Bone metastasis from a granulosa cell tumor of the ovary

Particular tumor of the pancreas: A case report

BACKGROUND

Granular cell tumor (GCT) of the pancreas is a rare neurogenic tumor. The first case of pancreatic GCT was described in 1975, and up to now, only 7 cases have been reported.

CASE SUMMARY

A 53-year-old male had a pancreatic mass for 1 mo. He was not treated at the local hospital, but referred to Henan Tumor Hospital for surgery. Preoperative imaging revealed a 2.0 cm × 2.5 cm-sized mass located in the body of the pancreas. At the microscopic level, a large number of eosinophilic particles are present in the oval tumor cells. The immunohistochemistry of this tumor cell display CD56 (+), blood vessels CD34 (+), Ki-67 (+) < 10%, and S-100 (+).

CONCLUSION

GCT of the pancreas should be recognized as a preoperative differential diagnosis of pancreatic tumors. Surgical resection of the tumor should be attempted; however, GCT of the pancreas has a certain rate of tumor metastasis and recurrence. Therefore, GCT of the pancreas requires regular and long-term follow-up.

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

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSION

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

Ovarian Granulosa Cell Tumor: A Clinicoradiologic Series with Literature Review

BACKGROUND

Ovarian granulosa cell tumors that originate from the sex cord-stromal cells represent 2% to 5% of all ovarian cancers. These tumors constitute two subgroups according to their clinical and histopathological features: juvenile granulosa cell tumors (JGCT) and adult granulosa cell tumors (AGCT). Granulosa cell tumor (GCT) is considered to be a low-grade malignancy with a favorable prognosis.

METHODS

This case series includes four patients who were admitted to our university hospital and had an MRI examination within 5 years.

RESULTS

The histopathological subtype of granulosa tumor was the adult type in 3 patients and juvenile type in 1 patient. Even though it is extremely rare, bone metastases were present in one of our patients. Liver metastases were also detected in one patient. The MRI examination of tumors revealed a heterogeneous solid mass that contained cystic components in 3 patients. In one of our patients, the tumor had a multiseptated cystic feature, and all of the tumors were ovoid or round with smooth margins. T1 signal hyperintensity, not suppressed on fat saturation sequences, was observed in 3 patients, which represents its hemorrhagic content.

CONCLUSION

Even though granulosa cell tumor shows a wide spectrum in terms of tumor appearance, some common findings have been shown and especially a hemorrhagic content could be a clue for us. The tumor is known to have a good prognosis, but it may have an unpredictable clinical course, so close follow-up is greatly important.

Mesenteric metastasis of granulosa cell tumor in a bitch – a case report

Anamnesis: A 5-year-old mixed breed entire bitch was presented with bloody vaginal discharge and abdominal distension. Clinical and laboratory findings: Physical examination and abdominal ultrasonography suggested the presence of a left ovarian tumor. At histopathological examination it was diagnosed as granulosa cell tumor. Treatment approach: An exploratory laparotomy was performed followed by ovariohysterectomy to remove the intra-abdominal mass. Conclusion: The clinical, ultrasonographic and histologic signs in this case support other literature reports. Ultrasonography, in combination with histopathologic analysis is a fundamental tool for detection of ovarian tumors, especially tumors of the granulosa cells.

Right trisectionectomy for liver metastasis of granulosa cell tumor: a case report and literature review

BACKGROUND

Granulosa cell tumor (GCT) is a type of ovarian sex cord-stromal tumor with low-grade malignancy, which can recur long after primary resection. All reports on GCTs in the liver describe cases of metastases, while there are no previous reports of primary GCTs originating from the liver. We report a case of GCT, with recurrence of liver metastasis long after ovariectomy, which was subsequently resected by a right trisectionectomy.

CASE PRESENTATION

A 76-year-old woman presented with a history of surgical resection of an ovarian tumor performed 30 years previously; no details of the tumor were available. When she was 68 years old, an abdominal ultrasound revealed a small liver mass, which was diagnosed as a hepatic hemangioma with slow growth. Outpatient follow-up was discontinued for 5 years, and the patient was not examined again until the age of 76 years. At this point, the tumor had substantially increased in size, and surgical resection was required owing to suspicion of malignancy. The patient was then referred to our hospital. Contrast-enhanced computed tomography (CT) showed a large tumor, approximately 18 cm in size, occupying the right lobe and medial section of the liver. After percutaneous transhepatic portal vein embolization, a right trisectionectomy was performed. The histopathological findings of the resected specimen showed that the tumor cells had "coffee bean-like" nuclear grooves, which are characteristic of a GCT. Acidophilic non-structural Call-Exner bodies were also observed. Inhibin-α, CD99, and CD56 markers of sex cord-stromal tumors were detected on immunohistological examination; all pathology suggested a GCT. We considered the tumor to be a liver metastasis of a previous ovarian GCT that was resected 30 years prior by ovariectomy. There was no recurrence for > 15 months after the hepatectomy.

