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Beyond the Surface: A Surprising Diagnosis of GIST of Ovarian Origin Agarwal A, Marwah S, Abhigya, Isha, Gaikwad HS, Bajaj B Senior resident, Associate professor, Postgraduate resident, Senior resident, Director Professor, Professor and HOD Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital, New Delhi Introduction- GISTs are a common mesenchymal tumor of the gastrointestinal tract. Extra-intestinal GISTs arising from the omentum, mesentery, retroperitoneum, uterus, and bladder have been documented. However, primary ovarian GIST is the rarest of rare entity. Aims and Objective- To emphasise on the existence of Ovarian GIST, which should be kept in mind as a differential diagnosis in woman presenting with large adnexal mass. Evaluation of abdomino-pelvic masses should include a battery of tests to rule out gastro-intestinal tumors. Case- A 72 year female, P12L9, presented with pain, bloating and rapidly growing abdominal lump since 5 months, with loss of appetite and weight. A large abdominopelvic mass around 18 weeks was noted. Further imaging suggested an endometrioma in left adnexa and 70*67 mm complex left ovarian cyst. CECT abdomen showed a normal uterus with 97*68mm cystic lesion in left adnexae with post contrast enhancement and diagnosis of ? Dermoid cyst given. Tumor markers CA-125, AFP and CEA were found raised. Discussion- The patient's clinical presentation, imaging findings, and elevated tumor markers initially pointed towards a benign ovarian cyst (possibly dermoid) or malignancy. However, surgical exploration revealed a large ovarian mass with adhered bowel and mesentry, and on further histopathological and immuno-histochemistry co-relation a diagnosis of Mature Cystic Teratoma with GIST Ovary with multiple omental and mesentric deposits was made. Surgical resection forms the cornerstone of treatment, with adjuvant therapy potentially benefiting selected patients with known mutations on immuno-histochemistry. Conclusion- This case underscores the rarity and diagnostic challenges of ovarian GISTs, which are far less common than other ovarian neoplasms such as dermoid cysts or ovarian carcinomas. Due to lack of clear distinguishing features on imaging studies, histopathological examination and immunohistochemistry (IHC) are crucial for diagnosis.The complexity of this diagnosis highlights the importance of considering less common diagnoses and routine evaluation to rule out gastrointestinal tumors masquerading as adnexal mass.