The pathological assessment of ovarian neoplasms. III: The malignant "epithelial" tumours

Primary Ovarian Mesothelioma: A Case Series with Electron Microscopy Examination and Review of the Literature

Primary ovarian mesothelioma is a rare, aggressive neoplastic disease with a poor prognosis. At onset, the tumor is only rarely limited to the ovaries and usually already widespread in the peritoneum. The rarity of this entity and the difficulties differentiating it from either ovarian carcinoma or peritoneal mesothelioma may lead to frequent misdiagnoses and may raise some concerns about its histogenesis. Thus, reporting such rare cases is fundamental to gain greater awareness of this neoplasm and try to answer unsolved questions. Herein, we described four cases of histological diagnoses of ovarian mesothelioma extrapolated by the regional mesothelioma register of Apulia (southern Italy). In all cases, a detailed medical history was collected according to national mesothelioma register guidelines. A broad panel of antibodies was used for immunohistochemistry to confirm the diagnoses. Moreover, ovarian tissue samples were also examined by transmission and scanning electron microscopy, detecting asbestos fibers and talc crystals in two cases. Because of the few cases described, we reviewed the English literature in the Medline database, focusing on articles about ovarian mesothelioma "misclassification", "misdiagnosis", "diagnostic challenge" or "diagnostic pitfall" and on unsolved questions about its histogenesis and possible risk factors.

Clinical outcome of isolated serous tubal intraepithelial carcinomas (STIC)

OBJECTIVE

Risk-reducing salpingo-oophorectomy (RRSO) is recommended for women with BRCA mutation due to increased risk of pelvic serous carcinoma. Serous tubal intraepithelial carcinoma (STIC) is a pathologic finding of unknown clinical significance. This study evaluates the clinical outcome of patients with isolated STIC.

MATERIALS/METHODS

We retrospectively reviewed the medical records of consecutive patients with a germline BRCA1/2 mutation or a high-risk personal or family history of ovarian cancer who underwent RRSO between January 2006 and June 2011. All patients had peritoneal washings collected. All surgical specimens were assessed using the sectioning and extensively examining the fimbria protocol, with immunohistochemistry when indicated. p53 signature lesions and secretory cell outgrowths were excluded.

RESULTS

Of 593 patients who underwent RRSO, isolated STIC was diagnosed in 12 patients (2%). Five patients (42%) were BRCA1 positive, 5 patients (42%) were BRCA2 positive, and 2 patients (17%) had high-risk family history. Preoperatively, all patients with STIC had normal CA-125 levels and/or pelvic imaging results. Seven patients underwent hysterectomy and omentectomy, 6 patients (46%) had pelvic node dissections, and 5 patients (39%) had para-aortic node dissections. With the exception of positive peritoneal washings in 1 patient, no invasive or metastatic disease was identified. No patient received adjuvant chemotherapy. At median follow-up of 28 months (range, 16-44 months), no recurrences have been identified.

CONCLUSIONS

Among the cases of isolated STIC after RRSO reported in the literature, the yield of surgical staging is low, and short-term clinical outcomes are favorable. Peritoneal washings are the most common site of disease spread. Individualized management is warranted until additional data become available.

CD44 standard form expression is correlated with high-grade and advanced-stage ovarian carcinoma but not prognosis

Single-chain glycoprotein CD44 is a major cell surface receptor for hyaluronan and mediates epithelial cell adhesion by its involvement in cell-cell and cell-matrix interactions. Recently, CD44 has been identified as a biomarker of cancer stem cells in many malignancies including ovarian carcinoma. However, its clinical significance in human ovarian carcinoma has been controversial until recently. The aim of our current study was to clarify the clinical role of CD44 expression in human ovarian carcinoma. Immunohistochemical staining of 483 primary ovarian carcinoma and 27 paired primary and recurrent ovarian carcinoma samples for CD44 standard form (CD44s) was performed using tissue microarray. The associations between CD44s expression and clinical factors (histologic types, tumor grade, International Federation of Gynecology and Obstetrics stage, and response to chemotherapy), and overall or disease-free survivals were analyzed. We observed CD44s expression in 38% of the ovarian carcinoma samples. Results of the Fisher exact test suggested that CD44s expression was associated with high-grade carcinoma (P = .013), advanced International Federation of Gynecology and Obstetrics stage (III-IV; P < .001), age at diagnosis less than 60 years (P = .011), and transitional cell carcinoma (P = .039). However, CD44s expression was not associated with overall survival (P = .529) or disease-free survival (P = .218) by the log-rank test. Moreover, there was no statistical difference in CD44s expression between the primary and recurrent ovarian carcinomas. Our results showed that CD44s expression is not a prognostic predictor in ovarian cancer.

Sex-determining region Y-box 2 expression predicts poor prognosis in human ovarian carcinoma

Sex-determining region Y-box 2 is proposed to be a key transcription factor in embryonic stem cells. The known roles of sex-determining region Y-box 2 in development and cell differentiation suggest that it is relevant to the aberrant growth of tumor cells. Thus, sex-determining region Y-box 2 may play an important role in tumor progression. However, its clinical significance in human ovarian carcinoma has been uncertain until recently. The aim of the present study was to clarify the clinical role of sex-determining region Y-box 2 expression in ovarian carcinoma. Immunohistochemical staining of 540 human ovarian carcinoma samples for sex-determining region Y-box 2 was performed using tissue microarray. The associations among sex-determining region Y-box 2 expression and clinical factors (diagnosis, tumor grade, International Federation of Gynecology and Obstetrics stage, and response to chemotherapy), overall survival, and disease-free survival were analyzed. We observed sex-determining region Y-box 2 expression in 15% of the ovarian carcinoma samples. Use of the Fisher exact test suggested that sex-determining region Y-box 2 expression was associated with high-grade carcinoma (P = .009), especially high-grade serous carcinoma (P = .048); International Federation of Gynecology and Obstetrics stage (II-IV; P = .005); and malignant mixed müllerian tumors (P = .048). Sex-determining region Y-box 2 expression was also associated with decreased disease-free survival durations (P = .035; log-rank test). Our results showed that sex-determining region Y-box 2 expression may be a potential marker related to tumor recurrence, as implicated by its role in cancer stem cells.

