- Email: [email protected]
Management of ovarian carcinoid syndrome
BRIEF COMMUNICATIONS
205
Table 1 Characteristics of the 17 patients diagnosed with placental site trophoblastic tumors. Patient
Age AP
Interval to Period of amenorrhea or bleeding diagnosis, months
1 2 3
30 25 38
Term Term Term
4 36 24
4 5 6 7 8 9 10 11. 12. 13 14
28 35 27 36 33 30 31 29 28 29 32
Term after IVF Term Term Term after IVF Abortion Term Term Term Term Term Term
15 16 17
41 28 38
Term Term Molar abortion
17 recurrent 42 case
hCG U/L
Stage Largest tumor size, cm
Outcome
2.5 3 3
Hysterectomy Hysterectomy + EMA-CO Hysterectomy + EMA-CO
AWNED AWNED AWNED
Hysterectomy Hysterectomy Hysterectomy Hysterectomy Hysterectomy + EMA-CO Hysterectomy + EMA-CO Hysterectomy Hysterectomy Hysterectomy Hysterectomy Hysterectomy + lobectomy + EMA-CO EMA-CO + hysterectomy Hysterectomy + EMA-CO Hysterectomy + EMA-CO
AWNED AWNED AWNED AWNED AWNED AWNED AWNED AWNED AWNED AWNED AWNED
15 4 6 10 12 24 10 7 10 18 10
Bleeding 50 days Amenorrhea 15 months Amenorrhea 12 months and bleeding 5 months Amenorrhea 3 months and bleeding 19 days Bleeding 1 month Bleeding 4 months Amenorrhea 56 days and bleeding 7 days Bleeding 2 days Bleeding 24 months Bleeding 7 months Bleeding 7 months Bleeding 4 months Amenorrhea 2 months Bleeding 10 months
48.67 157.0 175.2 204.03 1,024 5.02 175.78 48.29 145 389.25 125.8
I I I I I I I I I I III
2 2.5 2.5 5 4 2 2.7 6 3 2 2
36 13 3
Amenorrhea 6 months and bleeding 42 days Bleeding 6 months Amenorrhea 3 months and bleeding 14 days
6,256 322.1 34.5
III I I
5 3 1.5
hCG elevated 2 days
124.9 I 19.27 I 208.9 I
Treatment
186.2
No detectable EMA-CO tumor
AWNED AWNED Recurred after 4 years AWNED
Abbreviations: AP, antecedent pregnancy; AWNED, alive with no evidence of disease.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.06.008
Management of ovarian carcinoid syndrome Irene Pappa ⁎, George Peros, Chris Lappas, Pantelis Vassiliu, Nikolaos Arkadopoulos, Vassilios Smyrniotis Fourth Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 10 March 2011 Received in revised form 7 June 2011 Accepted 28 July 2011 Keywords: Carcinoid syndrome Insular carcinoid tumor Ovarian cancer
Ovarian cancer accounts for approximately 3% of all cancers in women, and is the fifth leading cause of cancer-related death among women in the USA [1]. According to WHO histologic classification [2], ovarian tumors belong to 3 main categories: epithelial tumors (75% of all ovarian tumors); sex cord–stromal tumors (5%–10%); and germ cell tumors (15%–20%). A small percentage of malignant ovarian germ cell tumors are ovarian carcinoid—an uncommon entity that accounts for 0.3% of all carcinoid tumors. Carcinoid tumors of the ovary can be insular (islet ⁎ Corresponding author at: Rimini 1, Haidari, Athens 12462, Greece. Tel.: + 30 6974318947. E-mail address: [email protected] (I. Pappa).
