Metallothionein expression and nuclear size in benign,borderline, and malignant serous ovarian tumours

Metallothioneins (MTs) are low-molecular-weight proteins involved in metalloregulatory functions such as cell proliferation, growth, and differentiation. In recent years, MT expression has been linked with carcinogenesis, resistance to cancer therapy, and tumour progression. However, the significance of MT expression in ovarian cancers is at present inadequately documented. In this study, MT immunohistochemistry was performed in 12 benign, 14 borderline, and eight malignant serous tumours of the ovary. The intensity of the immunostaining was evaluated by image analysis. There was a significantly higher number of MT-immunopositive cells in the multilayered epithelial cells of borderline serous tumours (atypical proliferative serous tumours) than in the single layered epithelial cells within the same tumour, and in the single cell layer of benign serous tumours. There was no difference in the expression of MTs in the single layered tumour cells of benign and borderline serous tumours. Significantly higher numbers of MT-immunopositive cells were observed in both the single and the multilayered epithelial cells of serous carcinomas, the highest number being observed in the multiple layers of serous carcinomas. The positively stained malignant tumour cells in both single and multiple layers were larger than the negatively stained cells in benign, borderline, and malignant serous ovarian tumours. There was moderate to intense staining. These findings indicate that there is increased expression of MTs in the progression of malignancy, which could be used as a marker in grading the three groups of ovarian serous tumours and for determining prognosis. Copyright © 1999 John Wiley & Sons, Ltd.     

Serous borderline tumours of the ovary

Serous borderline tumours of the ovaryIn this Expert Opinion we have invited articles from two leading groups, to discuss serous borderline tumours (serous tumours of low malignant potential) of the ovary from their own perspectives. Controversy remains over heterogeneity within this group of tumours and their relationship to ovarian cancer. Our authors discuss the histopathological classification of these tumours in relation to morphological appearances, molecular and clinical data. The significance of a micropapillary pattern is discussed, and issues related to extra-ovarian implants.     

Ovarian borderline tumours: a review with comparison of serous and mucinous types

Ovarian borderline tumours are relatively uncommon but not rare neoplasms. A large majority are of serous or mucinous type with other morphological variants being much more uncommon. In this review, the clinicopathological features of ovarian borderline tumours are discussed, concentrating on serous and mucinous neoplasms. Other morphological types are briefly discussed. A comparison is made between serous and mucinous borderline tumours which exhibit marked differences with regards to incidence of bilaterality, surface involvement, extraovarian spread, lymph node involvement, risk of malignant progression and prognosis. It has been suggested that the category of borderline tumour be abandoned for both serous and mucinous neoplasms but this terminology is useful for both types but for different reasons, namely the significant risk of extraovarian disease in serous borderline tumours and the large size and heterogeneity of mucinous borderline tumours which can result in an invasive focus being undetected by the pathologist.     

Evolutive peritoneal disease after conservative management and the use of infertility drugs in a patient with stage IIIC borderline micro-papillary serous carcinoma (MPSC) of the ovary: case report

A young nulliparous woman with stage IIIC bilateral borderline micro-papillary serous carcinoma (MPSC) of the ovary underwent conservative surgery with optimal preservation of future fertility. The left ovary and a substantial portion of the right ovary were removed. The patient became pregnant at the first IVF cycle attempted after conservative management. A Cesarean section was performed in the 37th week of pregnancy and combined with very precise exploration; there were multiple non-invasive implants on the peritoneal surface and liver, and contra-lateral ovarian tissue was of normal appearance. Abdominal hysterectomy and right oophorectomy were done as a definitive treatment 3 months after the Caesarean section. The patient showed a rapid progression to invasive ovarian carcinoma in this period of time. MPSC has the greatest risk of malignant transformation among the advanced stage serous borderline tumours. Fertility-sparing surgery is an option for young, childless women who would like to preserve their fertility. However, the treatment must be taken very cautiously and requires rigorous surveillance.     

