Oncological and endocrinological outcomes for children and adolescents with testicular and ovarian sex cord-stromal tumors. Results of the TGM13 National Registry

RATIONALE

Sex cord-stromal tumors (SCST) are hormonally active and rare. The aim was to describe their endocrinological presentation and outcomes.

METHOD

Patients (< 19 years) registered in the TGM13 registry between 2014 and 2021 for SCST were selected.

RESULTS

Sixty-three ovarian SCST (juvenile granulosa tumor (JGT) n = 34, Sertoli-Leydig cell tumor (SLCT) n = 17, other SCST n = 12) were included. Median age was 13.1 years (0.4-17.4). Germline DICER1 pathogenic variant was present in 9/17 SLCT. Sixty-one were FIGO stage I (IC n = 14). Adjuvant chemotherapy was administered for 15. Seven had recurrence (FIGO IA n = 3, IX n = 2, III n = 2), leading to one death. With a median follow-up of 42 months (2.5-92), the 3-year progression-free survival (PFS) was 89% (95% CI 76%-95%). Median age was 6.4 years (0.1-12.9) among the 15 testicular SCST (Leydig cell tumor n = 6, JGT n = 5, Sertoli cell tumor n = 3, mixed SCST n = 1). Tumor-nodes-metastases (TNM) stage was pSI in 14. Eight underwent a tumorectomy, 7 an orchiectomy. None experienced recurrence. Endocrinological data were reviewed for 41 patients (18 prepubescent). Endocrine symptoms were present at diagnosis in 29/34 females and 2/7 males (gynecomastia). After a median follow-up of 11 months, 15 patients had persistent endocrine abnormalities: gynecomastia/breast growth (2 males, 1 prepubescent female), precocious/advanced puberty (4 prepubescent females), and hirsutism/menstruation disorders/voice hoarseness/hot flashes (8 pubescent females). The mean height at the last follow-up was within normal ranges (+0.3 standard deviation).

CONCLUSIONS

SCSTs have a favorable prognosis. Tumorectomy appears safe with testicular primary. Endocrinological disorders, common at diagnosis, may persist warranting endocrinological follow-up.

Multicentric adrenocorticotropic hormone -producing steroid cell tumor of the fallopian tube & broad ligament in a 15 year old girl

Steroid cell tumors occur usually in the ovaries with very few reported cases of extra-ovarian origin. Our patient was a fifteen year old female, complaining from secondary amenorrhea and voice deepening. Values of serum cortisol, DHEA, FSH & LH were normal. Serum Testosterone was elevated while ACTH-pm was markedly elevated. MRI described bilateral solid para-ovarian masses. Exploration revealed two bilateral tubal extraluminal cysts & a right broad ligament cyst which were all excised. Pathological examination led to the diagnosis of steroid cell tumor. Serum testosterone & ACTH returned to normal levels after surgery with subsequent regression of the virilizing symptoms. We can conclude that extra-ovarian steroid cell tumors are extremely rare. They are usually presented with virilizing symptoms and hormonal abnormalities. Surgery is the main line of treatment.

MicroRNA expression profiles in non‑epithelial ovarian tumors

Ovarian germ cell tumors (OGCTs) and sex cord stromal tumors (SCSTs) are rare gynecologic tumors that are derived from germ and stromal cells, respectively. Unlike their epithelial counterparts, molecular pathogenesis of these tumor types is still poorly understood. Here, we characterized microRNA (miRNA) expression profiles of 9 OGCTs (2 malignant and 7 benign) and 3 SCSTs using small RNA sequencing. We observed significant miRNA expression variations among the three tumor groups. To further demonstrate the biological relevance of our findings, we selected 12 miRNAs for validation in an extended cohort of 16 OGCTs (9 benign and 7 malignant) and 7 SCSTs by reverse transcription-quantitative polymerase chain reaction. Higher expression of miR‑373‑3p, miR‑372‑3p and miR‑302c‑3p and lower expression of miR‑199a‑5p, miR‑214‑5p and miR‑202‑3p were reproducibly observed in malignant OGCTs as compared to benign OGCTs or SCSTs. Comparing with benign OGCTs, miR‑202c‑3p and miR‑513c‑5p were more abundant in SCSTs. Additionally, we examined Beclin 1 (BECN1), a target of miR‑199a‑5p, in the clinical samples using western blot analysis. Our results show that BECN1 expression was higher in malignant OGCTs than benign OGCTs, which is concordant with their lower miR‑199a‑5p expression. This study suggests that these miRNAs may have potential value as tumor markers and implications for further understanding the molecular basis of these tumor types.

Accessory ovarian steroid cell tumor producing testosterone and cortisol: A case report

RATIONALE

An accessory ovary is a rare structure containing normal ovarian tissue, which has a direct or ligamentous connection with a normal and eutopic ovary.

PATIENT CONCERNS

In the study, we reported a 46-year-old woman presented with secondary amenorrhea and virilization symptoms for 1 year.

DIAGNOSES

Endocrine evaluation revealed slightly elevated serum cortisol, extremely elevated 24-hour urinary-free cortisol and serum testosterone. Clinical assessment exhibited a large solid mass with heterogeneous enhancement in the left adnexauteri compounded with hypercortisolism and hyperandrogenemia. An accessory ovarian tumor attached to the infundibulum of the left fallopian tube was found, and a separate normal ovary was present on the same side.

INTERVENTIONS

The patient underwent a left adnexectomy.

OUTCOMES

During surgery, a 12 cm × 8 cm, gray-red, and well-circumscribed solid mass was be identified. The tumor had ligamentous attachment with the infundibulum of left fallopian tube. The sectioned surface was gray-brown, lobulated and did not exhibit either significant necrosis or hemorrhage. Pathological findings demonstrated that tumor cells had small round nuclei, mild atypia, no mitosis were arranged in a diffuse pattern of columns or nests separated by a rich vascular network and no crystals of Reinke were found. It was diagnosis ovarian steroid cell tumor (NOS) without malignant behavior by immunohistochemical staining. The patient was finally diagnosed as accessory ovarian steroid. The patient was discharged from the hospital on the seventeenth day after surgery. During postoperative follow-up, the first postoperative menstrual flow recovered and blood pressure regained 1 month after surgery. Furthermore, her Cushing syndrome regressed and hirsutism disappeared completely 4 months after surgery cell tumor.

LESSONS

It is vitally important to establish a final diagnosis according to the clinical manifestations and laboratory values in addition to imaging studies and laparoscopic examination of a rare coexistence of hyperandrogenemia and Cushing syndrome based on the accessory ovarian pathology.

