Primary squamous cell carcinoma of the endometrium: a case report with immunohistochemical and molecular study

Molecular Analysis of HPV-independent Primary Endometrial Squamous Cell Carcinoma Reveals TP53 and CDKN2A Comutations : A Clinicopathologic Analysis With Re-evaluation of Diagnostic Criteria

Human papillomavirus (HPV)-independent primary endometrial squamous cell carcinoma (PESCC) is a rare but aggressive subtype of endometrial carcinoma for which little is known about the genomic characteristics. Traditional criteria have restricted the diagnosis of PESCC to cases without any cervical involvement. However, given that modern ancillary techniques can detect HPV and characteristic genetic alterations that should identify the more common mimics in the differential diagnosis, including endometrial endometrioid carcinoma with extensive squamous differentiation and HPV-associated primary cervical squamous cell carcinoma, those criteria may benefit from revision. To further characterize PESCC, we identified 5 cases of pure squamous cell carcinoma dominantly involving the endometrium that had the potential to be PESCC: 1 case involving only the endometrium and 4 cases with some involvement of the cervix. Clinicopathologic features were assessed and immunohistochemical analysis (p16, estrogen receptor, progesterone receptor, and p53), HPV RNA in situ hybridization (high-risk and low-risk cocktails and targeted probes for 16 and 18), and molecular studies were performed. All tumors showed aberrant/mutation-type p53 expression, were negative for estrogen receptor, progesterone receptor, and p16, and had no detectable HPV. Per whole-exome sequencing, 4 of the 5 tumors demonstrated comutations in TP53 and CDKN2A (p16). Four patients died of disease within 20 months (range, 1 to 20 mo; mean, 9 mo), and 1 patient had no evidence of disease at 38 months. PESCC represents a unique, clinically aggressive subtype of endometrial cancer with TP53 and CDKN2A comutations. This characteristic profile, which is similar to HPV-independent squamous cell carcinoma of the vulva, is distinct from endometrioid carcinoma with extensive squamous differentiation and HPV-associated primary cervical squamous cell carcinoma and can be used to distinguish PESCC from those mimics even when cervical involvement is present. Diagnostic criteria for PESCC should be relaxed to allow for cervical involvement when other pathologic features are consistent with, and ancillary techniques are supportive of classification as such.

PAX8 Positivity, Abnormal p53 Expression, and p16 Negativity in a Primary Endometrial Squamous Cell Carcinoma: A Case Report and Review of the Literature

Primary endometrial squamous cell carcinoma (PESCC) is a rare entity. As the clinicopathologic features and the immunophenotype have not been completely defined yet, here we report our experience and review of the literature on this topic. A 73-yr-old nulliparous woman presented with pelvic pain and vaginal bleeding. Endometrial biopsy showed a carcinoma with squamous differentiation infiltrating the myometrium. Total hysterectomy with bilateral salpingo-oophorectomy and selective pelvic lymphadenectomy was performed. Definitive diagnosis was squamous carcinoma of the endometrium, with one lymph node metastasis (stage IIIC1). Immunohistochemistry evidenced immunoreactivity of the tumor cells for cytokeratin 5, p63, cytokeratin 7, PAX8, PTEN, and cyclin D1, aberrant p53 overexpression, and Ki-67 reactivity in ~70% of the tumor cells. Estrogen and progesterone receptor, PAX2, WT1, and p16 were negative. Our case was the first PAX8-positive PESCC in the literature, underlining the Mullerian system origin of this neoplasm. Abnormal p53 expression of this case confirmed its role in the pathogenesis of PESCC. Further studies on a large number of cases are needed to better understand the pathologic features and the immunophenotype of PESCC.

Primary squamous cell carcinoma of the endometrium associated with human papilloma virus in a young woman: a case report

Background

Primary squamous cell carcinoma of the endometrium is an extremely rare tumor with poorly understood pathogenesis.

