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2008, Volume 24, Number 3, Page(s) 186-189
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Incidental serous papillary ovarian carcinoma diagnosed on endometrial biopsy |
Çiğdem HİMMETOĞLU1, Alp USUBÜTÜN1, Ali AYHAN2, Türkan KÜÇÜKALİ1 |
1 Hacettepe University Medical Faculty Department of Pathology, ANKARA
2 Hacettepe University Medical Faculty Department of Gynecology and Obstetrics, ANKARA |
Keywords: Serous papillary carcinoma, ovarian, endometrial biopsy |
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We present a case of incidental locally advanced serous
papillary ovarian carcinoma in a 43-year-old women on
endometrial biopsy. On endometrial biopsy, findings of
serous carcinoma besides normal endometrial tissue
caused diagnostic confusion. However, by thorough clinical
investigation, we were able to detect bilateral ovarian
masses, which were proved to be serous papillary
cystadenocarcinoma. The possibility of a locally advanced
ovarian carcinoma should always be kept in mind
especially when trying to identify a serous papillary
carcinoma in an endometrial biopsy with no endometrial
involvement. |
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We are presenting a 43-year-old women
referred to Gynecology and Obstetrics Clinic of
our hospital with menstrual irregularities firstly
manifest in January 2004. Endometrial sampling
performed at that time revealed simple endometrial
hyperplasia without atypia and transvaginal
ultrasonography was unremarkable except
for myoma uteri. At her next referral with
similar symptoms in September 2005, her cervical
smear was reported to be negative for any intraepithelial
lesion or malignancy. However,
microscopic examination of her endometrial biopsy
was problematic due to the presence of
small serous papillary carcinoma fragments just
next to totally benign proliferative endometrial
glandular tissues (Figure 1A, 1B). P53 immunostaining
was performed in order to confirm
the malignant character of these papillary structures
with strong nuclear positivity. At this point,
contamination was considered to be the case,
owing to the age of the patient and the absence
of clinical suspicion. Serial sectioning was
done to rule out contamination occurring during
blocking of the tissues or during sectioning of
the paraffin block. The gynecologist was also
informed about the situation. A second endometrial
sampling was done which was free of
these malignant cell groups. However, further
examining and laboratory investigations were
surprising. Abdominal ultrasonography detected
intraabdominal ascites and prominently increased
serum CA15-3 and CA125 levels. Diagnostic
fine needle aspiration biopsy from the ascites
detected malignant epithelial cells in concordance
with adenocarcinoma. Abdominal computed
tomography lightened the case with the presence
of extensive peritoneal carcinomatosis, infraand
supracolic omental implants, a left ovarian
mass as well as bilateral pleural effusions.
Click Here to Zoom |
Figure 1: A, B: Small serous papillary carcinoma fragments just next to totally benign proliferative endometrial glandular tissues. C: Serous papillary ovarian cystadenocarcinoma. D: Abundant tumor fragments as well as accompanying inflamatory cells in the lumen of tuba uterina. |
Radical hysterectomy with bilateral salphingoopherectomy,
total omentectomy, bilateral
pelvic paraaortic lymphadenectomy and appendectomy
were performed. The right ovarian
mass, with an intact capsule, measured 7x5x3.5
cm. The left ovary, enlarged to 8x6x5 cm, had
papillary projections on its surface. The uterine
cavity and tuba uterina were macroscopically
free of disease. Whole endometrium was sampled but no invasive or pre-neoplastic lesion was
found. On the other hand, omentum and appendical
serosa were infiltrated with tumor. Microscopic
examination of the ovarian tumors and bilateral
tuba uterina determined the origin of the
serous papillary tumor fragments on the endometrial
biopsy: Bilateral serous papillary ovarian
cystadenocarcinoma (Figure 1C), abundant
tumor fragments as well as accompanying inflammatory
cells in the lumen of tuba uterina
elucidated the diagnosis (Figure 1D). |
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Abstract
Case Presentation
Disscussion
References
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There are striking clinical and histopathological
similarities between serous papillary carcinomas
of the ovary, endometrium and peritoneal
cavity. Serous papillary tumor of the ovary
(OSPC) is a highly malignant neoplasm with aggressive
behavior and poor prognosis. Uterine
serous papillary carcinoma (UPSC) is an estrogen
independent, type-II endometrial carcinoma
with adverse histological features, commonly
developing in atrophic or resting endometrium.
