Case Presentation - February, 2004

ThinPrep® Non-gyn Cytology

History: 49 year old, female

Symptoms: Increasing abdominal girth and mild respiratory distress; CA-125: 5,158

Specimen Type: Peritoneal Fluid

Case provided by: Patrick Fitzgibbons, MD, of Good Samaritan Hospital, Los Angeles, CA

NOTE: The diagnosis and analysis for this case study were provided by an independent physician. All conclusions and opinions are those of the physician and not Hologic, Inc.

Cytologic diagnosis: Adenocarcinoma consistent with ovarian primary

Histologic diagnosis: Poorly-differentiated papillary serous adenocarcinoma of the ovary, metastatic to the omentum

Patient follow-up: Patient received a TAH/BSO and omenectomy, followed by chemotherapy. At this time the patient is free of disease.

Epithelial ovarian cancer (EOC) is the sixth most common cancer in women and the second most common female genital tract malignancy. The mean age for EOC is 57 years. EOC occurs most commonly in white women in the industrialized countries of northern and western Europe and North America and least commonly in Asia and India. The risk of EOC is increased in women who have not had children and possibly those with early menarche or late menopause. In patients with a family history of EOC a small fraction have an inherited genetic abnormality. BRCA 1 and BRCA 2 genes that are usually associated with breast cancer and genes found in the Lynch II syndrome complex are associated with ovarian cancer. Approximately 1 person in 4000 in the general population carries a mutation of BRCA1 gene. Tumor markers such as CA 125 are not specific for EOC. CA 125 does not differentiate benign from malignant lesions in premenopausal women because the tumor marker is also elevated in benign conditions such as menstruation and endometriosis. CA 125 has much better accuracy in postmenopausal women.

Poorly differentiated papillary serous adenocarcinoma of the ovary is an epithelial ovarian tumor that often causes malignant peritoneal effusions. The tumor cells occur singly, in loose, pleomorphic groupings, and occasionally in papillary clusters. The papillary clusters, if present, are not usually well formed, showing a pseudopapillary appearance. Palisading arrangements at the periphery of the papillary structures, a feature of well-differentiated papillary serous adenocarcinoma, are not seen in the poorly differentiated variant. The nuclei of the tumor cells are large, round to oval with frequent prominent nucleoli and fine to coarsely granular chromatin. The cytoplasm of the tumor cells is scant and often vacuolated. Psammoma bodies are an uncommon finding in poorly differentiated papillary serous tumors as opposed to well-differentiated papillary serous adenocarcinoma where a varying number of psammoma bodies within the papillary structures are noticed in approximately 40% of the tumors. The differential diagnosis of poorly differentiated papillary serous adenocarcinoma of the ovary in a peritoneal effusion is malignant mesothelioma and other metastatic adenocarcinomas. The presence of two cell populations (Image 2: sheets of reactive mesothelial cells and malignant cells) along with the carcinomatous features of the malignant cells, decreases the likelihood of malignant mesothelioma.

Treatment and Prognosis
In the majority of patients, ovarian cancer recurs and the prognosis is poor. The overall 5-year survival rate is 42%, decreasing accordingly with the stage of the disease. Treatment for ovarian cancer may involve surgery; chemotherapy and radiation and often a combination of the three may be used. Standard postoperative chemotherapy is a combination of platinum and palclitaxel.

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