Metastasis from a granulosa cell tumour of the ovary presenting in the chest but arising below the diaphragm
G. J. COOPER'[', A. D. BULL*, A. H. KENNEDY* AND G. A. L. WILKINSON
Departments of Cardiothoracic Surgery and Pathology*, Northern General Hospital, Sheffield $5 7A U, U.K.
Introduction
While thoracic metastases from ovarian carcinoma are common, other forms of ovarian tumour seldom spread to the chest (1). When such spread does occur it is usually by the lymphatic or haematogenous routes. We report a case of a thoracic metastasis from an ovarian granulosa cell tumour that entered the chest by direct invasion through the diaphragm.
Case Report
A 54-year-old, non-smoking woman presented complaining of right-sided chest pain, back pain, one episode of haemoptysis and weight loss of I stone.
Received 23 May 1990 and accepted in revised form 10 December 1990.
tTo whom correspondence should be addressed.
Eighteen years previously she underwent total abdominal hysterectomy with bilateral salpingo- oophrectomy for a granulosa cell tumour of the left ovary. At that time there was no evidence of extra-ovarian spread.
She remained well until her current illness. Nothing abnormal was found on examination but her erythro- cyte sedimentation ratio was raised at 60 mm h -~. Other routine blood tests were normal. Chest X-ray showed a well-defined opacity on the right hemi- diaphragm (Plate 1). Computerized tomography (CT) confirmed the presence of a well circumscribed mass confluent with the right hemi-diaphragm but with nor- mal surrounding lung, there were gallstones but no other abnormality in the abdomen or pelvis. Further chest X-ray showed the mass to have increased in size and she was therefore admitted for surgery.
Plate 1
0954-6111/91/040327 + 03 $03.00/0
P.A. (a) and right lateral (b) chest X-ray on presentation.
Plate 2 The resected specimen showing superiorly the right lower lobe, below this is the tumour with a rim ofdiaphragm around its lower third.
Bronchoscopy showed external compression of the right lower lobe bronchi but no endo-bronchial lesion. At thoracotomy the right lower lobe was found to be collapsed; compressed by a well en- capsulated mass which was invading its inferior surface and arising from the diaphragm. Further dissection revealed that this mass extended through the diaphragm and was adherent to, but not invad- ing, the liver. The tumour was stripped from the liver and excised with a rim of diaphragm and the right lower lobe en-bloc.
The resected specimen weighed 1.5 kg and com- prised the lower lobe of the right lung with the tumour adherent to and infiltrating its inferior surface. The tumour was spherical, 9 cm in diameter, with a smooth surface and an attached rim of muscle (Plate 2).
Microscopically, the centre of the tumour was necrotic but at the edge groups of viable tumour cells were lying in dense collagen. These cells were small and darkly staining with very little cytoplasm; there was little nuclear pleomorphism and few mitoses but many nuclei showed nuclear grooving giving them a "coffee bean' appearance. The tumour cells had a variable arrangement, there were areas with a microfollicular growth pattern forming characteristic Call-Exner bodies and other less well-differentiated areas with cells arranged in a zig-zag or 'watered silk' pattern. These features were similar to those seen in the original ovarian tumour removed 18 yr previously and were tho~e o fa granulosa cell tumour.
Plate 3 High-power view of granulosa cells showing Call-Exner bodies and nuclear grooving.
Metastasis from a granulosa cell tumour 329
Following surgery the patient initially made a good recovery. A C T scan 2 months after operation, how- ever, showed a mass below the diaphragm, adjacent to the left crus. This was interpreted as being either malignant lymphadenopathy or a peritoneal deposit. This mass was not present on a repeat CT scan follow- ing a course of radiotherapy to this area but the liver was found to contain multiple metastatic deposits.
Discussion
Granulosa cell tumours comprise 3-10% of malig- nant ovarian tumours (2). They have low malignant potential but recurrence many years after initial treatment is well recognized (l). This is usually within the pelvis or abdomen (1) and is thought to arise from peritoneal seedlings (3). As they increase in size metastases tend to displace adjacent structures rather than invade them (3).
This metastasis extended through the diaphragm. We believe that it arose from a seedling on the perito- neum below the right hemi-diaphragm, the patient subsequently developed another sub-diaphragmatic deposit which responded to radiotherapy. In this position its capacity to expand into the abdomen is limited by the liver which cannot be displaced. Expanding into the chest it was able to compress the right lower lobe before starting to invade its inferior surface. The findings are against it being a pulmonary
metastasis and the lack of mediastinal involvement is against it arising there. Considering the known behav- iour of metastases from granulosa cell tumours, the radiological, operative and pathological findings are best explained by a sub-diaphragmatic origin of this metastasis which invaded into the chest.
To our knowledge, such an event has not been previously reported. The diaphragm is usually con- sidered a barrier to direct tumour spread but the finding of a mass arising from the upper surface of the diaphragm with a history of previous intra-abdominal malignancy should raise the possibility that it arose from below the diaphragm.
Acknowledgement
We thank Dr Judith Heaton for providing the histological slides of the original tumour.
References
1. Evans AT, Gaffay TA, Malksian GD, Annegers JF. Clinico-pathological review of 118 granulosa and 82 theca cell tumours. Obstet Gyneco11980; 52:231-238.
2. Steven-Piver M. Ovarian Malignancies. The Clinical Care of Adults and Adolescents. Edinburgh: Churchill Livingstone, 1980; 167-181.
3. Lusch C J, Meracino TM, Runyeos WK. Delayed recur- rence and chemotherapy of a granulosa cell tumour. Obstet Gyneco11978; 51: 505-507.
