Bilateral Salpingoopherectomy Research Articles

INTRAOPERATIVE FROZEN SECTION ANALYSIS OF ENDOMETRIOID OVARIAN BORDERLINE TUMOR: A DIFFICULT DIAGNOSIS

Abstract Introduction/Objective Borderline ovarian tumors (BOT) comprise approximately 15% of all primary ovarian neoplasms; of these endometroid borderline ovarian tumors (EBOT) are much rarer (2-3%). BOT is often potentially misdiagnosed as a malignant tumor based on its challenging histomorphological features and thus, treated aggressively. Herein, we present an unusual case of EBOT with adenofibromatous pattern in a 50-year-old gravida 3, para 2 female diagnosed on intraoperative frozen sections (IOFS). Methods/Case Report Patient with history of endometriosis presented with left lower quadrant abdominal pain. MRI revealed complex bilateral ovarian masses with solid and cystic components measuring 5 cm and 6.7 cm in right and left ovary, respectively. An ovarian malignancy was suspected. Patient underwent exploratory laparotomy, total abdominal hysterectomy with bilateral salpingo-opherectomy, and omentectomy. Grossly, bilateral ovaries (BO) showed intact capsule with solid and cystic components. On IOFS, the solid areas demonstrated endometrioid glands arranged in a lobular fashion with squamous morules. The cystic component demonstrated papillary projections with squamous differentiation. Cytology is mildly atypical at best. Based on these findings, a diagnosis of EBOT was made, necessitating staging. Differential diagnoses include atypical endometriosis, endometrioid adenofibroma (EAF) and endometrioid adenocarcinoma (EA). Lack of endometrial stroma surrounding the glands ruled out endometriosis. Presence of CC with papillary architecture ruled out EAF and lack of destructive stromal invasion with desmoplasia, confluence of glands and significant cytologic atypia ruled out EA. Final histopathological diagnosis of formalin-fixed paraffin-embedded specimen revealed EBOT, pT1bN0M0. Uterus and cervix revealed endometrial hyperplasia with atypia, adenomyosis, leiomyomas, and endocervical polyp. Results (if a Case Study enter NA) NA Conclusion The accurate diagnosis of BOT during IOFS is critical as it directs surgeons towards staging studies and in choosing conservative surgical treatment over aggressive treatment especially in cases of young women who desire future childbearing. As this is a rare entity, it serves the pathologist well to keep all relevant differential diagnoses in mind.

Does coexistence of endometrial cancer and adenomyosis affect survival outcomes? A retrospective cohort study

The aim of this study is to investigate cancer survival parameters in patients with a combination of adenomyosis and endometrial carcinoma in pathological specimens. This is a retrospective cohort study conducted in a tertiary health center. Between January 2010 and December 2016, a total of 370 patients with a diagnosis of endometrial carcinoma who had undergone at least total abdominal hysterectomy and bilateral salpingoopherectomy. After excluding the patients from the pathology after reviewing the reports, 76 patients with adenomyosis were included in the study group and 287 patients without adenomyosis were included in the control group. The mean age of all patients was 63.6 ± 8.2 years. The mortality rate was 9.2% in patients with adenomyosis and 12.9% in patients without adenomyosis (p = 0.382). Overall, the mean time from diagnosis to death was 41.8 ± 24.7 months, which did not differ between patients with adenomyosis (29.3 ± 18 months) and without adenomyosis (44.6 ± 25.4 months, (p = 0.117). The presence of adenomyosis did not significantly affect overall survival (p = 0.434) or disease-free survival (p = 0.146). Median disease-free survival was 119 months in patients without adenomyosis and 120 months in patients with adenomyosis. None of the factors we studied affected survival in patients with adenomyosis. In our study, the presence of adenomyosis was found in 20.9% of patients who underwent hysterectomy for endometrial cancer, and this association had neither a positive nor a negative impact on disease prognosis, i.e., mortality rate, disease-free survival and overall survival.

