Ovarian epithelial carcinoma with estrogen-producing stroma

Reevaluating the Role of Progesterone in Ovarian Cancer: Is Progesterone Always Protective?

Ovarian cancer (OC) represents a collection of rare but lethal gynecologic cancers where the difficulty of early detection due to an often-subtle range of abdominal symptoms contributes to high fatality rates. With the exception of BRCA1/2 mutation carriers, OC most often manifests as a post-menopausal disease, a time in which the ovaries regress and circulating reproductive hormones diminish. Progesterone is thought to be a "protective" hormone that counters the proliferative actions of estrogen, as can be observed in the uterus or breast. Like other steroid hormone receptor family members, the transcriptional activity of the nuclear progesterone receptor (nPR) may be ligand dependent or independent and is fully integrated with other ubiquitous cell signaling pathways often altered in cancers. Emerging evidence in OC models challenges the singular protective role of progesterone/nPR. Herein, we integrate the historical perspective of progesterone on OC development and progression with exciting new research findings and critical interpretations to help paint a broader picture of the role of progesterone and nPR signaling in OC. We hope to alleviate some of the controversy around the role of progesterone and give insight into the importance of nPR actions in disease progression. A new perspective on the role of progesterone and nPR signaling integration will raise awareness to the complexity of nPRs and nPR-driven gene regulation in OC, help to reveal novel biomarkers, and lend critical knowledge for the development of better therapeutic strategies.

Ovarian high-grade serous carcinoma with estrogenic manifestations in a postmenopausal woman: A case report

Background

Hormonally active ovarian tumors include a variety of pathologies such as sex-cord-stromal tumors, germ cell tumors, tumors with neuroendocrine differentiation, and tumors with functioning stroma. In addition, although the precise mechanism is unknown, epithelial ovarian cancers can be associated with elevated serum estrogen levels on rare occasions.

Case

A 56-year-old postmenopausal woman (gravida 3, para 3) with a history of hyperlipidemia was referred due to the discovery of a heterogenous right adnexal mass after presenting to her physician with genital bleeding and nipple discharge associated with breast tension. Her serum cancer antigen 125 (CA125) level was 136.5 U/mL at the initial examination, and serum estradiol and testosterone levels were 214.8 pg/mL and 236.3 ng/dL, respectively. Endometrial thickening was also observed. The diagnosis was a mixed cystic and solid right adnexal mass, implying malignant ovarian tumor but not completely ruling out sex-cord-stromal tumor. Laparoscopic-assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and partial omentectomy were performed. Cancer cells were detected in the peritoneal cytology of pooled ascites. Histological examination revealed high-grade serous carcinoma of the right ovary. Six cycles of paclitaxel and carboplatin chemotherapy were administered postoperatively. At three-year follow-up, there was no evidence of disease recurrence, including re-elevation of CA125, or of serum estradiol, or of testosterone.

Conclusions

Epithelial ovarian cancer should be considered in postmenopausal women presenting with a pelvic mass and raised hormonal profile, and these patients should be managed according to an epithelial ovarian cancer treatment paradigm.

Hyperestrogenism on 18F-FDG PET/CT in a Patient With Estrogen-Producing Ovarian Clear Cell Carcinoma

A 78-year-old woman was referred to the gynecologic outpatient department because she was suspected of having ovarian cancer based on an imaging study performed during a general medical examination. Further examination using F-FDG PET/CT revealed a bulky mass lesion with low FDG avidity, as well as surprisingly strong bilateral breast radiotracer uptake despite the patient's age. Thus, an estrogen-producing tumor was suspected. Bilateral salpingo-oophorectomy was performed, and surgical pathology diagnosed the tumor as clear cell carcinoma of the ovary.

Endometriosis and ovarian cancer: Their association and relationship

Objectives

To study endometriosis-associated borderline or malignant ovarian epithelial tumors by analyzing their differential clinical features, as well as the histological pattern, survival and immunohistochemical data compared with those without associated endometriosis.

Study design

Setting: Hospital Marina Baixa and San Juan University Hospital, Alicante, Spain. This retrospective study included clinical and pathological data from 36 operated cases with endometriosis-associated ovarian epithelial tumors and 305 cases of ovarian epithelial tumors without endometriosis, including borderline and invasive tumors. We also studied hormonal receptors and p53 protein expression in 13 cases with endometriosis-associated endometrioid and clear cell tumors, and report two cases with histologically-confirmed previous endometriosis.

Results

Associated endometriosis was observed in 10.5% of patients with borderline or invasive ovarian epithelial tumor, 53% of those with endometrioid, and 22% with clear cell tumors. Patients with endometriosis-associated ovarian epithelial tumors were younger, had lower parity, were more frequently premenopausal, had a lower tumor stage or were borderline, and in general had better prognosis and longer survival, although they also more frequently had an associated endometrial carcinoma. Associated endometriosis and endometrioid tumors were generally estrogen-receptor positive, whereas they were negative in the clear cell tumor component. p53 protein positivity was generally observed in clear cell tumors and in associated endometriosis. Two reported cases with previous, known endometriosis were followed in their evolution to borderline endometrioid carcinoma and clear cell carcinoma, respectively.

