The pathological assessment of ovarian neoplasms. II: The proliferating 'epithelial' tumours

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transforming Growth Factor-alpha and c-erbB-2 Oncogene Products in Ovarian Epithelial Tumors

The distribution of transforming growth factor-alpha (TGF-alpha) and c- erbB-2 proteins was immunohistochemically analyzed in 49 epithelial ovarian neoplasms to determine their implication as molecular modulators of epithelial ovarian cancer progression and as possible prognosticators of outcome. TGF-alpha cytoplasmic immunoreactivity was strongly positive in 100% of adenomas (ADs)(N=11) and tumors of low malignant potential (LMPs)(N=17) but in only 19% of invasive carcinomas (ICAs)(N=21). TGF-alpha immunoreactivity was selective of the ovarian epithelium. Interestingly, in the TGF-alpha-positive carcinomas, the monoclonal antibody decorated the better-differentiated areas of the tumor (ie, areas with papillary architecture), leaving the less differentiated solid areas unstained. Strong p185 c- erb B-2 protein cytoplasmic immunoreactivity was present in 45% of ADs but also in 48% of ICAs. The LMPs, however, expressed c -erbB-2 only at low frequency. These data suggest the involvement of c- erbB-2 in the progression of some ovarian carcinomas but not others. Conversely, the strong TGF-alpha expression in ADs and LMPs, which fades in ICAs, implies an alteration of the TGF-alpha expression in the progression of epithelial ovarian tumors. Failure of the poorly differentiated carcinomas to decorate with TGF-alpha seems to indicate that TGF-alpha is a marker of tumor grade. Int J Surg Pnthol4(3):00-00, 1997

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.

Ovarian tumors of borderline malignancy: a review of 247 patients from 1991 to 2004

Borderline ovarian tumors account for 15% of epithelial ovarian cancers and are different from invasive malignant carcinoma. Majority are early stage, occurring in women in the reproductive age group, where fertility is important. We reviewed retrospectively 247 such cases treated at the Gynaecological-Oncology Unit, KK Women's and Children's Hospital, between January 1991 and December 2004. The mean age was 38 years (16-89 years). Majority of the cases (92%) were FIGO stage I (Ia, 75%; Ib, 1%; and Ic, 16%). Seven (3.5%) patients were diagnosed as having stage II disease, six (2.5%) as stage IIIa, two (1%) as stage IIIb, and four (2%) as stage IIIc. Histological origin was as follows: mucinous (68%), serous (26%), endometrioid (2.6%), and clear cell (1.2%). Primary surgical procedures undertaken were as follows: hysterectomy with bilateral salpingo-oophorectomy (52%), unilateral salpingo-oophorectomy (33%), or ovarian cystectomy (15%). Adjuvant chemotherapy was administered in 13 patients (5.2% of cases), of which 4 patients were given chemotherapy only because of synchronous malignancies. There were six recurrences (2.4% of cases). Overall mean time to recurrence was 59 months. Recurrence rate for patients who underwent a primary pelvic clearance was 1.6% compared to fertility-sparing conservative surgery (3.3%; although P= 0.683). No significant difference was noted in recurrence and mortality between staged versus unstaged procedures. The overall survival rate was 98.0%. There were a total of five deaths (2.8%): three (1.5%) from invasive ovarian/peritoneal carcinoma and two from synchronous uterine malignancies. It appears that surgical resection is the mainstay of treatment, with conservative surgery where fertility is desired or pelvic clearance if the family is complete. Surgical staging is important to identify invasive extraovarian implants that portend an adverse prognosis. The role of adjuvant chemotherapy is not established.

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.

Conservative surgery for borderline ovarian tumors: a review

OBJECTIVE

Borderline tumor of the ovary is an epithelial tumor with a low rate of growth and a low potential to invade or metastasize. This review will outline the most recent information regarding the molecular pathogenesis, pathology, fertility and tumor recurrence rate after conservative management of young women with early-stage borderline ovarian tumors.

METHODS

We performed a MEDLINE literature search of relevant clinical trials for the scope of this review that evaluated conservative treatment of borderline ovarian tumors for young women with low-stage disease who wish to preserve their fertility.

RESULTS

Recently, investigators have begun to identify subsets of patients with a worse prognosis, such as patients with aneuploid tumors. A number of oncogenes are under investigation to determine their role in the pathogenesis of borderline ovarian tumors. Previous studies have suggested the safety of conservative surgery with unilateral salpingo-oophorectomy or cystectomy for patients with stage I borderline ovarian tumors. Laparoscopic treatment of adnexal masses has proved to be a safe and effective diagnostic and therapeutic tool in the hands of experienced laparoscopists. For women who are treated conservatively, follow-up is important. Surgery remains the most effective therapy for later stage lesions. Adjuvant therapy for advanced stage of borderline ovarian tumors remains controversial.

