Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
An unusual case of transitional cell ovarian carcinoma detected incidentally during surgery of uterine endometrioid adenocarcinoma M. Dolanbay, M. S. Kutuk, S. Uludag, M. T. Ozgun, F. Ozturk & I. S. Serin To cite this article: M. Dolanbay, M. S. Kutuk, S. Uludag, M. T. Ozgun, F. Ozturk & I. S. Serin (2014) An unusual case of transitional cell ovarian carcinoma detected incidentally during surgery of uterine endometrioid adenocarcinoma, Journal of Obstetrics and Gynaecology, 34:5, 448-449 To link to this article: http://dx.doi.org/10.3109/01443615.2014.897313
Published online: 04 Apr 2014.
Submit your article to this journal
Article views: 21
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Pennsylvania]
Date: 05 November 2015, At: 15:58
448
Gynaecology Case Reports
In conclusion, recognition of hydatids of Morgagni is emphasised, as it can be missed by many gynaecologists or sonologists. This is an important and most common differential diagnosis for ectopic pregnancy, as it has similar ultrasound findings. Increased awareness of this condition will lead to a better diagnosis and reduced intervention for suspected ectopic pregnancy. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Downloaded by [University of Pennsylvania] at 15:58 05 November 2015
References Cebesoy FB, Kutlar I, Dikensoy E et al. 2010. Morgagni hydatids: a new factor in infertility? Archives of Gynecology and Obstetrics 281:1015–1017. Karim H, Maeboud A. 1997. Hydatid cyst of Morgagni: Any impact on infertility? Journal of Obstetrics and Gynaecology Research 23:427–431. Kirk E, Bourne T. 2009. Diagnosis of ectopic pregnancy with ultrasound. Best Practice and Research Clinical Obstetrics and Gynaecology 23: 501–508. Kirk E, Papageorghiou AT, Condous G et al. 2007. The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy. Human Reproduction 22:2824–2828. Pansky M, Smorgick N, Lotan G et al. 2006. Adnexal torsion involving hydatids of Morgagni: a rare cause of acute abdominal pain in adolescents. Obstetrics and Gynecology 108:100–102. Perlman S, Hertweck P, Fallat M. 2005. Paratubal and tubal abnormalities. Seminars in Surgery 14:124–134. Rasheed SM, Abdelmonem AM. 2011. Hydatid of Morgagni: a possible underestimated cause of unexplained infertility. European Journal of Obstetrics, Gynecology, and Reproductive Biology 158:62–66. Schiebler ML, Dotters D, Baudoin L et al. 1992. Sonographic diagnosis of hydatids of Morgagni of the fallopian tube. Journal of Ultrasound in Medicine 11: 115–116.
An unusual case of transitional cell ovarian carcinoma detected incidentally during surgery of uterine endometrioid adenocarcinoma M. Dolanbay1, M. S. Kutuk1, S. Uludag1, M. T. Ozgun1, F. Ozturk2 & I. S. Serin1 Department of 1Obstetrics and Gynaecology and 2Pathology, Erciyes University Faculty of Medicine, Gevher Nesibe Hospital, Kayseri, Turkey DOI: 10.3109/01443615.2014.897313
Figure 1. Right ovary. Transitional cell areas (H&E, ⫻ 200).
Endometrial biopsy was reported as low grade endometrial adenocarcinoma. Her tumour markers were normal (CA125:18.4 units/dl, CA19–9: 487 units/dl, CA15–3: 22.8 units/dl). At laparotomy, a 0.5 cm papilliform projection on the right ovary was seen. Uterine corpus and left ovary were normal. The patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Frozen section of the right ovary was reported as malignant epithelial tumour and well-differentiated endometrioid adenocarcinoma of uterus without myometrial invasion. For surgical staging, total omentectomy, appendectomy, pelvic and para-aortic lymphadenectomy were performed. She was discharged from the hospital in good condition at postoperative day five. At histopathological examination, a big adenoid structure was found restricted to the capsule of the ovary with necrosis in the centre. The surface epithelium showed characteristics of transitional cells (Figure 1). Squamous cell differentiation was present in large areas. There was no normal Brenner area. Additionally, histopathological examination revealed that there was no serous component in the ovarian tumour. Immunohistochemical studies demonstrated positive staining for CK7, CK20 and P63 (Figures 2 and 3). The endometrioid adenocarcinoma was positive with oestrogen and progesterone receptors. Histopathological examination showed that the patient had FIGO stage IC ovarian and stage IA endometrial carcinomas (Figure 4). Therefore, the patient was referred to medical oncology for chemotherapy. Abdominal tomography revealed no residual or recurrent diseases and no findings consistent with urinary malignancy in the immediate postoperative period and four months after the opera-
Correspondence: M. Dolanbay, Department of Obstetrics and Gynaecology, Faculty of Medicine, Erciyes University, Gevher Nesibe Hospital, 38039 Kayseri, Turkey. E-mail: [email protected]
Introduction Concomitant ovarian cancer is seen in 1–6% of all women with endometrial cancer (Zaino et al. 2001). It may occur in three different ways: ovarian cancer with metastasis to endometrium, endometrial cancer with metastasis to ovary and concomitant primary ovarian and endometrial cancer. We present an unusual association of transitional cell cancer of the ovary with endometrial cancer in a premenopausal woman. According to the available literature, this is the first case of concomitant pure transitional cell cancer of the ovary and endometrial adenocarcinoma.
