of Borderline Papillary Serous Carcinoma of Ovary in Peritoneal Washing Cytology:A Case Report and Review of Literature. J Pharm

Transcription

1 JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES. Cytologic Identification of Borderline Papillary Serous Carcinoma of Ovary in Peritoneal Washing Cytology:A Case Report and Review of Literature. J Pharm Biomed Sci 2014; 04(04): The online version of this article, along with updated information and services, is located on the World Wide Web at: Journal of Pharmaceutical and Biomedical Sciences (J Pharm Biomed Sci.), Member journal. Committee of Publication ethics (COPE) and Journal donation project (JDP).

2 Case report Cytologic Identification of Borderline Papillary Serous Carcinoma of Ovary in Peritoneal Washing Cytology: A Case Report and Review of Literature Banushree C Srinivasamurthy MD DNB, Ambedkar Raj Kulandaivelu MD Affiliation:- 1 Assistant Professor, Department of Pathology & Lab Medicine, AIIMS, Bhubaneswar, India 2 Associate Professor, Department of Pathology, Sri Manakula Vinayagar Medical College, Puducherry, India The name of the department(s) and institution(s) to which the work should be attributed: 1. Department of Pathology & Lab Medicine, AIIMS, Bhubaneswar, India 2. Department of Pathology, Sri Manakula Vinayagar Medical College, Puducherry, India *To whom it corresponds:- Dr Banushree CS. Assistant Professor, Department of Pathology & Lab Medicine, AIIMS, Bhubaneswar, India Contact no: Abstract The most common cause of malignant ascites in women is intraperitoneal spread from an ovarian primary carcinoma, usually of the papillary serous type. Occasionally, women with serous borderline tumors present with ascites. Papillary serous neoplasms of the ovary and peritoneum need to be recognized in cytology specimens for appropriate diagnosis and/or staging purposes. Borderline serous carcinoma can go undetectable in intra-operative exploration alone, so cytological examination of peritoneal washings should be done. The distinction of reactive mesothelial cells from serous neoplasms in peritoneal fluids is possible in most patients by cell group architecture and cytological features. We encountered a rare case of borderline papillary serous carcinoma of ovary with presence of malignant cells in peritoneal washing in a forty-three year old female which helped in predicting the behavior and staging of the tumour and establishing proper line of management Keywords: Peritoneal washing; reactive mesothelial cells; papillary serous neoplasms; ovary. Article citation: Banushree C Srinivasamurthy, Ambedkar Raj Kulandaivelu. Cytologic identification of borderline papillary serous carcinoma of ovary in peritoneal washing cytology:a case report and review of literature. J Pharm Biomed Sci. 2014; 04(04): Available at INTRODUCTION P eritoneal washing cytology has been used in the evaluation of gynecologic malignancies since the early 1950s. The International Federation of Gynecology and Obstetrics (FIGO) introduced peritoneal washing as part of the staging of ovarian carcinomas in The presence of malignant cells in serous effusions signifies spread of disease beyond the organ of origin and is associated with significant therapeutic and prognostic implications. Unfortunately, the morphologic examination of cytologic specimens has not proven to be a sensitive or specific diagnostic tool. The malignant cells might be few in number and might be 279

3 unrecognized among a large population of mesothelial cells and/or macrophages. Mesothelial cells, on the other hand, might show reactive changes due to a wide variety of stimuli. These changes consist of marked nuclear enlargement, hyperchromasia, and cytoplasmic alterations, which can be misinterpreted as malignant cells 2-4. Benign conditions such as endosalpingiosis may be extremely difficult to differentiate from borderline ovarian tumors (tumors of low malignant potential) or low-grade serous carcinomas in cytologic specimens. Sometimes, misinterpretation of reactive mesothelial cells as malignant epithelial cells can also occur. As a positive peritoneal washing diagnosis leads to treatment with chemotherapy in many instances, diagnostic accuracy is essential. CASE REPORT Forty-three old female presented with abdominal distention. Clinical examination revealed ascites and mass per abdomen. Diagnosis of ovarian neoplasm was done on ultrasonography. Patient underwent total abdominal hysterectomy and salphingo-oophorectomy. Intra-operative peritoneal washings sent for cytological examination. CYTOLOGY Cellular smear showing cohesive, threedimensional, branched, smoothly contoured groups surrounding psammoma bodies without intercellular windows. Papillae had more than 10 cells with minimal nuclear overlapping, moderate nuclear atypia, high nuclear cytoplasmic ratio and prominent nucleoli. Cytological diagnosis of papillary serous borderline tumour/low grade papillary serouscarcinoma of ovary was given. GROSS Ovarian cyst measuring 11x 7x 5cm. Surface showing papillary projections with focal microcystic areas. MICROSCOPY The cyst wall showed broad focal complex papillary projections lined by columnar epithelium with focal microinvasion. The lining epithelium showed focal stratification with mild to moderate hyperchromatism and pleomorphism. psammoma bodies were seen in cyst wall and papillary core. Histopathological features suggestive of borderline serous cystadenocarcinoma of ovary. Figure 1. Microphotograph (10x)-MGG stain showing three dimensional branching papillae. 280