tumors), trabecular, mucinous, or mixed. At computed tomography (CT) and magnetic resonance imaging (MRI), ovarian carcinoid tumors display solid characteristics, making them almost indistinguishable from other solid malignancies of the ovary. In 2010, a 60-year-old woman attended the ATTIKON University Hospital, Athens, Greece, with peripheral edema, persistent watery diarrhea, and loss of 13 kg within the previous 4 months; she had experienced weakness, fatigue, and episodes of skin flushing lasting 3– 4 minutes during the past year. During this period, repeated checkup evaluation in primary medical facilities was unremarkable. The persistent specific symptomatology raised suspicion of a secreting tumor. Consequently, serum serotonin and urine 5-hydroxyindoleacetic acid (5-HIAA) levels were evaluated, both of which were remarkably elevated. Heart ultrasonography revealed severe tricuspid valve insufficiency and stenosis, with co-existence of severe pulmonary valve insufficiency. Carcinoid heart disease is the most prominent effect of carcinoid syndrome; it commonly affects the right valves of the heart (33% prevalence) more than the left valves (8% prevalence). There is a correlation between the prevalence of carcinoid heart disease and urinary 5-HIAA levels. Examination of the lower abdomen with MRI revealed a large left-sided mass measuring 12 cm in diameter, probably originating from the left ovary but in close relationship with the uterus and the colon. A small amount of fluid was seen in the cul de sac. Under general anesthesia, exploratory laparotomy was performed, followed by total abdominal hysterectomy and unilateral salpingo-
No
Yes No 33% Yes
TAH/BSO
TAH/BSO TAH/BSO USO or BSO, with or without TAH Carinelli [14] Trosić [15] Robboy [5]
A: 5 B: ND ND ND ND A: 40 years old (L, 1–3 cm) B: 59 years old (L, R) 66 years old 60 years old (L) 48 cases of IC Robboy [13]
Abbreviations: BSO, bilateral salpingo-oophorectomy; CTX, chemotherapy; D, deceased; IC, insular carcinoid tumor of the ovary; L, left ovary; ND, no data; R, right ovary; RT, radiotherapy; TAH, total abdominal hysterectomy; USO, unilateral salpingo-oophorectomy.
A: 22 mo, D (after RT and CTX ) B: 1 mo, D (liver metastases) 10 mo after RT, no recurrence 1.5 yr, no recurrence 95% survival at 5 yr; 88% at 10 yr (of 42 cases)
No follow-up 4 yr, no recurrence
Mixed IC, mucinous, and trabecular components Cystic and solid mass Malignant ascites A: 1 IC originating from cystadenoma of borderline malignancy B: 1 IC originating from mucinous adenocarcinoma Co-existence of uterine carcinosarcoma ND 1/3 with carcinoid syndrome had max. diameter 4–7 cm; 2/3 had max. diameter N 7 cm 12 3 53 years old (L, 9 × 16 × 18 cm) 60 years old (L, 21 × 10 × 8 cm) Kasantikul [11] Hilton [12]
Yes No
TAH/BSO TAH/BSO, omentectomy, appendectomy TAH/BSO TAH/USO Díaz-Montes [9] Müngen [10]
6 1
No Yes
6 wk, resolution of carcinoid syndrome 3 yr, no recurrence
3 yr, no recurrence ND USO TAH/BSO ND 6
44 years old (L) 57 years old (R, 23 × 17 × 13 cm + mature cystic teratoma, L) 80 years old (R, 6 cm) 47 years old (R, 10 × 10 × 7 cm) Lagoudianakis [7] Chatzipantelis [8]
No No
Stage I Stage I Predominantly IC with mixed trabecular histologic pattern Solid and partially cystic mass ND Mixed IC and mucinous cystadenoma of low malignant potential Stage I Mixed IC and trabecular carcinoid tumor TAH/USO TAH/BSO 12 4 60 years old (L, 12 × 12 × 12 cm) 55 years old (L, 11 × 7 × 5 cm) Present case Somak [6]
Yes No
Tumor characteristics Carcinoid syndrome Operation performed Duration of symptoms, mo Patient characteristics Study
Table 1 Published studies regarding management of insular carcinoid tumor, 1975–2011.