8453 Low Anterior Resection in Stage IV Endometriosis in a Post Hysterectomy Patient

<h3>Study Objective</h3> To demonstrate technique in resection of stage IV endometriosis in a post-hysterectomy patient, including parametrial dissection, ureterolysis, rectovaginal mobilization, and low anterior resection with reanastamosis. <h3>Design</h3> A narrated surgical video. <h3>Setting</h3> An endometriosis-focused surgical practice in the private setting. <h3>Patients or Participants</h3> The patient is a 40-year-old woman with three previous laparoscopies, including hysterectomy and bilateral salpingoopherectomy. She was notably told after her most recent laparoscopy that she had no residual disease. Patient presented for consult with severe dyschezia, dyspareunia, and pelvic pain. Exam findings were concerning for severe rectovaginal endometriosis at the pelvic cuff. <h3>Interventions</h3> The patient was taken to OR for diagnostic laparoscopy, and ultimately a full excision of endometriosis was performed, including parametrectomy, ureterolysis, and low anterior colon resection with stapled reanastamosis. <h3>Measurements and Main Results</h3> 6 months postop the patient reports near complete relief of her symptoms, and substantially improved quality of life. <h3>Conclusion</h3> Low anterior resection in stage IV endometriosis may be necessary even after hysterectomy for endometriosis. A previous negative laparoscopy does not rule out high grade disease, as inexperienced physicians may under diagnose even severe disease. Hysterectomy and salpingoopherectomy does not resolve pre-existing rectovaginal endometriosis, and symptoms may persist or even worsen despite this treatment.

Adherence to guideline-based preoperative and intraoperative care during risk-reducing bilateral salpingo-oophorectomy among gynecologist-oncologists compared to general gynecologists (335)

<b>Objectives:</b> Risk-reducing Bilateral Salpingoopherectomy (rrBSO) is the only intervention proven to reduce mortality from epithelial ovarian cancer in patients with hereditary breast and ovarian cancer (HBOC)-associated gene mutations. Optimal surgical technique for rrBSO includes five steps outlined in 2005 by the Society of Gynecologic Oncology and the American College of Obstetrics and Gynecology. These five steps include: <i>1)</i> Abdominal survey; <i>2)</i> Peritoneal washings; <i>3)</i> Entering retroperitoneal space and creating pedicle 2cm from the ovary; <i>4)</i> Dividing pedicle at the uterus; and <i>5)</i> Removal in an endoscopic bag. rrBSO can be performed by both general gynecologists (GYN) and gynecologist oncologists (GO). We aimed to evaluate adherence to surgical guidelines for rrBSO when performed by GO compared to GYN and assess the utility of preoperative (preop) CA-125 and pelvic ultrasound as predictors of malignancy identified at the time of rrBSO. <b>Methods:</b> A retrospective review of patients who underwent rrBSO from October 1, 2015, to December 31, 2020, by faculty and privately employed physicians at three high volume academic sites within a healthcare system was performed. The primary outcome was compliance with all five steps of rrBSO as dictated by a surgeon. Secondary outcomes included the presence of a pre-malignant or malignant lesion at the time of rrBSO and association with preoperative imaging or CA-125. Patient demographics and clinical characteristics were collected. Descriptive statistics for continuous variables were calculated. Univariable logistic regression was used to screen variables with a p-value criterion of p < 0.05 for entry into the model selection procedure. Multivariate regression was used to identify differences in practice patterns. <b>Results:</b> A total of 236 patients were included. Among them, 122 (52%) cases were performed by a GO. Among the cases documented by GO, 27 (22%) performed all five steps of the procedure, 65 (53%) performed four steps, 26 (21%) performed three steps, four (3%) performed two steps, and none performed only one step. Among the 114 cases by GYN, four (4%) performed all five steps, 17 (15%) performed four steps, 50 (44%) performed three steps, 40 (35%) performed two steps, and three (3%) performed only one step. Univariable analysis demonstrated no association between demographic variables and procedure compliance. GO were significantly more likely to adhere to all five recommended surgical steps, (OR: 7.816, 95% CI: 2.640-23.138, p=0.0002). In total, five patients (2.12%) had pre-malignant or malignant lesions diagnosed at the time of rrBSO. None of the five patients had documented preop CA-125 or preop imaging, and all five cases occurred in patients undergoing surgery with GYN. <b>Conclusions:</b> Our results show a statistically significant difference in compliance to procedural steps of rrBSO between GYN and GO. This demonstrates a need for institution-wide education and implementation of procedural standards and standardized nomenclature for dictations to ensure provider adherence to rrBSO guidelines. Fig. 1

