Ovarian Seromucinous Tumors: Pathogenesis, Morphologic Spectrum, and Clinical Issues

Extraovarian seromucinous borderline tumor: Case report and literature review

Seromucinous borderline tumors (SMBT) are papillary neoplasms without invasive capabilities. Originally categorized as ovarian tumors, SMBT, being an endometriosis-related tumor, can manifest beyond the ovaries. To date, only four cases of extraovarian SMBT have been documented in literature. In this report, we present our experience with the first case of SMBT in the uterine cervix, which exhibited highly elevated CA19-9 levels. The patient, initially clinically diagnosed with cervical cancer, underwent treatment with radical hysterectomy and was later pathologically diagnosed with SMBT of the uterine cervix. While extraovarian SMBT, especially in the uterine cervix, is extremely rare, this condition should be considered in patients with cervical masses lacking pathological evidence of malignant disease but displaying elevated CA19-9 levels.

Molecular landscape of borderline ovarian tumours: A systematic review

Borderline ovarian tumours (BOTs) show intriguing characteristics distinguishing them from other ovarian tumours. The aim of the systematic review was to analyse the spectrum of molecular changes found in BOTs and discuss their significance in the context of the overall therapeutic approach. The systematic review included articles published between 2000 and 2023 in the databases: PubMed, EMBASE, and Cochrane. After a detailed analysis of the available publications, we qualified for the systematic review: 28 publications on proto-oncogenes: BRAF, KRAS, NRAS, ERBB2, and PIK3CA, 20 publications on tumour suppressor genes: BRCA1/2, ARID1A, CHEK2, PTEN, 4 on adhesion molecules: CADM1, 8 on proteins: B-catenin, claudin-1, and 5 on glycoproteins: E-Cadherin. In addition, in the further part of the systematic review, we included eight publications on microsatellite instability and three describing loss of heterozygosity in BOT. Molecular changes found in BOTs can vary on a case-by-case basis, identifying carcinogenic mutations through molecular analysis and developing targeted therapies represent significant advancements in the diagnosis and treatment of ovarian malignancies. Molecular studies have contributed significantly to our understanding of BOT pathogenesis, but substantial research is still required to elucidate the relationship between ovarian neoplasms and extraneous disease, identify accurate prognostic indicators, and develop targeted therapeutic approaches.

Whole-tumor ADC histogram analysis for differentiating endometriosis-related tumors: seromucinous borderline tumor, clear cell carcinoma and endometrioid carcinoma

PURPOSE

To investigate the feasibility of whole-tumor apparent diffusion coefficient (ADC) histogram analysis for improving the differentiation of endometriosis-related tumors: seromucinous borderline tumor (SMBT), clear cell carcinoma (CCC) and endometrioid carcinoma (EC).

METHODS

Clinical features, solid component ADC (ADC_SC) and whole-tumor ADC histogram-derived parameters (volume, the ADC_mean, 10th, 50th and 90th percentile ADCs, inhomogeneity, skewness, kurtosis and entropy) were compared among 22 SMBTs, 42 CCCs and 21 ECs. Statistical analyses were performed using chi-square test, one-way ANOVA or Kruskal-Wallis test, and receiver operating characteristic curves.

RESULTS

A significantly higher ADC_SC and smaller volume were associated with SMBT than with CCC/EC. The ADC_mean was significantly higher in CCC than in EC. The 10th percentile ADC was significantly lower in EC than in SMBT/CCC. The 50th and 90th percentile ADCs were significantly higher in CCC than in SMBT/EC. For differentiating SMBT from CCC, AUCs of the ADC_SC, volume, and 50th and 90th percentile ADCs were 0.97, 0.86, 0.72 and 0.81, respectively. For differentiating SMBT from EC, AUCs of the ADC_SC, volume and 10th percentile ADC were 0.97, 0.71 and 0.72, respectively. For differentiating CCC from EC, AUCs of the ADC_mean and 10th, 50th and 90th percentile ADCs were 0.79, 0.72, 0.81 and 0.85, respectively.

CONCLUSION

Whole-tumor ADC histogram analysis was valuable for differentiating endometriosis-related tumors, and the 90th percentile ADC was optimal in differentiating CCC from EC.

