An asymptomatic ovarian steroid cell tumor with complete cystic morphology: A case report
A 52-year-old woman (2-0-1-2) was referred to the gynecology department of our hospital for a left adnexal mass incidentally found by liver computed tomography (CT). She was a hepatitis B carrier diagnosed with liver cirrhosis nine years previously, and the liver CT was part of her routine follow-up. Past surgeries included total abdominal hysterectomy for uterine myoma 14 years previously, and an exploratory laparotomy for abdominal adhesions and a peritoneal inclusion cyst 3 years ago. She had menarche at the age of 12 years, and her family history was unremarkable. She was taking hepatic protective medication.\nAbdominal examination revealed a fist sized palpable mass, without tenderness or rebound tenderness. On pelvic examination, the uterus was absent due to previous hysterectomy and the right adnexa was not palpable due to the central location of the left adnexal mass. No signs of virilization or hirsutism were observed. Laboratory analysis revealed normal values of blood count, hepatic-renal function, coagulation, and electrolytes. Tumor marker studies showed a slightly increased CA-19-9 of 40.62 U/mL (normal range, 0 to 37 U/mL), a normal carcinoembryonic antigen (CEA) of 3.69 ng/mL, and a normal CA-125 of 8.04 U/mL. Transvaginal ultrasound examination revealed no uterus and a large 10×8×7 cm3 sized well defined cystic mass located at the center of the pelvic cavity, with internal septation and no apparent solid portion (). The right adnexa was not clearly observed and no ascites within the pelvic cavity was found, suggesting a recurrent peritoneal inclusion cyst formed after the previous two surgeries.\nAn additional CT scan of the abdomen and pelvis showed a 10×8 cm sized round mass at the left adnexa, with internal septations and an enhancing solid portion, indicative of a borderline or malignant epithelial ovarian tumor. There was no lymph node enlargement or ascites, but the liver showed signs of cirrhosis ().\nThe patient underwent a laparoscopy under general anesthesia. The peritoneum and ileum displayed extensive adhesion from the umbilical trocar site to the previous laparotomy site, and although there was no ascites, the mass was not readily observed due to substantial adhesion. Adhesiolysis was performed on the adhesions to the surrounding peritoneum, small bowel, descending colon and sigmoid colon, revealing several septations of the mass and about 100 mL of dark brown serous fluid. As the adhesions were removed, no uterus was revealed, due to the previous hysterectomy, and adhesiolysis of the bladder revealed a 5×4 cm sized bluish left adnexal mass with a thin wall and serous contents. No abnormal signs were noted in the right adnexa, peritoneum, or omentum. After the left salpingo-oophorectomy, the ileum and sigmoid colon were injured from adhesiolysis by a tendency to tear easily, so laparotomy was performed with the general surgery department. The ileum had a 5 cm linear tear at 80 cm superior to the ileocecal valve and segmentectomy with anastomosis was performed. The sigmoid colon had a 3 cm linear tear, which was sutured. During surgery, gross examination and palpation of the internal abdominal organs yielded no notable abnormalities. The abdominal CT suggested a borderline or malignant epithelial ovarian tumor, but because of the patient's history of surgery 3 years before for abdominal adhesion and peritoneal inclusion cyst, and because extensive adhesion was noted during surgery, a recurrent peritoneal inclusion cyst was suspected and the surgery was concluded without any additional procedures.\nGross pathological findings showed a 6×6 cm sized mass, mostly cystic. The outer surface had heavy adhesions, and the mass was untidy internally, with a small inner solid portion, but no signs of hemorrhage or necrosis. Microscopic findings exhibited diffuse tumor cells with abundant eosinophilic granular cytoplasm and vacuolization, with no signs of nuclear atypicality and a mitotic count of 5 per 10 HPF (). Immunohistochemistry revealed a positive reaction to inhibin, calretinin, and vimentin, a moderately positive reaction to CD99, and a negative reaction to pan-CK, S-100, placenta-like alkaline phosphatase, and chromogranin (). The Ki-67 labeling index was low, under 5%. The histopathologic features supported a diagnosis of an ovarian steroid cell tumor, NOS.\nPostoperatively, the patient's testosterone level was normal, at 0.32 ng/mL (normal range, 0.14 to 0.76 ng/mL). No hormonal assays were done before surgery as there were no clinical manifestations of any hormone secretion. She is on regular follow-up at our outpatient clinic, with no evidence of recurrent disease for 21 months.