28596 Efficacy of laser CO2 treatment for lymphedema secondary to gynecologic cancer therapy

Genital lymphedema is a debilitating possible side effect of gynecologic and pelvic malignancies. With a prevalence of 2-3 million cases in the US, lymphedema is a common chronic inflammatory condition due to lymphatic insufficiency often occurring secondary to surgery, tumor burden, trauma or radiation. Studies estimate 1 in 5 breast cancer patients will experience chronic upper extremity edema; however, other malignancies are less explored. Genital lymphedema may significantly affect quality of life with sequela of lymphorrhea, swelling, and urinary retention. Suggested first line care is non-surgical management; however, no standard recommendations exist. We present a 62-year-old woman with stage IIB grade 3 cervical cancer presenting to dermatologic surgery for evaluation of chronic vulvar lymphedema after total abdominal hysterectomy with bilateral salpingoopherectomy and lymph node dissection with subsequent chemotherapy and pelvic radiation. She developed painful bilateral lower extremity, anterior pelvis and mons pubis lymphedema within two months of treatment. The patient experienced emotional distress due to seven episodes of cellulitis, admissions to the hospital, impaired ability to exercise and decreased aesthetic satisfaction. After failing traditional management with chronic antibiotic therapy, compression stockings and massage therapy and having been rendered a poor surgical candidate for lymph node transfer, she visited dermatology. Six sessions of fractional CO2 laser [Lumenis Deep Fx Fractional CO2 laser, Coherent USA] therapy have been performed with success in decreasing lymphorrhea, edema, and cellulitis episodes allowing stoppage of prophylactic antibiotics. This case explores and highlights the use of fractional CO2 laser therapy for treatment of lymphedema and its sequela.

Clinical Characteristics of 46,XX Males with Congenital Adrenal Hyperplasia

Objective:To retrospectively evaluate the follow-up data in patients with 46,XX congenital adrenal hyperplasia (CAH) who were raised male.Methods:A national database was created. The data of patients were asked to be recorded in the data form.Results:The median (range) age of diagnosis was three (0.1-18.3) years in 44 patients. Twenty nine cases were diagnosed after the age of two years. Most (95.4%) cases were stage 4-5 virilized. Hysterectomy and bilateral salpingoopherectomy, at a median age of 7.25 (2.4-25.3) years, was performed in 35 cases. Testicular prostheses were placed in 11 (25%) cases at a median age of 11.2 (2.8-17) years. The median final height was 149.2 (132.8-172) cms in 38 patients, including simple virilizing (n=18), salt-wasting (n=6), and 11-beta hydroxylase (n=12). Of the 16 patients above the age of eighteen, university education was completed in 25%.Conclusion:It was seen that most (65.9%) of the 46,XX CAH cases raised male were diagnosed after two years of age. In these cases, hysterectomy and bilateral salpingoopherectomy, genital corrective surgeries and testicular prosthesis operations were performed in a very wide age rage.

Intra-abdominal Breakage of Laparoscopic Needle Holder Tip and Its Retrieval Under Fluoroscopic Guidance.

Intra-operative breakage of laparoscopy instruments is a rare occurrence. It entails a risk of the foreign body being retained in the abdomen and may lead to medico-legal implications. The foreign body migrates due to bowel movements. Therefore, the retrieval of such foreign bodies can be challenging even for a highly skilled and experienced surgeon. Fluoroscopy can guide in locating the missing foreign body. The only preventive measure is the vigilance of the operating team and thorough inspection of all the instruments prior to completion of surgery. We present a case report of a 50-year-old lady who underwent total laparoscopic hysterectomy with bilateral salpingoopherectomy at a private nursing home. During the closure of the vault, the tip of the needle holder broke inside the abdomen and the primary surgeon was unable to retrieve it. The missing tip of the needle holder was removed from the right hypochondriac region, by a second laparoscopic surgery by an advanced laparoscopic surgeon under fluoroscopic guidance. Intra-operative breakage of laparoscopy instruments can occur, demanding a great deal of expertise for the retrieval of such foreign bodies. Fluoroscopy can guide in locating the missing foreign body which can be retrieved by an expert laparoscopic surgeon.

Table Sugar and Salt for the Reduction of Incarcerated Prolapse with Vescical Calculi- A Case Report

Incarcerated prolapse in association with bladder calculi is a rare occurrence. Table sugar and salt, which are both hygroscopic agents, have been used to reduce incarcerated bowel prolapse. Table sugar and salt was used in the following case of incarcerated procidencia with vescical calculi. Cystotomy with bladder stone removal was done by abdominal route. Total abdominal hysterectomy with bilateral salpingoopherectomy was done with pelvic floor repair and vault suspension.

