Mesonephric adenocarcinomas of the uterine cervix: a study of 11 cases with immunohistochemical findings

CD10 expression in the female genital tract: does it have useful diagnostic applications?

In the female genital tract, CD10 was initially found to be expressed in endometrial stromal tumors of the uterus as well as in mesonephric remnants and related lesions and was thought to be helpful in distinguishing these tumors from their mimics. However, new studies have shown CD10 to be expressed in a wide range of tumors of the female genital tract, making this antibody of limited diagnostic value. This review discusses diagnostic applications of CD10 in the female genital tract, with emphasis on CD10 use in mesenchymal tumors of the uterus and in the differential diagnosis of mesonephric versus non-mesonephric carcinomas, where CD10 positivity alone may be misleading in the final classification of a tumor. CD10 may be useful in establishing the diagnosis of endometriosis (with the exception of the cervix), distinguishing metastatic renal clear cell carcinoma from a primary ovarian clear cell carcinoma, and distinguishing mesonephric hyperplasia from other benign glandular proliferations of the cervix.

Adenocarcinoma of the cervix and vagina in pediatric patients

Here we report our combined analysis of vaginal mesonephric adenocarcinoma (MA) in a 13 years old treated at our institution and of reported vaginal or cervical MA and clear-cell adenocarcinoma in 37 patients 18 years old or younger. Tumors in 27 patients arose in the vagina; 8 (21%) had metastases at diagnosis. The predominant symptom was vaginal bleeding; 62% of patients were exposed to diethylstilbestrol in utero. The 3-year survival estimate was 71% +/- 11%. Surgical treatment and metastasis at diagnosis were significant predictors of survival. The association between tumor excision and excellent outcome suggests that radical hysterectomy or pelvic exenteration is unnecessary. Radiotherapy as an adjunct may have contributed to this outcome.

Malignant mesonephric tumors of the female genital tract: a clinicopathologic study of 9 cases

Nine malignant mesonephric tumors were obtained from the consultation files of one of the authors (J.P.) over a 13-year period (1988-2001). There were 4 adenocarcinomas (ACs) and 5 malignant mixed mesonephric tumors (MMMTs). The ACs were found in the cervix (3) and vagina (1). The MMMTs involved the uterus (1), cervix (3), and vagina (1). Most patients presented with abnormal vaginal bleeding. The 4 patients with mesonephric AC ranged in age from 24 to 54 years (mean, 41 years). The tumors measured 2 to 6 cm (mean, 3.7 cm). Two ACs were stage I and two were stage II. Two of the three patients with follow-up information were alive without clinical evidence of disease at 3 and 11.5 years, and the other was alive with recurrent tumor 8.5 years postoperatively. The 5 patients with MMMTs ranged in age from 37 to 62 years (mean, 49 years). The mean size of four tumors was 5.2 cm (range, 3.5-8 cm). The uterine MMMT infiltrated the entire myometrial wall extending to the endometrial cavity where it resembled an endometrial polyp. Although the most common histologic pattern in the current series was the glandular (ductal) pattern, retiform, tubular, and solid growth patterns were also encountered. Among the MMMT subgroup, the sarcomatous component was homologous in 3 cases (endometrial stromal or spindle cell) and heterologous in the other 2 cases (skeletal muscle and cartilage). Of the 4 patients with follow-up information available, 1 (stage II) died of disease 7 months after surgery, another (stage IV) was alive with bone metastases at 3.3 years, and the other 2 patients (stages IB and IC) had no clinical evidence of disease at 1 and 3.7 years, respectively. Evidence of mesonephric hyperplasia was found in 5 (42%) cases. The MMMT that arose in the corpus presented as an endometrial polyp. In this case, histologic differential diagnosis includes serous carcinoma, endometrial stromal sarcoma, and uterine tumor resembling ovarian sex cord-stromal tumor. Immunostainings are not helpful. Mesonephric ACs often present in early stage and have better prognosis than their müllerian counterparts. Surgery alone appears to be the treatment of choice. In contrast, MMMTs may present in advanced stage and are aggressive tumors, similar to malignant mixed müllerian tumors.

Pathology of Cervical Cancer

Squamous cell carcinoma is the most common malignant cervical tumor, but the incidence of adenocarcinomas has been rising during the past few decades. This article discusses the epidemiology and pathogenesis of the squamous cell carcinoma, its clinical and histologic features, including microinvasive carcinoma, its histologic grade, and variant tumors. The prognostic impact of these features and the differential diagnosis are also covered. The second portion of this article is devoted to the glandular tumors of the cervix, including adenocarcinoma in situ and invasive adenocarcinoma and its variants. The differential diagnosis of these tumors with tumor like glandular lesions is given special attention. Finally, less common malignant cervical tumors are covered, with an emphasis being placed on their significance.