Sex cord stromal tumours of the ovary, experience at Shifa International Hospital Islamabad

This descriptive study was carried out at Pathology Department, Shifa International Hospital from 2007 to 2016; all sex cord stromal tumours diagnosed during this time period were included. Epithelial, germ cell and metastatic tumours were excluded from the study. A total of 1254 Ovarian tumours were brought to Shifa of which47 (4%) were labeled as sex cord stromal tumours. Of these 36( 76 %)were granulosa cell tumour (adult33, juvenile3), 7 were labeled as sertoli leydig cell tumours (15%), 3 as thecoma/ fibroma group (7%)and only one case was labeled as microcystic stromal tumour of the ovary (2%). Overall age range for sex cord stromal tumours was 42 (12-71). Immunohistochemistry was done in 41 out of 47 cases. Sex cord stromal tumours of the ovary are rare tumours comprising 4% of the total. Adult Granulosa cell tumour is the commonest tumour seen in our study.

Sclerosing stromal tumor of the ovary in a perimenopausal woman: a case report

Sclerosing stromal tumor (SST) is a rare ovarian neoplasia deriving from the sex cord stromal tumor, which occurs usually in the sec- ond and third decades of life. However, the authors report a 46-year old multiparous woman who presented with a cystic-solid left pelvic mass, a large amount of ascites, and elevated serum CA-125, all suggesting a malignant tumor. Surgery was performed and final histopathological diagnosis of the specimen was diagnosed with SST. The authors herein report an extremely rare case of SST with a cystic-solid pelvic mass and a large amount of ascites, which is useful to demonstrate the possibility of SST in multiparous woman.

Sclerosing stromal tumour of the ovary: two case reports

Sclerosing stromal tumours are rare benign ovarian neoplasms of the sex cord stromal that occur predominantly in the second and third decades of life. Herein, we report two cases of sclerosing stromal tumour of the ovary. The two patients were 16 and 45 years old and both presented with pelvic pain. Ultrasonography demonstrated a heterogeneous solid mass of the left and right ovary, respectively, with some cystic foci in the second tumour. Laboratory tests including tumour markers and serum hormonal assays were normal in both cases. The two patients underwent left and right salpingo-oophrectomy, respectively. Microscopically, the tumours showed a pseudolobular pattern with cellular areas separated by oedematous and collagenous areas. The cellular areas were richly vascularized, with a hemangiopericytic pattern, and were composed of an admixture of theca-like and spindle-shaped cells. Immunohistochemical studies showed that the tumour cells were positive for smooth muscle actin, inhibin and vimentin, but negative for cytokeratin. The final pathological diagnosis was sclerosing stromal tumour. Postoperative course was uneventful for both patients.

Development of 99mTc-5-fluorouracil as a potential tumor diagnostic agent

5-Fluorouracil is a well know drug for chemotherapy of various types of cancer. In the present study, we radiolabeled 5-fluorouracil with (99m)Tc for a diagnostic study of cancer. After successful labeling of the drug we performed an animal study to evaluate the potential of this radiopharmaceutical as a tumor diagnostic agent. The results showed 98.1 ± 1.2% labeling efficacy of 5-fluorouracil with (99m)Tc. The in vitro stability of the radiolabeled drug at room temperature at 4 hr of post-labeling was >96.5 ± 0.4%. The binding of the radiolabeled drug with plasma proteins was 66.6 ± 3%. Partition coefficient results showed that this drug is hydrophilic in nature. Biodistribution study in rabbit models displayed faint uptake in liver. Both kidney and bladder were prominent as excretory route of the labeled drug. Bioevaluation was performed in Swiss Webster mice having naturally developed tumor. Mice were dissected, uptake of drug in various organs was studied and results showed prominent uptake in liver and tumor. Tumor was further investigated by histopathological study.

GATA-4 and FOG-2 expression in pediatric ovarian sex cord-stromal tumors replicates embryonal gonadal phenotype: results from the TREP project

AIM

GATA proteins are a family of zinc finger transcription factors regulating gene expression, differentiation and proliferation in various tissues. The expression of GATA-4 and FOG-2, one of its modulators, was studied in pediatric Sex Cord-Stromal tumors of the ovary, in order to evaluate their potential role as diagnostic markers and prognostic factors.

MATERIALS AND METHODS

Clinical and histological data of 15 patients, enrolled into the TREP Project since 2000 were evaluated. When available, immunostaines for FOG-2, GATA-4, α-Inhibin, Vimentin and Pancytokeratin were also analyzed.

RESULTS

In our series there were 6 Juvenile Granulosa Cell Tumors (JGCT), 6 Sertoli-Leydig Cell Tumors (SLCT), 1 Cellular Fibroma, 1 Theca Cell Tumor and 1 Stromal Sclerosing Tumor (SST). Thirteen patients obtained a complete remission (CR), 1 reached a second CR after the removal of a metachronous tumor and 1 died of disease. Inhibin was detectable in 11/15, Vimentin in 13/15, Pancytokeratin in 6/15, GATA-4 in 5/13 and FOG-2 in 11/15. FOG-2 was highly expressed in 5/6 JGCT, while GATA-4 was weakly detectable only in 1 of the cases. SLCT expressed diffusely FOG-2 (4/6) and GATA-4 (3/5). GATA-4 and FOG-2 were detected in fibroma and thecoma but not in the SST.

CONCLUSIONS

Pediatric granulosa tumors appear to express a FOG-2/GATA-4 phenotype in keeping with primordial ovarian follicles. High expression of GATA-4 does not correlate with aggressive behaviour as seen in adults, but it is probably involved in cell proliferation its absence can be associated with the better outcome of JGCT. SLCTs replicate the phenotype of Sertoli cells during embryogenesis in normal testis. In this group, the lack of expression of FOG-2 in tumors in advanced stages might reveal a hypothetical role in inhibiting GATA-4 cell proliferation pathway. In fibroma/thecoma group GATA-4 and FOG-2 point out the abnormal activation of GATA pathway and might be involved in the onset of these tumors.

