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Indian Journal of Cancer, Vol. 48, No. 3, July-September, 2011, pp. 361-362 Letter to Editor Dual malignancy: An interesting concurrent mixed epithelial ovarian tumor with esophageal carcinoma AK Chowhan1, A Jena2, SB Kinnera1, R Patnayak1, OM Reddy3, KM Reddy1 1 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India Code Number: cn11092 PMID: 21921338 DOI: 10.4103/0019-509X.84911 Sir, The occurrence of a second malignancy in a patient with a known malignant tumor is not very uncommon. Tumors of the ovary represent about 30% of all cancers of the female genital system, [1] half of which are epithelial tumors. [2] The reported incidence of mixed epithelial tumor (MET) varies from 0.5 to 4% of surface epithelial tumors. [1] Although a few cases of ovarian MET have been reported in the literature, [3],[4] yet none could be found in association with a second malignancy in contrast to the present case. A 50-year-old Indian female presented with complaints of progressive dysphagia for both solid and liquids since 4 months associated with a loss of appetite and weight. She was habituated tobacco chewer for the past 25 years, had four children and attained menopause 4 years back. There was no history of either using any oral contraceptive pills or hormonal therapy. No family history of malignancy was observed. A CT scan showed circumferential lesion of esophagus noted from the level of carina extending for a length of 8.8 cm with 2.2 cm thickness [Figure - 1] which was enhancing heterogeneously on contrast. Upper gastrointestinal endoscopy showed an ulceroproliferative growth in the middle one-third of esophagus at 24 cm from incisors. A biopsy was taken which revealed moderate to well-differentiated squamous cell carcinoma. The surgical plan was to perform transhiatal esophagectomy with a two field lymphadenectomy. Peroperatively, the growth was found to be abutting the pulmonary trunk. Multiple matted and hard celiac lymph nodes were also present, raising suspicion of metastasis, which was confirmed on the frozen section. It was decided to perform palliative feeding jejunostomy rather than resection of the growth and later to institute radiotherapy. Incidentally and interestingly a cystic lesion was noted in the left ovary, peroperatively thought to be benign cyst, a small biopsy of which was reported as papillary serous cystadenocarcinoma on the frozen section. Staging laparotomy was not taken up as the patient was already diagnosed of carcinoma esophagus with metastasis. The entire ovarian cyst was excised and sent for histopathological examination. An immediate postoperative CA-125 assay was found to be elevated. The ovarian cystic mass (20 × 10 × 7 cm 3 ) exhibited smooth to areas of the ragged outer surface with congested blood vessels. A cut section revealed mostly a multiloculated cyst filled with seromucinous fluid, multiple tiny papillary projections, and few solid areas [Figure - 2]. Microscopic examination revealed varying histological exhibitions comprising of mucinous and serous papillary cystadenocarcinoma [Figure - 3]a with few psammoma bodies. The solid areas revealed closely apposed endometrial looking glands exhibiting pleomorphic hyperchromatic nuclei and many atypical mitotic figures [Figure - 3]b. In addition some of the glands were exhibiting squamoid differentiation in the form of luminal keratinous debris and an occasional morule formation. Seventy percent of the tumor areas were of the mucinous type whereas serous and endometrioid components comprised 15% each, hence diagnosed as malignant MET comprising of papillary mucinous and serous cystadenocarcinomas admixed with endometrioid adenocarcinoma. The mucinous lining epithelial cells were strongly positive for the mucicarmine stain. [Figure - 3]c. Immunohistochemical stains revealed strong positivity for p53, Cerb-B2, and moderate to intense focal positivity for Ki-67 [Figure - 4]. The synchronous occurrence of a MET of ovary in a case of esophageal carcinoma being treated at present appears paradoxically a primary tumor entity of ovary rather than the usual suspected metastasis. [5] A patient with malignancy needs thorough and close follow up, so that a second malignancy can be detected at an early stage and treated promptly. Further, it is of importance for a pathologist to give generous sections of any solid-cystic ovarian mass including all variegated areas to identify various histopathological patterns which may be present. Acknowledgments We wish to thank senior technicians Mrs. Ushanandini and Mr. Ramanna for immunohistochemical stains. References
Copyright 2011 - Indian Journal of Cancer The following images related to this document are available:Photo images[cn11092f2.jpg] [cn11092f1.jpg] [cn11092f4.jpg] [cn11092f3.jpg] |
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