9 mo, no recurrence Lost to follow-up
BRIEF COMMUNICATIONS
Follow-up
206
oophorectomy—resecting the tumor in toto. The disease was isolated to the specific mass and no dissemination was identified in the omentum, the peritoneal surfaces, or other organs. Liver dimensions were increased but with no metastatic lesions. The patient recovered well in the postoperative period. All surgical specimens were evaluated histopathologically. Microscopically, the tumor comprised uniform cells with abundant eosinophilic cytoplasms and central round nuclei. Mitotic activity was rare. Immunohistochemical study revealed that the majority of neoplastic cells were positive for carcinoembryonic antigen, chromogranin, synaptophysin, and serotonin, and only a small number of cells were positive for cytokeratin (CK)20. The staining pattern indicated the neurosecretory nature of the tumor. The connective tissue of the tumor was positive for vimentin, smooth-muscle actin, and CD10 markers. The histologic and immunohistochemical findings classified the tumor as an insular carcinoid of the left ovary, and the malignancy was classified as early stage (stage I). The patient was discharged, with no adjuvant treatment indicated, and advised to attend regular follow-up visits; at the time of writing (9 months after removal of the tumor), she had no symptoms of carcinoid syndrome or evidence of tumor recurrence. Based solely on the symptoms of carcinoid syndrome, physicians should raise concern early and initiate serologic evaluation to enable diagnosis long before masses become palpable or evident in imaging studies. This is considered key for an early diagnosis, which can lead to curative resection and excellent prognosis [3]. Chromogranin blood test, 24-hour urine 5-HIAA testing, and somatostatin receptor scintigraphy are commonly used to detect carcinoid tumors. Other imaging methods are also helpful in detecting the neoplasm but definitive diagnosis depends on histopathologic examination of the tumor. Multiple immunohistochemical markers— such as synaptophysin and chromogranin—can reveal the neuroendocrine origin of neoplastic cells. A recent study revealed that other commonly used markers (e.g. thyroid transcription factor-1, CK7, and CK20) are not helpful in determining whether an ovarian carcinoid is primary or metastatic. Misdiagnosis of carcinoid syndrome puts the patient at risk of carcinoid crisis, which is a dangerous and potentially fatal condition characterized by a sudden and profound drop in blood pressure, tachycardia, high blood glucose, and severe bronchospasm— leading to shock. Even if this extreme complication does not occur, prolonged symptomatology or development of relative effects may distress a patient with a potentially curable disease. Based on the present case, a MEDLINE search revealed 11 articles from 1975 to 2011 (Table 1). The rarity of these ovarian tumors reflects the fact that they are under-investigated and explains the paucity of the literature references. Evaluation of the published cases shows that there is no consensus with regard to preferred surgical treatment. Most authors chose total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) because most patients were postmenopausal. Laparoscopic-assisted and robot-assisted TAH/ BSO are promising options for early-stage disease. There is also no clarity regarding follow-up programs. The literature reports 3–6-month intervals, with examination of urinary 5-HIAA, plasma serotonin, or CT scans and echocardiographic evaluation of valve function [4,5]. A consensus regarding diagnosis, treatment options, and follow-up is needed. Conflict of interest The authors have no conflicts of interest. References [1] National Center for Health Statistics. Surveillance, Epidemiology and End Results (SEER) Program. http://seer.cancer.gov/. [2] Kaku T, Ogawa S, Kawano Y, Ohishi Y, Kobayashi H, Hirakawa T, et al. Histological classification of ovarian cancer. Med Electron Microsc 2003;36(1):9–17.
