Endometrial carcinoma with trophoblastic differentiation. An aggressive form of uterine cancer

Dedifferentiated endometrioid adenocarcinoma with trophoblastic components: Prolonged remission after treatment with bleomycin, etoposide, and cisplatin

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DEAC with trophoblastic components is a rare neoplasm.

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The neoplasm is difficult to treat and has a poor overall prognosis.

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Multiple adjuvant chemotherapy treatment regimens have been reported.

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The neoplasm appears to have a good response to bleomycin, etoposide, and cisplatin.

Dedifferentiated endometrial adenocarcinoma (DEAC) with trophoblastic components is a rare neoplasm with an aggressive behavior and a poor prognosis. Only seven cases have been reported in the literature. We present a 61-year-old patient who was diagnosed with Stage IB dedifferentiated endometrioid adenocarcinoma with trophoblastic elements. A post-operative β-hCG was elevated at 1877 mIU/mL. The patient received 6 cycles of carboplatin and paclitaxel with normalization of β-hCG; however, three months after completion of chemotherapy, her β-hCG increased to 39 mIU/mL and a mass overlaying the psoas muscle was noted on imaging. The mass was resected and confirmed to be recurrent disease. Four cycles of bleomycin, etoposide, and cisplatin were administered, and the patient remains without evidence of disease 3 years after completing treatment. Due to the small number of reported cases of DEAC with trophoblastic components, there is limited information regarding the appropriate first-line adjuvant chemotherapy regimen.

The importance of hCG in human endometrial adenocarcinoma and breast cancer

Human chorionic gonadotropin (hCG) is a peptide hormone which plays an important role during pregnancy. But its impact is not limited to pregnancy; it also influences tumor formation and metastatic outgrowth, especially in endometrial adenocarcinoma and breast cancer. This review summarizes what has been written in the literature about the role of hCG as a tumor marker in these 2 gynecological malignancies and also about the signal transduction pathways in which hCG is involved. HCG can, on the one hand, be a marker for the progression of a malignant disease, and on the other hand, it may be a point for therapeutical intervention, so further research into this molecule would be very much worthwhile.

Endometrial Carcinoma With Trophoblastic Components: Clinicopathologic Analysis of a Rare Entity

Somatic endometrial carcinomas with trophoblastic components have only rarely been described. To better characterize this distinctive combination of histotypes, we report herein 4 new cases, representing the largest cohort reported thus far, and review previously reported cases. The 4 new patients ranged in age from 61 to 77 yr (mean, 68 yr). The first patient had a grade 2 endometrioid carcinoma, surgical International Federation of Gynecology and Obstetrics stage IA, that recurred 5 months later at the vaginal apex with purely choriocarcinoma elements, suggestive of unsampled trophoblastic areas in the uterus. The 3 other patients were all International Federation of Gynecology and Obstetrics stage III, and included 2 cases of dedifferentiated endometrial carcinoma with 40% and 20% choriocarcinoma components, and 1 case of grade 1 endometrioid carcinoma with a 40% choriocarcinoma component. Postoperative serum β-human chorionic gonadotropin was elevated in all patients. All received adjuvant combination chemotherapy, but all were dead of disease with distant metastases at an average of 11.75 mo (range, 7-16 mo) after primary staging. Data from our cases were combined with those from 24 cases that had previously been reported in the literature between 1972 and 2016. Analysis of this combined data indicates that endometrial carcinoma with trophoblastic component is a rare neoplasm that occurs primarily in postmenopausal patients. The trophoblastic component is most commonly a choriocarcinoma and the somatic component is most commonly an endometrioid carcinoma or an adenocarcinoma/carcinoma reported without further specification; the somatic component may be a diverse array of histotypes or histotype admixtures. Serum and/or urine β-human chorionic gonadotropin is elevated in almost all patients, and fluctuations of β-human chorionic gonadotropin generally correlated with tumor relapses or recurrences. The stage distribution and patient outcomes in the current and previously reported patients suggests that trophoblastic differentiation usually, but not invariably denotes clinical aggressiveness.

Dedifferentiated endometrioid adenocarcinoma with trophoblastic components and elevated serum alfa-fetoprotein: A case report and literature review

RATIONALE

Dedifferentiated endometrioid adenocarcinoma (DEAC) consisted of a combination of undifferentiated and differentiated carcinoma is more aggressive than other conventional endometrioid adenocarcinomas.

PATIENT CONCERNS

A 33-year-old woman with atypical vaginal bleeding was refereed to our hospital. She had an endometrial biopsy in a local clinic which showed differentiated endometrioid carcinoma with trophoblastic components. High levels of β-Human chorionic gonadotropin (β-hCG) and alfa-fetoprotein (AFP) were detected in the patient's serum.

