Ovarian collision tumour consisting of a fibroma and a serous cystadenoma: A case report

This article reports a case of an ovarian collision tumour consisting of an ovarian fibroma and a serous cystadenoma. A 60-year-old woman exhibited symptoms of post-menopausal bleeding and abdominal pain persisting for three months. Computerized tomography identified a solid mass with a cystic component in the right adnexa, and the patient underwent staging laparotomy. Gross examination of the right ovary revealed a cystic tumour with adjacent solid mass. The histopathological analysis identified a cystic mass that matched the characteristics of a serous cystadenoma, with an adjacent solid mass that matched the characteristics of a sex-cord stromal tumour, both located in the right ovary. Additionally, a small cyst that matched the characteristics of a serous cystadenoma was found in the left ovary. There have been only seven previously reported examples of this specific mix of ovarian tumours. Mostly affecting patients above 60 years of age, although tumour markers levels are normal, such cases may present with a complex clinical scenario, as in this case, and demand a comprehensive diagnostic and therapeutic approach.

Vaginal bleeding imitated rape in a 6-year old girl, a case report about granulosa cell tumor as a reason of peripheral precocious puberty

INTRODUCTION

Although female victims of sexual child abuse present with symptoms such as local pain and vaginal bleeding, however, before any definitive diagnosis a comprehensive physical examination along with a detailed history related to vaginal bleeding should be taken from the patient. Undoubtedly, we must not forget that only one of the causes of vaginal bleeding is rape. Therefore, before making a final diagnosis, other causes of this symptom must be carefully examined.

CASE PRESENTATION

The patient was a 6-years-old female who was hospitalized for notable generalized abdominal distention, acute lower abdomen pain associated with nausea and mild fever lasting 5 days progressively worsening, thelarche and vaginal bleeding. Ultrasound examination showed that multilocular-solid masses located in right side of abdomen which led to surgery and mass excision. Histopathology diagnosis was a juvenile granulosa cell tumor of the ovary.

DISCUSSION

Among the various causes of peripheral premature puberty, granulosa cell tumor (GCT) is rare but very important. Since in the two age groups - prepuberty and menopause - we don't expect to see vaginal bleeding, the occurrence of this disorder especially in association with breast enlargement in prepubertal group, need to appropriate imaging including pelvic ultrasound and bone age determination also laboratory data such as level of sex hormones and tumor markers to avoid misdiagnosis.

CONCLUSION

We report the case of a granulosa cell tumor patient with vaginal bleeding that a complete history and examination provides the right path to a diagnosis.

Squamous cell carcinoma malignant transformation in mature cystic teratoma of the ovary: a case report and review of the literature

BACKGROUND

Mature cystic teratoma of the ovary is classified among the benign ovarian germ cell neoplasms, and its malignant transformation occurs very rarely (in about 2%). As a result of nonspecific signs and symptoms, preoperative diagnosis of theses malignancies is a challenge to clinicians, resulting in delayed diagnosis (in advanced stages) and poor outcomes.

CASE PRESENTATION

We report the case of a 43-year-old Iranian woman with progressive distension of the abdomen and hypogastric pain, who was diagnosed with squamous cell carcinoma transformation in a mature cystic teratoma of the ovary confirmed by histopathology examination. Total abdominal hysterectomy, bilateral salpingooophorectomy, and comprehensive staging surgery were performed for the patient, and she was scheduled for chemotherapy after the surgery. She responded well to the treatment and is currently continuing her chemotherapy process.

CONCLUSION

There are a great number of reports in the literature regarding mature cystic teratoma of the ovary transformation into malignancy, so these neoplasms must be considered as a possible differential diagnosis and should be evaluated in older individuals with abdominal pain and palpable mass, or those with considerable tumor diameter and raised serum tumor markers.

Female genital schistosomiasis mimicking an ovarian neoplasm: A case report

OBJECTIVE

A case description of a rare occurrence of female genital schistosomiasis affecting the upper genital tract that presented with features mimicking an ovarian neoplasm.

CASE REPORT

Female genital schistosomiasis is a neglected clinical manifestation of the water-born parasitic disease which occurs due to the presence of schistosome eggs in the genitalia of women. A 23-year-old nulliparous woman presented with progressive abdominal distension. An abdominopelvic CT scan revealed a multilobulated right adnexal mass with gross ascites. Diagnosis of schistosomiasis was made by histology of biopsied specimens following laparotomy. Cervical colposcopic findings were consistent with female genital schistosomiasis. She was successfully treated with praziquantel.

CONCLUSION

Female genital schistosomiasis of the upper genital tract can mimic an ovarian malignancy. Hence there is a need for its consideration as a differential diagnosis in patients with non-classical presentations of pelvic tumours in schistosomiasis-endemic areas.

Histologic Subtypes in Endometriosis-Associated Ovarian Cancer and Ovarian Cancer Arising in Endometriosis: A Systematic Review and Meta-Analysis

The definition of the association between ovarian cancer and endometriosis was first reported by Sampson in 1925. He identified the following criteria: (a) clear evidence of endometriosis in proximity to the tumour, (b) exclusion of a metastatic tumour to the ovary, (c) presence of tissue resembling endometrial stroma surrounding epithelial glands. The naming of these cancers is "endometriosis-associated ovarian cancer" (EAOC). Scott proposed an additional stringent criterion: evidence of histological transition from endometriosis to cancer is to define "ovarian cancer arising in endometriosis" (OCAE). The aim of this systematic review is to analyse the distribution of different ovarian cancer histotypes in EAOC and OCAE to understand their similarities and differences. A total of 31 studies were included. Four studies added data for both EAOC and OCAE. Twenty-three studies were selected for EAOC, with a total of 800 patients, and 12 studies were selected for OCAE, with a total of 375 patients. The results show no significant differences in the distribution of histotypes in the two populations analysed. Clear cell carcinoma (CCC) and endometrioid carcinoma (EC) were the most common subtypes and were less frequent in EAOC compared to OCAE; the odd ratios were 0.58 (0.26-1.29) and 0.65 (0.33-1.26) respectively, although the difference was not statistically significant. The other histotypes were present in small proportions. This analysis shows that the histological profiles of EAOC and OCAE are similar, suggesting a similar aetiopathological mechanism, which requires further research to investigate whether EAOC and OCAE may be in the same way but at different points of the process to malignancy or have different pathways of progression to malignancy.

Exploring the unusual: a testosterone-secreting ovarian tumor

Ovarian steroid cell tumors are rare, representing less than 0.1% of all ovarian neoplasms. Among the myriad causes of hirsutism, ovarian tumors account for 1% of the reported cases. We present the case of a 49-year-old parous postmenopausal woman who sought medical attention for hirsutism for 2 years. This case illustrates the unusual and interesting connection between rare ovarian pathology and the clinical manifestation of hirsutism in a postmenopausal patient. Her ultrasonography and MRI showed a right adnexal mass of solid-cystic consistency with thin septations. Her laboratory workup revealed high levels of total testosterone of 256 ng/ml (8.4-48.1ng/ml) and free testosterone of 7.36 pg/ml (0.2-4.1 pg/ml), while DHEAS - 234 µg/dl (35.4-256 µg/dl) and CA125 - 15.8U/L (0.0-35 U/L) were in the normal range. She underwent exploratory laparotomy with a total abdominal hysterectomy and oophorectomy. Histopathological examination and immunohistochemistry conclusively established the presence of a steroid cell tumor, specifically classified as "Not Otherwise Specified"(NOS), in the right ovary.

Reclassifying BRCA1 c.4358-2A > G and BRCA2 c.475 + 5G > C variants from "Uncertain Significance" to "Pathogenic" based on minigene assays and clinical evidence

BACKGROUND

Pathogenic variants in BRCA genes play a crucial role in the pathogenesis of ovarian cancer. Intronic variants of uncertain significance (VUS) may contribute to pathogenicity by affecting splicing. Currently, the significance of many intronic variants in BRCA has not been clarified, impacting patient treatment strategies and the management of familial cases.

METHOD

A retrospective study was conducted to analyze BRCA intronic VUS in a cohort of 707 unrelated ovarian cancer patients at a single institution from 2018 to 2023. Three splicing predictors were employed to analyze detected intronic VUS. Variants predicted to have splicing alterations were selected for further validation through minigene assays. Patient and familial investigations were conducted to comprehend cancer incidence within pedigrees and the application of poly (ADP-ribose) polymerase inhibitors (PARPi) by the patients. In accordance with the guidelines of the American College of Medical Genetics and Genomics (ACMG), the intronic VUS were reclassified based on minigene assay results and clinical evidence.

RESULT

Approximately 9.8% (69/707) of patients were identified as carriers of 67 different VUS in BRCA1/2, with four intronic variants accounting for 6% (4/67) of all VUS. Splicing predictors indicated potential splicing alterations in splicing for BRCA1 c.4358-2A>G and BRCA2 c.475+5G>C variants. Minigene assays utilizing the pSPL3 exon trapping vector revealed that these variants induced changes in splicing sites and frameshift, resulting in premature termination of translation (p. Ala1453Glyfs and p. Pro143Glyfs). According to ACMG guidelines, BRCA1 c.4358-2A>G and BRCA2 c.475+5G>C were reclassified as pathogenic variants. Pedigree investigations were conducted on patients with BRCA1 c.4358-2A>G variant, and the detailed utilization of PARPi provided valuable insights into research on PARPi resistance.

