Evidence of hybrid cell of thyroid follicular cell and carcinoid cell in strumal carcinoid

Ovarian Strumal Carcinoid: Case Report, Systematic Literature Review and Pooled Analysis

BACKGROUND

Ovarian strumal carcinoid is a rare tumor in which thyroid (struma) and carcinoid components coexist. The disease is generally considered to be a borderline malignancy, however, cases with metastatic disease have been described. No data in the literature are available to guide diagnosis and therapy.

METHODS

We performed a pooled analysis and a systematic review of histopathological-confirmed strumal carcinoid cases published in the literature using the following keywords: "strumal carcinoid of the ovary", "strumal carcinoid case report". A case of strumal carcinoid tumor diagnosed and followed-up at the Medical Oncology Unit of Spedali Civili (Brescia, Italy) was also described and included.

RESULTS

Sixty-six eligible publications were identified, providing data from one hundred and seventeen patients, plus a case diagnosed at our institution. At presentation, among the eighty-eight patients with symptomatic disease, 37% of patients suffered from abdominal distention and 49% from pain due to a growing abdominal tumor mass, 37% from constipation (peptide YY was analyzed in only nine of them, resulting above the physiologic range). Surgery was the primary therapy in 99% of the patients. Three patients had metastatic disease at diagnosis and five patients underwent recurrence after radical surgery. Histology at disease recurrence concerned the thyroid component in two patients, the carcinoid component in two patients, both histologies in one patient. Median disease-free survival and overall survival in this series were not attained.

CONCLUSION

Strumal carcinoid of the ovary generally presents a benign behavior and surgery is curative in most cases. However, a small group of patients with this disease can undergo disease recurrence due to both the thyroid and the neuroendocrine (carcinoid) components. A follow-up in radically operated patients is therefore needed, particularly in those with a voluminous disease at diagnosis.

Strumal Carcinoid Presenting as Large Pelvic Mass: A Rare Case and Review of Literature

Strumal carcinoid is an unusual rare ovarian teratoma characterized by the presence of thyroid tissue with a carcinoid tumor. We report a case of a 60-year-old nulliparous woman, who presented with complaints of a decrease in appetite, urinary frequency, and left lower extremity edema. By ultrasound of the abdomen, a large multiloculated cystic lesion occupying almost the entire pelvis and measuring 24 x 14 x 20 cm with internal debris concerning either uterine or ovarian cystic carcinoma was seen. By MRI, it was confirmed to be an ovarian lesion. Labs revealed elevated cancer antigen 125 (CA125) of 105 U/ml and carcinoembryonic antigen (CEA) of 6.4 ng/ml. The patient underwent surgery and the intraoperative consultation confirmed teratoma with a neuroendocrine component. Grossly, it was a multicystic ovarian mass and on sectioning, it had partial solid and cystic areas with clear to mucoid fluid. Histopathology showed foci of ectopic thyroid tissue admixed with foci of well-differentiated neuroendocrine tumor, grade 1 (carcinoid) displaying insular and trabecular patterns consistent with the diagnosis of strumal carcinoid (monodermal teratoma). Thyroid transcription factor-1 (TTF-1) and thyroglobulin immunostains highlighted ectopic thyroid tissue and synaptophysin highlighted neuroendocrine component. Strumal carcinoids are almost invariably benign and pathologic staging is not warranted. Treatment of strumal carcinoid is salpingo-oophorectomy.

An Ovarian Carcinoid Tumor With Peptide YY-Positive Insular Component: A Case Report and Review of the Literature

Ovarian carcinoid tumors are uncommon and account for 1% of all carcinoid tumors. The insular type of ovarian carcinoid tumor is common in western countries; in contrast, the strumal and trabecular types seem to be common in Asian countries. Strumal and trabecular types are associated with peptide YY (PYY) production, which may cause constipation. Here, we report the case of a 70-yr-old Japanese woman with chronic constipation who was referred to Kumamoto University Hospital because of a right adnexal mass. Imaging tests suggested that the solid mass might be malignant; therefore, abdominal total hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. A subsequent histopathologic examination confirmed an insular carcinoid tumor with a trabecular component in the right ovary. Both components were positive for PYY but not for serotonin. The patient complained of diarrhea instead of constipation soon after the surgery. Because PYY-positive insular carcinoid tumor in the ovary has not been previously reported, we reviewed 19 reported cases of patients with PYY-positive ovarian carcinoid tumors. The origins, common histologic types and symptoms caused by specific peptides secreted in ovarian carcinoid tumors differ between western and Asian countries.

