Endocervical adenocarcinoma and its variants: their morphology and differential diagnosis.

Adenocarcinoma of the uterine cervix and its variants account for a much greater number of cases in routine practice of histopathology than they did several decades ago. The varied morphology of these tumours results in diverse problems in differential diagnosis. The overall area of glandular pathology of the cervix, of which invasive adenocarcinoma is only one subset, is further complicated by the fact that there are many benign glandular proliferations of the cervix that can potentially be misinterpreted as adenocarcinoma. In this review the histopathology of endocervical adenocarcinoma and its variants is presented with the emphasis on evaluation of routinely stained sections, still the bedrock of routine practice, relatively little aid being provided by immunohistochemistry or other new techniques, contrary to what is sometimes implied in the literature. Description of the appearance of each subtype of adenocarcinoma or variant thereof is followed by a section on their differential diagnosis. Eighty percent of endocervical carcinomas are of the so-called usual type being characterized by cells with eosinophilic cytoplasm and generally brisk mitotic activity. It is sometimes stated that endocervical adenocarcinomas are mucinous but the usual form just noted often has little or no mucin. Pure or almost pure mucinous adenocarcinoma do occur, however, and have an important subtype, the so-called adenoma malignum (minimal deviation adenocarcinoma). Although treacherous because of its bland cytological features and sometimes deceptive pattern, a cone biopsy or hysterectomy specimen showing this neoplasm typically has easily recognizable features that indicate the presence of an infiltrative adenocarcinoma. An important variant of usual endocervical adenocarcinoma is the well differentiated villoglandular papillary adenocarcinoma, a designation that should be reserved for tumours with grade 1 cytologic features as usual endocervical adenocarcinoma, which is typically grade 2, may have papillae. In our opinion all other variants of pure adenocarcinoma, including endometrioid, are rare and include in addition to the latter clear cell, serous and mesonephric neoplasms. Tumours with a glandular and nonglandular component are also reviewed: adenosquamous carcinoma, glassy cell carcinoma, adenoid basal carcinoma, 'adenoid cystic' carcinoma and adenocarcinoma admixed with a neuroendocrine tumour.

Endometriosis of the intestinal tract: a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation.

Endometriosis of the intestinal tract may mimic a number of diseases both clinically and pathologically. The authors evaluated 44 cases of intestinal endometriosis in which endometriosis was the primary pathologic diagnosis, and evaluated them for a variety of gross and histologic changes. Cases with preneoplastic or neoplastic changes were excluded specifically because they were the subject of a previous study. The patients ranged in age from 28 to 56 years (mean age, 44 years), and presenting complaints included abdominal pain (n = 15), an abdominal mass (n = 12), obstruction (n = 8), rectal bleeding (n = 2), infertility (n = 3), diarrhea (n = 2), and increasing urinary frequency (n = 1). The clinical differential diagnoses included diverticulitis, appendicitis, Crohn's disease, tubo-ovarian abscess, irritable bowel syndrome, carcinoma, and lymphoma. Forty-two patients underwent resection of the diseased intestine and two patients underwent endoscopic biopsies. In 13 patients there were predominantly mural masses, which were multiple in two patients (mean size, 2.6 cm). In addition, 11 cases had luminal stenosis or strictures, six had mucosal polyps, four had submucosal masses that ulcerated the mucosa (sometimes simulating carcinoma), three had serosal adhesions, one had deep fissures in the mucosa, and one was associated with appendiceal intussusception. Involvement of the lamina propria or submucosa was identified in 29 cases (66%) and, of these, 19 had features of chronic injury including architectural distortion (n = 19), dense lymphoplasmacytic infiltrates (n = 7), pyloric metaplasia of the ileum (n = 1), and fissures (n = 1). Three cases had features of mucosal prolapse (7%), ischemic changes were seen in four (9%), and segmental acute colitis and ulceration were seen in four and six cases (9% and 13%) respectively. In 14 patients, endometriosis formed irregular congeries of glands involving the intestinal surface epithelium, mimicking adenomatous changes. Mural changes included marked concentric smooth muscle hyperplasia and hypertrophy, neuronal hypertrophy and hyperplasia, and fibrosis of the muscularis propria with serositis. Follow-up of 20 patients (range, 1-30 years; mean, 7.8 years) revealed that only two patients had recurrent symptoms. None of the patients developed inflammatory bowel disease. Endometriosis can involve the intestinal tract extensively, causing a variety of clinical symptoms, and can result in a spectrum of mucosal alterations. Because the endometriotic foci may be inaccessible to endoscopic biopsy or may not be sampled because of their focality, clinicians and pathologists should be aware of the potential of this condition to mimic other intestinal diseases.