Conclusions

Our results and review of the literature suggest that the association of ovarian epithelial tumors and endometriosis is a factor for good prognosis for ovarian cancer and that this association might correspond in many cases to an intermediate stage in the development of endometriosis to endometrioid, clear cell, or other invasive carcinomas.

Estrogen producing ovarian fibrosarcoma: A case report

Fibrosarcoma is an extremely rare malignant sex-cord stromal tumor. Fibrosarcoma is generally unknown as an estrogen producing tumor. This report presents, for the first time, a case of estrogen producing ovarian fibrosarcoma in an 83-year-old female. We performed total hysterectomy, bilateral salpingo-oophorectomy and omentectomy. Histopathologically, the tumor of the left ovary had high cellularity, cellular atypia and 10-15 mitotic counts per 10 high power fields. The tumor contained small components composed of cells that were similar to Sertoli cells. In an effort to examine which component was producing estrogen, we checked aromatase expression; but both components were positive. We could not explain which component was producing estrogen. Postoperative clinical stage was IA. As she was geriatric patient, we did not recommend adjuvant chemotherapy. There were no signs of recurrence or increase in serum estradiol level at two years after the operation.

Endometriosis-associated Ovarian Cancers

Endometriosis-associated cancers include clear cell and endometrioid ovarian carcinoma. A history of endometriosis has long been considered to be a risk factor for later development of these malignancies; however, recent molecular genetic evidence has provided unequivocal evidence that these lesions are in fact the precursors for endometriosis-associated cancers. Herein, we will explore the relationship between endometriosis and ovarian carcinomas, similarities between the premalignant lesions and their cancerous counterparts, and the potential role of mutations and the ovarian microenvironment that may contribute to malignant transformation.

Steroid hormone synthesis by the ovarian stroma surrounding epithelial ovarian tumors: a potential mechanism in ovarian tumorigenesis

Epithelial ovarian tumors are responsive to steroid hormone stimulation and the ovarian stroma may have a direct role in this process. We evaluated immunohistochemical markers of sex-steroid differentiation and steroidogenesis (calretinin, inhibin, steroidogenic factor 1), steroid enzymes involved in hormone biosynthesis (CYP17, CYP19, HSD17β1, AKR1C3), and hormone receptors (estrogen receptor, progesterone receptor, and androgen receptor) in 101 epithelial ovarian tumors and in normal structures implicated in ovarian carcinogenesis (ovarian surface epithelium and cortical inclusion cysts) in an attempt to elucidate this process. We hypothesized that ovarian stroma immediately adjacent to tumors express markers of sex-steroid differentiation and steroidogenesis and steroid enzymes whereas the epithelium contains corresponding hormone receptors. As the findings in seromucinous, endometrioid, and clear cell neoplasms, tumors closely associated with endometriosis, were very similar, these were combined into a group designated 'endometriosis-related tumors.' Significantly increased expression of markers of sex-steroid differentiation and steroidogenesis was found in stroma immediately adjacent to endometriosis-related tumors (P=0.003) and mucinous tumors (primary and metastatic mucinous tumors were combined because of similar findings) (P<0.0001) compared with more remote ovarian stroma. In addition, sex-steroid enzymes were increased in stroma adjacent to endometriosis-related tumors (P=0.02) and mucinous tumors (P=0.02) compared with more distant stroma. Steroid hormone receptors showed greater expression in epithelium compared with stroma in the endometriosis-related tumors (P=0.0009), low-grade serous tumors (P<0.0001), and high-grade serous carcinoma (P=0.0036). In contrast, there was greater expression in stroma compared with epithelium (P<0.0001) in mucinous tumors, which may be due to the fact that they are not derived from müllerian epithelium. In conclusion, our findings strongly support the view that the stroma surrounding epithelial tumors in the ovary is activated to elaborate steroid hormones which may stimulate further neoplastic growth. The precise mechanisms by which this process might occur are complex and require further investigation.

17β Hydroxysteroid dehydrogenase type 12 (HSD17B12) is a marker of poor prognosis in ovarian carcinoma

OBJECTIVE

17β-hydroxysteroid dehydrogenase isoform 12 (HSD17B12) overexpression is associated with poor clinical outcome in invasive ductal carcinoma of the breast. Here, we evaluated HSD17B12 overexpression and its activity in ovarian carcinoma (OvCa) to determine its role in the growth and progression of this tumor.

METHODS

Immunohistochemical analysis of HSD17B12 expression was performed in 100 tissue samples of untreated OvCa and was correlated with clinicopathologic characteristics and patient outcome. In A2780 OvCa cell line expressing HSD17B12, siRNA knockdown of the enzyme was performed, and its effects on tumor cell growth and Annexin V binding were determined.

