MR findings of primary ovarian granulosa cell tumor with focus on the differentiation with other ovarian sex cord-stromal tumors

BACKGROUND

To describe magnetic resonance imaging (MRI) features of ovarian granulosa cell tumors (OGCTs) and compare with other sex cord-stromal tumors (OSCs) in ovary.

METHODS

MR findings of 18 patients with surgically confirmed ovarian granulosa cell tumor were retrospectively reviewed by two radiologists with consensus reading. All MR examinations were prospectively performed within one month. Clinical and imaging characteristics of OGCTs were evaluated and compared with OSCs (control group).

RESULTS

In 18 patients, 20 ovarian granulosa cell tumors were detected on MRI. Sixteen tumors appeared as solid or mostly solid mass (16/20), while 4 tumors as cystic mass. Pathological pelvic fluid was detected in 1 OGCT (1/18) and 11 OSCs (11/34) (p = 0.031).On T2 weighted imaging (T2WI), most of OGCTs displayed hyperintense signal and mixed signal (19/20); on T1 weighted imaging (T1WI), 11 OGCTs (11/20) displayed similar signal as on T2WI imaging. The lesion signal between OGCT and OSC differed significantly on both T1WI (p = 0.017) and T2WI (p = 0.002). Tumoral bleeding was detected in 6 OGCTs on MRI. On diffusion weighted imaging (DWI) images, OGCTs mostly appeared as high signal (16/20). Average apparent diffusion coefficient (ADC) value derived from DWI images in the OGCT group (0.84 ± 0.26× 10^- 3 mm²/s was less than the control group (1.22 ± 0.47 × 10^- 3 mm²/s) with statistical difference (p = 0.002).

CONCLUSIONS

MRI could provide important information in OGCT diagnosis. ADC value might be useful in differentiating OGCT from OSC.

A rare case report of ovarian juvenile granulosa cell tumor with massive ascites as the first sign, and review of literature: Case report and review of literature

RATIONALE

Massive ascites as the first sign of ovarian juvenile granulosa cell tumor (JGCT) in an adolescent is an extremely rare, and its clinical features and treatment methods have not been well described.

PATIENT CONCERNS

The clinical characteristics, diagnosis, and treatment methods in a 19-year-old girl who presented with massive abdominal distention and ascites was retrospectively reviewed. Abdominopelvic ultrasonography showed a large amount of ascites. The nature of ascites was exudate. All tumor markers were normal, but ascites and serum tumor CA125 levels were significantly increased. Abdominal CT showed left attachment area teratoma and right attachment area capsule solid change.

DIAGNOSES

Histological and immunohistochemical results were compatible with JGCT. Based on the FIGO classification, the patient with only malignant ascites was categorized into stage IC.

INTERVENTIONS

The patient underwent mass resection with salpingoophorectomy. Following the operation, she received 6 courses of adjuvant chemotherapy with Nedaplatin and Paclitaxel liposome.

OUTCOMES

The patient was followed up postoperatively for 6 months to date without recurrence.

LESSONS

We should be highly vigilant the JGCT with massive ascites as the first clinical manifestation.

Clinical presentation and outcome of adult-type granulosa cell tumors: a retrospective study of 30 patients in a single institute

BACKGROUND

Ovarian adult-type granulosa cell tumors (GCTs) are characterized as low-malignant and late-recurrent ovarian tumors. Although some clinical and pathological prognostic factors have been reported, other factors have yet to be sufficiently investigated for necessary confirmation. The aim of this study was to test the correlation between clinical factors and outcome, based on patients seen in a single institute.

METHODS

Thirty patients with pathologically confirmed adult-type GCTs between 1984 and 2010 were reviewed retrospectively. Among them, eight (26.7%) had recurrence, which subsequently contributed to two mortalities.

RESULTS

In a comparison of the clinical characteristics of the premenopausal and postmenopausal women with GCT, all of the postmenopausal women had symptoms (100% vs. 63.6%, p = 0.01). With regard to disease recurrence, only abnormal preoperative serum cancer antigen 125 level (≥ 35 U/mL) was significant (50% vs. 11%, p = 0.03), and residual tumor showed a borderline trend (100% vs. 21.4%, p = 0.06). Other factors, including International Federation of Gynecology and Obstetrics stage, tumor size, tumor rupture prior to or during operation, body mass index, parity, serum estrogen level, and adjuvant therapy, were not statistically significant.

CONCLUSION

Physicians should be alert to the difference in the symptom presentation of GCTs between pre- and postmenopausal women, giving particular attention to the usefulness of the preoperative serum level of cancer antigen 125 in patients with GCTs. More evidence is needed to confirm this observation.