Evolution of the concept and termiology of borderline ovarian tumours

The borderline category of ovarian tumours was established in the early 1970s because of the observation that a group of proliferative epithelial ovarian tumours lacking invasion that generally behaved in a benign fashion occasionally pursued an indolent malignant course. Over the last 25 years, a large database on these tumours has been accrued. Recent studies suggest that the borderline group can now be subclassified into benign and malignant neoplasms. The survival for patients with serous borderline tumours confined to the ovaries is virtually 100%. Patients with ovarian serous borderline tumours with invasive peritoneal implants have a 34% mortality rate; therefore, these cases are classified as low grade carcinomas. Micropapillary serous carcinoma, a distinctive neoplasm that fails to display unequivocal evidence of invasion and therefore has been included in the borderline category, is strongly associated with invasive implants and recurs as invasive carcinoma. After these neoplasms with invasive implants are excluded from the group of tumours classified as borderline, the remaining advanced stage serous borderline tumours (those with non-invasive implants) have a disease-specific survival rate of nearly 100% and should be considered benign. In a similar fashion, the vast majority of mucinous borderline tumours reported to display aggressive behaviour have been associated with the clinical syndrome of pseudomyxoma peritonei. It is now clear that pseudomyxoma peritonei is a condition of appendiceal origin in virtually all cases. In addition, there is a small group of mucinous carcinomas typically from the pancreas and biliary system that present with relatively bland-appearing metastases to the ovaries that closely simulate mucinous borderline tumours. Once these metastatic carcinomas and mucinous tumours associated with pseudomyxoma peritonei are removed from the borderline category, the remaining mucinous borderline tumours are always confined to the ovaries and have a benign behaviour. Finally, review of the literature indicates the other epithelial types of borderline tumours (endometrioid, clear cell and transitional cell) behave in a benign fashion. Since borderline tumours can now be classified into benign and malignant types, the borderline category has no further utility and can be abandoned. This will be of great benefit to patients and clinicians, and will also help in more clearly focusing research efforts on ovarian cancer.     

Primary neoplasia of the female peritoneum

Primary neoplasms of the female peritoneum may be mesothelial or Müllerian in nature. Primary mesotheliomas may be cystic, benign papillary or diffuse malignant. Primary Müllerian tumours of the peritoneum are thought to arise within the secondary Müllerian system: the overwhelming majority are serous in nature and probably develop from pre-existing endosalpingiosis. Primary peritoneal serous tumours of borderline malignancy are identical histologically to the peritoneal 'implants' found in association with ovarian serous tumours of borderline malignancy, whereas primary peritoneal serous adenocarcinomas are histologically identical to ovarian serous adenocarcinomas. The recognition of a primary peritoneal serous neoplasm of borderline malignancy rests on the presence of either normal ovaries, ovaries containing only a fully benign neoplasm or ovaries showing only minimal surface involvement. The diagnosis of a primary peritoneal serous adenocarcinoma is made if the ovaries are of normal size with either no tumour or only minimal surface involvement: in some cases normal ovaries will have previously been prophylactically removed because of a family history of ovarian cancer. The differential diagnosis between a primary serous adenocarcinoma and a diffuse malignant mesothelioma can be difficult and is often not resolved by either electronmicroscopy or immunocytochemistry.     

Different proportions of aneusomic cells in ovarian inclusion cysts associated with serous borderline tumours and serous high-grade carcinomas support different pathogenetic pathways

Ovarian serous tumours may arise from the ovarian surface epithelium or from ovarian cortical epithelial inclusion cysts. However, little is known about the pathogenetic mechanisms involved in the progression from ovarian surface epithelium or inclusion cysts to neoplastic disease. In the present study, chromosomal aberrations typical of ovarian serous tumours were studied in ovarian surface epithelium and inclusion cysts. Ten ovaries with inclusion cysts obtained from patients without a gynaecological tumour, as well as 15 serous borderline tumours and 16 invasive high-grade serous carcinomas with inclusion cysts either in the ipsi- or in the contralateral ovary, were investigated by fluorescence in situ hybridization (FISH) using centromere enumeration probes directed against chromosomes 1, 6, 7, and X. The proportions of aneusomic cells were assessed. Trisomies 1 and 7 and monosomies 6 and X were present in the surface epithelium, inclusion cysts, and tumours, providing evidence for a link between the surface epithelium, and inclusion cysts, and serous neoplasia. Inclusion cysts generally harboured more aneusomic cells than the associated surface epithelium, suggesting an influence of the ovarian stroma on the development of chromosomal instability. Moreover, inclusion cysts associated with borderline tumours displayed a higher proportion of aneusomic cells than inclusion cysts associated with invasive high-grade carcinoma and than inclusion cysts in ovaries without neoplastic disease. These results suggest a genetic field defect of the inclusion cyst epithelium in serous borderline tumours. Invasive high-grade serous carcinomas, by contrast, may arise from single cell clones subject to a different set of genetic events.     

