Ovarian dysplasia. A study of identical twins

Through the glass darkly: intraepithelial neoplasia, top-down differentiation, and the road to ovarian cancer

It is currently hoped that deaths from extra-uterine high-grade serous cancer (HGSC) will be reduced via opportunistic salpingectomy in healthy women. Accumulated data implicate the fimbria as a site of origin and descriptive molecular pathology and experimental evidence strongly support a serous carcinogenic sequence in the Fallopian tube. Both direct and indirect ('surrogate') precursors suggest that the benign tube undergoes important biological changes after menopause, acquiring abnormalities in gene expression that are often shared with malignancy, including PAX2, ALDH1, LEF1, RCN1, RUNX2, beta-catenin, EZH2, and others. However, the tube can be linked to only some HGSCs, recharging arguments that nearby peritoneum/ovarian surface epithelium (POSE) also hosts progenitors to this malignancy. A major sticking point is the difference in immunophenotype between POSE and Müllerian epithelium, essentially requiring mesothelial to Müllerian differentiation prior to or during malignant transformation to HGSC. However, emerging evidence implicates an embryonic or progenitor phenotype in the adult female genital tract with the capacity to differentiate, normally or during neoplastic transformation. Recently, a putative cell of origin for cervical cancer has been identified in the squamo-columnar (SC) junction, projecting a model whereby Krt7+ embryonic progenitors give rise to immunophenotypically distinct progeny under stromal influences via 'top down' differentiation. Similar differentiation can be seen in the endometrium with a parallel in juxtaposed mesothelial and Müllerian differentiation in the ovary. Abrupt mesothelial-Müllerian transitions remain to be proven, but would explain the rapid evolution, short asymptomatic interval, and absence of a defined epithelial starting point in many HGSCs. Resolving this question will require accurately distinguishing progenitor from progeny tumour cells in HGSC and pinpointing where initial transformation and trans-differentiation occur, whether in the tube or POSE. Both will be critical to expectations from prophylactic salpingectomy and future approaches to pelvic serous cancer prevention.

Tu-be or not tu-be: that is the question… about serous ovarian carcinogenesis

Our understanding of the early natural history of epithelial ovarian carcinoma is limited by the access to early lesions as the disease is very often diagnosed at advanced stages. The incessant ovulation theory from the last century that indicated the ovary as the site for the initiation of high-grade serous cancers is contrary to the newly emerging idea that ovarian cancer could arise from the distal fallopian tube. In view of the recent pathological and molecular studies, we propose to discuss the genesis of high-grade serous ovarian cancer.

Is There a Relationship between Ovarian Epithelial Dysplasia and Infertility?

Aim. Ovarian epithelial dysplasia was initially described in material from prophylactic oophorectomies performed in patients at genetic risk of ovarian cancer. Similar histopathological abnormalities have been revealed after ovulation stimulation. Since infertility is also a risk factor for ovarian neoplasia, the aim of this study was to study the relationship between infertility and ovarian dysplasia. Methods. We blindly reviewed 127 histopathological slides of adnexectomies or ovarian cystectomies according to three groups-an exposed group to ovulation induction (n = 30), an infertile group without stimulation (n = 35), and a spontaneously fertile control group (n = 62)-in order to design an eleven histopathological criteria scoring system. Results. The ovarian dysplasia score was significantly higher in exposed group whereas dysplasia score was low in infertile and control groups (resp., 8.21 in exposed group, 3.69 for infertile patients, and 3.62 for the controls). In the subgroup with refractory infertility there was a trend towards a more severe dysplasia score (8.53 in ovulation induction group and 5.1 in infertile group). Conclusion. These results raise questions as to the responsibility of drugs used to induce ovulation and/or infertility itself in the genesis of ovarian epithelial dysplasia.

Assessing the malignant potential of ovarian inclusion cysts in postmenopausal women within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a prospective cohort study

OBJECTIVE

To evaluate the malignant potential of ultrasound-detected ovarian inclusion cysts in the development of ovarian cancer (OC) in postmenopausal women.

DESIGN

Prospective cohort study.

SETTING

UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).

POPULATION

Postmenopausal women.

METHODS

In UKCTOCS, women in the ultrasound group have annual scans. Women with inclusion cysts (single/multiple anechoic ≤10-mm ovarian cysts) and normal ovaries (both uniform hypoechogenicity) on their first scan were identified and followed up through cancer registry/questionnaires.

MAIN OUTCOME MEASURES

Relative risk (RR) of developing OC, invasive epithelial ovarian cancer (iEOC), breast cancer (BC) and endometrial cancer (EC) in women with inclusion cysts relative to those with normal ovaries. The incidence was compared with UK age-adjusted expected rates (Office for National Statistics, 2005).

RESULTS

Postmenopausal women (n = 48,230) attended the year 1 (11 June 2001-6 December 2006) screen; 1234 (2.5%) had inclusion cysts alone and 22,914 had normal scans. By 1 November 2009 (median follow-up, 6.13 years; interquartile range, 4.96-6.98 years), four, three (one Type II), seven and 22 women with inclusion cysts and 32, 29 (20 Type II), 90 and 397 women with normal ovaries were diagnosed with OC, iEOC, EC and BC, respectively. The RR values for the respective cancers (OC [RR, 2.32; confidence interval [CI], 0.86-6.28], iEOC [RR, 1.92; CI, 0.62-5.92], EC [RR, 1.44; CI, 0.68-3.05], BC [RR, 1.12; CI, 0.73-1.73]) were not increased. There was no difference between the observed versus expected incidence rates for these cancers in women with inclusion cysts.

CONCLUSIONS

Postmenopausal women with ultrasound-detected inclusion cysts do not seem to be at increased risk of ovarian or breast/endometrial (hormone-dependent) cancers.

[Ovarian epithelial dysplasia: Description of a dysplasia scoring scheme]

INTRODUCTION

Precancerous ovarian epithelial dysplasia was first described after prophylactic oophorectomy (OP) for genetic risk (BRCA mutation) or because of a strong family history of ovarian and/or breast cancer. The objective of this study was to describe histopathological features of ovarian dysplasia and to propose a dysplasia scoring sheme with a cut-off.

PATIENTS AND METHOD

One hundred and twenty-five bilateral oophorectomies (genetic predisposition: n=35 and control group: n=90) were reviewed by two pathologists blinded to clinical data. Eleven epithelial cytological and architectural features were studied and an ovarian dysplasia score was defined to compare the degree of ovarian epithelial abnormalities between the two groups.