Endocervicosis involving the uterine cervix: a report of four cases of a benign process that may be confused with deeply invasive endocervical adenocarcinoma.

Four cases of endocervicosis that involved the outer cervical wall and paracervical connective tissue are reported; in one case there was also transmural involvement of the urinary bladder. A diagnosis of cervical adenocarcinoma was an initial concern of the referring pathologist in three cases. The patients were from 29 to 45 years of age; there was a history of cesarean section in two cases. Two patients presented with pelvic pain, one with dysmenorrhea, and one with symptoms related to an ovarian tumor. In three cases, a gross abnormality of the outer aspect of the cervix was noted at the time of hysterectomy and in the fourth at the time of macroscopic pathologic examination. The anterior wall of the cervix in each case was involved by a firm rubbery mass, 1 to 2.5 cm in maximal dimension, with cysts seen on sectioning in two. Microscopic examination disclosed a dominant population of glands of variable size and shape, including cystically dilated glands, lined by mucinous endocervical-type epithelium that ranged from columnar to flattened. All the glands had lining cells with bland cytologic features with absent to rare mitotic figures. A periglandular stromal reaction, present in two cases, was related to mucin extravasation. A cuff of endometriotic stroma was present around rare glands in one case. The appearance of the lesion was similar to that of endocervicosis of the urinary bladder, and as in that site, raised concern for adenocarcinoma, specifically for the minimal deviation (adenoma malignum) type of cervical adenocarcinoma. Awareness of the distinctive features of endocervicosis in this site, including its dominant location in the outer portion of the cervix and paracervical connective tissue and the typical presence of an uninvolved zone of cervical wall between the endocervicosis and the eutopic endocervical glands, facilitate the correct diagnosis.

Endometrial stromal tumors: an update on a group of tumors with a protean phenotype.

Endometrial stromal tumors are reviewed with emphasis on their wide morphologic spectrum and problems in differential diagnosis, highlighting issues that have received particular attention in the recent literature. These neoplasms are divided into two major categories--endometrial stromal nodules and endometrial stromal sarcomas--a distinction made on the basis of the lack of significant infiltration at the periphery of the former. The division of endometrial stromal sarcomas into low-grade and high-grade categories has fallen out of favor and the designation endometrial stromal sarcoma is now considered best restricted to neoplasms that were formally referred to as "low-grade" stromal sarcoma. Endometrial sarcomas without recognizable evidence of a definite endometrial stromal phenotype, designated poorly differentiated "endometrial sarcomas," are almost invariably high grade and often resemble the mesenchymal component of a malignant mullerian mixed tumor. Two features of endometrial stromal tumors that may cause confusion are smooth muscle differentiation and epithelial patterns. Cases in the former category often have a characteristic "starburst" pattern of collagen formation. The most common epithelial patterns resemble those seen in ovarian sex-cord stromal tumors. Much less common is endometrioid gland differentiation. Some endometrial stromal tumors have a prominent fibrous or myxoid appearance and the myxoid tumors should be distinguished from myxoid leiomyosarcoma. Other unusual features of endometrial stromal tumors are also discussed. Lesions in the differential diagnosis of uterine endometrial stromal neoplasms include highly cellular leiomyoma, cellular intravenous leiomyomatosis, adenomyosis with sparse glands, metastatic carcinoma, and lymphoma. Endometrial stromal sarcomas at extrauterine sites may be primary or metastatic from a uterine tumor, the latter sometimes being occult and difficult to definitively establish, particularly if there is a history of a remote hysterectomy for "leiomyomas." Endometrial stromal sarcomas of the ovary, whether primary or metastatic, may be difficult to distinguish from ovarian sex-cord stromal tumors. Extragenital endometrial stromal sarcomas may be confused with diverse lesions such as gastrointestinal stromal tumors, hemangiopericytoma, lymphangiomyomatosis, or mesenchymal cystic hamartoma of the lung. Immunohistochemistry may play a role in evaluating these tumors and in some instances establishing the diagnosis although conventional light microscopic analysis suffices in the majority of cases. The unusual tumor, the "uterine tumor resembling an ovarian sex-cord tumor," is also considered in this review as it is almost certainly of endometrial stromal derivation in many cases. These neoplasms may have a striking resemblance to granulosa cell tumors or Sertoli cell tumors, including those with a retiform pattern, and have recently been shown to be frequently inhibin positive.

