1. Clinico-Pathological Conference (CPC) Meet
Karpagam Medical College Hospital

2. Case History 37 yr. old female Puberty at 14 yrs
Regular menstrual cycles 3-4/30
Married at 17 yrs
Para 2 Live 2 MTP1
First Child -17 yrs, FTND, A&W
Second Child – 19 yrs, FTND, A&W
Sterilisation done . LCB – 14 yrs

3. Chief Complaints
Increased , continuous , and painless bleeding Per vaginum month
Cycles usually regular, once in 30 days, lasts for 3-4 days
Discomfort in the lower abdomen – 1 month
Bowel and micturition habits – normal
No loss of appetite/weight
Feeling of extreme lassitude

4. General Examination Moderately built and nourished Severe anemia
No jaundice or cyanosis
No significant lymphadenopathy
Vital signs -Normal

5. Abdominal Examination
Fullness in the lower abdomen
No enlarged veins over the abdominal wall
Swelling midline, about cm in size, uniform surface , non tender, firm to hard in consistency , Mobile – side to side
No free fluid

6. Pelvic Examination The exact size of uterus could not be made out
Swelling not palpable bimanually
No rectal nodes

7. Investigations BLOOD GROUP - AB+ve Hb - 8 gm%
Platelets count – 5.64 lakhs/cu.mm
Serology - Normal
Renal function tests – Normal
TSH IU/ml
CA- 125 = 25.5 U/ml
ECG, X-ray Chest PA - Normal

8. Ultrasound Abdomen Bulky Uterus - 9.1 x 6.6 x 6.1 cm
Thickened Endometrium cm
?Endometrial hyperplasia/polyp
Thick walled cystic area in right adnexa
?Cystic ovarian mass
?Broad ligament myxoma with degeneration

10. Differential Diagnosis
OVARIAN CYST
FIBROID UTERUS -? BROAD LIGAMENT
ABNORMAL UTERINE BLEEDING WITH

11. Gross Appearance
Specimen of Total Abdominal Hysterectomy with Bilateral Salphingo-oopherectomy (11x6x5cm).
Cross Section of the uterus – unremarkable.

12. Gross Appearance Right ovary is cystic and ms (9x9x4.5cm)
Cross Section: Variegated, solid and cystic growth (9x8.5x4.5cm)

13. Gross Appearance Left ovary (3x2x1cm) showed multiple cysts
Both tubes were unremarkable

14. Microscopy Patterns - microfollicular, trabecular and macrofollicular
Proliferation malignant cells having
round to oval nuclei , scanty cytoplasm
Some of these cells have prominent nucleoli and nuclear grooving
Foci showing Call-Exner bodies and hemorrhagic areas are also seen.

15. Microscopic Picture
Call-Exner bodies

16. Microscopic Picture

17. Differential Diagnosis
Granulosa cell tumor
Endometrioid tumor
Undifferentiated/poorly differentiated tumor

18. Ovarian tumor staging – FIGO (2014)
Stage
Definition I
Tumor confined to ovaries. IA
Tumor limited to one ovary (capsule intact); no tumor on ovarian surface; no malignant cells in the ascites or peritoneal washings. IB
Tumor limited to both ovaries (capsules intact); no tumor on ovarian surface; no malignant cells in the ascites or peritoneal washings. IC
Tumor limited to one or both ovaries, with any of the following:
IC1: Surgical spill intraoperatively.
IC2: Capsule ruptured before surgery or tumor on ovarian surface.
IC3: Malignant cells present in the ascites or peritoneal washings. II
Tumor involves one or both ovaries with pelvic extension (below pelvic brim) or peritoneal cancer (Tp).
IIA
Extension and/or implants on the uterus and/or fallopian tubes and/or ovaries.
IIB
Extension to other pelvic intraperitoneal tissues.

19. Stage
Definition
III
Tumor involves one or both ovaries, or primary peritoneal cancer, with cytologically or histologically confirmed spread to the peritoneum outside of the pelvis and/or metastasis to the retroperitoneal lymph nodes.
IIIA
Metastasis to the retroperitoneal lymph nodes with or without microscopic peritoneal involvement beyond the pelvis.
IIIA(i)
Positive retroperitoneal lymph nodes only (cytologically or histologically proven).
IIIA(ii)
Metastasis >10 mm in greatest dimension.
IIIA2
Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodes.
IIIB
Macroscopic peritoneal metastases beyond the pelvic brim ≤2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodes.
IIIC
Macroscopic peritoneal metastases beyond the pelvic brim >2 cm in greatest dimension, with or without metastases to the retroperitoneal nodes.a IV
Distant metastasis excluding peritoneal metastases.
IVA
Pleural effusion with positive cytology.
IVB
Metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity).

20. Report
Uterus with chronic cervicitis and endometrium with cystoglandular hyperplasia and adenomyosis. Right ovary shows features of Adult Granulosa Cell Tumor – Stage IA (T1a Nx Mx)*
Suggested further immuno histochemical studies for alpha-inhibin, CD99 & calretinin for definite diagnosis.

21. Review of literature
Granulosa cell tumors (GCT) were described for the first time in 1855 by Rokitansky.
characterized by a prolonged natural history and a tendency to late recurrences.
very rare ovarian malignancies; they represent <5% of all ovarian cancers. Limited data is available from India.
patients aged

22. Review of literature
Two distinct histological types—adult GCT (AGCT) and juvenile GCT (JGCT) which display different clinical and histopathological features
AGCTs are more common; usually seen in perimenopausal and postmenopausal women, peak incidence at 50–55 years
JGCTs are rare tumors, representing 5 % of all GCTs and occurring in premenarchal girls and young women
characterized by a good prognosis

23. Review of literature
The main immunohistochemical markers expressed by these cells are vimentin, CD99 and alpha inhibin.
The serum tumor markers are estradiol, inhibin, and anti-Müllerian hormone.

24. Review of literature
Various factors determine the prognosis. The most important prognostic variable is the stage.
Overall survival (approximately 90% at 5 years for early stage) is good, because most tumors are diagnosed early

25. Review of literature
A special feature - appearance of recurrences long after treatment of primary tumour, mean time is 5.6 years.
Recurrences after more than 10 years are reported.

26. TAKE HOME MESSAGE
Solid and cystic tumor with combination of yellow tissue and hemorrhage is highly suggestive of Granulosa cell tumor

27. Thank you