Minireview: animal models and mechanisms of ovarian cancer development

Ovarian cancer in women is a complex and deadly disease, where the molecular events that initiate and control tumor formation remain poorly defined. Therefore, mouse models provide one approach for determining the mechanisms by which specific oncogenic factors cause ovarian surface epithelial cell and granulosa cell transformation. This minireview summarizes the phenotypes of current mouse models that have been generated and some of the underlying mechanisms they have provided.

The importance of ERbeta signalling in the ovary

This review examines the evidence for a central role of oestrogen receptor beta (ERbeta or ESR2 as listed in the MGI Database) in folliculogenesis and hence reproductive biology. Knockout mouse models have been a valuable resource in this respect. The ERbeta-null mouse exhibits a granulosa cell phenotype associated with the partial arrest of folliculogenesis and ovulatory dysfunction. Phyto-oestrogens such as genistein, which preferentially activate ERbeta, have been shown to alleviate the ovarian phenotype of the oestrogen-depleted aromatase knockout mouse. In normal adult mice, genistein has been shown to cause reproductive defectives following neonatal administration. Studies of ovarian cancer have also informed the literature. A decline in ERbeta levels in epithelial ovarian cancers has been hypothesised to be associated with severity of disease and prognosis. Whereas the abundant expression of ERbeta in granulosa cell tumours (GCT) of the ovary and evidence that ERbeta signalling is transrepressed by the nuclear factor-kappaB pathway in GCT cell lines suggest a pathogenetic role for ERbeta in GCT. In recent years, studies into the impact of environmental oestrogens (either in the form of pesticides or plastics) on reproductive function have shown that ERbeta-selective toxins cause reproductive dysfunction and impair fertility. It remains to be established as to what genes are regulated by ERbeta in the ovary. Finally, ERbeta has been shown to be regulated by gonadotrophins, the pituitary hormones mediating ovarian function.

Expression of adrenomedullin in human ovaries, ovarian sex cord-stromal tumors and cultured granulosa-luteal cells

The aim of the present study was to characterise the expression pattern of the multifunctional vasoactive peptide adrenomedullin (ADM) in human ovarian tumors, and to find hormonal regulators of ADM expression in human ovaries. The expression of ADM messenger RNA (mRNA) was higher in granulosa cell tumors than in fibrothecomas and normal ovaries, as analysed by Northern blots. In normal ovaries, ADM immunoreactivity was localised in both granulosa and thecal cells. Eight of the 90 granulosa cell tumors (9%) showed moderate and 53 (59%) weak ADM immunoreactivity, whereas 27% (11/41) of the fibrothecomas displayed weak ADM staining. FSH, protein kinase A activator (Bu)(2)cAMP, prostaglandin E(2) (PGE(2)), activin A and the broad protein kinase regulator staurosporine decreased ADM mRNA accumulation in cultured granulosa-luteal cells time- and dose-dependently. FSH, (Bu)(2)cAMP and PGE(2) increased progesterone secretion and the accumulation of the steroidogenic acute regulatory protein mRNA in these cells. In conclusion, ADM is expressed in normal human ovaries and sex cord-stromal tumors, particularly in those of granulosa cell origin. FSH, PGE(2,) (Bu)(2)cAMP and activin A suppress ADM gene expression in granulosa-luteal cells. Expression of ADM in human ovaries and its hormonal regulation in granulosa cells suggests a paracrine role for ADM in ovarian function.

Common variable immunodeficiency: a new look at an old disease

Primary immunodeficiencies comprise many diseases caused by genetic defects primarily affecting the immune system. About 150 such diseases have been identified with more than 120 associated genetic defects. Although primary immunodeficiencies are quite rare in incidence, the prevalence can range from one in 500 to one in 500 000 in the general population, depending on the diagnostic skills and medical resources available in different countries. Common variable immunodeficiency (CVID) is the primary immunodeficiency most commonly encountered in clinical practice, and appropriate diagnosis and management of patients will have a significant effect on morbidity and mortality as well as financial aspects of health care. Advances in diagnostic laboratory methods, including B-cell subset analysis and genetic testing, coupled with new insights into the molecular basis of immune dysfunction in some patients with CVID, have enabled advances in the clinical classification of this heterogeneous disease.

Granulosa cell tumors of the equine ovary

The granulosa cell tumor is the most common ovarian tumor in mares. A clinical diagnosis can be made based on the presence ofa unilaterally enlarged ovary and a small inactive contralateral ovary. Endocrine testing may be beneficial to confirm a diagnosis. Surgical removal of the tumor eliminates the adverse effect on pituitary function and results in resumption of follicular development and ovulation in the opposite ovary over time.

