Uterine carcinosarcoma with melanocytic differentiation

The "Forgotten" Subtypes of Breast Carcinoma: A Systematic Review of Selected Histological Variants Not Included or Not Recognized as Distinct Entities in the Current World Health Organization Classification of Breast Tumors

Breast carcinoma is the most common cancer in women. Nineteen different subtypes of breast carcinomas are recognized in the current WHO classification of breast tumors. Except for these subtypes, there are a number of carcinomas with special morphologic and immunohistochemical features that are not included in the 5th WHO classification, while others are considered special morphologic patterns of invasive breast carcinoma of no special type. In this manuscript, we systematically review the literature on four different subtypes of invasive breast carcinoma, namely lymphoepithelioma-like breast carcinoma, breast carcinoma with osteoclast-like giant cells, signet-ring breast carcinoma, and metaplastic breast carcinoma with melanocytic differentiation. We describe their clinicopathological characteristics, focusing on the differential diagnosis, treatment, and prognosis.

Is Primary Poorly Differentiated Sarcomatoid Malignancy of the Parotid Gland Sarcomatoid Undifferentiated/Dedifferentiated Melanoma? Report of Three Unusual Cases Diagnosed by Fine-Needle Aspiration Combined with Histological, Immunohistochemical, and Molecular Analyses

INTRODUCTION

Poorly differentiated primary sarcomatoid parotid malignancies are extremely rare. These tumors have not been consistently studied by morphology, immunohistochemistry, or molecular techniques.

CASE PRESENTATION

We report three unusual cases of parotid gland poorly-differentiated sarcomatoid malignancy investigated by fine-needle aspiration and studied histologically, by immunohistochemistry and molecular investigations. Aspirates showed poorly specific polymorphous sarcomatoid malignancy in all cases. Histologically, all cases were polymorphous high-grade malignancies, and additionally, one case showed epithelial structures and was finally classified as salivary carcinosarcoma. Immunohistochemistry showed classical melanocytic markers negativity but positivity for PRAME, CD10, and WT1 in all three tumors and for CD56 in two tumors, which can potentially be supportive of melanocytic origin. Although not entirely specific, molecular characterization also suggested the melanocytic lineage of these tumors.

CONCLUSION

Although rare, primary malignant melanoma of salivary gland was already described, but undifferentiated/dedifferentiated amelanotic forms are unknown in this localization up today. Further case reports of similar presentations are required to confirm the unequivocal primary origin of these obscure neoplasms in the parotid gland.

Endometrial carcinoma with diffuse melanocytic differentiation: Clinicopathological and molecular analysis of a case with literature review and focus on differential diagnosis

Herein, we present a clinicopathological and molecular analysis of a case of endometrial carcinoma with diffuse melanocytic differentiation with literature review. A 72-year-old woman underwent hysterectomy due to a 14 cm endometrial mass. On histology, the tumor showed a serous carcinoma component and a solid component with giant eosinophilic and dyshesive multinucleated cells. Differential diagnosis included several entities, such as undifferentiated giant cell carcinoma and carcinosarcoma with rhabdomyoblasts. The solid component showed diffuse positivity for cytokeratin AE1/AE3, Melan A, Cathepsin K and S100, focal HMB45 positivity and loss of e-cadherin. The tumor was p53-abnormal, mismatch repair-proficient and POLE-wild-type. The patient had extrauterine metastases and was alive with disease at 12 months. Previous cases of endometrial and ovarian carcinomas with melanocytic differentiation (n = 7) did not show giant bizarre cells but showed melanin production; all cases were advanced and/or had unfavorable outcomes. In conclusion, endometrial carcinomas with melanocytic differentiation are highly aggressive tumors which should be distinguished from other entities. Being aware of this entity may help not to miss it.

Ovarian Sex Cord-stromal Tumors With Melanin Pigment: Report of a Previously Undescribed Phenomenon

We report 2 ovarian sex cord-stromal tumors, a luteinized adult granulosa cell tumor and a cellular fibroma, with melanin pigment. These occurred in 44 and 61-yr-old patients, respectively. As far as we are aware, melanin pigment has not been described previously in an ovarian sex cord-stromal tumor, although it has been reported in a testicular Sertoli cell tumor. We review ovarian neoplasms containing melanin pigment.

