Contributed by Dayne Ashman, MD and Esther Elishaev, MD
An elderly, Caucasian, postmenopausal female presented for her annual gynecological examination. Her main complaint was a three day history of rectal pressure, one month prior to presentation. Significantly, her previous pap smear (two years ago) was negative for intraepithelial lesion or malignancy. She denied having any abdominal pain or distension, early satiety, change in bowel or bladder habits, and no vaginal symptoms. On bimanual examination, she was noted to have a posterior uterine mass. Subsequent pelvic ultrasound revealed a thickened endometrial lining of 21.2mm, and a complex left adnexal, solid cystic mass measuring 13.9x7.3x10.5cm with thick/thin septations and a solid component with vascular flow. An elective left salpingo-oophorectomy was performed.
On gross examination, a 717.3g, left tubo-ovarian complex was noted with a 9.5 x 0.4 cm fimbriated fallopian tube and a large cystic 16.0 x 10.0 x 7.5 cm ovary. The surface of the left ovary was smooth and intact with no surface papillations identified. Sectioning revealed a multicystic sponge-like cut surface that exuded thick mucinous fluid. Neither solid areas nor any normal ovarian stroma was identified. The left fallopian tube was grossly unremarkable.
Microscopically, the tumor of the left ovary was predominantly cystic, composed of variable size cysts lined by mucinous- eosinophilic columnar epithelium (Fig. 1). The nuclei of the epithelium were hyperchromatic in areas, and displayed a range of atypia, varying from mild to moderate to marked nuclear atypia. In some areas, mitoses were readily identified (Fig. 2). A few foci of stromal micro-invasion were also identified (Fig. 3). The stromal component consisted of foci of intermediately differentiated Sertoli-Leydig cell tumor (SLCT) admixed with hyalinized areas and edematous areas (Fig. 4). Immunohistochemical stains revealed that the SLCT component was strongly positive for inhibin (Fig. 5) and calretinin (Fig. 6). The epithelial component showed cytoplasmic positivity for cytokeratin 7 (Fig. 7).