Assigning site of origin in metastatic neuroendocrine neoplasms: a clinically significant application of diagnostic immunohistochemistry

The neuroendocrine epithelial neoplasms (NENs) include well-differentiated neuroendocrine tumors (WDNETs) and poorly differentiated neuroendocrine carcinomas (PDNECs). Whereas PDNECs are highly lethal, with localized Merkel cell carcinoma somewhat of an exception, WDNETs exhibit a range of "indolent" biologic potentials-from benign to widely metastatic and eventually fatal. Within each of these 2 groups there is substantial morphologic overlap. In the metastatic setting, the site of origin of a WDNET has significant prognostic and therapeutic implications. In the skin, Merkel cell carcinoma must be distinguished from spread of a visceral PDNEC. This review intends to prove the thesis that determining the site of origin of a NEN is clinically vital and that diagnostic immunohistochemistry is well suited to the task. It will begin by reviewing current World Health Organization terminology for the NENs, as well as an embryologic and histologic pattern-based classification. It will present population-based data on the relative frequency and biology of WDNETs arising at various anatomic sites, including the frequency of metastases of unknown primary, and comment on limitations of contemporary imaging techniques, as a means of defining the scope of the problem. It will go on to discuss the therapeutic significance of site of origin. The heart of this review is a synthesis of data compiled from >100 manuscripts on the expression of individual markers in WDNETs and PDNECs, as regards site of origin. These include proteins that are considered "key markers" and others that are either useful "secondary markers," potentially very useful markers that need to be further vetted, or ones that are widely applied despite a lack of efficacy. It will conclude with my approach to the metastatic NEN of unknown origin.

Cytopathologic characteristics of the primary strumal carcinoid tumor of the ovary: a case report with emphasis on differential diagnostic considerations

Primary strumal carcinoid tumor of the ovary (SCTO) is an extremely rare entity, though the survival rate is excellent if the disease is confined to one ovary. A case is presented here in which intraoperative squash smears in a 45-year-old woman with a left adnexal mass revealed dispersed or small clusters of neoplastic cells forming loosely cohesive gland-like structures with abundant cytoplasm. The nuclear chromatin was finely granular with a "salt and pepper" appearance and occasional tiny nucleoli. The position of the nucleus presented a vaguely plasmacytoid appearance. Small fragments of thyroidal colloid-like structures were also identified. A cytopathologic diagnosis of a SCTO was suggested. Further evaluation and immunohistochemical studies were conducted on formalin-fixed, paraffin-embedded material. Cords or nests of uniform cells with abundant cytoplasm, and eccentric nuclei with coarse chromatin and occasional colloidal tissue were identified on H&E sections. The tumor cells showed diffuse and strong cytoplasmic staining for chromogranin A, synaptophysin, CD56, and vimentin but were negative for calretinin, α-inhibin or CDX2. The proliferative index with MIB-1 was around 3%. Thyroidal colloid-like structures were immunoreactive for thyroglobulin and TTF-1 stains. The diagnosis of primary SCTO was confirmed based on cytopathologic, histopathological, and immunohistochemical results, and the location of the tumor. Awareness of the cytopathological findings of SCTO can assist in diagnosing this rare entity correctly.

Expression of thyroid transcription factor-1 in strumal carcinoid and struma ovarii: an immunohistochemical study

Strumal carcinoid is an ovarian teratoma composed of thyroid tissue and carcinoid, intimately admixed in variable proportions. To further elucidate the histogenesis of strumal carcinoid, the expression pattern of thyroid transcription factor-1 (TTF-1) was evaluated in two cases of strumal carcinoid using immunohistochemical techniques. TTF-1 is a nuclear transcription protein that is selectively expressed in the thyroid and respiratory epithelium, and is thought to be expressed specifically in pulmonary and thyroid neoplasms. While the follicular lining cells of the strumal carcinoid showed positive staining for TTF-1, the carcinoid element was, for the most part, negative. These results confirm that TTF-1 is expressed in the thyroidal element of ovarian teratomas and also provide further evidence that the carcinoid component of the strumal carcinoid bears no relation to thyroidal differentiation.

Strumal carcinoid of the ovary associated with hyperinsulinaemic hypoglycaemia and cutaneous melanosis

Using immunohistochemical techniques ovarian carcinoid tumours can be shown to contain a wide variety of neuro-hormonal peptides but clinical effects, apart from the carcinoid syndrome, are very rare. Non-islet cell tumours with documented hyperinsulinaemic hypoglycaemia are also rare. This is the first recorded case of an ovarian strumal carcinoid associated with hyperinsulinaemic hypoglycaemia. Concurrent skin hyperpigmentation is believed to have resulted from the effects of tumour derived alpha-melanocyte stimulating hormone or an antigenically similar, biologically active peptide.

Prostatic acid phosphatase in strumal carcinoids of the ovary. An immunohistochemical study

BACKGROUND

Strumal carcinoids (SC) are ovarian tumors containing thyroid parenchyma admixed with carcinoid elements. Microscopically, the carcinoid component of SC usually presents a ribbon or trabecular pattern similar to the pattern exhibited by hindgut carcinoids. The authors designed an immunohistochemical study to ascertain further similarities of the carcinoid component of SC to rectal carcinoids.