MRI of Borderline Epithelial Ovarian Tumors: Pathologic Correlation and Diagnostic Challenges

Borderline epithelial ovarian tumors are a distinct pathologic entity characterized by increased epithelial proliferation and nuclear atypia, but without frank stromal invasion. Borderline tumor (BT) is now considered to represent an intermediate phase in the stepwise progression from benign to malignant ovarian epithelial tumor. Since BTs commonly manifest at early stages in women of reproductive age and are associated with a good prognosis, making the correct diagnosis is important in determining whether a patient is a candidate for fertility-sparing surgery. There are six histologic BT subtypes (serous, mucinous, seromucinous, endometrioid, clear cell, and Brenner), and each has different MRI features, reflecting their unique histologic architectures. Radiologists should be aware of the MRI features that can suggest BTs. These features include a hyperintense papillary architecture with hypointense internal branching, which can be observed with serous and seromucinous BTs on T2-weighted images; aggregates of microcysts that have hypointensity on T2-weighted images and reticular enhancement on contrast-enhanced T2-weighted images, which can be seen with mucinous BTs; and moderately high signal intensity on diffusion-weighted images along with relatively high apparent diffusion coefficient values, which can be observed regardless of the histologic subtype. Nevertheless, because the imaging features of BTs overlap with those of many benign lesions (eg, cystadenoma and cystadenofibroma, decidualized endometriosis, and polypoid endometriosis) and malignant tumors (ovarian cancers and metastases), histologic confirmation is required for the final diagnosis. Special emphasis is placed on the MRI features of BTs, pathologic correlation, and the challenges related to diagnosis. ^©RSNA, 2022.

Microscopic Evaluation of Ovarian Surface Epithelium Following Treatment with Conjugated Estrogens in a Mouse Model

BACKGROUND

This study was designed to evaluate the effect of different concentrations of conjugated equine estrogens (CEE) on the ovarian epithelium of female CD1 mice.

METHODS

Twenty-four female mice at 7 months with irregular estrus cycles were randomly divided into four groups of 6 mice each. Group one was considered as a control group and received a daily dose of 0.5ml of propylene glycol, for three weeks, while those in the treatment groups received a daily dose of 14μg/kg, 28μg/kg and 56μg/kg conjugated equine estrogens, respectively.

RESULTS

The results from this study showed a strong correlation between elevated concentrations of CEE and histological changes in ovarian surface epithelium (OSE). They also showed that administration of high-dose estrogen created the conditions for excessive proliferation of OSE which may progress into the development of cysts in the ovaries.

CONCLUSION

This study concluded that high concentrations of CEE may increase the chances of developing epithelial ovarian cancer.

Mutation Profiles of Ovarian Seromucinous Borderline Tumors in Japanese Patients

Ovarian seromucinous tumors (SMBTs) are relatively rare, and their carcinogenesis is largely unknown. In this study, the molecular features of SMBTs in Japan are assessed. DNA was extracted from microdissected paraffin-embedded sections from 23 SMBT cases. Genetic mutations (KRAS, BRAF, PIK3CA, and ERBB2) were evaluated using Sanger sequencing. Immunohistochemistry for p53, ARID1A, and PTEN was also performed as a surrogate for the loss of functional mutations in these tumor suppressor genes. The prevalence of KRAS, BRAF, PIK3CA, and ERBB2 mutations was 4.3% (1/23), 8.6% (2/23), 8.6% (2/23), and 17.3% (4/23), respectively. Overexpression or loss of p53 expression occurred in 26% (6/23), loss of ARID1A expression in 4.3% (1/23), and none of the cases showed expression of PTEN loss. These findings suggest that KRAS/BRAF/PIK3CA and PTEN mutations are rare carcinogenic events in SMBTs. The high frequency of positive p53 staining and a low frequency of loss of ARID1A staining suggests that SMBT carcinogenesis may be related to the alteration of p53 rather than that of ARID1A. ERBB2 oncogenic mutations may play an important role in the tumorigenesis of Japanese SMBTs.

Oncological and reproductive outcomes after fertility-sparing surgery in patients with seromucinous borderline ovarian tumor: Results of a large retrospective study

OBJECTIVE

To evaluate the oncological and reproductive outcomes in patients with seromucinous borderline ovarian tumors (SMBOT) treated with fertility-sparing surgery (FSS).

METHODS

We retrospectively reviewed the medical records of patients with SMBOT who underwent surgery between 2000 and 2019. A centralized histological review was performed and recurrence rates were compared between different surgical procedures.