Case report A 53-year-old premenopausal woman presented with bleeding for four weeks. Her medical history was unremarkable. On transvaginal ultrasonography, the uterus was 7 ⫻ 4 ⫻ 3 cm and endometrial thickness was 17 mm with irregular borders. Both ovaries were normal in appearance. The right ovary was 3 ⫻ 2 ⫻ 2.5 cm and the left ovary was 3.5 ⫻ 1.5 ⫻ 3 cm in diameter. There was no free fluid in the pelvis.
Figure 2. Histological section of transitional cell cancer showing positive immunoreactions to CK7 (⫻ 100).
Gynaecology Case Reports 449
Downloaded by [University of Pennsylvania] at 15:58 05 November 2015
Figure 3. Histological section of transitional cell cancer revealing positive immunoreactions to CK20 (⫻ 200).
tion. The patient completed four cycles of chemotherapy consisting of paclitaxel and cisplatin and was in good condition six months after the operation.
Discussion Ovarian cancers are the most lethal gynaecological malignancies. Efforts at early detection and new therapeutic approaches to reduce mortality have largely been unsuccessful, since the origin and pathogenesis of epithelial ovarian cancer are poorly understood. Transitional cell cancer of the ovary is a rare subtype of the ovarian surface epithelial cancers. In their large series, Silva et al. (1990) observed focal or diffuse transitional cell cancer pattern in 88 of 934 ovarian cancers (9%). In histopathological examination, it is important to distinguish transitional cell cancer from high grade serous cancers. It seems that areas of necrosis in solid serous cancers can give rise to an undulating or apparent macropapillary pattern mimicking the thick blunt papillae characteristic of transitional cell cancer. In our institution, the tumour is classified as serous cancer if any serous component is present (Seidman and Yemelyanova 2011). Histopathological examination of the ovarian tumour revealed no serous component in the reported case. Ovarian transitional cell cancers are positive for CK7 and generally negative for CK20. In the present case, the ovarian tumour was found positive for CK20. In this situation, it is important to differentiate primary ovarian tumour from metastatic urothelial carcinoma. In the present case, the patient’s symptoms, clinical and abdominal tomography findings were not consistent with urological malignancy. Additionally, urinary tract transitional cell cancers that metastasise to the ovaries are generally in advanced stage and clinically evident.
Figure 4. Endometrioid adenocarcinoma (H&E, ⫻ 40).
The common presenting symptoms of transitional cell cancer of the ovary are abdominal pain, abdominal swelling or distension and weight loss. The transitional cell carcinoma of the ovary is a primary ovarian carcinoma that is differentiated from Brenner tumour by the presence of urothelial features. Although Brenner tumour and transitional cell cancer of the ovary have common and similar pathological features, treatment protocols for these tumours are different. Patients with transitional cell cancer of the ovary have a better prognosis compared with patients with all other types of ovarian carcinomas following standardised chemotherapy. Optimal surgical resectability followed by cisplatin-based chemotherapy may contribute a survival benefit. Kommoss et al. (2005) reported that the estimated five-year survival following surgery was 37%, whereas for patients who received chemotherapy, survival was at 41%. Concomitant primary cancer of the uterus and ovary is uncommon. Ree et al. (2003) decided that transitional cell cancer of the ovary occurs in 4.9% of all endometrial cancers and 8.7% of all ovarian cancers. Eifel and associates (1982) have shown that patients with concomitant cancers have a better prognosis compared with endometrial and ovarian cancers alone. In Soliman’s study (2004) they emphasise that many tumours had concordant endometrioid histology of the endometrium and ovary; endometrioid/serous, endometrioid/mucinous and other histological types are seen less frequently. There are few cases with histology of mixed transitional and endometrioid type in the English literature. Although endometrial and ovarian cancers are commonly diagnosed in the sixth or seventh decade, the median age for concomitant ovarian and endometrial cancer is 41–54 (Soliman et al. 2004). Most of the ovarian epithelial cancers present in advanced stages. In our case, ovarian cancer was suspected from the appearance of a 0.5 cm papilliform projection on the surface of an otherwise normal ovary. Given the paucity of data, we cannot make any suggestion as to whether this kind of presentation is peculiar to transitional cell cancer of the ovary or incidental. In view of the rarity of association of transitional cell cancer of the ovary and endometrial cancer, it is impossible to draw a definite conclusion regarding gross appearance and clinical presentation of transitional cell cancer of the ovary, based on our report. However, it should be kept in mind that ovarian cancer may be seen as a small outgrowth on the ovarian surface and evaluation of suspicious ovaries by frozen section should be performed in order to guide appropriate surgical management. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Eifel P, Hendrickson M, Ross J et al. 1982. Simultaneous presentation of carcinoma involving the ovary and the uterine corpus. Cancer 50:163–170. Kommoss F, Kommoss S, Schmidt D et al. 2005. Survival benefit for patients with advanced-stage transitional cell carcinomas vs. other subtypes of ovarian carcinoma after chemotherapy with platinum and paclitaxel. Gynecologic Oncology 97:195–199. Ree YS, Cho SH, Kim SR et al. 2003. Synchronous primary endometrial and ovarian cancer with three different histologic patterns: a case report. International Journal of Gynecological Cancer 13:678–682. Seidman JD, Yemelyanova A. 2011. Uncommon epithelial ovarian tumors. In: Soslow RA and Tornos C, editors. Diagnostic pathology of ovarian tumors. New York: Springer. p 123–125. Silva E, Robey-Cafferty S, Smith T et al. 1990. Ovarian carcinomas with transitional cell carcinoma pattern. American Journal of Clinical Pathology 93: 457–465. Soliman PT, Slomovitz BM, Broaddus RR et al. 2004. Synchronous primary cancers of the endometrium and ovary: a single institution review of 84 cases. Gynecologic Oncology 94:456–462. Zaino R , Whitney C, Brady M et al. 2001. Simultaneously detected endometrial and ovarian carcinomas – a prospective clinicopathologic study of 74 cases: a Gynecologic Oncology Group Study. Gynecologic Oncology 83: 355–362.
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
An unusual case of transitional cell ovarian carcinoma detected incidentally during surgery of uterine endometrioid adenocarcinoma M. Dolanbay, M. S. Kutuk, S. Uludag, M. T. Ozgun, F. Ozturk & I. S. Serin To cite this article: M. Dolanbay, M. S. Kutuk, S. Uludag, M. T. Ozgun, F. Ozturk & I. S. Serin (2014) An unusual case of transitional cell ovarian carcinoma detected incidentally during surgery of uterine endometrioid adenocarcinoma, Journal of Obstetrics and Gynaecology, 34:5, 448-449 To link to this article: http://dx.doi.org/10.3109/01443615.2014.897313
Published online: 04 Apr 2014.
Submit your article to this journal
Article views: 21
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Pennsylvania]
Date: 05 November 2015, At: 15:58
448
Gynaecology Case Reports
In conclusion, recognition of hydatids of Morgagni is emphasised, as it can be missed by many gynaecologists or sonologists. This is an important and most common differential diagnosis for ectopic pregnancy, as it has similar ultrasound findings. Increased awareness of this condition will lead to a better diagnosis and reduced intervention for suspected ectopic pregnancy. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Downloaded by [University of Pennsylvania] at 15:58 05 November 2015
References Cebesoy FB, Kutlar I, Dikensoy E et al. 2010. Morgagni hydatids: a new factor in infertility? Archives of Gynecology and Obstetrics 281:1015–1017. Karim H, Maeboud A. 1997. Hydatid cyst of Morgagni: Any impact on infertility? Journal of Obstetrics and Gynaecology Research 23:427–431. Kirk E, Bourne T. 2009. Diagnosis of ectopic pregnancy with ultrasound. Best Practice and Research Clinical Obstetrics and Gynaecology 23: 501–508. Kirk E, Papageorghiou AT, Condous G et al. 2007. The diagnostic effectiveness of an initial transvaginal scan in detecting ectopic pregnancy. Human Reproduction 22:2824–2828. Pansky M, Smorgick N, Lotan G et al. 2006. Adnexal torsion involving hydatids of Morgagni: a rare cause of acute abdominal pain in adolescents. Obstetrics and Gynecology 108:100–102. Perlman S, Hertweck P, Fallat M. 2005. Paratubal and tubal abnormalities. Seminars in Surgery 14:124–134. Rasheed SM, Abdelmonem AM. 2011. Hydatid of Morgagni: a possible underestimated cause of unexplained infertility. European Journal of Obstetrics, Gynecology, and Reproductive Biology 158:62–66. Schiebler ML, Dotters D, Baudoin L et al. 1992. Sonographic diagnosis of hydatids of Morgagni of the fallopian tube. Journal of Ultrasound in Medicine 11: 115–116.