CONCLUSION

Two intronic VUS were reclassified as pathogenic variants. A precise classification of variants is crucial for the effective treatment and management of both patients and healthy carriers.

Atypical Presentation of Granulosa Cell Tumor in an Adolescent: A Case Report

BACKGROUND

Granulosa cell tumors (GCTs) frequently present with elevated levels of estrogen and inhibin. Most diagnoses in the pediatric and adolescent population are juvenile-type GCTs; adult-type GCTs in this population are rare.

CASE

We describe a 14-year-old female who presented with a large adnexal mass and clinical hyperandrogenism. Laboratory evaluation revealed elevated levels of free and total testosterone, low-normal estradiol, and mildly elevated alpha-fetoprotein (AFP). Other tumor markers, including inhibin, were within normal limits. Intraoperative assessment with unilateral oophorectomy, pathology, and imaging resulted in a diagnosis of a stage IA adult-type GCT.

SUMMARY AND CONCLUSION

GCTs often result in elevated estrogen and inhibin B levels; however, this case demonstrates that non-classic elevations in testosterone and normal inhibin levels should not eliminate concern for a GCT, particularly in the setting of a large ovarian mass.

Mature Cystic Teratoma of the Ovary Transforms into Squamous Cell Carcinoma: A Case Report

Mature cystic teratomas (MCTs) are benign ovarian tumors known to undergo malignant transformation in 1%-2% of cases. Most of these cases lead to squamous cell carcinomas (SCC), and the prognosis is often poor, particularly in advanced-stage disease. A 50-year-old postmenopausal woman presented with a large pelvic mass. The patient initially underwent suboptimal primary surgery and was later diagnosed with stage IIIA SCC arising from MCT. Following the first cycle of chemotherapy with carboplatin and paclitaxel, a computed tomography scan showed a rapidly growing large mass in the pelvic cavity after 4 weeks of primary surgery, leading to a second debulking surgery. However, the patient underwent only one cycle of chemotherapy after secondary debulking surgery because of her poor performance status. Subsequently, after 4 months of secondary debulking surgery, the patient developed rapidly progressive disease, leading to her death approximately after 8 months of diagnosis. While an appropriate multimodal treatment strategy has yet to be established, optimal cytoreductive surgery and adjuvant chemotherapy should be considered for treatment of advanced-stage diseases to improve survival outcomes.

Effects of epidural anesthesia on the prognosis of ovarian cancer-a systematic review and meta-analysis

INTRODUCTION

The global low survival rate among ovarian cancer patients has resulted in significant social and economic burdens. Nevertheless, previous studies have produced mixed results when exploring the link between anesthetic techniques and the prognosis of ovarian cancer. The study aims to compare the effect of epidural anesthesia with general anesthesia on survival time after cytoreductive surgery in patients with ovarian cancer.

METHODS

The PubMed (National Library of Medicine), Cochrane library, Web of science, Embase, CNKI (China National Knowledge Internet), Wanfang Med Online (China database), were systematically searched from inception to May, 2023, using the Medical Subject Headings [MeSH] of "Ovarian Neoplasm" and "Anesthesia, Epidural" and free words to identify systematic reviews or meta-analyses. The research methodology involved analyzing randomized controlled trials (RCTs), as well as prospective or retrospective cohort studies, which compared the long-term prognosis of patients with ovarian cancer under general anesthesia combined with epidural anesthesia (GEA) versus general anesthesia alone (GA). The Newcastle Ottawa Scale (NOS) was used to assess methodological quality and bias. Data extraction and assessment of study quality were conducted by two independent reviewers. A meta-analysis was then performed to calculate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). Overall survival (OS) was defined as the primary outcome, time to tumor recurrence (TTR) was the secondary outcome. Epidural anesthesia could be used intraoperatively and immediately postoperatively (EIP), or postoperatively only (EP). GEA includes EIP and EP.

RESULTS

In total, 8 retrospective cohort studies with 2036 participants met the inclusion criteria. The pooled results demonstrated that GEA could extend OS (HR 0.75, 95% CI 0.67-0.84, I2 = 0%, P < 0.05, fixed-effect model) when compared with GA in ovarian cancer patients undergoing cytoreductive surgery, but not TTR (sensitivity analysis revealed substantial heterogeneity among the included studies). The result of analyzing a total of 1490 patients in 4 studies was that EIP had a better prognosis on OS than GA (HR 0.68, 95%CI 0.55-0.85, I2 = 61%, P < 0.05, random-effect model). However, EP had no advantage in TTR (sensitivity analysis revealed it was unstable outcome). Ovarian cancer FIGO(International Federation of Gynecology and Obstetrics) stage III, stage IV compared to stage I on OS was statistically significant, HRs respectively are 3.67 (95%CI 2.25-5.98), I2 = 0%, fixed-effect model, P < 0.05, and 7.43 (95%CI 3.67-15.03), I2 = 31%, fixed-effect model, P < 0.05, but there was no statistically significant difference between stage II and stage I, HR 2.00, 95%CI0.98-4.09, I2 = 0%, fixed-effect model, P > 0.05. 1-10 mm tumor residuals shorten TTR compared with 0 residuals, HR 1.75, 95% CI1.50-2.04, I2 = 0%, fixed-effect model, P < 0.05.

CONCLUSIONS

It is hard to conclude that postoperative epidural analgesia offers greater benefits than GA. However, general anesthesia combined with epidural anesthesia (EIP) can improve overall survival in ovarian cancer patients, allowing the anesthesiologist to use anesthesia techniques to provide a favorable prognosis for the ovarian cancer patient. Tumor staging and the extent of cell reduction are also critical factors that significantly influence the long-prognosis of ovarian cancer patients.

Infected, giant borderline ovarian tumor: A case report

INTRODUCTION AND IMPORTANCE

Gigantic borderline ovarian cancer, also known as giant borderline ovarian tumor, is a rare subtype of borderline ovarian cancer. This type of ovarian cyst can be associated to various complication, including superinfection.

CASE PRESENTATION

We present the case of a 30-year-old woman who sought medical attention due to chronic abdominal pain and a rapid increase in abdominal girth over the past four months. Pelvic ultrasound and pelvic magnetic resonance imaging (MRI) revealed an abdominal-pelvic mass of 27 ∗ 12 cm. The tumoral markers were elevated. During her hospitalization, she developed a fever along with abdominal pain and biological inflammatory syndrome. Surgical intervention a 30-cm-long solid cystic mass located on the right ovary, accompanied by moderate ascites. The surgical procedure included a right adnexectomy, omentectomy, and appendicectomy, with cytology performed. Postoperative antibiotics were administered, and the patient showed favorable clinical and biological progress. The anatomopathological examination confirmed a 35-cm borderline mucinous tumor with signs of infection.

CLINICAL DISCUSSION

Giant borderline ovarian tumor is characterized by the presence of an ovarian mass measuring at least 10 cm in diameter. Infectious complications are rare, and their clinical features usually mimic those of a peritonitis. Treatment is based on antibiotics and chirurgical removal of the tumor based on the FIGO classification along with peritoneal biopsies and cytology.

CONCLUSION

This study explores the diagnosis, treatment, and prognosis of infected giant borderline ovarian tumors.

[Application of genetic counseling and preventive surgery in hereditary breast-ovarian cancer syndrome based on a rare family]

Objective: To investigate the genetic, clinical and pathological characteristics of families with hereditary breast-ovarian cancer syndrome (HBOCS) and to explore the implementation of genetic counseling and preventive surgery. Methods: Four siblings with HBOCS in Cancer Hospital/Chinese Academy of Medical Sciences were selected as the study subjects. BRCA gene testing and genetic counseling were performed, family history was traced and family map was drawn. Results: There were 7 cancer patients (Ⅰ 2, Ⅱ 4, Ⅱ 8, Ⅲ 7, Ⅲ 10, Ⅲ 11, Ⅲ 12) in three generations in the family. One patient (Ⅲ 7) had breast cancer and ovarian cancer successively. The first generation (Ⅰ 2) developed cancer at age 60, the second generation (Ⅱ4 and Ⅱ8) developed cancer at 55. The third generation (Ⅲ 7, Ⅲ 10, Ⅲ 11, Ⅲ 12) developed cancer at the age of 42-50 years. Four HBOCS patients were treated in our hospital, and all of them were found to have deleterious BRCA1 mutation. Two had already developed ovarian cancer (Ⅲ 10, Ⅲ 12), while in one case (Ⅲ 11), tubal carcinoma was found during preventive total hysterectomy and pelvic lymph node metastasis was found after the supplementary staging surgery. The other patient without cancer underwent preventive bilateral salpingectomy(Ⅲ 15). Conclusion: The HBOCS family reported in this study is relatively rare, the onset time of tumor was younger generation by generation. It is very important to pay attention to the genetic counseling of ovarian cancer patients and to timely detect the HBOCS families for genetic testing and prophylactic surgery.

Comparison of performance between O-RADS, IOTA simple rules risk assessment and ADNEX model in the discrimination of ovarian Brenner tumors

PURPOSE

To describe the clinical and sonographic features of ovarian benign Brenner tumor (BBT) and malignant Brenner tumor (MBT), and to compare performance of four diagnostic models in differentiating them.

