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9 DIAGNOSIS A. RIGHT OVARY: Krukenberg tumor (20 cm in maximum dimension, see comment). B. LEFT OVARY: Krukenberg tumor (8.5 cm in maximum dimension, see comment). C. UTERUS (130 Grams): Cervix: Metastatic mucinous adenocarcinoma with signet ring cell differentiation. Endometrium: Benign endometrial polyp with metastatic mucinous adenocarcinoma with signet ring cell differentiation. Myometrium: Mucinous adenocarcinoma with signet ring cell features identified within lymphatic spaces compatible with retrograde lymphangitic extension. COMMENTS: The bilateral ovaries are each involved with metastatic mucinous adenocarcinoma with signet ring cell differentiation. Metastatic tumor is also seen in the uterine cervix and endometrium, and there is retrograde lymphangitic extension to the uterine myometrium. Mucicarmine stain is weakly positive confirming the mucinous nature of this lesion. A small battery of immunostains was performed, and the CK20 and CDX2 are strongly positive while the CK7, TTF-1, and ER are negative. These findings strongly suggest a GI tract origin for the tumor, and in decreasing order of preference would include stomach, colon, appendix and biliary tract. Further workup to identify the site of origin for this process is suggested. The permanent section diagnosis differs from the frozen section diagnosis due to the presence of extensive amounts of ovarian troma present within the tumor, differentiated epithelial structures that simulate the appearance of sex cord structures, rare true signet ring cells within the material chosen for frozen section diagnosis, luteinized stromal cells, and the presence of a more watery consistency to the extracellular mucin. The case has been discussed with [NAME] on [DATE]. SPECIMEN DATA SPECIMENS: Right ovary, Left ovary, uterus. GROSS DESCRIPTION: A. Submitted fresh for intraoperative consultation and labeled right ovary is a lobulated rubbery dull grayish-tan mass measuring 20x17x9.5 cm and weighing grams. The outer surface is bosselated and has a blunt cerebriform appearance with areas of deep purplish discoloration. Identifiable cysts are not present. Sectioning reveals rubbery tan solid tissue that centrally demonstrates gelatinous myxoid degeneration. Prominent areas of deep reddish discoloration are noted, but are limited to the surface tissue. Further sectioning reveals areas of cystic change ranging from 0.6 to 4.0 cm in greatest dimension and containing pinkish serous fluid. Mural nodularity is not identified within the cysts. A section is submitted for frozen section analysis and in cassette FSA. Material for permanent sections are submitted in nine cassettes labeled A-I. FROZEN SECTION: FSA: Tumor with patter suggestive of sex cord/stromal tumors. B. Submitted fresh for intraoperative consultation and labeled left ovary is a lobulated reddish-tan kidneyshaped mass measuring 8.5x6.0x3.5 cm. The outer surface is bosselated and imparts a convoluted appearance. Sectioning reveals solid grayish-tan tissue towards the periphery intermixed with central areas of cystic change measuring up to 3.0 cm in greatest dimension. One of these cysts contains a mural nodule measuring 1.1 cm in greatest dimension. Areas of degenerative and myxoid change are not identified. A representative section is

10 submitted for frozen section analysis and in FSB. Material for permanent sections are submitted in five cassettes labeled J-N. FROZEN SECTION: FSB: Tumor with pattern suggestive of sex cord/stromal tumors. C. Submitted in (formatin) and labeled uterus is a uterine corpus with attached cervix measuring 7.8x6.5x4.6 cm and weighing 130 grams. The external cervical (os) is widely patent, and the endocervical canal is opened revealing a poorly defined squamocolumnar junction and wrinkled yellowish-tan endocervical mucosa. The serosal surface of the corpus is smooth and dull pinkish-tan. The corpus is bivalved revealing dull yellowish-tan tissue that fills the endometrial lumen, easily detaches from the underlying myometrium and measures 3.7x2.2x1.2 cm. Sectioning reveals soft pasty dull yellowish-tan cut surface that fragments readily. The surface, otherwise, is finely granular and dull grayish-tan. The myometrium is homogeneous brownish-tan and measure up to 2.5 cm in greatest thickness. There are no areas of nodularity or turnefaction on sectioning. Representative sections are submitted in five cassettes labeled O-S.

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