[Association of ovarian juvenile granulosa cell tumor with Maffucci's syndrome]

Ovarian Masses in Children and Adolescents: A Review of the Literature with Emphasis on the Diagnostic Approach

Most abdominal masses in the pediatric population derive from the ovaries. Ovarian masses can occur in all ages, although their incidence, clinical presentation and histological distribution vary among different age groups. Children and adolescents may develop non-neoplastic ovarian lesions, such as functional cysts, endometrioma, torsion, abscess and lymphangioma as well as neoplasms, which are divided into germ cell, epithelial, sex-cord stromal and miscellaneous tumors. Germ cell tumors account for the majority of ovarian neoplasms in the pediatric population, while adults most frequently present with epithelial tumors. Mature teratoma is the most common ovarian neoplasm in children and adolescents, whereas dysgerminoma constitutes the most frequent ovarian malignancy. Clinical manifestations generally include abdominal pain, palpable mass, nausea/vomiting and endocrine alterations, such as menstrual abnormalities, precocious puberty and virilization. During the investigation of pediatric ovarian masses, the most important objective is to evaluate the likelihood of malignancy since the management of benign and malignant lesions is fundamentally different. The presence of solid components, large size and heterogenous appearance on transabdominal ultrasonography, magnetic resonance imaging and computed tomography indicate an increased risk of malignancy. Useful tumor markers that raise concern for ovarian cancer in children and adolescents include alpha-fetoprotein, lactate dehydrogenase, beta subunit of human chorionic gonadotropin, cancer antigen 125 and inhibin. However, their serum levels can neither confirm nor exclude malignancy. Management of pediatric ovarian masses needs to be curative and, when feasible, function-preserving and minimally invasive. Children and adolescents with an ovarian mass should be treated in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome.

Stage I juvenile granulosa cell tumors of the ovary: A multicentre analysis from the MITO-9 study

OBJECTIVE

Juvenile type granulosa cell tumor (JGCTs) are extremely rare, mainly diagnosed in young women and pre-pubertal girls at stage I disease. Literature is scanty and guidelines regarding the optimal management are still controversial. The aim of this study is to add on the experience of the MITO group (Multicenter Italian Trials in Ovarian Cancer).

METHODS

Clinicopathological data from patients with stage I JGCTs were retrospectively collected. Descriptive statistics were used to characterize the patient population. Clinicopathological features and treatment variables were evaluated for association with relapse.

RESULTS

Seventeen patients were identified. Surgical approach was laparoscopic and open for 7 (41%) and 10 (59%) patients, respectively. Fertility sparing surgery (FSS) was performed in 15 patients (88%): unilateral salpingo-oophorectomy (USO) in 11 patients, cystectomy with subsequent USO in 2 patients and cystectomy alone in the remaining 2. Adjuvant chemotherapy was given in 2 cases. After a median follow up time of 80 months, no recurrences were registered.

CONCLUSIONS

Given the available data, minimally invasive surgery is safe in stage I JGCTs. Because of the good prognosis and of the young age of patients, FSS can be chosen in most of the cases. The role of cystectomy deserves further validation. The need of adjuvant chemotherapy in stage I disease is still unclear, even if available data does not seem to support treatment over surveillance.

Granulosa Cell Tumor of the Ovary Accompanying with Ollier's Disease: First Case of Contralateral Presentations

Objective

Granulosa cell tumor (GCT) is a rare entity of ovarian malignancies. Juvenile GCT is considered a malignant tumor with an indolent course and tendency toward late recurrence. However, the association of this tumor and multiple enchondromas has been reported.

Case Presentation

A 17-year-old female with abnormal uterine bleeding was referred to our center. Ultrasonographic evaluation revealed a mass with origin in right ovary. Patient was worked up to undergo salpingo-oophorectomy, she felt a dull pain in her left lower limb. X-ray imaging was indicative for Ollier's disease at the distal part of femur and proximal part of tibia. Postoperative pathological review was compatible with juvenile granulosa tumor of the right ovary.

Conclusion

This case was the first of its kind that ovarian tumor was contralateral to the side involved by enchondromatosis.

Gynecologic Manifestations of Less Commonly Encountered Hereditary Syndromes

This review covers gynecologic manifestations that may occur in rare hereditary syndromes. Recent advances in disorders, such as hereditary leiomyomatosis, renal cell carcinoma syndrome and tuberous sclerosis complex, are discussed as well as lesions that occur in von Hippel-Lindau syndrome, nevoid basal cell carcinoma syndrome, Cowden syndrome, Ollier disease/Maffucci syndrome, and Carney complex. Characteristic clinicopathologic features of each of these syndromes are discussed with an emphasis on the key features that enable pathologists to identify patients at highest risk for these diseases.

