MANAGEMENT OF METASTATIC MESENTERIC GRANULOSA CELL TUMOUR

MANAGEMENT OF METASTATIC MESENTERIC GRANULOSA CELL TUMOUR

Shailesh Shrikhande, Prakash Patil
Department of Oncosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India.
INTRODUCTION

Granulosa cell tumours of the ovary are rare and uncommon tumours. They are known to manifest metastatic disease years after treatment of the primary. A case of metastatic granulosa tumour of the mesentery is reported along with its surgical management. We believe this is the first reported case in the world literature.
CASE REPORT

A 46 year old lady presented with dull backache radiating to the left lower limb. She was a known case of granulosa cell tumour of left ovary[1] and had undergone panhysterectomy 10 years earlier. In view of her stage III disease, she was then advised adjuvant chemotherapy that she refused. She was asymptomatic in the intervening 10 years till her recent symptoms of backache.

On clinical examination she had a large left paraumbilical mass that was non-tender, non-pulsatile and mobile at right angles to the axis of the mesentery. Her pelvic examination did not suggest any local disease. Rest of her physical examination was unremarkable.

A CT scan of the abdomen showed a small bowel mesenteric mass (15 cm in diameter) completely engulfing the superior mesenteric artery near its origin and compressing the third part of the duodenum (Fig. 1). In view of these CT findings, the mass appeared unresectable since it would have entailed a complete small bowel resection. However the probability of finding a short length of uninvolved superior mesenteric artery at its origin prompted us to consider a CT angiography to reevaluate the possibility of surgical resection of this relatively chemo and radiotherapy resistant tumour.[2,3] The CT angiographic findings revealed a large tumour encasing the superior mesenteric artery shortly after its origin (approximately 4 cm). More importantly, a major left branch to the proximal jejunum appeared to be uninvolved. However, both right colic and ileo-colic vessels were involved by the tumour (Fig. 2). After explaining the possibility of a short gut syndrome, the patient was taken up for surgery with due risk.

Intraoperative findings corroborated with those of preoperative imaging studies. There was no other evidence of disease in the pelvis or in the liver. The left branch to the proximal jejunal loops was carefully dissected and preserved. Its significance in maintaining the viability of proximal jejunal loops was confirmed by application of bulldog vascular clamps. The main superior mesenteric artery was flush ligated beyond this main left branch to the proximal jejunum. Much to our surprise the terminal 2.5 feet of ileum retained its vascularity and viability. The tumour mass was excised and a small bowel anastomosis was possible thus avoiding the need of a right colonic resection.

Three pints of blood were transfused. The patient had a smooth post-operative recovery and was discharged home on the 8th post-operative day. The final histopathology was metastatic granulosa cell tumour.

DISCUSSION

We reviewed the literature over the last 30 years and believe ours is the first reported case of a metastatic mesenteric granulosa cell tumour. This case highlights the role of CT-angiographic studies in situations such as ours. What initially appeared to be an unresectable mass even on CT scan findings, proved to be a resectable one in view of the invaluable information gained on CT-angiography.

Fig.1 Abdominal CT scan reveals a large tumour near the origin of the superior mesentric artery and compressing the third part of the duodenum

Fig. 2 CT angiography reveals a left branch uninvolved by tumour supplying the proximal jejunal loops. The right colic and ileo-colic vessels are encased by the tumour.

The other interesting aspect was the observation that terminal ileal vascularity was well maintained and preserved by the middle colic artery via the marginal blood vessels of the ascending colonic mesentery. This ensured a significant length of small bowel was preserved thereby avoiding the development of a short gut syndrome.

These tumours have a propensity for indolent growth and late recurrence; they may recur even 25 years after initial treatment.[4] This case re-emphasizes the need for long-term follow-up of patients with stromal tumours of the ovary.

REFERENCES

Ahmed E, Young RH, Scully RE. Adult granulosa cell tumour of the ovary with foci of hepatic cell differentiation : a report of four cases and comparison with two cases of granulosa cell tumour with leydig cells. Am J Surg Pathol 1999; 23 (9) : 1089-93.

Wolf JK, Mullen J, Eifel PJ, Burke TW, Levenback C, Gershenson DM. Radiation treatment of advanced or recurrent granulosa cell tumour of the ovary. Gynaecologic oncology 1999; 73 (1) : 35-41.

Homesley HD, Bundy BN, Hurteau JA, Roth LM. Bleomycin, etoposide and cisplatin combination therapy of ovarian granulosa cell tumours and other stromal malignancies : A Gynaecologic Oncology Group Study. Gynaecologic oncology 1999; 72 (2) : 131-7.

Lee WL, Yuan CC, Lai CR, Wang PH. Haemoperitoneum is an initial presentation of recurrent granulosa cell tumours of the ovary. Japanese Journal of Clinical Oncology 1999; 29 (10) : 509-12.

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