CD133 expression associated with poor prognosis in ovarian cancer

As a putative marker for cancer stem cells in human malignant tumors, including ovarian cancer, CD133 expression may define a tumor-initiating subpopulation of cells and is associated with the clinical outcome of patients. However, at this time its clinical significance in ovarian cancer remains uncertain. The aim of this study was to clarify the clinical role of CD133 expression in human ovarian cancer. Immunohistochemical staining of CD133 expression was performed in 400 ovarian carcinoma samples using tissue microarray. The associations among CD133 expression and clinical factors (diagnosis, tumor grade, cancer stage, and clinical response to chemotherapy), overall survival and disease-free survival time were analyzed. CD133 expression was found in 31% of ovarian carcinoma samples. Fisher's exact test and one-way analysis of variance suggested that CD133 expression was associated with high-grade serous carcinoma (P=0.035), late-stage disease (P<0.001), ascites level (P=0.010), and non-response to chemotherapy (P=0.023). CD133 expression was also associated with shorter overall survival time (P=0.007) and shorter disease-free survival time (P<0.001) by log-rank test. Moreover, CD133 expression was an independent predictor of shorter disease-free survival time in an unconditional logistic regression analysis with multiple covariates (P=0.024). Our results thus show that CD133 expression is a predictor of poor clinical outcome for patients with ovarian cancer, supporting the proposed link between CD133 and cancer stem cells.

Low membranous expression of beta-catenin and high mitotic count predict poor prognosis in endometrioid carcinoma of the ovary

Mutations in the beta-catenin gene are common in ovarian endometrioid carcinoma. Few studies have addressed the association of beta-catenin expression with tumor characteristics and patient outcome, yielding controversial results. The purpose of this study was to retrospectively assess the expression of beta-catenin in ovarian endometrioid carcinoma and correlate its expression with the Gynecologic Oncology Group's (GOG) grading system, clinicopathological characteristics, and patient survival. A total of 49 patients with primary ovarian endometrioid carcinoma were included in this study. A four-tier score grading system was used for the membranous staining (negative, weak, moderate, and strong) and the percentage of positive cells for the nuclear staining of beta-catenin. The status of five morphometric parameters, nuclear morphology (uniform or pleomorphic), mitotic count, glandular pattern, degree of squamous differentiation, and status of papillary pattern, was assessed. We found that a low membranous expression of beta-catenin and a high mitotic count (>15 per 10 high-power fields) were significantly associated with poor prognosis and early recurrence of ovarian endometrioid carcinoma. In addition, cases with nuclear expression of beta-catenin showed an intermediate overall survival risk and late disease recurrence. Young age at the time of diagnosis, advanced disease stage, and suboptimal debulking were among the clinical factors predicting poor survival and early disease recurrence. The presence of squamous differentiation, a papillary pattern or nuclear pleomorphism did not show any correlation with overall survival or disease-free survival. Low membranous expression of beta-catenin and high mitotic count are poor prognostic indicators in patients with ovarian endometrioid carcinoma, whereas the GOG grading system showed no prognostic value. Our data suggest that there is a need to define a better grading system for ovarian endometrioid carcinoma. Molecular markers such as beta-catenin and mitotic count could aid in defining this grading system.

ALDH1 expression correlates with favorable prognosis in ovarian cancers

Aldehyde dehydrogenase 1 (ALDH1), a detoxifying enzyme responsible for the oxidation of intracellular aldehydes, was shown to have a function in the early differentiation of stem cells, through its function in oxidizing retinol to retinoic acid. It has been shown that ALDH1 is a predictor of poor clinical outcome in breast cancer. The authors hypothesized that the level of ALDH1 expression may be correlated with the clinical outcome of patients with ovarian cancer. Immunohistochemical staining of ALDH1 expression was analyzed in 442 primary ovarian carcinomas using tissue microarray. The associations between the expression of the ALDH1 and clinical factors (diagnosis, tumor grade, stage, and clinical response to chemotherapy), as well as overall and disease-free survival, were analyzed. Expression of ALDH1 was found in 48.9% of the samples. Fisher's exact test suggested that high expression of ALDH1 was significantly associated with endometrioid adenocarcinoma (P<0.0001), early-stage disease (P=0.006), complete response to chemotherapy (P<0.05), and a low serum level of CA125 (P=0.02). High percentage of cells expressing ALDH1 was associated with a longer overall survival time (P=0.01) and disease-free survival time (P=0.006) by log-rank test. In contrast to its function in breast cancer, ALDH1 was a favorable prognostic factor in ovarian carcinoma. ALDH1 therefore may have a different function in ovarian cancer than it does in breast cancer.

The rich history of gynaecological pathology: brief notes on some of its personalities and their contributions

The careers and contributions of some of those who have played a major role in the development of knowledge concerning gynaecological pathology are summarised. The emphasis is on workers of prior times beginning with those of the German-speaking school: Carl Ruge, Felix Marchand, Hermann Pfannenstiel, Oskar Frankl, Walter Schiller, and Robert Meyer. The two great Scandinavian investigators Lars Santesson and Gunnar Teilum are then considered, followed by those of the British school: John H. Teacher, Elizabeth Hurdon, Magnus Haines, Claud Taylor, Fred Langley, and Harold Fox. North American workers reviewed are: Thomas S. Cullen, Emil Novak, John Albertson Sampson, Arthur Hertig, and Robert E. Scully. The essay concludes with Australasian contributors, those considered in detail being: Hans Frederick Bettinger, Rupert A. Willis, Hazel (Mansell) Gore, Robert Barter, Harold Attwood, Andrew Ostör (the last two also noted historians), Denys Fortune, Alan Ng, and Peter Russell.

The role of constitutively active signal transducer and activator of transcription 3 in ovarian tumorigenesis and prognosis

BACKGROUND

Signal transducer and activator of transcription 3 (Stat3), which is a latent transcription factor that participates in the transcriptional activation of apoptosis and cell cycle progression, has been implicated as an oncogene in several neoplastic diseases. However, the specific role of Stat3 in ovarian carcinogenesis remains poorly understood. The objectives of the current study were to examine the effect of Stat3 activation on the phenotypic transformation of an immortalized, nontumorigenic ovarian epithelial cell line and to evaluate the expression of tyrosine-activated Stat3 (pStat3) in tissue microarrays from 303 ovarian carcinomas to determine its prognostic relevance and to correlate its expression with several upstream oncogenes of Stat3 and with the oncogenes involved in apoptosis and proliferation.

