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OJHAS Vol. 9, Issue 3:
(Jul - Sep, 2010) |
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| Uterine Papillary Serous Carcinoma with Mature Cystic
Teratoma of Left Ovary |
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Prasad K Shetty, Department
of Pathology,
Balaiah K, Department of Pathology,
Bafna UD, Department of
Gynac-Oncology,
Bhagwan Mahaveer Jain Hospital, Bangalore, India. |
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Address For Correspondence |
Surgical Pathologist,
Bhagwan Mahaveer Jain
Hospital,
Vasanth Nagar, Millers Road,
Bangalore
- 560052, India.
E-mail:
dr.pkshetty@gmail.com |
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Shetty PK, Balaiah K, Bafna UD. Uterine Papillary Serous Carcinoma with Mature Cystic
Teratoma of Left Ovary. Online J Health Allied Scs.
2010;9(3):19 |
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Submitted: Aug 21, 2010;
Accepted:
Sep 22, 2010; Published: Oct 15, 2010 |
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| Abstract: |
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Uterine
papillary serous carcinoma (UPSC) is an uncommon histologic variant of
endometrial carcinoma that typically arises in post menopausal women, that may present with extrauterine
spread, resulting in high relapse rate and poor prognosis. Mature cystic
teratomas (MCT) are common tumors that occur during the reproductive years. We report a case of
a 60 years old female with UPSC with MCT of left ovary. To
our knowledge, this is the second report of UPSC combined with ovarian
MCT.
Key Words: Uterine papillary serous carcinoma (UPSC); Mature cystic teratoma; CA 125
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A
60 year old female came with history of distention of abdomen and bleeding
per vagina since 1 year. Physical examination revealed abdominal distension
with abdominal tenderness. X-ray chest showed right pleural effusion.
Abdominal sonography revealed solid cystic left adnexal mass measuring
8.9x6.5cms, with moderate ascitis of approximately 700-800ml, with right
lobe of liver showing a cystic lesion measuring 4x2cms, suspected to be metastatic.
Her serum CA125 level was high >400IU/ml (normal 0-35IU/ml). A diagnostic
ascitic fluid tap was performed and subjected for analysis. Ascitic
fluid cytology reveled tumor cells in sheets and 3D clusters favoring
a diagnosis of metastatic adenocarcinoma.(Figure 1)
A preoperative diagnosis of
left ovarian carcinoma was made and a course
of neoadjuvant chemotherapy was administered over 3 months comprising
of 3 cycles of Carboplatin 600mg/cycle and subsequently an exploratory
laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy,
pelvic and aortic lymphnodes, peritoneal deposit, liver deposit sampling
and omentectomy was performed. Grossly, uterus with cervix was measuring
8.5x5.5x4cms, cut surface endometrium was 5mm thick with a gray white
and friable growth measuring 1.5x1.4cms in the isthmic region.(Figure 2) |
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Figure 1: 40x high power
view of ascitic fluid cytology shows tumor cells in 3D cluster, cells
have pleomorphic and hyperchromatic nucleus with clumped chromatin and
prominent nucleoli. |
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Figure
2: Gross photograph of uterus with cervix with a gray white tumor
in the isthmic region. |
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Figure 3: Gross photograph of
left ovary with solid cystic areas filled with cheesy material. |
Right
ovary was unremarkable. Left ovary was cystically enlarged and measured
7.5x5.5cms, cut surface was predominently cystic filled with cheesy
material mixed with mucinous material and hairs.(Figure 3)
Omentum
on dissection reveled multiple gray white nodules with largest being
2.5cms in diameter.
On
microscopy endometrium showed tumor cells arranged in papillary architecture
with tufting and secondary papillae. Papillae had broad based and hyalinized
stalks, lining tumor cells were stratified coloumnar, individual tumor
cells showed nucleomegaly with prominent nucleoli, clumped chromatin
and atypical mitotic figures, also seen were psamomma bodies, endometrium
adjacent to the tumor was atrophic, tumor was infiltrating >50% myometrium
with vascular invasion.(Figure 4)
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Figure 4: Uterine wall with
papillary serous carcinoma in a background of atrophic endometrium |
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Figure
5: Papillae lined by tumor cells with psamomma body in the stalk of the papillae |
Peritoneal
sample, pelvic and aortic lymphnodes and liver tissue showed metastatic
deposits. Left ovary showed mature cystic teratoma (MCT).
Based
on these findings a diagnosis of Uterine papillary serous carcinoma
(UPSC) stage IVA according to international federation of gynecology
and obsteretic cancer staging system (FIGO), with left ovarian MCT was
made. Postoperative stay was uneventful. Patient was advised to undergo
3 cycles of chemotherapy.