Case presentation

We report a case of a 28-year-old Togolese woman who had consulted for vaginal bleeding and pelvic pain. Ultrasound showed thickening of the lining of the endometrium, and biopsy curettage was done. Anatomopathological examination was noteworthy for a proliferation of squamous cells often connected by union bridges arranged in tumor lobules with dyskeratotic maturation. Immunohistochemistry showed epithelial membrane antigen positivity, anti-pancytokeratin 1 markers of tumor cells positivity, chromogranin A negativity, actin negativity, S100 negativity, estrogen receptor negativity, and progesterone receptor negativity. In situ hybridization had objectified human papillomavirus genotypes 16/18. The diagnosis of primary squamous cell carcinoma of the endometrium associated with human papilloma virus was retained. A hysterectomy was performed, and the tumor was classified pT1N0M0.

Conclusion

The pathogenesis of this endometrial cancer is complex, and its association with human papillomavirus does not explain its genesis.

Primary squamous cell carcinoma of endometrium: case report and literature review

In this paper, we report a case of primary squamous cell carcinoma of the endometrium (PSCCE) with a literature review. A 64-year-old woman was admitted because of postmenopausal bleeding. The gynecological exam found bleeding from the endocervix. The pelvic ultrasound objectified uterine regular contours, endometrial thickened was 10 mm, the presence of an intra cavitary lesion measuring 56/70 mm. The diagnostic hysteroscopy revealed a whitish appearance taking all the uterine cavity making evoke a tumor of the endometrium. Pelvic MRI showed a tumor limited to the uterine corpus endometrium (invasion by more than 50% of the myometrium) without invasion of the cervix. Radical hysterectomy, bilateral salpingo-oophorectomy, and lymph nodes dissection were performed. Grossly, the endometrial carcinoma was polypoid tumor occupying the entire uterine cavity. Histologically, the diagnosis of SCC was retained. No adenocarcinoma element was recognized. Neither squamous metaplasia nor dysplasia was recognized. No ectopic cervical tissue was found. The SCC was found to invade into deeper one half of the myometrium. No tumor cells were seen in other sites including the cervix, ovaries, parameters, and lymph nodes. The patients was FIGO 2009 stage IB (pT1B, N0), and was treated with adjuvant radiation. The patient had a disease progression in the pelvis 3 months after the irradiation. We reported a case of PSCCE which can help to enrich the literature for the treatment and prognosis of this disease.

Primary squamous cell carcinoma of the endometrium in a woman of reproductive age: a rare case report

Primary endometrial squamous cell carcinoma is an extremely rare tumor that tends to occur in postmenopausal women. We report on a 33-year-old woman who presented with a history of irregular vaginal bleeding for more than 2 years, and a vaginal mass for more than 1 month. Biopsy of the vaginal mass revealed an invasive poorly differentiated squamous cell carcinoma. The patient underwent radical hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic lymph node dissection, peritoneal sampling and vaginal tumor resection. On the basis of her medical history, auxiliary examination and postoperative pathology, the patient was diagnosed with stage IV endometrial squamous cell carcinoma. The patient was followed-up regularly and remained in good condition.

Primary squamous cell carcinoma of endometrium: case report and literature review

In this paper, we report a case of primary squamous cell carcinoma of the endometrium (PSCCE) with a literature review. A 64-year-old woman, was admitted because postmenopausal bleeding. The gynecological exam found bleeding from the endocervix. The pelvic ultrasound objectified uterine regular contours, endometrial thickened was 10 mm, the presence of an intra cavitary lesion mesuring 56/70 mm. The diagnostic hysteroscopy revealed a whitish appearance taking all the uterine cavity making evoke a tumor of the endometrium. Pelvic MRI showed a tumor limited to the uterine corpus endometrium (invasion by more than 50% of the myometrium) without invasion of the cervix. Radical hysterectomy, bilateral salpingo-oophorectomy, and lymph nodes dissection were performed. Grossly, the endometrial carcinoma was polypoid tumor occupying the entire uterine cavity. Histologically, the diagnosis of SCC was retained. No adenocarcinoma element was recognized. Neither squamous metaplasia nor dysplasia was recognized. No ectopic cervical tissue was found. The SCC was found to invade into deeper one half of the myometrium. No tumor cells were seen in other sites including the cervix, ovaries, parametres, and lymph nodes. The patients was FIGO 2009 stage IB (pT1B, N0), and was treated with adjuvant radiation. The patient had a disease progression in the pelvis 3 months after the irradiation. We reported a case of PSCCE which can help to enrich the literature for the treatment and prognosis of this disease