METHODS

Overexpression of pStat3 was weakly tumorigenic and produced measurable tumors in mice in 1 of 3 clones. Using tissue microarrays from a large group of patients with primary ovarian carcinoma, the expression of pStat3 was correlated with the expression of growth factor receptors (HER-2/neu and epidermal growth factor receptor [EGFR]), interleukin 6, and the proliferation and apoptosis markers Ki-67, Bcl-2, and Bcl-xL and with clinicopathologic variables and patient survival.

RESULTS

High pStat3 expression in the tumor tissue microarray was associated with high levels of HER-2/neu, EGFR, and Ki-67. No correlation was observed between overall pStat3 levels and any other clinicopathologic variables tested. High nuclear expression of pStat3 (>10% of positive-stained cells) was linked with poor overall survival.

CONCLUSIONS

The activation and translocation of pStat3 to the nucleus are frequent events in ovarian carcinoma that are associated with a poor prognosis. Further studies are needed to elucidate the mechanism of activation of Stat3, its effects on downstream targets, and its role in the neoplastic transformation of epithelial ovarian cells.

Insulin-like growth factor-binding protein 2 and 5 are differentially regulated in ovarian cancer of different histologic types

The family of insulin-like growth factor-binding proteins (IGFBPs) comprises six members, which bind and regulate the functions of insulin-like growth factors. Overexpression of IGFBP2 and IGFBP5 contributes to the invasiveness and progression of several human cancers, but their role and clinical significance in ovarian cancer has not been investigated in detail. We examined IGFBP2 and IGFBP5 expression levels using two tissue microarrays, one containing six normal surface epithelium, six benign serous cysts, 10 serous borderline tumors, eight low-grade, and 20 high-grade serous carcinomas. The other comprising 441 ovarian cancers of different histologic types linked to a clinicopathologic database. Each tumor was sampled in duplicate with a 1.0-mm punch core needle. Immunohistochemical staining was performed using antibodies against IGFBP2 or IGFBP5. The staining intensity was scored semiquantitatively as negative (0), weak (1-10%), moderate (10-50%), or strong (50-100%) using computerized image analysis. Statistical analyses used Fisher's exact test and Kaplan-Meier method. IGFBP2 and IGFBP5 were overexpressed in high-grade serous carcinomas compared to normal surface epithelium, benign serous cysts, serous borderline tumors, or low-grade serous carcinoma. They were differentially expressed in different types of ovarian carcinomas, being more often expressed at high levels in high-grade serous carcinoma, malignant mixed mullerian tumors and undifferentiated carcinoma, and more often expressed at low levels or not at all in clear cell and mucinous carcinomas. We concluded that IGFBP2 and IGFBP5 might play a role in the development of high-grade ovarian serous carcinoma, but not in mucinous or clear cell ovarian carcinomas.

Cyclin E expression is correlated with tumor progression and predicts a poor prognosis in patients with ovarian carcinoma

BACKGROUND

Cyclins, cyclin dependent kinases (cdks), and their inhibitors act in combination to regulate progression through the cell cycle and often are dysregulated in carcinoma. The authors hypothesized that cyclin E plays an important role in ovarian carcinogenesis and that its overexpression may be an indicator of a poor prognosis.

METHODS

Immunohistochemical analysis of cyclin E expression was performed by image analysis in normal ovaries, cystadenomas, tumors of low malignant potential, and 405 primary ovarian carcinomas by using tissue microarray technology.

RESULTS

Overexpression of cyclin E was found in 63.2% of the samples and was associated with clear cell, poorly differentiated, and serous carcinoma (P < or = .001), high-grade tumors (P < or = .001), late-stage disease (P = .002), age older than 60 years at the time of diagnosis (P = .04), and suboptimal cytoreduction (P = .001). A high percentage of cyclin E-expressing cells was associated with a poor outcome in univariate and in multivariate analyses. In addition, cyclin E levels also reduced survival in the late-stage disease group and in patients who underwent suboptimal debulking.

CONCLUSIONS

Cyclin E was identified as an independent prognostic factor in patients with ovarian carcinoma. The accumulation of cyclin E protein may be a late event in tumorigenesis and may contribute to disease progression in these patients.

Cystic clear cell tumor of borderline malignancy of the ovary lacking fibromatous components: report of two cases and a possible new histological subtype

BACKGROUND

All of the ovarian borderline clear cell tumors ever reported had, without exception, an adenofibromatous pattern.

CASE

We report two cases of borderline cystic clear cell tumor of the ovary without apparent invasive lesions or adenofibromatous components.

CONCLUSION

This is the first report of cystic clear cell tumors of borderline malignancy, indicating a possible new histological subtype.

Serous and mucinous borderline (low malignant potential) tumors of the ovary

The prognosis for stage I serous borderline ovarian tumors (SBOTs) is thought to be excellent, despite rare, late recurrences. The behavior of advanced-stage SBOTs primarily depends on the invasiveness vs noninvasiveness of associated extraovarian implants. Pelvic and abdominal lymph node involvement and foci of microinvasion do not seem to adversely affect prognosis. Serous tumors with a micropapillary and/or cribriform growth pattern seem to be more frequently bilateral and exophytic and manifest at an advanced stage with a higher incidence of invasive implants than typical SBOTs. Molecular data suggest that such tumors may represent an intermediate stage in the typical SBOT-invasive low-grade serous carcinoma progression. Limited experience with endocervical (müllerian)-type mucinous borderline tumors shows a possible relation to SBOTs in clinicopathologic features and biologic behavior Intestinal-type mucinous borderline ovarian tumors (I-MBOTs) and well-differentiated mucinous carcinomas manifest at stage I in most cases; the prognosis is excellent. Mucinous tumors associated with pseudomyxoma peritonei are almost always secondary to similar tumors of the appendix or other gastrointestinal sites and should not be diagnosed as high-stage I-MBOTs. Rare primary ovarian mucinous tumors associated with pseudomyxoma peritonei are those arising in mature cystic teratomas. Advanced-stage ovarian mucinous carcinomas typically show frank, infiltrative-type invasion; the prognosis is poor.

Subcellular Localization of p27kip1 Expression Predicts Poor Prognosis in Human Ovarian Cancer

Purpose: The cyclin-dependent kinase inhibitor p27kip1 regulates cellular progression from G1 to S phase. Several studies have shown that loss of p27kip1 protein expression is associated with disease progression in various malignancies. The purpose of this study was to evaluate the subcellular localization of this cyclin-dependent kinase inhibitor in a large cohort of primary ovarian carcinomas and compare the results with clinicopathologic variables and overall survival.

