Diagnosi, inquadramento clinico e chirurgia

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Tumori germinali, stromali e forme rare : stato dell arte, novità e prospettive Caravaggio 10-12

1 Tumori germinali, stromali e forme rare : stato dell arte, novità e prospettive Caravaggio giugno 2010 Giorgia Mangili IRCCS San Raffaele Milano Diagnosi, inquadramento clinico e chirurgia

2 SEX-CORD STROMAL TUMORS Granulosa-stromal cell tumors Granulosa cell tumors, thecoma-fibroma Sertoli-stromal cell tumors, androblastomas: well- differentiated, Sertoli-Leydig cell tumor of intermediate differentiation, Sertoli-Leydig cell tumor poorly differentiated (sarcomatoid), retiform Sex cord tumor with annular tubules Gynandroblastoma Unclassified Steroid (lipid) cell tumors: stromal luteoma, Leydig cell tumor, unclassified

3 The low incidence, varying histologic patterns and variable biologic behavior limit our knowledge on the optimal management of these tumors (Colombo 2007) Small numbers of cases to evaluate statistically Selection of patients Variation of treatment criteria over time Data collection from various centers over a range of years

4 SERTOLI LEYDIG virilization :amenorrhea, breast atrophy, hirsutism, deepening voice, male pattern baldness, acne, and clitoral enlargement production of either inhibin or alpha-fetoprotein pure Sertoli cell tumors are usually estrogenic and may also secrete renin, leading to refractory hypertension and hypokalemia. 2-3% have extraovarian spread at the time of diagnosis 20 percent display malignant behavior early recurrence is typical of Sertoli-Leydig cell tumors recurrences are most common with poorly differentiated tumors.

5 GRANULOSA OVARIAN TUMORS 0 to 0.9 case per women (Parking 2003) 2%-5% ovarian tumors (About 1997, Schumer 2003) Occur commonly perimenopausal period (About 1997, AbuRustum 2006) Long natural history and 25% may recur late (Uygun 1993) Survival: stage I 75%-90 %, stage II 55%-75%, stage II/IV 22%-50% (Colombo 2007) Mortality rates are approximately 20% (Enavs1980, Fox1975)

6 SYMPTOMS No specific symptoms Palpable abdominal/pelvic mass Large tumor size (> cm) Ovarian torsion abdominal pain Hemorrahagic rupture hemoperitoneum 2/3 pts with endocrinal manifestations

7 ENDOCRINE MANIFESTATIONS Estrogen production Post menopausal bleeding Irregular menses or secondary amenorrea Rarely infertility (unregolated inhibin secretion) Increase risk of breast cancer (incidence 3.7%-20%) Rarely virilization

8 ENDOMETRIUM AND GCT Association between GCT and both endometrial hyperplasia and adenocarcinoma Endometrial hyperplasia: 25% to 50% Endometrial carcinoma : 5 % to 10 % Endometrial adenocarcinoma associated with granulosa- stromal cell tumors is usually early stage and well differentiated if an adnexal mass is present

9 US AND GCT heterogeneous echogenicity of solid tissue swiss cheese Imaging of gynecological disease (3): clinical and ultrasound characteristics of granulosa cell tumors of the ovary. Van Holsbeke C, Ultras.Obstet Gynecol Apr;31(4):450-

11 MARKERS Estradiol is responsable for clinical manifestation Estradiol in 70 % of cases Inhibin elevated levels in GCT (Lappohn 1989) Marker of in pre-post menopausal No specific marker (mucinous EOC Robertson 2007) Antimullerian hormon Undetectable in normal postmenopausal 6 cases of GCT 2/6 normal level 4/6 elevated level Jobling cases of GCT 12/17 normal levels 5/17 elevated level Abu-Rustum 2006

12 DIAGNOSIS AND GCT The diagnosis is made by histology at time of surgical excision Since these are rare tumors, many expert gynecologic pathologists will not provide a definite diagnosis based upon intraoperative frozen section examination A histologic diagnosis is often made only after oophorectomy and upon final pathologic evaluation

13 SURGICAL TREATMENT Surgery: Diagnosis - Staging - Debulking Total abdominal hysterectomy and bilateral salpingo-oophorectomy for women with granulosa cell tumors who have completed childbearing (stage I) Conservative surgery Laparoscopy Lymphadenectomy Staging Debulking

14 CONSERVATIVE SURGERY Unilateral oophorectomy for women with stage I disease who wish to preserve fertility Bilateral tumor is uncommon (2%-8%) Endometrial biopsy Pankratz reported 57% recurrence incidence in conservative surgery, but many pts had avanced disease Studies found no disadvange for fertility-sparing surgery in premenopausal women with early stage disease

