diagnostic mistakes in gynaecological pathology: case...
TRANSCRIPT
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
Disclosure
I have no actual or potential conflict of interest in relation to this presentation.
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
Immunohistochemistryby the original pathologist
Positive Negative
WT-1 CEA
D2-40 TTF-1
Calretinin CA125
Cytokeratin(AE1/3)
Vimentin
Malignant mesothelioma ?
Differential diagnosis
• Malignant mesothelioma
• Adult granulosa cell tumor
• Low-grade serous carcinoma
• Peritoneal ependymoma
Immunohistochemistry
Positive Negative
WT-1 PAX8
D2-40 CK7
Calretinin inhibin-α
Cytokeratin(AE1/3) EMA
Vimentin GFAP
PgR ER
WT-1
Calretinin
D2-40
AE1/3
Progesterone receptorVimentin
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+
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
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
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
Final diagnosis
Peritoneal recurrence of ovarian adultgranulosa cell tumor
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
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
Take home message
•Ovarian adult granulosa cell tumor may recur in the peritoneum long after (>10yrs) initial surgery
• Patient’s history is always important