Residency Program - Case of the Month

Clinical History

The patient is a 68 years old female, presented with shortness of breath and lower extremity swelling. She reports a significant abdominal distension, early satiety and small caliber bowel movements for the past 2 weeks. She also reports significant pain diffusely throughout the abdomen. She also noticed significant weight loss over the past couple of months. She has not had gynecologic care in many years. She denies vaginal bleeding or discharge, fever or chills, nausea, vomiting.  There is no change in bladder function.

Past medical history is significant for hypertension. Family history: patient’s mom has breast cancer at 44 years old.

Physical exam findings include distended abdomen with active bowel sounds and no masses; pitting edema in lower leg ankle area with no erythema.

CT abdominal/Pelvis findings concerning for carcinomatosis. No pelvic organ masses identified.

The patient was admitted to the ER for her symptoms and underwent a paracentesis and fluids were sent for cytology evaluation. The procedure relieved her symptoms greatly, however fluid is reaccumulated.

Cytology Findings

The smears were cellular and revealed clusters of cells with enlarged nuclei, distinct nucleoli, irregular nuclear contours. The cytoplasm is abundant and contains intracytoplasmic vacuoles. Reactive mesothelial cells, histiocytes and blood are present in the background. Representative pictures for evaluation are shown in Figure 1-4.

Click on image to enlarge.

Figure 1 PAP Stain. 10x		Figure 2 PAP Stain. 40x
Figure 3 Giemsa Stain. 40x		Figure 4 Cell Block. 40x

What is most likely the diagnosis? What immunohistochemistry stains will you order to support your diagnosis?

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