Prognostic factors of ovarian granulosa cell tumor: a study of 35 patients and review of the literature

Hormonal Therapy in Pretreated Patients With Recurrent Ovary Granulosa Cell Tumor

Objective: To evaluate the effectiveness of hormonal therapy (HT) in patients with recurrent adult ovary granulosa cell tumors. Methods: The clinical and treatments features of the patients who received HT were studied retrospectively. The efficacy and safety of HT were evaluated. The Kaplan-Meier technique was used to conduct survival analysis. Results: The research involved a total of thirteen patients. The median age of the participants was 49 years (range: 34-61). Since diagnosis, the median number of surgeries has been three (range: 2-8). At least one chemotherapy regimen has been administered to 12 (92.3%) patients. Ten of the patients (76.9%) had at least two metastatic areas. Lung metastases were found in two (15.4%) of the patients. Inhibin B levels were elevated in 81.2% of patients before hormone treatment. The patients received different HTs (Leuprolide acetate + anastrozole-three patients, leuprolide acetate + tamoxifen-six patients, only anastrozole-three patients, only tamoxifen-one patients). The median progression-free survival was found 17.7 months (95 % CI: 14.7-20.6). In four (33.4%) patients, an overall response (complete or partial) was identified. A stable response was observed in eight (66.7%) patients. Conclusions: HT is effective in pretreated individuals with recurrent ovarian granulosa cell tumors, according to this research. Despite the limited number of patients and treatment variability, disease control was achieved in all patients. Also, we found that Inhibin B levels were associated with treatment response.

Relevance of Molecular Pathology for the Diagnosis of Sex Cord-Stromal Tumors of the Ovary: A Narrative Review

Ovarian sex cord-stromal tumors (SCSTs) account for 8% of all primary ovarian neo-plasms. Accurate diagnosis is crucial since each subtype has a specific prognostic and treatment. Apart from fibrosarcomas, stromal tumors are benign while sex cord tumors may recur, sometimes with a significant time to relapse. Although the diagnosis based on morphology is straightforward, in some cases the distinction between stromal tumors and sex cord tumors may be tricky. Indeed, the immunophenotype is usually nonspecific between stromal tumors and sex cord tumors. Therefore, molecular pathology plays an important role in the diagnosis of such entities, with pathognomonic or recurrent alterations, such as FOXL2 variants in adult granulosa cell tumors. In addition, these neoplasms may be associated with genetic syndromes, such as Peutz-Jeghers syndrome for sex cord tumors with annular tubules, and DICER1 syndrome for Sertoli-Leydig cell tumors (SLCTs), for which the pathologist may be in the front line of syndromic suspicion. Molecular pathology of SCST is also relevant for patient prognosis and management. For instance, the DICER1 variant is associated with moderately to poorly differentiated SLCTS and a poorer prognosis. The present review summarizes the histomolecular criteria useful for the diagnosis of SCST, using recent molecular data from the literature.

Is adjuvant chemotherapy necessary for 2014 FIGO stage IC adult granulosa cell tumor?: Multicentric Turkish study

AIM

The aim of our study is to examine the clinical, surgical, and pathological factors of stage 1C adult granulosa cell tumor (AGCT) patients and to investigate the effects of adjuvant therapy on recurrence and survival rates in this patient group.

METHODS

Out of a total of 415 AGCT patients treated by 10 tertiary oncology centers participating in the study, 63 (15.2%) patients with 2014 FIGO stage IC constituted the study group. The FIGO 2014 system was used for staging. Patient group who received adjuvant chemotherapy was compared with patient group who did not receive adjuvant chemotherapy in terms of disease-free survival (DFS), and disease-specific survival.

RESULTS

The 5-year DFS of the study cohort was 89%, and the 10-year DFS was 85%. Those who received adjuvant chemotherapy and those who did not were similar in terms of clinical, surgical and pathological factors, except for peritoneal cytology. In the univariate analysis, none of the clinical, surgical or pathological factors were significant for DFS. Adjuvant chemotherapy and type of treatment protocol had no impact on DFS.

CONCLUSION

Adjuvant chemotherapy was not associated with improved DFS and overall survival in stage IC AGCT. Multicentric and randomized controlled studies are needed for early stage AGCT in order to confirm these results and reach accurate conclusions.