CD10 Expression in Pure Stromal and Sex Cord-Stromal Tumors of the Ovary

CD10 has been recently advocated as a good immunohistochemical marker for endometrial stromal tumors. Metastatic endometrial stromal tumors to the ovary and primary endometrioid stromal sarcomas may show overlapping histological features with pure stromal and sex cord-stromal tumors (SCSTs). We investigated CD10 expression in a large series of pure stromal and SCSTs of the ovary to ascertain whether CD10 may aid in this differential diagnosis. Archival material from 11 fibromas, 10 thecomas, 10 sclerosing stromal tumors (SSTs), 10 adult granulosa cell tumors (AGCTs), 4 luteinized AGCTs, 9 juvenile granulosa cell tumors (JGCTs), 9 Sertoli cell tumors, 9 Sertoli-Leydig cell tumors, 11 sex cord tumors with annular tubules, 10 steroid cell tumors (StCTs), and 8 fibrosarcomas of the ovary were immunostained for CD10. The percentage of cells stained (<5%, 5%-39%, 40%-75%, and >75%) and intensity of staining (1+, 2+, 3+) were evaluated. CD10 was expressed in 7 of 10 thecomas (4 with 5%-75% and mostly 1+), 9 of 10 SSTs (7 with 5%-39% + cells, mostly 1+), 9 of 10 AGCTs (<5%-39%, four 1+, five 2+), 1 of 4 luteinized AGCTs (<5% and 1+), 8 of 9 JGCTs (mostly <5% to 39% and +1), 4 of 9 Sertoli cell tumors (either focal or >75% with variable intensity), 4 of 9 Sertoli-Leydig cell tumors (mostly <10% with variable staining), with the Leydig cells being positive in only 1 tumor (1+ and <5%), and 7 of 10 StCTs (4 tumors with more than 75% + cells, from 1+ to 3+). All fibromas, all but 1 fibrosarcoma (<5% and 1+), and all sex cord tumors with annular tubules were CD10 negative. CD10 expression was frequently seen in StCTs, SSTs, and thecomas of the ovary, although the latter 2 categories usually showed only faint immunoreactivity. In conclusion the frequency and intensity of CD10 immunoreactivity in pure stromal and sex cord-stromal ovarian tumors are low and contrast with the typical strong and diffuse immunostaining seen in endometrial stromal tumors; however, faint CD10 positivity is consistent with the diagnosis of ovarian SCST. Steroid cell tumors are often positive for CD10, but these tumors do not pose problems in differential diagnosis with endometrial stromal tumors. CD10 may play a useful role in aiding the differential between endometrial stromal tumors in the ovary and SCST and stromal tumors.

[Ovarian steroid cell tumor, not otherwise specified: a clinicopathologic study]

OBJECTIVE

To study the clinicopathologic features, diagnostic criteria, differential diagnosis and treatment options of ovarian steroid cell tumor, not otherwise specified (NOS).

METHODS

Light microscopy and immunohistochemical study was carried out in 8 cases of ovarian steroid cell tumor, NOS. The literature was reviewed.

RESULTS

The 7 cases of benign ovarian steroid cell tumor, NOS were composed mainly of polygonal cells with granular eosinophilic cytoplasm and larger cells with vacuolated cytoplasm. They resembled the architecture of normal adrenal gland, with formation of cell nests and trabeculae. The single case of malignant ovarian steroid cell tumor had evidence of significant cellular pleomorphism, haemorrhage and coagulative tumor necrosis. The mitotic count measured about 7 per 10 high-power fields. Immunohistochemical study showed that the tumor cells expressed calretinin and alpha-inhibin. Differential diagnosis included oxyphilic granulosa cell tumor, thecoma, Sertoli cell tumor and clear cell carcinoma. The treatment options of benign ovarian steroid cell tumor, NOS was local excision or ipsilateral salpingo-oophorectomy, while the malignant counterpart should be treated with a combination of surgery and chemotherapy, including administration of GnRH agonist.

CONCLUSIONS

Ovarian steroid cell tumor, NOS, is the most common type of ovarian steroid cell tumors. Most of which are associated with a benign clinical outcome. Immunohistochemistry is an important adjunct for diagnosis. The treatment options of ovarian steroid cell tumor, NOS depend on its malignant potential.

CD56 Is a Sensitive and Diagnostically Useful Immunohistochemical Marker of Ovarian Sex Cord-Stromal Tumors

Ovarian sex cord-stromal tumors comprise a heterogeneous group of neoplasms with wide morphological diversity, and they can be mistaken for a variety of other tumors. Some types, including granulosa and Sertoli cell tumor, may be confused with a neuroendocrine neoplasm. CD56 is a widely used neuroendocrine marker with a high sensitivity for neuroendocrine tumors and is commonly used as part of a panel to distinguish between a neuroendocrine neoplasm and other tumors in the differential diagnosis. In this study, we investigate CD56 staining in ovarian sex cord-stromal tumors. CD56 staining has not previously been studied in this group of neoplasms. We stained a large series of ovarian sex cord-stromal neoplasms (n = 85) with CD56. Neoplasms studied were adult granulosa cell tumor (n = 40), juvenile granulosa cell tumor (n = 8), Sertoli cell tumor (n = 1), Sertoli-Leydig cell tumor (n = 14), Leydig cell tumor (n = 2), steroid cell tumor, not otherwise specified (n = 2), sclerosing stromal tumor (n = 1), sex cord tumor with annular tubules (n = 2), and fibroma (n = 15). Three uterine tumors resembling ovarian sex cord tumor were also studied. Nonneoplastic ovaries, including 3 cases of pregnancy-related granulosa or Sertoli cell proliferation, were also included. In nontumorous ovaries, granulosa cells of follicular and corpus luteum cysts were consistently negative. The normal ovarian stroma was diffusely positive, as were the 3 pregnancy-related proliferations. All sex cord-stromal tumors except one were positive with CD56; staining ranged from focal to diffuse but was usually diffuse involving more than 50% of tumor cells. Staining was usually membranous with weaker cytoplasmic positivity. CD56 immunoreactivity is almost universal in ovarian sex cord-stromal tumors of all the major morphological types and is of no value in distinguishing a sex cord-stromal and a neuroendocrine neoplasm. Since CD56 is an extremely sensitive marker of ovarian sex cord-stromal tumors, it may be useful in the diagnosis of this group of neoplasms, especially in cases which are alpha inhibin or calretinin negative, and in distinguishing these from mimics which are CD56 negative.

Recurrent gynandroblastoma of ovary-A case report: a molecular and immunohistochemical analysis

Gynandroblastoma is a rare ovarian tumor that is composed of both Sertoli cells and granulosa cells. Only 23 cases have been reported in the literature, and recurrence has never been described. We report the first case of a recurrent gynandroblastoma along with its molecular analysis and immunohistochemical studies. A 49-year-old Gravida 0 woman with a 10-year prior diagnosis of ovarian-mixed stromal tissue tumor (well-differentiated Sertoli cell and granulosa cell tumor) and staging laparotomy, presented now with a retroperitoneal mass and an elevated inhibin level. CT scan was suspicious for recurrence. The patient had no prior adjuvant therapy. The histomorphological features of the recurrent tumor had both Sertoli cell and granulosa cell tumor. The molecular analysis of both primary and recurrent tumor showed minor genetic instability in the 17q12.2 gene locus with no dedifferentiation or progression, which is consistent with a low-grade tumor. The immunohistochemical staining profile showed positivity for CD99, inhibin, calretinin, and vimentin; focal positivity for cytokeratin AE1/AE3 and negative for EMA and melan-A. All the previously mentioned immunostainings support the diagnosis. We report the first case of a recurrent gynandroblastoma 10 years after initial presentation along with its molecular analysis and immunohistochemical studies.