Expression of Fas and FasL in human serous ovarian epithelial tumors

The expression of Fas and FasL was studied in 86 patients with benign, borderline, and malignant serous ovarian lesions. Four normal ovaries, and monolayer epithelial cultures from a human fetal ovary, a borderline, and a serous adenocarcinoma were used for comparison. Expression of Fas and FasL was studied immunohistochemically and flowcytometrically. Fas was expressed in all 90 lesions; FasL in 57 lesions, including 2 normal ovaries. Fas expression was significantly increased in borderline tumors compared with benign (P = 0.005, t = -2.94) or malignant serous tumors (P = 0.0001, t = 4.15). FasL expression was significantly increased in malignant tumors compared with benign (P = 0.039, t = -2.10) and borderline tumors (P = 0.0016, t = -3.33). Flow cytometry showed a range of Fas expression in short-term cultures isolated from normal, borderline, and malignant ovarian serous tissue; in the few samples studied, FasL was not expressed. Expression in three serous ovarian cell lines was similar. Fas and FasL expression differed throughout the spectrum of ovarian lesions. FasL expression was increased in malignant tumors, and Fas expression was increased in borderline tumors. Changes in Fas/FasL expression in ovarian surface epithelium might play a functional role in the biology of ovarian tumors.     

Androgen production by epithelial ovarian tumours in post-menopausal women

Peripheral serum concentrations of androstenedione (A) and testosterone (T) were measured in 31 post-menopausal women with epithelial ovarian tumours (12 cancer, 5 borderline malignant and 14 benign tumours), and in 20 post-menopausal women who were free from ovarian neoplasms. The levels of these androgens were also measured in ovarian venous blood in 17 women with ovarian tumours. No significant differences were found between the mean serum androgen levels in patients with malignant, borderline malignant or benign ovarian tumours or the control group. The measured levels of A and T in peripheral and ovarian venous blood were highest in women with mucinous ovarian tumours. Histopathological examinations of the ovarian tumours showed hyperplasia or luteinization in ovarian tumour stroma in 5 out of 17 cases (3 mucinous tumours, 1 endometrioid adenocarcinoma and 1 serous adenocarcinoma). The results indicate that of all epithelial tumours mucinous ovarian tumours most often demonstrate hormonal activity and that malignancy has no effect on hormonal activity.     

p53 protein expression in putative precursor lesions of epithelial ovarian cancer

p53 protein expression has been studied in epithelial inclusion cysts adjacent to and contralateral to serous carcinoma of the ovary and compared to epithelial inclusion cysts associated with borderline tumours and in normal ovaries. Atypia was found in epithelial inclusion cysts in eight of the thirteen advanced (stage III) serous ovarian carcinomas. Of these eight with atypical epithelial inclusion cysts, five showed immunoreactivity for p53. In the borderline tumours and normal ovaries no atypia in such cysts was found. p53 expression was also seen more frequently in surface epithelium associated with ovarian serous adenocarcinoma (ten of 13) than in normal ovaries (one of 13). We postulate that focal areas of atypia (ovarian intra-epithelial neoplasia) in epithelial inclusion cysts are the precursors of ovarian malignancy. In some cases, at least, p53 protein expression may precede overt cytological abnormalities.     

Genetic alterations of serous borderline tumors of the ovary compared to stage I serous ovarian carcinomas

Borderline tumors of the ovary comprise 10-20% of all epithelial ovarian tumors, and are placed between clearly benign and obviously malignant ovarian tumors. The issue of whether borderline tumors are precursors of invasive carcinoma or distinct clinical entities, however, is still the subject of discussion. To increase our understanding in relation to this issue, the aim of our study was to analyze both serous borderline and invasive ovarian tumors, and to investigate early carcinogenesis in serous ovarian tumors. Using comparative genomic hybridization, we compared cytogenetic changes in borderline ovarian tumors and stage I invasive tumors. The average number of genetic alterations differed significantly between the borderline and the invasive tumors (1.9 and 9.2, respectively). The most common genetic alterations among the borderline tumors were loss of chromosome 17, 20q, and 18p, and gain of 12p13 approximately q23. These changes were also found among the invasive tumors in a similar percentage. In conclusion, we found four distinct cytogenetic alterations that might be early events in serous ovarian tumors, and that might also characterize a subgroup of borderline ovarian tumors that may have the potential to progress and develop malignancy.     

