Abstract Objective To investigate the ovarian goiter carcinoid pathology and clinical features. Methods for clinical and pathological analysis of four cases of ovarian goiter carcinoid, immunohistochemical staining and electron microscopy, and follow-up and review of the literature. Three cases of mixed cases of nodular type of aneurysm wall; three cases were histologically beam-like structure, a beam-like structure-based, mixed island structure; immune phenotype on four cases NSE, Syn positive, 3 cases CgA, calcitonin-positive patients with 5  HT positive; TG, TTF  follicular zone positive, the carcinoid District negative. Conclusion ovarian goiter carcinoid is a unique clinical and pathological features of low grade neuroendocrine carcinoma associated with thyroid follicular differentiation.

Key words ovarian tumor goiter carcinoid neuroendocrine tumor Immunohistochemistry

   Ovarian goiter carcinoid occur in ovarian carcinoid tumors and thyroid follicular transition phenomenon between the two tumor. This cancer is rare, accounting for less than 0.1% of ovarian malignancies, so far, fewer than 100 cases reported abroad, domestic by Van Lang tai in 1983 first reported in [1], the domestic so far reported 20 cases in total, are case reports. The tumor clinicopathological less now, since 1995 encountered four cases with literature review are as follows.

    1 Materials and Methods

    1.1 Clinical data

    4 patients aged 37 to 54 years old, 44 years old on average. Are pelvic mass treatment, no abdominal pain, constipation, vaginal bleeding, hyperthyroidism symptoms.

    1.2 Methods

    Detailed review of four cases of ovarian goiter carcinoid clinical history and pathological data. Specimens with 10% buffered formalin fixed, paraffin-embedded, conventional producers. Representative paraffin blocks of each case were selected from 1 to 2, 6, each block re-slice thickness of 4 μm, respectively line HE, TG, TTF  1, Syn, CgA, NSE, calcitonin immune group the staining (Elivision Act) light microscope. The entire slice cytoplasm or nucleus was brown cells ≥ 15% positive. Four cases drawn from paraffin-embedded tissue, xylene dewaxing, glutaraldehyde, post-fixed in osmium tetroxide, and transmission electron microscopy.

    2 Results

    2.1 treatment situation

    Four cases underwent surgical resection, intraoperative findings mass smooth surface, no adhesion with the surrounding tissue, 6 to 11 cm diameter. Such postoperative chemotherapy. Four cases, three cases respectively after 2 years, 2 years, 3 years, alive, 1 patient was lost.

    2.2 Pathological examination

    2.2.1 Grossly tumor volume were 11 cm x 9 cm x 7 cm, 10 cm x 9 cm x 6 cm, 6 cm × 6 cm × 6 cm and 6 cm × 5 cm × 4 cm, encapsulated cut surface multilocular cystic. 3 See, for example, hair, grease teratoma component, one cases capsule filled with a brown liquid, see greyish yellow nodules within the tumor side of the wall, still clear boundaries containing gel-like substance, no bleeding and necrosis area of ​​5 cm × 4 cm.

    2.2.2 microscopic examination of the four cases are carcinoid tumors and thyroid follicular mixed composition, as shown in Figure 1. Beam-like structure of tumor cells in three cases, the other cases the main beam-like structure, mixed with island structure. Tumor cells were short spindle, more or less uniform size, abundant cytoplasm, eosinophilic. Nuclear small, rounded or oval, fine chromatin, nucleolus is not obvious, the long axis perpendicular to the beam-like tumor cells and see a small amount of tumor cells were nests. The above-mentioned two types of cells and thyroid follicles of varying sizes mixed follicles lined with flat or cuboidal the follicular the cavity containing acidophilus kind glue-like substance. The number of thyroid follicular great regional differences in the different tumor cystic area of ​​wall lined by class cancer cells, mixed a few goblet cells, capsule filling mucus.

    2.2.3 immune phenotype of four cases of goiter carcinoid tumors, including carcinoid District of NSE, Syn were positive, as shown in Figure 2,3; CgA, calcium, calcitonin 3 cases were positive, as shown in Figure 4; 5-HT cases were positive; follicular area TG, TTF  1 were positive, as shown in Figure 5, the carcinoid District negative.

    2.2.4 electron microscope electron microscopy examination, see the four cases the tumor cell nuclei were round, chromatin aggregation, filled with a lot of size more consistent round dense neuroendocrine granules within the cytoplasm, peripheral empty halo limiting membrane surrounding, and scattered of microfilaments and mitochondria, as shown in Figure 6.

    3 Discussion

    1970 Scully [2] for the first time will take place in ovarian carcinoid tumors and thyroid follicular both transition phenomenon named ovarian goiter carcinoid tumor [3]. International ovarian tissue typing (1973), this naming ovarian germ cell tumor group, this tumor included in 1989, and a high degree of specificity for single mesoderm teratoma. WHO in 2003 in the the tumor new classification will its classified single mesoderm teratoma, and proposed the two components of the tumor are the origin of teratoma endoderm [4]. The tumor incidence of 21 to 77 years of age, with an average of 53 years old, more than 2/3 of those over the age of 40. The age of onset in this group of 37 to 54 years old. Common clinical pelvic masses as the first symptom, no obvious symptoms; patients with intractable constipation as the first symptom, Kawano [5] reported one case that constipation may be secreted by tumor cells related to PYY (peptide YY). Patients may also be some endocrine symptoms; majority of patients with normal laboratory tests, the small number of patients may be associated with CEA, CA125, CA199 equivalents increased [6]; patients showed carcinoid syndrome. Literature pointed out that the island carcinoid, carcinoid syndrome occur in the source intestinal beam type carcinoid is no such symptoms [7]. Are on the clinical pelvic masses as the first symptom of patients with abdominal pain. Four cases were constipation, carcinoid syndrome, and other symptoms.