CD10 and calretinin staining of endocervical glandular lesions, endocervical stroma and endometrioid adenocarcinomas of the uterine corpus: CD10 positivity is characteristic of, but not specific for, mesonephric lesions and is not specific for endometrial stroma

AIMS

In the female genital tract CD10 has been used to assist in the evaluation of mesenchymal tumours of the uterus and in determining whether endometrial stroma is present. CD10 positivity has also been shown in cervical mesonephric remnants and this antibody has been suggested as a useful immunohistochemical marker of mesonephric lesions in the female genital tract. Calretinin has also been shown to be positive in mesonephric lesions. In this study the specificity of these two antibodies in evaluating cervical and uterine glandular lesions and the value of CD10 in determining whether stroma is endometriotic or not were investigated.

METHODS AND RESULTS

Cases of cervical tubo-endometrial metaplasia (TEM) (n = 11), microglandular hyperplasia (MGH) (n = 10), endometriosis (n = 8), mesonephric remnants/hyperplasia (n = 12), endocervical adenocarcinoma, usual type (n = 15), mucinous variant of minimal deviation adenocarcinoma (MDA) (n = 7) and mesonephric adenocarcinoma (n = 3) were stained with antibodies against CD10 and calretinin. Nine cases of endometrial adenocarcinoma of endometrioid type were also stained. In all the cervical cases normal endocervical glands were negative with both antibodies except for one case with strong positive luminal staining with CD10. All cases of TEM, MGH and endometriosis were negative with CD10 and calretinin except for focal staining with CD10 in one case each of MGH (cytoplasmic staining) and endometriosis (luminal staining). Most usual endocervical adenocarcinomas were negative with both antibodies, although one exhibited focal cytoplasmic staining with calretinin and five exhibited limited luminal positivity with CD10. All MDAs were negative with both antibodies. Ten of 12 mesonephric remnants/hyperplasia showed luminal positivity with CD10 and one exhibited cytoplasmic and nuclear staining with calretinin. Two of three mesonephric adenocarcinomas showed luminal positivity with CD10 and nuclear and cytoplasmic positivity with calretinin. Seven of nine endometrial adenocarcinomas were positive with CD10 (four cytoplasmic, two membranous and cytoplasmic, one luminal and cytoplasmic) and three with calretinin (two cytoplasmic, one nuclear and cytoplasmic). Positive staining of endometriotic stroma with CD10 was present in all endometriosis cases but normal cervical stroma was also strongly positive, especially around glands. Endometriotic stroma and cervical stroma were negative with calretinin.

CONCLUSIONS

We conclude that most endocervical glandular lesions, including mesonephric remnants/ hyperplasia, are negative with calretinin. However, the focal nuclear and cytoplasmic positivity with calretinin in two of three mesonephric adenocarcinomas suggests that this may be a useful indicator of a mesonephric origin of a cervical adenocarcinoma. Most mesonephric remnants/hyperplasias exhibit luminal positivity with CD10, although this is not invariable and staining is usually focal. Positive luminal staining of a benign endocervical glandular lesion with CD10 may help confirm mesonephric remnants. Although positive staining with CD10 was found in two of three mesonephric adenocarcinomas, the observed immunoreactivity of several conventional cervical adenocarcinomas limits the diagnostic value of CD10 in confirming a mesonephric origin for an adenocarcinoma. Since all cervical MDAs were negative with CD10, positivity with this antibody may be of value in distinguishing mesonephric hyperplasia from MDA, although this distinction rarely necessitates immunohistochemistry. Most endometrial adenocarcinomas of endometrioid type stain with CD10 and thus positivity with this antibody is not specific for a mesonephric origin of an endometrial adenocarcinoma. Positivity of normal cervical stroma limits the value of CD10 staining in confirming a diagnosis of cervical endometriosis.

Activity of chemotherapy with carboplatin plus paclitaxel in a recurrent mesonephric adenocarcinoma of the uterine corpus

BACKGROUND

Malignant lesions derived from mesonephric (Wolffian) remnants are uncommon. The course of these tumors is usually indolent, and the recurrence has only been documented in nine cases. Because of the small number of cases, no current recommendations exist regarding treatment, and little is known about the response to chemotherapeutic agents.

