Molecular Analyses in Endocrine Pathology
Dr. George Kontogeorgos
Dr. Robert Yoshiyuki Osamura
Dr. Jennifer Hunt
Section 2 -
Case Reports: Case 1
Department of Pathology,
G. Gennimatas General Hospital,
A 33-yr-old woman was referred to G. Gennimatas General Hospital of Athens with rapidly developing
symptoms/signs of hyperandrogenism, secondary amenorrhea, infertility and markedly elevated serum LH and
androgen. Her menarche was at the age of 15 years; after a period of regular menstruation she developed
oligomenorrhea and hirsutism and the diagnosis of PCOS was made. At the age of 22 years, following a
3-month treatment with oral clomiphen citrate and intramuscular β-hCG injections, the patient
became pregnant and underwent a successful pregnancy and delivery. After delivery, she again developed
oligomenorrhea and despite a 4-years treatment with the same scheme, she failed to conceive again. Two
years before this admission she developed severe acne, deepening of her voice, amenorrhea and worsening
hirsutism. Endocrine investigations revealed high serum androgen and LH levels, but normal serum DHEAS.
Ovarian ultrasonography revealed a 2.8 cm in diameter left ovarian solid tumor and slight enlargement of
the right ovary. Computer tomography (CT) and magnetic resonance imaging (MRI) of the pituitary were
normal. The patient underwent resection of the left ovarian tumor and a wide wedge resection of the
Case 1 - Figure 1 - Histology of ovarian luteinized granulosa-theca cell tumor (H&E 10X).
Case 1 - Figure 2 - Typical tumor composed of sheets of ovoid or polyhedral cells with plump acidophilic cytoplasm (H&E 20X).
Case 1 - Figure 3 - With higher magnification, the cells display round nuclei with conspicuous nucleolus (H&E 40X).
Case 1 - Figure 4 - Strong and diffuse cytoplasmic immunoreactivity for -inhibin (ABC 20X).
Case 1 - Figure 5 - Strong and diffuse cytoplasmic immunoreactivity for -inhibin (ABC 20X).
By light microscopy, the ovarian tumor was composed of clusters or sheets of ovoid or polyhedral
cells with plump acidophilic cytoplasm and discerning cytoplasmic borders (Fig. 1,2,3). The nuclei were
small, round possessing small nucleoli. By immunohistochemistry, the tumor cells were selectively
positive for α- and β-inhibin showing strong and diffuse cytoplasmic reactivity (Fig. 4,5).
The adjacent parenchyma included multiple atretic cystic follicles showing luteinization of the inner
theca at various stages of regression. In addition, multiple primary ovarian follicles were noted. The
initially resected right ovarian wedge showed foci of nodular hyperthecosis. Based on the histological
findings, the diagnosis of luteinized granulosa-theca cell tumor was made.
Postoperatively, androgen serum levels markedly decreased, but serum LH levels remained markedly
elevated. As pituitary imaging excluded the presence of an LH-secreting pituitary tumor a presumptive
diagnosis of severe PCOS was made and the patient was started on treatment with a long acting GnRH
analogue. However, after a 3-month treatment there was no reduction of the elevated LH serum levels,
whereas serum androgens rose to the pre-operative levels. Although imaging with helical CT-scan of the
chest, CT and MRI of the abdomen and scintigraphy with 111In-octreotide scan were suggested in
order to localize the tumor, the patient decided to proceed to a right ovariectomy; histological findings
were also consistent with a typical luteinized granulosa-theca cell tumor.
Case 1 - Figure 6 - This abdominal MRI shows a tumor at the tail of the pancreas, hypointense on T1-weighted images.
Case 1 - Figure 7 - On T2-weighted images the well-demarcated tumor appeared hyperintense.
Case 1 - Figure 8 - The octreoscan shows an abdominal of [111In]octreotide uptake corresponding to a 7-cm tumor at the tail of the pancreas.
On admission, a repeated MRI scan of the pituitary showed no evidence of a pituitary lesion.
Abdominal CT and MRI scans revealed normal adrenal glands and a 7 cm in diameter tumor at the tail of the
pancreas (Fig. 6,7), which corresponded to a well-demarcated area of intense uptake on
111In-octreotide scanning (Fig. 8). In view of these findings a presumptive diagnosis of
ectopic LH secretion from a pancreatic endocrine tumor possessing somatostatin receptors was made. The
patient underwent surgical exploration and removal of the pancreatic tumor.
Case 1 - Figure 9 - Low magnification of an endocrine tumor separated by thick fibrous band from the adjacent to pancreatic parenchyma (H&E 1X).
Case 1 - Figure 10 - Typical histology of endocrine tumor consisted of highly cellular anastomosing solid nests or trabecules, separated by delicate vascularized connecting tissue (H&E 10X).
Case 1 - Figure 11 - Small round tumor cells with pseudorosette formation (H&E 20X).
The pancreatic tumor admitted for histology was ovoid well-demarcated and encapsulated measuring
6.5X4.5X4.5 cm. On sectioning, it was solid, soft and yellow showing a homogeneous, partly lobular
appearance. Histologic examination was consistent with the diagnosis of a well-differentiated pancreatic
endocrine tumor. The tumor consisted of highly cellular solid nests or anastomosing trabecules,
separated by delicate vascularized connecting tissue (Fig. 9,10,11). The tumor cells were small round
with spherical nucleus and focally conspicuous nucleolus (Fig. 12,13).