Uterine adenomyomas excluding atypical polypoid adenomyomas and adenomyomas of endocervical type: a clinicopathologic study of 30 cases of an underemphasized lesion that may cause diagnostic problems with brief consideration of adenomyomas of other female genital tract sites.

We report 30 uterine tumors composed of an admixture of endometrioid glands, endometrioid stroma, and smooth muscle that lacked the characteristic features of atypical polypoid adenomyoma. The patients ranged from 26 to 64 (median 47) years of age. The usual presenting symptom was abnormal vaginal bleeding, which was "massive" in two patients. Six patients were treated by polypectomy only, with hysterectomy performed in the remainder. Twenty-seven adenomyomas were in the corpus (22 submucosal, two mural, and three subserosal) and three in the cervix. The subserosal and submucosal examples were polypoid. The tumors were 0.3 to 17 cm in greatest dimension, and firm with cystic areas often present on sectioning. Focal hemorrhage was described in five cases. On microscopic examination, the tumors were composed of glands and cysts lined by endometrial-type epithelium separated by endometrial stroma and smooth muscle, with smooth muscle predominating. Minor foci of tubal-type epithelium (14 cases), mucinous endocervical-type epithelium (2 cases), and squamous epithelium (1 case) were present. The smooth muscle component was cellular in three cases and contained occasional bizarre nuclei in three cases. The epithelial cells were uniformly bland. No mitotic activity was observed in the epithelial or mesenchymal elements in 20 cases. In the remainder, up to 5 mitotic figures/10 high-power fields were observed in the epithelium (3 cases), the stroma and smooth muscle (3 cases), or both compartments (4 cases). Follow-up in 14 cases revealed no recurrence or extrauterine spread in any case. A diagnosis of adenocarcinoma or adenosarcoma was entertained by the submitting pathologist in five of 14 consultation cases. Adenomyomas are unusual benign uterine tumors that can be misdiagnosed, in part, because the lesion has not often received attention in the literature. The most realistic considerations in the differential diagnosis are atypical polypoid adenomyoma and adenosarcoma. The former, by definition, has epithelial atypia and the latter a malignant (usually low grade) stromal component with typically absent or inconspicuous smooth muscle. Distinction of adenomyoma from adenosarcoma may have significant therapeutic implications, particularly in young women.

Neoplastic and pre-neoplastic changes in gastrointestinal endometriosis: a study of 17 cases.