Effects of granulosa cell-specific deletion of Rb in Inha-alpha null female mice

Our laboratory is interested in the gonadal growth regulatory properties of inhibins, members of the TGFbeta superfamily. We have previously shown that female mice lacking inhibins (Inha(-/-)) develop granulosa cell tumors and that concurrent loss of p27 accelerates tumor development. It has also been shown that the retinoblastoma protein RB regulates the G(1) to S phase transition of the cell cycle by controlling the activity of transcription factors and stabilizing the levels of the cell cycle inhibitor P27. Based on these data, we hypothesized that concurrent loss of Rb and inhibins in the ovary will exacerbate tumor formation. To test this hypothesis, we generated an ovarian granulosa cell conditional knockout (cKO) of Rb using the Cre/lox recombination system in the background of Inha(-/-) mice. Inha(-/-)/Rb cKO females show a modest increase in mortality rates compared with Inha(-/-) females. Although histologically similar to Inha(-/-) ovarian tumors, tumors from Inha(-/-)/Rb cKO females show increased number of mitotic figures and apoptotic rates. Interestingly, P27 levels are decreased in Inha(-/-)/Rb cKO ovarian tumors, likely due to the combined effect of Rb loss and increased Skp2 expression, which targets P27 to the proteosome. We propose that Rb loss may cause cell cycle delay or arrest, followed by apoptosis and that increases in p107 and p130 levels may compensate for Rb loss. These findings confirm the importance of P27 as a cell cycle regulator in granulosa cells and suggest functional compensation between RB-like proteins in ovarian tumorigenesis.

[Personal observations of puberty in girls after unilateral ovariectomy]

The authors present the course of puberty in three girls after surgery because of hormonally active ovarian tumours diagnosed and operated at the age of 3, 6 and 9 years, respectively. In the youngest patient with folliculoma ovari chemotherapy was also given, and girl No. 3 with luteinic capsule was treated for one year with decapeptyl because idiopathic precocious puberty was diagnosed. At present all three girls are in good physical condition with age-adequate development and puberty.

Molecular pathogenesis of granulosa cell tumours

Granulosa cell tumours (GCT) of the ovary arise from granulosa cells of the ovary on morphological, biochemical and molecular criteria. In order to understand the molecular pathogenesis of these tumours better we have sought to define their molecular phenotype, to identify activating mutations of the FSH-signalling pathway, to characterise their estrogen receptor expression and to explore the hypothesis that GCT may be resistant to inhibin. The pattern of gene expression observed in GCT suggests a phenotype which is similar to that of late preovulatory granulosa cells which would be consistent with activation of the FSH receptor signalling pathway, however, there is no evidence for activating mutations of either the FSH receptor or the associated trimeric G-proteins. Estrogen receptor beta is abundantly expressed in GCT. The various subunits and isoforms of the activin-inhibin receptor are expressed in GCT. These observations provide a basis for future studies of GCT, including further characterisation of signalling pathways known to be important in the regulation of granulosa cell growth and differentiation.

Ovarian granulosa cell tumors express a functional membrane receptor for anti-Müllerian hormone in transgenic mice

Anti-Müllerian hormone inhibits granulosa cell growth and function. Both anti-Müllerian hormone and its type II receptor are expressed in normal granulosa cells. We show by histologic and molecular analyses that ovarian tumors developing in transgenic mice, obtained by targeted oncogenesis using an anti-Müllerian hormone promoter-SV40 oncogene construct, are of granulosa-cell origin. Because tissue-specific, cell-surface molecules are of particular interest for the analysis and treatment of tumors, we examined the expression of anti-Müllerian hormone type II receptor in the ovaries of these transgenic mice. We demonstrate that the anti-Müllerian hormone type II receptor is expressed not only in normal ovarian follicles, but also in granulosa cell tumors. Using a cell line derived from one of these tumors, we show that the anti-Müllerian hormone type II receptor protein is present on the surface of tumor cells and binds anti-Müllerian hormone. Furthermore, we show that the anti-Müllerian hormone receptor is functional in the granulosa tumor cell line, with anti-Müllerian hormone treatment inducing selective activation of Smad1. In conclusion, in this study we present a new murine transgenic model of granulosa cell tumors of the ovary and, using this model, we demonstrate for the first time cell-surface expression of a highly tissue-specific molecule, anti-Müllerian hormone type II receptor, as well as the selective activation of Smad proteins by anti-Müllerian hormone, in granulosa tumor cells.

