子宫内膜息肉样腺肌瘤临床病理分析

目的:探讨子宫内膜息肉样腺肌瘤的临床病理特征。方法:对27例子宫内膜息肉样腺肌瘤的临床资料和病理特征进行回顾性分析。结果:27例子宫内膜息肉样腺肌瘤于宫腔镜下未能确诊,经病理检查明确诊断。其中息肉样腺肌瘤15例,由富含平滑肌组织的基质包绕大小和形态不等的子宫内膜腺体,但无不典型性改变;非典型性息肉样腺肌瘤12例,由杂乱无章的不规则腺体构成,具有明显的腺体结构复杂性和细胞非典型性,可见鳞状上皮化生。结论:子宫内膜息肉样腺肌瘤具有特异的病理特征,为良性病变,但是非典型性息肉样腺肌瘤存在低度恶性潜能,需完整切除肿物,防止复发,且应严密随诊。     

子宫非典型性息肉状腺肌瘤病理诊断及鉴别诊断

目的：探讨子宫非典型性息肉状腺肌瘤（APA）的临床病理特征及其鉴别诊断。方法：收集6例子宫非典型性息肉状腺肌瘤,综合分析其表现,并进行光镜观察。结果：患者年龄27－65岁,平均43．1岁。主要以阴道不规则出血和（或）不孕症为主诉。除1例部位不详外,2例发生在宫底,2例宫体下段,1例位于宫颈管内,光镜下表现为腺上皮呈不同程度的增生,并伴有一定异型性,1例出现鳞化灶,肿瘤间质可见增生的平滑肌组织,1例局部出现内膜间质的分化,1例部分区域间质水肿明显。1例镜下见肿物一部分为透明细胞癌,另一部分呈APA改变,两者之间有过渡,随访3个-11上,除继发透明细胞癌的老年患者术后16个月死亡外,其余均无复发。结论：子宫非典型性息肉状腺肌瘤应注意与高分化宫内膜样癌,宫内膜息肉,腺肌瘤等鉴别,其临床经过良好,但非典型性显著者,尤其是老年患者有继发内膜癌的可能性。     

Cytology of polypoid adenomyomas: a report of two cases

Uterine polypoid adenomyomas, both typical and atypical variants, often arise in the lower uterine segment or endocervical canal as pedunculated polypoid masses that may be accessible for cytologic sampling. However, their cytologic findings have rarely been described in the literature. Two women in their reproductive age presented with abnormal vaginal bleeding. The cervicovaginal smear of the first patient contained sheets and strips of reactive endocervical cells in an inflammatory background. In addition, loose aggregates of spindle-shaped smooth muscle cells were also noted. The findings were consistent with those of a typical polypoid adenomyoma. The cervicovaginal smears of the second patient consisted of tightly packed, crowded clusters of glandular cells which were initially interpreted as atypical glandular cells, suspicious of adenocarcinoma. In retrospect, loose aggregates of smooth muscle stromal cells were noted. Subsequent curettage revealed an atypical polypoid adenomyoma. The cytologic findings of typical polypoid adenomyoma were nonspecific except for the presence of loose aggregates of smooth muscle cells. The cytologic features of an atypical polypoid adenomyoma may mimic that of a neoplastic glandular process. The findings of tightly packed clusters of glandular cells and loose aggregate of bland-appearing smooth muscle cells in premenopausal patients may suggest the diagnosis of atypical polypoid adenomyoma. Diagn. Cytopathol. 2000;22:176-180.     