Experimental Design: Subcellular localization of p27kip1 was first assessed by Western blotting in nuclear and cytoplasmic extract from 13 cases of ovarian carcinoma. Subcellular localization of the p27kip1 protein was evaluated using tissue microarrays containing 421 cases of ovarian carcinoma.

Results: The presence of p27kip1 in the cytoplasm regardless of the nuclear stain correlated strongly with late-stage disease (P &lt; 0.03), extent of cytoreduction (P = 0.03), and shorter disease-specific survival (P &lt; 0.0001).

Conclusion: Cytoplasmic localization of p27kip1 predicts poorer prognosis in ovarian carcinoma, particularly in late-stage disease.

Characterization of a Carcinogenesis Rat Model of Ovarian Preneoplasia and Neoplasia

Animal models of ovarian cancer are crucial for understanding the pathogenesis of the disease and for testing new treatment strategies. A model of ovarian carcinogenesis in the rat was modified and improved to yield ovarian preneoplastic and neoplastic lesions that pathogenetically resemble human ovarian cancer. A significantly lower dose (2 to 5 mug per ovary) of 7,12-dimethylbenz(a)anthracene (DMBA) was applied to the one ovary to maximally preserve its structural integrity. DMBA-induced mutagenesis was additionally combined with repetitive gonadotropin hormone stimulation to induce multiple cycles of active proliferation of the ovarian surface epithelium. Animals were treated in three arms of different doses of DMBA alone or followed by hormone administration. Comparison of the DMBA-treated ovaries with the contralateral control organs revealed the presence of epithelial cell origin lesions at morphologically distinct stages of preneoplasia and neoplasia. Their histopathology and path of dissemination to other organs are very similar to human ovarian cancer. Hormone cotreatment led to an increased lesion severity, indicating that gonadotropins may promote ovarian cancer progression. Point mutations in the Tp53 and Ki-Ras genes were detected that are also characteristic of human ovarian carcinomas. Additionally, an overexpression of estrogen and progesterone receptors was observed in preneoplastic and early neoplastic lesions, suggesting a role of these receptors in ovarian cancer development. These data indicate that this DMBA animal model gives rise to ovarian lesions that closely resemble human ovarian cancer and it is adequate for additional studies on the mechanisms of the disease and its clinical management.

Intraperitoneal serous adenocarcinoma: a critical appraisal of three hypotheses on its cause

OBJECTIVE

Serous ovarian, Fallopian tube, and peritoneal adenocarcinomas are remarkably similar, both in their morphology, as well as in their clinical behavior. Despite extensive clinical and fundamental research, controversy still exists on the origin of serous female adnexal tumors. Difficulties in identification of site of origin at late stage the of disease at detection, when ovary, Fallopian tube, and the abdominal cavity are usually all involved, in addition to their macroscopic and microscopic resemblance, are major causes of this debate. In 3 hypotheses, 3 possible tissues of origin are proposed: the ovarian surface epithelium, the Fallopian tube epithelium, and the secondary Mullerian system.

STUDY DESIGN

We searched for all peer-reviewed articles and reviews that examined "serous ovarian carcinoma," "Fallopian tube carcinoma," "Mullerian system," "ovarian surface epithelium," "tubal epithelium," and "peritoneal." We included only articles that could give information on the origin of serous carcinomas. Additional articles were added by examining references of overview articles in relevant fields.

RESULTS

Discussed are the experimental data underlying these hypotheses.

CONCLUSION

An attempt is made to integrate the 3 hypotheses into a comprehensive model of serous intraperitoneal adenocarcinogenesis. It can be concluded that the Fallopian tubes play a major role in the development of female serous cancer.

Primary and metastatic mucinous adenocarcinomas in the ovaries: incidence in routine practice with a new approach to improve intraoperative diagnosis

Mucinous carcinomas are reported to comprise 6-25% of ovarian carcinomas (mean 12%), but recent refinements in the interpretation of histologic features of noninvasive and metastatic mucinous carcinomas suggest that this may be an overestimate. Mucinous carcinomas in the ovaries are commonly metastatic, but the proportion of primary versus metastatic mucinous carcinomas in unselected patients is unknown. To evaluate the histologic-type distribution of ovarian surface epithelial carcinomas, a consecutive series of 124 ovarian carcinomas was reviewed using uniform current criteria. Microinvasive and intraepithelial carcinomas and carcinomas arising in germ cell and stromal tumors were excluded. To evaluate the proportions of primary and metastatic tumors among the mucinous carcinomas, 52 consecutive mucinous carcinomas from nonreferral patients were reviewed. Three of 124 primary ovarian carcinomas were pure mucinous carcinomas (2.4%). Among 52 cases of mucinous carcinomas in the ovaries, 40 (77%) were metastatic and 12 (23%) were primary. Among the 12 primary mucinous tumors, three were atypical proliferative mucinous tumors with microinvasion and nine were invasive mucinous carcinomas. Among the 40 metastatic mucinous tumors, 18 (45%) were from the gastrointestinal tract, 8 (20%) were pancreatic, 7 (18%) were gynecologic malignancies (5 cervical, 2 endometrial), 3 (8%) were from the breast, and 4 (10%) were of unknown primary site. A simple rule that classifies all bilateral mucinous carcinomas as metastatic, unilateral mucinous carcinomas <10 cm as metastatic, and unilateral mucinous carcinomas >or=10 cm as primary correctly classified 90% of the neoplasms. This algorithm for distinguishing primary and metastatic mucinous carcinomas in the ovary can be used at the time of intraoperative consultation to guide surgical management. After careful exclusion of noninvasive, microinvasive, and metastatic tumors, pure mucinous adenocarcinoma primary in the ovary appears to be substantially less common than previously reported.

Molecular determinants of tumor differentiation in papillary serous ovarian carcinoma

In epithelial ovarian cancer, tumor grade is an independent prognosticator whose molecular determinants remain unknown. We investigated patterns of gene expression in well- and poorly differentiated serous papillary ovarian and peritoneal carcinomas with cDNA microarrays. A 6500-feature cDNA microarray was used for comparison of the molecular profiles of eight grade III and four grade I stage III serous papillary adenocarcinomas. With a modified F-test in conjunction with random permutations, 99 genes whose expression was significantly different between grade I and grade III tumors were identified (P < 0.01). A disproportionate number of these differentially expressed genes were located on the chromosomal regions 20q13 and all exhibited higher expression in grade III tumors. Interphase fluorescent in situ hybridization demonstrated 20q13 amplification in two of the four grade III and none of the three grade I tumors available for evaluation. Several centrosome-related genes also showed higher expression in grade III tumors. We propose a model in which tumor differentiation is inversely correlated with the overexpression of several oncogenes located on 20q13, a common amplicon in ovarian and numerous other cancers. Dysregulation of centrosome function is one potential mechanistic link between genetic/epigenetic changes and the poorly differentiated phenotype in ovarian cancer.

