational costs and expedite translational studies on ovarian carcinoma.

Agreement for tumor grade of ovarian carcinoma: analysis of archival tissues from the surveillance, epidemiology, and end results residual tissue repository

BACKGROUND

Emerging data suggest that ovarian cancers differ by tumor grade. However, the reliability of microscopic grade from paraffin tissue in the general medical community and as reflected in population-based cancer registries is unknown.

METHODS

We examined grade agreement between two gynecologic pathologists and the Surveillance Epidemiology and End Results Residual Tissue Repository (SEER). Grade agreement was assessed with percent observer agreement and kappa coefficients for 664 invasive ovarian carcinomas, using previously defined three-tier and two-tier grading systems. A random subset of ovarian carcinomas was selected to compare intra- and inter-pathologist agreement.

RESULTS

Five hundred and eighty-six of SEER's 664 tumors were confirmed invasive. Percent agreement was 49 % with fair kappa coefficient = 0.25 (95 % CI: 0.20-0.30) for the 664 tumors. Agreement improved slightly when restricted to the 586 confirmed invasive cancers; it was better for high grade than low grade tumors, for two-tier than three-tier grading systems, and within (66 %) than between study pathologists (43 %). Grade was not a robust independent predictor of ovarian cancer-specific survival.

CONCLUSIONS

Grade agreement was fair between SEER and study pathologists irrespective of grading system. Recorded grade in SEER should be used with caution and is probably not a reliable metric for ovarian cancer epidemiology.

Is tumor size the limiting factor in a laparoscopic management for large ovarian cysts?

PURPOSE

To assess the feasibility and short-term surgical outcome of laparoscopic surgery among women with large ovarian cysts.

METHODS

We retrospectively evaluated consecutive 81 patients who received laparoscopic management for ovarian cysts with diameter ≥ 10 cm and without radiologic features suggestive of malignancy, from March 2008 to September 2011.

RESULTS

Laparoscopic surgery was successful in 77 (95.1 %) of the total patients. The mean (range) operative time, estimated blood loss (EBL) and hospital stay were 107.6 (55-250 min), 226.9 (10-1300 mL) and 6.1 (4-15 days), respectively. The surgical procedures performed included salpingooophorectomy (SO) (n = 44), ovarian cystectomy (OC) (n = 22), adhesiolysis (n = 1), salpingectomy (n = 2) and total laparoscopic hysterectomy (TLH) with SO (n = 8). Conversion to laparotomy occurred with four patients. One patient had postoperative bleeding and one had minor complications associated with wound oozing at the umbilical port site. Histopathological examination revealed benign tumors in 76 patients (93.8 %), borderline ovarian tumor in three patients (3.7 %) and invasive epithelial ovarian cancer in two patients (2.5 %). Clinicopathological variables according to tumor size were not statistically different. Complications did not appear in any patients during the follow-up period.

CONCLUSION

With proper patient selection, laparoscopy is a feasible and safe treatment for women with large ovarian cysts and tumor size did not have effect on laparoscopic management. However, surgeons should carefully consider the potential risk of malignancy in such patients.

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.

High-Grade Serous Carcinoma Involving Fallopian Tube, Ovary and Peritoneum

The focus of this review is high-grade serous carcinoma (HGSC); for the purposes of this review, the term "pelvic SC" is used for HGSC that could be considered, based on historical definitions, to have arisen from ovary, fallopian tube, or peritoneum. These assignments of primary site are arbitrary and there is evidence that the distal fallopian tube is the site of origin of many pelvic HGSCs. The diagnosis of HGSC can be made readily based on routine histomorphologic examination in most cases; however, a variety of neoplasms can resemble HGSC. Thus, we review the key features of pelvic SC, current concepts of its pathogenesis, histopathological diagnostic criteria, discuss differential diagnosis, and review diagnostic ancillary studies that can be used in practice.

