Juvenile granulosa cell tumor

Juvenile granulosa cell tumor of the ovary: A comprehensive clinicopathologic analysis of 15 cases

OBJECTIVE

Juvenile granulosa cell tumor(JGCT) is an uncommon ovarian sex-cord stromal tumor, with diverse clinical, radiological and histopathologic features. The present study describes the clinicopathological and histomorphological spectrum of JGCTs, and highlights the key differentiating features from its mimics.

METHODS

A retrospective analysis of all cases reported as JGCTs during 2011-19 (8 years) was performed with detailed evaluation of clinical, histopathologic data and follow-up details.

RESULTS

Of a total 115 GCTs reported during the study period, 15(13%) were reported as JGCTs. The mean age at presentation was 17 years. Abdominal pain and distension were the most common clinical presentations. Five patients were pre-menarchal with 3 exhibiting precocious puberty. Majority of tumors were unilateral(left>right), solid-cystic, ranging in size from 4 to 20 cm. Microscopically, macrofollicular architecture was most frequent (n = 12;80%). The tumor cells depicted variable nuclear pleomorphism, small distinct nucleoli and moderate-abundant pale eosinophilic-clear/vacuolated cytoplasm. Mitotic activity ranged from 1 to 10/10HPFs. Uncommon histopathologic features included microcystic and tubulo-cystic architecture, myxoid degeneration, bizarre tumor giant cells, hob-nailing of the tumor cells, intracytoplasmic hyaline globules, multifocal calcification and thick hyalinized blood vessels. Majority(n = 12;80%) presented in stage I. Surgical treatment included unilateral salpingo-oophorectomy without any adjuvant chemotherapy, bilateral salpingo-oophorectomy (BSO) and total abdominal hysterectomy with BSO with adjuvant BEP chemotherapy (Bleomycin, etoposide, cisplatin).

CONCLUSIONS

JGCT is a rare ovarian tumor affecting young women and children with diverse histopathologic features. Despite an aggressive histopathology, these tumors have a good outcome, when diagnosed at an early stage.

Outcomes of fertility-sparing surgery in ovarian juvenile granulosa cell tumor

Objective

To analyze the clinical characteristics, diagnosis, and treatment of ovarian juvenile granulosa cell tumor.

Methods

The clinical and pathological data of six patients with ovarian juvenile granulosa cell tumor was collected.

Results

The mean age of disease onset was 20.5 years (range 12 to 33). All six patients had an adnexal mass located laterally in the pelvis, and two developed ascites. All patients had fertility-sparing surgery with complete staging. The mean size of the tumors was 15.3 cm (range 5 to 35). Ovarian sex cord stromal tumors were diagnosed or highly suspected from the frozen sections for all patients. Five patients received three to six courses of postoperative adjuvant chemotherapy, with three receiving a bleomycin/etoposide/cisplatin regimen and two receiving a paclitaxel/carboplatin regimen. The five stage I patients had no recurrence with 52 to 155 months of follow-up. The patient with stage IIIB disease had a recurrence 55 months’ later and underwent reoperation and chemotherapy. This patient remained disease-free 30 months after the reoperation.

Conclusions

Fertility-sparing surgery is the treatment of choice for ovarian juvenile granulosa cell tumor and the overall prognosis is good.

Juvenile granulosa cell ovarian tumor: clinicopathological evaluation of ten patients

OBJECTIVE

We aimed to analyze the clinical characteristics and management of ten patients who were diagnosed with juvenile granulosa cell ovarian tumor (JGCOT).

MATERIAL AND METHODS

The records of 10 patients diagnosed with JGCOT between April 1995 and January 2014 in the Gynecological Oncology Clinic of our institution were retrospectively evaluated.

RESULTS

The median age of the patients was 21.5 years (range; 13-36). Nine patients had stage IA disease and one had stage IC disease according to the International Federation of Gynecology and Obstetrics (FIGO) criteria. Five patients underwent pelvic and para-aortic lymph node dissection. None of them had lymph node involvement. All but two patients underwent unilateral salpingo-oophorectomy. One of the other two patients had cystectomy and the other had total abdominal hysterectomy and bilateral salpingo-oophorectomy. Three patients had adjuvant therapy after surgery. Two of these patients took chemotherapy and the other took radiotherapy. Four of the five patients who desired pregnancy achieved five term pregnancies. The median follow-up time of the patients was 58 months (range; 3-113). No recurrence was observed in the follow up period.

CONCLUSION

JGCOT generally occurs during childhood. The primary management of JGCOT is through surgery. The role of adjuvant therapy is controversial. Because survival is long at early stages and most of the patients are young, fertility sparing surgery could be safely suggested to these patients.

Neoplastic causes of abnormal puberty

BACKGROUND

Neoplasm-related precocious puberty (PP) is a rare presenting feature of childhood cancer. Moreover, evaluation of suspected PP in a child is complex, and cancer is often not considered. We characterized the clinicopathologic features of patients presenting with PP at a large pediatric cancer center, reviewed the relevant literature, and developed an algorithm for the diagnostic work-up of these patients.

