Adjuvant chemotherapy does not improve disease-free survival in FIGO stage IC ovarian granulosa cell tumors: The MITO-9 study

Identification of prognostic factors and construction of nomogram to predict cancer-specific survival for patients with ovarian granulosa cell tumors

BACKGROUND

Ovarian granulosa cell tumors (OGCTs) feature low incidence, indolent growth and late recurrence. Treatment for recurrent OGCTs is challenging.

METHODS

The present study was designed to explore the prognostic factors and establish a nomogram to predict cancer-specific survival (CSS) for OGCTs patients. Enrolled in the study were 1459 eligible patients in the Surveillance, Epidemiology, and End Results (SEER) database, who were randomized to the training (n = 1021) or testing set (n = 438) at a ratio of 7:3. Univariate and multivariate Cox regression analyses were employed to screen the prognostic factors. The predictors were determined by using the Least absolute shrinkage and selection operator (LASSO) regression analysis. The model was constructed via the Cox proportional hazards risk regression analysis. The performance and clinical value of the nomograms was assessed with C-index, calibration plots, and decision curve analysis.

RESULTS

Age, pTNM stage, tumor size, surgery of the primary tumor, surgery of regional lymph nodes (LNs), residual disease after surgery, and chemotherapy were considered as significant predictive factors for CSS in OGCTs patients. After screening, the prognostic factors except surgery of regional LNs and chemotherapy were employed to build the nomogram. With desirable discrimination and calibration, the nomogram was more powerful in predicting CSS than the American Joint Committee on Cancer staging system in clinical use.

CONCLUSION

This novel prognostic nomogram, which comprises a stationary nomogram and a web-based calculator, offers convenience for clinicians in personalized decision-making including optimal treatment plans and prognosis assessments for OGCTs patients.

Impact of surgery and chemotherapy in ovarian sex cord-stromal tumors from the multicentric Salomé study including 469 patients. A TMRG and GINECO group study

OBJECTIVE

Identifying prognostic factors and evaluating the impact of adjuvant chemotherapy in patients with sex cord stromal tumors (SCST) is crucial. In this study, we aimed to address these challenges.

METHODS

We conducted a retrospective analysis of data from 13 centers of the French Rare malignant gynecological tumors (TMRG) network. We enrolled 469 adult patients with malignant SCST who received upfront surgery since 2011 to July 2015.

RESULTS

75% were diagnosed with adult Granulosa cell tumors, and 23% had another subtype. With a median follow-up of 6.4 years, 154 patients (33%) developed a first recurrence, 82 (17%) two recurrences, and 49 (10%) three recurrences. Adjuvant chemotherapy was administered in 14.7% of patients at initial diagnosis. In relapse, perioperative chemotherapy was administered in 58.5%, 28.2%, and 23.8% of patients, respectively, in the first, second, and third relapse. In the first-line therapy, age under 70 years, FIGO stage, and complete surgery were associated with longer progression-free survival (PFS). Chemotherapy had no impact on PFS in early-stage disease (FIGO I-II). The PFS was similar using BEP or other chemotherapy regimens (HR 0.88 [0.43; 1.81]) in the first-line therapy. In case of recurrence, PFS was statistically prolonged by complete surgery, but perioperative chemotherapy use did not impact PFS.

CONCLUSION

Chemotherapy use did not impact survival in the first-line or relapse setting in SCST. Only surgery and its quality demonstrated benefit for PFS in ovarian SCST in any lines of treatment.

Is adjuvant chemotherapy necessary for 2014 FIGO stage IC adult granulosa cell tumor?: Multicentric Turkish study

AIM

The aim of our study is to examine the clinical, surgical, and pathological factors of stage 1C adult granulosa cell tumor (AGCT) patients and to investigate the effects of adjuvant therapy on recurrence and survival rates in this patient group.

METHODS

Out of a total of 415 AGCT patients treated by 10 tertiary oncology centers participating in the study, 63 (15.2%) patients with 2014 FIGO stage IC constituted the study group. The FIGO 2014 system was used for staging. Patient group who received adjuvant chemotherapy was compared with patient group who did not receive adjuvant chemotherapy in terms of disease-free survival (DFS), and disease-specific survival.

RESULTS

The 5-year DFS of the study cohort was 89%, and the 10-year DFS was 85%. Those who received adjuvant chemotherapy and those who did not were similar in terms of clinical, surgical and pathological factors, except for peritoneal cytology. In the univariate analysis, none of the clinical, surgical or pathological factors were significant for DFS. Adjuvant chemotherapy and type of treatment protocol had no impact on DFS.

CONCLUSION

Adjuvant chemotherapy was not associated with improved DFS and overall survival in stage IC AGCT. Multicentric and randomized controlled studies are needed for early stage AGCT in order to confirm these results and reach accurate conclusions.

The Prognostic Significance of Adjuvant Chemotherapy in Adult Ovarian Granulosa Cell Tumors: A Systematic Review and Meta-analysis

INTRODUCTION

This study aimed to evaluate the oncological and prognostic significance of adjuvant chemotherapy (CT) in patients with adult granulosa cell tumors of the ovary (AOGCT).