BRIEF COMMUNICATIONS [3] Reed N, Millan D, Verheijen R, Castiglione M, ESMO Guidelines Working Group. Non-epithelial ovarian cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21(Suppl 5):v31–6. [4] Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumors. Cancer 1997;79(4):813–29. [5] Robboy SJ, Norris HJ, Scully RE. Insular carcinoid primary in the ovary. A clinicopathologic analysis of 48 cases. Cancer 1975;36(2):404–18. [6] Somak R, Shramana M, Vijay S, Nita K. Primary carcinoid tumor of the ovary: a case report. Arch Gynecol Obstet 2008;277(1):79–82. [7] Lagoudianakis EE, Markogiannakis H, Karantzikos G, Papadima A, Alevizos L, Manouras A. Primary insular carcinoid of the ovary. Eur J Gynecol Oncol 2008;29 (5):554–5. [8] Chatzipantelis P, Mavrogiorgis A, Kairi-Vassilatou E, Pafiti A. Ovarian neoplasm composed of an insular carcinoid tumor and a borderline mucinous cystadenoma arising in a mature cystic teratoma: a case report. Eur J Gynecol Oncol 2006;27(6): 636–7. [9] Díaz-Montes TP, Rosenthal LE, Bristow RE, Grumbine FC. Primary insular carcinoid of the ovary. Gynecol Oncol 2006;101(1):175–8.
207
[10] Müngen E, Ertekin AA, Yergök YZ, Ergür AR, Baloğlu H. Primary mixed trabecular and insular carcinoid tumor of the ovary: a case report. Acta Obstet Gynecol Scand 1997;76(3):279–81. [11] Kasantikul V, Triratanachart S, Maneesri S, Panichabhongse V. Primary ovarian carcinoid: a mixture of insular, trabecular and mucinous components. J Med Assoc Thai 1996;79(3):200–4. [12] Hilton P, Tweddell A, Wright A. Primary insular argentaffin carcinoma of ovary. Case report and literature review. Br J Obstet Gynecol 1988;95(12):1324–31. [13] Robboy SJ. Insular carcinoid of ovary associated with malignant mucinous tumors. Cancer 1984;54(10):2273–6. [14] Carinelli SG, Acquati PG, Rossi P, Liverani CA, Cattaneo M, Carinelli I. Primary insular carcinoid of the ovary. Ann Ostet Ginecol Med Perinat 1981;102(4): 278–85. [15] Trosić A, Sterijev K, Tarle M, Ljubojević N, Pajtler M. Primary insular carcinoid tumor in a benign cystic teratoma of the ovary. Jugosl Ginekol Opstet 1981;21(3–4):75–8.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.06.017
205
Table 1 Characteristics of the 17 patients diagnosed with placental site trophoblastic tumors. Patient
Age AP
Interval to Period of amenorrhea or bleeding diagnosis, months
1 2 3
30 25 38
Term Term Term
4 36 24
4 5 6 7 8 9 10 11. 12. 13 14
28 35 27 36 33 30 31 29 28 29 32
Term after IVF Term Term Term after IVF Abortion Term Term Term Term Term Term
15 16 17
41 28 38
Term Term Molar abortion
17 recurrent 42 case
hCG U/L
Stage Largest tumor size, cm
Outcome
2.5 3 3
Hysterectomy Hysterectomy + EMA-CO Hysterectomy + EMA-CO
AWNED AWNED AWNED
Hysterectomy Hysterectomy Hysterectomy Hysterectomy Hysterectomy + EMA-CO Hysterectomy + EMA-CO Hysterectomy Hysterectomy Hysterectomy Hysterectomy Hysterectomy + lobectomy + EMA-CO EMA-CO + hysterectomy Hysterectomy + EMA-CO Hysterectomy + EMA-CO
AWNED AWNED AWNED AWNED AWNED AWNED AWNED AWNED AWNED AWNED AWNED
15 4 6 10 12 24 10 7 10 18 10
Bleeding 50 days Amenorrhea 15 months Amenorrhea 12 months and bleeding 5 months Amenorrhea 3 months and bleeding 19 days Bleeding 1 month Bleeding 4 months Amenorrhea 56 days and bleeding 7 days Bleeding 2 days Bleeding 24 months Bleeding 7 months Bleeding 7 months Bleeding 4 months Amenorrhea 2 months Bleeding 10 months
48.67 157.0 175.2 204.03 1,024 5.02 175.78 48.29 145 389.25 125.8
I I I I I I I I I I III
2 2.5 2.5 5 4 2 2.7 6 3 2 2
36 13 3