INTERVENTIONS

The patient underwent total hysterectomy with bilateral salpingo-oophorectomy, total omentectomy and systemic pelvic lymphadenectomy in our center.

DIAGNOSIS

Pathological investigation indicated that the tumor had well differentiated and undifferentiated adenocarcinoma as well as trophoblastic components.

OUTCOMES

Serum β-hCG and AFP dropped significantly after operation. But three weeks later, the patient had developed pulmonary metastases and elevation of serum β-hCG. She died of the disease five months after surgery.

LESSONS

DEAC with trophoblastic differentiation seems to follow an aggressive course with early metastasis and poor clinical prognosis. However, due to small number of cases, further studies are necessary.

Clear Cell Carcinoma of the Cervix With Choriocarcinomatous Differentiation: Report of an Extremely Rare Phenomenon Associated With Mismatch Repair Protein Abnormality

The presence of trophoblastic differentiation or nongestational choriocarcinoma in a carcinoma is rare but has been described in various organs, including in the female genital tract. We report a cervical clear cell carcinoma admixed with a component of choriocarcinoma in a 52-year-old woman, only the second report of this combination in the literature. Immunohistochemically, the tumor exhibited isolated loss of staining with the mismatch repair protein MSH6. We review the literature on trophoblastic differentiation in cervical carcinoma.

Hormone producing gynecological tumors: pathologic entities and clinical significance

INTRODUCTION

Due to their derivation from the cell types involved in gynecologic hormonal networks, many gynecologic tumors may produce hormones. In a normal physiological setting, these hormones are essential for regulating the biology and function of gynecological organs, the ovary and uterus in particular. Overproduction of hormones by the tumor may lead to abnormal clinical manifestations of the patients and spillage of excess hormonal products into the blood. Abnormal elevation of serum hormones may be considered as biomarkers that are important to pathologists and clinicians in making precise tumor diagnoses and likely useful in monitoring the tumor burden/recurrence to guide patient treatment options. This review will discuss gynecologic neoplasms that produce hormonal biomarkers and assess their relevance to pathological diagnosis, evaluation for therapeutic response and monitoring disease progression.

AREAS COVERED

Studies involving hormonal production by a gynecologic tumor were candidates for inclusion in this review.

EXPERT COMMENTARY

Serum hormonal biomarkers have clinical utility both in the diagnosis of gynecologic neoplasms and clinical monitoring of treatment efficacy and recurrence.

Primary Endometrial Yolk Sac Tumor With Endodermal-Intestinal Differentiation Masquerading as Metastatic Colorectal Adenocarcinoma

Yolk sac tumors (YSTs) with a somatic glandular pattern can be difficult to recognize histologically because they reproduce developing intestinal, hepatic, or lung tissue and can express markers such as CDX2 and TTF1. We report an unusual case of a primary endometrial YST showing florid endodermal-intestinal differentiation in a 63-yr-old woman with a history of colorectal adenocarcinoma. Histologically, the tumor exhibited a glandular and papillary architecture and showed widespread immunoreactivity for CDX2 and focal staining for CK20 and CEA, mimicking metastatic colorectal carcinoma on biopsy. The presence of subnuclear cytoplasmic clearing and positive staining for germ cell markers, however, pointed toward a diagnosis of primary endometrial YST, and this was supported by the radiologic and the subsequent pathologic finding of a primary endometrial-based lesion. YSTs in this age group usually arise in association with somatic tumors and in this case a small focus of coexistent endometrioid adenocarcinoma was identified within the uterus. Despite surgery and adjuvant chemotherapy, the patient showed disease progression with liver and lung metastases 6 mo postoperatively.

Yolk sac tumours of the female genital tract in older adults derive commonly from somatic epithelial neoplasms: somatically derived yolk sac tumours

AIMS

To report 18 yolk sac tumours (YSTs) of the female genital tract (17 ovary, one uterus) in patients aged 40 years or over, most arising from a somatic epithelial neoplasm.

METHODS AND RESULTS

Six patients had pure YST, two were associated with immature teratoma (one with an endometrioid adenocarcinoma) and in 11 there was an epithelial neoplasm comprising high-grade serous carcinoma (HGSC) (n = 5), clear cell carcinoma (n = 1), borderline clear cell adenofibroma (n = 1), endometrioid adenocarcinoma (n = 2), serous tubal intra-epithelial carcinoma (n = 1) and large-cell neuroendocrine carcinoma (n = 1). In one case of pure YST, there was an ipsilateral endometriotic cyst but no other neoplastic component. In two cases, the YST was a hepatoid variant and in most of the others it exhibited predominantly glandular morphology, closely mimicking an epithelial neoplasm.

