Borderline Brenner tumor with abnormally high serum level of carbohydrate antigen 199: a rare case report and literature review

Ovarian Brenner tumor with abnormally increased serum carbohydrate antigen 19-9 (CA19-9) level is extremely rare. A 70-year-old woman with abnormally elevated serum CA199 (1289 U/ml) found in routine physical examination. Pelvic CT and MRI scan revealed a large mass with large patches of calcification in the right adnexal area, and the patient achieved total hysterectomy and bilateral adnexectomy. Grossly, the right ovary had a solid enlargement of about 7.0 cm × 6.0 cm × 5.0 cm with irregular nodules and smooth surface and the cut surface of the mass showed that the tumor is cystic and solid. Microscopically, the tumor showed a background of fibrous tissue hyperplasia with nested and adenoid cell clusters with uniform cell size and clear boundaries. The cells were translucent with eosinophilic cytoplasm and calcification. Immunohistochemical staining showed CK7, CA125, and P63 presented diffusely strongly positive staining, while negativity for CK20, GATA3, AR, P53, and CgA. Ki-67 showed weak positive staining, about 1%. The serum CA199 level decreased significantly on the 5th day after surgery. Postoperative pathology and immunohistochemistry confirmed borderline Brenner tumor. This is the first to report a case of borderline Brenner tumor with an abnormally high serum level of CA199 before surgery. In clinical practice, the possibility of ovarian Brenner tumor should be considered when abnormal elevation of serum CA199 level cannot be reasonably explained.

Comparison of performance between O-RADS, IOTA simple rules risk assessment and ADNEX model in the discrimination of ovarian Brenner tumors

PURPOSE

To describe the clinical and sonographic features of ovarian benign Brenner tumor (BBT) and malignant Brenner tumor (MBT), and to compare performance of four diagnostic models in differentiating them.

METHODS

Fifteen patients with BBTs and nine patients with MBTs were retrospectively identified in our institution from January 2003 and December 2021. One ultrasound examiner categorized each mass according to ovarian-adnexal reporting and data system (O-RADS), international ovarian tumor analysis (IOTA) Simple Rules Risk (SR-Risk) assessment and assessment of different neoplasias in the adnexa (ADNEX) models with/without CA125. Receiver operating characteristic curves were generated to compare diagnostic performance.

RESULTS

Patients with MBT had higher CA125 serum level (62.5% vs. 6.7%, P = 0.009) and larger maximum diameter of lesion (89 mm vs. 43 mm, P = 0.009) than did those with BBT. BBT tended to have higher prevalence of calcifications (100% vs. 55.6%, P = 0.012) and acoustic shadowing (93.3% vs. 33.3%, P = 0.004), and lower color scores manifesting none or minimal flow (100.0% vs. 22.2%, P < 0.001). Areas under curves of O-RADS, IOTA SR-Risk and ADNEX models with/without CA125 were 0.896, 0.913, 0.892 and 0.896, respectively. There were no significant differences between them.

CONCLUSION

BBTs are often small solid tumors with sparse color Doppler signals, which contain calcifications with posterior acoustic shadowing. The most common pattern of MBT is a large multilocular-solid or solid mass with irregular tumor borders, and most were moderately or richly vascularized at color Doppler. These four models have excellent performance in distinguishing them.

Ovarian mucinous cystic tumor associated with sarcomatous mural nodule and benign Brenner tumor: A case report and literature review

RATIONALE

Ovarian mucinous tumor with malignant mural nodule is exceedingly rare. We report a case of ovarian mucinous cystic tumor associated with sarcomatous mural nodule and benign Brenner tumor and accompanied by nodular histiocytic aggregates in the greater omentum.

PATIENT CONCERNS

A 60-year-old postmenopausal woman was presented with a history of one month of lower abdominal discomfort, abdominal distension, nausea, and vomiting. A physical examination revealed a hard, palpable mass with mild tenderness in her right lower abdomen.

DIAGNOSES

The mucinous tumor was solid and cystic and contained benign, borderline, and malignant elements. Within the solid areas, two nodules representing pleomorphic undifferentiated sarcoma and benign Brenner tumor were identified. The diagnosis of malignant mural nodule was based on vascular invasion and marked nuclear atypia, including atypical mitoses and mitotic activity.

INTERVENTIONS

Bilateral salpingo-oophorectomy and partial omentectomy were performed. Malignant cells were not found on cytologic examination of the peritoneal washing fluid. The patient underwent three cycles of chemotherapy with 210 mg paclitaxel liposome via an intravenous drip, 20 mg nedaplatin via an intravenous drip, and 80 mg nedaplatin via intraperitoneal perfusion.

OUTCOMES

The patient has been followed up for 3 years without evidence of tumor recurrence and metastasis.

LESSONS

Careful classification of a mural nodule is important to triage patients in need of aggressive adjuvant treatment.

Malignant Brenner Tumor of the Ovary: Case Report with a Review of the Literature

A case of malignant Brenner tumor of the ovary is reported. From a survey of the literature some anatomo-clinical considerations are drawn and the histopathologic criteria for diagnosis are discussed.

Ovarian torsion of mixed epithelial tumor misdiagnosed as a malignancy in postmenopausal woman: A case report

RATIONALE

Adnexal torsion is 1 of the most common emergency gynecological disease. It is more often diagnosed in reproductive age, but rarely in postmenopausal women. The clinical symptoms of adnexal torsion are nonspecific in postmenopausal women. Epithelial ovarian tumors are common in adults, and the risk of malignancy increases with age, especially after menopause. So, it is difficult to diagnose adnexal torsion precisely compared with reproductive women, and most cases of adnexal torsion with postmenopausal women are diagnosed as a malignancy preoperatively. We report a case of ovarian torsion with mixed epithelial tumor misdiagnosed as a malignancy in postmenopausal woman.