First case of juvenile granulosa cell tumor in an adult with Ollier disease

Ollier's disease (OD) is a rare disorder associated with the presence of multiple enchondromas. Granulosa cell tumors are rare sex cord-stromal ovarian tumors. This is the first report of a patient in her fourth decade with a combination of OD and juvenile granulosa cell tumor.A 36-year-old woman with OD developed an ovarian tumor. The tumor was found at a routine MRI scan. During surgery a stage IIc granulosa cell tumor was removed; pathologic examination showed a juvenile type. A review of literature showed 8 previous cases of (juvenile) granulosa cell tumor associated with OD.The coexistence of granulosa cell tumors in patients with OD is more frequent than expected by chance. We suggest that patients with OD should undergo regular gynecological investigation.

[Maffucci syndrome and extensive verrucous epidermal nevi in the same leg]

BACKGROUND

Maffucci syndrome is a rare disorder characterized by multiple enchondromas associated with soft tissue haemangioma. We report a case of Maffucci syndrome associated with epidermal verrucous nevus.

CASE REPORT

A 33-year-old woman, with no previous history of note, had presented multiple episodes of vascular tumefaction of the toes and verrucous lesions of the right lower limb since childhood. Clinical examination revealed multiple pain-free and round haemangiomas on the toes; some were hard and evocative of chondromas while others were soft and suggested angiomas. In addition, there was an epidermal verrucous nevus of the right lower limb. Skeletal examination revealed multiple phalangeal enchondromas. A diagnosis of Maffucci syndrome associated with epidermal verrucous nevus was made.

DISCUSSION

Maffucci syndrome is a rare form of sporadic dysplasia characterized by superficial haemangiomas and cartilaginous tumours (enchondromas), with just over one hundred published cases to date. Localization in the bones of the hands is seen in 89% of cases, in contrast with our observation. While epidermal verrucous nevus may be associated with neurological or osseous anomalies, to our knowledge, association of epidermal verrucous nevus with Maffucci syndrome has not previously been described; the present association could of course be fortuitous.

Ovarian juvenile granulosa cell tumors in infants

Juvenile ovarian granulosa cell tumors (JGCTs) are described infrequently in pediatrics, and their finding in prepubertal patients is exceptional. Most of the tumors are benign, but recurrences up to 4 years of follow-up have been described. We present 2 cases of JGCT in infants: 1 with late recurrence of bilateral ovarian JGCT and 1 in a newborn with Ollier disease. Clinical diagnosis and treatment of JGCT are revised.

Maffucci syndrome associated with a pituitary adenoma and a probable brainstem tumor

Malignancies are a common feature of Maffucci syndrome, with chondrosarcomas being the most common tumor type. The authors present the first case of Maffucci syndrome associated with a pituitary adenoma and a probable brainstem glioma and review the literature concerning intracranial tumors related to this disease. They report the case of a 35-year-old woman with Marfucci syndrome (diagnosed when she was 22 years old) who presented with complaints of decreased visual acuity and visual field defect. Neuroimaging revealed a pituitary macroadenoma and a suspected brainstem tumor. The macroadenoma was partially removed. There were no postoperative complications and the patient experienced rapid improvement in visual acuity. On follow-up examination 2 years later, the lesion in the pons showed the same dimensions. No sarcomatous changes of enchondromas or hemangiomas occurred. To the authors' knowledge, including the present case, only 7 cases of Maffucci syndrome associated with glioma and 7 cases associated with pituitary adenoma have been reported in the literature. This report emphasizes that patients with this disease are at a higher risk for primary intracranial tumors and reinforces the concept of the multiplicity of tumors that may arise in this syndrome. It also underscores the importance of early diagnosis, regular clinical surveillance, and follow-up studies of these patients.

Maffucci's syndrome with extensive gastrointestinal involvement

A 10-year-old girl with cutaneous, oral and gastrointestinal vascular lesions was referred for consideration of laser treatment of her skin lesions. She was noted to have multiple venous malformations predominantly affecting the hands and feet, some of which had been present from birth. Her right hand was deformed by multiple venous malformations, and X-rays of this hand revealed enchondromata within metacarpal and phalangeal bones. She was known to have extensive involvement of her gastrointestinal tract by venous malformations, resulting in refractory iron-deficiency anaemia. In view of the multiple cutaneous and gastrointestinal vascular lesions, a diagnosis of blue rubber bleb naevus syndrome had been made many years earlier. However, after recognition of the characteristic enchondromata, this diagnosis has been revised to Maffucci's syndrome. In addition to her ongoing dermatological and paediatric follow up, she has now been referred to the orthopaedic surgeons for surveillance of her skeletal lesions.