Differences in tumor type in low-stage versus high-stage ovarian carcinomas

Although there are recognized differences in the type of ovarian carcinomas between those tumors diagnosed at low versus high stage, there is a lack of data on stage distribution of ovarian carcinomas diagnosed according to the current histopathologic criteria from large population-based cohorts. We reviewed full slide sets of 1009 cases of 2555 patients diagnosed with ovarian carcinoma that were referred to the British Columbia Cancer Agency over a 16-year period (1984 to 2000). On the basis of the reviewed cases we extrapolated the distribution of tumor type in low-stage (I/II) and high-stage (III/IV) tumors. We then compared the frequencies with those seen in a large hospital practice. The overall frequency of tumor types was as follows: high-grade serous-68.1%, clear-cell-12.2%, endometrioid-11.3%, mucinous-3.4%, low-grade serous-3.4%, rare types-1.6%. High-grade serous carcinomas accounted for 35.5% of stage I/II tumors and 87.7% of stage III/IV tumors. In contrast, clear-cell (26.2% vs. 4.5%), endometrioid (26.6% vs. 2.5%), and mucinous (7.5% vs. 1.2%) carcinomas were relatively more common among the low-stage versus high-stage tumors. This distribution was found to be very similar in 410 consecutive cases from the Washington Hospital Center. The distribution of ovarian carcinoma types differs significantly in patients with low-stage versus high-stage ovarian carcinoma when contemporary diagnostic criteria are used, with consistent results seen in 2 independent case series. These findings reflect important biological differences in the behavior of the major tumor types, with important clinical implications.

Ovarian carcinoma pathology and genetics: recent advances

In this review we summarize recent advances in the histopathological diagnostic criteria and molecular pathology of the main subtypes of ovarian surface epithelial carcinoma. These advances have greatly improved our understanding of the biology of ovarian carcinoma and are also relevant to patient management. With progress toward subtype-specific treatment of ovarian carcinoma, accurate, reproducible histopathological diagnosis of these subtypes by practicing pathologists is increasingly important.

IGF2BP3 (IMP3) expression is a marker of unfavorable prognosis in ovarian carcinoma of clear cell subtype

Clear cell carcinoma is an uncommon subtype of ovarian carcinoma, accounting for 10% of cases. Clear cell carcinoma typically presents with stage I or II disease, and in this setting prognostic markers could aid in management decisions, in particular the decision to treat with adjuvant chemotherapy. We tested whether expression of insulin-like growth factor 2 mRNA-binding protein 3 (IGF2BP3, also known as IMP3) can serve as a new biomarker to predict outcome for patients with clear cell carcinoma and other subtypes of ovarian carcinoma. The expression of IGF2BP3 was evaluated by immunohistochemistry in 475 ovarian carcinomas of different subtypes and correlated with disease-specific survival. IGF2BP3 antibody specificity was validated by correlation of IGF2BP3 protein with mRNA expression level in a series of 35 ovarian carcinomas (r=0.849, P<0.0001). IGF2BP3 protein expression was an independent marker of reduced disease-specific survival (risk ratio 2.9, 95% confidence interval 1.4-5.8) in the clear cell subtype (N=128), but not in high-grade serous (N=198) or endometrioid (N=121) carcinomas. The prognostic significance of IGF2BP3 expression for reduced disease-specific survival (risk ratio 2.6, 95% confidence interval 1.3-5.0) was confirmed in an independent series of cases (N=150) from three different centers in North America. We conclude that IGF2BP3 is the first biomarker of prognostic significance in ovarian clear cell carcinoma that has been validated in an independent case series.

A limited panel of immunomarkers can reliably distinguish between clear cell and high-grade serous carcinoma of the ovary

The distinction of ovarian clear cell carcinomas (CCCs) from high-grade serous carcinomas (HG-SCs) is sometimes a diagnostic challenge. With the recognition that CCCs respond poorly to conventional chemotherapy there are efforts to initiate clinical trials for CCC, making accurate diagnosis critical. The purpose of this study was to test and validate a set of antibodies that could aid in the diagnosis of CCC, using a series of cases from different centers in North America. Using a test set of 133 CCCs, we identified the following markers: Cyclin E, estrogen receptor, hepatocyte nuclear factor (HNF)-1beta, Ki-67, p21, p53, and Wilms tumor (WT)1 that show significant discrimination from 200 HG-SCs. For validation, these markers were characterized on an independent set of 104 CCCs from 3 other centers. There were no significant differences in expression of these 7 markers between the independent test and validation sets of CCC. Combining all CCC cases (N=237), HNF-1beta showed the highest sensitivity (82.5%) and specificity (95.2%) for CCC, and WT1 for HG-SC (sensitivity: 79.9%, specificity: 97.4%). A diagnostic panel consisting of WT1, ER, and HNF-1beta demonstrated nearly identical performance as a panel using all 7 markers in distinguishing CCCs from HG-SCs, correctly classifying 84% of cases. Three percent of cases were misclassified and 13% carried an uninformative triple negative immunophenotype. CCCs show a distinct, reproducible immunophenotype, compared with HG-SCs, and a panel of 3 immunomarkers can serve as a diagnostic aid in problematic cases.