CONCLUSION

Conservative management of borderline ovarian tumors is an appropriate therapeutic option for young women with early-stage lesions who wish to preserve their childbearing potential. Available data indicate that in these patients fertility, pregnancy outcome and survival remain excellent.

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.

Mucinous borderline ovarian tumors: Points of general agreement and persistent controversies regarding nomenclature, diagnostic criteria, and behavior

This report focuses on the borderline category of ovarian mucinous tumors and summarizes the points of general agreement and persistent controversies identified by experts in the field who participated in the Borderline Ovarian Tumor Workshop held in Bethesda, MD, in August 2003. Points of agreement and persistent controversies regarding nomenclature, diagnostic criteria, and behavior are addressed for the following ovarian mucinous tumor categories: mucinous borderline ovarian tumor (M-BOT; synonymously referred to as atypical proliferative mucinous tumor of ovary or mucinous ovarian tumor of low malignant potential), M-BOT with intraepithelial carcinoma, and M-BOT with microinvasion. The morphologic spectrum of M-BOTs with regard to distinction from mucinous cystadenoma and the confluent glandular/expansile type of invasive mucinous carcinoma is also addressed. Non-ovarian mucinous tumors, including the secondary ovarian mucinous tumors associated with pseudomyxoma peritonei and metastatic mucinous carcinomas with a deceptive pattern of invasion, are recognized as tumors that can simulate primary M-BOTs. Improved classification of these mucinous tumors has clarifed the behavior of true M-BOTs by excluding these simulators from the M-BOT category.

Serous borderline (low malignant potential, atypical proliferative) ovarian tumors: Workshop perspectives

Although the category of serous borderline ovarian tumor (S-BOT) was established more than 30 years ago, the nomenclature and prognostic significance of various histological features of these neoplasms continues to engender controversy. The Borderline Ovarian Tumor Workshop was held in Bethesda, MD, in August 2003 in an attempt to examine the existing data, establish areas of agreement, and identify areas needing further investigation. This report addresses 6 areas of controversy regarding S-BOT: (1) tumors with and without a micropapillary architecture (typical vs micropapillary type), (2) peritoneal implants, (3) stromal microinvasion, (4) ovarian surface involvement, (5) lymph node involvement, and (6) recurrent tumors. Each of these issues is addressed by summarizing the data in the literature on which the discussions were based, areas of agreement that emerged, divergent opinions and the reasoning behind them, and the conclusions of the participants with recommended nomenclature.

Noninvasive and invasive micropapillary (low-grade) serous carcinoma of the ovary: a clinicopathologic analysis of 135 cases

Reports describing the behavior of micropapillary serous carcinomas (MPSCs) of the ovary have focused on those that are noninvasive. There are only very limited data on the behavior of those that are invasive. To further characterize the behavior of MPSCs, invasive versus noninvasive primary tumors were distinguished based on the presence or absence of destructive infiltrative growth. To qualify for inclusion, invasive MPSCs, like the noninvasive tumors, were required to display a micropapillary architecture and low-grade nuclei. A total of 135 cases of MPSC were identified: 96 noninvasive and 39 invasive. On follow-up, survival for 10 patients with stage I noninvasive and invasive MPSCs was 100%, and survival for women with stage II and III noninvasive and invasive MPSCs with noninvasive implants was 80%. In contrast, the 5-year and 10-year survival for patients with stage II and III noninvasive MPSCs with invasive implants was 85% and 55%, respectively. The 5-year and 10-year survival for women with invasive MPSCs and invasive implants was 55% and 45%, respectively. The median time from diagnosis to death for women with noninvasive and invasive MPSCs with invasive implants was 60 months (range 33-240 months). The indolent behavior of these low-grade carcinomas distinguishes them from conventional serous carcinomas, which are high-grade aggressive neoplasms. Five of six patients with small (<5 mm) MPSCs in whom follow-up was available presented with high stage disease. Of these five women, three are alive and well and two are alive with disease (one with invasive and one with noninvasive implants). Nearly three fourths of noninvasive MPSCs were associated with atypical proliferative serous tumors, adenofibromas, or both, and 62% of invasive MPSCs were associated with noninvasive MPSCs, atypical proliferative serous tumors, and adenofibromas, alone or in combination. In addition to the frequent mixtures of these tumor components, transitions between them were common. These data in conjunction with recent molecular genetic studies strongly suggest that MPSCs (low-grade carcinomas) arise from atypical proliferative serous tumors unlike conventional serous carcinomas (high-grade carcinomas), which appear to develop de novo. The findings provide further support for the hypothesis that there are distinct pathways of carcinogenesis for low-grade and high-grade serous carcinoma of the ovary.