METHODS

We searched the Chinese National Knowledge Infrastructure, Clinical Trials, Wanfang Database, Web of Science, Cochrane Library, and MEDLINE electronic databases for articles published up to May 2023. Reference lists of the enrolled studies, Google Scholar, and scientific meeting reports were also manually searched.

RESULTS

We enrolled 5641 patients with AOGCT from 33 eligible studies, including 1674 (29.7%) and 3967 (70.3%) patients in the CT and non-CT groups, respectively. Based on the cumulative results, adjuvant CT did not affect the risk of recurrence or progression (R/P) (odds ratio [OR]: 1.67, 95% confidence interval [CI]: 1.01-2.78, I2 = 63%, P = .05) and 5-year overall survival (OR: .86, 95% CI: .70-1.04, I2 = 0%, P = .12) of patients with AOGCT. However, adjuvant CT might reduce the 5-year disease-free survival (OR: 2.90, 95% CI: 1.19-7.08, I2 = 55%, P = .02). Sub-group analysis revealed that adjuvant CT did not affect the risk of R/P in patients with early-stage AOGCT (OR: .78, 95% CI: .43-1.43, I2 = 2%, P = .43) and advanced or recurrent AOGCT (OR: .78, 95% CI: .43-1.43, I2 = 2%, P = .43).

CONCLUSION

This meta-analysis suggests that patients with AOGCT might not benefit from adjuvant CT, even those with advanced or recurrent disease. The results should be interpreted with caution because of the inherent limitations of retrospective studies.

Use of staging for sex cord stromal tumours

PURPOSE OF REVIEW

Sex cord-stromal tumours (SCSTs) are rare ovarian cancers. As in the literature, only small case series or case reports are published, gathering solid evidence about their management is challenging. Surgery plays a pivotal role, and accurate staging is one of the most important prognostic factors. This review focuses on the current evidence for surgical staging in the management of SCSTs.

RECENT FINDINGS

Staging procedures have been inferred by epithelial ovarian cancers; however, they are often only partially performed, and most SCSTs therefore end up incompletely staged, raising the issue of the need for restaging or further treatments. In addition, some parts of the staging procedure have been questioned over the years, and lymphadenectomy is now considered unnecessary for SCSTs.The generally favourable prognosis of SCSTs, the introduction of minimally invasive surgery and fertility-sparing approaches is empowering the question of which staging procedures are beneficial for these patients. We reviewed the role of each staging procedure proposed by the guidelines in light of new scientific updates.

SUMMARY

Surgical staging should always be performed. It includes peritoneal samplings (peritoneal washing, multiple peritoneal biopsies, omental biopsy and biopsy of any suspicious area), whereas lymphadenectomy could be omitted. Laparoscopy may be considered a feasible approach.

Fertility sparing surgery in sex-cord stromal tumors: oncological and reproductive outcomes

Sex cord stromal tumors are rare neoplasms, frequently diagnosed in young women often as early-stage disease. In patients who desire to preserve fertility, when possible, unilateral salpingo-oophorectomy with peritoneal surgical staging is a safe alternative to radical treatment. In this review, we analyze the available literature on the obstetrical outcomes after fertility-sparing surgery in a total of 255 patients with sex cord stromal tumors. We found that the spontaneous conception rate in granulosa cells tumor is encouraging (88.5%). In particular, juvenile granulosa cell tumors are associated with a more successful pregnancy rate than adult granulosa cells tumors (11/26 (42.3%) in juvenile granulosa cells tumors compared with 28.5% in adult granulosa cell tumors, respectively.) On the other hand, the results of obstetrical outcomes in Sertoli-Leydig cells tumors are less promising (7/36 (19.4%)). Unfortunately, no evidence on this topic is available for sex cord tumor with annular tubules due to the low incidence. Regarding the oncological outcomes of 900 cases of sex cord stromal tumors treated conservatively, data are reassuring with comparable outcomes between patients treated with conservative and radical surgery. Given the limited available data on this rare tumor, further studies are needed to evaluate the safety of conservative approaches and to define the obstetrical outcomes in this patient population.

Can adjuvant chemotherapy improve the prognosis of adult ovarian granulosa cell tumors?: A narrative review

ABSTRACT

Adult granulosa cell tumors (aGCTs) are rare ovarian neoplasms with a relatively favorable prognosis. They follow an indolent course, characterized by a prolonged natural history and a tendency to late recurrences, Around a quarter of patients develop recurrence and More than 70% of women with recurrence die from their disease, The percentage of patients received chemotherapy increases over time, whether adjuvant chemotherapy improve the prognosis of aGCTs is equivocal? The purpose of this review is to summarize the previously published evidence to evaluate whether adjuvant chemotherapy improve the prognosis of aGCTs to provide guidance for clinical practice. EMBASE, PubMed, Web of Science, WanFang Data and Chinese National Knowledge Infrastructure are searched up to December 2020, used the search strategy of ovar* and granulosa cell* and (tumor* or tumour* or malignan* or cancer* or carcinom* or neoplasm*) and chemotherapy. The screening process was conducted strictly based on inclusion and exclusion criteria. Clinical studies based on human including randomized controlled trial, quasi-randomised controlled trials, nonrandomised trials cohort study and case control study were included without restriction of time. The percentage of patients received chemotherapy increases over time, but the benefit of adjuvant chemotherapy is lack of high-grade evidence of prospective study, based on the current retrospective studies, we still do not have the evidence to confirm the survival benefit of adjuvant chemotherapy in early stage, advanced stage or recurrent aGCT with no residual tumor, but for inoperable disseminated disease or disease with suboptimal cytoreduction, adjuvant chemotherapy maybe an Optable options. Multinational prospective randomised controlled trials are urgently needed to validate the role of adjuvant chemotherapy. Further research on molecular mechanisms and developing novel targeted medicines may improve the survival of aGCTs.