Synchronous occurrence of two primary gynaecological tumors: A case report

Synchronous occurrence of two primary tumors is rare. Endometrial and ovarian cancers are the most frequently simultaneously occurring primary tumors. Here we are presenting, similar rare presentation of 40 years old lady who has been referred to us with complaint of abnormal uterine bleeding and lump abdomen since one year. Patient underwent total abdominal hysterectomy and bilateral salpingoopherectomy with surgical staging. Histopathological examination showed moderately differentiated endometroid ovarian carcinoma and endometroid adenocarcinoma of uterus with metastasis to cervix. Keywords: Synchronous, Primary tumors, Endometrial cancer, Ovarian cancer.

2548 Jejunal Perforation: A Very Rare Presentation of Jejunal Adenocarcinoma

INTRODUCTION: Small bowel malignancies constitute less than 5% of all gastrointestinal malignancies. The most common histological types of small bowel cancer are adenocarcinoma, neuroendocrine cancer, lymphoma and sarcoma. Adenocarcinoma represents 25-40% of primary small bowel malignancies, with the highest incidence in the duodenum and the incidence progressively decreasing down the small intestine. CASE DESCRIPTION/METHODS: A 69 year old previously healthy women presented with periumbilical pain for four weeks. She also reported early satiety but no weight loss. The night prior to presentation abdominal pain became severe with one episode of vomiting. There was no history of chronic NSAIDs use. She had a 40 pack-years smoking history. She had two cesarean sections and a total abdominal hysterectomy with bilateral salpingo-opherectomy. She did not have routine colorectal cancer screening. On abdominal examination she had a distended abdomen and mild periumbilical tenderness. Laboratory testing revealed leukocytosis of 15000/µL and a hemoglobin level of 10.2 g/dl with a low MCV 78.6 fl. Noncontrast CT of the abdomen showed wall thickening and focal perforation in a loop of jejunum. There was no bowel obstruction and no free intraperitoneal air seen. Exploratory laparotomy revealed a large inflammatory mass in the proximal jejunum densely adherent to the mid-transverse colon. There was a large perforation (3.5 cm of greatest dimension) of a jejunal mass. The mucosa surrounding the defect was hyperemic and thickened. Microscopic examination showed a well-differentiated adenocarcinoma invading into muscularis propria. There was no lymphovascular invasion and no metastasis were identified in 13 excised regional lymph nodes. Immunostains were negative for cytokeratin 7 (expressed in lung and pancreatic adenocarcinomas), focally positive for cytokeratin 20 (colorectal adenocarcinoma) and were positive for CDX2. CDX2 is a highly sensitive and specific marker of adenocarcinoma of intestinal origin. DISCUSSION: Jejunal adenocarcinoma is an extremely rare GI malignancy. The clinical presentation is often with abdominal pain and distension; only 10% present as a bowel perforation. Surgical resection is considered curative treatment for localized adenocarcinoma. Oxaliplatin-based adjuvant chemotherapy is suggested for patients with lymphovascular invasion. In our patient perforation per se was considered a high-risk feature and the patient was advised to have post-operative adjuvant chemotherapy.

Xanthogranulomatous Oophritis masquerading as ovarian neoplasm: a case report

Xanthogranulomatous inflammation is a special form of chronic inflammation that is destroying normal tissue of affected organs which are replaced by chronic inflammatory cell infiltrate admixed with foci or sheets of foam cells, fibroplasia, chronic inflammatory cell infiltrate and vascular proliferation. Only a few cases of xanthogranulomatous oophoritis have been reported.We report a case of 35 year old female who presented with lower abdominal pain and polymennorhea.A total hysterectomy with bilateral salpingoopherectomy was performed on the suspicion of an ovarian neoplasm.

Analysis of the effects of drugs and techniques used in anesthesia on tumour recurrence, metastasis and survival in ovarian serous adenocarcinoma