Amenorrhea 6 months and bleeding 42 days Bleeding 6 months Amenorrhea 3 months and bleeding 14 days
6,256 322.1 34.5
III I I
5 3 1.5
hCG elevated 2 days
124.9 I 19.27 I 208.9 I
Treatment
186.2
No detectable EMA-CO tumor
AWNED AWNED Recurred after 4 years AWNED
Abbreviations: AP, antecedent pregnancy; AWNED, alive with no evidence of disease.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.06.008
Management of ovarian carcinoid syndrome Irene Pappa ⁎, George Peros, Chris Lappas, Pantelis Vassiliu, Nikolaos Arkadopoulos, Vassilios Smyrniotis Fourth Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 10 March 2011 Received in revised form 7 June 2011 Accepted 28 July 2011 Keywords: Carcinoid syndrome Insular carcinoid tumor Ovarian cancer
Ovarian cancer accounts for approximately 3% of all cancers in women, and is the fifth leading cause of cancer-related death among women in the USA [1]. According to WHO histologic classification [2], ovarian tumors belong to 3 main categories: epithelial tumors (75% of all ovarian tumors); sex cord–stromal tumors (5%–10%); and germ cell tumors (15%–20%). A small percentage of malignant ovarian germ cell tumors are ovarian carcinoid—an uncommon entity that accounts for 0.3% of all carcinoid tumors. Carcinoid tumors of the ovary can be insular (islet ⁎ Corresponding author at: Rimini 1, Haidari, Athens 12462, Greece. Tel.: + 30 6974318947. E-mail address: [email protected] (I. Pappa).
tumors), trabecular, mucinous, or mixed. At computed tomography (CT) and magnetic resonance imaging (MRI), ovarian carcinoid tumors display solid characteristics, making them almost indistinguishable from other solid malignancies of the ovary. In 2010, a 60-year-old woman attended the ATTIKON University Hospital, Athens, Greece, with peripheral edema, persistent watery diarrhea, and loss of 13 kg within the previous 4 months; she had experienced weakness, fatigue, and episodes of skin flushing lasting 3– 4 minutes during the past year. During this period, repeated checkup evaluation in primary medical facilities was unremarkable. The persistent specific symptomatology raised suspicion of a secreting tumor. Consequently, serum serotonin and urine 5-hydroxyindoleacetic acid (5-HIAA) levels were evaluated, both of which were remarkably elevated. Heart ultrasonography revealed severe tricuspid valve insufficiency and stenosis, with co-existence of severe pulmonary valve insufficiency. Carcinoid heart disease is the most prominent effect of carcinoid syndrome; it commonly affects the right valves of the heart (33% prevalence) more than the left valves (8% prevalence). There is a correlation between the prevalence of carcinoid heart disease and urinary 5-HIAA levels. Examination of the lower abdomen with MRI revealed a large left-sided mass measuring 12 cm in diameter, probably originating from the left ovary but in close relationship with the uterus and the colon. A small amount of fluid was seen in the cul de sac. Under general anesthesia, exploratory laparotomy was performed, followed by total abdominal hysterectomy and unilateral salpingo-
No
Yes No 33% Yes
TAH/BSO
TAH/BSO TAH/BSO USO or BSO, with or without TAH Carinelli [14] Trosić [15] Robboy [5]
A: 5 B: ND ND ND ND A: 40 years old (L, 1–3 cm) B: 59 years old (L, R) 66 years old 60 years old (L) 48 cases of IC Robboy [13]
Abbreviations: BSO, bilateral salpingo-oophorectomy; CTX, chemotherapy; D, deceased; IC, insular carcinoid tumor of the ovary; L, left ovary; ND, no data; R, right ovary; RT, radiotherapy; TAH, total abdominal hysterectomy; USO, unilateral salpingo-oophorectomy.