Oncological Prognosis and Fertility Outcomes of Different Surgical Extents for Malignant Ovarian Sex-Cord Stromal Tumors: A Narrative Review

Background

Malignant ovarian sex-cord stromal tumors (MOSCSTs) are rare neoplasms that account for approximately 5–7% of all ovarian malignancies. The majority (70%) of patients had an early stage; thus, surgery is the predominant treatment. Patients were relatively young at the onset of the tumor. Moreover, the prognosis of patients with this tumor is better than that of malignant epithelial ovarian tumors and tends to recur late with an indolent clinical course. Thus, patients may be more inclined to conservative surgical procedures. There is, however, no objective criterion for selecting a suitable surgical procedure. Clinically, surgical extent depended on the preoperative evaluations, age, and willingness of patients, and gynecologists were relatively subjective when choosing surgery. The prognosis of patients with different surgical extents is still controversial. The review aimed to summarize the impacts of different surgical extents on oncological prognosis and fertility outcomes.

Methods

The literature search was performed in PubMed (https://www.ncbi.nlm.nih.gov/pubmed/), and publications between January 2011 and December 2021 in English including clinical cohort studies and case reports were eligible for inclusion.

Results

We finally identified 12 large-sample retrospective studies and 18 cases of MOSCSTs. The primary surgical procedures include fertility-spring surgery (FSS), total hysterectomy with unilateral or bilateral salpingo-oophorectomy (TAH-USO/BSO), FSS with complete staging procedure, complete staging surgery (CSS), and debulking surgery. FSS includes cystectomy (CYS), unilateral salpingo-oophorectomy (USO) or bilateral salpingo-oophorectomy (BSO) with uterine preservation that allows for potential future assisted reproductive approaches. Complete staging procedure includes peritoneal cytologic examinations, inspections of peritoneal surfaces, random peritoneal biopsies and omentectomy. FSS with complete staging procedure means surgical procedure with uterine preservation and complete staging procedure. And, generally, CSS means TAH-BSO with complete staging procedure.

Conclusion

It can be concluded that USO can be done in young, fertility-desired patients with tumors confined to the ovary but avoid CYS. FSS with complete staging procedure is feasible among stage IC-III patients who have fertility desire. Patients can choose to have a complete surgery once their family is complete or without fertility requirements. CSS is recommended for patients with risk factors such as high stage, poor differentiation, and large tumor size and without fertility desire. A close follow-up is essential.

Adjuvant and post-surgical treatment in non-epithelial ovarian cancer

Non-epithelial cancers arising from the ovary are uncommon malignancies. Germ cell tumors of the ovary arise from primordial germ cells, and sex cord-stromal tumors of the ovary represent a cluster of tumors arising from the sex cord and stromal compartment. Most patients diagnosed with germ cell tumors are young adults and adolescent females. In contrast, ovarian sex cord-stromal tumors more commonly occur in a mature age group. Advances in the adjuvant management of non-epithelial ovarian cancer following optimal surgical and pathological staging have improved patient survival outcomes. In addition, active surveillance is preferentially assigned to patients diagnosed with stage I germ cell tumor, stage 1A grade 1 immature teratoma, stage 1A yolk sac tumor, and stage 1AI sex cord-stromal tumors. This article discusses the importance of selecting the adjuvant treatment approach most suitable to the patients' surgical and pathological stages, thereby safeguarding patient outcomes.

Progress in the management of ovarian granulosa cell tumor: A review

Ovarian granulosa cell tumor (GCT) is a rare, low-grade malignant tumor that accounts for 70% of the sex cord-stromal tumors. It has two histopathologic types with different clinical and biologic features: adult GCT and juvenile GCT. Most women diagnosed with the adult GCT have a favorable prognosis, with a 5-year survival rate of 97%-98%, but adult GCT has a feature of late relapse; the recurrence time could be more than 20 years after diagnosis. Juvenile GCT has a survival rate of 97% in stage I and a 5-year survival rate of 0%-22% in advanced stage with earlier recurrence than adult GCT. Consequently, the scenario emphasizes the need for early diagnosis, standardized treatment protocols, and long-term follow up. However, there is a lack of consensus regarding accurate diagnosis of GCT and adjuvant treatment. Furthermore, GCT tends to occur in young women, which emphasizes the viability of fertility-sparing surgery. The current review performed a systematic literature review of 60 articles to summarize the latest advances in GCT, with an emphasis on the molecular pathogenesis and survival after fertility-sparing surgery. We found that young women with fertility-sparing surgery had a desirable reproductive and survival outcome compared with those undergoing radical surgery.