Extrauterine low-grade endometrial stromal sarcoma with florid endometrioid glandular differentiation

Endometrial stromal sarcoma of the uterus (ESS) is a rare lesion that can cause diagnostic difficulty especially when it presents with unusual histologic features such as diffuse endometrioid glandular differentiation. Only three such cases have been reported, all primary in the uterus. We report the first case of an extrauterine low-grade ESS with extensive glandular differentiation that appeared to arise in endometriosis.

Refined diagnostic criteria for implants associated with ovarian atypical proliferative serous tumors (borderline) and micropapillary serous carcinomas

Characterization of invasive peritoneal implants from patients with noninvasive serous ovarian tumors has important prognostic and treatment implications, but the criteria for distinguishing invasive and noninvasive implants vary among investigators and can be difficult to apply. The authors studied 148 implants from 60 patients, 33 with primary atypical proliferative serous tumor, and 27 with primary noninvasive micropapillary serous carcinoma, with a mean follow-up of 62 months (median follow-up, 52 months). Previously reported and newly proposed histologic features for implant classification were evaluated and correlated with clinical outcome. Three criteria were applied for the diagnosis of "invasive" implants: invasion of underlying normal tissue, micropapillary architecture, and solid epithelial nests surrounded by clefts. Implants displaying any one of these three features were classified as "invasive," whereas those lacking all three features were classified as "noninvasive." Sixty-six implants were invasive and 82 were noninvasive. Of the 31 patients with invasive implants, six were dead of disease (DOD), 13 were alive with progressive disease (AWPD), and 12 were alive with no evidence of disease (NED). Of the 29 patients with noninvasive implants, two were DOD, one was dead of uncertain causes, one was AWPD, and 25 were alive with NED. Eighty-nine percent of invasive implants had a micropapillary architecture and 83% had solid epithelial nests surrounded by clefts. A minority of invasive implants (14% of those with underlying normal tissue) demonstrated invasion of normal underlying tissue. Nuclear atypia, mitoses, calcification, necrosis, and identification of individual cells "infiltrating" the stroma did not correlate with implant type. The proposed criteria permitted recognition of implants that correlated strongly with adverse outcome. Sixty-one percent of patients with implants displaying any one of the three features used to diagnose invasive implants were AWPD or DOD compared with 10% of patients whose implants lacked these features (p = 0.00001). Because implants associated with an adverse outcome can be identified before they invade underlying normal tissue, the term invasive implant to describe them is inaccurate and misleading. These implants resemble patterns of growth in micropapillary serous carcinoma of the ovary and the recurrent tumor that is obvious carcinoma. Accordingly, we propose that these extraovarian lesions be designated "well-differentiated serous carcinoma."

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.

Mucinous tumors of the ovary: a clinicopathologic study of 196 borderline tumors (of intestinal type) and carcinomas, including an evaluation of 11 cases with 'pseudomyxoma peritonei'

Mucinous ovarian neoplasms other than cystadenomas and adenofibromas have been classified as either borderline tumors or carcinomas for many years. Borderline tumors have been subdivided more recently into endocervical-like (mullerian) and intestinal forms. Such a distinction is rarely made in the mucinous carcinoma category. We did not encounter a pure endocervical-like carcinoma in the present series. Criteria for distinguishing an intestinal-type mucinous borderline tumor from a mucinous carcinoma have been controversial. In this study of 164 mucinous borderline tumors of intestinal type and 32 mucinous carcinomas, the former were further subdivided into 74 cases with epithelial atypia only and 90 with focal intraepithelial carcinoma. Of the 67 stage I tumors in the borderline (with atypia) category, all 49 with follow-up data were clinically benign; in the seven cases that had been designated stage III, the intraoperative appearance was that of "pseudomyxoma peritonei," which was fatal in four cases. Most of these tumors, however, were probably metastatic to the ovary rather than truly primary borderline tumors, although failure to examine the appendix in six cases compromised their interpretation. All 90 mucinous borderline tumors that had foci of intraepithelial carcinoma were recorded as stage I, but two of the 69 patients with follow-up data (3%) had fatal recurrences. Both of these tumors were incompletely staged, however, and one had ruptured intraoperatively. Thirty-two invasive carcinomas were subdivided into 12 expansile and 20 infiltrative subtypes; within the latter category seven tumors were only microinvasive. All 12 carcinomas with only expansile invasion were stage I; none of the 10 with follow-up data recurred. All seven microinvasive infiltrative carcinomas were stage I; none of the five with follow-up data recurred. One of five patients with stage I infiltrative carcinomas that were more than microinvasive and were adequately followed had a fatal recurrence, but staging had been incomplete in that case. Seven of the remaining eight infiltrative carcinomas were higher than stage I: five of the six (83%) with follow-up data persisted or recurred and were fatal. Considering all stages, increasing tumor grade in the carcinoma category correlated with an unfavorable outcome. However, grade did not influence prognosis in stage I carcinomas. Among 13 stage I cases in all categories with either preoperative or intraoperative tumor rupture and follow-up data, one recurred, a tumor in the borderline with intraepithelial carcinoma category. "Pseudomyxoma peritonei" is an ill-defined term and should not be used as a pathologic diagnosis. The presence of mucin in the abdominal cavity requires careful histologic evaluation to characterize it for prognostic purposes. Adequate and sometimes extensive sampling of mucinous ovarian tumors, the appendix and the peritoneum in cases of "pseudomyxoma peritonei" is necessary to achieve an accurate diagnosis and prognosis.