Mitotic figures were rare. The
tumor was immunoreactive for synaptophysin CGR and NSE (Fig. 14,15). The tumor cells were strongly
immunoreactive for β-LH (Fig. 16,17) and α-SU (Fig. 18,19).
Case 1 - Figure 20 - Sustentacular cells positive for S-100 protein (ABC10X).
Case 1 - Figure 21 - Low Ki-67 labeling index as estimated at <1% (ABC10X).
Case 1 - Figure 22 - Electron microscopy of endocrine tumor cells with moderate development of membranous organelles, and scarce and small secretory granules mostly accumulated in the cytoplasmic processes (11,000X).
Immunostain for S-100 protein
disclosed several scattered cells representing sustentacular cells (Fig. 20). The Ki-67 labeling index
was estimated at <1% (Fig. 21). Immunostains were negative for insulin, glucagon, somatostatin, PP,
VIP, bombesin, hCG, GH, PRL, ACTH, β-TSH and β-FSH. By electron microscopy, the tumor
consisted of polyhedral or polar cells with spherical nuclei. The cytoplasm contained moderately
developed Golgi apparatus and several parallel profiles of rough endoplasmic reticulum. A fair number of
mitochondria and scarce secretory granules of 100 to 150 nm mostly accumulated in the cytoplasmic
processes (Fig. 22). In situ hybridization showed positivity in the tumor cells with the β-LH
α-SU mRNA antisense probes, whereas the sense probes produced no staining (Fig. 23,24).
Experiments of dispersed cell cultures following incubation with somatostatin resulted in suppression of
LH secretion by approximately 90% to 95%.
Postoperatively, serum LH levels significantly decreased, but still remained within the postmenopausal
range . After 2-month administration of long-acting GnRH analog (triptorelin depot), serum LH levels
decreased significantly, but failed to suppress completely, suggesting that part of the tumor was left
behind. A subsequent whole body octreoscan and abdominal MRI revealed a residual tumor of 1.5 cm in the
pancreatic tail. During the last 5 yr follow-up, no change in the size of the remaining tumor was noted.
Pancreatic endocrine tumors are rare neoplasms that occur either sporadically or as part of the
multiple endocrine neoplasia type 1 syndrome. According to the 2004 WHO classification they represent
1-2% of all pancreatic neoplasms; their reported incidence is estimated at 1/100,000 population per year
Approx. 40% of them are nonsynsdrominc (nonfunctioning). Functioning tumors secrete a variety of
peptide hormones; hypersecretion of such peptides is associated with characteristic clinical syndromes.
Among them, insulinomas represent the most common, followed by gastrinomas, glucagonomas, VIPomas and
somatostatinomas . Pancreatic endocrine tumors may also secrete peptide hormones that originate from
cells eutopically expressed in endocrine pancreatic tissue .
Several examples of Cushing's syndrome due to the ectopicsecretion of
either ACTH or CRH and cases of acromegaly due to GHRH secretionhave been
documented. Other less commonly secreted peptide hormones, such as growth hormone, parathyroid
hormone-related protein, calcitonin, calcitonin gene related peptide, pro-opiomelanocortin-derived
peptides, neuropeptide Yand GHrelin have also been described
recently only one case of documented ectopic LH production from a pancreatic endocrine tumor in a
40-year-old woman has been reported .
Based on their histology, pancreatic endocrine tumors are divided into three categories:
Well-differentiated endocrine tumors, and well-differentiated and poorly differentiated endocrine
carcinomas. Well-differentiated tumors are confined to the pancreas with no vascular or perineural
invasion and have a rather "benign" behavior. They are composed of relatively uniform cells with finely
granular cytoplasm and spherical nuclei, often with conspicuous nucleoli. They form solid trabecular or
glandular nests infrequently with pseudorosette arrangement. Typically the Ki-67 (clone MIB-1) index is
<2%. The tumor size is crucial for biological behavior. Tumors measuring >2cm or showing Ki-67
>2% or showing vascular or perineural invasion, are expected to have uncertain behavior, even confined
to the parenchyma. In general, a tumor size >2cm indicates increased risk for malignancy, whereas
tumors >3 cm, as a rule, are malignant. Nonsyndromic tumors are often larger that 2 cm in diameter.
Mixed endocrine-exocrine tumors are uncommon; their biological behavior depends on their exocrine cell
Ovarian stromal hyperthecosis is characterized by varying degrees of luteinized stromal cell
proliferation after sustain gonadotropin stimulation. Luteinized granulosa-theca cell tumors of the
ovaries are rare steroid producing lesions, under 3 cm in size, occurring mostly unilaterally in
postmenopausal women. Secretion of bioactive hCG has been shown to be a strong stimulus of ovarian or
testicular steroidogenesis. Similarly to hCG secreting trophoblastic tumors, pregnancy can induce
extensive hyperthecosis and luteinization of the ovarian stroma and rarely it may result to
granulosa-theca cell tumor, also known as pregnancy thecoma or luteoma. The present case offers a unique
opportunity to investigate the effect of long-standing elevated ectopically produced bioactive LH, on
ovarian morphology and function in a woman of the reproductive age
In summary, we have reported a rare case of a pancreatic endocrine tumor secreting bioactive LH
leading to luteinized granulosa-theca cell tumors of both ovaries.
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