S2447 Acute Abdominal Pain; The Answer Lies in the Remote History

Abstract

INTRODUCTION: Granulosa cell tumors (GCT) encompass 2-3% of ovarian tumors characterized by low malignancy potential and late relapse, which rarely metastasize to the liver. We describe a patient with a recurrent ovarian GCT with liver and diaphragm metastasis 12 years after her initial diagnosis. CASE DESCRIPTION/METHODS: 51-year-old diabetic female with a history of cholecystectomy, and stage IA granulosa cell tumor status post total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-SBO) with post-procedure chemotherapy with carboplatin-taxol in 2008, currently in remission; presented with intermittent and sharp right upper quadrant abdominal pain for a week. Her liver chemistry showed ALT: 379; AST: 254; ALP: 171 U/l. Her viral markers were negative. Abdominal imaging showed a new subcapsular liver lesion involving the right hepatic lobe concerning for hematoma versus metastases. MRI showed a persistent hepatic subcapsular process of unclear etiology. Diagnostic laparotomy was performed which showed multiple implants of soft, removable tissue throughout the dome of the liver, and the diaphragm. Pathology revealed granulosa cells consistent with the recurrence of granulosa cells as liver metastasis. The patient was later discharged with multidisciplinary outpatient follow up. DISCUSSION: Granulosa cell tumors (GCT) are the most common type of sex cord-stromal tumors which represent 2–3 % of total ovarian tumors. GCT tends to bleed, often presenting with intrapelvic bleeding and lower abdominal pain. They are associated with a favorable prognosis, especially when they are detected in the early stages. Reported 5-year survival rates range from 55% to 97%. Several series have shown the recurrence rates range between 9 and 35%. GCTs are associated with a low incidence of hepatic metastasis (<5–6%). Call-Exner bodies are pathognomonic for its diagnosis with immunohistochemistry analysis positive for CD56, CD99, inhibin-alfa, and S-100. Long-term free disease periods can prolong in some cases to more than 20 years. Surgical resection of the liver lesion remains to be the most successful approach to provide a better percentage of remission, quality of life, and disease-free intervals despite its possible complications. It is usually followed by systemic chemotherapy to obtain better tumor control and an improved long-term survival rate.Figure 1.: Subcapsular process along the right lobe of the liver.Figure 2.: Lower and high magnification tumor cells consistent with granulosa cell tumor.Figure 3.: Call-exner body.