Carcinosarcoma of the Ovary

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1 Carcinosarcoma of the Ovary A Rare Finding Presented By: Kathryn Kiely Anisa I. Kanbour School of Cytotechnology of the University of Pittsburgh Medical Center Pittsburgh, PA

2 Patient History 55 year old female Hypothyroidism and Eccrine Carcinoma 2013 Gyne: G3P2, Menopause at 41 Medicine: Synthroid and Vitamin D Family: Brother with rare spinal tumor at 27, Father with prostate cancer and coronary artery disease

3 History & Symptoms June Removal of Eccrine carcinoma from the left axilla. Elevated CA 125. December Post-menopausal bleeding(pmb), no mention of CA 125 levels March Left side pelvic discomfort. Postmenopausal spotting. June Bilateral adnexal masses were found on ultrasound.

4 Procedure 8/14/2015 Bilateral salpingo oophorectomy Hysterectomy Adnexal mass removal Omentectomy Left and right pelvic and periaortic lymph node dissection

5 Specimens Cytology: Pelvic wash: 1 ThinPrep, 1 direct smear and 1 cytospin stained with a Pap stain. A cell block stained with H&E. Histologic slides were made for all tissues removed and stained with H&E. IHCs done on surgical specimens.

6 Direct Smear 40x Pap

7 ThinPrep 40x Pap

8 Cytologic Diagnosis Positive for Malignancy

9 Carcinosarcoma Cytologically Most prominent component will be the epithelial portion Rarely see sarcomatous portion in wash Presentation depends on the type of epithelial cancer (Del Carmen, 2012)

10 High grade serous carcinoma - Clusters or isolated cells - Variation in nuclear size - Hyperchromatic nuclei - Prominent nucleoli - Vacuolated cytoplasm (Cibas, 2014)

11 Histology 40x H&E

12 IHCs IHC Target Carcinoma Stroma CK7 Carcinoma + + CK20 Carcinoma - - Ki-67 WT1 Proliferation Marker Serous Carcinoma Slight Increase Slight Increase + + Vimentin Mesenchyme - +

13 Histologic Findings Majority of the tumor was high grade serous carcinoma Focal sarcoma area with malignant stroma Heterologous cartilage formation

14 Diagnosis Carcinosarcoma or Malignant Mixed Mullerian Tumor In order to be a MMMT there must be: - an epithelial malignancy - a mesenchymal malignancy (DeMay, 2012)

15 Differential Diagnosis Reactive Mesothelium - Enlarged, central nuclei - Prominent nucleoli - Knobby, flower-like borders - Microvilli, lacy-skirt cytoplasm - Pale to dense cytoplasmic staining - Bi-nucleation is common - Fine to coarse chromatin - Monomorphic cell population (Varley, 2016)

16 Carcinosarcoma of the Ovary Median survival rate of less than 18 months Diagnosis is usually in the 7 th decade Postmenopausal with low parity Presents with pelvic pain, bloating, and abdominal distention 90% will have spread from the ovary at presentation 90% have increased serum CA-125 levels (Del Carmen, 2012)

17 Treatment IV/IP adjuvant therapy was intended but IP port placement was aborted due to significant adhesive disease. 9/4/2015- Chemotherapy Carbo AUC6/Taxol 80mg/m2 Completed 6 cycles of Chemotherapy

18 Similar Case Report 57 year old female, G3P3 and postmenopausal Presented with lower abdominal pain and elevated CA-125 A fallopian tumor was found and surgery was performed Fluid cytology of blood in the peritoneum was Positive for Malignancy Histology found a majority of serous carcinoma with sarcoma and malignant cartilage The tumor spread to the omentum, pelvic peritoneum, and right ovary. Treated with chemotherapy and is disease free 8 months after surgery

19 Conclusion 55 year old woman with PMB and pelvic pain Bilateral adnexal masses found on radiology Specimens were taken from surgery and a pelvic wash Both surgical and pelvic wash were positive A final diagnosis of Carcinosarcoma was reached Patient was treated with chemotherapy and is disease free

20 Varley, Karyn(Feb 10, 2016). Benign Effusion. Class Lecture. Works Cited Cibas, E.S., & Ducatman, B.S. (2014). Cytology: Diagnostic Principles and Clinical Correlates. Philadelphia, PA: Elsevier. del Carmen, M. G., Birrer, M., & Schorge, J. O. (2012). Carcinosarcoma of the ovary: A review of the literature. Gynecologic Oncology, 125(1), DeMay, R. M. (2012). The Art & Science of Cytopathology, 2 nd Edition. Vol. 1, p 112. Chicago, IL: American Society for Clinical Pathology. Gupta, R., & Jenison, E. L. (2012). A rare case of carcinosarcoma of the fallopian tube presenting with torsion, rupture and hemoperitoneum.gynecologic Oncology Case Reports, 2(1), 4 5.

21 Kathryn Kiely, Student Anisa I. Kanbour School of Cytotechnology of the University of Pittsburgh Medical Center Pittsburgh, PA I would like to thank Karyn Varley, my program director, for her guidance throughout this process.

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