The clinicopathologic features of neoplasms arising in gastrointestinal endometriosis have not been well characterized. In this series, we report 17 cases of gastrointestinal endometriosis complicated by neoplasms (14 cases) or precancerous changes (three cases). Four patients, one of whom also had hypermenorrhea, presented with chronic abdominal pain and five had obstructive symptoms; one of these also had rectal bleeding. One patient presented with an acute abdomen and fecal peritonitis, one had vaginal bleeding, and one had a progressive change in bowel habits. Nine patients had a long history of endometriosis, 11 patients had had hysterectomies, and eight of these had also received unopposed estrogen therapy. The lesions involved the rectum (6), sigmoid (6), colon, unspecified (2), and small intestine (3), and comprised 8 endometrioid adenocarcinomas (EA), 4 mullerian adenosarcomas (MAS), 1 endometrioid stromal sarcoma (ESS), 1 endometrioid adenofibroma of borderline malignancy (EBA) with carcinoma in situ, 2 atypical hyperplasias (AH), and one endometrioid adenocarcinoma in situ (ACIS). The tumors ranged in size from 2 to 15 cm and all involved the serosa and muscularis propria. Two tumors extended into the mucosa, with mucosal ulceration in one. Follow-up was available in 11 cases. One patient with EA was dead of disease at 1 year, one had two recurrences at 1 and 2 years, and three were alive with no evidence of disease (ANED) at 9 months to 13 years (mean, 68 mos). The patient with the EBA was ANED at 3 months. Two patients with MAS were ANED at 2 and 3 years. The patient with ESS had a recurrence at 3 years and was ANED 6 years after her original diagnosis. One woman with AH was ANED at 60 months and the patient with ACIS was ANED at 16 months. One of the carcinomas was originally misdiagnosed as a primary intestinal adenocarcinoma. The pathologist should be aware of the possibility of a tumor of genital tract type when evaluating intestinal neoplasms in females, particularly if they have a history of endometriosis and have received unopposed estrogen therapy.

The pathology of uterine smooth muscle tumors and mixed endometrial stromal-smooth muscle tumors: a selective review with emphasis on recent advances.

This review focuses on the pathology of uterine smooth muscle tumors (SMTs), with a particular emphasis on those studies published in the past 15 years that have expanded our knowledge of these tumors which still present diagnostic challenges for the pathologist. Leiomyoma variants, leiomyosarcoma, SMTs of low or uncertain malignant potential, epithelioid SMTs, SMTs with unusual growth patterns, and mixed endometrial stromal-SMTs are discussed.

Myxoid and fibrous endometrial stromal tumors of the uterus: a report of 10 cases.

Ten endometrial stromal tumors of the uterus with a prominent myxoid or fibrous appearance, or both, that led to problems in interpretation are reported. The patients were 32 to 52 (mean 39) years of age. Three presented with dysfunctional uterine bleeding and one with abdominal pain. An enlarged uterus or a pelvic mass was palpated in five patients; the tumor was an incidental postpartum finding in one patient. All patients underwent hysterectomy. The tumors ranged from 4 to 20 cm in greatest dimension. Six were soft, polypoid intracavitary masses and four were predominantly intramyometrial; two were gelatinous. On microscopic examination, nine tumors infiltrated the myometrium (stromal sarcomas) and one was well circumscribed (stromal nodule). Six tumors had a predominantly fibrous component with the neoplastic cells separated by variable amounts of collagen; extensive areas of hyalinization were present in three tumors. Two tumors were predominantly composed of hypocellular areas with an abundant myxoid matrix, and two had both components in roughly equal proportions. Alcian blue staining was positive, with the staining eliminated by hyaluronidase predigestion, in the myxoid areas. The typical morphologic features of endometrial stromal neoplasia were present focally in four tumors. All of them contained numerous small thin-walled vessels. Vimentin and smooth muscle actin were positive in nine of nine and seven of nine tumors, respectively, whereas desmin was negative in six of nine tumors and only focally positive in the other three. One patient had omental nodules at the time of the initial diagnosis and another had a pelvic recurrence 2 years after hysterectomy. Follow-up information is unavailable or short in the other cases. These tumors should be considered of endometrial stromal origin in view of the typical location of most of them, their growth pattern, content of characteristic arterioles, presence of typical endometrial stromal neoplasia in the primary or recurrent tumor in some cases, and absence of evidence of origin from a cell type other than endometrial stroma. These tumors may be identical, in some instances at least, to tumors referred to in the older literature as "myxofibrosarcomas."

