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  Table of Contents    
CASE REPORT  
Year : 2016  |  Volume : 59  |  Issue : 4  |  Page : 530-531
Minimal deviation adenocarcinoma of endometrium: A rare entity in a 72-year-old female


1 Department of Pathology, Government Medical College, Kottayam, Kerala, India
2 Department of Pathology, DDRC, Kottayam, Kerala, India

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Date of Web Publication10-Oct-2016
 

   Abstract 

Minimal deviation adenocarcinoma (MDA) of endometrium is considered a differentiated state of endometrioid adenocarcinoma. It is a low-grade tumor associated with areas histologically typical of endometrioid adenocarcinoma in the majority of the cases. Due to deceptively benign microscopy, MDA may be overlooked leading to incorrect assessment of tumor extend and staging.

Keywords: Adenocarcinoma, endometrium, minimal deviation

How to cite this article:
Renu T, Siji M, Shilpa N, Vijayalakhmi A. Minimal deviation adenocarcinoma of endometrium: A rare entity in a 72-year-old female. Indian J Pathol Microbiol 2016;59:530-1

How to cite this URL:
Renu T, Siji M, Shilpa N, Vijayalakhmi A. Minimal deviation adenocarcinoma of endometrium: A rare entity in a 72-year-old female. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Dec 5];59:530-1. Available from: http://www.ijpmonline.org/text.asp?2016/59/4/530/191817



   Introduction Top


Minimal deviation adenocarcinoma is a well described entity in cervix. Other sites including endometrium, though rare are reported in literature. MDA of endometrium is a low grade tumor associated with areas of typical endometrioid adenocarcinoma in majority of the cases.


   Case Report Top


A 72-year-old female patient presented with vaginal discharge. Pap smear was negative for intraepithelial lesion or malignancy. Radiological findings were negative for malignancy, and she underwent a vaginal hysterectomy. Gross examination showed uterus measuring 7 cm 4 cm 3 cm with elongated cervix. On cut section, endometrium was 1-2 mm thick and myometrium eccentrically thickened and trabeculated [Figure 1]a. Microscopy showed focal in situ adenocarcinomatous areas in the endometrium [Figure 1]b. There was a lesion composed of proliferating closely packed glands with minimal atypia, dissecting through the smooth muscle fibers without stromal, and inflammatory response [Figure 1]c and d. Mitosis was rare. Cribriform pattern, branching, and back to back arrangement of glands characteristic of endometrioid carcinoma were absent. Cervix showed chronic cervicitis and was free of the tumor. Due to the relatively bland histology and the paucity of mitotic figures, a possibility of adenomyoma was considered. However, the lesion lacked circumscription, and there was an in situ adenocarcinomatous area in the endometrium which prompted a further detailed examination and literature search. The"adenoma malignum" like appearance as in our case is reported in literature and so we proceeded with immunohistochemical (IHC) markers. Ki-67 labeling showed low proliferative index in the tumor cells [Figure 1]f. CD10, which is a marker for nonneoplastic as well as neoplastic endometrial stroma, was also done in this case. It turned out to be negative, indicating the absence of endometrial stroma and thus we excluded adenomyoma from the differential diagnosis [Figure 1]e. Hence, the final diagnosis given was adenocarcinoma endometrium with minimal deviation like pattern.
Figure 1: (a) Gross specimen of the uterus with eccentrically thickened myometrium. (b) Endometrium showing in situ adenocarcinomatous area and the tumor (H and E, ×200). (c) Neoplastic cells arranged in glandular pattern permeating through the myometrium without desmoplastic response (H and E, ×200). (d) Neoplastic glands show minimal atypia and no desmoplastic reaction (H and E, ×400). (e) IHC show negative CD 10 (×400) and (f) low Ki-67 labeling index (×400)

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   Discussion Top


Minimal deviation adenocarcinoma (MDA) was originally reported in the uterine cervix, characterized by infiltrative glands with mild nuclear atypia, and absent to minimal desmoplastic stromal reaction. [1],[2] There are only a few reports of endometrioid adenocarcinomas showing this pattern. Other rare sites were adenocarcinoma with MDA like pattern are described include gall bladder and urinary bladder. [3] Preoperative radiological examinations such as ultrasound computed tomography, and magnetic resonance imaging may not identify the diffuse pattern of infiltrative tumor. [4] Endometrioid adenocarcinoma shows cribriform or back-to-back arrangement of neoplastic glands. It rarely shows a diffusely infiltrative growth pattern as seen in cases of MDA of the uterine cervix. The diagnostic features of MDA include enlarged uterus with thickened and gray-white firm myometrium, scattered infiltrative glands with mild nuclear atypia, absent to minimal desmoplastic reaction, and rare mitotic figures. MDA of endometrioid type more often develops as a result of differentiation from typical endometrioid adenocarcinoma rather than de novo. [1],[5] Pure cases are very rare. The proportion of MDA varied from <10% to >90%. [1] In our case, the predominant pattern was MDA with in situ adenocarcinoma and areas of typical endometrioid adenocarcinoma were not identified. The studies have shown that endometrioid adenocarcinoma with prominent MDA pattern frequently invades the cervix. [1] When there is endocervical involvement, a possibility of the second primary should be excluded from the study.

The histological diagnosis of MDA is often challenging because of low stromal reaction, simple tubular structures, and subtle nuclear changes. The low proliferative index in MDA correlates with the lack of p53 immunoreactivity. [1] In our case, p53 was not done due to the unavailability of the IHC marker. The treatment of endometrioid adenocarcinoma with MDA like pattern is similar to the typical adenocarcinoma as per International Federation of Gynecology and Obstetric stage. [2] It should be kept in mind that the bland histological appearance of the tumor may mask the degree of infiltration and therefore erroneously appear as lower stage disease. There are reports where this tumor has behaved aggressively.

This case is reported to highlight the deceptively benign gross and microscopic appearance of MDA, which may be overlooked or misinterpreted as adenomyosis and may lead to incorrect assessment of tumor depth and pathological stage. [1],[2]

Acknowledgment

I would like to thank Prof. Francisco Nogales, University of Granada, Spain for the help in diagnosis and providing the IHC studies required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Landry D, Mai KT, Senterman MK, Perkins DG, Yazdi HM, Veinot JP, et al. Endometrioid adenocarcinoma of the uterus with a minimal deviation invasive pattern. Histopathology 2003;42:77-82.  Back to cited text no. 1
[PUBMED]    
2.
Abiko K, Baba T, Ogawa M, Mikami Y, Koyama T, Mandai M, et al. Minimal deviation mucinous adenocarcinoma ('adenoma malignum') of the uterine corpus. Pathol Int 2010;60:42-7.  Back to cited text no. 2
[PUBMED]    
3.
Kanomata N, Muramaki M. Well-differentiated adenocarcinoma of the urinary bladder with minimal deviation adenocarcinoma-like features. J Cytol Histol 2013;4:189.  Back to cited text no. 3
    
4.
Nakao Y, Yamasaki F, Yokoyama M, Aihara S, Yasunaga M, Iwasaka T. Minimal deviation endometrioid adenocarcinoma of the endometrium and its MRI findings. Eur J Gynaecol Oncol 2014;35:185-7.  Back to cited text no. 4
[PUBMED]    
5.
Ioffe OB. Recent developments and selected diagnostic problems in carcinomas of the endometrium. Am J Clin Pathol 2005;124 Suppl 1:S42-51.  Back to cited text no. 5
    

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Correspondence Address:
Thambi Renu
Department of Pathology, Government Medical College, Kottayam, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.191817

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