CONCLUSIONS

Pathologists should be aware of the association between YST and an epithelial neoplasm, the former probably arising from the latter through a process of neometaplasia/retrodifferentiation. Those rare gynaecological pure glandular YSTs in adults may arise secondary to total overgrowth of an epithelial neoplasm. Pathologists need a high index of suspicion to diagnose the YST component, as the morphology is characteristically of a glandular variant with marked morphological overlap with adenocarcinomas. There is also often significant immunophenotypical overlap with epithelial neoplasms, as the YST component may be positive with epithelial membrane antigen (EMA), BerEP4 and cytokeratin 7 (CK7), as well as YST markers. We propose the term 'somatically derived YSTs' for these neoplasms and suggest unification of the terminology between different sites where such neoplasms occur.

Uterine Carcinoma With Serous and Choriocarcinomatous Differentiation

Nongestational, nongonadal, and nonteratoma-related choriocarcinoma is an extremely rare entity. The tumor may be pure or associated with carcinoma. Six cases of primary endometrial carcinomas with the presence of syncytiotrophoblastlike beta-human chorionic gonadotropin (beta-HCG)-positive cells have been reported. We describe a case of endometrial carcinoma in a postmenopausal woman, that was composed almost entirely of syncytiotrophoblastic and cytotrophoblastic elements, except in the areas of lymphatic and myometrial invasion, where the neoplasm expressed a papillary serous carcinoma conformation with numerous psammoma bodies. There was not a clear transition between choriocarcinoma and serous carcinoma components. Immunohistochemically, beta-HCG was strongly positive in trophoblastic cells, whereas papillary areas expressed epithelial membrane antigen. These results suggest a double differentiation from malignant stem cells toward an extraembryonal germinal line and a papillary epithelial line. A poor prognosis is expected for this type of neoplasm with extraembryonic differentiation. In the present case, the histologic subtype of uterine papillary serous carcinoma could be an additional risk factor.

Endometrial carcinoma with yolk sac tumor-like differentiation and elevated serum β-hCG: a case report and literature review

Endometrial carcinoma with a germ cell tumor component is a rare event. Here we report a uterine neoplasm with a unique combination of endometrioid adenocarcinoma and mixed germ cell malignant elements. A 28-year-old woman with abnormal vaginal bleeding, an abdominal mass, and elevated alfa-fetoprotein and beta-human chorionic gonadotropin (β-hCG) levels had a history of biopsy of an omental mass and chemotherapy in another hospital one month before her referral to our department. Histologic examination of the mass removed from the omentum revealed an endometrioid adenocarcinoma with yolk sac tumor-like differentiation. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, and removal of metastatic disease were then undertaken at our hospital. Postoperative chemotherapy was given. Eight months postoperatively, serum alfa-fetoprotein and β-hCG rose again. Cases with primary yolk sac tumors of the endometrium or endometrial carcinoma with trophoblastic differentiation in the literature were reviewed.

Endometrioid adenocarcinoma with choriocarcinomatous differentiation: A case report and review of the literature

A choriocarcinomatous component is rarely present in carcinomas of certain sites and few cases of choriocarcinomatous differentiation in endometrioid adenocarcinoma have been reported. The present study reports a case of endometrioid adenocarcinoma of the uterine corpus with choriocarcinomatous differentiation, and discusses the clinicopathological features of this rare tumor. A 59-year-old post-menopausal female presented with abnormal vaginal bleeding. Magnetic resonance imaging demonstrated a relatively well-circumscribed tumor in the uterine corpus and a total cystectomy was subsequently performed. A histopathological examination revealed two distinct components in the uterine corpus tumor. The first component comprised ~80% of the tumor and was composed of poorly-differentiated endometrioid adenocarcinoma. The remaining component consisted of mononucleated and syncytial giant cells containing rich eosinophilic cytoplasm and large pleomorphic nuclei with coarse chromatin. An immunohistochemical analysis revealed that these syncytial giant cells were positive for β-human chorionic gonadotropin (hCG). Therefore, a diagnosis of endometrioid adenocarcinoma with choriocarcinomatous differentiation was confirmed. The clinicopathological features of nine previously reported cases of this tumor were analyzed in addition to the present case. The majority of the patients were post-menopausal. Endometrial choriocarcinoma may be considered to have a highly aggressive clinical course, since nine of the 10 cases displayed metastases and four patients succumbed to the disease. The pathogenesis of the choriocarcinomatous component is not well understood. However, genetic studies have demonstrated that conventional carcinoma and choriocarcinomatous components share common genetic alterations. The choriocarcinomatous component represents aberrant differentiation of the conventional carcinoma, however, genetic analyses of endometrioid adenocarcinoma with choriocarcinomatous differentiation have not been performed.