CONCLUSIONS

We report a case of a GCT in the liver, which was identified to be a liver metastasis. Right trisectionectomy was subsequently performed for tumor resection. Clinicians should be aware that ovarian GCTs may recur in the liver, and that GCT recurrence may occur long after ovariectomy of the primary ovarian GCT.

Ovarian adult-type granulosa cell tumor: focusing on endocrine-based therapies

Adult-type granulosa cell tumors (GCTs), although rare, are the most commonly diagnosed neoplasms arising in the endocrine-active ovarian stroma. They are characterized by excessive production of estrogens, antimullerian hormone and inhibins. In 2009, a specific mutation in FOXL2 was identified to be pathognomonic of GCTs. How dysregulation of this transcription factor, resulting in upregulation of aromatase, leads to unchecked proliferation, and progression to a malignancy, remains unclear. The key pathological and clinical feature of GCTs that affects their usually favorable outcomes is a diagnosis of greater than Stage 1 disease at presentation. Chemotherapy is given as adjuvant upon an advanced stage diagnosis; however, its effect on survival upon recurrence is modest. On the other hand, aromatase inhibitors also lead to tumor regression and are suitable for long-term maintenance.

Supraclavicular Metastases from a Sex Cord Stromal Tumor of the Ovary

Metastases to the supraclavicular fossa usually originate from head and neck or infraclavicular tumors. Ovarian primaries of supraclavicular metastases are very rare. Sex cord stromal tumors of the ovary account for 5–8% of all ovarian malignancies and there have been only a few case reports on distant metastases from these tumors. A 46-year-old woman presented to us with a left supraclavicular mass. She had had a sex cord stromal tumor in the right ovary four years before. Comprehensive clinical investigation and fine-needle aspiration cytology were performed. The lesion had the characteristics of a sex cord stromal tumor. To our knowledge, this is the first report of such a case in the English literature. We discuss its pathological and clinical features in the light of the current knowledge.

Osseous Metastases in Gynaecological Epithelial Malignancies: A Retrospective Institutional Study and Review of Literature

INTRODUCTION

Osseous metastasis in gynaecological epithelial tumours is an extremely rare phenomenon occurring in less than 1% of these cancers.

AIM

To analyse the clinical characteristics and prognosis in patients with gynaecological epithelial cancers with bone metastases.

MATERIALS AND METHODS

This was a single institutional retrospective study done with the data available from January 2008 to January 2015. Out of 1686 patients with epithelial gynaecological malignancies there were a total 18 (1.07%) patients with osseous metastasis. Clinico-pathologic characteristics were tabulated in Microsoft Excel 2013 and data were analysed using SPSS software Version 21. A p-value< 0.05 was taken to be statistically significant. Survival analysis was done by using Kaplan-Meier method and log-rank test was used to find out the difference in survivals.

RESULTS

Out of the 18 gynaecological epithelial cancer patients with bone metastases, 12 had cervical cancer, three had ovarian cancer, two had endometrial carcinoma and one patient had vulvar malignancy. Twelve patients had squamous cell histology, while the rest had adenocarcinoma. The mean interval from primary diagnosis of cancer to the detection of bone metastases was 31.9 months (range, 1 - 60 months). Solitary bone lesion was present in seven patients. The most common site of bone metastasis was lumbar vertebra. Extra-osseous metastasis was present in 12 patients. The mean follow-up period was 8.3 months. During the follow-up period 12 out of the 18 patients died. There was significant difference in survival (p = 0.005) between patients with solitary bone metastasis and patients with multiple osseous metastases. Near significant survival difference (p = 0.056) was also noted in patients with extra-osseous metastases when compared to the patients without. Improved survival was also found in patients with controlled local disease (p = 0.003) when compared to patients with local failure.

