2. CLINICAL DETAILS:-
A 66 years female presented with -
Swelling over abdomen since 6 months.
Lower abdominal pain since 3 months.
Obstetric history:- P2L1D1 and attain her menopause since15 years
back.
3. ON EXAMINATION
General examination:- Pallor +
Per-abdomen- A diffuse large mass was palpated in midline lower
abdomen extending from supraumbilical region up to pelvis, measuring
30x20cm .
- Smooth, non tender, well defined margins, mobile side to side,
Per vaginal examination:-
OS patulous, B /L fornices free (no growth, no bleeding).
Per speculum examination:-
Cervix and vagina – healthy ( no growth, no discharge, no bleeding).
4. RADIOLOGICAL FINDINGS
USG whole abdomen:- Ill defined heterogenous intra-abdominal mass hypo to hyperechoic
with multiple necrotic anechoic cystic lesion showing vascularity, measuring approximately
23x10x8cm likely arising from right adnexa.
Superiorly the lesion is extending up to lower middle of left kidney and inferior border of
liver, left laterally extending up to lower pole of left kidney
Posteriorly the lesion is pushing bowel loops, abdominal aorta, inferior Vana cava
posteriorly.
Inferiorly the lesion is extending up to superior border of urinary bladder with herniated fat
plane.
Features are suggestive of O’RADS (Ovarian-Adnexal imaging Reporting Data System )
V Lesion.
5. CT abdomen :-
Well defined heterogeneously enhancing mixed solid cystic mass is seen in midline
lower abdomen extending from supraumbilical region up to pelvis, measuring
16.3x14.4x10.6cm.
Right ovary is not seen separately from the lesion.
The mass is displacing bowel loop laterally.
Anteriorly it is seen to reach up to anterior abdominal wall without signs of infiltration.
Left ovary appears atretic .
Suggestive of Malignant etiology ? Right ovarian origin. 5
6. CYTOPATHOLOGICAL EXAMINATION
Site of aspiration:- Right sided ovarian swelling.
Nature of aspiration:- Blood mixed material.
Microscopic findings :-
Smears show clusters and singly scattered epithelial cells with marked atypia, high N/C ratio,
hyperchromatism, moderate cytoplasm in hemorrhagic background.
Impression :- Features suggestive of Malignancy.
8. Gross findings :-
A single, soft to firm tissue mass
measuring 19x15x14cm with attached
tubular stump measuring 2.5cm in
length was received.
• Outer surface- Grey-white to grey-
brown, bosselated with areas of
haemorrhage and few dilated blood
vessels identified. Multiple small cysts
also identified.
• Cut surface- Grey-white to grey-
brown, nodular, cystic to solid,
predominantly solid.
• Cut surface of cyst- Mucinous
material came out.
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9. Specimen of uterus with cervix with bilateral
fallopian tubes and left ovary was received.
• Uterus measuring 4x4x3.5cm.
• Outer surface- Grey-white to grey-brown with some
areas of haemorrhage.
• A grey-white, firm to hard growth (Subserosal)
identified measuring 3.5x3.5x3cm.
• On cut- Grey-white, solid, homogenous, calcified.
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13. HISTOPATHOLOGICAL EXAMINATION
• Studied sections show biphasic tumour
comprising of carcinomatous and sarcomatous
components.
• Carcinomatous component- ill defined
glandular formations lined by malignant
cuboidal to columnar epithelial cells showing
overcrowding and stratification with scant
cytoplasm and enlarged pleomorphic
hyperchromatic nuclei.
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H&E, 4x view
14. 14
glandular formations
cuboidal to columnar epithelial
overcrowding and stratification
H&E 10x Low power view
H&E 40x High power view
15. 15
Ill defined glandular formation.
H&E 40x High power view
H&E 40x High power view
scant cytoplasm and enlarged
pleomorphic hyperchromatic nuclei.
16. • Sarcomatous component - diffuse sheets of round to
spindled sheets of malignant cells, at places showing
rhabdomyoblastic differentiation characterised by
presence of rhabdomyoblast in different stages of
differentiation with bright eosinophilic cytoplasm and
eccentric nuclei.
• Binucleated, multinucleated and bizarre forms are
frequently noted.
• Mitosis is frequent.
• Liposarcomatous differentiation also noted
• Intervening stroma show lymphoplasmacytic infiltration.
Large areas of necrosis noted.
• Attached fallopian tube is unremarkable but peri tubal
area shows tumour deposits.
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H&E 10x Low power view
17. 17
H&E 40x High power view
H&E 40x High power view
Rhabdomyoblast- bright eosinophilic cytoplasm
and eccentric nuclei.
Diffuse sheets of round to spindled sheets of
malignant cells
18. Uterus with adnexa show-
• Endocervix- Multiple Nabothian cysts and chronic inflammation.
• Endometrium- Cystically dilated atrophic glands.
• Myometrium- Subserosal leiomyoma with calcification and hyalinization.
• Attached ovary, attached fallopian tube , right and left parametrium- Unremarkable.
• Omentum :- unremarkable.
• 2 lymph nodes-free from tumour. Perinodal area show tumour deposits. (0/2)
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22. DIFFERENTIAL DIAGNOSIS
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MICROSCOPIC FINDING DIFFERENTIATING FEATARES
Carcinosarcoma
Heterologous Age- postmenopausal
Usually lack the neural and other germ
cell elements of teratoma
Immature teratoma Heterologous
Component of 3 germs layers with neuroectodermal elements.
Immature neuroepithelium- sarcomatoid, rosette, primitive
tubules, individual cell- scant cytoplasm, hyperchromatic nuclei,
frequent mitosis.
Age - children and adolescent
Prominent features of neuroectodermal
differentiation
Adenosarcoma Benign or atypical epithelial component and a low grade
malignant stromal component. Conspicuous non-invasive glands
within a predominant malignant stroma, either homologous or
heterologous. Variable stromal mitotic count.
Other features: glands widely spaced throughout stroma (90%),
occasional sarcomatous overgrowth (30%), sex cord-like
elements (15%), heterologous elements (12%)
Age- elderly
m/c site- endometrium and cervix.
They do not appear as bizarre and
undifferentiated as in the classic
MMMT
23. CARCINOSARCOMA
• Also called malignant mixed mullerian tumor(MMMT)
• Two variety:-
1. homologous variety (with nonspecific malignant stroma)
2. heterologous variety (with malignant heterologous elements)
• Two components:-
1. carcinomatous- may be serous, endometrioid, squamous or clear
cell type.
2. sarcoma like- chondrosarcoma (m/c), osteosarcoma, rhabdomyosarcoma,
or angiosarcoma.
• Hyaline droplets containing- α1 antitrypsin- present in cytoplasm of the tumor cells.
• Overall prognosis is extremely poor.
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