Fallopian tube precursors of ovarian low‐ and high‐grade serous neoplasms

Traditionally, it was thought that ovarian high‐grade serous carcinoma arises from the ovarian surface epithelium and epithelial inclusion glands and that the pathogenesis is de novo; nonetheless, a convincing precursor in the ovary or peritoneum has not been identified to date. During the last few years, however, there has been a dramatic shift in thinking, and a candidate precursor is now recognized in the fallopian tube, especially within the fimbriated end – serous tubal intra‐epithelial carcinoma (STIC). Accordingly, STIC is probably the earliest histologically recognizable lesion in the pathogenesis of high‐grade serous carcinoma, but steps in this pathway which precede STIC have also been proposed. With subsequent progression, STIC implants onto the ovary and then develops into an invasive high‐grade serous carcinoma with rapid tumour growth. For invasive low‐grade serous carcinoma, it is well‐established that its pathogenesis begins with serous cystadenoma/adenofibroma, which develops sequentially into atypical proliferative serous tumour (typical serous borderline tumour), non‐invasive micropapillary (low‐grade) serous carcinoma (micropapillary serous borderline tumour) and then invasive low‐grade serous carcinoma in a relatively slow stepwise process. It is presumed that cystadenoma/adenofibroma arises from epithelial inclusion glands in the ovary, but recent evidence suggests that epithelial inclusion glands originate in the fallopian tube. Alternatively, it has been proposed that the other early precursors in the low‐grade pathway, including serous borderline tumours, non‐invasive implants and endosalpingiosis, may also arise directly from tubal mucosa. Therefore, the precursor of most ovarian high‐grade serous carcinomas originates in the fallopian tube, and that for low‐grade serous tumours may also be derived from the tube. This review paper provides an overview of the fallopian tube's potential role in the pathogenesis of both types of serous neoplasms of the ovary.     

The role and prognostic value of inducible nitric oxide synthase (iNOS) and interleukin-33 (IL-33) in serous and mucinous epithelial ovarian tumours

Understanding different mechanisms contributing to the aggressive behaviour of epithelial ovarian cancer (EOC) is a large challenge. Interaction between inflammation, immunity and carcinogenesis occurs in different cancers; however, the potential roles of different molecules involved in these processes in relation to ovarian carcinogenesis were not fully investigated. Inducible nitric oxide synthase (iNOS) and interleukin-33 (IL-33) are implicated in carcinogenesis. iNOS is an NOS isoform that generates nitric oxide, which plays important roles in various stages of carcinogenesis. IL-33 is a cytokine implicated in modulation of anti-tumour immunity and tumour growth. This work aimed at studying the immunohistochemical expression of iNOS and IL-33 in serous and mucinous epithelial ovarian tumours to investigate their role and prognostic significance. Immunohistochemical expressions of iNOS and IL-33 were assessed in 90 patients with epithelial ovarian tumours (45 serous and 45 mucinous tumours, categorized as benign, borderline, and malignant tumours). iNOS and IL-33 showed significantly higher expressions in borderline and malignant serous and mucinous tumours compared to benign ones (p = 0.0001). The differences between borderline and malignant tumours were statistically insignificant (p = 0.2351&0.6321). iNOS showed significantly higher expression with increasing tumour grade in malignant mucinous tumours (p = 0.0011). IL-33 showed significantly higher expression with increasing tumour grade in both malignant serous and mucinous tumours (p = 0.0074 and 0.0007). Upregulation of iNOS and IL-33 expression in borderline and malignant epithelial ovarian tumours indicates their involvement in the development and progression of EOC, and their increased expression in less differentiated cancers suggests their association with poor prognosis in this category of tumours.     