METHODS

We examined the records of all patients with a neoplasm and concomitant PP treated at St. Jude Children's Research Hospital from January 1975 through October 2011, reviewed the available literature, and analyzed the demographic, clinical, endocrine, and neoplasm-related features.

RESULTS

Twenty-four of 13,615 children and adolescents (0.18%) were diagnosed with PP within 60 days of presentation. Primary diagnoses included brain tumor (12), adrenocortical carcinoma (5), hepatoblastoma (4), and others (3). PP was observed 0-48 months before diagnosis of neoplasm; 17 patients had peripheral PP and 7 had central PP.

CONCLUSIONS

Neoplasm-related PP is rare and takes the form of a paraneoplastic syndrome caused by tumor production of hormones or by alteration of physiologic gonadotropin production. PP can precede diagnosis of malignancy by months or years, and neoplastic causes should be considered early to avoid delayed cancer diagnosis. Treatment of the primary malignancy resolved or diminished PP in surviving patients with an intact hypothalamic-pituitary-gonadal axis.

[Juvenile granulosa-cell tumor: clinical and molecular expression]

Ovarian sex cord-stromal tumors are rare tumors that originate from the nongerminal cells of ovary. Two decades ago, the identification of juvenile granulosa-cell tumors (GCT), as a specific entity inside this group, allowed a better treatment of these tumors in children. However, little data have been reported on the natural course of the disease and reliable prognostic factors have not been yet defined. We here review the clinical and genetics aspects of granulosa tumors, based on a series of 40 children. This national collaborative study involved the French Society of Children Cancer and eight clinical departments of pediatric endocrinology. We found that early diagnosis of a tumor, revealed by clinical signs of hyperoestrogeny, is an important prognostic factor. The pathophysiology of these tumors is still debatable and several cellular- and molecular-abnormal signals could be implicated in their development. The role of growth factors and oncogenes through the signaling pathway of MAP kinase is still discussed. According to our data, FSH signaling-transduction pathway, such as a constitutionally activated Galphas, could also be implicated in the induction of granulosa cell proliferation and seems to modulate the invasiveness of the tumor. Last, we have described a low-expression pattern or an extinction of an ovarian-determination gene, FOXL2, which is related to a worse prognosis of this tumor.

Granulosa and theca cell tumors in children: a report of 17 cases and literature review

The files of the Emil Novak Ovarian Tumor Registry (ENOTR) were searched for granulosa and theca cell tumors in children aged 12 years and less. In addition, an extensive literature search was done for English publications on children with these tumors aged 10 years or less. Of the 17 children from the ENOTR, 5 had adult-type granulosa cell tumors, 6 had juvenile granulosa cell tumors, and 1 had a luteinized granulosa cell tumor. In addition, there were three cases with gonadal stomal tumors, one theca cell tumor, and one granulosa-theca cell tumor. Precocious pseudopuberty was present in 70 percent of the children, abdominal pain in 24 percent, and ascites in 18 percent. The literature review revealed a tumor-related mortality rate of 9 percent (based on 163 cases with granulosa cell tumors, including the juvenile type). Some of these tumors are large with acute pain, but nevertheless, the prognosis is good, particularly in cases with precocious puberty. Treatment can be conservative.

Juvenile granulosa cell tumors of the ovary in children and adolescents: results from 33 patients registered in a prospective cooperative study

Clinical and pathological data from 33 prospective registered patients who suffered from juvenile granulosa cell tumors (JGCT) were evaluated according to treatment and outcome. The median age at the time of diagnosis was 7.6 years (range, 6 months to 17.5 years). Fourteen patients showed signs of a pseudo-precocious puberty. In 1 patient premenarcheal bleeding was the only clinical symptom of the disease. A pelvic tumor or an abdominal distention was found in 6 children, revealing signs of an acute abdomen in 3 children. Tumor staging was performed according to the FIGO (International Federation of Gynecology and Obstetrics) classification for ovarian tumors. Twenty children and adolescents were classified as FIGO stage Ia; 8 children had stage Ic tumors. In 4 patients stage IIc and in 1 patient stage IIIc tumors were observed. For local tumor control all 33 patients underwent tumor resection and oophorectomy, which was complete in 28 patients. Adjuvant combination chemotherapy was used in 1 girl who presented with high mitotic pathological index features in FIGO stage Ia. In 8 other children between FIGO stage Ic and IIIc, treatment was also intensified by multidrug chemotherapy. After a follow-up period of 168 months, an event-free survival of 0.75 +/- 0.07 was observed. From our data we conclude that multidrug chemotherapy including cisplatin-based regimens may be useful to enhance treatment results of JGCT, especially in advanced FIGO stages.

