Year : 2010 | Volume
: 53 | Issue : 1 | Page : 119--121
Cytomorphology of adult granulosa cell tumor in ascitic fluid
Kalpana Azad, Jitender M Khunger
Department of Pathology, V.M.M.C and Safdarjung Hospital, New Delhi, India
Flat no-74D, Block-D2A, Janak Puri, New Delhi-110 058
Adult granulosa cell tumors (AGCT) are associated with ascites in 10% of the cases. Although these tumors form two per cent of all ovarian tumors, they may create a diagnostic challenge in cytologic preparations. The tumor cells are not readily shed in the fluid. A case of a 47-year-old woman with presence of granulosa tumor cells in ascitic fluid is presented. Because of its rarity, AGCTs can be confused with other ovarian tumors.
|How to cite this article:|
Azad K, Khunger JM. Cytomorphology of adult granulosa cell tumor in ascitic fluid.Indian J Pathol Microbiol 2010;53:119-121
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Azad K, Khunger JM. Cytomorphology of adult granulosa cell tumor in ascitic fluid. Indian J Pathol Microbiol [serial online] 2010 [cited 2020 Jan 21 ];53:119-121
Available from: http://www.ijpmonline.org/text.asp?2010/53/1/119/59200
Adult granulosa cell tumors (AGCT) account for two per cent of all ovarian tumors and 95% of all granulosa cell tumors. , Granulosa cell tumors are derived from granulosa cells, which are responsible for estradiol production.  Adult granulosa cell tumors are active neoplasms that secrete high levels of estrogen, which can lead to abnormal uterine bleeding, endometrial hyperplasia and ultimately may lead to adeno carcinoma.
Although the histology of ovarian AGCTs is well documented- AGCT is rarely encountered in cytological specimens. Although 10% cases are associated with ascites; tumor cells do not readily shed in fluid. , Because of the bland cytomorphologic appearance of the neoplastic cells, the cells may be misdiagnosed on cytological screening. 
We describe a case of 47-year-old postmenopausal woman showing features of adult granulosa cell tumor of the ovary in ascitic fluid.
A 47-year-old postmenopausal female presented with complaints of abdominal distension of one year duration and bleeding per vagina since three months. Ultrasonography showed a hetero-echoic mass lesion measuring 11x7x3cm with multi-cystic areas, arising from right adnexa along with ascites.
Ascitic tap was done and fluid was examined. The smears were cellular and showed both individually dispersed and aggregated neoplastic cells. The characteristic Call Exner bodies, microfollicular pattern which includes small central spaces that contain eosinophilic fluid, were also seen [Figure 1]a. The tumor cells were uniform in appearance and had scanty pale cytoplasm with ill-defined cell borders. They had single nuclei which were round to oval. Occasional, nuclear grooves were also seen [Figure 1]b. Mitotic figures were infrequent.
The patient was treated by bilateral salpingo-oophoretomy with total abdominal hysterectomy. Gross examination of the specimen showed a solid cystic tumor involving the right ovary. The cut surface showed cysts filled with blood. Microscopic examination of the tumor showed granulosa cells arranged in characteristic microfollicular pattern [Figure 2]. There was no atypia, necrosis or mitosis in the tumor. The left ovary was normal. The endometrium showed simple hyperplasia. The patient has been followed for one year without recurrence or metastasis.
AGCTs are relatively rare functional neoplasms of the ovary. Patients with AGCT require long term clinical follow-up because of the unknown, unpredictable, recurring or metastasizing behavior many years after a disease free interval; ,, even in those with stage I or stage II tumor at diagnosis. ,
Histological examination of an AGCT reveals granulosa cells arranged in a variety of patterns, which are commonly admixed.  The better differentiated tumors typically have a microfollicular, macrofollicular, insular, trabecular and solid- tubular pattern. The less well differentiated forms have a watered silk, gyriform or diffuse pattern, alone or in combination.  The nuclear features of AGCT are characteristic; pale, relatively uniform nuclei, at least some of which contain nuclear grooves. ,
The cytological features described in the literature for AGCT are distinctive; such as three dimensional clusters, loose monolayer and individual cells, monotonous cells, microfollicular pattern and nuclear grooves. ,, We found all these characteristic features in our case. The tumor cells are uniform and lack a significant degree of nuclear hyperchromasia and pleomorphism.  They may be mistaken for mesothelial cells and missed on cytological screening of ascitic fluid and peritoneal washings. Indistinct cell borders, high nuclear cytoplasmic ratio and indentation of the nuclear membrane are helpful features in distinguishing granulosa tumor cells from mesothelial cells. Cells of carcinoid and pancreatic islet tumors share many features of granulosa cells, but they have more cytoplasm and lack nuclear membrane indentation.  Also, the rosettes of carcinoid may be confused with Call Exner bodies. But they can be distinguished as the centre of rosettes in carcinoid is composed of cytoplasm and lacks the matrix material of Call Exner bodies. 
Nuclear features, especially nuclear grooves, are one of the classic features of AGCT. However, they are also seen in two other primary ovarian tumors. They are proliferating Brenner tumor and sex cord tumors with annular tubules (SCTAT). These three ovarian tumors are all composed of sheets and trabecular structures lined by a pseudo-stratified layer of relatively monotonous cells with the so called coffee bean shaped nuclei. Proliferating Brenner tumor and Sex Cord tumor with Annular Tubules (SCTAT) have small nucleoli, which can be helpful in differentiating from AGCT. Immunohistochemistry can also be useful in differential diagnosis as AGCT is immunoreactive for Inhibin and CD99. , The epithelial rests of Brenner tumor are immunoreactive for cytokeratin and epithelial membrane antigen.  SCTAT is mainly the differential diagnosis on the basis of rosettes, with or without a central acellular core comprising of basement membrane material.
Occasionally, AGCT with a diffuse pattern can be mistaken for a poorly differentiated carcinoma.  The nuclear appearance can be very helpful as the AGCT has characteristic pale, relatively uniform nuclei which are often grooved, while the nuclei of differentiated carcinomas are hyperchromatic without grooves and unequal in size and shape. AGCT has less common nuclear atypia and mitosis; very commonly seen in differentiated carcinoma.
Because of its rarity, AGCTs may create a diagnostic challenge. The distinctive cytologic picture, along with clinical history, will help in their correct diagnosis.
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