A mural nodule of anaplastic carcinoma with sarcomatoid differentiation in a background of ovarian borderline mucinous cystadenoma

Abstract

Ovarian mucinous cystic tumours with mural nodules are rare tumours of the ovary that are often missed out during diagnosis. They are classified under the ovarian mucinous surface epithelial-stromal tumours. These mural nodules can be sarcoma-like (benign), anaplastic carcinoma, sarcomas, or mixed malignant (carcinosarcoma). However, very few cases of anaplastic malignant mural nodules have been reported. Here, we present a case of a borderline ovarian mucinous cystadenoma with anaplastic mural nodule that has sarcomatoid differentiation, in a 39-year-old woman who presented with a 1-year history of progressive abdominal swelling and pain. There were intraoperative findings of huge right ovarian cystic tumour with omental and umbilical deposits. Differential diagnosis of possible germ cell tumours, vascular tumours, melanoma, sarcoma and sarcoma-like nodules were ruled out with routine histology (Haematoxylin & Eosin), histochemical (reticulin) and immunohistochemical stains (CK AE1/3+, CD30+, AFP-, HCG-, EMA-, S100 protein-, CD31-, and CD34-) and the final diagnosis of a mural nodule of anaplastic carcinoma with sarcomatoid differentiation in a borderline ovarian mucinous cystadenoma established. Unfortunately, due to the aggressive nature of the tumour and disease progression, the patient passed on a few months after the surgery. This rare tumour, especially the ones with anaplastic carcinoma or mixed tumours, usually has an aggressive clinical course with most patients presenting late when the disease is advanced with poor clinical outcomes as is seen with the index patient. A high index of suspicion of this tumour with early detection and a multidisciplinary approach to its management is advised.

Keywords: anaplastic carcinoma; case report; mucinous cystic neoplasms; mural nodules; ovarian tumour; sarcomatoid differentiation.

Figure 1.. Gross picture of the cystic ovarian mass, omental deposit and umbilical subcutaneous nodular deposit. (a): Gross picture of the cystic ovarian mass. (b): Gross picture of the omental deposit. (c): Gross picture of the umbilical subcutaneous nodular deposits.

Figure 2.. Photomicrographs (H&E) stains of the ovarian anaplastic mural nodule and omental deposit. (a) H&E x100 and x400 (inset) magnification of the ovarian malignant anaplastic mural nodule. (b) H&E x100 and x400 (inset) magnification of focal areas of ovarian borderline mucinous cystic tumour. (c) H&E x 200 magnification of the omental deposit.

Figure 3.. Photomicrographs of the immunohistochemical stains (CK AE1/3, CD 30, vimentin), and histochemical stains (reticulin) of the tumour cells. (a): Immunohistochemical staining (×40 magnification) shows reactivity for CK AE1/3. (b): Immunohistochemical staining (×40 magnification) shows focal reactivity for CD30. (c): Immunohistochemical staining (×40 magnification) shows reactivity for vimentin. (d): Reticulin histochemical staining (×40 magnification) stains reactive stromal cells.