METHODS

Fifteen patients with BBTs and nine patients with MBTs were retrospectively identified in our institution from January 2003 and December 2021. One ultrasound examiner categorized each mass according to ovarian-adnexal reporting and data system (O-RADS), international ovarian tumor analysis (IOTA) Simple Rules Risk (SR-Risk) assessment and assessment of different neoplasias in the adnexa (ADNEX) models with/without CA125. Receiver operating characteristic curves were generated to compare diagnostic performance.

RESULTS

Patients with MBT had higher CA125 serum level (62.5% vs. 6.7%, P = 0.009) and larger maximum diameter of lesion (89 mm vs. 43 mm, P = 0.009) than did those with BBT. BBT tended to have higher prevalence of calcifications (100% vs. 55.6%, P = 0.012) and acoustic shadowing (93.3% vs. 33.3%, P = 0.004), and lower color scores manifesting none or minimal flow (100.0% vs. 22.2%, P < 0.001). Areas under curves of O-RADS, IOTA SR-Risk and ADNEX models with/without CA125 were 0.896, 0.913, 0.892 and 0.896, respectively. There were no significant differences between them.

CONCLUSION

BBTs are often small solid tumors with sparse color Doppler signals, which contain calcifications with posterior acoustic shadowing. The most common pattern of MBT is a large multilocular-solid or solid mass with irregular tumor borders, and most were moderately or richly vascularized at color Doppler. These four models have excellent performance in distinguishing them.

Primary ovarian choriocarcinoma occurring in a postmenopausal woman: A case report

BACKGROUND

Nongestational ovarian choriocarcinoma (NGOC) is a rare but aggressive neoplasm with limited sensitivity to chemotherapy and a very poor prognosis. Few cases of NGOC have been reported, and there is limited information regarding its clinical features, treatment protocols, or prognosis.

CASE SUMMARY

A postmenopausal woman in her 5^th decade of life visited our clinic because of abnormal vaginal bleeding and an abdominal mass. Although she had been menopausal for more than eight years and her last abortion occurred nine years ago, she had an increased level of serum β-human chorionic gonadotropin (β-hCG). Thus, an ovarian neoplasm of trophoblastic origin was suspected, and exploratory laparotomy was performed. Based on the patient’s clinical history and the histopathological examination and immunohistochemistry results obtained postoperatively, we concluded that she most likely had primary NGOC. Cytoreductive surgery was performed in combination with adjuvant chemotherapy comprising bleomycin, etoposide, and cisplatin. Serum β-hCG levels decreased to normal after two cycles, and there was no evidence of recurrence after four cycles of chemotherapy.

CONCLUSION

Even in postmenopausal women, ovarian choriocarcinoma should be considered in the initial differential diagnosis for an adnexal mass.

Retrospective study of characteristics and hyperthermia intraperitoneal perfusion in mucinous borderline ovarian tumor and mucinous ovarian carcinoma

Background

Previous clinical trials regarding the therapy in epithelial ovarian tumors have involved patients with all types of ovarian tumors. Mucinous borderline tumors may progress to invasive carcinoma even after therapy and Patients with mucinous ovarian cancer (MOC) often have a worse prognosis. Our objectives were to investigate the use of hyperthermic intraperitoneal perfusion therapy (HIPE) and the clinicopathological features of mucinous borderline ovarian tumor (MBOT) and MOC.

Methods

A retrospective study was conducted on 240 patients with MBOT or MOC. The clinicopathologic feature included age, preoperative serum tumor markers, surgical procedures, surgical and pathological staging, frozen pathology, treatment, and recurrence. The effect of HIPE in MBOT and MOC were examined and the occurrence of adverse events was analyzed.

Results

The median age was 34 years in 176 MBOT patients. Some 40.1% of patients had elevated CA125, 40.2% had elevated CA199, and 5.6% had elevated HE4. The accuracy rate for frozen pathology of resected specimen was 43.8%. The was no statistical difference in the recurrence rate between fertility-sparing and non-fertility-sparing surgery. Due to a short follow-up time in the HIPE group, no significant recurrence rate was found. The median age was 59 years in 64 MOC patients. Some 90.5% patients had elevated CA125, 95.3% had elevated CA199, and 75% had elevated HE4. There were 28 patients diagnosed with Federation International of Gynecology and Obstetrics (FIGO) stage I or II. For FIGO stage III and IV patients, the median progression-free survival (PFS) was 27 months in the HIPE group and the median overall survival (OS) in patients treated with HIPE was 53 months, which was significantly longer than that the other group (19 and 42 months). There was no severe fatal complication in all HIPE group.

Conclusions

MBOT was usually diagnosed at an early stage and has a good prognosis. Hyperthermic intraperitoneal perfusion chemotherapy (HIPEC) can improve the survival of patients with advanced MOC and is safety. Combined use of CA125, CA199, HE4 can assist in the differential diagnosis of mucinous borderline neoplasms and mucinous carcinoma. Randomized studies evaluating dense HIPEC in the management of advanced ovarian cancer should be warranted.

Small Cell Carcinoma of Ovary, Hypercalcemic Type: A Rare Case Report

BACKGROUND

Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT), is a rare neoplasm that occurs mostly in women younger than 40 years of age. The unknown histogenesis makes the diagnosis of SCCOHT difficult. SCCOHT was recently shown to be associated with SMARCA4 gene mutation. Serum calcium levels can be used as a marker of treatment response and relapse in SCCOHT.

CASE REPORT

Here we report on a 16-year-old girl who presented with pelvic mass and hypercalcemia. SCCOHT was diagnosed histopathologically. However, loss of neither BRG1 nor INI1 expression was detected.

SUMMARY AND CONCLUSION

The diagnosis of SCCOHT should be among the differential diagnoses in adolescents presenting with pelvic mass and hypercalcemia. We would like to share our experience with this rare case, discuss recent management, and emphasize the importance of a multidisciplinary approach. Although it is known that almost all cases have a loss of BRG1 expression and a small group exhibit loss of INI1, our patient indicates that there could be exceptional cases with hitherto undescribed genetic abnormalities.

Mathematical modeling of the early modeled CA-125 longitudinal kinetics (KELIM-PARP) as a pragmatic indicator of rucaparib efficacy in patients with recurrent ovarian carcinoma in ARIEL2 & STUDY 10

BACKGROUND

PARP inhibitors (PARPi) have revolutionized the management of advanced ovarian carcinoma, and were investigated as forefront treatment in recurrent disease. The objective was to explore if mathematical modeling of the early longitudinal CA-125 kinetics could be used as a pragmatic indicator of the subsequent rucaparib efficacy, like it is for platinum-based chemotherapy.

METHODS

The datasets of ARIEL2 and Study 10 involving recurrent HGOC patients treated with rucaparib were retrospectively investigated. The same strategy as those successfully developed for platinum chemotherapy, based on CA-125 ELIMination rate constant K (KELIM™), was implemented. Individual values of rucaparib-adjusted KELIM (KELIM-PARP) were estimated based on the longitudinal CA-125 kinetics during the first 100 treatment days, and then scored as favorable (KELIM-PARP ≥1.0) or unfavorable (KELIM-PARP <1.0). The prognostic value of KELIM-PARP regarding treatment efficacy (radiological response, and progression-free survival (PFS)) was assessed using univariable/multivariable analyses, with respect to platinum-sensitivity and homologous recombination deficiency (HRD) status.

FINDINGS

The data from 476 patients were assessed. The CA-125 longitudinal kinetics during the first 100-treatment days could be accurately assessed using the KELIM-PARP model. In patients with platinum-sensitive diseases, BRCA mutational status KELIM-PARP score and were associated with subsequent complete/partial radiological responses (KELIM-PARP: odds-ratio = 2.81, 95% CI 1.86-4.52), and PFS (KELIM-PARP: hazard-ratio = 0.67, 95% CI 0.50-0.91). The patients with BRCA-wild type cancer and favorable KELIM-PARP experienced long PFS with rucaparib regardless of HRD. In platinum-resistant disease patients, KELIM-PARP was associated with subsequent radiological response (odds-ratio = 2.80, 95% CI 1.82-4.72).

INTERPRETATION

This proof-of-concept study confirms the early CA-125 longitudinal kinetics during rucaparib in recurrent HGOC patients are assessable by mathematical modeling, to generate individual a KELIM-PARP score associated with the subsequent efficacy. This pragmatic strategy might be useful for selecting the patients for PARPi-based combination regimens, when identifying efficacy biomarker is challenging. Further assessment of this hypothesis is warranted.

FUNDING

The present study was supported by Clovis Oncology with a grant to academic research association.

Computed tomography-based texture assessment for the differentiation of benign, borderline, and early-stage malignant ovarian neoplasms

OBJECTIVE

This study was performed to examine the value of computed tomography-based texture assessment for characterizing different types of ovarian neoplasms.

METHODS

This retrospective study involved 225 patients with histopathologically confirmed ovarian tumors after surgical resection. Two different data sets of thick (5-mm) slices (during regular and portal venous phases) were analyzed. Raw data analysis, principal component analysis, linear discriminant analysis, and nonlinear discriminant analysis were performed to classify ovarian tumors. The radiologist's misclassification rate was compared with the MaZda (texture analysis software) findings. The results were validated with the neural network classifier. Receiver operating characteristic curves were analyzed to determine the performances of different parameters.

RESULTS

Nonlinear discriminant analysis had a lower misclassification rate than the other analyses. Thirty texture parameters significantly differed between the two groups. In the training set, WavEnLH_s-3 and WavEnHL_s-3 were the optimal texture features during the regular phase, while WavEnHH_s-4 and Kurtosis seemed to be the most discriminative features during the portal venous phase. In the validation test, benign versus malignant tumors and benign versus borderline lesions were well-distinguished.