Background: Numerous factors affect the risk of recurrence and metastasis after cancer surgery. Studies have observed that anaesthetic techniques have effects on tumour recurrence. Methods: Medical records of newly diagnosed ovarian serous adenocarcinoma patients who underwent radical hysterectomy with bilateral salpingoopherectomy from 1995-2008 were analysed for the effect of anaesthetic techniques and drugs on tumour recurrence & metastasis free survival rate and mortality rate. Univariate association between overall survival and anaesthesia technique was assessed using Kaplan-Meier survival estimates and Cox regression. Multivariate association was tested after adjusting potential confounding factors . Results: The overall survival rate (RR at 95% CI=3.16(1.79-5.60) was significantly better in patients who received regional anaesthesia for surgery than those who had general anaesthesia. Other factors significantly associated with overall survival rate in univariable analysis were,perioperative blood transfusion,preoperative Ca 125 level, FIGO stage, tumour size and lymphatic metastasis.Kaplan Meier survival curve showed that regional anesthesia group had higher overall survival rate.Recurrence rate did not show significant difference in univariable(Odds 95% CI 1.42 P = 0.273)and multivariable(Odds 95% CI = 0 P = 0.846) analysis.Al1the 18 patients who had metastasis underwent surgery under GA. Conclusions: This study showed marked increase in overall survival rate in patients who underwent surgery under regional anaesthesia when compared to those who had surgery under general anaesthesia. Prospective randomized control trials are needed for better evaluation.

Deep aggressive angiomyxoma in the pelvic region: a case report

Introduction: Aggressive angiomyxoma is a rare soft tissue neoplasm that usually arises within perineum of woman of reproductive age. A mass in vulva, which clinically can be diagnosed as a Bertholin gland cyst, should have aggressive angiomyxoma in differential diagnosis. Rarely, cases reported in males and children. Case report: A case of 40yrs female, presented with complaints of pain in abdomen and distension of abdomen since 20 days, is being reported. On abdominal palpation: Tender, abdominal mass felt corresponding to 24-26 weeks. Per speculum examination revealed that cervix taken up. Ultrasound abdomen suggestive of 36x23x15cms neoplastic abdomino-pelvic mass, heterogenous, hypoechoic & solid. Uterus bulky with loss of endometrialmyometrial complex. Total abdominal hysterectomy with bilateral salpingoopherectomy done. Grossly, a huge 32x20x14cms tumor, weighing 2500gm, was received; whose histological diagnosis was deep aggressive angiomyxoma. Conclusion: Aggressive angiomyxoma is a rare, mesenchymal neoplasm, which infiltrates surrounding tissue. It is more common in women.

English

Germ cell tumors account for a majority of all ovarian tumors. Ninety five percent of germ cell tumors are dermoid cysts (Mature cystic teratoma). Carcinomas arising from mature cystic teratoma are quite rare. The most common malignancy being Squamous cell carcinoma (75%). In the present study we report a case of Squamous cell carcinoma arising in a mature cystic teratoma. A 45 year old female presented with mass in abdomen, pain abdomen and dysuria since one month. Total abdominal hysterectomy with bilateral salpingo-opherectomy was done. Histopathology showed well differentiated invasive squamous cell carcinoma arising in the background of mature cystic teratoma (dermoid cyst). Purpose of this report was to create awareness among practitioners to consider this possibility in dermoid cysts of large size in older patients.

Rare Metastasis of Colon Carcinoma Mimicking Endometrial Cancer

Background: Colon cancer rarely mimics colon cancer, given that this type of cancer rarely metastasizes to the female genital tract. This case report describes a rare recurrence of colon cancer presenting with symptoms of primary endometrial cancer. Case: A 40-year-old woman had undergone colon resection for sigmoid-colon cancer 4 years prior to being admitted to the current authors' gynecology clinic because she had vaginal bleeding. An endometrial biopsy revealed metastases of colon adenocarsinoma. As noted on whole-body positron emission tomography/computerized tomography (PET /CT), the hypermethabolic malign involvement was located only in the patient's endometrium. Total abdominal hysterectomy and bilateral salpingo-opherectomy (TAH+BSO) was performed. Based on the pathologic examination of specimen that was removed surgically, a final diagnosis of sigmoid-colon cancer metastasis was confirmed. Results: Follow-up PET/CT did not show any evidence of malignancy. Conclusions: When a patient presents with abnormal vaginal bleeding and has a history of colorectal carcinoma, an unusual metastasis to the endometrium should be considered. (J GYNECOL SURG 29:262)

Does Helica treatment of early endometriosis confer short- and long-term benefits in terms of pain relief and sub-fertility?

