Luteinized Thecomas (“Thecomatosis”) with Sclerosing Peritonitis (LTSP): Report of 2 Cases and Review of an Enigmatic Syndrome Associated with a Peritoneal Proliferation of Specialized (vimentin+/keratin+/CD34+) Submesothelial Fibroblasts

Sex Cord-Stromal Tumors of the Ovary: An Update and Review. Part I-Pure Ovarian Stromal Tumors

In two separate reviews, we reviews the time-honored but still frequently challenging features of ovarian sex cord-stromal tumors, and also emphasize new developments including unusual morphologic appearances that, despite the relative rarity of many of the tumors, result in a disproportionate number of differential diagnostic problems, variant immunohistochemical profiles, and specific molecular and syndromic associations. These neoplasms are also of historical interest as current knowledge is still based in significant part on the contributions of 2 giants of gynecologic pathology, Dr Robert Meyer and Dr Robert E. Scully. In part I, we present the major clinical, pathologic, and genomic features of the pure ovarian stromal tumors including comments on differential diagnosis and briefly note significant historical contributions. In part II we will discuss pure sex cord and sex cord-stromal tumors.

Sex Cord-Stromal Tumors of the Ovary

Ovarian sex cord-stromal tumors (OSCSTs) are a rare group of ovarian neoplasms that can be benign or malignant. They are classified into pure sex cord tumors, pure stromal tumors, and mixed SCST. The most common malignant OSCSTs are adult granulosa cell tumors. In contrast to the more common ovarian epithelial malignancies, OSCSTs present in younger patients, often at early stages, with better prognoses. Imaging features are variable, and pathology is required for diagnosis. However, certain tumors demonstrate characteristic imaging appearances that can be useful in narrowing the differential diagnosis.

Multimodality Imaging Approach to Ovarian Neoplasms with Pathologic Correlation

Ovarian neoplasms can be categorized on the basis of histopathologic features into epithelial surface cell tumors, germ cell tumors, sex cord-stromal tumors, and metastases. While their imaging appearance is often nonspecific, it closely parallels the gross pathologic appearance, and radiologic-pathologic correlation is helpful to aid in a deeper understanding of the subtypes. Epithelial cell neoplasms are the most common category, and they can be benign, borderline, or malignant. Specific subtypes include serous (most common), mucinous, seromucinous, endometrioid, clear cell, Brenner, and undifferentiated. High-grade serous cystadenocarcinoma accounts for the majority of malignant ovarian tumors and the most ovarian cancer deaths. While serous neoplasms are often unilocular and bilateral, mucinous neoplasms are larger, unilateral, and multilocular. Solid components, thickened septa, and papillary projections, particularly with vascularity, indicate borderline or malignant varieties. Endometrioid and clear cell carcinomas can arise within endometriomas. Fibrous tumors (cystadenofibroma, adenofibroma, fibroma or fibrothecoma, and Brenner tumors) demonstrate low T2-weighted signal intensity of their solid components, while teratomas contain lipid. The nonspecific imaging appearance of additional malignant ovarian germ cell tumors can be narrowed with tumor marker profiles. Sex cord-stromal tumors are often solid, and secondary signs from their hormonal secretion can be a clue to their diagnosis. The authors review the anatomy of the ovary and distal fallopian tube, the proposed origins of the histologic subtypes of tumors, the clinical features and epidemiology of ovarian neoplasms, and the applications of US, CT, and MRI in imaging ovarian neoplasms. The main focus is on the radiologic and pathologic features of the multiple ovarian neoplasm subtypes. An algorithmic approach to the diagnosis of ovarian neoplasms is presented. Online supplemental material is available for this article. ^©RSNA, 2020.

Luteinized thecoma (thecomatosis) with sclerosing peritonitis: a systematic review of the literature of the last 25 years

INTRODUCTION

Luteinized thecoma (thecomatosis) with sclerosing peritonitis (LTSP) is a very uncommon syndrome, characterized by the presence of single or bilateral ovarian thecomas and peritoneal fibrotic lesions. The disease occurs in young women and it can lead to peritoneal fibrosis and bowel obstruction. The pathogenesis of this syndrome remains still largely unknown. Surgery represents the cornerstone of treatment, but resection alone does not always allow a complete disease control. Attempts at medical treatments have been reported in recent years, but a real standard therapy has not yet been defined.

AREAS COVERED

We performed a systematic review of literature, collecting all the papers that reported cases of LTSP, since its first description in 1994. We found that, in these 25 years, less than 50 cases have been described in literature.

EXPERT OPINION

Along with the established role of surgery, adjuvant treatment with hormonal agents, in particular in estrogen receptor expression, seems to be a promising approach. However, more efforts must be carried out to describe treatment and outcome of new cases, improving knowledge about this rare condition.

COMPLETE REMISSION OF MEDICALLY TREATED LUTEINIZED THECOMAS WITH SCLEROSING PERITONITIS

We describe the first French patient treated for sclerosing peritonitis syndrome associated with lutheinized thecomas. At 42 years old, she had respiratory distress with increased abdominal volume. Physical examination revealed ascites, pleural effusions, and two mobile latero-uterine masses. Radiological examinations revealed bilateral ovarian masses of 10 cm. Bilateral adnexectomy was performed by laparotomy. Histological analysis concluded that there were benign luteinized thecomas. Until the 36th postoperative day, the general condition of the patient deteriorated to become critical. A second surgical procedure was attempted revealing sclerosing fibrosis preventing access to the peritoneal cavity. Subsequently, a medical treatment combining parenteral nutrition, high intravenous doses of corticosteroids, antiestrogens, colchicine and sandostatin was administered and effective allowing continuity recovery 15 months later. The clinical outcomes has been favorable at 24 month later.

Abdominal cocoon: an unexpected cause of ascites in a healthy patient

Abdominal cocoon is the idiopathic fibrotic encasement of abdominal organs. It classically presents as small bowel obstruction in young women. In this case report, we present a rare example of a patient presenting solely with massive ascites of presumed gynecologic origin, who upon surgical exploration was found to have abdominal cocoon. We discuss the patient’s unique disease presentation, unrevealing work-up and the treatment strategy pursued, and provide a review of the literature.

Acute Abdominal Distension Due to Disseminated Peritoneal Neoplasia in a Rhesus Macaque (Macaca mulatta)

This report describes the clinical, radiographic, and pathologic findings in a female rhesus macaque that presented with acute abdominal distension and tympany. The macaque was euthanized after evidence of severe colonic distension on radiography and observation of widespread peritoneal adhesions on exploratory laparotomy. Gross and histopathologic evaluation revealed extensive entrapment of gastrointestinal and reproductive tracts by serosal fibrovascular proliferative tissue containing foci of endometriosis. The diagnosis of endometrial stromal sarcoma was supported by expression of CD10, Wilm tumor 1, estrogen receptor, and progesterone receptor and failure to express immunohistochemical markers characteristic of a range of differential diagnoses. In humans, this relatively uncommon neoplasm can arise from sites of endometriosis and often presents clinically as intestinal obstruction, similar to the presentation in this macaque.