An unusual case of transitional cell ovarian carcinoma detected incidentally during surgery of uterine endometrioid adenocarcinoma M. Dolanbay1, M. S. Kutuk1, S. Uludag1, M. T. Ozgun1, F. Ozturk2 & I. S. Serin1 Department of 1Obstetrics and Gynaecology and 2Pathology, Erciyes University Faculty of Medicine, Gevher Nesibe Hospital, Kayseri, Turkey DOI: 10.3109/01443615.2014.897313
Figure 1. Right ovary. Transitional cell areas (H&E, ⫻ 200).
Endometrial biopsy was reported as low grade endometrial adenocarcinoma. Her tumour markers were normal (CA125:18.4 units/dl, CA19–9: 487 units/dl, CA15–3: 22.8 units/dl). At laparotomy, a 0.5 cm papilliform projection on the right ovary was seen. Uterine corpus and left ovary were normal. The patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Frozen section of the right ovary was reported as malignant epithelial tumour and well-differentiated endometrioid adenocarcinoma of uterus without myometrial invasion. For surgical staging, total omentectomy, appendectomy, pelvic and para-aortic lymphadenectomy were performed. She was discharged from the hospital in good condition at postoperative day five. At histopathological examination, a big adenoid structure was found restricted to the capsule of the ovary with necrosis in the centre. The surface epithelium showed characteristics of transitional cells (Figure 1). Squamous cell differentiation was present in large areas. There was no normal Brenner area. Additionally, histopathological examination revealed that there was no serous component in the ovarian tumour. Immunohistochemical studies demonstrated positive staining for CK7, CK20 and P63 (Figures 2 and 3). The endometrioid adenocarcinoma was positive with oestrogen and progesterone receptors. Histopathological examination showed that the patient had FIGO stage IC ovarian and stage IA endometrial carcinomas (Figure 4). Therefore, the patient was referred to medical oncology for chemotherapy. Abdominal tomography revealed no residual or recurrent diseases and no findings consistent with urinary malignancy in the immediate postoperative period and four months after the opera-
Correspondence: M. Dolanbay, Department of Obstetrics and Gynaecology, Faculty of Medicine, Erciyes University, Gevher Nesibe Hospital, 38039 Kayseri, Turkey. E-mail: [email protected]
Introduction Concomitant ovarian cancer is seen in 1–6% of all women with endometrial cancer (Zaino et al. 2001). It may occur in three different ways: ovarian cancer with metastasis to endometrium, endometrial cancer with metastasis to ovary and concomitant primary ovarian and endometrial cancer. We present an unusual association of transitional cell cancer of the ovary with endometrial cancer in a premenopausal woman. According to the available literature, this is the first case of concomitant pure transitional cell cancer of the ovary and endometrial adenocarcinoma.
Case report A 53-year-old premenopausal woman presented with bleeding for four weeks. Her medical history was unremarkable. On transvaginal ultrasonography, the uterus was 7 ⫻ 4 ⫻ 3 cm and endometrial thickness was 17 mm with irregular borders. Both ovaries were normal in appearance. The right ovary was 3 ⫻ 2 ⫻ 2.5 cm and the left ovary was 3.5 ⫻ 1.5 ⫻ 3 cm in diameter. There was no free fluid in the pelvis.
Figure 2. Histological section of transitional cell cancer showing positive immunoreactions to CK7 (⫻ 100).
Gynaecology Case Reports 449
Downloaded by [University of Pennsylvania] at 15:58 05 November 2015
Figure 3. Histological section of transitional cell cancer revealing positive immunoreactions to CK20 (⫻ 200).
tion. The patient completed four cycles of chemotherapy consisting of paclitaxel and cisplatin and was in good condition six months after the operation.