Long-term efficacy of megestrol acetate and tamoxifen in a recurrent adult granulosa cell tumor of the ovary

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Recurrent, non-resectable ovarian granulosa cell tumor has no standard treatment.

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Estrogen/progesterone receptor signaling regulates granulosa cell tumor growth.

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Granulosa cell tumor responds well to alternating megestrol and tamoxifen therapy.

Retrospective analysis of clinicopathological characteristics of 19 ovarian juvenile granulosa cell tumor cases

AIM

To describe the clinical and pathological characteristics, diagnosis, treatment, and outcomes of juvenile granulosa cell tumor (JGCT).

METHODS

We retrospectively analyzed the data of 19 patients with histopathologically confirmed juvenile granulosa cell tumors treated in two medical centers in Wuhan city of China between 1999 and 2019.

RESULTS

Totally, 19 patients were included during the period. The median age at diagnosis was 8.25 years (range, 0.25-28 years). The most common clinical presentation was abdominal pain, five out of 10 prepubertal children presented with precocious puberty. Three patients underwent radical surgery (including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic and para-aortic lymphadenectomy), the other 16 patients had fertility-sparing surgery (cystectomy or ipsilateral salpingo-oophorectomy with or without omentectomy and lymphadenectomy). Eighteen patients had the international federation of gynecology and obstetrics (FIGO) stage I tumors, one patient had FIGO stage II disease. Twelve patients received postoperative adjuvant chemotherapy. The median follow-up time from the time of diagnosis was 35 months (range, 13-250 months). One patient experienced relapse and died of the disease 32 months after the initial diagnosis. Eighteen patients were alive and had not experienced recurrence during the follow-up period. The reproductive age patients that received fertility-sparing surgery had regular menstruation.

CONCLUSIONS

A majority of JGCTs are diagnosed as FIGO stage I tumors and have favorable clinical outcomes. Adjuvant chemotherapy seems to improve outcomes for patients with advanced-stage JGCTs; however, the value of chemotherapy in stage Ic patients is still unknown. Fertility sparing surgery should be considered in young patients who wish to bear children.

Outcomes after Fertility-sparing Surgery for Women with Ovarian Cancer: A Systematic Review of the Literature

OBJECTIVE

To compare reproductive and oncologic outcomes of patients diagnosed with early-stage epithelial ovarian carcinoma, borderline ovarian tumors, or nonepithelial ovarian carcinoma according to receipt of fertility-sparing surgery or conventional surgery.

DATA SOURCES

PubMed was searched from January 1, 1995, to May 29, 2020.

METHODS OF STUDY SELECTION

Studies were included if they (1) enrolled women of childbearing age diagnosed with ovarian cancer between the ages of 18 years and 50 years, (2) reported on oncologic and/or reproductive outcomes after fertility-sparing surgery for ovarian cancer, and (3) included at least 20 patients.

TABULATION, INTEGRATION, AND RESULTS

The initial search identified 995 studies. After duplicates were removed, we abstracted 980 unique citations. Of those screened, 167 publications were identified as potentially relevant, and evaluated for inclusion and exclusion criteria. The final review included 44 studies in epithelial ovarian cancer, 42 in borderline ovarian tumors, and 31 in nonepithelial ovarian carcinoma. The narrative synthesis demonstrated that overall survival does not seem to be compromised in patients undergoing fertility-sparing surgery compared with those undergoing conventional surgery, although long-term data are limited. Areas of controversy include safety of fertility-sparing surgery in the setting of high-risk factors (stage IC, grade 3, and clear cell histology), as well as type of surgery (salpingo-oophorectomy vs cystectomy). It seems that although there may be some fertility compromise after surgery, pregnancy and live-birth rates are encouraging.

CONCLUSION

Fertility-sparing surgery is safe and feasible in women with early-stage low-risk ovarian cancer. Pregnancy outcomes for these patients also seem to be similar to those of the general population.

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.

In Vitro Systematic Drug Testing Reveals Carboplatin, Paclitaxel, and Alpelisib as a Potential Novel Combination Treatment for Adult Granulosa Cell Tumors

Adult granulosa cell tumors (AGCTs) arise from the estrogen-producing granulosa cells. Treatment of recurrence remains a clinical challenge, as systemic anti-hormonal treatment or chemotherapy is only effective in selected patients. We established a method to rapidly screen for drug responses in vitro using direct patient-derived cell lines in order to optimize treatment selection. The response to 11 monotherapies and 12 combination therapies, including chemotherapeutic, anti-hormonal, and targeted agents, were tested in 12 AGCT-patient-derived cell lines and an AGCT cell line (KGN). Drug screens were performed within 3 weeks after tissue collection by measurement of cell viability 72 h after drug application. The potential synergy of drug combinations was assessed. The human maximum drug plasma concentration (Cmax) and steady state (Css) thresholds obtained from available phase I/II clinical trials were used to predict potential toxicity in patients. Patient-derived AGCT cell lines demonstrated resistance to all monotherapies. All cell lines showed synergistic growth inhibition by combination treatment with carboplatin, paclitaxel, and alpelisib at a concentration needed to obtain 50% cell death (IC50) that are below the maximum achievable concentration in patients (IC50 < Cmax). We show that AGCT cell lines can be rapidly established and used for patient-specific in vitro drug testing, which may guide treatment decisions. Combination treatment with carboplatin, paclitaxel, and alpelisib was consistently effective in AGCT cell lines and should be further studied as a potential effective combination for AGCT treatment in patients.