CONCLUSIONS

Computed tomography-based texture features provide a useful imaging signature that may assist in differentiating benign, borderline, and early-stage ovarian cancer.

Hematometra Due to Cervical Stenosis in a Postmenopausal Woman with Incidental Ovarian Steroid Cell Tumor: A Case Report

Vaginal bleeding is reported among 4%-11% of postmenopausal women. Hematometra is commonly associated with cervical stenosis due to senile atrophy, radiotherapy, or a uterine neoplastic lesion in women of postmenopausal age. Ovarian steroid cell tumor is a rare hormone-secreting tumor subtype accounting for approximately 0.1% of all ovarian tumors. Here we report a case of hematometra in a postmenopausal woman with high estrogen levels who was later diagnosed with a steroid cell tumor.

Long-term surgical outcomes in pediatric ovarian neoplasms: 20-year single-center experience

PURPOSE

The management of pediatric ovarian neoplasms (ON) is based on finding a balance between adequate surgical treatment and future reproductive capacity. We aimed to evaluate long-term results of patients who underwent surgery for ON.

METHODS

A retrospective cohort study design was used. Medical records of patients with ON were reviewed. They were invited to participate in a telephone-based survey assessing complaints, menstrual status, and post-surgical recurrence.

RESULTS

Eighty-five patients were operated for ON between 1995 and 2015. Median age at surgery was 14.7 years. 62.4% of patients had ovary-sparing surgery (OSS). Median tumor size in oophorectomy group was significantly larger than OSS group (p = 0.029). Median length of follow-up was 5.1 years. Recurrent/metachronous disease was not significantly different between OSS and oophorectomy groups (p = 1.000). In OSS group, irregular menses (p = 0.004) and painful menses (p = 0.002) were significantly higher than oophorectomy group.

CONCLUSION

The main goal of treatment in pediatric ON is to find the right balance between adequate and appropriate tumor resection and maximal effort for fertility preservation. Our results showed no difference between oophorectomy and OSS in the terms of recurrence. Although irregular and painful menses were found to be significantly higher in the OSS group, longer follow-up and prospective studies are needed to clarify this issue.

Lymphadenectomy in ovarian cancers: a meta-analysis of hazard ratios from randomized clinical trials

BACKGROUND

The debate surrounding systematic lymphadenectomy in the epithelial cancers of the ovary (EOC) was temporarily put to rest by the LION trial. However, there was a glaring disparity between the number of patients registered and the number of patients randomized suggesting inadvertent selection. A subsequent meta-analysis after this trial included all types of studies in the literature (randomized, non-randomized, case series, and, retrospective cohort), thus diluting the results.

METHODS

We conducted a meta-analysis of hazard ratios of randomized controlled trials, to study the role of systematic para-aortic and pelvic lymph node dissection in the EOC. A detailed search of MEDLINE, Cochrane, and Embase databases was done to look for the published randomized controlled trials (RCT) comparing lymphadenectomy versus no lymphadenectomy in EOC. A meta-analysis of hazard ratios (HR) was performed for overall survival (OS) and progression-free survival (PFS) using fixed and random effect models. The quality of the RCTs was evaluated on Jadad's score, and the risk of bias was estimated by the Cochrane tool.

RESULTS

A total of 1342 patients with EOC were included for quantitative analysis. On meta-analysis, HR for PFS was 0.9 (95% CI 0.79-1.04) favoring lymphadenectomy. HR for OS was 1 (95% CI 0.84-1.18) signifying no benefit of systematic lymphadenectomy.

CONCLUSION

The results show a trend towards increased PFS which did not reach statistical significance nor translate into any meaningful benefit in OS. There is still a need for a greater number of well-conducted, suitably powered trials to convincingly answer this question.

The BUMPy road of peritoneal metastases in ovarian cancer

Ovarian cancer is the most common cause of death due to gynecologic malignancies, with more than 70% of patients presenting with advanced stage disease at the time of diagnosis. The extent and distribution of tumor guide primary treatment selection and clinical management. While primary cytoreductive surgery with complete tumor resection improves survival, patients with extensive peritoneal disease may benefit from neoadjuvant chemotherapy first to reduce tumor burden followed by interval cytoreductive surgery. Imaging plays an essential role in triaging patients including selecting patients who may benefit from neoadjuvant chemotherapy before cytoreductive surgery. Interestingly, there are no universally established criteria to predict resectability and local practices depend on local guidelines and surgeon preferences. Nevertheless, certain anatomical tumor locations are known to be difficult to resect and are associated with suboptimal cytoreduction or require special surgical considerations. This review discusses the recent advances in the initial management of patients with ovarian cancer, a practical approach to the assessment and communication of peritoneal metastases locations on CT and MRI. It also explores recent advances in genomics profiling and radiomics that may influence the initial management of these patients.

Multi-Institutional Review of the Preoperative Diagnostic Accuracy for Pediatric Ovarian Mature Cystic Teratomas

STUDY OBJECTIVE

To assess the preoperative imaging impression and surgeon diagnostic accuracy for pediatric ovarian mature cystic teratomas (MCTs) DESIGN: Retrospective review SETTING: Eleven pediatric hospitals PARTICIPANTS: Patients ages 2 to 21 who underwent surgical management of an ovarian neoplasm or adnexal torsion with an associated ovarian lesion INTERVENTION: None MAIN OUTCOME MEASURES: Preoperative imaging impression, surgeon diagnosis, tumor markers, and pathology RESULTS: Our cohort included 946 females. Final pathology identified 422 (45%) MCTs, 405 (43%) other benign pathologies, and 119 (12%) malignancies. Preoperative imaging impression for MCTs had a 70% sensitivity, 92% specificity, 88% positive predictive value (PPV), and 79% negative predictive value (NPV). For the preoperative surgeon diagnosis, sensitivity was 59%, specificity 96%, PPV 92%, and NPV 74%. Some measures of diagnostic accuracy were affected by the presence of torsion, size of the lesion on imaging, imaging modality, and surgeon specialty. Of the 352 masses preoperatively thought to be MCTs, 14 were malignancies (4%). Eleven patients with inaccurately diagnosed malignancies had tumor markers evaluated and 82% had at least 1 elevated tumor marker, compared with 49% of those with MCTs.

CONCLUSIONS

Diagnostic accuracy for the preoperative imaging impression and surgeon diagnosis is lower than expected for pediatric ovarian MCTs. For all ovarian neoplasms, preoperative risk assessment including a panel of tumor markers and a multidisciplinary review is recommended. This process could minimize the risk of misdiagnosis and improve operative planning to maximize the use of ovarian-sparing surgery for benign lesions and allow for appropriate resection and staging for lesions suspected to be malignant.

Stage Ia squamous cell carcinoma as the malignant transformation of giant and unusual mature teratoma of the ovary in an elderly patient

Background

Mature cystic teratomas of the ovary (MCTO) are a type of germ cell tumor that may contain well-differentiated tissues developed from three germ cell layers and constitute about 20% of ovarian germ cell tumors. They are rare ovarian tumors with an annual incidence variable from 1.2 to 14.2 cases per 100,000 that occur mainly in women of reproductive age. They are frequently benign with a slow growth rate, even if they can undergo a malignant transformation in about 1–2% of cases.

Case presentation

Here, we present the case of an elderly woman referred to gynecological first aid for acute abdominal pain and showing a giant and unusual MCTO at rapid growth with malignant transformation in squamous cell carcinoma (FIGO stage Ia). The patient underwent pelvic mass removal trough emergency longitudinal midline laparotomic incision with intraoperative frozen pathologic examination. A complete surgical staging during the first surgery was performed. After about 9 years of follow-up, she died of non-oncological reasons without recurrence.

Conclusions

Present case highlights that CMTO with malignant transformation should always be suspected in elderly women in presence of pelvic mass at rapid growth, even if in absence of other clinical and ultrasonographic signs of malignancy. An intraoperative frozen pathologic examination may drive the best treatment.

Laparoscopy versus laparotomy for pediatric ovarian dermoids

BACKGROUND

With increased surgeon comfort using laparoscopy, we hypothesized resection of pediatric ovarian dermoids using laparoscopy would yield a shorter length of stay and no increase in morbidity or recurrence compared to laparotomy.

METHODS

A retrospective review was performed amongst eleven pediatric hospitals. Patients aged 2 to 21 who underwent resection of an ovarian dermoid from 2010 to 2020 were included. Patient characteristics, operative details, and outcomes by approach were evaluated using Chi-squared and Wilcoxon-Mann tests.

RESULTS

466 patients were included, with a median age of 14.4 and median follow-up of 4.0 months. 279 patients underwent laparoscopy (60%), 139 laparotomy (30%), and 48 laparoscopy converted to laparotomy (10%). There were no differences in rates of tumor spillage by approach (p = 0.15). 65% underwent ovarian-sparing surgery and 35% underwent oophorectomy. Length of stay was significantly shorter amongst patients who underwent laparoscopy (1 day versus 2 days for laparotomy and converted, p<0.0001). There were no differences in rates of suspected recurrence or reoperation (p = 0.19 and p = 0.57, respectively).

CONCLUSION

Patients who underwent laparoscopy experienced no differences in the rates of tumor spillage, recurrence, or reoperation and had a shorter length of stay compared to laparotomy. Laparoscopy is an acceptable approach for resection of pediatric ovarian dermoids.

