GnRH agonist therapy in a patient with recurrent ovarian granulosa cell tumors

Abstract

A 65-yr-old woman presented 17 yr status post-hysterectomy with bilateral ovarian salpingo-oophorectomy, attributable to ovarian cancer. She was admitted to our hospital, with multiple cystic liver masses and multiple large seeded masses in her abdomen and pelvic cavity. Histological examination of the pelvic masses demonstrated granulosa cell tumors. After two courses of systemic combination chemotherapy, with paclitaxel and carboplatin, the masses in the abdomen and pelvic cavity increased, and debulking surgery also failed because of peritoneal dissemination with severe adhesion. Finally, she underwent palliative radiotherapy for only the pelvic masses obstructing the urinary and GI tracts, and monthly hormonal therapy with a gonadotrophin-releasing hormone agonist; leuprorelin 3.75 mg IM. Subsequently, multiple masses beyond the range of the radiation as well as those within the radiotherapy field partially decreased. This partial response had been maintained for more than 8 months as of the last follow-up visit. Owing to its long and indolent course and the low metabolic rate of the tumors, advanced or recurrent granulosa cell tumor (GCT) requires treatment options beyond chemotherapy, surgery, and radiotherapy. Hormonal agents may provide another treatment option for advanced or recurrent GCT in those who are not candidates for surgery, chemotherapy, or radiotherapy.

Keywords: Granulosa Cell Tumor; Hormone Therapy; Leuprolide.

Fig. 1

Images before and after treatments. (A) A CT scan performed before systemic chemotherapy shows multiple metastatic masses in the abdomen and pelvis. (B) A PET scan performed before systemic chemotherapy shows multiple hypometabolic masses in the abdomen and pelvis. (C) A CT scan performed before radiotherapy and hormonal therapy shows multiple metastatic masses with increased size in the abdomen and pelvis. (D) A CT scan performed after radiotherapy and hormonal therapy shows a partial response to this therapy. The insert shows a radiotherapy planning radiography.

Fig. 2

Photomicrographs of recurrent granulosa cell tumor. Note the classic grooved nuclei, known as "coffee bean" nuclei, in the malignant granulosa cells (A: H&E, ×40; B: H&E, ×400) and the positive immunohistochemical staining for inhibin (C: ×400), progesterone receptor (E: ×400), and negative staining with estrogen receptor (D: ×400).

Fig. 3

The estradiol levels according to therapies. Pre-CT, pre-chemotherapy; Post-CT, post-chemotherapy; Post Op, post-operation; Pre-RT/HT, pre-radiotherapy/hormone therapy; Post-RT/HT, post-radiotherapy/hormone therapy; Post-HT, post-hormone therapy.