Primary Endometrial Squamous Cell Carcinoma In Situ: Report of a rare disease

Squamous cell carcinoma (SCC) of the endometrium, whether primary or secondary to cervical cancer, is a rare entity. Primary endometrial squamous cell carcinoma in situ is even more uncommon; it usually occurs in postmenopausal women and has a strong association with pyometra. We report a 60-year-old multiparous postmenopausal woman who presented to the Hakeem Abdul Hameed Centenary Hospital, New Delhi, India, in May 2014 with a lower abdominal swelling corresponding in size to a pregnancy of 26 gestational weeks and vaginal discharge of one year's duration. A total abdominal hysterectomy with a bilateral salpingooophorectomy was performed, which revealed an enlarged uterus with pyometra. Histopathology showed that the entire endometrial lining had been replaced with malignant squamous cells without invasion of the myometrium. Immunohistochemistry revealed that the tumour cells were positive for p63 with a high Ki-67 labelling index. No adjuvant therapy was required and the patient was disease-free at a seven-month follow-up.

Primary squamous cell carcinoma of the endometrium unrelated to human papilloma virus: a molecular study

In this paper we report a molecular study of a case of Primary Endometrial Squamous Carcinoma (PESC), in which a Human Papilloma Virus (HPV) infection had been previously excluded by Polymerase Chain Reaction (PCR). The studies performed in an effort to explain the carcinogenesis included immunohistochemical over-expression of p53 and p16 proteins as previously observed in our own papers, plus microsatellite analysis of D10S1765 at 10q23.3 (PTEN) and TP53 at 17p13.1 (P53) as well as the methylation status of the of BRCA1 and p16 promoters using specific PCRs. In this rare malignancy, we found allelic imbalance (AI) at 17p13.1 (P53). Instead, AI at D10S1765 (PTEN) gene was absent. The genetic alteration of p53, with hyper-expression of p53 protein and an absence of abnormalities in the PTEN gene are consistent with the similarities between Uterine Serous Carcinoma (USC) and our case of PESC. The aberrant methylation of both p16 and BCAR1 promoters was not detected in our case. This finding too could imply that ESC is more similar to Uterine Serous Carcinoma than Uterine Endometrioid Carcinoma (UEC). Moreover, the lack of aberrant methylation of p16, which is in accordance with over-expression of p16 immunoreactivity, in the absence of HPV infection may be related to other unknown genetic alterations. In our opinion, it is hard to reach any definite conclusion concerning the carcinogenesis of PESC, because of its rarity and the very few molecular studies reported in the literature. Further studies with more numerous cases and larger molecular analyses are mandatory for this malignancy, to confirm whether it is more closely related to papillary endometrial cancer than to endometrioid carcinoma.

Primary endometrial squamous cell carcinoma: a case report and review of relevant literature on korean women

Primary endometrial squamous cell carcinoma (PESCC) is an extremely rare tumor with unclear pathogenesis. A 54-year-old postmenopausal woman presented with a 6-month history of vaginal bleeding. The patient was provisionally diagnosed with uterine submucosal leiomyoma. This was followed by total hysterectomy with a bilateral salpingo-oophorectomy under the laparoscopic guidance. Histopathologically, the tumor was PESCC which was accompanied by a lack of the tumor in the uterine cervix. The tumor showed positive immunoreactivity for p^16INK4a. But there was no evidence of human papillomavirus (HPV) on in situ hybridization and HPV DNA chip analysis. We also present a review of the relevant literature on Korean women.

