Endometrioid adenocarcinoma of the vagina with a microglandular pattern arising from endometriosis after hysterectomy

Primary endometrioid adenocarcinoma rarely occurs in the vagina. Occasionally, endometrioid adenocarcinoma has a microglandular pattern. Herein, a case of primary endometrioid adenocarcinoma of the vagina with a microglandular pattern arising from pre‐existing endometriosis long after a hysterectomy, is described. A 57‐year‐old postmenopausal woman developed a vaginal discharge over one decade after undergoing a hysterectomy. Microscopic examination of the vaginal smear and a biopsy specimen demonstrated an atypical glandular proliferation composed of columnar cells with occasional intracytoplasmic mucin and bland nuclear morphology, showing microcysts and numerous neutrophils within and around cysts. Immunohistochemically, the neoplastic cells were diffusely positive for CK7, MUC1, ER, and PR, and focally positive for vimentin, CEA, CK5/6, p63, p16^INK4a, and p53. A portion of residual endometrioid adenocarcinoma was identified adjacent to foci of endometriosis in the vaginectomy specimen. The patient has done well without evidence of recurrent disease for 1 year after surgery. Pathologists are encouraged to be aware of the occurrence of endometrioid adenocarcinoma associated with endometriosis in the vaginal stump after hysterectomy, and microglandular morphology which might be a source of misinterpretation.     

Primary endometrioid adenocarcinoma of the large intestine arising in colorectal endometriosis

AIMS: Three cases of endometrioid adenocarcinoma arising in colorectal endometriosis are described with discussion of their macroscopic and microscopic pathology and diagnosis, using immunohistochemistry. METHODS AND RESULTS: Three middle-aged women presented with symptoms and signs of colorectal mass effect. Two had a preceding history of gynaecological endometriosis and all three had either been on hormone replacement therapy or had functioning ovaries prior to presentation with colorectal disease. Each underwent resection of tumours of the distal large intestine. The definitive diagnosis was dependent on histological examination and immunohistochemistry, which was used to demonstrate an origin in endometriotic tissue. CONCLUSIONS: Endometrioid adenocarcinoma is a rare complication of colorectal endometriosis, this report contributing to a total of 25 cases in the literature. Definitive diagnosis, aided by immunohistochemical studies, is important to enable the identification of the optimal management for this uncommon condition.     

Ovarian atypical endometriosis: its close association with malignant epithelial tumours

The incidence of ovarian atypical endometriosis and its association with malignant epithelial tumours in a consecutive series of cases during the period 1987 to 1995 were studied. Atypical glandular changes were observed in four (1.7%) of 255 ovarian endometriosis cases and one patient with ovarian atypical endometriosis developed subsequent endometrioid carcinoma in the abdominal wall. Fifty-four (24.1%) of the 224 ovarian cancers were associated with ovarian endometriosis; 21 with typical and 33 with atypical endometriosis. Clear cell carcinomas and endometrioid carcinomas were most frequently associated with endometriosis, with 54% (27 of 50 cases) and 41.9% (13 of 31), respectively. Atypical endometriosis was found in 18 clear cell carcinomas, in seven endometrioid carcinomas, in four serous carcinomas, in three mucinous borderline tumours, and in one serous borderline tumour. In 13 cases, the atypical endometriosis was in contiguity with malignant epithelial tumours. We consider that atypical endometriosis possesses a precancerous potential or is most frequently associated with clear cell and endometrioid carcinomas. Close screening of cellular atypia or hyperplasia in ovarian endometriosis and careful long-term follow-up of patients with atypical endometriosis is required.     