    Growth and where the location of the tumor were divided into three types: (1) the aneurysm wall nodules; (2) pure; (3) hybrid. The group of four cases, three cases of mixed type, visible fat hair, one cases of aneurysm wall nodules. Endoscopic tumor tissues from carcinoid tumors, thyroid follicular and (or) other ingredients. Carcinoid type of beam-like or beam-like island-type mixed rare pure island type. Three cases of carcinoid area for the beam-like type 1 cases for the beam-like, island-type mixed. Class cancer cells secrete a variety of neural peptide hormone, usually calcium, calcitonin, CgA, Syn, NSE, EMA, varying degrees of expression. The carcinoid tumors District of NSE, Syn-positive, three cases of CgA positive calcium, calcitonin, 5  HT positive. Normal thyroid follicular or in the form of giant follicular structure, lined by flat, cuboidal or columnar epithelium, eosinophilic cavity filled glue-like substance. The few were thyroid adenoma-like performance and can be seen even in grade Ⅰ nipple. Other ingredients for the columnar mucus epithelium, a single or a plurality of cells, or are epithelial glands, carcinoid component mixed or located carcinoma vicinity. The interstitial mostly dense fibrous connective tissue associated with hyaline degeneration can the amyloid calm and stromal luteinized. The group of four cases of thyroid follicular normal or less part of the region was a giant follicular structure. Most studies suggest that thyroid follicular cell memory in thyroglobulin were measured by immunohistochemistry results showed that the tumor of the thyroid follicular TG (thyroid globulin), TTF  1 positive. TTF  1 expression in thyroid component in ovarian teratoma, thyroid carcinoid tumors, ovarian goiter carcinoid carcinoid area did not express further pointed out that the thyroid carcinoid tumors, ovarian goiter carcinoid carcinoid component with thyroid differentiation independent of [8]. The four cases TG, TTF  1 the follicular area are positive, carcinoid District negative.

    Sarcevic [9] 1990 determination of class cancer pale, the deep two types of light cells accounted for about 90% or more, pressure on the deep cells, dispersed in a pale cells. Sparse electron density of the light cells, nuclear, rich euchromatin, irregular nuclear shape, prominent nucleoli. Cytoplasm, with round or oval mitochondria and rough endoplasmic reticulum, occasionally Golgi complex, multivesicular bodies, free ribosomes and microfilaments. Required to contain the limiting membrane of secretory granules of the ball diameter (1.850 to 2.500) x the 10  7m, the center of the particle as a dense core, between the core and the limiting membrane around the electron transparent with carcinoid or follicular epithelial cell cytoplasm, The cone-shaped light cell follicles lined by tumor cells, its tip microvilli. Glue-like substance droplets, micro-bodies and lysosomes in the cytoplasm. The this group electron microscopy carcinoid District visible neuroendocrine granules no thyroid follicular area.

    The diagnosis of this disease is more difficult, mostly found that the carcinoid cell and thyroid-like tissue mixed Pathological diagnosis and argyrophilic cells, pro-silver, thyroglobulin positive characteristics. Performance of the carcinoid syndrome, constipation endocrine disorders, should identify the following diseases. (1) ovarian granulosa cell tumor: goiter carcinoid with thyroid follicular structure Call  Exner bodies be confused with granulosa cell tumors, goiter the carcinoid follicular contains thyroglobulin gum-like material, the lack of nuclear grooves or luteinized, at the same time, combined with immunohistochemical staining to identify with them; (2) ovarian goiter: unilateral carcinoid syndrome; pathology only see without class cancer of the thyroid tissue, and immune staining T3, T4 the determination factors exhibited strong positive tumor cells and follicular glue-like substance; (3) malignant ovarian goiter: thyroid cancer microscopic morphology similar to follicular, mixed tumor of the nipple or follicular papilla main; (4) primary ovarian carcinoid: Some researchers ovarian goiter carcinoid classified as a subtype of primary ovarian carcinoid, the main difference for the pathology of the presence or absence of thyroid tissue in morphology and immunohistochemistry of is difficult to distinguish.

    The low incidence of this tumor, so treatment of various reports vary, most scholars believe that this tumor was malignant degrees lower tumor. Therefore, normal young patients with contralateral ovarian tumor capsule integrity, no other metastases, only underwent unilateral oophorectomy can [10]; older who reported some cases line hysterectomy oophorotomy; also coupled with the appendix and omentum resection reported [11]. Abroad in recent years, laparoscopic removal of the side attachment multi-the domestic more hysterectomy and bilateral oophorectomy. The group of four cases, only 1 patients underwent unilateral oophorectomy, and the remaining 3 patients underwent a total hysterectomy + double Annex + omentum resection. Thyroid follicular tumor component was papillary or follicular cancer, patients should be supplemented with chemotherapy or radiotherapy. Because this tumor is a germ cell tumors it is relatively high with BVP. Four cases in this group, only 1 patient line BVP regimen of two cycles, and the remainder did not undergo after other treatments. Concurrency more or carcinoid syndrome, should be given the appropriate treatment; metastasis in patients with possible metastases resection and chemotherapy; carcinoid syndrome patients should avoid the use of catecholamines.