RESULTS

A total of 105 patients fulfilled the inclusion criteria, of whom 65 underwent FSS and 40 were treated with radical surgery (RS). Fourteen patients had recurrent disease after a median follow-up time of 59.6 months (range: 22.1-256.8 months). All but one relapsed with SMBOT. There was no significant difference in disease-free survival (DFS) between the two groups (P = 0.141). Multivariate analysis showed that only bilateral involvement was associated with increased recurrence (P = 0.008). In the subgroup of patients treated with conservative surgery, there was no significant difference in DFS with regard to surgical procedures (ovarian cystectomy vs salpingo-oophorectomy, P = 0.487). Of the 12 patients in the FSS group who developed recurrence, 11 underwent a second round of FSS and all remained alive with no evidence of disease at the end of follow-up. Of 20 patients desiring pregnancy, 16 patients were successful and resulted in 17 term deliveries.

CONCLUSIONS

FSS is feasible for young patients who wish to preserve their fertility. Patients initially treated with ovarian cystectomy may be managed by close surveillance if post-operative imaging are negative. Repeat FSS remains a valuable alternative for young patients with recurrent SMBOT after thorough communication.

PAX2, PAX8, and PR are correlated with ovarian seromucinous borderline tumor with endometriosis

BACKGROUND

Ovarian "seromucinous carcinoma" has been recently removed in 2020 5^th Edition of WHO classification of Female Genital Tumors and is considered as a subtype of endometrioid carcinoma with mucinous differentiation, while "seromucinous borderline tumor" remains and exists as a distinct entity. Both diseases may be considered as no more same lineage. However, ovarian seromucinous borderline tumor (SMBT) is also one of the endometriosis-related neoplasm of ovary similar to endometrioid tumor, featuring that about 50% of ovarian SMBTs combine endometriosis. The present study was aimed to investigate whether the ovarian SMBTs are different in clinical features and molecular patterns, according to the presence of combined endometriosis.

RESULTS

There were no statistical differences in clinical findings between two groups. There was also no significant difference in pregnancy outcomes and recurrence between two groups. In immunohistochemical patterns, there was a statistically significant difference in PAX2 and PAX8 expression between in ovarian SMBT with or without endometriosis (P = 0.016, P < 0.001). Only a few cases of ovarian SMBT with endometriosis showed expression of PAX2 and conversely, most of the cases showed expression of PAX8. PR positivity was more prominent in ovarian SMBT with endometriosis than without endometriosis (P = 0.018), although there was no difference in positive ER expression. There were no statistical differences in WT1, CK20 and CDX2 expressions between two groups.

CONCLUSIONS

Ovarian SMBT with endometriosis did not clinically differ from that without endometriosis. However, the molecular patterns were different between two groups and ovarian SMBT with endometriosis is close to endometrioid tumor types unlike SMBT without endometriosis. Further, a direct comparison study between seromucinous borderline tumor and endometrioid borderline tumor is needed with a gene profiling study to prove their relationship.

Trousseau's syndrome associated with an ovarian borderline tumour

A 71-year-old woman was admitted to our hospital because of sudden onset of weakness on the left side of her body. Her medical history was unremarkable, and on physical examination, hemiparesis and hyperreflexia on the left side were found. MRI of the brain showed multiple areas of restricted diffusion in both parietal lobes and in the cerebellum, consistent with embolic shower. Magnetic resonance angiography showed no abnormal findings. A contrast-enhanced CT scan revealed multiple pulmonary emboli. Abdominal MRI showed a 135 mm left ovarian tumour composed of a solid and a cystic component with liquid level formation. After a total hysterectomy and bilateral adnexectomy, the histopathology confirmed a seromucinous borderline tumour. Therefore, the patient was diagnosed with Trousseau's syndrome associated with an ovarian seromucinous borderline tumour. To our knowledge, this is the first report mentioning a borderline ovarian tumour detected as Trousseau's syndrome.

Cytological Appearances of Ovarian Seromucinous Borderline Tumor in Ascites: Presentation of 2 Cases

BACKGROUND

Seromucinous borderline tumor (SMBT) is a rare neoplasm which was newly defined in the 2014 WHO classification. Although the clinical and histopathological characteristics of SMBT have been well described, its cytological characteristics have not. We recently experienced 2 cases of SMBT which were defined by cytological findings of ascites.

CASE PRESENTATION

Case 1 was a 65-year-old Japanese woman. Preoperative imaging studies revealed abundant ascites and a cystic tumor, with a solid component measuring 13 cm on the left ovary. Radical surgery was performed during the intraoperative diagnosis of ovarian borderline tumor, made by histological examinations of frozen tumor sections. The cytological smears of preoperatively and intraoperatively collected ascites showed many atypical cells resembling reactive mesothelial cells. Alcian-blue staining of cell block sections revealed intracytoplasmic mucin, and the results of immunohistochemistry were consistent with SMBT. The final pathological diagnosis of tumor was SMBT. Case 2 was a 28-year-old Japanese woman. Preoperative imaging studies revealed a small amount of ascites and cystic tumors with solid components in the bilateral ovaries. She initially underwent fertility preservation surgery. SMBT was suspected by cytological examination of smears of intraoperatively collected ascites and the findings of cell block. She underwent additional radical surgery based on a final pathological diagnosis of SMBT.

