AJR 2004; 182:1534-1536
© American Roentgen Ray Society
Papillary Serous Adenocarcinoma of the Endometrium: CT–Pathologic Correlation
I. M. Van Mieghem1,
S. Gryspeerdt1,
M. Baekelandt1,
B. van Holsbeeck1,
P. Lefere1,
M. Haspeslagh2 and
I. Dalle2
1 Department of Radiology, Stedelijk Ziekenhuis, Bruggesteenweg 90, Roeselare
8800, Belgium.
2 Department of Pathology, Stedelijk Ziekenhuis, Roeselare 8800, Belgium.
Received August 14, 2003;
accepted after revision October 8, 2003.
Address correspondence to S. Gryspeerdt.
Introduction
Papillary serous adenocarcinoma of the female genital tract is a well-known
tumor that is characterized by papillary projections and frequently contains
psammoma bodies that may calcify
[1]. Most papillary serous
adenocarcinomas are located in the ovary, and many authors have reported
visualization of calcified psammoma bodies on CT
[2]. Much less frequently, the
analogue counterpart is detected in the endometrium
[3]. We report a case of a
papillary serous adenocarcinoma of the endometrium that was identified on CT
on the basis of the presence of calcified psammoma bodies in the endometrial
cavity.
Case Report
A 73-year-old woman presented with anorexia, unexplained weight loss over
the previous 4 months, abdominal pain, and constipation. Abdominal distention
was noted at physical examination. Results of laboratory studies showed
C-reactive protein and cancer antigen (CA) 125 levels were elevated.
CT with IV, oral, and rectal contrast material revealed a hyperdense
endometrial cavity (Fig. 1A)
with endometrial density measurements of 450 ± 12 H (mean ±
standard deviation), consistent with calcifications.
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Fig. 1A. —73-year-old woman with papillary serous adenocarcinoma of
endometrium presenting with psammoma bodies. (Courtesy of Haspeslagh M,
Roeselare, Belgium) Axial contrast-enhanced CT scan obtained after oral and
rectal contrast administration shows hyperdense aspect of endometrium
(arrows), which is caused by calcified psammoma bodies.
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Ascites, outlining peritoneal metastatic implants especially in the pelvis,
omental implants, slight right ovarian enlargement, and left ovarian atrophy
were also present (Fig. 1B). No
hepatic lesions were found.
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Fig. 1B. —73-year-old woman with papillary serous adenocarcinoma of
endometrium presenting with psammoma bodies. (Courtesy of Haspeslagh M,
Roeselare, Belgium) Axial contrast-enhanced CT scan obtained after oral and
rectal contrast administration shows right ovary (o), adjacent to opacified
small bowel (s), and diffuse peritoneal implants, which are clearly outlined
by presence of ascites (a). Calcifications (arrows), typical of
psammoma bodies, are also visible.
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Peritoneal spread of primary papillary serous carcinoma of the endometrium
with psammoma bodies or endometrial metastasis from other papillary serous
carcinoma containing psammoma bodies, explaining the calcified endometrium,
was postulated. Therefore, subsequent curettage of the endometrium was
performed. Histologic examination of the curetted tissue revealed psammoma
bodies in an atrophic endometrium that was diffusely infiltrated by the
micropapillary serous carcinoma (Fig.
1C).
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Fig. 1C. —73-year-old woman with papillary serous adenocarcinoma of
endometrium presenting with psammoma bodies. (Courtesy of Haspeslagh M,
Roeselare, Belgium) Photomicrograph of histopathologic specimen shows numerous
psammoma bodies (arrows), identified as concentric calcifications,
and some papillary epithelial proliferations (arrowheads) with slight
nuclear atypia. (H and E, x400)
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A laparoscopic examination was subsequently performed and revealed small
tumoral implants covering the peritoneum, mesentery, and surface of the right
ovary. Histologic examination showed psammoma bodies in each of these
implants.
A first course of neoadjuvant chemotherapy was administered over 3 months.
This treatment resulted in a decrease of CA 125 levels. Subsequently, a
hysterectomy and bilateral oophorectomy with debulking were performed. After
surgery, a second course of adjuvant chemotherapy was applied over another 3
months.
Histologic examination showed that the stroma of both the right and left
ovaries was normal and confirmed the earlier diagnosis of diffusely spread
epithelial nests of papillary serous adenocarcinoma throughout the peritoneum
and mesentery with psammoma bodies. Exactly 1 year after the diagnosis, the
patient returned for follow-up with elevated CA 125 levels and pain in the
right hypochondrium. Subsequent abdominal CT revealed tumor recurrence with
peritoneal implants beneath the liver capsule.
Discussion
Our patient presented with pathologically confirmed papillary serous
adenocarcinoma in the endometrium with peritoneal and ovarian surface implants
containing psammoma bodies at each location. The ovarian stroma was normal,
thus excluding the possibility of primary serous carcinoma of the ovary. Based
on these findings, possible diagnoses were primary surface papillary serous
adenocarcinoma of the ovary, primary papillary serous carcinoma of the
(female) peritoneum, and primary papillary serous adenocarcinoma of the
endometrium. According to Gilks et al.
