Granulosa-Theca Cell Tumors Workup

• Order a pregnancy test in all reproductive-aged patients (even at the extremes of reproductive age) who present with abdominopelvic symptoms.
• The standard workup for a patient with an adnexal mass varies depending on patient age.

  • In patients who are prepubertal or younger than 30 years, especially if the mass has solid components present, obtain blood to check for beta–human chorionic gonadotropin (bhCG), alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and cancer antigen 125 (CA125). Each of these may be elevated in women with ovarian malignancies and in patients with a normal or abnormal pregnancy. CA125 levels in menstruating women can be slightly to moderately elevated due to a host of benign disorders including, but not limited to, endometriosis, uterine leiomyoma, appendicitis, pancreatitis, and inflammatory bowel disease. In this group of patients, CA125 level is not as useful as a diagnostic test, but it may be helpful in monitoring patients long term if they are found to have a tumor that causes elevation of this tumor marker.
  • In reproductive-aged women older than 30 years, CA125 level should be checked; remember that this can be elevated in benign disorders in women who still are menstruating. Serum inhibin levels are now clinically available for work-up of masses suspicious for GCT and should be considered in such patients (see below). This is now the most specific marker for GCTs that is currently clinically available.^[23] Serum levels for estrogen, testosterone, and dehydroepiandrosterone can be drawn if elevation of these hormones is suggested based on clinical findings. Abrupt onset or rapid progression of endocrinologic manifestations should heighten the suspicion for a neoplastic process.
  • In postmenopausal women, obtain blood for a CA125 test. A CA125 level higher than 60 U/mL in a postmenopausal woman has a good positive predictive value for malignancy. Again, serum sex hormone levels can be ordered based on clinical findings consistent with excess hormone production.
• Other ancillary laboratory studies that may be useful in narrowing the differential include stool guaiac testing, CBC count with differential, blood chemistries, urinalysis, and cervical cultures for gonorrhea and chlamydia.
• Several other tumor markers have been evaluated in patients with GCTs.

  • Inhibin has been studied in women with granulosa cell tumors.
    • Inhibin is a peptide hormone produced by ovarian granulosa cells that plays a role in regulation of FSH secretion by the pituitary. It is composed of an alpha subunit and 1 of 2 beta subunits (BA or BB). Although inhibin A and inhibin B levels can both be elevated in patients with granulosa cell tumors, inhibin B level is usually elevated in a higher proportion of these tumors. Furthermore, this increase in serum levels from baseline is often higher as well. Typical cutoffs for normal inhibin levels in postmenopausal or oophorectomized women are less than or equal to 5 ng/L and 15 ng/L for inhibin A and B, respectively.
    • Studies of inhibin in patients with GCTs have shown that levels are elevated preoperatively and return to the reference range postoperatively in both adult and juvenile types of tumors. In a 2002 study by Robertson et al, total serum inhibin level was elevated in 100% of GCTs and 100% of thecomas.^[34] Additionally, 84% of patients with mucinous ovarian carcinomas had elevated inhibin levels. However, only 18% of patients with serous and 54% of patients with endometrioid ovarian cancers had elevation of total serum inhibin level. Current inhibin assays allow us to distinguish between inhibin A and inhibin B.
    • Mom et al evaluated the use of serum inhibin levels in 30 women with granulosa cell tumors. The sensitivities and specificities for inhibin A were 67 and 100% and for inhibin B were 89 and 100%, respectively. They also noted that inhibin A level was elevated before or at the time of first clinical recurrence in 58% of patients while inhibin B level was elevated in 85%. Lead time from elevation of inhibin levels to clinical recurrence was estimated to be 11 months. Inhibin A and B levels were not elevated in any of the 17 patients who were postoperatively disease free. Serum inhibin levels are currently available for diagnosis and clinical follow-up of women with granulosa cell tumors of the ovary.^[27]
  • Müllerian-inhibiting substance (MIS), or antimüllerian hormone (AMH), has been studied more recently.
    • This hormone is produced exclusively by granulosa cells in postnatal females and both prenatally and postnatally by the Sertoli cells in the male testis. This hormone functions in male fetuses to induce regression of the mullerian system. Normally, MIS/AMH is found in low levels in reproductive-aged females and functions as a paracrine inhibitory factor decreasing resting ovarian follicle response to follicle stimulating hormone (FSH). This insures the emergence of a single dominant follicle. Serum MIS/AMH may be a marker of ovarian reserve and typically disappears from the serum after menopause or bilateral oophorectomy. However, in patients with GCTs, levels have been shown to parallel the extent of disease.
    • In a 1999 study, Lane et al found that 76% of patients with GCTs had elevated MIS/AMH levels preoperatively.^[22] No patient with levels within the reference range postoperatively experienced recurrence, whereas 6 of 15 patients with elevated levels had a recurrence. On average, elevated levels were detected 3 months before clinical evidence of recurrence was found. In a 2000 Long used an ultrasensitive ELISA assay and found elevated MIS/AMH levels in 14 of 15 patients with recurrent tumor and the levels were within the reference range in all but 1 of 23 patients with no evidence of recurrence.^[25]
    • Anttonen et al reported that MIS gene expression was significantly decreased in 87% of tumors greater than 10 cm.^[2] This inverse relationship between MIS expression and tumor size raised concerns that MIS/AMH may not be a useful marker in advanced cases of GCT.
    • Serum MIS/AMH levels correlate well with tumor presence in patients with GCTs. This marker is highly specific for GCT in postmenopausal or oophorectomized women. It may also be elevated in women with Sertoli-Leydig cell tumors of the ovary, but is not typically produced by other gonadal or extragonadal tumors. This is in sharp contrast to inhibin and estradiol levels, both of which may be elevated in a variety of other extraovarian disorders. This marker may eventually be used for diagnosis and follow-up evaluations of patients with GCTs. Preclinical research is ongoing to evaluate the clinical use of targeting the MIS/AMH receptor for therapy of cancers expressing this receptor.
    • Serum MIS/AMH levels are not currently available for routine clinical use. However, a commercial version of the ultrasensitive ELISA assay has become available and may lead to wider clinical use of MIS/AMH in the future.

