Cervicovaginal cytology in carcinosarcoma [malignant mixed mullerian (mesodermal) tumor] of the uterus

Effusion cytology of metastatic carcinosarcoma

Objectives

Carcinosarcomas (CSs) are rare gynecological neoplasms seen in elderly females. These are composed of malignant epithelial and mesenchymal components, which appear as adenocarcinoma and high-grade sarcoma. Effusions are encountered uncommonly in CS.

Material and Methods

The study focuses on the cytomorphology of 10 cases of metastatic CS in effusions. In 6 years, there were 10 (0.45%) cases of metastatic CS in effusion samples out of 2240 malignant effusion samples. The samples were processed by SurePath™ and centrifuge technique. Both May-Grünwald-Giemsa and Papanicolaou stained smears were evaluated for cytomorphological features, and the findings were correlated with subsequent histopathology.

Results

The cells were predominantly arranged in ball-like clusters and discretely. The cells had abundant vacuolated cytoplasm and enlarged pleomorphic nuclei. Occasional cases showed scattered spindle cells. The cases were diagnosed as metastatic adenocarcinoma (7/10) and positive for malignant cells (3/10). None of the cases was diagnosed as CS. The primary of these cases was in the uterus (7/10) and ovary (3/10).

Conclusion

The cytological evaluation of such effusion samples rarely demonstrates the classical biphasic pattern of these tumors. Mostly, the carcinomatous component is evident, and the sarcomatous element is inapparent and readily missed.

USG guided fine needle aspiration cytology along with immunocytochemistry to diagnose primary malignant mixed mullerian tumors: A three-year study from a tertiary care center

Aims and Objectives:

To study the diagnostic utility of fine-needle aspiration cytology (FNAC) and immunocytochemistry in diagnosing primary malignant mixed Mullerian tumors (MMMT).

Materials and Methods:

A 3-year retrospective study carried out in a tertiary care hospital, which included all the gynecological patients who underwent USG-guided FNAC of their abdominopelvic masses.

Observations and Results:

Out of the 324 total cases, 05 (1.5%) were reported as primary malignant mixed Mullerian tumors. Out of these 05 cases, 03 were ovarian, 01 was uterine, and 01 involved both uterus and one-sided adnexa. The FNA smears from the masses revealed cytomorphological features of a biphasic neoplasm with elongated pleomorphic spindle cells and dispersed, focal attempted acinar pattern, thus indicating the possibility of MMMT. Immunocytochemistry was further carried out which showed both vimentin and cytokeratin positivity. The diagnosis was confirmed on subsequent biopsy and immunohistochemistry (without any histopathological-cytological discrepancy).

Conclusion:

Though the literature is replete in establishing a histo-pathological diagnosis of MMMT, the diagnosis on USG-guided FNAC has been rarely described. Emphasis should be made on the careful examination of small sarcomatous elements in smears. Utilization of cell block and immunocytochemistry with histopathological correlation should be done to avoid misdiagnosis.

Staging MRI of uterine malignant mixed Müllerian tumors versus endometrial carcinomas with emphasis on dynamic enhancement characteristics

PURPOSE

To determine whether staging pelvic magnetic resonance imaging (MRI) can distinguish malignant mixed Müllerian tumor (MMMT) from EC.

METHODS

Thirty-seven treatment-naïve patients with histologically proven uterine MMMT and 42 treatment-naïve patients with EC, treated at our institution, were included in our retrospective study. Staging pelvic MRI scans were reviewed for tumor size, prolapse through cervical os, and other features. Time-intensity curves for tumor and surrounding myometrium regions of interest were generated, and positive enhancement integral (PEI), maximum slope of increase (MSI), and signal enhancement ratio (SER) were measured. The Fisher's exact test or Wilcoxon rank-sum test was used to compare characteristics between disease groups. Multivariate and univariate logistic regression models were used to distinguish MMMT from EC. Receiver operating characteristic analysis and the area under the curve (AUC) were used to evaluate prediction ability.

RESULTS

MMMTs were larger than ECs with higher rate of tumor prolapse and more heterogeneous tumor enhancement compared to ECs. During the late phase of contrast enhancement, 100% of ECs, but only 84% of MMMTs, had lower signal intensity than the myometrium. Threshold PEI ratio ≥ 0.67 predict MMMT with 76% sensitivity, 84%, specificity and 0.83 AUC. Threshold SER ≤ 125 predict MMMT with 90% sensitivity, 50% specificity, and 0.72 AUC.