Prognostic factors in Paget's disease of the vulva: a study of 21 cases.

Twenty-one cases of vulvar Paget's disease were studied to assess possible prognostic indicators, including presence and depth of invasion, status of resection margins, tumor DNA cell content, and immunoreactivity for p53 and estrogen receptor proteins. Immunostaining for cytokeratin 7 (CK7), cytokeratin 20 (CK20), and gross cystic disease fluid protein-15 (GCDFP) were also performed. Patients were 45 to 82 years of age (mean, 66.9 years). Ten of 21 patients (47.6%) had invasive Paget's disease. Dermal invasion was < or = 1 mm in 7 of 10 cases and 2 mm, 3 mm, and 8 mm in the remaining three invasive tumors. Of the seven patients with minimally invasive Paget's disease (< or = 1 mm depth of invasion), five are alive with no evidence of disease, one died of an unrelated illness, and one is alive with biopsy-proven in situ Paget's disease, having refused operative treatment. Of the three patients with more than minimally invasive Paget's disease (> 1 mm), all had nodal metastases; one patient is alive with no evidence of disease, one died of undertermined causes, and one died of metastatic Paget's disease. The remaining 11 patients had Paget's disease confined to the epidermis and its adnexal structures. Seven of these patients were alive at last follow-up with no evidence of disease. Of the remaining four patients, one died of metastatic cervical cancer, one died of metastatic bladder cancer, one died of an unrelated illness, and one patient is alive with biopsy-proven in situ Paget's disease and awaiting operative treatment. Twenty of the 21 cases represented primary vulvar Paget's disease while one represented possible local spread from a cervical adenocarcinoma. The immunoprofiles were GCDFP+/CK7+/CK20- in 14 cases, GCDFP+/CK7+/CK20+ in 4 cases, and GCDFP-/CK7+/CK20- in 2 cases. All tumors were estrogen receptor-negative. Immunostaining for p53 was positive in 16 tumors and negative in four tumors. Seven of 12 (58%) patients with positive margins experienced local recurrence of Paget's disease, while the disease recurred in 1 of 4 patients with negative margins. Recurrence was observed in 3 of 5 patients with diploid tumors and in 4 of 10 patients with aneuploid tumors. Neither of these differences is statistically significant. This study supports the recognition of a category of minimally invasive vulvar Paget's disease that has a low risk of distant metastasis and death caused by disease. Status of surgical resection margins, tumor cell DNA ploidy, estrogen receptor expression, and p53 immunoreactivity are not predictive of local recurrence.

Lobular endocervical glandular hyperplasia, not otherwise specified: a clinicopathologic analysis of thirteen cases of a distinctive pseudoneoplastic lesion and comparison with fourteen cases of adenoma malignum.

We report 13 cases of a previously undescribed pseudoneoplastic lesion of the uterine cervix, which we have designated "lobular endocervical glandular hyperplasia, not otherwise specified." The patients' ages ranged from 37 to 71 years (mean, 45 years; median, 49 years). Three (27%) patients had a history of hormone use. Seven lesions were incidental findings in hysterectomy specimens. In the six other cases, the patient came to clinical attention because of a mucoid cervical discharge (two cases), increased vaginal discharge (two cases), abdominal discomfort (one case), or a 3.5-cm cervical mass found when being examined because of ovarian carcinoma (one case); hysterectomy was performed in each of these six cases. Microscopic examination showed a distinctly lobular proliferation of small to moderately sized rounded glands often centered around a larger central gland. The lobular proliferation was well to poorly demarcated and usually confined to the inner half of the cervical wall. Glands within the lobules were usually separated from each other by unaltered or hypercellular cervical stroma and were lined by columnar mucinous cells similar to the normal endocervix. Occasional reactive atypia of the endocervical cells and mitoses were seen, but no significant cytologic atypia was identified. Neither of the two cases stained showed cytoplasmic immunoreactivity for carcinoembryonic antigen. Follow-up of seven patients showed no evidence of recurrence of the cervical lesion, with an average length of follow-up of 3.4 years; three patients were lost to follow-up and three cases are recent. The principal consideration in the differential diagnosis was adenoma malignum (minimal deviation adenocarcinoma). The features most helpful in this distinction, in addition to the orderly lobular arrangement of the glands, were a lack of the following: irregular stromal infiltration, a desmoplastic stromal response, and focal malignant cytologic features. Lobular endocervical gland hyperplasia should be added to the list of previously described pseudoneoplastic glandular lesions of the cervix and, like them, not misinterpreted as neoplastic.