RESULTS

HSD17B12 expression was detected in all tumor samples, but the staining intensity was variable. Normal ovarian epithelium was negative. Patients with tumor showing weak/moderate expression of HSD17B12 had a better overall survival than those with strongly positive tumors (p<0.001). The time to first recurrence was longer for patients with tumors with heterogeneous staining relative to patients with tumors that were uniformly positive (p<0.001). Upon silencing of HSD17B12 in tumor cells, their growth was inhibited (p<0.005) and apoptosis was increased (p<0.05). Arachidonic acid but not estradiol reversed the growth inhibition mediated by HSD17B12 knockdown.

CONCLUSION

HSD17B12 overexpression is shown to be a marker of poor survival in patients with OvCa. Expression in the tumor and function of this enzyme facilitates OvCa progression.

Estrogen-producing endometrioid adenocarcinoma resembling sex cord-stromal tumor of the ovary: a review of four postmenopausal cases

Abstract

The 4 present cases with endometrioid adenocarcinoma (EMA) of the ovary were characterized by estrogen overproduction and resemblance to sex cord-stromal tumor (SCST). The patients were all postmenopausal, at ages ranging from 60 to 79 years (av. 67.5), who complained of abdominal discomfort or distention and also atypical genital bleeding. Cytologically, maturation of the cervicovaginal squamous epithelium and active endometrial proliferation were detected. The serum estrogen (estradiol, E2) value was preoperatively found to be elevated, ranging from 48.7 to 83.0 pg/mL (av. 58.4). In contrast, follicle stimulating hormone was suppressed to below the normal value. MR imaging diagnoses included SCSTs such as granulosa cell tumor or thecoma for 3 cases because of predominantly solid growth, and epithelial malignancy for one case because of cystic and solid structure. Grossly, the solid part of 3 cases was homogeneously yellow in color. Histologically, varying amounts of tumor components were arranged in solid nests, hollow tubules, cord-like strands and cribriform-like nests in addition to the conventional EMA histology.

In summary, postmenopausal ovarian solid tumors with the estrogenic manifestations tend to be preoperatively diagnosed as SCST. Due to this, in the histological diagnosis, this variant of ovarian EMA may be challenging and misdiagnosed as SCST because of its wide range in morphology.

Virtual slides

http://www.diagnosticpathology.diagnomx.eu/vs/6096841358065394

Synchronous ovarian endometrioid adenocarcinoma with a functioning stroma and endometrial endometrioid adenocarcinoma by different loss of heterozygosity findings

PURPOSE

Mucinous epithelial ovarian tumors generally have estrogenic stroma, although the frequency of endometrioid adenocarcinoma with functioning stroma is very low. And while synchronous development of carcinomas in the endometrium and ovaries is a fairly common phenomenon, the distinction of a single clonal tumor with metastasis from two independent primary tumors may present a diagnostic challenge. We present a rare case of a 31-year-old woman with endometrioid adenocarcinoma of the ovary with functioning stroma and endometrial endometrioid adenocarcinoma who showed symptoms of virilization. Her preoperative levels of serum testosterone and estradiol were as high as 553 ng/dL and 177 pg/mL, respectively, and her serum gonadotropin levels were suppressed. After surgery, the serum levels of testosterone and estradiol decreased and that of follicle-stimulating hormone increased.

METHODS

To develop a mean of differentiating a single tumor with metastasis from synchronous primary ovarian and endometrial cancers, we performed a microsatellite analysis. Twenty-five dinucleotide microsatellite markers were selected, and microsatellite analysis was performed by a high-resolution method using fluorescence-labeled polymerase chain reaction and laser scanning.

RESULTS

In this case, both ovarian carcinoma and endometrial carcinoma demonstrated loss of heterozygosity (LOH). However, the LOH findings of the ovarian tumor and endometrial tumor were different.

CONCLUSIONS

Loss of heterozygosity analysis may be helpful to differentiate synchronous primary ovarian and endometrial cancers from a single tumor with metastasis.

Hormone therapy for epithelial ovarian cancer

PURPOSE OF REVIEW

Hormonal therapy has been used erratically to treat epithelial ovarian cancer since the mid 1960s; however, there has been little progress until recently in our understanding of which patients might benefit from treatment. Some clarity in the field is now beginning to emerge from recent studies, which have started to define biomarkers within epithelial ovarian cancers that link with hormonal response and thereby indicate which cohort of patients might be amenable to hormonal treatment.

RECENT FINDINGS

Oestrogen-deprivation therapy in the form of the aromatase inhibitor letrozole has demonstrated activity in three clinical studies. As only a minority of patients will benefit from hormonal approaches, recent efforts have focussed on the use of molecular markers to help identify which subgroup of patients might respond to treatment. Parallel laboratory studies using primary cancer material for which endocrine response is known and model-based findings have identified components of oestrogen signalling pathways that may help predict outcome.

SUMMARY

Use of the antioestrogen letrozole in ovarian cancer has consistently demonstrated a significant level of activity and the larger clinical studies have linked response with oestrogen receptor alpha expression and other biomarkers.