Chromosomal instability in fallopian tube precursor lesions of serous carcinoma and frequent monoclonality of synchronous ovarian and fallopian tube mucosal serous carcinoma

OBJECTIVES

Pelvic serous carcinomas are classified according to the location of greatest mass of tumor as ovarian, peritoneal or fallopian tube. Recent studies suggest these cancers may arise in the fallopian tube. This study explores the relationship between ovarian cancers and fallopian tube mucosal involvement.

METHODS

Sixteen consecutive cases of epithelial ovarian malignancy were prospectively identified and the fallopian tubes submitted in toto for histopathological examination for tubal mucosal involvement. Immunohistochemical staining for p53 and Ki-67, and fluorescent in situ hybridization (FISH) analysis for chromosomal copy number changes were performed on 10 cases. Three cases of mucosal epithelial abnormalities identified in risk-reducing salpingectomy specimens were similarly characterized.

RESULTS

Of sixteen cases, twelve were high-grade serous carcinoma, stage III, and four cases were stage I, two borderline mucinous, one borderline serous, and one low-grade mucinous carcinoma. Ten cases of high-grade serous carcinoma showed either unilateral fallopian tube mucosal involvement (n = 7) or tubal obliteration ipsilateral to the dominant ovarian mass (n = 3), compared to none of the other carcinomas. FISH analysis showed similar copy number changes in the ovarian and fallopian tube mucosal carcinoma in 3 cases, suggesting a unifocal origin; one case had differences suggesting multifocal origin of cancer. One case had equivocal FISH results. From risk-reducing salpingectomy cases, the multiple foci of tubal intraepithelial carcinoma and focus of invasive carcinoma showed similar gene copy number changes within each case, suggesting monclonality. Both cases of epithelial atypia/dysplasia showed gene copy number changes.

CONCLUSIONS

Fallopian tube mucosal and ovarian tumors have similar genetic abnormalities in most cases, indicating a monoclonal origin that may originate either from the ovary, peritoneum or fallopian tube. In situ epithelial lesions of the fallopian tube from risk-reducing salpingectomies show gene copy abnormalities consistent with these being early lesions of serous carcinoma and suggest that chromosomal instability is a very early event in serous carcinogenesis.

Pathology of stage I versus stage III ovarian carcinoma with implications for pathogenesis and screening

The progression of ovarian carcinoma from stage I when it is confined to the ovaries and curable to disseminated abdominal disease, which is usually fatal, is poorly understood. An accurate understanding of this process is fundamental to designing, testing, and implementing an effective screening program for ovarian cancer. Pathologic features of the primary ovarian tumors in 41 FIGO stage I ovarian carcinomas were compared with those in 40 stage III carcinomas. The primary ovarian tumors in stage I cases, when compared with stage III, respectively, were significantly larger (15.4 versus 9.8 cm), were less frequently bilateral (12% versus 75%), more frequently contained a noninvasive component (88% versus 30%), had a higher proportion of a noninvasive component (42% versus 8%), and were more often nonserous (83% versus 20%) (P< 0.001 for all five comparisons). There are significant pathologic differences between the primary ovarian tumors in stage I and III ovarian carcinomas that are very difficult to explain by a simple temporal progression. These findings along with the growing body of literature suggest that early- and advanced-stage ovarian cancers are in many instances biologically different entities. This knowledge may have significant implications for our understanding of the biology of early- and advanced-stage ovarian cancer and therefore on the development of screening strategies for ovarian cancer.

Do clear cell ovarian carcinomas have poorer prognosis compared to other epithelial cell types? A study of 1411 clear cell ovarian cancers

OBJECTIVE

To compare the clinico-pathologic characteristics and survival of women with clear cell versus other epithelial ovarian cancers.

METHODS

Data were obtained from the Surveillance, Epidemiology and End Results Program between 1988 and 2001 and analyzed using Kaplan-Meier and Cox proportional hazards models.

RESULTS

Of 28,082 women with epithelial ovarian cancer, 1411 (5%) had clear cell, 13,835 (49.3%) papillary serous, 3655 (13%) endometrioid, 2711 (9.7%) mucinous, and 6470 (23%) had unspecified histologies. The median age of overall patients was 64 years; with clear cell patients presenting at younger age (55 years). The proportion of clear cell histology was significantly higher in Asians versus Whites, Blacks, and others (11.1% versus 4.8%, 3.1%, and 5.5%; p<0.001). Clear cell carcinoma is more likely to be diagnosed at early-stage (67.3%) compared to 19.2% in serous, 61.6% endometrioid, and 61.3% in mucinous carcinomas (p<0.005). Retroperitoneal lymph node metastases were found in 13.6% of serous carcinomas, 7.9% clear cell, 7.3% endometrioid, and 3.8% of mucinous (p<0.001). Adjusted for stage, the 5-year disease-specific survival of patients with clear cell carcinoma is worse compared to serous: 85.3% vs. 86.4% for stage I, 60.3% vs. 66.4% stage II, 31.5% vs. 35.0% stage III, and 17.5% vs. 22.2% for stage IV, respectively (p<0.001). On multivariate analysis, age, stage, grade, histology, and surgical treatment were independent predictors of disease-specific survival.

