The multifaceted granulosa cell tumours-myths and realities: a review

Immunohistochemical markers for equine granulosa cell tumors: a pilot study

Sex cord-stromal tumors (SCSTs), generally referred to as granulosa cell tumors (GCTs) or granulosa-theca cell tumors (GTCTs) in equids, show complex compositions and variable numbers of hormone-producing cells. These tumors can be difficult to diagnose, especially in early stages. Therefore, we tested a panel of antibodies for vimentin, smooth muscle actin, laminin, Ki-67, E-cadherin, calretinin, moesin, p-ezrin, AMH, and aromatase, markers used for tumor composition and classification, progression, and prognosis in human SCSTs, on an exemplary grapefruit-size equine GCT within the left ovary of a 13-year-old mare with stallion-like behavior and elevated testosterone levels in comparison with normal ovarian tissue. The tumor showed a low proliferation rate and prominent moesin and p-ezrin staining in granulosa cells. E-cadherin, calretinin, aromatase, and AMH are suggested to be potential markers for different cell components of equine SCSTs that can support tumor diagnosis and classification.

A case report of ovarian granulosa cell tumor in patient with polycystic ovarian syndrome

RATIONALE

Granulosa cell tumors (GCTs) account for less than 2% of all ovarian malignancies and are the second most common ovarian sex cord stromal tumors after fibroma/thecomas.GCTs occur most frequently in postmenopausal women with a peak age of 50 to 55, are usually diagnosed in their early stages, and have a good prognosis. GCTs usually present with features of hyperestrogenism, with an average size is 10 to 15 cm.

PATIENT CONCERNS

A 31-year-old nulligravida diagnosed with polycystic ovarian syndrome (PCOS) 10 years prior, had a 20-mm mass in her right ovary found on ultrasonography 2 years ago. She had been taking dienogest 2 mg for 2 years for a misdiagnosed endometrioma, but over a 2-year course, the mass increased to 50 mm.

DIAGNOSES

An ultrasound scan revealed a 47 × 37-mm round solid mass in the right ovary with a spongiform appearance and little vascularity. The pathologic findings showed an adult-type granulosa cell tumor with necrosis and hemorrhage. The tissue stained positive for inhibin-α, Wilms' tumor-1, CD56, and negative for cytokeratin 7.

INTERVENTIONS

We finally performed right salpingo-oophorectomy, endometrial biopsy, peritoneal biopsy, and partial omentectomy. The pathological findings were adult-type granulosa cell tumor. The International Federation of Gynecology and Obstetrics staging was IA. The patient did not require additional treatment.

OUTCOMES

Surprisingly, her normal menstruation returned 2 weeks after the operation, and she had a normal pregnancy and parturition. The patient had been followed-up regularly for 3 years following the surgery. The patient has not experienced any complications and has remained disease-free.

LESSONS

GCTs should be considered in the differential diagnosis if a female patient with PCOS and amenorrhea shows a unilateral small solid mass. They are extremely rare malignant ovarian tumors that must be differentiated from other benign ovarian tumors, especially endometriomas and dermoid cysts. It was difficult for us to suspect a granulosa cell tumor because the patient already had PCOS symptoms such as mild hirsutism and amenorrhea. This case highlights the importance of physicians being aware of and suspicious for GCTs in similar cases, along with knowing their characteristics in considering possible differential diagnoses.

A complex case of a granulosa cell tumour

This is a case of a 73-year-old woman who first presented in 2020 with a fullness in her abdomen. After several thorough investigations and unforeseen complications, the fullness was diagnosed as a granulosa cell tumour. In 2003, she had been diagnosed with a granulosa cell tumour of the ovary. Complete excision was performed, however she was not given a follow-up appointment after the procedure. This case highlights the importance of frequent follow-up of these tumours, the high recurrence rate, the severe complications which may result and the awareness of possible variations in this tumour's histologic appearance.

Granulosa cell ovarian cancer with synchronous multiple bone metastases: case report of extreme rarity

BACKGROUND

Adult granulosa cell tumor (AGCT) of the ovary generally has a good prognosis. Recurrences tend to be late and confined to the abdominopelvis. Bone metastases are extremely rare. We report an extremely rare case of AGCT with synchronous multiple bone metastases and discuss diagnostic procedures and management.

CASE DESCRIPTION

A 35-year-old woman presented with abdominal bloating. On the day of surgery, acting on the complaint of right shoulder pain, an X-ray revealed a permeative lesion involving the neck of humerus, suggestive of a metastatic pathologic fracture. The patient underwent a full staging debulking surgery. Further imaging demonstrated multiple bone metastases. Histology confirmed an AGCT of the ovary. Diagnosis was established by a core bone biopsy from the left femur showing cells consistent with those seen with granulosa cell tumor. The patient received adjuvant chemotherapy with concurrent zoledronic acid as targeted therapy for her bone metastases. Endocrine systemic maintenance treatment was given. The patient rapidly deteriorated and died from her disease at 20 months from the initial diagnosis.

CONCLUSION

Unpredictable biological behavior and clinical manifestations raise a high degree of suspicion for accurate AGCT diagnosis. Management of bone metastases often warrants input from the multidisciplinary team, and treatment may involve chemotherapy, palliative radiotherapy, or orthopaedic interventions.

