Cytomorphologic features of low-grade endometrial stromal sarcoma

Cytologic features of undifferentiated and dedifferentiated carcinomas of the endometrium

BACKGROUND

Undifferentiated carcinoma (UC) is a rare, aggressive subtype of endometrial carcinoma. Dedifferentiated carcinomas (DCs) are UCs associated with a component of well differentiated endometrioid carcinoma. The authors sought to describe the morphologic features of UCs and DCs in cytologic specimens.

METHODS

Cytologic specimens from 23 women (aged 46-86 years; median age, 59 years) were reviewed, including cervicovaginal specimens (n = 7), peritoneal washings (n = 5), touch preparations of core biopsies from various sites (n = 5), fine-needle biopsies of lymph nodes (n = 3), ascitic fluid (n = 1), pleural fluid (n = 1), and intrauterine fluid (n = 1).

RESULTS

There were 10 UCs (43%) and 13 DCs (57%). Tumor cells were arranged as single cells (9 UCs, 90%; 12 DCs, 92%) and 3-dimensional groups (8 UCs, 80%; 11 DCs, 85%). Most cases showed high nuclear-to-cytoplasmic ratios. Nuclear molding was observed in 3 UCs (30%) and in 5 DCs (38%). Nuclear chromatin was often coarsely granular 6 UCs, 60%; 9 DCs, 69%). Nucleoli were inconspicuous in some cases (6 UCs, 60%; 8 DCs, 62%) but were appreciable in others. Necrosis was observed in 5 UCs (50%) and in 5 DCs (38%). Most cases exhibited clean backgrounds, and a few showed acute inflammation. Comparison of the cytologic features of UCs and DCs did not reveal any statistically significant differences.

CONCLUSIONS

UCs and DCs have a spectrum of cytomorphologic appearances that are not pathognomonic, but the presence of some of these (relatively uniform population of predominantly singly dispersed cells with high nuclear-to-cytoplasmic ratios and variably conspicuous nucleoli) should prompt consideration of UC and DC in the differential diagnosis.

Metastatic low-grade endometrial stromal sarcoma after 24 years: A case report and review of recent molecular genetics

Low-grade endometrial stromal sarcoma (LGESS) is a rare malignant uterine tumor with the potential to metastasize years after the primary resection. There is a broad differential diagnosis for endometrial stromal sarcomas (ESS), including both benign and malignant entities. Herein, we present the case of a 64-year-old female with metastatic LGESS to the lung, diagnosed by cytology, 24 years after her initial presentation. This report discusses the cytomorphologic and histopathologic characteristics, and ancillary studies including immunohistochemical stains and recent advances in molecular diagnostics of ESS. Accurate diagnosis of spindle cell lesions in the lung can be challenging. As such, this case highlights the instrumental role of ancillary testing and molecular diagnostics to achieve a more definitive diagnosis.

Myeloid sarcoma identified on liquid-based cervical cytology samples: A report of two cases

The purpose of the Papanicolaou (Pap) smear is to detect primary squamous lesions of the uterine cervix. Although most successful at detection of squamous lesions, the Pap may also detect metastatic carcinomas, sarcomas, and melanomas. We report two rare cases of myeloid sarcoma (MS) of the uterine cervix identified on screening Pap smears with concurrent confirmatory cervical biopsies. The purpose of our study is to identify and report cytologic features of MS on Pap smears utilizing a liquid-based ThinPrep method, which has not been previously documented in literature. Two Pap smears were identified from the pathology laboratory information system, both with positive cervical biopsy findings of MS. Both women, age 40 and 39, presented with ureteral obstruction, hydronephrosis, and past medical histories significant for acute myeloid leukemia (AML). On imaging, cervical masses were identified, and subsequent work-up with Pap smears and biopsies were performed. Cytologic examination of the ThinPrep Pap smears were negative for squamous intraepithelial lesion. Atypical hematologic cells were seen in the background with irregular nuclear contours, increased nuclear to cytoplasmic ratios, variably prominent nucleoli, and variable amounts of agranular cytoplasm. The biopsy confirmed these findings to represent MS. MS is defined as a tumor mass of myeloblasts or immature myeloid cells occurring in an extramedullary site. This rarely involves the female genital tract, about 50 reported cases. Although very rare, MSs in the setting of a history of AML are able to be identified on liquid-based ThinPrep smears.

