1. Gynecology 성균관대학교 의과대학 2007313075 손의영

2. C.C. & P.I. 정 O 록, F/76 Previously healthy 2011.04 보라매병원에서 건강검진 시행 MRI 상 Granulosa cell tumor 의심 수술 권유 받음 2011.05.04 본원으로 전원 후 w/u

3. Other History PMHx. HTN/DM/Tb/hepatitis/Allergy ( - / - / - / - / - ) Hypothyroidism (+), MDD (+) 약물력 : 씬지로이드 (40YA) 정신과약 – 가스모틴, 사미온정, 자나팜정, 졸로푸트정 수술력 : 없음 FHx. 당뇨 : 넷째 여동생, 다섯째 여동생 위암 : 첫째 오빠 SHx. Marriage : 기혼 smoking: no alcohol: no

4. Review of system GW / EF ( - / - ) Weight change (-) fever/chill ( - / - ) Headache/dizziness ( - / - ) Rhinorrhea/ cough /sputum ( - / - / - ) Dyspnea (-) chest pain / palpitation ( - / - ) anorexia/nausea/vomiting ( - / - / - ) abdominal pain/discomfort ( - / - ) constipation/diarrhea ( - / - ) hematemesis/melena/hematochezia ( - / - / - ) Urinary Sx (-) Arthralgia (-) Myalgia (-)

5. Physical Exam Vital Sign2011-05-22 17:26 147/69 mmHg - 45 - 20 - 36 ℃ G/AGenerally well-looking appearance MentalityAlert & well orientation AbdomenPalpation – Soft & flat No tenderness/rebound tenderness

6. CT (2011-04-08, 보라매 병원 )

7. MRI (2011-04-21, 보라매 병원 ) ( 장축 6.5 cm)

8. PET (2011-05-04, 보라매 병원 )

9. Problem List / Assessment Problem List #1. Left ovary mass #2. Hypothyroidism Assessment #1. : R/O ovary cancer

10. Therapeutic Plan Surgery & Biopsy Laparoscopy assisted vaginal hysterectomy Bilateral Salphingo-Oophorectomy Total Omentectomy, adhesiolysis

11. Pre-op. Tumot Marker CEA/CA19-9/CA 125 : 1.4/14/10

12. Surgery

13. 수술중 발견사항 Pelvic cavity Adhesion : (Yes) ; Omentum 과 abdominal anterior wall 이 붙어 있었음  adhesiolysis was done Ascites : Serous small amount Adnexa Rt. size: normal Lt. size: goose egg shape: cystic capsule: intact

14. 수술중 발견사항 Omentum : None Skin incision :subumbilical 5mm, RUQ 5mm LLQ 12mm, suprapubic 5mm Pelvic cavity : small amount fluid collection  washing cytology, adhesion (-), bleeding (-) Uterus :grossly normal, size normal, no adhesion Mass (+) 2cm in EM (frozen : cystic hyperplasia) Adnexa : Lt ovary tumor (over hens egg size) adhesion (+) Lt ov tumor 와 uterus, tube 사이 frozen : granulosa tumor PCDS : obliteration (-), ascites (-)

15. Pathology Granulosa cell tumor, adult type, left ovary 1) tumor size : 7 x 6 x 4 cm 2) surface involvement : cannot be evaluated 3) mitosis : 2/10 HPF 4) confined to left ovary Complex hyperplasia w/o atypia Chronic cervicitis, cervix No diagnostic abnormalities recognized left salpinx, right ovary and salpinx No evidence of malignancy, omentum

16. Progression

17. Tumors derived from gonadal Stroma 1. Granulosa-stromal-cell tumors Granulosa-cell tumor Tumors in thecoma-fibroma group 1) Thecoma ( 난포막종 ) 2) Fibroma ( 섬유종 ) 3) Unclassified ( 미분류종양 ) 2. Sertoli-Leydig-cell tumors Well-differentiated 1) Sertoli cell tumor 2) Sertoli-Leydig-cell tumor 3) Leydig-cell tumor ; hilus cell tumor Moderately differentiated Poorly differentiated With heterologous elements 3. Gynandroblastoma 4. Unclassified

18. Feature; Sex cord-Stromal Tumor 5~8% of ovarian malignancy Synthesis of gonadal and adrenal steroid hormones Estrogens, progesterone, testosterone ……

19. Granulosa cell tumor Features Low grade malignancy m/c stromal ovarian tumor Usually unilateral All age group (mean : 51y) Symptoms Abnormal uterine bleeding Pelvic or abdominal pain Pelvic mass Ascites Hormonal effect by Estrogen (EM hyperplasia, Mens irregularity) 과립막 세포종

20. Granulosa cell tumor Pathology Granulosa cells w/ large, pale, oval nuclei Coffee bean grooving Microfollicullar pattern(Call-Exner bodies) – m/c Treatments Surgery : USO, TAH w/ BSO Post-op radiation : Recurrent disease 의 예방

21. Granulosa cell tumor Prognosis Late relapse Residual tumor 의 크기가 가장 중요 Stage and Survival of Ovarian sex cord-stromal tumors Adult Granulosa cellSertoli-Leydig cell Stage at Dx I II-IV 80~90% 10~20% 97% 2~3% 5YSR I II-IV 85~95% 30~50% 90~95% 10~20% William’s Gynecology TABLE 36-6

22. FIGO stage