RESULTS

Mean ovarian dysplasia score was significantly higher in prophylactic oophorectomy group than in control group (9.0 versus 3.5, P<0.001). Dysplasia was more severe in OP with BRCA mutation than in OP without (11.6 in BRCA 1; 7.6 in BCRA 2; 7.1 in family history). The cut off for dysplasia was 8 with a sensitivity of 60% and a specificity of 93.3%.

CONCLUSION

The increased dysplasia score in OP and the gradation in dysplastic severity in OP with proven BRCA mutations may suggest that ovarian dysplasia could be a pre-malignant non invasive histopathological lesion. The 11 cytological and architectural features in the dysplasia scoring sheme could be a useful tool to study ovarian dysplasia.

Ovarian epithelial dysplasia and prophylactic oophorectomy for genetic risk

To make an accurate histopathological description of ovarian dysplasia in a population at genetic risk of ovarian cancer and devise an ovarian dysplasia score.

MATERIALS AND METHODS

In this retrospective cohort study, 90 patients who had undergone bilateral oophorectomy or ovarian cystectomy between 1992 and 2005 and whose ovaries were reported as normal were divided into two groups: Group A comprising prophylactic oophorectomies for genetic predisposition (N = 28), and Group B or control group, fertile and non-cancerous (N = 62). Eleven epithelial cytological and architectural features were defined. Ovaries were analysed and reviewed by four pathologists blinded to clinical data. An ovarian dysplasia score was devised to quantify extent of ovarian epithelial abnormalities. The degrees of ovarian epithelial abnormalities (dysplasia scores) were compared between the two groups.

RESULTS

Mean dysplasia score was significantly higher in Group A (prophylactic oophorectomies) than in Group B (control group) (9.67 vs. 4.19, P < 0.001). In Group A, we observed a gradation in the severity of the dysplastic lesions between (i) proven BRCA mutations and prophylactic oophorectomies without mutations (11.26 vs. 8.1), and (ii) according to age (10.27 after age 50 years vs. 8.6 before age 50 years, P = 0.2962).

CONCLUSION

These results suggest abnormalities in ovaries from high risk women. The ovarian dysplasia may be a pre-malignant, non-invasive histological lesion that could be an important step in early neoplasia.

[Ovarian epithelial dysplasia: myth or reality? Review]

Ovarian epithelial dysplasia has been described in the ovarian surface epithelium by histologic, morphometric and nuclear profile studies. It could represent a potential precursor of ovarian malignancy in patients with genetic risk of ovarian cancer, although its natural history and progression to carcinoma are unpredictable. Diagnosis and identification of ovarian dysplasia would certainly be useful to understand the early steps of ovarian carcinogenesis. However, dysplasia in relation with ovulation induction seems to have a different pattern. We report dysplasia definitions and the current clinical management.

Macrophages in human fallopian tube and ovarian epithelial inclusion cysts

Epithelial inclusion cysts (EICs) are considered a preferential site for ovarian carcinogenesis. Local inflammation, associated to ovulatory wound repair and epithelial inflammatory conditions, facilitates EIC formation and involves activation of macrophages. The aim of this study was to analyse the presence and numbers of macrophages in the ovarian surface epithelium (OSE), in EICs, and in the fallopian tubes, as tubal metaplasia is a common finding in EICs. Immunohistochemical analysis of macrophages was performed in 25 fallopian tubes in different phases of the menstrual cycle, and in 30 ovaries showing EICs from cycling and postmenopausal women. In the fallopian tube, macrophages were abundant and underwent cyclic changes during the menstrual cycle, being particularly abundant within the epithelium at early and mid-luteal phases. Macrophages were not found in the normal OSE. However, OSE areas and EICs showing tubal metaplasia were invariably associated with infiltration by abundant macrophages. Macrophages were present among epithelial cells, infiltrating the cyst wall, as well as free in the cyst lumen. No significant differences existed between follicular and luteal phases of the cycle, or between cycling and postmenopausal women. This study has demonstrated that macrophages are associated with metaplastic EICs, and raises the possibility that these cells contribute to the particular microenvironment of EICs through secretion of cytokines and growth factors that may reach bioactive concentrations in the confined space of the EICs.

Clinicopathologic study of the putative precursor lesions of epithelial ovarian cancer in low-risk women

Possible precursor lesions for epithelial ovarian cancer (EOC) have been defined in the ovaries of women with contralateral EOC, with breast cancer susceptibility gene (BRCA)-1 mutations, or with positive family history. We aimed to investigate the prevalence of these lesions in women without any recognizable risk and to correlate these lesions with clinical ovulatory markers. The study group consisted of 184 women who were operated for benign gynecological conditions. Patients were requested to fill a questionnaire about anthropometric characteristics and medical and reproductive history. Oophorectomy specimens were examined for presence of epithelial inclusion cysts (EIC), cortical invaginations (CI), stromal hyperplasia (SHPP), epithelial pseudostratification (EPS), and surface papillomatosis (SP). Women with EIC were older, had lower age at menarche, and had higher menarche-to-pregnancy and menarche-to-operation time. SHPP was found to be related with age, menarche-to-operation time, history, and the duration of oral contraceptive use. Women with SP had lower age at menarche, lower menopausal age, and longer duration of hormone replacement therapy. No significant correlations were established between CI and any clinical parameters. Only one patient had EPS. Our findings suggest that these lesions correlate closely with reproductive features. Exact mechanisms that lead to development of these lesions should be clarified before implying them as precursor lesions of EOC.

The effects of ovulation induction on ovarian epithelium dysplasia scores and Ki67 expression: an experimental study on rats

We aimed to evaluate the effects of ovulation induction on Ki67 expression and dysplasia scores of female rat ovaries. Twenty female Wistar rats were randomized either to receive 150 IU/kg human menopausal gonadotropin on estrous day 2 and 75 IU/kg human chorionic gonadotropin on the day of preestrous (induction group, n= 10) or saline as placebo on the corresponding days (control group, n= 10). After five estrous cycles bilateral oophorectomy was performed to compare the Ki67 expression and dysplasia score of the ovarian epithelium. The mean number of the cells that stained positive for Ki67 was 159.6 +/- 101.92 in the follicles, 283.4 +/- 42 in the corpus luteum, and 151 +/- 75.1 in the stroma of the study group compared to 41.8 +/- 35.6 (P= 0.03), 43.2 +/- 28.3 (P= 0.007), and 55.6 +/- 18.6 (P= 0.01), respectively, in the control group. The mean number and rate of cells that stained positive for Ki67 in the epithelium was significantly higher in the ovulation induction group (758 +/- 71 and 63 +/- 1.6%, respectively) compared to the control group (386 +/- 23, P < 0.001; and 60 +/- 1.1%, P < 0.001; respectively). The mean dysplasia score was significantly higher (9.6 +/- 1.3) in the study group compared to the control group (5.08 +/- 0.9, P < 0.001). Ovulation induction in rats resulted in increased Ki67 expression and dysplastic features in the ovarian epithelial cells.