Papanicolaou tests associated with cervical mucosal endometriosis: An analysis of cellular features and comparison to endocervical adenocarcinoma in situ

Endometrium directly sampled from endocervical mucosal endometriosis can mimic endocervical adenocarcinoma in situ (AIS) in Papanicolaou (Pap) tests. We analyzed a series of Pap tests to investigate the cellular features of mucosal endometriosis and to assess the utility of stroma and apoptotic bodies in the differential diagnosis with AIS. Pap test samples from patients known to have endocervical mucosal endometriosis were compared with samples containing AIS. Pap tests from patients with mucosal endometriosis had lesional cells in 13 (62%) cases which includes glandular and stromal cells (10 cases), stroma only (two cases), and glandular cells only (one case). Three (23%) cases had gland‐stromal aggregates. Three (23%) cases had mitotic figures and two (15%) had apoptotic bodies. By comparison, only one (8%) AIS case had endometrial‐type stroma. Seven (58%) AIS cases had apoptotic bodies and three (25%) had mitotic figures. We conclude that Pap tests from patients with mucosal endometriosis usually (62%) have lesional cells. These lesional cells almost always include stroma, which is useful in the differential diagnosis with AIS. We identified stroma significantly more often in endometriosis cases (92%) than in AIS cases (8%). Pathologists should look for endometrial stroma when considering an interpretation of directly sampled endometrium. In the absence of stroma, AIS should be considered. Diagn. Cytopathol. 2010;38:551–554. 2009 Wiley‐Liss, Inc.     

No evidence of endometriosis within serous and mucinous tumors of the ovary

Ovarian endometriosis can transform into malignant tumors. The author retrospectively examined HE slides of 112 serous tumors and 75 mucinous tumors for the existence of ovarian endometriosis. When endometriosis is present within the tumors, the term "endometriosis-derived tumor" was applied. When endometriosis is recognized adjacent to the tumor, the term "endometriosis-associated tumor" was used. Of the 112 serous tumors (46 benign, 18 borderline, and 50 malignant), 4 (3.5%) (2 benign and 2 malignant) were endometriosis-associated tumors. None was endometriosis-derived tumor. Of the 75 mucinous tumors (30 benign, 26 borderline, and 19 malignant), 4 (5%) (1 borderline and 3 benign) were endometriosis-associated tumors. No tumors showed endometriosis-derived tumors. The data suggest that endometriosis does not transform into serous and mucous tumors. The author felt the limitation of retrospective survey, because the limited numbers of slides (5 to 15) were obtained from each tumor. The author also felt that endometriosis can be difficult to discern because of degenerative changes and other similar lesions such as fallopian tube, fimbria, inclusion cysts, rete ovarii, paraovarian cyst, and Müllerian ducts remnants. Prospective study using whole ovarian examination is required.     

Rectal mucosal endometriosis primarily misinterpreted as adenocarcinoma: a case report and review of literature

Endometriosis involving intestinal mucosa is relatively uncommon. It poses a diagnostic challenge for clinicians and pathologists. We herein report a case of colonoscopic specimen revealing rectal mucosal endometriosis. A 39-year-old woman complained of red rectal bleeding and intermittent abdominal pain. Colonoscopic examination showed a rectal mass with ulceration and circum wall involvement. Biopsy was processed in the suspicious of carcinoma. Morphologically, irregular glands replaced residual colorectal ones, displayed mucin depletion, nuclear stratification and subtile subnuclear vacuoles. The stroma was full of spindle cells with abundant pink cytoplasm and unclear boundary. Due to subjectively interpreting as dysplastic glands in desmoplastic setting, primary rectal adenocarcinoma was firstly raised. Immunohistochemically, CK7, ER and CD10 identified the essence of ectopic endometrium. CK20 and CDX2 highlighted residual glands. In case of misdiagnosis, any pathologists should be aware of intestinal endometriosis for each female’s colorectal biopsy, especially for that morphology not typical for primary adenocarcinoma or endometriosis. Reading slides carefully combined with a panel of immunomarkers would solve the pitfall.     

Cytological features of atypical carcinoid combined with adenocarcinoma of the uterine cervix

