Bilateral Malignant Mixed Serous Adenocarcinoma and Malignant Transitional Cell Carcinoma of the Ovaries: an Extremely Rare Neoplasm

Interventional Medicine & Applied Science, Vol. 7 (3), pp. 132–134 (2015) CASE REPORT Bilateral malignant mixed serous adenocarcinoma and malignant transitional cell carcinoma of the ovaries: An extremely rare neoplasm

OZHAN OZDEMIR1,*, MUSTAFA ERKAN SARI1, CEMAL RESAT ATALAY1, ERTUGRUL SEN1, ESRA OZHAMAM2

1Department of Obstetrics and Gynecology, Ankara Numune Education and Research Hospital, Ankara, Turkey 2Department of Clinics Pathology, Ankara Numune Education and Research Hospital, Ankara, Turkey *Corresponding author: Ozhan Ozdemir; Department of Obstetrics and Gynecology, Ankara Numune Training and Education Hospital, 06010, Ankara, Turkey; Phone: +905052255078; E-mail: [email protected]

(Received: April 8, 2015; Accepted: June 3, 2015)

Abstract: Mixed epithelial ovarian carcinomas are extremely rare and comprise less than 4% of all malignant ovarian tumors. We report a 61-year-old postmenopausal woman with bilateral adnexal masses. In the postoperative histopathological evaluation, mixed epithelial carcinoma with areas of disseminated serous adenocarcinoma and less prevalent areas of malignant transitional cell carcinoma was observed. Up-to-date, there have been only two cases with mixed serous adenocarcinoma and malignant transitional cell carcinoma reported in the English literature, and our case is the ﬁ rst case with bilateral tumors.

Keywords: mixed carcinoma, serous adenocarcinoma, malignant transitional cell carcinoma

Introduction pelvic examination. The transvaginal ultrasonogram (TV-USG) revealed a 33 × 35 mm and a 38 × 35 mm Epithelial carcinomas are the most common malignant multiloculated cystic mass with solid areas in the right tumors of the ovaries, and they are generally pure in ovary and left ovary, respectively. Bilateral pelvic masses histopathology. Presence of two or more epithelial sub- were observed by computed tomography (CT), where- types in the same tumor tissue is called “mixed epithe- as no lymphadenopathies were detected. While the lial ovarian carcinoma”. Mixed epithelial ovarian carci- routine hemogram and biochemical parameters were in nomas are extremely rare and comprise less than 4% of normal ranges, Ca 125 was found extremely high (1326 all malignant ovarian tumors [1]. The most common IU/ mL). Laparotomy was performed with the predi- combinations are simultaneous appearance of serous– agnosis of a malignant ovarian tumor. Approximately endometrioid, serous–transitional cell, and endometri- 100 cc of ascites was observed intraoperatively and was oid–clear cell carcinoma [2]. sampled for cytological evaluation. A tumoral implant Up-to-date, there have been only two cases of mixed with 2-cm diameter was detected on the omentum, serous adenocarcinoma and malignant transitional cell whereas other peritoneal surfaces were macroscopi- carcinoma reported in the English literature, and our cally normal. Bilateral salpingo ooforectomy was per- case is the ﬁ rst bilateral case in the literature [2, 3]. formed in the ﬁ rst place. As the frozen section revealed malignant tumor, total abdominal hysterectomy with infracolic omentectomy and pelvic lymph node dissec- Case Report tion were performed for surgical staging. No paraaortic lymph node was palpated. Macroscopically, masses with A 61-year-old postmenopausal woman applied to our irregular surfaces with 3.5 cm- and 4 cm-diameters in clinic with groin pain ongoing for 3 months. Bilateral the right and left ovaries, respectively, were observed. ovaries were palpable and had irregular surfaces in the In the sectioning, cystic areas with grayish solid parts

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(WT-1) was mildly positive in both histopathological components. Tumor cells were present in the sample taken for cytology, and metastasis was detected on the omentum. Pelvic lymph nodes were free of tumor. The patient was referred to the medical oncology, and adju- vant chemotherapy was planned.

Discussion

Epithelial ovarian tumors are the most common ovarian neoplasms and have subtypes of serous, endometrioid, mucinous, transitional cell, and clear cell. Malignant epithelial tumors of the ovary, which are composed of one histopathological type, are generally pure; however, more than one subtype may be observed in the same tumor which is called “mixed epithelial ovarian carcinoma” [2]. Although there is no term as “mixed carcinoma” in the latest classifi cation of epithelial ovarian tumors which was agreed by World Health Organization (WHO) in 2014, neoplasms containing the minor com- Fig. 1. Mixed ovarian neoplasm showing serous adenocarcinoma ponent more than 10% were named as mixed carcino- and malignant transitional cell carcinoma of the left ovaries mas in previous classifi cations [4]. Even the new classifi - (hematoxylin and eosin, 20× magnifi cation) cation of WHO recommends to specify all morphologic subtypes in diagnosis even though they are represented were detected. The tumor invaded the surfaces of both less than 10% [5]. The previous “mixed serous-endome- ovaries and extended through left uterine tube together trioid carcinoma”, and “mixed serous-clear cell carcino- with an implant on the omentum. Microscopically, dis- ma” are now called “high-grade serous carcinoma with seminated areas of serous adenocarcinoma (85%) with pseudoendometrioid areas” and “high-grade serous car- less prevalent areas of malignant transitional cell carci- cinoma with cytoplasmic clearing areas”, respectively. noma (15%) were detected in both ovaries, and bilateral In the majority of cases with the diagnosis of malig- mixed malignant epithelial ovarian tumor (high-grade nant mixed epithelial tumor, combinations of serous– serous adenocarcinoma, and high-grade transitional cell endometrioid, serous–transitional cell, and endometri- carcinoma) was diagnosed (Figs 1 and 2). In the im- oid–clear cell carcinoma have been observed. Clinical munohistochemical analysis, Wilms tumor protein-1 behavior of mixed epithelial ovarian carcinomas gener-