PATIENT CONCERNS

A 65-year-old woman presented lower left abdominal pain, and there was slight abdominal distension, but no tenderness or rebound tenderness on abdominal palpation.

DIAGNOSES

Radiologic assessments showed a huge multiseptated cystic mass with solid portion in the left ovary, and malignancy was suspected. The test for serum tumor markers revealed normal levels of cancer antigen 125 (CA-125).

INTERVENTIONS

The patient underwent a laparotomy and there was torsion of the left ovary. We conducted frozen biopsy of left ovary for confirming malignancy before performing staging surgery.

OUTCOMES

The result of a frozen section biopsy confirmed a borderline Brenner tumor associated with a benign mucinous tumor. Subsequently, total hysterectomy and right salpingo-oophorectomy were performed. The operation was completed without addition procedures LESSONS:: Ovarian torsion is benign in most cases and malignancy is rare. Although very rare, ovarian torsion can occur in postmenopausal women, and it should be taken into consideration that the possibility of malignancy is low in postmenopausal women with normal CA-125 levels. Instead of performing staging surgery, it appears to be appropriate to carry out surgery based on the result of intraoperative frozen section biopsy so that we were able to avoid unnecessary surgical procedures.

Vaginal Brenner tumor with literature review: does this tumour originate from Walthard nests?

Vaginal Brenner tumor is extremely rare. Only five cases have been reported in the English literature to date. Here we report a vaginal Brenner tumor in a 76-year old postmenopausal woman, who presented with a 2.5cm-sized sessile vaginal polyp. Microscopically, it showed characteristic features of Brenner tumor consisting of three components; transitional islands, glands, and dense fibrous stroma. The epithelial tumor cells were positive for GATA-3, p63 and ER, but negative for PAX8. The origin of Brenner tumors in the vagina is unclear, but previous reports suggested of Müllerian origin. However, our case revealed that vaginal Walthard nests could be possible precursor lesions based on their immunohistochemical staining results.

Is Imprint Cytology Useful to Diagnose Malignancy for Brenner Tumors? A Case Series at a Single Institute

BACKGROUND

The aim of this study was to investigate cytological features of Brenner tumors according to tumor grade using imprint cytology.

CASE

Between 2004 and 2015, intraoperative imprint cytology was performed on 8 patients with Brenner tumors suspected to be malignant neoplasmas on gross examination because of their large size and solid part. These consisted of 1 benign, 3 borderline, and 4 malignant tumors. In patients with benign and borderline tumors, naked nucleus-like stromal cells and tumor cells in a sheet-like arrangement were observed against a clear background. The nuclei were round to oval-shaped with finely granular chromatin patterns and small nucleoli. Papillary cell clusters and high nucleus-to-cytoplasm ratios were only observed in 1 borderline case. In cases with malignancy, the background was necrotic. The tumor cells occurred in large papillary clusters. The nuclei showed a high degree of nuclear atypia. Nuclear grooves were present in 6 of our 8 cases and they were scant in the malignant cases.

CONCLUSION

Imprint cytology of Brenner tumors provided no characteristic findings to enable a definitive distinction of benign versus borderline tumors, but it enabled discrimination between malignant and other tumors. Imprint cytology can facilitate intraoperative diagnosis and aid in selecting the appropriate surgical procedure.

Brenner tumour of the ovary--an incidental histological finding

Brenner tumours of the ovary are uncommon neoplasms and mostly benign. There is general agreement that Brenner tumors are derived from the surface epithelium of the ovary or the pelvic mesothelium through transitional cell metaplasia. It is essential to categorise these tumours as benign, borderline or malignant type as the biologic behaviour and choice of surgery differs in all of the three categories. The authors report a case of Brenner tumour that had only a single area with a beginning indistinct stroma vessel invasion. However the presence of characteristic epithelial nests, fibromatous stroma, and marked cytological metaplasia without atypia provided important clues to the correct diagnosis--proof of a benign tumour.

Borderline Brenner tumors associated with ovarian cyst - case presentation

Borderline Brenner tumors represent quite a rare entity of ovarian tumors (about 2%) that develop from the surface ovarian epithelium. They are formed from papillary structures made of fibrovascular conjunctive axes covered by a transition epithelium, similar to the urinary bladder epithelium. According to the WHO classification, Brenner tumors present the following forms: benign, borderline and malignant. The benign ones are the most frequent, representing about 95%, the borderline represent about 5%, and the malignant ones less than 1%. We present the case of a 64-year patient who was diagnosed with right ovary cyst. The histopathological examination highlighted the presence of a borderline Brenner tumor at the same time with the cystic lesion, on the same ovary. The surgical treatment led to a complete cure of the patient, so that the yearly ultrasound reexamination did not trace the presence of any tumoral relapse.

[Clinicopathologic features observation of ovarian transitional cell tumors]

OBJECTIVE

To assess clinical and pathological features of ovarian transitional cell tumors.

METHODS

Fourteen cases of ovarian transitional cell carcinoma (TCC) were selected and investigated for their clinical and pathological features. Their immunohistochemical profiles were compared with 12 cases of serous adenocarcinoma (SC) admixed with TCC and 4 cases of EC admixed with TCC 20 cases of pure high-grade serous adenocarcinoma (HG-SC), 15 cases of endometrioid adenocarcinoma (EC), 6 cases of Brenner tumor (BT, 2 cases of malignant BT and 4 cases of benign BT).

