Primary retroperitoneal mucinous cystoadenocarcinomas: an immunohistochemical and molecular study

Primary Retroperitoneal Carcinomas: New Insights into Pathogenesis and Clinical Management in Comparison with Ovarian Carcinomas and Carcinoma of Unknown Primary

Primary retroperitoneal carcinomas are very rare tumors. Their pathogenesis remains unknown but may be associated with that of ovarian carcinomas, considering the similarity in morphology and gender preference. Although metaplasia of coelomic epithelium is the most widely accepted theory, the pathogenesis of retroperitoneal carcinomas may differ by histologic subtype, like ovarian carcinomas. Mucinous carcinoma, which develops in both women and men, may originate in both primordial germ cells and Walthard cell nests that may be derived from the fallopian tube. Serous carcinomas may be associated with endosalpingiosis, the presence of fallopian tube-like epithelium outside the fallopian tube, and a remnant Müllerian tract. Endometrioid and clear cell carcinomas appear to be associated with extraovarian endometriosis. Additionally, both carcinomas in the retroperitoneal lymph nodes may be metastatic diseases from endometrial and/or renal cell cancer that regress spontaneously (carcinoma of unknown primary). Retroperitoneal carcinomas are difficult to diagnose, as they have no characteristic symptoms and signs. Surgery is the cornerstone of treatment, but the necessity of chemotherapy may depend on histological subtype. Further studies are necessary, in particular studies on endosalpingiosis, as endosalpingiosis is a poorly understood condition, although it is associated with the development of both serous and mucinous carcinomas.

Primary retroperitoneal mucinous cystadenocarcinoma (PRMCa): a systematic review of the literature and meta-analysis

PURPOSE

Primary retroperitoneal mucinous cystadenocarcinoma (PRMCa) is a rare tumour. Prognosis and optimal management are not well established. In view of a case managed in our Centre, we performed a systematic review and meta-analysis.

METHOD

Systematic review of medical electronic databases for published data (1950-12/10/2015). No RCTs identified. Individual patient data detracted from case reports and case series were analysed

RESULTS

In total, 73 female and 5 male cases of PRMCa identified including our case. Median age at diagnosis was 42.0 years (range 18-86 years), with women being significantly younger than men at diagnosis (42.0 years versus 62.2 years, p = 0.005). A palpable abdominal mass and abdominal pain were the most common presentations in 42.9 and 23.8 % of cases, respectively. Twenty-six women were <38 years old. There were 16 women <38 years old that had surgical data reported, of which 14 underwent fertility-sparing surgery with excision of the mass. Adjuvant chemotherapy was given in 24.1 % (13/72) women. Follow-up ranged from 1 to 130 months with a median of 15 months. Of the 57 cases that had follow-up reported, recurrence occurred in 23 cases (40.4 %) within a median of 8 months from diagnosis. Median disease-free survival was 15 months (range 1-130 months). Of the women who recurred, 14 died of their disease giving 1, 2 and 5-year disease-specific survival rates of 85.9, 80.7 and 75.4 %, respectively.

CONCLUSION

PRMCa are rare and potentially aggressive tumours that often occur in young women. Removal of the tumour, adequate staging and adjuvant chemotherapy needs to be considered.

Precancerous lesions of the pancreas

Pancreatic cancer has a very poor prognosis, with a five year survival of only 5%. New studies have shown that it takes over 11 years for cells to develop invasive capability. This provides an opportunity to intervene if precursor lesions can be detected. This paper reviews the molecular, pathological, clinical findings and management of pancreatic intraepithelial neoplasia (PanIN), intraductal pancreatic mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN), three precursor lesions which can give rise to invasive carcinoma of the pancreas.

Mucinous cystic neoplasm of the pancreas is not an aggressive entity: lessons from 163 resected patients

OBJECTIVE

Mucinous cystic neoplasms (MCNs) of the pancreas have often been confused with intraductal papillary mucinous neoplasms. We evaluated the clinicopathologic characteristics, prevalence of cancer, and prognosis of a large series of well-characterized MCNs in 2 tertiary centers.

METHODS

Analysis of 163 patients with resected MCNs, defined by the presence of ovarian stroma and lack of communication with the main pancreatic duct.