CONCLUSIONS

Our data suggest that women with clear cell ovarian cancer present at a younger age, are more likely to be Asian, and have a poorer prognosis compared to serous cancers.

Poor prognosis of intraoperative rupture of mature cystic teratoma with malignant transformation

OBJECTIVE

To present the phenomenon of the postoperative rapid progression of mature cystic teratoma (MCT) with malignant transformation (MT) when intraoperative spillage occurs during operation.

CASE REPORTS

Two patients with MCT were treated, one with total hysterectomy plus bilateral salpingo-oophorectomy in an exploratory laparotomy, and the other with cystectomy with laparoscopy, respectively. Tumor spillage occurred during both operations. The postoperative pathology showed MCT with MT (squamous cell carcinoma type). Both patients were referred to our hospital and underwent treatment (3 months and 8 days, respectively, after the initial operation). At the secondary laparotomy for staging surgery, tumor dissemination was observed in both patients.

CONCLUSION

Whether or not tumor dissemination is correlated with tumor rupture during operation, we emphasize that any patient with a preoperative diagnosis of MCT should have it removed intact to avoid the possibly catastrophic event of tumor dissemination.

Clear cell carcinoma of the ovary: a retrospective multicentre experience of 254 patients with complete surgical staging

A retrospective analysis was performed to evaluate the clinical characteristics and prognostic factors in the patients with clear cell carcinoma (CCC) of the ovary. After central pathological review and scanning of the medical records of nine Japanese institutions between 1992 and 2003, a total of 254 patients with CCC of the ovary were enrolled in the present study. Mean age was 52.4 years (range 23–73 years). Tumours were 13% (33/254) stage Ia, 36% (92/254) stage Ic, 13% (33/254) stage II, 30% (80/254) stage III, and 6% (16/254) stage IV. Five-year progression-free survival and overall survival was 84 and 88% in stage I, 57 and 70% in stage II, 25 and 33% in stage III and 0 and 0% in stage IV, respectively. Retroperitoneal lymph node metastasis was observed in 9% in pT1a tumours, 7% in pT1c tumours, 13% in pT2 tumours, and 58% in pT3 tumours, respectively. There was no survival benefit according to chemotherapeutic differences in the patients who received complete surgical staging procedures and conventional chemotherapy. Peritoneal cytological status was an independent prognostic factor in stage Ic patients (P=0.03) and only residual tumour diameter was an independent prognostic factor in stage III, IV patients (P=0.02). Our results suggest that cytoreductive surgery resulting in no residual tumour only could improve the prognosis of advanced CCC patients.

Diagnosis and management of epithelial ovarian cancer

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States. Although there has been a statistically significant improvement in 5-year survival, in 2005 more than 16,000 women were expected to die of this disease. To date, there is no reliable method to screen for ovarian cancer; therefore, the majority of cases are diagnosed with advanced disease. For early ovarian cancer, appropriate surgical staging and adjuvant chemotherapy for selected cases will result in survival rates of 90-95%. For advanced ovarian cancer, survival depends primarily on the success of the initial surgical procedure. Patients with complete cytoreduction to microscopic disease are often cured with adjuvant chemotherapy. There is growing evidence that these patients with microscopic residual disease are excellent candidates for intraperitoneal chemotherapy, and this mode of chemotherapy delivery may be their best opportunity for cure. Patients with optimal cytoreduction also may benefit from intraperitoneal chemotherapy, but cure is less likely. For patients with suboptimal cytoreduction, intravenous chemotherapy with a combination of carboplatin and paclitaxel is the current standard therapy. Most of these patients will experience recurrence of the cancer, with small chance of cure. Salvage chemotherapy is important in ovarian cancer because many patients respond to several salvage regimens. Because of the high response rate of ovarian cancer, even after relapse, it is probably better to consider 10-year survival as the ideal end point. Finally, new biologic agents, in combination with traditional surgery and chemotherapy, may result in further improvement in survival for patients with ovarian cancer.

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.

