Journal of Islamabad Medical & Dental College (JIMDC); 2015:4(2):88-90 Case Report

Papillary Carcinoma Arising in Ovarian : A Report of Three Cases

Adeel Haider1, Mudassar Hussain 2, Usman Hassan3 and Asif Loya4

1Resident Histopathology, Department of Pathology, Shaukat Khanum Memorial Cancer Hospital Lahore 2Consultant Histopathologist, Department of Pathology, Shaukat Khanum Memorial Cancer Hospital, Lahore 3Consultant Histopathologist, Department of Histopathology, Bristol Royal Infirmary Hospital, Bristol, England 4Consultant Histopathologist, Department of Pathology, Shaukat Khanum Memorial Cancer Hospital Lahore

Abstract the capsule. Fallopian tube was unremarkable. Histological Somatic malignancies arising in mature cystic teratomas examination revealed a neoplasm composed of follicles are rare events and thyroid tumors are very few among lined by cuboidal tumor cells having round to oval optically these. Papillary thyroid carcinoma is the most common clear nuclei with finely dispersed chromatin. thyroid malignancy encountered in ovarian tumors. We are Frequent nuclear grooves and occasional intranuclear presenting three such cases. Two cases show papillary cytoplasmic inclusions were appreciated. Follicles also carcinoma arising in the mature cystic teratomas contained amorphous eosinophilic thick colloid. Omental containing structures of all three germ layers while one biopsy revealed metastatic deposits. TTF1 papillary carcinoma is arising in . Metastatic immunohistochemical stain performed on the ovarian tumor deposits were appreciated in fallopian tube wall and was positive (Fig 4). A diagnosis of papillary thyroid omentum in one mature associated and one carcinoma, follicular variant arising in Struma ovarii was struma ovarii associated carcinoma. made. (Fig 1) Keywords: Ovary, Papillary carcinoma, Teratoma Case 2: A left salpingoophorectomy of a 25 year lady was sent to our lab with history narrating complaint of left Introduction ovarian cyst. Gross examination revealed a cyst measuring Mature cystic teratoma is the most common type of ovarian 11x9.5x7.5 cm filled with yellowish cheesy material germ cell neoplasm and thyroid tissue is a frequent containing hairs. A solid area of 2.5 cm was identified. constituent of mature cystic teratoma demonstrated in 15-20 Histological examination of mature teratomatous component % of the cases.1 Struma ovarii is the term reserved for the comprised of skin with associated adnexal structures, fat, lesions comprising either entirely or predominantly of cartilage and respiratory epithelium. A tumor arranged in thyroid tissue; at least 50%.2 Most cases of struma ovarii are papillary architecture was also appreciated. Lining cells had benign however malignant transformation can occur in 5% oval nuclei showing nuclear overlapping, grooving and of the cases. Papillary thyroid carcinoma including its intranuclear cytoplasmic inclusions. A diagnosis of papillary follicular variant is the most common type of carcinoma thyroid carcinoma arising in the background of teratoma was arising in struma ovarii followed by follicular carcinoma.3 rendered. (Fig 2) Case 3: A 65 year lady underwent total abdominal Case Reports hysterectomy with bilateral salpingoophorectomy. Specimen was sent to our lab. Gross examination revealed a right Case 1: A 20 year female underwent left ovarian mass measuring 8.5x5.5x3 cm. Mass had solid and salpingoophorectomy and omental biopsy and specimen was cystic cut surface. Total solid area measured 2.8x2.5 cm. sent to our laboratory with history of left ovarian cyst and Cyst was filled with thick yellowish material and tufts of increased serum CA125 levels. On gross examination there hair. Histological examination revealed mature teratomatous was a solid gray white ovarian mass measuring 15x10x6 cm components represented by benign thyroid parenchyma, skin almost entirely replacing ovarian parenchyma and rupturing with adnexal structures and cartilage. Admixed with thyroid parenchyma was a tumor arranged in papillary and follicular Corresponding author: pattern. Tumor cells exhibited nuclear clearing, overlapping Dr Usman Hassan and grooving. A histological diagnosis of papillary thyroid Email:[email protected] carcinoma arising in mature cystic teratoma was given. (Fig th Received: August 25 2015; Accepted: Sept 27 2015 3)