Lineage tracing of mutant granulosa cells reveals in vivo protective mechanisms that prevent granulosa cell tumorigenesis

Ovarian granulosa cell tumors (GCTs) originate from granulosa cells (GCs) and represent the most common sex cord-stromal tumor in humans. However, the developmental regulations and molecular mechanisms underlying their etiology are largely unknown. In the current study, we combined a multi-fluorescent reporter mouse model with a conditional knockout mouse model, in which the tumor suppressor genes Pten and p27 were deleted in GCs, to perform cell lineage tracing of mutant GCs. We found that only 30% of ovaries with substantial mutant GCs developed into GCTs that derived from a single mutant GC. In-depth molecular analysis of the process of tumorigenesis demonstrated that up-regulation of immune evasion genes Cd24a and Cd47 led, in part, to the transition of mutant GCs to GCTs. Therefore, treatment with the Cd47 inhibitor RRX-001 was tested and found to efficiently suppress the growth of GCTs in vivo. Together, our study has revealed an immune evasion mechanism via CD24/CD47 upregulation to GCT formation, shedding light on the future potential clinical therapies for GCTs.

The Prognostic Significance of Adjuvant Chemotherapy in Adult Ovarian Granulosa Cell Tumors: A Systematic Review and Meta-analysis

INTRODUCTION

This study aimed to evaluate the oncological and prognostic significance of adjuvant chemotherapy (CT) in patients with adult granulosa cell tumors of the ovary (AOGCT).

METHODS

We searched the Chinese National Knowledge Infrastructure, Clinical Trials, Wanfang Database, Web of Science, Cochrane Library, and MEDLINE electronic databases for articles published up to May 2023. Reference lists of the enrolled studies, Google Scholar, and scientific meeting reports were also manually searched.

RESULTS

We enrolled 5641 patients with AOGCT from 33 eligible studies, including 1674 (29.7%) and 3967 (70.3%) patients in the CT and non-CT groups, respectively. Based on the cumulative results, adjuvant CT did not affect the risk of recurrence or progression (R/P) (odds ratio [OR]: 1.67, 95% confidence interval [CI]: 1.01-2.78, I2 = 63%, P = .05) and 5-year overall survival (OR: .86, 95% CI: .70-1.04, I2 = 0%, P = .12) of patients with AOGCT. However, adjuvant CT might reduce the 5-year disease-free survival (OR: 2.90, 95% CI: 1.19-7.08, I2 = 55%, P = .02). Sub-group analysis revealed that adjuvant CT did not affect the risk of R/P in patients with early-stage AOGCT (OR: .78, 95% CI: .43-1.43, I2 = 2%, P = .43) and advanced or recurrent AOGCT (OR: .78, 95% CI: .43-1.43, I2 = 2%, P = .43).

CONCLUSION

This meta-analysis suggests that patients with AOGCT might not benefit from adjuvant CT, even those with advanced or recurrent disease. The results should be interpreted with caution because of the inherent limitations of retrospective studies.

Clinical and paraclinical features, outcome, and prognosis of ovarian granulosa cell tumor: A retrospective study of 28 Vietnamese women

Background: Granulosa cell tumor of the ovary is a rare disease and presents with two clinically and molecularly distinct subtypes: the juvenile and the adult type. GCT is considered as a malignant tumor with an indolent course and a tendency toward late recurrence. Purpose: To assess the clinical and paraclinical features, treatment findings, survival outcomes, and explored the prognostic factors in the granulosa cell tumor. Methods: The current study was conducted on 28 GCT patients who had surgical operations and adjuvant chemotherapy (stage IC-IV) by applying a retrospective cohort analysis. The clinical and paraclinical characteristics were recorded. Recurrent status was evaluated for analysis with clinical and paraclinical features and survival. All GCT patients' survival were analyzed by using Kaplan-Meier and Log-Rank models. Results: 17.9% of patients experienced a relapse and two patients died due to disease. The mean time from initial diagnose to recurrence was 40.21 months. The 5-year OS and DFS of stage I-II were 100% and 80.8%, and of stage III were 50% and 25%, respectively. In survival analyses, using the log-rank test, age ≥50 years, irregular menstruation, stage I-II, and absence of residual lesion were all significant predictors for the improved DFS. Stage I-II and absence of residual lesion were associated significantly with better OS. Mean of age, FIGO stage, and residual lesion during surgery had significant differences to recurrent rate (p < <0.05). The multivariate model revealed that these factors didn't remain as an independent prognostic variable. Conclusion: FIGO stage and residual lesion during surgery had significant differences in survival and recurrent rate.