CONCLUSION

In our experience, the tumor cells of SMBT in ascites mimicked reactive mesothelial cells. The nuclear atypia of SMBTs was intermediate between that of reactive mesothelial cells and serous carcinoma. The immunohistochemistry and mucin staining using cell block were very helpful for facilitating the cytodiagnosis of SMBT.

Synchronous Occurrence of Ovarian Seromucinous Carcinoma and Endometrial Mucinous Carcinoma: A Case Report

Endometrioid carcinoma is the most common histological type of concurrent synchronous cancers of the uterus and ovary. Here we report a case of synchronous seromucinous carcinoma of the ovary and mucinous carcinoma of the endometrium with a literature review. A 51-year-old multiparous female complained of irregular bleeding and shortness of breath. Computed tomography revealed a large pelvic mass that consisted of cystic and solid components, a tumor of the endometrium, and a large amount of pleural effusion. An endometrial biopsy indicated adenocarcinoma, and adenocarcinoma cells were found in the pleural fluid. The patient with advanced ovarian cancer or endometrial cancer with massive pleural effusion received three courses of neoadjuvant chemotherapy (NAC) with paclitaxel and carboplatin followed by interval debulking surgery (IDS). The NAC was effective, and IDS was performed with no gross residual lesions. The post-operative diagnosis was seromucinous carcinoma of the ovary in FIGO (2014) stage IVA (ypT3cNxM1a) and mucinous carcinoma of the endometrium in FIGO (2008) stage IA (ypT1aNXM0). Three courses of postoperative TC therapy were performed, and maintenance therapy with Bevacizumab is ongoing. The patient is well without evidence of recurrence, sixteen months after surgery.

Ovarian seromucinous tumors: clinicopathological features of 10 cases with a detailed review of the literature

Background

The 2014 WHO Classification of ovarian neoplasms introduced a new entity of seromucinous tumors associated with endometriosis. These tumors encompassed a spectrum from benign to malignant and included seromucinous cystadenoma/ cystadenofibroma, seromucinous borderline tumor/atypical proliferative seromucinous tumor and seromucinous carcinoma. However, the 2020 WHO Classification of Female Genital Tumours removed seromucinous carcinomas as a distinct entity and recategorized them as Endometrioid carcinomas with mucinous differentiation. Here we describe clinico-morphologic features of seromucinous tumors recategorizing cases originally diagnosed as seromucinous carcinoma in light of 2020 WHO classification and present detailed review of literature.

Methods

Slides of seromucinous tumors were reviewed. Special emphasis was given to evaluation of stromal invasion. Follow-up was obtained.

Results

Ten cases were diagnosed. Mean age was 40 years. Four cases were bilateral. Mean size was 19 cm. Grossly; luminal papillary projections were seen in 6 cases. Tumors demonstrated a papillary architecture with papillae lined by stratified seromucinous epithelium showing nuclear atypia. Stromal invasion was seen in 4 cases. Six cases were reported as borderline seromucinous tumors and 4 cases originally diagnosed as seromucinous carcinoma were recategorized as endometrioid carcinoma with mucinous differentiation on review. Endometriosis was seen in 4 cases. CK7, PAX8 and ER were positive in 7/7 cases. Two cases showed extra-ovarian involvement. Follow up was available in 7 cases. Six patients were alive and well at follow up ranging from 8 to 46 months. Six patients received chemotherapy postoperatively. One patient with carcinoma died of disease 18 months postoperatively.

Conclusion

In our series, 4 cases were originally diagnosed as seromucinous carcinomas. However, these were recategorized in light of the 2020 WHO Classification of Female Genital tumors as endometrioid carcinomas with mucinous differentiation. Six cases were diagnosed as seromucinous borderline tumors. Thus, majority of cases were borderline in agreement with published literature.

[Molecular genetic profile of seromucinous ovarian tumors]

Seromucinous tumors belong to a group of ovarian epithelial tumors. They were originally described as tumors characterized by Müllerian endocervical differentiation. Molecular genetic studies have indicated these tumors as endometriosis-associated tumors due to the presence of ARID1 gene mutations. However, the histogenesis of these neoplasms is still unstudied.