RESULTS

The patients' age ranged from 36-63 years (mean, 56 years). All cases underwent surgery and postoperative chemotherapy with TP or CAP program. Clinical follow-up was available in 9 cases, of which 2 patients died. Histologically, all cases showed features of transitional cell carcinoma without BT component. Immunohistochemically, 13 of 14 TCCs were positive for WT-1 and all were positive for CK7, ER, PR and CA125, but negative for Uroplakin III and CK20.Similar immunohistochemical staining patterns were seen in SC admixed with TCC and pure HG-SC. Percentage of the 14 TCC cases were also diffusely positive for BRCA1. All SCs admixed with TCC and pure HG-SCs were diffusely or heterogeneously positive for WT-1, with a sharp contrast and mottled distribution pattern in the heterogeneous cases. All TCCs were diffusely and strongly positive for p53, while 16 of 20 cases of pure HG-SC were positive. The positive ratio of p53 in SCs admixed with TCC cases was 11/12.WT-1 expression in TCCs was significantly higher than BTs, ECs and ECs admixed with TCC (P < 0.01), while no obvious difference was seen when compared with SCs admixed with TCC and pure HG-SCs.SCs admixed with TCC, TCCs and EC were positive for BRCA1 except pure ECs and BTs. The positive rate of Ki-67 of BTs was low, while it was higher in TCCs, SCs admixed with TCC and pure HG-SCs. Only BTs expressed Uroplakin III.

CONCLUSIONS

Ovarian TCC has characteristic morphological and immunohistochemical features, similar to SC but different from BT. Therefore, TCC should be considered as a morphological variant of HG-SC.

Different staining patterns of ovarian Brenner tumor and the associated mucinous tumor

The association of ovarian Brenner tumors and adjacent mucinous tumors is well known but not completely understood. In this study, we analyzed immunohistochemical markers on Brenner tumors and their associated mucinous tumor to explore Mullerian as well as Wolffian and germ cell derivation and determine if the mucinous component is independent or related to the Brenner tumor. Of 32 consecutive cases of Brenner tumors, 8 were identified with significant mucinous component, and 7 additional cases included foci of mucinous epithelium within the Brenner transitional nests. All Brenner tumors were diffusely positive for GATA3 and negative for Paired box gene 8, PAX2, and Sal-like protein 4. Interestingly, the areas of mucinous epithelium as well as mucinous tumors, intermixed and adjacent to the Brenner tumor, were negative for all 4 markers; however, occasional basal-like cells retained expression of GATA3. The immunoprofile of mucinous tumors associated with Brenner tumors shares the lack of Mullerian markers PAX2 and Paired box gene 8 with the Brenner tumor but differs in the expression of GATA3 only in the Brenner tumor component.

[Brenner tumor: one case report and bibliographic review]

Brenner tumor is a rare tumor that represents approximately 1.5% of the tumors of ovary. It is defined as a tumor of transitional cells composed by urothelial cells arranged in solid or cystic groups absorbed in a fibrous stroma. It classifies in benign Brenner tumor (95%), borderline (3-4%) and malignant (1%). Let's sense beforehand the clinical case of a 46-year-old patient who underwent surgery having an adnexal mass of which the pathological intraoperative report brought a benign Brenner tumor.

An unusual case of a borderline Brenner tumor associated with bilateral serous cystadenoma and endometrial carcinoma

Brenner tumor accounts for 1.5 to 2.5% of ovarian tumors. Nearly all are benign and 1% malignant. Less than twenty-five cases of borderline Brenner tumor have been reported worldwide. Our case is the first one related to a bilateral ovarian serous cystadenofibroma and endometrioid adenocarcinoma. This unusual case increases the limited data for borderline Brenner tumors.

Coexistence of three benign and a borderline tumor in the ovaries of a 52-year-old woman

PURPOSE OF INVESTIGATION

In this paper, the authors describe a rare case of four simultaneous ovarian tumors.

MATERIALS AND METHODS

A 52-year-old postmenopausal woman underwent total hysterectomy and bilateral salpingo-ophorectomy. Multiple slides from the ovaries were examined.

RESULTS

Histological examination revealed the presence of three ovarian tumors on the right ovary, of the following types: cystadenoma, mucinous borderline ovarian tumor and mature teratoma, and also a benign Brenner tumor on the left ovary.

CONCLUSION

Pathologists must examine multiple sections of both ovaries, regardless of the macroscopic or clinical specimen's appearance, in order to exclude the presence of malignancy, which could alter the surgical approach. Particular attention should also be paid to the frozen section of the contralateral ovary, as depending on the result, it could change the surgical approach. From the surgeon's perspective, bilateral salpingo-ophorectomy with total hysterectomy should be the treatment of choice in postmenopausal women with multiple ovarian tumors. The diagnosis of a malignant or borderline tumor on a normal-appearing ovary changes the radicality of the surgical approach. In such a case, staging surgery, including omentectomy, multiple peritoneal biopsies, and washes are required.

A case of ovarian psammocarcinoma with homolateral serous cystoadenofibroma and thecoma associated with Brenner tumour and cystoadenofibroma of the contralateral ovary

Psammocarcinoma of the ovary is a rare serous neoplasm, with only 32 cases reported in the international literature. Characteristically, this tumour shows extensive formation ofpsammoma bodies, low-grade cytological features, and invasion of the ovarian stroma, peritoneum or intraperitoneal viscera. The behaviour of this entity is unpredictable, with benign, low malignant and metastatic potential. Herein the authors report a case ofpsammocarcinoma of the ovary with homolateral serous cystoadenofibroma and thecoma, which were associated with Brenner tumour and adenofibroma of the contralateral ovary, in a 78-year-old woman. Thus, this example shows an unpredictable tumour associated with multiple benign epithelial neoplasms and a benign stromal tumour. Moreover, this example of psammocarcinoma is very interesting because it measures only 1.5 x 0.5 x 1.5 cm and, to the best of the author's knowledge, represents the smallest case ofpsammocarcinoma described so far in the literature.