Noninvasive, microinvasive, and invasive mucinous carcinomas of the ovary: a clinicopathologic analysis of 40 cases

BACKGROUND

Whether ovarian mucinous tumors with epithelial stratification of more than three cell layers in the absence of stromal invasion (i.e., carcinomas diagnosed according to the Hart and Norris criteria) should be placed in the same category as mucinous tumors with stromal invasion (i.e., unquestionable carcinomas) remains controversial. Because individual mucinous tumors frequently contain benign, borderline, and malignant components, the adequacy of sampling has been emphasized.

METHODS

We examined 21 mucinous carcinomas with no destructive stromal invasion (MCNI), 4 mucinous carcinomas with microinvasion (MCMI) of < 2 mm, and 15 mucinous carcinomas with invasion (MCI) of > or = 2 mm. Tumors were diagnosed as MCNI according to Hart and Norris criteria (12 tumors) or when severe nuclear atypia was present (9 tumors). Cases of MCNI were selected for review if a section had been taken for each 2 cm or less of the tumor's greatest diameter. The International Federation of Gynecology and Obstetrics stage and follow-up data of each case were examined, and differences among MCNI, MCMI, and MCI were analyzed.

RESULTS

All 21 patients with MCNI and all 4 patients with MCMI had Stage I disease; there was no recurrence or death in these cases. In contrast, 7 of 15 patients with MCI had Stage II or III disease, and 8 patients died.

CONCLUSION

MCNI clearly should be distinguished from MCI and be classified as noninvasive carcinomas after the absence of destructive stromal invasion has been confirmed by examining a sufficient number of sections.

Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators

BACKGROUND

The behavior of ovarian serous borderline tumors (SBTs) and significance of various prognostic factors are unclear and difficult to evaluate because of inconsistencies and confusion in the literature. Recent studies have suggested that the morphological features of the primary tumor (presence or absence of micropapillary features) and the peritoneal "implants" (presence or absence of invasive features) can reliably subclassify SBTs into benign and malignant types. The aim of the current review was to test two hypotheses. First, that the alleged malignant behavior of SBTs is poorly documented, and second, that the morphological features of the primary ovarian tumors and the associated peritoneal implants are sufficient to separate SBTs into benign and malignant types, thereby obviating the need for the category.

METHODS

245 studies reporting approximately 18,000 patients with borderline ovarian tumors were reviewed. After excluding series that lacked clinical follow-up or were not analyzable for other reasons, there remained 97 reports that included 4,129 patients. In addition to recurrences and survival, we evaluated the type of peritoneal implants, microinvasion, lymph node involvement, late recurrences, and progression to carcinoma, as these features have served as the underpinning of the concept of "borderline malignancy" or "low malignant potential."

RESULTS

Among 4,129 patients with SBTs reviewed, the recurrence rate after a mean follow-up of 6.7 years was 0.27% per year for stage I tumors, the disease-free survival was 98.2%, and the overall disease-specific survival rate was 99.5%. For patients with advanced-stage tumors, the recurrence rate was 2.4% per year. However, the majority (69%) of reported recurrences were not pathologically documented, and only 26 cases (8.4% of all recurrences) were documented to have recurred from an adequately sampled ovarian tumor. The most reliable prognostic indicator for advanced stage tumors was the type of peritoneal implant. After 7.4 years of follow-up, the survival of patients with noninvasive peritoneal inplants was 95.3%, as compared with 66% for invasive implants (P < .0001). Microinvasion in the primary ovarian tumor was associated with a 100% survival rate at 6.7 years, and lymph node involvement was associated with a 98% survival rate at 6.5 years. The few reported cases of stage IV disease, progression to invasive carcinoma, and very late (>20 years) recurrences were poorly documented. The survival for all stages among approximately 373 patients in 6 prospective randomized trials followed for a mean of 6.7 years was 100%.

CONCLUSION

Surgical pathological stage and subclassification of extraovarian disease into invasive and noninvasive implants are the most important prognostic indicators for SBTs. Survival for stage I tumors is virtually 100%. Survival for advanced stage tumors with noninvasive implants is 95.3%, whereas survival for tumors with invasive implants is 66%. Invasive implants behave as carcinomas and are most likely metastatic. The precise nature of so-called noninvasive implants is not clear, but they behave in a benign fashion. The presence of a micropapillary architecture in the primary ovarian tumor is a strong predictor of invasive implants. These data support the recommendation that ovarian tumors with a micropapillary architecture be designated "micropapillary serous carcinomas," and those lacking these features, "atypical proliferative serous tumors."