Prognostic Factors of Granulosa Cell Tumors: A Retrospective Study in a Tertiary Care Cancer Centre of Eastern India

Background and Aims  The main objective of this study was to analyze the clinicopathological profile and prognostic factors of granulosa cell tumor (GCT).

Method  All the cases of ovarian cancer which were seen at our institute between January 2000 and December 2017 were reviewed. Data were analyzed with failure-free survival (FFS) as the primary end point.

Results  GCTs consisted of 2.66% of all ovarian cancers at our institute. The median age was 43 years. Majority of the patients (62.5%) were unstaged. Six patients (25%) had a fertility-preserving procedure. Forty two percent of the patients received adjuvant chemotherapy. Thirty eight percent of the patients developed recurrence. Considering tumor-related prognostic factors, there was a statistically significant decrease in FFS with the presence of hemorrhage ( p  = < 0.001), larger tumors ( p  = 0.042), and juvenile variant ( p  = 0.002). On the contrary, when treatment-related factors were considered, there was no statistically significant improvement in FFS with the performance of lymphadenectomy ( p  = 0.218), omentectomy ( p  = 0.453), fertility sparing surgery ( p  = 0.152), or administration of adjuvant chemotherapy ( p  = 0.45).

Conclusion  Inherent tumor-related biological factors tend to play a more important role compared with treatment-related factors in GCTs. Hence, the traditional practice of performance of extensive staging procedures and routine adjuvant chemotherapy should be reviewed. Fertility-preserving surgery appears safe to be offered in early stages when desired. Although it is common knowledge that GCTs tend to be hemorrhagic tumors, this factor has not been well recognized as a prognostic indicator till date. Our study sheds some light on this aspect. Since these tumors have a tendency toward late recurrences, a long follow-up is prudent.

GnRHa as a treatment for letrozole-resistant recurrent adult granulosa cell tumors: A case report

INTRODUCTION

The optimal management of recurrent ovarian granulosa cell tumors is still unknown, and hormone therapy may be an alternative for chemotherapy-resistant cases.

PATIENT CONCERNS

A 46-year-old woman presented with a third recurrence after primary treatment of granulosa cell tumors. She developed tumor progression and drug-induced nephritis after 6 cycles of combined treatment with cisplatin and paclitaxel for the second recurrence and failed to benefit from chemotherapy, after the third optimal cytoreduction and tumor progression after 6 months of letrozole treatment.

DIAGNOSIS

Letrozole-resistant recurrent ovarian granulosa cell tumors.

INTERVENTIONS

Intramuscular Diphereline 3.75 mg q28d.

OUTCOMES

Computed tomography showed the metastatic neoplasm resolved. Progression-free survival is 20 months.

CONCLUSION

Hormone therapy may be an alternative to treat recurrent granulosa cell tumors, and gonadotropin-releasing hormone agonists may be a rescue treatment for aromatase inhibitor-resistant cases.

Prognostic predictors in recurrent adult granulosa cell tumors of the ovary: a systematic review and meta-analysis

BACKGROUND

Ovarian adult granulosa cell tumours are low-grade malignant sex cord-stromal neoplasm with a low recurrence rate. Prognostic factors for recurrence include tumor stage, tumor rupture in Stage I neoplasms and the presence of residual tumors after surgery. However, in recurrent tumors, prognostic factors for overall survival (OS) are lacking. In the present paper, we conducted a systematic meta-analysis with the aim to assess prognostic factors for OS in patients with recurrent GCT.

METHODS

Electronic databases were searched for all studies assessing prognostic factors in recurrent adult granulosa cell tumor of the ovary. Student T test, Fisher's exact test and Kaplan-Meier survival analysis with long-rank test were used to assess differences among groups; a p value < 0.05 was considered significant.

RESULTS

Eleven studies analyzing 102 recurrent tumors were included in the systematic review. Tumor stage and localization of recurrent tumors were significantly associated with OS on Kaplan-Meier analysis; Cox regression analysis showed a HR of 0.879 for the stage II, of 3.052 for the stage III, and of 2.734 for stage IV tumor was significantly associated with OS (p = 0.037); observed HRs for abdominal and thoracic locations were of 2.405 and of 4.024, respectively.

