Right mucinous ovarian carcinoma and uterine leiomyomas with intravenous leiomyomatosis

Case contributed by Yew Shiong Leong

Presentation

Abdominal distension.

Patient Data

Age: 55 years
Gender: Female
  1. Large right adnexal complex cystic mass.

  2. Uterine leiomyomatosis.

  3. Extensive venous thrombosis, extending from right ovarian vein, into and along entire IVC, with right atrial thrombus.

  4. Obstructive uropathy, worse on the right.

Case Discussion

The patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO), and IVC and right atrial thrombectomy.

HISTOPATHOLOGY REPORT
TOPOLOGY : Myometrium
MORPHOLOGY: Leiomyoma

Macroscopy
A) Received a distorted TAHBSO without cervix. Specimen weighing 1780gram. The entire specimen measure 210x140mm. The right intact turboovarian mass measures 130x120x100mm and the rest turbo ovarian mass measuring 70x30x20mm. Serial sectioning of the right turboovarian complex shows solid cystic tumor with mucus content. A possible tubal structure is seen, likely dilated and containing blood measuring 100mm in length and 50mm largest diameter. A dilated possible appendix is seen containing feces and densely adhered to left fallopian tube and uterus measuring 60mm in length and 20mm in largest diameter. The uterus measures 120mm from fundus to LUS, 175mm from medial to lateral and 105mm anteroposterior diameter. There are 2 subserosal pedunculated fibroids measuring 40 to 55mm in diameter. Cut section of uteus show multiple intramural fibroids (more than 10) measures 7 to 50mm in diameter. All of the fibroids show grayish cut surface with whorled appearance. Endometrium thickness measures 3 to 4mm in thickness.

Myometrium is trabeculated measuring 40 to 50mm. A small nodule structure, tagged with suture as appendix measures 10mm in length and 5mm in largest diameter. Cut section show whitish surface. Separately received a nodualr structure measuring 25x20x4mm. This structure has a whitish cut surface. Unable to identify the left ovary in this specimen.

A1: Anterior LUS
A2: PosteriorLUS
A3: Endomyometrium
A4-A9: Representative section from intramural fibroid
A10-A16: Representative section from solid cystic right ovarian mass (External surface inked blue
A17: Tumor (adjacent possible right fallopian tube (the inner surface of right fallopian tube inked)
A18: Tumor with right fallopian tube and adjacent myometrium
A19: Left lateral myometrium and adhered appendix and left fallopian tube
A20: Structure tagged as appendix
A21-A22: Representative section from subserosal fibroids.
A23: Separately received nodular structure, half submitted

B) POD fibroid:
Received grayish nodular tissue measuring 70x40x20mm. Serial sectioning show grayish whitish cut surface with whorled appearance with cystic degeneration and area of hemorrhage. Representative section in 2 blocks.

C) Cervix and right paracolpus fibroid:
Received amputated cervix measuring 45mm in length and 30mm in diameter. Posterior vaginal cuff tissue measuring 20x3mm and attached grayish nodular structure at 9 o'clock measuring 25x40x15mm. The ectocervix and cervical mucosa appear unremarkable. The grayish nodular structure has a whitish whorled appearance.
C1: Anterior cervix
C2: Posterior cervix with vaginal cuff (blue)
C3: Grayish nodular structure adhered to right side of cervix

D) Right paravaginal fibroid:
Received a grayish nodular structure measuring 25x20x15mm. Serial sectioning show grey whitish whorlde appearance. Representative section in one block.

E) Intravascular tumor (Fibroid):
Received multiple pieces of whitish tissue measuring 170mm in aggregate diameter. Serial sectioning show whitish appearance with pin point hemorrhage.

Representative section in 4 blocks.

Microscopy
A) Sections from the right ovarian tumor show invasive carcinoma forms marked glandular crowding and papillae with little intervening stroma, creating a labyrinthine appearance. Some areas exhibit cribriform pattern. The malignant cells lining the glands and papillae show moderate cytological atypia with nuclear enlargement and stratification. Mitotic activity is frequent. There are also areas show a continuum of architecture and cytological atypia that includes both benign and borderline elements. Extracellular mucin are abundant and extensive tumor necrosis is also evident. Adjacent right fallopian tube is unremarkable. No apparent lymphovascular permeation seen. The myometrium show multifocal adenomyosis and multiple fibroids without nuclear atypia, coagulative necrosis and increased in mitotic activity. The appendix is densely adhered to the myometrium and fallopian tube without malignant cells involvement. The separate nodular structure received in composed of fibroid. The lower uterine segment and endometrium is unremarkable.

B,C,D,E)
Sections show a circumscribed lesion composed of interlacing bundles of smooth muscle cells separated by hyalinized stroma. The smooth muscle cells have spindle to oval nuclei, without atypia seen. Mitotic activity is rare. No coagulative necrosis present. The cervix and vaginal cuff are unremarkable.

Diagnosis
A) Right ovary: Mucinous carcinoma (pTIa, FIGO Grade 1A)
Uterus: 1) Leiomyomata 2) Adenomyosis
B) POD Fibroid: Leiomyoma
C) Right paracorpus fibroid: Leiomyoma
D) Right paravaginal fibroid: Leiomyoma
E) Intravascular tumor(fibroid): Leiomyoma

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