Peritoneal and Nodal Gliomatosis with Endometriosis, Accompanied with Ovarian Immature Teratoma: A Case Study and Literature Review
A 34-year-old female (G2P2A0L2) visited our hospital with an eight-month history of a palpable abdominal mass. She had a history of two cesarean sections. Normal beta-human chorionic gonadotropin with increased alpha-fetoprotein (22.7 ng/mL), cancer antigen (CA) 125 (61.7 U/mL), and CA19-9 (553.7 U/mL) were observed. Contrast-enhanced computed tomography showed a large solid and cystic mass in the left lower abdomen and pelvis. A huge left ovarian tumor filling the peritoneal cavity was found during laparotomy, and yellow-colored ascites (200 mL) was expelled. The external surface of the tumor was pinkish-tan, transparent, smooth, and intact. No pelvic adhesions were observed. Multiple firm, gray-white nodules measuring 0.1 to 0.3 cm were observed on the omentum, uterine serosa and posterior cul-de-sac peritoneum. One surface hemorrhagic nodule that measured 0.3 cm was found on the right ovary. Left salpingo-oophorectomy, right wedge resection, partial omentectomy, and biopsy of the uterine serosal nodules were performed. Under the impression of ovarian malignant tumor, intraoperative frozen biopsies were taken from the omental nodules, left ovary and salpinx. For staging, pelvic lymph node sampling, partial omentectomy and posterior cul-de-sac peritoneal resection were performed.\nGrossly, the excised left ovarian mass measured 21.0 cm in diameter and weighed 2,350 g. A predominantly solid mass with multicystic changes, which were filled with clear watery fluid, was observed on the cut surface (). Thirty sections were taken from the ovarian tumor, and various mature tissues of tridermal lineage were demonstrated (); the mass was comprised predominantly of mature glial tissue (90%) with focal immature neuroepithelial cells forming rosette-like structures with few mitosis (). Some mature neurons were also observed within the glial tissue. Choroid plexuses were also found. These immature neuroectodermal foci, including primitive mesenchyma, led to the diagnosis of an immature teratoma, grade 1, according to the classification of Robboy and Scully. There were no other germ cell tumor components, including a yolk sac tumor. The peritoneum, cul-de-sac and uterine serosa, as well as the opposite ovarian surface, showed involvement of glial peritonei (grade 0). Nodules of the right ovary, peritoneum and omentum were composed of glial tissue (grade 0) (). Out of 32 dissected lymph nodes, one left hypogastric lymph node showed one mature glial implant, i.e., nodal gliomatosis (grade 0) (, inset). Endometrial glands with stromata were found within the peritoneal nodules (). Some scattered psammoma bodies were observed in peritoneal and nodal gliomatosis, as well as brain tissue in the ovarian immature teratoma. Immunohistochemically, glial fibrillary acidic protein (prediluted, polyclonal, Dako, Glostrup, Denmark) (, left) immunostaining confirmed the glial nature of the tissue. The endometrial stroma of endometriosis was stained with CD10 (56C6, prediluted, Dako) (, right).\nThree cycles of chemotherapy of bleomycin, etoposide and cisplatin (BEP) were performed. After the surgery, alpha-fetoprotein, CA125, and CA19-9 levels reached the normal range. During the nine-month post-operative follow-up period, the patient had an uneventful course.