Atypical polypoid adenomyomas of the uterus

We performed a clinicopathological immunohistochemical, ultrastructural, and flow cytometric study on six cases of atypical polypoid adenomyoma of the uterus including one with an adenocarcinoma within it. The tumours occurred in nulliparous women aged 22–48 years (average, 33.0 years); three arose in the uterine corpus, and three in the endocervix. Histologically, they were composed of endometrial glands admixed with a stromal component of interlacing bundles of smooth muscle cells. The glands exhibited varying degrees of architectural and cytological atypia. Most of the stromal cells showed strong staining for HHF35, alpha-smooth muscle actin, and vimentin, and some cells contained desmin. Electronmicroscopy, in one case, confirmed the presence of a well-differentiated smooth muscle component. The stromal component may arise as a result of extensive metaplasia of endometrial stromal cells. Uninvolved endometrium showed ciliated cell metaplasia in three patients, and atypical complex hyperplasia in two. One patient had a well-differentiated adenocarcinoma of endometrioid type arising in an endocervical atypical polypoid adenomyoma. All tumours had a diploid DNA content and relatively small S phase fraction (average, 6.23%). The follow-up periods ranged from 4 to 42 months (average, 13.5 months), and all patients were alive and well. Although the histogenesis of atypical polypoid adenomyoma of the uterus remains uncertain, it is suggested that it may arise because of oestrogen-related factors.     

Adenomyoma of the small intestine: report of two cases and review of the literature

Adenomyoma of the small intestine is a rare tumor-like lesion composed of exocrine-type ducts and hypertrophic smooth muscle. We describe two cases of adenomyoma of the small intestine. One was an ileal adenomyoma that presented with intussusception occurring in a 7-month-old boy. The other was a jejunal adenomyoma found incidentally in a 63-year-old man with colon cancer. Histologically, the lesions composed of benign ducts and bundles of smooth muscle. The second case was detected on contrast-enhanced computed tomography scan as a small enhancing polypoid mass. We review the previous literature of adenomyoma of the small intestine.     

Adenomyolipoma of the uterus: a case report

Adenomyolipoma of the uterus is a rare, benign, polypoid lesion considered to be of hamartomatous origin or represent an unusual type of benign Müllerian mixed tumour with a heterologous element. The authors present a case of uterine adenomyolipoma and discuss its pathogenesis. A 62-year-old woman complained of lower abdominal pain and postmenopausal bleeding. Imaging techniques revealed a solid ovarian mass and a polypoid intrauterine lesion. The frozen section diagnosis of the ovarian mass was a thecoma. A total hysterectomy and bilateral salpingo-oophorectomy were performed. On gross examination a pedunculated, polypoid lesion of 7x4.5x3cm was found in the uterine cavity. Microscopically, the polypoid lesion contained both epithelial and mesenchymal elements. The epithelial elements were endometrial glands of various size, formed by proliferative endometrial cells. The mesenchymal elements were composed of endometrial stroma, smooth muscle and mature adipocytes. Both the epithelial and the mesenchymal elements showed a benign appearance, were intermingled with each other and periglandular stromal condensation was absent. The lesion had an irregular surface. Microscopic diagnosis was an adenomyolipoma. The peculiar shape and microscopic features of this lesion suggested that it was a variant of benign Müllerian mixed tumour.     

40岁以下妇女子宫内膜癌刮宫活检的病理诊断问题

目的 探讨40岁以下妇女子宫内膜癌刮宫活检的病理诊断。方法对20例40岁以下子宫内膜癌患者的临床病理资料进行回顾性分析。结果子宫内膜样腺癌18例,腺鳞癌(腺癌伴鳞状上皮分化)1例,浆液性乳头状癌并透明细胞癌1例。子宫内膜样腺癌的组织学特点是子宫内膜腺体失去极性,细胞核变大、变圆、核仁突出,染色质粗或呈空泡状,同时子宫内膜间质消失,代之为肉芽组织或纤维组织,常有炎性反应。子宫内膜样腺癌多数仅累及浅肌层,皆无转移。1例子宫内膜腺鳞癌呈双侧卵巢转移;1例浆液性乳头状癌有盆腔淋巴结转移。结论40岁以下妇女的子宫内膜癌多数为高分化子宫内膜样腺癌,应注意与子宫内膜不典型增生及不典型息肉状腺肌瘤鉴别。     