The management of borderline epithelial tumors of the ovary

The histopathological diagnosis and treatment of borderline epithelial tumors of the ovary (BTO) still pose problems to both pathologists and gynecologists. BTO is a disease of younger, fertile females and generally has an excellent prognosis. A minority of patients, however, succumb to this disease. A review of the literature is given addressing aspects of epidemiology, histology, treatment and prognosis, resulting in a proposal for the management of serous and mucinous borderline tumors of the ovary.

Clinical relevance of retroperitoneal involvement from epithelial ovarian tumors of borderline malignancy

Rota SM, Zanetta G, Ieda N, Rossi R, Chiari S, Perego P, Mangioni C. Clinical relevance of retroperitoneal involvement from epithelial ovarian tumors of borderline malignancy. Ovarian tumors of borderline malignancy have an outstanding prognosis. The need for aggressive surgical staging is questionable and the need for retroperitoneal node sampling is debated. From 1982 to 1996, 81 women underwent surgical staging including retroperitoneal sampling. Three patients (3.7%) with serous tumor had microscopic nodal involvement. Retroperitoneal metastases were found in two intraperitoneal stage I tumors and in one stage IIIA tumor. Positive nodes were found in 1/31 (3.2%) women undergoing sampling of para-aortic nodes and in 2/69 (2.8%) women undergoing sampling of pelvic nodes. With a median follow-up of 79 months we observed five recurrences, but none involved the retroperitoneum. The three patients with positive nodes remain alive without disease. Among 236 patients with diagnosis of borderline tumor but without sampling of the nodes, we observed one retroperitoneal recurrence (0.4%) in a serous tumor. There are no indications for retroperitoneal sampling of mucinous borderline tumors. For serous tumors this procedure should only be performed as a part of prospective trials. The clinical relevance of retroperitoneal involvement in borderline tumors appears minimal and does not justify routine aggressive surgery.

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.

Pseudomyxoma ovariilike posttherapeutic alteration in prostatic adenocarcinoma: a distinctive pattern in patients receiving neoadjuvant androgen ablation therapy

Neoadjuvant combination endocrine therapy that uses leuprolide and flutamide may result in various histologic changes in nontumoral and cancerous prostatic tissues. Posttreatment pseudomyxoma ovariilike change in prostatic adenocarcinoma is a distinctive alteration that may be the only evidence of regressed tumor and can be potentially confused with mucinous carcinoma. We studied 53 clinically localized prostatic adenocarcinomas after 3 to 5 months of treatment with leuprolide and flutamide. Alterations in prostatic adenocarcinoma in posttreatment radical prostatectomy specimens were assessed and compared with pretreatment needle biopsies. All radical prostatectomy specimens exhibited previously well-characterized therapy-associated changes in benign and malignant elements. Thirteen (20%) cases exhibited a distinctive alteration not seen in pretreatment needle biopsies that consisted of minute to large pools of extravasated secretions that resembled pseudomyxoma ovarii and that dissected through prostatic stroma with an infiltrative appearance when viewed at low power. Associated recognizable tumor was present in 10 of 13 (77%) of these cases. Secretions were basophilic in routine sections and contained occasional degenerated cells. Rare pancytokeratin positive cells were seen at the secretion/stroma interface with uniformly negative staining for the high molecular weight keratin 34 beta E-12. The secretions were periodic acid-Schiff positive after diastase digestion and were mucicarminophilic and reactive with Alcian blue at a pH of 2.5. These foci comprised < 5% of the tumor in 5 cases and 5-40% in 5 cases. In 3 cases, 1-2 foci < 1.0 mm exhibited the pseudomyxoma ovariilike changes and were the only evidence of treated tumor. There was no correlation between the presence of pseudomyxomalike change and dose/duration of neoadjuvant therapy, postprostatectomy clinical follow-up, original or final Gleason pattern/score, or pathologic stage. Pseudomyxoma ovariilike change consists of extravasated acid mucin, lacks prostatic basal cells, often occurs in intimate association with residual prostatic adenocarcinoma in posttreatment radical prostatectomy specimens, and probably represents tumor regression as a result of tumor cell attrition secondary to androgen ablation.

