A 49-year-old woman, gravida 2, para 2, comes to the office due to 10 months of irregular vaginal bleeding. Her last menstrual period was 3 years ago. She has a history of hypothyroidism and takes levothyroxine daily. Ultrasound reveals a thickened endometrium and a solid left adnexal mass. Endometrial biopsy is abnormal, and the patient requires surgery. Intraoperatively, the ovarian mass is yellow and firm. Pathology reports small cuboidal cells in sheets with gland-like structures containing acidophilic material. The cells are arranged in a microfollicular pattern around a pink, eosinophilic center. Which of the following is most likely secreted by this patient's tumor?

Question

A 49-year-old woman, gravida 2, para 2, comes to the office due to 10 months of irregular vaginal bleeding.  Her last menstrual period was 3 years ago.  She has a history of hypothyroidism and takes levothyroxine daily.  Ultrasound reveals a thickened endometrium and a solid left adnexal mass.  Endometrial biopsy is abnormal, and the patient requires surgery.  Intraoperatively, the ovarian mass is yellow and firm.  Pathology reports small cuboidal cells in sheets with gland-like structures containing acidophilic material.  The cells are arranged in a microfollicular pattern around a pink, eosinophilic center.  Which of the following is most likely secreted by this patient's tumor?

Quizplus · Accepted Answer

11ec160b_3921_cb8c_9249_e792b8064700_MD0001_00 Granulosa cell tumors comprise approximately 5% of all ovarian tumors and are primarily identified in postmenopausal women. These tumors are derived from the ovarian stroma and are classified as sex cord-stromal tumors, which contain a predominance of granulosa cells and a scattering of theca cells. The granulosa cells are small and cuboidal in shape, grow in cords or sheets, and form follicle- or rosette-like structures (Call-Exner bodies) that have a gland-like appearance with a pink eosinophilic center and coffee bean nuclei (black arrows). Theca cells are plump with lipid contents, which give the mass a yellow color on gross inspection. Typically, granulosa-theca cell tumors are unilateral and large. Unlike epithelial ovarian cancers, these masses secrete estrogen and can present with endometrial hyperplasia (eg, postmenopausal bleeding with thickened endometrium on ultrasound). The unopposed estrogen leads to hyperplasia of the endometrial cells and glands, and the increased cellular division of the hyperplastic cells in turn increases the risk of cellular atypia and endometrial carcinoma. In young patients, excessive estrogen levels may cause precocious sexual development. (Choice A) α-fetoprotein (AFP) is normally produced by the fetal liver and yolk sac, but it can also be used as a tumor marker in patients with hepatocellular, nonseminomatous testicular, or ovarian carcinomas. (Choice B) β-hCG is used to confirm pregnancy and screen for gestational trophoblastic disease and germ cell tumors. (Choice C) Cancer antigen 125 (CA-125) is elevated in epithelial carcinomas of the ovary (eg, serous, endometrioid, clear cell). Stromal tumors do not release significant amounts of CA-125. (Choice E) Testosterone is produced by Sertoli-Leydig tumors, another type of ovarian sex cord tumor. Affected patients present with evidence of hyperandrogenism (eg, hirsutism, clitoromegaly, deepening voice). (Choice F) Struma ovarii is a germ cell tumor of the ovary that can cause hyperthyroidism by secreting thyroxine. Histopathology of this tumor reveals mature thyroid tissue. Educational objective: Granulosa cell tumors are sex-cord stromal tumors of the ovary that secrete estrogen and can cause endometrial hyperplasia. Call-Exner bodies (cells arranged in a microfollicular or rosette pattern) are seen on microscopy. On gross pathology, the tumor appears yellow due to the lipid content in theca cells. __________ References: Pathology of the adnexal mass. (http://www.ncbi.nlm.nih.gov/pubmed/25608250)

A 49-Year-Old Woman, Gravida 2, Para 2, Comes to the Office