Mixed germ cell sex cord–stromal tumors of the testis and ovary. Morphological, immunohistochemical, and molecular genetic study of seven cases

We present the morphological, immunohistochemical, and molecular genetic features of three cases of testicular and four cases of ovarian mixed germ cell sex cord-stromal tumors (MGSCT). The germ cells in the testicular MGSCTs morphologically differed from those in classical seminomas by lacking the typical "square off" quality of the nuclei. In contrast to the nuclei in classical seminomas, their size in testicular MGSCTs was smaller and nucleoli were inconspicuous and the cytoplasm was Periodic Acid-Schiff (PAS) negative. Quite on the contrary, the variability in the size of the nuclei of the germ cells in the testicular MGSCTs was more similar to that seen in the germ cells of spermatocytic seminomas. Immunohistochemically, the germ cells of MGSCTs in one case reacted positively with antibody to AE1-AE3 by paranuclear dot-like or rodlike positivity. All three testicular MGSCTs had a negative reaction with the rest of antibodies, including placental alkaline phosphatase (PLAP), OCT4, and c-kit protein. Ovarian MGSCT in our series differed from the testicular lesions in both the germ cell component and the sex cord component. The germ cells in all four ovarian cases had cytomorphological and immunohistochemical features identical to those in classical seminomas/dysgerminomas. They possessed the typical "square off" quality of the nuclei, which were much more blastic, with more mitoses compared with the testicular tumors in our series, and they were PLAP (4/4), OCT4 (4/4) and c-kit protein (3/4) positive immunohistochemically. The cytoplasm of the germ cells in ovarian neoplasms contained PAS positive glycogen. Germ cells in one ovarian MGSCTs showed amplification of 12p. All other germ cells were negative for amplification of 12p. All five successfully analyzed cases showed no mutation in all studied exons and exon-intron junctions in c-kit and PDFGRA genes.

Uterine tumors resembling ovarian sex cord tumors are polyphenotypic neoplasms with true sex cord differentiation

In this study, we present the clinicopathologic features and immunophenotypic characteristics of five cases of uterine tumors resembling ovarian sex cord tumors and three cases of endometrial stromal tumors with sex cord-like elements, with emphasis on immunohistochemical markers of sex cord differentiation. The mean patient age was 42 years (range 19-69 years), and vaginal bleeding was the most common clinical presentation. The tumors were usually polypoid masses arising in the uterine fundus, with a mean tumor size of 6.7 cm. Sex cord patterns in uterine tumors resembling ovarian sex cord tumors, including anastomosing cords, trabeculae, small nests, tubules, and in one case, a striking retiform architecture with Leydig-like cells, comprised from 70 to 100% of the tumor volume. All uterine tumors resembling ovarian sex cord tumors were positive for two or more markers of sex cord differentiation; all five cases showed strong immunoreactivity for calretinin, with coexpression of CD99 (four cases), Melan-A (two cases), and inhibin (two cases). Endometrial stromal tumors with sex cord-like elements were less frequently positive for markers of sex cord differentiation, with each case positive for one marker (calretinin, two cases; CD99, one case). In addition, all eight cases were frequently positive for cytokeratin, CD10, vimentin, estrogen receptor, and progesterone receptor; desmin immunoreactivity, when present, was limited to minor foci of smooth muscle. Overall, the morphologic and immunohistochemical findings in uterine tumors resembling ovarian sex cord tumors strongly support that these unusual uterine tumors are polyphenotypic neoplasms with true sex cord differentiation.

Pediatric sex cord-stromal tumor with composite morphology: a case report

A 12-year-old female with developmental delay/mental retardation and a family history of gynecologic cancers presented with nonspecific abdominal complaints and was found to have a 4.5-kg, 25- x 23- x 15-cm pelvic mass with solid and cystic components and associated retroperitoneal and mesenteric lymphadenopathy. Laboratory studies revealed increased serum levels of CA-125 and inhibin B. Histologically, the tumor exhibited several different morphologic appearances including adult granulosa cell tumor, juvenile granulosa cell tumor (with areas of marked atypia), and Sertoli cell tumor. Immunohistochemically, the tumor was positive for calretinin, MIC-2 (CD99), S100 protein, PGP 9.5, and neuron-specific enolase. Electron microscopy of the Sertoli cell tumor-like areas showed Charcot-Bottcher filaments, a distinguishing feature of Sertoli cells. Together, these findings supported a diagnosis of mixed sex cord-stromal tumor including granulosa cell tumor of adult and juvenile types and intermediate- to high-grade Sertoli cell tumor, with large areas of markedly atypical sex cord-stromal tumor.

Uterine tumour resembling an ovarian sex cord tumour

Endometrial stromal sarcomas account for 0.25% of all uterine malignancies. These tumours were originally divided into low grade and high grade stromal sarcomas, but the recent World Health Organisation classification (2003) recognises low grade stromal sarcoma and undifferentiated endometrial sarcoma. Low grade sarcomas may exhibit other forms of differentiation, including smooth muscle and sex cord differentiation. In the latter form, the tumour contains epithelial-like or sex cord-like elements often with epithelioid appearance, arranged in nests, cords, trabeculae, solid, or tubular structures. If this element predominates, the tumour is considered to be a uterine tumour resembling ovarian sex cord tumour, and may cause diagnostic difficulties. This case report describes the histological and immunohistochemical features of a uterine stromal sarcoma showing exclusively a pattern reminiscent of ovarian sex cord tumour.

Role of insulin in the progression of ovarian sex cord stromal tumors in rats

PURPOSE

This study examined the effect of insulin on sex cord stromal tumors in the rat.

METHODS

Sex cord stromal tumors were induced by transplantation of ovaries under the splenic capsule of ovariectomized rats (Lewis-inbred). These tumors were then transplanted into new inbred rats. Hyperglycemic conditions were induced by treatment with streptozotocin (STZ, which selectively destroyed pancreatic islet cells) and hypoglycemic conditions by treatment with a subcutaneously implanted insulin pump (Alzet). The animals were killed 28, 56, and 84 days later. Tumor growth, animal weight, food and water consumption, and serum concentrations of glucose, FSH, LH, and estradiol were measured.