CONCLUSIONS

In conclusion, the present article emphasizes the prognostic significance of tumor stage > II and extrapelvic anatomic sites of recurrences in patients with recurrent granuolase cell tumors of the ovary.

Role of adjuvant chemotherapy in the management of stage IC ovarian granulosa cell tumors

Objective

The aim of the present study was to investigate the patterns of use and prognostic significance of adjuvant chemotherapy (CT) for patients with stage IC ovarian granulosa cell tumors (GCTs).

Methods

We identified patients with stage IC GCTs diagnosed between 2004 and 2015 in the National Cancer Data Base (NCDB). Logistic regression was performed to identify variables independently associated with chemotherapy administration. Overall survival (OS) was evaluated for patients diagnosed between 2004 and 2014 following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for known confounders.

Results

A total of 492 patients with stage IC GCTs were identified, of which 166 (33.7%) received CT. Tumor size > = 10 cm (OR: 1.85, 95% CI: 1.21, 2.82) was independently associated with the administration of CT. There was no difference in OS between patients who did (n = 145) and did not (n = 282) receive CT, p = 0.52; 5-yr OS rates were 93.7% and 91.6% respectively. After controlling for patient age (<50 vs ≥50 years), tumor size and performance of lymphadenectomy (LND), the administration of CT was not associated with a survival benefit (HR: 1.07, 95% CI: 0.52, 2.21).

Conclusions

Approximately one in three patients with stage IC GCTs received CT in the NCDB, however CT was not associated with a survival benefit.

Adult Granulosa Cell Tumors of the Ovary: A Retrospective Study of 36 FIGO Stage I Cases with Emphasis on Prognostic Pathohistological Features

Objective

Adult granulosa cell tumors (AGCTs) represent 2%-5% of all ovarian malignancies. The aim of this study was to analyze clinical and pathohistological parameters and their impact on recurrence, overall, and disease-free survival in FIGO stage I AGCT patients.

Methods

The tumor specimens analyzed in this retrospective study were obtained from a total of 36 patients with diagnosis of ovarian AGCT surgically treated at the Department of Gynecology, Rijeka University Hospital Centre, between 1994 and 2012. Clinical, pathological, and follow-up data were collected.

Results

The mean age at diagnosis was 54.5 years with a range of 24-84. The majority of the patients, 30 (83%), were in FIGO stage IA, 3 (8%) in stage IC1, 1 (3%) in stage IC2, and 2 (6%) in stage IC3. During follow-up period (median 117.5 months, range 26-276), recurrence occurred in 4 patients (12%) with 2 deaths of the disease recorded. In univariate analysis, the 5-year survival rates were significantly shorter in patients with FIGO substage IC (p = 0.019), with positive LVSI (p = 0.022), with presence of necrosis (p = 0.040), and with hemorrhage (p = 0.017). In univariate analysis, the 5-year disease-free survival rates were significantly shorter in patients treated with fertility surgery (p = 0.004), with diffuse growth pattern (p = 0.012), with moderate and severe nuclear atypia (p = 0.032), and with presence of hemorrhage (p = 0.022). FIGO substage IC proved to be independent predictor for recurrence (OR = 16.87, p = 0.015, and OR = 23.49, p = 0.023, resp.) and disease-free survival (p = 0.0002; HR 20.84, p = 0.02) at the uni- and multivariate analyses.

Conclusions

FIGO substage IC is predictive of recurrence and disease-free survival in patients with early-stage AGCTs. LVSI, presence of necrosis and hemorrhage, diffuse growth pattern, and nuclear atypia in AGCTs seem to be associated with overall and disease-free survival, so these pathological features should be taken into consideration when managing patients with AGCT.

An elderly woman with a mediastinal granulosa cell tumour: a rare presentation

Mediastinal lesions occur in a wide variety of clinical conditions. Metastatic granulosa cell tumour (GCT) in the mediastinum is a rare occurrence. We report a case of a woman who had a metastatic (GCT) in her mediastinum 40 years after treatment of the initial neoplasm. Surgical resection of the mediastinal mass revealed a low‐grade epithelioid neoplasm with coffee bean‐shaped nuclei and immunohistochemical stains that were consistent with metastatic GCT.