A: 22 mo, D (after RT and CTX ) B: 1 mo, D (liver metastases) 10 mo after RT, no recurrence 1.5 yr, no recurrence 95% survival at 5 yr; 88% at 10 yr (of 42 cases)
No follow-up 4 yr, no recurrence
Mixed IC, mucinous, and trabecular components Cystic and solid mass Malignant ascites A: 1 IC originating from cystadenoma of borderline malignancy B: 1 IC originating from mucinous adenocarcinoma Co-existence of uterine carcinosarcoma ND 1/3 with carcinoid syndrome had max. diameter 4–7 cm; 2/3 had max. diameter N 7 cm 12 3 53 years old (L, 9 × 16 × 18 cm) 60 years old (L, 21 × 10 × 8 cm) Kasantikul [11] Hilton [12]
Yes No
TAH/BSO TAH/BSO, omentectomy, appendectomy TAH/BSO TAH/USO Díaz-Montes [9] Müngen [10]
6 1
No Yes
6 wk, resolution of carcinoid syndrome 3 yr, no recurrence
3 yr, no recurrence ND USO TAH/BSO ND 6
44 years old (L) 57 years old (R, 23 × 17 × 13 cm + mature cystic teratoma, L) 80 years old (R, 6 cm) 47 years old (R, 10 × 10 × 7 cm) Lagoudianakis [7] Chatzipantelis [8]
No No
Stage I Stage I Predominantly IC with mixed trabecular histologic pattern Solid and partially cystic mass ND Mixed IC and mucinous cystadenoma of low malignant potential Stage I Mixed IC and trabecular carcinoid tumor TAH/USO TAH/BSO 12 4 60 years old (L, 12 × 12 × 12 cm) 55 years old (L, 11 × 7 × 5 cm) Present case Somak [6]
Yes No
Tumor characteristics Carcinoid syndrome Operation performed Duration of symptoms, mo Patient characteristics Study
Table 1 Published studies regarding management of insular carcinoid tumor, 1975–2011.
9 mo, no recurrence Lost to follow-up
BRIEF COMMUNICATIONS
Follow-up
206
oophorectomy—resecting the tumor in toto. The disease was isolated to the specific mass and no dissemination was identified in the omentum, the peritoneal surfaces, or other organs. Liver dimensions were increased but with no metastatic lesions. The patient recovered well in the postoperative period. All surgical specimens were evaluated histopathologically. Microscopically, the tumor comprised uniform cells with abundant eosinophilic cytoplasms and central round nuclei. Mitotic activity was rare. Immunohistochemical study revealed that the majority of neoplastic cells were positive for carcinoembryonic antigen, chromogranin, synaptophysin, and serotonin, and only a small number of cells were positive for cytokeratin (CK)20. The staining pattern indicated the neurosecretory nature of the tumor. The connective tissue of the tumor was positive for vimentin, smooth-muscle actin, and CD10 markers. The histologic and immunohistochemical findings classified the tumor as an insular carcinoid of the left ovary, and the malignancy was classified as early stage (stage I). The patient was discharged, with no adjuvant treatment indicated, and advised to attend regular follow-up visits; at the time of writing (9 months after removal of the tumor), she had no symptoms of carcinoid syndrome or evidence of tumor recurrence. Based solely on the symptoms of carcinoid syndrome, physicians should raise concern early and initiate serologic evaluation to enable diagnosis long before masses become palpable or evident in imaging studies. This is considered key for an early diagnosis, which can lead to curative resection and excellent prognosis [3]. Chromogranin blood test, 24-hour urine 5-HIAA testing, and somatostatin receptor scintigraphy are commonly used to detect carcinoid tumors. Other imaging methods are also helpful in detecting the neoplasm but definitive diagnosis depends on histopathologic examination of the tumor. Multiple immunohistochemical markers— such as synaptophysin and chromogranin—can reveal the neuroendocrine origin of neoplastic cells. A recent study revealed that other commonly used markers (e.g. thyroid transcription factor-1, CK7, and CK20) are not helpful in determining whether an ovarian carcinoid is primary