4 Figure 2. Photomicrograph (40x)-MGG stain showing branching papillae with moderate nuclear atypia and prominent nucleoli. Figure 3. Photomicrography(10x)H&E-section from omentum showing bodies in papillary core. psammoma 281

5 Figure 4. Microphotograph(10x)H&E-showing exophytic papillary projections with focal stratification. DISCUSSION The distinction of reactive mesothelial from serous neoplasms in peritoneal fluids is possible in most patients by examination of cell group architecture, nuclear atypia, and nuclear size. Differentiation of serous borderline tumour from grade 1 serous carcinoma of ovary is not reliable, meriting a differential diagnosis. Rare studies have reported that the features of serous borderline tumour and grade 1 ovarian serous carcinoma in fluids are indistinguishable 5,6. In our present case we could only give a differential diagnosis of serous borderline tumour and low grade serous carcinoma. Later, borderline tumour was confirmed on histopathology. The features of serous borderline tumour in fluid specimens have been examined in small series by a few authors 5-8. Typically, reports describe serous borderline tumour in fluids as papillary groups with branching and smooth group contours comprised of small, uniform cells with high nuclear cytoplasmic ratios, and prominent. Johnson and others found that irregular papillae contours, moderate-to-many single tumor cells, large tumor cells (> 8 neutrophil size), moderate-to-marked pleomorphism nucleoli were statistically significant distinguishing features between serous borderline tumour specimens and ungraded serous carcinoma specimens 9. The presence of malignant cells in peritoneal washings leads to classification as International Federation of Gynecology and Obstetrics stage IC or higher in ovarian carcinomas 10. Endosalpingios is might be nearly impossible to distinguish from welldifferentiated serous neoplasms such as serous borderline tumor and low-grade serous carcinoma. It is important to remember that psammoma bodies might be present in cases of endosalpingiosis. The distinction of endosalpingiosis from serous borderline tumor is based on the presence of large papillary clusters with architectural disorganization in the latter. These findings are better appreciated in cell blocks. The presence of nuclear molding and nucleoli in papillary clusters also suggest a neoplastic process. The presence of malignant cells in serous effusions signifies spread of disease beyond the organ of origin and is associated with significant therapeutic and prognostic implication. REFERENCES 1.P. Tauchi S, N. Caraway, L. D. Truong, A. L. Kaplan, and I. Ramzy. Serous surface carcinoma of the peritoneum: useful role of cytology in differential diagnosis and follow-up. Acta Cytol : Lee, A, Z. W. Baloch, G. Yu, and P. K. Gupta. Mesothelial hyperplasia with reactive atypia: diagnostic pitfalls and role of immunohistochemical studies a case report. Diagn Cytopathol : Zuna, R. E, M. L. Mitchell, K. A. Mulick, and W. M. Weijchert. Cytohistologic correlation of peritoneal washing cytology in gynecologic disease. Acta Cytol : Ziselman, E. M., S. E. Harkavy, M. Hogan, W. West, and B. Atkinson. Peritoneal washing cytology: uses 282

6 and diagnostic criteria in gynecologic neoplasms. Acta Cytol 1984;28: Covell JL, Carry JB, Feldman PS. Peritoneal washings in ovarian tumors. Potential sources of error in cytologic diagnosis. Acta Cytol. 1985;29: Ravinsky E. Cytology of peritoneal washings in gynecologic patients. Diagnostic criteria and pitfalls. Acta Cytol.1986;30: Gurley AM, Hidvegi DF, Cajulis RS, Bacus S. Morphologic and morphometric features of low grade serous tumours of the ovary. Diagn Cytopathol.1994; 11: Mulvany N. Cytohistologic correlation in malignant peritoneal washings. Analysis of 75 malignant fluids. Acta Cytol 1996;40: Johnson TL, Kumar NB, Hopkins M, Hughes JD. Cytologic features of ovarian tumors of low malignant potential in peritoneal fluids. Acta Cytol1988; 32: Oscar Lin. Challenges in the Interpretation of Peritoneal Cytologic Specimens. Arch Pathol Lab Med. 2009; 133: Source of support: None Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript. Copyright 2014.This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 283