Two-dimensional and three-dimensional T2 weighted imaging-based radiomic signatures for the preoperative discrimination of ovarian borderline tumors and malignant tumors

BACKGROUND

Ovarian cancer is the most women malignancy in the whole world. It is difficult to differentiate ovarian cancers from ovarian borderline tumors because of some similar imaging findings.Radiomics study may help clinicians to make a proper diagnosis before invasive surgery.

PURPOSE

To evaluate the ability of T2-weighted imaging (T2WI)-based radiomics to discriminate ovarian borderline tumors (BOTs) from malignancies based on two-dimensional (2D) and three-dimensional (3D) lesion segmentation methods.

METHODS

A total of 95 patients with pathologically proven ovarian BOTs and 101 patients with malignancies were retrospectively included in this study. We evaluated the diagnostic performance of the signatures derived from T2WI-based radiomics in their ability to differentiate between BOTs and malignancies and compared the performance differences in the 2D and 3D segmentation models. The least absolute shrinkage and selection operator method (Lasso) was used for radiomics feature selection and machine learning processing.

RESULTS

The radiomics score between BOTs and malignancies in four types of selected T2WI-based radiomics models differed significantly at the statistical level (p < 0.0001). For the classification between BOTs and malignant masses, the 2D and 3D coronal T2WI-based radiomics models yielded accuracy values of 0.79 and 0.83 in the testing group, respectively; the 2D and 3D sagittal fat-suppressed (fs) T2WI-based radiomics models yielded an accuracy of 0.78 and 0.99, respectively.

CONCLUSIONS

Our results suggest that T2WI-based radiomic features were highly correlated with ovarian tumor subtype classification. 3D-sagittal MRI radiomics features may help clinicians differentiate ovarian BOTs from malignancies with high ACC.

The Risks of Breast and Ovarian Cancer Associated with the Ashkenazi Jewish Founder Allele BRCA2 6174delT

Approximately one percent of the Ashkenazi Jewish population carries the BRCA2 6174delT (c.5946del) pathogenic variant. It is important to have accurate knowledge of the risks of breast and ovarian cancer associated with this specific variant so that women may be counselled accordingly. In this prospective study, we estimated the risks of breast and ovarian cancer associated with the 6174delT variant compared with the risks for other pathogenic variants in the BRCA2 gene. The annual risk for developing breast cancer was significantly lower in 246 women who carried the 6174delT variant compared with 721 non-Jewish women who carried a variant at any other locus in BRCA2 (1.2% per year vs. 2.4% per year, p=0.003). We estimated the cumulative risk of breast cancer from age 30 to 70 to be 39% for carriers of the BRCA2 6174delT variant and 61% for carriers of other BRCA2 variants. The annual risk for ovarian or fallopian tube cancer was 0.51% per year for the 233 women who carried the 6174delT variant compared to 0.22% per year for the 1128 carriers of other BRCA2 variants; the difference was not significant. Lower risks for breast cancer associated with 6174delT may not impact screening and prevention choices, however, the discussion should be based on accurate risk assessment.

Borderline ovarian tumor frozen section diagnoses with features suspicious of invasive cancer: a retrospective study

Background

A frozen section diagnosis of a borderline ovarian tumor with suspicious features of invasive carcinoma (“at least borderline” or synonymous descriptions) presents us with the dilemma of whether or not to perform a full ovarian cancer staging procedure. Quantification of this dilemma may help us with the issue of this clinical decision. The present study assessed and compared both the prevalence of straightforward borderline and “at least borderline” frozen section diagnoses and the proportion of these women with a final histopathological diagnosis of invasive carcinoma, with a special interest in histologic subtypes.

Methods

A retrospective cohort study was performed in three hospitals in The Netherlands. All women that underwent ovarian surgery with perioperative frozen section evaluation in one of these hospitals between January 2007 and July 2018 were identified and included in case of a borderline or “at least borderline” frozen section diagnosis and a borderline ovarian tumor or invasive carcinoma as a final diagnosis.

Results

A total of 223 women were included, of which 41 women (18.4%) were diagnosed with “at least borderline” at frozen section. Thirteen of forty-one women (31.7%) following “at least borderline” frozen section diagnosis and 14 of 182 women (7.7%) following a straightforward borderline frozen section diagnosis were diagnosed with invasive carcinoma at paraffin section evaluation (p < 0.001). When compared to straightforward borderline frozen section diagnoses, the proportion of women diagnosed with invasive carcinoma increased from 3.1 to 35.7% for serous tumors (p = 0.001), 10.0 to 21.7% for mucinous tumors (p = 0.129) and 50.0 to 75.0% (p = 0.452) in case of other histologic subtypes following an “at least borderline” frozen section diagnosis.

Conclusions

Overall, when compared to women with a decisive borderline frozen section diagnosis, women diagnosed with “at least borderline” frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis (7.7% vs 31.7%). Especially in the serous subtype, full staging during initial surgery might be considered after preoperative consent to prevent a second surgical procedure or chemotherapy in unstaged women. Further studies are needed to evaluate whether additional sampling in case of an “at least borderline” diagnosis may decrease the risk of surgical over-treatment.

Pearls and Potential Pitfalls for Correct Diagnosis of Ovarian Cystadenofibroma in MRI: A Pictorial Essay

Ovarian cystadenofibroma is a benign ovarian tumor that is characterized by a consistent percentage of masses, which remain indeterminate in ultrasonography and require magnetic resonance (MR) investigation; they may mimic borderline or malignant lesions. Three main morphologic patterns, resembling different ovarian neoplasms, can be identified in cystadenofibromas: multilocular solid lesions, unilocular cystic lesions with parietal thickening, and purely cystic masses. However, a cystoadenofibroma has typical features, such as T2-weighted hypointensity associated with no restrictions in diffusion-weighted imaging (the so-called "dark-dark appearance") and progressive post-contrast enhancement (type I perfusion curve). The purpose of this study was to review the features of ovarian cystadenofibromas in MR imaging and to suggest pearls and pitfalls regarding their correct diagnosis.

Misdiagnosis of appendiceal neoplasms as ovarian tumors: Impact of prior gynecologic surgery on definitive cytoreduction and HIPEC

BACKGROUND

Female patients with pelvic/adnexal masses often undergo gynecologic operations due to presumed ovarian origin. The diagnosis of an appendiceal tumor is often only made postoperatively after suboptimal cytoreduction has been performed. We hypothesized that an index gynecological procedure increases the morbidity of definitive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in patients with appendiceal mucinous tumors.

METHODS

A single-center retrospective review was performed to identify female patients undergoing CRS/HIPEC for appendiceal tumors from 2012 to 2020.

RESULTS

During the 8-year period, CRS/HIPEC was performed in 36 female patients with appendiceal mucinous tumors. Eighteen patients (50.0%) had received a prior pelvic operation by gynecologists (PPO Group) for presumed ovarian origin before referral for definitive CRS/HIPEC. The median peritoneal cancer index (PCI) was higher in the PPO group (21 vs. 9, p = 0.04). The median number of days from gynecologic procedure to definitive CRS/HIPEC was 169 days. Compared to patients who did not undergo a prior gynecologic operation, those in the PPO group had higher intraoperative blood loss (650 vs 100 mL, p < 0.01) during CRS/HIPEC as well as longer length of stay (12 vs 8 days, p = 0.02) and higher overall morbidity (72.3% vs 33.3%, p = 0.02). After controlling for PCI, prior gynecologic operation increased risk of 30-day morbidity after definitive CRS/HIPEC (OR 11.6, p < 0.01).

CONCLUSION

A multi-disciplinary approach is needed for the primary evaluation of patients with pelvic masses of undetermined origin. A gynecological resection is associated with increased morbidity during definitive cytoreduction and HIPEC for appendiceal mucinous tumors.

Benign, Borderline, and Malignant Pediatric Adnexal Masses: A 10-Year Review

STUDY OBJECTIVE

To investigate the incidence, clinical features, tumor markers, radiologic findings, types of surgeries, and histologies for adnexal masses in female pediatric and adolescent patients.

DESIGN

Retrospective chart review.

SETTING

Children's Health in Dallas and Plano, Texas from 2009 to 2018.

PARTICIPANTS

Female patients younger than 19 years old who underwent surgical management of an adnexal mass.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Imaging characteristics, tumor markers, surgical procedures, and histopathology.

RESULTS

In total, 752 patients (mean age, 13.7 years) underwent 756 surgical procedures for 781 adnexal masses. Of these, 732/781 (93.7%) were benign, 7/781 (0.9%) were borderline, and 42/781 (5.4%) were malignant. Of all 781 masses, 520/781 (66.6%) were ovarian and 261/781 (33.4%) were paratubal or tubal. Benign masses were associated with Hispanic race, pain, simple or cystic characteristics on imaging, and negative tumor markers. Borderline and malignant masses were associated with white race, pain, mass or distension, larger size, and heterogeneous appearance on imaging. Borderline masses were associated with negative tumor markers. Malignant masses were associated with elevated alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase.