Origins and molecular pathology of ovarian cancer

Epithelial ovarian cancer comprises the majority of malignant ovarian tumors in adult women. These neoplasms are classified into distinct morphologic categories based on the appearance of the epithelium into tumors of serous, mucinous, endometrioid, clear cell, transitional, squamous, mixed and undifferentiated type. Current data indicate that each of these histologic subtypes is associated with distinct morphologic and molecular genetic alterations: high-grade serous and possibly endometrioid carcinomas most probably arise from surface epithelial inclusion glands with TP53 mutations and dysfunction of BRCA1 and/or BRCA2; low-grade serous carcinomas probably arise in a stepwise fashion in an adenoma-borderline tumor-carcinoma sequence from typical to micropapillary borderline tumors to low-grade invasive serous carcinoma via activation of the RAS-RAF signaling pathway secondary to mutations in KRAS and BRAF; mucinous carcinomas arise via an adenoma-borderline tumor-carcinoma sequence with mutations in KRAS; low-grade endometrioid carcinomas arise from endometriosis via mutations in CTNNB1 (the gene encoding beta-catenin) and PTEN. Although the morphologic data strongly support an origin of clear cell carcinoma from endometriosis, there is limited data on the genetic alterations in these uncommon tumors. Thus it is likely that most low-grade, relatively indolent ovarian carcinomas of serous, mucinous and endometrioid type arise from pre-existing cystadenomas or endometriosis whereas most high-grade serous carcinomas arise without an easily identifiable precursor lesion.

Intraperitoneal serous adenocarcinoma: a critical appraisal of three hypotheses on its cause

OBJECTIVE

Serous ovarian, Fallopian tube, and peritoneal adenocarcinomas are remarkably similar, both in their morphology, as well as in their clinical behavior. Despite extensive clinical and fundamental research, controversy still exists on the origin of serous female adnexal tumors. Difficulties in identification of site of origin at late stage the of disease at detection, when ovary, Fallopian tube, and the abdominal cavity are usually all involved, in addition to their macroscopic and microscopic resemblance, are major causes of this debate. In 3 hypotheses, 3 possible tissues of origin are proposed: the ovarian surface epithelium, the Fallopian tube epithelium, and the secondary Mullerian system.

STUDY DESIGN

We searched for all peer-reviewed articles and reviews that examined "serous ovarian carcinoma," "Fallopian tube carcinoma," "Mullerian system," "ovarian surface epithelium," "tubal epithelium," and "peritoneal." We included only articles that could give information on the origin of serous carcinomas. Additional articles were added by examining references of overview articles in relevant fields.

RESULTS

Discussed are the experimental data underlying these hypotheses.

CONCLUSION

An attempt is made to integrate the 3 hypotheses into a comprehensive model of serous intraperitoneal adenocarcinogenesis. It can be concluded that the Fallopian tubes play a major role in the development of female serous cancer.

Expression of candidate tumor markers in ovarian carcinoma and benign ovary: evidence for a link between epithelial phenotype and neoplasia

EpCAM, epithelial membrane antigen (EMA)-mucin 1 (MUC1), mesothelin, and CD9 have been reported to be overexpressed at the RNA level in ovarian carcinomas. By using immunohistochemistry, we profiled the protein expression of these gene products in ovarian carcinoma tissues and compared them with benign ovarian surface epithelium (OSE) and cortical inclusion cysts (CICs). Immunoreactivity for EMA and calretinin were used to define epithelial and mesothelial differentiation in nontumor tissues, respectively. Papillary serous (n = 16) and endometrioid (n = 10) tumors were immunopositive for EMA/MUC1 (100%), mesothelin (75% and 30%, respectively), CD9 (88% and 90%, respectively), and EpCAM (100%). All ovarian carcinomas and carcinoma cell lines tested were negative for calretinin. In nonneoplastic ovary, both OSE and CICs ranged from flat-to-cuboidal to stratified and ciliated in appearance. OSE with a cuboidal morphology had a similar immunoreactivity as omental peritoneum, expressing calretinin, mesothelin, and CD9. In contrast, CICs with stratified and ciliated epithelium show expression patterns similar to those in fallopian tubes. They frequently expressed EMA, EpCAM, mesothelin, and CD9. This immunophenotype is preserved in ovarian carcinomas, suggesting that Müllerian metaplasia signals the acquisition of these markers and that their expression is maintained in ovarian carcinomas that originate from this epithelium.

Effects of ovulation induction on ovarian morphology: an animal study

OBJECTIVE

The aim of this study was to investigate whether the ovulation induction has relation with postneoplastic lesions.

MATERIALS AND METHODS

Seventy-eight female, 90-day-old rats were enrolled for the trial. They were divided into three groups. In the first group, 13 rats received one cycle of ovulation induction with Follitropin Beta and human chorionic gonadotropin. The second group of 13 rats received three cycles of ovulation induction, and the third study group consisted of 13 rats which received six cycles of ovulation induction. Each group had a control group consisting of same number of rats that had not received ovulation induction. At the 12th month after the ovulation induction protocols ended, rat ovaries were extirpated for histopathological examination. In histopathological examination, malignant lesions, ovarian cyst and cyst diameter, epithelial stratification, epithelial tufting, mitotic index, polymorphism of epithelial cells and nucleus, epithelial cell nuclear diameter, chromatin density nuclear atypia, and mitotic activity in ovarian cyst epithelium were evaluated.

RESULTS

No malignant ovarian lesion was found in the three groups. Ovarian cyst development was most frequent in the rats that underwent six cycles of ovulation induction. Epithelial stratification and tufting were most frequent in the rats which underwent ovulation induction six times. Significant difference was found between induction and control groups in second and third groups for cellular and nuclear polymorphism, presence of nucleolus, and nuclear chromatin density.

CONCLUSIONS

Although development of malignant lesion were not found in any of the rat ovaries after ovulation induction, increase in the prevalence of epithelial dysplasia especially with increase in the number of induction cycles shows that some ovarian pathologies can occur subsequent to ovulation induction.

Premalignant lesions in the contralateral ovary of women with unilateral ovarian carcinoma

OBJECTIVES

A limited number of studies have looked at premalignant lesions of ovaries and the results are conflicting. Our goal is to identify, histologically and by immunohistochemistry, any features that may represent premalignant changes in the ovaries.