CASE

A 33-year-old woman was diagnosed with a mesonephric adenocarcinoma arising in the uterine corpus. Ten months after initial surgery and radiotherapy she presented with local and pulmonary relapse. Salvage chemotherapy with carboplatin plus paclitaxel was administered with a good response.

CONCLUSIONS

Mesonephric adenocarcinomas are uncommon neoplasms. Their treatment remains elusive. We report a case of a recurrent uterine mesonephric adenocarcinoma that presented a good response to therapy with carboplatin plus paclitaxel. A review of the previous literature is also presented.

Benign mixed tumor of the vagina: case report with expanded immunohistochemical profile

We present a case of benign mixed tumor of the vagina with its typical clinicopathologic and expanded immunohistochemical features. The strong coexpression of the mesenchymal spindle cell component with epithelial markers such as CK7, together with strong CD10, Bcl2, and estrogen and progesterone receptors favors a mullerian derived tumor. The tumor is best labeled as benign mixed mullerian tumor as originally designated.

Uterine tumor resembling ovarian sex-cord tumor: report of a case mimicking cervical adenocarcinoma

Uterine tumors resembling ovarian sex-cord tumors (UTROSCTs) are unusual neoplasms with histologic features that resemble those within ovarian Sertoli and granulosa cell tumors. We report the case of a 24-year-old woman with a UTROSCT presenting as a cervical mass, which on initial evaluation was thought to represent cervical adenocarcinoma. The patient's cervical biopsy specimen contained epithelioid cells arranged in tubules and anastomosing cords, without significant cellular atypia or mitotic activity. Because this morphology elicited a broad differential diagnosis, immunohistochemical studies were performed. The tumor was found to be diffusely positive for cytokeratin cocktail, calretinin, and desmin, focally positive for CK7 and SMA, and negative for EMA, CEA, inhibin, CD10, CK20, chromogranin, and synaptophysin. Ultrastructural examination revealed occasional gland-like lumens with cells joined by desmosomes and a continuous basal lamina. UTROSCTs have features that may cause them to be confused with more common tumors, especially in limited biopsy samples, and should be included in the differential diagnosis when a gland-forming neoplasm with an unusual appearance is identified in a cervical or endometrial biopsy specimen.

Microglandular adenocarcinoma of the uterus mimicking microglandular cervical hyperplasia

We present a rare case of microglandular carcinoma of the uterus occurring in 76-year-old woman. The tumor tissue in the curettage specimen showed strong similarity with microglandular hyperplasia of the cervix. Microglandular aggregates of glands with only mild nuclear atypia but without any structures of conventional endometrioid carcinoma were seen. Therefore, a microglandular hyperplasia of the cervix was seriously considered. The following features were helpful in the differential diagnosis: numerous neutrophils and "dirty" amount within glandular lumens; very scarce (but nevertheless present) mitoses; isolated single glands with more endometrioid than endocervical appearance; and strong expression of vimentin, which is unusual for microglandular hyperplasia of the cervix. In the resectate, a conventional well-differentiated endometrioid adenocarcinoma with microinvasion of the myometrium (under 1 mm of depth) was found. Microglandular differentiation has been, however, present in plaque-like proliferation replacing the endometrium and on the surface of conventional adenocarcinoma. Eleven months after the hysterectomy, the patient has no signs of recurrence or metastasis. Our case shows the difficulties in the diagnosis of this lesion and confirms a low aggressiveness that was observed in all 10 cases described to date.

Mesonephric remnants or hyperplasia can cause abnormal pap smears: a study of three cases

Three postmenopausal women were found to have abnormal Pap smears attributable to cells derived from mesonephric remnants or mesonephric hyperplasia of the cervix (one patient) or the upper vagina (two posthysterectomy patients). Mesonephric remnants or hyperplasia may represent the sole cause of abnormal Pap smears.

Endocervical glandular lesions: controversial aspects and ancillary techniques

The incidence of malignant and premalignant endocervical glandular lesions is increasing. This review covers controversial and difficult aspects regarding the categorisation and diagnosis of these lesions. The terminology of premalignant endocervical glandular lesions is discussed because of the differences between the UK terminology and the widely used World Health Organisation classification. The morphology and histological subtypes of premalignant endocervical glandular lesions are described. Early invasive adenocarcinoma and difficulties in the diagnosis and recognition of this entity are covered, as is the measurement of early invasion within cervical adenocarcinoma. Several benign endocervical glandular lesions can mimic malignant and premalignant endocervical glandular lesions, and the distinction of these benign mimics from premalignant and malignant lesions using ancillary immunohistochemical studies is also covered. Antibodies used to distinguish between endometrial and endocervical adenocarcinoma, in the diagnosis of cervical minimal deviation adenocarcinoma of mucinous type (adenoma malignum), and in the diagnosis of cervical mesonephric lesions are also reviewed.