Pathogenesis and treatment of adult-type granulosa cell tumor of the ovary

Adult-type granulosa cell tumor is a clinically and molecularly unique subtype of ovarian cancer. These tumors originate from the sex cord stromal cells of the ovary and represent 3-5% of all ovarian cancers. The majority of adult-type granulosa cell tumors are diagnosed at an early stage with an indolent prognosis. Surgery is the cornerstone for the treatment of both primary and relapsed tumor, while chemotherapy is applied only for advanced or non-resectable cases. Tumor stage is the only factor consistently associated with prognosis. However, every third of the patients relapse, typically in 4-7 years from diagnosis, leading to death in 50% of these patients. Anti-Müllerian Hormone and inhibin B are currently the most accurate circulating biomarkers. Adult-type granulosa cell tumors are molecularly characterized by a pathognomonic somatic missense point mutation 402C->G (C134W) in the transcription factor FOXL2. The FOXL2 402C->G mutation leads to increased proliferation and survival of granulosa cells, and promotes hormonal changes. Histological diagnosis of adult-type granulosa cell tumor is challenging, therefore testing for the FOXL2 mutation is crucial for differential diagnosis. Large international collaborations utilizing molecularly defined cohorts are essential to improve and validate new treatment strategies for patients with high-risk or relapsed adult-type granulosa cell tumor. Key Messages: Adult-type granulosa cell tumor is a unique ovarian cancer with an indolent, albeit unpredictable disease course. Adult-type granulosa cell tumors harbor a pathognomonic somatic missense mutation in transcription factor FOXL2. The key challenges in the treatment of patients with adult-type granulosa cell tumor lie in the identification and management of patients with high-risk or relapsed disease.

Prognostic Factors in Adult Granulosa Cell Tumor: A Long Follow-Up at a Single Center

Objective

In this study, we aimed to demonstrate characteristics, recurrence rates, survival numbers, and factors associated with survival of patients with adult granulosa cell tumor (AGCT) from a single institution. Our secondary goal was to evaluate the necessity of staging surgery and the importance of a comprehensive lymphadenectomy in these patients.

Methods

The data of 158 patients in our institution who were diagnosed with AGCT between 1988 and 2013 were evaluated. The data were obtained from the files of the patients, electronic database of the gynecologic oncology clinic, operation notes, and pathology records.

Results

The median (range) age of the patients was 50.3 (22–82) years. The main symptom was postmenopausal bleeding (25.9%). Seventy-six percent of the patients underwent staging surgery including lymphadenectomy. Among these patients, 3 (2.5%) had lymph node metastasis. The median (range) follow-up time was 97 (1–296) months. In the follow-up period, 18 patients (12.5%) had recurrence. Menopausal status (P = 0.016), advanced age (P = 0.024), cyst rupture (P = 0.001), poorly differentiated tumor (P = 0.002), and advanced stage (P < 0.001) were associated with recurrence. Stage was the only independent prognostic factor for the development of recurrence. None of the patients had lymph node failure.

Conclusions

In the present study with a long follow-up period and in which most of the patients had staging surgery including lymphadenectomy (76.6%), lymph node recurrence was not observed and the total recurrence rate (12.5%) was lower than that reported in the literature. The study showed the importance of surgical staging in patients with AGCT.

Hyperthermic intraperitoneal chemotherapy for women with granulosa cell tumors of the ovary: a systematic review of the literature

Background: Adult and juvenile granulosa cell tumors of the ovary are rare functional sex-cord-stromal ovarian neoplasms characterized by low malignant potential and late relapse. Evidence-based management options for primary and recurrent juvenile (JGCT) and adult (AGCT) granulosa cell tumors are limited and treatment options have not been standardized. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may be an option to treat these women effectively. Methods: Systematic literature review using PubMed and the Cochrane Central Register of Controlled Trials. Results: No reports of HIPEC among women with a first diagnosis of AGCT were identified. We identified 5 reports on the safety and therapeutic efficacy of CRS and HIPEC in 19 patients with recurrent AGCT and one patient with JGCT. The pooled rate of complete cytoreduction was 95 % (18/19) with 16 % (3/19) severe morbidity and no procedure-related mortality. The median time of follow-up was 30 (range, 3 to 72) months, during which 6/19 (31 %) patients experienced a recurrence and two patients (10 %) died of the disease. Conclusion: CRS and HIPEC are a safe and potentially effective treatment option for selected women with recurrent AGCT limited to the abdomen.