Endometrial carcinoma with choriocarcinomatous differentiation: a case report and review of the literature

BACKGROUND

Choriocarcinomas unrelated to pregnancy, teratomas, or germ cell tumors have been found in the stomach, lungs, colon, esophagus, bladder, breast, renal pelvis and other sites.

CASE

We present a case of a 58-year-old woman with endometrial carcinoma with choriocarcinomatous differentiation. She received surgery and chemotherapy for endometrial adenocarcinoma. However, a metastatic tumor of choriocarcinomatous element appeared at the vaginal cuff 9 months after surgery. Additional chemotherapy for choriocarcinoma resulted in a decrease in the serum hCG and the tumor regressed. Fifty months following surgery, she is alive without disease.

CONCLUSION

Treatment and follow-up must be performed not only for the adenocarcinoma element but also for the choriocarcinoma element in patients presenting with endometrial carcinoma with choriocarcinomatous differentiation.

Endometrioid carcinoma of the endometrium with choriocarcinomatous differentiation: a case report and review of the literature

OBJECTIVE

An endometrioid adenocarcinoma (EAC) with true trophoblastic differentiation is a rare event with a highly aggressive clinical course.

CASE

We report an endometrioid adenocarcinoma of the endometrium in which there was a morphologically conventional-appearing EAC component admixed with multinucleated giant cells and large pleomorphic tumor cells that resembled a choriocarcinoma without an elevated serum level of human chorionic gonadotropin (hCG) in a 42-year-old unmarried woman with a history of abnormal uterine bleeding. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection were performed. Histopathologic study of the specimen showed endometrioid adenocarcinoma extended to the deep myometrium with a focus of hemorrhagic and necrotic tumor composed of multinucleated giant cells, large pleomorphic tumor cells, suggesting choriocarcinomatous differentiation (CD). Immunohistochemical studies demonstrated intense reactivity of tumor cells for human chorionic gonadotropin (hCG) confirming the diagnosis. A complete clinical workup ruled out metastatic spread to the brain, lungs, skeleton, or abdomen. The patient was alive with no evidence of disease 6 months later.

CONCLUSION

Although endometrioid adenocarcinoma with choriocarcinomatous differentiation is known to behave in a more aggressive course, this disease may have a good prognosis with a clinically indolent course when it is small, and without elevated serum hCG levels.

Proliferation and cell-cell fusion of endometrial carcinoma are induced by the human endogenous retroviral Syncytin-1 and regulated by TGF-beta

Endometrial carcinomas (EnCa) predominantly represent a steroid hormone-driven tumor initiated from prestages. The human endogenous retrovirus HERV-W envelope gene Syncytin-1 was significantly increased at the mRNA and protein levels in EnCa and prestages compared to controls. Steroid hormone treatment of primary EnCa cells and cell lines induced Syncytin-1 due to a new HERV-W estrogen response element and resulted in increased proliferation. Activation of the cAMP-pathway also resulted in Syncytin-1 upregulation, but in contrast to proliferation, classic cell-cell fusions similar to placental syncytiotrophoblasts occurred. Cell-cell fusions were also histologically identified in endometrioid EnCa tumors in vivo. Clonogenic soft agar experiments showed that Syncytin-1 is also involved in anchorage-independent colony growth as well as in colony fusions depending on steroid hormones or cAMP-activation. The posttranscriptional silencing of Syncytin-1 gene expression and a concomitant functional block of induced cell proliferation and cell-cell fusion with siRNAs proved the essential role of Syncytin-1 in these cellular processes. TGF-beta1 and TGF-beta3 were identified as main regulative factors, due to the finding that steroid hormone inducible TGF-beta1 and TGF-beta3 inhibited cell-cell fusion, whereas antibody-mediated TGF-beta neutralization induced cell-cell fusions. These results showed that induced TGF-beta could override Syncytin-1-mediated cell-cell fusions. Interactions between Syncytin-1 and TGF-beta may contribute to the etiology of EnCa progression and also help to clarify the regulation of cell-cell fusions occurring in development and in other syncytial cell tumors.

Serous carcinoma of the endometrium with choriocarcinomatous differentiation: a case report and review of the literature indicate the existence of 2 prognostically relevant tumor types

Nongestational choriocarcinomas rarely occur outside the gonads or teratomas. We report a serous carcinoma of the endometrium with a choriocarcinomatous component and review of the literature. A 61-year-old woman underwent hysterectomy and bilateral salpingo-oophorectomy for a serous carcinoma with choriocarcinomatous component. Immunohistochemistry showed a strong p53 staining of the serous component and the cytotrophoblastic cells of the choriocarcinomatous component; the syncytiotrophoblast was negative. The initial serum human chorionic gonadotropin (hCG) was 225,000 IU/L. Postoperatively, the patient developed diffuse pulmonary metastatic disease. Despite chemotherapy, the patient died 2 months after initial diagnosis. Abstracting the data from the reported cases and from the literature, it can be assumed that 2 different tumor types exist. The first one is morphologically and clinically more related to the gestational choriocarcinoma with strongly elevated serum hCG levels, early onset of (distant) metastatic disease, and consecutively rapid and often fatal clinical course. The second type presents as an endometrial carcinoma with single syncytiotrophoblast-like cells, associated with low serum hCG, no distant metastatic disease, and, consequently, a better prognosis. The prognostically relevant component for long-time survival in the latter variant is the nontrophoblastic component.