Management of recurrent granulosa cell tumor of the ovary: Contemporary literature review and a proposal of hyperthermic intraperitoneal chemotherapy as novel therapeutic option

Granulosa cell tumors of the ovary (GCT) are the most common type of sex cord stromal tumors. Although most of patients are diagnosed at early stage and has favorable 5-year overall survival rate, 16-23% of GCT ultimately develop recurrent disease. Recurrences are characterized by disseminated peritoneal metastasis. The treatment options include systemic chemotherapy, secondary CRS or palliative localized radiation therapy have not yet standardized due to the rarity of disease. Aggressive CRS followed up by hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to provide benefit in other peritoneal disease but limited data available for recurrent GCT. We have a case of recurrent Adult-type GCT (AGCT) who was treated with CRS followed by HIPEC with mitomycin C and doxorubicin. The patient has no evidence of recurrence for approximately 11 years. An electronic search of the PubMed database with the following search terms: GCT, HIPEC showed that there were total 21 patients with recurrent GCT treated in seven different studies and 13 of 21 (61.9%) patients had no evidence of disease during follow-up ranging from 6 to 100 months. Three patients (14.2%) died of the disease. Six studies used cisplatin for HIPEC. At least 76.2% (16 of 21, data not available for five patients) had complete cytoreduction with total 16 cases of perioperative complications but no perioperative mortality was observed. Although further investigation is needed, we propose that CRS and HIPEC can be an effective therapeutic option for recurrent GCT at experienced institutions.

Laparoscopic treatment of ovarian granulosa cells tumor developed in the pelvic anterior preperitoneal space 20 years after laparotomic salpingo-oophorectomy: case report and review of literature

Granulosa cells (GC) tumors are rare tumors which account for approximately 2-3% of all ovarian malignancies with a favorable prognosis. We report a case of a 54-year-old postmenopausal woman who developed an ovarian GC tumor in the pelvic anterior preperitoneal space 20 years after laparotomic salpingo-oophorectomy due to small part of the cyst could drop or remain entrapped into the abdominal wound during the closure of laparotomy 20 years before. Then, the patient underwent a second laparoscopic procedure with peritoneal washing, a type A radical hysterectomy, omentectomy, appendectomy, and pelvic and para-aortic lymphadenectomy. This rare case of ovarian GC tumor developing in the site of previous laparotomy demonstrates the importance of a correct and clean surgical procedure to avoid the risk of leaving even small portions of the cyst exposing the patients to either the risk of malignancy or additional surgical procedures.Precis: This rare case of ovarian granulosa cells tumor developed from residual ovarian tissue intrapped into the abdominal wound 20 years after laparotomic ovariectomy.

Mutant FOXL2C134W Hijacks SMAD4 and SMAD2/3 to Drive Adult Granulosa Cell Tumors

The mutant protein FOXL2^C134W is expressed in at least 95% of adult-type ovarian granulosa cell tumors (AGCT) and is considered to be a driver of oncogenesis in this disease. However, the molecular mechanism by which FOXL2^C134W contributes to tumorigenesis is not known. Here, we show that mutant FOXL2^C134W acquires the ability to bind SMAD4, forming a FOXL2^C134W/SMAD4/SMAD2/3 complex that binds a novel hybrid DNA motif AGHCAHAA, unique to the FOXL2^C134W mutant. This binding induced an enhancer-like chromatin state, leading to transcription of nearby genes, many of which are characteristic of epithelial-to-mesenchymal transition. FOXL2^C134W also bound hybrid loci in primary AGCT. Ablation of SMAD4 or SMAD2/3 resulted in strong reduction of FOXL2^C134W binding at hybrid sites and decreased expression of associated genes. Accordingly, inhibition of TGFβ mitigated the transcriptional effect of FOXL2^C134W. Our results provide mechanistic insight into AGCT pathogenesis, identifying FOXL2^C134W and its interaction with SMAD4 as potential therapeutic targets to this condition. SIGNIFICANCE: FOXL2^C134W hijacks SMAD4 and leads to the expression of genes involved in EMT, stemness, and oncogenesis in AGCT, making FOXL2^C134W and the TGFβ pathway therapeutic targets in this condition. GRAPHICAL ABSTRACT: http://cancerres.aacrjournals.org/content/canres/80/17/3466/F1.large.jpg.

Comparison between laparoscopy and laparotomy in the surgical re-staging of granulosa cell tumors of the ovary

OBJECTIVE

To evaluate the role of laparoscopic (LPS) and laparotomic (LPT) re-staging in patients with incompletely surgically staged ovarian granulosa cell tumors (OGCT).