CD10 expression in epithelial tissues and tumors of the gynecologic tract: a useful marker in the diagnosis of mesonephric, trophoblastic, and clear cell tumors

We tested 417 cases of formalin-fixed, paraffin-embedded normal or hyperplastic gynecologic tissues as well as neoplasms involving the gynecologic tract with a monoclonal antibody against CD10 (clone 56C6), with special emphasis on epithelial and epithelial-like structures and tumors. CD10 was always expressed in mesonephric remnants (mesonephric remnants of the uterine cervix, epoophoron, rete ovarii) and tumors (mesonephric adenocarcinoma of the uterine cervix, tumors of wolffian origin of the broad ligament and ovary). CD10 was also positive in the syncytiotrophoblast, cytotrophoblast, and intermediate trophoblast of normal gestations, partial and complete moles, choriocarcinoma, and placental site trophoblastic tumors. Finally, CD10 was positive in several metastatic neoplasms to the gynecologic tract (100% in metastatic renal clear cell and intestinal carcinomas and melanomas). In contrast, CD10 was almost invariably negative in müllerian epithelia of the female genital tract and in their corresponding tumors, with the exception of focal expression found in squamous epithelia and tumors with squamous differentiation. Thus, the expression of CD10 may be useful in the establishing the diagnosis of mesonephric and trophoblastic tumors and in the differential diagnosis between gynecologic clear cell carcinoma (always negative) and metastatic clear cell carcinoma of renal origin.

Symposium part II: special types of adenocarcinoma of the uterine cervix

This report provides a comprehensive review of several special types of adenocarcinoma of the uterine cervix. The clinicopathologic features of three tumors that may cause difficulties in diagnosis are detailed: adenoid basal carcinoma (epithelioma), adenoma malignum (minimal deviation adenocarcinoma), and mesonephric adenocarcinoma. Updated information on classification and clinical behavior are presented, as is data on their histochemical, immunohistochemical, and molecular profiles.

Intracellular distribution of intermediate filaments in vimentin-positive gastric carcinomas: confocal laser scanning microscopy using formalin-fixed paraffin-embedded specimens

Intermediate filaments are known as cytoskeletal elements. Recently, additional vimentin expression has been reported in some carcinomas; however, the function of such expression remains unclear. We studied the intracellular distribution of low-molecular weight cytokeratin and vimentin by immunohistochemistry in 17 vimentin-positive gastric carcinomas using confocal laser scanning microscopy. All materials were formalin-fixed and paraffin-embedded. Low-molecular weight cytokeratin expression showed a membranous pattern with a prominent deposition just below the cytoplasmic membrane in both tubular and solid components of the carcinomas. This unique membranous deposition was frequently absent in diffuse components. On the other hand, vimentin expression showed a fibrillary pattern in all components and also showed a unique basal distribution in the tubular components. We also recognized an aggregate pattern of the intermediate filament expression in diffuse components. We conclude that the significance of vimentin expression in carcinoma cells cannot be explained as a simple substitution for low-molecular weight cytokeratin because the distribution of vimentin and low-molecular weight cytokeratin is different.

Endocervical adenocarcinoma and its variants: their morphology and differential diagnosis

Adenocarcinoma of the uterine cervix and its variants account for a much greater number of cases in routine practice of histopathology than they did several decades ago. The varied morphology of these tumours results in diverse problems in differential diagnosis. The overall area of glandular pathology of the cervix, of which invasive adenocarcinoma is only one subset, is further complicated by the fact that there are many benign glandular proliferations of the cervix that can potentially be misinterpreted as adenocarcinoma. In this review the histopathology of endocervical adenocarcinoma and its variants is presented with the emphasis on evaluation of routinely stained sections, still the bedrock of routine practice, relatively little aid being provided by immunohistochemistry or other new techniques, contrary to what is sometimes implied in the literature. Description of the appearance of each subtype of adenocarcinoma or variant thereof is followed by a section on their differential diagnosis. Eighty percent of endocervical carcinomas are of the so-called usual type being characterized by cells with eosinophilic cytoplasm and generally brisk mitotic activity. It is sometimes stated that endocervical adenocarcinomas are mucinous but the usual form just noted often has little or no mucin. Pure or almost pure mucinous adenocarcinoma do occur, however, and have an important subtype, the so-called adenoma malignum (minimal deviation adenocarcinoma). Although treacherous because of its bland cytological features and sometimes deceptive pattern, a cone biopsy or hysterectomy specimen showing this neoplasm typically has easily recognizable features that indicate the presence of an infiltrative adenocarcinoma. An important variant of usual endocervical adenocarcinoma is the well differentiated villoglandular papillary adenocarcinoma, a designation that should be reserved for tumours with grade 1 cytologic features as usual endocervical adenocarcinoma, which is typically grade 2, may have papillae. In our opinion all other variants of pure adenocarcinoma, including endometrioid, are rare and include in addition to the latter clear cell, serous and mesonephric neoplasms. Tumours with a glandular and nonglandular component are also reviewed: adenosquamous carcinoma, glassy cell carcinoma, adenoid basal carcinoma, 'adenoid cystic' carcinoma and adenocarcinoma admixed with a neuroendocrine tumour.

