Download CLINICAL SOCIETY MEETING 30-01-2015

Clinico-Pathological Conference
(CPC) Meet
Karpagam Medical College Hospital
30-01-2015
Case History
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37 yr. old female
Puberty at 14 yrs
Regular menstrual cycles 3-4/30
Married at 17 yrs
Para 2 Live 2 MTP1
First Child -17 yrs, FTND, A&W
Second Child – 19 yrs, FTND, A&W
Sterilisation done . LCB – 14 yrs
Chief Complaints
• Increased , continuous , and painless bleeding
Per vaginum - 1 month
• Cycles usually regular, once in 30 days, lasts for
3-4 days
• Discomfort in the lower abdomen – 1 month
• Bowel and micturition habits – normal
• No loss of appetite/weight
• Feeling of extreme lassitude
General Examination
• Moderately built and nourished
• Severe anemia
• No jaundice or cyanosis
• No significant lymphadenopathy
• Vital signs -Normal
Abdominal Examination
• Fullness in the lower abdomen
• No enlarged veins over the abdominal wall
• Swelling midline, about 8-10 cm in size, uniform
surface , non tender, firm to hard in
consistency , Mobile – side to side
• No free fluid
Pelvic Examination
• The exact size of uterus could not be made
out
• Swelling not palpable bimanually
• No rectal nodes
Investigations
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BLOOD GROUP - AB+ve
Hb - 8 gm%
Platelets count – 5.64 lakhs/cu.mm
Serology - Normal
Renal function tests – Normal
TSH- 0.55 IU/ml
CA- 125 = 25.5 U/ml
ECG, X-ray Chest PA - Normal
Ultrasound Abdomen
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Bulky Uterus - 9.1 x 6.6 x 6.1 cm
Thickened Endometrium - 2.0 cm
?Endometrial hyperplasia/polyp
Thick walled cystic area in right adnexa
?Cystic ovarian mass
?Broad ligament myxoma with degeneration
Differential Diagnosis
• OVARIAN CYST
• FIBROID UTERUS -? BROAD LIGAMENT
• ABNORMAL UTERINE BLEEDING WITH
OVARIAN CYST
Gross Appearance
– Specimen of Total Abdominal Hysterectomy with
Bilateral Salphingo-oopherectomy (11x6x5cm).
– Cross Section of the uterus – unremarkable.
Gross Appearance
 Right
ovary is
cystic and ms
(9x9x4.5cm)
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Cross Section:
Variegated,
solid and cystic
growth
(9x8.5x4.5cm)
Gross Appearance
• Left ovary (3x2x1cm) showed multiple cysts
• Both tubes were unremarkable
Microscopy
• Patterns - microfollicular, trabecular and
macrofollicular
• Proliferation malignant cells having
– round to oval nuclei , scanty cytoplasm
– Some of these cells have prominent nucleoli and
nuclear grooving
 Foci
showing Call-Exner bodies and hemorrhagic
areas are also seen.
Microscopic Picture
Call-Exner
bodies
Microscopic Picture
Differential Diagnosis
• Granulosa cell tumor
• Endometrioid tumor
• Undifferentiated/poorly differentiated tumor
Ovarian tumor staging – FIGO (2014)
Stage
Definition
I
Tumor confined to ovaries.
IA
Tumor limited to one ovary (capsule intact); no tumor on ovarian surface; no
malignant cells in the ascites or peritoneal washings.
IB
Tumor limited to both ovaries (capsules intact); no tumor on ovarian surface; no
malignant cells in the ascites or peritoneal washings.
IC
Tumor limited to one or both ovaries, with any of the following:
IC1: Surgical spill intraoperatively.
IC2: Capsule ruptured before surgery or tumor on ovarian surface.
IC3: Malignant cells present in the ascites or peritoneal washings.
II
Tumor involves one or both ovaries with pelvic extension (below pelvic brim) or
peritoneal cancer (Tp).
IIA
Extension and/or implants on the uterus and/or fallopian tubes and/or ovaries.
IIB
Extension to other pelvic intraperitoneal tissues.
Stage
Definition
III
Tumor involves one or both ovaries, or primary peritoneal cancer, with cytologically or
histologically confirmed spread to the peritoneum outside of the pelvis and/or metastasis to
the retroperitoneal lymph nodes.
IIIA
Metastasis to the retroperitoneal lymph nodes with or without microscopic peritoneal
involvement beyond the pelvis.
IIIA(i)
Positive retroperitoneal lymph nodes only (cytologically or histologically proven).
IIIA(ii)
Metastasis >10 mm in greatest dimension.
IIIA2
Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without
positive retroperitoneal lymph nodes.
IIIB
Macroscopic peritoneal metastases beyond the pelvic brim ≤2 cm in greatest dimension, with
or without metastasis to the retroperitoneal lymph nodes.
IIIC
Macroscopic peritoneal metastases beyond the pelvic brim >2 cm in greatest dimension, with
or without metastases to the retroperitoneal nodes.a
IV
Distant metastasis excluding peritoneal metastases.
IVA
Pleural effusion with positive cytology.
IVB
Metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes
outside of the abdominal cavity).
Report
• Uterus with chronic cervicitis and endometrium with
cystoglandular hyperplasia and adenomyosis.
Right ovary shows features of Adult Granulosa Cell
Tumor – Stage IA (T1a Nx Mx)*
• Suggested further immuno histochemical studies for
alpha-inhibin, CD99 & calretinin for definite
diagnosis.
Review of literature
• Granulosa cell tumors (GCT) were described for the
first time in 1855 by Rokitansky.
• characterized by a prolonged natural history and a
tendency to late recurrences.
• very rare ovarian malignancies; they represent <5%
of all ovarian cancers. Limited data is available from
India.
Review of literature
• Two distinct histological types—adult GCT
(AGCT) and juvenile GCT (JGCT) which display
different clinical and histopathological features
• AGCTs are more common; usually seen in
perimenopausal and postmenopausal women,
peak incidence at 50–55 years
• JGCTs are rare tumors, representing 5 % of all
GCTs and occurring in premenarchal girls and
young women
• characterized by a good prognosis
Review of literature
• The main immunohistochemical markers expressed
by these cells are vimentin, CD99 and alpha inhibin.
• The serum tumor markers are estradiol, inhibin, and
anti-Müllerian hormone.
Review of literature
• Various factors determine the prognosis. The most
important prognostic variable is the stage.
• Overall survival (approximately 90% at 5 years for
early stage) is good, because most tumors are
diagnosed early
Review of literature
• A special feature - appearance of recurrences long
after treatment of primary tumour, mean time is 5.6
years.
• Recurrences after more than 10 years are reported.
TAKE HOME MESSAGE
• Solid and cystic tumor with combination
of yellow tissue and hemorrhage is highly
suggestive of Granulosa cell tumor
Thank you