Imaging in gynecological disease (7): clinical and ultrasound features of Brenner tumors of the ovary

OBJECTIVES

To describe clinical and ultrasound features of Brenner tumors of the ovary.

METHODS

In this retrospective study, the databases of the International Ovarian Tumor Analysis (IOTA) studies and one tertiary center were searched to identify patients who had undergone an ultrasound scan before surgery for an adnexal mass that proved to be a Brenner tumor. Twenty-eight patients with 29 Brenner tumors were included, most of which had been collected within the framework of the IOTA studies. An experienced ultrasound examiner reviewed available ultrasound images (available for 14 tumors), searching for a pattern specific to Brenner tumors.

RESULTS

Most patients were postmenopausal and asymptomatic. Twenty-four (83%) tumors were benign, two (7%) were borderline and three (10%) were malignant. Most benign tumors (17/24, 71%) contained solid components and manifested no or minimal blood flow on Doppler examination (19/24, 79%). Information about calcifications was available for 15 benign tumors, and in 13 (87%) calcifications were present. The five borderline and invasively malignant tumors contained solid components less often than did the benign ones (3/5, 60%) and were more richly vascularized on Doppler examination. Information about calcifications was available for four borderline or invasively malignant tumors, and in three (75%) calcifications were present.

CONCLUSION

We failed to demonstrate ultrasound features specific to Brenner tumors. A prospective study is needed to determine if ultrasound features of calcifications can discriminate between Brenner tumors and other types of ovarian tumor.

Ovarian cystic tumor composed of Brenner tumor and struma ovarii

Ovarian tumor composed only of Brenner tumor and struma ovarii is very rare; only 6 cases have been reported in the English literature, to the best of the author's knowledge. A 66-year-old woman underwent right oophorectomy because of torsion of right ovarian cyst. Macroscopically, the ovarian cyst was hemorrhagic and red. Cystic content was hemorrhagic fluid. Microscopically, the cyst walls were composed only of Brenner tumor (50% in area) and struma ovarii (50% in area). Hemorrhage and ischemic changes were seen. Other elements were not recognized. No malignant transformation was noted. These two elements were separately present, and no mergers between them were recognized. Immunohistochemically, the Brenner tumor element was positive for cytokeratins (AE1/3 and CAM5.2) and Ki67 (labeling=3%), but negative for thyroglobulin, TTF-1, p53, CA125, and vimentin. The struma ovarii element was positive for cytokeratins (AE1/3 and CAM5.2), thyroglobulin, TTF-1 and Ki67 (labeling=5%), but negative for p53, CA125 and vimentin. The findings suggests that there were cases of ovarian cyst composed only of Brenner tumor and struma ovarii, that such a case may be monodermal mature cystic teratoma or the Brenner tumor element was derived from surface epithelium in the preexisting struma ovarii, and that such a tumor manifest as cystic torsion.

[Borderline ovarian tumors and global radiation in relation with climate change impact]

There is limited information on borderline ovarian tumor detected intra-surgically and its most favorable treatment in relation with global radiation and climate changes.

AIM

To study the pre-surgery and intra-surgery differentiation criteria of borderline ovarian tumors from invasive carcinoma, and to make a very complex analysis of the frequency, distribution, and variation in time of global radiation, temperature, and precipitation in North-East Romania.

MATERIAL AND METHOD

The 54 patients (age range 20-78 years, mean age 46 years) included in this study had borderline ovarian tumors surgically treated during the last 22 years (January 1988 - December 2009) at the 4th Gynecological Clinic at Iaşi, and representing 4.87% of the total 1107 ovarian tumors detected and treated during this interval. The histological types were: serous (18 cases), mucinous (27 cases), mixed (8 cases), and Brenner tumor (1 case). In order to analyze the impact of climate changes on borderline ovarian tumors a thorough study on the frequency of global radiation in relation with climate changes based on data recorded in the last 55 years was also carried out.

RESULTS

The distribution of these cases depending on when surgery was performed was analyzed. In our study the frequency of ovarian borderline tumors (4.87%) is lower than in similar reports in the literature being due, in our opinion, to the influence of global radiation in relation with climate changes.

CONCLUSIONS

In our study global radiation is probably responsible for a progression to invasive carcinoma in 0.7% of the borderline ovarian tumors.

Virilising ovarian tumour: a case associating a Sertoli-Leydig cell tumour and a Brenner tumour