Atypical polypoid adenomyoma of the uterus. A report of 27 cases

Twenty-seven atypical polypoid adenomyomas of the uterus were reviewed. The tumors occurred in women ages 21-53 (average 39.7) years old, who presented with abnormal uterine bleeding in most cases. Two of the patients had Turner's syndrome. The adenomyomas most frequently involved the lower uterine segment, measured up to 6 (average 1.9) cm in greatest dimension, and were characteristically polypoid and well circumscribed. Microscopic examination disclosed endometrial glands with varying degrees of hyperplasia and atypicality up to the appearance of carcinoma in situ within neoplastic smooth muscle. Squamous differentiation was common within the glands; the smooth muscle occasionally was atypical. Follow-up data suggested that the lesion is benign, although it persisted in two patients treated by curettage alone. Atypical polypoid adenomyomas should be distinguished from endometrial carcinomas and other malignant uterine neoplasms with which they are often confused, particularly in curettage specimens.     

Coexistent atypical polypoid adenomyoma and complex atypical endometrial hyperplasia in the uterus

We report a case of atypical polypoid adenomyoma (APA) concomitantly identified with complex atypical endometrial hyperplasia (CAH) in the uterus. Since an initial endometrial smear revealed atypical endometrial cells, a diagnosis of CAH was made. Even though a concomitantly performed uterine cervical smear contained both atypical epithelial and stromal cells, the diagnosis of APA was not initially made because the cytological criteria for APA had not been established. Histologically, we recognized both CAH in the uterine corpus and APA in the lower uterine segment in the hysterectomy material. Retrospectively, the cells in the first cervical smear were interpreted as part of APA because the same types of cells were observed in the intraoperative cytology sample. Although the APA and CAH lesions were interposed by normal endometrium, estrogen was suspected to be the common etiological factor. Reports regarding the cytology of APA are currently scarce. To our knowledge, this is the first report showing cytological presentation of association of APA with CAH in addition to the first cervical smear of APA containing both epithelial and stromal components. Identification of abnormal proliferation of epithelium and stromal cells of smooth muscle origin is useful in the cytological diagnosis of APA. Diagn. Cytopathol. 2010. © 2009 Wiley‐Liss, Inc.     

Fallstricke bei der histopathologischen Diagnostik des Endometriumkarzinoms und seiner Vorstufen

Making an incorrect histopathological diagnosis of an endometrial lesion may lead to unwanted loss of fertility and therapy-associated morbidity; therefore, endometrial carcinomas need to be correctly typed and differentiated from hyperplastic precursors, benign lesions and artifacts. Typical diagnostic pitfalls are described in this article. Misdiagnosing endometrial lesions can be avoided by paying thorough attention to gross as well as microscopic features and by taking crucial differential diagnoses into consideration. These are, in particular, well-differentiated endometrioid adenocarcinoma of the endometrium versus atypical endometrial hyperplasia, myoinvasive endometrioid adenocarcinoma versus atypical polypoid adenomyoma and endometrioid carcinoma versus serous carcinoma of the endometrium with a predominantly glandular pattern. It is also important to consider the possibility of a false positive diagnosis of atypical endometrial hyperplasia or carcinoma in cases of biopsy-induced artifacts.     

Uterine-like mass with features of an extrauterine adenomyoma presenting 22 years after total abdominal hysterectomy-bilateral salpingo-oophorectomy: a case report and review of the literature