Subclassification of serous borderline tumors of the ovary into benign and malignant types. A clinicopathologic study of 65 advanced stage cases

Poor outcome in serous borderline tumors (SBT) of the ovary is limited to patients with advanced stage disease. This study was designed to determine whether there are histologic features among advanced-stage SBTs (International Federation of Gynecology and Obstetrics [FIGO] stages II and III) that predict behavior. The 65 cases in the study were divided into three groups: typical SBTs, with noninvasive implants (51 cases), SBTs with invasive implants (three cases), and a recently described tumor, designated micropapillary serous carcinoma (MPSC) (11 cases), a proliferative serous ovarian neoplasm that often lacks destructive infiltrative growth but appears to behave as a low-grade invasive carcinoma. When the tumor lacks infiltrative growth, as it did in the 11 cases in this series, it qualifies as a borderline tumor. After censoring nontumor deaths, the 5- and 10-year actuarial survival rates were 98% for SBTs with noninvasive implants, 33% for SBTs with invasive implants, and 81% at 5 years and 71% at 10 years for MPSCs. The mean follow-up was 100 months. Two (4%) of 51 patients with SBTs with noninvasive implants subsequently developed invasive carcinoma, and one (2%) died of carcinoma. In contrast, two (67%) of three women with SBTs accompanied by invasive implants developed invasive carcinoma, and both died of disease. Finally, of the 11 patients with MPSC, seven (64%), all of whom had invasive implants, developed recurrences of invasive carcinoma and/or died of tumor. MPSCs had significantly higher rates of mortality (p < 0.001) and recurrence as invasive carcinoma (p < .002) than SBTs with noninvasive implants. The recognition that SBTs can be divided into benign and malignant subtypes provides the basis for replacing the borderline category. The benign subgroup is composed of typical SBTs, including those with noninvasive implants for which the term atypical proliferative serous tumor is appropriate. In contrast, tumors displaying a micropapillary growth pattern (MPSC) and SBTs with invasive implants should be classified as carcinomas and treated accordingly.

Micropapillary serous carcinoma of the ovary. A distinctive low-grade carcinoma related to serous borderline tumors

According to the International Federation of Gynecology and Obstetrics (FIGO) and the World Health Organization (WHO), stromal invasion, defined as destructive infiltrative growth, is the sole criterion used to distinguish serous borderline tumors from invasive serous carcinomas of the ovary. Although this criterion effectively identifies most malignant tumors, it does not permit the identification of a small subset of well-differentiated ovarian carcinomas that do not display destructive infiltrative growth but that may be associated with malignant behavior. In this study, we describe a group of such serous neoplasms that have distinctive morphologic features and that are often associated with progressive, invasive disease. We have designated these tumors micropapillary serous carcinomas (MPSC). They are characterized by a filigree pattern of highly complex micropapillae arising directly from large, bulbous papillary structures. The micropapillae are covered by round to cuboidal cells with a high nuclear-to-cytoplasmic ratio. Typical serous borderline tumors tend to display a hierarchical pattern of branching terminating in small papillae or tufts, and the cells covering the papillae tend to be more columnar and often ciliated compared with cells of MPSC. We reviewed more than 400 cases of serous ovarian borderline tumors and well-differentiated serous carcinomas and identified 26 cases of MPSC. Seventeen tumors lacked destructive infiltrative growth (noninvasive), and nine contained areas of invasion ranging from minimal to extensive. Eight of the 26 tumors were stage I, and none of the patients developed recurrence whether or not their tumors had demonstrable invasion. In contrast, of the 16 women presenting with stage II disease or higher and who had more than 1 year of follow-up, eight (50%) have either died of intra-abdominal carcinomatosis or are alive with carcinoma. Twenty-four (92%) of MPSCs contained areas of serous borderline tumor. The frequent association of MPSCs with serous borderline tumors suggests that MPSCs arise from the latter and may account for the few cases of serous borderline tumors that have been associated with progression to invasive carcinoma.

The role of DNA flow cytometry in borderline malignant ovarian tumors

BACKGROUND

The role of flow cytometric DNA analysis in predicting prognosis of patients with borderline malignant ovarian tumors has been controversial.

METHODS

Fifty cases of patients with borderline malignant ovarian tumors were analyzed by histology and by flow cytometry on paraffin embedded tissue. Multiple tissue blocks and serial sections were analyzed for each tumor. The results of DNA analysis were correlated to clinicopathologic data.

RESULTS

DNA aneuploidy was demonstrable in 4 cases (8%) when the most atypical section was analyzed. The overall rate of aneuploidy was 14% if additional blocks and serial sections were studied. Two patients died from tumor. One of the two patients had an initial diagnosis of Stage IIc mucinous borderline tumor with DNA indices (DI) of 1.12, 1.42, and 2.04. She had a recurrence in the contralateral ovary 1 year later (DI = 1.83), and a second frankly malignant recurrence diffusely in peritoneum (DI = 1.89). The other patient had an initial diagnosis of Stage IIIc mucinous borderline ovarian tumor with pseudomyxoma peritonei. DNA diploidy was obtained in all of the samples from the primary tumor. An aneuploid peak (DI = 1.28) was demonstrated in only one serial section of the peritoneal implants. Of the other 5 patients who had aneuploid histograms but were disease-free, the DNA indices were 1.35, 1.14/1.18, 1.15, 1.20, and 1.31 and were demonstrable only in either 1 or 2 of the blocks or unproven on serial sections. All patients with diploid-peridiploid tumors were alive and disease free.

