Case 896 -- A Woman in her 50s with Severe Pain in Right Lower Quadrant and Vomiting

Contributed by Michelle Heayn, MD, PhD and Jeffery Fine, MD


A woman in her early 50's presented to the emergency department with severe right lower quadrant pain and vomiting. She reported a slight decrease in appetite and intermittent abdominal pain over the past month. She denied any changes in bowel or bladder habits or weight. She also denied shortness of breath, leg swelling, or early satiety. She reported postmenopausal spotting over the past week. On examination she was found to have rebound tenderness and guarding.


Pelvic ultrasound was notable for a 19 cm, complex, cystic and solid lesion with vascularity in the right adnexa. The endometrial lining was also abnormally thickened. CT of the abdomen and pelvis confirmed the presence of the mass, a lobulated portion of which was imposing extrinsic pressure on the adjacent bowel. A preoperative uterine biopsy demonstrated complex atypical hyperplasia.


At the time of the total abdominal hysterectomy and bilateral oophorectomy the ovarian mass was found to be disrupted and partially adherent to the pelvic wall. Frozen section examination of the ovarian mass demonstrated an adenocarcinoma which appeared endometrioid, however colorectal origin could not be ruled out. Frozen section examination of the uterus demonstrated at least complex atypical hyperplasia.


On gross examination the right ovary consisted of a disrupted 20x16x9 cm mass which occupied 80% of the ovarian surface. The right fallopian tube was grossly adhered to, but not involved by, the ovarian mass. The left ovary measured 4x3x1 cm and contained a cystic structure containing dark brown fluid which measured less than 1cm in diameter. The left fallopian tube was grossly unremarkable. The uterus measured 10x6x4 cm on gross examination. The serosal surface, ectocervix, and endocervix were grossly unremarkable. The endometrial lining measured up to 0.6 cm and did not grossly invade the myometrium. The appendix was 2.5 cm in length and 1 cm in diameter. The serosa was notable for a small amount of adhesions. The omentum was grossly unremarkable.


Histologic sections confirmed that the right ovary consisted of adenocarcinoma with papillary and glandular growth patterns (Figures 1 and 2). Immunohistochemical analysis confirmed ovarian origin (Pax-8 positive, Cytokeratin 7 positive, Cytokeratin 20 negative, ER mostly weak to moderate positive, PR moderate to strong positive, Vimentin patchy positive, HNF negative, and CDX2 negative). The tumor largely replaced the ovary, although residual areas with atypical endometriosis were present (Figures 3 and 4). The left ovary also showed focal atypical endometriosis (Figures 5 and 6).

Histologic sections of the endometrium demonstrated focal endometrioid adenocarcinoma in a background of complex atypical hyperplasia (Figures 7 and 8) with superficial invasion of the myometrium (Figures 9 and 10). Histologic sections of the appendix demonstrated endometriosis of the serosa (Figures 11 and 12). Endometriosis was also found in the omentum.


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