Adult Granulosa Cell Tumor of the Ovary: A Clinico Pathologic Study of 35 Cases

Increasing hirsutism due to a granulosa-cell tumor in a woman with polycystic ovary syndrome: case report and review of the literature

BACKGROUND

Granulosa-cell tumors (GCT), rare malignancies that arise from sex-cord stromal cells, account for less than 5% of ovarian tumors. These tumors present with an endocrine syndrome and mass signs. Surgery is the primary treatment approach. The risk of recurrence is more frequent in the juvenile-onset form.

CASE REPORT

We report the case of an obese 18-year-old Caucasian women with hirsutism and oligomenorrhea. Abdominal palpation revealed a voluminous firm mass. Hormonal evaluation documented severe hyperandrogenism. The ovary-specific tumor marker CA125 was elevated, whereas human-chorionic-gonadotropin was in the normal range. Abdominal imaging examination revealed a 19 cm mass in the left ovary. Twenty-four hours after removal of the mass, menstrual flow reappeared and androgens progressively normalized. Microscopically, the predominant pattern was one of uniform, bland, epithelioid to spindle-shaped cells. After three months, a significant weight loss was recorded, hirsutism had decreased slightly and oligomenorrhea reappeared. Δ4-Androstenedione levels remained elevated (4200 ng/L), whereas CA125 had normalized. In light of the pre-existing polycystic-ovary-syndrome (PCOS), the patient started estrogen-progestin treatment.

CONCLUSION

We report an interesting case of a woman with severe hirsutism due to GCT, and a history of oligomenorrhea caused by PCOS. After surgery, a dramatic clinical improvement was observed, whereas PCOS signs persisted.

Analysis of selected oncogenes (AKT1, FOS, BCL2L2, TGFbeta) on chromosome 14 in granulosa cell tumors (GCTs): a comprehensive study on 30 GCTs combining comparative genomic hybridization (CGH) and fluorescence-in situ-hybridization (FISH)

In previous studies, we have demonstrated a number of cytogenetic alterations in granulosa cell tumors (GCTs), especially on chromosomes X, 12, 14, and 22. However, little is known about specific loci on 14q, which could play an important role in tumor pathology. Therefore, we assessed four important genes in 30 GCTs using fluorescence-in situ-hybridization (FISH). Comparative genomic hybridization (CGH) was performed on paraffin-embedded material. Then, we applied FISH with gene-specific DNA probes for AKT1 (14q32.32), FOS (14q24.3), BCL2L2 (14q11.2-q12), and TGFbeta3 (14q24), and tried to find a correlation between CGH, FISH, tumor stage, and survival. In CGH, 7 of 30 cases (23.3%) showed complete gains on chromosome 14. FISH of the four loci revealed gains of hybridization signals in 8 of 30 cases (26.6%), indicating trisomy of the whole chromosome arm. The same aberration was detected by FISH in 2 of 30 cases (6.6%), which were negative using CGH. One case (1 of 30; 3.3%) was found to have a gain on chromosome 14 by CGH, which could not be confirmed by FISH. A correlation with tumor stage or survival could not be established. Our results suggest that GCTs may be characterized by trisomy of chromosome 14. A specific oncogene that could play a particular role in the tumorigenesis of GCTs was not identified on chromosome 14.

Granulosa Cell Tumor of the Ovary: Tumor Review

Granulosa cell tumors of the ovary are rare neoplasms that originate from sex-cord stromal cells. The long natural history of granulosa cell tumors and their tendency to recur years after the initial diagnosis are the most prominent of their characteristics. The secretion of estradiol is the reason for signs at presentation such as vaginal bleeding and precocious puberty. Abdominal pain and hemoperitoneum, which occasionally can occur, are attributable to tumor rupture. The most common finding in pelvic examination is a tumor mass, which is subsequently confirmed with imaging techniques. Surgery is the mainstay of initial management for histological diagnosis, appropriate staging, and debulking. A more conservative unilateral salpingo-oophorectomy is indicated in patients with stage I disease and patients of reproductive age. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the appropriate surgical treatment for postmenopausal women and those with more advanced disease. The stage of disease is the most important prognostic factor associated with the risk of relapse. There are no clear conclusions regarding the role of postoperative chemotherapy or radiotherapy in stage I disease and in those with completely resected tumor. The use of adjuvant chemotherapy or radiotherapy has sometimes been associated with prolonged disease-free survival and possibly overall survival. Chemotherapy is the treatment of choice for patients with advanced, recurrent, or metastatic disease, and BEP (bleomycin, etoposide, and cisplatin) is the preferred regimen. Although the overall rate of response to treatment is high, the impact of treatment on disease-free or overall survival is unknown. Prolonged surveillance is mandatory because tumors tend to recur years after the initial diagnosis.

