J Clin Pathol: first published as 10.1136/jcp.40.12.1443 on 1 December 1987. Downloaded from J Clin Pathol 1987;40:1443-1448 Sarcoma-like mural nodules in cystic serous ovarian tumours T J CLARKE From the Department ofHistopathology, Derriford Hospital, Plymouth SUMMARY The morphology, immunohistochemistry, ultrastructure and natural history of sarcoma- like mural nodules in two serous cystic ovarian tumours are described. Primary ovarian sarcomas are rare; they comprised anorexia, and malaise. On examination she was found only 43 of a series of 2400 ovarian tumours (1 8%).' to have an enlarged right supraclavicular lymph node Sarcomatous and epithelial elements can be found and a firm pelvic mass. At laparotomy a Tru-cut together in ovarian tumours, most commonly in biopsy of the cervical lymph node was taken and a an immature teratoma or a malignant mixed large, cystic left ovary and an enlarged para-aortic mesodermal tumour (MMMT).' Sarcomas arising in lymph node were removed. The left ovary was rup- epithelial ovarian tumours are rare and those found tured on removal but was considered to be clinically in serous tumours are extremely rare, with only benign, and the right ovary, which appeared normal, two recorded cases: a leiomyosarcoma in a serous was left in situ. The uterus and liver appeared normal cystadenoma,2 and a leiomyosarcoma in a serous and there was no ascites. A right iliac crest bone mar- cystadenocarcinoma.3 In this paper two further cases, row trephine biopsy specimen was taken because copyright. diagnosed as cystic serous ovarian tumours with lymphoma was suspected. sarcoma-like mural, nodules are reported. CASE 2 Material and methods A 72 year old nulliparous woman presented with a three month history of anorexia, constipation, and Sections were stained with haematoxylin and eosin, vomiting. A fixed pelvic mass and ascites were pal- periodic acid Schiff with and without diastase pre- pable. At laparotomy ascites, peritoneal and omental treatment, alcian blue (pH 2.5) and Caldwell and metastases, and a large cystic right ovarian mass were http://jcp.bmj.com/ Rannie reticulin stain. The indirect peroxidase- found. A bilateral salpingo-oophorectomy, hysterec- antiperoxidase method was used with antibodies tomy, and omentectomy was performed. She died against cytokeratin, vimentin, carcinoembryonic anti- eight days later. At necropsy, metastatic tumour was gen (CEA), CA125, monoclonal antibody OC125 found in the liver, para-aortic and mediastinal lymph (from CIS UK) and myoglobin. OC125 is a mono- nodes, and encircling the small intestine in several clonal murine antibody raised against the antigen places. The bone marrow was normal. CA125 derived from the human ovarian serous papil- on September 24, 2021 by guest. Protected lary cystadenocarcinoma cell line OVCA433.4 CA125 Pathology is expressed in most non-mucinous human ovarian epithelial tumours.56 Portions of the ovarian mural CASE 1 nodules were reprocessed from formalin fixed mate- On histological examination, the left ovary was found rial and examined using a JEM-1200EX transmission to be replaced by a thin walled, unilocular cyst 9 cm in electron microscope. diameter. A rough surfaced grey mural nodule mea- suring 3 x 3 x 1-5 cm projected into the cyst cavity. Case reports The external surface ofthe cyst was smooth except for slight roughening over the mural nodule. CASE 1 The cyst was found to be a serous tumour of low A 49 year old, multiparous, postmenopausal woman grade ("borderline") malignancy; the columnar epi- presented with a two month history of weight loss, thelium lining the cyst showed focal moderate cellular pleomorphism, loss of orientation, multilayering, Accepted for publication 25 June 1987 occasional mitoses and tuft formation. The epi- 1443 J Clin Pathol: first published as 10.1136/jcp.40.12.1443 on 1 December 1987. Downloaded from 1444 Clarke thelium had ulcerated over the inner aspect of the tured at operation. Several well circumscribed, yel- mural nodule, which was covered by inflammatory lowish and tan coloured mural nodules (0-2cm to exudate. The nodule was composed of sheets of large, 2-5 cm in diameter) were present on the inner surface round, and spindle cells with hyperchromatic nuclei, of the cyst. A solid pale grey mass 5-5 cm in diameter, and there was no differentiation into recognisable with a whorled cut surface, was present in the wall of connective tissue or epithelial elements. Mitoses were the cyst. The omentum bore several grey nodules of common and many were atypical (fig 1). The diffuse tumour. The uterus contained a cystic endometrial inflammatory cell infiltrate of neutrophils and polyp 2cm in diameter. eosinophils that permeated the nodule was unrelated The right ovarian cyst was for the most