Establishment and characterization of a steroidogenic human granulosa-like tumor cell line, KGN, that expresses functional follicle-stimulating hormone receptor

We established a steroidogenic human ovarian granulosa-like tumor cell line, designated KGN, from a patient with invasive ovarian granulosa cell carcinoma. KGN had a relatively long population doubling time of about 46.4 h and had an abnormal karyotype of 45,XX, 7q-, -22. A steroid analysis of the cultured medium by RIA performed 5 yr after the initiation of culture showed that KGN was able to secrete pregnenolone and progesterone, and both dramatically increased after stimulation with (Bu)(2)cAMP. However, little or no secretion of 17alpha-hydroxylated steroids, dehydroepiandrosterone, androstenedione, or estradiol was observed. The aromatase activity of KGN was relatively high and was further stimulated by (Bu)(2)cAMP or FSH. These findings showed a pattern similar to that of steroidogenesis in human granulosa cells, thus allowing analysis of naturally occurring steroidogenesis in human granulosa cells. Fas-mediated apoptosis of KGN was also observed, which mimicked the physiological regulation of apoptosis in normal human granulosa cells. Based on these findings, this cell line is considered to be a very useful model for understanding the regulation of steroidogenesis, cell growth, and apoptosis in human granulosa cells.

An association of hypothalamic hamartoma, central precocious puberty and juvenile granulosa cell tumour in early childhood

A case of central precocious puberty from infancy due to a hypothalamic hamartoma and associated with an ovarian juvenile granulosa cell tumour is presented. Central precocious puberty was diagnosed by gonadotropin stimulation tests and LHRH agonist therapy was successful. A MR scan, but not a CT scan, demonstrated the hypothalamic hamartoma. The possible influence of early LH stimulation for the development of the granulosa cell tumour is discussed.

Adult granulosa cell tumor of the ovary with foci of hepatic cell differentiation: a report of four cases and comparison with two cases of granulosa cell tumor with Leydig cells

We report four ovarian granulosa cell tumors of the adult type containing small foci of hepatic cell differentiation. The patients ranged in age from 35 to 54 years and had unilateral adnexal masses. The smallest tumor was 4.0 cm in diameter and the largest, 11.0 cm in diameter. Three tumors were solid and cystic, and one was cystic. Microscopic examination showed typical patterns of adult granulosa cell tumor, with the additional finding of scattered islands of large cells with abundant eosinophilic, slightly granular cytoplasm and central round nuclei containing single prominent nucleoli. Bile pigment was detected in canaliculi between some of the large cells in three tumors. The hepatic cells were positive immunohistochemically for cytokeratin (CAM 5.2) and epithelial membrane antigen in two cases and alpha-fetoprotein in one of two cases. Carcinoembryonic antigen was stained in a canalicular pattern in two cases. Staining for vimentin and alpha-inhibin was negative. Liver cells in granulosa cell tumors must be differentiated from Leydig cells, which are found very rarely in granulosa cell tumors, and luteinized stromal and granulosa cells, which are present more commonly in these tumors; all three of the latter cell types are positive for alpha-inhibin.

Direct luteinizing hormone action triggers adrenocortical tumorigenesis in castrated mice transgenic for the murine inhibin alpha-subunit promoter/simian virus 40 T-antigen fusion gene

Transgenic (TG) mice, expressing the Simian Virus 40 T-antigen (Tag) under a 6-kb fragment of the murine inhibin alpha-subunit promoter (inh alpha p), develop gonadal tumors of granulosa/theca or Leydig cell origin. We showed previously that adrenocortical tumors develop if the TG mice are gonadectomized but never develop in intact animals. However, if functional gonadectomy was induced by GnRH antagonist treatment or by cross-breeding the TG mice into the hypogonadotropic hpg genetic background, neither gonadal nor adrenal tumors appeared. Since the most obvious difference between the gonadectomized and GnRH-antagonist-treated or Tag/hpg double mutant mice is the elevated gonadotropin secretion in the first group, we examined whether the adrenal tumorigenesis would be gonadotropin-dependent. Surprisingly, both the adrenal tumors and a cell line (C alpha 1) derived from one of them expressed highly functional LH receptors (LHR), as assessed by Northern hybridization, immunocytochemistry, ligand binding, and human CG (hCG)-stimulated cAMP and steroid production. No FSH receptor expression was found in the adrenal tumors by RT-PCR. hCG treatment of the C alpha 1 cells stimulated their proliferation, as measured by [3H]thymidine incorporation. This effect was related to hCG-stimulated steroidogenesis since progesterone, testosterone, and estradiol, at physiological concentrations, also stimulated the C alpha 1 cell proliferation. Different adrenocortical cells expressed initially LHR and Tag, whereas both were highly expressed in the tumor cells. In conclusion, the high level of functional LHR in the adrenal tumors indicates that this receptor can function as tumor promoter when ectopically expressed and stimulated by the ligand hormone.