RESULTS

Treatment with STZ and insulin with osmotic Alzet pumps induced continuous hypoglycemic and hyperglycemic conditions, respectively. No significant influence of the hypoglycemic or hyperglycemic status on tumor growth was measured during the first 28 and 56 days. Eighty-four days after transplantation and substitution of 1 or 2 IU/100 g body weight/d insulin, there was a significant stimulation of tumor growth (2.2-fold and 2.7-fold, respectively). In hyperglycemic animals (treated with STZ), no influence on tumor growth was found in comparison with the controls.

CONCLUSION

This study confirms that hyperinsulinemic conditions contribute to the progression of tumors.

The utility of calretinin, inhibin, and WT1 immunohistochemical staining in the differential diagnosis of ovarian tumors

Calretinin has been proposed as a novel marker of ovarian sex cord-stromal tumors (SCST); this study aims to determine whether calretinin can complement or supplant the established utility of inhibin in the differential diagnosis of SCST. WT1 has been shown to be expressed in ovarian serous, but not mucinous neoplasms; its expression in a variety of ovarian tumors is also examined. Formalin-fixed, paraffin-embedded archival tissues from 111 primary ovarian tumors were analyzed with commercially available antibodies using semi-automated immunohistochemistry. Results were graded on a 4-tiered scale with staining of more than 0 but less than 5% of cells considered focal. Of 27 SCST, 56% were calretinin and 56% inhibin positive overall; 90% of granulosa cell tumors, 57% of Sertoli-Leydig cell tumors, 33% of thecomas, and 14% of fibromas were calretinin positive. Inhibin was expressed in 60% of granulosa cell tumors, 71% of Sertoli-Leydig cell tumors, 43% of fibromas, and 33% of thecomas. Of 35 surface epithelial tumors (SET), 8% of serous papillary tumors were calretinin positive, whereas 8% of serous papillary tumors and 13% of poorly differentiated carcinomas expressed inhibin. WT1 was expressed in 29% of all endometrioid carcinomas, 10% of borderline mucinous tumors, and no mucinous carcinomas; however, most of the other SETs were positive (77% serous papillary and 88% poorly differentiated carcinomas). Among the SCST, WT1 stained only granulosa cell tumors (75%), though often weakly or variably. Calretinin has only slightly greater sensitivity (76% versus 65%) and equal specificity to inhibin (92%) in the differential staining of granulosa or Sertoli-Leydig cell tumors, that is, nonstromal SCST. Hence, calretinin cannot replace but could complement inhibin as part of an immunohistochemical panel used for diagnostically challenging SCST. Although WT1 should be reliably positive in non-mucinous SET, staining of granulosa cell tumors and lack of expression in a sizable subset of endometrioid carcinomas may confound interpretation.

[Ovarian tumors with endocrine function]

OBJECTIVE

To analyze the clinicopathological features of ovarian tumors with endocrine function.

METHODS

Twenty-four cases of ovarian tumor with endocrine manifestation were collected from the hospital. Their clinical presentation and histopathologic features were reviewed, along with a panel immunohistochemistry stainings (EnVision method). The antibodies were AE1/AE3, epithelial membrane antibody (EMA), alpha-inhibin, calretini and smooth myoglobin (SMA).

RESULTS

The main clinical endocrinological manifestations were related to an excess production of sex steroids. Histologically, the principle histological subtype of these tumors was ovarian sex cord-stroma tumors, including 13 cases ovarian type (8 granulosa cell tumors, 2 thecofibromas, 3 sclerosing stromal tumors), 7 cases testicular type (1 sertoli cell tumors, 5 sertoli-Leydig cell tumors, 1 Leydig cell tumor, and 2 cases of steroid cell tumor (NOS). Another 2 cases were ovarian epithelial tumors. Grossly, 50% (11/22) ovarian sex cord-stromal tumors were less than 5 cm in diameter. However, 4 tumors were quite larger, up to 18 cm in diameter. Most of these tumors were solid or solid-cystic and their cut surfaces were brown, pink, yellow or grey in color. The 2 primary ovarian epithelial tumors were larger, being 12 cm and 14 cm in diameter, respectively. Immunohistochemically, ovarian sex cord-stromal tumors showed positive staining for alpha-inhibin in all cases (22/22) and for calretinin in majority cases (18/22), and that the intensity of reactivity correlated with the degree of tumor differentiation. The non-neoplastic, luteinized stromal cells in 2 ovarian primary epithelial tumors also showed positive staining. Five cases of fibrothecomas and sclerosing stroma tumors were all positive for SMA. Although 6 of the 22 ovarian sex cord-stromal tumors were AE1/AE3 positive, all were EMA negative.

CONCLUSIONS

Most endocrinological syndromes in ovarian neoplasia reflect an overproduction of sex steroids, but the clinical manifestations do not correlate with the tumor histological subtypes. Most functional ovarian tumors are sex cord-stromal tumors and are usually of small to medium in size, but few are larger or giant. The size of the tumor does not correlate with the duration and the degree of clinical manifestations. Ovarian tumors of non-sex cord-stromal type may also be clinically functional. The immunohistochemical results suggests that alpha-inhibin and/or calretinin expression are useful markers in support of a diagnosis of sex cord-stromal tumor of the ovary. Although some of these tumors are AE1/AE3 positive, EMA negativity may be useful for the differential diagnosis with epithelial ovarian tumors.

Sulfatides in ovarian tumors: clinicopathological correlates

OBJECTIVES

To investigate the expression of sulfatides in the tissue homogenates of malignant ovarian tumors, benign ovarian tumors, and control tissues and to study the relation between this marker and other clinico-pathological criteria such as the tumor type, grade of differentiation, surgical stage and ovulatory years.

DESIGN

Cross-sectional study.

SETTING

Department of Obstetrics and Gynecology and Department of Biochemistry, Assuit university hospital.

SUBJECTS

Forty-six patients had malignant ovarian tumors. Sixteen patients had benign ovarian neoplasm. Thirty patients, with normal ovaries, represented the control group.

METHODS

A sample of the tumor or from the normal ovary (the control group) was sent for histopathological and biochemical examination. Sulfatides were measured by a rapid and sensitive spectrophotometric method.

RESULTS

There was a significant rise in benign tumors [median and range 43 (38-53)], than in the control group, 21 (18-31), P-value = 0.000. In malignant tumors, the median value of sulfatides was significantly higher than in benign tumors [127 (71-193), P-value = 0.000]. Sulfatides were significantly higher in patients with more ovulatory years and tumors of advanced stages (stage III/IV) and poor differentiation.

CONCLUSIONS

Sulfatides may play a role in the pathogenesis of benign and malignant ovarian tumors. It may also predict advanced stages in patients who are apparently early stage. It is also a candidate to study of their association with response to chemotherapy.

