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Case Presentation

Case Presentation . Gynecology 성균관대학교 의과대학 2007313075 손의영. C.C. & P.I. 정 O 록 , F/76 Previously healthy 2011.04 보라매병원에서 건강검진 시행 MRI 상 Granulosa cell tumor 의심 수술 권유 받음 2011.05.04 본원으로 전원 후 w/u Tumor Marker CEA/CA19-9/CA 125 : 1.4/14/10. Other History. PMHx .

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Case Presentation

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  1. Case Presentation Gynecology 성균관대학교 의과대학 2007313075 손의영

  2. C.C. & P.I. • 정O록, F/76 • Previously healthy • 2011.04 보라매병원에서 건강검진 시행MRI 상 Granulosa cell tumor의심수술 권유 받음 • 2011.05.04 본원으로 전원 후 w/u • Tumor Marker • CEA/CA19-9/CA 125 : 1.4/14/10

  3. Other History • PMHx. • HTN/DM/Tb/hepatitis/Allergy ( - / - / - / - / - ) • Hypothyroidism (+), MDD (+) • 약물력 : 씬지로이드(40YA)정신과약– 가스모틴, 사미온정, 자나팜정, 졸로푸트정 • 수술력: 없음 • FHx. • 당뇨 : 넷째 여동생, 다섯째 여동생 • 위암 : 첫째 오빠 • SHx. • Marriage : 기혼 • smoking: no • alcohol: no

  4. Review of system • GW / EF ( - / - ) • Weight change (-) • fever/chill ( - / - ) • Headache/dizziness ( - / - ) • Rhinorrhea/ cough /sputum ( - / - / - ) • Dyspnea (-) • chest pain / palpitation ( - / - ) • anorexia/nausea/vomiting ( - / - / - ) • abdominal pain/discomfort ( - / - ) • constipation/diarrhea ( - / - ) • hematemesis/melena/hematochezia ( - / - / - ) • Urinary Sx (-) • Arthralgia (-) • Myalgia (-)

  5. Physical Exam • Vital Sign 2011-05-22 17:26147/69 mmHg - 45 - 20 - 36℃ • G/A Generally well-looking appearance • Mentality Alert & well orientation • Abdomen Palpation – Soft & flat No tenderness/rebound tenderness

  6. CT (2011-04-08, 보라매 병원)

  7. MRI (2011-04-21, 보라매 병원) (장축6.5 cm)

  8. PET (2011-05-04, 보라매 병원)

  9. Problem List / Assessment • Problem List • #1. Left ovary mass • #2. Hypothyroidism • Assessment • #1. : R/O ovary cancer

  10. Therapeutic Plan • Surgery & Biopsy • Laparoscopy assisted vaginal hysterectomy Bilateral Salphingo-Oophorectomy • Total Omentectomy, adhesiolysis

  11. Surgery

  12. 수술중 발견사항 • Pelvic cavity • Adhesion : (Yes) ; Omentum과 abdominal anterior wall이 붙어 있었음 adhesiolysis was done • Ascites : Serous small amount • Adnexa • Rt. size : normal • Lt. size : goose egg shape : cysticcapsule : intact

  13. 수술중 발견사항 • Omentum : None • Skin incision : subumbilical 5mm, RUQ 5mm LLQ 12mm, suprapubic 5mm • Pelvic cavity : small amount fluid collection  washing cytology, adhesion (-), bleeding (-) • Uterus : grossly normal, size normal, no adhesion Mass (+) 2cm in EM (frozen : cystic hyperplasia) • Adnexa : Lt ovary tumor (over hens egg size) adhesion (+) Lt ov tumor와 uterus, tube 사이 frozen : granulosa tumor • PCDS : obliteration (-), ascites (-)

  14. Pathology • Granulosa cell tumor, adult type, left ovary • 1) tumor size : 7 x 6 x 4 cm • 2) surface involvement : cannot be evaluated • 3) mitosis : 2/10 HPF • 4) confined to left ovary ( Stage IA) • Complex hyperplasia w/o atypia • Chronic cervicitis, cervix • No diagnostic abnormalities recognized • left salpinx, right ovary and salpinx • No evidence of malignancy, omentum

  15. Progression (2011-06-01) • V/S stable (129/67 - 62 - 20 - 36.2) • Hemoglobin • 12.8(pre) → 10.0(#1) → 8.7(#3)Hemo-Q → 11.4(#5) • Albumin • 2.9(#1) → 3.1(#3) → 3.4 (#5) • Electrolyte • wnl(#1) → 143/5.2/113(#3) → 143/4.2/108(#4) • 금일 아침 GO(+) • L-tube drain • N/V (-/-) • Plan • Ambulation • L-tube remove • 추가 치료 없이 외래 경과 관찰

  16. Tumors derived from gonadalStroma<WHO classification of Sex core-Stromal tumor> • 1. Granulosa-stromal-cell tumors • Granulosa-cell tumor • Tumors in thecoma-fibroma group • 1) Thecoma (난포막종) • 2) Fibroma (섬유종) • 3) Unclassified (미분류종양) • 2. Sertoli-Leydig-cell tumors • Well-differentiated • 1) Sertoli cell tumor • 2) Sertoli-Leydig-cell tumor • 3) Leydig-cell tumor ; hilus cell tumor • Moderately differentiated • Poorly differentiated • With heterologous elements • 3. Gynandroblastoma • 4. Unclassified

  17. Feature; Sex cord-Stromal Tumor • 5~8% of ovarian malignancy • Synthesis of gonadal and adrenal steroid hormones • Estrogens, progesterone, testosterone ……

  18. Granulosa cell tumor 과립막세포종 • Features • Low grade malignancy • m/c stromal ovarian tumor • Usually unilateral • All age group (mean : 51y) • Symptoms • Abnormal uterine bleeding • Pelvic or abdominal pain • Pelvic mass • Ascites • Hormonal effect by Estrogen (EM hyperplasia, Mens irregularity)

  19. Granulosa cell tumor • Pathology • Granulosa cells w/ large, pale, oval nuclei • Coffee bean grooving • Microfollicullar pattern(Call-Exner bodies) – m/c • Treatments • Surgery : USO, TAH w/ BSO • Post-op radiation : Recurrent disease 의 예방

  20. Granulosa cell tumor • Prognosis • Late relapse • Residual tumor의 크기가 가장 중요 • Stage and Survival of Ovarian sex cord-stromal tumors William’s Gynecology TABLE 36-6

  21. FIGO stage

  22. FIGO stage

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