CONCLUSION

MMMTs may show more frequent tumor prolapse, more heterogeneous enhancement, delayed iso- or hyper-enhancement, higher PEI ratios, and lower tumor SERs compared with EC. MRI can be used as a biomarker to distinguish MMMT from EC based on the enhancement pattern.

Cytological features of uterine carcinosarcoma: A retrospective study of 20 cases with an emphasis on the usefulness of endometrial cytology

BACKGROUND

Carcinosarcoma of the endometrium is a relatively rare but aggressive neoplasm. Endometrial cytological features of this type of tumor have been rarely reported. This study aimed to clarify the usefulness of endometrial cytological examination in the diagnosis of endometrial carcinosarcoma.

METHODS

Patients histopathologically diagnosed with endometrial carcinosarcoma who underwent preoperative endometrial or endocervical cytological examination were enrolled. The endometrial and/or endocervical specimens were conventionally stained with Papanicolaou stain, and the cytological characteristics, including arrangement and shape of the neoplastic cells, and the nuclear and cytoplasmic features were reviewed.

RESULTS

Twenty patients were enrolled in the study. In the endometrial specimens, carcinomatous component was detected in almost all cases (94.4%), including those suspicious of carcinoma despite a small volume of carcinomatous cells. Sarcomatous component was observed in 6 of 18 cases (33.3%) and was significantly more frequently detected in the heterologous type (5 of 9 cases) compared to the homologous type (1 of 9 cases) (P = 0.046). In the endocervical specimens, carcinomatous component was present in 76.5% of cases, but sarcomatous component was detected in only 17.6% of cases.

CONCLUSION

Although endocervical cytology can detect the carcinomatous component in more than 50% of endometrial carcinosarcoma cases, it has lesser capability to detect sarcomatous component. In conclusion, endometrial cytological examination is a more useful and accurate method to detect sarcomatous component of endometrial carcinosarcoma, particularly in the heterologous type, compared to endocervical cytological examination.

Rare primary malignant mixed Müllerian tumor of the mediastinum: A case report

RATIONALE

Malignant mixed Müllerian tumor (MMMT) of extragenital organs is rare, especially in male. To our knowledge, this is the first reported case of primary MMMT at the mediastinum in male.

PATIENT CONCERNS

A 54-year-old male was admitted to the hospital due to repeated stimulating dry cough for 2 years. His systemic examination was unremarkable. Laboratory workup revealed that all blood indicators were within normal limits. But subsequent computerized tomography (CT) scans of chest showed an abnormal soft tissue density in the area of its left, measuring approximately 4 cm in anterior-posterior dimension and 7 cm in maximum transverse dimension.

DIAGNOSES AND INTERVENTIONS

The pathogenesis of these tumors remains controversial. The diagnosis is combined with biopsy and immunohistochemical staining. So, the patient underwent radical surgical resection and pathologic examination of the excised specimen was consistent with the diagnosis of MMMT. After surgery, he was treated by sequential chemoradiotherapy.

OUTCOMES

The patient died from tumor recurrence 16 months later.

LESSONS

MMMT is a rare, highly aggressive tumor associated with interesting embryological origin, a definite diagnosis of which is only confirmed on pathological assessment. Due to its high degree of malignancy and high rate of recurrence, complete macroscopic excision of the tumor is recommended as soon as possible.

Therapy Modalities, Prognostic Factors, and Outcome of the Primary Cervical Carcinosarcoma: Meta-analysis of Extremely Rare Tumor of Cervix

Objective

The aim of this study was to evaluate the prognostic factors, treatment options, and survival outcomes of primary carcinosarcomas of the uterine cervix.

Methods

An electronic search of the literature was conducted from 1951 to February 2017 to identify articles on primary cervical carcinosarcoma. After comprehensive evaluation of case series and case reports, 81 cases were included in the study.

Results

The most common clinical FIGO (International Federation of Gynecology and Obstetrics) stage was IB at 53% of cases. Median follow-up time was 15 months (range, 1.75–156 months). Two-year disease-free survival (DFS) and overall survival (OS) of the entire cohort were 49% and 60%, respectively. Both 2-year DFS and OS were significantly higher in patients with stage I than in those with stage II disease or greater (73% vs 22%, P = 0.000 and 82% vs 33%, P = 0.000, respectively). Two-year OS was 17% for patients who received primary radiotherapy, whereas it was 68% for those who underwent only surgery (P = 0.003). Surgery followed by adjuvant radiotherapy with or without chemotherapy was significantly associated with improved DFS and OS compared with primary radiotherapy. Two-year DFS was 63% in patients who underwent primary surgery, whereas it was 100% in patients treated with primary surgery followed by adjuvant radiotherapy with chemotherapy (P = 0.030). Stage alone was an independent prognostic factor for risk of both recurrence and death (hazard ratios, 9.8 [P = 0.004] and 14 [P = 0.018], respectively).