Adenomyoma is a benign tumor composed of smooth muscle and benign endometrium. These tumors typically originate within the uterus. An extrauterine adenomyoma is a rare entity. We report a uterine-like mass consistent with an extrauterine adenomyoma presenting 22 years following a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The mass was pear-shaped with uterine-type smooth muscle and a cavity lined by functional endometrial glands and stroma. To our knowledge, only 4 other cases of an extrauterine uterine-like mass are reported in the literature. Three involved the ovary, while one was located adjacent to the broad ligament with normal pelvic organs. Although none of these other uterus-like masses were described as adenomyomas with uterine-like features, the histologic findings are strikingly similar. An understanding of the müllerian system suggests that either an embryologic malformation or a differential multipotentiality existing in the subcoelomic tissues in response to hormonal stimulation results in a supernumerary müllerian structure like a uterus, as observed in this case. The presence of endometrial glands and stroma in the mass confirms that the tissues in this mass are hormonally responsive. It is most likely that this uterine-like mass arose from the tissues of the secondary müllerian system in response to estrogenic stimulation.     

Adenomyoma of the jejunum

Adenomyoma of the small intestine is an extremely rare condition characterized by abnormal glandular structures surrounded by smooth muscle. We report a case of adenomyoma of the jejunum. The patient was a 61-year-old female with cancer of the sigmoid colon and multiple liver cysts, who was sent to the operation room for exploratory laparotomy and sigmoidectomy. At surgery, a polypoid lesion was incidentally found in the lower jejunum, which was resected. On histologic examination, the morphologic features were typical of adenomyoma. However, new histopathological and immunohistochemistry features are described here, providing evidence that adenomyoma of the jejunum is a form of intestinal epithelial hamartoma.     

Atypical polypoid adenomyoma of the uterus: A reappraisal of the clinicopathological and immunohistochemical features

Atypical polypoid adenomyoma (APAM) is an uncommon uterine mixed epithelial and mesenchymal tumor. The discrimination from endometrial carcinoma remains to be clarified. In this study, we compared the clinicopathological and immunohistochemical features between 36 APAMs and 48 endometrial carcinomas. APAM with a highly complex structure (n?=?13) coexisted with atypical hyperplasia (n?=?5) and endometrial carcinoma (n?=?1). Two patients had endometrial carcinomas at 1 and 102 months. Four patients recurred at 1–57 months but none died of disease. The fibromuscular stroma demonstrated 3 uncharacterized features: a broad bundle (10/36), a lobular structure separated by the stromal branches (26/36), and the extension of fibromuscular stroma underneath the surface epithelium (31/36). However, these features were not seen in endometrial carcinomas except the vaguely lobular pattern. Both APAM and endometrial carcinoma showed a similar immunostaining pattern except high Ki67 index in endometrial carcinomas (p?<?0.05). Our study suggests that the distinct features of the fibromuscular stroma can aid in the differential diagnosis between APAM and endometrial carcinoma.     

CD10 immunostaining distinguishes atypical polypoid adenomyofibroma (atypical polypoid adenomyoma) from endometrial carcinoma invading the myometrium

