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