Adenocarcinoma of the uterine cervix with choriocarcinomatous metastasis

BACKGROUND

Nongestational choriocarcinoma, in very rare instances, has been described as a component of other malignancies with a tendency for a very poor prognosis.

CASE

A 55 year old woman was diagnosed with adenocarcinoma of the cervix, and incompletely treated with only external beam radiation. Adjuvant radical hysterectomy demonstrated no residual tumor, but the patient developed a tumor metastasis mimicking a pulmonary artery thrombus which by histology and immunohistochemistry was pure choriocarcinoma. While chemotherapy was successful in achieving a complete remission, the patient succumbed to complications of her pulmonary metastasis.

CONCLUSION

Choriocarcinomatous dedifferentiation of cervical adenocarcinoma is extremely rare, with only one other case reported in the literature. While the prognosis for patients with such a tumor is generally poor, aggressive combination chemotherapy may be of benefit in some.

Choriocarcinome utérin en péri-ménopause

We report a case of a primary uterine choriocarcinoma associated with adenocarcinoma occurring during peri-menopausal age, and review the literature. The clinical course and the histopathology of the case were reviewed and a Medline literature search for other cases was performed. BHCG and analysis of uterine curettage provided the diagnosis of choriocarcinoma. Polychemotherapy, started immediately after the patient's clinical condition deteriorated, was successful. Colpohysterectomy and pelvic lymphadenectomy were performed 5 months later. Treatment was completed by vaginal curietherapy. Histopathologic examination of the surgical specimen revealed only adenocarcinoma. The patient was followed for 18 months without evidence of recurrence. The literature search revealed that primary forms are exceptional; the etiology is unknown. Treatment is based on polychemotherapy. Primary choriocarcinomas are rare tumours, associated with other histopathological forms. We document a case occurring during the peri-menopausal period and review the literature on this pathology. The very poor prognosis in the past has changed with early polychemotherapy.

Malignant transformation of atypical endometrial hyperplasia after progesterone therapy showing germ-cell tumor-like differentiation

A 31-year-old woman was treated for atypical endometrial hyperplasia (AEH) with high-dose medroxyprogesterone acetate (MPA) therapy to preserve fertility. The AEH was found by repeated cytologic and histologic examinations to have completely disappeared with the therapy, but 3 years after her last follow up she required emergency surgery to treat severe genital bleeding. The hysterectomied uterus consisted mostly of poorly differentiated adenocarcinoma, G3 endometrioid type. Minor AEH was present in the exophytic area, in which some glands were cystically dilated. Part of the AEH had transformed into other histologic features with germ-cell-like differentiation, demonstrated by immunohistochemical positive reaction of placental alkaline phosphatase, alpha-fetoprotein, and human chorionic gonadotrophin. Recurrent AEH had undergone malignant transformation, resulting in the development of well- and poorly differentiated adenocarcinoma and tumor exhibiting germ-cell-like differentiation. The patient died of a massive tumor extension 7 months after surgery. The AEH before MPA therapy and the recurrent tumors had genetically different characteristics based on evidence of a loss of heterozygosity, detected at D8S1132 (chromosomal locus, 8q22.1) in the latter but not in the former, by analysis of genetic alterations using microsatellite markers.

Non-endometrioid carcinomas of the uterine corpus: a review of their pathology with emphasis on recent advances and problematic aspects

This review considers the clinical and pathologic features of the various histologic subtypes of endometrial carcinoma excluding those of pure endometrioid type, as the latter tumors were the subject of a previous contribution in the Journal (Vol. 9, No. 2). Non-endometrioid carcinomas, which account for about 10% of endometrial carcinomas, may pose a great array of problems in differential diagnosis, including their distinction not only from benign lesions but also endometrioid carcinoma and various tumors that may secondarily involve the uterine corpus. The most common subtypes are serous, mucinous, and undifferentiated. Rarer tumors are clear cell, squamous, transitional cell carcinomas, and a variety of poorly differentiated carcinomas with unusual forms of differentiation, such as hepatoid carcinoma, carcinomas with trophoblastic elements, and giant cell carcinoma. Mixed carcinomas, which are common, are also discussed, including those with a component of endometrioid carcinoma. The final section deals with endometrial involvement by metastatic tumors, lesions that, albeit rare, are sometimes neglected in the differential diagnosis of endometrial carcinomas. Important aspects emphasized are: (1) The potential for serous carcinoma to be mimicked by various forms of papillary endometrioid carcinoma. (2) The rarity of clear cell carcinoma and the greater frequency of clear cells in endometrioid carcinoma. (3) The frequency of mucinous epithelium in tumors of mixed cell type. (4) The frequency with which neoplastic mucinous epithelium originates from the endometrium. (5) The striking degree of differentiation of some squamous cell carcinomas. (6) The occasional predominance of non-endometrioid carcinomas (especially serous or undifferentiated carcinoma) within malignant mullerian mixed tumors. (7) The spectrum of reactive epithelial changes and other non-neoplastic abnormalities that may mimic serous or clear cell carcinoma.