Primary endometrial large cell neuroendocrine carcinoma with melanocytic differentiation

High-grade endometrial carcinomas are aggressive neoplasms of difficult histological classification. Neuroendocrine differentiation in endometrial carcinomas is rare. This is the report of an endometrial large cell neuroendocrine carcinoma with foci of melanocytic differentiation in a 75-year-old woman with abnormal post-menopausal uterine bleeding for 2 years. Two initial biopsies were inconclusive. Histopathological examination of the uterus revealed large cell neuroendocrine carcinoma associated with endometrioid carcinoma and foci of melanocytic differentiation, pT3a (FIGO IIIA). There were metastases in the rectum serosa and lungs. After 8 months of diagnosis and surgical treatment, the patient is on chemotherapy and radiotherapy. We highlight the morphological characteristics and criteria that allow the definitive anatomopathological diagnosis, including immunohistochemical markers used to identify the cell types present in this unprecedented association.

A practical approach to the diagnosis of mixed epithelial and mesenchymal tumours of the uterus

The current 2014 World Health Organization (WHO) Classification of mixed epithelial and mesenchymal tumours of the uterus includes categories of carcinosarcoma, adenosarcoma, adenofibroma, adenomyoma and atypical polypoid adenomyoma, the last two lesions being composed of an admixture of benign epithelial and mesenchymal elements with a prominent smooth muscle component. In this review, each of these categories of uterine neoplasm is covered with an emphasis on practical tips for the surgical pathologist and new developments. In particular, helpful clues in the distinction between carcinosarcoma and dedifferentiated endometrial carcinoma will be discussed. In addition, salient features to help distinguish between adenofibroma, adenosarcoma, embryonal rhabdomyosarcoma and other mesenchymal neoplasms in the differential diagnosis will be outlined. Finally, a discussion of adenomyoma and its main differential diagnostic considerations will be covered.

Sarcoma of the Uterus. Guideline of the DGGG (S2k-Level, AWMF Registry No. 015/074, August 2015)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Due to their rarity and their heterogeneous histopathology uterine sarcomas remain challenging tumors to manage and need a multidisciplinary approach. To our knowledge so far there is no evidence-based guideline on the appropiate management of these heterogeneous tumors. Methods: This S2k-guideline is the work of an representative committee of experts from a variety of different professions who were commissioned by the DGGG to carry out a systematic literature review of uterine sarcoma. Members of the participating scientific societies developed a structured consensus in a formal procedure. Recommendations: 1. The incidence and histopathologic classification of uterine sarcoma. 2. The clinical manifestations, diagnosis and staging of uterine sarcoma. 3. The management of leiomyosarcoma. 4. The management of endometrial stromal sarcoma and undifferentiated uterine sarcoma. 5. The management of adenosarcoma as well as carcinosarcomas. 6. The management of morcellated uterine sarcoma.

Endometrioid adenocarcinoma concurrent with a blue nevus of the endometrium and uterine cervix: A case report

A blue nevus is a benign melanocytic lesion that is composed of spindle-shaped pigmented melanocytes. Although the uterine cervix is believed to be the most common extracutaneous location of blue nevi, the occurrence of these lesions in the endometrial stroma has been reported, albeit rarely. The present study describes a case of endometrioid adenocarcinoma concurrent with a blue nevus of the endometrium and uterine cervix. A 58-year-old female presented with abnormal vaginal bleeding. A biopsy from the endometrium revealed an endometrioid adenocarcinoma and subsequently, a total hysterectomy was performed. Histopathological study revealed the proliferation of columnar cells that formed irregularly-shaped tubular and cribriform glands. The neoplastic columnar cells had large, round to oval nuclei containing a single small nucleolus. Focal squamous differentiation was noted. In the stroma of the non-neoplastic endometrium, single or small aggregates of short spindle-shaped cells containing melanin without atypia were observed. These melanocytes were also present in the endocervix. Therefore, the final diagnosis was of endometrioid adenocarcinoma concurrent with a blue nevus of the endometrium and cervix. This is the first documented case of a blue nevus of the endometrium and endocervix. The pathogenesis of blue nevi of the genital tract is not yet completely understood. Possible origins of these cells include Schwann cells or perineural cells of the peripheral nerve fiber or the abnormal migration of neural crest-derived cells.