Granulosa cell tumor in a mare with a functional contralateral ovary

A functional corpus luteum was found in the ovary contralateral to the ovary with a granulosa cell tumor in a 24-year-old Standardbred mare. The mare was ovariectomized because she was to be used as a jump mare for collection of semen from stallions. The blood concentration of progesterone was 2.2 ng/ml, and the luteal tissue progesterone concentration was 6.3 micrograms/mg. Atrophy of the contralateral ovary is one of the major signs used in diagnosis of granulosa cell tumor; however, our findings indicate that the ovary contralateral to a granulosa cell tumor is not invariably nonfunctional.

Gonadotropin, steroid, and thyroid hormone milieu of young SWR mice bearing spontaneous granulosa cell tumors

Young SWR mice possessing spontaneous ovarian granulosa cell (GC) tumors were examined for evidence of endocrine dysfunction associated with tumorigenesis. Tissue levels of hormones in tumor host and normal control females were measured by radioimmunoassays, ovarian luteinizing hormone (LH) receptors by uptake of 125I-labeled human chorionic gonadotropin (hCG) administered iv, and ovarian 3-beta-hydroxysteroid dehydrogenase (3-beta-OH) activity by histochemical techniques. When data from tumor host mice were compared with control data, hypothalamic gonadotropin releasing hormone content was not significantly different. Pituitary LH and follicle-stimulating hormone (FSH) contents were significantly decreased. Serum FSH, but not LH, levels were significantly reduced. No specific uptake of 125I-labeled hCG by tumor tissue was detected, whereas uptake by nontumorous contralateral ovaries was identified and found to be similar to that of control ovaries. With respect to serum steroids in tumor host mice, progesterone, dihydrotestosterone, and testosterone were significantly reduced, whereas androstenedione, dehydroepiandrosterone, corticosterone, estrone, and estradiol were normal. Frozen sections of tumor tissue failed to show any 3-beta-OH activity, whereas prominent activity was observed in non-tumorous contralateral and control ovaries. Serum thyroxine levels, evaluated because of the known depressive effects of hypothyroidism on reproductive function, were found to be significantly elevated in tumor host mice. The above results suggest that in SWR mice with spontaneous GC tumors, gonadotropins are moderately suppressed; the granulosa tumor cells do not have LH-hCG receptors; steroidogenesis by tumor tissue is reduced, whereas peripheral conversion of adrenal androgen precursors to estrogens is normal; and elevated serum thyroxine levels have a secondary role in established GC tumors.

Clinical survey of tumours and tumour-like lesions in horses in south east Queensland

The results of a retrospective survey of tumours and tumour-like lesions encountered in horses in a veterinary practice in south east Queensland between 1956 and 1978 are presented. Forty-two per cent of the lesions were examined histologically. The most commonly occurring neoplasms were the equine sarcoid, papilloma and squamous cell carcinoma of the eye and external genitalia. Neurofibroma was an important problem in the eyelid region. Intra-abdominal tumours were rarely encountered in this series.

Abnormalities in the oestrous cycle in the mare

The situations and conditions that can disrupt the mares normal oestrous cycle are described. Season of the year is a major influence; maximum reproductive efficiency does not totally coincide with the artificially defined "breeding season". Other abnormalities are associated with spontaneously persistent luteal function, psychological influences over behavioural activity, the presence of endometritis, multiple ovulation, reproductive behavior after pregnancy failure and granulosa cell tumours.

Androgenic function of a granulosa cell tumor

Virilizing granulosa cell tumors are uncommon and have not been well studied hormonally. A hirsute woman with a cystic granulosa cell tumor of the ovary is presented. Plasma hormone levles obtained before and after surgery indicate testosterone production by the tumor with LH and FSH suppression. Plasma testosterone (T) and T-index returned to normal after tumor removal, and ovulation resumed.

Equine granulosa cell tumors

Unilateral ovariectomy was performed on 3 mares affected with granulosa cell tumors. Tumor fluid in each mare was found to contain estrogen, testosterone, and progesterone. In 2 mares, preoperative blood plasma concentrations of these hormones were comparable to those of a series of clinically normal mares. The other mare, which had a history of aggressive, masculine behavior, had higher testosterone content in the tumor fluid and in the preoperative blood sample. After surgical removal of the tumors, each mare developed follicles and ovulated with the remaining ovary. Each was eventually bred and 2 conceived. The probability of metastasis of these tumors in mares appears uncertain. Data from other species suggests a guarded long-term prognosis may be justified.