GCTs are the most common estrogen-producing neoplasms in females and are found to produce estradiol in approximately 40-60% of patients. This estradiol production is dependent on stimulation by testosterone secreted by the theca cells. However, not all GCTs are hormonally active or have theca cells that secrete testosterone, and this type of testing lacks sensitivity and specificity.

• Sonography

  • Transvaginal sonography (TVS) is by far the best primary modality for imaging pelvic structures. This may allow for delineation between ovarian, tubal, uterine, and other pelvic masses. If an adnexal mass is identified, the presence of cystic or solid components should be noted and remarks on the internal architecture of cystic structures (eg, septations, excrescences) should be made. Free pelvic fluid also can be identified readily on TVS images. The presence of solid, complex, cystic, or bilateral masses, with or without free fluid, increases the possibility of malignancy.
  • GCTs have a heterogeneous appearance on both sonographic and CT imaging, depending on the histologic pattern. Most commonly, they appear as round-to-ovoid masses that are multicystic, sometimes with solid components at the center or periphery. Fewer cases appear as unilocular simple or complex cysts or even homogeneous solid masses. The average size of these tumors is 12 cm, but they can range from 2-50 cm.
• Roentgenography

  • Chest radiography is useful in helping exclude pulmonary spread of malignant diseases of the ovary. Abdominopelvic CT scanning or MRI may help in diagnosing intraperitoneal spread or involvement of other organ systems prior to surgery. Abdominopelvic imaging also can be used in follow-up evaluations to confirm the presence of recurrent tumor identified after clinical examination.
  • Abdominal radiography, intravenous pyelography (IVP), barium enemas, and upper GI series also can be useful adjuncts in patients with symptoms involving the GI or genitourinary tracts.
  • Perform a barium enema or colonoscopy in any patient with a pelvic mass prior to surgical intervention to help rule out colonic involvement, colon cancer, or both as the primary tumor in women older than 40 years. However, if abdominopelvic CT scanning with oral and intravenous contrast already has been performed, IVP, colonoscopy, and barium enema are not required.
• Mammography

  • The preoperative workup also should include mammography for women older than 40 years who have not had one in the preceding 6-12 months.
  • This is especially important in women with estrogen-producing tumors because these may increase the risk of breast malignancies.
  • Additionally, breast cancers can metastasize to the ovaries and are often bilateral. Mammography can help rule out the possibility of a nongynecologic primary neoplasm in the breast.

Grossly, tumors can be cystic, solid, or a mixture of both. On cut section, they usually are multicystic and may contain areas of hemorrhage. Solid tumors appear grayish if they are nonsteroidogenic or yellow if they are steroid-producing neoplasms. Androgen-producing tumors more commonly are unilocular or solid in contrast to the multilocular tumors that make up most GCTs.

Microscopically, GCTs are composed of granulosa cells, theca cells, and fibroblasts in varying amounts and combinations. The term granulosa-theca cell tumor had been applied to all tumors in which both cell types were identified, regardless of the amounts present. Young and Scully proposed a system that required a tumor to be composed of at least 25% of the second cell type before the tumor could be designated as a true granulosa-theca cell tumor.^[1] Otherwise, the tumor would be designated as a granulosa cell tumor or a theca cell tumor based on the predominant cell type. This has led to some confusion in the literature because some theca cell tumors, which are essentially benign neoplasms, have been given the dual designation of granulosa-theca cell tumors, suggesting a malignant potential among this benign group of tumors.

