Case 394 -- A woman in her 60s with an incidental finding in the left ovary

Contributed by Suzanne Bakdash, MD, MPH and Gloria Carter, MD
Published on line in July, 2004


CLINICAL HISTORY AND GROSS DESCRIPTION:

This 60-year-old post-menopausal female underwent an exploratory laparotomy and bilateral salpingo-oophorectomy for a 30.0 cm mass of the right adnexa, which was found to be a fibrothecoma of the right ovary with cystic degeneration. On gross examination, the left ovary was somewhat obscured by adhesions and measured approximately 4.5 x 3.0 x 1.2 cm by palpation. The left fallopian tube and two simple paratubal cysts, up to 0.5 cm in diameter, were also identified. The cut surface of the ovary was tan with a few white and light yellow nodules. Representative cross sections, to include ovary and adhered fallopian tube, were submitted for microscopic evaluation.

MICROSCOPIC EXAMINATION:

The hematoxylin and eosin stained sections demonstrate a portion of ovary with adherent fallopian tube and fibrovascular meso-ovarian soft tissue. The fallopian tube is attached to the ovary by fibrovascular adhesions. The dense ovarian stroma consists mainly of wavy spindle-shaped stromal cells with scanty cytoplasm arranged in whorls and storiform patterns. A few well-circumscribed nodules of dense collagen with convoluted borders (corpora albicans) remain in the ovarian medulla near the hilus (Figure 1). In addition to the above structures, a 0.9 cm nodule, composed of large polygonal cells, with abundant granular eosinophilic cytoplasm and large vesicular nuclei, is noted in the mesovarium (Figures 2 - 5). Similar cells surround and lie within nerves (Figures 6- 8). One focus showed a number of these cells entrapped in a sclerotic background, singly and in clusters (Figure 9).

The cells in the meso-ovarian nodule, nerve and sclerotic focus are all positive for inhibin on paraffin section immunohistochemistry (figures 2a-3a, 6a-7a and 9a, respectively). An extensive search in sections stained with Masson's Trichrome revealed rare cells with homogenous, non-refractile, blunt-ended rod-shaped cytoplasmic crystals (Reinke crystals) (Figures 10 and 11).

    Figure 1: Left ovary, H&E x20
    Figure 2: Left ovary with cellular nodule, H&E x20
    Figure 2a: Left ovary with cellular nodule, inhibin immuohistochemical stain (IHC) x20
    Figure 3: Cellular nodule in left ovary, H&E x100
    Figure 3a: Cellular nodule in left ovary, inhibin IHC x100
    Figure 4: Cellular nodule in left ovary, H&E x200
    Figure 5: Cellular nodule in left ovary, high magnification, H&E x400
    Figure 6: Polygonal cells in relation to nerve - 1, H&E x100
    Figure 6a: Polygonal cells in relation to nerve - 1, inhibin IHC x 00
    Figure 7: Polygonal cells in relation to nerve - 2, H&E x200
    Figure 7a: Polygonal cells in relation to nerve - 2, inhibin IHC x200
    Figure 8: Polygonal cells in relation to nerve - 3, H&E x400
    Figure 9: Polygonal cells in sclerotic background, H&E x200
    Figure 9a: Polygonal cells in sclerotic background, inhibin IHC x200
    Figure 10: Hilus cells with Reinke crystals, Masson's Trichrome x200
    Figure 11: Hilus cells with Reinke crystals, Masson's Trichrome x400

FINAL DIAGNOSIS


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