METHODS

We conducted a medical chart retrospective analysis of all patients with sex cord stromal tumors (SCSTs) who were managed in our division between March 1994 and March 2017. After a complete review of surgical and pathological notes, patients with incomplete staging were restaged according to the FIGO guidelines. Statistical analysis was conducted using Statistical Package version 20.0 for Windows (SPSS, Inc., Chicago, Illinois).

RESULTS

Out of a total of 170 patients SCSTs, 84 patients (49,5%) received primary surgery that included a hysterectomy; 86 patients (50,5%) underwent fertility-sparing surgery. Eighty-one patients (48%) with diagnosis of OGCT were incompletely surgically staged at another institution. We evaluated our results in terms of laparoscopic approach (56 patients) and open treatment (25 patients). Among the IA patient's group, 1 was upstaged to IIB stage and 2 to IIIB; among patients with IC stage, 1 was upstaged to IIA, 2 to IIB and 1 to IIIB stage. Adjuvant chemotherapy was given to the upstaged patients with final stage IIB-IIIC. No statistically significant difference between laparoscopy and open-surgery was detected in terms of upstaged patients after second surgery (p = 0,36).

CONCLUSION

According to our series, laparoscopic restaging compared to the open approach seems to be a feasible and efficient technique to complete surgical staging in patients with GCTs incorrectly staged. Surgical restaging seems to upstage a considerable number of OGCT, mainly in the initial stage IC group of patients. However, the impact of restaging on final outcome and survival remains to be demonstrated.

Role of adjuvant chemotherapy in the management of stage IC ovarian granulosa cell tumors

Objective

The aim of the present study was to investigate the patterns of use and prognostic significance of adjuvant chemotherapy (CT) for patients with stage IC ovarian granulosa cell tumors (GCTs).

Methods

We identified patients with stage IC GCTs diagnosed between 2004 and 2015 in the National Cancer Data Base (NCDB). Logistic regression was performed to identify variables independently associated with chemotherapy administration. Overall survival (OS) was evaluated for patients diagnosed between 2004 and 2014 following generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for known confounders.

Results

A total of 492 patients with stage IC GCTs were identified, of which 166 (33.7%) received CT. Tumor size > = 10 cm (OR: 1.85, 95% CI: 1.21, 2.82) was independently associated with the administration of CT. There was no difference in OS between patients who did (n = 145) and did not (n = 282) receive CT, p = 0.52; 5-yr OS rates were 93.7% and 91.6% respectively. After controlling for patient age (<50 vs ≥50 years), tumor size and performance of lymphadenectomy (LND), the administration of CT was not associated with a survival benefit (HR: 1.07, 95% CI: 0.52, 2.21).

Conclusions

Approximately one in three patients with stage IC GCTs received CT in the NCDB, however CT was not associated with a survival benefit.

Emerging biomarkers in ovarian granulosa cell tumors

OBJECTIVE

Although the majority of ovarian granulosa cell tumors can be successfully managed with surgery, a subset require chemotherapy for residual and recurrent disease. The benefit of chemotherapy in this population, however, remains controversial. There is therefore interest in the development of more tolerable and effective treatment options for advanced ovarian granulosa cell tumors. We report the use of immunohistochemistry to investigate how biomarkers could inform clinical trials in granulosa cell tumors with an emphasis on emerging androgen antagonistic, immunotherapeutic, and anti-angiogenic approaches.

METHODS

Immunohistochemistry for androgen receptor, the immune markers programmed cell death ligand 1, indoleamine-2,3 dioxygenase, and cluster of differentiation 8, and the vascular marker cluster of differentiation 31 were evaluated on formalin-fixed paraffin-embedded whole tissue sections from 29 cases of adult-type granulosa cell tumors. Results were evaluated with clinicopathologic variables including recurrence.

RESULTS

59% of granulosa cell tumors were androgen receptor-positive, suggesting a potential role for anti-androgen therapy in this tumor type. In contrast, the targetable immune modulatory molecules programmed cell death ligand 1 and indoleamine-2,3 dioxygenase were scarcely expressed, with no cases showing tumorous programmed cell death ligand 1 and a single case demonstrating very focal tumorous indoleamine-2,3 dioxygenase staining. A minority of cases expressed programmed cell death ligand 1 in occasional tumor-associated macrophages and indoleamine-2,3 dioxygenase in peritumoral vessels. Tumor-infiltrating cytotoxic T cells were also scarce in granulosa cell tumors, arguing against a significant role for immunotherapy in the absence of additional immunostimulation. Cluster of differentiation 31 immunostaining revealed a range of vascular densities across granulosa cell tumors, and future studies evaluating the role of vascular density as a predictor of response to angiogenesis inhibition are warranted. None of the biomarkers investigated were significantly correlated with recurrence, and the only clinicopathologic feature significantly correlated with outcome was stage at presentation.

CONCLUSIONS

Biomarker data suggest that many ovarian granulosa cell tumors could be candidates for anti-androgen therapy, while the potential role for immunotherapy appears more limited. Vascular density could be useful for identifying optimal candidates for angiogenesis inhibition. Incorporation of these biomarkers into clinical trials could help optimize patient selection.

