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Year : 2017  |  Volume : 60  |  Issue : 4  |  Page : 620-621
Polypoid adenosarcoma of uterus with chondroid differentiation: A rare diagnosis


Department of Pathology, University College of Medical Sciences, New Delhi, India

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Date of Web Publication12-Jan-2018
 

How to cite this article:
Tanveer N. Polypoid adenosarcoma of uterus with chondroid differentiation: A rare diagnosis. Indian J Pathol Microbiol 2017;60:620-1

How to cite this URL:
Tanveer N. Polypoid adenosarcoma of uterus with chondroid differentiation: A rare diagnosis. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Nov 14];60:620-1. Available from: http://www.ijpmonline.org/text.asp?2017/60/4/620/222986




A 40-year-old previously healthy woman P2L2 presented to the gynecology outpatient department with a 6-month history of bleeding per vaginum and dull aching pain abdomen. She was a known case of type II diabetes mellitus and hypothyroidism and was on regular medications for these conditions. Her general physical examination was unremarkable except for mild pallor. Her routine laboratory investigations were within normal limits except for hemoglobin of 11.2 g%. A hysteroscopic examination revealed an endometrial polyp measuring about 6 cm in maximum dimension, and polypectomy was performed.

On gross examination, the polyp was 6.0 cm × 4.2 cm × 2.4 cm in size with few small cystic spaces. Few myxoid areas were also identified. Areas of hemorrhage were seen; however, no necrosis was noted. Histopathologic examination of the polyp showed cystically dilated glands with an unusually cellular stroma [Figure 1]a and [Figure 1]b. There was periglandular accentuation of the stroma with focal chondroid and skeletal muscle differentiation [Figure 2]d. There was moderate stromal atypia with mitosis (>2 per 10 high-power fields in the periglandular areas) [Figure 2]a,[Figure 2]b,[Figure 2]c. The sarcoma component did not comprise >25% of the tumor. Hence, a diagnosis of polypoid Mullerian adenosarcoma with chondroid differentiation without sarcomatous overgrowth was made.
Figure 1: (a) Gross photograph of the endometrial polyp measuring 6 cm in maximum dimension. (b) Highly cellular stroma with periglandular accentuation (H and E, ×10)

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Figure 2: Periglandular stroma showing moderate atypia (H and E, ×20) (a) and mitotic figures (H and E, ×40) (b). The epithelial lining is benign (H and E, ×20) (c). Foci of chondroid differentiation and skeletal muscle differentiation are noted (H and E, ×10) (d)

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Computed tomography scan performed after the surgery showed bulky uterus with heterogeneously enhancing soft-tissue lesion arising from posterior myometrium and projecting submucosally and extending to the endometrial canal. No significant lymphadenopathy was reported.

The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph node sampling. The uterus and cervix with bilateral fallopian tubes and ovaries measured 11.5 cm × 9 cm × 4.5 cm. Residual tumor measuring 4 cm × 3 cm × 2.2 cm was identified invading less than half of the myometrial wall. Bilateral fallopian tubes and ovaries were within normal limits.

Histopathology revealed Mullerian adenosarcoma invading <50% of the uterine wall thickness, and the single left external iliac lymph node sampled was free of tumor. No stromal overgrowth or lymphovascular invasion was identified. The final diagnosis of Mullerian adenosarcoma uterine corpus, pT1bN0, was given. She was put on regular follow-up and was disease free at 6 months' postsurgery.

Mullerian adenosarcoma is a rare malignant biphasic tumor composed of benign epithelial component and malignant albeit low-grade stromal component. The incidence of this tumor is highest in the perimenopausal and postmenopausal age group though no age group is exempt. A large proportion of patients are asymptomatic; however, patients may present with bleeding per vaginum or pelvic pain.[1] Uterine corpus is the most common site and other sites include cervix, fallopian tubes, ovary, vagina, and outside the female genital tract from preexisting endometriosis. The architectural patterns include a phyllode-like pattern and a rigid cyst-like pattern. The rigid cyst-like pattern as seen in our case shows large dilated cysts lined by benign epithelium and surrounded tightly by malignant stroma. Periglandular cuffing of the stromal cells is characteristic and is appreciated on low-power microscopic examination.[1],[2] The epithelial component is usually endometrioid and may demonstrate squamous or mucinous metaplasia. Mitotic figures (2 per 10 high-power fields) are a must for diagnosis. Atypical mitosis is only seen in areas of sarcomatous overgrowth. Heterologous differentiation in the form of skeletal muscle, fat, cartilage, and sex cord differentiation may be seen in 10%–15% of the cases.

Benign endometrial polyps can focally show some of the features of Mullerian adenosarcoma. These polyps have been designated as atypical endometrial polyps or endometrial polyps with atypical features. The key point to note in this differential diagnosis is that the atypical features are usually focal and other areas of conventional appearing polyp are present.[3] The extent of involvement of the polyp by these atypical features is not prognostically important. In a recent study, the authors have cautioned against making a diagnosis of atypical endometrial polyp if the size is >3.5 cm.[3]

Sarcomatous overgrowth is defined as the presence of pure sarcoma (without any epithelial component) in at least 25% of the tumor. Sarcomatous overgrowth is associated with deeper myometrial invasion and lymphovascular invasion. Sequential radiotherapy and chemotherapy are recommended in cases presenting with risk factors such as sarcomatous overgrowth, lymphovascular invasion, lymph node metastasis, and deep myometrial invasion.[4] None of these risk factors were present in this case. The patient was put on regular follow-up.

Shveiky et al. reported six cases of unexpected uterine mesenchymal tumors diagnosed following pathologic examination of specimens obtained during hysteroscopy to evaluate intrauterine lesions. They concluded that intrauterine lesions considered to be benign endometrial polyps or myomas clinically can turn out to be malignant mesenchymal uterine tumors. Hence, hysteroscopic evaluation and biopsy might offer early diagnosis and treatment to these patients.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Pinto A, Howitt B. Uterine adenosarcoma. Arch Pathol Lab Med 2016;140:286-90.  Back to cited text no. 1
    
2.
McCluggage WG. A practical approach to the diagnosis of mixed epithelial and mesenchymal tumours of the uterus. Mod Pathol 2016;29 Suppl 1:S78-91.  Back to cited text no. 2
    
3.
Howitt BE, Quade BJ, Nucci MR. Uterine polyps with features overlapping with those of Müllerian adenosarcoma: A clinicopathologic analysis of 29 cases emphasizing their likely benign nature. Am J Surg Pathol 2015;39:116-26.  Back to cited text no. 3
    
4.
Morales FD, Medina RM, Trujillo LM, Beltrán MI, Dulcey IC. Müllerian adenosarcoma of the uterine cervix with sarcomatous overgrowth: A case report of aggressive disease in a young patient. Int J Surg Case Rep 2016;27:155-61.  Back to cited text no. 4
    
5.
Shveiky D, Revel A, Rojansky N, Benshushan A, Shushan A. Diagnosis of malignant mesenchymal uterine tumors by hysteroscopic excisional biopsy. J Minim Invasive Gynecol 2005;12:29-33.  Back to cited text no. 5
    

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Correspondence Address:
Nadeem Tanveer
Department of Pathology, University College of Medical Sciences, Dilshad Garden, New Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_70_17

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