Ovarian Sertoli-Leydig cell tumours (SLCT), also termed arrhenoblastomas, are the most frequent virilising tumours in women of reproductive age. Very rare secretory Brenner tumours (BT) have been described, generally after the menopause. A 31-year-old woman sought medical advice for secondary amenorrhoea, progressive hirsutism and a 5-year history of virilisation syndrome with clitoromegaly. Testosterone was markedly high (285 ng/dl, N<85) with moderate elevation of delta 4-androstenedione (D4AD) (311 ng/dl, N <270), dehydroepiandrosterone sulfate (DHEAS) (366 μg/dl, N <340) and 17-hydroxyprogesterone (17OHP) (275 ng/dl). LH was 9 IU/l, FSH 4.3 IU/l, estradiol 60 pg/ml and progesterone 314 ng/100 ml. Cortisol was decreased (1.3 μg/dl) after the dexamethasone suppression test. Pelvic MRI showed a 5-cm right ovarian tumour with a 2.5 cm nodular component and cystic areas, and two nodules measuring 11 mm and 15 mm above the right and left ovaries. After right ovariectomy by laparoscopy, pathological examination concluded on a 3-cm SLCT and a 2-cm BT; the nodules above the ovaries were dysembryoplastic cysts. Postoperatively, testosterone level was normal after 24 h (26 ng/dl), estradiol and progesterone rapidly decreased, cyclic secretion then resumed and the patient menstruated at day 27. To our knowledge, this is the first report of an ovarian tumour associating a Sertoli-Leydig cell tumour and a Brenner tumour in a patient with virilisation syndrome which resolved after ovariectomy.

[Ovarian tumors of low malignant potential (borderline ovarian tumors)]

Ovarian borderline tumors are rare, their good prognosis depending on their stage at the time of diagnosis, and the presence of invasive implants. There is little information on tumor type identified intra-surgically, as well as on the most favorable treatment in borderline ovarian tumors.

AIM

To determine the criteria of identification and presurgery and intra-surgery differentiation of the ovarian borderline tumors from the invasive carcinoma and benign ovarian tumors.

MATERIAL AND METHODS

This study included 54 patients with TPMS (ovarian borderline tumors) surgically treated in the past 22 years (January 1988-December 2009) at the 4th Gynecological Clinic of the lasi "Gr. T. Popa" University of Medicine and Pharmacy. In this interval 1,107 ovarian tumors: 575 benign, 478 malignant, and 54 TPMS (4.87%) were recorded. The age of the patients with borderline tumors ranged between 20 and 78 years, mean age 46 years, and the histological types were: mucinous (27 cases), serous (18 cases), mixed (8 cases), and Brenner tumor (1 case).

RESULTS

We have analyzed the distribution of these cases according to the time when surgical treatment was performed. The frequency of borderline ovarian tumors in our study is 4.87%, lower than in the literature. We believe that this low percentage in our study is due to missing the microscopic data in some macroscopic benign tumors.

CONCLUSIONS

By this research we aimed at elaborating a therapeutic strategy for each case using with discernment the modern treatment (surgery, chemotherapy, radiotherapy), as well as new chemical drugs with the goal of obtaining better results and longer survival. There are no tumor markers which could predict the progression of a borderline ovarian tumor to invasive tumors, but the invasive course is only 0.7%.

Proliferative Brenner tumor of the ovary. clinicopathological study of two cases and review of the literature

BACKGROUND

Ovarian Brenner tumors are rare epithelial tumors that account for 1%-2% of all ovarian neoplasms. They can be subdivided into benign, borderline or proliferative, and malignant neoplasms. In the vast majority of cases, these lesions are benign. Tumors of borderline malignancy are less frequent and only about 1% of Brenner tumors are malignant. We present two cases of Brenner tumors with borderline malignancy which were treated in our Department together with a review of the literature.

CASES

A 50-year-old, gravida 1, para 1, patient was admitted for abnormal vaginal bleeding. Clinical examination, abdominal ultrasound (US), and computed tomography (CT) revealed a cystic multilobulated tumor of the right ovary with solid elements measuring 20 x 19 x 15 cm in diameter. In the other case a 70-year-old, gravida 2, para 2, patient presented with severe urinary difficulties. Palpation revealed a mobile abdominopelvic tumor 10 x 15 in diameter. US and CT exhibited a cystic tumor with multiple solid elements and calcifications of the left ovary. Both patients underwent exploratory laparotomy. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and total omentectomy were performed in both cases, while pelvic lymphadenectomy was decided only in the second case. Histologically, in both cases the diagnosis confirmed borderline Brenner tumor.

CONCLUSION

Although Brenner tumors are rare and the majority of them are benign, the correct histological diagnosis at frozen section with identification of the small proportion of malignant tumors, allows the extent of the operation to be adapted if needed.

Predominant Brenner tumor combined with struma ovarii containing a papillary microcarcinoma associated with benign peritoneal strumosis: report of a case and histologic features

Brenner tumor and struma ovarii, two uncommon ovarian tumors arising alone or together with dermoid cysts or adenomas, are both rare entities. Both tumors rarely become malignant and rarely metastasize. Few published reports describe coexisting Brenner tumor and malignant struma ovarii. Patients in whom these malignancies coexist only occasionally have peritoneal spreading, strumosis, or a history of thyrotoxicosis. The patient we describe, a 74-year-old woman, presented with a 2 months' history of lower abdominal pain and episodic intestinal subocclusion due to a complex pelvic mass. The mass consisted predominantly of a Brenner tumor associated with struma ovarii containing a single small island of thyroid tissue that had undergone malignant transformation into a well-differentiated papillary carcinoma and also normal thyroid tissue that had spread to the peritoneum. The patient underwent radical surgical treatment and after 7 years follow-up is disease free.

Unique cytomorphologic features of Brenner tumor of the ovary: a case report

BACKGROUND

Breast carcinomas are very well known to metastasize to the ovary. Hence, it is justified to think of an ovarian mass, in a known case of breast carcinoma, as a metastasis from the same.

CASE

A 70-year-old woman underwent ultrasound-guided fine needle aspiration cytology (FNAC) from a unilateral ovarian mass to confirm its nature. Cytosmears were highly cellular and showed cohesive clusters of small to intermediate-sized cells with bland nuclear chromatin and moderate cytoplasm in a background of mucinous material. A unique feature was the presence of microcystic spaces, around which the cells were arranged in an orderly fashion. Only occasional nuclear grooves were seen; however, they were helpful in suggesting the diagnosis of Brenner tumor. The subsequent histopathology specimen confirmed the diagnosis, with an excellent cytohistologic correlation.