Stage I granulosa cell tumours: A management conundrum? Results of long-term follow up

Optimal management of women with early stage granulosa cell tumours (GCT) presents a management conundrum - they have excellent prognosis but a third will relapse. Advances uncovering the molecular characteristics of GCT have not been matched by improvements in our understanding and treatment.

METHODS

Stage I GCT patients referred to Auckland City Hospital (1955-2012) and Princess Margaret Cancer Centre (1992-2012) were identified. Baseline characteristics, histopathology and outcomes were recorded retrospectively.

RESULTS

One hundred and sixty stage I GCT patients were identified with a median age of 49 years. Median follow-up was 7.0 years (range 0.1-44.2 years). Fifty-one patients (32%) relapsed with a median time to relapse (TTR) of 12.0 years (1.3-17.7 years) - 20 initial relapses occurred 10 years post-diagnosis. Higher relapse rates (43% vs. 24% p=0.02) and shorter TTR (10.2 vs. 16.2 years p=0.007) were seen with stage Ic versus stage Ia disease. Cyst rupture was associated with increased relapse (p=0.03). Surgery was the main therapeutic modality at relapse. Eighty six percent of patients received non-surgical management at least once post-relapse. Clinical benefit rate was 43% with chemotherapy, 61% with hormonal therapy and 86% with radiation. Five- and 10-year overall survival (OS) were 98.5 and 91.6%, respectively. Median OS was similar in patients with (24.3 years) and without relapse (22.3 years).

CONCLUSION

Surgery remains fundamental at diagnosis and relapse. Caution should be exercised in recommending adjuvant chemotherapy at initial diagnosis given median OS was greater than 20 years even with relapse. Hormonal therapy at relapse appears encouraging but needs further assessment. Novel treatment strategies need exploration with international collaboration essential for this.

Recent advances in granulosa cell tumor ovary: a review

Granulosa cell tumors constitute less than 5 % of all ovarian tumors. Unlike epithelial ovarian tumors, they occur in a younger age group, are usually detected in an early stage and often have features of hyperestrogenism. The presenting symptoms are usually nonspecific with abdominal pain or distension. They follow an indolent course and are characterized by a long natural history. Mutation of FOXL2 (402C->G) seen in 97 % of adult GCT may be pathognomonic for adult GCT. Only stage of the disease has been consistently shown in various studies to affect survival of patients with GCT. The initial management of patients, for whom fertility is not an issue, is total abdominal hysterectomy, bilateral salpingo-oophorectomy and removal of all gross disease. Nodal dissection is not a significant factor for survival and is not recommended in surgical staging of GCT. Fertility preserving surgery with unilateral salpingo-oophorectomy is feasible in young patients with stage Ia GCT. Patients with early stage disease (stage I and II) have a very good prognosis with 5 year DFS and OS of 89 % and 99 % respectively and these groups of patients usually don't require any postoperative treatment. Patients with stage Ic disease associated with poor prognostic factors like large tumor size or high mitotic index and stage II, have a higher chance of relapse, and may benefit with postoperative treatment but role of chemotherapy is still debatable. In advanced stage disease (stage III and IV) the 5 year DFS and OS disease was 72 % and 80 % respectively hence the option of postoperative treatment with 6 cycles of BEP should be considered in this group. Recently paclitaxel is being investigated as an effective tool in GCT. The efficacy of radiation in GCT is not well defined but in optimally debulked cases postoperative radiation is a viable option. Due to high chance of recurrence even years after apparent clinical cure of the primary tumor, lifelong follow up with clinical examination and tumor markers like inhibin B is recommended. About 25 % GCT develop recurrence and the median time to recur is usually 4-5 years. Most recurrences are intraperitoneal and usually a complete debulking of the disease is feasible even in the recurrent setting. Postoperative chemotherapy (platinum based) is usually given after surgery more so in cases with widespread disease or after suboptimal cytoreduction. Recurrent chemoresistant, progressive non-responding GCT or patients with high surgical risk are ideal candidates for targeted therapy.