[4], the diagnosis of primary
surface papillary serous adenocarcinoma of the ovary or primary papillary
serous carcinoma of the female pelvis is made when the following findings are
noted: destructive invasion of the ovarian stroma or its vascular supply; in
cases of extraovarian involvement, invasion of peritoneal viscera; no more
than moderate nuclear atypicality; no areas of solid epithelial proliferation
except occasional nests no more than 15 cells in diameter; and at least 75% of
papillae or nests are associated with or completely replaced by psammoma
bodies [4].
In our patient, destructive invasion of the ovarian stroma was not present,
so the possibility of primary surface papillary serous adenocarcinoma of the
ovary was excluded. A large tumoral focus was found in the endometrium, which
is not consistent with the diagnostic criteria for primary papillary serous
carcinoma of the female pelvis (e.g., absence of areas of solid epithelial
proliferation). Therefore, a primary papillary serous carcinoma of the
endometrium—stage IIIC, according to the International Federation of
Gynecology and Obstetrics cancer staging system—was diagnosed. Moreover,
the clinical behavior of psammocarcinoma of the ovary and peritoneum more
closely resembles that of a borderline serous tumor than of a serous
carcinoma, resulting in a relatively favorable prognosis compared with
endometrial papillary serous carcinoma
[4].
At the time of follow-up, exactly 1 year after diagnosis, the patient
presented with tumoral recurrence. This unfavorable evolution is compatible
with primary papillary serous adenocarcinoma of the endometrium because it is
a highly aggressive tumor [3]
that is characterized by serous proliferations and, in one third of the cases,
by the presence of psammoma bodies.
Psammoma bodies are calcifications that can be found in patients with
benign conditions [5], such as
Asherman's syndrome, and in those with copper-bearing intrauterine devices;
these calcifications are also a rare sequela to spontaneous abortion
[6] and to treatment with
exogenous hormone therapy with clomiphene
[7]. As patients age, psammoma
bodies are, however, more frequently associated with primary or secondary
malignancy. Secondary tumoral lesions can be found in the endometrium, ovary,
and female peritoneum. Primary malignancies include primary papillary serous
adenocarcinoma of the ovary; primary surface papillary serous adenocarcinoma
of the ovary; primary papillary serous carcinoma of the (female) peritoneum;
or, as in the case presented here, primary papillary serous adenocarcinoma of
the endometrium. Obviously, the primary or secondary nature cannot reliably be
determined on the basis of radiologic evaluation. However, it is reasonable to
assume that the largest tumoral focus— the endometrium in our
patient—is caused by the primary neoplasm.
Cancer of the endometrium is the most common pelvic gynecologic malignancy
and accounts for 13% of all cancers in women. The most common endometrial
cancer cell type is endometrioid carcinoma. This type of endometrial carcinoma
accounts for 75–80% of affected patients and usually is associated with
estrogen-related endometrial hyperplasia; in most of the cases, CT, although
insensitive and nonspecific compared with MRI, shows an enlarged hypodense
endometrium in most of the cases
[8].
The papillary serous type of carcinoma, on the other hand, is known to be a
rare type of endometrial tumor that comprises only 5–10% of endometrial
carcinomas and in which psammoma bodies are found in one third of the cases.
Factor [9] suggested that the
extremely low incidence of serous papillary adenocarcinoma of the endometrium
with psammoma bodies might be misleading because this type of carcinoma might
be misdiagnosed as a metastatic ovarian carcinoma. Furthermore, papillary
serous carcinoma of the endometrium exhibits many of the same clinical
features as ovarian cancer, including a high metastatic potential and response
to platinum-based chemotherapy; serum CA 125 level is a useful indicator of
disease response or progression in patients with papillary serous carcinoma of
the endometrium [10].
This type of adenocarcinoma occurs in women older than those seen with the
endometrioid cell type and commonly arises in atrophic endometrium of
postmenopausal patients, as was the case in our patient. For this reason, this
type of tumor does not necessarily entail an enlarged hypodense endometrium on
CT. The presence of psammoma bodies may result in a hyperdense endometrium, as
we have described. Psammoma bodies are found in only one third of patients
with this type of tumor. The rarity of this entity probably explains the fact
that hyperdense endometrium on CT leading to the diagnosis of papillary serous
carcinoma of the uterus has, to our knowledge, not yet been described in the
literature.
In conclusion, if a hyperdense uterine cavity is depicted on CT, a
presentation most often associated with a benign pathology, the radiologist
should consider the possibility of a malignant serous tumor, either primary or
secondary, of the endometrium. A hypodense uterine cavity is not an essential
sign of malignancy.
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Introduction
Case Report