Adrenocortical neoplasia: evolving concepts in tumorigenesis with an emphasis on adrenal cortical carcinoma variants

Adrenocortical carcinoma (ACC) is a rare, heterogeneous malignancy with a poor prognosis. According to WHO classification 2004, ACC variants include oncocytic ACCs, myxoid ACCs and ACCs with sarcomatous areas. Herein, we provide a comprehensive review of these rare subtypes of adrenocortical malignancy and emphasize their clinicopathological features with the aim of elucidating aspects of diagnostic categorization, differential diagnostics and biological behavior. The issue of current terminology, applied to biphasic tumors with pleomorphic, sarcomatous or sarcomatoid elements arising in adrenal cortex, is also discussed. We additionally present emerging evidence concerning the adrenal cortical tumorigenesis and the putative adenoma-carcinoma sequence as well.

Melanoma in a carcinoma ex pleomorphic adenoma of the parotid gland: a case report and putative histogenesis

A rare example of melanoma arising in carcinoma ex pleomorphic adenoma is presented. The diagnosis, differential diagnosis, and putative histogenesis of the melanoma component are discussed.

Carcinosarcoma of the uterus with melanocytic differentiation

Carcinosarcomas (CSs) are rare biphasic neoplasms of the female genital tract, with the presence of malignant epithelial and mesenchymal components. The occurrence of non-epithelial or non-mesenchymal differentiations in CSs is extremely rare. A case of a 54-year-old woman with a history of treatment for breast carcinoma is reported. The patient presented with a uterine tumor showing histological, immunohistochemical, and ultrastructural features of an extremely rare CS, with signs of melanocytic differentiation. The lesion was a 7.0 x 5.6 cm polypoid tumor mass arising from the endometrium and metastasizing in the abdominal cavity as a malignant melanoma - the most aggressive component of CS. Despite adjuvant chemotherapy, she died 8 months after the initial diagnosis due to the metastatic spread of CS. In line with current knowledge, we assess the melanocytic differentiation as one of a hypothetic differential line with the ability of multidirectional stem cell differentiation. We discuss a possible pathogenesis of this lesion and the role of tamoxifen in the tumor development as well. To the best of our knowledge, only one case of uterine CS with melanocytic differentiation has been reported in the English literature.

Perivascular epithelioid cell (PEC) tumors of the uterus: a clinicopathologic study of two cases with aggressive features

We report the clinicopathologic, immunohistochemical and ultrastructural features of two unusual tumors of the uterus composed of spindle and epithelioid cells strongly positive for HMB45. The two patients of 56 and 48 years of age had, respectively, hemoperitoneum and abnormal uterine bleeding. Morphologically, both tumors showed atypia and extensive necrosis. The neoplastic cells express immunohistochemically both melanogenesis (HMB45) and smooth muscle markers (actin). Ultrastructural analysis showed the presence of intracytoplasmic membrane-bound granules. We viewed these neoplasms as perivascular epithelioid cell (PEC) tumors with aggressive features. Follow-up has shown the death of one patient whereas the other is alive without disease 36 months after the surgery. The two patients were evaluated for signs of tuberous sclerosis complex, and findings were negative.

Pigmented lesions in unusual anatomic sites

This review considers pigmented melanin-containing lesions arising in extracutaneous locations. It includes reactive lesions as well as benign and malignant neoplasms. Melanocytic lesions of the mucosae, nervous system, and individual organs are discussed, and rarer pigmented tumors in unusual sites are also covered. A brief description of the histology and clinical behavior along with proposed explanations for their ectopic location are provided. Emphasis is given to the reality that detailed morphological evaluation and application of ancillary techniques can establish the melanocytic nature and biologic potential of such tumors, but cannot, by themselves, determine the primary or metastatic nature of these lesions.

Blue nevus of the endometrium

A 36-year-old woman with a long history of amenorrhea underwent endometrial curettage. An aggregate of short spindle cells containing a finely granular, dark brown pigment with the histochemical characteristics of melanin was detected in the endometrial stroma. This finding is considered analogous to the occurrence of similar cells in the endocervical stroma and is most appropriately designated a "blue nevus" of the endometrium. The occurrence of nonneoplastic, melanin-laden cells in the endometrial stroma is an extremely rare phenomenon, which has been reported only once previously.