A Case of A Serous Cystadenofibroma

This was from a 67 year-old female that presented with bilateral ovarian new growth (enlarged ovaries). I don’t have the gross pictures here but you’re not missing out on what it looks like live if you refer to this unruptured image, and opened., I don't own those images. These things usually present as ovarian new growths that increase in size over time. Sometimes they'll be an incidental finding on ultrasound because the aren't large enough to cause obstructive or pressure symptoms.

Taken at scanner view 40x magnification

This is the cyst wall, sometimes these can be so thin that you can take the image of an entire wall. Grossly, they can range around less than <0.1cm to >0.6cm thick. You can already see the prominent fibroblastic component on the stroma.

Comparing the stroma between a cystadenoma and cystadenofibroma

Taken at low power view, 100x magnification.

Taken at high power field, 400x magnification.

This is one of the textbook images to compare it from.

These can be lined by pseudostratified or columnar epithelium. On this case, you can see some tiny tufts of hair like structures on the cells (cilia).

It’s a classic textbook image of what a Serous Cystadenofibroma under microscopic examination. But I still have trouble distinguishing between cystadenoma vs cystadenofibroma where the latter has a prominent stromal fibroblastic component (just the stroma looking more fibrous). This is a small detail and doesn’t affect the prognosis of the patient. It’s one of those situations where you have to encounter them often to get your eyes used to the small details. I get around 1 out of 10 adenofibromas in cases where I thought it’s cystadenoma.

These cases can range for small to large sized ovarian new growth. When grossing this specimen, I look for three things, the type of fluid it contains if it isn’t ruptured, the contents within the walls of the inner cyst especially solid parts, and how many loculations it has.

If the fluid is serous (think of clear to brown water and its consistency), this gives me a lead that I may be dealing with a serous cyst. If the contents look and feel gelatinous (think of semi-solid or gelatin texture), I may be dealing with a mucinous cyst. Mucinous cyst, especially large ones mean I would have to do 2 sections per 1 cm as per recommended guidelines because these can have some areas that may hide malignant transformation. If I suspect a serous cyst, it’s just going to be 1:1 section per cm in size of the tumor.

These maybe hollow or have some focal areas where there are nodule-like thickening. I pick these areas for sectioning because these areas may contain possible malignant transformation. Even if you’re general idea of the case is benign on grossing, if you’re not looking specifically for malignancy, you may miss it, a lot of things can affect your judgment especially if there wasn’t meticulous sampling done. If I happen to section a solid part and then found out that there are skin adnexal structures or organ tissues usually found on other areas of the body, the diagnosis on gross may shift from serous cystadenoma to a mature/immature teratoma.

A cyst may be unilocular or multilocular. Think of an egg with one hollow chamber if you’re dealing with unilocular cyst. Now imagine if you opened the egg but it has multiple compartments which makes it multiloculated. I’m not explaining this in a strict conceptual textbook definition because this is my mental imagery and mnemonics how I remember things so don’t quote me on this. Multiloculations are more associated with malignancy especially when it appears vascular on ultrasound imaging. This just means I need to be more meticulous with sampling.

Some specimens would have a papillary like projections on their lining but nothing like that seen in this case specifically. These type of cases are within the beginner level given how common they are and how easy to process they can be.

If you made it this far reading, thank you for your time.

Posted with STEMGeeks