A critical appraisal of the value of immunohistochemistry in diagnosis of uterine neoplasms

In recent years there have been a plethora of publications regarding the value of immunohistochemical studies in diagnosis in gynecological pathology. In many instances, papers are published initially that suggest that a certain antibody or panel of antibodies is of value in the diagnosis of a particular neoplasm and in the distinction of this from mimics. However, this is usually quickly followed by other studies that somewhat contradict these findings. The aim of this review is to present a critical appraisal of the value of immunohistochemical studies in the diagnosis of uterine neoplasms with emphasis on the recent literature. It is stressed that immunohistochemistry is necessary in relatively few cases and a knowledge of the potential immunoreactivity of utilized antibodies is required. With regard to endometrial carcinoma, topics discussed in this review include antibodies of value in the distinction between type 1 and type 2 carcinoma, in the characterization of focal serous proliferations in endometrial polyps and non-polypoid endometrium, in the sometimes problematic distinction between an endometrial and an endocervical adenocarcinoma, and in the distinction between a uterine and ovarian serous carcinoma. The value of CD10 as a proposed marker of mesonephric adenocarcinoma is also discussed. With regard to uterine mesenchymal neoplasms, a critical appraisal of the value of relatively new antibodies, including CD10 and h-caldesmon, in distinguishing between a smooth muscle and an endometrial stromal neoplasm is discussed as is the immunophenotype of two rare uterine mesenchymal neoplasms, uterine tumor resembling ovarian sex cord tumor (UTROSCT) and perivascular epithelioid cell tumor (PEComa).

Comparative Immunohistochemical Analysis of Granulosa and Sertoli Components in Ovarian Sex Cord-Stromal Tumors with Mixed Differentiation: Potential Implications for Derivation of Sertoli Differentiation in Ovarian Tumors

Granulosa cell tumors of the ovary occasionally show admixed Sertoli components, just as tumors that are predominantly Sertoli or Sertoli-Leydig cell tumors can contain minor granulosa elements. Although the immunoprofiles of pure granulosa cell tumors and pure Sertoli cell tumors have been characterized, little is known regarding what immunophenotypic relationships exist between the granulosa and Sertoli components in ovarian sex cord-stromal tumors that contain both elements. Furthermore, it is not completely understood why sex cord-stromal tumors of the ovary with female-type (granulosa) differentiation can produce male-type (Sertoli) differentiation. To better understand why simultaneous differentiation into female-type and male-type components occurs, eight tumors with mixed differentiation were stained with a panel of antibodies to androgen receptor (AR), calretinin, CD10, CD99, estrogen receptor, inhibin, Ki-67, low molecular weight cytokeratin, pancytokeratin, progesterone receptor, p53, and vimentin. Immunohistochemical composite scores were determined separately for the matched pairs of granulosa and Sertoli components in each case. Differences between both components were statistically analyzed using the Wilcoxon signed rank test. AR and vimentin expression showed a difference at the 10% statistical significance level (p < 0.1), demonstrating higher levels of expression in the granulosa components. The differences between the granulosa and Sertoli components in expression of CD99, inhibin, or pancytokeratin were not statistically significant (p > 0.1, each). Statistical calculations could not be made for calretinin, CD10, estrogen receptor, Ki-67, low molecular weight cytokeratin, progesterone receptor, or p53, although the overall mean levels of expression of CD10 and low molecular weight cytokeratin were substantially higher in the Sertoli components. Not surprisingly, the granulosa and Sertoli components of ovarian sex cord-stromal tumors with mixed differentiation show overlapping immunophenotypic profiles consistent with derivation from a common lineage rather than reflecting a composite tumor. However, because components of a sex cord-stromal tumor simultaneously differentiate along granulosa or Sertoli lines, they seem to show preferential expression of certain antigens. CD10 and low molecular weight cytokeratin are more often associated with Sertoli cell differentiation, whereas AR and vimentin expression seem to reflect granulosa differentiation.

Ovarian sex cord-stromal tumors: an immunohistochemical study including a comparison of calretinin and inhibin

Because ovarian sex cord-stromal tumors (SCST) are morphologically heterogeneous neoplasms that are relatively infrequently encountered, their diagnosis can be difficult. Immunohistochemical staining may be useful for establishing the diagnosis in problematic cases. We studied 53 ovarian SCSTs to characterize their immunohistochemical staining pattern: 17 adult granulosa cell tumors (AGCTs), 4 juvenile granulosa cell tumors (JGCTs), 3 sex cord tumors with annular tubules (SCTATs), 9 Sertoli-Leydig cell tumors (SLCTs), 10 fibromas, 5 fibrothecomas (FTs), and 5 thecomas. In 8 of the 53 cases, the tissue studied was from a metastatic site. The immunopanel included calretinin, inhibin, WT1, cytokeratin cocktail, epithelial membrane antigen (EMA), and cytokeratin 5/6 (CK5/6). The fibromas and FTs were also tested with CD10. The extent of staining was assessed in a semiquantitative fashion and ranked on a scale of 0 through 4+. All of the tumors, except for 1 metastatic SLCT, were positive for calretinin. Forty-five of the cases (85%) stained for inhibin; 1 metastatic AGCT, 3 fibromas, and 4 FTs were negative. WT1 was present in 39 tumors (74%), with expression most prominent in the SLCTs. The cytokeratin cocktail stained 23 of the 53 tumors (43%), whereas just 1 tumor was positive for EMA (1+ in a JGCT). All tumors were negative for CK5/6, and the 15 fibromas and FTs were negative for CD10. We conclude that because cytokeratin is frequently expressed by SCSTs, in particular by granulosa cell tumors, SLCTs, and SCTATs, the inclusion of EMA in a panel may help to exclude epithelial neoplasms. In addition, WT1, present in normal granulosa cells, is expressed by a majority of SCSTs. Finally, these results demonstrate that calretinin is at least as sensitive as inhibin for ovarian SCSTs overall and that it is more sensitive than inhibin for fibromas and FTs.