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

Atypical proliferative (borderline) endometrioid tumors (APTs) and well-differentiated endometrioid carcinomas of the ovary constitute a spectrum of morphologically diverse proliferative tumors. There is currently no agreement on the criteria for distinguishing them. We report the clinicopathologic features of 56 proliferative endometrioid tumors focusing on the criteria for invasion, the clinical significance of microinvasion and cytologic atypia, and prognosis. Endometriomas, adenofibromas, adenosarcomas and moderately to poorly differentiated carcinomas were excluded, as were patients with concurrent endometrioid carcinoma of the endometrium. The tumors were classified as atypical proliferative tumor (APT) (33 tumors), APT with intraepithelial carcinoma (high-grade cytology in a tumor lacking stromal invasion) (three tumors), APT with microinvasion (invasion <5 mm) (five tumors), and invasive carcinoma (invasion > or = 5 mm) ( 15 tumors). All tumors were confined to the ovary (stage I). In 50 patients, the tumor involved one ovary, and in three patients, the tumors were bilateral. The predominant growth pattern was adenofibromatous in 29 tumors and glandular or papillary in 27 tumors. In 8 (24%) of 41 APTs, areas of benign adenofibroma were identified, and in 13 (87%) of 15 carcinomas, areas of associated APT were identified. Stromal invasion was manifested by confluent glandular growth in all 15 invasive carcinomas and all tumors with microinvasion. Destructive infiltrative growth was also present in 2 (13%) of 15 carcinomas. Confluent glandular growth was the most common manifestation of stromal invasion and therefore served as the best criterion for the diagnosis of carcinoma. Squamous differentiation was observed in 24 tumors, and mucinous differentiation was seen in 20 tumors and was most often seen in APTs. Endometriosis was present in 14 patients with APTs and one patient with carcinoma. Four patients had hyperplasia or atypical hyperplasia of the endometrium. One patient with an APT had a concurrent peritoneal serous neoplasm. Twenty-one patients had available clinical follow-up. Twenty (95%) of 21 patients, including six with invasive carcinoma, two with microinvasion, one with intraepithelial carcinoma, and 11 with APT were alive with no evidence of disease with a mean follow-up of 47 months. One patient with carcinoma had recurrent tumor after 46 months and was alive 40 months after resection of the recurrent tumor. In this large series of proliferative endometrioid tumors, all were stage I and only one patient had a recurrence. Most carcinomas contained evidence of a precursor APT, and in some APTs, an associated benign adenofibroma was identified. Microinvasion or intraepithelial carcinoma occurred in 19% of APTs. This finding likely reflects the various stages of endometrioid carcinogenesis in the ovary. For clinical management, we suggest that these tumors be divided into two categories-APTs and well-differentiated carcinoma-because based on the available data, cytologic atypia and microinvasion appear not to affect the prognosis.

Evaluation of diagnostic criteria and behavior of ovarian intestinal-type mucinous tumors: atypical proliferative (borderline) tumors and intraepithelial, microinvasive, invasive, and metastatic carcinomas

Histologic criteria for the distinction of ovarian mucinous borderline tumors (MBTs) from invasive mucinous carcinomas (MUCCAs) and the definitions of intraepithelial (noninvasive) carcinoma and microinvasion are controversial. Accurate assessment of the behavior of these tumors has been obscured by inclusion of cases of pseudomyxoma peritonei (PMP), an entity of extraovarian origin, and misclassification of the ovarian tumors in PMP and metastatic mucinous carcinomas (METCAs) as either advanced-stage MBTs or primary ovarian MUCCAs. One hundred thirty-six intestinal-type ovarian mucinous tumors without PMP were evaluated for the presence of stromal invasion, marked cytologic atypia, epithelial stratification of more than three cell layers, and necrosis. Criteria for the diagnosis of MBT, MBT with intraepithelial carcinoma, MBT with microinvasion (MIBT), MUCCA, and METCA were established and correlated with behavior. Twenty-three (59%) of 39 patients whose tumors had stromal invasion of more than 5 mm died of disease. Stromal invasion of more than 5 mm was the sole feature that correlated with a poor prognosis. In the absence of this feature, marked cytologic atypia, epithelial stratification of more than three layers, microinvasion (<5 mm), or necrosis did not have an adverse effect on survival. Tumors were classified as MBT (n = 65; 48%) based on absence of stromal invasion, regardless of degree of cytologic atypia or epithelial stratification; of these, 28 (43%) qualified as intraepithelial carcinoma based on epithelial stratification of more than three cell layers or marked cytologic atypia. Tumors with stromal invasion of less than 5 mm were classified as MIBT (n = 8; 6%). Tumors with stromal invasion of more than 5 mm were classified as MUCCA (n = 24; 18%). Tumors with a nodular pattern of stromal invasion, morphology inconsistent with ovarian origin, or a primary site elsewhere were classified as METCA (n = 35; 26%). Four tumors could not be definitively classified. Of the 86 cases with follow-up (median, 33 months) all MBTs (n = 44) and MIBTs (n = 6) were stage I, with 5-year survival rates of 100%. MUCCAs (n = 17) that were stage I had a 5-year survival rate of 91%; all patients with advanced-stage MUCCA died of disease. Five-year survival rate for METCAs (n = 19) was 11%. METCAs were more common than MUCCAs but can mimic MUCCAs and MBTs clinically and histologically. In the absence of a primary site elsewhere, METCA should be strongly suspected when there is bilateral surface involvement and a characteristic nodular pattern of invasion. It is important to recognize this pattern because 5-year survival rate for METCA (11%) was substantially less than that of MUCCA (all stages, 51%) and MBT (100%). Because all MBTs, regardless of degree of atypia or stratification, were stage I and benign, we prefer to designate them as atypical proliferative mucinous tumors. Marked cytologic atypia, epithelial stratification of more than three layers, and microinvasion (<5 mm) had no effect on the behavior of MBT. Noninvasive mucinous tumors with marked cytologic atypia or excessive epithelial stratification can be interpreted as atypical proliferative tumors with intraepithelial carcinoma and those with microinvasion can be designated as atypical proliferative tumors with microinvasion; these tumors appear to represent transitional stages in ovarian mucinous carcinogenesis.

