|Year : 2017 | Volume
| Issue : 5 | Page : 497-499
Giant brenner tumor of ovary
Rupali Bavikar, Sunita Bamanikar, Harsh Kumar, Megha Jha, Yamini Ingale
Department of Pathology, Dr DY Patil Medical College, Hospital and Research Centre, Dr DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||24-Oct-2016|
|Date of Acceptance||01-Mar-2017|
|Date of Web Publication||14-Nov-2017|
C 505, Siciliaa, BT Kawde Road, Ghorpadi, Pune - 411 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Brenner tumor is a rare ovarian tumor that is a part of the surface epithelial group of ovarian neoplasm. It is usually asymptomatic, and most of the times, it is an incidental pathological finding. They can be subdivided into benign, borderline or proliferative, and malignant neoplasms. The majority of Brenner tumors are benign in nature. Tumors of borderline malignancy are less frequent, and only about 1% of tumors are borderline. Here, we present a rare case of giant Brenner tumor of ovary measuring 28 cm in diameter. This is the case is presented because the giant size of Brenner tumor, although rare gynecologist should be aware of this rare entity.
Keywords: Brenner, giant, ovarian tumor
|How to cite this article:|
Bavikar R, Bamanikar S, Kumar H, Jha M, Ingale Y. Giant brenner tumor of ovary. Med J DY Patil Univ 2017;10:497-9
| Introduction|| |
Brenner tumor of the ovary is fibroepithelial tumors of the ovary, the epithelial component being transitional like cells. The average age at presentation is 50 years with 71% of the patients being more than 40 years. It constitutes 1.4%–2.5% of all ovarian tumors and has a predilection for the postmenopausal woman. They are generally asymptomatic, but rarely they can cause postmenopausal bleeding and rarely can they present with ascites and hydrothorax in a rare pseudo-Meig's syndrome. Some may secrete estrogen leading to abnormal uterine bleeding and uterine enlargement. Rarely, they can reach up to size if 25–30 cm and such huge tumors are usually malignant in nature.
| Case Report|| |
A 75-year-old multiparous woman attended the gynecology outpatient department with a history of abdominal distension for 4 months, pain in abdomen for 3 months and fever for 1 month. On per vaginal examination, the uterus was approximately 34–36 week size. Ultrasonography (USG) showed large cystic mass lesion extending from epigastrium up to pelvic region having well-defined walls and fluid filled spaces with internal echoes within with few septal and mural nodules Computer tomography (CT) abdomen [Figure 1]a and pelvis and magnetic resonance imaging pelvis was done and was suggestive of large multilocular cystic lesion in pelvis extending superiorly up to epigastric region showing multiple septations and solid component. The left ovary was not separately visualized from this lesion suggesting the possibility of ovarian neoplastic mass-mucinous cystadenoma/mucinous cystadenocarcinoma arising from right ovary. Ca 125 was done, and it was 223.6 μ/ml. The patient was prepared for laparotomy. Total abdominal hysterectomy with bilateral salpingectomy with left sided oophorectomy was performed with proper hemostasis. Grossly, the tumor was 28 cm × 24 cm × 15 cm in size and 7.5 kg in weight. External surface was grayish brown with few dark areas. Congestive blood vessels were also seen [Figure 1]b. Cut surface showed multiple cysts with papillary elevations. Few thickened areas were also seen measuring 1.5 cm in diameter. On histopathology, examination sections show multicystic ovarian mass showing a transitional cell tumor composed of nests with sheets of uniform transitional epithelial cell nests surrounded by fibrous stroma [Figure 2]a. Also seen were branching fibrovascular broad papillae surrounded by transitional epithelium showing cytological atypia mild to moderate and brisk mitosis with areas of necrosis and stromal calcific deposits [Figure 2]b. Mucinous cystic metaplasia and occasional squamous metaplasia was prominent in some islands of transitional papillae. Cell nests showing grooved coffee bean nuclei were noted. Sections from Fallopian tube More Details showed no evidence of tumor deposits. All the above features of left ovarian mass and fallopian tube were suggestive of transitional cell tumor most likely borderline (Proliferative) Brenner tumor. Immunohistochemistry was done, and the tumor was positive for epithelial membrane antigen and cytokeratin 7 [Figure 3]a and [Figure 3]b.
|Figure 1: (a) Computed tomography scan of abdomen show contrast enhancing large solid, cystic lesion arising from left ovary. (b) Well encapsulated huge tumor. External surface is smooth gray-white with congested blood vessels|
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|Figure 2: (a) Benign component of tumor in the form of nests of transitional cells surrounded by fibrous stroma. (b) Borderline Brenner tumor in the form of papillary projections with central fibrovascular core over lined by multilayered transitional epithelium|
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|Figure 3: (a) Cytokeratin 7 positivity in tumor cells. (b) Epithelial membrane antigen positivity in tumor cells|
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Right ovary and fallopian tube showed normal morphological features. No malignant cell was seen on cytology of peritoneal fluid. The postoperative period was uneventful, and the patient was discharged with the advice of regular follow-up.
