Case Presentation Gynecology 2007313075 C C P I

Case Presentation Gynecology 성균관대학교 의과대학 2007313075 손의영

C. C. & P. I. �정O록, F/76 �Previously healthy � 2011. 04 보라매병원에서 건강검진 시행 MRI 상 Granulosa cell tumor의심 수술 권유 받음 � 2011. 05. 04 �Tumor Marker 본원으로 전원 후 w/u �CEA/CA 19 -9/CA 125 : 1. 4/14/10

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 (-)

Physical Exam �Vital Sign �G/A �Mentality �Abdomen 2011 -05 -22 17: 26 147/69 mm. Hg - 45 - 20 - 36℃ Generally well-looking appearance Alert & well orientation Palpation – Soft & flat No tenderness/rebound tenderness

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

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

Surgery

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

수술중 발견사항 � Omentum : None � Skin incision : subumbilical 5 mm, RUQ 5 mm LLQ 12 mm, suprapubic 5 mm � Pelvic cavity : small amount fluid collection washing cytology, adhesion (-), bleeding (-) � Uterus : grossly normal, size normal, no adhesion Mass (+) 2 cm 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 (-)

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

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

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. Gynandroblastoma � 4. Unclassified

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

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

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

Granulosa cell tumor �Prognosis �Late relapse �Residual tumor의 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% 5 YSR I II-IV 85~95% 30~50% 90~95% 10~20% William’s Gynecology TABLE 36 -6

FIGO stage

FIGO stage