Toward the development of a universal grading system for ovarian epithelial carcinoma. I. Prognostic significance of histopathologic features--problems involved in the architectural grading system

OBJECTIVE

Because there is no universally accepted grading system for ovarian epithelial carcinoma, we attempted to compare the prognostic utility of the individual components used in some systems--both architectural and cytologic features, as well as mitotic activity and histologic tumor type--to determine which of these components fit best with survival.

METHODS

We studied 461 patients with invasive ovarian carcinoma who had uniform treatment, complete clinical data including staging and follow-up, and slides available for review. Each tumor was assigned a histologic subtype, architectural grade (based on whether the predominant pattern was glandular, papillary or solid), nuclear grade, mitotic count, and FIGO grade (based on the system for endometrial carcinoma). These features were compared with each other and with tumor stage and survival.

RESULTS

The architectural grade, nuclear grade, and mitotic count were independent variables both in stage I/II and stage III/IV disease. Each of them correlated with survival for most combinations of histologic type and stage. By multivariate analysis, in stage I/II cancer, nuclear grade and architectural grade were significantly correlated with survival, mitotic count showed only a trend, and FIGO grade did not correlate. In stage III/IV disease, nuclear grade, architectural grade 3, and mitotic count were significant, and FIGO grade was not.

CONCLUSION

The new architectural grading system proposed worked better than the FIGO system in this study. Furthermore, it could be applied to all histologic subtypes of carcinoma. The nuclear grade and mitotic count were also independent of each other, correlated with survival, and could be utilized for all histologic types. These data support the development of a grading system which combines these architectural, nuclear, and mitotic features and can be applied regardless of the histologic type of carcinoma, modeled after the Nottingham system for grading of breast carcinoma.

Endometrioid ovarian carcinoma in a premenarchal girl: report of a case

In children and adolescents, ovarian neoplasms are predominantly germ cell and sex cord stromal tumors. Carcinomas are quite rare, and, in particular, endometrioid adenocarcinomas are extremely rare in this age group. We report the case of a 13-year-old girl with FIGO stage I, grade I endometrioid adenocarcinoma of the ovary. To our knowledge this is the first report of an endometrioid carcinoma of the ovary occuring in the premenarchal age group and only the second case reported before age 15. Our patient has been treated by conservative surgery without postoperative chemotherapy. Menarche occured 3 months after surgery. Twelve months after surgery she is free of disease.

Pseudomyxoma peritonei: a cytohistopathologic study of nine cases

Cytologic examination of seven peritoneal fluids from nine patients with pseudomyxoma peritonei revealed papillary clusters and isolated neoplastic cells. In all patients, one or both ovaries were replaced by proliferating (borderline) mucinous epithelial tumors of grade I-II intestinal type while three patients had synchronous appendiceal tumors of similar morphologic appearance. Four of the nine patients demonstrated positive correlation between the presence of neoplastic cells in the ovarian interstitial mucin (pseudomyxoma ovarii), the extraovarian peritoneum, and the free peritoneal fluid. Two patients demonstrated a negative correlation. The submission of an inadequate amount of ovarian or appendiceal tissue for histologic examination may account for the discordance in three patients. It is concluded that pseudomyxoma peritonei is a distinct clinicopathologic entity which can be subdivided into two types, acellular and cellular. This distinction, unlike the specific cytomorphologic features, may have prognostic significance.

Expression of the 67 kD laminin receptor in human ovarian carcinomas as defined by a monoclonal antibody, MLuC5

Previous immunohistochemical data from our laboratory have demonstrated that expression of the 67 kD laminin receptor (67LR), a cancer-associated, high-affinity laminin-binding protein, is upregulated in ovarian carcinoma cells compared with normal serosal cells, and that this increased expression in cancer cells could be related to patient outcome. The aim of this study was to validate MLuC5, a monoclonal antibody that recognises the 67LR, as a tool to perform future immunohistochemical studies on larger populations of ovarian carcinoma patients. Expression of the 67LR was determined in 51 primary human ovarian carcinoma samples using immunohistochemistry and MLuC5. The 67LR was detected in ovarian carcinoma cell clusters of variable extent. Analysis of the data determined that 67LR expression was significantly increased in the samples from patients with disease progression, compared with those with no evidence of disease after completion of primary therapy, and in pooled grade 2 and 3 tumours compared to borderline and grade 1 tumours (P < 0.05, chi-squared test). No other significant correlation between 67LR expression and other clinicopathological parameters could be established. These data suggest that the 67LR is correlated to ovarian tumour progression. Detection of the 67LR using this monoclonal antibody could constitute an interesting parameter in prognosis determination of ovarian cancer.

An evaluation of prognostic factors in advanced ovarian cancer

A summary is presented of currently available prognostic factors in advanced ovarian cancer of the common epithelial types. The emphasis is on the most promising clinical, classical pathological, biochemical, immunohistochemical, molecular biological and quantitative pathological factors.

Current concepts in management of epithelial ovarian tumors of low malignant potential

Approximately 15 percent of epithelial ovarian tumors are tumors of LMP. Epithelial stratification, cellular atypia, mitotic activity, and abscence of ovarian stromal invasion set the histopathological criteria for diagnosis. Serous and mucinous tumors of LMP represent 80 to 95% of all cases. These tumors occur in patients at a younger age than those with invasive cancer and many times in fertile women who have not accomplished their family planning yet. Ovarian tumors of low malignant potential carry a favorable prognosis in comparison to invasive epithelial ovarian cancer. The recurrence rate after surgery for these tumors ranges from 10 percent to 30 percent, occurring as late as 10 or more years after presentation. The majority of patients (80-92 percent) with ovarian tumors of LMP present with stage I disease. Peritoneal implants display a range of histologic appearances, ranging from benign glands to those with features of invasive disease. Tumor markers such as CA-125 are not as useful in tumors of LMP as in invasive ovarian carcinoma. Elevated CA-125 are found only in patients with advanced serous tumors of LMP; thus, other markers such as transvaginal Doppler measurements of vascular resistant index has been suggested for possible differentiation between a benign and LMP ovarian tumors before surgery. Primary conservative surgery consisting of unilateral salpingo-oophorectomy is considered to be an appropriate treatment for young women with stage Ia ovarian tumors of LMP who wish to retain their fertility potential. Up to 70 percent of women who underwent conservative surgery subsequently conceive.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors in well-differentiated early-stage epithelial ovarian cancer

BACKGROUND

The prognosis of patients with early ovarian cancer is good as compared with that of patients with advanced disease. However, there are no methods for predicting prognosis of early ovarian cancer, on which treatment decisions can be based.