METHODS

Our cases included 29 patients with unilateral ovarian cancer. These were compared to 19 controls that had unilateral benign ovarian pathology and to 39 controls with bilateral normal ovaries. Tissue sections from the contralateral normal ovary were examined. Analysis of histological features and immunohistochemical staining for the apoptosis inhibitor Bcl-2, the proliferation marker Ki-67 and the tumor suppressor gene p53 was performed.

RESULTS

Epithelial stratification, nuclear atypia, and inclusion cysts were more often seen in the cases than in the two control groups. Epithelial stratification and nuclear atypia was statistically significantly more common among the cases than the normal controls. Inclusion cysts were present in more of the cases (P = 0.017) and in higher numbers than in the normal controls. Bcl-2 overexpression was statistically more commonly seen in the cases with contralateral ovarian cancer (39%) than in the normal controls (15%), while it was present in 28% of cases with contralateral benign pathology.

CONCLUSIONS

Epithelial alterations and Bcl-2 overexpression was seen in all three groups studied. However, the epithelial alterations and Bcl-2 overexpression was more commonly seen in the contralateral ovary of women with unilateral ovarian cancer. This suggests an association between these changes and ovarian cancer. Although it is tempting to label the above changes premalignant, women with the above changes are at possibly higher risk of developing ovarian cancer rather than having acquired an oncogenic change that would inevitably lead to ovarian cancer.

Cytology of human ovarian surface epithelial brushings

BACKGROUND

The human ovarian surface epithelium (HOSE) is the putative source of ovarian epithelial cancer, the most lethal gynecologic malignancy that affects women in the United States. The current study was designed to provide a database of normal HOSE cell features for diagnostic and research applications.

METHODS

HOSE was harvested from 42 women undergoing laparoscopy or laparotomy for benign gynecologic disorders, infertility problems, or pregnancy. Of the 42 women, 12 were postovulatory and 20 were receiving hormonal regimens. Cells were harvested with a sterile brush inserted through a laparoscopic port or with a sterile cell scraper at laparotomy.

RESULTS

Two HOSE populations were identified, ranging in size from 8 to 10 microm and from 15 to 20 microm, respectively. The cells measuring 15-20 microm exhibited slight anisonucleosis, more prominent nucleoli, fine cytoplasmic metachromasia, and an overall reparative or squamoid morphology. Cells were single or arranged in small clusters, sheets, or papillae. They coexpressed cytokeratin and vimentin but did not overexpress p53. Cellularity and proliferation (up to 3.2% +/- 0.8) were higher and papillae more frequent in postovulatory and cyst-bearing ovaries, including polycystic ovaries, suggesting underlying ovarian or hormonal influences. Representative HOSE brushings yielded a mean of 23,133 cells per patient (range, 4250-64,500 cells), equivalent to an estimated 0.58, 0.46, and 0.14 microg of nuclear protein, cell RNA, and nuclear DNA, respectively. Within 7-10 days of explantation, HOSE cells formed confluent monolayers with immunohistochemical and ultrastructural epithelial features.

CONCLUSIONS

The current study defined baseline features of HOSE cells important to pathologists and clinicians evaluating women at risk for ovarian epithelial cancer and to researchers investigating the pathobiology of this aggressive gynecologic malignancy.

Prophylactic oophorectomy

BACKGROUND

The tumorigenesis of ovarian carcinoma is poorly understood. The authors studied morphologic features and immunohistochemical expression patterns of neoplasia-associated markers in prophylactically removed ovaries, normal ovaries, and papillary serous ovarian carcinomas to identify possible preneoplastic changes in ovarian surface epithelium.

METHODS

Morphologic features and immunohistochemical expression patterns of CA-125, Ki-67, p53, E-cadherin, and Bcl-2 were evaluated in 21 normal ovaries, 31 ovaries that were removed prophylactically for increased carcinoma risk, and 7 ovarian papillary serous carcinomas. Representative slides from formalin-fixed, paraffin-embedded tissue blocks were submitted to immunohistochemical staining and were evaluated independently by three gynecologic pathologists. For statistical analyses, Fisher exact tests, multivariate analyses, Spearman rank correlation coefficients, Wald statistics, Kruskal-Wallis tests, and Mann-Whitney tests were used. Immunohistochemical staining results were correlated with morphologic findings.

RESULTS

The authors found progressive increases in reactivity with the lowest expression in normal ovarian epithelium, stronger expression in epithelium from prophylactically removed ovaries, and the highest expression in carcinomas for Ki-67 and p53. A similar trend was observed for CA-125. Positivity for Ki-67 and p53 was seen predominantly in the epithelium of inclusion cysts and deep invaginations, including those areas that had been identified as hyperplastic or dysplastic on routine hematoxylin and eosin-stained sections.

CONCLUSIONS

The current results suggest biologic/molecular evidence for the existence of preneoplastic changes in ovarian surface epithelium and support the previously proposed concept of ovarian dysplasia. Subtle morphologic alterations of the ovarian epithelium may be biologically significant.

Ovarian surface epithelium: family history and early events in ovarian cancer

Ovarian cancer is the most common cause of death from gynecological cancers in the Western world. There are many genetic and environmental factors which can influence a woman's risk of getting ovarian cancer. A strong family history of breast or ovarian cancer is definitely one of the most important and best-defined epidemiological risk factors. This review evaluates current knowledge of hereditary ovarian cancer. Histologic, cytologic and molecular studies on the ovarian surface epithelium (OSE), which is the origin of ovarian epithelial carcinomas, from women with a strong family history for ovarian carcinomas or with a mutation in one of the two known cancer susceptibility genes - BRCA1 and BRCA2, provide a background to facilitate understanding of the early changes in ovarian carcinogenesis. This overview is followed by a discussion of recent hypotheses and research on two questions. First, is there a mutational hotspot of BRCA mutation for ovarian cancer? Second, why do mutations in BRCA1 and BRCA2, which are ubiquitously expressed genes that participate in general cellular activities, lead preferentially to breast and ovarian cancer?

Challenges in the early diagnosis and staging of Fallopian-tube carcinomas associated with BRCA mutations

The histopathologic diagnosis of fallopian-tube carcinoma has been traditionally made at an advanced stage. More recently, predictive genetic BRCA testing is leading to the recognition in prophylactic oophorectomy specimens of clinically occult tubal carcinomas that are frequently in situ or small early-stage invasive carcinomas. These early lesions present a challenge in diagnosis and staging because the available criteria for the histopathologic diagnosis and staging of tubal carcinoma were derived from the clinicopathologic experience derived from the usual high-stage tubal carcinomas. The detection of early-stage tubal carcinomas requires that all tubal tissue be submitted for histologic examination. The diagnostic criteria for tubal in situ carcinoma have been defined, although the natural history of this lesion is unclear. Similarly defined criteria for a diagnosis of tubal dysplasia are lacking. Any early, invasive tubal carcinoma should be staged using a refined staging system suitable for early stage and fimbrial carcinomas. The adoption of these methods should increase our knowledge of early-stage tubal carcinoma and may add to our understanding of the development of ovarian-epithelial neoplasia.