CONCLUSIONS

Reproducible DNA aneuploidy of high DI may be predicting a poor outcome, whereas the significance of inconsistently reproducible aneuploidy of low DI remains to be determined. Further studies of prospective DNA analysis with adequate sampling are necessary to define the role of flow cytometry in patients with borderline malignant ovarian tumors.

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.

Management of stage-I borderline ovarian tumors

OBJECTIVE

To evaluate the surgical management and outcome of stage-I borderline ovarian tumors.

METHODS

A series of 95 cases of FIGO stage-I borderline ovarian tumors was retrospectively reviewed.

RESULTS

The age of the patients ranged from 17.6 to 88.9 years (mean 52.7 years). Serous and mucinous tumors were equally represented (47.5% and 47.4%, respectively), endometrioid and clear cell tumors comprising the remaining three (3.2%) and two (2.1% cases. Extirpative primary surgery was performed on all patients. Three patients received postoperative chemotherapy. Nineteen of the 28 patients (67.9%) who were younger than 40 years underwent conservative surgery in which ovarian tissue and the uterus were preserved in order to maintain reproductive potential, and nine of them had successful pregnancies later. Ninety patients were followed regularly for 0.75-21.3 years (average 7.3 years). Seven patients suffered a tumor relapse (7.8%) within 0.6-4.3 years, and four (57.1%) of them (three with mucinous tumors, one with clear cell tumor) died of the disease within 1-10.8 years. The 5- and 10-year overall survival rates were 97.0% and 86.3%, respectively, and the disease-free survival rates were 90.8% in both 5- and 10-year follow-ups.

CONCLUSIONS

Even though the prognosis of surgically treated stage-I borderline ovarian tumors is excellent, mucinous and clear cell subtypes are associated with potential mortality.

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)

FIGO stage, histology, histologic grade, age and race as prognostic factors in determining survival for cancers of the female gynecological system: an analysis of 1973-87 SEER cases of cancers of the endometrium, cervix, ovary, vulva, and vagina

The prognostic impact of FIGO stage, histology, histologic grade, age and race in survival for cancers of the female gynecological (cervix, endometrium, ovary, vulva, vagina) were examined using cases obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program that were diagnosed between 1973 and 1987. Utilizing Cox proportional hazards modeling and relative survival rates analysis of 17,119 cases of cervical cancer indicated that the International Federation of Gynecology and Obstetrics (FIGO) stage, histology, histological grade, lymph node status, and age at diagnosis were all independently prognostic. No evidence was found of survival differences between squamous cell carcinoma and adenocarcinoma. Younger women were not found to have a poorer prognosis, survival declined with increased age. Analysis of 41,120 cases of endometrial cancer indicated that FIGO stage, histology, histologic grade, lymph node status, age at diagnostic, and race were all prognostic factors. Clear cell adenocarcinoma, leiomyosarcoma, and mixed mullerian tumors were all found to have poorer prognosis. Analysis of 21,240 cases of ovarian cancer indicated that FIGO stage, histology, histologic grade, lymph node status, age at diagnosis, presence of ascites, and race were all prognostically significant. Analysis of 2,575 cases of vulvar cancer indicated that FIGO stage, histology, histologic grade, age, and race were all prognostically significant. Analysis of 916 cases of vaginal cancer indicated that FIGO stage, histologic grade, lymph node status, and age are all prognostically significant. Additional analysis of the data by combinations of independent prognostic factors indicates that the interaction of factors may be more predictive of outcome than any one factor separately.

Serous borderline tumors of the ovary. A clinicopathologic, immunohistochemical, and quantitative study of 44 cases

The clinicopathologic features of 44 serous borderline tumors (SBT) of the ovary were evaluated. Nineteen were Stages II and III, and 9 had invasive peritoneal implants. All 19 patients received chemotherapy and 4, who had invasive implants, died of disease after 3, 4.3, 8, and 9 years. The other 25 patients were free of tumor 1-14 years (mean, 5.3 years) after surgery. Coexpression of low molecular weight keratins (AE1, CAM 5.2) and vimentin was found in all tumors and their implants. No significant differences were found between SBT with different volume-corrected mitotic indices (M/Vi) with respect to gross features, presence or absence of implants, stage, and survival. Cytometric DNA analysis also was performed on the primary ovarian tumors and the implants. Twenty-one primary tumors had diploid or tetraploid histograms, and 23 had aneuploid histograms. DNA ploidy of the primary ovarian tumors did not correlate with gross features, the presence or absence of implants, M/Vi, stage, and survival. The data from this study confirm that most SBT are clinically benign, but SBT with invasive implants may behave aggressively. Expression of intermediate filaments, M/Vi, and DNA ploidy evaluation of the primary ovarian tumors seem to be of no value in predicting prognosis. However, four of seven patients with aneuploid DNA implants died of tumor.

