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Year : 2011  |  Volume : 54  |  Issue : 2  |  Page : 402-404
Metastatic immature teratoma: A diagnostic challenge on fine-needle aspiration cytology

1 Department of Pathology, Kasturba Medical College and Hospital, Manipal University, Manipal, Karnataka, India
2 Department of Surgical Oncology, Kasturba Medical College and Hospital, Manipal University, Manipal, Karnataka, India

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Date of Web Publication27-May-2011

How to cite this article:
Monappa V, Valiathan M, Bhat SS, Ray S, Chidambaram C. Metastatic immature teratoma: A diagnostic challenge on fine-needle aspiration cytology. Indian J Pathol Microbiol 2011;54:402-4

How to cite this URL:
Monappa V, Valiathan M, Bhat SS, Ray S, Chidambaram C. Metastatic immature teratoma: A diagnostic challenge on fine-needle aspiration cytology. Indian J Pathol Microbiol [serial online] 2011 [cited 2020 Jul 16];54:402-4. Available from: http://www.ijpmonline.org/text.asp?2011/54/2/402/81632

A 20-year-old woman presented with complaints of abdominal distension, vomiting and weight loss of 1 month duration. Local examination showed a midline vertical scar from previous surgery, details of which were not available. A hard mass with well-defined borders, measuring 15 × 10 cm was seen in the lower abdomen. Computed tomography examination illustrated a large heterogeneously contrast-enhancing mass lesion with specks of calcification measuring 10.5 × 12.5 × 12.7 cms in the pelvis, posterior to the uterus closely abutting the bowel loops and the left ureter with evidence of peritoneal metastasis and spread to anterior abdominal wall. Ovaries were not seen separately from the mass. Clinicoradiologic suspicion was of malignant tumor, possibly arising from the ovary. CA 125 was 44 IU/mL.

Fine-needle aspiration cytology (FNAC) of the pelvic mass was performed and the smears were received in our laboratory. The smears were alcohol fixed and Papanicolaou stained. The smears were hypercellular and showed near uniform small cells with round to oval nucleus, high N:C ratio, uniform granular chromatin and inconspicuous nucleoli, scant cytoplasm arranged in singles, large aggregates and sheets with rosette-like pattern in a fibrillary background. Frequent mitosis, apoptotic bodies and streaks of nuclear material were seen. Swirling sheets and aggregates of spindle-shaped cells with hyperchromatic nucleus, monolayered sheets of bland-looking cuboidal cells with round nucleus, moderate amphophilic to clear cytoplasm and rare giant cells were seen in a hemorrhagic background with prominent endothelial cell fragments and bare nuclei.

A FNAC diagnosis of small round cell tumor, possibly small cell neuroendocrine carcinoma was offered.

Histopathologic examination of tumor following debulking surgery revealed grade 3, immature teratoma metastases from ovarian primary.

A retrospective review of the FNAC smears showed features consistent with immature teratoma: primitive neuroepithelial elements (small round cells), glial tissue (rosettes), primitive mesenchyme (swirling sheets of spindle cells), and root sheath elements (sheets of cuboidal cells). Also seen were scattered anucleate squames [Figure 1], [Figure 2], [Figure 3] and [Figure 4].
Figure 1: (a) Cellular smear shows small round cells with coarse chromatin arranged in singles and in rosettoid pattern (arrow) (Papanicolaou, ×400). (b) Corresponding histopathology image showing immature neural tissue (H and E, ×200)

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Figure 2: (a) Hypercellular smear shows swirling sheets and aggregates of spindle-shaped cells with hyperchromatic nucleus (Papanicolaou, ×200). (b) Histopathology section showing immature mesenchyme (H and E, ×400)

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Figure 3: (a) Smear shows large cells with fine granular chromatin, inconspicuous cytoplasm arranged in rosettes in a fibrillary background (Papanicolaou, ×200). (b) Histopathology image showing glial tissue (H and E, ×200)

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Figure 4: (a) Smear shows monolayered sheets of bland-looking cuboidal cells (Papanicolaou, ×400). (b) Histopathology section shows longitudinal section of hair follicle with thick external root sheath (H and E, ×400)

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   Discussion Top

Immature teratomas (IMT) of the ovary, like mature teratomas are composed of tissues derived from all the three germ cell layers with variable admixture of mature and immature elements. FNAC is not a very well accepted means for diagnosing ovarian neoplasms. Yet its role in diagnosing metastatic tumors is well received. A review of the literature reveals random reports and infrequent studies regarding the same.

The various cytologic features of IMT described in the literature include cellular smears, small round cells with coarse chromatin, rosettes, neuropil/glia, and primitive mesenchyme. Less common findings include giant cells, bare nuclei, and squamous and glandular elements. [1],[2],[3] Additional findings in our case included the presence of numerous apoptotic bodies, mitosis, streaks of nuclear material, and endothelial cell fragments. Streaks of nuclear material, is a smearing artifact, also described in small cell (neuroendocrine) carcinoma. This further contributed to the diagnostic indecisiveness.

Also seen were sheets of benign cuboidal cells (hair follicle), not previously described in the literature. Considering the fact that IMT is composed of a mixture of mature and immature elements, this finding highlights the importance of acknowledging the possible admixture of benign-looking elements in an aspirate from IMT.

In cases where a definitive diagnosis is not possible, classifying the tumor as small round cell tumor is reasonable. However, as observed in our case, a thorough search for the diverse components, such as the mesenchyme, glandular elements and glia, is of prime importance for accurate cytologic diagnosis.

Our case was initially considered as small round cell tumor. Small round cells or undifferentiated cells can be seen in a broad spectrum of malignant tumors. The various differential diagnosis for IMT described in the literature include primitive neuroectodermal tumor, neuroblastoma, Wilm's tumor, desmoplastic small round cell tumor, small cell carcinoma, hypercalcemic type, and non-Hodgkin's lymphoma and are illustrated in [Table 1].
Table 1: Differential diagnoses of IMT on cytology[4],[5]

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To conclude, the awareness of the varied cytomorphology of IMT, the possible admixture of benign elements and undifferentiated small round cells, and more importantly the comprehension to exclude its cytologic mimics holds the key in arriving at the right diagnosis.

   Acknowledgment Top

We would like to acknowledge N Ganesh Prasad, Artist, Department of Pathology, KMC, Manipal, India, for the help rendered in compiling the photographs. [5]

   References Top

1.Ramalingam P, Teague D, Nicholson MR. Imprint cytology of high grade immature ovarian teratoma. Diagn Cytopathol 2008;36:595-9.  Back to cited text no. 1
2.Kamiya M, Tateyama H, Fujiyoshi Y, Tada T, Eimoto T, Shibata H, et al. Cerebrospinal fluid cytology in immature teratoma of the central nervous system: A case report. Acta Cytol 1991;35:757-60.  Back to cited text no. 2
3.Motoyama T, Yamamoto O, Iwamoto H, Watanabe H. Fine needle aspiration cytology of primary mediastinal germ cell tumors. Acta Cytol 1995;39:725-32.  Back to cited text no. 3
4.Sahu K, Pai RR, Khadilkar UN. Fine needle aspiration cytology of Ewing's sarcoma family of tumors. Acta Cytol 2000;44:332-6.  Back to cited text no. 4
5.Akhtar M, Iqbal MA, Maurad W, Ali MA. Fine needle aspiration biopsy of small round cell tumors of childhood: A comprehensive approach. Diagn Cytopathol 1999;21:81-91.  Back to cited text no. 5

Correspondence Address:
Vidya Monappa
Department of Pathology, Kasturba Medical College, Manipal University, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.81632

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

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