The Value of Cell Proliferation and Angiogenesis in the Prognostic Assessment of Ovarian Granulosa cell Tumors

Objectives

Most cases of granulosa cell tumors (GCT) of the ovary are characterized by a relatively good outcome. However, some tumors behave aggressively and some tend to recur many years after the initial diagnosis. Tumor growth depends on cell proliferation and angiogenesis. Thus, proliferative indices and microvessel density were studied to determine possible valuable methods to assess the GCT patient's outcome.

Methods and study design

Paraffin-embedded tissue blocks were available for 60 patients with primary GCT and were investigated by immunostaining with monoclonal antibodies against PCNA, Ki-67 and factor VIII-related antigen. The follow-up was available for 51 patients and ranged from 25 to 206 months. A clinical follow-up distribution of patients was made: 8 patients with recurrence (group I); 6 patients who lived with no evidence of recurrence for 100 months or more (group II), and 37 patients alive with no evidence of recurrence in the follow-up period of less than 100 months (group III).

Results

There was a statistical correlation between PCNA and Ki-67 proliferative indices. A significant increase (P «0.05) of mean PCNA and Ki-67 proliferative indices and mean tumor size was seen in patients of Group I compared to those of Group II. The mean PCNA proliferative index positively correlated with the mean Ki-67 proliferative index for Groups I and II. Mean microvessel density showed a positive correlation with mean PCNA and Ki-67 proliferative indices and with mean tumor size for Group I, whereas it was negatively correlated with PCNA proliferative index and tumor size for Group II. A positive correlation was found between mean mitotic count and both proliferative indices only for Group II. The following features were indicative of a relatively poor prognosis: GCT measuring >9 cm in diameter, PCNA >4.0%, Ki-67 >1.2%, and diffuse, insular and sarcomatoid histologic patterns.

Conclusions

The findings support the importance of proliferative factors, tumor size and histologic patterns as possible prognostic indicators for estimating the biologic behavior of patients with GCT. Unfortunately, angiogenesis did not seem to be a useful determinant parameter of a possible aggressive behavior. However, a longer follow-up period with larger series may be required to assess the value of the parameters in prediction of patient survival.

Ovarian granulosa cell tumors frequently express EGFR (Her-1), Her-3, and Her-4: An immunohistochemical study

OBJECTIVE

Up to 50% of patients with ovarian granulosa cell tumors (GCTs) will develop recurrences; some of these recurrences can be seen as late as 30 years following the initial surgical treatment. Combined chemotherapy and radiotherapy are currently used for patients with advanced or recurrent disease. The aim of this study was to investigate the possible eligibility of patients with GCTs for anti-Her therapy.

METHODS

The immunohistochemical expression of EGFR (Her-1), Her-2, Her-3, and Her-4 was analyzed in a group of ovarian GCTs encompassing 38 adult type and 2 juvenile type.

RESULTS

Thirty-one cases (77.5%) were positive for at least one of the receptors EGFR (Her-1), Her-3, and Her-4. Twenty-six out of 40 (65%) GCTs showed positive reaction for EGFR (Her-1). Eight tumors (20%) were exclusively positive for EGFR (Her-1). None of 40 cases showed a positive reaction for Her-2. Positive reactions for Her-3 and Her-4 were observed in 18 (45%) and 23 (57.5%) tumors. Only one case (2.5%) was exclusively positive for Her-4. Four tumors (10%) showed positivity for Her-3 and Her-4 but were negative for EGFR (HER-1). While one of the two JGCTs was negative for all members of the Her-family, one showed reactivity for EGFR (Her-1), Her-3, and Her-4.

CONCLUSION

In this study, most of the ovarian GCTs express at least one of the receptors EGFR (Her-1), Her-3, and Her-4. These findings provide some evidence to further explore the potential use of agents targeting these receptors (particularly EGFR) in the treatment of ovarian GCTs.

[The role of Ki-67, mutant suppressor gene p53 and low mitotic levels in defining the prognosis for adult granulosa cell tumor of the ovary]

Clinico-morphological examination of adult granulosa cell tumors of the ovary was carried out in 17 patients (mean follow-up duration--146.2 +/- 22.16 months). Overall and relapse-free survival appeared significantly higher in low expression of Ki-67 (8.63 +/- 1.4%), mutant suppressor gene p53 (3.55 +/- 1.9%) and low mitotic levels in tumor (2.33 +/- 0.9 per 10 fields of microscope) (p < 0.05).

Monoclonal antibodies against inhibin represent key markers of adult granulosa cell tumors of the ovary even in their metastases. A report of three cases with late metastasis, being previously misinterpreted as hemangiopericytoma