CONCLUSION

Most adnexal masses in the pediatric and adolescent population are benign. Benign masses were significantly smaller, more likely to have negative tumor markers, and appear simple or cystic. There is little standardization with respect to preoperative tumor markers for adnexal masses. High-yield tumor markers for malignancy include alpha fetoprotein, beta human chorionic gonadotropin, cancer antigen 125, and lactate dehydrogenase. Low-yield tumor markers include inhibin A and B. Gynecologists performed more fertility-preserving surgeries including mini-laparotomies and fewer laparotomies for benign masses than pediatric surgeons.

Hyperthermic intraperitoneal chemotherapy as consolidation treatment of advanced stage ovarian cancer

Objective

To investigate the therapeutic efficacy of hyperthermic intraperitoneal chemotherapy (HIPEC) as consolidation treatment after completing first-line treatment in patients with advanced ovarian cancer.

Methods

A retrospective chart review was conducted on patients treated at the Comprehensive Gynecologic Cancer Center between January 2014 and 2019. Based on the inclusion criteria, 24 eligible patients who received HIPEC (paclitaxel 175 mg/m², for 90 minutes, at 42°C) (HIPEC group) as consolidation treatment after terminating the adjuvant chemotherapy were identified. Another 24 patients who met the inclusion criteria and did not receive HIPEC were matched, representing the non-HIPEC group. Disease-free survival (DFS) and overall survival (OS) were examined between the two groups.

Results

The median DFS was 28.7 and 24.2 months in the HIPEC and non-HIPEC groups, respectively (P=0.688). The 3-year DFS rates in the HIPEC and non-HPEC groups were 39.5% and 32.6%, respectively. However, the median OS was not determined. The 5-year OS rates in the HIPEC and non-HIPEC groups were 86.2% and 81.3%, respectively (P=0.850). One patient developed grade 3 neutropenia. Other patients experienced mild adverse events after HIPEC.

Conclusion

This study suggests that consolidation HIPEC could not support the survival benefit after completing the first-line treatment for patients with advanced ovarian cancer, although no severe specific safety issues were found. Therefore, randomized trials evaluating consolidation HIPEC for the management of ovarian cancer are warranted.

Early life exposure to tobacco smoke and ovarian cancer risk in adulthood

BACKGROUND

Ovarian cancer risk in adulthood may be affected by early life exposure to tobacco smoke. We investigated this relationship in two large prospective cohorts, the Nurses' Health Study (NHS) and NHSII.

METHODS

In total, analyses included 110 305 NHS participants (1976-2016) and 112 859 NHSII participants (1989-2017). Self-reported early life smoking exposures were queried at baseline or follow-up questionnaires. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of ovarian cancer overall and by tumour histotype.

RESULTS

Overall, ovarian cancer risk was not different among participants whose mothers did versus did not smoke during pregnancy (HR = 1.05, 95% CI: 0.87-1.27); however, an increased risk was observed among women who themselves were never smokers (HR = 1.38, 95% CI: 1.05-1.81) but not among ever smokers (HR = 0.86, 95% CI: 0.66-1.14; Pheterogeneity = 0.02). Compared with women who never smoked, ovarian cancer risk was similar for women who started to smoke at age <18 (HR = 0.98, 95% CI: 0.86-1.11) or ≥18 (HR = 1.02, 95% CI: 0.93-1.12). These associations did not differ by histotype (Pheterogeneity ≥0.35). Parental smoking in the home during childhood/adolescence was related to a 15% increased risk of ovarian cancer in adulthood (HR = 1.15, 95% CI: 1.04-1.27) and this association was suggestively stronger among women with non-serous/low-grade serous tumours (HR = 1.28, 95% CI: 1.02-1.61) versus high-grade serous/poorly differentiated tumours (HR = 1.09, 95% CI: 0.93-1.28; Pheterogeneity = 0.25).

CONCLUSIONS

Exposure to parental tobacco smoke in the home, but not early initiation of smoking, was associated with a modest elevated risk of ovarian cancer. Further investigations are required to confirm these findings and elucidate underlying mechanisms.

Clinical analysis of 12 cases of ovarian cystic mature teratoma with malignant transformation into squamous cell carcinoma

OBJECTIVE

This study aimed to examine the clinicopathological characteristics, treatment, and prognostic factors in 12 cases of malignant transformation of mature cystic teratoma of the ovary (MCTO).

METHODS

We performed a retrospective study of 12 patients with malignant transformation of MCTO who were admitted to the Affiliated Hospital of Qingdao University from 2003 to 2019. We examined case records, clinical parameters, and biological assessments.

RESULTS

The median age of the patients was 56.5 years and seven of them were postmenopausal. The average tumor size was 18.5 cm. All patients had pelvic masses at their first hospital visit. Nine of the patients had discomfort in the lower abdomen, two presented with a lower abdominal palpable mass, and three were complicated by fever. The median follow-up time was 73 months (12‒193 months). Ten patients survived with a disease-free status and two died.

CONCLUSIONS

There is a low incidence of malignant transformation of MCTO, and its most common histological type is squamous cell carcinoma. Age and tumor size are important factors in malignant transformation of teratomas. While there is a lack of treatment guidelines for malignant transformation of MCTO, early diagnosis and treatment may be beneficial for these patients.

Prognostic significance of autophagy-related genes Beclin1 and LC3 in ovarian cancer: a meta-analysis

OBJECTIVE

Beclin1 plays a central role in the activation of the autophagy signaling pathway. Beclin1 and LC3-related proteins are involved in the initial steps of autophagy, which are closely related to the occurrence and development of tumors. The current meta-analysis aimed to clarify the correlation between expression of Beclin1 and LC3 and prognosis of ovarian cancer.

METHODS

We searched PubMed, Embase, The Cochrane Library, Web of Science, and CNKI using predefined selection criteria. Pooled hazard ratios and relative risks with 95% confidence intervals were used to evaluate the correlation between autophagy-related genes Beclin1 and LC3 and overall survival (OS), progression-free survival (PFS), and International Federation of Gynecology and Obstetrics (FIGO) stage.

RESULTS

In total, 1497 patients from 10 articles were enrolled in this meta-analysis. Expression of Beclin1 was significantly correlated with improved OS and PFS, and increased expression of Beclin1 was correlated with early FIGO stage, but not with lymph node metastasis or histological grade. No association was found between LC3 expression and prognosis in patients with ovarian cancer.

CONCLUSIONS

Expression of Beclin1 is an independent risk factor for the progression of ovarian cancer. Thus, Beclin1 is a promising indicator in predicting prognosis in patients with ovarian cancer.

Jejunal GIST masquerading as an ovarian mass: A case report

INTRODUCTION AND IMPORTANCE

Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors originating in the wall of the gastrointestinal tract. Jejunal GIST is the rarest subtype. Large GIST can present with an abdominopelvic mass which can be preoperatively misdiagnosed as a gynecological tumor.

CASE HISTORY

A 44-year regularly menstruating woman presented with lower abdominal pain which was diagnosed as a malignant ovarian tumor preoperatively with an MRI. However, intraoperatively, a lobulated mass was present in the abdominal cavity arising from a jejunal portion of the small intestine. With an intraoperative diagnosis of jejunal GIST, the mass was excised and jejunum anastomosed. Histopathology examination report showed GIST which was further confirmed by immunohistochemistry.

DISCUSSION

GIST presenting as a large abdominopelvic mass can mimic a gynecological tumor. Contrast-enhanced CT scan is the preferred imaging modality for the evaluation of patients with suspected GIST to determine the extent of the tumor, the presence or absence of metastatic disease alongside evaluation of the possibility of complete resection. Adjuvant imatinib therapy following complete excision can decrease the disease recurrence.

CONCLUSION

Gynecologists should keep in mind that primary gastrointestinal tumors can present as a pelvic mass. A proper histopathological examination helps to confirm the diagnosis. Complete surgical removal of the tumor should be obtained as it determines the prognosis of the disease.

The attributive value of comprehensive surgical staging in clinically early-stage epithelial ovarian carcinoma: A systematic review and meta-analysis

BACKGROUND

Tumor positivity and upstaging rates from various surgical staging steps performed in clinically early-stage epithelial ovarian carcinoma (EOC) vary widely in literature.

AIM

To quantify tumor positivity and upstaging rates for all staging surgery steps in EOC patients. Differences between subgroups based on their clinical and histological characteristics are explored.

METHODS

A systematic search using synonyms of 'ovarian cancer', 'neoplasm staging', and 'neoplasm metastasis' was conducted in PubMed, Embase, and the Cochrane Library. Meta-analysis was performed on 23 included studies, comprising 5194 clinical stage I or II EOC patients who underwent comprehensive surgical staging. Studies were assessed using the Newcastle-Ottawa Scale risk-of-bias tool. Pooled proportions and 95% confidence intervals were calculated using an inverse variance weighted random-effects model.

RESULTS

Overall upstaging rate of clinically early-stage EOC patients was 18.7% (95%CI: 14.1-23.4%). Serous histology or high grade EOC showed the highest upstaging rate at 35.3% (95%CI: 21.8-48.7%) and 40.9% (95%CI: 35.6-46.2%). Lymph node involvement resulted in an upstaging rate of 8.7% (95%CI: 6.2-11.3%). Tumor was identified in uterus, cytology, peritoneal biopsies, omentum and appendix in 6.2% (95%CI: 1.8-10.7%), 18.4% (95%CI: 13.8-22.9%), 9.7% (95%CI: 3.8-15.6%), 5.2% (95%CI: 1.7-8.8%) and 3.6% (95%CI: 0.0-7.5%) of EOC patients. The corresponding upstaging rates were 5.9% (95%CI: 1.4-10.4%), 8.5% (95%CI: 1.8-15.2%), 3.5% (95%CI: 1.0-6.0%), 3.9% (95%CI: 1.4-6.3%) and 1.6% (95%CI: 0.0-3.4%), respectively.