CONCLUSION

There is very limited experience with the FNAC findings of this tumor, and it is usually a diagnostic dilemma for the cytopathologist. This case highlights certain unique cytomorphologic features that may aid in diagnosis on cytology alone.

Ascitic fluid cytology in malignant Brenner tumor: a case report

BACKGROUND

Peritoneal effiusion is rare in malignant Brenner tumors and has been found in only 10% of patients.

CASE

A 77-year-old woman presented with malignant Brenner tumor and ascites. The cytology of the ascitic fluid revealed many activated mesothelial cells intermingled with squamous tumoral cells. These cells were either isolated or arranged in small clusters. They were often round or oval with irregular and moderately hyperchromatic nuclei.

CONCLUSION

Presence of squamous cells in ascitic fluid associated with an ovarian tumor should raise the possible diagnosis of malignant Brenner tumor in addition to malignant transformed teratoma and secondary squamous carcinoma of the ovary.

Endometroid adenocarcinoma of the uterus, borderline tumor of the ovary and Brenner tumor of the contralateral ovary in a 63-year-old woman

Synchronous primary cancers of the endometrium and ovary occur in approximately 10% of all women with ovarian cancer and 5% of all women with endometrial cancer. The pathogenesis of synchronous endometrial and ovarian cancer is unclear. Synchronous tumors tend to be low grade and early stage. The prognosis is much better with survival approaching ten years than if the disease was classified as a single organ disease with metastasis. We report a case of unusual co-existence of endometroid adenocarcinoma of the uterus, serous borderline tumor of the ovary and Brenner tumor of the contralateral ovary in a 63-year-old woman. The patient recieved a surgical treatment and postoperative irradiation.

A rare malignant Brenner tumor of the ovary in a 77-year-old woman: a case report

BACKGROUND

A malignant Brenner tumor is a rare form of invasive epithelial ovarian cancer and is extremely uncommon in women > 65 years of age. We present a case of an invasive Brenner tumor of the ovary in a woman greater than age 70.

CASE

A 77-year-old woman presented with a rare, invasive Brenner tumor of the ovary. She was referred for evaluation of a complex pelvic mass and elevated serum CA-125. Treatment included complete surgical resection and staging procedure. Pathology revealed a malignant Brenner tumor. Immunohistochemical staining with cytokeratin 7 was positive, with cytokeratin 20 was negative, and was positive for uroplakin III and thrombomodulin.

CONCLUSION

The histologic appearance of malignant Brenner tumor is similar to that of transitional cell cancer of the ovary and transitional epithelium of the urinary bladder. Immunohistochemical staining of malignant Brenner tumor often demonstrates positivity for uroplakin III, thrombomodulin and cytokeratin 7 and negativity to cytokeratin 20. The mainstay of treatment is surgical resection, but the exact regimen and benefit of adjuvant therapy remain unknown.

Primary ovarian leiomyosarcoma associated with Brenner tumor

BACKGROUND

Primary ovarian leiomyosarcoma (POL) is rare. To the best of our knowledge, POL associated with a Brenner tumor has not been previously documented.

CASE

A case of POL associated with a Brenner tumor is reported. Although the poorly differentiated component of the tumor was negative for SMA, the presence of spindle cells in the higher differentiated component with fascicle arrangement and immunoreactivity for SMA and strong staining of a poorly differentiated component for desmin and vimentin established the diagnosis.

CONCLUSION

This case indicates that since malignant tumor cells may lose some antigen markers, thorough sampling and immunohistochemistry are necessary. EMA-immunopositivity only could not preclude the diagnosis of leiomyosarcoma.

Invasive lobular carcinoma of the breast diagnosed from an ovarian tumour

Invasive lobular carcinoma of breast is well known to be able to metastasise to unusual places, including the gastrointestinal and gynaecological tracts. However, it is very unusual for breast cancer to present in an ovarian Brenner tumour. This case highlights the diagnostic difficulties of patients presenting with unilateral ovarian masses, and the merits of thorough histological assessment of the entire pathological specimen despite the presence of one obvious pathological diagnosis.

Transitional cell tumors of the ovary: a compact group with a heterogeneous histological and immunophenotypical pattern

A small percentage of ovarian neoplasms are transitional cell tumors, which proves to be a distinct group with various histological and immunohistochemical patterns. In this study, 13 archived formalin-fixed paraffin-embedded samples of transitional cell tumors of the ovary have been assessed using standard HE stain and the indirect tristadial ABC peroxidase IHC method for 11 antibodies (CA125, CK7, CEA, EMA, MNF116, CK20, Vim, ER, PgR, PCNA, Ki-67). More than 50% were malignant Brenner tumors. CA125 was positive in all malignant tumors (of Brenner type and transitional cell carcinomas), but not in benign and borderline tumors, while CK7 was positive in approximately 70% of all cases. These two antibodies have shown a high sensitivity and low specificity, but do not correlate to each other. PCNA was positive in the study batch with a mean value of 40% and Ki-67 with a mean value under 25%. A direct correlation statistically significant has been noted between the aforementioned proliferation factors and the tumor grade (r = 0.4, p = 0.05). The other markers were unspecific, with low sensitivity and independently of the histopathological type.

p63 expression in ovarian tumours: a marker for Brenner tumours but not transitional cell carcinomas

AIMS

To investigate p63 expression in ovarian neoplasms.