Clinical and pathologic prognostic factors in adult granulosa cell tumors of the ovary

The objective of this study was to determine the clinicopathologic prognostic factors in adult granulosa cell tumors of the ovary. A retrospective review of the records of patients of granulosa tumors who were treated at our institute over a period of 10 years (1995-2005) was done. Clinical, pathologic, and follow-up data were collected. A total of 34 patients who were treated during this period were subjected to analysis. Cox univariate analysis and Wilcoxon's test for multivariate analysis were used as part of the SPSS software for examining the data. It was found that optimal cytoreduction (P = 0.02), presence of nuclear atypia (P < 0.001), and increased mitoses (P = 0.03) were the three factors that impacted significantly on survival. Age, stage of the tumor, parity, and size of the tumor had no significant effect on survival. Patients who received chemotherapy had a better median disease-free survival than those who did not (60 vs 48 months), but this did not reach statistical significance (P = 0.08). Optimal cytoreduction, nuclear atypia, and increased mitoses are the statistically significant prognostic factors and may be used for selecting patients for adjuvant therapy.

Granulosa cell tumor of the ovary

Ovarian granulosa cell tumors (GCTs) are uncommon neoplasms that arise from the sex-cord stromal cells of the ovary. GCTs are characterized by long natural history and their tendency to recur years after the initial diagnosis. They present with symptoms and signs due to estradiol secretion, including vaginal bleeding and precocious puberty. Occasionally, tumor rupture causes abdominal pain and hemoperitoneum. GCT is usually associated with a mass on pelvic examination which is subsequently confirmed with imagine techniques. Surgery is the mainstay of initial management for histological diagnosis, appropriate staging and debulking surgery. In patients with stage I disease and those in reproductive age a more conservative unilateral salpingo-oophorectomy is indicated. In postmenopausal women and those with more advanced disease a total abdominal hysterectomy with bilateral salpingo-oophorectomy is the appropriate surgical treatment. The most important prognostic factor associated with a higher risk of relapse is the stage of disease. The role of post-operative chemo- or radiotherapy in stage I disease and those with completely resected tumor has not been defined. Nevertheless, the use of adjuvant chemotherapy or radiotherapy has sometimes been associated with prolonged disease-free survival and possibly overall survival. Chemotherapy should be considered for patients with advanced, recurrent or metastatic disease and the BEP (bleomycin, etoposide, cisplatin) is the currently preferable regimen. Although overall response rate (RR) is high, the impact on disease-free or overall survival is unknown. Due to their tendency to recur years after the initial diagnosis, prolonged surveillance is essential.

Clinical and pathological predictive factors in women with adult-type granulosa cell tumor of the ovary

Granulosa cell tumor (GCT) is a rare neoplasm hallmarked by a very indolent course and late recurrences. Although numerous clinical and pathological parameters have been implicated as prognostic factors for GCT, their role remains controversial. We performed a retrospective study at our institution where we identified 48 patients with GCT from our tumor registry. Demographic and clinical course information was recorded from the medical record. Twenty of 48 formalin-fixed, paraffin-embedded blocks were retrieved from archived specimens. Pathological parameters such as nuclear atypia, mitotic count, Ki-67 index using immunohistochemistry, and quantitative DNA ploidy were performed. DNA aneuploidy by quantitative method was associated with patients' overall survival. The degree of nuclear atypia, mitotic count, Ki-67 index, and DNA aneuploidy was not predictive of tumor recurrence. Multi-institutional collaboration is imperative to create a comprehensive national database for investigation into ways that may better indicate prognosis in these patients.

Mechanisms regulating the constitutive activation of the extracellular signal-regulated kinase (ERK) signaling pathway in ovarian cancer and the effect of ribonucleic acid interference for ERK1/2 on cancer cell proliferation

The ERK1/2 MAPK pathway is a critical signaling system that mediates ligand-stimulated signals for the induction of cell proliferation, differentiation, and cell survival. Studies have shown that this pathway is constitutively active in several human malignancies and may be involved in the pathogenesis of these tumors. In the present study we examined the ERK1/2 pathway in cell lines derived from epithelial and granulosa cell tumors, two distinct forms of ovarian cancer. We show that ERK1 and ERK2 are constitutively active and that this activation results from both MAPK kinase-dependent and independent mechanisms and is correlated with elevated BRAF expression. MAPK phosphatase 1 (MKP-1) expression, which is involved in ERK1/2 deactivation, is down-regulated in the cancer cells, thus further contributing to ERK hyperactivity in these cells. Treatment of these cancer cell lines with the proteasome inhibitor ZLLF-CHO increased MKP-1 but not MKP-2 expression and decreased ERK1/2 phosphorylation. More importantly, silencing of ERK1/2 protein expression using RNA interference led to the complete suppression of tumor cell proliferation. These results provide evidence that the ERK pathway plays a major role in ovarian cancer pathogenesis and that down-regulation of this master signaling pathway is highly effective for the inhibition of ovarian tumor growth.

