Estrogen synthesizing rare malignant Brenner tumor of the ovary with the presence of progesterone and androgen receptors in the absence of estrogen receptors

Malignant Brenner tumor of the ovary: Review and case report

Ovarian neoplasms are a heterogeneous group of tumors with varying incidence in the general population. The most common are the surface epithelial tumors which include transitional cell tumors. Transitional cell tumors include both transitional cell carcinoma and Brenner tumor. The vast majority of Brenner tumors are benign, often incidental findings; however, malignant Brenner tumors (MBT) do occasionally occur. MBT present similarly to other ovarian neoplasms with abdominal pain and bulk symptoms. On imaging, these tumors demonstrate nonspecific findings. Microscopically, they demonstrate areas of conventional benign Brenner tumor juxtaposed with regions of frank malignancy showing marked cytologic atypia and infiltration. There is no consistent tumor marker for these tumors, but CA-125, CA 72-4 and SCC have been reported in singular instances. Tumors express several immunohistochemical markers of urothelial differentiation including uroplakin III, thrombomodulin, GATA3, p63, as well as cytokeratin 7. The primary treatment modality is surgical excision. Due to their rarity, the precise role and regimen of adjuvant chemo-radiation therapy for MBT has not been established. We herein review a case of MBT with emphasis on primary treatment and treatment of recurrent disease, including the use of adjuvant pelvic radiation, discuss the current state of the literature and standards of practice regarding this malignancy.

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Histologic differentiation of MBT from TCC is critical for diagnosis.

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Surgical staging should be performed for all cases of MBT.

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The role of adjuvant strategies for MBT is poorly defined.

Virilising ovarian tumour: a case associating a Sertoli-Leydig cell tumour and a Brenner tumour

Ovarian Sertoli-Leydig cell tumours (SLCT), also termed arrhenoblastomas, are the most frequent virilising tumours in women of reproductive age. Very rare secretory Brenner tumours (BT) have been described, generally after the menopause. A 31-year-old woman sought medical advice for secondary amenorrhoea, progressive hirsutism and a 5-year history of virilisation syndrome with clitoromegaly. Testosterone was markedly high (285 ng/dl, N<85) with moderate elevation of delta 4-androstenedione (D4AD) (311 ng/dl, N <270), dehydroepiandrosterone sulfate (DHEAS) (366 μg/dl, N <340) and 17-hydroxyprogesterone (17OHP) (275 ng/dl). LH was 9 IU/l, FSH 4.3 IU/l, estradiol 60 pg/ml and progesterone 314 ng/100 ml. Cortisol was decreased (1.3 μg/dl) after the dexamethasone suppression test. Pelvic MRI showed a 5-cm right ovarian tumour with a 2.5 cm nodular component and cystic areas, and two nodules measuring 11 mm and 15 mm above the right and left ovaries. After right ovariectomy by laparoscopy, pathological examination concluded on a 3-cm SLCT and a 2-cm BT; the nodules above the ovaries were dysembryoplastic cysts. Postoperatively, testosterone level was normal after 24 h (26 ng/dl), estradiol and progesterone rapidly decreased, cyclic secretion then resumed and the patient menstruated at day 27. To our knowledge, this is the first report of an ovarian tumour associating a Sertoli-Leydig cell tumour and a Brenner tumour in a patient with virilisation syndrome which resolved after ovariectomy.