Juvenile granulosa cell tumor of the ovary in infants: a clinicopathologic study of three cases and review of the literature

The clinical and pathological features of three cases of juvenile granulosa cell tumors occurring in infants were studied. Precocious pseudopuberty developed in two patients and acute abdominal symptoms related to the rupture of the tumor developed in one. Surgery was the only treatment in each case and no adjuvant therapy was delivered. No patient experienced relapse. Histological examination showed a predominantly diffuse pattern with prominent luteinization. Call-Exner bodies were absent. Two tumors had multilocular thin walled cysts containing large amounts of estradiol, the third one contained rudimentary microfollicles. The prognosis of juvenile granulosa cell tumors in infancy appears more favorable than those occurring in older patients. No case of tumor recurrence has been reported in infancy so far. Surgery appears to be the state-of-the-art treatment of these tumors and additional therapy (chemotherapy or radiotherapy) must be discussed with caution, even in advanced stages.

An association between precocious puberty and fragile X syndrome?

STUDY OBJECTIVE

To determine the FMR1 gene status in a 10-year, 10-month-old girl with a history of precocious puberty and a family history of fragile X syndrome.

DESIGN

Case report.

SETTING

The outpatient facility of the Division of Adolescent Medicine and the Division of Genetic and Metabolic Disorders at Children's Hospital of Michigan and the Medical Genetics and Birth Defects Center of Henry Ford Hospital, Detroit, Michigan.

PARTICIPANT

A 10-year, 10-month-old girl with a history of precocious puberty.

INTERVENTION

Evaluation for menorraghia, DNA extraction, and fragile X gene analysis of blood samples from the patient and her mother.

MAIN OUTCOME MEASURES

Identification of a full mutation in the FMR1 gene.

RESULTS

Southern blot analysis of the FMR1 gene identified a full mutation in the daughter with approximately 750 repeats of the CGG sequence. Methylation studies showed that the full mutation was completely methylated. FMR1 DNA studies on her mother identified a premutation of approximately 100 repeats.

CONCLUSIONS

This report identifies a young girl with a history of precocious puberty and fragile X syndrome. It is also the first report of molecular genetic FMR1 studies in a female with precocious puberty. A possible association between the two conditions is suggested and warrants further investigation.

Juvenile granulosa cell tumor of the infantile testis. Evidence of a dual epithelial-smooth muscle differentiation

We report the ultrastructure and immunohistochemical profile of seven juvenile granulosa cell tumors of the infantile testis. The infants' ages ranged from 1 day to 11 months. All tumors had characteristics ultrastructure with a mixture of spindle smooth-muscle and theca cells and polygonal granulosa cells. Clusters of polygonal granulosa cells were invested by a continuous basal lamina and contained bundles of distinct cytoplasmic filaments with evenly distributed dense bodies resembling smooth muscle. These filaments were occasionally attached to well-developed, prominent desmosomes. Tumor cells had a conspicuous rough endoplasmic reticulum and Golgi complex and occasional neutral fat droplets. In all tumors, mitochondria had laminated cristae and only rarely were there cristae with a tubulovesicular pattern characteristic of steroid secreting cells. Tumor cells stained focally with low-molecular-weight cytokeratins (8,18, and 19), smooth-muscle-specific actin, desmin, and more noticeably with vimentin. These ultrastructural and immunohistochemical features of dual epithelial-mesenchymal differentiation and distinct muscle-like filaments with dense bodies are characteristic of the juvenile granulosa cell tumor of the infantile testis.

Juvenile granulosa cell tumor of the testis: a comparative immunohistochemical study with normal infantile gonads

This study concerns the nature of two different cell populations in a juvenile granulosa cell tumor (GCT) of the infantile testis. Immunohistochemical features of the tumor were compared with those of normal infantile testes (six cases) and ovaries (six cases). The testicular neoplasm showed follicles, cysts and solid nodules composed of an internal layer of polyhedral cells that expressed cytokeratin and vimentin. Most of the follicles and nodules were surrounded by an external layer of spindle cells that reacted to muscle-specific actin, vimentin, and focally to desmin. A neoplastic rather than reactive origin of the spindle cell population is favored by their concentric arrangement in a peritubular-like or theca-like fashion and by their immunohistochemical correlation with normal peritubular-myoid and theca external cells. Sertoli and granulosa cells of normal infantile gonads were positive for cytokeratin and vimentin; peritubular myoid and theca externa cells expressed muscle-specific actin, vimentin, and focally desmin. The occurrence of two well-differentiated components in the tumor favors its origin from the primitive specialized gonadal stromal cell that during neoplastic transformation develops bidirectional differentiation toward epithelial-like and smooth muscle-like lineages. The possibility that this tumor is composed of immature Sertoli and peritubular myoid cells is discussed.

Juvenile granulosa cell tumor in a 2-year-old infant: report of a case complicated with ascites and acute respiratory distress

A two-year-old girl with a juvenile granulosa cell tumor (JGCT) and with acutely progressive hydrothorax and ascites is presented. She had precocious pseudopuberty and an elevated level of serum estradiol. Sudden onset of respiratory distress, due to a pleural effusion and severe abdominal distention, led to an emergency laparatomy. Unilateral salpingo-oophorectomy induced a rapidly favorable course. Histological examination showed no evidence of invasion or peritoneal metastasis. This is the first case of JGCT associated with an acute respiratory emergency as a main clinical feature.