CONCLUSION

The attributive value of comprehensive surgical staging in clinically early-stage EOC patients remains substantial, particularly in serous and high grade tumors.

Ovarian teratoma in a woodchuck (Marmota monax) with hepatocellular carcinoma: radiologic and pathologic features

Background

Teratomas are germ cell neoplasms composed of a wide variety of tissues. In the woodchuck, only one testicular teratoma has been described in the literature. The objective of this report was to describe the radiologic and pathologic findings in a female woodchuck (Marmota monax) with an ovarian teratoma consisting of mature tissues originating from all three germ layers.

Case presentation

A 2-year-old female woodchuck that had been infected at birth with woodchuck hepatitis virus and subsequently developed hepatocellular carcinoma was incidentally discovered to have a mobile 6.6 × 4.8 × 4.7 cm abdominal mass on computed tomography (CT) imaging. The tumor was predominantly solid and heterogenous on CT with soft tissue, fat, and areas of dense calcification. The teratoma did not enhance with intravenous contrast administration. On ultrasound, the tumor was solid with heterogeneous echogenicity, reflecting the fat content and areas of calcification. Sonolucent areas were present that may have represented cysts. There was heterogeneously increased signal on T1-weighted magnetic resonance imaging (MRI) and heterogeneous hyperintensity in T2-weighted imaging. Fat was evident within the tumor. At necropsy, the tumor was attached to the distal end of the right uterine horn. Histopathology showed mature tissue types representing all three germ layers.

Conclusions

Ovarian teratoma should be considered in the differential diagnosis of ovarian or abdominal masses in woodchucks. The tumor displayed mature tissue derived from all three germ layers. CT, ultrasound, and MRI findings were presented in detail and matched the typical imaging appearance of teratomas.

Does uterine preservation affect survival outcomes of patients with stage I ovarian sex cord-stromal cell tumours? A multi-institutional study

OBJECTIVE

Sex cord-stromal tumours of the ovary are relatively uncommon neoplasms that account for 3 % of all ovarian cancers. Uterine preservation with careful staging is achievable; however, conservative surgery remains controversial. This study examined the prognostic effects of uterine preservation in patients with stage I sex cord-stromal tumours.

STUDY DESIGN

This retrospective cohort study was undertaken between January 1986 and February 2019, and the clinicopathological data of 4897 women with malignant ovarian tumours were collected. Seventy-seven patients with stage I sex cord-stromal tumours were eligible for inclusion. The characteristics and survival outcomes of these patients were examined. To investigate the prognostic effects of uterine-preserving surgery, baseline imbalances between patients with and without uterine-preserving surgery were adjusted using an inverse probability of treatment weighting with propensity scores composed of independent clinical variables.

RESULTS

The mean ages of patients in the uterine-preserving surgery and non-uterine-preserving surgery groups were 39.8 and 57.8 years, respectively. After inverse probability of treatment weighting adjustments, no significant differences in overall survival (p = 0.205) or recurrence-free survival (p=0.071) were observed between the uterine-preserving surgery and non-uterine-preserving surgery groups. Estimated 10-year overall survival rates were 98.7 % in the uterine-preserving surgery group and 95.9 % in the non-uterine-preserving surgery group, and 10-year recurrence-free survival rates were 87.2 % in the uterine-preserving surgery group and 78.2 % in the non-uterine-preserving surgery group. Uterine-preserving surgery did not significantly affect the site of tumour recurrence.

CONCLUSION

Uterine-preserving surgery may be a feasible surgical option for patients with stage I sex cord-stromal tumours. Further research is needed to guarantee prognostic accuracy and develop effective therapeutic approaches for sex cord-stromal tumours.

Serous borderline tumor of the ovary with isolated cardiophrenic lymph node spread at diagnosis

•

Serous borderline tumor outside of the peritoneal cavity is rare.

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Involvement of cardiophrenic lymph nodes with serous borderline tumor can occur.

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Preoperative imaging may aid surgical planning even in serous borderline tumor cases.

•

Sequencing can help confirm a diagnosis of serous borderline tumor at distant sites.

Germline PALB2, ATM variants in a patient with breast and ovarian cancer at risk for familial cancer syndrome: Is there a role for risk-reducing salpingo-oophorectomy?

A 50-year-old non-Hispanic white Caucasian female was diagnosed with breast cancer and was subsequently found to possess the tumorigenic ataxia telangiectasia mutated (ATM) and PALB2 variants but not the BRCA1 and BRCA2 variants. She visited the gynecologic oncology office for routine counseling about risk-reducing salpingo-oophorectomy (RRSO). Although the patient was asymptomatic, an adnexal mass was discovered in the physical examination performed by palpation. Upon using pre-operative imaging techniques, an 8 cm complex adnexal mass was identified. Her CA-125 level was elevated. She underwent complete cytoreductive surgery. Pathological analysis showed a stage IC clear cell carcinoma of the left ovary; subsequently, she received 6 cycles of adjuvant chemotherapy with a combination of carboplatin and paclitaxel. The patient exhibited no signs ovarian cancer in a follow-up appointment after 32 months of treatment. However, bilateral RRSO is not recommended for patients positive for ATM and PALB2. Breast cancer patients with PALB2 and ATM mutations should extensively discuss the risks and benefits of RRSO in light of current data.

Approaches to the management of pediatric ovarian masses in the 21st century: Systematic review and meta-analysis

BACKGROUND

Laparoscopy is increasingly being adopted for the treatment of ovarian pathologies in adults. However, its implementation for the management of pediatric ovarian masses varies and the evidence, to date, has not been comprehensively analyzed. This review aims to compare laparoscopic and open surgical management of pediatric ovarian masses.

METHODS

We searched PubMed, Cochrane Library and Google Scholar from the year 2000 till April 2017. Studies selected for this included those on epidemiological trends of pediatric ovarian lesions, assessing outcomes of laparoscopic management and comparison of laparoscopic and open surgical techniques for pediatric ovarian masses. A meta-analysis comparing outcomes of both modalities was performed using standard methodology.

RESULTS

A total of 44 studies met the inclusion criteria of which 15 were on histological types of ovarian lesions, 24 assessed laparoscopic management only and five compared laparoscopy with open surgery for pediatric ovarian masses. Nonneoplastic lesions were the most common ranging from 36.5% to 73.7%, with cystic lesions being the most prevalent. Neoplastic lesions ranged between 26.3% and 63.5%, with germ cell tumors being the most common, while malignancy ranged between 3.5% and 10.8%. Laparoscopic management was generally advocated for managing benign lesions with a cautious approach for suspicion of malignant lesions. In comparison to open surgery, laparoscopic surgery had shorter operating time (MD = -33.24 min, 95% CI = -34.29 to -32.19, p < 0.0001), less intraop bleeding (MD = - 61.46 ml, 95% CI = -62.69 to -60.24, p < 0.0001), and reduced length of hospital stay (MD = -2.78 days, 95% CI= -2.82 to -2.74, p<0.0001). Complication rates were equivocal between the two approaches. Spillage rates could not be assessed.

CONCLUSION

Limited evidence suggests that laparoscopic approach to presumptively benign ovarian masses have better outcomes when compared to open surgery with regards to operating time, blood loss and hospital stay. However, complication rates were similar between the two approaches. Studies with rigorous scientific methods are needed for a definitive recommendation, especially in resource limiting settings. However malignant lesions should still be managed with an open surgical approach to avoid upstaging of disease status.

LEVEL OF EVIDENCE

II.

Trametinib response in heavily pretreated high-grade ovarian cancer: One step towards precision medicine

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New therapies are needed for advanced or recurrent high-grade ovarian cancer.

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Genetic and molecular tests may help in directing therapeutic options according to sensitivity profiles.

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Trametinib showed promising response in our patient affected by heavily pretreated high-grade ovarian cancer.

Traditional treatment failure in recurrent ovarian cancer remains a challenge for clinicians. Tumor genetic testing is a promising tool which has been proved able to identify sensitivity profiles in patients affected by cancers. This may be helpful in choosing targeted systemic treatments, aiming to overcome histology boundaries and to avoid unnecessary toxicity. We describe the case of a patient affected by recurrent high-grade serous ovarian cancer responsive to MEK-inhibitors, who had undergone multiple lines of therapy. To our knowledge, this is the first reported case of recurrent high-grade ovarian cancer showing remarkable clinical, radiologic and biochemical response to trametinib. This report suggests that trametinib could be effective in high-grade serous ovarian cancer, although most of promising scientific data on this molecule have focused on low-grade ovarian cancer. Molecular profiling has gradually become part of care for patients affected by recurrent ovarian cancer, however further randomized studies are needed to prove its efficacy in everyday clinical practice.

Impact of age on clinicopathological features and survival of epithelial ovarian neoplasms in reproductive age

BACKGROUND

Little is known about the effect of age on the prognosis of epithelial ovarian neoplasms. In the reproductive age, fertility-sparing surgery had been widely implemented. This study aimed to elucidate impact of age on the clinicopathologic characteristics and survival of epithelial ovarian neoplasms in the reproductive age.