Lung metastasis from an ovarian granulosa cell tumor 36 years after the initial diagnosis: report of a case

This report presents the case of a late relapse of an ovarian granulosa cell tumor (GCT) that metastasized to the lung 36 years after the initial diagnosis. A 72-year-old female demonstrated multiple nodules with extrapleural signs on chest computed tomography. Positron emission tomography with (18)F-fluorodeoxyglucose ([(18)F]FDG-PET) showed that the nodules had no FDG avidity. The nodules, which appeared as polypoid lesions of the visceral pleura on thoracoscopy, were resected and diagnosed as pulmonary metastases from the GCT. This case report indicates that thorough thoracoscopic exploration of the pleural cavity is essential when intrathoracic nodules are seen on postoperative imaging examinations in GCT patients, even when the [(18)F]FDG-PET results are negative.

Laparoscopical management ovarian early sex cord-stromal tumors in postmenopausal women: a proposal method

BACKGROUND

Ovarian sex-cord stromal tumor (SCST) comprises 5% of the ovarian neoplasm; it occurs as an ovarian mass or hemoperitoneum, and the surgical management of SCST is not well defined at early stage and in adult patients.

PURPOSE OF THE STUDY

The authors tested to test the total not radical laparoscopic management of SCST in postmenopausal women at early stage.

METHODS

Three postmenopausal women were admitted in University-affiliated hospitals for pelvic pain, ovarian complex mass and genital bleeding. Preoperative clinical and instrumental examination suspected an ovarian tumor; therefore, a total laparoscopic approach was attempted. All patients underwent laparoscopic oophorectomy with the frozen section, who suggested for ovarian SCST; one woman received a total laparoscopic hysterectomy plus other oophorectomy, two received only the complementary oophorectomy, all without intensive surgical staging by with pelvic and para-aortic lymphadenectomy, appendectomy, peritoneal biopsies, and omentectomy.

RESULTS

All patients completed surgery without intrasurgical and postsurgical complications, with a fast dismissal. They are, currently, in long-term follow-up, with a 100% of survival after 3 years and with none morbility and morbidity.

CONCLUSIONS

In order to fast restore and preserve women's integrity, total laparoscopic approach of early SCST in adult age, without intensive radical staging, could be an appropriate clinical choice, since these tumors at slow growth, recurring locally and only a long time after initial treatment. This minimally invasive management could be suggested in association with a long-term follow-up, as possible "wait and see" postoperative option.

Adult granulosa cell tumors of the ovary: tumor dissemination pattern at primary and recurrent situation, surgical outcome

OBJECTIVE

Granulosa-cell-tumors of the ovary (GCT) constitute a rare group of neoplasms with malignant potential. Due to the rarity of the disease intraoperative tumor-dissemination-patterns are not well defined and are mostly based on retrospective data. Aim of the present study was to describe surgical and clinical outcome and dissemination pathways in the primary and recurrent situation of the disease.

METHODS

All primary and relapsed GCT-patients, operated between 01/2001 and 02/2010 in our institution were evaluated using a systematic intraoperative documentation-tool (IMO). Surgical outcome, intraoperative tumor-dissemination-pattern and pathological and findings were separately analyzed for the primary and recurrent situation.

RESULTS

Overall, 45 patients were analyzed; including eighteen patients with primary and 27 patients with recurrent GCT. Tumor-dissemination-patterns differed significantly between primary and recurrent patients, by the latter having significantly higher rates of diffuse peritoneal involvement (15.8% vs. 52%; p=0.027) and of extraovarian tumor involvement of the middle (15.8% vs. 48.1%; p=0.05) and upper abdomen (0 vs. 33.3%; p=0.006). While all primary patients could be operated tumor-free, this was the case for 85.2% of the relapsed patients (p=0.13). A multivisceral operative approach with extensive peritonectomy, intestinal or diaphragmatic resection, splenectomy and partial hepatectomy/panceratectomy had to be performed only in recurrent GCT (55.6%).

CONCLUSIONS

Tumor-dissemination-pathways followed in primary and recurrent GCT differ significantly by higher rates of multivisceral tumor involvement in the recurrent situation of the disease. While at primary presentation extrapelvic involvement with peritoneal carcinosis appears only rare, surgical cytoreduction during relapse is more challenging involving a multivisceral approach.