CONCLUSION

Bone metastasis in gynaecological epithelial malignancies is a rare phenomenon, but with grave prognosis. Multiple sites of bone involvement, recurrence at the primary tumour site and presence of other non-osseous metastases are poor prognostic indicators. Treatment in these patients should be tailored according to the patient's need.

Transforming growth factor alpha (TGFα) regulates granulosa cell tumor (GCT) cell proliferation and migration through activation of multiple pathways

Granulosa cell tumors (GCTs) are the most common ovarian estrogen producing tumors, leading to symptoms of excessive estrogen such as endometrial hyperplasia and endometrial adenocarcinoma. These tumors have malignant potential and often recur. The etiology of GCT is unknown. TGFα is a potent mitogen for many different cells. However, its function in GCT initiation, progression and metastasis has not been determined. The present study aims to determine whether TGFα plays a role in the growth of GCT cells. KGN cells, which are derived from an invasive GCT and have many features of normal granulosa cells, were used as the cellular model. Immunohistochemistry, Western blot and RT-PCR results showed that the ErbB family of receptors is expressed in human GCT tissues and GCT cell lines. RT-PCR results also indicated that TGFα and EGF are expressed in the human granulosa cells and the GCT cell lines, suggesting that TGFα might regulate GCT cell function in an autocrine/paracrine manner. TGFα stimulated KGN cell DNA synthesis, cell proliferation, cell viability, cell cycle progression, and cell migration. TGFα rapidly activated EGFR/PI3K/Akt and mTOR pathways, as indicated by rapid phosphorylation of Akt, TSC2, Rictor, mTOR, P70S6K and S6 proteins following TGFα treatment. TGFα also rapidly activated the EGFR/MEK/ERK pathway, and P38 MAPK pathways, as indicated by the rapid phosphorylation of EGFR, MEK, ERK1/2, P38, and CREB after TGFα treatment. Whereas TGFα triggered a transient activation of Akt, it induced a sustained activation of ERK1/2 in KGN cells. Long-term treatment of KGN cells with TGFα resulted in a significant increase in cyclin D2 and a decrease in p27/Kip1, two critical regulators of granulosa cell proliferation and granulosa cell tumorigenesis. In conclusion, TGFα, via multiple signaling pathways, regulates KGN cell proliferation and migration and may play an important role in the growth and metastasis of GCTs.

Bone metastases from gynaecological epithelial cancers

The aim of this study was to investigate the clinical features and prognosis in patients with gynaecological epithelial cancers metastasised to bones. A total of 26 patients were studied retrospectively. Clinical and pathological data were analysed along with a follow-up. It was found that the interval from primary diagnosis of cancer until bony relapse varied between 0 and 163 months (31.4 ± 36.8). Bone metastases were solitary in 11 cases and multifocal in 15 cases. A total of 14 patients demonstrated only bony metastases while 12 had both bony and non-bony metastases. The time to follow-up from the diagnosis of osseous relapse varied between 1 and 43 months (10.0 ± 10.4). During follow-ups, 13 patients died and 13 patients survived. In both univariate and multivariate analyses, synchronous non-bony metastases and symptomatic treatment without oncological therapy impaired prognosis. It was concluded that even in the presence of multiple bone metastases, some patients may benefit from radiotherapy, chemotherapy or a combination of both, rather than palliative care alone, providing they do not have additional soft tissue metastases.

GnRH agonist therapy in a patient with recurrent ovarian granulosa cell tumors

A 65-yr-old woman presented 17 yr status post-hysterectomy with bilateral ovarian salpingo-oophorectomy, attributable to ovarian cancer. She was admitted to our hospital, with multiple cystic liver masses and multiple large seeded masses in her abdomen and pelvic cavity. Histological examination of the pelvic masses demonstrated granulosa cell tumors. After two courses of systemic combination chemotherapy, with paclitaxel and carboplatin, the masses in the abdomen and pelvic cavity increased, and debulking surgery also failed because of peritoneal dissemination with severe adhesion. Finally, she underwent palliative radiotherapy for only the pelvic masses obstructing the urinary and GI tracts, and monthly hormonal therapy with a gonadotrophin-releasing hormone agonist; leuprorelin 3.75 mg IM. Subsequently, multiple masses beyond the range of the radiation as well as those within the radiotherapy field partially decreased. This partial response had been maintained for more than 8 months as of the last follow-up visit. Owing to its long and indolent course and the low metabolic rate of the tumors, advanced or recurrent granulosa cell tumor (GCT) requires treatment options beyond chemotherapy, surgery, and radiotherapy. Hormonal agents may provide another treatment option for advanced or recurrent GCT in those who are not candidates for surgery, chemotherapy, or radiotherapy.