Fig. 2. Mixed ovarian neoplasm showing serous adenocarcinoma and malignant transitional cell carcinoma of the right ovaries (hematoxylin and eosin, 100× magniﬁ cation). a) Section showing a serous adenocarcinoma with invasion of stroma by solid nests and glandular structures. b) Section showing closely packed malignant transitional cell nests

Unauthenticated | Downloaded 09/26/21 10:00 AM UTC Ozdemir et al. ally diff ers according to the prominent component in the histopathological sections should be evaluated for the ex- tumor [3]. In our case, the clinical behavior resembled act diagnosis of mixed carcinomas in ovarian neoplasms. that of pure serous adenocarcinoma which was the dom- inant component, and the metastasis on the omentum * * * was metastatic serous carcinoma. Funding sources: None. Malignant transitional cell carcinomas are rare forms Authors’ contribution: Concept, Design, Analysis and/or Interpreta- of invasive epithelial ovarian cancers, and pure forms tion, Literature Search and Writing: OO; Supervision and Resource: comprise only 1% of ovarian surface epithelial cancers MES; Materials: ES, EO; Critical Reviews: CRA. The paper has been [6]. Transitional cell carcinomas are mostly pure, and checked over and approved by all authors. only two cases of mixed epithelial ovarian tumor with malignant transitional cell component have been report- Confl ict of interest: The authors do not have a confl ict of interest. ed in the English literature [2, 3]. Our case is the fi rst malignant mixed epithelial tumor case with malignant References transitional cell tumor componentin both ovaries. 1. Kurman RJ, Shih IM: The origin and the pathogenesis of ovarian The distinction between intermediate high-grade cancer: a proposed unifying theory. Am J Surg Pathol 34, 433– transitional cell carcinoma, high-grade serous carcinoma, 443 (2010) and undiff erentiated carcinoma is crucial. In transitional 2. Gupta N, Ahuja A: Malignant mixed epithelial tumour ovary-pap- cell carcinoma, undulating thick bands with diff erent illary serous adenocarcinoma and malignant Brenner’s tumour: histologic patterns including insular, trabecular, or un- an exceedingly rare neoplasm. J Clin Diagn Res 5(8), 1651–1652 (2011) diff erentiated components may be observed. Papillae of 3. Adlekha S, Chadha T: Malignant mixed epithelial tumour of ova- transitional cell carcinoma are generally broad whereas ry-serous papillary cystadenocarcinoma and transitional cell carci- they are fi ne-shaped in serous carcinoma [3]. Immuno- noma with tubo-ovarian torsion: a rare tumour with rare presenta- histochemical parameters may be helpful for diff erential tion. Malays J Med Sci 20(5), 79–82 (2013) diagnosis. Transitional cell carcinomas are positive for 4. Lee KR, Tavassoli FA, Prat J, Dietel M, Gersell DJ, Karseladze AI, Hauptmann S, Rutgers J, Russell P, Buckley CH, Pisani P, all serous immune markers such as CK7, CA125, and Schwartz P, Goldgar DE, Silva E, Caduff R, Kubik-Huch RA WT-1 and negative for all urothelial markers such as uro- (2003): Tumours of the Ovary and the Peritoneum: Surface Epi- plakin, thrombomodulin, and CK 20 [3]. Our case was thelial Stromal Tumours. In: World Health Organisation Classifi - also positive for WT-1 in both serous and transitional cell cation of Tumours of the Breast and Female Genital Organs, eds. carcinoma components. Tavassoli FA, Devilee P, IARC Press, Lyon, p. 144 5. Kurman RJ, Carcangiu ML, Herrington CS, Young RH (2014): WHO Classifi cation of Tumours of the Female Reproductive Or- Conclusions gans. WHO Classifi cation of Tumours. IARC Press, Lyon 6. Silva EG, Robey-Caff erty SS, Smith TL, Gershenson DM: Ovar- In conclusion, mixed epithelial tumors are rare, and ow- ian carcinomas with transitional cell carcinoma pattern. Am J Clin ing to this, they may lead to a diagnostic dilemma. Several Pathol 93(4), 457–465 (1990)

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