Ovarian sex cord-stromal tumors: an update on clinical features, molecular changes, and management

Sex cord stromal-tumors are rare tumors of the ovary that include numerous tumor subtypes of variable histological features and biological behavior. Surgery is the main therapeutic modality for the management of these tumors, while chemotherapy and hormonal therapy may be used in some patients with progressive and recurrent tumors. Several studies investigated molecular changes in the different tumor types. Understanding molecular changes underlying the development and progression of sex cord-stromal tumors provides valuable information for diagnostic and prognostic biomarkers and potential therapeutic targets for these tumors. In this review, we provide an update on the clinical presentation, molecular changes, and management of sex cord-stromal tumors.

Disruption of 17β-estradiol secretion by persistent organic pollutants present in human follicular fluid is dependent on the potential of ovarian granulosa tumor cell lines to metabolize estrogen

Endocrine-disrupting chemicals (EDCs), such as perfluorooctanoate, perfluorooctane sulfonate, 2,2-dichlorodiphenyldichloroethylene, hexachlorobenzene, and polychlorinated biphenyl 153 are persistent pollutants that are found in human follicular fluid (FF). These compounds may affect endocrine function, disrupt steroid secretion by granulosa cells, and play a role in granulosa cell tumor (GCT) development. GCTs demonstrate endocrine activity, expressing aromatase and secreting 17β-estradiol (E2). We aimed to determine the effects of a mixture of EDCs, similar to that found in human FF, on human granulosa tumor cell lines representing the juvenile (JGCT) and adult (AGCT) forms (COV434 and KGN cells, respectively). We found that all the individual compounds and mixtures tested altered granulosa tumor cell function by disrupting E2 secretion. In KGN cells, which possess significantly higher basal aromatase gene expression, and therefore secrete more E2 than JGCT cells, EDC mixtures activated estrogen receptors (ERs) and G protein-coupled receptor-30 signaling, thereby stimulating E2 secretion, without affecting aromatase expression. By contrast, in COV434 cells, which demonstrate higher CYP1A1 expression, a key mediator of estrogen metabolism, than KGN cells, EDC mixtures reduced E2 secretion in parallel with increases in the 2-hydroxyestrogen 1/E2 ratio and CYP1A1 expression, implying an upregulation of E2 metabolism. These results indicate that the EDC mixture present in FF disrupts E2 secretion in JGCT and AGCT cells according to the estrogen metabolic potential of the cell type, involving both classical and non-classical ER pathways.

Occult Gallbladder Carcinoma Presenting as a Primary Ovarian Tumour: a Case Report and Review of Literature

The ovary is a common site of metastasis from various organs. However, little is known about gallbladder carcinoma metastasising to the ovaries and presenting as a primary ovarian tumour. We report a case of a metastatic gallbladder carcinoma which mimicked a primary ovarian tumour in a 31-year-old woman who presented with menstrual symptoms and an ovarian mass without obvious signs and symptoms related to gallbladder carcinoma. Postoperatively histopathological examination diagnosed primary ovarian germ cell tumour for further chemotherapy. However, postoperative re-evaluation with radiology suggested the possibility of a primary gallbladder carcinoma. Exact diagnosis could only be made after repeat histopathological evaluation of the ovarian mass.

Abnormal vaginal bleeding in women with gynaecological malignancies

Abnormal vaginal bleeding is a common gynaecological symptom, and most causes are benign. International Federation of Gynaecology and Obstetrics proposed a PALM-COEIN classification in 2011 to decrease heterogeneity in studies. The gynaecological malignancies that present with abnormal bleeding vary according to the age of the patient and the origin (upper versus lower genital tract). It is important that a thorough history and examination is performed to make this distinction. The common malignancies presenting symptoms and treatment are discussed in this article according to the age of the patient. There is a considerable overlap between the reproductive age and menopause. This article focuses on children, adolescents and women in the reproductive age group.

Juvenile Granulosa Cell Tumour of the Ovary with Unilocular Pure Cystic Presentation: A Case Report and Review of Literature

Background

Granulosa cell tumours of the ovary are rare, hormonally active, oestrogen-secreting tumours of the ovary existing in two forms: the adult form and the even rarer juvenile form. These tumours present as predominantly solid lesions while the cystic, unilocular presentation is uncommon.

Case Report

We present an 18-year-old unmarried girl who presented with complaints of chronic pain, abdominal distension and presence of facial hair. Radiological examination revealed a large, purely cystic, unilocular lesion without any solid components, debris or septations. Histopathological diagnosis was of a juvenile granulosa cell tumour.

Conclusions

Radiological criteria suggestive of malignant ovarian masses include thick, irregular walls and septae; papillary projections and solid, echogenic foci. Nonetheless, we propose that a malignant ovarian lesion should be included in the differential diagnosis of a unilocular, purely cystic ovarian lesion.

