Case Presentation Gynecology

성균관대학교 의과대학2007313075 손의영

C.C. & P.I. 정 O 록 , F/76

Previously healthy

2011.04 보라매병원에서 건강검진 시행MRI 상 Granulosa cell tumor

의심수술 권유 받음

2011.05.04 본원으로 전원 후 w/u

Other HistoryPMHx.

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

Review of systemGW / 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 (-)

Physical ExamVital Sign 2011-05-22 17:26

147/69 mmHg - 45 - 20 - 36℃G/A Generally well-looking appear-

anceMentality Alert & well orientationAbdomen Palpation – Soft & flat

No tenderness/rebound tenderness

CT (2011-04-08, 보라매 병원 )

MRI (2011-04-21, 보라매 병원 )

( 장축 6.5 cm)

PET (2011-05-04, 보라매 병원 )

Problem List / AssessmentProblem List

#1. Left ovary mass#2. Hypothyroidism

Assessment#1. : R/O ovary cancer

Therapeutic PlanSurgery & Biopsy

Laparoscopy assisted vaginal hysterectomy Bi-lateral Salphingo-Oophorectomy

Total Omentectomy, adhesiolysis

Pre-op. Tumot Marker

CEA/CA19-9/CA 125 : 1.4/14/10

Surgery

수술중 발견사항Pelvic cavity

Adhesion : (Yes) ; Omentum 과 abdominal ante-rior wall 이 붙어 있었음 adhesiolysis was done

Ascites : Serous small amount

AdnexaRt. size : normalLt. size : goose egg

shape : cysticcapsule : intact

수술중 발견사항Omentum : 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 tumor 와 uterus, tube 사이frozen : granulosa tumor

PCDS : obliteration (-), ascites (-)

PathologyGranulosa 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

Complex hyperplasia w/o atypia

Chronic cervicitis, cervix

No diagnostic abnormalities recognized left salpinx, right ovary and salpinx

No evidence of malignancy, omentum

Progression

Tumors derived from gonadal Stroma <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. Gynandroblastoma4. Unclassified

Feature; Sex cord-Stromal Tumor5~8% of ovarian malignancy

Synthesis of gonadal and adrenal steroid hormonesEstrogens, progesterone, testosterone ……

Granulosa cell tumorFeatures

Low grade malignancym/c stromal ovarian tumorUsually unilateralAll age group (mean : 51y)

SymptomsAbnormal uterine bleedingPelvic or abdominal painPelvic massAscitesHormonal effect by Estrogen (EM hyperplasia, Mens irregu-

larity)

과립막 세포종

Granulosa cell tumorPathology

Granulosa cells w/ large, pale, oval nucleiCoffee bean groovingMicrofollicullar pattern(Call-Exner bodies) – m/c

TreatmentsSurgery : USO, TAH w/ BSOPost-op radiation : Recurrent disease 의 예방

Granulosa cell tumorPrognosis

Late relapseResidual tumor 의 크기가 가장 중요

Stage and Survival of Ovarian sex cord-stromal tumors

Adult Granulosa cell Sertoli-Leydig cell

Stage at Dx I II-IV

80~90% 10~20%

97% 2~3%

5YSR I II-IV

85~95% 30~50%

90~95% 10~20%

William’s Gynecology TABLE 36-6

FIGO stage

FIGO stage