Imaging of gynecological disease (3): clinical and ultrasound characteristics of granulosa cell tumors of the ovary

OBJECTIVES

To describe the clinical and ultrasound characteristics of granulosa cell tumors (GCTs) of the ovary, and to define the ultrasound appearance of GCTs based on pattern recognition.

METHODS

Databases of four gynecological ultrasound centers were searched to identify patients with histologically proven GCTs who had undergone a standard preoperative ultrasound examination.

RESULTS

A total of 23 women with confirmed GCT were identified. Twelve (52%) women were postmenopausal, nine (39%) were of fertile age and two (9%) were prepubertal. Clinical symptoms were abdominal distension (7/23, 30%), pain (5/23, 22%) and irregular vaginal bleeding (6/23, 26%). Seven patients (30%) were asymptomatic. Endometrial pathology was found in 54% (7/13) of the patients from whom endometrial biopsies were taken. On ultrasound scan 12/23 (52%) masses were multilocular-solid, 9/23 (39%) were purely solid, one mass (4%) was unilocular-solid and one mass was multilocular (4%). Multilocular and multilocular-solid cysts typically contained large numbers of small locules (> 10). The echogenicity of the cyst content was most often mixed (6/16, 38%) or low level (7/16, 44%). Papillary projections were found in only four women (17%). The GCTs were large tumors with a median largest diameter of 102 (range, 37-242) mm and manifested moderate or high color content at color Doppler examination (color score 3 in 13/23 tumors (57%); color score 4 in 8/23 tumors (35%)).

CONCLUSIONS

At ultrasound examination, most GCTs are large multilocular-solid masses with a large number of locules, or solid tumors with heterogeneous echogenicity of the solid tissue. Hemorrhagic components are common and increased vascularity is demonstrated at color/power Doppler ultrasound examination. The hyperestrogenic state that is created by the tumor often causes endometrial pathology with bleeding problems as a typical associated symptom.

Management of ovarian stromal cell tumors

PURPOSE

To describe the clinical management of ovarian stromal cell tumors, which are a heterogeneous group of neoplasms that develop from the sex cords and the ovarian stroma.

DESIGN

We reviewed the current evidence on the clinical management of these relatively rare ovarian malignancies, which are typically detected at an early stage and may recur as late as 30 years following the initial treatment. The overall prognosis is favorable with a long-term survival ranging from 75% to 90% for all stages. Adult granulosa cell tumor (GCT) is the most common malignancy among these tumors.

RESULTS

Surgery is the cornerstone of initial treatment. In women of childbearing age and with disease limited to one ovary, a fertility-sparing surgery can be a reasonable approach. Tumor stage represents the most important clinical parameter of prognostic relevance. The value of postoperative adjuvant therapy for high-risk patients has not been proven by prospective randomized studies. Platinum-based chemotherapy is used currently for patients with advanced stages or recurrent disease, with an overall response rate of 63% to 80%. Taxane and platinum combination chemotherapy seems to be a reasonable candidate for future trials. Little evidence exists for the use of radiation or hormonal therapy, and these modalities should be restricted to selected cases. Given the propensity of GCT for late relapse, prolonged follow-up is required.

CONCLUSION

Surgery remains the most effective treatment for ovarian stromal tumors and, whenever feasible, for relapsing disease. Platinum-based chemotherapy is currently used in metastatic or recurrent tumors.

Prognostic factors of ovarian granulosa cell tumor: a study of 35 patients and review of the literature

