17 July 2009 – Case of the Week #152
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(1) We have posted the Skin-Melanocytic Tumors chapter in our new format. We have also posted these new / revised markers in the Stains chapter: HE4 (serum marker for ovarian carcinoma), Oscar Keratin (wide-spectrum keratin) and GCDFP-15 (marker of apocrine function). They also include Product Placement links from Covance. We are starting to update Soft Tissue Tumors 3 - Muscle, Vascular, Nerve, Other.
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(3) Thanks to Dr. Angel Fernandez-Flores, Hospital El Bierzo and Clinica Ponferrada, Spain, for contributing images of folliculitis decalvans for the Skin-nontumor chapter under Alopecia. Thanks to Jennifer Stumph, MD, Spectrum Health, for contributing images of schistosomiasis to the Parasitology chapter.
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Thanks to Dr. Siobhan O’Connor and Dr. Mamatha Chivukula, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (USA), for contributing this case and the discussion. To contribute a Case of the Week, email NatPernick@Hotmail.com with the clinical history, your diagnosis and diagnostic microscopic images (textbook quality) in JPG, GIF or TIFF format (send as attachments, we will shrink if necessary). Please include any other images (gross, immunostains, etc.) that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you $35 (US dollars) by check or PayPal for your time after we send out the case. Please only send cases with high quality images and a diagnosis that is somewhat unusual (or a case with unusual features).
Case of the Week #152
A 54 year old woman presented with cough, vomiting and headache. Her medical history was significant for smoking cigarettes for forty years. A urinary tract infection was suspected and she was treated with Ciprofloxacin, but her symptoms did not improve.
An abdominopelvic ultrasound showed multiple leiomyomata and a normal right ovary. The left ovary was not visualized, but a large complex mass was seen in the left adnexa, 11.8 x 7.5 x 9.4 cm. A CT scan revealed a 1.4 cm nodule in the left lower lobe of the lung, multiple necrotic conglomerate lymph node masses within the mediastinum up to 3.7 cm, a 1.5 cm necrotic right pretracheal lymph node and the pelvic mass. Colonoscopy showed tubular and tubulovillous adenomas. Mammography was negative.
The patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy, appendectomy and pelvic biopsies. Histologic sections of the left ovary showed the following:
Low power Medium power High power
CK7 CK20 low power CK20 high power
TTF low power TTF high power
What is your diagnosis?
Pulmonary adenocarcinoma metastatic to ovary
The tumor consists of cells arranged in nests and, in some areas, forming glandular structures. The cells show high grade morphology with pleomorphism and prominent nucleoli.
CK7 showed strong, diffusely staining. CEA and ER (not shown) were focally positive, though ER was weak. TTF-1 showed moderately strong, diffusely positive staining. p16 (not shown) also showed positive staining. CK20, Mammaglobin, GCDFP, CDX-2, Villin, WT-1, CD10, and Vimentin all showed negative staining.
Based on histology, the tumor is a high grade adenocarcinoma, and the staining pattern suggests lung origin.
While metastases to the ovary are common (Ovary-tumor chapter of PathologyOutlines.com), metastasis of pulmonary adenocarcinoma to ovary is rare. In one study of 325 metastases to the female genital tract, only one lung primary was identified (Cancer 1984;53:1978). The metastasis was the first evidence of disease in only 21 cases. In autopsy series, pulmonary metastases to ovary may account for up to 2 to 5% of ovarian metastases (Gyn Oncol 1985;21:337). For diagnostic and treatment purposes, it is important to distinguish between primary ovarian cancer and metastases to the ovary. Metastatic papillary adenocarcinomas may be difficult to discriminate from ovarian primaries because of their resemblance to papillary serous adenocarcinoma of the ovary. When the adenocarcinoma is poorly differentiated, as in this case, the differential is broad, since it may include an ovarian primary as well as metastasis from any glandular organ.
Several case studies have demonstrated ovarian metastases from lung (Jpn J Clin Oncol 2003;33:404). In one study, the pulmonary origin was confirmed by immunohistochemical positivity for carcinoembryonic antigen, E-cadherin, and surfactant in combination with negativity for CA-125, N-cadherin, and vimentin (Arch Pathol Lab Med 2002;126:1101). Another group demonstrated positive immunohistochemical staining for CK7 and TTF-1 along with negativity for CK20, similar to the pattern in this case. Sensitivity and specificity of TTF-1 for lung adenocarcinoma have been reported at 62% and 100%, respectively (Pathol Res Prac 2000;196:835). Another study documented the usefulness of TTF-1, CK7, CK20, and PE-10 (Cancer 2001;93:330). When a poorly differentiated adenocarcinoma is located in the ovary, a large panel may be required to identify its origin, and if the tumor is positive for CK7 and TTF-1, while being negative for CK20, it is most likely a metastasis from lung.
Nat Pernick, M.D., President
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