METHODS

The prognostic significance of DNA flow cytometric and morphometric analysis was evaluated in 64 surgically treated patients with well-differentiated early-stage (International Federation of Gynecology and Obstetrics [FIGO] Stage IA, IB, IC, and IIA) epithelial ovarian cancer. The extent of the well-defined staging procedure was assessed strictly in every patient.

RESULTS

Only five patients died of recurrent ovarian cancer; all of these patients belonged to the inaccurately staged group. No significant relationship was found between clinicopathologic characteristics, such as menopausal status, FIGO stage, histologic cell type, and 5-year disease-free survival rate. Forty-two of the tumors had a mitotic activity index (MAI) of less than 30, and 43 of the tumors showed a volume percentage epithelium (VPE) of less than 65. Neither as a single parameter nor in combination did MAI and VPE correlate significantly with disease-free survival. Thirty-two tumors (50%) were DNA diploid, 15 were considered wide-CV-diploid, and 17 were aneuploid. Nearly 90% of the tumors showed DNA indices (DI) of 1.40 or less. The 5-year disease-free survival rate was significantly lower (61%) for patients with DI greater than 1.40 than for those with DI of 1.40 or less (96%) (P < 0.005). From the total number of five patients who died of their disease, three had tumors with DI in the tetraploid range.

Pseudomyxoma peritonei--experience from a tertiary referral centre

Pseudomyxoma peritonei is a clinical diagnosis of massive abdominal swelling by a gelatinous material, produced usually from an ovarian or appendiceal primary. It is a rare entity that is usually histologically benign but behaves clinically in a malignant fashion with recurrent growth, although not demonstrating histological stromal invasion. The disease remains localized to the peritoneal cavity and the clinical course is one of repeated episodes of intestinal obstruction caused by extrinsic compression that seem only to be relieved by surgical debulking. Variable responses have been obtained with adjuvant chemo-, radio- and immunotherapy, but these isolated responses are unable to be reproduced and so there is no accepted adjuvant treatment for this disease.

Bilateral ovarian carcinoma: cytogenetic evidence of unicentric origin

Cytogenetic analyses were performed on the tumors from both ovaries in 15 patients with bilateral ovarian carcinoma. In 4 of them, omental implants were also examined. Abnormal karyotypes were detected in 11 cases. The baseline karyotypes in the 2 tumorous ovaries were identical in each patient, indicating that bilateral ovarian cancer develops by metastatic spreading. There was no clear-cut evidence of differences in the clonal evolution between the tumors of the 2 ovaries, and hence the side harboring the primary tumor could never be determined. The metastatic nature of the omental implants was proved by the fact that their karyotypes were indistinguishable from those of the ovarian tumor tissue.

Epithelial ovarian tumors of borderline malignancy

Between January 1975 and January 1987, 80 patients underwent primary surgery at Brigham and Women's Hospital for epithelial ovarian tumors of borderline malignancy. Surgical staging revealed 52 (65%) patients with stage IA, 2 (2.5%) with stage IB, 10 (12.5%) with stage IC, 4 (5%) with stage II, 11 (13.8%) with stage III, and 1 (1.2%) with stage IV. All 37 patients with mucinous tumors had stage I disease, whereas 13 (33%) of 39 patients with serous tumors had stage II-IV disease. The mean sizes of mucinous and serous ovarian tumors were 18.7 and 10 cm, respectively. At initial surgery, 48 (60%) patients had a total abdominal hysterectomy with bilateral salpingo-oophorectomy and 16 (20%) had an oophorectomy. Sixteen (20%) patients underwent cystectomy, 6 (37.5%) of whom subsequently had an oophorectomy. All 10 patients treated by cystectomy alone have remained disease free. CA-125 levels were normal in 5 patients with stage I disease, but were elevated in 6 of 8 patients with more advanced tumors. Current disease status was determined in 72 patients (90%); 69 (95.8%) are alive and disease free, 1 (1.4%) patient is alive with tumor, and 2 (2.8%) patients died, free of disease.

Ovarian serous borderline tumors with stromal microinvasion: a report of 21 cases

The clinicopathologic features of 21 cases of otherwise typical serous borderline tumors that contained small foci of stromal invasion were reviewed. The mean age of the patients was 43 years and six of them were pregnant at the time of diagnosis. Nineteen tumors were stage I, one was stage III (para-aortic lymph node involvement) and one was stage IV (parenchymal liver metastasis). The tumor invaded the stroma predominantly as individual cells or nests or clusters of cells with abundant eosinophilic cytoplasm (17 cases), as small confluent nests with a cribriform pattern (two cases) and as rounded aggregates of papillae (two cases). Seven women were treated with bilateral salpingo-oophorectomy and hysterectomy; 13 had less than bilateral oophorectomy. Of the 17 patients for whom followup data were available, 16 were without evidence of disease 1 to 11 (mean, 5.2) years postoperatively, and one patient had a serous borderline tumor with microinvasion in a conserved contralateral ovary 2.8 years postoperatively, but was well 6 months after a partial oophorectomy. These data suggest that serous borderline tumors with microinvasion have a prognosis similar to that of the usual serous borderline tumor, and that conservation of the contralateral ovary and uterus may be acceptable therapy in young women who wish to preserve their fertility.

Prognostic value of ovarian carcinoma grading methods--a method comparison study

The prognostic value of subjective histological and morphometric grading was studied in 75 primary ovarian carcinomas. Histological grading methods recommended by Czernobilsky and by Russell and the morphometric method of Baak and co-workers were compared in a two-observer system. The 5-year survival could be correctly predicted in about two-thirds of the patients with all three methods. When mitotic counting (volume corrected mitotic index, M/V-index) was compared with the above grading methods by using a receiver operating characteristic curve) the M/V-index was generally superior in its prognostic power regardless of the sensitivity/specificity level chosen. The morphometric grading method and the grading method based on the M/V index were also shown to be readily reproducible.