Ovarian steroid cell tumors: an immunohistochemical study including a comparison of calretinin with inhibin

Ovarian steroid cell tumors, not otherwise specified (SCTs, NOS) are uncommon sex cord-stromal tumors that may be difficult to distinguish from other oxyphilic or clear-cell neoplasms. Immunohistochemical staining for inhibin, although generally useful in the diagnosis of SCTs, NOS, is not positive in every case and not all laboratories have this marker available. Recently, it has been reported that calretinin is expressed by sex cord-stromal tumors. We studied six SCTs, NOS for both calretinin and inhibin expression to evaluate the sensitivity of calretinin in comparison to inhibin. We also tested for CD99, Melan-A (A103), and S-100, other markers reported to be positive in these tumors. HMB-45 and MART-1 (Ab3) completed our panel of markers. All six tumors were positive for both calretinin and inhibin. Calretinin positivity was present in 60% to >90% of tumor cells, whereas inhibin reactivity ranged from <5% to >90% of tumor cells. Membranous staining for CD99 was present in one tumor. S-100-positive cells were seen in two tumors, whereas four tumors were immunoreactive for HMB-45. All six tumors were positive for Melan-A (A103), but in general the staining was less diffuse than with calretinin. All of the tumors were essentially negative for MART-1 (Ab3). The consistent diffuse staining of the tumors in this study for calretinin, in comparison to inhibin and Melan-A (A103), suggests that it is a sensitive marker for SCTs, NOS. MART-1 (Ab3) immunostaining may be useful for cases in which melanoma is considered in the differential diagnosis.

Ascites and elevated androgen level in a pregnant patient with an ovarian sclerosing stromal tumor

We report the case of a 31-year-old woman with an androgen-producing sclerosing stromal tumor found during the eighth week of gestation in association with ascites and elevated serum androgen and cancer antigen (CA)-125 levels. The combined features of ascites, elevated serum androgen and elevated CA-125 in association with this rare type of ovarian tumor is unusual. Surgical removal of the tumor resulted in relief of symptoms, resolution of ascites, and decreases in serum androgen and CA-125 levels. The pregnancy was uneventful.

Utility of immunostaining for S-100 protein subunits in gonadal sex cord-stromal tumors, with emphasis on the large-cell calcifying Sertoli cell tumor of the testis

This study concerns the immunohistochemical localization of S-100 alpha, S-100 beta, and whole brain S-100 (wbS-100) in testicular large-cell calcifying Sertoli cell tumor (LCCSCT). We examined 8 LCCSCTs (7 benign and 1 malignant), 6 Sertoli cell tumors not otherwise specified (SCTs-NOS), 6 Leydig cell tumors (LCTs), 5 ovarian Sertoli-Leydig cell tumors (SLCTs), and 7 gonadoblastomas (GBLs). The 8 LCCSCTs showed immunoreactivity for S-100 alpha, S-100 beta, and wbS-100. Five of the 6 LCTs and the Leydig cell components in the ovarian SLCTs stained positively for S-100 alpha and wbS-100 but were negative for S-100 beta. SCTs-NOS and the Sertoli cell components in the SLCTs occasionally showed focal and weak/moderate positivity for S-100 alpha, S-100 beta, and wbS-100. Sex cord cells of the GBLs were positive for S-100 beta and wbS-100 and negative for S-100 alpha. Germ cell elements of the GBLs were negative for S-100 alpha, S-100 beta, and wbS-100. In nonneoplastic testicular parenchyma adjacent to the above-mentioned tumors, there was S-100 alpha reactivity in Leydig cells, rete testis, and a few Sertoli cells. S-100 beta reactivity was seen in a few Sertoli cells, Schwann cells, and some endothelial cells. WbS-100 reactivity was present in Leydig cells, a few Sertoli cells, rete testis, Schwann cells, and some endothelial cells. The results indicate that S-100 alpha and S-100 beta can potentially be used as immunohistochemical markers for LCCSCT, especially when differentiating it from LCT, which may mimic LCCSCT on routine histopathology. Although the biological significance of both S-100 subunits expression in LCCSCT remains unknown, these notable calcium-binding proteins may be associated with the characteristic calcification in LCCSCT through regulation of calcium levels in the tumor cells.

Uterine tumors resembling ovarian sex-cord tumors producing parathyroid hormone-related protein of the uterine cervix

A case of uterine tumors resembling ovarian sex-cord tumors (UTROSCT) producing parathyroid hormone-related protein (PTH-rP) of the uterine cervix is reported. A 66-year-old woman underwent total hysterectomy with bilateral salpingo -oophorectomy due to the possibility of a malignant uterine tumor. A fairly well-circumscribed tumor, measuring 8 x 5 x 7 cm, was present in the myometrium of the cervix and extended into the endocervical mucosa. Histologically, the tumor showed predominantly sex-cord-like differentiation and the features of conventional endometrial low-grade stromal sarcoma were observed in part. Immunohistochemically, the tumor cells were negative for CD10. From these findings, we diagnosed the present case as Clement and Scully's group II UTROSCT arising from the uterine cervix. To our knowledge, this is the first report of the cervical occurrence of UTROSCT. Furthermore, in this tumor, production of PTH-rP was demonstrated by normalization of serum PTH-rP after the tumorectomy and immunoreactivity for PTH-rP in the tumor cells.

Role of gonadotropins in malignant progression of sex cord stromal tumors produced by sequential auto- and isogenic transplantation of ovarian tissue in ovariectomized rats

PURPOSE

In this study the effect of continuous stimulation of gonadotropins on sex cord stromal tumors in the rat was examined.

METHODS

Sex cord stromal tumors were induced by transplantation of ovaries under the splenic capsule of ovariectomized rats. Beginning 180 days after transplantation, these tumors were taken out and cut into several pieces, which were then retransplanted (by isotransplantation) under the splenic capsule of 80 either intact or ovariectomized rats.

RESULTS

Most of the tumor grafts grew up to a median size of 0.7 cm in ovariectomized rats. However, some of the tumors recovered from recipient rats that were retransplanted with donor tumors differed significantly from the others. Characterized by a high mitotic rate, nuclear atypia, size (up to 3.8 cm) as well as growth in intact animals, these tumors were defined as malignant. They could be kept in culture and always led to the development of metastases after retransplantation into other rats.

CONCLUSION

Benign sex cord stromal tumors can show malignant growth after transplantation. This study for the first time demonstrates that gonadotropins are involved in the induction of ovarian malignancies.