Primary non-Hodgkin's lymphoma and malakoplakia of the vagina: a case report.

The vagina is a rare site for both primary non-Hodgkin's lymphoma and malakoplakia. We report a case of concurrent diffuse large B-cell lymphoma and malakoplakia of the vagina in a 67-year-old woman presenting with a vaginal discharge and a vaginal mass. The patient had two biopsy specimens reported as showing malakoplakia only, followed by a third biopsy specimen 10 months later which was diagnosed as diffuse large B-cell lymphoma. Review of the first two biopsy specimens showed areas of histiocytes with Michaelis-Gutman bodies merging with areas of cells with slightly larger nuclei and more amphophilic cytoplasm. Immunohistochemistry for the B-cell marker L-26 (CD20) and polymerase chain reaction analysis of the immunoglobulin heavy chain gene were helpful in retrospectively distinguishing the population of diffuse large B-cell lymphoma from the areas of malakoplakia. The third biopsy specimen showed sheets of large atypical lymphoid cells characteristic of a large cell lymphoma. Malakoplakia has been described in association with a variety of cancers, and this is only the second report of malakoplakia associated with non-Hodgkin's lymphoma. Considering the rarity of these two entities in the vagina, it is unlikely that the association in this case is coincidental, raising the possibilities of an unusual reaction to the presence of lymphoma or a common pathogenesis such as underlying chronic inflammation. Epstein-Barr virus DNA was detected in the second biopsy specimen, suggesting a possible role in the pathogenesis of this lymphoma.

Cytologic features of villoglandular adenocarcinoma of the uterine cervix: comparison with typical endocervical adenocarcinoma with a villoglandular component and papillary serous carcinoma.

BACKGROUND: To the authors' knowledge, the cytologic features of villoglandular adenocarcinoma (VGC) have been described in very few publications. The malignant cells are difficult to separate from reactive glandular cells and the majority of VGCs are missed on screening cytology. METHODS: The cytologic findings of a retrospective study of four cases of pure VGC are described and are contrasted with those of papillary serous adenocarcinoma and typical mucinous endocervical adenocarcinoma with a focal component of VGC. RESULTS: Although atypical glandular cells of endocervical origin were reported when the smears from the VGC cases were examined in the screening program, none of the cases was recognized as malignant prior to histologic diagnosis. The smears showed many groups of endocervical glandular cells. Important architectural features included large cohesive groups and sheets of cells showing nuclear crowding and loss of the normal honeycomb pattern. True papillary structures comprising stromal cores covered by well polarized columnar cells with a smooth surface were characteristic. It is important to note that a "feathered edge" appearance of the cell groups was absent. The neoplastic cells were mildly atypical, showing a slight increase in the nuclear-cytoplasmic ratio but minimal hyperchromatism. The cytology smears of four cases of typical adenocarcinoma of endocervical type that had a focal VGC pattern showed cell groups with irregular borders and "feathered" edges comprised of distinctly atypical columnar cells with elongated and irregular hyperchromatic nuclei. Free-lying atypical cells and ball-like clusters of atypical cells also were present in the latter cases but not in pure VGCs. The primary high grade papillary serous adenocarcinomas of the cervix exhibited extreme cytologic atypia that was interpreted readily as malignant. CONCLUSIONS: The diagnosis of VGC on cytology smears often is missed. Papillary fragments, nuclear crowding, and subtle atypia may suggest the diagnosis.