Ovarian granulosa cell tumors (GCT) are rare tumors with a tendency of late relapse and good prognosis. FIGO stage, tumor size, degree of cellular atypia, and mitotic index have been reported to predict recurrence. The objective of this study is to evaluate treatment practice and prognostic factors of GCT. For this purpose, a detailed review of patient files and histopathologic evaluation of tumor samples, including estimation of growth pattern, presence of Call-Exner bodies, nuclear atypia, mitotic index, and immunohistochemical staining for inhibin and Ki-67 were analyzed. Thirty-five patients had histologically confirmed GCT. Four patients had a simultaneous endometrial adenocarcinoma. Median follow-up time was 135 months (range 19-334 months). Recurrent disease was detected in seven patients. Time from diagnosis to the first recurrence varied from 24 to 141 months. There was no difference in tumor size, nuclear atypia, mitotic index, presence of Call-Exner bodies, or Ki-67 staining between nonrecurred and recurred patients. The only factor associated with risk of recurrence was rupture of the tumor (P < 0.0001), and the only factor associated with overall survival was FIGO stage (P = 0.032). The disease-free and overall survivals were not statistically different between patients treated (N = 18) or not treated (N = 17) with adjuvant therapy. One patient has experienced seven recurrences, has been treated with surgery, radiation therapy, chemotherapy, and hormonal therapy, and is still alive 26 years from diagnosis. FIGO stage and tumor rupture were the only factors associated with the outcome of GCT. Treatment of relapse, even in case of multiple recurrences, is usually worthwhile.

Ovarian granulosa cell tumors frequently express EGFR (Her-1), Her-3, and Her-4: An immunohistochemical study

OBJECTIVE

Up to 50% of patients with ovarian granulosa cell tumors (GCTs) will develop recurrences; some of these recurrences can be seen as late as 30 years following the initial surgical treatment. Combined chemotherapy and radiotherapy are currently used for patients with advanced or recurrent disease. The aim of this study was to investigate the possible eligibility of patients with GCTs for anti-Her therapy.

METHODS

The immunohistochemical expression of EGFR (Her-1), Her-2, Her-3, and Her-4 was analyzed in a group of ovarian GCTs encompassing 38 adult type and 2 juvenile type.

RESULTS

Thirty-one cases (77.5%) were positive for at least one of the receptors EGFR (Her-1), Her-3, and Her-4. Twenty-six out of 40 (65%) GCTs showed positive reaction for EGFR (Her-1). Eight tumors (20%) were exclusively positive for EGFR (Her-1). None of 40 cases showed a positive reaction for Her-2. Positive reactions for Her-3 and Her-4 were observed in 18 (45%) and 23 (57.5%) tumors. Only one case (2.5%) was exclusively positive for Her-4. Four tumors (10%) showed positivity for Her-3 and Her-4 but were negative for EGFR (HER-1). While one of the two JGCTs was negative for all members of the Her-family, one showed reactivity for EGFR (Her-1), Her-3, and Her-4.

CONCLUSION

In this study, most of the ovarian GCTs express at least one of the receptors EGFR (Her-1), Her-3, and Her-4. These findings provide some evidence to further explore the potential use of agents targeting these receptors (particularly EGFR) in the treatment of ovarian GCTs.

Adult granulosa cell tumour of the testis and bony metastasis. A report of the first case of granulosa cell tumour of the testicle metastasising to bone

Granulosa cell tumour is among the rarest forms of testicular cancer. Only 21 cases have been reported to date and only 4 have metastasised. All documented metastases are intra-abdominal. We present the first case of granulosa cell tumour of the testis metastasising to bone (tibia), presenting 6 years after orchidectomy. This highlights the need to maintain a high index of suspicion for extra-abdominal metastases during long-term follow-up in patients with previous testicular granulosa cell tumour.

Update on granulosa cell tumours of the ovary

PURPOSE OF REVIEW

Granulosa cell tumours of the ovary are an uncommon ovarian sex-cord stromal tumour. These neoplasms provide a spectrum of clinical presentations that span from the first to the tenth decade. Surgery represents the primary therapy for early stage disease; however, management of women with advanced disease is less clear. Because of their relative rarity, evidence to support decision-making in the management of granulosa cell tumours is limited. The purpose of this review is to provide the clinician with an updated knowledge of the clinical and molecular aspects of granulosa cell tumours in order to guide therapy.

RECENT FINDINGS

The clinical stage, mitotic index and cellular atypia correlate most strongly with prognosis. However, these tumours may demonstrate heterogeneous genetic aberrations that can predict behaviour and response to therapy. Case series and reports suggest that postoperative combination chemotherapy is of most benefit in advanced disease. Serial measurements of serum inhibin may be helpful in the follow-up of these women, particularly in the post-menopausal group.

SUMMARY

The pathology and treatment of women with granulosa cell tumours of the ovary is complex. Such women should be managed in a multidisciplinary gynaecological oncology unit. A better understanding of the molecular pathology may assist treatment.