Immunohistochemical localization of c-erbB-2 protein and epidermal growth factor receptor in normal surface epithelium,surface inclusion cysts,and common epithelial tumours of the ovary

Summary The c-erbB-2 (HER-2/neu) protein is a membrane glycoprotein growth factor receptor showing molecular homology with the epidermal growth factor receptor (EGFR). We examined the immunohistochemical reactivity of monoclonal antibodies against both of these proteins in normal surface epithelium, surface inclusion cysts, and common epithelial tumours of the ovary. The ovarian tumours were classified as benign (16), borderline malignant (2), and malignant (19). Normal surface ovarian epithelium was weakly positve for both c-erbB-2 protein and EGFR. In surface inclusion cysts, however, the epithelial cells lining the lumen exhibited stronger staining for c-erbB-2 protein, but no staining for EGFR. All 16 benign ovarian tumours and the 2 borderline malignant ovarian tumours were positive for c-erbB-2 protein and negative for EGFR. Of the ovarian carcinomas, 13 of the 19 (68.4%) were positive for c-erbB-2 protein and negative for EGFR, while 4 showed positivity for both c-erbB-2 protein and EGFR. Two cases were negative for both proteins. Expression of both c-erbB-2 protein and EGFR was found in endometrioid carcinoma with squamous differentiation and in clinically advanced poorly differentiated serous carcinomas. Expression of c-erbB-2 protein appears to be increased and that of EGFR is reduced in the early stage of epithelial ovarian oncogenesis. The expression of EGFR with c-erbB-2 protein in ovarian carcinoma is related both to histological differentiation and/or advanced clinical stage.     

High-grade ovarian serous carcinoma exhibits significantly higher p16 expression than low-grade serous carcinoma and serous borderline tumour

AIMS: A dualistic pathway of ovarian serous carcinogenesis is now well established whereby high-grade serous carcinoma and low-grade serous carcinoma represent two distinct tumour types with a different underlying pathogenesis. The aim of this study was to compare expression of p16 INK4A (p16) in these two tumour types. We also included cases of serous borderline tumour, since these are considered to represent a precursor lesion of low-grade serous carcinoma. METHODS AND RESULTS: Cases of serous borderline tumour (n = 18), low-grade ovarian serous carcinoma (n = 22) and high-grade ovarian serous carcinoma (n = 24) were stained with a monoclonal antibody against p16. Cases were scored both with respect to intensity of immunoreactivity (weak, 1+; moderate, 2+; or strong, 3+) and distribution (0, negative or occasional positive cells; 1+, < 10% cells positive; 2+, 10-25% cells positive; 3+, 26-50% cells positive; 4+, 51-75% cells positive; or 5+, 76-100% cells positive). An immunohistochemical composite score was also calculated (0-15) by multiplying the intensity and distribution scores. There was a statistically significant difference in p16 immunoreactivity with respect to intensity, distribution and composite score between high-grade serous carcinoma and each of the other two groups, with the high-grade neoplasms exhibiting stronger and more diffuse positivity. Most high-grade serous carcinomas exhibited positivity of close to 100% of tumour cells. There was no significant difference in p16 expression between the borderline tumours and low-grade serous carcinomas. CONCLUSIONS: The increased expression of p16 in high-grade serous carcinoma compared with low-grade serous carcinoma and serous borderline tumour is in keeping with a different underlying pathogenesis. p16 may be implicated in the development of high-grade serous neoplasia within the ovary and elsewhere within the female genital tract.     

Expression of transmembrane carbonic anhydrases IX and XII in ovarian tumours

AIMS: Carbonic anhydrase (CA) isozymes IX and XII have been suggested to play a role in oncogenic processes. The aim of the present study was to investigate CA IX and XII expression in patients with ovarian tumours. METHODS AND RESULTS: A series of ovarian tumours was immunostained for CA IX and XII and the results were correlated with histopathological and clinical parameters. Most cases of borderline mucinous cystadenomas, mucinous cystadenocarcinomas and serous cystadenocarcinomas were moderately or strongly positive for CA IX. In malignant tumours, the staining was most prominent in hypoxic regions. Expression of CA XII was detected in all tumour categories, although the mean staining intensity was weaker than for CA IX in all groups except for clear cell carcinomas. CONCLUSIONS: The wide expression of CA IX and XII in ovarian tumours suggests that these isozymes could represent potential targets in ovarian cancer therapy. The expression pattern of CA IX suggests that it could also serve as a useful histopathological marker protein for hypoxia in malignant ovarian tumours.     

