Case report: A Metastatic Transitional Cell Carcinoma of the Ovary

Background: Transitional cell carcinoma (TCC) is a rare type of ovarian epithelial cancer. This type of ovarian cancer accounts for only 1% of superficial epithelial carcinomas. Ovarian cancer is a major clinical challenge in obstetrics and gynecology. The reason of this is the lack of specific symptoms for ovarian cancer before the recurrence and progression of the tumor, so many cases are not diagnosed until the onset of metastatic disease. Overall, ovarian cancer accounts for 4% of all diagnosed cancers and 5% of all mortality due to cancer. Malignant ovarian tumors are divided into several categories, including epithelial, germ cell tumors, and sex stromal cord tumors. Early diagnose of small ovarian-limited tumors is an important prognostic factor. Ovarian cancer has no specific symptoms and does not show itself in the early stages. The most common early manifestations are bloating, pain, frequent urination and constipation. Therefore, patients do not pay attention to the symptoms. The clinical manifestations of transitional cell carcinoma of the ovary are indistinguishable from other types of ovarian cancer. However, early detection of this type of tumor is important because of the favorable response to chemotherapy compared to other ovarian epithelial cancers. Case report : The patient is a 43-year-old woman (G2P2L2) who referred to a hospital in Tehran with vaginal bleeding and abdominal pain. The results of sonography showed the presence of a suspected mass of uterine leiomyoma with dimensions of 90 * 58 mm and two cysts with a diameter of 43 and 39 mm in the right ovary. The patient is a candidate for myomectomy due to bleeding. In October 2019, during surgery, the surgeon discovered that the mass was not a leiomyoma and the mass was of ovarian origin.so she underwent curettage and the right ovarian mass were removed and sent for pathology, the diagnosis of “High grade serous carcinoma of the right ovary” is reported. Due to the malignancy, the pathology result, patient was referred to Firoozgar Medical Center in Tehran, In the review of the pathology report in this center by the gynecologist pathologist,  primary ovarian transitional cell carcinoma was reported without need to do IHC(ImmunoHistoChemistry)because of the net diagnosis  and the new ultrasound showed a hypoechoic, homogeneous, well defined and oval mass without clear vascularity with dimensions of 28 * 36 * 47 mm anterior to inferior vena cava (IVC) and proximal location of aortic artery bifurcation to common iliac and the effect of compression on IVC and Its displacement was seen. In spiral CT scan, a circular solid mass with dimensions of 42 * 33 * 51 mm corresponding to the location of the aortocaval with compressive effect on IVC and multiple mesenteric metastatic lymphadenopathy with a maximum SAD = 10 mm was seen. No free fluid was seen in the abdomen. The uterus had normal dimensions. Neurogenic masses such as paraganglioma and metastatic lymphadenopathy were presented in the differential diagnosis. Other normal abdominal areas were reported. Endoscopy and colonoscopy were also reported to be normal. The patient did not have complete surgery, hence it was decided that in addition to the uterus and ovaries, the tumor between the duodenum and IVC would be removed in the reoperation. Therefore, on December 20, 2019, a complete laparotomy and debulking of the ovarian tumor, including a complete hysterectomy, removal of bilateral fallopian tubes and ovaries and remnants of the right ovarian tumor were performed. Appendectomy and omentectomy were performed also The tumor was removed on IVC. In the pathology report from the second surgery, primary  Transitional Cell carcinoma of the ovary with metastasis and involvement of right and left ovaries, parameter, lesion removed from the rectum, sigmoid mesentery, posterior cul-de-sac, seeding into the adipose tissue of the peritoneal lymph nodes of the right and left pelvis were reported. One month after reoperation, the patient underwent 6 courses of chemotherapy every 3 weeks with paclitaxel 300 mg and carboplatin 480 mg with AUC-6 according to the advice given to the patient in the tumor board. Now that 2 years have passed since the patient's reoperation, the patient is in good general condition and no trace of the tumor or its recurrence, has been observed in regular follow-ups. In addition, the CA-125 patient before her reoperation is 450U / ml, and one month after surgery, who also received one course of chemotherapy, its rate decreased to 25U / ml, and after 6 courses of chemotherapy, its rate was 15U / ml. At present, the CA-125 level of patient is 10U / ml. Discussion: Transitional cell carcinoma is a rare type of ovarian epithelial cancer that is in the latest WHO classification, Introduced as” high grade serous tumor with transitional cell differentiation”. Primary ovarian TCC is differentiated from benign, metaplastic, or proliferative Brenner and has two subtypes; 1. Papillary 2. Malignant pseudo-Brenner. This tumor was first defined by Austin and Norris in 1987. They reported a group of patients with ovarian tumors that had tissue characteristics similar to malignant Brenner tumors, while these patients lacked benign Brenner tumor characteristics and no prominent stromal calcification. According to the World Health Organization (WHO), depending on the histological pattern, Transitional cell tumors are classified as benign, borderline or malignant tumors Brenner and TCC that accounts for 2% of all ovarian tumors. Primary ovarian TCC is similar to bladder and urinary TCC but is differentiated in immunochemistry and pathology. Ovarian TCC is negative for CK20 but is usually positive for vimentin, ca125, wilms tumor1 and also strongly estrogen receptor (ER). Also, transitional carcinoma of the ovary is much more invasive than malignant Brenner tumor (MBT) and must be isolated. Silva et al observed TCC in 88 of 934 ovarian cancers (9%). Young et al in their study, stated that TCC tumor cell nuclei were longitudinal or round, often with nuclei with longitudinal grooves. The cytoplasm was often pale and granular, rarely clear or eosinophilic. Common clinical signs of ovarian TCC include abdominal pain, ascites, bloating, and weight loss. Occasionally, there may be signs of uterine bleeding, back pain, urinary or abdominal symptoms. The clinical manifestations of this cancer are indistinguishable from other types of ovarian cancers. Our patient also referred to the hospital with symptoms of uterine bleeding and pain in the abdomen. Due to the absence of abdominal ascites and the generality of the symptoms, the tumor was not diagnosed in time. According to the sonography and symptoms, the first surgeon suspects leiomyoma and operates on the patient, but during the surgery, he notices that the mass is malignant. In the study by Ihan et al, age of women with ovarian TCC ranged from 46 to 87 years, with an average age of approximately 59 years. Most patients had menopause. But in our study, the patient's age (43 years) is lower than the average age of previous studies. Most studies show that surgery with chemotherapy (cisplatin) increases the life expectancy of patients. In the study of Silva et al, 5-year survival after surgery was reported to be 37% for 88 patients, while in the group with chemotherapy, it was 41%. The standard chemotherapy regimen recently used for patients with ovarian epithelial cancers includes paclitaxel and carboplatin on a six-period basis, our patient has also undergone chemotherapy with the same drugs. Conclusion: A woman with a suspected ovarian mass should be examined and treated by a gynecologist oncologist. Histopathological examination of these tumors is necessary to distinguish them from other ovarian cancers. Immunohistochemistry features are useful in its diagnosis. Para-clinical methods can be used to evaluate metastasis. Surgery is the main method of treatment followed by standard chemotherapy. This case is important because the patient had this tumor before menopause at the age of 43, who underwent surgery and chemotherapy with paclitaxel and carboplatin for 6 periods due to extensive metastasis to other abdominal organs. A noteworthy point in the above patient and similar patients is that, due to the non-specificity of ovarian cancer symptoms, whenever there is a suspected adnexal mass, referral to a gynecologist oncologist is recommended for beginning of appropriate treatment plan and surgery or chemotherapy to increase Survival and improvement of patient's quality of life.