Endometrioid carcinoma of the uterine corpus: a review of its pathology with emphasis on recent advances and problematic aspects

This review considers the pathologic features of endometrioid carcinoma of the uterine corpus, which accounts for approximately 80% of endometrial adenocarcinomas, with an emphasis on its histologic features, recent advances, and problematic aspects. In addition to typical endometrioid carcinoma, the variants of endometrioid carcinoma covered include secretory carcinoma, villoglandular endometrioid carcinoma, endometrioid carcinoma with small nonvillous papillae, endometrioid carcinomas with microglandular and sertoliform patterns, and endometrioid carcinomas with metaplastic changes. These changes include a variety of different appearances of squamous epithelia (ranging from mature and keratinizing to immature with only subtle evidence of a squamous nature), clear cells, surface changes resembling syncytial metaplasia or microglandular hyperplasia, ciliated cells, oxyphilic cells, and spindled epithelial cells (sarcomatoid carcinoma). The last is one of several variants that may cause a biphasic appearance, all of which should be distinguished from the malignant müllerian mixed tumor. Rare findings in endometrioid carcinomas include hyalinization, psammoma bodies, and foci of stromal metaplasia such as osteoid. Unusual growth patterns of endometrioid carcinomas include involvement of adenomyosis, the "diffusely" infiltrating pattern of myoinvasion, and a previously unemphasized pattern of myoinvasion with "pinched off" glands that may be cystic or have a pseudovascular appearance, often with a myxoid stromal reaction. Other aspects of endometrioid carcinoma discussed are its immunoprofile, grading, cervical involvement (including a hitherto undescribed "burrowing" pattern of extension within the cervix that can result in underdiagnosis of stage IIB disease), carcinoma arising in the lower uterine segment, carcinoma arising in polyps and adenomyomas, carcinoma in young women, tamoxifen-related carcinoma, associated ovarian endometrioid carcinoma, and peritoneal keratin granulomas. Finally, the differential diagnosis of endometrioid carcinoma is briefly considered with a section on benign mimics, including curettage-related changes, menstrual changes, adenomyosis-related problems, metaplastic changes, atypical polypoid adenomyoma, radiation atypia, and papillary proliferations, and a section on metastatic colonic carcinoma.

Coexistent choriocarcinoma and malignant mixed mesodermal tumor of the uterus

OBJECTIVE

The purpose of this article is to report a case of coexisting uterine choriocarcinoma and uterine malignant mixed mesodermal tumor (MMMT). The relevant literature is reviewed and possible pathogenesis discussed.

METHODS

The clinical course and histopathology of the case were reviewed and a Medline literature search for other cases was performed.

RESULTS

The patient's uterine tumor contained syncytiotrophoblastic and cytotrophoblastic cells that stained positively for the beta subunit of human chorionic gonadotrophin consistent with uterine choriocarcinoma. Pathology also revealed a second distinct neoplasm composed of adenocarcinoma admixed with sarcoma, compatible with a uterine MMMT. The patient experienced metastatic choriocarcinoma to her lungs, lymph nodes, and brain. She suffered a complicated clinical course and died 7 months after her initial diagnosis. The literature search revealed that various gynecologic and nongynecologic carcinomas with trophoblastic differentiation have been described, but an association with uterine MMMT has not been previously reported.

CONCLUSIONS

Trophoblastic differentiation and choriocarcinoma associated with gynecologic and nongynecologic tumors is rare. We document the presence of uterine MMMT coexisting with uterine choriocarcinoma that followed an aggressive clinical course and review the possible pathogenesis of this lesion.