The origin of a serous tumor may only be determined
with thorough examination of the surgical
staging specimen according to the criteria
suggested by the Gynecologic Oncology Group.
The nature of papillary structures in endometrial
sampling is a diagnostic challenge for the pathologist.
Such structures might be both benign
and malignant so morphological characteristics
such as nuclear atypia, increased nuclear/cytoplasmic
ratio and presence of mitosis should be
searched for. Immunostaining of such cells with
p53 might also be of help. Clinical information,
prior diagnosis and age of the patient should be
reconsidered but most important of all, the biopsy
should be evaluated in total by examining
all endometrial glands, as presence of an endometrial
intraepithelial carcinoma or endometrial
glandular dysplasia might explain the whole
picture and point out a USPC. In case of our patient,
papillary structures were of malignant
character with prominent atypia and strong p53
positivity. However, neither the patient's age
nor the rest of the endometrial glands were concordant
with these serous papillary tumor fragments.
Contamination was tried to be ruled out
via serial sectioning and a second endometrial
biopsy was done with no evidence of malignancy.
Only thorough clinical investigation was
able to lighten the case. The first diagnostic
challenge in case of malignant papillary structures
in endometrial curetting is the exclusion of
USPC. The absence of accompanying endometrial
glandular dysplasia or endometrial intraepithelial
carcinoma is of use. The term endometrial
intraepithelial carcinoma (EIC) as a putative
precursor lesion of USPC, was first proposed by
Sherman et al. in 1992 1,2. EIC is defined
morphologically as replacement of endometrial
surface epithelium and glands, without myometrial
invasion by frankly malignant cells identical
to USPC tumor cells. Zheng et al. recently described
a new entity called endometrial glandular
dyplasia (EmGD), which bridges benign resting
endometrium and serous EIC 3,4. Still the distinction
of OSPC and USPC can certainly be done
after surgical staging of the excised sample.
Kern B in his review of 234.318 cervicovaginal
smears, described 7 cases with psammoma
bodies, in which 3 of them were associated
with benign conditions and 4 with cancer (2
USPC, 1 OSPC and 1 primary peritoneal serous
papillary carcinoma). Psammoma bodies may
be seen in cervicovaginal smears and should always
alert the pathologist for the existence of
OSPC 5,6. The vaginal smear of our patient
had no significant finding and endometrial biopsy
didn't contain psammoma bodies. Diagnosis
of OSPC through endometrial sampling has
not been reported in the literature and our case
is the first to our knowledge. Similar to superficial
extension of endometrial tumors to ovaries,
it is theoretically possible for a serous ovarian
tumor to involve fallopian tubes as well as the
endometrial lining. Therefore, the possibility of
a locally advanced ovarian carcinoma should always
be kept in mind in when trying to diagnose a serous papillary carcinoma in an endometrial
biopsy due to the spilling character of serous
papillary tumors. |
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Abstract
Case Presentation
Discussion
References
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1) Sherman ME, Bitterman P, Rosenshein NB, Delgado G, Kurman RJ. Uterine serous carcinoma. A morphologically diverse neoplasm with unifying clinicopathologic features. Am J Surg Pathol 1992;16:600-610.
2) Ambros RA, Sherman ME, Zahn CM, Bitterman P, Kurman RJ. Endometrial intraepithelial carcinoma: a distinctive lesion specifically associated with tumors displaying serous differentiation. Hum Pathol 1995; 26:1260-1267.
3) Zheng W, Schwartz PE. Serous EIC as an early form of uterine papillary serous carcinoma: recent progress in understanding its pathogenesis and current opinions regarding pathologic and clinical management. Gynecol Oncol 2005;96:579-582.
4) Zheng W, Liang SX, Yu H, Rutherford T, Chambers SK, Schwartz PE. Endometrial glandular dysplasia: a newly defined precursor lesion of uterine papillary serous carcinoma. Part I: morphologic features. Int J Surg Pathol 2004;12:207-223.
5) Kern B. Prevalence of psammoma bodies in Papanicolaou-stained cervicovaginal smears. Acta Cytol 1991; 35:81-88.
6) Hallman KB, Nahhas WA, Connelly PJ. Endosalpingiosis as a source of psammoma bodies in a Papanicolaou smear. A case report. J Reprod Med 1991;36:675-678. |
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Abstract
Case Presentation
Discussion
References
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