Neuroendocrine tumors of the uterine cervix (UC) are rare, and atypical carcinoid (AC) combined with adenocarcinoma of the uterine cervix (ACAUC) is particularly rare. Only the histopathology has been investigated in the English literature. A 49-year-old female with a polypoid lesion of the UC visited Yamanashi Prefectural Central Hospital. Scraping cytology, biopsy, and hysterectomy was performed. EC smears showed solid, rosette, honeycomb,true tubular, and trabecular clusters. Solid clusters were oval, thin-edge, delicate, small-large nuclei, pale, granular, scant, nothing,and well-preserved (though ill-defined border) cytoplasm. Rosette clusters were eccentric, oval nuclei, mixture of coarsely granular chromatin and euchromatin, and cyanophilic luminal content. Solid and rosette clusters impress AC. Honeycomb clusters involved a clearly defined border and translucent mucin. True tubular clusters were oval nuclei of fine chromatin or euchromatin, thick cytoplasm,and orange luminal content. Honeycomb and true tubular clusters suspected adenocarcinoma. Trabecular clusters were fusiform, columnar, cuboidal, and polygonal cell shapes of small,monotonous nuclei, and contained coarsely granular chromatin with occasionally intracytoplasmic translucent mucin and were difficult to differentiate typical carcinoid and adenocarcinoma.Histology was AC combined with adenocarcinoma. The aim of this study was to investigate the cytological characteristics of ACAUC.     

Endometrioid adenocarcinoma arising from adenomyosis: report and immunohistochemical analysis of an unusual case

A case of endometrioid adenocarcinoma arising from adenomyosis is reported. The patient was a 53-year-old woman who complained of vulvar itching. Smear cytology of the endometrium revealed adenocarcinoma. Magnetic resonance imaging of the pelvis revealed a lesion with a slightly high intensity in the uterine fundus on a T2-weighted image. Semiradical total hysterectomy and bilateral adnexectomy were performed, followed by chemotherapy. Histologically, the lesion in the uterine fundus was composed mostly of adenocarcinoma with stromal invasion. There were many adenomyotic foci in and around the carcinoma, including some showing transition to adenocarcinoma. There was no malignant finding in the normally situated endometrium. The carcinoma invaded in the myometrium, involving the uterine serosa, but no dissemination to the peritoneal cavity was found. The carcinoma was, therefore, considered to be endometrioid adenocarcinoma arising from adenomyosis. Immunohistochemistry showed expression of p53 oncoprotein and Ki-67 antigen in the carcinoma cells. The value of immunohistochemistry in predicting prognosis is discussed.     

Intestinal adenocarcinoma arising in a mature cystic teratoma of the ovary: a case report

Gastrointestinal adenocarcinoma arising in mature cystic teratomas of the ovary is extremely rare. We report a case of well-differentiated intestinal adenocarcinoma arising in a mature cystic teratoma of the ovary in a 77-year-old woman, presenting as acute abdomen with ovarian torsion. An immunohistochemical study revealed expression of CK20 and CK7, and the tumor was also positive for MUC2. The patient had no evidence of disease after 12 months of follow-up.     

Endometrioid carcinoma arising in pericecal endometriosis clinically mimicking Crohn's disease

A case of endometrioid carcinoma arising in pericecal endometriosis that clinically and radiologically mimicked Crohn's disease is presented. After developing several complications of steroid therapy for presumed Crohn's disease, a 48-year-old woman developed intestinal obstruction and underwent a right hemicolectomy. A pericecal mass composed of endometriosis and endometrioid carcinoma and a locally metastatic ileal carcinoid tumor were resected. The patient recovered fully and is clinically free of tumor at 36 months. The pertinent literature is reviewed and the etiologic, therapeutic, and prognostic implications of this case are discussed.     

Primary sex cord‐like variant of endometrioid adenocarcinoma arising from endometriosis

Endometriosis, a relatively common disease generally affecting women in the reproductive age group, is mostly found in the pelvic organs. Although endometriosis is a benign disease, some malignant tumors have been reported to develop in endometriotic lesions, most commonly in the ovary. The relationship between endometriosis and malignancy is not well known, but the majority of endometriosis‐associated ovarian malignancies are usually endometrioid adenocarcinomas and clear cell carcinomas. The sex cord‐like variant of endometrioid adenocarcinoma is a rare tumor that histologically closely resembles the sex cord‐stromal tumor. Despite its rarity, the correct histological diagnosis of the sex cord‐like variant of endometrioid adenocarcinoma is crucial to avoid misdiagnosis of a less aggressive tumor. We here report a 53‐year‐old woman who was diagnosed as having this very rare subtype of endometroid adenocarcinoma curiously arising from an endometriotic lesion at the site of previous salpingo‐oophorectomy. The tumor was diagnosed based on light microscopy and immunohistochemistry.     