Prognosis of ovarian carcinomas: prediction by histoquantitative methods

Prediction of prognosis of ovarian carcinomas by morphometric, histopathological and clinical indices was estimated in 105 tumours. Morphometric parameters included mitotic activity index, volume-corrected mitotic index (M/V index), volume fraction of neoplastic epithelium, nuclear area, nuclear perimeter, shortest and longest nuclear axis and form factor of nucleus. Cox's multivariate regression model showed that the clinical stage was the best predictor of prognosis followed by the M/V index, which expresses the mitotic activity as the number of mitotic figures per square millimeter of neoplastic epithelium in the microscope field. In all tumour subgroups studied the M/V index was the best prognostic factor and for stage I tumours it was the only parameter selected by the Cox's model as a significant and independent prognostic predictor. We conclude that the M/V index can be used as a significant prognostic factor in ovarian carcinomas.

An evaluation of CA125, CA1 and peanut lectin immunoreactivity in epithelial ovarian neoplasms: correlation with histopathological features, prognostic variables and patient outcome

The ability to produce monoclonal antibodies to tumour associated antigens, together with advances in immunocytochemistry, provide the potential for establishing a new functional classification of human tumours. This approach was used to investigate whether the expression of CA125, CA1 and the Thomsen-Friedenreich antigens reflected the biological behaviour of ovarian tumours and, if so, had a potential role in the clinico-pathological assessment of ovarian neoplasms. Expression of these antigens was assessed in benign, borderline and malignant ovarian epithelial tumours and attempts were made to determine if there was any correlation between immunoreactivity and tumour grade, histological subtype, FIGO Stage, tumour ploidy or patient outcome. There was no evidence that expression of these antigens had clinical significance, although it is possible that reactivity with antibody OC125 might identify patients in whom CA125 antigen levels in the sera could be used as a marker to monitor disease progress.

Ovarian epithelial tumors in Thai women: a histological analysis of 291 cases

A semiquantitative histological analysis on 291 epithelial tumors of the ovary in Thai women was done to assess the association between stromal invasion and a number of other histological features. Cribriform pattern, back-to-back growth, and epithelial stratification deeper than three cells were significantly related with stromal invasion in all types of ovarian epithelial tumors combined as well as in mucinous tumors alone. This finding suggests that the three histological characteristics serve as additional criteria of malignancy when unequivocal stromal invasion cannot be demonstrated. Histological classification of ovarian epithelial tumors in Thai women, together with age distribution, laterality, extraovarian spread, and some associated pathology, are presented and discussed.

Neuroendocrine cells in cystic mucinous tumours of the ovary

This histogenesis of cystic mucinous ovarian tumours is still controversial. It has been proposed that these neoplasms may arise from metaplastic ovarian surface epithelium. Others have suggested that these tumours represent monophyletic (intestinal) types of teratoma. Against this background we have studied the presence of different types of neuroendocrine cells in a series of cystic mucinous ovarian tumours. Argyrophil neuroendocrine cells were found almost exclusively in tumours which were histologically classified as borderline or low-grade mucinous carcinomas, whereas these cells were very rare in mucinous cystadenomas and in grade III and IV carcinomas. Several gut peptide hormones could be demonstrated in these cells, but only in borderline tumours and low-grade mucinous carcinomas. Mucin histochemistry did not reveal characteristic patterns in these neoplasms. The results confirm that with regard to the presence of endocrine cells the epithelium of borderline mucinous cystadenomas and mucinous cystadenocarcinomas bears strong resemblance to intestinal epithelium. These findings do not rule out the possibility that these tumours arise by metaplasia from ovarian germinal epithelium but are equally compatible with a teratomatous origin. The epithelium of most benign mucinous cystadenomas resembles that of ovarian inclusion cysts.

The pathological assessment of ovarian neoplasms V: The germ cell tumours

All neoplasms of the ovary encountered in a 25-yr study period of King George V Memorial Hospital were classified according to the World Health Organisation (WHO) Histological Classification of Ovarian Tumours. Of just fewer than 1700 tumours, 467 fell into the category designated as germ cell tumours: 4 dysgerminomas, one endodermal sinus tumour, one primary choriocarcinoma, 6 immature and 454 mature teratomas and one mixed malignant germ cell tumour. Two additional cases of gonadoblastoma with associated dysgerminoma were encountered and included for discussion. A detailed histological assessment is presented and the major clinical correlates are documented.

The pathological assessment of ovarian neoplasms. IV: The sex cord-stromal tumours

All neoplasms of the ovary encountered in a 25-yr study period at the King George V Memorial Hospital were classified according to the World Health Organisation (WHO) Histological Classification of Ovarian Tumours. Of just less than 1700 tumours, 168 fell into the category designated as sex cord-stromal tumours, this report analysing their major clinical and pathological correlates. A detailed histological assessment is then presented, including 4 cases of the recently separated subcategory of sclerosing stromal tumour of the ovary.

Prospective study with HEXA-CAF combination in ovarian carcinoma

The value of combination chemotherapy with HEXA-CAF was analyzed in 31 patients with histologically documented epithelial ovarian cancer in advanced stages (minimal or gross disease). No patient had been previously treated with chemotherapy. Peritoneoscopy with diaphragmatic inspection, peritoneal cytology, lymphography, and chest X-ray were routinely used in staging and restaging the patients. Complete (CR) plus partial (PR) responses were obtained in 13/31 fully restaged patients (41.9%). CR was recorded in seven patients (22.5%) and PR in six patients (19.3%). Remission duration was significantly longer in patients who achieved CR (20 months) than in those who attained PR (9.5 months) (P Less Than 0.01). In all treated patients the median duration of survival was 16.5 months. Survival was significantly longer in patients with CR than in patients who did not achieve CR (P Less Than 0.05). Nevertheless, considering the rate of CR in patients with gross disease (20.6%), HEXA-CAF combination seems a useful but not yet a hopeful treatment for patients with advanced ovarian carcinoma.

Extrauterine mesodermal (müllerian) adenosarcoma. A case report

Extrauterine mesodermal (müllerian) adenosarcomas have only recently been described, and this is the first reported case from Australia. These tumours fall within the category of common epithelial tumours' in the World Health Organisation (W.H.O.) classification of ovarian tumours and comprise benign looking epithelial structures (glands, papillae) in association with sarcomatous stroma. They are thus distinct from malignant mesodermal mixed tumours in which both epithelial and stromal elements are cytologically malignant.