Borderline epithelial tumors of the ovary

The concept and terminology of borderline epithelial tumors of the ovary have been controversial for over a century, in spite of the acceptance of a borderline category in almost all current classifications of ovarian tumors. Typically, borderline tumors are noninvasive neoplasms that have nuclear abnormalities and mitotic activity intermediate between benign and malignant tumors of similar cell type. Borderline tumors of all surface epithelial cell types have been studied. The most common and best understood are serous borderline tumors and mucinous borderline tumors of intestinal type, which are the subject of this review. Some of the most challenging issues for serous tumors include: the criteria and clinical behavior of stromal microinvasion; the high prevalence of synchronous extraovarian disease; the classification and histopathologic features of associated peritoneal tumor implants, especially invasive implants; and, the prognostic significance of micropapillary tumors. The mucinous borderline tumors of intestinal type have a different set of considerations, including: their frequently heterogeneous composition with coexisting benign, borderline and malignant elements; the classification and significance of accompanying noninvasive carcinoma; the recognition of stromal invasion, including microinvasion and expansile invasion; and, the historically misunderstood relationship to pseudomyxoma peritonei. All of these issues are discussed in this presentation, as are the important gross and microscopic features of serous and mucinous borderline tumors and pertinent information on their treatment and prognosis.

Her-2/neu expression and amplification in early stage ovarian surface epithelial neoplasms

OBJECTIVE

The aim of this study is to examine Her-2/neu gene amplification and protein overexpression in a spectrum of ovarian neoplasms using both immunohistochemical (IHC) and fluorescence in situ hybridization (FISH) techniques that are FDA approved. This study is focused on early stage tumors including both carcinomas and borderline tumors.

METHODS

FDA-approved IHC and FISH for Her-2/neu were performed on formalin-fixed, paraffin-embedded tissue from 79 ovarian neoplasms representing a broad spectrum of tumor types as well as four normal ovaries. All tumors were either stage I or stage II. Tumor and normal tissue were studied collectively using a tissue microarray (TMA). HercepTest (DAKO) and PathVysion Her-2/neu probe kit (Vysis Inc.) were used for IHC and FISH analysis.

RESULTS

FISH analysis of serous carcinomas demonstrated Her-2/neu gene amplification in 3 (18%) of 17 cases. Two of three cases showing Her-2/neu gene amplification were scored 1+ using IHC, while the remaining case was scored as 0. Analysis of endometrioid carcinomas demonstrated Her-2/neu amplification using FISH in 1 of 10 (10%) cases. IHC in this case was scored 2+ (positive). None of the remaining 44 tumors, including clear cell carcinoma (n = 12), transitional cell carcinoma (n = 1), mixed epithelial carcinoma (n = 7), carcinoma not otherwise specified (n = 1), and 31 borderline tumors (mucinous, n = 17; endometrioid, n = 7; serous, n = 7), showed Her-2/neu gene amplification or protein overexpression. Normal ovaries were negative as well.

CONCLUSIONS

Amplification of Her-2/neu in early stage ovarian neoplasms is infrequent, 6.7% overall. Due to the limited number of informative cases, we were unable to determine the clinical significance of Her-2/neu amplification in this study. Her-2/neu amplification was restricted to carcinomas and was not encountered in ovarian borderline tumors.

Borderline ovarian tumors: diverse contemporary viewpoints on terminology and diagnostic criteria with illustrative images

The National Cancer Institute sponsored a Borderline Ovarian Tumor Workshop held in August 2003 in Bethesda, MD. This report was developed from discussions at the Workshop. The participants acknowledged several areas of disagreement on basic terminology issues and agreed that a glossary with example images would help clarify many commonly misunderstood issues. This report defines terminology used in the pathological description of borderline tumors and their variants, and illustrates examples of each of the most common entities. It also addresses controversial aspects of the definitions and issues involving specimen handling and reporting. For those issues where there is disagreement, the terminology and diagnostic approaches reflecting the differing views are presented.

Current challenges and opportunities for research on borderline ovarian tumors

This article summarizes key issues for future research on borderline ovarian tumors that emerged at a National Cancer Institute-sponsored Borderline Ovarian Tumor Workshop held in August 2003 in Bethesda, MD. Limitations in existing research and opportunities for future advances have been highlighted. The application of new molecular techniques in combination with improved study designs holds promise for elucidating the pathogenesis of these tumors and revealing the source of the extra-ovarian lesions ("implants") with which they are frequently associated. Clarification of the etiology of borderline tumors and the pathogenesis of their associated implants is critical for improving pathological diagnosis, revising the classification system of ovarian neoplasms, and developing optimal, evidence-based clinical management algorithms.