Sex cord-gonadal stromal tumor

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Sex cord-gonadal stromal tumor

411 - W15 - Infertility

411 - W15 - Infertility

Anatomy of the pelvic girdle
Anatomy of the pelvic cavity
Arteries and veins of the pelvis
Anatomy of the male reproductive organs of the pelvis
Nerves and lymphatics of the pelvis
Anatomy of the inguinal region
Anatomy of the perineum
Anatomy of the male urogenital triangle
Anatomy clinical correlates: Male pelvis and perineum
Anatomy of the breast
Anatomy of the female urogenital triangle
Anatomy of the female reproductive organs of the pelvis
Anatomy clinical correlates: Breast
Anatomy clinical correlates: Female pelvis and perineum
Anatomy and physiology of the female reproductive system
Puberty and Tanner staging
Estrogen and progesterone
Menstrual cycle
Menopause
Pregnancy
Oxytocin and prolactin
Stages of labor
Breastfeeding
Amenorrhea
Ovarian cyst
Premature ovarian failure
Polycystic ovary syndrome
Ovarian torsion
Krukenberg tumor
Sex cord-gonadal stromal tumor
Surface epithelial-stromal tumor
Germ cell ovarian tumor
Uterine fibroid
Endometriosis
Endometritis
Endometrial hyperplasia
Endometrial cancer
Choriocarcinoma
Cervical cancer
Pelvic inflammatory disease
Urethritis
Female sexual interest and arousal disorder
Orgasmic dysfunction
Genito-pelvic pain and penetration disorder
Mastitis
Fibrocystic breast changes
Intraductal papilloma
Phyllodes tumor
Paget disease of the breast
Breast cancer
Hyperemesis gravidarum
Gestational hypertension
Preeclampsia & eclampsia
Gestational diabetes
Cervical incompetence
Placenta previa
Placenta accreta
Placental abruption
Oligohydramnios
Polyhydramnios
Potter sequence
Intrauterine growth restriction
Preterm labor
Postpartum hemorrhage
Chorioamnionitis
Congenital toxoplasmosis
Congenital cytomegalovirus (NORD)
Congenital syphilis
Neonatal conjunctivitis
Neonatal herpes simplex
Congenital rubella syndrome
Neonatal sepsis
Neonatal meningitis
Miscarriage
Gestational trophoblastic disease
Ectopic pregnancy
Fetal hydantoin syndrome
Fetal alcohol syndrome

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A 65-year-old woman comes to the clinic due to pelvic heaviness and discomfort for the past few months. The patient also discloses bloody spotting on her underwear, which has required intermittently changing throughout the day. The patient has had no urinary symptoms or weight loss. She does not smoke or use alcohol or illicit drugs. The patient’s last menstrual cycle was 6 years ago. Her last Pap smear 2 years ago was normal. Vitals are within normal limits. On physical examination, a right-sided adnexal mass is palpated. Pelvic ultrasound shows a thickened endometrial stripe. Endometrial biopsy reveals an early stage, well-differentiated adenocarcinoma. The patient subsequently undergoes excision of the mass. The histopathological analysis is shown below:


Reproduced from: Wikimedia Commons

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With sex cord-stromal ovarian cancer, Ovarian refers to “ovary”, of which women have two that sit along either side of the uterus. The term sex cord refers to an embryonic structures that develop into ovarian follicles and stromal cells are the connective tissue of any organ. So a sex cord-stromal ovarian cancer is a type of tumor that develops from either ovarian follicle cells or connective tissue cells.

Each ovary has multiple follicles. Each follicle is made up of an oocyte, which is an immature egg, surrounded by two types of cells - theca cells and granulosa cells. Granulosa and theca cells work together to support follicle development. Luteinizing hormone stimulates theca cells to generate androgens and follicle stimulating hormone stimulates granulosa cells to convert those androgens to estradiol using the enzyme aromatase. A large increase in estradiol triggers ovulation.

During ovulation, the oocyte pops out of the ovary, causing a bit of damage to the surface. Fibrocytes detect that damage and differentiate into fibroblasts and lay down collagen to help repair the damage.

If any of those cells starts to divide uncontrollably, it can either form a benign tumor which means that it doesn’t invade nearby tissue or spread to other parts of the body, or it can be a malignant tumor which means that it can invade nearby tissue and spread to other parts of the body. Compared with benign tumor cells, malignant tumor cells have key features like not having a clearly defined border or like having slightly less organized nuclei.

The first main type of sex-cord stromal tumor is a granulosa-theca cell tumor. And these are the most common malignant stromal tumors and they’re associated with middle-aged women. These tumors often end up producing way too much estradiol, and this can cause very specific hormone associated symptoms like uterine bleeding, breast tenderness, and early puberty in young girls. Under the microscope, these tumors classically develop little fluid pockets scattered throughout the tissue that are called Call-Exner bodies.

The second type of tumors, fibromas, are made of fibroblasts and are benign tumors. Under the microscope, they look like thin needle-like strands with elongated nuclei that are bundled together. Benign fibromas are often seen in combination with ascites, a fluid buildup in the peritoneal cavity, as well as pleural effusion, a fluid buildup in the pleural cavity.

In fact, the clinical triad of a benign ovarian tumor with ascites and a pleural effusion, is better known as Meigs syndrome. The exact pathogenesis here, though, is unclear, but it’s thought that the solid ovarian tumor irritates the peritoneal and pleural surfaces which leads to a transudative fluid buildup in both spaces. Fibromas can occasionally grow to the size of an orange and can cause a pulling sensation in the groin when it compresses the round ligament of the uterus.

Summary

Sex cord-stromal ovarian cancer is a type of tumor that develops from either ovarian follicle cells, or connective tissue cells. Some of these tumors are granulosa-theca cell tumors and Sertoli-Leydig cell tumors. Granulosa-theca cell tumors produce excess estradiol, which can cause very specific hormone-associated symptoms like uterine bleeding, breast tenderness, and early puberty in young girls. Sertoli-Leydig cell tumors can secrete excess testosterone, which can cause women to have more masculine features like hirsutism, which is increased hair growth.

Sources

  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Mucinous Tumors of the Ovary: Current Thoughts on Diagnosis and Management" Current Oncology Reports (2014)
  6. "Sex Cord-Gonadal Stromal Tumor of the Rete Testis" Advances in Urology (2009)
  7. "Ovarian sex cord?stromal tumors?a clinicopathological study of 72 cases from the Kiel Pediatric Tumor Registry" Virchows Archiv (2003)
  8. "CD56 Is a Sensitive and Diagnostically Useful Immunohistochemical Marker of Ovarian Sex Cord-Stromal Tumors" International Journal of Gynecological Pathology (2007)