or metastatic. Misdiagnosis of carcinoid syndrome puts the patient at risk of carcinoid crisis, which is a dangerous and potentially fatal condition characterized by a sudden and profound drop in blood pressure, tachycardia, high blood glucose, and severe bronchospasm— leading to shock. Even if this extreme complication does not occur, prolonged symptomatology or development of relative effects may distress a patient with a potentially curable disease. Based on the present case, a MEDLINE search revealed 11 articles from 1975 to 2011 (Table 1). The rarity of these ovarian tumors reflects the fact that they are under-investigated and explains the paucity of the literature references. Evaluation of the published cases shows that there is no consensus with regard to preferred surgical treatment. Most authors chose total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) because most patients were postmenopausal. Laparoscopic-assisted and robot-assisted TAH/ BSO are promising options for early-stage disease. There is also no clarity regarding follow-up programs. The literature reports 3–6-month intervals, with examination of urinary 5-HIAA, plasma serotonin, or CT scans and echocardiographic evaluation of valve function [4,5]. A consensus regarding diagnosis, treatment options, and follow-up is needed. Conflict of interest The authors have no conflicts of interest. References [1] National Center for Health Statistics. Surveillance, Epidemiology and End Results (SEER) Program. http://seer.cancer.gov/. [2] Kaku T, Ogawa S, Kawano Y, Ohishi Y, Kobayashi H, Hirakawa T, et al. Histological classification of ovarian cancer. Med Electron Microsc 2003;36(1):9–17.
BRIEF COMMUNICATIONS [3] Reed N, Millan D, Verheijen R, Castiglione M, ESMO Guidelines Working Group. Non-epithelial ovarian cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21(Suppl 5):v31–6. [4] Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumors. Cancer 1997;79(4):813–29. [5] Robboy SJ, Norris HJ, Scully RE. Insular carcinoid primary in the ovary. A clinicopathologic analysis of 48 cases. Cancer 1975;36(2):404–18. [6] Somak R, Shramana M, Vijay S, Nita K. Primary carcinoid tumor of the ovary: a case report. Arch Gynecol Obstet 2008;277(1):79–82. [7] Lagoudianakis EE, Markogiannakis H, Karantzikos G, Papadima A, Alevizos L, Manouras A. Primary insular carcinoid of the ovary. Eur J Gynecol Oncol 2008;29 (5):554–5. [8] Chatzipantelis P, Mavrogiorgis A, Kairi-Vassilatou E, Pafiti A. Ovarian neoplasm composed of an insular carcinoid tumor and a borderline mucinous cystadenoma arising in a mature cystic teratoma: a case report. Eur J Gynecol Oncol 2006;27(6): 636–7. [9] Díaz-Montes TP, Rosenthal LE, Bristow RE, Grumbine FC. Primary insular carcinoid of the ovary. Gynecol Oncol 2006;101(1):175–8.
207
[10] Müngen E, Ertekin AA, Yergök YZ, Ergür AR, Baloğlu H. Primary mixed trabecular and insular carcinoid tumor of the ovary: a case report. Acta Obstet Gynecol Scand 1997;76(3):279–81. [11] Kasantikul V, Triratanachart S, Maneesri S, Panichabhongse V. Primary ovarian carcinoid: a mixture of insular, trabecular and mucinous components. J Med Assoc Thai 1996;79(3):200–4. [12] Hilton P, Tweddell A, Wright A. Primary insular argentaffin carcinoma of ovary. Case report and literature review. Br J Obstet Gynecol 1988;95(12):1324–31. [13] Robboy SJ. Insular carcinoid of ovary associated with malignant mucinous tumors. Cancer 1984;54(10):2273–6. [14] Carinelli SG, Acquati PG, Rossi P, Liverani CA, Cattaneo M, Carinelli I. Primary insular carcinoid of the ovary. Ann Ostet Ginecol Med Perinat 1981;102(4): 278–85. [15] Trosić A, Sterijev K, Tarle M, Ljubojević N, Pajtler M. Primary insular carcinoid tumor in a benign cystic teratoma of the ovary. Jugosl Ginekol Opstet 1981;21(3–4):75–8.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.06.017