Leiomyomatosis peritonealis disseminata and ovarian Brenner tumor associated with tamoxifen use

Tamoxifen is frequently administered as adjuvant therapy for breast carcinoma and produces weak estrogen agonist effects in estrogen sensitive tissues. In addition to producing a measurable increase in the risk of endometrial carcinoma, tamoxifen has also been associated with increasing size of uterine leiomyomata as well as the development of new leiomyomata. As the indications for tamoxifen therapy expand, surveillance for additional potential associated adverse outcomes is warranted. A 44-year-old woman with a history of bilateral breast carcinoma presented with leiomyomatosis peritonealis disseminata and a right ovarian Brenner tumor 18 months after beginning adjuvant tamoxifen therapy. Although a causal link cannot be proven, this case is the second reported association between leiomyomatosis peritonealis disseminata, an ovarian Brenner tumor, and tamoxifen use for the treatment of breast carcinoma. Given the hormonal sensitivity of leiomyomatosis peritonealis disseminata, both mutagenic and mitogenic effects of tamoxifen on this rare entity must be considered. In the setting of continued hormonal treatment for breast carcinoma, the management of leiomyomatosis peritonealis disseminata presents unique clinical challenges.

Case report of a malignant Brenner tumor with hyperestrogenism

A rare malignant Brenner tumor of the ovary presenting with hyperestrogenism in a 79 year old woman was examined immunohistochemically and by light and electron microscopy. High pre-operative serum and urinary estrogen concentrations, low serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, and histologically confirmed atypical endometrial hyperplasia suggested the presence of hyperestrogenism. The reduction in serum and urinary estrogen and the increase in serum LH and FSH concentrations after tumor removal confirmed that the tumor was synthesizing estrogen. Histologically, the malignant element was predominantly a squamous cell carcinoma. Transitional cell carcinoma was partially found on the cyst wall. There was a spectrum of morphologic changes between benign and malignant elements with an intermediate area with a proliferating Brenner tumor. Immunohistochemically, only the carcinoembryonic antigen was positive exclusively on the malignant element as well as in the microcyst in the benign epithelial cord, whereas all of the markers for germ cell tumors were negative. The ultrastructural features of the stromal cells were of two types: fibroblasts and steroid-producing cells. The latter type of cells might correspond morphologically to estrogen-producing cells. The present case is the fourth report showing a malignant Brenner tumor combined with apparent hyperestrogenism.

What's new in the localization of sex steroids in the human ovary and its tumors?

It is important to understand the distribution of steroidogenesis in steroid producing tissues in order to obtain a better understanding of steroid metabolism. Recent advances in purification and subsequent generation of antibodies against cytochromes P-450 specific for steroid hormone biosynthesis have made it possible to localize the sites of steroidogenesis immunohistochemically. This review provides the localization of sex-steroid hormone biosynthesis in normal and pathological human ovaries including sex-cord stromal tumors, hyperthecosis and Brenner tumor, as determined by the tissue distribution of immunoreactivity of individual enzymes specific for different stages of the biosynthetic process.

Brenner tumor of the ovary: immunoanalysis of steroidogenic enzymes in 23 cases

Immunohistochemical analysis of cytochromes P-450 aromatase and P-450 17 alpha-hydroxylase, which catalyze the production of estrogens and androgens, respectively, was performed for 23 cases of ovarian Brenner tumor. Immunoreactivity for P-450 aromatase was observed in the epithelial cells of the tumor distinctly in two cases and faintly in four cases, while immunoreactivity for P-450 17 alpha-hydroxylase was seen in two cases. No immunoreactivity was observed in the stromal cells of the tumors, nor were luteinized cells observed in the cases examined. No correlation was observed between the immunoreactivity of cytochromes P-450 in the epithelial cells of the tumor and endometrial abnormalities. These findings, together with a review of the literature, suggest that the usual Brenner tumor is not associated with specific steroidogenesis. Rare massive Brenner tumors may, however, be capable of androgenic or estrogenic activity.

Proliferative and malignant Brenner tumours (BT) and their differentiation from metastatic transitional cell carcinoma of the bladder: a case report and review of the literature

Up to now 110 cases of malignant Brenner tumour (BT) and 45 cases of proliferative BT have been reported in the accessible literature. To delineate the diagnostic criteria and to determine the differences between these tumours and metastatic tumours of the urinary tract, 94 cases of malignant BT and 37 cases of proliferative BT were reviewed. The difficulties encountered in determining these differences are illustrated by means of a case history.