DNA cytophotometry and prognosis in ovarian tumors of borderline malignancy. A clinicomorphologic study of 80 cases

Surgical specimens of 80 ovarian tumors of borderline malignancy (OTBM) were investigated by scanning DNA cytophotometry. Diploid or euploid DNA histograms were found for 21 tumors, whereas 59 OTBM showed noneuploid or aneuploid DNA patterns. All patients were followed-up after surgery for at least 3 years (mean observation period, 6.7 years). Follow-up showed 11 cases of recurrent disease and 6 deaths. DNA findings and several other morphologic and clinical details (including patient age, histologic type and stage of disease, and extent of therapy) were correlated to the postoperative course. Statistical analyses disclosed that, of these parameters, only DNA content significantly affected prognosis. Recurrences and deaths resulting from tumor exclusively were observed among patients with noneuploid or aneuploid OTBM, whereas none of the diploid or euploid tumors recurred (P less than 0.05). DNA cytophotometry thus might be regarded as an effective complementary means to assess the prognosis of individual OTBM cases.

Mucinous carcinoma of the ovary. Pathologic prognostic factors

Thirty-four ovarian mucinous carcinomas defined by nuclear stratification in excess of three layers (noninvasive mucinous carcinoma, NIMC) or stromal invasion (invasive mucinous carcinoma, IMC) were examined to define prognostic indicators. Twenty-two patients had NIMC (Stage I, 15; Stage II, 1; Stage III, 5; and Stage IV, 1). Twelve patients had IMC (Stage I, one; Stage II, one; and Stage III, ten). Fifteen patients died, ten with IMC and five with NIMC (mean survival, 16.7 months). Nineteen patients survived, two with IMC and 17 with NIMC (mean follow-up, 12 years). Ten of the 12 patients with IMC who died had Stage III disease. Five of the 22 patients with NIMC who died included four with Stage III and one with Stage I disease. Among patients who died, those with IMC tended to have a shorter mean survival than those with NIMC. No differences among groups were identified with respect to nuclear grade, mitotic activity, percentage of tumor displaying more than three cell layers, or amount of invasion. In ovarian mucinous carcinoma, clinical stage and stromal invasion are the most important prognostic variables, and they are interrelated. Stage I NIMC rarely pursues an aggressive course.

Retroperitoneal lymphatic involvement with epithelial ovarian tumors of low malignant potential

A comprehensive understanding of retroperitoneal lymphatic involvement is lacking in tumors of low malignant potential. This study was undertaken to evaluate retroperitoneal lymphatic involvement in patients with ovarian tumors of low malignant potential. One hundred seventy-one patients were diagnosed with epithelial ovarian tumors of low malignant potential between 1979 and 1989. Thirty-four (20%) of these patients underwent surgical staging which included lymph node sampling. The stage distribution was Stage I in 17 patients (50%), Stage II in 4 patients (12%), and Stage III in 13 patients (38%). The histology of the tumors was serous in 26 patients (76%), mucinous in 7 patients (21%), and seromucinous in 1 patient (3%). The incidence of retroperitoneal lymphatic involvement was 21%. The occurrence of positive pelvic and para-aortic nodes was 17 and 18%, respectively. Patients with localized intraperitoneal disease were upstaged in 22% of the cases based on retroperitoneal lymphatic involvement. Four of twenty-one patients (19%) with intraperitoneal disease confined to the ovary and two of six patients (33%) with intraperitoneal disease confined to the pelvis were upstaged to Stage III as a result of retroperitoneal lymphatic disease. Although the nodal status of patients did not significantly affect survival, those patients with localized intraperitoneal disease and nodal involvement had a higher incidence of recurrence which was statistically significant (P = 0.025). Accordingly, retroperitoneal lymph node sampling at the time of initial laparotomy may provide valuable prognostic information regarding recurrence in patients with tumors of low malignant potential.

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.

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.

Histologic sampling requirements in ovarian carcinoma: a review of 51 tumors

In a review of 29 serous and 22 mucinous adenocarcinomas of the ovary, we quantitated the various histologic patterns seen in these neoplasms in order to document histologic variability and assess current anecdotal recommendations (one section per 1-2 cm of maximum tumor diameter) for adequate histologic sampling of epithelial ovarian neoplasms. Mucinous carcinomas showed more histologic variation than serous carcinomas, but both showed substantial portions with benign or borderline histology in many neoplasms. One serous and one mucinous carcinoma were likely to have been classified as borderline tumors if only current sampling recommendations had been followed. The remaining adenocarcinomas were adequately sampled by current standard practice. The two tumors in question had unusual clinical and histological features which prompted additional sampling. Caution is particularly warranted when initial frozen section sampling shows features of borderline tumor histology or low grade epithelial atypia, especially in mucinous epithelial neoplasms where histologic variability is greatest.