Expression of a homeobox gene (SIX5) in borderline ovarian tumours

AIMS: To assess the expression of SIX5 (a homeobox gene) mRNA in surface coelomic epithelium, endocervical epithelium, Fallopian tube epithelium, and benign, borderline, and malignant epithelial ovarian tumours. METHODS: 10 normal premenopausal ovaries, 10 normal Fallopian tubes, 10 normal cervices, 10 normal postmenopausal ovaries, 10 benign epithelial ovarian tumours, 10 malignant epithelial ovarian tumours, and 40 borderline epithelial ovarian tumours were studied retrospectively. The tissues had been fixed in formalin and embedded in paraffin wax. The tumours had previously been typed into mucinous, serous, or mixed tumours and assigned to the borderline category according to the FIGO/WHO criteria. Expression was assessed by in situ binding of SIX5 specific sense and antisense riboprobes. Hybridization of the riboprobes was detected using a standard immunohistochemical technique and the results correlated with expression in the normal epithelium of the endocervix, Fallopian tube, surface coelomic epithelium, and ovarian tumours. RESULTS: Expression of SIX5 mRNA was demonstrated in normal Fallopian tube epithelium and normal endocervical epithelium. SIX5 mRNA was not detected in normal ovarian epithelial tissue at any of the times studied during the menstrual cycle. Expression of SIX5 was not shown in benign epithelial ovarian tumours or in any of the malignant epithelial ovarian tumours. In 31 of 37 borderline epithelial ovarian tumours (84%), SIX5 expression was found in the epithelial cells. CONCLUSIONS: SIX5 expression is present in the normal epithelium throughout most of the female reproductive tract, suggesting it may have a role in maintaining epithelial differentiation in these tissues. SIX5 expression appears to be restricted to borderline epithelial ovarian tumours and may be a marker of epithelial differentiation in these tumours; thus borderline ovarian tumours may not be part of a continuum of disease between benign and malignant epithelial ovarian tumours. Further investigation of expression of SIX5 may clarify the molecular processes that promote differentiation of the ovarian surface epithelium.     

Immunohistochemical localization of survivin in serous tumors of the ovary.

The aim of this study was to determine the immunohistochemical distribution of survivin in benign, borderline, and malignant serous tumors of the ovary. Survivin was localized by an indirect immunoperoxidase method in 42 cases of serous tumors of the ovary (15 cystadenomas, 15 borderline tumors, and 12 cystadenocarcinomas). Nuclear staining and cytoplasmic staining were separately scored. Cytoplasmic staining was detected in 27% of adenomas/borderline tumors and in 58% of carcinomas. Nuclear staining was detected in 87% of adenomas/borderline tumors but in only 42% of carcinomas. Although the differences in the intensity of cytoplasmic staining between adenomas and borderline tumors versus carcinomas were not significant, the differences in the intensity of nuclear staining between low-grade versus malignant tumors were significant. These findings suggest that survivin is widely expressed in benign, borderline, and malignant serous tumors but that nuclear localization of survivin is more common in benign or borderline tumors than in malignant serous tumors of the ovary. The molecular mechanisms that determine the subcellular distribution of this protein may reflect the role of survivin in the regulation of apoptosis during the processes of malignant transformation.     

基质金属蛋白酶-7在卵巢浆液性肿瘤中的表达

目的：探讨MMP－7在卵巢浆液性肿瘤中的表达情况。方法：采用免疫组化SP法对6例正常卵巢、12例卵巢浆液性囊腺瘤、6例交界性囊腺瘤及22例卵巢浆液性囊腺癌MMP－7的表达进行了研究。结果：正常卵巢不表达MMP－7。大部分卵巢浆液性肿瘤的胞浆及间质中都有MMP－7的阳性表达。MMP－7的卵巢良性，恶性及交界性浆液性肿瘤胞浆中的表达无明显差异；而在肿瘤间质中，恶性及交界性卵巢浆液性肿瘤中的表达远高于良性肿瘤（P＜0．05）。在交界性及恶性浆液性卵巢肿瘤中，部分肿瘤细胞的细胞核中也有MMP－7的表达，为国内外首次报道。结论：MMP－7可能在卵巢浆液性肿瘤的进展中发挥重要作用。