Key words: sex cord stromal tumor,
ovarian malignancy, neck metastases,
Correspondence to: Prof Dr Murat
Ünal, Mersin Universitesi Tip Fak. Has-
tanesi, KBB AD, Zeytinlibahce cad.,
33079 Mersin, Turkey.
Tel +90-324-337 43 00;
fax +90-324-337 43 05;
Received March 7, 2008;
accepted July 4, 2008.
Supraclavicular metastases from a sex cord
stromal tumor of the ovary
Onur Ismi1, Yusuf Vayisoglu1, Tuba Karabacak2, and Murat Ünal1
1Department of Otorhinolaryngology,2Department of Pathology, Mersin University School of
Medicine, Mersin, Turkey
Metastases to the supraclavicular fossa usually originate from head and neck or infr-
aclavicular tumors. Ovarian primaries of supraclavicular metastases are very rare. Sex
cord stromal tumors of the ovary account for 5-8% of all ovarian malignancies and
there have been only a few case reports on distant metastases from these tumors. A
46-year-old woman presented to us with a left supraclavicular mass. She had had a
sex cord stromal tumor in the right ovary four years before. Comprehensive clinical
investigation and fine-needle aspiration cytology were performed.The lesion had the
characteristics of a sex cord stromal tumor.To our knowledge, this is the first report of
such a case in the English literature. We discuss its pathological and clinical features
in the light of the current knowledge.
Metastases to the supraclavicular fossa can originate from head and neck and infr-
aclavicular tumors. The principal metastatic sites from the head and neck region are
the hypopharynx, tonsil and nasopharynx1. Infraclavicular primary sites are mostly
lung, breast and cervix2. Left supraclavicular lymph node enlargement can also occur
as a gastric carcinoma metastasis. Ovarian malignancies are rare primary sites for
Sex cord stromal tumors (SCSTs) are generally considered to have a low malignant
potential and a favorable prognosis.They are non-epithelial ovarian tumors originat-
ing from the sex cords or the stroma and mesenchyme of the ovary. These tumors
have been classified as granulosa stromal cell tumors, Sertoli-Leydig cell tumors, gy-
nandroblastoma, sex cord tumor with annular tubules, and unclassified3,4. SCSTs ac-
count for 5-8% of all ovarian malignancies. Granulosa cell tumors (GCTs) are low-
grade malignancies and account for approximately 70% of SCSTs. SCST may spread
by direct local extension or intraperitoneal seeding. Recurrences occur mostly in the
pelvis and abdominal cavity. The tumors may also spread hematogenously, with pa-
tients developing metastases in the lungs, liver, and brain even years after the initial
diagnosis5,6.To our knowledge, there have been no published reports on supraclavic-
ular lymph node metastases from SCST.We present the case of an adult woman who
had a GCT in the right ovary with neck metastases, and discuss its pathological and
metastatic features in the light of the current knowledge.
A 46-year-old woman was admitted to our otorhinolaryngology department with a
mass in the left neck that had been there for 1 month. She had a history of total ab-
dominal hysterectomy and bilateral salpingo-oophorectomy because of a right ovar-
ian SCST (GCT) 4 years previously. In the ear-nose-throat examination, a 3 × 3.5 cm
solid, fixed mass was found in the left supraclavicular region. Endoscopic examina-
tion of the upper airway was normal. Computerized tomography (CT) of the neck re-
SUPRACLAVICULAR METASTASES FROM AN OVARIAN TUMOR 255
vealed a 45 × 27 mm lymphadenopathy in the left supr-
aclavicular region (Figure 1). The lymphadenopathy ex-
tended into the infraclavicular region. There were mul-
tiple metastatic nodules in both lungs. Abdominal CT
revealed lymphadenopathies on both sides of the para-
aortic region. Fine-needle aspiration cytology from the
supraclavicular mass was performed. Homogeneous
eosinophilic globular material and oval cells with light
chromatin in the nuclei were seen in the cytological
specimen (Figure 2). The cells were arranged in a follic-
ular pattern and stained positive with inhibin and CD99
(Figure 3).The pathological diagnosis was in agreement
with an SCST. Histologically the lesion was reported to
ovarian mass. The patient was referred to the gynecolo-
gy and oncology department for further therapy. A cis-
platinum-based chemotherapy regimen was adminis-
tered but she died within 2 weeks due to the toxic side
effects of this therapy.
The differential diagnosis of supraclavicular lym-
phadenopathy is broad: it includes benign lym-
phadenopathy, congenital cysts and tumors, specific in-
fections, nonspecific inflammation, primary and
phadenopathy is often malignant (58-83%). It occurs
mainly on the left side7,8. Most of the metastases origi-
nate from sites other than the head and neck including
lung, breast and cervix2,7. Intra-abdominal metastases
are also located on the left side and left supraclavicular
lymph nodes may be involved in gastric carcinoma
metastasis (Virchow’s node)8.
These lesions tend to present as an asymptomatic
mass that progresses slowly and is firm on palpation.