Antibodies against human inhibin, a peptide hormone produced by ovarian granulosa cells to inhibit FSH, are widely applied to determine serum inhibin levels. Recently, they were, however, proved also to stain follicle cells in ovarian tissue by immunoreactions in histological sections. The commercially available inhibin antibody produced by Serotec, applied to sections of paraffin blocks, stained follicle epithelia in 6/6 samples of ovarian tissue from females under the age of 40 recruited from the archives. Adult granulosa cell tumor tissue samples from primary tumors of the ovary showed positive reaction in 6/6 cases. No positive reaction was found in staining tissues from hemangiopericytomas from males (0/3), leiomyomas, leiomyosarcomas, and a malignant melanoma (0/5), serving as negative controls. No positive reactions could be observed in tumor cells of 10 ovarian carcinomas, whereas in two of these cases single cells of the specialized ovarian stroma stained positively with inhibin. Positive immunostainings were revealed in three late metastases (two within the liver) from granulosa cell tumors in females, primarily misinterpreted as hemangiopericytomas or leiomyosarcomas, because the previously resected primaries of the ovary were not known at the time of liver surgery. The recognition of granulosa cell tumors, especially the distinction of the sarcomatoid growth type from soft tissue tumors, may be difficult, even if immunostaining for intermediate filaments are applied. Immunostaining by antibodies against inhibin, which can be applied reliably in histopathology, may therefore provide a useful tool to distinguish between granulosa cell tumors and genuine soft tissue tumors. This is also of clinical importance, because treatment of the former by cisplatin-based polychemotherapy and antisex hormone therapy proved to be helpful. Furthermore, the inhibin antibody can be used as an early serum marker for detecting tumor recurrence months before clinical evidence.

Tumor-associated antigen Ca 125 before and during the treatment of ovarian carcinoma

Serum concentrations of Ca 125, a tumor-associated antigen of epithelial ovarian cancer, were measured in 29 ovarian cancer patients before cytoreductive surgery and in 112 patients during and after treatment. Ca 125 levels were increased (greater than 30 IU/mL) in 89.8% of patients with clinically demonstrable ovarian tumors and were negative in 92.1% of clinically disease-free patients. Low levels of Ca 125 were associated with early clinical stages or a minimal tumor burden, and predicted a successful response to treatment and a low recurrence rate. High values indicated advanced disease and a poor response to cytotoxic chemotherapy. In 77% of patients the operation was explorative, with a preoperative Ca 125 level higher than 1000 IU/mL, whereas all the patients with values less than 100 IU/mL could be operated radically. Serum levels of Ca 125 were increased in similar frequency in epithelial, sex cord, and germ cell ovarian malignancies. The assay of Ca 125 seems to be a reliable noninvasive method for monitoring the presence and clinical behavior of ovarian cancer. Preoperative values have prognostic significance in predicting operability and response to chemotherapy.

Cellular differentiation in ovarian sex-cord-stromal and germ-cell tumors studied with antibodies to intermediate-filament proteins

Seventy ovarian sex-cord-stromal and germ-cell tumors were immunohistochemically studied for the presence of intermediate-filament proteins of different types used as markers for cellular differentiation. Cells of ovarian granulosa-cell tumors constantly expressed vimentin and appeared to lack cytokeratin. Two tumors previously classified as granulosa-cell tumors were reclassified as poorly differentiated "common" epithelial tumors based on their cytokeratin positivity, vimentin negativity, and morphologic features. Dysgerminomas and Leydig-cell tumors showed only vimentin positivity. Tubular structures in androblastomas, which are considered to represent Sertoli-cell differentiation, were cytokeratin positive, and thus differed from the majority of normal Sertoli cells that are known to express vimentin and not cytokeratin. Embryonal carcinomas, choriocarcinomas, and endodermal sinus tumors showed cytokeratin positivity in the neoplastic cells whereas vimentin was observed in the stromal cells. In immature teratomas, epithelial differentiation was demonstrated with cytokeratin antibodies, and neural and glial differentiation was also frequently demonstrated by immunostaining with antibodies to neurofilaments and glial fibrillary acidic protein. The results show that antibodies to intermediate filaments can be used in the differential diagnosis between ovarian epithelial and nonepithelial tumors, and they provide a very accurate additional method to characterize the cellular differentiation of ovarian neoplasms.

[The clinical significance of CA125 in patients with gynecological tumors--a comparative study on CA125 and other tumor markers]

Serum CA125 levels were measured by radioimmunoassay patients with various gynecological tumors. Elevated levels of CA125 were detected in the serum of patients with malignant ovarian tumors. Among patients with uterine tumors, CA125 levels were elevated in those with malignant uterine tumors, but not with uterine myomas. The correlations between tumor markers (CA125, IAP, ferritin, PTA) and malignant ovarian tumors were measured, and only CA125 levels were found to correlate with progression or regression of the disease in patients with malignant ovarian tumors. These results suggest that CA125 may be a useful marker for monitoring the response to treatment in patients with malignant ovarian tumors.

Carcinoembryonic antigen (CEA) in ovarian cancer: factors influencing its incidence and changes which occur in response to cytotoxic drugs

We report the serum levels of carcinoembryonic antigen (CEA) in 109 patients with ovarian cancer. Histology, degree of differentiation, and clinical stage influenced the incidence of positive CEA. Although CEA was significantly raised in patients with a variety of tumours, the highest incidence (77 per cent) was found in those with serious cystadenocarcinoma. Nearly all (94 per cent) of the poorly differentiated tumours were associated with a positive CEA result. Serial CEA levels provided a useful guide to management during cytotoxic chemotherapy, rapidly falling levels indicating a favourable tumour response which was reflected clinically. However, only two-thirds of tumours were associated with detectable CEA levels in serum, day-to-day variations in individual serum levels occurred, and CEA levels tended to fall paradoxically during terminal illness. The significance of persistently low levels in the apparent absence of disease was uncertain.