Early events in ovarian epithelial carcinogenesis: progress and problems in experimental approaches

The etiology and early events in the progression of epithelial ovarian carcinomas are among the least understood of all major human malignancies. There are no adequate means for early detection of these neoplasms and, as a result, they are usually diagnosed in late stages. The purpose of this review is to point out some of the peculiar problems and limitations that have hampered progress in ovarian carcinogenesis research and to summarize new approaches and recent advances in our understanding of this process. The review first presents an overview of the properties of the ovarian surface epithelium (OSE) which is thought to be the source of epithelial ovarian carcinomas, followed by a discussion of recent research based on human OSE. This includes sections on methodology for the attainment and study of OSE, investigations of OSE from women with predisposing mutations, and attempts to convert normal OSE to malignancy. This overview is followed by a discussion of the contributions, potential, and limitations of animal models. The knowledge gained by these approaches will likely lead to improvements in our ability to prevent, diagnose, and treat ovarian cancer.

Peritoneal lavage cytology: an assessment of its value during prophylactic oophorectomy

OBJECTIVE

Prophylactic oophorectomy (PO) is an accepted treatment strategy for women who are at high risk for the development of ovarian carcinoma, particularly women who are BRCA mutation-positive. This study sought to assess the utility of peritoneal lavage cytology at the time of PO in detecting occult malignancy in this group of patients.

METHODS

Thirty-five high-risk women, who were not suspected of having any malignancy or ovarian mass, underwent peritoneal lavage at the time of PO. Thirty-one of the thirty-five women had undergone BRCA mutation analysis (BRCA1+, 18; BRCA2+, 10; BRCA-, 3). Intensive histopathologic examination was used in all 35 cases to identify occult carcinoma. Lavage specimens were reviewed for the presence of malignant cells and endosalpingiosis. The cytologic review was conducted without knowledge of either the histopathologic or BRCA results.

RESULTS

In 32 of the 35 lavage specimens no malignancy was detected. In the remaining three cases malignant cells were detected; in two of these cases histopathologic examination confirmed an ovarian/tubal occult carcinoma. Two of these women were BRCA1 mutation positive. Endosalpingiosis was detected in the peritoneal lavage specimens of 7 of the 32 cases showing no evidence of malignancy. All of these 7 women were BRCA mutation positive or unknown.

CONCLUSION

Peritoneal lavage cytology can detect occult carcinoma at the time of PO and should be performed at PO. The significance of occult carcinoma detected by either histopathologic or cytopathologic examination is uncertain. Whether the prevalence of endosalpingiosis detectable by lavage cytology is increased in BRCA mutation-positive patients requires further study.

Occult carcinoma in prophylactic oophorectomy specimens: prevalence and association with BRCA germline mutation status

Prophylactic oophorectomy (PO) is an option for women at increased risk for ovarian carcinoma. In this study the value of intensive pathologic examination of PO specimens and accompanying resected tissues in the identification of occult carcinoma and any association of occult carcinoma with BRCA germline mutation status were ascertained. Specimens from 60 consecutive PO patients, who were not suspected of having any ovarian tumor at the time of surgery, were subjected to standardized, complete pathologic examination in a prospective study over an 8-year period. Extra-ovarian tissues were examined as well, but they were not subject to the same standardized protocol. Any occult carcinoma of the ovaries or fallopian tubes was noted. The BRCA status and follow-up of patients were obtained, if available. Fifty-five of the 60 PO specimens did not show any evidence of malignancy. Of the 32 patients in this group followed for >1 year, all are alive and well. The remaining five patients, all BRCA1 mutation positive, showed occult carcinoma of the ovaries and/or in situ or invasive carcinoma of a fallopian tube. One of these five patients has died of abdominal carcinomatosis; four continue to be well, but follow-up is <4 years in all cases. Occult carcinoma is present in a small proportion of BRCA-positive or unknown PO patients and may be of prognostic significance. The entire ovaries and tubes from PO patients should be submitted for histologic examination to identify malignancy.

Ovarian epithelial dysplasia in relation to ovulation induction and nulliparity

OBJECTIVE

The goal of this study was to assess the relationship between ovulation induction, nulliparity, and ovarian epithelial dysplasia.

METHODS

This retrospective cohort study was performed in one teaching and one district general hospital in London. The subjects, 83 women who had undergone hysterectomy and bilateral oophorectomy and whose ovaries were reported as "normal," were divided into three groups: ovulation induction (13), nulliparity (20), and fertile controls (50). These ovaries were independently reviewed by two pathologists who assigned a score of 0, 1, or 2 to nine epithelial cytological and architectural features. The main outcome measure was the total dysplasia score, which was used to quantify the degree of ovarian epithelial abnormality in the three groups.

RESULTS

The mean dysplasia score was significantly higher in the women who had undergone ovulation induction than in the fertile controls (7.92 vs 5.70, P = 0.012). The magnitude of the difference between the ovulation induction group and controls remained similar after adjusting for age, parity, and duration of oral contraceptive use (2.17, 95% CI: -0.11-4.44). However, the statistical significance of this difference was reduced (P = 0.062). We did not find any evidence of a difference in dysplasia score between nulliparous women and controls, neither before (P = 0.85) nor after adjusting for age and duration of oral contraceptive use (P = 0.87).

CONCLUSIONS

These results suggest a possible association between ovarian epithelial dysplasia and ovulation induction therapy, in accord with previous reports of increased risk of ovarian cancer in women with a history of fertility treatment. The higher dysplasia score could be attributable to the drugs used to induce ovulation or to a genetic susceptibility to ovarian cancer.

k-ras mutation may be an early event in mucinous ovarian tumorigenesis

We explored the possible pathogenetic pathway for mucinous ovarian tumorigenesis by examining the k-ras mutational patterns in ovarian mucinous tumors (OMTs) with benign, borderline, and invasive epithelium in which the different types of mucinous epithelium are in close proximity. Sixteen patients with ovarian mucinous borderline tumors (OMBTs) and 4 patients with grade 1 ovarian mucinous adenocarcinomas (OMCs) were selected for the presence of a single histologic section which contained a clear "transition" zone from benign mucinous epithelium to borderline mucinous epithelium, and in four cases, to invasive epithelium. A PixCell II Laser Capture Microscope was used to microdissect and retrieve benign, borderline, and invasive epithelium separately from the 20 OMTs. Normal ovarian stroma from the same histologic section in each case was also microdissected and retrieved for use as a control. k-ras mutations were detected in these samples by PCR-SSCP analysis followed by direct PCR cycle sequencing. k-ras mutations were found in 8/16 (50%) of the OMBTs and 2/4 (50%) of the grade 1 OMCs. In 6 of these 10 cases (4 in OMBTs, 2 in grade 1 OMCs), the same k-ras mutation was found in both the benign and borderline (and invasive) regions. In 3 cases in which k-ras mutations were identified, the mutation was found in either the benign or borderline tissue samples alone, and in one case, two distinct mutations were found. No k-ras mutations were identified in the normal ovarian stroma. The presence of a k-ras mutation in adjacent benign and borderline regions of a single OMT may suggest a progression in the development of OMTs from benign to borderline and grade 1 OMCs. k-ras mutations, when they occur, are likely early genetic changes but may not alone be sufficient for malignant transformation of ovarian epithelium.