Conclusions

In due course of presentation, the tumor stage has a great importance because it is the only independent factor for prognosis. Surgery followed by adjuvant radiotherapy with or without chemotherapy seems to be related with better OS and DFS.

Atypical Findings on Cervicovaginal Smears Correlate with Cervical Involvement by Malignant Mixed Müllerian Tumors of the Uterus

OBJECTIVE

A malignant mixed müllerian tumor (MMMT) is a high-grade neoplasm commonly arising from the uterus. Patients present with bleeding and a mass protruding from the cervix. This study was designed to correlate Papanicolaou (Pap) smear findings with histological findings in women diagnosed with MMMT.

STUDY DESIGN

Women diagnosed with MMMT were identified. Preoperative Pap tests were correlated with histological findings. Statistical analysis was performed to assess associations between abnormal Pap tests and histological findings.

RESULTS

Forty patients with MMMT were included in the study. Age ranged from 37-85 years and tumor size ranged from 1.2 to 21 cm. In presurgical Pap tests (4 conventional and 36 liquid based), 11 smears (27.5%) were diagnosed as negative, 5 (12.5%) as atypical squamous cells of undetermined significance, 6 (15%) as atypical glandular cells, 16 (40%) as malignant and 2 (5%) as high-grade squamous intraepithelial lesion. Malignant cells detected on Pap smears showed a strong correlation with endocervical involvement by MMMT (p = 0.002). Larger tumors were more likely to involve the cervix (p = 0.0115).

CONCLUSIONS

The Pap test can predict cervical involvement by MMMT. On Pap smears, MMMT cells showed no correlation with other adverse histological features (lymphovascular invasion, myoinvasion or adnexal involvement).

Primary malignant mixed müllerian mesodermal tumor mimicking a rectosigmoid carcinoma: a case report and review of the literature

We report a case of a 53-year-old female who presented with chronic constipation and abdominal discomfort for six months. Her past surgical history was significant for a total abdominal hysterectomy with bilateral salpingooophorectomy, performed eight years ago, for uterine fibroids and endometriosis. Workup revealed a mass measuring 5 × 4.5 × 2 cm in the rectosigmoid colon. Patient underwent a low anterior resection and a fungating, centrally ulcerated rectosigmoid mass with a positive mesorectal margin was removed. Histopathology revealed a heterologous mixed mesodermal tumor (chondroid and osteoid elements). The epithelial component was compatible with a grade 2 endometrioid adenocarcinoma. Immunohistochemical stains were supportive, with positive expression for CK7 and ER, negative for CK20, and only very focally and weakly positive for both CDX2 and p63. Chromogranin, synaptophysin, and TTF-1 were negative. Following surgery, she was treated with five cycles of carboplatin (AUC 6) and paclitaxel (175 mg/m²), followed by irradiation. Twenty-six months later, patient continues to be asymptomatic and disease-free. Mixed müllerian mesodermal tumors mimicking colorectal cancer have been reported in the past. Our case highlights the rarity and the challenges encountered in diagnosing and treating these rare tumors.

Malignant mixed Müllerian tumor with an extensive squamous-cell carcinomatous component: a potential pitfall in liquid-based cervical cytology

BACKGROUND

Malignant mixed Müllerian tumors (MMMTs) are aggressive tumors arising in the female lower genital tract and characterized by the presence of both a malignant epithelial and a mesenchymal component. Here, we report a case of an MMMT of the uterine corpus with an extensive squamous-cell carcinomatous component processed by liquid-based cytology (LBC).

CASE REPORT

An 84-year-old woman with a prior history of anal squamous-cell carcinoma, who complained of vaginal bleeding, was discovered to have a mass protruding from the uterine cervix. A Papanicolaou (Pap) test was performed and the LBC (ThinPrep) preparation showed a background of neutrophils and cellular debris. Atypical cells were identified that presented with hyperchromatic nuclei, nuclear membrane irregularities, multinucleation and abundant cytoplasm with focal keratinization. Scattered nucleolated malignant elements were also identified. The cytological diagnosis resulted in 'suspicious for squamous-cell carcinoma', favoring primary cervical carcinoma rather than extracervical (anal) carcinoma. The histological examination showed that it was an MMMT with an extensive squamous-cell carcinomatous component.