METHODS

The clinical records of patients diagnosed as epithelial ovarian cancer or epithelial borderline ovarian tumor at the age of 40 years or younger at multiple institutions in the Tokai Ovarian Tumor Study Group were reviewed retrospectively. All patients were stratified into two age groups: group A (≤ 30 years) and group B (31-40 years). Univariate and multivariate analyses were performed to evaluate overall survival and disease-free survival.

RESULTS

A total of 583 patients (325 patients: cancer, 258 patients: borderline) were included. The median follow-up time was 62.0 months (range 1-270 months). Compared with group B, group A had a significantly higher rate of borderline tumor (66.7% vs. 32.7%, p < 0.001); stage I disease (85.9% vs. 70.4%, p < 0.001); mucinous type (69.2% vs. 35.6%, p < 0.001); conservative surgery (83.8% vs. 41.6%, p < 0.001); no adjuvant chemotherapy (67.2% vs. 44.7%, p < 0.001); and CA125 ≤ 35 U/mL (39.4% vs. 28.8%, p < 0.05). There was a significant difference in the overall survival (p = 0.0051) and the disease-free survival (p = 0.0039) between the two groups. Multivariate analysis revealed that the independent prognostic factors for the overall survival were age, stage, histology, and ascitic fluid cytology.

CONCLUSION

In epithelial ovarian neoplasms, younger patients had a survival advantage over older patients.

Platelet-lymphocyte ratio as a potential prognostic factor in gynecologic cancers: a meta-analysis

PURPOSE

Cancer-related inflammation plays an important role in tumor development and progression. Platelet-lymphocyte ratio (PLR) has been studied as a biomarker for prognosis in gynecologic cancers. But, the results of previous studies were controversial, so we performed this meta-analysis.

METHODS

We searched the scientific database of PubMed, Embase, Web of Science, Wanfang, and China National Knowledge Infrastructure (CNKI) using free text and MeSH keywords. Crude HR (hazard ratio) with 95% confidence interval was used to evaluate the risk association between PLR and overall survival (OS) or progression-free survival (PFS) in gynecologic neoplasms.

RESULTS

There totally 23 studies, including 6869 patients who were eligible, most of which are published after 2015 or later. PLR greater than the cut-off was associated with poorer survival prognosis in ovarian cancer [OS: HR 1.80 (95% CI 1.37-2.37), p = 0.000; PFS: HR 1.63 (95% CI 1.38-1.91), p = 0.000] and cervical cancer [OS: HR 1.36 (95% CI 1.10-1.68), p = 0.005; PFS: HR 1.40 (95% CI 1.16-1.70), p = 0.002], but not in endometrial cancer [OS: HR 1.95 (95% CI 0.65-5.84), p = 0.234].

CONCLUSIONS

The current meta-analysis revealed that pretreatment PLR was a simple, promising prognostic indicator for OS and PFS in ovarian and cervical cancers. But, its significance of prognosis did not agree with endometrial neoplasm. However, due to the limited number of original studies, future large-scale studies with more well-designed, high-quality studies are still needed.

Diagnostic Accuracy of Frozen Section and Its Influence on Intraoperative Management of Indeterminate Epithelial Ovarian Tumors

The objective of this study is to determine the diagnostic accuracy of frozen section in detecting epithelial ovarian tumor histological types and its effect on management. A retrospective review was done of all patients who had an intraoperative frozen section for an indeterminate ovarian tumor over a six-year period. The reference standard was final histology. The validity indices for frozen section in diagnosing benign, borderline, and malignant lesions were determined. One hundred thirty-five intraoperative frozen section-diagnosed epithelial ovarian tumors were reviewed. The mean age was 44.9 ± 14.2 years, the median parity was 2, and 57% (77/135) of patients were post-menopausal. The commonest histological subtype was mucinous 48.1% (65/135) on frozen section and 46.7% (63/135) on final histology. The overall concordance rate of frozen section to final histology was 81.5% (ƙ = 0.719, p = 0.0001). The accuracy, sensitivity, specificity, and positive predictive value of frozen section to diagnose benign lesions were 86.7%, 85.7%, 97.2%, and 79.2% respectively. In borderline tumors, the diagnostic test characteristics were 88.1%, 81.2%, 90.3%, and 72.2%. For malignant lesions, these values were 88.1%, 77.8%, 95.1%, and 91.3% respectively. The odds ratios for frozen section being correct were 40.9 (95% CI 14.8-113.5) for benign lesions, 40.3 (95% CI 13.4-121.3) for borderline tumors, and 67.4 (95% CI 20.5-222.0) for malignancy. Over-treatment or under-treatment occurred in 19.3% of patients. Intraoperative frozen section is useful in situations where the nature of the ovarian tumor is uncertain. However, borderline ovarian tumors are more likely to be over-diagnosed. About a fifth of patients received inappropriate treatments based on the frozen section report.

Wide spectrum targeted metabolomics identifies potential ovarian cancer biomarkers

AIMS

Despite of almost a hundred years of research on cancer metabolism, the biological background of cancerogenesis and cancer-related reprogramming of metabolism remains not fully understood. In order to comprehensively and effectively diagnose and treat the deadliest diseases, the mechanisms underlying these diseases have to be discovered urgently. Among the gynecological malignancies, ovarian cancer is the most common cause of death. The aim of the study was to search for potential cancer-related differences in concentrations of metabolites and interactions between them in serum of women with ovarian cancer and benign ovarian tumor in comparison with healthy controls using targeted metabolomics. These metabolites might serve as biomarkers in the future.

MAIN METHODS

We used wide spectrum targeted metabolomics to evaluate serum concentrations of metabolites related to ovarian cancer and compared them against benign ovarian tumors and healthy controls. The measurements were performed using high performance liquid chromatography coupled with triple quadrupole tandem mass spectrometry technique in highly-selective multiple reaction monitoring mode.

KEY FINDINGS

In this study we confirmed our previous findings about the role of histidine and citrulline in ovarian cancer as well as we indicated new lipid compounds (lysoPC a C16:1, PC aa C32:2, PC aa C34:4 and PC aa C 36:6) potentially involved in cancer metabolism.

SIGNIFICANCES

We indicated interesting interactions between metabolites for further in-depth research which could potentially serve as clinically useful biomarkers in future. Moreover, the presented work attempts to visualize a possible 3D-network of relationships between the molecules found to be related to ovarian malignancy.

A combined score of clinical factors and serum proteins can predict time to recurrence in high grade serous ovarian cancer

OBJECTIVE

To investigate the utility of a combined panel of protein biomarkers and clinical factors to predict recurrence in serous ovarian cancer patients.

METHODS

Women at Augusta University diagnosed with ovarian cancer were enrolled between 2005 and 2015 (n = 71). Blood was drawn at enrollment and follow-up visits. Patient serum collected at remission was analyzed using the SOMAscan array (n = 35) to measure levels of 1129 proteins. The best 26 proteins were confirmed using Luminex assays in the same 35 patients and in an additional 36 patients (n_total = 71) as orthogonal validation. The data from these 26 proteins was combined with clinical factors using an elastic net multivariate model to find an optimized combination predictive of progression-free survival (PFS).

RESULTS

Of the 26 proteins, Brain Derived Neurotrophic Factor and Platelet Derived Growth Factor molecules were significant for predicting PFS on both univariate and multivariate analyses. All 26 proteins were combined with clinical factors using the elastic net algorithm. Ten components were determined to predict PFS (HR of 6.55, p-value 1.12 × 10^-6, CI 2.57-16.71). This model was named the serous high grade ovarian cancer (SHOC) score.

CONCLUSION

The SHOC score can predict patient prognosis in remission. This tool will hopefully lead to early intervention and consolidation therapy strategies in remission patients destined to recur.

Prognostic significance of supradiaphragmatic lymph node metastasis detected by 18F-FDG PET/CT in advanced epithelial ovarian cancer

Background

Supradiaphragmatic lymph node metastases (SdLNM) are frequently identified using ¹⁸F-FDG positron emission tomography/computed tomography (PET/CT) in advanced epithelial ovarian cancers (AEOC). This study aimed to determine the prognostic significance of SdLNM detected by PET/CT in patients with AEOC.

Methods

Medical records of patients diagnosed with AEOC were retrospectively registered from January 2009 to July 2015. Patients were categorized according to PET/CT stage: PET/CT stage III, PET/CT stage IV with SdLNM, and PET/CT stage IV with other metastases. Clinicopathologic characteristics, recurrence patterns, survival outcomes were compared according to PET/CT stage. Anatomical distribution of SdLNM and effect of thoracic debulking surgery were estimated.

Results

A total of 295 patients were identified, including 176 patients who underwent primary debulking surgeries (PDS). Progression-free (P = 0.671) and overall (P = 0.525) survival did not differ significantly between patients with PET/CT IV with SdLNM and PET/CT IV with other metastases; however, patients with PET/CT IV with SdLNM had significantly poorer progression-free (P < 0.001) and overall (P = 0.016) survival than those with PET/CT stage III. Recurrence patterns were similar in all groups; intraperitoneal metastasis was the most common (78.8%) and thoracic recurrence alone accounted for less than 10%. Debulking of SdLNM lesions did not improve progression-free survival (P = 0.425) or overall survival (P = 0.465) of patients with AEOC.

Conclusions

SdLNM detected using preoperative PET/CT are a negative prognostic factor in AEOC. Resection of suspicious SdLNM may not have effect to survival of patients with AEOC.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5067-1) contains supplementary material, which is available to authorized users.