AGCTs have multiple histomorphologies, including well-differentiated and less well-differentiated types. The well-differentiated group is composed of microfollicular, macrofollicular, trabecular, and insular patterns. Microfollicular is the most common pattern of all of these subtypes and contains characteristic Call-Exner bodies. These bodies consist of small rings of granulosa cells surrounding eosinophilic fluid and basement membrane material (see image below).

Macrofollicular GCTs are composed of a large cyst or collection of large cysts, each lined by a single layer of granulosa cells. Trabecular and insular patterns have cells arranged in nests and bands, with an intervening fibrothecomatous stroma found in the trabecular type.

The less well-differentiated group includes diffuse and watered-silk (moiré) or gyriform patterns. Monotonous sheets of cells arranged in no distinguishable pattern characterize the diffuse subtype (see image below).

Watered-silk and gyriform patterns have cells that often line up single-file in undulating lines (see image below).

The nuclear appearance is the same in both groups of adult GCTs. The nuclei usually are large pale ovoid or angular structures containing nuclear grooves that give them a "coffee-bean" appearance (see image below).

Usually only a small amount of cytoplasm is present, although luteinization of the tumor, characterized by larger amounts of dense cytoplasm with occasional vacuoles, sometimes can be found. Mitotic figures generally are few in number, and only mild nuclear atypia is found in most cases. Nuclear appearance and mitotic rate often are the key elements differentiating GCTs from other malignant tumors. Low-grade stromal sarcomas, small cell carcinomas, carcinoid tumors, and melanomas may look similar to GCTs on low power, but these other tumors lack nuclear grooves, are more hyperchromatic, and often contain more mitotic figures than GCTs.

JGCTs have little morphologic similarity to those of the adult type. However, their gross appearance can be similar to AGCTs in that they often are a mixture of solid and cystic components with many areas of hemorrhage. Microscopically, they have a distinct appearance with round hyperchromatic nuclei, most often lacking the nuclear grooves found in the adult type (see image below). Nuclear atypia often is more severe with more mitotic figures than are found in the adult type, consistent with their more aggressive phenotype. The cytoplasm often is more abundant and dense in JGCTs.

Thecomas usually are tan or yellow with an average size of 7-8 cm. These tumors are bilateral in fewer than 3% of cases. Microscopically, they are composed of round or ovoid cells with pale nuclei and a lipid-rich cytoplasm. Mitoses usually are less than 4 per 10 high-power fields. Hyaline bands often are found interspersed between cells (see image below).

Luteinized thecomas also contain cells with a lipid-rich cytoplasm but are set within a more fibromatous stroma (see image below). Most of these tumors are hormone-producing tumors and cause postmenopausal bleeding in as many as two thirds of patients. Luteinized thecomas also may be androgenic and, if so, tend to occur in younger women.

Ovarian carcinoma is a surgically staged disease. The current staging classification system is based on 1987 International Federation of Gynecology and Obstetrics (FIGO) nomenclature.

• Stage I: Tumor is confined to the ovaries.

  • Stage Ia: Tumor is limited to one ovary with an intact capsule. No tumor is present on the external surface of the capsule, and no ascites containing malignant cells are present.
  • Stage Ib: Tumor involves both ovaries, with intact capsules. No tumor is present on the external surface of the capsule, and no ascites containing malignant cells are present.
  • Stage Ic: Tumor is stage Ia or Ib with tumor on the external surface of one or both ovaries, or ruptured capsule(s) or malignant cells are present in ascitic fluid or peritoneal washings.
• Stage II: Tumor involves one or both ovaries, with pelvic extension.

  • Stage IIa: Extension and/or metastases to the uterus and/or fallopian tubes are present.
  • Stage IIb: Extension to the bladder, rectum, or other pelvic tissues occurs.
  • Stage IIc: Tumor is stage IIa or IIb, with tumor on the external surface of one or both ovaries or ruptured capsule(s), or malignant cells are present in ascitic fluid or peritoneal washings.
• Stage III: Tumor involves one or both ovaries, with peritoneal implants outside of the pelvis and/or positive retroperitoneal lymph nodes. Superficial liver metastases also are included in stage III.

  • Stage IIIa: Tumor is grossly confined to the pelvis but with microscopic seeding of the abdominal peritoneal surfaces. Lymph nodes are negative.
  • Stage IIIb: Tumor implants are present on the abdominal peritoneum, none larger than 2 cm in diameter. Lymph nodes are negative.
  • Stage IIIc: Tumor implants on the abdominal peritoneum 2 cm or more are present, and/or retroperitoneal or inguinal nodes are positive.
• Stage IV: Distant metastases are present.

  • Pleural effusions must be confirmed cytologically to classify a case as stage IV.
  • Metastases to the liver parenchyma also are included in stage IV.