Early-stage endometriosis is a known contributing factor for chronic pelvic pain and sub-fertility. To determine whether Helica Thermal Coagulation is an effective short- and long-term treatment for endometriosis-associated chronic pelvic pain and sub-fertility. Thirty six patients were followed up from 6 weeks to 1 year post-Helica treatment of early endometriosis. Pain relief was assessed subjectively. Eight of the women suffered from sub-fertility in addition to pelvic pain, while three patients suffered from sub-fertility alone. Ninety-three percent were pain free at 6 weeks, 75 % were pain free at 6 months and 37.5 % remained pain free at 1-year follow-up. Of those who continued to have pain at 1-year follow-up, three had repeated Helica treatment, two had hysterectomy and bilateral salpingoopherectomy, and the rest were commenced on different hormonal treatment to control endometriosis. Ten women (62 %) conceived within 1 year of treatment. Helica coagulation seems to be an effective way of treating early endometriosis-associated pelvic pain and sub-fertility. However, its effects only seem to be short term, with a decline in symptom relief and pregnancy rate over the 12-month post-operative period. Larger RCT are required.

Primary Cervical Choriocarcinoma: Case Report and the Review of Literatures

Background: Primary choriocarcinoma of the cervix is a very rare entity. Case: A 35-year-old patient had been admitted to our hospital with vaginal bleeding for 7 months. A cervical mass measured 4 × 4 cm was palpated on the anterior surface of the cervix. Biopsy of the lesion demonstrated extensive necrosis and was in favor of squamous cell carcinoma. Patient was accepted as FIGO stage Ib1-2 and underwent type II hysterectomy with bilateral salpingoopherectomy and bilateral pelvic lymph node dissection was carried out. Post operative pathologic evaluation of the surgical specimen evinced that the case was primary cervical choriocarcinoma. Conclusion: Primary choriocarcinoma of the cervix should be considered in patients in their reproductive years with cervical lesion and negative cervical cytology. Beta-hCG assay and transvaginal color Doppler sonography are useful for early diagnosis.

Cerebellar metastasis from serous adenocarcinoma of the ovary mimicking pilocytic astrocytoma

Serous adenocarcinoma of the ovary rarely can present with solitary solid -cystic cerebellar metastasis, mimicking pilocytic astrocytoma. A middle aged women, who underwent total abdominal hysterectomy with bilateral salpingoopherectomy and adjuvant chemotherapy for ovarian adenocarcinoma, presented to us with the history of headache, vomiting, and imbalance. Contrast enhanced magnetic resonance imaging (MRI) showed solitary cerebellar, solid cystic lesion with cyst lining and solid portion enhancing on contrast which was mimicking pilocytic astrocytoma and there was no perilesional edema. Gross total excision of the cerebellar lesion was done followed by resolution of her symptoms. Histopathology showed metastatic adenocarcinoma consistent with the primary ovarian carcinoma. In patients of ovarian carcinoma, presenting with features of raised intracranial pressureICP] thorough investigations must be done to rule out metastasis. Solitary metastasis of the cerebellum because of ovarian carcinoma may mimic pilocytic astrocytoma.

A Rare Complication of Radial Artery Cannulation

The radial artery is well known for its consistent anatomic accessibility, ease of cannulation, and low rate of complications, which have made the radial artery the preferred and most common site for arterial cannulation. A 63-year-old woman undergoing elective laparotomy for transabdominal hysterectomy and bilateral salpingo-opherectomy with possible clearance of any other cancerous pelvic mass. After completion of the operation, while removing the arterial catheter, accidental fracture of radial artery catheter during patient transfer, giving rise to an intravascular retained foreign body was noted by the anaesthetist. Successful surgical removal was completed under ultrasound guidance. The retrieval of a retained foreign body in the peripheral arteries under ultrasound guidance is highly recommended.

Transitional Cell Carcinoma of the Ovary: A Case Report

Abstract Background: Transitional cell carcinoma (TCC-O) is a rare subtype of ovarian carcinoma. It has been described as primary ovarian carcinoma with definite urothelial features without any benign or proliferative Brenner component. The biggest challenge is to distinguish this entity from a malignant Brenner tumor, and the metastases from transitional cell carcinoma of the bladder (TCC-B). The immunohistochemistry (IHC) is of great help, as TCC-O has an IHC staining pattern very different from that of TCC-B, and is similar to other surface ovarian carcinomas, thus indicating that TCC-O arises from pluripotent surface epithelium of the ovary. Case: A 40-year-old woman presented with a progressively enlarging abdominal mass on the right side, of 1 year's duration. Abdominal ultrasound showed a homogenous solid cystic mass in right ovary. Preoperative CA-125 was markedly raised. The patient underwent a staging operation including total abdominal hysterectomy with bilateral salpingo-opherectomy (TAH-BSO),...