15 CONSERVATIVE SURGERY : MITO 9 DATA stage conservative surgery radical surgery relapse cons. Relapse rad. IA 56 (61.5%) /21(19%) 6/35(17.1%) IB 3 (3.3%) 0 3-0/3 IC 21 (23%) /5 (60%) 7/16(44%) IX 11 (12%) 4 7 3/4 (75%) 3/7 (43%) TOT /30 (33%) 16/61 (26%) NS NS NS NS

16 LAPAROSCOPY MITO 9 DATA stage laparoscopy laparotomy Relapse laparoscopy Relapse laparotomy IA 56 (61.5%) /16 (0%) 10/40 (25%) IB 3 (3.3%) IC 21 (23%) /3 (67%) 8/18 (44%) IX 11 (12%) 3 8 1/3 (33.3%) 5/8 (63%) Few data in literature No contraindications for laparoscopy

17 LYMPHADENECTOMY AND GCT PRO 16 lymphadenectomy None positive 5/34 (14.7%) positive node at recurrence Conclusion :This may be a more realistic occult nodal involvement. GCT staging similar EOC (Abu-Rustum NR Gynecol Oncol ) CONTRA 58 lymphadenectomy None positive 6/117 (5%) positive nodes at recurrence (SCTT) 5/99 (5.%) positive nodes at recurrence (GCT) Conclusion.: Lymphadectomy may be deleted from staging procedure for sex-cord- stromal tumors (Brown J et al Gynecol. Oncol ) yes Lymphadectomy 10 50% ND no Lymphadectomy 81 26% MITO 9

18 SURGICAL STAGING The surgical staging procedure should include: Exploration of pelvis and abdominal cavity Peritoneal washing Peritoneal biopsies Omental biopsy Biopsy of any sospicious area Cytoreduction Brown J et al Gynecol. Oncol

19 RECURRENCE Indolent course Propensity fo late reccurence Median time to relapse 4-6 year (case >20) No standard approach for relapse Repeat surgical resection for optimal cytoreduction is a reasonable option

20 DETECTION of RECURRENCE Long time follow-up: Bi manual pelvic examination Markers TC PET Prognostic factors

21 SITES OF FIRST RECURRENCE of OVARIAN GRANULOSA CELL TUMORS Location of recurrence Naadem et al MITO 9 Pelvis only 70% 44% Abdominopelvic 9% 12% Retroperitoneum only 6% 12% Pelvis and retroperitoneum 6% 12% Pelvis/abdomen/retroperitoneum 3% 0% Abdomen only 3% 20% Bone 3% 0%

22 GCT and PET Few cases of PET in the management of GCT The role for PET imaging in the management of GCT recurrence has to be further investigated A negative PET does not exclude a GCT recurrence

23 PET CT PET/CT

24 ELEVATED INHIBIN LEVELS PREDATE CLINICAL RECURRENCE Complete resection of recurrent GCT inhibin recurrenc e months Complete resection of recurrent GCT months Complete resection of stage IB months Complete resection of recurrent GCT months. Boggess JF, Soules MR, Goff BA, Greer BE, Cain JM, Tamimi HK. Serum inhibin and disease status in women with ovarian granulosa cell tumors. Gynecol Oncol Jan;64(1):64-9

25 INHIBIN ROLE IN IDENTIFYING PATIENTS MOST AT RISK FOR RELAPSE Boggess JF, Soules MR, Goff BA, Greer BE, Cain JM, Tamimi HK. Serum inhibin and disease status in women with ovarian granulosa cell tumors. Gynecol Oncol Jan;64(1):64-9

26 PATIENTS CHARACTERISTICS MITO 9 Age at diagnosis (years) mean 49.6 (range 16-82) Follow-up (months) median 67 (range 1-765) Histology Number of mitosis Stage Juvenile granulosa cell Adult granulosa cell few (less than 4) moderate (4-10) high (over 10) Ix I II III IV 10 (9.3%) 97 (90.7%) 55% 35% 9% 11 (10%) 80 (75%) 6 (6%) 8 (7%) 2 (2%) Tumor size Median 7.25 (range 1-20) Surgery conservative radical 32 (30%) 75 (70%) Lymphadenectomy 15 (14%) Adjuvant treatment no adjuvant treatment chemotherapy radiation 78 (73%) 27 (25%) 2 (2%)