The major differential diagnostic problem presented by atypical polypoid adenomyofibroma (atypical polypoid adenomyoma) (APA), which usually affects young women, is the exclusion of well-differentiated endometrial carcinoma invading the myometrium. This distinction, however, is of great clinical importance from the standpoint of treatment because reproductive conservation is feasible for patients with APA. Recently, CD10, known to be a marker of endometrial stromal cells, was reported to be also expressed in cells immediately surrounding the neoplastic glands invading the myometrium [Am J Surg Pathol 27 (2003) 786-789; Mod Pathol 16(1) (2003) 22-27]. However, CD10 expression in the myofibromatous component of APA has not been previously examined in the literature. We therefore decided to examine whether the CD10-immunostaining pattern in APA is different from that in myoinvasive carcinoma. Furthermore, we also attempted to obtain any histopathologic findings that may offer some insight regarding the histogenesis of APA. Seven cases of APA were immunostained for CD10 using curettage or polypectomy specimens, in addition to hysterectomy specimens in 1 case. Areas with more fibrotic rather than muscular stroma were focally observed in 4 cases. The pattern of staining was compared with hysterectomy specimens taken from 19 cases in which well- to moderately differentiated endometrioid adenocarcinoma had deeply invaded the myometrium (outer two thirds of the myometrium) but was not associated with adenomyosis. In 6 of 7 cases of APA, CD10 was never expressed in the myofibromatous stromal components. In 1 case of APA, the fascicles of fibrotic and muscular mesenchymal cells in the interglandular areas were focally and weakly positive for CD10. All 19 myoinvasive carcinomas expressed CD10 to some extent in cells immediately surrounding the neoplastic myoinvasive glands (fringe-like staining pattern). The proportion of the myoinvasive nests immediately surrounded by CD10-positive mesenchymal cells was as follows: mean, 74%; median, 80%; minimum, 5%; maximum, 100%. The fringe-like CD10-staining pattern was not observed in APA. Furthermore, we identified a gradual transformation from preexisting endometrial stromal cells (CD10 positive) into the typical myofibromatous stromal component (CD10 negative) of APA in 1 case. In conclusion, this study demonstrated differences in the CD10 immunoreactivity or immunostaining pattern between the stromal components of APA and myoinvasive endometrial carcinoma. This difference should lead to a more accurate diagnosis of APA (pseudo-myoinvasive lesion). Furthermore, the histogenesis of APA may perhaps be explained by "myofibromatous metaplasia" of the endometrial stromal cells.     

Uterine endometrial stromal sarcoma with smooth muscle and glandular differentiation

This report describes a uterine tumour exhibiting areas of both endometrial stromal and smooth muscle differentiation. There was extensive intravascular permeation within the myometrium as well as extrauterine vascular involvement. The endometrial stromal component had a myxoid appearance and the smooth muscle component exhibited the typical features of intravenous leiomyomatosis. An additional feature was the presence of numerous benign endometrial-type glands within the neoplasm. In many areas a "zoning" phenomenon was present, with endometrial glands surrounded by endometrial stroma, which was in turn surrounded by smooth muscle. This unique combination of endometrial glands, endometrial stroma, and smooth muscle has, to the best of our knowledge, not been described previously and adds to the morphological spectrum of mixed endometrial stromal-smooth muscle tumours. This report discusses the differential diagnosis of this lesion, which has been designated a low grade endometrial stromal sarcoma with smooth muscle and glandular differentiation.     

A case of atypical polypoid adenomyoma with intramural myoma-like growth

We encountered a case of a large atypical polypoid adenomyoma (APA) which showed characteristic intramural appearance. As many cases of APA of the uterus have been reported in recent years, macro- and microscopic findings of the lesion and its clinical characteristics have been investigated. However the pathogenesis and the natural history of the lesion remained to be solved owing to still limited number of the cases. We report this case to discuss the macroscopic findings and clinicopathologic characteristics of the lesion.     

Mixed endometrial stromal and smooth muscle tumor: Report of a case with focal anaplasia and early postoperative lung metastasis

A rare case of a mixed endometrial stromal and smooth muscle tumor arising in the uterus of a 74‐year‐old woman is reported. The patient underwent hysterectomy for an enlarging uterine mass, and a large intramural tumor, showing marked central hyaline necrosis with calcification, was found. The tumor consisted of an admixture of a low‐grade endometrial stromal sarcoma (ESS) and a fascicular proliferation of spindle cells suggesting smooth muscle differentiation, and a characteristic ‘star‐burst’ appearance was found. In the ESS region, there were a few small foci of anaplasia where large polygonal cells with atypical nuclei and abundant eosinophilic cytoplasm proliferated, and the proliferative activity was locally increased in these foci. A small metastatic nodule appeared in the lung nine months after the hysterectomy, and the resected metastatic lesion showed features of anaplastic spindle cell sarcoma which was immunoreactive for CD10 but not for smooth muscle markers. Mixed endometrial stromal and smooth muscle tumors should be regarded as malignant neoplasms with the potential for hematogenous metastasis, particularly when they contain foci of cellular anaplasia.     