CONCLUSION

This case illustrates the potential diagnostic pitfall of MMMTs with extensive squamous-cell carcinomatous components in LBC Pap smears. Cytopathologists should keep in mind this diagnostic possibility in postmenopausal women who experience vaginal bleeding or spotting.

Cytomorphology of unusual primary tumors in the Pap test

Rare entities in the Pap test, which include neoplastic and non-neoplastic conditions, pose challenges due to the infrequent occurrence of many of these entities in the daily practice of cytology. Furthermore, these conditions give rise to important diagnostic pitfalls to be aware of in the Pap test. For example, cases with adenoma malignum (AM) have been called benign. Recognition of these conditions can help correctly interpret Pap tests as abnormal and thereby ensure that patients get appropriately diagnosed. In this paper, we illustrate and discuss selected uncommon primary neoplastic lesions of the cervix and the vagina that may be seen in Pap test, with a focus on cytomorphology, differential diagnosis and the role of possible ancillary studies. These cases include high-grade squamous intraepithelial lesion cells with small cell morphology; small cell carcinoma; large neuroendocrine carcinoma; glassy cell carcinoma; AM; malignant mixed Müllerian tumor; clear cell carcinoma and primary malignant melanoma. Recognition of these rare variants/neoplasms is important so that involved Pap tests are not diagnosed as benign and that patients with these conditions get additional follow-up.

MRI appearances of uterine malignant mixed müllerian tumors

OBJECTIVE

Uterine malignant mixed müllerian tumors (MMMTs) are rare aggressive tumors with a high incidence of lymphatic, peritoneal, and pulmonary metastases. Preoperative differentiation from endometrial adenocarcinoma would be beneficial because their prognoses differ.

MATERIALS AND METHODS

We retrospectively reviewed MRI examinations of 51 histologically confirmed MMMTs. Tumor size, growth pattern, and imaging characteristics were recorded. Data were compared with MRI appearances of 73 endometrial adenocarcinomas.

RESULTS

On T1-weighted images, MMMTs were predominantly isointense to myometrium (76%) and endometrium (71%), with heterogeneous texture in 33% of cases and hyperintense foci in 27% of cases. On T2-weighted images, 92% of MMMTs were hyperintense to myometrium and either hypointense (55%) or isointense (41%) to endometrium. In 12% of cases, large heterogeneous MMMTs obliterated uterine architecture and were aggressive in appearance, whereas in 88% of cases, the appearances were indistinguishable from those of endometrial adenocarcinoma. Significantly more MMMTs than endometrial adenocarcinomas had cervical invasion (p = 0.008) and nodal enlargement (p = 0.00008). Dynamic contrast-enhanced images (available for 19 of 51 patients) obtained at less than 1 minute after administration of contrast agent showed MMMT enhancement to be hypointense (42%; 5/12 patients) or isointense (33%; 4/12 patients) to myometrium; between 1 and 4 minutes after administration of contrast agent, tumors were hypointense (58%; 7/12 patients); and at more than 4 minutes after administration of contrast agent (n = 18), MMMTs were isointense in 56% of cases. This finding is significantly different from that for endometrial adenocarcinoma, where enhancement is less than that of myometrium in 90% of cases (p = 4 × 10⁻⁸).

CONCLUSION

MMMTs do not have a pathognomonic MRI appearance. However, radiologic suspicion should increase in the presence of large heterogeneous infiltrative tumors or when tumoral enhancement equals or exceeds that of myometrium.

Cervicovaginal (Papanicolaou) smear findings in patients with malignant mixed Müllerian tumors

Malignant mixed Müllerian tumor is a rare neoplasm that occurs most frequently in elderly patients. It is characterized by a mixture of malignant epithelial and sarcomatous components. Little has been published about Papanicolaou smear findings pertaining to malignant mixed Müllerian tumors. We present our experience, with an emphasis on cytologic detail. Nine patients (median age, 65 yr) met our study criteria. All available smears and surgical specimens were reviewed. Four smears were positive for malignancy, with a sensitivity of 44% (3 adenocarcinoma, and 1 squamous-cell carcinoma, small-cell type). The results of our study showed that Papanicolaou smear findings pertaining to malignant mixed Müllerian tumors are seen in patients with advanced-stage disease with involvement of the lower uterine segment or cervix. The usual finding is large numbers of high-grade epithelial malignant cells in a necrotic background. The mesenchymal component rarely sheds cells visible on Papanicolaou smear.

