October 2018 - Presented by Dr. Ying Liu (Mentored by Dr. Anthony Karnezis)

Clinical History

Patient is a 37-year-old G5P2032 with no significant past medical history who presents with severe abdominal pain. CT abdominal and pelvis reveal bilateral ovarian masses with central necrosis in addition to moderate ascites and nodularity suspicious for ovarian malignancy. She underwent diagnostic laparoscopy, exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, supracolic omentectomy, cytoreductive surgery for ovarian cancer.

Pathology Review

Gross examination reviews showed bilateral solid ovarian masses (Right ovary: 14 x 13 x 8 cm, Left ovary: 9 x 8 x 6 cm) with smooth serosal surfaces and multinodular cut surfaces. Firm tan-white nodule (1.2 x 0.9 x 0.5 cm) is found on the left posterior serosa of uterus. Appendix (3.9 x 1.2 x 1.1 cm) reveals a pinpoint lumen devoid of contents, cut surfaces are tan white and firm to gray and mucinous. Omentum (25 x 7 x 4 cm) reveals tan-yellow and firm cut surfaces.

Microscopically, numerous high grade signet ring cells (mucin pushes nucleus to periphery) forming small glands, infiltrate as individual cells or small clusters are identified in the left and right ovary, uterus, omentum and appendix. Right mesosalpinx is extensively involved by tumor. Implants are identified on right and left tubal serosal as well as uterine serosa. Left tubal lymphatics and myometrial lymphatic invasion is also identified. A 3.9 cm appendiceal mass is identified covering the entire length of appendix. Immunohistochemical stains of the tumor cells are positive for CK20, CDX2, negative for CK7, PAX8, Synoptophysin, and Chromogranin.   Representative pictures are shown below.


Click on image to enlarge

Figure 1
Left ovarian mass, gross picture


Figure 2
Left ovarian mass, cross section

Figure 3
Appendix, cross section

Figure 4
Appendix, 2x

Figure 5
Appendix, 20x

Figure 6
Appendix, 40x

Figure 7
Ovarian mass, 2x

Figure 8
Ovarian mass, 10x

Figure 9
Ovarian mass, 40x
Figure 10
Representative Immunohistochemistry stains

Which of the following is most likely the diagnosis?

Choose one answer and submit.


The correct answer is

B.) Primary signet ring cell carcinoma of appendix

> Learn more about this diagnosis.