FOXO1/3 and PTEN Depletion in Granulosa Cells Promotes Ovarian Granulosa Cell Tumor Development

The forkhead box (FOX), FOXO1 and FOXO3, transcription factors regulate multiple functions in mammalian cells. Selective inactivation of the Foxo1 and Foxo3 genes in murine ovarian granulosa cells severely impairs follicular development and apoptosis causing infertility, and as shown here, granulosa cell tumor (GCT) formation. Coordinate depletion of the tumor suppressor Pten gene in the Foxo1/3 strain enhanced the penetrance and onset of GCT formation. Immunostaining and Western blot analyses confirmed FOXO1 and phosphatase and tensin homolog (PTEN) depletion, maintenance of globin transcription factor (GATA) 4 and nuclear localization of FOXL2 and phosphorylated small mothers against decapentaplegic (SMAD) 2/3 in the tumor cells, recapitulating results we observed in human adult GCTs. Microarray and quantitative PCR analyses of mouse GCTs further confirmed expression of specific genes (Foxl2, Gata4, and Wnt4) controlling granulosa cell fate specification and proliferation, whereas others (Emx2, Nr0b1, Rspo1, and Wt1) were suppressed. Key genes (Amh, Bmp2, and Fshr) controlling follicle growth, apoptosis, and differentiation were also suppressed. Inhbb and Grem1 were selectively elevated, whereas reduction of Inha provided additional evidence that activin signaling and small mothers against decapentaplegic (SMAD) 2/3 phosphorylation impact GCT formation. Unexpectedly, markers of Sertoli/epithelial cells (SRY [sex determining region Y]-box 9/keratin 8) and alternatively activated macrophages (chitinase 3-like 3) were elevated in discrete subpopulations within the mouse GCTs, indicating that Foxo1/3/Pten depletion not only leads to GCTs but also to altered granulosa cell fate decisions and immune responses. Thus, analyses of the Foxo1/3/Pten mouse GCTs and human adult GCTs provide strong evidence that impaired functions of the FOXO1/3/PTEN pathways lead to dramatic changes in the molecular program within granulosa cells, chronic activin signaling in the presence of FOXL2 and GATA4, and tumor formation.

Ovarian granulosa cell tumor: clinical features, treatment, outcome, and prognostic factors

Background:

Granulosa cell tumors are rare neoplasms characterized by long natural history and favorable prognosis.

Aims:

The objective of this study was to determine the clinical presentation, treatment, outcome, and prognostic factors for patients of granulosa cell tumors.

Materials and Methods:

A retrospective analysis of 26 patients of granulosa cell tumor of ovary from 2002 to 2011 was carried out. The records of all patients were analyzed to determine clinical presentation, treatment, survival, and prognostic factors.

Results:

The median age of the patients was 50 years (range, 17-71 years). Abdominal pain was the most common presenting symptom. The median follow-up was 71.4 months (range, 21.6-149.9 months). The estimated 5 and 10 year overall survival (OS) was 84.6 and 72.5%, respectively. Event-free survival (EFS) was 76.5 and 52.9% at 5 and 10 years, respectively. Advanced stage was significant independent poor prognostic indicator for both OS and EFS.

Conclusion:

Majority of the patients with granulosa cell tumors of the ovary present in early stage. Surgery is the primary treatment modality for granulosa cell tumors. Advanced stage and presence of residual disease were associated with inferior survival, but only prospective studies can ascertain their definite role.

Massive ascites as the only sign of ovarian juvenile granulosa cell tumor in an adolescent: a case report and a review of the literature

Ovarian neoplasms are relatively rare in childhood and adolescence; only 5% to 8% of the cases are of sex cord stromal origin. Granulosa cell tumors are a group of estrogen producing sex cord stromal tumors of the ovary. They occur in 95% of the cases in adults, and only about 5% of the cases, which differ in histologic characteristics, are of juvenile type. A 13-year-old girl is reported who presented with massive abdominal distention and ascites. An abdominopelvic computed tomography scan showed a predominantly cystic mass lesion with septations arising from the left ovary. All tumor markers were normal, but serum inhibin level was increased. The patient underwent mass resection with salpingoophorectomy. Histopathology was compatible with the juvenile granulosa cell tumor. Interestingly, menarche was started in the patient soon after the surgery. To the best of our knowledge, massive ascites as the only clinical manifestation in the juvenile granulosa cell tumor has not reported as yet.

Anti-müllerian hormone and its clinical use in pediatrics with special emphasis on disorders of sex development

Using measurements of circulating anti-Müllerian hormone (AMH) in diagnosing and managing reproductive disorders in pediatric patients requires thorough knowledge on normative values according to age and gender. We provide age- and sex-specific reference ranges for the Immunotech assay and conversion factors for the DSL and Generation II assays. With this tool in hand, the pediatrician can use serum concentrations of AMH when determining the presence of testicular tissue in patients with bilaterally absent testes or more severe Disorders of Sex Development (DSD). Furthermore, AMH can be used as a marker of premature ovarian insufficiency (POI) in both Turner Syndrome patients and in girls with cancer after treatment with alkylating gonadotoxic agents. Lastly, its usefulness has been proposed in the diagnosis of polycystic ovarian syndrome (PCOS) and ovarian granulosa cell tumors and in the evaluation of patients with hypogonadotropic hypogonadism.