Ascitic fluid cytology of adenosarcoma of the ovary: a case report

Extrauterine adenosarcoma is very rare and originates in the ovary, adnexa, or myometrium. Cytologic study of ascites is very important to determine clinical staging of malignant ovarian tumors and provide adequate therapy for recurrence. The cytomorphologic features of adenosarcoma have been only rarely described. A 77-yr-old woman visited a hospital with a complaint of lower abdominal pain for 1 mo. A tumor originating from the right adnexa in the pelvis, and involving the rectum, was found in surgery. In the ascitic fluid cytology, a few dispersed tumor cells with large cytoplasm and nuclei were oval-shaped, with nuclear invagination. The chromatin was finely granular; one or two nucleoli were conspicuous. To our knowledge, this is the fifteenth reported case of adenosarcoma of the ovary, and there have been no prior reports describing the cytological features of ascitic fluid cells in adenosarcoma of the ovary.

Diagnosis of recurrent uterine carcinosarcoma by fine-needle aspiration cytology: report of a case

Uterine carcinosarcomas are uncommon, aggressive neoplasms usually afflicting postmenopausal women. Histologically, they are characterized by the presence of both malignant epithelial and stromal cells. The latter may be either homologous or heterologous in nature. The cytologic diagnosis of carcinosarcoma via fine-needle aspiration (FNA) was previously described for primary tumors arising in the parotid gland, breast, lung, and ovary. Although the diagnosis of uterine carcinosarcoma via cervicovaginal, endometrial, and peritoneal fluid cytology has been described, the FNA cytology diagnosis of recurrent uterine carcinosarcoma has only been rarely described. We present a case of recurrent uterine carcinosarcoma in a 59-yr-old woman, diagnosed by ultrasound-guided FNA cytology. Cytologic smears showed a biphasic neoplasm consisting of both malignant columnar epithelial and spindle cells, in a background of tumor diathesis. This case illustrates the diagnostic utility of aspiration cytology in the investigation of recurrent carcinosarcoma in clinically suspicious lesions arising postsurgery.

Serous effusion cytology in gynecologic malignant mixed müllerian tumors

We reviewed 51 serous effusions (50 peritoneal/one pleural) from 38 patients with uterine (30 cases) and ovarian (eight cases) malignant mixed Müllerian tumors (MMMT). There were 16 patients (42%) with positive effusion cytology specimens; 13 cases (81%) were diagnosed as adenocarcinoma with three cases (19%) interpreted as having a sarcomatous component. Eight of 16 positive effusion specimens had cell block material available for immunoperoxidase (IP) study that included cytokeratin (AE1/3), vimentin, muscle specific actin (HHF) and S-100 protein to determine if unsuspected mesenchymal components were present in the cases originally diagnosed as carcinoma (six cases), or sarcomas (two cases). In the six cases originally interpreted as carcinoma, three were diagnosed as adenocarcinoma and three as poorly differentiated carcinoma. All three of the cases considered adenocarcinoma and two of those diagnosed as poorly differentiated carcinoma reacted only with AE1/3 and vimentin. The remaining case, considered a poorly differentiated carcinoma, stained only with vimentin. In the two cases having cell blocks interpreted as having a sarcomatous component, only vimentin was positive in one while AE1/3, vimentin, HHF, and S-100 were positive in the other. The case where all immunohistochemical stains were reactive contained both carcinomatous and sarcomatous components. In the three cases considered sarcomatous, the cytomorphologic features helpful in the recognition of a mesenchymal component included a dissociated smear pattern of pleomorphic round to oval cells and/or spindle cells. In retrospect, the IP stains did not alter any of the original diagnoses.(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant mixed Müllerian tumors of the uterus

OBJECTIVE

To review the prognostic factors of Chinese women with mixed Müllerian tumors of the uterus.

METHOD

A retrospective review of 21 cases of malignant mixed Müllerian tumors of the uterus treated during the 10-year period from 1980 to 1990.

RESULTS

All patients except one were postmenopausal. The incidence of previous pelvic irradiation was 9.5%. The most common presenting symptom was abnormal vaginal bleeding. One-third of patients yielded an abnormal cervical smear. Treatment included surgery, chemotherapy and radiotherapy in the majority of patients. Prognosis was poor with only three long-term survivors, all with stage-I homologous tumors with superficial myometrial invasion. The survival rate for stage-I and -II disease at 2 years was 50% and for more advanced disease extending beyond the uterus was 0%. The survival rate for all stages at 5 years was 14.3%, and the cumulative probability of survival at 5 years was 0.165.

CONCLUSION

The most important prognostic factors appear to be the extent of tumor involvement at the time of diagnosis and the depth of myometrial invasion.