Familial ovarian cancer and early ovarian cancer: biologic, pathologic, and clinical features

Women with ovarian cancer have poor overall survival rates, largely because the disease is so often diagnosed at an advanced, less curable stage. Because women with early ovarian cancer experience good survival rates, there is great interest in the study and detection of early disease. Familial ovarian cancer has been relevant to the study of early ovarian cancer in two different ways. First, women from ovarian cancer families often undergo prophylactic oophorectomy to prevent development of this disease. These ovaries have been studied for pathologic or molecular features that might represent early preinvasive disease. Second, screening tests to detect presymptomatic ovarian cancer have selectively targeted this population because of the increased positive predictive value of these tests in this population. A review of the clinical, pathologic, epidemiologic, and molecular biologic aspects of familial ovarian cancer provides a background to facilitate understanding these issues.

Histology of prophylactically removed ovaries from BRCA1 and BRCA2 mutation carriers compared with noncarriers in hereditary breast ovarian cancer syndrome kindreds

OBJECTIVE

The literature reports conflicting studies claiming premalignant histological features in benign ovaries from women who may have hereditary predilections for ovarian carcinoma. To test the veracity of these claims, this investigation studied ovaries prophylactically removed from members of hereditary breast ovarian cancer (HBOC) syndrome families who carry BRCA1 and BRCA2 mutations and compared these with the ovaries of mutation-negative women from the same HBOC syndrome kindred.

METHODS

Sixty cases of women from HBOC syndrome families who had undergone prophylactic oophorectomies and whose BRCA1 and BRCA2 mutation status had been tested were selected from our database. Thirty had tested positive for BRCA1 mutations, 3 carried BRCA2 mutations, and 27 were negative for both BRCA1 and BRCA2 germline mutations. Histologic material from each case was examined by light microscopy blinded to the mutation status. Histologic features, previously reported to be possible precursor lesions for ovarian cancer, were quantified. Data from BRCA1 and BRCA2 mutation carriers were compared with those from mutation-negative cases in the direct line of genetic inheritance from the same HBOC syndrome families.

RESULTS

Statistical analysis found that a more frequent occurrence of ovarian surface micropapillae in 87% of mutation carriers compared with just 55% of mutation-negative cases was the only histologic feature which was significantly different between the two groups (P = 0.39). Cortical clefts tended to be deeper in the ovaries of mutation carriers, but this did not reach significance (P = 0.051). There were no other significant histologic differences between the ovaries removed from mutation carriers and those from noncarriers.

CONCLUSIONS

The results of our large and prospectively controlled, blinded study contrast with those reported from smaller, unblinded investigations. Except for the possible biological significance of surface micropapillae on ovaries from BRCA1 and BRCA2 mutation carriers, we found no histologic evidence for a genetically determined ovarian carcinoma precursor lesion.

Absence of premalignant histologic, molecular, or cell biologic alterations in prophylactic oophorectomy specimens from BRCA1 heterozygotes

BACKGROUND

The high mortality associated with ovarian carcinoma is largely a reflection of the inability to diagnose the disease at an early stage; the identification of a histologic lesion or molecular marker associated early stages of transformation would represent an important advance in understanding the natural history of this cancer. The existence of individuals with germline mutations in the ovarian and breast carcinoma susceptibility gene BRCA1 represents a unique opportunity to search for such premalignant alterations in ovarian tissues that are at unusually high risk for tumorigenesis. In this study, the authors addressed the hypothesis that pathologically normal ovaries removed from BRCA1 heterozygotes are likely to display premalignant histologic, molecular, and/or cell biologic alterations that may provide insight into early stages of ovarian tumorigenesis.

METHODS

Ovarian tissues from 18 BRCA1 heterozygotes and from 20 age-matched controls were examined in a blinded fashion for histologic evidence of surface epithelial pseudostratification, epithelial inclusion cysts, deep cortical invaginations of surface epithelium, increased stromal cell activity, and surface papillomatosis. Immunohistochemical analyses for expression of BRCA1, p53, and ERBB-2 and quantitation of cell proliferation (Ki-67 expression) and apoptosis (TUNEL assay), were also performed on all specimens.

RESULTS

Although histologic alterations were observed, there was no difference in frequency between cases and controls. Analysis of BRCA1 expression revealed ubiquitous nuclear immunoreactivity in the surface epithelial cells of all ovaries. Similarly, no evidence was found of p53 overexpression in any ovarian tissue or of a difference in ERBB-2 expression between cases and controls. Finally, no differences were observed in epithelial cell proliferation or apoptosis.

CONCLUSIONS

Clinically, normal ovaries from BRCA1 heterozygotes do not show evidence of premalignant alterations in histology, molecular markers, cell proliferation, or apoptosis, indicating that such changes are likely rare.

Prophylactic surgery in women with a hereditary predisposition to breast and ovarian cancer

PURPOSE

To review the published literature on the efficacy and adverse effects of prophylactic mastectomy (PM) and prophylactic oophorectomy (PO) in women with a hereditary predisposition to breast and ovarian cancer and to provide management recommendations for these women.

METHODS

Using the terms "prophylactic," "preventive," "bilateral," "mastectomy," "oophorectomy," and "ovariectomy," a MEDLINE search of the English-language literature for articles related to PM and PO was performed. The bibliographies of these articles were reviewed to identify additional relevant references.

RESULTS

There have been no prospective trials of PM or PO for the reduction of breast cancer or ovarian cancer incidence or mortality. Most of the available retrospective studies are composed of women who had surgery for a variety of indications and in whom genetic risk was not well characterized. However, some reports in women at increased risk of breast or ovarian cancer have shown that PM and PO can reduce cancer incidence.