Florid cystic endosalpingiosis with tumor-like manifestations: a report of four cases including the first reported cases of transmural endosalpingiosis of the uterus.

Four cases of endosalpingiosis presenting as masses that resembled neoplasms are described in women 20, 41, 43, and 74 years of age. Each case was referred in consultation because of difficulties in pathologic diagnosis. In two patients, multiple cysts that involved the serosal surfaces of the uterus and adnexa in one case, and the colon, rectosigmoid, pelvic sidewalls, and the cul-de-sac in the other, were excised. In the other two cases, hysterectomy was performed for an enlarged cystic cervix in one case and presumed uterine leiomyomas in the other. In both of these cases, the uterine cervix and lower part of the uterine corpus were extensively involved by multiple cysts on gross examination, and in one of them, a frozen section of the cervical lesion was initially interpreted as "suspicious for invasive minimal deviation adenocarcinoma." On microscopic examination, benign endosalpingiotic glands and cysts were found in all four cases, with striking transmural involvement of the uterine cervix and lower uterine segment and contiguous corpus in the two cases with uterine involvement. The latter two cases are the first examples, to our knowledge, of endosalpingiosis involving the wall of the uterus; the differential diagnosis in these cases includes minimal deviation adenocarcinoma and florid tubal metaplasia with cystification. The four cases in this report, and rare previously reported cases, indicate that although usually a microscopic finding, endosalpingiosis can rarely present as a clinically or grossly evident mass that can be confused with a neoplasm.

Presence of asbestos in peritoneal malignant mesotheliomas in women.

Heller DS, Gordon RE, Clement PB, Turnnir R, Katz N. Presence of asbestos in peritoneal malignant mesotheliomas in women. Asbestos plays a causal role in pleural mesotheliomas. The role in peritoneal mesotheliomas is less clear, particularly in women, who are less likely to have an exposure history. Seven peritoneal malignant mesotheliomas in women with no recorded asbestos exposure were analyzed in this report. Tissue digestion was performed on paraffin blocks of tumor. Transmission electron microscopy, energy-dispersive spectroscopy, and electron diffraction were performed for tissue fiber burden and fiber identification. Asbestos fiber burdens were present in 6 cases. Two showed crocidolite, 2 showed chrysotile, one showed chrysotile and amosite, and one showed chrysotile and tremolite. Fiber burdens ranged from 56,738 to 1,963,250 fibers per gram wet weight tissue. All fibers counted were between 1 and 5 microns. This study demonstrates asbestos in peritoneal mesotheliomas in women. Asbestos may play a role in the development of these tumors.

Superficial endometriosis of the uterine cervix: a report of 20 cases of a process that may be confused with endocervical glandular dysplasia or adenocarcinoma in situ.

Twenty cases of superficial endometriosis of the uterine cervix that occurred in patients from 20 to 51 (mean 37.1) years of age are described. The majority of the cases were seen in consultation and were usually referred because of diagnostic problems; endocervical glandular dysplasia, adenocarcinoma in situ, or rarely invasive adenocarcinoma were a frequent consideration of the contributor. The endometriosis was almost always an incidental microscopic finding. The endometriotic foci were usually confined to the superficial third of the cervical wall, but in one case there was also involvement of the middle third of the cervical wall. Deep cervical endometriosis was not present in any case. The endometriotic glands were typically evenly spaced and were surrounded at least focally by endometriotic stroma in all cases. The endometriotic stromal cells, however, were significantly obscured by inflammatory cells (two cases), inflammatory cells and hemorrhage (two cases), hemorrhage (four cases), and in one case by smooth muscle metaplasia causing initial failure to recognize the stromal component of the process. The presence of mitotic figures in the glandular epithelium contributed to an initial diagnosis of a premalignant or malignant glandular lesion being made or seriously entertained in 10 cases. Awareness that mitotic figures may be conspicuous in endometriosis from women of reproductive age, the usually bland cytologic features of the endometriotic epithelium, and the presence of associated endometrial stromal cells all facilitate establishing the correct diagnosis.

