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12 December 2013 - Case of the Week #294

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Case of the Week #294

Clinical History:
A 43 year old woman presented with uterine bleeding, leading to an endometrial biopsy. She subsequently underwent a total abdominal hysterectomy.

Micro images:

Endometrial biopsy


Total abdominal hysterectomy



What is your diagnosis?































Diagnosis:
Endometrioid adenocarcinoma, corded and hyalinizing pattern

Discussion:
In 2005, Young et. al. described uterine endometrioid carcinomas with epithelial cords, spindle cells and a hyalinized stroma that sometimes formed osteoid, mixed with classic endometrial carcinoma, which they termed "corded and hyalinized endometrioid carcinoma" (Am J Surg Pathol 2005;29:157). The mean patient age was 52 years, and 65% were stage I, despite the appearance of a sarcoma. In addition, 70% exhibited squamous differentiation, and 50% had background endometrial hyperplasia. Unusual features included cords of cells without a hyalinized stroma, and areas of diffuse fusiform cells resembling endometrial stromal cells. Two thirds of the tumors were grade 1, and the remainder were grade 2. The classic endometrial carcinoma component was keratin positive, with weaker / variable staining in the epithelial cords. The cords were negative for muscle markers (desmin, actin), CD10, inhibin and p53. A subsequent study showed nuclear beta-catenin expression and complete loss of membranous E-cadherin expression in all cases, due to mutation of exon 3 of the beta-catenin gene in spindled or corded areas (Histol Histopathol 2009;24:149). These patients have a good prognosis after hysterectomy, with 83% alive with no evidence of disease at follow-up in the original study.

The differential diagnosis includes carcinosarcoma / MMMT, which has high grade carcinomatous and sarcomatous components, and an aggressive clinical course. Of note, in this case, the biopsy was signed out initially as carcinosarcoma. Other diagnoses to consider include uterine tumor resembling ovarian sex cord tumors, and epithelioid smooth muscle tumors. Of note, an ovarian serous carcinoma with this corded and hyalinized pattern was recently described (Arch Pathol Lab Med 2013;137:275).

Nat Pernick, M.D., President
and Palak Thakore, Associate Medical Editor
PathologyOutlines.com, Inc.
30100 Telegraph Road, Suite 408
Bingham Farms, Michigan (USA) 48025
Telephone: 248/646-0325
Email: NatPernick@Hotmail.com
Alternate email: NatPernick@gmail.com