Residency Program - Case of the Month

Clinical history:

The patient is a 37-year-old female with a two to three month history of abdominal pain, burning on urination, occasional fevers, weight loss of 10 lbs. and amenorrhea for a period of 6 months. Physical exam was significant for bilateral lower quadrant pain as well as a mass palpated above the pubic symphysis, extending  halfway to the umbilicus. Pelvic exam was within normal limits. CT scans of her abdomen and pelvis revealed a large heterogeneous mass, measuring 10.0 x 12.0 x 13.0 cm, which appeared to be contiguous with the uterus. The left ovary could not be visualized. Laboratory measurements were significant only for elevated CA-125 (85U/ml; normal <35U/ml).  An exploratory laparotomy was subsequently undertaken and, ultimately, a total hysterectomy was performed.

Gross description:

Initially, received fresh for frozen section was the left fallopian tube and ovary. The fallopian tube measured 10.0 x 4.1 cm and showed no gross abnormalities. The left ovary was firm and lobulated, measuring 21.4 x 14.3 x 14.0 cm. Sectioning revealed yellow-tan cut surfaces with small cystic spaces, fibrous septae and foci of hemorrhage and necrosis. The subsequently received right fallopian tube and ovary, as well as the uterus, showed no evidence of malignancy. However, accompanying omental masses had a similar appearance to that of the left ovary.

Microscopic photographs:

Immunohistochemical Stains:

Figure 1: Inhibin

Figure 2: Melan-A

Figure 3: Chromogranin

ANSWER