RESULTS

MCNs were seen mostly in women (95%) and in the distal pancreas (97%); 25% were incidentally discovered. Symptomatic patients typically had mild abdominal pain, but 9% presented with acute pancreatitis. One hundred eighteen patients (72%) had adenoma, 17 (10.5%) borderline tumors, 9 (5.5%) in situ carcinoma, and 19 (12%) invasive carcinoma. Patients with invasive carcinoma were significantly older than those with noninvasive neoplasms (55 vs. 44 years, P = 0.01). Findings associated with malignancy were presence of nodules (P = 0.0001) and diameter > or =60 mm (P = 0.0001). All neoplasms with cancer were either > or =40 mm in size or had nodules. There was no operative mortality and postoperative morbidity was 49%. Median follow-up was 57 months (range, 4-233); only patients with invasive carcinoma had recurrence. The 5-year disease-specific survival for noninvasive MCNs was 100%, and for those with invasive cancer, 57%.

CONCLUSIONS

This series, the largest with MCNs defined by ovarian stroma, shows a prevalence of cancer of only 17.5%. Patients with invasive carcinoma are older, suggesting progression from adenoma to carcinoma. Although resection should be considered for all cases, in low-risk MCNs (< or =4 cm/no nodules), nonradical resections are appropriate.

Primary retroperitoneal mucinous cystadenocarcinoma: report of two cases

Background

Retroperitoneal cystadenocarcinomas are rare lesions, the majority of cases presented as one-patient reports.

Methods

We present two cases of retroperitoneal cystadenocarcinoma, both in women of reproductive age: one with aggressive behavior, and the remaining case, with a more indolent clinical evolution.

Results

One case presented as pelvic tumor, was treated with surgical resection of the disease, but manifested with recurrent disease a few months later despite use of chemotherapy. The second case involved a patient with diagnosis of abdominal tumor; during laparotomy, a retroperitoneal tumor was found and was totally removed. At follow-up, the patient is disease-free with no other treatment.

Conclusion

The behavior and treatment of retroperitoneal cystadenocarcinoma are controversial. We suggest aggressive surgery including radical hysterectomy and bilateral salpingoopherectomy with adjuvant chemotherapy in these cases.

Primary retroperitoneal mucinous cystadenocarcinoma in a male patient

Primary retroperitoneal mucinous cystadenocarcinomas (PRMCs) are rare. This is the first reported case in the literature in English of PRMC in a man. The 64-year-old man presented with a large retroperitoneal cystic tumour measuring 24 x 20 x 16 cm3, which was removed intact. Areas ranging from a benign mucinous cyst to borderline mucinous tumour to mucinous cystadenocarcinoma were observed on microscopy. Strong patchy staining for cytokeratins 7 and 20 and strong diffuse staining for MUC2 and MUC5AC core peptides, similar to staining patterns in ovarian mucinous tumours, were shown in the benign and atypical epithelium. Staining for CA19.9 and carcinoembryonic antigen was also shown by both components. The theory of its origin from the mucinous metaplasia of peritoneal (mesothelial) inclusion cysts, rather than from ectopic ovarian tissue or ovarian teratomas, is supported by the occurrence of such a tumour in a male patient.

A primary retroperitoneal serous cystadenocarcinoma with clinically aggressive behavior

CASE REPORT

We describe a 44-year-old woman with a primary retroperitoneal serous cystadenocarcinoma as the fourth report in the world literature. A contrast-enhanced computed tomographic scan of the abdomen demonstrated a mass with enhanced solid mural nodules and septa in the left retroperitoneum. Serum CA19-9 was elevated at 181 U/ml. The patient underwent a complete resection of the retroperitoneal tumor with a partial resection of the psoas major muscle and its fascia. Pathological examination showed a well-differentiated papillary serous cystadenocarcinoma of ovarian type and locoregional lymph node metastases. Seven months after surgery, the patient developed a pelvic recurrence, and underwent a total hysterectomy, a left salpingo-oophorectomy and a resection of the metastatic mesenteric mass. Two months after the second surgery, serum CA19-9 and CA125 increased to 1,114 U/ml and 218 U/ml, respectively. A solitary liver metastasis was confirmed on a computed tomographic scan. The patient is now being treated with weekly docetaxel and carboplatin.