Endocervicosis presenting as a painful vaginal mass: a case report.

A case of endocervicosis presenting as a painful vaginal mass in a 36-year-old woman is reported. No previous similar cases have been found in the literature.

Small cell carcinoma of the uterine cervix: cytologic findings in 13 cases.

BACKGROUND: There are few reports on the cytologic features of small cell carcinoma (SMCC) of the uterine cervix. METHODS: The clinical records, histopathology, and available cervical smears from all cases of SMCC of the uterine cervix in the files of the British Columbia Cancer Agency between 1985 and 1997 were reviewed. RESULTS: Cervical smears were available from 11 of 13 identified cases. Six cases had a pretreatment smear containing numerous definitely malignant cells. In the seven cases with reported negative smears, review of the most recent smears detected a missed high grade squamous intraepithelial lesion in one case and rare suspicious epithelial cells in a second case. These two cases were considered to be false-negative smears on review. None of the six malignant smears were diagnosed as SMCC on cervical smears. These smears were reported as malignant epithelial cells, not otherwise specified in three cases and misclassified as adenocarcinoma in three cases. These malignant smears contained cells dispersed as single cells or arranged as loosely cohesive sheets or gland-like aggregates. Tumor cells, ranging from small to large, had extremely pleomorphic, angulated nuclei that were hyperchromatic and showed nuclear molding and smearing. Mitotic figures were common and karyorrhectic debris was identified in all cases. CONCLUSIONS: The routine cervical smear is a relatively insensitive and nonspecific method of detecting SMCC. The specific diagnosis of SMCC on cervical smears is difficult. SMCC can mimic inflammatory cells, follicular cervicitis, endometrial cells, endocervical adenocarcinoma, squamous cell carcinoma of small cell type, non-Hodgkin's lymphoma, and other unusual malignant neoplasms. The suspicion of SMCC on a cervical smear should prompt an urgent biopsy to establish the diagnosis and initiate prompt treatment.

Mixed endometrial stromal and smooth muscle tumors of the uterus: a clinicopathologic study of 15 cases.

Uterine tumors composed of a prominent component of smooth muscle (SM) and endometrial stroma (ES) (so-called stromomyomas) have received little attention in the literature. The features of 15 of these tumors, defined as those containing more than 30% of each component, were evaluated. Many of the tumors were referred because of problems in the differential diagnosis. Patient age ranged from 29 to 68 years (mean, 46 years). The tumors ranged from 3 to 27 cm (average 9.6 cm) in diameter, and most were grossly well circumscribed. The sectioned surfaces often had soft, tan-yellow areas admixed with firm, whorled areas. Microscopic evaluation disclosed that nine tumors were well circumscribed, and six had infiltrating tongues typical of endometrial stromal sarcoma (ESS). The endometrial stromal component, which predominated in five cases, typically was characterized by a diffuse growth of closely packed, minimally atypical small cells accompanied by numerous arterioles and was desmin-negative in all cases tested, except for rare desmin-positive cells in three tumors. Five tumors showed sex-cord-like differentiation in these areas. The smooth muscle component, which predominated in seven cases, was composed predominantly of spindle cells in disorganized short fascicles, longer fascicles, or nodules with prominent central hyalinization. This component appeared benign, except in one case with moderate cytologic atypia, focal tumor cell necrosis, and 4 mitotic figures/10 high-power fields. The smooth muscle component was strongly desmin-positive in all the tumors tested. Follow-up of more than 1 year was available for seven patients. Six patients were alive and well, but one tumor with infiltrative borders recurred at 48 months as a pure endometrial stromal sarcoma. Mixed endometrial stromal and smooth muscle tumors should be distinguished from highly cellular leiomyomas, pure endometrial stromal tumors, and "uterine tumors resembling ovarian sex cord tumors," at least until knowledge of their clinicopathologic features is more complete. For treatment purposes, these tumors should be reported as endometrial stromal nodules or as endometrial stromal sarcomas with smooth muscle differentiation and any unusual features of either component recorded in a notation.