Comprehensive genomic profiling reveals ubiquitous KRAS mutations and frequent PIK3CA mutations in ovarian seromucinous borderline tumor

The molecular underpinnings of seromucinous borderline tumor (SMBT) - an uncommon ovarian epithelial neoplasm characterized by association with endometriosis, frequent bilateral ovarian involvement, and occasional progression to invasive carcinoma - remain poorly understood. Here, we sought to comprehensively characterize the mutational landscape of SMBT and elucidate the clonal relationship between bilateral ovarian SMBTs. We also compared the mutational profiles between SMBTs and concurrent invasive carcinomas. Formalin-fixed, paraffin-embedded tissue specimens were retrieved from 28 patients diagnosed with SMBT. Massively parallel sequencing of 409 cancer-related genes was conducted to identify somatic mutations in 33 SMBT samples and four concurrent invasive carcinoma specimens. TERT promoter mutations were assessed by Sanger sequencing, whereas immunohistochemistry was used as a surrogate tool for detecting deletions or epigenetic silencing of relevant tumor suppressor genes. Twenty-six (92.9%) of the 28 patients were diagnosed with stage I SMBTs. Seven (25%) cases showed bilateral ovarian involvement and 13 (46%) had concomitant endometriosis. Concurrent ovarian carcinomas were identified in three patients, whereas one case had a synchronous endometrial carcinoma. Somatic mutations in the KRAS, PIK3CA, and ARID1A genes were identified in 100, 60.7, and 14.3% of SMBT samples, respectively. In contrast, TERT promoter mutations and DNA mismatch repair deficiencies were absent. Sequencing of paired specimens from patients with bilateral SMBT revealed the presence of at least two shared somatic mutations, suggestive of a clonal relationship. Similarly, we identified shared somatic mutations between SMBT samples and concurrent ovarian carcinoma specimens. Taken together, these findings demonstrated a distinct mutational landscape of SMBT in which (1) KRAS is invariably mutated, (2) PIK3CA is frequently mutated, and (3) TERT promoter mutations and DNA mismatch repair deficiencies are absent. Our findings represent the first extensive characterization of this rare ovarian neoplasm, with potential implications for disease classification and molecular diagnostics.

Three cases of seromucinous carcinoma of the ovary arising in endometriotic cysts

Ovarian seromucinous carcinoma (SMC) is an uncommon neoplasia and is composed predominantly of serous and endocervical-type mucinous epithelium. Due to its low frequency and difficult diagnosis, the natural history, characteristic imaging findings, and pathological features of SMC have not been adequately described in the literature thus far. We herein report three cases of ovarian SMC along with magnetic resonance imaging (MRI) findings. The diagnosis of SMC was made after staging laparotomy in all cases, and systemic chemotherapy was performed in two cases. No recurrence was observed in any of the cases. The MRI findings in SMC were so varied that characteristic imaging features useful for diagnosis were not found. In two cases, MRI suggested endometriotic cysts, and endometriosis and seromucinous borderline tumors (SMBTs) were detected concurrently in all cases by histological examination. Thus, it was suggested that SMC develops in multiple stages via endometriosis and SMBT. The cooccurrence of endometriosis and SMBT could also make the diagnosis of SMC more convincing.

Down-regulation of circ_0061140 attenuates ectopic endometrial cell proliferation, migration and invasion in endometriosis via inactivating Notch2

Endometriosis is a frequent gynecologic disease in the world. CircRNAs can exert a crucial role in various diseases. Nevertheless, little is known about its roles in endometriosis. We investigated the involvement of circ_0061140 in endometriosis. Tissues from endometriosis women displayed an increased expression of circ_0061140. Then, we found loss of circ_0061140 significantly repressed ectopic endometrial cell proliferation, migration and invasion. Meanwhile,miR-140-3pcan demonstrate an important role in several cancers.Here, we reported miR-140-3p was reduced in ectopic endometrial cells and it acted as a target of circ_0061140. Moreover, miR-140-3p was able to reverse the effect of circ_0061140 on ectopic endometrial cells. Furthermore, Notch2 was predicted as a putative target of miR-140-3p. A positive correlation between circ_0061140 and Notch2 was indicated. miR-140-3p and Notch2 were operated as downstream effectors in the circ_0061140 mediated signaling in endometriosis. Decrease of circ_0061140 could depress endometriosis progression through modulating miR-140-3p and Notch2.