CONCLUSION

The present case illustrates the clinically aggressive nature of a primary retroperitoneal serous cystadenocarcinoma.

Treatment of a case of primary retroperitoneal mucinous cystadenocarcinoma: is adjuvant hysterectomy and bilateral salpingo-oophorectomy justified?

OBJECTIVE

We present a case of primary retroperitoneal mucinous cystadenocarcinoma in a 38-year-old woman.

STUDY DESIGN

The tumor was resected with a segment of adjacent descending colon. Five years after the operation, the patient is well, without evidence of recurring disease, based on clinical investigation and modern imaging techniques.

RESULTS

In the light of the literature, it appears most likely that this rare tumor is caused by coelomic metaplasia. On the basis of the histopathologic findings in our case and the reports from the literature, we recommend radical tumor excision en bloc with all infiltrated adjacent structures.

CONCLUSION

Added removal of unaffected uterus and adnexes makes young women infertile and climacteric and is not yet validated by long-term results.

Retroperitoneal mucinous cystadenoma

Primary retroperitoneal mucinous cystadenoma is an uncommon tumor found exclusively in women. Herein, we describe a patient who had resection of a large retroperitoneal cystic mass. Histologic, immunohistochemical, and electron microscopic examination of the lining epithelial cells showed features of mesothelial cells in addition to ovarian mucinous cystadenoma. These findings suggest that these tumors arise from inclusions of mesothelial cells and subsequent mucinous metaplasia of the lining cells to form a cystadenoma. Estrogen receptors may be implicated in tumor promotion, explaining the occurrence exclusively in women.

Mucinous cystic tumors of the pancreas: clinicopathological features, prognosis, and relationship to other mucinous cystic tumors

The clinicopathological features of 56 patients with mucinous cystic tumors (MCTs) of the pancreas were studied. Particular attention was paid to the prognosis of MCTs and the relationship to their ovarian, hepatic, and retroperitoneal counterparts. To distinguish MCTs from pancreatic intraductal papillary-mucinous tumors, MCTs were defined as tumors lacking communication with the duct system and containing mucin-producing epithelium, usually supported by ovarian-like stroma. All 56 tumors occurred in women (mean age 48.2 years) and were preferentially (93%) located in the body and tail of the pancreas. In accordance with the WHO classification, MCTs were divided into adenomas (n = 22), borderline tumors (n= 12), and noninvasive and invasive carcinomas (n = 22). Survival analysis revealed the extent of invasion to be the most significant prognostic factor (p<0.0001). Malignancy correlated with multilocularity and presence of papillary projections or mural nodules, loss of ovarian-like stroma, and p53 immunoreactivity. Stromal luteinization with expression of tyrosine hydroxylase, calretinin, or alpha inhibin was found in 66% of the cases. We conclude that the biologic behavior of MCTs is predictable on the basis of the extent of invasion. The similarities (i.e. gender, morphology, stromal luteinization) between pancreatic MCT and its ovarian, hepatobiliary, and retroperitoneal counterparts suggest a common pathway for their development.

Primary retroperitoneal mucinous tumor of low malignant potential: histogenetic aspects and review of the literature

We report an unusual mucinous tumor of low malignant potential, of ovarian-like type, arising in the retroperitoneum of an otherwise healthy 33-year-old woman. This is the fifth described case of such a tumor in the world literature, and the first reported in Scandinavia or Europe. We also discuss aspects of the histogenesis of this type of tumor and review the available literature. The histological heterogeneity and metastatic potential of the tumor warrant careful histopathologic analysis and follow-up of patients presenting with such lesions.

Primitive mucinous cystadenocarcinoma of the retroperitoneum. Case report and diagnostic considerations

The combination of ultrasonography (US) and computed tomography (CT) proved useful in recognizing and defining the characteristics of a primitive mucinous cystadenocarcinoma of the retroperitoneum, a rare anatomopathological finding which consistently presents certain macroscopic features that help in the formulation of a diagnosis with imaging techniques.