METHODS AND RESULTS

Immunohistochemistry using an antibody that detects all p63 isoforms was performed on 103 primary ovarian neoplasms of different histological types. Diffuse nuclear immunoreactivity of p63 was demonstrated in the 17 benign and five borderline Brenner tumours. Only one of the six malignant Brenner tumours displayed p63 expression. p63 immunoreactivity was absent in all the ovarian transitional cell carcinomas (TCC), but was demonstrated extensively in TCCs of the urinary bladder. Besides focal p63 expression in epidermal basal cells of immature and mature teratomas, all other ovarian lesions were devoid of p63 expression. p63 expression was also demonstrated in cervical transitional cell metaplasia and Walthard cell nests of fallopian tubes.

CONCLUSIONS

Expression of p63 protein is apparently cell lineage specific and in ovarian neoplasms is confined to benign and borderline Brenner tumours. The loss of expression in malignant Benner tumours suggests a role for p63 in Brenner carcinogenesis. The distinct patterns of p63 expression in TCCs in the ovary and urinary bladder may help in their differential diagnosis.

Transitional Cell Carcinoma of the Endometrium Associated With Benign Ovarian Brenner Tumor

Transitional cell carcinoma of the endometrium (TCCE) is a subtype of endometrial carcinoma, characterized by a prominent papillary pattern, resembling the papillary carcinoma of the urothelium. This neoplasm is very rare, with only 13 cases reported in the international literature. In this paper, a new case of TCCE associated with benign ovarian Brenner tumor is described. This association is extremely rare, with only 1 other case reported. A review of the literature is performed to delineate the clinico pathologic features of this malignancy. Moreover, immunohistochemical and molecular studies are carried out in the effort to establish the phenotype and etiology of this rare neoplasm. The molecular study, by polymerase chain reaction (PCR) failing to reveal the presence of HPV DNA, demonstrates that neither the TCCE nor the ovarian Brenner tumor is caused by an HPV infection. The association of TCCE with benign ovarian Brenner tumor could be a coincidental event. Conversely, this finding could be the manifestation of a multicentric metaplastic process (neometaplasia), involving both the coelomic epithelium of the ovary and the Mullerian epithelium of the uterus, or the evidence of "field effect" that manifests differently at different anatomical sites. In our view, other cases of TCCE associated with ovarian Brenner tumor should be reported to confirm the last 2 hypotheses.

Three synchronized neoplasms of the female genital tract: an extraordinary presentation

INTRODUCTION

We report a case of unusual co-existence of multiple primary neoplasms of female genital tract.

CASE

A 62-year-old gravida 2, para 2 was referred with spotting and vaginal discharge for about 6 months. Fractionate curettage was performed and documented endocervical squamous cell carcinoma in situ. Subsequently total abdominal hysterectomy and bilateral salphingo-oophorectomy was performed. Final pathological report demonstrated cervical squamous cell carcinoma, right ovarian Brenner tumor, left ovarian granulosa tumor and endometrial polyps.

DISCUSSION

Multiple primary neoplasms of female genital tract is a well-recognized yet rare occurrence. Although the presented case is probably an incidental event, the pathogenesis of the neoplastic process affecting the tissues with different embryological origin needs further research and evaluation. It is important to distinguish multiple primary neoplasms from metastatic disease because of the fact that overall survival as well as treatment would vary considerably.

Bilateral Brenner tumor with endometrial adenocarcinoma in a postmenopausal woman

Brenner tumor is a rare ovarian neoplasm which is generally monolateral, more rarely bilateral, and often associated with endometrial disorders related to oestrogenic production. However, there is no considerable evidence that the possible oestrogenic production of this tumor may be the cause of endometrial disorders. A case of bilateral Brenner tumor with endometrial adenocarcinoma in a postmenopausal woman is presented and the features are briefly discussed, with the conclusion that hormone-producing Brenner tumors may exert their promoter effect on the development of endometrial carcinoma causing an imbalance in the oestrogen and progesterone ratio rather than producing a large amount of oestrogen.

Brenner tumors of the ovary: sonographic and computed tomographic imaging features

OBJECTIVE

The purpose of this study was to describe the sonographic appearance of ovarian Brenner tumors with computed tomographic (CT) correlation.

METHODS

Twenty-two female patients (age range, 32-78 years; mean, 58 years) with 25 ovarian Brenner tumors were identified from pathologic records from 1990 to 2005. Corresponding pathologic reports and images (17 sonographic and 14 CT) were reviewed independently.

RESULTS

Tumors ranged in size from 0.3 to 12 cm (mean, 2.5 cm); all were benign. Sixteen (64%) of 25 were found incidentally. Eight (36%) of 22 patients had a total of 12 associated benign ovarian neoplasms (1 was contralateral); 3 patients had bilateral Brenner tumors. Eight (47%) of 17 tumors were not seen on sonography, and 5 (36%) of 14 were not seen on CT. Of the tumors seen on imaging, most were solid (67% on sonography and 78% on CT). Four tumors appeared at least partially cystic, of which 3 had coexistent cystic ovarian lesions.

CONCLUSIONS

Brenner tumors are most often solid neoplasms found incidentally and frequently seen in association with other benign ovarian epithelial neoplasms.