Fertility sparing surgery for ovarian sex cord stromal tumors: a nine case series

Ovarian Sex Cord Stromal Tumors (SCST) are a rare disease carrying a good prognosis. They generally affect young women; therefore fertility preservation is a critical issue. Fertility Sparing Surgery (FSS) showed promising results in both oncologic safety and fertility preservation. A retrospective case series involving 9 patients diagnosed with SCST and treated with fertility sparing surgery at our institution was conducted between January 2000 and May 2015. The median age was 24 years old (10 to 39). The main clinical manifestation was pelvic pain seen in seven patients. Five patients complained about menstrual cycle disorders. The nine patients went through fertility sparing surgery; seven had conservative staging and the other two had a unilateral salpingo-oophorectomy. Three patients out of nine had a pelvic unilateral lymphadenectomy. Two patients received adjuvant chemotherapy. Only two patients presented locoregional recurrence that occurred respectively after 7 and 192 months. The treatment combined chemotherapy and surgery based on mass resection. One patient achieved a natural pregnancy after the treatment. FSS seems to be a suitable approach for SCST. However, more case series and meta-analysis should be conducted.

Adult Granulosa Cell Tumors of the Ovary: A Retrospective Study of 36 FIGO Stage I Cases with Emphasis on Prognostic Pathohistological Features

Objective

Adult granulosa cell tumors (AGCTs) represent 2%-5% of all ovarian malignancies. The aim of this study was to analyze clinical and pathohistological parameters and their impact on recurrence, overall, and disease-free survival in FIGO stage I AGCT patients.

Methods

The tumor specimens analyzed in this retrospective study were obtained from a total of 36 patients with diagnosis of ovarian AGCT surgically treated at the Department of Gynecology, Rijeka University Hospital Centre, between 1994 and 2012. Clinical, pathological, and follow-up data were collected.

Results

The mean age at diagnosis was 54.5 years with a range of 24-84. The majority of the patients, 30 (83%), were in FIGO stage IA, 3 (8%) in stage IC1, 1 (3%) in stage IC2, and 2 (6%) in stage IC3. During follow-up period (median 117.5 months, range 26-276), recurrence occurred in 4 patients (12%) with 2 deaths of the disease recorded. In univariate analysis, the 5-year survival rates were significantly shorter in patients with FIGO substage IC (p = 0.019), with positive LVSI (p = 0.022), with presence of necrosis (p = 0.040), and with hemorrhage (p = 0.017). In univariate analysis, the 5-year disease-free survival rates were significantly shorter in patients treated with fertility surgery (p = 0.004), with diffuse growth pattern (p = 0.012), with moderate and severe nuclear atypia (p = 0.032), and with presence of hemorrhage (p = 0.022). FIGO substage IC proved to be independent predictor for recurrence (OR = 16.87, p = 0.015, and OR = 23.49, p = 0.023, resp.) and disease-free survival (p = 0.0002; HR 20.84, p = 0.02) at the uni- and multivariate analyses.

Conclusions

FIGO substage IC is predictive of recurrence and disease-free survival in patients with early-stage AGCTs. LVSI, presence of necrosis and hemorrhage, diffuse growth pattern, and nuclear atypia in AGCTs seem to be associated with overall and disease-free survival, so these pathological features should be taken into consideration when managing patients with AGCT.

Treatment of recurrent granulosa cell tumor with metformin and letrozole, a case report

•Cytotoxic chemotherapy has questionable efficacy against granulosa cell tumor.•Aromatase inhibitors may provide alternative treatment for granulosa cell tumors.•Metformin may be a beneficial adjunct in treating recurrent granulosa cell tumors.

Adjuvant chemotherapy in patients with operable granulosa cell tumors of the ovary: a surveillance, epidemiology, and end results cohort study

Adjuvant chemotherapy is recommended for patients with resected high-risk adult granulosa cell tumors (GCT), although strong data to support this are lacking. The objective of this study was to assess the outcomes of GCT patients, with the specific focus on patients that received adjuvant chemotherapy with curative intent (stage I-III), reported in a large national cancer registry. Data from the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2013 were used for analysis. Patient and disease characteristics were extracted and analyzed for association with administration of chemotherapy. Impact on disease-specific survival (DSS) was analyzed using log-rank test. A total of 739 patients with surgically treated adult GCT were identified. Median age was 51 years. 570 (77%) patients were stage I, 87 (12%) were stage II, and 82 (11%) were stage III. Adjuvant chemotherapy was administered to 176 (24%) patients. Young age, higher stage, and hysterectomy were associated with chemotherapy administration. Higher disease stage was associated with decreased five-year DSS (IA/B 98.5%, IC 95.1%, II 86.1%, III 83.5%, P < 0.01). Notably, administration of adjuvant chemotherapy was not associated with improved five-year DSS (P = 0.45) regardless of disease stage (stage IA/B: 96% with chemotherapy vs. 99% without chemotherapy; P = 0.64), (stage IC: 97% with chemotherapy vs. 94% without chemotherapy; P = 0.49), (stage II: 89% with chemotherapy vs. 83% without chemotherapy; P = 0.56), (stage III: 73% with chemotherapy vs. 93% without chemotherapy; P = 0.18). In this analysis, chemotherapy was not found to be associated with improved DSS of patients with operable disease regardless of stage, questioning the role for adjuvant chemotherapy in GCT.