| Discussion|| |
Brenner tumor is uncommon tumor arising from surface epithelium. The origin and hormonal activity of tumor have many controversies. It was suggested that these tumors arise from Walthard cell nest. However, there is a disparity in the location of such nests and Brenner's tumor., Other suggestions are origin from germ cells, germinal epithelium, the rete ovarii, follicular structures or from the gonadal stroma, but perhaps the most acceptable is that the tumor is formed from the urinary tract epithelium, arising either from the mesonephric remnants or by metaplasia of the germinal epithelium.
Brenner tumor of the ovary is a solid ovarian tumor that is generally asymptomatic. Although they are predominantly solid on imaging and pathologic examination, association with serous and mucinous cystadenomas is up to 30%. It is usually an incidental pathological finding. Among symptomatic patients, common symptoms include vaginal bleeding, a palpable pelvic mass, and pelvic pain. Most of the time it is found to be unilateral. Bilaterality is seen only in 5%–7% of the cases. The histological patterns observed in Brenner tumor are typically benign, with a few reports of borderline or malignant counterparts.
Transitional cell tumors as defined by the World Health Organization are those composed of epithelial cells that resemble histologically the cells of the urothelium. The cells of transitional cells Brenner tumors are characterized by oval shaped nuclei that exhibit frequent longitudinal grooves. Roth and Sternberg described Brenner borderline ovarian tumors or APBOTs in 1971. The Brenner tumor has some transitional differentiation, but the transitional cell carcinoma without a benign Brenner component is a variant of high-grade serous carcinoma. The transitional-type cells of the Brenner tumors are histologically similar to the cells of the Walthard rests. The prognosis for patients with transitional cell borderline Brenner tumor or APBOT is excellent.
It is difficult to diagnose Brenner tumor with imaging studies. USG and CT, both the techniques are limited in specificity because of the tumor's nonspecific appearance. In imaging studies, benign Brenner tumors are generally similar to those of other solid ovarian masses such as fibroma, fibrothecoma, and pedunculated leiomyoma.
Grossly benign Brenner tumors are well circumscribed, with a hard or fibromatous, gray, white, or slightly yellow cut surface. Occasionally, the tissue becomes gritty because of calcific deposit. Borderline Brenner tumors are characteristically cystic and unilocular or multilocular with cauliflower-like papillomatous masses protruding into one or more of the locules as was seen in our case. They can grow up to 5–20 cm in size. Borderline Brenner growing up to 28 cm is rarely described in the literature. Malignant Brenner tumor may be solid or cystic with mural nodules; they usually do not have any distinctive features.
Microscopically, they are made of abundant dense fibrous stroma with epithelial nests of transitional cells resembling those lining the urinary bladder. The fibrous component is less prominent in borderline or malignant tumors than in benign lesions. Complex cystic tumors contain varying amounts of stroma and are more commonly found with borderline or malignant histologic findings, often in the form of papillary solid projections within a cystic mass.
Histologically, borderline Brenner shows a greater degree of epithelial complexity than that observed in the benign tumors. The epithelial complexity is created by fibrovascular papillae with a branching pattern that project into the cyst lumen. The papillary fibrovascular cores are covered by transitional-type epithelium that may exhibit the same histological changes observed in the transitional cell tumors of the urinary bladder. As mentioned in the gross description, a focus of benign Brenner tumor is almost always present in borderline or malignant Brenner tumors; this focus could be easily missed because of its small size. Mitotic activity is increased, and focal necrosis is rather common. Mucinous metaplasia is observed sometimes and could be quite prominent. The tumors have a large fibroma or thecoma component, which may be responsible for the hormonal effect (usually estrogenic) seen in some patients with Brenner tumor.
Most Brenner tumors are candidates for surgical resection. Because of they are circumscribed tumors, they are easily located and do not typically affect surrounding tissue. Surgical resection is often curative and will reverse symptoms if they are present. Malignant Brenner tumors may affect surrounding tissue and metastasize into other structures, but such incidents are so rare that a standard treatment has not been developed. Even malignant Brenner tumors, if diagnosed early, they can be treated with surgical excision.
To conclude, Brenner tumor can grow up to size 28 cm and radiologically it is difficult to differentiate from other ovarian tumors. The final histopathological examination is mandatory for diagnosis and these tumors are curative surgically. The clinician should be aware of such large Brenner tumor.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]