Pleiotropic roles of melatonin in endometriosis,recurrent spontaneous abortion,and polycystic ovary syndrome

Melatonin is a neurohormone synthesized from the aromatic amino acid tryptophan mainly by the pineal gland of mammals. Melatonin acts as a broad‐spectrum antioxidant, powerful free radical scavenger, anti‐inflammatory agent, anticarcinogenic factor, sleep inducer and regulator of the circadian rhythm, and potential immunoregulator. Melatonin and reproductive system are interrelated under both physiological and pathological conditions. Oxidative stress, inflammation, and immune dysregulation are associated with the pathogenesis of the female reproductive system which causes endometriosis (EMS), recurrent spontaneous abortion (RSA), and polycystic ovary syndrome (PCOS). Accumulating studies have indicated that melatonin plays pleiotropic and essential roles in these obstetrical and gynecological disorders and would be a candidate therapeutic drug to regulate inflammation and immune function and protect special cells or organs. Here, we systematically review the pleiotropic roles of melatonin in EMS, RSA, and PCOS to explore its pathological implications and treatment potential.     

Endometrioid adenocarcinoma of the uterus with a minimal deviation invasive pattern

AIMS: Minimal deviation adenocarcinoma of endometrioid type is a rare pathological entity. We describe a variant of typical endometrioid adenocarcinoma associated with minimal deviation adenocarcinoma of endometrioid type. METHODS AND RESULTS: One 'pilot' case of minimal deviation adenocarcinoma of endometrioid type associated with typical endometrioid adenocarcinoma was encountered at our institution in 2001. A second case of same type was received in consultation. We reviewed 168 consecutive hysterectomy specimens diagnosed with 'endometrioid adenocarcinoma' specifically to identify areas of minimal deviation adenocarcinoma of endometrioid type. Immunohistochemistry was done with the following antibodies: MIB1, p53, oestrogen receptor (ER), progesterone receptor (PR), cytokeratin 7 (CK7), cytokeratin 20 (CK20), carcinoembryonic antigen (CEA), and vimentin (VIM). Four additional cases of minimal deviation adenocarcinoma of endometrioid type were identified. All six cases of minimal deviation adenocarcinoma of endometrioid type were associated with superficial endometrioid adenocarcinoma. In two cases with a large amount of minimal deviation adenocarcinoma of endometrioid type, the cervix was involved. The immunoprofile of two representative cases was ER+, PR+, CK7+, CK20-, CEA-, VIM+. MIB1 immunostaining of four cases revealed little proliferative activity of the minimal deviation adenocarcinoma of endometrioid type glandular cells (0-1%) compared with the associated 'typical' endometrioid adenocarcinoma (20-30%). The same four cases showed no p53 immunostaining in minimal deviation adenocarcinoma of endometrioid type compared with a range of positive staining in the associated endometrioid adenocarcinoma. CONCLUSIONS: Minimal deviation adenocarcinoma of endometrioid type more often develops as a result of differentiation from typical endometrioid adenocarcinoma than de novo. Due to its deceptively benign microscopic appearance, minimal deviation adenocarcinoma of endometrioid type may be overlooked and may lead to incorrect assessment of tumour depth and pathological stage. There was a tendency for tumour with a large amount of minimal deviation adenocarcinoma of endometrioid type to invade the cervix.     

Endometrioid carcinoma arising from endometriosis of the sigmoid colon: A case report

A case of endometrioid carcinoma arising from endometriosis of the sigmoid colon is reported. The histogenesis of the endometriosis in this patient was thought to be artificial secondary implantation of the endometrial tissue into the invaded wall of the sigmoid colon from the ovarian endometriosis during an operative procedure.     