27 RECURRENCES OVERALL RECURRENCE RATE= 30.3% MEDIAN TIME TO RECURRENCE= 56.4 months Rate of recurrence: 29% I stage 17% II stage 63% III stage 50% IV stage I STAGE IB-IC Time to recurrence: 85% to 10 years 9% from 20 to 30 years 6% from 30 to 60 years Ix IA p=0.001

28 RISK FACTORS FOR RECURRENCE (I stage) factor No. Of patients Recurrence rate P Primary Surgery in MITO center Primary Surgery elsewhere % 59% < Laparoscopy approach Laparotomy approach % 34% 0.05 Conservative surgery Radical surgery % 26% NS Stage IA Stage IB-IC % 42% Stage Ix Stages IA-IB-IC % 25% Complete staging unstaged % 20% Adjuvant treatment No adjuvant treatment % 27% NS Lymphadenectomy No lymphadenectomy % 26% NS

29 PROGNOSTIC FACTORS Cox Regression Univariate Analysis Cox Regression Multivariate Analysis FACTORS P - RR older age of diagnosis (>50 ys) stage at diagnosis (I-II vs III-IV) number of mitosis histology MITO-elsewhere surgical approach complete staging-unstaged NS NS NS NS NS FACTORS P - RR older age at diagnosis stage at diagnosis < lymphadenectomy NS Residual disease at first surgery Adjuvant treatment Tumor size NS NS

30 SURVIVAL ANALISYS 1- Overall survival: 5-years overall survival=98% 20-years overall survival=70% I-II vs III-IV stage I-II III-IV p=0.011

31 SURVIVAL ANALISYS 2- Age > or > 50 years Residual disease < 50 ys RD=0 > 50ys p=0.038 RD>1 cm p=0.001

32 PROGNOSTIC FACTORS Older age of diagnosis (years) Advanced stage Kaplan Meir disease-specific survival by stage and by age at diagnosis M Zhang et Gynecol Oncol

33 TREATMENT there is no standard approach of relapsed GCT surgery/chemotherapy/radioterapy abdominal recurrence may be amenable to repeat surgical resection (Schumer JCO )

34 CONCLUSIONS It is possible that some gynecologist assume that GCT is a rare benign ovarian tumor because rare disseminate peritoneal disease or ascites at initial diagnosis many patients do not receiced chemotherapy after primary surgery late recurrences Unfortunately GCT are not a benign variant of ovarian neoplasms and can metastasize, recur, and cause death Abu- Rustum 2006

36 RISK FACTORS FOR RECURRENCE stage mito elsewhere Relapse mito Relapse elsewhere IA 56 (61.5%) /41 (7%) 7/15 (47%) IB 3 (3.3%) IC 21 (23%) /11 (27%) 7/10 (70%) IX 11 (12%) 4 7 1/4 (25%) 5/7 (71%) p=0.001 p=0.05 NS stage complete staging unstaged relapse compl.staging relapse unstaged IA 56 (61.5%) /36 (14%) 5/20 (25%) NS IB 3 (3.3%) IC 21 (23%) /9 (44%) 6/12 (50%) IX 11 (12%) 3 8 1/3 (33.3%) 5/8 (63%) NS NS

37 TREATMENT of SERTOLI LEYDIG abdominal hysterectomy with bilateral salpingo-oophorectomy and complete surgical staging is recommended for women who have completed childbearing when preservation of fertility is desired, unilateral oophorectomy can be performed chemotherapy in nonmetastatic Sertoli-Leydig cell tumors that are poorly differentiated or contain heterologous elements.

38 SCTAT sex cord tumor with annular tubules accounted for 6 percent of all ovarian sex cord-stromal tumors associated with PJS are benign and do not have malignant potential SCTAT non-pjs associated are unilateral, the affected population is also younger (mid to late 20s) SCTAT without PJS have a 20 percent incidence of metastasis at initial surgery

39 SERTOLI LEYDIG : MITO 9 Number of patients 19 Age at diagnosis (years) mean 44.4 (range 16-76) Follow-up (months) median 52.3 (range 6-339) grade (21%) 9 (47%) 6 (32%) Stage Surgery Adjuvant treatment IA IC IIB IIIC conservative radical no adjuvant treatment chemotherapy 15 (79%) 1 (5%) 1 (5%) 2 (11%) 9 (47%) 10 (53%) 14 (74%) 5 (27%) recurrence 7 (37%)

IMMATURE TERATOMA: SURGICAL TREATMENT

CARAVAGGIO 10-12 MAGGIO 2010 IMMATURE TERATOMA: SURGICAL TREATMENT G. Mangili, E. Garavaglia, C. Sigismondi R VIGANO Dipartimento Materno Infantile, UF Ginecologia Oncologica IRCCS San Raffaele Milano