METHODS

Five cases of SC were examined by light microscopic study with hematoxylin and eosin and immunoperoxidase staining with a group of neurohormonal peptides, thyroglobulin, prostatic acid phosphatase, and prostate specific antigen.

RESULTS

All tumors were positive for thyroglobulin, chromogranin, prostatic acid phosphatase (PAP), and glucagon. They were consistently negative for prostate specific antigen and variably positive to the other antibodies.

CONCLUSIONS

The consistent positivity of the carcinoid component of SC to PAP immunostaining is a further similarity of these tumors to rectal carcinoids, in which positive immunostaining to PAP has been observed. The similarity is not well understood, however, as all evidence points to the origin of SC from germ cells in mature cystic teratomas without any embryologic relationship to the hindgut.

Functioning ovarian carcinoids induce severe constipation

Five patients with ovarian carcinoid who had severe constipation for a long period preoperatively showed marked reduction of this symptom postoperatively. Because this phenomenon was believed to be caused by some biologically active substance rather than a mechanical effect of the tumor, reactivity to 17 amine and peptide hormones was studied immunohistochemically in these patients. Numerous peptide YY (PYY)-positive cells were detected, with PYY-positive cells representing more than 50% of all carcinoid tumor cells in each patient. PYY, which has a pharmacologic inhibitory action on intestinal motility, was presumably the cause of the constipation in these patients.

Intermediate thyroid carcinoma in humans and ultimobranchial tumors in bulls: A comparative morphological and immunohistochemical study

The intermediate type of thyroid carcinoma in humans has been defined as having characteristics of both follicular and parafollicular cell carcinoma. The ultimobranchial (UB) body in mammals is believed to harbor stem cells capable of developing both follicular and parafollicular cells. Hyperplastic and neoplastic lesions of the UB remnants and of the parafollicular cell system frequently occur in bulls. Such lesions, found in 64 individuals (6%) derived from an autopsy material of 1,101 bulls, have been compared structurally and immunohistochemically with 18 human cases of thyroid carcinoma of the intermediate type, in order to define their possible biological relationship. UB changes in bulls formed a continuum ranging from hyperplastic nodules to gross tumors. They contained all epithelial components present in the normal UB remnants in cattle: UB cysts and tubules and solid nests of small basophilic immature cells, which were immunocytochemically indifferent, as wellas mature follicular and neuroendocrine cells. The indifferent cell component dominated in most bull tumors; a minority were mainly formed by mature follicular or parafollicular cells. Human tumors resembled the bull UB tumors structurally and immunohistochemically, although generally the degree of maturation was higher in human tumors. A few were mainly formed by indifferent immature cells and contained typical UB cysts and tubules. One bull tumor and one human tumor contained amyloid. UB changes in bulls were invariably associated with a marked hyperplasia of the parafollicular cell system, in some cases even with tumor development. A similar hyperplasia, but without neoplastic change, was found in 4 of 11 human cases in which nontumorous thyroid parenchyma was available for examination.The findings suggest that intermediate thyroid carcinoma rather than medullary carcinoma is the human equivalent to the bull UB tumors. It is concluded that although both the medullary and the intermediate type of carcinoma appear to be histogenetically related to the UB body, the former shows evidence of a pure parafollicular cell differentiation, whereas the latter develops both follicular and parafollicular, as well as intermediate, cell forms and sometimes also immature structures of the type seen in UB remnants of the adult human thyroid gland.

Hormone-producing tumors of the ovary

The ovary is an endocrine organ that gives rise to a wide variety of neoplastic and tumorlike nonneoplastic conditions, some of which are associated with endocrine activity. The hormones produced may be steroidal or nonsteroidal. The ovary is unique among endocrine organs in reacting to the presence of nonendocrine tumors within it by abnormal or inappropriate production of sex steroidal hormones. A classification of hormone-producing ovarian lesions is proposed based on the World Health Organization's histologicai typing of ovarian tumors.

Prostate-specific acid phosphatase in carcinoid tumors

Although prostate-specific acid phosphatase (PASP) has been recognized as a specific marker of tissue of prostatic origin, several investigators have pointed out that some of the carcinoid tumours and islet cell tumours of the pancreas reacted immunohistochemically to PSAP. We investigated 50 cases immunohistochemically comprising 44 carcinoids of the G-I tract, 3 of the bronchus, 1 each of the ovary, kidney and middle ear. PSAP positive cases were, 30 in G-I tract, one each in ovary and kidney. Eighty percent of tumours of hindgut origin were positive. Apart from the immunohistochemical study, the content of PSAP in preoperative serum and tumour tissue was estimated in a case with a rectal carcinoid. Extremely elevated PSAP was confirmed in both the serum and tumour tissue. Neuroendocrine tumours such as pheochromocytoma, medullary thyroid carcinoma, and islet cell carcinoma were investigated as controls. No cells immunoreactive to PSAP were observed in these control cases. Prostate specific antigen was definitely negative in carcinoids. We would emphasize that PSAP may be an excellent marker of carcinoids especially when derived from hindgut.