The associated symptoms are often related to the pri-
mary site of the neoplasm and include odynophagia,
dysphonia, otalgia and weight loss. Cervical lymph
node metastases are a common feature in head and
neck malignancies and infraclavicular tumors. The ma-
jority of patients with metastases in the lower neck
(supraclavicular fossa and posterior triangle) have
squamous cell carcinoma. The next most common his-
tological diagnosis is lymphoma, followed by adenocar-
cinoma and undifferentiated carcinoma9. Other occult
malignant neoplasms such as melanomas, sarcomas
and germ cell tumors rarely metastasize to the neck.
When the enlarged nodes are in the supraclavicular re-
gion, the digestive tract, the tracheobronchial tree, the
breast, the genitourinary tract and the thyroid gland
Figure 1 - Computed tomography of the left supraclavicular mass.
Figure 2 - Tumor cells in the fine needle aspirate.
Figure 3 - Tumor cells stained with CD99 and inhibin.
256O ISMI,YVAYISOGLU, T KARABACAK, M ÜNAL
though the role of postoperative chemotherapy and ra-
diotherapy is not well defined, these treatment modali-
ties have in some cases been associated with prolonged
disease-free and overall survival4-6.
Although ovarian cancer rarely metastasizes to the
cervical lymph node chain, it should always be consid-
ered in the differential diagnosis of lymph node en-
largement in the cervical area of adult women.
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results of a series of 309 cases biopsied by fine needle aspi-
ration. Head Neck, 21: 239-246, 1999.
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tion, Berek JS (Ed), pp 1245-1321, Lippincott, Williams &
Wilkins, Philadelphia, 2002.
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should be taken into consideration as possible primary
SCSTs are histologically considered to be malignant.
GCT is the most common among these tumors. GCTs
are divided into 2 subgroups based on clinical presenta-
tion and histological characteristics: juvenile and adult
GCTs, the former accounting for only 5% of cases. Im-
munohistochemical staining for inhibin may be of help
in the pathological diagnosis of GCTs, as this character-
istic is very rarely present in other ovarian lesions12.
Different biological behaviors of sex cord tumor have
been described in the literature.There are reported cas-
es of lung, liver, brain, bone-skeleton, diaphragm, ab-
dominal wall, and adrenal gland metastases from SC-
STs13-17. Lymphadenopathy in the neck is an unusual
presentation of malignant neoplasms of the ovary. Only
a few cases have been reported of neck metastases as-
sociated with ovarian malignancies. In a series of 100
autopsies of women who died of ovarian carcinoma,
supraclavicular lymphadenopathy was found in only
4%18. Table 1 gives a summary of case reports for ovari-
an tumors with cervical metastases. Although SCSTs are
generally considered to have low malignant potential
and a favorable prognosis, they may generate distant
metastases. Since distant metastases can occur as late
as 30 years after the initial diagnosis, patients must be
followed up for many years even when the primary tu-
mor is occult4,5. In the present case, supraclavicular
metastasis occurred 4 years after the primary tumor.
Fine-needle aspiration biopsy for cervical lymph
nodes has 92.7% sensitivity and 98.5% specificity for the
primary site. Recent studies using fine-needle aspira-
tion reported the ovary as the primary site in 0.8-9% of
cases of supraclavicular lymph nodes7,8.
Since very few cases of distant metastases from SCSTs
have been reported in the literature, there is no well-de-
fined treatment protocol. The low incidence of SCSTs,
their multiple histological patterns, and their variable
biological behavior limit our knowledge regarding the
optimalmanagement of these tumors. Surgery remains
the most effective treatment for ovarian stromaltumors.
SCSTs are characterized by a long natural history and a
tendency to recur years after the initial diagnosis. Al-
Table 1 - A brief review of the current case reports for ovari-
an tumors with cervical metastases
Author YearNo. of casesPathology
Malpica et al.11
20015 Serous tumor
Serous borderline tumor
Granulosa cell tumor
Gupta et al.8
Euscher et al.19
Mayadevi et al.20
Verbruggen et al.10
Ismi et al.*
16. Liu K, Layfield LJ, Coogan AC: Cytologic features of pul- Download full-text
monary metastasis from a granulosa cell tumor diagnosed
by fine-needle aspiration: a case report. Diagn Cytopathol,
16: 341-344, 1997.
17. Williams RJ, Kamel HM, Jilaihawi AN, Prakash D: Metasta-
tic granulosa cell tumour of the diaphragm 15 years after
the primary neoplasm. Eur J Cardiothorac Surg, 19: 516-
18. Dvoretsky PM, Richards KA, Angel C, Rabinowitz L, Stoler
MH, Beecham JB, Bonfiglio TA: Distribution of disease at
autopsy in 100 women with ovarian cancer. Hum Pathol,
19: 57-63, 1988.
19. Euscher ED, Silva EG, Deavers MT, Elishaev E, Gershenson
DM, Malpica A: Serous carcinoma of the ovary, fallopian
tube, or peritoneum presenting as lymphadenopathy. Am J
Surg Pathol, 116: 336-340, 2004.
20. Mayadevi S, Nagarajan S,Van DerVoet JC, Nevin J, Cruick-
shank DJ: Metastatic adenocarcinoma of right supraclavic-
ular fossa – delayed presentation of ovarian primary. J Ob-
stet Gynaecol, 25: 528-529, 2005.
SUPRACLAVICULAR METASTASES FROM AN OVARIAN TUMOR 257