Is adjuvant chemotherapy beneficial for patients with FIGO stage IC adult granulosa cell tumor of the ovary?

Background

To evaluate the association between adjuvant chemotherapy and clinical outcomes in patients with stage IC adult granulosa cell tumor (AGCT).

Methods

We performed a retrospective study of patients with stage IC AGCT diagnosed at our hospital from January 1985 to September 2015. We analyzed descriptive statistics, and performed univariate and multivariate and Kaplan–Meier survival analyses.

Results

Sixty stage IC AGCT patients were identified, including 28 in the no adjuvant chemotherapy group (NACG) and 32 in the adjuvant chemotherapy group (ACG). The median follow-up time was 88 months (range: 9–334 months). Sixteen patients developed recurrences, including nine in the NACG and seven in the ACG groups. Univariate analysis identified incomplete surgical staging and initial treatment place as associated with disease-free survival (DFS) (P = 0.003 and 0.038, respectively). Incomplete surgical staging remained a risk factor for recurrence in multivariate analysis (hazard ratio (HR) = 3.883, 95% confidence interval (CI): 1.123–13.430, P = 0.032). The 5-year DFS rates in the NACG and ACG groups were 76.3% and 87.5% respectively (P = 0.197). Adjuvant chemotherapy was thus not associated with improved DFS. Furthermore, the number of chemotherapy cycles was not associated with recurrence rate (≤3 cycles vs. > 3 cycles, HR = 0.613, 95% CI: 0.112–3.351, P = 0.572).

Conclusion

Administration of adjuvant chemotherapy does not improve DFS in patients with stage IC AGCT. Further studies with larger samples involving multi-institutional collaboration are needed to validate new treatment regimens for this disease.

Laparoscopic surgery in the treatment of stage I adult granulosa cells tumors of the ovary: Results from the MITO-9 study

OBJECTIVE

Surgery represents the mainstay of treatment of stage I adult type granulosa cell tumors of the ovary (AGCTs). Because of the rarity and indolent course of the disease, no prospective trials are available. Open surgery has long been considered the traditional approach; oncological safety of laparoscopy is only supported by small series or case reports. The aim of this study was to compare the oncological outcomes between laparoscopic and open surgery in stage I AGCTs treated within the MITO (Multicenter Italian Trials in Ovarian cancer) Group.

METHODS

Data from patients with stage I AGCTs were retrospectively collected. Clinicopathological features were evaluated for association with relapse and death. Survival curves were calculated using the Kaplan-Meier method and compared with the log-rank test. The role of clinicopathological variables as prognostic factors for survival was evaluated using Cox's regression model.

RESULTS

223 patients were identified. Stage 1A, 1B and 1C were 61.5%, 1.3% and 29.6% respectively. 7.6% were apparently stage I. Surgical approach was laparoscopic for 93 patients (41.7%) and open for 130 (58.3%). 5-years DFS was 84% and 82%, 10-years DFS was 68% and 64% for the laparoscopic and open-group (p = 0.6).5-years OS was 100% and 99%, 10 years OS was 98% and 97% for the laparoscopic and open-surgery group (p = 0.8). At multivariate analyses stage IC, incomplete staging, site of primary surgery retained significant prognostic value.

CONCLUSION

The present study suggests that surgical route does not affect the oncological safety of patients with stage I AGCTs, with comparable outcomes between laparoscopic and open approach.

Safety of Fertility-Sparing Surgery for Premenopausal Women With Sex Cord-Stromal Tumors Confined to the Ovary

Objective

The aim of this retrospective population-based study was to investigate the oncologic safety of fertility-sparing surgery (FSS) for premenopausal women with malignant sex cord-stromal tumors (SCSTs) confined to the ovary.

Methods

A cohort of women aged 18 to 49 years and diagnosed with a stage I malignant SCST between 1984 and 2013 was drawn from the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Based on site-specific surgery codes, women who had FSS, defined as unilateral oophorectomy/tumor resection without hysterectomy, and definite surgery were identified. Cancer-specific survival and overall survival were evaluated after generation of Kaplan-Meier curves, whereas comparisons between the 2 groups were made with the log-rank test.

Results

A total of 255 women who met the inclusion criteria were identified; 161 (63.1%) underwent FSS whereas 94 (36.9%) had definitive surgery (bilateral salpingo-oophorectomy and hysterectomy). Median follow-up was 104 months. Cancer-specific survival (P= 0.015) but not overall survival (P= 0.76) was superior for women who had definite surgery.

Conclusions

In this retrospective population-based cohort of premenopausal women with SCSTs confined to the ovary, FSS was associated only with a worse long-term cancer-specific survival compared with definitive surgery. Women undergoing FSS for early stage SCSTs should be extensively counseled and closely monitored.