Ovarian pathology and high incidence of sex cord tumors in follitropin receptor knockout (FORKO) mice

In this investigation we describe our observations of the status of the aging ovary in mice with disruption of the receptor for FSH. Knockout mice at 3-5 months of age are acyclic and sterile, with very small, underdeveloped ovaries. Thus, they exhibit hypergonadotropic-hypogonadism with high levels of circulating FSH similar to the postmenopausal state in women. By 12 months more than 92% of these animals developed various kinds of ovarian pathology, including neoplasms of sex cord-stromal type as well as cysts. Interestingly, the majority of tumors were located in the right ovary, with the contralateral ovary remaining unaffected but atrophic. The ovary from heterozygotes also showed pathology after 15 months. None of the age-matched wild-type mice that remained fertile developed any sign of ovarian tumors. Circulating LH and FSH levels were increased in follitropin receptor knockout mice and remained severalfold higher in tumor-bearing animals. The histological appearances of ovarian tumors were similar to the pathology observed in some types of sex cord-stromal neoplasms in women. The tumor burden caused weight loss and cachexia in follitropin receptor knockout mice. Based on these characteristics as well as the high incidence of ovarian pathology in the aging mutant, we propose that the loss of the FSH receptor signaling mechanisms predispose the ovary to molecular and structural changes leading to tumor formation. Hence, in the intact and fertile animal, FSH receptor signaling offers a protective mechanism that is lost upon reproductive senescence (menopause in women). Further studies are warranted in this genetic model to explore the molecular changes underlying the development of ovarian neoplasia.

Immunohistochemical staining for calretinin is useful in the diagnosis of ovarian sex cord-stromal tumours

AIMS

Ovarian sex cord-stromal tumours are a heterogeneous group of neoplasms which may be confused morphologically with a wide variety of tumours. Calretinin positivity has previously been demonstrated in a small number of ovarian sex cord-stromal tumours. The aim of this study was to investigate calretinin staining in a series of these tumours and their histological mimics in order to determine the value of calretinin staining in a diagnostic setting.

METHODS AND RESULTS

Seventy-two neoplasms, including 37 ovarian sex cord-stromal tumours and 35 miscellaneous neoplasms which may enter into the differential diagnosis, were stained with a commercially available polyclonal antibody against calretinin. All sex cord-stromal tumours exhibited positivity except for a single fibrothecoma. In this group of tumours staining was generally diffuse and strong. Small numbers of the miscellaneous group of neoplasms exhibited positivity but this tended to be focal and weak, although this was not always the case. There was consistent strong positive staining of granulosa cells in follicular cysts and corpora lutea. There was also positive staining of luteinized stromal cells in two cases of ovarian stromal hyperplasia and hyperthecosis.

CONCLUSIONS

Calretinin is a sensitive immunohistochemical marker of ovarian sex cord-stromal tumours and may be useful in a diagnostic setting. However, the value is somewhat limited since occasional neoplasms which enter into the morphological differential diagnosis may be positive. Be that as it may, calretinin positivity may be of value in the diagnosis of an ovarian sex cord-stromal tumour and its differentiation from other neoplasms. In this regard, calretinin should always be used as part of a larger panel.

Androgen-secreting steroid cell tumor of the ovary

We present the case of a 93-year-old virilized woman with an androgen-secreting ovarian tumor. This rare ovarian sex cord stromal tumor behaved in a malignant fashion. Various aspects of the presentation, diagnosis, and treatment of these tumors are discussed.

Transcription factors GATA-4 and GATA-6 and a GATA family cofactor, FOG-2, are expressed in human ovary and sex cord-derived ovarian tumors

Previous studies have implicated transcription factors GATA-4 and GATA-6 in the regulation of murine ovarian development and function. In rodents, GATA-4 is expressed in granulosa cells of primary and early antral follicles, whereas GATA-6 is expressed in granulosa cells of late antral follicles and luteal glands. Both transcription factors can be detected in lesser amounts in theca cells and interstitial cells. We have now examined the expression of GATA-4 and GATA-6 in human ovaries, human granulosa-luteal (GL) cells and sex cord-derived tumors. We show by in situ hybridization and immunohistochemistry that GATA-4 and GATA-6 messenger RNA (mRNA) and GATA-4 protein are present in granulosa and theca cells in both preantral and antral follicles. Both human ovarian tissue samples and freshly isolated GL cells derived from preovulatory follicles of gonadotropin-treated women express GATA-4, GATA-6, and FOG-2 transcripts, and GATA-6 mRNA expression in GL cell cultures is stimulated by human CG and 8-bromo-cAMP. The vast majority of granulosa and theca cell tumors examined expressed GATA-4 and GATA-6. We also found that mRNA for FOG-2, a recently discovered regulator of GATA-4, is coexpressed with GATA-4 in human ovary samples, normal granulosa cells, and in sex cord-derived tumors. Our results demonstrate that GATA-4, GATA-6, and FOG-2 are expressed in human ovary and in granulosa and theca cell tumors. Our findings support a role for GATA-binding proteins in human ovarian folliculogenesis. Moreover, these data suggest that GATA factors may contribute to the phenotypes of sex cord-derived ovarian tumors.

A case of a sclerosing stromal ovarian tumor that expresses VEGF

A case of a sclerosing stromal tumor (SST) of the ovary is presented. One of the tumor's characteristics was its high vascularity. On immunohistochemical staining, the vascular endothelial growth factor (VEGF) was positive for both cellular and edematous areas in the tumor. VEGF was thought to be a factor that affected the clinicopathological features of this tumor.

Sertoliform endometrioid carcinomas of the ovary: a clinicopathologic and immunohistochemical study of 13 cases

Ovarian endometrioid carcinomas with sertoliform features (SECs) are infrequent and often misinterpreted as sex cord-stromal tumors. The clinicopathologic features and immunohistochemical expression of keratin, epithelial membrane antigen (EMA), inhibin, and estrogen and progesterone receptors were evaluated in 13 cases of SEC. The women were 41 to 89 years of age (mean, 60 yr) with abdominal enlargement secondary to a unilateral ovarian mass as the most frequent clinical presentation. One patient displayed virilization. At presentation, 10 patients were Stage I, one was Stage II and two were Stage III. The tumors were composed of compact anastomosing cords and small tubules embedded within a fibrous stroma. Nuclear features were Grade 1 or 2 in all but one tumor. Areas of conventional endometrioid carcinoma were observed in 12 cases. An adenofibromatous component comprising 5 to 60% of the lesion was present in seven cases. All 12 cases examined immunohistochemically were positive for keratin and EMA and negative for inhibin with focal, luteinized stromal cells positive for inhibin in 10 cases. Estrogen and progesterone receptors were positive in 10 and 11 cases, respectively. Follow-up on 6 of 10 patients with Stage I and the one patient with Stage II disease displayed no evidence of disease 10 to 120 months (mean, 57 mo). Progressive disease and death occurred at 12 and 72 months only in the two women with Stage III disease, one of which had an associated serous carcinoma in the contralateral ovary. Adequate sampling, a careful search for areas of conventional endometrioid carcinoma, and immunohistochemical studies (including EMA, keratin, and inhibin) are helpful in the evaluation of ovarian tumors with sex cord-stromal features. SEC should be considered a well-differentiated endometrioid carcinoma despite the presence of a solid, sex cord-like proliferation, with a good prognosis when confined to the ovary.