Adenocarcinoma of the uterine cervix with choriocarcinomatous and hepatoid differentiation: report of a case

A case of adenocarcinoma of the uterine cervix that showed choriocarcinomatous and hepatoid differentiation was encountered in a 65-year-old woman. She presented with genital bleeding and had multiple metastatic nodules in the lungs. At operation, a large, hemorrhagic, and necrotic tumor was found in the uterine cervix. The major portion of the tumor consisted of typical choriocarcinoma admixed with minor areas of hepatoid carcinoma and endocervical adenocarcinoma. Human chorionic gonadotropin and alpha-fetoprotein were detected in tumor cells in the choriocarcinomatous and hepatoid areas, respectively. The patient died of pulmonary metastasis 4 months after the operation. The coexistence of choriocarcinomatous and hepatoid carcinoma in an endocervical adenocarcinoma has not been reported previously. Both heterotopic components were probably derived from aberrant differentiation (or neometaplasia) of the somatic epithelial cells of the endocervical adenocarcinoma.

Endometrial adenocarcinoma with trophoblastic differentiation

OBJECTIVE

To report a case of stage IIIc poorly differentiated endometrial adenocarcinoma with trophoblastic differentiation and to review previously reported cases.

METHODS

The clinical course and histopathology of the case were reviewed, and a literature search for other reported cases was performed.

RESULTS

The tumor contained syncytiotrophoblast-like giant cells that stained positively for the beta subunit of human chorionic gonadotropin (beta-hCG), and the patient's serum beta-hCG level was elevated (95 mIU/ml), but became undetectable after treatment. Beta-hCG was used as a tumor marker during further therapy. At 16 months' survival, she remains without evidence of disease and with a beta-hCG (level < 5 mIU/ml). Nine other cases of trophoblastic differentiation in gynecologic nontrophoblastic tumors have been reported, five in endometrial carcinomas which we review.

CONCLUSIONS

Trophoblastic differentiation in gynecologic nontrophoblastic tumors is rare. Beta-hCG may be useful as a tumor marker in these cases. The clinical behavior of these tumors has been aggressive, with advanced stages at diagnosis, early widespread metastases or recurrences and poor patient outcomes. The patient presented in this report, however, remains without evidence of disease 16 months following diagnosis and may be the longest survivor with this tumor reported to date.

Ovarian endometrioid tumors with yolk sac tumor component, an unusual form of ovarian neoplasm. Analysis of six cases

The clinical, morphological, and immunohistochemical findings in six cases of ovarian endometrioid tumors (five endometrioid carcinomas and one carcinosarcoma) with a yolk sac tumor (YST) component are described. The age of the patients ranged from 31 to 73 years (average, 53), and only two patients were premenopausal. Two cases were stage Ia tumors, three stage III, and one stage IV. A substantial postoperative elevation of alpha-fetoprotein (AFP) was seen in two patients and a mild increase in another two. All six patients had surgery and postoperative cisplatin-based chemotherapy regimens, four of whom died of tumor 3 to 14 months after surgery without response to treatment. Only a stage Ia patient is alive and well 1 year after surgery. The tumors were large (average, 17 cm). Benign endometrioid lesions were found in the homolateral ovary in two cases and in the contralateral ovary in another two. All cases had endometrioid ovarian carcinomas (EOC) of various types admixed with typical YST components. Immunohistochemically, EOC areas differed from YST in their positivity for OC 125, CA 19.9, and nuclear estrogen and progesterone receptors and in their negativity for AFP, which was conspicuously positive in the YST areas. The clinicopathological profile of ovarian endometrioid tumors with YST also differs from that of YST in that it occurs in the same age range as EOC, it shows coexistence of benign endometrioid lesions, and it has a poor response to chemotherapy. The histological pattern in transitional areas may be difficult to differentiate from "endometrioid-like" (enteroblastic) YST and clear cell tumors. Ovarian endometrioid tumors with YST component should be considered a variant of endometrial carcinoma. Its recognition is necessary in view of its unusually aggressive behavior and poor prognosis.

Germ cell tumour as a diagnostic pitfall of metastatic carcinoma

AIM

Testicular germ cell tumours may present as metastases in cervical lymph nodes, yet the primary tumours remain clinically occult. The aim of the study is to alert pathologists and clinicians to this uncommon but important presentation and highlight the clues and the diagnostic adjuncts to its correct diagnosis.

METHODS

The clinical, cytological, histological, and immunohistochemical features of two patients with germ cell tumour initially presenting as cervical lymphadenopathy were described and analysed.

RESULTS

Both patients were young adult males, who were found to have metastatic undifferentiated carcinoma on fine needle aspiration of the enlarged cervical lymph nodes. The tumour cells in both cases were positive for placental alkaline phosphatase (PLAP) and negative for epithelial membrane antigen (EMA).

CONCLUSIONS

Clinicians and pathologists should be aware of the possibility of germ cell tumour when encountering a young adult male with metastatic poorly differentiated carcinoma. Positivity for PLAP and negativity for EMA are helpful adjuncts in arriving at the correct diagnosis.