CONCLUSION

Interest in and use of PM and PO are high among physicians and high-risk women. PM and PO seem to be associated with considerable reduction in the risk of breast and ovarian cancer, albeit incomplete. The surgical morbidity of PM and PO is low, but the complications of premature menopause may be significant, and few studies address quality-of-life issues in women who have opted for PM and PO. Management recommendations for high-risk individuals are presented on the basis of the available evidence.

Managing hereditary ovarian cancer risk

Ovarian cancer is the fourth leading cause of cancer deaths in American women. About 10% of cases are thought to have a hereditary basis, and family history is the strongest known risk factor. In the past, prophylactic oophorectomy has been advocated for women with two or more affected first-degree relatives. More recently, with the identification of the genes responsible for most hereditary ovarian cancers (BRCA1, BRCA2), oophorectomy can now be offered specifically to women who are mutation carriers. Conversely, noncarriers in these families can be reassured that their risk of ovarian cancer is not increased. The value of oophorectomy in mutation carriers has not yet been proven, however, and concern exists that the benefit may be less than intuitively expected. First, although the lifetime risk of ovarian cancer initially was reported to be as high as 60%, more recent studies have suggested risks in the range of 15 to 30%. A better understanding of the factors that underlie variable penetrance in mutation carriers is needed to augment our ability to counsel individual women. In addition, peritoneal papillary serous carcinoma indistinguishable from ovarian cancer occurs in some women after oophorectomy. Studies that better define the frequency with which this occurs are needed to establish the magnitude of the protective effect conferred by prophylactic oophorectomy. In view of the uncertainty regarding the efficacy of prophylactic oophorectomy, chemopreventive and early detection approaches also deserve consideration as strategies for decreasing ovarian cancer mortality in women who carry mutations in ovarian cancer susceptibility genes.

Genetic susceptibility testing and prophylactic oophorectomy

About 10% of ovarian cancer cases are thought to have a hereditary basis and family history is the strongest risk factor for the development of this disease. In the past, prophylactic oophorectomy has been advocated for women with two or more affected first-degree relatives. More recently, with the identification of the genes responsible for most hereditary ovarian cancers (BRCA1, BRCA2), oophorectomy can now be offered specifically to women who are mutation carriers. Conversely, non-carriers in these families can be reassured that their risk of ovarian cancer is not increased. The value of oophorectomy in mutation carriers has not yet been proven, however, and there are concerns that the benefit may be less than intuitively expected. First, although the lifetime risk of ovarian cancer initially was reported to be as high as 60%, more recent studies have reported risks in the range of 15-30%. A better understanding of the genetic and/or environmental basis of variable penetrance is needed to augment our ability to counsel women regarding their risk. In addition, peritoneal papillary serous carcinoma indistinguishable from ovarian cancer occurs in some women following oophorectomy. Studies that better define how often this occurs also are needed to establish more firmly the value of prophylactic oophorectomy. In view of the uncertainty regarding the efficacy of prophylactic oophorectomy, chemopreventive and early detection approaches also deserve consideration as strategies for decreasing ovarian cancer mortality in women who carry mutations in ovarian cancer susceptibility genes.

Altered surface and cyst epithelium of ovaries removed prophylactically from women with a family history of ovarian cancer

Despite intensive investigation, the nature of epithelial ovarian cancer precursors remains controversial. Because women with a strong family history of ovarian cancer have a high probability of developing ovarian cancer themselves, ovaries removed prophylactically from such patients provide an opportunity to identify early neoplastic changes. Ovaries removed from 64 consecutive patients undergoing prophylactic oophorectomy and from 30 women with normal ovaries and no known family history of ovarian cancer were examined by light microscopy for a number of histopathologic features and by image cytometry for abnormalities of the cyst and surface epithelium. All analyses were performed without knowledge of the family history. Seven benign, but no tumors of low malignant potential or malignant epithelial tumors were found in the prophylactic oophorectomy group. There were more cortical inclusion cysts in the prophylactically removed than controls ovaries (P = .016), but no other architectural features differed between the two groups. No abnormalities were found in the surface or cyst epithelium in either group by light microscopy. In contrast, image analysis identified differences in the nuclei between the two groups, indicating that those from the surface epithelium of prophylactically removed ovaries were larger and contained more heterogeneously dense chromatin than those of controls, and that nuclei of the cyst epithelium had more irregular outlines. Ovarian epithelium from prophylactically removed ovaries exhibit abnormalities that are only identified by image analysis, and which might represent early preneoplastic changes. Such ovaries may be useful for identifying early molecular changes in ovarian cancer.

Ovarian dysplasia in epithelial inclusion cysts. A morphometric approach using neural networks

BACKGROUND

Ovarian dysplasia has been described in the ovarian surface epithelium by histologic and morphometric studies. This study evaluates ovarian dysplasia in epithelial inclusion cysts adjacent to overt carcinoma and also incidentally found in ovaries removed for nonneoplastic diseases, including oophorectomies for family history of ovarian cancer, using an artificial neural network.

METHODS

Histologic sections from 37 ovaries of which 26 were diagnosed with dysplasia in epithelial inclusion cysts (10 adjacent to carcinoma and 16 incidental) and 11 with benign epithelial inclusion cysts were evaluated by tracing nuclear profiles and assessing measures of nuclear area, shape, and texture. These sections were analyzed using artificial neural networks and also statistically using the Kruskal-Wallis test with the Dunn procedure to compare the morphologic similarity of dysplasia found incidentally in inclusion cysts unrelated to carcinoma from that in inclusion cysts adjacent to carcinoma.

RESULTS

Neither statistical nor artificial neural network analysis was able to distinguish between incidental and adjacent dysplasia. Both types differed significantly from the control cases.

CONCLUSIONS

Neural networks are powerful classification tools when applied to multiple variables extracted from individual cases. In this study, they helped to substantiate the similarity between dysplasia found incidentally and that adjacent to ovarian carcinoma. Because dysplasia represents a potential precancerous lesion, its incidental finding may help identify patients at risk for developing ovarian carcinoma.

Potential criteria for cohort selection in chemoprevention trials of epithelial ovarian cancer

Epithelial ovarian cancer is a heterogeneous disease. Epidemiologic studies have identified risk factors for this disease including advanced age, nulliparity, history of infertility, early age at menarche, late age at menopause, and perhaps ovulation induction. Cohort selection that includes women who have potential precursor lesions and alterations of select biomarkers may prove useful in the design of chemoprevention trials of epithelial ovarian cancer. Nuclear morphometry, specific genetic alterations, and markers of proliferation and differentiation may be useful biomarkers to monitor the efficacy of specific interventions.