part a to the occasional small areas of haemorrhage and serous tumour of low grade ("borderline") malig- necrosis that were present. The borders of the nodule nancy, but there were also small foci of superficial, were poorly defined, and undifferentiated neoplastic well differentiated invasive papillary serous ade- cells extended into the cyst wall adjacent to the nocarcinoma containing psammoma bodies. The tan nodule. coloured mural nodules were composed of Reticulin stains showed a loose alveolar pattern in undifferentiated spindle and round cell tumour similar the mural nodule. There was no evidence of endo- to that seen in case 1, and were covered by serous metriosis, teratomatous organoid differentiation, epithelium (fig 2). A delicate pericellular reticulin osteoclast-like multinucleate giant cells, or heterolo- pattern was present, in contrast to case 1, and there gous elements. Vascular invasion by tumour cells was was no evidence of endometriosis or teratomatous not seen. differentiation. The solid grey ovarian mass noted macroscopically was a typical ovarian fibroma. The CASE 2 left ovary was atrophic. The right ovary was replaced by a smooth surfaced, The endometrium was atrophic and bore a benign thin walled, unilocular cyst 22 cm in diameter with the microcystic endometrial polyp with glands lined by fallopian tube stretched across it. The cyst had rup- flat, inactive epithelium. The omental deposits consis- copyright. s. .o .. , Ge't .. .. http://jcp.bmj.com/ PI * d.. I* .4.6 0 n". 1: \ .* % - 0-ii. *r. M -.. fk 6 f: t'. 41 ..., -i -t-V ... 4W." k '.. t i, -q. 'k on September 24, 2021 by guest. Protected p 116% dfl ..'. ,h. Z .,: 'Uo I ig, ,qp.. .., I . ..' 0 f ;-. j.:4 tv .~i- g~~47 Fig I Case 1: detail ofsarcoma-like nodule with prominent polymorphonuclear leucocyte inflammatory Fig 2 Case 2: sarcoma-like nodule covered by serous infiltrate. (Haematoxylin and eosin.)W6F.FsU Na , ; epithelium (Haematoxylin and eosin.) J Clin Pathol: first published as 10.1136/jcp.40.12.1443 on 1 December 1987. Downloaded from Sarcoma-like mural nodules in cystic serous ovarian tumours 1445 9 |.4~~~~~~~*zvs w , ; * o . t .i~4.A ~~ A~~~~O Al AFX~~~~~'S~~~~~~~~~~~~~>~~A A r a tour~-~f 4 .' _4%A, diLa ! S AAAd 0.6~~~~~~~~~~~~~~~~~~~. * t ^* v J s ' s~ f L copyright. Fig 3 Case 2: omental nodule containing metastatic serous cystadenocarcinoma and spindle cell tumour. (Haematoxylin and eosin.) ted mainly of metastatic undifferentiated spindle cell tumour similar to the ovarian mural nodules, though Al in some areas there was metastatic papillary serous cystadenocarcinoma (fig 3). http://jcp.bmj.com/ Immunohistochemistry CASEl The serous epithelium showed apical CA125 and cyto- j plasmic cytokeratin positivity and there was no CEA t expression. The cells in the nodule were positive forS cytokeratin and did not express vimentin, CA125, on September 24, 2021 by guest. Protected CEA, or myoglobin, nor was there intracellular neu- tral mucin. Ultrastructurally, the neoplastic cells con- tained moderate numbers of mitochondria, scanty rough endoplasmic reticulum, and occasional desmosomes with convergent tonofilaments (fig 4). Microvilli and intracellular lumina were absent and pericellular basal laminar material was scanty. The cervical and para-aortic lymph nodes and iliac crest trephine biopsy specimen all contained meta- static undifferentiated tumour morphologically and - * immunohistochemically identical with that in the ovarian nodule. Despite chemotherapy with cis- platinum, adriamycin, cyclophosphamide, and numerous blood transfusions, the patient gradually Fig 4 Case 1: ulttrastructure ofundifferentiated cells in deteriorated and died five months after laparotomy. nodule. Note two adesmosomes (arrowed). (Uranyl acetate An abdominal ultrasound examination shortly before and lead citrate.) J Clin Pathol: first published as 10.1136/jcp.40.12.1443 on 1 December 1987. Downloaded from 1446 Clarke a - 4~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~o....'7Y,4t ar * AV.~~~~~~~~~~a'*V A~~~~~~~~~~~~~~~~~~~~~A '';"~~~~~~~~~~~~~~V ~~~~~~~~~~A'S *.'~~~~~~~~~~~~~ ,&t.-.,t,r) ~~~~~~~~~~~~~~~~~~~~~~A q"b *~~~~~~~~~~~~~ 4kjk.'y* ~~~~~~~~~~'~~~-Afr~~~~~4 *49; ' * V.~~~~~~~~4 VJ. - WA ~ ~ ~ ~ A *~#.% -;,~~- 4R,'t Th2i.t¼k#i. 00,~ * '~v ~~ Fig 5 Case 2: metastasis adherent to small intestine containing squamous carcinoma. (Haematoxylin and eosin.) copyright. death showed hepatic metastases. Consent for nec- ropsy was not obtained. CASE 2 The serous lining epithelium was positive for cyto- plasmic cytokeratin and apical CA125, and negative for CEA. The cells in the nodules were uniformly http://jcp.bmj.com/ .,. positive for vimentin with no expression of cyto- keratin, CA125, CEA, or myoglobin. Electron * 5 a ,; _ do} microscopy