Ovarian carcinomas with choriocarcinomatous differentiation

BACKGROUND

Ovarian carcinomas may produce human chorionic gonadotropin (HCG) or HCG-like substances and may even contain syncytiotrophoblast cells, but a true choriocarcinomatous component has not been described in these tumors.

METHODS

Two cases of poorly differentiated ovarian carcinoma with choriocarcinomatous components are reported. Pathologic findings were correlated with immunohistochemical stains, hormonal effects, and clinical behavior.

RESULTS

Each tumor contained a circumscribed, extensively necrotic and hemorrhagic brown nodule. Microscopically, the nodules exhibited a mixture of cytotrophoblast and syncytiotrophoblast. The syncytiotrophoblast capped cytotrophoblast and was strongly positive for beta-HCG. In one of the cases, a transformation zone composed of poorly differentiated carcinoma with occasional beta-HCG-positive cells was observed between a mucinous cystadenoma and the choriocarcinomatous elements. The two cases exhibited activation of the ovarian stroma in the form of condensation and luteinization. Extra-abdominal metastases developed early in both patients and, despite multiagent chemotherapy, they died shortly postoperatively.

CONCLUSIONS

Choriocarcinoma may rarely develop as a result of dedifferentiation of common epithelial ovarian tumors. Recognition of choriocarcinomatous components in ovarian carcinomas is important because of its association with aggressive behavior.

Urinary chorionic gonadotropin subunits and beta-core in nonpregnant women. A study of benign and malignant gynecologic disorders

BACKGROUND

The presence of urinary excretion products of human chorionic gonadotropin (hCG) has been proposed as a tumor marker. To ascertain the clinical value in gynecologic cancers, the authors studied 612 nonpregnant women.

METHODS

Three different assays in four clinical groups were compared: no disease, benign disease, malignant disease, and complete remission of previously treated malignant disease. The assays were for the urinary beta-core, "total" beta-hCG, and free alpha-subunit.

RESULTS

Measurement of the alpha-subunit was of no obvious clinical value. In some patients with benign disease, hCG metabolites were elevated. In the 141 patients with active gynecologic malignancy the sensitivity of the total beta-hCG assay was 47% and that of the beta-core assay was 36%. The specificities were 80.3% and 90.4%, respectively. Advanced cancers generally had higher levels of total beta-hCG and beta-core. Squamous cell and poorly differentiated cervical tumors had higher levels of total beta-hCG than did adenocarcinomas and well-differentiated cervical tumors. Invasive, serous, endometrioid, and germ cell ovarian tumors had higher total beta-hCG, beta-core, and alpha-subunit levels than did borderline, mucinous, and clear cell ovarian tumors. Six of 16 patients with disease in complete remission had elevated levels.

CONCLUSION

The excretion of hCG and its metabolic fragments is a common event in gynecologic cancer, but sensitivity and specificity are low, and there is little consistent relationship between tumor stage and histologic type.

Immature endodermal teratoma of the ovary: embryologic correlations and immunohistochemistry

Two grade 2 ovarian immature, predominantly endodermal teratomas are reported. The teratomas were in stage I and occurred in two girls, 9 and 10 years of age, who were treated with triple chemotherapy. These neoplasms differed from the usual immature ovarian teratoma as they contained no neuroectodermal components and had high alpha-fetoprotein and low human chorionic gonadotropin levels as their serum markers despite the absence of other concomitant germ cell tumors. The epithelia of the teratomas demonstrated exclusively the embryologic development of endoderm, ranging from early endoderm to tissues similar to esophagus, liver, and intestinal structures. All epithelial derivatives were positive for alpha-fetoprotein and alpha 1-antitrypsin. Liver and esophagus expressed fibrinogen, while intestine and esophagus were positive not only for carcinoembryonic antigen and chromogranins but also for thyroglobulin, thus reflecting yet another type of endodermal differentiation into thyroid. Focal human chorionic gonadotropin positivity associated with primitive intestinal and esophageal epithelia may reflect the early embryologic relationships between endoderm and trophoblast. These cases demonstrate that simultaneous alpha-fetoprotein and human chorionic gonadotropin secretion may occur in immature teratoma. The mesenchymal component also showed a wide range of differentiation, from primitive mesoblastic cells to differentiated cells, such as hemopoietic foci, smooth muscle, bone, and cartilage. Both the primitive endoderm and the mesenchyme co-expressed vimentin and keratin, reflecting their intimate developmental relationships and possibly supporting the hypothesis of mesenchyme originating from endoderm, as suggested by previous embryologic studies. Since endodermal and mesenchymal areas similar to those described here are found in association with yolk sac tumors and embryonal carcinoma, it is possible that the present cases may represent an endodermal differentiation accomplished by either of these developmentally related germ cell tumors.