Pathology of ovarian cancer precursors

Ninety percent of ovarian cancers in the Western world are epithelial cancers derived from the surface epithelium of the ovary and its inclusion cysts. The so-called surface epithelium is mesothelium that comes to resemble epithelium as it is reflected over the surfaces of the ovaries. At various ages, but particularly in women in the reproductive, menopausal, and postmenopausal age groups, this epithelium migrates into the ovarian stroma to form inclusion cysts. These cysts probably results from a dynamic interplay of surface epithelium and underlying ovarian stroma, but can also develop as a result of periovarian adhesions. There is abundant evidence that their formation is not related to repair of ovulation. It is generally accepted that benign and malignant ovarian epithelial tumors arise from surface epithelium and its cystic derivatives because they both, but particularly the latter, have a potential to differentiate into epithelia similar to those of normal müllerian derivation (tubal, endometrial, and endocervical epithelia) and their tumors resemble those of the fallopian tube, endometrium, and endocervix. Also, both intraepithelial carcinomas and precarcinomatous lesions can be observed in the surface epithelium and its cystic derivatives. These carcinomas may arise de novo or as a transformation of pre-existing benign tumors and non-neoplastic lesions of similar derivation. Surface epithelial inclusion cysts have a greater propensity to undergo neoplasia than does the surface epithelium itself. This difference has been recognized for many years most epithelial ovarian tumors are intraparenchymal, rather than being located on the ovarian surface. More recent evidence includes the immunohistochemical demonstration of various ovarian carcinoma antigens far more frequently in inclusion cyst epithelium than in surface epithelium; and the much more frequent presence of tubal metaplasia in the cyst epithelium than in the surface epithelium. Tubal metaplasia is encountered in non-neoplastic ovaries contralateral to ovarian carcinomas two to three times as frequently as in control ovaries, suggesting that the metaplastic epithelium is more prone to the development of carcinoma that non-metaplastic epithelium. Carcinoma precursors occur in the ovary, as in the cervix and endometrium, but have been reported only rarely because they are easily overlooked and have not been searched for by pathologists.

Screening for ovarian carcinoma: hopeful and wishful thinking

OBJECTIVE

The purpose of this study was to review the published articles on screening for ovarian carcinoma.

STUDY DESIGN

A retrospective review was performed of the articles published in the English literature during the past 10 years. The articles of Herbst and Cohen, included in this panel discussion, were reviewed as part of this study.

RESULTS

Compared with the prevalence of other cancers screened for by gynecologists, that of ovarian cancer is low. Neither CA 125 nor vaginal ultrasonography has consistently provided the mandatory high specificity and sensitivity values required for successful screening of a disease of low prevalence. The cost of vaginal ultrasonography and color flow Doppler studies is too high for mass screening programs.

CONCLUSION

There is little evidence to support widespread screening of large populations of women who do not have familial or genetic risk factors for ovarian carcinoma. An informed patient and an informed physician should weigh the risk-benefit ratios of periodic screening versus prophylactic oophorectomy in the individual high-risk patient. The effectiveness of periodic screening has not been established or proved even for the high-risk patient.

Ovarian dysplasia: nuclear texture analysis

BACKGROUND

Ovarian dysplasia has been defined by histologic and morphometric studies focusing on architectural and nuclear profile changes. A new technique is used to enhance the accuracy of this diagnosis by a quantitative evaluation of the nuclear texture that represents the nuclear chromatin pattern on which conventional diagnoses of malignancy are usually made.

METHODS

Histologic sections from 35 ovaries classified as malignant (12), dysplastic (12), and normal (11) were evaluated by tracing boundaries of nuclear profiles and measuring "textons" (texture primitives) with a histogram analysis of three zones of gray level densities (called for simplification white, gray, and dark). The average combined area was tabulated for specimens with the same diagnosis, and linear regression plots compared the texton area with total nuclear area.

RESULTS

The dimensions of textons originally hidden inside the chromatin and revealed by histograms were found to be closely clustered in normal epithelium, and increasingly dissociated from the containing nucleus as the lesion progressed from dysplastic to malignant. The statistical multivariate analysis including nine parameters correctly classified the three diagnostic categories as normal, dysplastic, and malignant.

CONCLUSIONS

Computerized image analysis of nuclear texture adds accuracy to the recently elaborated morphometric methods to define ovarian dysplasia, a potential precursor of ovarian carcinoma.

Primary peritoneal carcinoma after prophylactic oophorectomy in women with a family history of ovarian cancer. A report of the Gilda Radner Familial Ovarian Cancer Registry

BACKGROUND

According to previous reports, primary peritoneal carcinoma indistinguishable from primary ovarian adenocarcinoma had developed in five women with a history of familial ovarian cancer who had undergone prophylactic oophorectomy.

METHODS

The records from the Gilda Radner Familial Ovarian Cancer Registry were reviewed for instances of prophylactic oophorectomy and cases of primary peritoneal carcinoma occurring after prophylactic oophorectomy.

RESULTS

From 1981 through July 1992, the Gilda Radner Familial Ovarian Cancer Registry accessioned 931 families (a total of 2221 cases of familial ovarian cancer). Currently, 324 women in these families have undergone prophylactic oophorectomy as a preventive measure against the subsequent development of ovarian cancer. Primary peritoneal carcinoma indistinguishable histologically from primary ovarian adenocarcinoma has developed in six of these women 1-27 years after prophylactic oophorectomy.

CONCLUSIONS

Based on this finding and other reports of such primary peritoneal carcinoma, a prospective international study is planned. This study will compare the incidence of peritoneal carcinoma in first- or second-degree relatives who underwent prophylactic oophorectomy because of a family history of ovarian cancer with that of those who did not undergo prophylactic oophorectomy.

Clinicostatistical study of low potential malignancy ovarian cystadenoma (borderline cases)

The number of ovarian cystadenoma of low potential malignancy (abbreviation: LPM) was 31 (5.7%) among common epithelial tumors [benign cystadenoma = 400 (74.0%), carcinoma = 110 (20.3%)]. Their mean ages, bilaterlity, frequency of ascites and nulligravidity were situated intermediately between those of benign cystadenoma and carcinoma. Abdominal tumor, distention, pain and metromenorrhagia were the main symptoms, although gastrointestinal complaints were rare in LPM cystadenoma. With LPM cystadenoma, 19 (61.3%) patients were at stage I, 7 (22.6%) at stage II and 5 (16.1%) at stage III, but with carcinoma, 44 (40.0%) were at stage III-IV [33 (30.0%) at stage I, and 31 (28.2%) at stage II]. The 5-year actuarial survival rate was 90% for LPM cystadenoma, but 43% for carcinoma. These results suggest that the clinical and biological features as well as the histological definition of LPM cystadenoma are situated intermediately between those of benign cystadenoma and carcinoma.