High grade endometrial stromal sarcoma on thinprep

High grade endometrial stromal sarcoma (HGESS) is an uncommon malignancy recently re-defined in the new WHO classification of endometrial stromal tumors. In this article, we discuss the differential diagnoses of metastatic HGESS in a fine needle aspiration (FNA) of a lymph node and compare the cytomorphology of HGESS in ThinPrep [(TP), Hologic Inc., Boxborough, MA] to conventional smears (CS). The patient had a history of stage I HGESS, status-post supracervical hysterectomy without regional lymph node metastases. Her post-operative course was complicated by pelvic fluid collections and enlarging para-aortic lymph nodes. Diff-Quik (DQ)-stained and Papanicolaou (Pap)-stained smears from a para-aortic lymph node FNA demonstrated a cellular specimen with monomorphic population of plump to oval cells with scant, wispy cytoplasm in aggregates and as single cells. The nuclei showed fine chromatin and small inconspicuous nucleoli. Compared to the CS, HGESS cells in the TP showed similar cytological features, with the exception that the nuclei were slightly smaller, hyperchromatic, and the chromatin pattern was attenuated. In the absence of prior clinical history, the cytomorphology of metastatic HGESS in a lymph node can be difficult to differentiate from a lymphoma, a variety of metastatic spindle cell tumors or metastatic carcinoma. Immunohistochemical analysis and comparison with the primary tumor can be useful in proving the nature of the malignant cells. The cytomorphology of HGESS on TP correlated well in both single cells and aggregates when compared to CS. The differences noted were decreased nuclear size, nuclear hyperchromasia, and slightly attenuated nuclear detail on TP.

Abdominopelvic washings: A comprehensive review

Intraperitoneal spread may occur with gynecological epithelial neoplasms, as well as with non-gynecological malignancies, which may result in serosal involvement with or without concomitant effusion. Therefore, washings in patients with abdominopelvic tumors represent important specimens for cytologic examination. They are primarily utilized for staging ovarian cancers, although their role has decreased in staging of endometrial and cervical carcinoma. Abdominopelvic washings can be positive in a variety of pathologic conditions, including benign conditions, borderline neoplastic tumors, locally invasive tumors, or distant metastases. In a subset of cases, washings can be diagnostically challenging due to the presence of co-existing benign cells (e.g., mesothelial hyperplasia, endosalpingiosis, or endometriosis), lesions in which there is only minimal atypia (e.g., serous borderline tumors) or scant atypical cells, and the rarity of specific tumor types (e.g., mesothelioma). Ancillary studies including immunocytochemistry and fluorescence in situ hybridization may be required in difficult cases to resolve the diagnosis. This article provides a comprehensive and contemporary review of abdominopelvic washings in the evaluation of gynecologic and non-gynecologic tumors, including primary peritoneal and mesothelial entities.

Endometrial stromal sarcoma: A review of the literature

Endometrial stromal sarcomas are rare malignant tumors of the uterus, and most of the information available in literature is based on small series or case reports. A proper preoperative diagnosis is difficult and in most cases the diagnosis is confirmed after hysterectomy for a presumed benign disease. Endometrial sampling, ultrasound, and magnetic resonance imaging can provide diagnostic clues. Total hysterectomy with bilateral salpingo-oopherectomy is the main line of management and for early disease complete cure is a reality. Ovarian conservation may be possible in young women with early stage disease and the role of lymphadenectomy is controversial. Adjuvant hormone therapy in the form of progesterone, gonadotropin releasing hormone analogues, and aromatase inhibitors are found to be effective in preventing recurrences. Hormone therapy, radiotherapy and surgical excision of the metastasis are recommended for recurrences.

Low-Grade Endometrial Stromal Sarcoma and Undifferentiated Endometrial Sarcoma: A Comparative Analysis Emphasizing the Importance of Distinguishing Between These Two Groups

Endometrial stromal sarcomas (ESSs) are rare tumors whose classification is still controversial. In this study, the authors studied 19 patients diagnosed with ESS at the Hospital S João, Porto, Portugal; reviewed their files and material; and performed immunohistochemical study for CD10, desmin, and smooth muscle actin markers, aiming to compare low-grade endometrial stromal sarcomas (LG-ESSs) and undifferentiated endometrial sarcomas (UESs) using the World Health Organization (WHO) classification. Twelve cases (63%) were classified as LG-ESS and 7 (37%) as UES. The median age at diagnosis was 49 years, and women with LG-ESS tended to be younger than those with UES. Most cases (7/11) had a previous echographic diagnosis of leiomyoma. A biopsy or curettage was performed in 6 cases, providing a definitive diagnosis of malignancy in 4. Frozen section was performed in 4 patients. The majority (63%) of patients were FIGO stage I. Twelve (63%) cases showed diffuse or focal expression of CD10. Desmin and smooth muscle actin expression was focal in 4 (21%) tumors. Patients with LG-ESS had a significant better overall survival than those with UES ( P = .026). Mitotic count had no prognostic significance. Our data emphasize the clinical importance of the WHO classification in ESS. It is of utmost importance to establish a proper classification to increase the consistency of data that may be useful for improving clinical and therapeutic management of patients with ESS.