Polypoid uterine lesions mimicking endometrial stromal sarcoma

Two polypoid submucosal uterine lesions were examined histologically and immunohistochemically with monoclonal antibodies to desmin and alpha smooth muscle actin. One case comprised a leiomyoma and the other a polypoid form of adenomyosis. Both polyps had prolapsed through the external cervical os. The lesions had an ulcerated surface with focal areas of marked increased cellularity and pronounced vascularity throughout, such that they mimicked a low grade endometrial stromal sarcoma infiltrating the myometrium. The cellular areas showed diffuse positivity for desmin and alpha smooth muscle actin, confirming them to be of smooth muscle origin. The changes of marked hypercellularity and pronounced vascularity within polypoid submucosal uterine lesions have not been emphasised in published reports up to now. Pathologists should be aware of these morphological features in order to avoid misdiagnosis of such cases as endometrial stromal sarcomas. The changes described here are likely to be secondary to trauma associated with a polypoid lesion prolapsing through the external cervical os.     

Unsuspected endometrial pathology in the subfertile woman

Routine sampling of the endometrium is not considered necessary in the investigation of female infertility in the presence of normal menstruation. We present the cases of five women diagnosed with endometrial pathology during the course of fertility investigations. Three women had atypical polypoid adenomyoma, one had complex endometrial hyperplasia and one had stage 1 endometrial adenocarcinoma. Only the latter described any abnormality in menstruation. No woman had polycystic ovarian syndrome nor any other reason in her history to suspect endometrial pathology. Two women had abnormal transvaginal ultrasound findings. Atypical polypoid adenomyoma is frequently associated with subfertility. Although usually biologically benign, malignant transformation has been reported. With current trends of increasing obesity and later age at attempted conception, the possibility of discovering endometrial pathology during fertility investigation is likely to increase. We believe that a thorough menstrual history and careful assessment of the endometrium is warranted in all women with fertility problems. A transvaginal pelvic ultrasound should be performed in the follicular (early) phase of the cycle. If this ultrasound examination and the woman's menstrual history are both normal, no further evaluation of the endometrial cavity is routinely required. Sonohysterography is superior to pelvic ultrasound in detecting intracavitary pathology and is thus recommended prior to IVF treatment. Hysteroscopy is the gold standard in the detection of intrauterine pathology and is well tolerated in the office setting. Where abnormality is suspected or detected at screening, futher investigation and concomitant treatment is essential. This is ideally performed via hysteroscopy with endometrial sampling or excision of focally abnormal areas.     

Low-grade endometrial stromal sarcoma with intracardiac extension. Evolution of extensive smooth muscle differentiation and usefulness of immunohistochemistry for its recognition and distinction from intravenous leiomyomatosis.

This case, a rare example of low-grade endometrial stroma sarcoma with extensive smooth muscle differentiation which extended to the inferior vena cava and cardiac chambers closely resembling intravenous leiomyomatosis grossly and microscopically, illustrates the importance of extensive sectioning and the usefulness of immunohistochemistry. Although spindle cell components arranged in interlacing bundles consistent with smooth muscle differentiation were recognizable in the primary tumor (on retrospective review), extensive smooth muscle differentiation in the recurrent tumors masked prototypical morphologic features of stromal sarcoma and only small neoplastic stromal components were preserved in limited areas, leading to initial failure to distinguish the lesion from intravenous leiomyomatosis. The immunophenotyping disclosed two distinct cell populations in the tumor: i.e. vimentin-positive and smooth muscle marker negative stromal cells, and vimentin-negative spindle-shaped desmin-positive smooth muscle cells. Our observation suggests that the predominance of a smooth muscle component in such a tumor can be misleading and does not always warrant a diagnosis of intravenous leiomyomatosis, nor does it predict a benign clinical course. This case also provides an insight into the relationship of the endometrial stroma and myometrium, and their cell of origin and the histogenesis of endometrial stromal sarcoma.