Sister Mary Joseph's nodule associated with rare endometrial squamous cell carcinoma

BACKGROUND

Umbilical metastasis (Sister Mary Joseph's nodule) is a rare physical sign seen only in 1-3 % of patients with an intra-abdominal and/or pelvic malignancy. Here, we present a case of Sister Mary Joseph's (SMJN) nodule originating from a primary squamous cell carcinoma of the endometrium, a rare histological subtype.

CASE HISTORY

SMJN was detected in a 30-year-old woman after a preoperative CT scan for a suspected umbilical hernia. Subsequent laparotomy and histopathological examination confirmed endometrial squamous cell carcinoma metastasizing to the umbilical region.

CONCLUSION

The SMJN may be the first presenting sign of an intra-abdominal and/or pelvic malignancy and may co-exist with an umbilical hernia. Therefore, malignancy should be considered one of the differentials of an umbilical mass.

Pathology of uterine malignancies

This overview covers epithelial, stromal and mesenchymal malignancies of the body of the uterus, excluding the cervix. The distinction of type I and type II endometrial adenocarcinoma with the morphological variants of this tumour is discussed and some molecular aspects are explored. The concept of carcinosarcoma representing a metaplastic adenocarcinoma of the endometrium that behaves more like a carcinoma than a sarcoma is explained. Some types of mixed epithelial and stromal neoplasm are described and contrasted with carcinosarcoma. The concept of stromal sarcoma and high-grade uterine sarcoma is described and an outline of malignant smooth muscle tumours of the uterus includes a description of smooth muscle tumours of uncertain malignant potential and worrying benign smooth muscle lesions.

P16INK4a overexpression independent of Human Papilloma Virus (HPV) infection in rare subtypes of endometrial carcinomas

In the current study, we evaluated p16 expression in rare subtypes of endometrial carcinomas, whose HPV status has been previously examined in order to establish the role of this protein in their pathogenesis. These rare subtypes of endometrial carcinomas are primary squamous endometrial carcinoma (ESCC), endometrial mucinous microglandular adenocarcinoma (EMMA), and endometrial transitional cell carcinoma (ETCC). All tissues, obtained at the time of hysterectomy, were fixed in 10% phosphate-buffered formalin and embedded in paraffin. Serial sections were made for hematoxylin and eosin staining and for immunohistochemistry. Although a previous PCR study has demonstrated that none of these neoplasms showed any signal for HPV DNA, these malignancies did display immunoreactivity for P16(INK4a). In ESCC, P16(INK4a) immunoreactivity was diffuse in 100% of neoplastic cells. In two cases of EMMA, positivity for P16INK4a was zonal. In ETCC, scattered cells were positive for P16INK4a protein. These findings suggest that alteration of p16 could play an etiologic role, without any association to HPV infections, in these rare endometrial carcinomas. However, in our view, other cases of these rare malignancies should be investigated in order to confirm this hypothesis.

Verrucous carcinoma of the endometrium: Case history, pathologic findings, brief review of literature and discussion

BACKGROUND

Verrucous carcinoma is a rare condition. A defined disease of the oral cavity, larynx, esophagus, skin, vulva, vagina and cervix. But a verrucous carcinoma arising from the endometrium without evidence of cervical malignancy or endometrial adenocarcinoma is extremely rare.

CASE

A 67-year-old G2P2 menopausal patient that was referred for consultation 1 year after presenting with vaginal bleeding to her gynecologist who subsequently underwent several endometrial biopsies where the pathological findings were repetitively similar: papillary squamous proliferation, cytologically bland with low mitotic activity but extensive proliferation. A hysterectomy with bilateral salpingo-oophorectomy was performed. The final histologic examination revealed a squamous cell carcinoma of endometrium, verrucous and well differentiated, and there was no cervical invasion identified.

CONCLUSION

This is a rare form of endometrial cancer with apparent favorable prognosis that must be considered when squamous cells are identified on endometrial samplings.