Endometrioid carcinoma of the endometrium with an invasive component of minimal deviation carcinoma

Minimal deviation endometrioid adenocarcinoma is a rare pathological variant of endometrioid adenocarcinoma. We describe a case representing another rare variant of endometrioid adenocarcinoma composed of both typical and minimal deviation endometrioid adenocarcinoma in a 45-year-old woman. Macroscopically, the cervix was of normal size but it had an indurated consistency. The myometrium was unremarkable. Microscopically, in addition to the typical endometrioid adenocarcinoma that involved 75% of the endometrium, there was a proliferation of mildly atypical endometrial type glands sparsely distributed in the fibrovascular tissue, typical of minimal deviation endometrioid adenocarcinoma. The latter component extended downward from the endomyometrial junction and involved focal areas of the uterine body and isthmus, diffusely invaded the entire cervix and focally the cervical resection margins. Focal transitional areas between typical and minimal deviation endometrioid adenocarcinoma were identified. Due to a relatively normal gross appearance and the microscopic deceptively benign looking appearance, minimal deviation endometrioid adenocarcinoma may pose problems of obtaining adequate sampling and evaluating the thickness of invasion of the endometrial carcinoma on gross, as well as microscopic, examination. HUM PATHOL 33:856-858.

Mesonephric adenocarcinoma of the uterine corpus: CD10 expression as evidence of mesonephric differentiation

Mesonephric (wolffian) neoplasms of the female genital tract are infrequent and found in sites where embryonic remnants of wolffian origin are usually detected, such as the uterine cervix, broad ligament, mesosalpinx, and ovary. Their diagnosis is difficult because of the absence of specific immunohistochemical markers for mesonephric derivatives. We present the first report of adenocarcinoma of mesonephric type arising as a purely myometrial mass without endometrial or cervical involvement in the uterine corpus of a 33-year-old woman. The tumor showed a combination of patterns, with retiform areas, ductal foci, and small tubules with eosinophilic secretion, which merged with solid sheets of cells with a sarcomatoid appearance. Immunohistochemically, neoplastic cells were diffusely positive for cytokeratin 7, epithelial membrane antigen, and CD15 and focally positive for BerEP4 and vimentin. A hitherto unreported feature was the positivity for CD10 in neoplastic cells, which was also present in a large number of control tissues obtained from male mesonephric derivatives and female mesonephric remnants and tumors. Furthermore, CD10 was negative in controls from müllerian epithelia of the female genital tract and in their corresponding tumors. Therefore, the expression of CD10 by mesonephric remnants may be useful in establishing the diagnosis of tumors with mesonephric differentiation.

A comparison of epithelial membrane antigen overexpression in benign and malignant endometrium

OBJECTIVE

The aim of this study was to analyze the value of epithelial membrane antigen (EMA) overexpression in benign and malignant endometrium and its prognostic significance.

METHODS

EMA immunostaining was performed in 178 paraffin-embedded specimens including 105 endometrial cancers, 40 endometrial hyperplasias, and 33 benign endometriums. EMA immunostaining was correlated with traditional prognostic factors and progression-free survival in endometrial cancer specimens.

RESULTS

EMA overexpression was observed more frequently in adenocarcinomas (60%) than in hyperplasias (15%) or benign endometrium (9.1%). EMA overexpression was observed in two patients with endometrial hyperplasia who progressed to carcinoma. In adenocarcinomas, EMA overexpression had a positive correlation with nonendometrioid subtypes (P = 0.012). In multivariate analysis, FIGO stage (P = 0.025) and EMA overexpression (P = 0.017) were independent prognostic factors for progression-free survival.

CONCLUSIONS

EMA overexpression appears to be a marker of malignant transformation in the endometrium and it is an independent predictor of recurrent disease in endometrial cancer.