Expression of p53, c-erbB-2, Ki-67, and CD34 in granulosa cell tumor of the ovary

The purpose of this study is to investigate the expression of p53, c-erbB-2, Ki-67, and angiogenic activity and their correlation with the clinicopathologic characteristics in a series of granulosa cell tumors of the ovary (GCTO). Eighteen GCTO cases assisted at the Department of Obstetrics and Gynecology, School of Medical Science, UNICAMP, after diagnostic confirmation by three pathologists, were submitted to immunohistochemistry for assessment of p53, c-erbB-2, Ki-67, and CD34 expressions. The mean tumor size was 13 cm (range: 4-30 cm). Six (33%) cases presented with extraovarian disease. Thirteen (72%) cases presented some solid diffuse or sarcomatoid pattern and six (33%) moderate or strong atypia. Fourteen cases presented </=2 mitoses/10 HPF. Thirteen cases were focally positive for Ki-67. The mean Ki-67 proliferative index was 1.0%. One case presented positive expression for mutant p53 but all cases were negative for c-erbB-2 expression. The mean microvascular density was 28.9/mm2 (range: 0-50). No significant correlations could be established between the biologic markers and clinicopathologic variables. GCTO showed a markedly low rate of immunohistochemical staining for p53 or c-erbB-2 overexpression/amplification, as well as low proliferative and angiogenic activities. Further studies are urgently needed to elaborate the factors responsible for the highly unpredictable clinical course of GCTO.

Splenic Rupture from Metastatic Granulosa Cell Tumor 29 Years after Curative Resection: Case Report and Review of the Literature

Granulosa cell tumors account for 2 to 3 per cent of all ovarian neoplasms. This case report describes a patient with splenic rupture from a bulky metastatic deposit 29 years after her initial surgery. A review of the literature regarding the patterns and timing of recurrence is also discussed.

Ovulatory surges of human CG prevent hormone-induced granulosa cell tumor formation leading to the identification of tumor-associated changes in the transcriptome

Granulosa cell tumors comprise approximately 10% of ovarian tumors and, although rare, are clinically important due to their potential for malignancy and recurrence. Although their morphological features have been carefully described, the global changes in gene expression associated with their formation remain undetermined. To initiate this characterization, we used a transgenic mouse model in which granulosa cell tumors occur with 100% penetrance in CF-1 mice that harbor a novel transgene encoding a chimeric LHbeta subunit. When this transgene is expressed in other strains of mice, including (C57BL/6 female symbol x CF-1 male symbol,Tg) F1 hybrids, luteomas develop even though levels of LH remain high. This dichotomous response permits a longitudinal comparison of global changes in transcriptomes uniquely associated with either granulosa cell tumors or luteomas. Herein we report numerous changes in the transcriptome, including a decrease in LH receptor mRNA and increases in several mRNAs that encode secreted proteins previously associated with granulosa cell tumors. Furthermore, we identified a constellation of mRNAs that encode proteins that may serve as new markers for this tumor phenotype. Additional experiments indicated that periodic treatment with human CG prevented formation of granulosa cell tumors in mice genetically predisposed to tumor development and, instead, led to the appearance of luteomas. More importantly, ovarian transcriptomes from the luteomas induced by ovulatory doses of human CG permitted refined confirmation of gene expression changes that were uniquely associated with either granulosa cell tumors in the permissive CF-1 genetic background or in luteomas in the F1 hybrids. Together, these dynamic changes in the ovarian transcriptome indict various signaling pathways potentially involved in mediating the actions of LH over time and, depending on genetic background, the formation of either a luteoma or a granulosa cell tumor.

Hemoperitoneum is an initial presentation of recurrent granulosa cell tumors of the ovary

Ovarian sex cord-stromal tumors account for less than 5% of all ovarian carcinoma, of which granulosa cell tumors account for 70%. These tumors have a propensity for indolent growth and late recurrence; they may even occur 25 years after initial treatment. We report a 44-year-old woman with hemoperitoneum (acute abdomen) after initial treatment 10 years earlier for granulosa cell tumor of the ovary. This case re-emphasizes the need for long-term follow-up in patients with stromal cell tumors of the ovary and considers the possibility of recurrence when presented with acute abdomen after conservative treatment.