CLINICAL HISTORY:
A 52-year-old postmenopausal and nulliparous woman with a familial past medical history of gynecological cancer, presented with a four-month history of progressive diffuse abdominal pain, and distension. Physical examination revealed an abdominal swelling with perception of pelvic masses. Contrast-enhanced computed tomography scan of the abdomen revealed bilateral variegated ovarian masses with heterogeneous enhancement (Figure 1A). The right ovarian mass measured 43x53x60 mm and the left ovarian mass measured 75x76x89 mm. The preoperative serum level of cancer antigen 125 (CA125) was elevated to 67 U/ml (normal range: < 35.0), whereas the carcinoembryonic antigen (CEA) and cancer antigen 19-9 (CA19-9) values were within the respective normal ranges. At laparotomy, the surgeon found bilateral ovarian masses and massive ascites. The left ovarian mass was adherent to the uterus and to the sigmoid colon. Intraoperative frozen section analysis of both ovarian masses concluded to a malignant neoplasm. The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph node dissection, para-aortic lymph nodal sampling, peritoneal biopsies, and total omentectomy.
Grossly, both ovarian masses were ill defined, lobulated and friable with capsular rupture. The external surface showed numerous fragmented pieces, which were soft, encephaloid, grey, glistening with areas of hemorrhage (Figure 1B). On cut section, the tumors were solid, grey white showing variegated appearance with areas of hemorrhage and necrosis (Figure 1C). We did not notice residual ovarian tissue. Moreover, there was tumor invasion on the left side of the uterine corpus (Figure 1D). Histological examination of both ovarian masses showed a malignant biphasic tumor proliferation. The major part of the tumor was sarcomatous (Figure 2A) with the carcinomatous part well differentiated serous adenocarcinoma (Figure 2C). Heterologous elements including cartilage (Figure 2B) and adipose tissue (Figure 2 D) were found in the tumor. Mitotic activity was frequent (8-9/10 high power field). We also noted the presence of tumor necrosis. Immunohistochemical study showed positive immunostaining of the sarcomatous component with Demin, Smooth Muscle Actin and Calponin. Cytokeratin highlighted the epithelial component. Omentum, lymph nodes and peritoneal biopsy were negative for malignant cells. Cytological examination of the ascitic fluid did not reveal the presence of malignant cells. Based on the histopathological and immunohistochemical findings, the final diagnosis was that of bilateral ovarian carcinosarcoma classified as stage IIA according to the International Federation of Gynecology and Obstetrics (FIGO) 2014. The postoperative course was uneventful. The patient was planned for adjuvant chemotherapy: six cycles of combination with paclitaxel and carboplatin. At present, she is still being followed-up.