88 Journal of Islamabad Medical & Dental College (JIMDC); 2015:4(2):88-90

Fig 1: A focus of follicular variant of papillary thyroid Fig 4: TTF1 IHC Immunostain carcinoma Discussion Mature cystic teratoma is most common type of ovarian teratoma and comprises approximately 20% of all ovarian neoplasms.4 It is most common during the reproductive years, however they are often seen over a wide range of age and can be encountered from infancy to old age. Mature teratoma constitutes well differentiated structures representing all three germ layers each of which has a potential to undergo malignant transformation. Struma ovarii is the term designated to a teratoma when at least 50% of the component is thyroid parenchyma. Malignant transformation is quite rare in mature cystic teratoma comprising approximately 2% of the cases. is the most common secondary malignancy (75%) followed by adenocarcinoma and 5 Fig 2: A focus of papillary thyroid carcinoma along with sarcoma. Papillary thyroid carcinoma arising in a mature teratoma. component of mature cystic teratoma is extremely rare. Various case reports have been published over the past few years regarding the histological diagnoses and treatment options. The diagnoses of thyroid carcinomas arising in teratomas should be made following the guidelines for diagnosing carcinomas in thyroid gland. is treatable with good out come in most cases. Only 7% and 14% of patients with papillary carcinoma and typical follicular carcinoma, respectively died of disease.6 Due to rarity of disease no consensus on treatment has been made, however treatment options include oophorectomy, additional , radioactive iodine and long term follow up with serum measurement. An online search by the name of malignant struma ovarii and teratoma revealed many case reports and reviews.7,8 Two such case reports and series review noted average ages of 42.9 and 44 years and pain as the most common Fig 3: Papillary carcinoma along with normal presenting symptom. However in our case series two of the thyroid tissue patients are quite young with 20 and 25 years of age.

89 Journal of Islamabad Medical & Dental College (JIMDC); 2015:4(2):88-90

Recurrence rates were reported as 15 and 38% in reviews 2. Roth LM, Talerman A. Recent advances in the pathology and with average time to recurrence was 4 years. A review classification of ovarian germ cell tumors. Int J Gynecol Pathology 2007; 39:139. published in 2002 included 24 patients: 16 patients without 3. Devaney K. Proliferative and histologically malignant and 8 patients with adjuvant treatment, most commonly strumaovarii: a clinicopathologic study of 54 cases. Int J thyroidectomy and one of the 24 patients experienced GynecolPathol1993; 12: 333-343. persistent disease postoperatively, but 8 of 23 recurred after 4. Peterson WF, Prevost EC, Edmunds FT, Huntley JM, Morris FK. Benign cystic teratomas of the ovary. A clinicostatistical complete response to initial surgery. All eight recurrences study of 1007 cases with review of literature. Am J were noted in patients who did not receive adjuvant therapy. ObstetGynecol1955; 70:368. No recurrences were noted in the group of seven patients 5. Park JY, Kim DY, Kim JH, Kim YM, Nam JH.Malignant receiving adjuvant therapy after complete response to initial transformation of mature cystic teratoma of the ovary: surgery. experience at a single institution. Eur J ObstetGynecolReprodBiol 2008; 141:173-8. Another case report and literature review published by 6. Roth LM, Talerman A, Miller A.W. Typical thyroid Salman et al in 2010 suggests that standard treatment of a carcinoma arising in strumaovarii: a report of four cases and patient with thyroid malignancy in struma ovarii is total review of literature “International Journal of gynecological abdominal hysterectomy, bilateral salpingo-oophorectomy, Pathology 2008; 27(4):496-506. 7. S. Makani, W. Kim, and A. R. Gaba. Struma Ovarii with a and complete surgical staging, including peritoneal focus of papillary : a case report and review of washings for cytology, pelvic and para-aortic the literature.Gynecologic Oncology 2004; 94 (3): 835–839. sampling, and omentectomy.9,10 8. C. P. DeSimone, S. M. Lele, and S. C. Modesitt, “Malignant struma ovarii: a case report and analysis of cases reported in the literature with focus on survival and I131 therapy,” Conflict of interest Gynecologic Oncology 2003; 89 (3): 543–548. There is no conflict of interest to declare by any author. 9. W. D. Salman, M. Singh, and Z. Twaij. A case of papillary thyroid carcinoma in strumaovarii and review of the literature.Patholog Res Int. 2010 Aug 2;2010:352476. doi: References 10.4061/2010/352476 1. Medeiros F. Germ cell tumors of the ovary. In: Diagnostic 10. K. Matsuda, T. Maehama, K. Kanazawa.Malignant Gynecologic and Obstetric Pathology 2006: 920-921. . strumaovarii with thyrotoxicosis. Gynecologic Oncology 2001; 82(3): 575–577.

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