diagnostic mistakes in gynaecological pathology: case...
TRANSCRIPT
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Diagnostic mistakes in gynaecological pathology: Case 4
Takako Kiyokawa, M.D., Ph.D.Department of Pathology, The Jikei
University School of Medicine
Tokyo, JAPAN1
31st European Congress of Pathology
Sept. 8th, 2019, Nice
Slide Seminar
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Disclosure
I have no actual or potential conflict of interest in relation to this presentation.
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Clinical history
• A 76-year-old woman
• Chief complaint: abdominal distension
• Past history: hysterectomy and bilateral salpingo-oophorectomy for cervical carcinoma 15 years before
• Imaging study: massive ascites and multiple nodular lesions in the pelvic peritoneum and omentum
• Laparoscopic biopsy was performed
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Immunohistochemistryby the original pathologist
Positive Negative
WT-1 CEA
D2-40 TTF-1
Calretinin CA125
Cytokeratin(AE1/3)
Vimentin
Malignant mesothelioma ?
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Differential diagnosis
• Malignant mesothelioma
• Adult granulosa cell tumor
• Low-grade serous carcinoma
• Peritoneal ependymoma
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Immunohistochemistry
Positive Negative
WT-1 PAX8
D2-40 CK7
Calretinin inhibin-α
Cytokeratin(AE1/3) EMA
Vimentin GFAP
PgR ER
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WT-1
Calretinin
D2-40
AE1/3
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Progesterone receptorVimentin
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Differential diagnoses
Immunohistochemistry
Mesothelioma WT-1+, D2-40+,Calretinin+, AE1/3+,vimentin+/-, CK7+/-, PAX8-,ER-, PgR-
Granulosa cell tumor WT-1+, D2-40+,Calretinin+, AE1/3+, PAX8-,ER+/-, PgR+/-
Serous carcinoma WT-1+, AE1/3+ , ER+, PgR+,PAX8+, CK7+
Ependymoma ER+/-, PgR+/-, GFAP+
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Adult granulosa cell tumorHistological features
Wide variety of growth patterns Diffuse, corded, gyriform, follilclles(macro, micro [Call-Exner bodies]), sarcomatoid
Granulosa cells • Scant eosinophilic cytoplasm,
indistinct cytoplasmic membrane• Uniform, round to ovoid nuclei, pale
chromatins, nuclear grooves• Mitotic rate: variable
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Adult granulosa cell tumorImmunohistochemistry
Positive
Markers of sex-cord differentiation
inhibin, carletinin, SF-1, WT-1, FOXL2
Positive/negative
AE1/3, CAM5.2, SMA, desmin, S100, vimentin, PR, ER
Negative
PAX8, CK7 , EMA
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Diagnosis
• Malignant mesothelioma
• Adult granulosa cell tumor
• Low-grade serous carcinoma
• Peritoneal ependymoma
Her medical record from 15 years before wasrecovered to reveal
adult granulosa cell tumor in her resected ovary
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Final diagnosis
Peritoneal recurrence of ovarian adultgranulosa cell tumor
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Adult granulosa cell tumor
• Most common ova malignant sex cord stromal tumor
• 2-3% of malignant ova tumors
• Most common ova tumor with estrogenic manifestation
• FOXL2 missense point mutation > 90%AGCTs
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Ovarian adult granulosa cell tumor
• 95% stage I, most unilateral
• Prognostic factor: stage
• 10 year survival
86-96%(stage I) vs 26-49% (high stage)
• Recurrence rates 10% - 34%
Bryk S, et al. Int J Gynecol Cancer 2015, 25:33-41
• Late abdominopelvic recurrence
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Take home message
•Ovarian adult granulosa cell tumor may recur in the peritoneum long after (>10yrs) initial surgery
• Patient’s history is always important
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