June 2023 – Presented by Dr. Larry Ha (Mentored by Dr. Kurt Schaberg)
Clinical History
A 44-year-old female with no significant past medical history presents to the ED with bilateral ovarian masses. CT of the abdomen shows enhancement and mural thickening concerning for cystic ovarian neoplasm. Tumor markers showed:
| AFP: 4.6 | [ref < 8.8ng/mL) |
| B-HCG: negative | |
| CA125: 55 | [ref < 35 U/mL] |
| CA19-9: 20 | [ref < 37 U/mL] |
| CEA: <0.5 | [ref < 5 ng/mL] |
| Estradiol: 300 | [ref 30-550 pg/mL] |
| Inhibin A: 50 | [ref 2-80 pg/mL] |
| Inhibin B: 19 | [ref 1-107 pg/mL] |
| LDH: 145 | [ref 135-225 U/L] |
Gross Examination
Specimen received fresh after intraoperative consult and hysterectomy and bilateral salpingo-oopherectomy. Right ovary and fallopian tube weighs 2000 grams and measures 25 x 14 x 11 cm ovary with attached 8 cm in length by 1.0 cm in diameter fimbriated fallopian tube. Left ovary and fallopian tube weighs 230 grams and measures 10 x 6 x 4 cm ovary with attached 5.5 cm in length by 0.6 cm in diameter fimbriated fallopian tube. The intact ovarian surface is pink-tan and smooth without papillary excrescences. The specimen is sectioned to reveal a homogenous smooth pink-tan rubbery cut surface with a peripheral tan firmer area. There are also scattered smooth-walled cysts ranging in size from 0.5 cm to 7.5 cm in greatest dimension with scant clear serous fluid.
Grossly normal appearing uterus and cervix.
Right ovary bivalved
Left Ovary bivalved
Microscopic Features
Histologic sections of the mass demonstrate the following:
20x
Possible Signet Ring
Immunohistochemistry
Immunohistochemical (IHC) staining demonstrates that the specimen is positive for CK7, CK20, CDX2, and negative for PAX-8.
CK7
CK20
CDX2
Pax8
The correct answer is:
Not A. Primary endometrioid carcinomas are typically PAX8 positive and unilateral. But certainly high on the differential during frozen section!
Not B. Sex cord stromal tumors typically have elevated estradiol, inhibin A or B. In addition, CK7 is typically negative. CK7 is helpful in distinguishing Sertoli-Leydig tumors from epithelial tumors.
Not C. Struma ovarii has a thyroid component. PAX8 is typically positive.
Not D. Breast carcinomas are negative for CDX2.
The answer is E. Patient also found to have a gastric poorly differentiated adenocarcinoma.
The correct answer is:
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