Discussion Ovarian cancers are the most lethal gynaecological malignancies. Efforts at early detection and new therapeutic approaches to reduce mortality have largely been unsuccessful, since the origin and pathogenesis of epithelial ovarian cancer are poorly understood. Transitional cell cancer of the ovary is a rare subtype of the ovarian surface epithelial cancers. In their large series, Silva et al. (1990) observed focal or diffuse transitional cell cancer pattern in 88 of 934 ovarian cancers (9%). In histopathological examination, it is important to distinguish transitional cell cancer from high grade serous cancers. It seems that areas of necrosis in solid serous cancers can give rise to an undulating or apparent macropapillary pattern mimicking the thick blunt papillae characteristic of transitional cell cancer. In our institution, the tumour is classified as serous cancer if any serous component is present (Seidman and Yemelyanova 2011). Histopathological examination of the ovarian tumour revealed no serous component in the reported case. Ovarian transitional cell cancers are positive for CK7 and generally negative for CK20. In the present case, the ovarian tumour was found positive for CK20. In this situation, it is important to differentiate primary ovarian tumour from metastatic urothelial carcinoma. In the present case, the patient’s symptoms, clinical and abdominal tomography findings were not consistent with urological malignancy. Additionally, urinary tract transitional cell cancers that metastasise to the ovaries are generally in advanced stage and clinically evident.
Figure 4. Endometrioid adenocarcinoma (H&E, ⫻ 40).
The common presenting symptoms of transitional cell cancer of the ovary are abdominal pain, abdominal swelling or distension and weight loss. The transitional cell carcinoma of the ovary is a primary ovarian carcinoma that is differentiated from Brenner tumour by the presence of urothelial features. Although Brenner tumour and transitional cell cancer of the ovary have common and similar pathological features, treatment protocols for these tumours are different. Patients with transitional cell cancer of the ovary have a better prognosis compared with patients with all other types of ovarian carcinomas following standardised chemotherapy. Optimal surgical resectability followed by cisplatin-based chemotherapy may contribute a survival benefit. Kommoss et al. (2005) reported that the estimated five-year survival following surgery was 37%, whereas for patients who received chemotherapy, survival was at 41%. Concomitant primary cancer of the uterus and ovary is uncommon. Ree et al. (2003) decided that transitional cell cancer of the ovary occurs in 4.9% of all endometrial cancers and 8.7% of all ovarian cancers. Eifel and associates (1982) have shown that patients with concomitant cancers have a better prognosis compared with endometrial and ovarian cancers alone. In Soliman’s study (2004) they emphasise that many tumours had concordant endometrioid histology of the endometrium and ovary; endometrioid/serous, endometrioid/mucinous and other histological types are seen less frequently. There are few cases with histology of mixed transitional and endometrioid type in the English literature. Although endometrial and ovarian cancers are commonly diagnosed in the sixth or seventh decade, the median age for concomitant ovarian and endometrial cancer is 41–54 (Soliman et al. 2004). Most of the ovarian epithelial cancers present in advanced stages. In our case, ovarian cancer was suspected from the appearance of a 0.5 cm papilliform projection on the surface of an otherwise normal ovary. Given the paucity of data, we cannot make any suggestion as to whether this kind of presentation is peculiar to transitional cell cancer of the ovary or incidental. In view of the rarity of association of transitional cell cancer of the ovary and endometrial cancer, it is impossible to draw a definite conclusion regarding gross appearance and clinical presentation of transitional cell cancer of the ovary, based on our report. However, it should be kept in mind that ovarian cancer may be seen as a small outgrowth on the ovarian surface and evaluation of suspicious ovaries by frozen section should be performed in order to guide appropriate surgical management. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Eifel P, Hendrickson M, Ross J et al. 1982. Simultaneous presentation of carcinoma involving the ovary and the uterine corpus. Cancer 50:163–170. Kommoss F, Kommoss S, Schmidt D et al. 2005. Survival benefit for patients with advanced-stage transitional cell carcinomas vs. other subtypes of ovarian carcinoma after chemotherapy with platinum and paclitaxel. Gynecologic Oncology 97:195–199. Ree YS, Cho SH, Kim SR et al. 2003. Synchronous primary endometrial and ovarian cancer with three different histologic patterns: a case report. International Journal of Gynecological Cancer 13:678–682. Seidman JD, Yemelyanova A. 2011. Uncommon epithelial ovarian tumors. In: Soslow RA and Tornos C, editors. Diagnostic pathology of ovarian tumors. New York: Springer. p 123–125. Silva E, Robey-Cafferty S, Smith T et al. 1990. Ovarian carcinomas with transitional cell carcinoma pattern. American Journal of Clinical Pathology 93: 457–465. Soliman PT, Slomovitz BM, Broaddus RR et al. 2004. Synchronous primary cancers of the endometrium and ovary: a single institution review of 84 cases. Gynecologic Oncology 94:456–462. Zaino R , Whitney C, Brady M et al. 2001. Simultaneously detected endometrial and ovarian carcinomas – a prospective clinicopathologic study of 74 cases: a Gynecologic Oncology Group Study. Gynecologic Oncology 83: 355–362.