Endometrial
cancer is one of the common gynecologic malignancy and accounts for
13% of all cancers in women. The most common endometrial cancer is endometroid
carcinoma and accounts for 75-80% and is associated with endometrial
hyperplasia. UPSC on the other hand is known to be a rare type of endometrial
tumor that comprises only 5-10% of endometrial carcinoma which usually
arises in an background of atrophic endometrium and psamomma bodies
are found in one third of cases.3,5
UPSC
is a distinct type of endometrial carcinoma which resembles Papillary
serous carcinoma of ovary, clinically, it has an aggressive biologic
behavior with a propensity for lymphatic invasion, myometrial invasion
and extrauterine spread, a tumor behavior similar to ovarian carcinoma,
in stead of typical endometrial carcinoma.2,6 Unlike
the typical endometrial carcinoma, it has a poor clinical survival
and even a small focus of UPSC can be life threatening.7,8
UPSC, which was
formerly known as tubal carcinoma, was shown to be more aggressive than
conventional endometrial carcinoma and was established as a distinct
entity by Lauchlan and Hendrickson et al in 1982.1,2 It
has long been recognized that excessive estrogens and obesity are associated
with endometrial cancers. Bokhman proposed a hypothesis that there were
two distinct types of endometrial cancers. Type I is the commonest of
the two and is associated with obesity with excess estrogen as a result
of aromatase activity in peripheral adipose tissue. Type II tumors are
thought to develop through a separate pathway of tumorigenesis and not
associated with excess estrogen, clinically there are much more aggressive
and often spread outside the uterus by the time of diagnosis.9
UPSC is the most common type of type II tumors, it is always diagnosed
in postmenopausal women with 10 Yrs older than usual endometroid carcinoma.7-9
Based
on aggressive nature associated with an advanced stage at initial presentation,
Geisler et al. concluded that patients with UPSC should undergo a staging
laparotomy including lymphadenectomy and omentectomy similar to the
procedure undertaken for patients with ovarian carcinoma.10
In
the presented case, although pre-operatively it was misdiagnosed as
ovarian carcinoma due to left ovarian mass (MCT) and raised serum CA
125 levels (which is also raised in UPSC), a preoperative chemotherapy
and staging laparotomy of TAH+BSO, pelvic lymphnode dissection and peritoneal
cytology were performed as per the protocol for Ovarian carcinoma.11
MCT make upto
25% of all ovarian neoplasms and is commonly found in reproductive age
group. It is unilateral in 88% of the cases. Tumors are usually uniloculated
with average size of 7-8cms and can undergo malignant transformation
in 1% of cases.12 MCT of ovary is frequently associated with
mucinous tumors ovary.13 On reviewing the literature we found
only one case associated with UPSC.14
In conclusion,
UPSC is very rarely associated with MCT and UPSC by itself is an uncommon
type of endometrial carcinoma which is highly aggressive and usually
would have disseminated by the time of clinical presentation, it is
associated with high CA125, and the treatment protocol is as that of
a ovarian carcinoma.
- Lavie O, Beller U, Neumann
M, Rosemann E, Dinamant Y. Serous papillary adenocarcinoma of the endometrium:
a unique entity with a grave prognosis—case report and review of the
literature. Eur J Gynaecol Oncol 1993;14:46–50
- Katsube Y, Berg J W, Silverberg
S G 1982 Epidemiologic pathology of ovarian tumours: a histopathologic
review of primary ovarian neoplasms diagnosed in the Denver Standard
Metropolitan statistical Area, 1 July – 31 December 1969 and 1 July
31 December 1979. Int J Gynecol Pathol. 1982;1(1):3–16.
- Powell JL, McDonald TJ, White
WC. Serous psammocarcinoma of the ovary. South Med J 1998;91:477 –480.
- Hendrickson M. Ross J. Eifel
PJ, Cox RS. Martinez A. Kempson R. Adenocarcinoma of the endometrium:
analysis of 256 cases with carcinoma limited to the uterine corpus.
Gynecol Oncol 1982;13: 373-392.
- Ramirex-Gonazles CE, Adamsons
K, Mangual-Vasquex TY, Wallach RC. Papillary adenocarcinoma in the endometrium.
Obstet Gynecol 1987;70:212-215.
- Sherman ME, Bitterman P,
Rosenshein NB, Delgado G, Kurman RJ. Uterine serous carcinoma: A morphologically
diverse neoplasm with unifying clinicopathologic features. Am J Surg
Pathol 1992;6:600-610.
- Silva EG, Jenkins R. Serous
carcinoma in endometrial polyps. Mod Pathol 1990;3:120-128.
- Lauchlan SC. Tubal (serous)
carcinoma of the endometrium. Arch Pathol Lab Med 1981;105:615-618.
- Bokhman JV. Two pathogenetic
types of endometirla carcinoma. Gynecol Oncol. 1983;15:10-17.
- Geisler JJP, Geisler HE,
Melton ME, Wiemann MC. What staging surgery should be performed on patients
with uterine papillary serous carcinoma? Gynecol Oncol 1999;74:465-467.
- Price FV, Chambers SK, Carcangiu
ML, Kohorn EI, Schwartz PE, Chambers J. Intravenous Cisplatin, doxorubicin,
and cyclophosphamide in the treatment of uterine papillary serous carcinoma
(UPSC). Gynecol Oncol 1993;51:383-389.
- Russell P. The Pathological
assessment of ovarian neoplasms. I. Introduction to the common “epithelial”
tumours and analysis of benign “epithelial” tumours. Pathology
1979;11:5–26.
- Hynter V, Barnhill D. Jadwin
D. Crooks L. Ovarian mucinous cystadenocarcinoma of low malignancy potential
associated with a mature cystic teratoma. Gynecol Oncol 1988;29:250-254.
- Hsin-Wang Lin, Dah-Wei Ling,
Li-Mien Chen, Yia-Tang Yiang, Chih-Ping Han and Yu-Gi Liu. Uterine papillary
serous carcinoma involving the benign cystic teratoma of ovary: An unusual
case report and review of literature. J Med Sci 2000;20(9):511-518.
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