Increasing expression of extracellular matrix metalloprotease inducer in ovary tumors: tissue microarray analysis of immunostaining score with clinicopathological parameters

Ovary cancer invasion is responsible for both local tissue destruction and distant metastasis. Invasion is largely mediated by matrix metalloproteases that are thought to be induced by tumor cell-derived extracellular matrix metalloprotease inducer (EMMPRIN) in surrounding fibroblasts. We hypothesized that EMMPRIN isoverexpressed in ovary tumors. Immunohistochemical analysis of EMMPRIN was performed in tissue microarrays of ovary neoplasms including 84 cases of serous adenocarcinoma, 23 cases of mucinous adenocarcinoma, 10 cases of endometrioid adenocarcinoma, 12 cases of yolk sac tumor, 12 cases of clear cell carcinoma, 8 cases of dysgerminoma, 8 cases of granulosa cell tumor, 6 cases of transitional cell carcinoma, and 6 cases of Brenner tumor. All malignant ovary tumors showed significant immunohistochemical expression of EMMPRIN. The EMMPRIN scores in malignant ovary tumors were significantly higher than their nontumor counterparts (313+/-28 for serous adenocarcinoma; 308+/-25 for mucinous adenocarcinoma; 187+/-19 for endometrioid adenocarcinoma; 265+/-23 for yolk sac tumors; 87+/-13 for clear cellcarcinoma; 126+/-15 for dysgerminoma; 243+/-26 for granulosa cell tumor; 87+/-16 for transitional cell carcinoma). The EMMPRIN score was significantly higher in serous adenocarcinomas than in serous adenomas and serous borderline tumors and was correlated with nodal stage. Our findings show for the first time that EMMPRIN is overexpressed in all malignant ovary tumors.

Increasing expression of serine protease matriptase in ovarian tumors: tissue microarray analysis of immunostaining score with clinicopathological parameters

Matriptase is a type II transmembrane serine protease expressed by cells of surface epithelial origin, including epithelial ovarian tumor cells. Matriptase cleaves and activates proteins implicated in the progression of cancer and represents a potential prognostic and therapeutic target. The aim of this study was to examine the expression of matriptase in ovarian tumors and to assign clinicopathological correlations. Immunohistochemical analysis of matriptase was performed in tissue microarrays of 164 ovarian neoplasms including 84 serous adenocarcinomas, 23 mucinous adenocarcinomas, 10 endometrioid adenocarcinomas, six yolk sac tumors, 12 clear cell carcinomas, six dysgerminomas, eight granulosa cell tumors, four transitional cell carcinomas, five fibromas, and six Brenner tumors. All ovarian tumors except the fibromas and Brenner tumors showed significant expression of matriptase. The matriptase scores were significantly higher in the tumors than in their nontumor counterparts (304+/-26 for serous adenocarcinoma; 361+/-28 for mucinous adenocarcinoma; 254+/-17 for endometrioid adenocarcinoma; 205+/-19 for yolk sac tumor; 162+/-16 for clear cell carcinoma; 109+/-11 for dysgerminoma; 105+/-9 for granulosa cell tumor; and 226+/-18 for transitional cell carcinoma). Matriptase scores in serous adenocarcinoma were correlated with TNM stage and FIGO stage. Our findings demonstrate for the first time that matriptase is overexpressed in many malignant ovarian tumors. It may be a novel biomarker for diagnosis and treatment of malignant ovarian tumors.

Expression and subcellular localization of maspin in human ovarian epithelial neoplasms: correlation with clinicopathologic features

BACKGROUND AND PURPOSE

Maspin is an inhibitor of serine proteinases with tumor suppressor activity that is down-regulated in breast and prostate cancer, but overexpressed in pancreatic carcinoma. However, there were very few published data regarding the role of maspin in ovarian carcinoma. The aim of the present study was to evaluate maspin expression in ovarian epithelial neoplasms and correlate its expression with some clinicopathologic parameters.

MATERIAL AND METHODS

Seventy eight paraffin embedded ovarian specimens from patients with ovarian epithelial neoplasms comprised the material of this study. They included 18 benign, 14 low malignant potential (LMP) and 46 malignant epithelial ovarian neoplasms, in addition to seven specimens from normal ovarian tissues as a control.

RESULTS

Immunohistochemical study of maspin expression using streptavidin biotin immunoperoxidase method revealed that, normal ovarian surface epithelium did not express maspin as well as benign serous and mucinous ovarian epithelial neoplasm. However, all benign Brenner ovarian tumors were maspin positive. On the other hand, 57.14% of LMP tumors showed weak maspin expression and 63% of malignant ovarian epithelial tumors showed maspin expression with 39.1% over expression. The two malignant Brenner tumors studied were maspin negative. There was a trend for maspin expression with high grade, high stage, bilateral tumors and tumors with metastasis. Tumors that showed maspin over-expression showed higher mitotic index (MI) (p=0.02). Invasive cancers were more likely to have predominantly cytoplasmic staining compared to LMP tumors.

CONCLUSION

Maspin was expressed in a substantial proportion of ovarian tumors with poor prognostic parameters. These results may offer new insights regarding the role of maspin in ovarian cancer that may also impact diagnosis and treatment strategies. Moreover, variation in maspin expression between Brenner tumor and other epithelial surface ovarian tumors may indicate that the different histological types probably represent distinct disease entities and involve different molecular pathways.

Left ovarian Brenner tumor

Ovarian Brenner tumors are uncommon neoplasms of the ovary, representing approximately 2% of all ovarian neoplasms. Nowadays there is general agreement that Brenner tumors are derived from the surface epithelium of the ovary or the pelvic mesothelium through transitional cell metaplasia. Association with other surface-derived neoplasms, either in the ipsilateral or contralateral ovary, is reported in 30% of the cases. We report a case of benign ovarian Brenner tumor and discuss the typical features on magnetic resonance imaging (MRI) and computed tomography (CT) scan as well as the differential diagnosis.