Smad1-Smad5 ovarian conditional knockout mice develop a disease profile similar to the juvenile form of human granulosa cell tumors

Granulosa cell tumors (GCTs) of the ovary are rare sex cord stromal tumors. Although generally indolent, GCTs recur, and if not diagnosed and treated in early stages, survival rates are significantly shortened. Very little is known regarding GCT etiology. Because of the low incidence of cases and lack of standard diagnostics, mouse models for granulosa cell tumors are a valuable tool for studying GCTs and provide models for developing diagnostic and treatment strategies. We recently developed a novel mouse model of metastatic granulosa cell tumors by genetic deletion of the bone morphogenetic protein signaling transcription factors (SMADs) in granulosa cells of the ovary. Histological and serum hormone analyses reveal that this mouse model most closely resembles the juvenile form of GCT. We further analyzed samples of human juvenile GCT (JGCT) for expression of anti-Müllerian hormone and activation of two major signaling pathways: TGFbeta/SMAD2/3 and wingless-related mouse mammary tumor virus integration site (Wnt)/beta-catenin. The TGFbeta family is active in mouse Smad1-Smad5 double knockout tumors, and here we show that this pathway, but not the beta-catenin pathway, is activated in samples of human JGCT. These data suggest that the SMAD family, possibly through disruption of SMAD1/5 or activation of SMAD2/3 may contribute to the pathogenesis of JGCT in humans.

Prognostic factors in adult granulosa cell tumors of the ovary: a retrospective analysis of 80 cases

OBJECTIVE

Ovarian granulosa cell tumors are rare malignancies with a relatively favorable prognosis. However, patients still suffer from disease-related mortality. Therefore, the prognostic factors should be clarified. The purpose of this study was to investigate the clinical and pathologic characteristics related with disease recurrence and mortality in adult type ovarian granulosa cell tumors.

METHODS

Eighty surgically staged patients with granulosa cell ovarian tumor treated at the Hacettepe University Hospital between 1982 and 2006 were retrospectively reviewed. Clinical and pathological characteristics were analyzed.

RESULTS

Granulosa cell ovarian tumors accounted for 4.3% of malignant ovarian neoplasms. Mean age was 47.6 years. The most common presenting symptom was abnormal uterine bleeding (53.7%). Endometrial pathology was detected in 51.2% of patients preoperatively. Seventy percent of patients were diagnosed at stage I, and 53.8% of patients received adjuvant treatment. Mean follow-up was 67.5 months. Overall 5-year and 10-year survival was 91% and 86%, respectively. Mean survival was 147.1 months. Recurrence rate was 11.2%. In univariate analysis, advanced stage, advanced age, residual disease after surgery, and need for adjuvant treatment were associated with disease-related mortality and advanced stage disease and absence of initial staging surgery were associated with disease recurrence. However, in multivariate analysis, only initial stage was found to be a significant prognostic factor.

CONCLUSION

Initial stage seems to be the single most important prognostic factor in ovarian granulosa cell tumors. Therefore, a comprehensive staging surgery should be attempted to document the real extent of disease and to estimate the oncologic outcome more accurately.

Predictors of recurrence of ovarian granulosa cell tumors

OBJECTIVE

The prognosis of granulosa cell tumors (GCTs) is overall favorable, but a proportion of patients will experience recurrence. We report one of the largest series of patients with GCT for whom clinical, morphologic, and immunohistochemical markers have been assessed for their roles as predictors of recurrence.

METHODS

Patients with the diagnosis of GCT were identified at 2 hospitals from 1974 to 2004; a detailed chart analysis was performed. Tissue blocks were analyzed immunohistochemically for mitotic index, luteinization, inhibin staining, epidermal growth factor receptor, and Ki67 expression. Univariate and multivariate analyses were performed.

RESULTS

Sixty-seven patients were identified. Follow-up data up to 30 years were available. The mean age at diagnosis was 48.1 years. Twenty-five patients experienced recurrence. A statistically significant correlation (P < 0.05) was observed for age at diagnosis, with earlier age being an adverse factor (43.6 vs 50.9, P < 0.01), and use of adjuvant chemotherapy postoperatively (24% vs 40% in the nonrecurrence group). Luteinization and the immunohistochemical markers, such as inhibin, Ki67, and epidermal growth factor receptor, seemed to significantly increase the risk of recurrence if expressed. A multivariate analysis model confirmed that younger age at diagnosis and higher expression of inhibin and Ki67 are significant risk factors of GCT recurrence.

CONCLUSIONS

Identification of patients who are at a high risk for recurrence of GCT is critical. Routine treatment for all patients with cytotoxic chemotherapy is not justified. We report a set of predictors of recurrence for GCT that identified subsets of patients who may benefit from prolonged surveillance and/or adjuvant systemic chemotherapy.