KRAS mutations in ovarian low-grade endometrioid adenocarcinoma: association with concurrent endometriosis

The association between ovarian endometrioid adenocarcinoma and endometriosis is well established. However, not all endometrioid adenocarcinomas are directly related to endometriosis, and it has been suggested that there may be clinicopathologic differences between endometriosis-positive and endometriosis-negative tumors. Molecular alterations in endometrioid adenocarcinoma include KRAS and BRAF mutations, but the incidence of these abnormalities in previous reports has been highly variable (0%-36% and 0%-24%, respectively). This may be explained by relatively small sample sizes in earlier studies but could also reflect difficulties in accurately classifying high-grade ovarian malignancies. In the current study, we investigated KRAS and BRAF mutations in 78 low-grade (FIGO grade 1 and 2) endometrioid adenocarcinomas and compared the results with the presence of endometriosis in the tumor-associated ovary and/or in other pelvic sites. KRAS mutations were identified in 12 (29%) of 42 endometriosis-associated endometrioid adenocarcinomas with satisfactory analysis but in only 1 (3%) of 29 tumors in which endometriosis was not identified. BRAF mutation was identified only in a single endometriosis-associated case. These findings support the hypothesis that endometriosis-associated and independent endometrioid adenocarcinoma may develop via different molecular pathways and that KRAS mutations have an important role only in the former tumors. In contrast, BRAF mutations do not appear to have a significant role in either endometrioid adenocarcinoma subgroup. This may be relevant to future targeted therapies in patients with high-stage or recurrent disease and indicate that histopathologists should carefully examine endometrioid adenocarcinoma specimens, including nonneoplastic tissues, for the presence of endometriosis.     

Smooth muscle metaplasia in ovarian endometriosis

AIMS: Little is known about smooth muscle metaplasia (SMM) in ovarian endometriosis. The clinicopathological significance of SMM in ovarian endometriosis is analysed. METHODS AND RESULTS: Three hundred and twenty-seven consecutive cases of ovarian endometriosis, including 58 cases associated with malignant ovarian epithelial tumour, between 1987 and 1996 were retrieved from hospital files and clinicopathologically analysed. The ages of the patients who showed SMM in ovarian endometriosis ranged from 28 to 70 years (average, 43. 8 years). SMM was observed in 58 cases (17.7%); in 51 of 269 cases without tumour (19.0%) and in seven of 58 with tumour (12.1%). The differences in the incidence of SMM in cases with and without tumour were not statistically significant. SMM was a focal, microscopic change and there was neither smooth muscle tumour nor uterus-like mass. Sixteen cases had short fascicles or stellate foci of SMM in the endometriotic stroma, an incomplete rim of SMM surrounding the endometriotic cysts was present in 32 cases, and 10 cases showed SMM in both the endometriotic stromal and incomplete rim of the endometriotic cysts. There was no significant histological difference in SMM between cases with and without malignant ovarian epithelial tumour. CONCLUSIONS: SMM in ovarian endometriosis is not an uncommon phenomenon. SMM may be explained in two ways. First, smooth muscle originates from metaplastic endometrial stromal cells in endometriotic foci. Second, it originates from metaplastic ovarian stromal cells in the rim of endometriosis.     

Combined tubular adenocarcinoma and hepatoid adenocarcinoma arising in Barrett esophagus

Hepatoid adenocarcinoma arising in the esophagus is extremely rare. To date, there are only 3 cases in the world English literature. We report the fourth case here. A 76-year-old Japanese man was admitted to our hospital because of the deterioration of nephritic syndrome. He presented with chest burn, and the endoscopic examination of upper digestive tract disclosed the tumor in the lower esophagus. The subtotal esophagectomy was undertaken because of esophageal cancer. The postoperative histologic examination showed the finding of combined tubular adenocarcinoma and hepatoid adenocarcinoma arising in Barrett esophagus. Immunohistochemically, hepatoid adenocarcinoma cells were positive for a-fetoprotein, hepatocyte, a1-antitrypsin, a1-antichymotrypsin, and CDX2, but negative for MUC5AC and MUC6. Esophageal hepatoid adenocarcinoma seems to be closely associated with Barrett esophagus and show the intestinal phenotype rather than gastric phenotype.     

Squamous cell carcinoma arising in endometriosis of the ovary.

Squamous cell carcinoma arising in ovarian endometriosis is extremely rare, but a case is reported in a 62 year old woman. If such an ovarian tumour is discovered evidence of teratoma, Brenner tumour, or endometriosis should be sought. Extensive sampling is mandatory as the developing tumour often overgrows the foci of endometriosis, thus obliterating evidence of its origin.