Contributed by Humberto Trejo Bittar, MD, R. Marshall Austin, MD, PhD and Chengquan Zhao, MD
The patient is a 65-year-old female who presented to her primary care physician for routine annual examination. At that time, a large pelvic mass was palpated. The patient reported that her pants were fitting tighter but she was otherwise asymptomatic. She denied nausea, vomiting, early satiety, bowel or bladder dysfunction and gynecological symptoms.
Additionally, the patient has history of hypertension, hyperlipidemia and uncomplicated type-2 diabetes. The patient is G2/P2, her menarche was at age 12 with a course of irregular and heavy menses and she was unsure when she went through menopause. She denied hormone replacement therapy use and her previous Pap smears had no abnormal findings.
Her surgical history includes two cesarean sections and hysterectomy due to multiple uterine fibroids. The patient denies family history of breast, gynecologic or colon cancer.
On physical examination the patient was in no acute distress with no particular physical complaints, she was noted to have a large mass filling the pelvis and lower abdomen, extending to approximately 2 cm above the umbilicus, somewhat firm and mobile. The rest of her physical exam was unremarkable. Laboratory results were otherwise unremarkable, CA-125 and CA-19-9 were ordered but never performed.
A pelvic ultrasound was performed and revealed a very large left adnexal complex, predominantly solid that measured 23.6 x 20.7 x 14.2cm. Given its location it was probably ovarian in origin. The finding was highly suspect for underlying ovarian neoplasm until proven otherwise by tissue diagnosis (Figure 1).
Computed tomography of the abdomen and pelvis with contrast showed a large mixed cystic and solid appearing mass in the left abdominal and pelvic region measuring at least 23.1 x16.1 x 20.7cm. The left ovarian vein appeared dilated. There was no ascites, nor a definite abdominal or pelvic adenopathy. What was believed to represent the right ovary, appeared to be unremarkable (Figures 2 and 3).
SURGERY FINDINGS AND INTRAOPERATIVE CONSULTATION
Giving the radiologic findings, there was a high suspicious for ovarian cancer. The patient was scheduled for a left salpingo-oophorectomy with tumor debulking aiming for optimal cytoreduction, right pelvic node dissection and omentectomy. During the procedure a 25 cm mass was excised arising from the left ovary that was growing into the mesentery of the sigmoid colon. The mass was extensively adherent to the left pelvic sidewall. There was no evidence of right sided disease. There was no evidence of upper abdominal disease. The omentum appeared to be normal. Most of the disease was essentially in the pelvis with no evidence of enlarged nodes on the left side. After surgery there was no evidence of visible disease. Giving the malignant appearance of the mass an intraoperative consultation (frozen section) was performed and reported as poorly differentiated adenocarcinoma (Figure 4).
The left adnexal mass measured 27.5 x 20.0 x 13.2 cm and its external surface appeared mottled, lobulated, shaggy, red to tan-yellow; serial sections revealed an heterogeneous, tan-yellow to brown-red, mottled cut surface containing both solid and cystic components. The multiple cystic spaces ranged from 0.7 cm to 8.0 cm in greatest dimension and were filled with tan-yellow serous fluid and dark red, hemorrhagic serous fluid. No papillary excrescences were grossly identified. The solid components ranged from soft to firm and had focally necrotic and focally hemorrhagic areas.
HISTOLOGIC AND IMMUNOHISTOCHEMICAL FINDINGS
Microscopic analysis of representative sections of the adnexal mass revealed a solid (Figure 5) and cystic well encapsulated mass. The solid component appeared lobulated, with poorly differentiated hyperchromatic spindled-shaped cells showing severe nuclear atypia, conspicuous nucleoli and scant cytoplasm (Figure 6). In the periphery, some rudimentary tubule formation was present, in which cells gained a clearer cytoplasm and basally located nuclei, a delicate fibrous stroma separated the poorly developed tubules from each other and the solid areas (Figures 7, 8 and 9). Mitotic figures averaged 5 per 10 high power fields.
Immunohistochemical analysis of the tumor showed diffuse strong positivity for inhibin (Figure 10) and vimentin. CD99 and CAM5.2 were patchy moderately positive. Calretinin was positive in scattered tumor cells (Figure 11). EMA and ER were negative.